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Do area-based interventions to reducehealth inequalities work? A systematicreview of evidenceLisel A. O’Dwyer a , Fran Baum a , Anne Kavanagh b & ColinMacdougall aa Department of Public Health , Flinders University , Adelaide,South Australiab Key Centre for Women's Health in Society , School of PopulationHealth, University of Melbourne , Victoria, AustraliaPublished online: 13 Dec 2007.
To cite this article: Lisel A. O’Dwyer , Fran Baum , Anne Kavanagh & Colin Macdougall (2007) Doarea-based interventions to reduce health inequalities work? A systematic review of evidence,Critical Public Health, 17:4, 317-335, DOI: 10.1080/09581590701729921
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Critical Public Health, December 2007; 17(4): 317–335
Do area-based interventions to reduce healthinequalities work? A systematic review of evidence
LISEL A. O’DWYER1, FRAN BAUM1, ANNE KAVANAGH2, &COLIN MACDOUGALL1
1Department of Public Health, Flinders University, Adelaide, South Australia and 2Key Centre
for Women’s Health in Society, School of Population Health, University of Melbourne,
Victoria, Australia
AbstractReducing health inequalities by focusing health promotion efforts on specific areas rather thanindividuals is based on the premise that changing something about a place may improve healthoutcomes for people living in that place. This paper examines the evidence base regarding theefficacy of area-based interventions by reviewing evaluations of interventions aimed at reducinginequities between groups and which are based on changing a specific place. Only 24 papers metour review criteria. The overall success of area-based interventions was difficult to gauge due to theuse of multiple strategies, inadequate evaluation reports, variation in the size or type of area,insufficient funding for implementation, policy changes over the course of the program and lack oflong-term evaluations. However, the value of changing a place, area or location in some way wasdemonstrated in several studies which were adequately funded and evaluated. Thus, there is someevidence that area-based interventions reduce inequities, but more well-designed and well-timedevaluations of outcomes are necessary to draw any firmer conclusions. Explicit attention must alsobe given to geographical concepts associated with an area-based approach, such as area, scale,location and locality, neighbourhood, community and place.
Keywords: Health inequalities, community-based intervention, area based intervention
Introduction
There has been an increasing focus on the ways in which place affects health outcomesin the public health and social sciences literature (Boyle, Curtis, Graham, & Moore,2004; Gatrell, 2002; Shaw, Dorling, & Mitchell, 2002) in recent years. Much of thisinterest stems from the paper by Macintyre, MacIver and Sooman (1993), whichidentifies four features of place that might affect health outcomes: physical features of
Correspondence: Lisel O’Dwyer, Department of Public Health, G1 The Flats, Flinders Medical Centre, SturtRd, Bedford Park 5042, South Australia, Australia. Tel: 61 8 2046150. Fax: 61 8 374 0230.E-mail: [email protected]
ISSN 0958-1596 print/ISSN 1469-3682 online/07/040317–335 � 2007 Taylor & FrancisDOI: 10.1080/09581590701729921
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the environment such as air, water quality or climate; the provision of servicesincluding health, welfare and education; socio-cultural features of areas (ethnic makeup, local customs, level of social capital); and the reputation of an area (that mayimpact on self-esteem).The Macintyre et al. (1993) paper has been followed by many studies (see, for
example, the collection in Kawachi & Berkman, 2003) that examine the differences inhealth between areas (variously defined). An important issue in this literature has beenthe extent to which variations in health status reflect the social, economic and healthsituations of people living in the areas, or the physical and environmentalcharacteristics of the areas—this debate has become known as the compositionversus contextual debate. It has been noted in this debate (Kaplan, 1999, p. 744;Pickett & Pearl, 2001) that recent studies of place and health have shown that socialand economic properties of communities can predict the health of individuals who livein those communities independently of individual or compositional characteristics.In terms of health promotion strategies the place and health literature offers someguide to potential interventions by virtue of establishing the fact that health statusdoes, in part, result from contextual factors and in some cases it helps identify whatthose factors are (e.g. presence of paths for walking). However, there seems to be littlein the literature that considers interventions that are designed to improve places insuch a way that they promote health equitably.None the less, the increasing attention paid to the role of context in health has
meant that policy attention over the past decade has expanded from persuadingindividuals to change their behaviour to adapting environments to be more healthpromoting. Much of this policy development has focused on urban environmentsbecause that is where most people live and work in Organisation for EconomicCo-Operation and Development (OECD) countries. This interest in the impact of theurban environment on health has also given rise to policy initiatives that have focusedon both improving the health chances for individuals and improving the environmentthrough social, economic and environmental changes. An important distinction hasbeen made in the literature between ‘community-level’ and ‘community-based’interventions (Patrick & Wickizer, 1995, p. 52 and Lomas, 1998). This conceptualisa-tion sees ‘community-level’ interventions as attempts to modify an entire communitythrough mobilisation of existing social resources and community-wide change, whereas‘community-based’ interventions may be programmes that focus solely on individualbehaviour such as diet, exercise, and drug usage that are based in communities. Therationale and understanding of these two types of programmes are quite different.Further, some community-level interventions have been explicitly seen as ‘area-based’,where the community is defined (loosely) on the basis of its physical size and locationrather than any social commonality. Our contention is that community-levelinterventions aimed at areas have not been evaluated rigorously.Most community-level interventions will also have community-based interventions
embedded. For example, the UK Health Action Zones (HAZs) were originally intendedto focus on areas, but many of their interventions were, in fact, aimed at individuals(Judge & Bauld, 2001). In recent years, the cutting edge of health promotioninterventions have tended to address both contextual and compositional factors (seeSubramanian, Lochner, & Kawachi, 2003) that aim to reduce health inequities: eitherbetween people within a community or between areas.Place-based initiatives re-emerged in public health in the 1980s when the Ottawa
Charter (WHO, 1986) promoted the strategy of creating supportive environments, which
