A systematic review of the effectiveness of

health service interventions aimed at reducing

inequalities in health

Lorna Arblaster. Mark Lambert*. Vikki Entwistle t • Martin Forster;. Deirdre Fullerton t •
Trevor Sheldon t • Ian Watt t
*United Health Commission, South Humberside; tNHS Centre for Reviews and Dissemination, University of York; ~Department of Economics
and Related Studies, University of York, UK

Objective: To review the available evidence in order to identify effective interventions which health services alone or
in collaboration with other agencies could use to reduce inequalities in health.
Methods: A search of the literature was undertaken using a number of databases including Medline (from 1990),
Applied Social Science Index and Abstracts (1987-1994), and the System for Information on Grey Literature in
Europe (1984-1994), on a large range of key words. Studies were included if they assessed interventions designed to
reduce inequalities in health or improve the health of a population group relevant to the review, and could be carried
out by a health service alone or in collaboration with other agencies. Only studies evaluating interventions using an
experimental design were included. Papers in any language were considered. In addition, systematic reviews of the
research on the effectiveness of health promotion and the treatment of conditions where there are significant health
inequalities were identified in order to illustrate the potential for reducing inequalities in health.
Results: 94 studies were identified which satisfied all the inclusion criteria and 21 reviews were included. A number
of interventions have been shown to improve the health of groups who are disadvantaged by socio-economic class,
ethnicity or age and, if properly targeted, could be expected to reduce health inequalities. H a health intervention
is being used, there should be evidence that it has an impact on health status. Attention should then be given to the
way in which the intervention is delivered and the characteristics of a programme to promote implementation.
Characteristics of successful interventions specifically aimed at reducing health differentials include: systematic
and intensive approaches to delivering effective health care; improvement in access and prompts to encourage
the use of services; strategies employing a combination of interventions and those involving a multi-disciplinary
approach; ensuring interventions address the expressed or identified needs of the target population; and the involve-
ment of peers in the delivery of interventions. However, these characteristics alone are not sufficient for success, nor
are they universally necessary.
Conclusions: Although it is likely that the most significant contributions to reducing health inequalities will be
in improving economic and social conditions and the physical environment, there are interventions which health
services, either alone or in collaboration with other agencies, can use to reduce inequalities in health.
Journal of Health Services Research and Policy Vol. 1 No 2,1996: 93-103 © Pearson Professional Ltd 1996

Introduction Concern about the implications of these inequalities

Levels of health in Western countries have steadily im-
proved during this century. Despite this, inequalities in
health have persisted throughout the post Second World
War era and, in recent years, inequalities in mortality
rates between socio-economic groups in some countries
have been increasing.'
Lorna Arblaster MBBS, Independent Researcher, Mark Lambert
MBBS, Senior Registrar in Public Health Medicine, United Health
Commission, South Humberside; Vikki Entwistle PhD, Research
Fellow; Deirdre Fullerton MSc, Research Fellow; Trevor Sheldon MSc,
Professor; Ian Watt MPH, Honorary Consultant in Public Health
Medicine, NHS Centre for Reviews and Dissemination, University of
York, York YOI 5DD, UK Martin Forster MSc, Postgraduate Student,
Department of Economics and Related Studies, University of York,
York, UK Correspondence to TS.
has led to the commissioning of a number of govern-
ment reports." As part of the government's report for
England.! the NHS Centre for Reviews and Dissemina-
tion (CRD) carried out a systematic review of evaluations
of interventions aimed at increasing the poor health of
disadvantaged groups.' This paper reports the results of
an extended review with the aim of identifying health
care interventions which health services can use alone or
in collaboration with other agencies to reduce inequali-
ties in health. The health categories considered are: acci-
dents; cancers; coronary heart disease (CHD)jstroke;
sexual health and mental illness (areas prioritized as part
of the government's strategy for health in England") as
well as pregnancy and childbirth. The main inequalities
considered are those related to socio-economic status,

J Health Serv Res Policy Volume 1 Number 2 April 1996 93

A systematic review of the effectiveness of health service interventions
age and ethnicity. Consideration of other areas such as
oral health, child health and development and nutrition
are the subject of a further extension to this review.
The factors which influence inequalities in health have
been described extensively.l" Benzeval and colleagues?
have proposed a framework for tackling them which sug-
gests four levels for intervention: improving the physical
environment; addressing social and economic factors;
reducing barriers to adopting a healthier personal life-
style; and improving access to appropriate and effective
health and social services.
In focusing only on interventions which health serv-
ices either alone or in collaboration with other agencies
can use to address health inequalities, this paper ignores
many of the options contained within Benzeval's frame-
work. No consideration is given here to addressing the
more fundamental inequalities which exist in society and
which are linked to inequalities in health.
The interventions considered in this paper fall into
two main categories:
1. Those which target effective health services or inter-
ventions at the groups with the greatest health needs.
