International Journal of Public Health

, Volume 59, Issue 1, pp 3–14 | Cite as

A scoping review of unintended harm associated with public health interventions: towards a typology and an understanding of underlying factors

  • L. K. Allen-ScottEmail author
  • J. M. Hatfield
  • L. McIntyre



Unintended harm theory as related to public health interventions (PHI) is under developed, with harm evaluation and reporting often absent or incomplete. This review presents a typology for, and underlying factors linked to, PHI-associated unintended harm.


This scoping review was conducted electronically and includes articles from 1992 to June of 2013. Out of 2,490 originally identified titles, 26 full-text articles were included that discussed unintended harm associated with PHI. An iterative data analysis process was utilized to identify both a typology and underlying factors associated with unintended harm.


A typology of PHI-associated unintended harm was identified: (1) physical; (2) psychosocial; (3) economic; (4) cultural and (5) environmental. Five underlying factors associated with PHI unintended harm emerged: (1) limited and/or poor quality evidence; (2) prevention of one extreme leads to another (boomerang effects); (3) lack of community engagement; (4) ignoring root causes; and (5) higher-income country PHI implementation in a lower- or middle-income country.


PHI planning and evaluation frameworks may benefit from the consideration and potential incorporation of the unintended harm typology and underlying factors.


Public health interventions Unintended harm Unanticipated consequences Typology Underlying factors Evaluation 



L.K. Allen-Scott is funded by the Vanier Canada Graduate Scholarships for her PhD dissertation. L. McIntyre holds a Canadian Institutes for Health Research Chair in Gender and Health.


