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Liu JJ, Davidson E, Bhopal RS, et al. Adapting Health Promotion Interventions to Meet the Needs of Ethnic Minority Groups: Mixed-Methods Evidence Synthesis. Southampton (UK): NIHR Journals Library; 2012 Nov. (Health Technology Assessment, No. 16.44.)

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Adapting Health Promotion Interventions to Meet the Needs of Ethnic Minority Groups: Mixed-Methods Evidence Synthesis.

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4Summarising evidence on effective health promotion interventions from guidelines and systematic reviews

Abstract

Background:

A key assumption underpinning this project is that health promotion interventions found to be effective in the general population are, if appropriately adapted, likely to also prove effective in ethnic minority populations. We therefore began our work by seeking evidence-based recommendations for health promotion interventions found to be effective in the general population.

Objectives:

We sought to identify and summarise information on health promotion interventions for smoking cessation, increasing physical activity and improving healthy eating that are recommended for use in populations at large.

Methods:

We undertook a systematic review of the evidence for health promotion interventions for smoking cessation, increasing physical activity and improving healthy eating in UK guidelines and these searches were supplemented by additional scrutiny of international systematic reviews. Relevant guidelines were identified from the Clinical Evidence, National Institute for Health and Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) databases. We also searched for international systematic reviews from established databases of evidence, namely The Campbell Collaboration, The Cochrane Library, the Database of Abstracts of Reviews of Effects (DARE) and the National Institute for Health Research Health Technology Assessment (NIHR HTA) databases, in order to identify additional and more recent evidence that had not yet been incorporated into the guidelines. Two reviewers independently searched for and identified the literature and extracted data on recommended interventions for the general population. We created summary tables of the evidence identified according to health promotion topic and also a table for behaviour change interventions in general (not specific to any topic). These tables were then further categorised by six Tannahill-based intervention ‘strategies and activities’ (i.e. environment, policy, setting based, techniques, provider and resource).

Results:

We identified 15 relevant guidelines and 111 systematic reviews. Most of the evidence we identified was targeted at individuals. There were considerably stronger recommendations for smoking cessation than for interventions aiming to increase physical activity and/or improve healthy eating. The strongest evidence and guidance in relation to smoking cessation was for pharmacological treatments and approaches aiming to promote the use of these pharmacological therapies. In contrast, there was relatively little in the way of strong or consistent guidance in relation to interventions that were successful for promoting changes in diet and exercise patterns that were sustained over time, or those directed at societal level-mediated change.

Conclusions:

We have identified a number of guidelines and systematic reviews that have summarised and sought to provide guidance on how best to promote smoking cessation, increase physical activity and improve healthy eating. This evidence is strongest and most consistent in relation to pharmacological treatments for smokers and approaches aimed at increasing use of these products. Based on this work we suggest the need for improved communication between guideline developers and research commissioners with a view to catalysing research into finding effective and sustainable interventions for promoting physical activity and improving healthy eating. There is, in particular, a need for more evidence on the providers and resources that can meaningfully increase physical activity and improve healthy eating, and, more generally, for policy- and environmental-based interventions for smoking cessation, increasing physical activity and improving healthy eating.

Introduction

Health promotion is fundamental in the drive to reduce the growing burden of chronic disease worldwide66,67 and to address the considerable and persistent health inequalities now seen in many economically developed countries (see Chapter 1).5,6 Inequalities in morbidity and mortality attributable to, for example, CVD and diabetes are observed among a number of ethnic minority populations.6,65 It is therefore widely accepted that increasing access to and participation in health promotion interventions represents an important component of strategies aiming to reduce health inequalities with respect to ethnicity (see Chapter 1).67,69,7275 Foremost among these preventive efforts are finding effective and cost-effective ways of promoting smoking cessation, increasing physical activity and improving healthy eating – the key modifiable risk factors for the majority of chronic diseases.51

As with any intervention, the recommendations for these health promotion interventions should be based on the most rigorous evidence available104 and on studies that are at low risk of bias.105 Ideally, this evidence would be derived from randomised controlled trials (RCTs) and systematic reviews of RCTs because of their unique ability to control for known and unknown confounders.106 For public health practice, technical issues may, however, limit investigators’ ability to undertake the simpler RCT designs, as interventions aimed at promoting behavioural change are more often than not ‘complex’ – that is, they have multiple interacting components.107 Interventions aimed at the level of the household, school/workplace, community or indeed any other grouping of individuals should ideally be studied using cluster RCT designs to reduce contamination,108 but this may not prove possible, in which case other experimental designs may need to be employed.108 Given the ethical and methodological challenges that are inherent to developing a rigorous and comprehensive evidence base for public health interventions, it is perhaps unsurprising that there are at times differing and/or conflicting conclusions drawn with regards to the most effective health promotion interventions,109 including interventions for smoking cessation, increasing physical activity and improving healthy eating. There is therefore a need to develop a detailed overview of the current state of evidence for promoting sustainable changes in relation to these key risk factors.

