Effects of government policies on health behaviour must be studied

EDITOR—The Heartbeat Wales programme,1 in common with several other community health promotion projects that aim to reduce the risk of cardiovascular diseases,2 has reported no net changes in intervention compared with control regions. Tudor-Smith et al report these negative findings in an exemplary way, using a straightforward analysis.1 Their study concludes that more debate on the most appropriate methods of assessing the effectiveness of such programmes is needed.

The investigators suggest that lack of power and contamination of the control region explain their failure to detect effects of the programme. The study had sufficient power to detect a 5% difference in prevalence between intervention and control regions. If the other community based interventions that were previously reviewed2 were included in a meta-analysis, the power would increase, but the lack of effect would still be apparent as these other programmes also had essentially negative results.

Contamination of the control region is a possible explanation for the findings. Similar community health promotion programmes conducted from the 1970s to the 1990s have, however, reported consistent findings—no net difference in risk factors or clinical events attributable to the intervention. Moreover, the downward secular trends in mortality from cardiovascular disease in countries with diverging practices in health promotion suggests that these programmes are ineffective.

The notion that alternative study designs can be found that will produce the right answer is fallacious. Quasi-experiments at community level and randomised controlled trials at the workplace, among families, or individual people show a consistency of small changes to the risk factor in effect only and no significant reduction in mortality.3 Similar interventions applied to populations at high risk (such as people with hypertension or pre-existing cardiovascular disease) are, however, effective.2 Consequently, health promotion programmes in their current form have only a limited potential for improving the health of the population.

The response to rigorous evaluations that showed little or no added value of health promotion programmes for cardiovascular disease has been that either the design and execution of potentially misleading and methodologically flawed studies,4 for which exorbitant claims are made,5 or the methods are not appropriate in this situation.

If more money is to be spent on research into health promotion an understanding of the effects of employment (changing socioeconomic position), food (pricing and availability), and transport (travel concessions) policies on health behaviours and risk factors would be a better investment than an attempt to shift the goalposts.

Market researchers are not suitable for collecting health data

EDITOR—Tudor-Smith et al admit that they underestimated the difficulties they would encounter in evaluating their health promotion programme.1 When they first put their project forward, many of us predicted this result, but the project fitted the political fashions and public relations requirements of that time, in the only place that mattered—the then unelected and unaccountable Welsh Office.

We already had the experience of the multiple risk factor intervention trial in the United States, which prevented 12 coronary deaths at a cost of $115m (£72m) and produced no significant difference between reference and control populations, because it was not possible to isolate controls from media information.2 The suggestion that contamination of the Yorkshire reference group might be attributed to the Heartbeat Wales programme, more than the many other initiatives pursued at all levels throughout the United Kingdom at that time,3 is as unconvincing as were the expectations that Heartbeat Wales raised at its launch.

There are two lessons to be learnt from the failed programme. The first is to remain sceptical when governments offer to pay for inquiries into questions for which they are already sure they know the answers. The second is never to do epidemiology on the cheap by farming out data collection to market research companies, instead of developing and maintaining dedicated research teams in house. To apply questionnaires to a random sample of the population and measure blood cholesterol concentrations and arterial pressure in a subset is not demanding.

There were reasons to think that non-respondents would be at highest risk, and high response rates were therefore especially important. Response rates in this study ranged from 61% to 88%, far below the standards established by Cochrane, Elwood, and other researchers in the tradition of South Wales epidemiology.4 High response rates and good data depend on generally unrecognised, underpaid women (rarely men), who are honest, persistent, patient, and friendly even when they feel they could scream. Market researchers who have just come off detergents and will move on to vacuum cleaners will never be the same.

Health promotion is a waste of time and money

EDITOR—Tudor-Smith et al admit that the efficacy of the Heartbeat Wales programme in attempting to change behavioural risks associated with cardiovascular disease in Wales could not be concluded definitely.1 Does this admission hide a more serious conclusion—namely, that most health promotion is expensive and a wasted effort?

The 1990 contract forced disinterested general practitioners to collect meaningless data and to hold health promotion clinics. Only worried well patients attended—never those who drank, smoked or ate chips and whose habits might endanger their health. The only reason for general practitioners to hold a health promotion clinic was the £45 fee. Any doctor who said publicly that the emperor had no clothes was considered not politically correct. General practitioners were diverted from their main task of treating ever more patients with diminishing resources.

The “self” (sic) promotion units were amazing self publicists, preaching to the converted with humourless, messianic zeal. Patients do not, however, listen to general practitioners or heed health promotion campaigns. They copy the behaviour of soap and pop stars, follow fashions, teen magazines, and the current media scare (until it is superseded by the next one)—and may finally modify their behaviour after the government intervenes by banning advertising or inflating prices. Schools, a key influence on children, have abandoned home economics (teaching hygiene, nutrition, cooking, home care, etc). No wonder fats and convenience food flourish among the groups perceived to be most at risk.

Should this sacred cow now be investigated to determine if most health promotion is cost effective and evidence based? Instead of employing expensively trained staff issuing pamphlets, health promotion units could be replaced by shelves. Patients can then pick up the leaflets themselves.