Palfrey, C.The Future for Health Promotion. Bristol: Policy Press. 2018. 224 pp £24.99 (pbk) £24.99 (ebk) ISBN 978‐1447341239

Abstract

The Future for Health Promotion is the most recent monograph from Colin Palfrey. He sets out to ‘examine the evidence relating to the effectiveness and cost-effectiveness of health promotion policies and projects, specifically but not exclusively in the UK’ (p.1). Highlighting the political context in which there is pressure on the National Health Service to meet an increasing demand for services with decreasing resources, he concludes that health promotion interventions have produced little research-based evidence as to their effectiveness. In order to make this case, Palfrey looks critically at methods of evaluation used within health promotion (chapter 3), strategies for health promotion in each country of the UK (chapter 4) and the principles of health economics (chapter 5). Other chapters provide the historical (chapter 2) and international (chapter 7) context for health promotion in the UK, as well as looking in detail at mental health promotion (chapter 6). The reader is encouraged to question what the purposes of health promotion are, and to recognise the significance of social determinants of health. Within each chapter, Palfrey summarises important reports, policies and conferences, and defines key terms, effectively positioning this book as an introductory text. Bearing this in mind, this intended audience may feel frustrated by the lack of clear structure. Sections within chapters, while interesting in their own right, do not always link to form a coherent argument that one can follow throughout the book. Additional signposting, and in some cases clearer introductions to the subject of each chapter, would be a helpful addition. Although the various chapters include much useful descriptive content (such as lists of mental health charities and settings for mental health promotion), their relevance in this particular text are not always made clear. This is particularly evident in the concluding chapter, which introduces additional topics, rather than drawing together threads from throughout the book. Palfrey attempts to look critically at the stated aims of health promotion, particularly empowerment. He questions how far people are ‘empowered’ if the purpose of health promotion initiatives is to deter people from making the ‘wrong’ choices (p.16). I would agree that the term empowerment needs to be considered critically, and Palfrey does acknowledge that this framing of health promotion ignores the impact structural forces. However, as has previously been argued, analysing the use of ‘empowerment’ involves a multidimensional conception of power (Robertson and Minkler 1994). While it is relevant to question the terminology involved in various initiatives, paying attention to the operation of power allows us to understand why behavioural health promotion is so appealing to governments (Baum and Fisher 2014). Clearly it is important to assess this book on its own terms; Palfrey is writing as an expert on policy evaluation. Nevertheless, readers of this journal may wish to go beyond this text in order to further problematise the underlying principles of health promotion. The issue of how best to evaluate policy is also fundamental to this book. Palfrey is concerned that health promotion policies often have unmeasurable objectives. He critiques performance indicators and randomised controlled trials, pointing to the risk of unjustified inferences in the case of the former and questioning how the latter are evaluated. Specifically, he suggests that too often those working in public health accept the project output as the endpoint, rather than evaluating the outcome in terms of the set objectives. Although this is an interesting point, there seems to be a disconnection between the hypothetical illustrative example, and some of the examples of studies briefly discussed. Palfrey also acknowledges the possible contribution of qualitative research, although he glosses over the potentialities of methods such as interviews and observation with superficial ‘positives’ and ‘negatives’. I was left with the sense that Palfrey has missed the opportunity to consider pertinent issues regarding the future of health promotion research in more depth, at the expense of providing a broad overview. Throughout the book, Palfrey makes claims regarding the lack of evidence or lack of consideration on several key issues. However, he appears to ignore relevant examples. For instance, the introductory chapter refers to ‘the dearth of empirical studies gathering evidence from people living in areas of relative deprivation about their lifestyle’ (p.13). There are many qualitative studies which do just that, and which also address attitudes towards government policies and health promotion initiatives. By not examining this evidence, Palfrey is limited in the extent to which he is able to meet his own aim with this book.