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gave rise to the world-wide Healthy Cities movement comprising varied initiatives withthe shared aims of promoting health while trying to reduce health inequities in a settingsuch as a city, village, island, school or prison (Baum, 2008). Unfortunately, theseprojects were not generally established with an evaluation budget sufficient to monitortheir progress and eventual outcomes. Researchers have noted that traditional researchfunding bodies were not attracted to funding the evaluations because they generally callfor somewhat messy social science methods (DeLeeuw & Skovgaard, 2005). Thus little-documented evidence emerged from the Healthy Cities movement despite theimplementation of many practical projects. The problems of evaluating community-based interventions have been well-described. The difficulties of applying randomisedcontrol trials (RCTs) in local communities have often been acknowledged (see, forexample, Baum, 2008, pp. 218–220; Green & Tones, 1997; Judge & Bauld, 2001;Kemm, 2006; Speller, Learmouth, & Harrison, 1997). These include the impossibility ofestablishing meaningful community controls, because no two communities are identicaland there are ethical concerns in applying interventions in the test community and not thecontrol community. Kemm (2006) also points that that just as RCTs are little help inguiding the treatment of a particular individual, so the context of communities means thatit is problematic making the assumption that interventions used in one setting can beassumed to be effective in another. He warns that in ‘answering the question ‘‘does thisintervention work?’’ it is always necessary to consider not only the intervention, theoutcome and the link between the two but also the context’ (Kemm, 2006, p. 322). Theinability to make effective use of RCTs in public health means making attributionsbetween interventions and outcomes is extremely difficult. There are many other national,regional political, economic and social changes that could affect the outcome ofinterventions (Baum, 2008, pp. 218–220). We have found that methodological difficultiesin programme delivery and evaluation are compounded with the inclusion of ‘area’ as abasis for the intervention. Researchers have noted that traditional research funding bodieswere not attracted to funding such evaluations because they generally call for somewhatmessy social science methods (DeLeeuw & Skovgaard, 2005). Thus little documentedevidence emerged from the Healthy Cities movement despite the implementation of manypractical projects.There is of course a huge international literature demonstrating the extent of health
inequities between groups based on their socio-economic status (see, for example,literature reviews in Bartley, 2004; and Marmot & Wilkinson, 1999) and, more recently,growing consensus that ‘places’ may be the way in which these inequities are bothmanifested and produced (Kawachi & Berkman, 2003; Macintyre, Ellaway, & Cummins,2002; Popay et al., 2003). There is also a consensus in public health literature that theseinequities should be reduced. Yet there is no clear body of evidence about measures thatare most likely to reduce health inequities. The aim of this paper is to contribute to theevidence base regarding the efficacy of area or locational interventions. We reviewinterventions that have aimed to reduce inequities between groups and which are basedon changing a locality or specific place. Specifically we seek to:
(a) identify evaluations of ‘area-based’ interventions;(b) describe the interventions;(c) document the questions, approaches and methods used for evaluation;(d) document the quality of the evaluations (eg whether multiple perspective sought); and(e) assess the effects (planned and unplanned) of the interventions.
We then discuss the implications of the findings.
Area-based interventions 319
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Method
The literature appraisal and review utilises the Schema for Evaluating Evidence on PublicHealth Interventions developed by Rychetnik and Frommer (2002). This schema wasdeveloped because the Cochrane approach to assessing evidence is based on the medicalmodel of research and does not work well for evaluating public health interventions(Rychetnik & Frommer, 2002, p. 1). The schema was developed after extensiveconsultation with senior public health researchers and practitioners and refined with aseries of trials. As it accounts for settings and the social and political environmentsof interventions and evaluations, it is the most comprehensive template for conductingliterature reviews in public health of which we are aware. All themes listed by Rychetnik andFrommer relevant to the subject of the review andmeasuring quality of results were used asa framework for reviewing the literature evaluating area-based interventions in healthinequalities. Themes included in the Schema but not used in this review are those that applyto interventions to individuals or demographic groups and cannot be applied to areas.
Inclusion criteria
The inclusion criteria were relatively broad. No date restrictions were used but all paperswere published in English. The papers included must have reported the results ofevaluations of interventions applied to areas, not individuals or social groups, with theconcept of ‘area’ explicitly included in the title or abstract. We included both formal(published in peer-reviewed journal) and ‘grey literature’ (refers to any unpublished ornon-peer reviewed literature in the public domain).
Description of search process
The aim was to identify all references relating to the efficacy of area-based interventionsaiming to reduce health inequality. After initial piloting and discussions amongst thereview team, the search strategy and terms were refined, and a comprehensive search wasundertaken between 1 November 2003 and 14 September 2004. More than 20 electronicbibliographic databases were searched, covering biomedical, health-related, science,social science, and grey literature. The reference lists of relevant articles were checked andselected websites were also searched for eligible reports. A combination of free-text andthesaurus terms were used. The ‘area’ terms (e.g. place, geographic, area, zone, region,location, neighbourhood, etc.) were combined with the ‘intervention’ terms (e.g. social,socioeconomic, inequality, inequity, population, groups, etc.). It should be noted that theterms ‘community’ and ‘neighbourhood’ are often used synonymously with ‘area’ or‘location’ but are also used to refer to specific population groups. Hits therefore includeinterventions which are not technically area-based, but which take place in a specifiedplace, neighbourhood or community. These papers were excluded after reading theabstract and/or full paper.We attempted to identify grey literature not in the public domain by emailing
80 national and international organisations and individuals likely to be involved in oraware of such interventions to ask if they had or knew of any unpublished evaluations.They were identified from the literature, professional networks, and websites foundusing internet search engines. Some of these contacts were located in non-Englishspeaking countries.The searches yielded 85 items. Titles and/or abstracts were screened for inclusion and
52 reports were identified as potentially relevant. Full papers were requested, and 28 of
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these were not relevant. The remaining 24 papers (see Appendix A) were identified asmeeting the inclusion criteria and their quality assessed by two independent reviewersusing rating items derived from the Rychetnik and Frommer Schema. A third revieweradjudicated on any rating criteria where the first two reviewers disagreed.The quality criteria framework and definitions of the ratings used are presented in
Table I. Full details of the search terms, databases and rating items are available onrequest from the first author.
