Health promotion and the randomised controlled trial: a square peg in a round hole?

Ruth Freeman

doi:10.1186/1472-6831-9-1

Abstract

In their paper published in BMC Oral Health in March, Barker and Horton present qualitative data which explored Latino parents' main concerns regarding accessing dental care for their pre-school children. In the radical discourse of health promotion the use of participant narratives is a first and essential step in community development interventions. While there is agreement regarding the development and implementation of health promotion, the means by which it is evaluated or the type of evaluation design used, is hotly debated. This commentary outlines the rationale of adopting a randomised controlled trial methodology, contrasts it with realistic evaluation and considers design evaluation in the light of the Medical Research Council's (MRC) guidance of 2000 and 2008. It is at this juncture that the commentary suggests that, despite the MRC's acknowledgement of the limitations of its 2000 guidance, there remains, in the 2008 guidance, an underlying insistence to use design evaluations which control for selection bias and confounding extraneous factors. For the evaluation of health promotion interventions it may remain a case of fitting a square peg into a round hole.

Highlights

In their paper published in BMC Oral Health in March 2008, entitled 'An ethnographic study of Latino preschool children's oral health in rural California: intersections among family, community, provider and regulatory sectors', Barker and Horton [1] examined the barriers experienced by immigrant parents when accessing dental care for their pre-school children
At a more personal level parents' concerns included; language differences and literacy problems; health professionals' lack of cultural sensitivity and how their children's dental fears would be managed. This cocktail of concerns, worries and anxieties resulted in parents delaying treatment visits and increasing oral health disparities in this ethnic minority group
Why should Barker and Horton's [1] work be of importance: why should an in-depth examination or assessment of community concerns be of relevance? What is the relevance of participants' narratives, as an expression of their internal world, for the radical discourse of health promotion and its evaluation?

Summary

Introduction

In their paper published in BMC Oral Health in March 2008, entitled 'An ethnographic study of Latino preschool children's oral health in rural California: intersections among family, community, provider and regulatory sectors', Barker and Horton [1] examined the barriers experienced by immigrant parents when accessing dental care for their pre-school children. The importance of Barker and Horton's [1] work is that they used qualitative research methodologies By doing so they enabled parents' voices and their health concerns to be heard – the first essential steps in the radical discourse of health promotion. Despite the rigours of the RCT methodology, it is considered by some to be inappropriate for the evaluation of community development interventions This is the case where extraneous environmental factors out-with the intervention and psycho-social factors internal to the participants may contaminate and dilute the intervention effect. While the MRC does not 'intend the revised guidance to be prescriptive' [13] it is perhaps with a sense of resignation that followers of a more radical discourse of health promotion may feel compelled to fit the square peg of community development assessment into the round hole of the RCT design evaluation

Laverack G

Glaser B