A key assumption underpinning the call for research (see Appendix 1) and our approach was that health promotion interventions of proven effectiveness for use in the general population are also, if appropriately adapted, likely to be effective in ethnic minority populations (see Chapter 1).9 Our formative work therefore sought to develop a detailed, evidence-based and up-to-date overview of the evidence for health promotion interventions aimed at promoting smoking cessation, increasing physical activity and improving healthy eating in the general population.

Research question

The research question we addressed in this chapter arose from Phase 1A of our study (see Chapter 2), namely:

  • What health interventions are recommended for the general population for smoking cessation, increasing physical activity and improving healthy eating?

Methods

Overview of methods

The UK has some of the most well-established and respected guideline development procedures in the world. These guidelines therefore represented the principal source of evidence that we sought to identify and scrutinise. Because of their lengthy and rigorous development processes, guidelines, however, inevitably remain a step behind the evidence and are thus less likely to contain as up-to-date information as is contained within the systematic review literature on which they predominantly draw. We therefore supplemented our guideline-based searches with data derived from international systematic reviews of evidence.

Searches for guidelines and systematic reviews

We searched for and retrieved any pertinent guidelines on interventions for smoking cessation, increasing physical activity and improving healthy eating in the Clinical Evidence, NICE and SIGN databases using the following broad key search terms:

  • diet
  • exercise
  • healthy eating
  • obesity
  • physical activity
  • smoking
  • tobacco.

We also conducted searches in The Campbell Collaboration (Campbell), The Cochrane Library (Cochrane), the DARE databases and the NIHR HTA database for systematic reviews and health technology assessments (HTAs) of interventions for smoking cessation, increasing physical activity and improving healthy eating from January 1950 to April 2009 using the same broad search terms detailed above. HTA reports use systematic methods110 to provide independent research information about the effectiveness, costs and broader impact of health-care treatments and tests for those who plan, provide or receive care in the NHS and henceforth in this report will be referred to under systematic reviews.

Selection of eligible guidelines and systematic reviews

Two researchers (JJL and ED) independently screened and selected guidelines and systematic reviews based on predefined inclusion/exclusion criteria (Table 2), first by scrutinising titles and then, if necessary, the abstracts and full text of manuscripts. Disagreements regarding inclusion/exclusion of papers were resolved through discussion. If consensus could not be reached a third reviewer (AS) was consulted. The full text of all eligible records was retrieved; 12 full-text papers were translated into English from Danish, French, Norwegian, Spanish and Swedish.

TABLE 2. Inclusion/exclusion criteria for effective health promotion interventions.

TABLE 2

Inclusion/exclusion criteria for effective health promotion interventions.

Data extraction and synthesis

We extracted relevant evidence from the guidelines and systematic reviews onto a customised data extraction form (see Appendix 9). We extracted statements pertaining to the effectiveness of smoking cessation, increasing physical activity and improving healthy eating interventions, the quality of the evidence (when reported) and the quality assessment tool used (when reported). These evidence statements were compiled in two tables (see Appendix 10) where they remain attributed to the guideline(s) or systematic review(s) from which they were derived. The tables of evidence statements therefore incorporated two levels of evidence – guidelines that have been developed through a collaborative scrutiny of the evidence, as in the case of NICE and SIGN guidelines, and systematic reviews, which have been subject to quality control by peer reviewers and journal editors.

Subsequently, the evidence statements were organised in a summary framework of effective interventions according to the health promotion topic: health behaviour in general (not specific to one health promotion topic), smoking cessation, increasing physical activity and improving healthy eating (see Tables 3–6). We adapted the revised Tannahill model of health promotion (Box 2)111 to categorise the evidence statements according to six broad categories of ‘strategies and activities’ (Box 3).

Box Icon

BOX 2

Revised Tannahill definition of health promotion. Sustainable fostering of positive health and prevention of ill health through policies, strategies and activities in the overlapping areas of: social, economic, physical and environmental factors

Box Icon

BOX 3

Definitions of six categories of ‘strategies and activities’ used in health promotion interventions. Environment: Intervention that alters the social, economic and physical space, with the potential to affect a more general population (more...)

