Health Education Research, Vol. 17, No. 3, 376-377,
June 2002
© 2002 Oxford University Press
BOOK REVIEW |
Health Promotion: Effectiveness, Efficiency and Equity, 3rd edn
Keith Tones and Sylvia Tilford Nelson Thornes, Cheltenham, 2001 524 pp, ISBN 0-7487-4527-0 (pb)
Research Centre for Health Promotion
University of Bergen
Norway
My starting point for this book review was to rummage my bookshelves for good old, tried and true Health Education: Effectiveness and Efficiency, by Tones, Tilford and Robinson (1990).
Right off, the physical contrast of the First and Third Editions is notable with regard to the thickness, width, length and density (the Third Edition has over 700 words on its densest pages!).
The result is a Third Edition that is easily twice as long as the First Edition and harder to read than the First Edition—harder not because the difficulty level has been raised, but simply because tired old eyes have difficulty jumping to the correct lines in the tightly packed columns of the book. I don't know the first thing about the economics of book publishing, but I suggest nevertheless that the Fourth Edition be considered as a two volume work, with much more white space on the pages.
But that is enough complaining about packaging—what about substance?
The basic structure and flow of the Third Edition is similar to the First Edition, and that is indeed positive (I cannot compare the Third and Second Editions, as my copy of the Second has disappeared from my bookshelves). Both books begin with Introductions, of course, but the one provided in the Third Edition is particularly well worth reading. It sets the tone for the book, and the tone is...exclamatory! Tones and Tilford feel quite obviously a degree of passion for their points of view, they let the passion through and it is infective. There are many exclamation marks in my copy of the book, those of the authors and mine in the margins. I really do like this `personality' of the book very much.
With this book the authors' continue their previous emphasis on the need for effective and ever more efficient interventions, built on sound theoretical frameworks. These themes are taken seriously, and issues of effectiveness, efficiency and the central role of theory are taken up repeatedly throughout the book. There is also some emphasis on equity, but this theme does not receive near the degree of emphasis that effectiveness and efficiency do. The inclusion of `equity' in the book's subtitle raised this reviewer's hopes for a deeper treatment of the subject than is provided. There are a few other disappointments and these are reported below, but only after a happy report about the book's significant strengths.
Prime among these is that a great deal of the book is devoted to providing examples of solid health promotion intervention in a variety of settings and defining the conditions necessary to success. In my view, this book stands out from all other `competitors' with regard to the depth and soundness of analysis that is provided. This is not merely a compendium of health promotion exemplars, but an analysis of the conditions that are essential to the development and delivery of quality health promotion programmes. The authors expect the reader to work—the level of complexity is high and this is not a once-over-lightly-with-a-highlighter book!
Another significant strength is Chapter 1, worth the price of the book all by itself. All the key concepts that are needed to follow the rest of the book are presented with the depth and critical analysis that characterize the whole work. The heart of the chapter, and of the book, is an empowerment model of health promotion, in which education and policy are inputs that provide the individual and environmental conditions necessary to health. Despite some changes in terminology, the empowerment model is almost identical to the health promotion model around which the First Edition was organized. That there are almost no changes in the model 15 years after it was first proposed does not indicate laziness or lack of development on the part of the authors. It reflects, rather, the solidness of the original and simple idea—that health promotion is distinguishable from other approaches to managing health by its emphasis on the synergism of health education and healthy public policy.
No single book can serve all the needs of its readers and it is not fair to be too critical because of what a book does not contain. However, this reviewer cannot help but regret a hole in the work, a hole that perhaps only another book can fill.
Tones and Tilford define a most simple, and thereby elegant, anatomy for health promotion: it is the product of health education and healthy public policy. There is not, however, equal attention to these two elements in the book nor, perhaps, is it reasonable to expect there to be. The foundation for the book is health education, not healthy public policy.
The result is that a number of critical questions about effectiveness and efficiency in health promotion are not taken up at all. How can health education practice and research influence policy-making processes? What are the rational and irrational aspects of those processes, and when and how does `evidence' make a difference? What are the most effective lobbying, advocacy and mediation strategies in policy influencing exercises? What are the most effective ways for NGOs to influence policy? What roles do think tanks play in the development of policy and how can health promotion learn from what they do well? How do the World Bank and the IMF influence health policy, and how can the health promotion community influence the World Bank and the IMF? What are the answers to parallel questions at the national, regional and local levels?
As this reviewer works in an interdisciplinary research center with policy analysts from the political and social sciences, he is aware of (though not familiar with) a quite large literature on these and similar questions, the answers to which are critical if the theoretical synergy of health education and healthy public policy is to be better realized. There is no question but that Tones and Tilford have more than a passing acquaintanceship with these matters, as demonstrated by a few well-written pages early in the book and scattered throughout it. Perhaps the answer is a two volume Fourth Edition, providing the space needed to expand on the second term in the health promotion equation—effectiveness and efficiency in creating and maintaining healthier public policy.
However, that is another book; what can be said in summary about this book? Simply that it is a very good, advanced text on health promotion. It calls for the creation of healthy public policy, but does not dwell on how this may be achieved. It calls for effective and efficient interventions in a wide range of settings, and is brilliant in showing how this may be achieved.
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