  1. Allison DB, Weber MT (2003) Treatment and prevention of obesity: what works, what doesn’t work, and what might work. Lipids 38(2):147–155PubMedCrossRefGoogle Scholar
  2. Arksey HaLOM (2005) Scoping studies: towards a methodological framework. Int J Soc Res Methodol 8:19–32CrossRefGoogle Scholar
  3. Armstrong R et al (2008) Improving the reporting of public health intervention research: advancing TREND and CONSORT. J Public Health (Oxf) 30(1):103–109. doi: 10.1093/pubmed/fdm082 CrossRefGoogle Scholar
  4. Atkinson RL, Nitzke SA (2001) School based programmes on obesity—increase knowledge about nutrition but do not change eating habits by much. Brit Med J 323(7320):1018–1019PubMedCrossRefGoogle Scholar
  5. Bacon L, Aphramor L (2011) Weight science: evaluating the evidence for a paradigm shift. Nutr J 10:9. doi: 10.1186/1475-2891-10-9 PubMedCentralPubMedCrossRefGoogle Scholar
  6. Balog JE (2009) The moral justification for a compulsory human papillomavirus vaccination program. Am J Public Health 99(4):616–622. doi: 10.2105/AJPH.2007.131656 PubMedCrossRefGoogle Scholar
  7. Barr D, Amon JJ, Clayton M (2011) Articulating a rights-based approach to HIV treatment and prevention interventions. Curr HIV Res 9(6):396–404PubMedCentralPubMedCrossRefGoogle Scholar
  8. Bell K (2011) Legislating abjection? Secondhand smoke, tobacco control policy and the public’s health. Crit Public Health 21(1):49–62. doi: 10.1080/09581596.2010.529419 CrossRefGoogle Scholar
  9. Bernal-Delgado E, Fisher ES (2008) Abstracts in high profile journals often fail to report harm. BMC Med Res Methodol 8:14. doi: 10.1186/1471-2288-8-14 PubMedCentralPubMedCrossRefGoogle Scholar
  10. Blake SM, Ledsky R, Goodenow C, Sawyer R, Lohrmann D, Windsor R (2003) Condom availability programs in Massachusetts high schools: relationships with condom use and sexual behavior. Am J Public Health 93(6):955–962PubMedCrossRefGoogle Scholar
  11. Bronfenbrenner U (1979) The ecology of human development. Harvard University Press, CambridgeGoogle Scholar
  12. Brown VA, Harris JA, Russell JY (2010) Tackling wicked problems through the transdisciplinary imagination. Earthscan, Washington, DCGoogle Scholar
  13. Brownson RC, Fielding JE, Maylahn CA (2009) Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health 30:175–201. doi: 10.1146/Annurev.Publhealth.031308.100134 PubMedCrossRefGoogle Scholar
  14. Burnard P (1992) A method of analysing interview transcripts in qualitative research. Nurs Educ Today 11:461–466CrossRefGoogle Scholar
  15. Callahan J (1996) Negative effects of a school suicide postvention program—a case example. Crisis 17(3):108–115PubMedCrossRefGoogle Scholar
  16. Callery WE, Hammond D, O’Connor RJ, Fong GT (2011) The appeal of smokeless tobacco products among young Canadian smokers: the impact of pictorial health warnings and relative risk messages. Nicotine Tob Res 13(5):373–383. doi: 10.1093/ntr/ntr013 PubMedCrossRefGoogle Scholar
  17. Carter FA, Bulik CM (2008) Childhood obesity prevention programs: how do they affect eating pathology and other psychological measures? Psychosom Med 70(3):363–371. doi: 10.1097/Psy.0b013e318164f911 PubMedCrossRefGoogle Scholar
  18. Carter JC, Stewart DA, Dunn VJ, Fairburn CG (1997) Primary prevention of eating disorders: might it do more harm than good? Int J Eat Disorder 22(2):167–172CrossRefGoogle Scholar
  19. Chalmers I (2003) Trying to do more good than harm in policy and practice: the role of rigorous, transparent up-to-date evaluations. Ann Am Acad Polit Ss 589:22–40. doi: 10.1177/0002716203254762 CrossRefGoogle Scholar
  20. Christakis NA (2009) Only connect indirectly doing harm. Brit Med J 339. doi: 10.1136/bmj.b3980
  21. Clifford A, Jackson Pulver L, Richmond R, Shakeshaft A, Ivers R (2009) Disseminating best-evidence health-care to indigenous health-care settings and programs in Australia: identifying the gaps. Health Promot Int 24(4):404–415. doi: 10.1093/heapro/dap039 PubMedCrossRefGoogle Scholar
  22. Cooper HM, Hedges LV, Valentine JC (2009) The handbook of research synthesis and meta-analysis, 2nd edn. Russell Sage Foundation, New YorkGoogle Scholar
  23. Daniels NA et al (1999) First do no harm: making oral rehydration solution safer in a cholera epidemic. Am J Trop Med Hyg 60(6):1051–1055PubMedGoogle Scholar
  24. Davies M, Macdowall W (2006) Health promotion theory. Open University Press, MaidenheadGoogle Scholar
