Issues in Synthesising Qualitative and Quantitative Evidence:

1
Leicester Warwick Medical School
Healthcare Evaluation, Provision and Policy
Public health and health promotion Mary
Dixon-Woods
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Objectives

• Explain why health promotion is seen as important
• distinguish between primary, secondary, and
  tertiary promotion
• distinguish between three health promotion
  strategies

3
Objectives

• illustrate some of the dilemmas raised by health
  promotion
• recognise some of the difficulties of evaluating
  health promotion
• Assess policy initiatives such as Our Healthier
  Nation

4
Objectives

• Identify the range of public health issues
  confronting todays doctors
• Show how individual behaviour affects the health
  of the population

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A short history of public health the rise

• Big emphasis on public health in Victorian times

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Thomas Crapper

• Patent holder for a range of Victorian
  sanitaryware
• Though NOT the inventor of the flushing toilet
  and NOT..

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Location of the Broad Street Pump Epidemic
John Snow
Saint Paul's Cathedral
Houses of Parliament
Thames River
continue
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Decline of Public Health

• Britain had a health service but no policy for
  health by 1950 achievements of public health
  taken for granted
• 1970s criticism of the role of medicine in health
  gain
• Fierce criticism of health education in 1980s

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Criticisms of traditional health education

• Sought to regulate private behaviours on behalf
  of the state surveillance and interference
• Encouraged individuals to take responsibility
  BUT not everyone starts from the same basis of
  opportunity

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Public health rises again

• Move away from public health now seen as a BIG
  MISTAKE
• Rise of the new public health in late 1980s.

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The new public health

• Draws on WHO definition of health and Health for
  all by the year 2000
• Emphasis on partnership, participation and
  empowerment
• Rejection of didactic models of health education
  but big emphasis on prevention

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Why the emphasis on prevention?

• Need to promote good health as well as treating
  illness
• Positive conception of health
• Cheaper to prevent than cure (maybe)
• Change in disease burden

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Why emphasis on prevention?

• Growing elderly population
• Demand for health services is infinite
• Implications for the economy
• Inequalities in health ARE avoidable

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Inequality social classExcess death rates for
men in non-professional classes
I - Professional
280
II - Managerial
300
IIIN - Skilled (non-manual)
426
493
IIIM - Skilled (manual)
492
IV - Partly Skilled
806
V - Unskilled
European standardised mortality ratio per
100,000 population for men aged 20 - 64
England Wales 1991-93
7
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Complex influences on health
Wider influences
Lifestyle factors
Health individuals communities
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Three levels of prevention

• PRIMARY PREVENTION aims to prevent onset of
  disease
• SECONDARY PREVENTION aims to detect and cure a
  disease at an early stage
• TERTIARY PREVENTION aims to minimise effects of
  established disease

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Examples of primary prevention

• Cutting out smoking could help prevent lung
  cancer from developing
• Avoiding asbestos could help prevent mesothelioma
• Putting babies to sleep on their backs could help
  prevent SIDS

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Examples of secondary prevention

• Screening for cervical cancer
• Checking patients blood pressure
  opportunistically
• Checking for glaucoma when eye tests are done

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Examples of tertiary prevention

• Renal transplants (to prevent someone dying of
  renal failure)
• Steroids for asthma (to prevent asthma attacks)
• Beta-blockers for high blood pressure (to prevent
  strokes)

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Three strategies for health promotion

• Health education
• Clinical prevention
• Intervention at social and environmental level

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Example lifestyleUnholy trinity of diet,
smoking and exercise

• smoking-related disease kills 100,000 per year
• diet associated with 35 of all cancers
• alcohol implicated in 40,000 deaths per annum

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Can we change peoples lifestyles?

• Strategy 1 Health education assumes people
• are rational individuals
• make sensible choices based on credible
  information
• have means to modify behaviour in response to
  information
• are equally able to make changes

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Dilemmas with health education strategy

• little understood, complex process
• can ignore social context
• cannot tackle wider influences
• may result in victim blaming
• may result in cultural imperialism
• hard to produce evidence of attributable outcome

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Health education dilemmas

• accusations of medicalisation
• can reinforce negative stereotypes
• Implementing the advice is often left up to women

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The fallacy of empowerment

• Some would argue that health education fails
  because poor lifestyles are not due to ignorance
  but due to adverse circumstances.
• Health education perpetuates fallacy of
  empowerment that giving people the information
  gives them the power.

