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Short research communication

Tahir Turk^1,2 and Wasiq Khan³

¹Dow University of Health Sciences, School of Public Health, Karachi, Pakistan (Correspondence to: T. Turk: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). ²Communication Partners International (CPI), Springfield, NSW, Australia, ³World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Abstract

Background: Health promotion and education (HPE) is a valuable component of initiatives to improve health and prevent disease in the Eastern Mediterranean Region (EMR).

Aims: To assess the type and scope of HPE interventions in the EMR and analyze lessons learned.

Methods: A rapid review was conducted using a PICOS (participants, interventions, comparisons, outcomes and study approaches) framework guiding approach.

Results: We identified a growin interest in HPE approaches in the EMR, with the majority of studies published within the past five years. Few high-quality studies were identified. Formative research predominated with nearly half of the studies recommending the need toscale up HPE interventions. There was little emphasis on implementation and evaluation of priority HPE interventions.

Conclusion: The findings highlight the need to: (1) up-scale resource-efficient HPE interventions; (2) implement HPE programmes addressing noncommunicable disease priorities; and (3) capacity building to operationalize high-quality interventions and evaluations.

Keywords: health promotion, health education, burden of disease, EMR

Citation: Turk T; Khan W. Health promotion/education interventions in the Eastern Mediterranean Region: a rapid evidence review. East Mediterr Health J. 2022;28(1):58-68. https://doi.org/10.26719/emhj.21.057
Received: 03/02/21; accepted: 16/06/21

Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

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Introduction

Health promotion and education (HPE) are considered essential for the prevention of disease in high-income countries (1–3). This may be more applicable in low- and middle-income countries (LMICs) because of the higher disease burdens, limited resources to deal with chronic conditions, and greater inequities due to socioeconomic, cultural and other factors (4). As greater understanding of the social determinants of health evolved, the United Nations established the Sustainable Development Goals to help improve the conditions under which people in developing countries live (5,6). The Ottawa Charter for Health Promotion (7) and the Jakarta Declaration (8) have provided guidance to the global community about the relevance and importance of HPE strategies.

It is, therefore, not surprising that HPE has garnered increasing interest for its potential application in LMIC settings, including the 22 countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR), that experience volatility (e.g. conflict, regime change, natural disasters and grinding poverty) and high burdens of disease (9, 10). However, despite the potential of HPE interventions to support health programmes and policies, to date, no comprehensive reviews have been conducted to identify the type, scope and evaluation of HPE interventions in the EMR.

The aim of this study was to systematically review the literature to assess the type of HPE interventions in the EMR and synthesize lessons to be learned for the development, implementation and evaluation of future HPE interventions in the region.

Methods

A best practice procedure for rapid evidence reviews was adopted, in line with WHO recommendations for swift knowledge generation for priority health issues (11). The rapid review process is premised on the fact that research methods in resource-constrained LMIC settings need to be highly efficient and focussed to provide evidence from which to form effective policies and programmes and make crucial decisions about health systems’ response in emergency situations, as well as in routine decision-making. Procedures involved completing the review in a timely fashion, limiting the search to main databases of published literature, and having one reviewer extract data while another reviewer verified the findings (12,13). The search used 27 online databases including

ABI/INFORM Complete, ProQuest, Ovid Medline, Sage Journals Online, NCBI, Project Muse, Wiley Online Library, Index Medicus for the Eastern Mediterranean Region, and Google Scholar, with keywords including “health promotion” and “health education” paired separately with the 22 WHO EMR countries of Afghanistan, Bahrain, Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates and Yemen. Inclusion criteria were peer-reviewed journal articles, conference proceedings and the grey literature relating to the EMR, available in English and published between January 2000 and March 2019. A PICOS framework (participants, interventions, comparisons, outcomes and study approaches) guided the study approach, research questions and the literature search (14).