For example, there exist marked social class inequali-
ties in the rate of childhood accidents. Therefore, an
intervention designed to reduce these accidents, if
equally effective in all social classes (or more effective
in disadvantaged groups), could reduce social class
inequalities.
2. Specific interventions to reduce morbidity in age, sex,
socio-economic and ethnic groups suffering poorer
health outcomes (e.g. specific uptake promotion ac-
tivities targeted at women in disadvantaged groups
who have an abnormal cervical smear result) .
Literature addressing the first of these strategies is not
considered in a comprehensive way since it would mean
a review of the effectiveness of all health care interven-
tions in which relevant groups had poorer health out-
comes. However, by summarizing a number of reviews in
specific health areas, it is possible to illustrate how the
results of such reviews can be applied to health inequali-
ties. This paper also summarizes the results of nearly
100 evaluations of specific interventions to improve
health in disadvantaged groups which fall into the
second category detailed above.
Methods
In order to assess evaluations of interventions aimed
at reducing inequalities in specific health categories, 21
relevant systematic reviews were identified using a series
of reviews of health promotion commissioned by the
NHS Centre for Reviews and Dissemination and related
databases. Results of these reviews are presented by
health category in the next section and, where possible,
are supplemented by examples of specific interventions
which have demonstrated success at improving the health
of a disadvantaged group.
To identify characteristics that could affect the success
of such interventions, 94 papers reporting evaluations of
94 J Health Serv Res Policy Volume 1 Number 2 April 1996
Review article
interventions aimed at reducing health inequalities were
reviewed.
These papers were identified via a search of the litera-
ture using a number of computerized databases includ-
ing Medline (from 1990), Applied Social Science Index
and Abstracts (1987-1994), and the System for Informa-
tion on Grey Literature in Europe (1984-1994), on a
large range of key words. In addition two existing reviews
relevant to this area,B,g experts, people attending relevant
conferences and a UK network of public health practi-
tioners were used to identify studies. More details are
provided elsewhere."
The papers were checked for relevance according to
health outcomes and the target population. Studies were
included if they assessed interventions designed to re-
duce inequalities in health or to improve the health of a
population group in the health areas detailed in the in-
troduction, and could be carried out by health services
alone or in collaboration with other agencies. Studies
had to report outcomes which were either health out-
comes or intermediate outcomes for which the reviewers
were aware of evidence of an impact on health (e.g.
smoking), or it was plausible that there was an impact on
health. Only intervention studies with an experimental
design (before after studies with or without controls;
randomized and non-randomized) were included. Pa-
pers in any language were considered, though only those
studies relevant to developed countries were included.
Since intervention settings, populations and health out-
comes were extremely diverse, a narrative review of the
individual study results was carried out in an attempt to
identify relevant characteristics.
Summary of reviews assessing the
effectiveness of health care interventions
This section summarizes the results of reviews which
assess the success health care interventions have had in
influencing specific health outcomes or their associated
risk factors, arranged by health category. For each health
category, a brief discussion of the inequalities addressed
in this paper is presented before the relevant reviews
are summarized and, where necessary, reference is
made to interventions which have demonstrated success
at improving the health outcome of a disadvantaged
group.
Accidents
In the UK, unintentional injury in childhood is the lead-
ing cause of death in those aged 1-15 years and deaths
from unintentional injury have a steeper occupational
social class gradient than any other cause of death in
childhood." Older people are also at high risk of acci-
dents with more than eight times as many people over 65
as under 15 dying annually as a result of accidents in the
UK..II The targeting of effective interventions at children
in more deprived communities and at older people may
reduce some of these inequalities.
Review article A systematic review of the effectiveness of health service interventions
1. Accident prevention in children and adolescents
Towner et al" reviewed 135 studies and 9 reviews eva-
luating interventions aimed at tackling unintentional
injuries on the road, in the home and in the leisure envi-
ronment. The interventions shown to be most successful
at reducing childhood injury include promotion of bicy-
cle helmet use by legislation or education; promoting
the use of child restraint devices and seat belts using le-
gislation, education and loan schemes; area-wide urban
safety measures such as traffic calming; and educating
children and parents about pedestrian injuries.
Towner et aPI found few studies that had analyzed re-
sults by occupational social class. Of those that did, some
found that the interventions were less successful among
lower social classes." Some studies reported success in
targeting the lower social classes. For example, Colver et
al" showed that pre-arranged personal home visits to
iden tify specific targets for change in families living in a
deprived area of Newcastle encouraged them to make
changes in their homes that would be expected to re-
duce the risk of childhood accidents. Because there may
be a disproportionately low uptake by those at higher
risk, it may be important to target such groups with ap-
propriately designed interventions.
2. Accident prevention in older people
In their review, Oakley et aPI identified nine studies that
were considered to be sufficiently methodologically
sound and one meta-analysis. The principal finding
from the research is that exercise, especially that which
includes an element of balance training, reduces the risk
of falls in older people. For example, Wolf et aP4 used
Tai Chi to improve balance as part of the 'Frailty and In-
juries Co-operative Studies of Intervention Techniques'
(FICSIT) trials in the USA.