Environment applied to interventions that alter the social, economic and physical space (as opposed to place), with the potential to affect a more general population. Policy included organisational, local or national policies. Setting based represented specific places or communities identified as effective locations to deliver an intervention, and which often target ‘captive audiences’, such as children at schools or employees at worksites. Techniques described the wide-ranging types and formats of interventions that have been found to be effective, including education and learning, but it also captured behavioural techniques and other elements that can enhance the effectiveness of a variety of interventions. Provider also included persons singled out as important partners in the intervention delivery process. Resource encompassed the materials or products given to participants as the intervention. Unlike in the Tannahill model, provider represented a specific type of resource, referring to the specialised personnel or services designated for intervention delivery.

These categories referred to the ‘strategies and activities’ utilised in health promotion interventions (not to the interventions themselves) and are overlapping and additive in that combinations of ‘strategies and activities’ may be used in any one intervention. These categories facilitated the examination, and cross-comparison, of such a large and diverse body of evidence for smoking cessation, increasing physical activity and improving healthy eating.

Results

We identified 189 records from NICE, of which 10 were included. We were unable to search SIGN and Clinical Evidence using keywords and instead manually searched these databases using the provided topic headings related to our health topics of interest and identified three and two additional relevant guidelines, respectively. Therefore, from the three guideline databases, 15 guidelines satisfied our inclusion/exclusion criteria (Figure 4). Although these guidelines were the products of different processes of evidence evaluation, from the descriptions of the methods used, they appeared to have undergone a broadly comparable approach to identifying studies and extracting evidence.

FIGURE 4. Study selection process for guidelines and systematic reviews.

FIGURE 4

Study selection process for guidelines and systematic reviews. CE, Clinical Evidence.

From Cochrane, Campbell, DARE and NIHR HTA we identified 2399 potentially relevant systematic reviews. Of these, 111 records satisfied our inclusion criteria and provided data on effective interventions. We included only strong evidence of effectiveness for smoking cessation, but strong/moderate evidence of effectiveness for physical activity and healthy eating (see Figure 4). The reasoning behind including moderate evidence for physical activity and healthy eating was that, in general, this body of evidence was at an earlier stage of development than the literature on smoking cessation.

Summary framework of effective ‘strategies and activities’

The evidence statements extracted from these included guidelines and systematic reviews were compiled in tables (see Appendix 10) and then synthesised into our summary framework according to health topic and the six categories of health promotion ‘strategies and activities’ discussed above. The following four tables represent the summary framework to guide behaviour change in general (see Table 3), smoking cessation (see Table 4), increasing physical activity (see Table 5) and improving healthy eating (see Table 6). Each table will be described in turn.

TABLE 3. Effective ‘strategies and activities’ for behaviour change interventions in general (not specific to health promotion topic; individual and/or population level).

TABLE 3

Effective ‘strategies and activities’ for behaviour change interventions in general (not specific to health promotion topic; individual and/or population level).

TABLE 4. Effective ‘strategies and activities’ for smoking cessation interventions.

TABLE 4

Effective ‘strategies and activities’ for smoking cessation interventions.

TABLE 5. Effective ‘strategies and activities’ to increase physical activity.

TABLE 5

Effective ‘strategies and activities’ to increase physical activity.

TABLE 6. Effective ‘strategies and activities’ for interventions to improve healthy eating.

TABLE 6

Effective ‘strategies and activities’ for interventions to improve healthy eating.

Behaviour change in general

There was minimal information on effective ‘strategies and activities’ for behaviour change in general, which was not specific to any particular health promotion topic and was aimed at individuals and/or populations (Table 3). This evidence was therefore separately examined and summarised. The majority of information in this area was concentrated in the environment category. Evidence of effective environmental approaches included working in partnership and in collaboration to develop programmes; reducing or removing barriers (e.g. social, financial and environmental); holding national and local advertising and mass media campaigns; and developing health-enhancing social, physical and service environments.112Policy wise, fiscal and legislative interventions were reported to be effective for behaviour change.112Setting-based evidence highlighted two main sites for interventions: brief counselling held in primary care113 and longer-term, multicomponent interventions held in schools.112,114Techniques included feedback on individual biomarkers for disease risk,115 face-to-face interventions116 and the recommendation that interventions should be tailored to individuals.112,116 For biomarkers the evidence indicated that this strategy was most effective if multiple biomarkers were used, or if one biomarker was used at more than one time point, as well as if biomarker feedback was delivered in conjunction with other treatments.115Resources included web-based117 and computer-generated messages as interventions.116

