CONSTRUCTING THE EVIDENCE BASE ON THE SOCIAL DETERMINANTS OF HEALTH
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Constructing the evidence base on
the social determinants of health:
A guide
Authors:
Josiane Bonnefoy, Antony Morgan, Michael P. Kelly
Jennifer Butt, Vivian Bergman
With Peter Tugwell, Vivian Robinson, Mark Exworthy, Johan Mackenbach,
Jennie Popay, Catherine Pope, Thelma Narayan, Landon Myer,
Sarah Simpson, Tanja Houweling, Liliana Jadue
November 2007
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Constructing the evidence base on the social determinants of health: A guide
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Constructing the evidence base on the social determinants of health: A guide
The Measurement and Evidence Knowledge Network (MEKN) of the WHO
Commission on Social Determinants of Health is co-chaired by Michael P. Kelly and
Josiane Bonnefoy. The hub which coordinates the MEKN is run by Universidad del
Desarrollo, Chile, and National Institute for Health and Clinical Excellence, United
Kingdom.
Five key words for indexing purposes:
Social determinants of health, health equity, evidence into policy, evidence into
practice, inequalities/ inequities in health.
Statement on conflict of interest:
We declare that we have no conflicts of interest.
This work was made possible through funding provided by the World Health
Organization (WHO) and undertaken as work for the Measurement and Evidence
Knowledge Network (MEKN) established as part of the WHO Commission on Social
Determinants of Health. The views presented in this guide are those of the authors
and do not necessarily represent the decisions, policy or views of WHO or
Commissioners.
The authors would like to thank Somsak Chunharas, John Lynch, Carlos Silva,
Cesar G Victora and Michael C Wolfson for their peer reviews of the MEKN final
report.
The authors are also grateful for comments received both on the MEKN
scoping paper and the draft final report from Knowledge Network colleagues
Ted Schrecker and Ron Labonte (Globalization) and Piroska Ostlin and Gita
Sen (Women and Gender Equity).
The authors are very pleased to acknowledge our Measurement and Evidence
Knowledge Network colleagues fortheir involvement in the network meetings
and their contributions to and comments on the different pieces of work.
2
Constructing the evidence base on the social determinants of health: A guide
11
12
13
14
15
Learning from practice................................................
145
11.1
Why do we need to collect knowledge from practice9
146
11.2
What do we know about the features ofan effective system for learningfrom practice?.. 148
11.3
What sorts ofinformation should be collected?............................................................ 149
11.4
Related reading
150
11.5
Specific tools....
151
Monitoring........
152
12.1
Introduction
152
12.2
Use ofdata to monitor health inequities................
153
12.3
Sources ofhealth data.........................................
164
12.4
Issues in interpreting key equity stratifiers............
174
12.5
Special issues in low and middle income countries.
184
12.6
Special issues in high income countries................
189
12.7
Improvements in monitoring systems....................
194
12.8
Illustrative case studies.......................................
195
12.9
Related reading
196
199
Further issues for consideration
13.1
Attribution ofeffects and outcomes.........................
199
13.2
The challenge ofpolicy...........................................
205
13.3
Hierarchies ofevidence..........................................
206
13.4
Equity: relative or absolute?...................................
208
13.5
Where further research and development is required
209
211
Conclusion.
14.1
Social structure and the operation ofthe determinants ofhealth inequities
211
14.2
Towards a causal hypothesis
............
214
14.3
A pleafor action....................................................................................
218
References
Appendix I - Illustrative case studies.
220
244
Case study 1: United Kingdom - Using evidence to inform health policy: the Acheson Inquiry ...246
Case study 2: Brazil, Peru and United Republic of Tanzania - Failure to equity proof interventions
for children in low and middle income countries....................................................................... 248
Case study 3: Bolivia — Evaluating Bolivia’s Social Investment Fund..............................
250
Case study 4: Brazil - Use ofsurvey data to determine and refine state-wide policies and
programmes: persistent inequities between rich and poor...............................................
255
Case study' 5: Canada-A decade ofchildren’s policies based on evidence (1990-2001)...
257
Case study 6: Mexico - Use ofevidence to reform national health system........................
261
Case study 7: Thailand - Introduction of universal health coverage................................
264
Case study 8: Various countries - Linking research and evidence to policy-making.........
267
5
Constructing the evidence base on the social determinants of health: A guide
Case study 9: Thailand - Use of locally-defined health determinants to push for change, Mun River
dam......................................................................................................................................... 271
Case study 10: Brazil and Chile Use ofnational conferences to bring together policy and
evidence...........................................................................................................................