Cancers
This section considers interventions aimed at reducing
the prevalence and incidence of cervical cancer, and
lung cancer (via smoking reductions). In the UK, in-
equalities exist in smoking behaviour and smoking-
related deaths by social class," and there is a social class
gradient in the incidence of and mortality from cervical
cancer. 15
1. Smoking
A review by Sanders" found that health care settings are
a useful site for smoking cessation interventions and that
interventions can be given by a number of health care
professionals.
Brief advice from a GP to stop smoking in a general
consultation can help a small (about 3%) but significant
number of individuals to stop smoking and remain non-
smokers for at least a year. 16 Such advice can be improved
by offering follow-up appointments, health education
and self-help booklets, concentrating on the short-term
as opposed to long-term benefits, negotiating a date to
J Health Serv Res Policy Volume 1 Number 2 April 1996
stop and informing smokers that their progress will be
checked on subsequent visits.
Sanders" found that the more intensive the interven-
tion, the higher the likely success rate. Simple techniques
such as putting reminder stickers on a patient's notes
increased the effectiveness of advice, and when staff were
given additional training in methods of helping smokers
to quit, their motivation to discuss smoking increased.
Sanders" recommends that primary care facilitators and
health promotion departments should provide relevant
short, accessible training programmes with follow-up
support for primary care staff. Silagy et al,'? in a separate
review, found that training had a measurable impact on
professional performance.
Reviews have shown that the use of nicotine replace-
ment therapy (nicotine gum or patches), can help in
smoking cessation interventions. IS However, patches
are expensive and in the UK are not available on NHS
prescription.
Connett and Stamler" have shown that interventions
can be successfully carried out to reduce the incidence
of smoking in deprived groups. Their intensive medical
treatment and education programme in the USA suc-
ceeded in inducing extensive changes in the eating and
smoking habits of middle aged black and white Americans
of varying socio-economic backgrounds.
2. Cervical cancer
Organized cervical cancer screening achieving a wide
coverage of ages is effective at reducing risk." If wide
coverage is assumed and uptake of high-risk (in particu-
lar inner city) groups is attained, then cervical smear
screening programmes may be effective in reducing
social class and regional inequalities in mortality. Marcus
et al 21 showed that prompts and incentives improved at-
tendance for follow-up appointments after women living
in a deprived urban community received an abnormal
smear result.
McAvoy and Raza" showed that a home visit with
support materials in relevant languages increased the
attendance for cervical smears by Asian women in the
UK, though these groups are at lower risk of cervical
cancer than the UK population as a whole.
There is evidence that women over the age of 65 would
benefit from cervical and breast cancer screening."
Some of the age inequality in cervical and breast cancer
mortality may be avoidable by extending the upper age
limit for the cervical and breast cancer screening pro-
grammes in the UK beyond the age of 65.
Coronary heart disease (CHD)/stroke
There exists a marked social class gradient in deaths
from CHD and stroke in the UK. 2 Furthermore, because
some health care professionals mistakenly assume that
treatments are less effective in older people, they use age
rather than physiological status - age discrimination - to
determine care." There are also inequalities by ethnicity.
Death rates from CHD in people of South Asian origin
95
A systematic review of the effectiveness of health service interventions
living in the UK are about 40% higher than those of the
white population and people of Afro-Caribbean origin
have double the stroke mortality and many times greater
rates of death associated with high blood pressure than
the rest of the population.P
1. CHD and stroke prevention in older people
Ebrahim and Davey Smith" found strong evidence to
support the use of medical (drug) treatments for even
mild degrees of hypertension in older people. The treat-
ments are equally effective in relative terms at younger
and older ages up to the age of 80-85 years with absolute
effects being far greater at older rather than younger
ages. Of single non-drug interventions, weight reduction
and exercise were found to be of value in lowering blood
pressure.
The authors found the effectiveness of cholesterol
lowering using older cholesterol lowering agents such as
the fibrates to be dependent upon the level of risk.
Those at low overall risk of CHD were unlikely to derive
substantial benefits from cholesterol lowering by these
drugs and the authors recommend that widespread use
of such drugs for cholesterol lowering in older people
should not be promoted unless they are at particularly
high risk of developing, or already have, CHD. The recent
West of Scotland pravastatin trial, however, has shown
substantial overall benefit in those at lower risk, al-
though it is not clear what effect pravastatin has in older
people." Ebrahim and Davey Smith" found that very low
fat diets may lower cholesterol levels, although the level
of reduction is dependent upon compliance and severity
of the regimen imposed.
Ebrahim and Davey Smith" found that whilst multiple
interventions among general and working populations
can modify risk factors, the changes achieved are rela-
tively small, especially when compared to pharmacologi-
cal therapy.
