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Health promotion has emerged in the last decade as an important force to improve both quality and quantity of people’s lives. Sometimes termed ‘the new public health’ it seeks to support and encourage a participative social movement that enables individuals and communities to take control over their own health. (Bunton,R & Macdonald,G 1992) Health promotion plays an important part in everybody’s life and the lives our children and our children’s children.
The purpose of this assignment is to discuss and give justification for evidence based health promotion, some people may ask why we need evidence based health promotion and practice, this paper goes some way to identifying the answer to this question. Health promotion can be defined in may ways, as defined by the World Health Organisation health promotion is the process of enabling people to increase control over and to improve their health. (www. who. int accessed November 2007)
Tannahill (1985) defined health as ‘the process of enhancing health and reducing risk of ill health through the overlapping spheres of health education, health protection and disease control,’ ultimately they all accept that lifestyle and ecological elements play a critical part in any health promotion strategy. The topic of evidence based health promotion is a timely one given the resolution of the World Health Assembly that all members state: ‘adopt an evidence-based approach to health promotion using the full range of quantitative and qualitative methodologies. WHO, 51st World Health Assembly, Geneva, 1998) (www. who. int accessed November 2007) In the past few years significant advances have been made in health promotion to generate readily accessible systematic reviews of evidence on the effectiveness of interventions and programs.
The influence of this evidence on policy and practice has, however, been unpredictable and proponents of evidence based health practice are identifying ways to increase the use of research in decisions about health promotion interventions. www. oxfordjournals. org) Health promotion is a process directed towards enabling people to take action and control over their own health, it is not something that is done on or to people, it is done by, for and with people either as individuals or as groups. In Choosing Health (DOH, 2004) the Government insist a positive way forward is to promote and to motivate the nation to make healthier lifestyle choices.
Ewles and Simnett (2003) state that health promotion is about raising the health status of individuals and communities – this means improving health, advancing, supporting, encouraging and placing it higher on personal and public agendas. The purpose of health promotion is to strengthen the skills and capabilities of individuals to take action and the capacity of groups or communities to act collectively to exert control over the detriments of health and achieve positive health. Evidence based health promotion assists people in this aim.
The response to the current need for evidence has been two fold, on the one hand we have witnessed an increase in the number of published systematic reviews, together with more robust evaluations from the field. On the other hand there has been considerable debate about the nature of evidence and how we can assess effectiveness. Concerns about the possible dominance of a positive methodological agenda and its limited applicability to health promotion have been more fully discussed elsewhere. Signs are emerging that these concerns are being beginning to be addressed.
There is increasing recognition of the broad epistemological basis of health promotion research, the value of methodological pluralism and the particular capacity of qualititative methods to provide illuminating perspectives. (www. oxfordjournals. org) Evidence based health promotion asks us, how do we know? who says so? , it is based on inspiration, values, experiences, statistics, data, samples and research. Research is about proving and disproving and is completed to ensure data is valid and reliable; we depend on evidence based health promotion to contribute to the development of our knowledge.
It is a crucial means of producing evidence which informs practice, offers guidance and prescription, It makes the practitioner an informed individual who practice is less likely to be questioned as unsafe or unreliable. Government documents are increasingly emphasising the importance and their support for evidence based health promotion such as the document better health Wales in 1998 which covers many areas of health, although some years ago the content is still as relevant today. The dominant model for reviewing health care interventions is that established by the Cochrane Collaboration (1994).
This is a bio-medical model, in which the ultimate effectivness of interventions is expressed as ‘hard’ outcomes such as changes in mortality and morbidity and behavioural outcomes. Accumulating scientific proof of the effectiveness of a clinical intervention can be complex and can involve randomized controlled trial’s meta-analysis and undertaking systematic reviews. ( Webb,D 1999) So what are these trials and why are they used? A randomized controlled trial is an experiment with a group of patients which seeks to determine which outcomes are obtained with a particular intervention.
Of course it is always possible that a clinical outcome may be a consequence of some factor other than the intervention This possibility is ‘controlled for’ by incorporating into the design of the trial a second group, the ‘control group’ who do not receive the intervention. Patients are randomly assigned to either the intervention or the control group through randomising the allocation of patients to intervention or control groups it becomes likely that factors which might influence an outcome, for example socio economic differences are equally distributed and therefore cancel each other out.
The random controlled trial provides the best assurance that outcome differences can be attributed to the intervention and not to extraneous factors. ( Webb,D 1999) Randomized controlled trials are the most rigorous way of determining whether a cause effect relation exists between treatment and outcome and for assessing the cost effectiveness of a treatment. They are used to establish efficiency of a treatment as well as frequency of side affects.
This is meant to address issues such as, effects of treatment may only be small and therefore undetectable except when studied methodically on a large scale, also biological organisms are complex and do not react to the same stimulus in the same way, which makes influence from single clinical reports very unreliable and generally unacceptable as scientific evidence. Finally, it is also known and has been proven that when administering the treatment it can have psychological effects on a person this is known as the placebo effect.
