An effectiveness hierarchy of preventive interventions: neglected paradigm or self-evident truth?

Abstract

Non-communicable disease prevention strategies usually target the four major risk factors of poor diet, tobacco, alcohol and physical inactivity. Yet, the most effective approaches remain disputed. However, increasing evidence supports the concept of an effectiveness hierarchy. Thus, ‘downstream’ preventive activities targeting individuals (such as 1:1 personal advice, health education, ‘nudge’ or primary prevention medications) consistently achieve a smaller population health impact than interventions aimed further ‘upstream’ (for instance, smoke-free legislation, alcohol minimum pricing or regulations eliminating dietary transfats). These comprehensive, policy-based interventions reach all parts of the population and do not depend on a sustained ‘agentic’ individual response. They thus tend to be more effective, more rapid, more equitable and also cost-saving. This effectiveness hierarchy is self-evident to many professionals working in public health. Previously neglected in the wider world, this effectiveness hierarchy now needs to be acknowledged by policy makers.

Socioeconomic position and the impact of increasing availability of lower energy meals vs. menu energy labelling on food choice: two randomized controlled trials in a virtual fast-food restaurant

“…A key difference between information provision and structural-based interventions is the level of individual agency required [22]. Because information provision interventions require conscious motivation and effort on the part of the individual, whereas structural-based interventions do not, it has been argued that structural-based interventions are likely to be more effective than information provision interventions [23]. However, there have been few direct comparisons of the effectiveness of information provision vs. structural-based interventions on food choice, particularly in the context of the OOH food sector.…”

A Secondary Analysis of the Childhood Obesity Prevention Literature through a Wider Determinants of Health Lens: Implications for Research Funders, Researchers, Policymakers and Practitioners

“…If the evidence base is focussed on downstream determinants, it is somewhat inevitable that this type of strategy will be implemented. By the same token, researchers working within health (and public health) are often pressed to generate high-quality evidence which demonstrates the e cacy, and effectiveness, of a given intervention (39)(40)(41). This often means that researchers work within a medicalised paradigm, which focuses on the alteration of speci c parts of the system in isolation.…”

The QUEST for Effective and Equitable Policies to Prevent Non-communicable Diseases: Co-Production Lessons From Stakeholder Workshops

“…Although a wide array of societal factors are known to influence health, the evidence regarding the specific interventions to best address them is sparse, particularly at local and regional levels. 28,29 A comprehensive communications strategy was considered essential, targeting professionals, public, policy-makers and politicians. The contribution of 'elite actors' (ministers, public sector leaders) was therefore seen as key to the success of policies, including emotional 'buy in' from leaders about a specific topic, and robustly negating opposition from commercial vested interests.…”