Results of review
Types of interventions
Over half of all interventions used a combination of strategies rather than one clearlyarticulated and identifiable action. This makes evaluating the outcomes and attributingcause and effect to any one of these strategies more difficult. The other interventionsincluded stand-alone strategies and changing the area; which included a naturalexperiment (Wrigley et al., 2002). The interventions are summarised in Table II.It should be noted that several of the evaluations refer to the same intervention program,albeit at different stages. Fauth et al. (2004), Feins et al. (1995), Katz et al. (2000) andKling et al. (2004) all address the Moving To Opportunity (MTO) programme, whileBenzeval (2003a) addresses Sheffield HAZ; Benzeval (2003c) addresses London HAZ;Benzeval (2003d) address North Staffordshire HAZ and Benzeval (2003b) considers allthree together.
Quality of evaluations
The review team considered two-thirds of the evaluations to be of high quality, and nearlyone-quarter to be of average or moderate quality, based on how well they met most reviewcriteria and the authors’ affiliation with formal research institutions or reputableconsulting organisations contracted by government departments. None of the averageto high-quality papers met all criteria well. The most common items to be inadequatelyaddressed in these cases were whether the intervention was adequately implemented,failure to report whether there were unplanned effects, and lack of clarity of authors’ideological position. Interestingly, this group of papers included three of the four papers inthe review which were peer-reviewed and published in the formal literature. Only twopapers were considered to have low credibility (Squires, 2002 and Bostock & Sharpe,2002) on the grounds that most of the review criteria were poorly met. Neither paperprovided a clear description of the data collection and analysis methods, nor did theydescribe the social or political context of the intervention. Further, Squires (2002) did notseek multiple perspectives on the effect of the intervention, while the number ofperspectives sought was not clear in the Bostock and Sharpe (2002) evaluation.Even though evaluations of area-based interventions are more likely to be found in the
grey literature, this does not necessarily mean they are of inferior quality (see Table III).The few (n¼5) ‘primarily successful’ interventions were felt to be of high quality with
one exception of average quality. These were all evaluations of HAZs. Three of the fourMTO evaluations were rated as high quality, with the Katz et al. MTO study rated asaverage. These were all classified as ‘partly successful’ or ‘mostly successful’.
Area-based interventions 321
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Table I. Quality criteria and rating categories.
ItemComment as
free text Rating category
Reviewer ID 1, 2, 3, 4Bibliograpic reference ˇAim of intervention ˇDid intervention achieve specified
objectives?Yes; Mostly; Partly; No; Don’t Know
Type of intervention Several Strategies; Health PromotionCampaign; Change Environment, Unclear/Don’t Know, Other
Spatial dimension Local; Part Of City; Whole Of City; HAZ; Don’tKnow; Other
Country where intervention wasimplemented
UK; USA; Other
Whether the political environmentaffected intervention
Yes; No; Partly/Somewhat; Don’t Know/NotDiscussed; Other
Whether the social environment affectedintervention
Yes; No; Partly/Somewhat; Don’t Know/NotDiscussed
Was intervention adequatelyimplemented
Yes; No; Unclear/Don’t Know
Are the intervention and resultsgeneralisable?
Yes; No; Partly; Other
Considers cost-effectiveness Yes; No; Don’t Know/Unclear; Not RelevantConsiders alternative interventions Yes; No; Not RelevantConsiders limitation of alternative
approachesYes; No; Not Relevant
Who conducted the evaluation? Academics; Private Consultants; InternalEvaluation; Don’t Know/Unclear;Combination of Above; Other
Stage of intervention at time of evaluation Immediately After Completion; Preliminary;Halfway; Don’t Know/Unclear; Several YearsOr More After Completion; Near End OfProgram; Other
Were unplanned effects identified Yes; No; Don’t Know/UnclearType of unplanned effects ˇResearch design of evaluation Interview Managers Only; Interview Managers
& Stakeholders; Interviews & Survey;Interviews/Survey & Review Of Docs;Interviews/Surveys & Focus Groups;Unclear/Not Stated; Other
Single or multiple perspectives Single; Multiple; Not Clear/Not StatedClear description of data collection and
analysis techniqueYes; No
If qualitative analysis of data was it doneby more than one researcher?
Yes; No; Don’t Know/Unclear; Other
Credibility of evaluation findings High; Moderate; LowPeer reviewed Yes; No; Don’t Know/UnclearAuthor’s ideological perspective clear Yes; No; Don’t Know/UnclearClear research question Yes; NoState research question ˇAre there other lessons to be learnt from
this study?Yes; No; Don’t Know/Unclear
State lessons ˇConsiders strength of location approach Yes; No; Don’t Know/Unclear; Yes But Not
Central ConcernEthical issues addressed appropriately Yes; No; Don’t Know/Unclear; None IdentifiedFormal or grey Formal; GreyQuality rating High; Average; Low
322 L. A. O’Dwyer et al.
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Tab
leII.
Typ
eofinterven
tion.