Smoking cessation

Evidence on effective ‘strategies and activities’ for smoking cessation was primarily concentrated in the resource, provider and technique categories, with comparatively fewer ‘strategies and activities’ in the environment, policy and setting-based categories (Table 4). Environment strategies included mass media118121 and other campaigns120 to promote cessation. Mass media interventions were, however, felt to be less effective when directed at young people and were highlighted as requiring further research.119 Health coalitions,122 defined as partnerships among three or more organisations or constituencies, could further enhance the environment for behaviour change. Policy initiatives included workplace smoke-free policies,118,120 increases in tobacco prices118 and decreases in the cost of cessation therapies.118

Setting based included the workplace123127 to provide information and onsite services as well as to tailor support and treatment to the needs and preferences of employees,127 along with primary care to provide advice for nicotine replacement therapy (NRT) and brief structured counselling.128 Smoke-free workplaces were reported to show reductions in smoking prevalence of 3.8% [95% confidence interval (CI) 2.8% to 4.7%] and lower cigarette consumption by those who continued to smoke.125

Techniques included counselling129 in a variety of formats: individual based,120,130,131 group based120,131133 and telephone counselling118,120,131,134136 as well as counselling129 alongside pharmacotherapy,134 self-help134 and support.120 Intensive individual counselling was reported to have no significantly greater effect than brief individual counselling.130 Advice, whether brief or intensive,137,138 was recommended, along with tailored advice,120,130,139 that is, advice sensitive to individual’s ‘preferences, needs and circumstances’.112 There was, for example, some evidence that self-help materials were more effective if tailored for the individual smoker.140 Auricular acupuncture141 was also recommended, although acupuncture in general was not shown to be effective in another review.171

A range of providers were recommended for delivering smoking cessation interventions – family physicians/general practitioners134,139,143146 providing brief advice,131,147,148 psychologists,146,148 nurses,120,131,139,143,145,146,149,150 dentists120,145 providing counselling,151 trained counsellors,143 telephone quit-line counsellors,120,127 midwives,120 pharmacists120 – in essence, all health professionals.120 Brief advice by physicians delivered in a single routine consultation was reported to have a quit rate of approximately 2% (95% CI 1% to 3%) with no relapse at 1 year,147 and physicians were reported to be the most effective provider of brief advice, although perhaps not the most cost-effective. 145 Furthermore, community-based clinicians, nurses, dentists, pharmacists, community workers and hospital physicians were recommended to make referrals to more intensive cessation programmes.139

Resources for cessation included pharmacotherapy,118,120,139,151153 such as NRT,118,120,131,134,137,143,148,154, 155,157159 for example patches,156,160162 antidepressants,143,163 including bupropion hydrochloride (Zyban®, GSK)120,131,134,137,158,159,164 and nortriptyline (Allegron®, King),165 and varenicline (Champix®, Pfizer).120,159,166168 NRT used independently, with no additional support, was reported in one review to increase the rate of quitting by 50–70%.154 A review that specifically looked at long-term follow-up (average 4.3 years) found that the addition of NRT to brief advice or behavioural support contributed to a 70–90% increase in the cessation rate achieved without NRT; however, although this appears to be successful, the long-term quit rate without NRT was relatively small and so even with a 70–90% increase, the overall number of participants who managed to quit long term was still just 7% of those attempting to quit.155 If quit status was maintained for 3 years post intervention, these effects appear to be sustained.155 NRT was usually delivered by health-care providers such as physicians, psychologists and nurses, and these providers can be effective in providing smoking cessation interventions without NRT; however, NRT was again found to result in a twofold increase in the quit rates achieved by most of these providers.146 For other pharmacotherapies, varenicline compared with placebo was reported at ≥ 6 months to have a pooled risk ratio for continuous abstinence of 2.33 (95% CI 1.95 to 2.80),167 and antidepressants (nortriptyline and bupropion hydrochloride) were reported as having similar efficacy to NRT.163 Use of NRT prior to quitting156,170 and NRT-supported reduction (e.g. ‘cut down to quit’) are additional strategies;142 however, the latter has been recommended only as part of research studies.120

Education was recommended as another effective resource,129 which could be given as part of an intervention, as were self-help materials120,140,143 and self-help materials given along with pharmacotherapy.134 Telephone quit-lines120 providing cessation advice143 were found to be effective, with some evidence of a dose-dependent response with three or more calls increasing the chances of success.136 Mobile telephone texts and calls, sometimes combined with internet/e-mail delivery, were reported to show effectiveness in the short term (results from relatively small literature on four trials).169

Physical activity

Evidence on effective ‘strategies and activities’ for increasing physical activity was reasonably abundant for the categories of resource, environment and technique but relatively sparse for the category of provider compared with the smoking cessation literature (Table 5).