273
Case study 11: Uganda - Community-based monitoring and evaluation of Poverty Action Fund 275
Case study 12: Various countries - Synthesis ofqualitative studies ofeffectiveness oftuberculosis
treatment.................................................................................................................................. 277
Case study 13: Various countries - Synthesis ofdifferent types ofevidence to assess the impact of
schoolfeeding..........................................................................................................................282
Case study 14: United Kingdom - Development ofevidence based guidance.
286
Case study 15: Slovenia - Health impact assessment ofagriculture, food and nutrition policies.. 288
Case study 16: United Kingdom - Health impact assessment ofa housing estate regeneration
project..................................................................................................................................
293
Case study 17: Mexico - Use ofmonitoring and evaluation to continuously improve the
Oportunidades programme.................................................................................................... 296
Case study 18: Sweden - Use ofevidence to develop the intersectoral National Public Health
Strategy and the challenges of monitoring its implementation.................................................
298
Case study 19: Bangladesh - Evaluating the Foodfor Education programme using existing data
sources.................................................................................................................................... 301
Case study 20: Kenya - Impact ofgrassroots involvement in gathering data on successful
introduction ofchange....................................................................................................
303
Case study 21: The Netherlands - Introduction ofa multi-level surveillance system for monitoring
health inequalities..................................................................................................................... 305
Appendix II - Low and middle income countries by income group, equity and health
indicators, and data sources................................................................................................... 309
Appendix III - Content of standard surveys
325
Appendix IV - Recommendations from MEKN final report
332
Appendix V - List of abbreviations
334
6
Constructing the evidence base on the social determinants of health: A guide
Constructing the evidence base on the social
determinants of health:
A guide
i. Introduction
This guide is designed for practitioners interested in developing and implementing
policies and programmes to tackle the social determinants of health inequities. It sets
out state of the art recommendations on how best to measure the social
determinants of health and the most effective ways of constructing an evidence base
which provides the basis for translating evidence into political action. It is the final
product of the work of the Measurement and Evidence Knowledge Network of the
World Health Organization’s Commission on Social Determinants of Health (CSDH).
Work of the Measurement and Evidence Knowledge Network
In March 2005, as part of the launch of the CSDH in Santiago, Chile, the World
Health Organization (WHO) sponsored an expert consultation on measurement
which set out some initial parameters for the work of the Measurement and Evidence
Knowledge Network (MEKN). Participants at this consultation represented a broad
range of constituencies involved in the evaluation of knowledge and the application of
diverse sources and types of evidence to policies. They began discussions about
developing an expert consensus on the sources of evidence for the social
determinants of health and health inequities (Kawachi, 2005).
MEKN was established in late 2005 and based on two organizational co-hubs:
•
National Institute for Health and Clinical Excellence (NICE), UK:
Prof Michael Kelly and Mr Antony Morgan.
•
Universidad del Desarrollo, Chile:
Dr Josiane Bonnefoy, Dr Liliana Jadue, Ms Vivian Bergman,
and Ms Francisca Florenzano.
MEKN’s members were:
•
Dr Francisco Espejo, UN World Food Program, Italy
7
Constructing the evidence base on the social determinants of health: A guide
•
Dr Mark Exworthy, University of London, United Kingdom
•
Dr Gao Jun, Ministry of Health, China
•
Prof Ichiro Kawachi, Harvard University, United States
•
Prof Johan Mackenbach, Erasmus University, The Netherlands
•
Dr Landon Myer, University of Cape Town, South Africa
•
Dr Thelma Narayan, Community Health Cell, India
•
Prof Jennie Popay, Lancaster University, United Kingdom
•
Dr Peter Tugwell, University of Ottawa, Canada
•
Two representatives from the CSDH Secretariat: Ms Sarah Simpson
(WHO/CSDH - Geneva) and Dr Tanja Houweling (University College
London).
The main objective of MEKN was to collect, assess and synthesize global knowledge
on existing methodologies to evaluate the effectiveness of policies, interventions and
actions on social determinants of health which are aimed at improving health
outcomes and health equity.
The MEKN did its work through network meetings, email / teleconference
discussions, participation in the work of the themed knowledge networks and the
participation of MEKN members in wider networks and projects.