2. CHD/stroke prevention in South Asians and
Mro-Caribbeans
McKeigue and Chaturvedi" reviewed the evidence on
preventing cardia-vascular disease in Afro-Caribbean
and Asian ethnic groups in Britain.
a) CHD and South Asians. McKeigue and Chaturvedi'"
found that raised death rates appear to be related to cen-
tral obesity (where a high proportion of body fat is
deposited on the abdomen and trunk) and a higher
prevalence of insulin resistance in South Asians, in addi-
tion to the standard risk factors. Additionally, Hughes
et al 28 reported evidence that people with CHD from
an ethnic minority were diagnosed later in the disease
process. Since a high proportion of South Asians are
registered with a GP, primary care can be an important
site for implementing CHD prevention strategies."
McKeigue and Chaturvedi" suggest that health proma-
tion programmes can be enhanced if the range of facili-
ties in inner city practices can be improved with trained
personnel and access to bilingual staff or interpreters.
96 J Health Serv Res Policy Volume 1 Number 2 April 1996
Review article
Primary care screening should be used to identify and
target those who are at high risk.
b) Cardio-vascular disease and stroke prevention in Afro-
Caribbeans. Weight reduction and blood pressure control
using drugs are both likely to reduce blood pressure
and hence the high rates of stroke in Afro-Carribeans."
However, since lifestyle changes such as weight reduction
are difficult to induce and maintain, blood pressure is
more effectively controlled using drugs. Not all classes
of anti-hypertensive drugs may be equally effective in
Mro-Caribbeans; drugs acting mainly on the renin-
angiotensin system such as beta-blockers and ACE inhibi-
tors may be less effective than low dose diuretics."
Despite the fact that effective interventions such as
those described above are available to reduce CHD and
stroke risk in older people, Afro-Caribbean and Asian
ethnic groups and lower social classes, there is evidence
that many people go undetected or are poorly managed
even when detected as being at high risk." Studies show-
ing success in tackling these problems include Stamler et
al 30 who vigorously targeted an at-risk population in the
USA to improve their access to hypertensive care. Tudor
Hart et aPI found that intensive GP-based case finding
and vigorous follow-up in a deprived population im-
proved health outcomes.
Gunnel and Smith'" in a review showed that coronary
artery bypass grafting (CABG) and angioplasty are effec-
tiv~ at reducing distress and improving survival for peo-
ple with symptomatic CHD. However, there is some
evidence that in England, people in more deprived areas
have lower CABG procedure rates in relation to need
than those living in more affluent areas with lower levels
of morbidity.'" Ensuring better access to CABG surgery
for people with CHD in more deprived areas may there-
fore help reduce inequalities in death rates.
Sexual health, HIV/AIDS and preventing
teenage pregnancy
As HIV and other STDs are communicated by specific
patterns of risky behaviours including unprotected sex
(vaginal and anal), or the sharing of needles, variations
exist by age, race, gender and sexual orientation." In
the USA, minority groups are over-represented among
those with HIV.
There are inequalities in teenage pregnancy rates in
young people by social class" and ethnicity" and the
young, lower social classes are more likely to suffer adverse
consequences from early unintended pregnancies."
1. Sexual health and HIV/ AIDS
The five recent reviews of this area34,37-4 0 comment on the
poor quality of the evaluative research in the area. Inter-
ventions which aim to change community norms may be
a more effective and acceptable way to reduce high-risk
behaviours and prevent HIV than attempting to bring
about change on an individual level." This approach has
been successfully applied with young people using the
Review article A systematic review of the effectiveness of health service interventions
peer-led approach to education and with gay men III
community mobilization programmes.
Effective sexual health promotion, particularly in
young people, involves the provision of clear information
on how STDs are and are not transmitted.tv" the provi-
sion of condoms, skills building (in condom use and in
sexual negotiation), assertiveness training,34.37,41 and role
playing." Programmes which are based on formal social
psychological theory are found to be more effective than
studies based on the assumption that knowledge trans-
lates directly into behavioural change or those with no
theoretical basis.37.4O.41
Interventions also need to be tailored to address
the needs of the target populations. For example, re-
views have identified outreach as a successful means of
providing health promotion to hard-to-reach groups
such as sex workers, injecting drug users, and men who
have sex in public places.
Jemmott et al 42 evaluated the effectiveness of an inner
city AIDS risk reduction programme targeted at young
black men in Philadelphia, PA, and found that 'cul-
turally relevant learning' involving videos, games and
exercises resulted in a reduction in those engaging in
risky behaviour. Behavioural interventions in the USA
involving AIDS education, cognitive-behavioural self-
management and sexual-assertion training with high-risk
gay men led to reductions in the frequency of risky
sexual behaviour (anal intercourse) and increased use of
refusal skills in white gay/bisexual men.P
2. Pregnancy prevention in young people
There is little reliable evidence of the effectiveness of
special programmes of sex education over and above
that which is routine in achieving reductions in preg-
nancy rates. 40.41 Nonetheless, successful programmes
provide basic, accurate information about risks of unpro-
tected intercourse and methods of avoiding unprotected
intercourse," involved the young person, the family and
the community'? and aimed to improve young people's
education, employment or economic situations."