Results

A total of 181 articles and reports were identified of which 22 were duplicates. Of the remaining 159 articles/reports reviewed, 59 were excluded from further consideration because they did not conform to the PICOS framework criteria, and a further 12 articles were removed because they were not available as full text and/or in English, leaving a sample of 88 articles/reports. Following a second independent review of the full-text items, a further 30 items were excluded because they did not have clear HPE focus and/or did not meet all of the quality design checklist criteria, leaving a total of 57 studies that met the selection criteria (Figure 1)

The number of HPE articles was calculated according to the inclusion criteria to identify the range of HPE best-practice approaches within the EMR and the specific types of interventions undertaken. The largest number of HPE items was from the Islamic Republic of Iran (17); followed by Sudan (5); Tunisia and Yemen (4); Pakistan, Palestine and Saudi Arabia (3); Oman and Syrian Arab Republic (2); and Afghanistan, Bahrain, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Qatar and UAE (1). There were no HPE items from Morocco and Somalia. Most of the reviewed articles (35, 61%) were published between 2014 and 2018, with 13 (23%) published in 2017 alone. An additional 20 (35%) of the articles were published between the years 2008–2013, with only 2 (3%) of HPE articles published in 2002–2007.

Enumeration of the PICOS criteria and subcategories was undertaken to gain a granular understanding of the scope, purpose, methodology and outcomes of the reviewed interventions and studies. Figure 2 shows a schematic representation of each criterion with its associated subclassifications, including the total number of items identified from the search, abstracts screened for inclusion, and number of full-text items screened at each of the two reviews.

Of the 57 articles reviewed (Appendix 1), 11 with high quality evaluation components were benchmarked against five best-practice quality criteria including: (1) clear study description, (2) appropriate comparison groups and situations, (3) clear description of methods, (4) rigorous and well-described analysis, and (5) clearly articulated findings and recommendations aligned to the analysis. Furthermore, a star ranking was applied for achievement of each of the criteria (Appendix 2). A detailed review of the 11 HPE study outcomes identified significant positive outcomes for demand-side beneficiaries on communicable disease prevention (e.g. improvements in polio coverage and immunization rates, enhanced tuberculosis knowledge and behavioural outcomes, and improved maternal health outcomes; P < 0.05). Supply-side studies indicated HPE interventions in the form of health worker training programmes can also lead to significant positive outcomes.

Discussion

We identified a growing interest in HPE approaches in the EMR, as demonstrated by the fact that most of the studies (57, 61%) were published within the past five years. However, the findings also suggest that the use of HPE approaches was nascent and largely directed toward formative research. Moreover, the findings from the small subset of evaluation-focused studies, while largely supportive of HPE approaches, currently lack the rigor needed to build an evidence base for the scaling-up of HPE interventions in the EMR, particularly if the goal is to use the data to drive policy development and implementation.

Our findings raise three key issues. The first relates to best-practice approaches, with few of the studies identified by the review receiving a 5-star rating

(57, 9%) according to best-practice criteria. This identifies the need to expand capacity-building initiatives within the EMR, given the fundamental need for high-quality studies and evaluations to build the evidence base on what works. To this end, EMR stakeholders – ministry of health officials, epidemiologists and policy-makers – may benefit from regional efficiencies afforded through sharing lessons learned, and adaptation of resources and policies from successful HPE programmes from more advanced EMR economies, as well as global resources. The development of a repository or online portal for HPE interventions within the region may facilitate the sharing of knowledge among stakeholders.

The second key issue is that 57 (42%) of the reviewed studies recommended scaling up HPE interventions and policy initiatives going forward. This speaks to the need to move from policy formulation to making operational priority HPE interventions in the EMR. This will require political will as well as more direct engagement of donors to build local technical capacity for the design, implementation and evaluation of HPE initiatives, with knowledge transfer initially being derived from international advisors.

Third, we identified an underemphasis on imple-mentation and evaluation of priority health issues known to contribute to the major burdens of disease in the EMR, including noncommunicable diseases, communicable diseases, maternal and child health, and road accidents and injuries. Of the 11 best-practice intervention studies, only six dealt with high-priority issues. Given the potential for chronic conditions to overwhelm healthcare systems, the need to prioritize HPE preventative interventions is urgent. Health outcomes could be improved with small investments in public health priorities, using best-practice HPE demonstration projects aligned with Vision 2023 Eastern Mediterranean Region (15). HPE priorities should consider the epidemiological data, that highlight the scale of health problems – disease burden, health care, social and development costs – the amenability to effect change using HPE approaches, and the political and social will to effect the changes.

Given the reliance on online published papers, a key limitation of the rapid review relates to publication bias, with the possibility that local HPE interventions were not reported in the peer-reviewed literature, did not appear under the search terms, or were not in English. Although the review findings from the small subset of studies that formally evaluated interventions were largely positive, caution is warranted in not overinterpreting the findings.

