Biomedical subjects
Publications and source records attributed to L Rychetnik.
"Screening is the systematic application of a test or inquiry, to identify individuals at sufficient risk of a specific disorder to benefit from further investigation or direct preventive action, among persons who have not sought medical attention on account of symptoms of that disorder."
Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.
Concerns about the ethics of evidence-based medicine (EBM) relate to possible alterations in the humane basis of clinical care. In collecting the evidence for EBM, scientists and doctors, not consumers, determine research objectives, interpret the data and implement the findings, and in doing so may disregard patients' priorities. Ethical standards, and what counts as evidence, are determined by socially or commercially powerful groups connected to powerful institutions. Such groups can generate evidence and determine "gold standard" knowledge, filtering out other, "inferior" knowledge. Applying the available evidence to predicting outcomes for individual patients involves uncertainty. Full disclosure of this uncertainty is a component of informed consent, but requires sensitivity to patients' tolerance of ambiguity. Ongoing debate about the ethics of EBM on all levels will ensure that EBM manifests intended and preferred social values and takes its rightful place in the practice of medicine and the development of health policy.
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A thematic analysis was undertaken of 72 editorials in three leading health promotion journals, Health Education Research: Theory & Practice, Health Education Quarterly and Health Promotion International, from 1989 to 1994. The three main themes which emerged were (1) the need to broaden health promotion interventions, (2) the need to promote rigour and professionalism in the discipline of health promotion, and (3) the need to respond to the information requirements of practitioners. Against this context, we conducted a content analysis of the journals, examining the nature of the 649 peer-reviewed publications in the same time period. Categories from the traditional bio-medical 'stages of research' models had to be adapted before full classification of articles published was feasible. The largest number of articles published could be termed descriptive research, followed by studies developing and validating health promotion measurement tools and health promotion theory. The proportion of program evaluations was small and the proportion of randomized controlled trials ('highest quality evidence' of effectiveness) decreased over time. Dissemination studies were also poorly represented in spite of this being identified in editorials as an important professional need. Ways to redress some of the imbalances observed are discussed.