There are some limits of a randomized controlled trial such as ethical concerns, some might say it is unethical to expose a patient to treatment that is inferior to one already currently available, however some might say how can we progress until these trials are performed and results are found. It is widely acknowledged that random controlled trials are not well suited to explaining how something happens, rather than what happens (Pawson & Tilley, 1997), However, understanding how something was implemented and what effect this has on outcomes, is absolutely crucial to health promotion.
Since the late 1970’s Meta analysis has emerged as a powerful tool for synthesising the results of independent trials. In essence, it is an overview of clinical trials in a particular area of treatment, in which the results are presented in the form of numeric summary. ( Webb,D 1999) There are some weaknesses of using this method, one is that sources of bias are not controlled by this. Even if you have a good design of meta analysis if you have a bad study you will get bad results, it can be argued that only methodologically sound studies should be used in meta analysis, a practice called by Robert Slavin as ‘ best evidence meta analysis’.
Systematic reviews of the literature on clinical effectiveness are being undertaken to provide clinicians, managers and policy makers with a more efficient means of accessing information about effective interventions. Systematic reviews are intended to provide a synthesis of research findings in given areas and present the results in ways which are manageable, Systematic reviews can seek to establish whether research findings are consistent, can be generalised across target groups and settings or determine whether they vary by particular sub sets (Mulrow, 1995).
In addition to the need for systematic reviews to incorporate less stringent inclusion criteria for research designs is the criticism that they have been predominantly concerned with the quality of the research design and have not considered in detail the range and quality of the interventions in each study. (Speller & Webb 1997) Both quantitative and qualitative research test on rich and varied traditions that come from multiple disciplines and both have been employed to address almost any research topic you can think of.
To put it simply qualitative data typically consists of words while quantitative data consists of numbers. Although there are clear differences between to two anything that is qualitative can be assigned meaningful numeric values, these values can then be manipulated to help us achieve greater insight into the meaning of the data and to examine specific hypotheses. (www. socialresearchmethods. et)
Qualitative data is extremely varied in nature it can include almost any information that can be captured that is not numerical in nature such as interviews, observations and written documents. Another difference between the two is that in quantitative research, the researcher is ideally and objective who neither participates in nor influences what is being studied. In qualitative research, however, it is thought that the researcher can learn the most by participating or being immersed in a research situation.
These basic underlying assumptions of both methodologies guide and sequence the types of data collection methods employed. (www. writing. colostate. edu) Research in several countries provides consistent evidence of a ‘theory practice gap’ in health, clear disparities have been demonstrated between the best practice ideals and values that are taught and those actually encountered in everyday practice. (www. eprints. soton. ac. uk)
Larsen et al (2002) said it is obvious that almost everyone spontaneously experiences a gap between theory and practice. Theory and practice exist in their own right as two kinds of knowledge, theoretical knowledge and practical knowledge. This statement of relations between theory and practice challenges not only theorists and practitioners but also basic thinking in modern, western cultural circles that has been in place since the enlightenment.
The experience of a gap is a social construct, it is a product of history and society. While most of the literature on the subject of theory practice gap sees it as a problem it has been suggested that a positive benefit of the gap is that it can provide you with an opportunity to develop problem solving skills. Eraut et al (1995) offers a more precise typology of theory practice gaps, focusing on different types of knowledge and its implication for use in practice.
The ideal and the real world for care delivery, the difference between generic and specific application of theory, the problems of translation and implementation (transfer of learning) and the need to identify the relevant from the irrelevant ( often dependent on the setting and the resources available) Research has shown that there can be many factors involved in causing the gap, such as rapid changes in the clinical setting that affect the nature and setting of care delivery, sequencing of theory and practice, lack of recent clinical experience by nurse educators, lack of collaboration between clinical areas and educational institutions and the need to be an educational generalist who can cover a wide subject range whilst clinical areas are becoming increasingly specialist and even super specialist. (www. who. org) Solutions that have been suggested to bridge the theory practice gap such as an innovative curriculum allowing closer sequencing of theory and practice, improving collaboration between clinical areas and educational institutions.
The creation of joint appointments (between education and services) where the role is to facilitate the application of theory to practice, promote effective collaboration between the two services and education: promote research based practice: and facilitate the development of nursing practice. And by using the use of tools such as the skills grid that sets out the knowledge, skills, behaviour and outcomes are linked and supported by research evidence. ( Knight C M et al) Then role of evidence based practice in health promotion has amplified over the years, this is due to the increased amount of evidence available and the willingness of the specialist’s and practitioners, also the need for precision when it comes to health promotion. Evidence based health promotion is an aide to health promotion and an essential part of advancement in the health field.
Health promotion, in order to be effective needs both quantitative and qualitative research to best inform practice, even with all the methods of research it still depends on the rigour and the extent to which the investigator is methodical in the collection and analysis of the data and its limitations. Qualitative approaches are able to explore the different meanings that individuals attach to health and to the different variations, given that health promotion is committed to the idea that there are many different definitions of health and that the role of health promotion is to help meet some of the diverse needs and aspirations of different communities as can be seen in the Ottawa chart. (Webb 1999) Evidence based health promotion starts from skills and qualities which many health promoters have already. It complements reflective practice by adding the experience of others, presented in various forms.