Interventions to reduce socioeconomic health

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Interventions to reduce socioeconomic health differences A review of the international literature ANNEMEKE GEPKENS, LOUISE J. GUNNING-SCHEPERS •

Key words: socioeconomic health differences, interventions, evaluation


en years after the Black report was published, health inequalities have been found in all countries where research on socioeconomic health differences (SEHD) is performed.1 In the Netherlands people with a lower socioeconomic status also appear to be less healdiy dian people with a higher socioeconomic status.2"^ The WHO Health for All strategyfocusedon unfair or unacceptable inequalities in health, sometimes called inequities.8 The first target of the WHO is to reduce die actual differences in health status between countries and between groups within countries by at least 25%, by die year 2000, by improving die level of healdi of disadvantaged nations and groups.9 In die Netherlands an SEHD committee executed a research programme aimed at die description and explanation of SEHD. The final project of die programme was a review to collect examples of interventions to reduce SEHD and to analyse studies to identify possible conditions for success.10 A literature search was performed to identify studies in developed countries from published and unpublished sources. This literature search provides examples for potential policy options and serves as a starting point for die second phase of die SEHD pro* A. Gepkens1. U . Gunning-Scheoeri1

1 AcedemkMedkalCemer. UnK/erjity erf Arnsterdam. Institute of Sodal Medicine. Amsterdam. The Netherlands Correspondence Annemleke Gepkens, University of Amsterdam, Institute of Social Medidne. Meibercjdreef 15. 1105 AZ Amsterdam. The Netherlands, teL +31 20 5664892. fax +31 20 £972316

gramme in which intervention studies will play a cardinal role. In diisreviewwe will present die interventions we identified and discuss some of die methodological impediments to a quantitative estimate of our potential to reduce SEHD. METHODS

The literature search yielded 298 SEHD publications and 31 'grey literature' reports. The 298 SEHD publications were found using thefollowingmediods. • Performing a literature search in die 'SEHD documentation centre' at Erasmus University in Rotterdam as well as a literature search dirough Medline (all publications until June 1993) and tracking down references. • Consulting die recent issues of die most relevant journals. • Consulting experts in die field of SEHD. Sixty of die 298 publications dius identified, proved to be background articles, offering insight into SEHD and causes, explanations and policy dimensions on SEHD. The remaining publications describe eidier a proposal for an intervention or an intervention policy (140 publications) or an actual intervention (98 publications). Publications diat described an intervention aimed at improving die healdi of a specific study population and which reported die effects by SES (socioeconomic status), were included in diis last category. Occasionally, 2 publications on 1 intervention study are included if diey describe distinctly different aspects of die intervention.

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The objective of this study was to review information on evaluated interventions to reduce sodoeconomic hearth differences (SEHD) and analyse studies to identify possible conditions for success. The analysed interventions were from published and unpublished sources. They were evaluated in terms of sodoeconomic health outcomes. Ninety-eight publications on actual interventions to reduce SEHD and 31 so-called 'grey literature' interventions were identified. Many of the interventions described are reported to be effective. Many of the local experimental interventions, however, were not formally evaluated. Structural measures appear to be effective most often, but cannot be taken to affect all determinants. Interventions often Involve hearth education. This, however, only appears to be successful If providing information is combined with personal support or structural measures. Many very creative interventions to reduce SEHD have been reported. Several appear to be effective, but all address only a small aspect of hearth Inequalities. Regrettably the lack of standardized measures and a common methodology hamper our ability to Integrate and compare the results. However, all the studies show that there is room for improvement in our existing heafth policies to reach everyone in our population to the same degree of effectiveness.

Interventions on health inequalities

Over half of the 98 publications concern the USA, approximately 20% the UK and approximately 20% the Netherlands. The remaining publications are from Belgium, Israel, Canada, Norway and Sweden. Besides reviewing regular publications on SEHD interventions, an attempt has been made to give an impression of die so-called 'grey literature', for example internal reports from local healdi departments describing smallscale interventions (31 publications). By contacting professionals in the field of community health 23 Dutch studies were identified and 8 British studies were included as examples. The British studies were chosen because Great Britain has a long-standing SEHD tradition and thus could well serve as a comparison with the Netherlands.

