Is there enough evidence of public health benefit to support the ubiquity of health awareness days? Photo credit: Judith E. Bell, CC BY-SA 2.0

“We contend that the health awareness day has not been held to an appropriate level of scrutiny given the scale at which it has been embraced,” write Jonathan Purtle, DrPH and Leah Roman, MPH in a peer-reviewed commentary published online ahead of print today in the American Journal of Public Health.

Purtle, an assistant professor at the Drexel University School of Public Health, and Roman, a public health consultant, were prompted to investigate the prevalence of evaluation data for health awareness days based on their observation of two trends: On one hand, health awareness days were seemingly ubiquitous. For example, there were nearly 200 health awareness days, weeks or months on the 2014 U.S. Department of Health and Human Services’ National Health Observances calendar. On the other hand, the guidance from public health leaders was to develop and implement “evidence-based” interventions. So they wondered, to what extent are awareness initiatives grounded in evidence?

Their answer, in short, after reviewing the health literature: Not much.

They found 74 English-language articles in the PubMed database of scientific and medical research that referenced “awareness day(s)” in the title or abstract. Of these, only five articles were empirical studies evaluating the impact of an awareness day. All five of these articles were published since 2006 and none evaluated U.S.-based initiatives. In the remaining articles, awareness days were mentioned in the context of editorials or commentaries publicizing an awareness day, or in the context of studies investigating concepts other than the awareness day itself—such as an awareness day being included as a study recommendation.

But despite the thin evidence they turned up demonstrating awareness days’ impact as a public health intervention, Purtle and Roman aren’t calling for an end to awareness days, nor do they want to criticize the good intentions and efforts of people who take part in them.

They do want to stimulate a dialogue about awareness days and how the concept of “awareness” is used in public health, noting that the concept is often vaguely defined and hard to measure. And they offer recommendations for how health awareness days can be evaluated and improved, in order to maximize their impact on health in measurable ways.

“Awareness is not a bad thing,” said Purtle, but “it’s just that it’s far from sufficient to improve population health.”

The key word there is “population.” The authors argue that awareness day initiatives tend to focus on changing health knowledge and behavior at the individual level. While important, this approach over-emphasizes the role of individual responsibility for promoting health more broadly.

Such strategies—teaching people to eat healthier, exercise more, get regular cancer screenings when they are at-risk—are only one piece of the picture of what makes populations healthier. Social and environmental factors have vast impacts on population health outside of individuals’ choices in their day-to-day lives. And these social determinants of health are emphasized less frequently in public awareness campaigns.

“People have free will, but the choices they make, and the extent to which they are ‘healthy,’ are significantly influenced by their level of wealth and the social and physical environments in which they live and work. This is abundantly clear from public health research that has amassed over the past three decades,” Purtle said.

For example, he added, a low-income family living in a house with lead paint, miles away from a supermarket, with no car, can’t improve their health through more awareness or knowledge. “People need to understand that we need to change public policies (e.g., stricter lead paint enforcement laws, stricter environmental regulation, zoning and tax laws that incentivize vendors of fresh food to operate in low-income neighborhoods, a higher minimum wage or standard living wage) if we really want to see improvements in population health and the elimination of health disparities between social groups.”

“Awareness days can potentially have very positive impacts, in my opinion, if they raise awareness around specific policy issues and advocate for policy change—not just individual change,” he said.

Purtle and Roman recommend that public health practitioners commit to researching the effectiveness of awareness days and to developing resource guides so that organizers of awareness days—even those without formal public health training—can develop programs according to evidence-based principles of health promotion practice. They cite the National Cancer Institute’s “Making Health Communication Programs Work” as an example of the type of guide that could benefit awareness day efforts.

“The development and implementation of these days can be incredibly resource intensive, so we should approach them with the same scrutiny with which we approach other types of public health interventions,” Roman said. For organizers and participants in awareness days, “we want to make sure that the passion, time and effort you put into these events are directed towards an intervention that will actually bring about meaningful change.”