Antony Morgan

1

Evidence based health promotion do we ever
learn - does it make a difference?

• Antony Morgan
• National Institute of Health and Clinical
  Excellence (NICE), England

2
Reflections on evidence based health promotion

• 10 years of systematic reviewing what have we
  learned
• Overcoming deficiencies the NICE Model
• Issues for capacity building

3
What is NICE?

• The National Institute for Health and Clinical
  Excellence (NICE) is the independent organisation
  responsible for providing national guidance on
  the promotion of good health and the prevention
  and treatment of ill health.

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We produce guidance in three areas

• Public health guidance on the promotion of good
  health and the prevention of ill health for those
  working in the NHS, local authorities and the
  wider public and voluntary sector
• Health technologies guidance on the use of new
  and existing medicines, treatments and procedures
  within the NHS
• Clinical practice guidance on the appropriate
  treatment and care of people with specific
  diseases and conditions within the NHS.

5
Archie Cochranes Principles (1979)

• The best care available to all- universalism
• The need for a means to determine what was
  best-empirical
• The importance of rooting out harmful or useless
  practice-compassion
• The necessity of ascertaining costs and
  benefits-accountability

6
The legacy

• The Cochrane and Campbell Collaborations
• The importance of the systematic review and meta
  analysis
• The importance of making evidence based decisions
• The importance of dealing with health
  inequalities

7
In the beginning

• Health Education Authority 1997-2000
• First series of systematic reviews in England to
  prove the worth of health promotion
• Results equivocal - more research needed.

8
An early systematic review health promotion in
young people for the prevention of substance
misuse (White and Pitts, 1997)

• Why? In the 1990s the misuse of drugs was
  widespread in secondary schools in the UK, often
  starting as early as 13.
• Key question to identify interventions that have
  been effective in preventing or reducing use of
  illicit substances in young people
• Key results Current research evidence is
  inadequate to allow confident recommendations to
  plan and implement substance abuse policies for
  young people. No specific intervention programmes
  for substance misuse prevention in young people
  have been shown to be effective in the long term

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The example continued

• Key findings
• interventions tend not to consider the varying
  contexts in which drug misuse occurs
• There needs to be better understanding of what
  young people believe about drugs and their
  consequences if plausible and relevant
  interventions are to be developed.
• Alternative evaluation strategies are needed to
  assess the impact of harm minimisation
  interventions and other programmes targeting hard
  to reach groups
• There is a need for an assessment of which
  elements or mix of elements are most effective as
  well as an assessment of the programme as a whole

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A systematic review, for NICE guidance -
community based drug interventions for young
people (John Moores University, 2007)

• Why? Illicit drug use in the UK is the most
  prevalent among young people aged 16 to 24 years.
  Vulnerable young people were 5 times more likely
  to use drugs than less vulnerable peers
• Key Question What community based interventions
  are effective and cost effective in reducing
  substance misuse among the most vulnerable and
  disadvantaged children and young people
• Key findings
• Almost all of the studies of interventions to
  reduce problematic substance misuse have looked
  at the effects over the short term
• There is a lack of evidence on the specific
  components of a substance misuse intervention
  that make it effective
• Few rigorous evaluations have been carried out in
  the UK on the effectiveness and cost
  effectiveness of community based interventions to
  reduce or prevent substance misuse.

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How systematic reviews have disappointed

• Not paying enough attention to the right
  questions too much on the what questions and
  not enough on the how
• Trying to cover too much ground broad questions
  broad answers
• And the most cynical..
• Too much journal impact factor and not enough
  population health impact factor

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A limited evidence base .

• Evidence about what works to reduce inequalities
  very limited
• Rich in description, weak on solution.
• More on what is effective but little on how
  things can be done to improve things

13
And why?

• Gaps in the initial formulation of primary
  research studies.
• Gap between evidence and practice
• Failure to distinguish between determinants of
  wellbeing and determinants of inequalities in
  well being
• Much more focus on deficit /risk factor model
  than asset based/ resources model

14
However..

• Still possible to produce recommendations that
  support the improvement of standards in practice
  through
• Mix method approaches to collecting and collating
  evidence
• Expert opinion
• Lay knowledge
• Stakeholder testing and validation

15
Core principles of all NICE guidance

• Comprehensive evidence base
• Expert input
• Patient and carer involvement
• Independent advisory committees
• Genuine consultation
• Regular review
• Open and transparent process.