For die 31 local interventions a less structured approach has been used. The brief and incomplete reporting made only a qualitative judgement possible.

Table 1 Classification of specific entry points for literature search and the results Entry points Material deprivation


Physical housing conditions


Environmental circumstances


Traffic circumstances


Physical working conditions/»chool environment


Intra-utenne exposure


Social environment Social security Labour market position


Social insurance!

Psychosocial influencet/social networks, including family composition Social support


(Long-lasting) life events


Living conditions Social working conditions


Social housing conditions


Health care (preventive and curative) Accessibility Financial







RESULTS Results of the mtervenaon


Physical environment


The starting point for the literature search was a classification of determinants at which interventions to reduce SEHD might be aimed. It should be noted drat a single intervention can be aimed at more than 1 determinant at a time. A comparison between this classification and the intervention publications found (table 1) showed that not all the determinants have been the object of intervention. This might be due to a real limitation of the interventions carried out or a failure of the search strategy used to track down publications on odier determinants. In particular the physical and social environmental factors rarely appear to have been die object of interventions aimed at reducing SEHD. The accessibility of health care and the behavioural risk factors are frequently the object of interventions. The intervention determinants vary among countries. For instance, the majority of the financing

Behavioural risk factors Smoking




Sexual habits


Alcohol consumption


Drug abuse


Physical activity


Hygiene (including dental care) Healdi behaviour

+ +++

Behaviour related to safety in housing conditions


Leisure activities Mental development a. -: no fruervenuoro found aimed at the determinant concerned; +: £5 Interventions; ++-. 6-10 lruerventioni; -H-H £11 intervenuom


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The intervention publications have been analysed with regard to the following aspects: target population, the intended effects of the intervention, the determinants at which die intervention was aimed, the type of intervention, the method of evaluation and the actual effects. When classifying the intervention publications as to their effectiveness, the authors' (health) outcome measures, operationalizarion of SES and reported effectiveness of the intervention have been used. In most publications effectiveness was evaluated in terms of die targeted outcome of the intervention (performance indicator) over social groups and not in terms of a reduction of health inequalities. In the present review an intervention is called effective when die outcome measure shows a positive result and when it is as least as effective for the lowest socioeconomic status (SES) groups as for the highest. An intervention is called ineffective when it had no or a negative effect on the target groups or when the intervention was more effective for the higher SES groups dian for the lower. When die evaluation of an intervention is lacking or is insufficient, the effect of die intervention has been called dubious.

studies are to be found in the USA. The types of intervention programmes within the European countries are more comparable. The examination of the intervention publications reveals that l) some health problems and their interventions involve specific age groups, especially children, ii) some interventions are aimed at specific diseases and iii) some interventions are aimed at more general health determinants. This classification may be useful to (health) practitioners who are involved in die field of SEHD, who are searching for examples of interventions for dieir target


group. A review of the intervention publications, classified by the 3 above-mentioned categories is presented in table 2 by number and references. Three important types of interventions can be distinguished, which differ in frequency and reported effectiveness (table 3). Firstly, diere are structural measures on determinants of health, which seem to be effective, but many of which aim at the financial accessibility of health Table 2 Categories of intervention publications with number and references

Interventions aimed at reducing specific diseases Cardiovascular diseases (CVD)/cancer CVD in children CVD/cancer in adults Smoking in adults Screening for breast and cervical cancer Interventions aimed at health determinants Unemployment Accessibility of health care Accessibility of health care (general) Accessibility of health care (financial) Accessibility of health care (cultural)