All of the environmental recommendations were made by NICE, which included the provision of public parks and facilities,172 national campaigns for children and young people (minimum duration of 5 years),172 increased access to walking or cycling routes112 and linking these routes to schools and workplaces173 and the development and maintenance of space to encourage stair use.173 The concerns of local people with regard to the costs, expectations, dangers and misinformation174 surrounding physical activity should also be addressed, as well as the prioritisation of pedestrians and cyclists when developing/maintaining infrastructure.173 Removing barriers,172,174 building partnerships172 and maximising opportunities for exercise172,174 were also recommended.

The policy recommendations included policies to increase opportunities for physical activities174,175 and, more specifically, workplace/organisational policies174,176 that would increase the level of physical activity of employees.

Setting-based recommendations included use of schools114,172,173,174,177181,210,214 to promote physical activity and education during school hours,172 as well as during school break periods,172 and to encourage active transport173 to and from school. It was recommended that schools provide a playground that would allow for varied physical activities.173,177,179 Multicomponent school-based interventions with family or community involvement172,177,201 were also thought to be effective. Even school-based strategies with a minimum of printed educational materials and changes to the school curriculum were found to result in positive changes in activity levels.178 It was noted that there was ‘very limited but good evidence’ that children exposed to these settings would go on to lead active adult lives.181 Physical activity strategies were also found to be effective when delivered in the home,174,178,187189 at leisure centres,182 at nurseries174 and childcare facilities174 and, for older adults (> 50 years), in health-care settings183 such as primary care-based counselling184 and brief interventions. Finally, worksite interventions185 that promoted active travel,174 supported incentive schemes and provided education and promotion programmes174 and were multicomponent in nature174,176 demonstrated effect in increasing physical activity levels.

Techniques was a category for physical activity that contained a wide range of ‘strategies and activities’. Counselling, including telephone counselling,186,187 was recommended for the general population. Counselling143,188191 was recommended to increase the intensity of physical activity for those who are active191 and also to increase the activity levels of sedentary people.212 Goal setting,213 exercise on prescription189,192 and walking prescriptions187,193,194 along with exercise referral schemes182,195 and stage-based interventions196 were also recommended; however, walking and cycling schemes were only recommended as part of research studies by one NICE guideline.79 Walking advice193,194 and active transport for adults197 and children173,198 were recommended, along with the reduction of sedentary behaviour to increase activity levels.174,199 It was recommended that sedentary people be targeted to increase walking, along with other behaviours.202 Regular follow-ups193,194 by telephone191 and the provision of ongoing support in person, by telephone, by mail or via the internet174 were also recommended. As with smoking cessation there was a dose–response reported with telephone interventions with a longer duration and higher number of calls, characteristics associated with more positive outcomes.186 Similarly, booster interventions were suggested for longer-term effectiveness.189 Whether recommended activities were formal172 and structured201 or informal and unsupervised,172,201 and taking place within an occupational role or during leisure time,137 guidelines suggested enhanced effect if they were tailored to individuals174 – to their needs,174,202 characteristics,184 preferences and circumstances.174 Furthermore, the recommended intensity of activity ranged from low199 to moderate137,193,194 to increasing activity levels to high if already active,137 and these activities could be delivered to individuals,202 households202 or groups.202,203,211

Providers included health-care professionals in general to deliver advice, support and counselling201,204 and, more specifically, primary care practitioners to identify, advise and monitor and to consider individuals’ needs, preferences and circumstances.79 No other providers were recommended in the guidelines or systematic reviews. The remainder of the recommendations suggested involving parents and carers172174 in supportive roles to help plan school-based interventions174 and for monitoring television/video use,173,179 and involving children and young people in the design, planning and delivery of interventions.172 Finally, a few guidelines encouraged adults (parents and carers) to set an example for their children in terms of being physically active, and encouraged them to be active along with their children.172

Resources included education,172,173,203 either through print or through technology,189 such as the internet205,206 or computer-tailored207 materials. Interventions including written materials79,184 were recommended in guidelines and appeared to be associated with increased effectiveness. These written materials,211 which included follow-up191 as well as, for example, specific signs that encouraged increased stair use,175,176 were reported to have evidence of effectiveness. The provision by local authorities of personalised travel plans for active travel174 was also recommended, and this was sometimes observed within specific settings, as suggested above. Pedometers were reported to increase users’ physical activity by almost a third over baseline.208 One guideline, however, advised that pedometers should be recommended only for use as part of research studies.79 Finally, education and monitoring of television/video use179,200,209 was thought to decrease sedentary behaviour, particularly in children.

