Rankin David, Backett-Milburn Kathryn, Platt Stephen
The University of Edinburgh, Medical School, Edinburgh EH8 9AG, UK.
Soc Sci Med. 2009 Mar;68(5):925-32. doi: 10.1016/j.socscimed.2008.12.013. Epub 2009 Jan 10.
Little is known about how health practitioners tasked with tackling health inequalities account for their own programmes and actions. This paper attempts to address this gap by drawing on data collected in the course of an evaluation of the Healthy Living Centre (HLC) programme, which was designed to address the wider determinants of health, in particular social exclusion and socioeconomic disadvantage, through targeting services at the most deprived local communities. Six Scottish HLC case studies explored in depth how HLC practitioners conceptualised 'health inequalities' and applied the construct to legitimate their public health and health improvement work. Practitioners drew on multiple explanations of health inequalities, sought to apply holistic approaches to service provision, and developed activities that took account of classed practices intended to overcome class-related disempowerment and stigma. They discussed the challenges of positioning services to appeal to and reach target groups and the difficulties in assessing the impact of their work on reducing health inequalities. Responses to tackling inequalities were variable across time and between HLCs, resulting from uneven learning about target groups and their changing needs, an evolving policy agenda and consideration given to the longer-term sustainability of HLC sites. Although practitioners' work to address health inequalities was limited by the programme's focus on working with disadvantaged groups, findings illustrate how classed practices are linked to the challenges of attracting and successfully engaging with such groups. Practitioner accounts highlighted the importance of gaining acceptance to overcome barriers to engagement with disadvantaged communities, the time required to achieve a satisfactory level of engagement, the proximity of service providers to clients and the adaptability of services necessary to address evolving needs.
对于负责解决健康不平等问题的医疗从业者如何解释他们自己的项目和行动，我们所知甚少。本文试图通过利用在健康生活中心（HLC）项目评估过程中收集的数据来填补这一空白。该项目旨在通过针对最贫困的当地社区提供服务，解决更广泛的健康决定因素，特别是社会排斥和社会经济劣势。六项苏格兰HLC案例研究深入探讨了HLC从业者如何将“健康不平等”概念化，并运用这一概念来证明其公共卫生和健康改善工作的合理性。从业者借鉴了对健康不平等的多种解释，试图采用整体方法提供服务，并开展了一些活动，这些活动考虑到了旨在克服与阶级相关的无权和耻辱感的阶级实践。他们讨论了定位服务以吸引和覆盖目标群体的挑战，以及评估其工作对减少健康不平等的影响的困难。应对不平等的措施在不同时间和不同HLC之间存在差异，这是由于对目标群体及其不断变化的需求的学习不均衡、政策议程的演变以及对HLC场所长期可持续性的考虑所致。尽管从业者解决健康不平等问题的工作受到该项目专注于与弱势群体合作的限制，但研究结果表明了阶级实践与吸引此类群体并成功与之互动的挑战之间的联系。从业者的叙述强调了获得认可以克服与弱势社区互动障碍的重要性、达到令人满意的互动水平所需的时间、服务提供者与客户的接近程度以及满足不断变化的需求所需的服务适应性。