Number References 5


3 2

16-18 19-20

5 4

21-25 26-29

4 5 3 1

30-33 34-38 39-41 42

5 3

43-47 48-50

2 12 4


51-52 53-64 65-68 69-75





11 5

86-96 97-101

Results of the interventions in 'grey literature' Many local, small-scale interventions aimed at the reduction of SEHD have been performed in die Netherlands and in England. 109 " 139 These interventions present a number of problems. They are very hard to find, because often they have not been officially published. For diat reason it always remains uncertain whether the search has been exhaustive. In addition, die interventions have often hardly been formally evaluated and in most cases health effects were not used as an outcome measure. The Dutch grey literature yielded 23 intervention studies 109 " 131 and die British literature 8 . 1 3 M 3 9 It should be noted diat we are not attempting to present an exhaustive overview of die grey literature, but merely give some creative and inspiring examples. Within die grey literature we find die same 3 types of interventions, as discussed in the above paragraph on intervention publications. An example of a structural measure is a British intervention, which consists of providing free school meals or school milk to children from primary or secondary schools, which seems especially important for children of low-income parents. Another example of a structural measure is a British intervention that sets out to install a heating system in houses were such is lacking, in order to fight cold and dampness. An intervention initiated widiin the existing health system is a project started by die local health department of Rotterdam, the Netherlands,



Table 3 Types of intervention and their effectiveness Types of intervention Structural measures Existing health care Health education Providing information Providing information + personal support Health promotion + structural measures Remainder Total






11 5

4 3

1 3

16 11

6 32 2 2

6 12 1 1

4 5 -

16 49 3 3





consisting of teaching Turkish and Moroccan women to give health information to their compatriots. Their work as freelance health promoters seems to be very successful. A similar project was started for the elderly. One healdi promotion and education intervention is called 'die health information point'. It has been set up

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Categories of intervention publications Interventions aimed at specific age groups Prenatal care Children aged 0-4 years Infant care Preventive care for young children Children aged 1-8 years Development in children Nutrition Schoolchildren Tooth decay prevention Safety in the children's environment General health promotion Alcohol, smoking, drugs Adults (Adolescent) mothers Adult women

services. Secondly, there are interventions within existing curative or preventive programmes in die healdi care system, such as cancer screening programmes. Thirdly, diere are healdi education approaches in the community including the following. • Programmes providing only information, which seem to be effective especially in the higher SES groups. • Programmes providing information in combination with personal support (for example, by a health visitor), which seem to be the most effective type of intervention for all SES groups. • Health promotion in combination with structural measures. Three cases illustrate the 3 types of intervention performed in 3 different countries (figure). For more examples we refer to the report we wrote about this study, in which an extensive analysis of all 98 intervention publications is presented. 10

Interventions on health inequalities

Casel" Key words Population

Intervention Purpose Method of evaluation Results

Ca*e2 52 Keywords Population Intervention


Key words Population Intervention

Purpose Mediod of evaluation Results

Water fluoridation Reduce caries levels, especially reducing differences in caries experience between social groups Canes was clinically recorded at die cavitation stage/ by means of a questionnaire, the percentages of subjects who had ever had toothache, teeth extracted, or a general anaesthesia for dental extractions, were located Fluoridation was effective in all social class groupings/ because caries levels were higher in die lowest social classes, fluoridation brought about greater benefit for those groups than for the higher social classes these effects were shown in both the clinical and questionnaire data

Intervention/ disease-specific/ providing information in combination with personal support/ USA/ 1990/ effective in short term 11 low-SES hypertensive black children, mean age is 11,5 years; significant hypertension (blood pressure measures above the 95th percentile) 12-week aerobic exercise programme; children exercised jogging/walking or with a stationary bike 3 days a week, gradually increasing to 30 minutes a day Reduce blood pressure Measurement of blood pressure, heart rate during rest and exercise, and circulatory fitness assessments as a result of die exercise; follow-up blood pressure and aerobic fitness assessments were conducted 2 and 4 months after completion of the exercise programme Vigorous exercise seems to decrease the blood pressure of low-SES hypertensive black children; at 4 months follow-up, however, blood pressure and heart beat are returned to baseline levels