16
Developing NICE guidance key stages

• Topic referral
• Scoping
• Development
• Validation
• Publication

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Scoping
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Scoping the guidance

• Clear definition of the intervention or
  programmes
• Background information on public health issues
  and need for guidance (including policy context)
• Identifies key audience (s)
• Sets out key questions.

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Key questions

• What is effective?
• What is ineffective?
• What is harmful or dangerous?

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Areas of enquiry

• Our reviews aim to address the following areas
  looking explicitly at evidence on variation and
  inequalities
• Intervention aims objectives, delivery mode,
  intervener
• Target group characteristics views
• Setting context
• Intensity/duration
• Cost
• Implementation feasibility

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Getting the questions right review stage

• Distinguishing between impact, process and
  experience
• Distinguishing between audience, high level
  policy makers or local providers of services.

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Development
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Development reviewing the evidence

• Extensive use of reviews and primary research
• Rapid reviews
• assess quality and strength of evidence
• assess applicability
• Economic appraisal
• economic evaluations and modelling

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Finding, collating and synthesising evidence

• Broad spectrum of possibilities,
• Quality of the research, not privileging types of
  or hierarchies of evidence
• Ongoing consultation (expert consultations)
• New ways of searching the literature e.g.
  evidence mapping

25
Development drafting the recommendations

• Advisory committees (PHIAC/PDG) meet to agree
  draft recommendations
• Expert Witnesses, Cooptees
• Recommendations
• strength and applicability of evidence
• cost effectiveness
• impact, including on inequalities in health
• risks, benefits
• implementability

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Validation
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Validation

• Recommendations for consultation
• Fieldwork
• Review meeting
• stakeholder comments on draft recommendations
• fieldwork data
• additional evidence
• revise recommendations and produce guidance

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What does the guidance look like?

• Recommendations
• Who is the target audience
• Who should take action
• What action should they take.
• Considerations
• Critical conditions for success, caveats
• Gaps in research
• Improve the evidence base next time round

29
Capacity issues whats coming next?
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New frameworks for constructing the evidence base
work of the Measurement and Evidence Network
(Kelly et al, 2007)

• Commitment to the value of equity (1) they
  exist between and within societies and that they
  are unfair.
• Taking and evidence based approach (2) research
  is high quality, and relevant
• Methodological diversity (3) appropriate
  methods, right questions
• Gaps and gradients (4) analysis of structures
  if inequities in a given society
• Causes, determinants and outcomes (5) social
  and biological factors interacting together.
• Social structure (6) and social dynamics (7)
  dimensions of inequity, power structures in
  different societies the importance of context
• Explicating bias (8) scientific, political,
  ideological making it explicit

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Public health Review Group in Cochrane

• 1996 Health Promotion Field (based in UK and
  Canada)
• 1999-2006 Health Promotion and Public Health
  Field (2000 Australia)
• 2007 Joint editing role on PH titles with EPOC
• 2008 (mid-April) Public Health Review Group
  registered
• Contact database 442 members, from 48 different
  countries

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From a Field to a Public Health Review Group

• Current Review Groups tend to address single
  interventions with straightforward outcomes not
  congruent with PH interventions and outcomes.
• Need for a CRG to tackle the complex,
  multi-sectoral, multi-component, upstream
  interventions called for in public health
• Ensure that high quality evidence reviews focus
  on what works for whom and why understandable
  to public health folkas well as those from other
  sectors
• Need to engage sectors outside health (eg.
  Transport, urban planning, education etc.)

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Commitment and challenges

• Support for more involvement in Cochrane from
  those working in public health
• Recruiting experienced public health reviewers to
  undertake Cochrane reviews
• Determining and supporting the production of high
  priority reviews
• Establishing closer ties with other public health
  organisations globally
• Engaging with sectors outside of health (to be
  true to our upstream, multisectorial scope)
• Potential co-registration opportunities with
  Campbell Collaboration (education, social welfare
  and criminal justice topics)

34
Key messages

• Need to take look at the benefits and limits of
  systematic reviews in evidence based health
  promotion how far can they go to answer our key
  questions.
• Evidence based health promotion should be about
  science policy and practice and all the processes
  in between. e.g the NICE model.
• Need to find ways of building capacities and
  skills in new generations of health promotion
  professionals through
• Skills development programmes that help
  professionals diversify e.g. more health
  promotion professionals doing systematic reviews
• More person to person knowledge transfer
  inter-generational exchange

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10 years is a relatively short time in health
promotion but it would be both depressing and
inexcusable if someone else was able to repeat
this presentation in 2018

• Cautionary note