HealthPromotionusinged
uca-
tion/publicaw
aren
ess/beh
a-viourch
ange
Improve
Environmen
t/Structural
Chan
geM
ove
peo
ple
todifferentarea
Combinationofat
leasttw
ostrategies
including
communityinvo
lvem
ent,org’lpartnership;health
promotion,structuralch
ange
N¼2
N¼1
N¼5
N¼16
Longet
al.(2002)focu
sedpro-
gram
mes,ch
angesin
delivery
andgo
vernan
ce,mainstream
-ingan
dsharingthelearningin
Man
chester,
Salford
and
Trafford
(MaS
T)HAZ
Wrigley
etal.(2003)co
nstruction
ofsupermarketin
fooddesert
Fau
thet
al.(2004)short-term
effectsofmovinglow-inco
me
householdsto
middle-class
neigh
bourhoodsin
Yonkers,
USA
(MTO)
Ben
zeval(2003c)
Regen
eratinglocalco
mmunitiesan
dmodernisinglocalservices
inEastLondonan
dthe
CityHAZ
Platt
etal.(2003)co
mmunity-
based
anti-smokingprogram
me
inlow-inco
mearea
inEdinburgh,Sco
tlan
d
Feinset
al.(1995)interim
eva-
luationofM
TO
in5UScities
Sullivan
etal.(2004)Stakeholder
perceptionsoflocal
impactofHAZs
Katzet
al.(2000)M
TO
inBoston
Adam
set
al.(2000)SmokingCessationServices
inHealthActionZones
Klinget
al.(2004)
Neigh
bourhoodeffectsonad
ult
economic
self-sufficiency
and
health(partofM
TO)in
5US
cities
Barnes
etal.(2001)Developmen
tofco
llab
orative
capacity
Leven
thal
&Brooks-G
unn(2003)
neigh
bourhoodeffectson
men
talh
ealth(partofM
TO)in
New
York
City,
USA
Ben
zeval(2003a)
Interven
ingin
localpolicy
system
sin
SheffieldHAZ
Ben
zeval(2003d)Interven
ingin
localpolicy
system
sin
NorthStaffordshireHealthActionZone
Bostock
&Sharpe(2002)PublicInvo
lvem
entW
ork
inNorthumberlandHAZ
Bau
ldet
al.W
hole
system
sap
proachto
chan
gein
all
HAZs
Bau
ld&
MacKinnonJudge
lessonsforNDCsfrom
health-sectorinterven
tions
Dunsw
orthet
al.(1999)W
eedan
dseed
toim
prove
the
qualityoflife
intargeted
high-crimeareasof8US
cities
Squires
(2002)Service
modernisationin
HAZs
Tilford
etal.(2002)Focu
sonpartnership
working,
healthyliving,
ethnicity,
modernisationin
Leeds
HAZ
Ben
zeval(2003b)In
dep
thwork
withtargeted
popu-
lationgroups,
allHAZsan
d3case
studies
Hen
dersonet
al.(2004)Im
provingaccess
toservices
andmakingbestuse
ofresources
inBradford
HAZ
Law
sonet
al.(2002)
Wakefield
HAZ
(2001)
Area-based interventions 323
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Success of area-based interventions
Studies that examined similar intervention strategies, with similar research questions, didnot necessarily produce consistent results. The 11 papers evaluating HAZs showed theinterventions to have varying levels of success in the reviewers’ opinions—three wereconsidered at least mostly successful, four were partly successful, the success of three wereunclear and one was unsuccessful. The quality of the HAZ evaluations as a group wasgenerally high (8 of the 11 were rated by the reviewers as high-quality and 3 as average).Only 5 of the 24 evaluations showed interventions that were generally successful (see
Table IV).Table V identifies the wholly and mostly successful interventions along with some of the
key characteristics of good evaluations (Rychetnik & Frommer, 2004).Most of the successful types of interventions took place in large geographic areas
(HAZs) and consisted of a combination of strategies. However, it is not possible to stateunequivocally that the combination of strategies was integral to the overall success,because this was also a feature of partly successful and unsuccessful intervention. Thestrategies included a range of programmes and projects, some targeted at specific groupswithin an area, such as creative expression for young African and Caribbean men withmental health problems in East London, and others aimed at the general population of anarea, such as smoking cessation in HAZs. It is also interesting to note that someinterventions were successful in spite of an insecure political climate and inadequatefunding support.Successful interventions which employed a number of different strategies all included:
improvements to management systems by increasing the number of strategic partnershipsand degree of partnership with parts of government and community organisations; waysof empowering people and various health promotion activities aimed at specific healthissues such as smoking, heart disease and mental health. There were also five evaluationstudies where the success of the intervention was not clear (Bauld, Judge, Lawson,Mackenzie, Mackinnon, & Truman, 2001; Dunworth, & Mills, 1999; Squires, 2002, andTilford et al., 2002).The Leventhal and Brooks–Gunn evaluation of the MTO programme in New York
City shows that changing the area people live in is effective in improving some aspects oftheir health and well-being: for example, by moving them to a different area with bettereconomic and housing opportunities, economic opportunities, the social and physicalenvironment, community norms and values, and quality of the school system. The othertwo evaluations of the MTO programme (Fauth et al., 2004 and Kling et al., 2004),which were considered to be high-quality evaluations, reported only partial success. Theseinterventions took place in different sites—Yonkers and Boston. Although all MTO sites
Table III. Quality and peer review status.
Peer reviewed
Quality rating Yes No (grey) Don’t know/unclear Total
High 3 13 1 17Average 1 4 1 6Low 0 1 0 1Total 4 18 2 24
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Tab
leIV
.Successofarea-based
interven
tion.
