Published: 07/11/2002, Volume II2, No. 5830 Page 14 15
Prevention and reduction of alcohol misuse is the subject of the Health Development Agency's first evidence briefings on crucial areas of public health intervention. Alison Moore reports
What makes smokers give up - or stops young people ever starting? How do you devise effective programmes to reduce teenage pregnancies? And what interventions will help a heavy drinker cut down?
Difficult questions: but they are ones that many healthcare workers have to deal with every day, whether they are a health promotion strategist drawing up a teenage pregnancy programme, a GP dealing with a young smoker with a cough or a nurse in accident and emergency stitching a middle-aged woman who has got in a fight while drunk.
In some cases, there has been an abundance of evidence - some of it of a very high standard - but also 'greyer' evidence, which may be observational studies or based on small-scale programmes. Other areas are less well researched.
Few health professionals have the time or opportunity to weigh up the evidence on every subject:
consequently time, effort and money is possibly being spent on interventions which are ineffective or even harmful.
One of the tasks set to the Health Development Agency when it was established was to map the evidence available and translate it into standards for public health and health promotion. That work was started 18 months ago and is beginning to bear fruit, with the publication of the first of 16 evidence briefings on crucial areas of public health intervention.
Prevention and reduction of alcohol misuse: evidence briefing will be followed by similar booklets on low birth weight, community development and the prevention of obesity, among others, over the next three to six months. A team of 20, plus external consultants, have been working on the project: the evidence base has now been assessed, although work is continuing on how to integrate nonreview sources into the scheme.
There probably will not be any dramatic surprises about what works, but the guidance will also highlight areas where evidence of effectiveness is lacking or simply is not robust enough.
But they will not be promoting a single solution, a panacea which cures all ills, says Professor Mike Kelly, HDA's director of research and information.
'Early public health intervention was of that sort: our problems now are more intractable than the organism in the water, ' he says. 'Now the solutions tend to be multi-faceted and do not make for easy sound bites.
'Sometimes it is easy to know that we should do X because X works in laboratory conditions.
But X in a population with busy practitioners... becomes much more difficult to implement in the practical world.'
The second stage of the project will look at some of these practicalities and how evidence can be translated into practice, drawing on the experience and views of people working in the field.
The cost of the project has been about£3m so far, but the benefits could be many times more - and the guidance produced will determine much of the future thrust of HDA's work.
The sole briefing published so far - on alcohol abuse - will probably make uncomfortable reading for policymakers, more than for health promotion professionals.
The picture on interventions to reduce and prevent alcohol abuse is fairly mixed, but there is probably enough evidence to ensure that healthcare workers carry on doing roughly what they have done. But some of the most effective interventions looked at go far beyond the health sphere.
Wider societal changes which could have an impact - such as restricting alcohol availability - may be too hot to handle for the politicians.
Professor Kelly acknowledges that some of these are unlikely to get on the political agenda immediately.
'Our business is not to change the world overnight.'
It has taken 40 years since the publication of a clear association between smoking and ill-health to get to the current position where the NHS offers smokers help to quit and many work and transport environments are smokefree, he points out.
HDA's work - thought to be the first time a health system has undertaken this sort of systematic review looking at the effectiveness of interventions - has won praise from many quarters.
Eddie Coyle, chair of the British Medical Association's public health committee, says looking at the evidence could help to put public health on a level playing field with other areas of healthcare, where there is a strong evidence base for what works and what doesn't. This could influence funding decisions as 'that is the standard to which we are now expected to work if we are spending public money.'
UK Public Health Association chair Geof Rayner points out that knowing what the evidence suggests will work is just the first stage - practitioners have to be given the budget to adopt 'best practice' and individuals have to be persuaded to change their behaviour, often against a backdrop of opposing advertising and societal pressure.
'It is a long process of turning around our culture, ' he says.
'The culture has become the problem - for example, you get TV programmes about driving around in fast cars, not ones about walking.'