What Works in Tackling Health Inequalities? Pathways, policies and practice through the lifecourse . Bristol : The Policy Press . 2006 xii + 612pp . £24.99 ISBN 10-1 86134 674 3 (pbk) £65 IBSN 1 86134 675 1 (hbk)and
This book confirms the statement on its back cover that it is both authoritative and comprehensive and, to add to Professor Dorling's endorsement, it is painstaking in its review of existing evidence, clear-sighted in its generalisations and likely to be a useful work of reference for researchers.
The book comprises three parts. It opens with ‘The research and policy context of health inequalities’ in which the scene is set with an overview, emphasising the necessity and timeliness of a lifecourse approach. The second part contains the bulk of the book's material and is made up of five sets of twin chapters which deal first with research evidence and second with policy and practice across the five ages of humankind: early life; childhood and youth; adulthood; older age. The third and final part of the book reflects on this evidence, considering how public health research could be constructively reconfigured.
Section 2, with its detailed treatment of published material, constitutes a useful resource for the research community. The comprehensive review of inequalities literature is focussed on England, but retains an international view with references to comparative material from, for instance, UNICEF and WHO.
Section 3 evaluates the preceding work, noting that 125 systematic reviews and 29 reviews of reviews have been considered and that according to this formal evidence base very few public health interventions actually work in tackling health inequalities; a somewhat deflating conclusion after more than 500 pages. Despite the well-rehearsed strengths of systematic reviews, they have very little to say about health inequalities, and tend to miss the particular responses of different sub-sections of the population to public health interventions. Review-level findings can be supplemented by grey literature and other published sources, which often contradict the formal evidence in showing that the experience and local knowledge of small-scale interventions indicates a reduction in health inequalities.
The inability of the formal evidence base to discriminate sub-populations’ responses to methodologically rigorous interventions is partially explained by the fact that these interventions tend to be aimed at easy-to-reach population segments, rather than the multiply-deprived sections that both service providers and researchers find hard to reach. The apparent contradiction between the formal evidence base and the local knowledge is cause for concern since it suggests that the methods employed in evidence-based public health simply cannot detect the potential effectiveness of public health interventions. The narrow hierarchical approach to evidence in public health, as epitomised by the systematic review, and the consequent knowledge deficits, including a failure to control adequately for context and an overwhelming focus on publication in English, mitigate against international comparison.
Asthana and Halliday propose an alternative framework based on the comparison of policies and interventions adopted by different public health regimes at various levels. This approach is demonstrated through an examination of the significant dimensions of the public health regime in England and compared to the key domains and indicators relating to the reduction of nutritional inequalities in Finland.
The main message of the book is directed towards researchers and policy makers in public health and constitutes a challenge to reassess the narrowness of the evidence currently admitted. In formulating their challenge Asthana and Halliday have reviewed the relevant data so carefully, that whether or not you agree with their conclusions, the preamble is a useful document.