Interven
tionoutcome
Successful
Mostly
orpartlysuccessful
Don’tkn
ow/unclear
Unsuccessful
Ben
zeval(2003c)
regenerating
localco
mmunitiesan
dmoder-
nisinglocalservices
inEast
Londonan
dtheCityHAZ
Adam
set
al.(2000)Smokingcessation
services
inHealthActionZones
Bau
ldet
al.,whole
system
sap
proachto
chan
gein
allH
AZs
Ben
zeval(2003b)in
dep
thwork
withtargeted
population
groups,
allHAZsan
d3case
studies
Hen
dersonet
al.(2004)
Improvingaccess
toservices
andmakingbestuse
of
resources
inBradford
HAZ
Barnes
etal.(2001)Developmen
tof
collab
orative
capacity
Bau
ld,&
MacKinnonJudge,les-
sonsforNDCsfrom
health-
sectorinterven
tions
Longet
al.(2002)focu
sedpro-
gram
mes,ch
angesin
delivery
andgo
vernan
ce,mainstream
-ingan
dsharingthelearningin
Man
chester,
Salford
and
Trafford
(MaS
T)HAZ
Sullivan
etal.(2004)stakeh
older
perceptionsoflocalim
pactof
HAZs
Ben
zeval(2003a)
interven
iningin
local
policy
system
sin
SheffieldHAZ
Dunsw
orthet
al.(1999)W
eed
andseed
toim
prove
thequality
oflife
intargeted
high-crime
areasof8UScities
Plattet
al.(2003)co
mmunity-
based
anti-smokingprogram
me
inlow-inco
mearea
inEdinburgh,Sco
tlan
dW
akefield
HAZ
(2001)
Ben
zeval(2003d)interven
ingin
local
policy
system
sin
NorthStaffordshire
HealthActionZone
Squires
(2002)servicemoderni-
sationin
HAZs
Wrigley
etal.(2003)co
nstruction
ofsupermarketin
fooddesert
Fau
thet
al.(2004)short-term
effectsof
movinglow-inco
mehouseholdsto
middle-class
neigh
bourhoodsin
Yonkers,USA
(MTO)
Tilford
etal.(2002)Focu
son
partnership
working,
healthy
living,
ethnicity,
modernisation
inLeedsHAZ
Feinset
al.(1995)interim
evaluationof
MTO
in5UScities
Katzet
al.(2000)M
TO
inBoston
Klinget
al.(2004)Neigh
bourhood
effectsonad
ulteconomic
self-suffi-
cien
cyan
dhealth(partofM
TO)in
5UScities
Law
sonet
al.(2002)Buildingcapacity
forco
llab
orationin
8HAZs
Bostock
&Sharpe(2002)Public
Invo
lvem
entW
ork
inNorthumberlandHAZ
Leven
thal
&Brooks-G
unn(2003)
neigh
bourhoodeffectsonmen
tal
health(partofM
TO)in
New
York
City,
USA
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Tab
leV.
Characteristicsofsuccessfularea-based
interven
tions.
Study
Quality
rating
Successful?
Typ
eofinterven
tion
Typ
eof
area
Political
support
Adeq
uately
implemen
ted
Tim
ingof
evaluation
Ben
zeval
(2003c)
high
yes
severalstrategies;healthim
pacttoolkitfrom
those
invo
lved
inurban
regeneration;cu
lturallysensi-
tive
healthpromotionactivities
aroundfoodan
dexercise
toim
prove
cardiovascularhealth;
employworkersto
facilitate
communityinput
into
policy
makingrelatingto
childrenan
dyo
uth,refugees
andmen
talhealth;telephone
interpretingservice;
creative
expressionfor
youngAfrican
andCaribbeanmen
(Mellow
project)
HAZ
yes
no
Halfw
ay
Sullivan
etal.
(2004)
high
yes
severalstrategies
(lookedat
number
ofHAZs);
betterservices
forch
ildrenan
dfamilies,
men
tal
healthoutreach
;healthylivingcentres,inter-
med
iate
care;co
mmunityparticipation;sm
oking
cessation;HIA
;GIS
HAZ
don’tkn
ow
no
don’tkn
ow/unclear
Hen
dersonet
al.
(2004)
high
yes
severalstrategies;policy/service
deliverych
ange;
attitudinal
andbeh
aviouralch
ange
ofproviders;
therap
euticperform
ingarts;skills
developmen
twithin
both
professional
anduserco
mmunities;
communitycentres
whole
of
city
don’tkn
ow
unclear/don’t
know
through
out
program
me
Wrigley
etal.
(2003)
high
yes
Improveden
vironmen
tbybuildingsupermarketin
fooddesert
local
partly/somew
hat
yes
immed
iately
after
completion
Wakefield
HAZ
(2001)
average
yes
severalstrategies;partnership
planning;
case
study
approaches
includingCan
cerCarePathways
Voluntary
ActionW
akefield;Volunteer
Bureau
PublicParticipationNetwork
Ben
efitsTake-Up
Cam
paign
Youngpeo
ple’sSexual
HealthProject
partof
city
yes
yes
nearen
dof
program
me
Leven
thal
&Brooks-G
unn
(2003)
high
mostly
Movedrandomly
selected
householdsfrom
low
tohighSESareas
other
yes
yes
severalyearsormore
afterco
mpletion
Bostock
&Sharpe
(2002)
average
mostly
severalstrategies;publicinvo
lvem
entin
neigh
-bourhoodregeneration,partnershipsbetween
organ
isationsan
dco
mmunities,
support
groups,
ongo
ingtraining;
providinggran
ts;im
proving
serviceresponsiveness;
evaluationsofpublic
invo
lvem
ent
HAZ
no
unclear/don’t
know
Preliminary
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were selected on the basis of similar size (populations of at least 400,000 in metropolitanareas of at least 1.5 million people (Feins et al., 2001) the economic and social structureof the cities as a whole may be a significant factor which was not taken into account.Ostensibly a randomised controlled trial, the MTO interventions have methodologicallimitations. For example, households in the targeted neighbourhoods were assignedrandomly to one of three groups (experimental group, the comparison group and thecontrol group), but the sampling frame for all groups consisted of households whovolunteered to participate in the programme. There were demographic differencesbetween households who volunteered and those who did not (Feins & Schroder, 2005).Also, there were public housing authority screening requirements which may have causedsome families to decide against applying.However, the idea of changing people’s environment in some way is also supported by
the study of Wrigley et al. (2003). The intervention was the construction of a newsupermarket in a food desert. There were significant changes to people’s nutrition whenthey were able to buy fruit and vegetables at affordable prices (Wrigley et al., 2003).There was no clear relationship between the scale of geographic area and the success of
outcomes. Interventions showing partial success in reducing health inequalities addressedareas ranging from the small local areas to large areas, such as HAZs.