  25. Feinberg J (1984) Harm to others. The moral limits of the crimimal law, vol 1. Oxford University Press, New York, p 11Google Scholar
  26. Gallagher JE et al (2010) Public health aspects of tobacco control revisited. Int Dent J 60(1):31–49. doi: 10.1922/IDJ_2533Gallagher19 PubMedGoogle Scholar
  27. Garner P, Kramer MS, Chalmers I (1992) Might efforts to increase birth-weight in undernourished women do more harm than good. Lancet 340(8826):1021–1023PubMedCrossRefGoogle Scholar
  28. Glanz K, Bishop DB (2010) The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health 31:399–418. doi: 10.1146/Annurev.Publhealth.012809.103604 PubMedCrossRefGoogle Scholar
  29. Greer AG, Ryckeley JB (2011) Ethics of obesity legislation and litigation: a public-health policy debate. Bariatr Nurs Surg Patient Care 6(4):173–177. doi: 10.1089/bar.2011.9945 CrossRefGoogle Scholar
  30. Henriksen L, Dauphinee AL, Wang Y, Fortmann SP (2006) Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect. Tob Control 15(1):13–18. doi: 10.1136/tc.2003.006361 PubMedCrossRefGoogle Scholar
  31. Ioannidis JP, Lau J (2001) Completeness of safety reporting in randomized trials: an evaluation of 7 medical areas. JAMA 285(4):437–443 (pii: joc00579)PubMedCrossRefGoogle Scholar
  32. Jefferson T, Rivetti A, Di Pietrantonj C, Demicheli V, Ferroni E (2012) Vaccines for preventing influenza in healthy children. Cochrane Database Syst Rev (8). doi: 10.1002/14651858.CD004879.pub4
  33. Johnston RB (2008) Will increasing folic acid in fortified grain products further reduce neural tube defects without causing harm?: Consideration of the evidence. Pediatr Res 63(1):2–8PubMedCrossRefGoogle Scholar
  34. Kohatsu ND, Robinson JG, Torner JC (2004) Evidence-based public health—an evolving concept. Am J Prev Med 27(5):417–421. doi: 10.1016/J.Amepre.2004.07.019 PubMedGoogle Scholar
  35. Leatherdale ST, Ahmed R (2010) Alcohol, Marijuana, and Tobacco use among Canadian youth: do we need more multi-substance prevention programming? J Prim Prev 31(3):99–108. doi: 10.1007/s10935-010-0211-y PubMedCrossRefGoogle Scholar
  36. Levac D, Colquhoun H, O’Brien KK (2010) Scoping studies: advancing the methodology. Implement Sci: IS 5:69. doi: 10.1186/1748-5908-5-69 PubMedCrossRefGoogle Scholar
  37. Lucas T, Alexander S, Firestone I, Lebreton JM (2009) Belief in a just world, social influence and illness attributions: evidence of a just world boomerang effect. J Health Psychol 14(2):258–266. doi: 10.1177/1359105308100210 PubMedCrossRefGoogle Scholar
  38. Lykkesfeldt J, Poulsen HE (2010) Is vitamin C supplementation beneficial? Lessons learned from randomised controlled trials. Br J Nutr 103(9):1251–1259. doi: 10.1017/S0007114509993229 PubMedCrossRefGoogle Scholar
  39. Marmot M (2006) Social determinants of health. Oxford University Press, New YorkGoogle Scholar
  40. McDaniel RR Jr, Jordan ME, Fleeman BF (2003) Surprise, Surprise, Surprise! A complexity science view of the unexpected. Health Care Manag Rev 28(3):266–278CrossRefGoogle Scholar
  41. McMichael C, Waters E, Volmink J (2005) Evidence-based public health: what does it offer developing countries? J Public Health (Oxf) 27(2):215–221. doi: 10.1093/pubmed/fdi024 CrossRefGoogle Scholar
  42. McVey GL, Walker KS, Beyers J, Harrison HL, Simkins SW, Russell-Mayhew S (2013) Integrating weight bias awareness and mental health promotion into obesity prevention delivery: a public health pilot study. Prev Chronic Dis 10:E46. doi: 10.5888/pcd10.120185 PubMedCentralPubMedCrossRefGoogle Scholar
  43. Merriam-Webster (2013a) Economic definition. In. ( Accessed 31 May 2013
  44. Merriam-Webster (2013b) Environmental definition. In. ( Accessed 31 May 2013
  45. Merriam-Webster (2013c) Psychosocial definition. In. Accessed 31 May 2013
  46. Merton RK (1936) The unanticipated consequences of purposive social action. Am Sociol Rev 1(6):894–904. doi: 10.2307/2084615 CrossRefGoogle Scholar
  47. Mill J (1859) On liberty. In: Wishy B (ed) Prefaces to liberty: selected writings. University Press America, LanhamGoogle Scholar
  48. Moreira J et al (2009) Weighing harm in therapeutic decisions of smear-negative pulmonary tuberculosis. Med Decis Making 29(3):380–390. doi: 10.1177/0272989X08327330 PubMedCrossRefGoogle Scholar
  49. NICE (2013) Public Health Guidance: Scope. National Institute for Health and Clinical ExcellenceGoogle Scholar
  50. O’dea JA (2005) Prevention of child obesity: ‘First, do no harm’. Health Educ Res 20(2):259–265. doi: 10.1093/Her/Cyg116 PubMedCrossRefGoogle Scholar