Overall, the body of evidence for physical activity promotion was weak in terms of providing evidence for interventions with longer-term effectiveness215 and maintenance of behaviour changes. In addition, it was unclear if these behaviour changes translated into gains in health status. Finally, for some interventions, the evidence was predominately from the USA and thus the generalisability of the evidence to other countries was unclear.

Improving healthy eating

There were relatively fewer resources and providers recommended for interventions to improve healthy eating compared with smoking cessation and, as was the case for interventions to increase physical activity, the bulk of the evidence comes under setting-based and technique-oriented ‘strategies and activities’ (Table 6). Policies such as workplace and university point-of-purchase policies216 and other point of sales initiatives were recommended to improve access to healthy foods.174Environmental changes of interest included food subsidies to increase general access to healthier foods,217 as well as working with caterers, shops, supermarkets, restaurants, cafes and voluntary community services to promote healthy choices through signs, posters, pricing and positioning of healthier food products.174 It was highlighted that, in creating a health-enhancing environment,218 the concerns of local people, for example costs, expectations, dangers and misinformation,174 also needed to be addressed.

Setting-based approaches included focusing on nurseries and childcare facilities174 as well as on schools174,219224 to promote healthy eating and increase fruit and vegetable intake in children through activities and education; these approaches were found to be particularly effective for young women.224 Workplaces were also noted as being settings that could effectively promote fruit and vegetable intake and fat reduction222,225,226 as they could accommodate incentive schemes and education and promotion programmes.174 Religious settings227 such as churches,226 primary care settings222 and health-care settings for older adults (aged > 50 years)183 were all recommended as effective sites to deliver interventions. Sites located in the community222,228 and within the family174,229 were also felt to be effective in making changes to dietary behaviours.

Techniques such as counselling,129,218,230 whether face-to-face228 or by telephone,186,228,231 were shown to be effective. A dose-dependent effect was observed for healthy eating counselling by telephone.186 Counselling contact can be one-to-one232 or group based211,229,232 and can be intensive, involving more contacts,233 representing both social229 and ongoing support.174 Goal setting213 advice,234 particularly when tailored to individuals,174 was noted as being helpful. Motivational interviewing was recommended, but only alongside education.235

There were few suggestions on who should be the provider of healthy eating interventions. The guidelines did recommend, however, that parents and carers174,220,233,236 should be involved in planning school-based interventions174 and family-based interventions,112 although there was no definitive evidence that this was effective.

In terms of resources, monetary incentives to influence purchases and consumption behaviours,237 along with education,129,218,228 written material211,232 and perhaps computer-tailored interventions,207,228 were suggested as being effective for changing behaviours associated with healthy eating. Clear messages,233 particularly about people’s risk of chronic disease,232 were also thought to be effective. Several reviews suggested that, in general, interventions delivered to those who were at risk of, or diagnosed with, disease were more effective than those delivered to low-risk populations.229232

As with physical activity interventions there was a lack of long-term evidence for many of the included healthy eating interventions, with few studies examining behaviour change for longer than a year. Studies of longer duration had difficulties with participants maintaining changes in behaviour.222 Furthermore, for changes in diet and healthy eating, the actual changes in lifestyle were often quite small,212 for example one review reported an average increase in fruit and vegetable intake of 0.6 servings a day229 and another review reported a change from seven effective studies ranging from +0.3 to +1.0 servings a day.220 Whether or not these changes are sufficient to prevent disease remain unclear.

Discussion

An examination of the summary tables (see Tables 3–6) and evidence statements (see Appendix 10) revealed that there was a difference in the strength of evidence for interventions for smoking cessation in the general population compared with evidence for interventions to increase physical activity or improve healthy eating. Guidance on smoking cessation interventions was on the whole reasonably well developed, described and supported by the systematic review literature (particularly in relation to pharmacological treatments). In contrast, interventions for promoting physical activity and improving healthy eating in the general population were less likely to be underpinned by robust evidence.