Evaluation research designs
The evaluation research designs generally included interviews with programme managers,occasionally in combination with a survey and/or a review of documentation. Only onestudy employed focus groups, but several compared data collected at baseline with datacollected later, namely the USMTO projects. Perspectives were sought from stakeholdersother than project managers in just over half of the 24 cases but 9 studies focused solely onproject managers. These tended to be the evaluations of process. Most (83.3%) of theevaluations included a clear description of the data collection and analysis technique, butit was unclear whether any qualitative analysis was conducted by more than oneresearcher in nearly two-thirds (n¼ 11) of the cases where qualitative data were collected.
Geographic scale of area
The UK Health Action Zones (HAZs) have the largest geographic scale, ranging froma few wards to many towns and cities. They are also the most common form of area-basedintervention (just under half of all studies identified). Consequently the literature hasa UK flavour (17 papers were British, 7 American). One-quarter of reviewed studiesfocused on small areas, defined as the neighbourhood.
Role of political and social context in success of intervention
Political influences such as sudden changes in policy direction alongside ministerialchanges and insecure long-term funding is a striking feature of the literature. Over half ofthe evaluations identified the political environment as affecting the outcome of theintervention, and most (70%) of these were UK. Only 5 of the 24 papers did not identifysignificant political influences (3 UK, 2 US), while another 5 did not state whether thiswas an important factor.
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Adequacy of implementation
The literature is equally divided as to whether interventions were adequatelyimplemented, i.e. given sufficient resources and time (in the opinion of the evaluationreports’ authors, nine were adequately implemented, while another nine were not), butone-quarter of papers did not address or acknowledge this issue. All nine interventionsthat were not adequately implemented were in the UK.
Generalisability
Only 5 of the 24 papers concluded that the results of the intervention could begeneralisable to other areas or countries (2 UK, 3 US). Nine of the 10 papers suggestingthat the intervention was not directly transferable were from the UK, reflecting thedominance of UK literature about area-based health interventions.
Cost-effectiveness
Most (18 of the 24) papers neither reported on the cost-effectiveness of the intervention,nor considered alternative interventions. Cost-effectiveness is difficult for evaluations toaddress because the analyses are costly, lengthy exercises in themselves.
Timing of evaluation
The stage of the intervention at the time of evaluation is important in terms of being ableto measure success. It is obvious that area-based interventions are likely to require a longtime frame within which to operate and produce measurable and lasting outcomes.Yet only 4 of the 24 evaluations were conducted 3 years or more after the completion ofthe intervention programme. It is arguable whether even 3 years post-interventionis sufficient. The short time frame for evaluations is probably a reflection of the politicalimperative to show quick results and to justify further resources to enable theinterventions to continue. The timing of the evaluations also dictates the type ofevaluations, resulting in evaluations of process rather than outcome. Half (12)of the papers evaluated process only, while 3 considered both process and outcome and9 evaluated outcomes.
Unplanned effects
The literature is split on whether the interventions had unplanned effects. Ten papersindicated there were unplanned effects, but it is unclear whether 11 papers did not reportunplanned effects because they were absent or because the evaluators did not ask aboutand/or report them. There were also three papers which were unclear about whether ornot some effects were planned (Barnes, Sullivan, & Matka, 2001; Fauth et al., 2004;Kling, Liebman, Katz, & Sanbonmatsu, 2004).
Ideological positions of evaluators
Most (20 of the 24) papers were written by academics (all from social sciencebackgrounds), rather than private consultants. The two evaluations conducted by privateconsultants (backgrounds unclear but presumably social science) were both in the US andboth addressed the Moving to Opportunity programme.Authors’ ideological positions on the need for and how to address health inequalities
were reasonably clear in half of the papers (all of HAZs) from their support of the
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‘theories for change’ framework and from the often lengthy descriptions of the extentof inequities (e.g. Bauld et al., 2001; Benzeval, 2003a, 2003b, 2003c, 2003d;Long, Porcellato, Siddall, Springett, & Young, 2002), but ideological positions weregenerally not stated explicitly. This may reflect attempts to appear neutral and objective.The theory of change does however involve the authors in making reducing inequity asa goal of the intervention explicit. Thus the HAZ interventions did argue the case for whythe particular intervention was expected to have the outcome anticipated. This focus onthe underlying theory of why the change is to be expected draws on the work of theAspen Institute’s Roundtable on Comprehensive Community Initiatives for Childrenand Families (Connell & Kubisch, 1998) or the similarly focused realistic evaluation(Pawson & Tilley, 1997).
Consideration of ethical issues
Few papers mentioned ethical issues associated with area-based interventions abouthealth inequalities, even though there are obvious ethical implications associated with theselection of some areas over others, and the role of area versus individuals.