Intervention/ more general health determinant/ within existing health care/ Trie Netherlands/ 1985/ effective Turkish and Moroccan children from 50 and 17 families respectively, who never visited a health centre before or whose parents have communication difficulties at the health centre in their own district Starting a health centre for Turkish and Moroccan children in a Dutch city; a Turkish or Moroccan speaking health worker is present at every consultation; the healrh centre is also open in rhe evening to give the father rhe opportunity to accompany his wife and children to rhe health centre Improve health care, especially for migrants, by offering them a special healdi centre and get rhem ready to return to the regular health centre in their district Over a period of almost two years measurement of the number of children visiting a special healrh centre and the reasons for absenteeism and measurement of the number of interventions, especially vaccinations 60% of the migrants visiting the special health centre had never visited a healdi centre before; the rate of vaccination Increased indicating an increase in rhe use of general care offered by this health centre; rhe foreign health centre is going to be a standard provision of the health service

Figure Three illustrations of interventions toreducesocial inequalities in health within the Healthy Cities Project in the Netherlands. This intervention is based on the observation of a welfare district civil servant that women, as pivots of the household, eventually get to know all the family's problems which makes them the most appropriate target for information on health. Another health promotion and education intervention, in which providing information is combined with personal support, is a development stimulating project targeted at mothers and small children of 4-6 years old from ethnic groups. It supports mothers m raising their children by offering a variety of training programmes. The majority of the grey literature interventions found are Healthy Cities Projects or projects aiming at improving the health of specific deprived groups, such as youths or migrants. The type of intervention found most often is a 'health education' intervention performed at the local level.

DISCUSSION The interventions described here show a lot of creativity and initiative in the field of community health. The interventions provide us with information on how new intervention programmes can be initiated. The evaluation of the interventions, however, is too limited to allow a recommendation as to which is the most cost-effective policy for reducing SEHD. The reason for this is not the quality of the interventions described, but the fragmentary character of the experiments (not all potential possibilities are looked at) and the diversity in the presented effects and costs of the interventions (so the results of the interventions cannot be compared). In this discussion we want to elaborate on these points, because it will be very important for the scientific community to reach agreement on these aspects, so that knowledge in this field can really cumulate. A surprisingly large number of intervention studies reported on in official publications was found. This is due partly to the large number of American studies included.

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Purpose Method of evaluation

Intervention/ age-specific/ structural measure/ England/ 1989/ effective 457 5-year-old children who had lived continuously in fluoridated (at 1.0 mg.F/litre) Newcastle, where fluoridation Marred in 1969, and 370 5-year-old children in non-fluondated (less than 0.1 mg.F/litre) South Northumberland; social groups were defined by parental occupation