MEKN published the following papers which were used in constructing this guide:
1. The Development of the Evidence Base about the Social Determinants of Health
(Kelly et al., 2006a) (the scoping paper). This discussion paper describes a series
of methodological, theoretical and epistemological principles that should inform
the development of the evidence base about the social determinants of health. It
was directed mainly at the work of the other thematic knowledge networks (KNs).
It includes a commitment to finding the best possible evidence about the social
determinants. It develops the principle that a variety of types of evidence are
required for policy-making. This discussion paper was written in consultation with
Commissioners, other KNs and Commission stakeholders. The key principles
from this paper are summarized in chapter 1.
2. Guide for the Knowledge Networks for the Presentation of Reports and Evidence
about the Social Determinants of Health (Kelly et al., 2006b). This was prepared
8
Constructing the evidence base on the social determinants of health: A guide
by the MEKN co-hubs and the Secretariat of the Commission in collaboration with
MEKN members and in consultation with KNs. The purpose of the guide was to
help facilitate inclusion in the KNs’ work of a broad scope of evidence gathered
using a coherent approach, and to assist in presenting the output of the work of
the knowledge networks.
3. The social determinants of health: Developing an evidence base for political
action (Kelly et al., 2007). This is the final report of the MEKN and summarizes
the contents of this guide. However it has a different focus from the guide in that it
is aimed at policy-makers and researchers as well as practitioners. The
recommendations from the report are repeated in appendix V of this guide.
Structure of the guide
The guide is divided into two parts:
I
Issues and principles
II
Tools and techniques.
The first part contains three chapters which look at a series of overarching principles
and issues relating to developing the evidence base in the social determinants of
health: The challenge of measurement and evidence about the social determinants of
health; Taking an evidence based approach; and Gaps and gradients.
In the first chapter in the second part we outline a Framework for developing,
implementing, monitoring and evaluating policy. In the following chapters we look at
each of the five parts of this framework in turn: Getting social determinants on the
policy agenda; Generating evidence for policy and practice; Evidence synthesis and
action; Effective implementation and evaluation; and Learning from practice. We then
look at Monitoring, which underpins the whole framework.
We then review some Further issues for consideration which were raised in the guide
and through the MEKN’s work and in the Conclusion we describe a possible general
causal pathway.
At the end of each chapter, where relevant, we list the case studies in appendix I
which illustrate the themes of the chapter and we give a list of tools which readers
may find helpful to implement the suggestions in the guide.
9
Constructing the evidence base on the social determinants of health: A guide
Issues and Principles
10
Constructing the evidence base on the social determinants of health: A guide
1
The challenge of measurement and evidence
about the social determinants of health
The social determinants of health (SDH) must be addressed through effective
policies based on sound global and local evidence. However, generating,
synthesizing and interpreting evidence on the SDH is a challenge. Implementing
programmes to affect SDH and monitoring their impact is feasible but also difficult.
This chapter outlines the nature of the challenge. First, six conceptual and theoretical
problems relating to measurement and evidence are outlined. Second, eight
principles for dealing with these problems are described.
1.1
Conceptual and theoretical issues
1.1.1
Causal pathways
The social determinants of health approach uses the language of causation. This is
entirely appropriate especially in the context of taking action to reverse the iniquitous
health-damaging effects of the social determinants. The precise ways in which the
social determinants of health operate is an area of considerable research interest.
Much is known. It is clear that at population and individual level poor health is linked to
social and economic disadvantage. The unequal distribution of the social and economic
determinants of health such as income, employment, education, housing and
environment produce inequities in health (Graham, 2000). The determinants are
systematically associated with social disadvantage and marginalization (Braveman,
2003). However, while the general relationship between social factors and health is well
established (Marmot & Wilkinson, 1999; Solar & Irwin, 2007), the relationship is not
precisely understood in causal pathway terms (Shaw et al., 1999). Consequently the
policy imperatives necessary to reduce inequities in health are not easily deduced from
the known data. Although the precise causal pathways are not yet fully understood,
enough is known in many areas, and the evidence is good enough, for us to take
effective action. Nevertheless in the long run it is important to develop better
understandings of the causal pathways.