Overall, smoking cessation interventions were well represented in the categories of resources, providers and techniques, which suggests that we have strong evidence available on the resources that work and which can be delivered easily, with a range of defined providers of those resources. These three categories reflect individual-oriented ‘strategies and activities’ in which a provider and resource (usually pharmacotherapy) are employed to help an individual achieve cessation. Once successfully smoke free, that is, abstinent for 3 years post intervention,155 individuals are unlikely to relapse, although they may always be vulnerable to smoking. Therefore, it appears that relatively short-term, didactic and resource-dependent interventions can successfully affect behaviour change for smoking cessation.

On the other hand, evidence of effectiveness for increasing physical activity and improving healthy eating were featured more prominently under the ‘strategies and activities’ categories of setting based, techniques and environment, with less definitive evidence underpinning recommendations on what resources can be delivered easily and who would be best positioned to provide them. These categories, in contrast to individual-oriented ‘strategies and activities’ observed for smoking, are relatively more immersive and interactive, and may reflect the nature of the health issues themselves. Engaging in physical activity and improving healthy eating present lifelong challenges, and may require immersion in health-enhancing settings and environments along with techniques that engage the individual to make and maintain healthy behaviour changes, through educational but also experiential and practical opportunities.

These findings could also be related to the nature of the health issue, whereby smoking cessation represents the reduction of a particular behaviour, and increasing physical activity represents the addition of behaviours. Meanwhile, improving healthy eating can involve both reduction and addition behaviours. These characteristics appear to relate to intervention design, with interventions for a reduction of a behaviour, such as smoking cessation, mapping onto ‘strategies and activities’ generally undertaken at an individual level and, conversely, the ‘strategies and activities’ for promoting the addition of behaviours, such as increased exercise or fruit and vegetable intake, generally undertaken at a community or population level.238

The work undertaken in this chapter has allowed us to investigate our underpinning rationale, that is, to focus on adapting those interventions for which we have the strongest evidence of effects in the general population. If we pursued this line of thinking we would predominantly target individual-level interventions for smoking cessation and, to an extent, setting-based, interactive interventions for increasing physical activity and improving healthy eating. A blind pursuit of this task would, however, be at odds with one of the key recommendations to emerge from our launch user engagement conference (see Chapter 3). Overwhelmingly, our research users highlighted the need to pay more attention to environmental and structural-level interventions.

The work undertaken in this chapter to identify effective interventions has also illuminated how six different categories of ‘strategies and activities’ may have potentially varying scope for adaptation. For example, governmental policy and whole population-level environmental interventions can represent immersive conditions, which may be difficult to adapt for specific population groups. Within these immersive conditions, then, it is essential to consider possible differential impact and, in response, to have a clear commitment to ensuring equality – these then may involve more targeted individual- or community-level modifications. On the other hand, organisational policy, setting-based interventions, and techniques can provide more interactive conditions to catalyse behaviour change. These interventions may be relatively more readily available to modify and cater for specific population groups, therefore providing a much greater scope for adaptation. Providers are also more amenable than policy or environmental conditions. Through matching, for example, or utilising lay health workers and peer providers, an intervention can be made more acceptable for a particular ethnic minority group. Lastly, resources have perhaps the greatest scope for adaptation, as they involve the relatively straightforward (but not always) task of, for example, translating educational materials or piloting the appropriate incentives for a particular population. The exception for the resources category is of course pharmacotherapy, although engagement of the population and the acceptability of drug treatment remain areas for consideration for modification within pharmacotherapy.

Challenged by these initial findings and feedback, we developed a model (Figure 5) to begin thinking about the relationship between intervention ‘strategies and activities’, the levels of health promotion interventions best suited to affect behaviour change and the scope for adaptation for ethnic minority populations.

FIGURE 5. ’Strategies and activities’ in health promotion interventions and their relationship to intervention level and scope for adaptation.

FIGURE 5

’Strategies and activities’ in health promotion interventions and their relationship to intervention level and scope for adaptation.

By distinguishing between different health promotion intervention ‘strategies and activities’ according to the six categories, while at the same time recognising their overlapping and additive nature, we were able to demonstrate their distribution across the differing levels of interception – from individual to population level. We were also able to identify where there were gaps in the literature and where, in particular, evidence needs to be pursued. For example, noticeably absent were designated specialist providers to deliver physical activity and healthy eating interventions. Guidelines and systematic reviews may recommend who should be involved, such as parents and carers, but more clarity is needed on who should be delivering these interventions. There was also a lack of long-term studies for physical activity and healthy eating interventions that were able to demonstrate changes in behaviour that are sufficient in magnitude and sustained to the extent that they can meaningfully alter risk factors for disease. Although evidence for effective interventions for increasing physical activity and improving healthy eating is, as yet, wanting, the patterns observed possibly point to the need for different approaches for different health issues.