Two reviews 44 •45 suggest that improving availability, ac-
cessibility and acceptability of contraceptive services may
improve effectiveness. Services should be confidential
and well advertised; be developed in collaboration with
key statutory agencies, relevant voluntary groups and
community groups; should be broad-based; should be
easily accessed outside school hours; should be staffed
by people trained to work with young people.'" should
operate informally; and be shaped to meet the needs of
the community served.
Mental health
Mental health is more profoundly affected by socio-
economic factors than many other dimensions of'health."
Health care interventions by themselves may be much
less likely to have a significant impact on health inequali-
ties in this area. Indeed, policy makers might usefully tar-
get some of their health budgets on social expenditure
(e.g. housing and employment) rather than treatment.
J Health Serv Res Policy Volume 1 Number 2 April 1996
Cochrane and Sashidhararr" identified a number of
areas in the UK where ethnic minorities suffer adverse
mental health consequences. The authors note that
primary care appears to be failing as a pathway to spe-
cialist care with referrals often more likely to be through
the criminal justice system than GPs. Cochrane and
Sashidharan"? recommend that better training should be
provided for GPs and other professionals to help them
identify and treat psychological distress in South Asian
women.
Few good evaluations of interventions aimed at im-
proving mental health in deprived populations were
identified. Some of the effective interventions used sim-
ple prompts (telephone calls and letters) to encourage
attendance at mental health clinics." An intervention
which restructured the delivery of psychiatric rehabilita-
tion to the homeless mentally ill was also found to be
effective, reducing days spent homeless and improving
measures of mental health.f
Pregnancy and childbirth
1. Social, financial and psychological support
during pregnancy and childbirth
For those on a low income there is a close association
between lack of support for health care costs and low
uptake of health care services.50 Social support, particu-
larly for mothers who are socially disadvantaged, can
reduce the likelihood of adverse outcomes for the baby,
including child alfuse/neglect, severe nappy rash, otitis
media (middle ear infection), high blood pressure and
delayed appropriate immunization." Supported mothers
are also less likely to become pregnant again in the 18
months following childbirth. However, a review of eight
RCTs including over 8000 women found that social
support for at-risk pregnant women was not associated
with any improvements in any medical outcomes of preg-
nancy such as low birth weight or prematurity.50
2. Smoking during pregnancy
Since smoking reduces birthweight, smoking cessation
programmes have a definite place in antenatal care.
Trial results show that behavioural self-help strategies are
more effective than advice and feedback in reducing
smoking in pregnancy. There is no evidence that coun-
selling is effective.50
3. Dietary modification in pregnancy
a) Folic acid supplements before and around the time of
conception for women who are at increased risk of
giving birth to a child with neural tube defects reduce
the risk of a recurrence by more than two-thirds.50 Ways
of ensuring that the intake of folic acid reaches the re-
quired level within affordable, available and palatable
food sources for each ethnic minority should be sought
within each country. This is a priority for public health
nutrition advice.
b) Other vitamin or mineral supplementation. Vitamin
D deficiency and subsequent hypocalcaemia can occur
97
A systematic review of the effectiveness of health service interventions
in women whose clothing leaves little exposed skin. Con-
trolled trials in vulnerable populations showed a reduc-
tion in hypocalcaemia (low blood calcium levels) with
vitamin D supplements. Supplementation at the end of
pregnancy should be considered in vulnerable groups
such as Asian women in Northern Europe."
4. Breastfeeding
Efforts to provide social and psychological support may
increase the likelihood that mothers will breastfeed their
babies successfully. Research suggests that continued
personal support from an individual who is knowledge-
able about breastfeeding is most effective/"
5. Screening for Chlamydia infection in high
prevalence populations
In the USA there are high rates of infection with
Chlamydia bacteria among young women, unmarried
women and black women, as well as women from low
socio-economic groups and those attending inner-eity
antenatal clinics. Congenital infection with Chlamydia
trachomatis is the most common cause of neonatal con-
junctivitis, and there is a risk (3-8%) that an infant born
to an infected mother will develop chlamydial pneumo-
nia. If the prevalence of maternal infection among preg-
nant women is greater than 6% it is cost-effective to
screen those at risk and to treat infected individuals."
Characteristics of successful interventions
aimed at improving the health of
disadvantaged groups
This section attempts to identify the characteristics of
interventions which have demonstrated success at im-
proving the health of disadvantaged groups. The charac-
teristics have been found to be common to a number
of the interventions included in a review of 94 studies of
interventions designed to reduce health inequalities," as
well as the reviews contained within the previous section
of this paper.
Intensive approaches
Vigorous or intensive approaches have been shown to
improve the identification and subsequent effective
treatment of individuals, particularly those from deprived
populations. Levine and Bone," working in the USA,
used community health workers to screen, counsel,
follow-up and monitor people with high blood pressure,
focusing their efforts on young black males recruited
from the hospital casualty department. A similar ap-
proach was used by Stamler et al." Tudor Hart et aPI
found this approach useful in tackling a wider range of
health problems such as high blood pressure, smoking,
and obesity in a UK primary care setting.