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Other problems with health education

• Quality of educational material traditionally
  poor
• Access to educational material traditionally poor
• Both now improving but
• Health education may depend on a set of
  competencies (eg functional literacy)

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Strategy 2 Clinical intervention

• Mainly centres on use of screening
• However, screening programmes for lifestyle would
  need to be carefully evaluated eg cholesterol and
  blood pressure screening for particular age groups

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Strategy 3 Social and environmental intervention

• Involves govt and public authorities in adopting
  policies to tackle causes of ill-health. State
  can use
• financial powers
• legislative/regulatory powers

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Examples of social and environmental intervention

• Social intervention control age of cigarette
  buying
• Environmental intervention adding fluoride to
  water to improve dental health

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Dilemmas of social and environmental intervention
approach

• May
• involve interference in personal choice
• be costly
• cause problems elsewhere

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Problems in evaluating health promotion

• May involve very long-term social, behavioural or
  environmental changes
• Outcomes not easily measured or defined
• Difficult to control influences external to
  strategies

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Policies Health of the Nation (1992)

• Identified 5 key areas for action
• - coronary heart disease and stroke
• - cancers
• - mental illness
• -HIV/AIDS and sexual health
• - accidents
• Set 27 targets in these 5 areas

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Implementation of HoN

• Only 4 targets went the wrong way
• BUT
• worries about usefulness and validity of targets
  as focus of activity
• HoN may have lacked social perspective
• May not have considered role of social
  deprivation in ill-health

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Our healthier nation (1999)
CHIEF MEDICAL OFFICERS PROJECT TO STRENGTHEN THE
PUBLIC HEALTH FUNCTION IN ENGLAND A REPORT OF
EMERGING FINDINGS
Independent Inquiry into
Inequalities in Health
REPORT
CHAIRMAN SIR DONALD ACHESON
A Contract for Health A Consultation Paper
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Saving lives Our Healthier Nation

• Attempts to recognise that health depends on
  social, economic and environmental policies
• Connected problems require joined-up solutions
• Partnership between government, local services,
  and the individual

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Goals of Our Healthier Nation
Improve health To improve the health of the
population as a whole by increasing the length of
peoples lives and the number of years people
spend free from illness
Narrow the health gap To improve the health of
the worst off in society and to narrow the health
gap FOCUS ON INEQUALITIES IN HEALTH

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Four priority areas

• Cancer http//www.york.ac.uk/inst/crd/contents1.ht
  m
• Coronary heart disease stroke
• Accidents
• Mental health

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Wider action

• On a range of areas eg smoking, sexual health,
  food safety, black and minority ethnic health.
• Recognition that most of the means to improve
  health lie outside the health service.

17
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Range of strategies

• The National School Fruit Scheme which entitles
  school children aged four to six to a free piece
  of fruit each school day.
• Reduce salt, sugar and fat in the diet work with
  the Food Standards Agency and the food industry
  to improve overall balance of the diet.
• Local action to tackle obesity and physical
  inactivity informed by advice from the Health
  Development Agency.
• Tackle smoking by making Nicotine Replacement
  Therapy available on prescription.

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Measuring monitoring progress

• National targets
• Tailored local targets
• Performance management and regular reviews
• Underpinning measures eg research and investment
  to support achievement of targets

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Concerns about OHN

• Outcome targets are mortality measures
• Policies may not show effects for a long time
• Expectations may be too high
• Resources may not be adequate to deliver
• May be too much for PCTs and others to cope with

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Dilemmas of health promotion

• Do you stop spending money on sick?
• Hard to demonstrate effectiveness
• Problems with social acceptability of some
  strategies
• Implications for personal freedom
• Accusations of medicalisation
• Modest benefits in relation to cost

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Prevention is better than cure?

• Difficult to redress balance between prevention
  and treatment services
• Social and economic policies largely responsible
  for health divides have to address them first
• Persistent concern about whether health promotion
  really works.

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Conclusions

• The new public health emphasises social
  responsibility for health
• 3 levels of prevention
• 3 main strategies for prevention
• Latest policies reflect the New Public Health
  philosophies
• But many dilemmas remain