Other lessons
Ninety percent (n¼ 22) of the papers reported that there were other lessons to be learntfrom the intervention. These included the need to account for consultation fatigueamongst community members and staff; the importance of having local evaluationcapacity in place before interventions are put in place; difficulties associated with avoidingcontamination of non-intervention communities; the need for political commitment;the tendency for health portfolio policy makers to retreat to ‘disease and treatment’mindsets; the role of local politics; the need to integrate area-based interventions intohealth inequalities with community development; and the recognition that interventionscan do harm.
Discussion
There is some evidence that area-based interventions reduce inequities. Seven studies didfind substantial effects and nine found partial effects. Area-based interventions tended towork best when: there was a change or difference in the physical environment; fundingwas adequate; there was good leadership and partnership with communities; there wereappropriate and well-designed programmes; political support was firm; the objectives didnot change over the course of the programme; and the size of the area was appropriate tothe particular inequality.Unfortunately, the evidence is limited, largely due to: very few studies; poorly
conducted evaluations; and inadequately implemented interventions. The review findingsdo not definitively answer the review question due to the mixed results, a focus on processand limited evaluations of outcomes, the premature timing of the evaluations, weakresearch designs and variation in social, political and geographic context. Nevertheless,the review makes an important contribution to the evidence base by highlighting thepaucity of outcome evaluations and identifying the strengths and weaknesses of theexisting literature. The key message is that there is a need for more long-term, systematicevaluations of interventions that are ideally not subject to shifting objectives.
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Limitations of available evidence
There are significant gaps in the limited evidence available. There is great variation inscale of areas, strategies used and quality and research methods of the evaluations.Definitions of places, areas and localities differ between policy makers, administrativeorganisations, stakeholders and the general public. Administrative areas are often thefocus of interventions and these will often not coincide with local, lay understandings ofcommunity and neighbourhood. There were also clear differences in political contextsbetween the UK and US studies.There are few evaluations of area-based interventions which focus solely on outcomes
and even very few are conducted several years or more after the intervention. Many ofthe evaluations did not consider the views of all the stakeholders and concentrated onprogramme managers and analysis of documentation. Community groups areconspicuously absent (e.g. Bauld et al., 2001; Benzeval, 2003a, 2003d; Bostock &Sharp, 2002; Squires, 2002). Community groups are more likely to be included when theevaluation is of outcomes, but they should also be seen as a key part of an intervention’simplementation process, as was shown to be important by Dunworth and Mills (1999).The limited success of some interventions appears due to extraneous factors (lack of
political support, insufficient funding and staffing, etc). Although perhaps politicallydifficult, contingency plans for these factors should also be considered along with processand timeframes when planning future area-based interventions, and evaluationapproaches need to be planned well before an intervention is implemented.The effectiveness of area-based interventions outside the UK and US is not known,
probably due to a lack of evaluations, rather than interventions. There have been somerelevant interventions through the Healthy Cities movement in other countries butthe evaluations have been limited to process evaluation of pilot projects (e.g. Baum &Cooke, 1992) and funding has not been made available for more detailed evaluations(De Leeuw, 2003).Finally, findings frequently may not be generalisable because they are highly
context-dependent. Each of these problems is intractable and will not easily be overcome,making it difficult to establish a firm evidence base for area base interventions.
Controlled trials in area-based interventions
Randomised controlled trials are viewed as the most robust and reliable form of researchdesign for many research problems, but for practical and ethical reasons are rarelypossible in public health research in which the units of analysis are groups, communitiesand populations rather than individuals or households which by their very nature cannotbe meaningfully controlled. The MTO interventions are the closest type of design studyto a controlled study (although they changed environments by moving people to differentareas rather than changing areas), but they are still subject to the limitations listed above.
The importance of geographic concepts in area-based interventions
Although the interventions in this review were chosen because they were based on areas,the value of using an area-based approach was usually not the central concern of theevaluation, but rather was taken for granted. Issues associated with location and area werenot given explicit attention other than as a reference point or context for the intervention.This is unfortunate, because the concept of ‘area’ should not be used merely as a way ofdescribing the bounds of a project, but rather as a determinant of access to services,
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employment, education and social life and as a context for social processes. Nine of the 24papers did consider the strength of an area-based approach in addressing the contextualfeatures of a defined area but there were no specific characteristic features that unitedthem—they covered a range of different geographic areas, research designs andinterventions and were conducted in both the UK and US. Geographic scale is importantbecause area-based interventions will not work if the areas are too small or too large forthe scale of the problem. This point was identified by some stakeholders in a HAZevaluation, who questioned whether reducing health inequalities was a goal that couldeven be addressed locally, suggesting that solutions may lay at the national level(Benzeval, 2003b, p. 36).The physical size of the setting can also directly affect the social and political processes
of implementing an intervention. For example, a neighbourhood-level approach topoverty is inappropriate if the determinant of poverty in that area is related to national orinternational industrial restructuring. Many determinants of population health arenational and even global and so there are limits to localism.Yet, some issues are better addressed at the local level. For example, health inequalities
related to social isolation would ideally be addressed at the local level. Previous work hasalso shown that community stakeholders’ knowledge and, therefore, participation indecision-making, is enhanced at smaller geographic scales (Harker & Natter, 1995).Localism can also be used to test new approaches where appropriate. However, ‘scaling
up’ from local place-based interventions to larger regional scales may sometimes createanalytical, institutional and political challenges, because the change of geographic scalewill mean different delegations of responsibility (local organisations may be responsiblefor a neighbourhood, local governments will be responsible for their area of jurisdiction,state government departments for the whole of states). Scaling down a successfulregional-level intervention is possible in some circumstances, if a good example has beenset to other stakeholders at the more local level. By initially focusing on regional ornational scales, interest groups can mobilise broad public support for policies that mayotherwise fail when considered at smaller scales.If the intervention is implemented on too large a scale, there is a risk that established
voluntary and community organisations may be ‘leapfrogged’ and their potentialcontributions overlooked, and productive social interaction among stakeholders can beinhibited. Too large an area for the specific interventions implemented might be a factorin the lack of success in some of the HAZ studies. Previous work has shown that localissues can be easily usurped by non-local social and political forces focusing on largerregional issues (Agnew, 1987; Bondi, 1993). Cheng and Daniels (2003) suggest breakingthe larger region into smaller sub regions with which stakeholders more readily identify,but warn that this response can have mixed effects over the long term if smaller-scaleregions are not integrated with broader, regional efforts.Geographic scale affects individual stakeholders’ perceptions, knowledge and especially
their ways of understanding of issues affecting them. For small-scale areas, stakeholderperceptions tend to be subjective, relying on diverse personal experiences and specificplace features; for large-scale areas, stakeholder understanding relies more on scientificanalyses and symbolic abstractions (Cheng & Daniels, 2003). Geographic scale combineswith other factors, such tensions between lay people and so-called experts, to affectworking relationships in participatory collaborations. Understanding these relationships isimportant to process evaluations of area-based interventions where communityparticipation is involved, and stakeholder views form the basis of the evaluation.Although there were four process evaluations in this review, no discussion or
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acknowledgment of the relationship between geographic scale and stakeholder views wereidentified. Area-based approaches to health inequalities cannot take geographic scale forgranted, especially if collaborative stakeholder participation is seriously encouraged.