11
Constructing the evidence base on the social determinants of health: A guide
At least four groups of theories have been proposed to explain inequities in health and
its relation to socioeconomic position. The materialist/structuralist theory proposes that
inadequacy in individual income levels leads to a lack of resources to cope with
stressors of life and thus produces ill health (Goldberg et al., 2003; Frohlich et al., 2001;
Macintyre, 1997). The psycho-social model proposes that discrimination based on one’s
place in the social hierarchy causes stressors of various kinds which lead to a
neuroendocrine response that produces disease (Karasek, 1996; Siegrist & Marmot,
2004; Evans & Stoddart, 2003; Goldberg et al., 2003). The social production of health
model is based on the premise that capitalist priorities for accumulating wealth, power,
prestige and material assets are achieved at the cost of the disadvantaged. The eco-
social theory brings together psycho-social and social production of health models, and
looks at how social and physical environments interact with biology and how individuals
‘embody’ aspects of the contexts in which they live and work (Goldberg et al., 2003;
Krieger, 2001). It builds on the ‘collective lifestyles’ approach and the neo-Weberian
theory that lifestyle choices are influenced by life chances defined by the environment in
which people live (Frohlich, 2001; Cockerham, 1997).
What is missing in these theoretical accounts is the underlying certainty about cause
and effect associated with some other branches of science including clinical
medicine. We see instead mostly associational or probabilistic types of explanations
(Link & Phelan, 2005; Mechanic et al., 2005). Of course clinical medicine has its own
uncertainties in relation to causation. Etiology is sometimes unknown, tenuous,
partial and often multifaceted, and morbidities are frequently present in ways which
are not typical, as co-morbidities or as multiple morbidities. The effects of treatments
are also uncertain (Chalmers, 2004). The disease categories used by medicine to
describe pathology are nominalist rather than essentialist and therefore change and
evolve over time, reflecting new knowledge and understanding. Data and evidence
are surrounded by uncertainty (Griffiths et al., 2005), and in the end the skill of the
doctor is in working through and with these uncertainties, not resolving them.
Despite the uncertain and contingent nature of the understanding of bio-medical
processes, medicine operates successfully with an underlying epistemological
principle: health outcomes have preceding causes and the isolation of cause is the
basis of effective intervention. This logic can be applied, subject to all the
uncertainties just outlined, to the social determinants of inequities in health. Real
pathological changes in the human body occur, but in highly patterned ways in whole
populations or sub-population groups. Both the pathologies and their patterning have
12
Constructing the evidence base on the social determinants of health: A guide
causes. In other words, social and biological causes work in tandem. The social
causes explain the patterning while the biological causes explain the pathology. As
well as the social and biological causes working in tandem, there will be some
interaction between the two. It is this interaction where our understanding tends to be
less well developed. The task is to map the social and biological processes and the
interaction between them in order to develop an explanation. In classic scientific
terms, there ought to be covering scientific social and biological laws (Hempel, 1965).
What needs to be explained is why the biological systems in the human body change
in ways that are determined by social as well as biological/ biochemical processes.
This is at the heart of the intellectual challenge of the social determination of health
and the corresponding inequities in health. As a result of differential contextual stimuli
and their respective interactive chains, the molecules in the human body behave
differently according to the social position someone occupies, the country they live in,
the global political situation around them. The molecules behave differently according
to the job someone does, according to their experience of class, gender and ethnic
relations, according to their education, and according to a whole range of social
factors which affect them over their life course. Their genetic structure and their
immunity, their nutritional status, their resilience, their ability to cope - all act as
mediating factors, but ultimately there is a plausible causal pathway from a number of
social factors or social determinants to biological structures in the individual human
body.
In the clinical realm (in which the social is to a significant degree controlled out of the
equation) the randomized controlled trial (RCT) provides the best way of determining
what the mechanisms of cause are and what precisely is effective in ameliorating the
cause (Chalmers, 1998). The RCT provides the most secure basis for valid causal
inferences about the effects of treatments (Chalmers, 1998). Inter alia, to what extent
can similar methods be applied in the social realm? In principle they can be, but in
practice the available evidence will be very limited. This is because the causal
pathways are still to be defined with the appropriate degree of exactness and the
covering laws are not yet known with certainty. And in any event the factors involved
are extremely complex and in many cases quite unsuitable for investigation using
trial methods. We probably have many decades of research ahead of us before the
covering laws are described. However, the challenge remains of conjoining the social
and the biological, and of developing plausible explanatory models.
With respect to the social determinants of health, we are able to identify some of the
13
Constructing the evidence base on the social determinants of health. A guide
necessary and the sufficient conditions involved in causation but their nature, under
what circumstances, and how they operate from the social to the biological is not
always very clear. The core candidates can be listed relatively easily because the
extant literature has explored them at length:
•
Poverty
•
Hunger
•
Occupational exposure to hazards
•
Occupational experience of relations at work
•
The social and economic effects of aging
•
The experience of gender relations
•
The experience of ethnic relations including direct experience of racism
•
Home circumstances
The degree and ability to exert self efficacy especially through disposable
income
Dietary intake
Habitual behaviours relating to food, alcohol, tobacco and exercise
Position now and in the past in the life course
The accumulated deficits associated with particular life courses
Schooling
Marital status
Socioeconomic status.