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A mediodological problem is that different SES operaThe American studies are of little direct relevance to rionalizations are used in the different publications. This European policy, because the interventions described are makes it difficult to compare the outcomes of the different often already a regular part of the general system of health interventions. The problem of the different SES operaservices in European countries. The American studies tionalizations used is combined with the problem that may however support the importance of an accessible different populations are addressed by the interventions. health service and a good social security system in preSome aim at all SES groups, some only at low SES or venting the occurrence of SEHD. deprived groups, while others describe interventions ofThe determinants identified are not all (equally) represfered to a population in general and which are only ented in the intervention studies discussed. A notably analysed by SES afterwards. This means that an evaluhigh proportion of interventions are aimed at those deation sometimes can tell us whedier an intervention is terminants that are within the domain of regular preventeffective at improving the health of the lowest SES group ive care, including behavioural factors. Fewer intervenbut not necessarily whether it will reduce inequalities. tions have been found targeted at determinants that do The more informal literature from die grey sector posed not come under the direct responsibility of the health the largest problem to diis literature review. Firsdy, beservice or public health organizations, such as the social cause diis literature is often hard to find and, secondly, or physical environment. This may be partly because and even more importandy, because the descriptions of many of these interventions lack an evaluation in terms these interventions are often limited and lack an effect of health effects and have therefore not been included in evaluation. Therefore, the reports from the so-called grey this search, which does not imply that these interventions literature can hardly serve as a basis for making recomdo not have any health effects. mendations on potentially useful or effective interThere is a connection between die limited number of ventions. However, they often show a lot of creativity. It determinants involved in the interventions and die freis unfortunate that these interventions are not followed quency of die types of interventions used. Half the interup by a proper evaluation study, because, as it is, the ventions found consist of providing information in comusefulness of the experiments to odiers remains limited bination with personal support [a healdi education and and the knowledge gained is rendered untransferable. It promotion intervention (HEP)]. Structural measures, inwill be of great importance to develop a common evaluterventions within the existing healdi service and HEP ation methodology for community interventions during interventions odier than the one mentioned earlier, are the period of die second Program Committee on SEHD. found less often. Evaluating the HEP interventions shows Despite the promising yield of experiments in this review, diat providing information alone is especially effective in it is clear that we do not yet have sufficient scientific data die higher SES groups. Combining providing information on which to base a rational policy to reduce socioecowith personal support appears to be effective for die lower nomic healdi differences. For that we will need data SES groups. Structural measures might be much more direcdy linking the interventions to the differentials in effective though in quantitative terms and their success healdi we are trying to reduce. To achieve that, we will depends much less on those who initiated the interneed to agree upon a standardization of evaluation revention. The existing health care system offers an approsearch both in terms of measures and of study design, so priate framework for interventions. Hence, in designing diat results can be integrated and compared. We should new interventions, the advantages of these 3 types of try to combine this scientific interest with the current intervention could be combined more often. widespread interest in (local) governments in trying to set It is very difficult to determine whedier an intervention up community programmes to reduce inequalities. If only is effective in terms of reducing SEHD, because health a few of these were linked with carefully designed evalueffects are rarely measured. Most interventions are aimed at increasing the level of knowledge or at behaviour . ation studies, we would reap the benefits in a few years. Secondly, meta-analysis of randomized controlled trials changes. Sometimes, interventions are actually aimed at offers an important tool for translating scientific results health effects, but to measure these effects a long followinto guidelines for good medical practice for clinicians. up is needed. This often goes beyond the rime- or costSimilarly we need to find a way to translate these experilimit of the study. The follow-up period therefore is often ences into acceptable and well-founded guidelines for too short to guarantee a lasting effect of the intervention, good public health practice. However, because of the crucial for some of die health behavioural aspects. The diversity of potential interventions to reduce SEHD, rime lags between some of die study outcomes and the meta-analysis in the traditional sense is not easily perultimate health benefit is another obstacle to clear effect formed. Computer simulation models, may prove to be a estimates. Interventions should be aimed at health effects more effective method of integrating results for decisionand die evaluation of the studies should be aimed at making purposes.1'40 measuring these healdi effects. Only then will it become possible to translate die effects of an intervention in terms of possible decreased SEHD. Finally the necessary input CONCLUSIONS The 3 different methods of intervention each have their (financial or otherwise) should be linked to die reported own advantages and disadvantages. Structural measures outcome and a standard evaluation method should be appear to be effective most often, but cannot be assumed used.

Interventions on heakh inequalities

to be of use for all determinants. Interventions often involve health promotion and education. This, however, appears to be successful only if providing information is combined with personal support or structural measures. If a long-term commitment is necessary it may be wise to embed the intervention in existing (health) services. Quite a large number of interventions have been tried. They show the remarkable creativity of public health practitioners when confronted with liard to reach groups'. Some interventions are reported to be effective but not all of them, despite their good intentions. As such the reported successes and failures are valuable material for any group envisioning an action programme to reduce social inequalities in health. All of the studies show that there is room for improvement in our existing health policies to reach everyone in our population to the same degree of effectiveness.