  51. Oxford (2013) Definition of harm in english. Accessed 9 Sept 2013
  52. Parkes MW, Bienen L, Breilh J, Hsu L, McDonald M, Patz JA, Rosenthal JP, Sahani M, Sleigh A, Waltner-Toews D, Yassi A (2005) All hands on deck: transdisciplinary approaches to emerging infectious disease. EcoHealth 2:258–272CrossRefGoogle Scholar
  53. Petrosino A, Turpin-Petrosino C, Finckenauer JO (2000) Well-meaning programs can have harmful effects! Lessons from experiments of programs such as scared straight. Crime Delinq 46(3):354–379CrossRefGoogle Scholar
  54. Qadir M et al (2010) The challenges of wastewater irrigation in developing countries. Agric Water Manag 97(4):561–568. doi: 10.1016/j.agwat.2008.11.004 CrossRefGoogle Scholar
  55. Rashid JR et al (2009) Eliminating health disparities through transdisciplinary research, cross-agency collaboration, and public participation. Am J Public Health 99(11):1955–1961. doi: 10.2105/AJPH.2009.167932 PubMedCrossRefGoogle Scholar
  56. RCHI Roshan Cultural Heritage Institute (2013) Culture definition. In. ( Accessed 31 May 2013
  57. Rosenthal R (1979) The "file drawer problem" and tolerance for null results. Psychol Bull 86(3):638–641CrossRefGoogle Scholar
  58. Stokols D (1996) Translating social ecological theory into guidelines for community health promotion. Am J Health Promot: AJHP 10(4):282–298PubMedCrossRefGoogle Scholar
  59. Story M et al (2003) An after-school obesity prevention program for African–American girls: the Minnesota GEMS pilot study. Ethn Dis 13(1 Suppl 1):S54–S64PubMedGoogle Scholar
  60. Striegel-Moore RH (2001) The impact of pediatric obesity treatment on eating behavior and psychologic adjustment. J Pediatr 139(1):13–14PubMedCrossRefGoogle Scholar
  61. Taal M, Edelaar M (1997) Positive and negative effects of a child sexual abuse prevention program. Child Abuse Negl 21(4):399–410PubMedCrossRefGoogle Scholar
  62. Thomson H, Jepson R, Hurley F, Douglas M (2008) Assessing the unintended health impacts of road transport policies and interventions: translating research evidence for use in policy and practice. Bmc Public Health 8:339. doi: 10.1186/1471-2458-8-339 PubMedCentralPubMedCrossRefGoogle Scholar
  63. Tickner JA (2004) Commentary: barriers and opportunities to changing the research agenda to support precaution and primary prevention. Int J Occup Med Environ Health 17(1):163–173PubMedGoogle Scholar
  64. Upshur REG (2002) Principles for the justification of public health intervention. Can J Public Health 93(2):101–103PubMedGoogle Scholar
  65. Vartanian LR, Smyth JM (2013) Primum non nocere: obesity stigma and public health. J Bioethical Inq 10(1):49–57. doi: 10.1007/s11673-012-9412-9 CrossRefGoogle Scholar
  66. Werle CaCC (2012) The boomerang effect of mandatory sanitary messages to prevent obesity. Mark Lett 23:883–891CrossRefGoogle Scholar
  67. Whittemore R, Knafl K (2005) The integrative review: updated methodology. J Adv Nurs 52(5):546–553PubMedCrossRefGoogle Scholar
  68. WHO (2013) In. Accessed 31 May 2013
  69. WHO (2010) A conceptual framework for action on the social determinants of health. In: WHO (ed) Social determinants of health discussion paper 2. World Health Organization, GenevaGoogle Scholar
  70. Williams GC, Patrick H, Niemiec CP, Ryan RM, Deci EL, Lavigne HM (2011) The smoker’s health project: a self-determination theory intervention to facilitate maintenance of tobacco abstinence. Contemp Clin Trials 32(4):535–543. doi: 10.1016/j.cct.2011.03.002 PubMedCentralPubMedCrossRefGoogle Scholar
  71. Wolitski RJ, Parsons JT, Gomez CA, Teams SaSS (2004) Prevention with HIV-seropositive men who have sex with men—lessons from the Seropositive Urban Men’s Study (SUMS) and the Seropositive Urban Men’s Intervention Trial (SUMIT). Jaids-J Acq Imm Def 37:S101–S109Google Scholar
  72. Zimet GD, Mays RM, Sturm LA, Ravert AA, Perkins SM, Juliar BE (2005) Parental attitudes about sexually transmitted infection vaccination for their adolescent children. Arch Pediat Adol Med 159(2):132–137Google Scholar

Copyright information

© Swiss School of Public Health 2013

Authors and Affiliations

  • L. K. Allen-Scott
    • 1
    Email author
  • J. M. Hatfield
    • 1
  • L. McIntyre
    • 1
  1. 1.Department of Community Health Sciences, Faculty of MedicineUniversity of CalgaryCalgaryCanada

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