These are the media through which the social world impacts directly on life
experiences and exerts direct effects on the human body. They in turn are linked to
macro variables like the class system, the housing stock, the education system, the
operation of markets in goods and labour, and so on (see Solar & Irwin, 2007).
Because of the uncertainty about the precise causal mechanisms and the theoretical
differences in explanations, there has been little guidance available internationally to
assist policy-makers and practitioners to incorporate and act upon the full range of
social determinants of health. Still less have there been easily available tools and
techniques for integrating equity considerations into policy and programme design or
into the collection of data and evidence (Oxman et al., 2006). This guide is a small
step towards resolving the lack of guidance and support.
14
Constructing the evidence base on the social determinants of health: A guide
Cause is important, because ultimately tackling the social determinants of health will
involve knowing enough about causes to intervene on them directly and in a cost
effective way. Presently we are not in a position always to organize interventions in this
way, although some of the extant knowledge provides very useful guidance and enough
to make a significant start.
There is another important point about cause which needs to be elaborated. This is
considered next.
1.1.2
The difference between the causes of health and the
causes of health inequities
The factors which lead to general health improvement - improvements in the
environment, good sanitation and clean water, better nutrition, high levels of
immunization, good housing - do not always reduce health inequity. This is because
the determinants of good health are not necessarily the same as the determinants of
inequities in health (Graham & Kelly, 2004). It is necessary to distinguish therefore
between the causes of health improvement and the causes of health inequities. As
was noted above, inequities are linked to social disadvantage. If generalized health
improvement is not linked to questions of social disadvantage, while everybody’s
health overall may be improving (although at different rates across the social
spectrum) inequities may remain.
The reason for this is that the factors which improve overall health have differential
effects on the population with the better off always benefiting disproportionately when
universal interventions are applied (Kelly et al., 2006a). Sometimes there is a
catching up effect with the less well off making up ground later, but a differential
remains (Antonovsky, 1967; Victora et al., 2000). It may be argued that the widening
differential does not matter as everyone is benefiting to some degree, so the
differential is not a reason not to carry out general health improvement. It is important
however not to define universal and targeted approaches as simple alternatives.
Hybrid policies which contain elements of, for example, universal actions with
targeted follow through, will sometimes be the most appropriate way to tackle
problems of inequities.
15
Constructing the evidence base on the social determinants of health: A guide
Where equity is the explicit focus there are two potential policy implications: (a) a
clear description of the social structure is required in order to target and tailor
interventions and to nuance universal interventions appropriately; and (b) there must
be a focus on the determinants of the inequities. The causes and the dynamics
whereby different groups respond differentially to health initiatives and the ways in
which health damaging effects operate need to be specified in any intervention
(NICE, 2007). The ‘causes of the causes’ of inequities, as they are sometimes
referred to, are located in the divisions of labour within and between societies, the life
course and life worlds of individuals, and the interaction between them (NICE, 2007;
Kelly et al., 2006a).
To understand the causes of the causes we must turn to a concept of cause which
mirrors the kinds of precision about cause which clinical medicine is capable of
delivering, subject also to the uncertainties of such explanations. This requires a
classical scientific explanation: neither historical nor sociological explanations will do
(Danto, 1968). This is because the phenomena being explained are not historical or
social - they are physical. An explanation which stops at the social level is
insufficient for these purposes. We need a model of cause which traverses a number
of levels of analysis which academic disciplines traditionally keep separate. Some of
the observed patterns which are manifested in mortality and morbidity data are no
doubt accounted for genetically or by other biological mechanisms, but it seems
inconceivable that the health variations which follow sets of social arrangements so
closely could all be accounted for in this way. Other processes are at work and they
are amenable to causal analysis involving a pathway from the social to the biological.
In this sense the concern is not inequities in health perse, but much more specifically
the social determinants of inequities in illness. The research question is to find out
what the social determinants of mortality and morbidity are and to describe how they
work and how they interact with the biological.
The level, or levels of analysis, need to be identified (Kelly et al., 1993). This means
examining the evidence, and regardless of its disciplinary provenance, assessing
whether the dynamics of what is described could plausibly work at a physical,
societal, organizational, community or individual level. In other words, to what degree
is the supposed action based on biological, social or technical plausibility? To what
extent is it possible to ascertain time periods and the chronology in the evidence?