Conclusions and recommendations
The aim of this paper was to answer the question ‘Do area-based interventions to reducehealth inequities work?’ Based on this systematic review, there cannot yet be a definitiveanswer.The finding that only 5 out of 24 studies were primarily successful does not constitute
an argument that area-based interventions have failed. Half of the studies employed sucha combination of strategies that attributing specific cause and effect was difficult. Moststudies were difficult to interpret because they used imprecise and inadequate definitionsof ‘area’ and do not explain why a particular scale of geographic area was used. Further, asBauld et al. (2001, p. 47) also observe, area-based initiatives are sometimes expected toaddress problems which have more to do with wider social or economic forces than thesocial or environmental characteristics of the area itself.Few studies actually framed their questions to examine area-based interventions in
relation to health inequities even if the extent of inequities was part of the background tothe study or part of the broader policy justification (as in the case of the HAZs). It wasclear from the study that the data collected rarely allowed for the disaggregation thatwould be necessary to be able to determine the impact on health inequities within theareas. Comparing the study areas with mean or modal data from broader areas was not inthe remit of any of the studies. Yet these types of data would be required in order to makestatements about whether the interventions had had an impact on reducing healthinequities.Our study also suggests that interventions are often inadequately implemented, even
when conceptually sound. Political and administrative changes means that the initiativesare often required to change their focus, objectives and directions which further hampersrigorous evaluations. This, together with the lack of investment in adequate and flexibleevaluations, may explain the absence of evidence regarding the effectiveness of area-basedinterventions.There are broader methodological questions that arise from this systematic review. It is
clear that funding bodies rarely either allocate resources to commence outcomeevaluations before an intervention starts, or continue the evaluation after the life of theintervention. Consequently, many studies are constrained to reporting evaluations ofsnapshots of processes.In addition, the systematic review suggests that many of the interventions themselves
were profoundly influenced by political and social contexts in both funding andimplementation. One example is the way in which political decisions so significantlyaltered the course of the intervention that it became impossible to evaluate the originalintent. Disturbingly, political decisions actually moved interventions further away fromstrategies that were taking area and health inequities seriously. Moreover, despite theimportance of the social and political context to both intervention and evaluation, too fewstudies provided thick or rich details of these contexts. There is some evidence showingthat area-based interventions could be successful, no firm or convincing evidence thatthey are not useful, and a plethora of unanswered questions.
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The challenge is to build the evidence for or against the effectiveness of interventions atthe area level to reduce inequity so that it can inform policy and practice decision-making.For this to happen, we offer the following recommendations, based on the identified gapsand weaknesses in the existing evidence base.
. Adequate baseline data must be collected before an intervention commences.
. Evaluations of outcomes should be conducted at both the conclusion of theintervention programme and again three or more years later.
. Policy makers need to consider how support can be ensured over the long term.
. In an ideal world, area-based interventions should proceed only if process and supporthave first been carefully planned and secured, and where there are contingency plans inplace for changes in political direction.
. More evaluations, particularly of outcomes, must be undertaken in order to form asufficient body of evidence that can inform policy and practice decisions.
. Future evaluations must consider all stakeholders, particularly local communities in theareas that are the subject of the interventions.
. The appropriate geographic scale of the intervention needs more attention toconceptual underpinnings about the scale at which social and policy processeswork—the growing body of literature on health geography shows that issues of scale,boundary and location matter, but none of the papers in this review acknowledged thiswork, even when the evaluators were affiliated with university geography departments(e.g. Benzeval 2003a, 2003b, 2003c; Wrigley et al., 2003).
. Evaluation methodologies must be sufficiently robust and flexible to deal with thecomplexity of area-based interventions.
. Area-based interventions should be compared with similar non-intervention areas withsimilar communities on the admittedly rare occasions this is possible.
A clear policy success must demonstrate major long-term impacts, ideally achieved withvalue for money. Funders of interventions and evaluators need to enter into long-termrelationships which start before the interventions, measure both processes and outcomesthroughout the life of the intervention, and continue to measure rigorously anticipatedand unanticipated effects and outcomes for as long as a cogent theoretical case is made forthe time needed for health, area and equity outcomes to change as a result of theintervention(s).
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