However, intensively targeting interventions is not
necessarily successful. 52
98 J Health Serv Res Policy Volume 1 Number 2 April 1996
Review article
Community commitment
A number of reviews l o,44,53 emphasised the importance of
ensuring that the community in which the intervention
was taking place supported the intervention, possibly
because of concern that focusing only on the individual
ignored the more fundamental structural determinants
of social behaviour.
Multidisciplinary approaches
A 'multidisciplinary approach' in which a number of
agencies were involved in the intervention can facilitate
the adoption of different strategies, the development
of improved information systems and harness more re-
sources. For example, Davidson et al 54 used a coalition of
local agencies to improve play areas, involve children
and adolescents in safe, supervised activities and to pro-
vide injury and violence prevention education and safety
equipment (e.g. bicycle helmets) at reasonable cost.
Ebrahim and Davey Smith" recommend the promotion
of local health alliances as well as changes in national
and fiscal legislation to achieve reductions in smoking,
dietary fat consumption, and the promotion of exercise
in attempts to reduce the risks of CHD and stroke. This
is also a strong message emerging from the reviews of
pregnancy prevention" and sexual health."
Multifaceted interventions
Several successful programmes employed a combination
of interventions to improve the health of deprived
populations. For example, intensive 'stepped care' of
hypertensives involved specialist treatment combined
with attempts to improve access to the service."
Dannenberg et al 55 found that combining education
and legislation was more effective than education alone
in modifying children's behaviour in relation to bicycle
helmet use.
Client-directed
interventions
Structured
interventions Flexible
interventions
Professionally-
directed interventions
Figure Dimensions of face-to-face interventions.
Review article A systematic review of the effectiveness of health service interventions
Face-to-face interactions
Many interventions involved face-to-face interactions
with individuals or small groups, often in an informal set-
ting. Broadly, these can be categorized in terms of two
general dimensions (Figure). The horizontal axis ranges
from structured interventions, such as a standardized
presentation to improve knowledge and attitudes to flex-
ible interventions in the form of highly individualised
meetings between clients and professionals. The vertical
axis ranges from interventions tailored to the clients'
expressed preferences or established needs, to profes-
sionally directed interventions.
There is no clear evidence as to when it is appropriate
to deliver an intervention to groups and when to deliver
it to individuals.
Settings
Interventions in a variety of settings have been shown to
be effective and it is likely that this depends on other
contextual factors. For example, many successful inter-
ventions involved home visiting. However, these varied
greatly by who was visited at home; by whom they were
visited; what was done during the visit; how long the
home visits lasted and how frequently they occurred and
what they were trying to achieve.
However, home visiting was not associated with an in-
crease in uptake of breast cancer screening in an ethnic
minority group in one study."
Prior needs assessment to inform intervention
design
Some studies reported a form of needs assessmen t of the
target group to allow tailoring of the intervention. For
example, Colver et aP3 identified hazards in family
homes before providing specific advice on preventing
domestic accidents.
Ensuring interventions are culturally
appropriate
A related issue is the need for sensitivity to the culture of
the target group. For example, McAvoy and Raza'" used
an identifiably Muslim assistant to visit women of South
Asian Muslim descent at home and produced videos and
leaflets in relevant languages to improve uptake of cervi-
cal screening in this group. However, Hoare et al 55 found
that home visiting of Bangladeshi and Pakistani women
by culturally matched linkworkers failed to improve the
uptake rates of breast screening.
The importance of the agent delivering the
intervention
The people who deliver the intervention may be as im-
portant as the intervention and its setting. Several suc-
cessful interventions were carried out by non-professional
volunteers, often recruited from the target population
and trained to perform a task such as delivering a par-
ticular message. For example, Freeborn et al 57 used
J Health Serv Res Policy Volume 1 Number 2 April 1996
trained outreach workers recruited from disadvantaged
communities to encourage appropriate use of ambula-
tory care services by other low-income families.
Training those delivering the intervention
A number of reviews highlighted the importance of
training the individuals delivering the intervention,
whether they were non-professional volunteers or not.
For example, Sanders" recommends training nurses, GPs
and other health care professionals on smoking cessation
techniques and Oakley et aPI emphasise the importance
of training carers when they are running exercise classes
for older people to help them maintain balancing skills.
Freeborn et al 57 trained their outreach workers to
address a number of issues to improve the uptake of
ambulatory care services by families with low income.
Support materials
Several interventions used educational materials such as
booklets and videos. However, the impact of these mate-
rials has rarely been assessed specifically. In some cir-
cumstances, educational materials may actually increase
inequalities in health. For example, Hibbard et al58 gave
an educational booklet to pregnant women and encour-
aged them to attend mothercraft classes and found
that women in higher social classes showed far greater
improvements in knowledge between early and late
pregnancy than those in lower social classes.