Background lltertture 1 Smith GD, Bartley M, Blane D. The Black report on sodoeconomk Inequalities In hearth 10 yean on. BMJ 1990:301:373-7. 2 WRR. De ongelijke verdellng van gezondheid. Verslag van een conference gehouden op 16-17 maart 1987 (The unequal distribution of hearth: report from a conference, 16-17 March 1987). Serte "Voorstudles en achtergronden', V58. 's-Gravenhage: WRR, Staatsuitgeverij, 1987. 3 Walle-Severoter J de, Kok GJ. Gezondheidsbevorderlng en armoede (Hearth promotion and poverty). Bleiswijk: NKB-Urtgeveri), 1991. 4 Bos van den GAM, Lenlor ME. Sodale ongelijkheid in chronlsche aandoeningen, beperklngen en zorggebmlk (Social inequalities in chronic diseases, limitations and the use of hearth care). Amsterdam: Instituut voor Sodale Geneeskunde, Unrversrteit van Amsterdam, 1991. 5 CBS, Nederiands Instituut voor Praeventieve Gezondheldszorg TNO. Sodaal-economische status, gezondheid en medbche comumptie (Sodoeconomk status, hearth and medical consumption). 's-Gravenhage: SDU-urtgeverij, 1991. 6 Garretsen HR, Raat H. Gezondheid in de vier grote rteden (Hearth In four large cities). Serie Voorstudies en achtergronden', V65, WRR. 's-Gravenhage: SDU-uitgeverij, 1989. 7 Stronks K. Terugdringen van sodaal-economische gezondheidsverschlllen: wenselljk en mogelijk? (Reducing SEHD: desirable and possible?) Tijdschr Soc Gezondheldsz 1992.-70-J45-50. 8 Tsouros AD. Equity and the Healthy Cities Project Hrth Promot 1989;4C):73-5. 9 World Hearth Organization. Targets for hearth for all: targets In support of the European regional strategy for health for all. Copenhagen: Wortd Health Organization, Regional Office for Europe, 1985. 10 Gepkens A, Gunning-Schepen U. Interventies ter vermindering van sodaal-economtsche gezondheldsverschillen: een evaluatle van reeds uitgevoerde Nederlandse en buitenlandie interventies ter vermindering van

Intervention publications 11 Davis B, Reis J. Implementation and preliminary evaluation of a community-based prenatal hearth education program. Family Commun Hrth 1988;11(1):8-16. 12 Haas JS, Udvarhelyi S, Morris CN, Epstein AM. The effect of providing hearth coverage to poor uninsured pregnant women in Massachusetts. JAMA 1993;269(1):87-91. 13 Kistin N, Benton D, Rao S, Sullivan M. Breast-feeding rates among black urban low-income women: effect of prenatal education. Pediatrics 199O;86(5):471-6. 14 Scholl TO, Miller LX, Salmon RW, Cofsky MC, Shearer J. Prenatal care adequacy and the outcome of adolescent pregnancy: effects on weight gain, preterm delivery, and birth weight Obstet Gynecol 1987;69(3):312-6. 15 Wood J. A review of antenatal care Initiatives In primary care settings. Br J Gen Pract 1991;41(342)-J6-30. 16 Madeley RJ, Hull D, Holland T. Prevention of postneonatal mortality. Arch Dls Child 1986;61(5):459-63. 17 Madeley RJ. "Positive discrimination'In child hearth: an interim report from Nottingham. Public Hrth 1982;96(6):3S8-64. 18 Rocheron Y, Dickinson R. The Asian Mother and Baby Campaign: a way forward in health promotion for Asian women? Hrth Educat J 1990:49:128-33. 19 Colombo TJ, Freebom DK, Mullooty JP, Bumham VR. The effect of outreach workers' educational efforts on dlsadvantaged preschool children's use of preventive services. Am J Publk Hrth 1979;69(S):465-8. 20 Johnson RH. An antipoverty delivery system model: intervention strategies for families with children below the age of three years. Birth Defects 1974; 10(2): 119-29. 21 George NM, Braun BA, Walker JM. A prevention and early Intervention mental hearth program for dlsadvantaged pre-school children. Am J Occup Ther 1982:36(2)^9-106. 22 Kames MB, Teska JA. Hodgins AS, Badger ED. Educational Intervention at home by mothers of disadvantaged Infants. Child Devel 1970:41:925-35. 23 Mayer JB, Meshel R. An early intervention program for high-risk children in a health care setting. Soc Work Hrth Care 1981:7(1)35-43. 24 Parti H, Zllber N, Kark SL A community-orientated earty intervention programme Integrated In a primary preventive child hearth service: evaluation of activities and effectiveness. Commun Med 1982;4

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