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What Works in Tackling Health Inequalities? Pathways, Policies and Practice
Sheena Asthana and Joyce Halliday
ISBN: 1-861346-74-3 2006 612 pages The Policy Press
Lareen Newman
At 612 pages, this book reflects the size of the current challenge to researchers, practitioners and policymakers of how to achieve real change in reducing what are considered unfair differences in health outcomes in developed countries. This makes the promise in the book's title, that it will give us answers to ‘what works?', very inviting. I found the content both useful and timely in providing an overview of developments in health inequalities research and theory, and in illustrating and discussing how these might affect initiatives and policies at different levels.
The book focuses on developments in the UK since the 1980 Black Report and subsequent Acheson Inquiry into Health Inequalities (1998). Two opening chapters set the background context: one details developments in research describing and explaining the nature and scale of health inequalities, and the other describes the UK's national policy context. In the main section which follows, the authors structure their discussion using the currently popular lifecourse approach. This section has ten chapters, with two companion chapters (one on ‘research evidence' and one on ‘policy and practice') for each of five lifecourse stages: early life; childhood and youth (health inequalities), childhood and youth (inequalities in health behaviour), adulthood, and older age. For each stage there is analysis and discussion of the state of research evidence and examples of local initiatives which have ‘worked' to varying degrees. Each chapter has summary tables of the evidence for ‘what works' and areas where there is a lack of review-level evidence. The authors also illustrate how evidence and local initiatives relate at least to the rhetoric (if not also with the actual objectives) of national and local policy agendas. I found the discussions about the complexities of linking research evidence with initiatives and policies particularly useful.
A further attraction of the book is the way in which the authors bring together a wide range of information around each topic and provide detailed analysis of particular issues. For example, the Early Life chapters consider theoretical explanations of poorer health outcomes for children in lower socio-economic groups, including biological, contextual and compositional factors. They then discuss, for example, the medical evidence that the higher prevalence of cigarette smoking and poorer nutrition among pregnant mothers from low socio-economic backgrounds is causally linked to babies' lower birth-weight and consequently to worse child health outcomes for lower-status groups. They explain how such evidence tends to lead to behaviourally-based policies to reduce smoking in pregnancy (often for all women), rather than to targeted initiatives addressing the complex social and economic circumstances associated with smoking behaviour for low-status women. The conclusion that such behaviour-based initiatives have ‘only a modest effect on cessation rates and a tendency not to reach those at highest risk, potentially exacerbating the inequalities dimension' (2006: 155) leads to later discussion of the limitations of particular evidence bases. The authors also point out that even when the formal evidence suggests that an initiative should ‘work', it can still be rendered ineffective by a lack of consideration for the broader social context (of smoking cessation and relapse in this case), or by the political imperative for initiatives to show quick results.
The book clearly demonstrates the important role played by quantitative (and mainly medical / epidemiological) research in highlighting the distribution, impacts and pathways of health inequalities. The authors choose the ‘systematic review' as the main criterion to assess the formal evidence on ‘what works' because they see this as the most accepted approach to synthesising evidence in Public Health, although they admit it is limited in scope and type. However, they conclude that on this evidence base ‘remarkably little actually works', even though local interventions based on ‘sparse, equivocal evidence' can make a difference (2006: 561). This raises a point very salient for current researchers and policymakers: when policy and practice is required to be evidence based, and the main evidence base stems predominantly from quantitative research in medicine and epidemiology, it encourages a focus on the ‘downstream' determinants (individual behaviour) rather than the broader ‘upstream' structural determinants (such as differences in education, housing and employment). The latter factors which place more responsibility for action onto government are being increasingly considered (particularly in Europe) as underpinning more effective ways to reduce health inequalities. Readers of this journal will be encouraged to see the authors conclude by calling for public health to broaden its evidence base through undertaking more qualitative research within social science, and particularly health sociology. The authors believe that alternative or complementary evidence to systematic reviews will allow better consideration of theories of change and local context that will help policies and initiatives to be more effective in reducing health inequalities.
The book concludes by offering a framework encouraging researchers, practitioners and policymakers to give greater consideration to the upstream determinants by analysing the public health regime in their country / area, since this is where they see many of the barriers and complexities lying in achieving real change. They show how the framework would apply, using the UK as an example. The whole book is in essence a case study of the UK (and predominantly England's) experience of research, policy and practice. However, since the UK is ahead of many other countries in comprehensively documenting and attempting to address health inequalities in policy and practice, readers outside the UK should benefit from reflecting on the UK's ‘lessons learned'. Although somewhat daunting in size, the book will be useful for anyone working in health or in social research, for students to gain a broad, theoretical, current and practical understanding of the state of the health inequalities field, and for health practitioners and policymakers who want to consider what really works for their area.
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