Developing skills
Some of the interventions aimed to develop skills which
might facilitate the adoption of more health-promoting
activity. For example, Kelly et al 59 used group sessions to
help disadvantaged young Afro-American women to rec-
ognize personal triggers to risk-taking sexual behaviour,
and to develop assertive techniques which would enable
them to reduce their risk of HIV infection.
Provision of material support and resources
Some interventions offered material support in attempts
to reduce barriers to the uptake of health services or to
increase participation in group activities. This included
free transportation to antenatal and child health clinics
for women living in poor rural areas. 50
Setting up a citizens' advice bureau in a primary
care or mental health day centre has been shown to help
people in disadvantaged groups gain greater access to
advice and resources, including welfare payments or
benefits. 51
Provision of prompts and reminders to attend
Several successful interventions used prompts or per-
sonal reminders to encourage people to use services or
keep appointments. PIanos and Glenwick" found that
attendance rates for a scheduled mental health assess-
ment were higher with a telephone or postal reminder
1 or 2 days ahead.
99
A systematic review of the effectiveness of health service interventions Review article

Discussion
The interventions delivered
The evidence summarized in the previous two main sec-
• Would an assessment of the target group's needs
tions has shown that there are a range of interventions
help shape the interventions appropriately?
which can be promoted through health services to re-
• Are the intended interventions acceptable, and cul-
duce health inequalities. Two clear messages emerge.
turally and educationally appropriate to the target
Firstly, if a health intervention is being used, there
group? (A pilot test might be advisable to assess
should be reasonable evidence that it has an impact on
this) .
health status. Secondly, having identified effective inter-
• Will members of the target group be involved in
ventions, care needs to be given to the way in which the
the design or development of the interventions?
intervention is delivered and the characteristics of an
• Will the interventions be fixed (delivered in the
implementation programme. These characteristics are
same way to everyone) or will they be flexibly
summarized in the Box.
delivered?
However, many of the interventions reviewed were
• Will the form and content of the intervention be
complex and involved a number of longitudinal, inter-
directed by the target group or by the provider?
personal and group interactions with people from de-
• How many component interventions will be
prived communities. It is often difficult to attribute
involved?
cause and effect from such evaluations, and it has been
• What opportunities will there be to reinforce the
suggested that a 'pluralistic' approach to evaluation is
in terventions?
needed for this form of intervention, incorporating both
qualitative and quantitative methods, as appropriate. 52 Setting and participants
Furthermore, only a few of the evaluations reviewed
• Is the setting accessible to and accepted by the
were of good quality and a number of common but
target audience?
avoidable problems with the design and execution of
• How homogeneous is the population of interest?
studies were identified, and are summarized below:
Would it be more appropriate to deliver the inter-
1. A number of studies gave only a limited description ventions to individuals or to groups? If to groups,
of the nature and content of the interventions used. what might be their best composition and size?
2. The sample sizes used were often too small.
Individual delivering the intervention
3. Many evaluations were conducted without any
attempt to identify a control group. • Who might be the most appropriate agent to de-
4. When a control group was included, many studies liver the interventions (e.g. health professional,
failed to carry out and/or report baseline measurements. teacher, community volunteer, trained peer)?
5. The follow-up periods used were often too short to • How credible are these people to the target group?
enable the potential value of an intervention to be assessed. How readily does the target group identify with
6. In some studies which randomly allocated people these people and what personal skills, training and
to different study groups, the randomisation was broken support might they need?
in the reporting of results.
Support materials/resources
In view of these points, care must be taken not to over-
• If the intervention requires the use of written or
analyse the study results in an attempt to extract
audiovisual materials what are the most appropriate
lessons for practice that are notjustified by the evidence.
materials (e.g. leaflets, videos, audiocassettes) con-
For example, although it might be tempting to draw con-
sidering the language abilities, literacy skills and
clusions about the relative effectiveness of different ap-
preferences of the target group?
proaches to increasing the uptake of cervical screening
• Would the provision of assistance with transport
among disadvantaged women, the relatively small number
and/or child care make it easier for members of
of studies, their heterogeneity and complexity would
the target group to attend the health care interven-
make any firm conclusions unreliable.
tion?
We did not systematically review the results of observa-
tional studies of health service interventions aimed to
Box Checklist of points to consider when designing
improve health in disadvantaged groups. This reflects
an intervention
both time constraints and the problems of attributing
changes in health outcomes to the interventions in ob-
servational study designs. In order to assess the effect of health coverage programmes for the poor uninsured,
excluding non-experimental designs, recent reviews in pre-natal care, pre-school use of preventive services, early
this area which did not exclude observational studies education, nutritional supplementation of children or
were examined.v" Of 98 papers in a major Dutch pregnant women, stress management, general preven-
review," were excluded because they did not fit at tive mass media and direct health education campaigns,
least one of the inclusion criteria and only three of the unemployment-related interventions, patient informa-
studies included in Bunton et al" were included in the tion leaflets and advocacy especially for ethnic minority
current review. groups. The results of evaluations of these interventions
The excluded studies examined interventions such as seem broadly in line with those reported in this review.