Conclusion

This is the first systematic review of HPE studies in the EMR. The findings suggest that to realize the latent potential of HPE within the EMR, a regional approach to identification of health priorities and the scaling-up of HPE interventions is needed and should be implemented alongside capacity building to up-skill local stakeholders involved in the development, delivery and evaluation of HPE campaigns and policy initiatives in a region of high need.

Funding: This project was funded by the World Health Organization Regional Office for the Eastern Mediterranean.

Competing interests: None declared.

Interventions en matière de promotion de la santé et d'éducation sanitaire dans la Région de la Méditerranée orientale : examen rapide des bases factuelles

Résumé

Contexte : La promotion de la santé et l'éducation sanitaire constituent un élément précieux des initiatives visant à promouvoir la santé et à prévenir les maladies dans la Région de la Méditerranée orientale.

Objectifs : Évaluer le type et la portée des interventions de promotion de la santé et d'éducation sanitaire dans la Région de la Méditerranée orientale et faire la synthèse des enseignements tirés.

Méthodes : Un examen rapide a été réalisé avec un cadre d'orientation des approches portant sur les participants, les interventions, les comparaisons, les résultats et les approches d'étude.

Résultats : Un intérêt croissant pour les approches de promotion de la santé et d'éducation sanitaire dans la Région de la Méditerranée orientale a été identifié, la majorité des études ayant été publiées au cours des cinq dernières années. Peu d'études de qualité ont été identifiées. La recherche formative était prédominante, près de la moitié des études recommandant la nécessité d'intensifier des interventions en matière de promotion de la santé et d'éducation sanitaire. La mise en œuvre et l'évaluation des interventions prioritaires de promotion de la santé et d'éducation sanitaire ont fait l'objet d’une attention limitée.

Conclusion : Les résultats soulignent la nécessité : 1) d'intensifier les interventions efficaces en termes de ressources en matière de promotion de la santé et d'éducation sanitaire ; 2) de mettre en œuvre des programmes de promotion de la santé et d'éducation sanitaire visant à répondre aux priorités relatives aux maladies non transmissibles ; et 3) de renforcer les capacités pour appliquer des interventions et des évaluations de qualité.

تدخلات تعزيز الصحة/التثقيف الصحي في إقليم شرق المتوسط: استعراض سريع للدلائل

طاهر ترك، واثق خان

الخلاصة

الخلفية: يمكن أن يكون تعزيز الصحة والتثقيف الصحي من العناصر القيمة لمبادرات تعزيز الصحة والوقاية من الأمراض في إقليم شرق المتوسط.

الأهداف: هدفت هذه الدراسة إلى تقييم نوع التدخلات المعنية بتعزيز الصحة والتثقيف الصحي ونطاقها في إقليم شرق المتوسط، وجمع الدروس المستفادة.

طرق البحث: هدفت هذه الدراسة الى اجراء استعراض سريع باستخدام الأساليب التوجيهية لإطار "PICOS" (المشاركين والتدخلات والمقارنات والنتائج وأساليب الدراسة).

النتائج: ازداد الاهتمام بأساليب تعزيز الصحة والتثقيف الصحي في إقليم شرق المتوسط، إذ نُشرت معظم الدراسات خلال السنوات الخمس الماضية. وتم تحديد عدد قليل من الدراسات العالية الجودة. وأوصت البحوث التكوينية، التي مثَّلت ما يقرب من نصف الدراسات، بالحاجة إلى توسيع نطاق التدخلات المعنية بتعزيز الصحة والتثقيف الصحي. كما كان هناك قصور في التركيز على تنفيذ التدخلات ذات الأولوية المعنية بتعزيز الصحة والتثقيف الصحي، وتقييمها.

الاستنتاجات: تؤكد النتائج على الحاجة إلى ما يلي: (1) توسيع نطاق التدخلات المعنية بتعزيز الصحة والتثقيف الصحي على نحو يتسم بالكفاءة في استخدام الموارد، (2) تنفيذ برامج تعزيز الصحة والتثقيف الصحي التي تتناول أولويات علاج الأمراض غير السارية، (3) بناء القدرات لتنفيذ التدخلات والتقييمات العالية الجودة.

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