Advocating Evidence Based Health Promotion in Physiotherapy

There has been a significant acceleration in the development ofhealth promotion in Africa over the last 20 years. Health promotion is a practicalapproach to achieving greater equity in health. It has thus become an essentialcomponent of health delivery for all health professionals. Health promotionstrategies can develop and change lifestyles as well as have an impact on thesocial, economic and environmental conditions that determine health. The mostvisible challenge for health promotion development in Africa is the fact that people only passively participate in thehealth promotion process. Health professionals such as doctors and nurse control the majority of the programmes andthe question remains: “What is the role of Physiotherapy in health promotion?” This paper thus aims to highlight andrecommend the role of Physiotherapy in evidence-based health promotion

1. building healthy public policy 2. creating supportive environments 3. strengthening community action 4. developing personal skills 5. re-orienting health services According to the Ottawa Charter, health promotion is defined as the "process of enabling people to exert control over the determinants of health and thereby improve their health.Physiotherapists can play a role in all five areas identified by the Ottawa Charter.Nutbeam (1998) stated that health promotion is not something that is done on or to people but it is something that is done with people.The emergence of diseases such as AIDS and chronic diseases of lifestyle has taught us the importance of remaining vigilant in our public health and health promotion efforts relating to the well-being of our population as these are diseases mainly influenced by risky behaviour and can be prevented.Health is a basic human right and is essential for social and economic development.Potter (1998) stated that changing disease patterns and increased pressures on health care services have important implications for health promotion.Thus as the pressure increases on health care services, the need for effective implementation and evaluation of health promotion programmes arises.The purpose of this paper is to highlight the role that physio-therapists can play in the promotion of health promotion programmes and ensuring that it is evidence based.As health care providers, physiotherapists are in an ideal position to address health promotion issues (Higgs et al 2001). .

EVIDENCE-BASED HEALTH PROMOTION -THE FIRST CHALLENGE
In many cases physiotherapists believe that the success of an intervention needs to be scientifically based to demonstrate its effectiveness but how is this evidence to be obtained?The lack of support for evidence based health promotion activities could have a negative effect on implementation of evidence based policy efforts (McQueen 2001), especially in the area of physiotherapy.Turner (2001) indicated that at that time physiotherapy had a weak research evidence base and highlighted the need for the physiotherapy profession to monitor growth of evidence for the profession.
According to McQueen (2001), health promotion will fall or rise based on its ability to demonstrate in a scientific way that is an effective field.The World Health Assembly (1998) stated that health promotion practitioners and researchers should base their work on evidence.Evidence-based medicine has been defined as the use of the current best evidence namely individual clinical expertise and external clinical practice, in making decisions about the care of individual patients (Sackett, Rosenberg, Gray, Haynes and Richardson, 1996).Even though evidence based medicine has been applied to mainly clinical decision making, the concept could be expanded to include other aspects of health care decision making e.g. the selection of health promotion programmes.According to Rada, Ratima and Howden-Chapman (1999), evidencebased health promotion is an approach to practicing health promotion in which the health care provider and client are aware of the evidence supporting selected strategies and the strength of that evidence.Speller et al (1997) (2004), evidence refers primarily to information derived from evaluation research that has assessed the effects and outcomes of potential interventions.The important aspect is to focus on health promotion outcomes.Nutbeam (1998) stated that health promotion outcomes should reflect modification to those personal, social and environmental factors, which are a means of improving people's control and thereby changing the determinants of health.Thus health promotion activities should have outcomes that are set by all key stakeholders to avoid outcomes being seen as negative.According to Whitehead (2004), outcomes can be positive and negative.A positive outcome relies on the capacity of communities and individuals within communities to become politically and socially empowered, so that they can prioritize and act upon health promotion issues based on local need.The author further states that a negative outcome occurs when health professionals enforce disempowering health policy decisions on a community that are not based on the needs of the community.Nutbeam (1998) indicated that criteria for evaluating the success of health promotion programmes should include factors such as: • programme reach (did the programme reach the target population?),• programme acceptability and • programme integrity.
The greatest strength of health promotion is that it cuts across sectors and various disciplines.However, many of these traditional disciplines have produced their standards for evidence-based practice.Thus the challenge for health promotion is to foster and develop high quality and acceptable standards for evidencebased health promotion and physiotherapy should form part of this process.
According to Rapheal (2000), enough evidence is available to justify health promotion as a discipline that can improve the health of the population.The author suggests the following guidelines for making decisions and using evidence in health promotion: • Be explicit as possible regarding the principles and values regarding your health promotion activities • Recognize the tensions and interaction between structural and individual determinants of health and between values and facts • Use multiple sources of evidence • Show awareness of the decisions you make concerning the evidence: be a reflective practitioner

PHYSIOTHERAPY IN EVIDENCE-BASED HEALTH PROMOTION
According to Rea et al (2004), physiotherapists are addressing health promotion topics with patients but are these topics and programmes being evaluated and meeting the basic guidelines suggested for evidence-based health promotion?Within the physiotherapy profession there is a need to agree on criteria for effectiveness and quality of health promotion programmes.As health promotion programmes conducted by physiotherapists take place in a variety of settings such as communities, workplace and schools the criteria for effectiveness should be clearly defined and based on clear outcomes.Aro, van den Broucke and Räty (2005), concluded that success in evidence based health promotion is dependent on how the gap between research and practice is bridged.
Based on all the information presented and information from Tang, Ehsani and McQueen (2003); Ader, Berensson, Carlsson, Granath and Urwitz (2001) and Koelen, Vaandrager and Colomér (2001), the author would like to suggest that physiotherapists consider the following information when designing and implementing health promotion programmes as quality indicators (Table 1).
A typical example that can be used in South Africa is back week.This is a national intervention programme targeting a large population group of all ages.However, the effectiveness of this national programme has not been evaluated.Using the recommended outcomes the South African Society of Physiotherapy (SASP) should consider evaluating the back week programme according to knowledge, environmental and behavioral changes.The results of such a study would impact on physio-therapists and physiotherapy students as it is the one big event in which all universities participate.The events highlighted in the physioforum are evidence that excellent programmes are being implemented but we should provide therapists and students with the information to be able to evaluate the effectiveness of these programmes.

CONCLUSION
The inclusion of health promotion programmes by physiotherapists in the management of patients is universal.However, effective evaluation of these programmes has been hindered by lack of outcome measures for these health promotion programmes.The author hopes that the article will offer physiotherapists a basis for indicators when implementing health promotion programmes.
stated that the effect of health promotion activities should be assessed across the breadth of its activities and settings, and not just by changes in individual health behaviour.The authors further stated that systematic review methods need to be revised in order to be able to include a broader range of studies and research methods, including qualitative research.ThusRychetnik and Wise (2004)identified the types of evidence that may be sought to support evidence-based health pro-