100 J Health Serv Res Policy Volume 1 Number 2 April 1996

Review article A systematic review of the effectiveness of health service interventions
Two population-wide programmes in the USA de-
signed to tackle the effects of poverty on growth, devel-
opment and education have been extensively evaluated
and are worthy of mention. The Special Supplemental
Food Programme for Women, Infants and Children
(WIC) was initiated in 1972 to improve the nutrition of
low-income women and children who had at least one
nutritional risk factor. This provides packages of highly
nutritious food and nutrition education, along with the
provision of health services to low income nutritionally
at-risk women who are pregnant or breast feeding and
children up to the age of five. An evaluation of this pro-
gramme using a longitudinal study from 1980-1985
showed that there was a statistically significant correlation
between the intensity of the WIC service and health-
related outcomes such as mean birthweight and reduc-
tion in late fetal death, particularly in the poorest and
most high risk groups. 53 A recent meta-analysis of various
evaluations of the WIC programme estimated that pro-
viding the WIC programme to pregnant women reduced
low birth weight and very low birth weight rates in disad-
vantaged groups by 25% and 44% respectively and would
pay for itself by savings in medical costs."
A second major welfare programme started in 1965 in
the USA. Project Head Start provided pre-school chil-
dren and their families with education, health and social
services. There have been several longitudinal studies
evaluating the effect of pre-school education which col-
lectively appear to show short- and long-term benefits on
cognitive and health-related outcomes. 55•56 Both these
programmes have characteristics which have been iden-
tified from the trials as being associated with success in
reducing variations in health, in particular their intensity
or targeting of those in need and their broad, multi-
disciplinary perspective including, for example, social
services, nutrition and health-related interventions.
It should not be assumed that the general application
of an effective health care intervention will reduce in-
equalities. If, for example, uptake or effect differs by so-
cial group inequalities may actually widen. Experimental
studies in the areas of accident prevention" and the use
of educational booklets for pregnant womerr" showed
greater impact in people from higher social classes. A
cross-sectional study examining the effect of an interven-
tion to increase immunization uptake in a region of the
UK showed that although overall coverage for pertussis,
diphtheria and measles immunization rose very signifi-
cantly, inequalities between deprived and affluent areas
persisted or became wider." This highlights the impor-
tance of targeting interventions and evaluating their
impact.
Community development programmes aimed at re-
ducing inequalities in health may also be effective. How-
ever, since few of these have been evaluated, they are
not dealt with in this review.
Conclusions
Significant progress has been made since the establish-
ment of the NHS in the UK in reducing the geographical
J Health Serv Res Policy Volume 1 Number 2 April 1996
variations in the provision of services and in improving
health care for people who are poor, principally through
free access to health care and attempts to ensure a more
equitable distribution of health services.'" The provision
of universal access to health care free at the point of
delivery can itself be considered an intervention to re-
duce variations in health. However, evidence also exists
to show that, while removing financial barriers may be a
necessary condition to improving equity, it is not in itself
sufficient. 59
This review has shown that interventions to reduce
health inequalities can be evaluated using rigorous
experimental methods such as randomized controlled
trials. Without such evaluation and monitoring, invest-
ments in such activities, whilst appearing to address this
important agenda, may be having little impact and be
better used in other ways. It is important that strategies
developed to reduce inequalities are not assumed to
be having a positive impact simply because the aim is
'progressive' and so rigorous evaluations of promising
interventions are important.
This review has concentrated only on interventions
which health services can implement alone or in collabo-
ration with other agencies. Since it is likely that non-
health service factors contribute most to health
inequalities in developed countries, they are likely to
have a crucial role to play in the reduction of inequalities
in health. Strategies available to tackle inequalities in
health range from social and economic policy aimed at
addressing the more fundamental inequalities in society
such as those of income distribution, to health care inter-
ventions such as those included in this paper which
essentially leave the system which generates the ine-
qualities intact and target health services at those at
greatest risk." The relative effectiveness and efficiency of
different approaches is an empirical question which re-
quires more research; for example, to be in a position to
estimate the proportion of the total variation in health
which could be reduced by each approach. In the ab-
sence of comprehensive empirical evidence, the ultimate
choice of strategy is political.
Note
The full text of the review is available from the NHS Centre for Reviews
and Dissemination at the University if York, UK.
Acknowledgements
We are grateful for the advice and support given by George Davey Smith,
Louise Gunning-Scheppers, Jennie Popay, Margaret Whitehead,
Annemieke Gepkens,Julie Glanville, Sally Baker and Paula Press.
The NHS Centre for Reviews and Dissemination is funded by the
NHS Executive and the Health Departments of Scotland, Wales and
Northern Ireland; a contribution to the Centre is also made by the
University of York. The views expressed in this publication are those of
the authors and not necessarily those of the NHS Executive or the Health
Departments of Scotland, Wales and Northern Ireland.
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