Strengths and limitations

The four summary tables (see Tables 3–6) succinctly summarise the current evidence available for effective ‘strategies and activities’ for behaviour change in general, smoking cessation, increasing physical activity and improving healthy eating. In the systematic reviews we searched for compelling evidence of effectiveness that had not yet found its way into the guideline literature; in contrast, we deliberately excluded interventions that have not yet accumulated a sufficient body of evidence of effect. Thus, for example, we excluded a review of nicotine vaccines239 and cytisine240 for smoking cessation, a review of eHealth interventions for physical activity and/or diet241 and a review of clinical counselling for increasing physical activity.242 The summary tables have therefore captured the most up-to-date and relevant evidence for smoking, physical activity and healthy eating health promotion interventions.

Because of the large volume of evidence identified, and the fact that this was one part of a much larger mixed-methods study (see Chapter 2), we were unable independently to quality appraise each guideline and systematic review and instead relied on the quality control measures in place for producing and publishing guidelines and systematic reviews. When reported we extracted whether or not the quality of the evidence and the recommendations was appraised and the appraisal tool used (see Appendix 10). To an extent this approach represented a limitation. In the case of contradictory evidence statements (e.g. if an intervention was reported as effective in one systematic review and not effective in another), we were unable to investigate the reasons underpinning this difference in evidence. In such cases we opted to describe both evidence statements.

Our review of guidelines was limited to UK-based bodies, which is a further potential limitation. The above described ‘strategies and activities’ thus provide a detailed and comprehensive overview of the UK recommendations; however, as the UK guidelines draw on international evidence and because, in addition, we identified international systematic reviews, the state of the evidence described should also on the whole reflect the international evidence base in relation to these three areas of enquiry. In the absence of also interrogating guidelines from other countries (which we were unable to do because of resource constraints), however, we cannot be sure.

The definition of health promotion adopted for this study111 was adapted to produce the six categories of ‘activities and strategies’; this has a potential limitation in that the categories are overlapping and not mutually exclusive. In addition, not all interventions could easily be assigned directly to a level of health promotion intervention. For example, policies can be implemented at the organisational or population level and providers could deliver interventions individually or in groups. In support of this approach these categories are placed across a spectrum, from individual- to population-level ‘strategies and activities’, which loosely corresponds to their scope for adaptation. Despite these potential limitations it was overall still helpful to have an organising framework to describe these strategies and actions to allow the examination, and cross-comparison, of such a large and diverse body of evidence.

Conclusions

In this review of UK guidelines and international systematic reviews we have assessed and aggregated the evidence for interventions for smoking cessation, increasing physical activity and improving healthy eating, and created a summary framework of effective interventions as a potential basis for those interested in developing adapted health promotion interventions for ethnic minority populations. The strength of evidence on interventions for smoking cessation in the general population was greater than that on interventions to increase physical activity or improve healthy eating. Examining these effective interventions according to the six categories (i.e. environment, policy, setting based, technique, provider and resource) has helped to clarify which ‘strategies and activities’ have accrued more evidence and which areas remain sparsely populated. These categories, although overlapping, reflect levels of health promotion intervention from individual to population level and demonstrate important relationships between the health topic and the level and nature of the intervention.

Overall, there was considerably more evidence of clinically important effects for individual-centred pharmacologically based smoking cessation interventions and approaches aimed at increasing access to and use of these treatments, but only moderately supportive guidance for setting-based immersive and interactive interventions for increasing physical activity and improving healthy eating. In terms of health promotion interventions for ethnic minority populations, we have argued that there is perhaps less need and scope for adaptations of individual-focused drug interventions than of the more provider- and setting-based approaches to improve access to these drugs. Similarly, there is considerable scope for adaptation of population-level and setting-based interventions of the kind that are being studied in the context of promoting physical activity and healthy eating. We further explore the extent to which these guidelines and systematic reviews provide clarity on the effectiveness of these interventions for ethnic minority populations in the following chapter (see Chapter 5) and consider in more detail how suited various ‘strategies and activities’ of health promotion interventions are for adaptation, for ethnic minority populations, and how this may influence prioritisation in terms of implementation and further research in Chapter 8.

© 2012, Crown Copyright.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK115655

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