Based on a paper presented at the 14th Annual Conference

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(No Transcript)
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Based on a paper presented at the 14th Annual
Conference of the Australian Health Promotion Ass
ociation
Sydney 16-19 June 2002
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Dilemmas, Directions, and
DialecticsRandom Contradictions in Health
Promotion(with apologies to Archie Cochrane)

• Gauden Galea
• Regional Adviser NCD
• WHO WPRO

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I come to carry hilt erosion and not to grease it

• (with apologies to William Shakespeare)

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The Hot Towel Barter

• Hilt erosion is the grossest, oft impelling pips
  in grease-gun rollover, and to degroove their
  belt
  
• Live firing ranges
• Kilt wealthy rustic polity
• Klee ate, supped, or tasted in virement
• Disport quaternary section
• Leave, elope for sonic thrills
• Circumvent debt servants

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Oops, sorry
Or is it my left?
My right brain is playing up again
And we (it?) wont do it again
In any case one of them is!
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Topics

• A joke (youve had that)
• Some self-contradictory comments
• Some more jokes (if you behave)
• Please dont agree with anything I say
• Its either intuitive
• Or its evidence-based
• (Sure to upset half the audience)

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Health PromotionA Clash of Two Cultures?(with
apologies to C P Snow)

• Art Science
• Holistic Thematic
• Ideology Programme
• Population High-Risk
• Network Linear
• Upstream Downstream
• Multi Mono
• Environments Behaviors
• Process Outcome
• Qualitative Quantitative

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Difficulties 1Logistics, and Balancing World
Views

• What is a community-based approach? How do you
  set it up, and sustain it with sufficient
  measurable dose and coverage?

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Healthy IslandsThe Visionary Approach

• I wept from sorrow as the hordes came down
• Upon my love, as they, with force and guile,
• Did steal her strength, usurped her healthful
  crown,
  
• And left her weak, and ill, my love, my isle.
• I wept from hope when all her people stirred
• And in their heart they found the will to fight
• And with one shout the end of sleep declared,
• As when the earth awakes to dawning light.
• And now I weep, from joy, as young and old
• Can walk once more in health, and know with
  pride
  
• That this new life arose from visions bold
• Of strength renewed where strength had been
  denied.
  
• The time for tears and pain is now no more,
• Time now to save what has been lost before.

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Healthy IslandsThe Reductionist View
Where A resultant of island health influence
s j level of influence (from local to regional
) h health sector influences h non-health
-sector influences i factor related to island
characteristics
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Settings Approach versus NCD InterventionTowards
Healthy Islands Fiji

• Project adopted a tikina-by-tikina approach
  (community-by-community)
  
• Guiding principles
• Community development
• Problem-solving approach
• Difficulties
• Burden of logistic support
• Inconsistent priority selection (from NCD
  perspective)
  
• Only process evaluation possible

Is it possible that parts of our intervention
need to be non-specific, process-based, creating
a culture of health? What balance?How to
invest in these areas?
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Difficulties 2Evidence of Effectiveness

• How to cope with the tug of war between
  evidence and intuition?

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thus, Posner (1977) concludes

• there are considerable uncertainties
  surrounding the reliable diagnosis of diabetes
  and the effectiveness of treatment, while some of
  the common treatments are claimed to be
  ineffective
• when doctors are faced with a situation of
  great uncertainty and the possibility of serious
  and life-threatening complications, it is
  understandable that they need to feel they can
  control it
• the medical theory of the treatment of diabetes
  is a belief system

As quoted in Sociological Approaches to Health
and Medicine Eds. Morgan, Calnan, Manning (1985
, reprinted 1991, p. 131)
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Diabetes can be prevented (or delayed)
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Controlling Blood Glucose and Blood Pressure
Reduces Diabetes Complications
UKPDS Type 2 DM, 10-year cohort. Reduction in
Risk in Conventional versus intensive therapy
Source UKPDS Group. Lancet. 1998352837-853
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Evidence and IntuitionWhat is the effect of
school health interventions on childhood obesity?

• Multiple high profile programs exist
• e.g. Trim and Fit (TAF) in Singapore
• No published evidence on outcome
• But can we afford to ignore the possibility?

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Difficulties 3Theory and Practice The Great
Divide

• Is an environmental approach really more
  accessible? Is it health promotion any longer?

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Prevention StrategiesHigh Risk vs. Population
Truncate high risk end of exposure distribution
(e.g. organise an obesity clinic). Clinical
approach to disease prevention.
Reduce a little risk in most people (e.g. reduce
fat a little in fast-food outlets). Lifestyle
change combined with an environmental approach.
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Projected number of stroke deaths based on annual
rate of change (), Japan, 1990-2030
1 increase
no change (impact of ageing)
Number of stroke deaths
-1 decrease
-2 decrease
Bonita R. Based on rates from World Health
STATISTICS Annual, WHO
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Potential benefit of preventive interventions
equivalent benefits from population vs. high
risk interventions
Variable

Population
High risk strategy

strategy




Source Rose G. CHD epidemiology. Oxford. Med Pub
1995 (slide by Ruth Bonita)
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Teaching an Old Dog New Tricks The Causes of
Energy Imbalance
Education, behavioural medical interventions
Technology, engineering
Policy, Legislation, Social change
Source Egger Swinburn BMJ 1997 315477-480
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Small changes x large volumes significant
population benefits

• 90 of crisps sold are 35 fat
• 10 are lower fat (25)
• To reduce the fat burden from crisps by 10
• Reduce the total volume of chips sold by 10
• Increase the proportion of lower fat crisps sold
  to 44
  
• Reduce the fat content of regular crisps from 35
  to 31

Source Swinburn B, Influencing Environments to
Reduce Obesity Prevalence 2002
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And in practice?

• Tobacco control
• predominantly environmental, well-established
  evidence base (has it stopped being health
  promotion?)
  
• Diet and Physical Activity
• Good diagnosis tools available (e.g. ANGELO
  framework)
  
• But what prescriptions?
• Implementation
• What are the intersectoral processes that work?
  Does the tobacco experience suggest more
  blinkered approaches?

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Is there a New Dichotomy?

• Old Dichotomy
• Art and Science, Health promotion and
  intervention
  
• Macro-environmental approach
• Deals with larger issues (WTO, poverty and
  equity, integration into financing health
  service reform)
  
• is this the work of our Forum and Regional
  Networks? Are we doing it?
  
• Micro-environmental approach
• community-based interventions
• is this the work of our demonstration projects?

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Hank Few!

• Oops! I did it again!
• (with apologies to Britney Spears)