Are the purported relationships logically possible in chronological terms? Do certain
events precede others? What dynamic processes are described in terms of the
16
Constructing the evidence base on the social determinants of health: A guide
component parts of social systems? This is particularly important in multi-factorial
explanations, where the sequencing of events may be hidden or at least difficult to
discern, and where multi-factorial explanations are often no explanations at all
(Brownson et al., 2003).
1.1.3
Accuracy of descriptions of the social structure
To tackle the social determinants of health, the social structure of societies and the
populations within them must be precisely described - sociologically, geographically
and economically.. There are key axes of social differences in populations - class,
status, education, occupation, income/assets, gender, ethnicity, race, caste, tribes,
religion, national origins, age and residence. These factors intersect, interact, overlap
and cluster together in their effects. Some of these factors may also change
independently of each other. They vary in their salience in different societies with
different modes of production or political systems for example.
These social inequalities are the building blocks of differences in health and in health
inequities. As well as the conventional tools of social epidemiology, the kinds of
population and social structure descriptions which modern mapping and computer
based accounts of populations permit should be pressed into service wherever
possible (Burrows & Gane, 2006). This will allow the categories of class, gender and
so on to be used more effectively and forcefully and will allow a better understanding
of the way they interact with each other.
Ethnicity, race, gender, sexuality, age, area, religion and national origins represent
linked but separate dimensions of inequity. While these discrete dimensions of social
difference are seldom denied as important, when they interact the respective weights
of each one of them in respect of health outcomes tends to be underdeveloped
empirically and theoretically in the literature on social determinants. Consequently,
there is little in the extant evidence about the relationships between these different
dimensions and the ways they interact to produce health effects (Graham & Kelly,
2004). This is a point of considerable importance because it is clear from the
evidence that does exist that different segments of the population respond very
differently to identical public health interventions. This means that we need to
anticipate a wide range of responses to policies across and within societies, by virtue
of the nature of the variation in populations.
17
Constructing the evidence base on the social determinants of health: A guide
What these different and variable axes of differentiation have in common is that they
result in differences in life chances. These differences in life chances are literal: there
are marked social differences in the chances of living a healthy life. This has been
most systematically captured in occupation-based measures of socioeconomic
position - but differences in people’s health experiences and their patterns of
mortality are also observed across other axes of social differentiation. It is an
important challenge to develop measures of inequality that embrace these axes. If,
as the evidence suggests, dimensions of disadvantage interlock and take a
cumulative toll on health, these dimensions need to be summed in order both to map
and to understand the health penalty of social inequality.
One of the key principles therefore is to acknowledge and to identify the different
axes of social difference (Graham & Kelly, 2004) and to recognize that these
dimensions overlap (Davey Smith et al., 2000). Within the axes of differentiation (like
gender) different aspects interplay as well (like income access to power and prestige)
(Bartley et al., 2000). The specific health impacts will be mediated by proximal factors
like social position, specific exposures, the nature of specific illnesses and injuries,
and their social significance in different cultural contexts (Whitehead et al., 2000).
1.1.4
Context
Context is very important. By this we mean the country, area or population group to
which the data apply. There are some important considerations which need to be
borne in mind when dealing with the different contexts of discussions about health
inequities and their social determinants. There are two main dimensions to this.
First, much of the data are country or locality/ region specific. This raises a question
about the generalizability, scalability and transferability of the findings to other
contexts and settings. This has three elements:
•
External validity - whether that which has been observed under controlled
circumstances still applies without strict scientific control in ordinary
settings
•
Replicability - the extent to which the findings from one setting would be
replicated if carried out in a different context
•
Epistemological framework - the degree to which the cultural context has
generated the conceptual structure of the original studies and their
subsequent interpretation.
18
Constructing the evidence base on the social determinants of health: A guide
For example, literatures on health inequities generated in western Europe, Australia,
New Zealand, Canada and the United States reflect the specific concerns of those
societies. British studies, for instance, tend to derive from long standing interests in
social class in that country. In the United States on the other hand, the focus has
been rather more on issues of race and and/or socioeconomic groupings (rather than
class in its sociological sense). Indeed the use of the words inequity or inequality
reflects the cultural differences, with inequality being the preferred term in AngloSaxon influenced societies and inequities or disparities being the preferred usage
elsewhere. These preoccupations reflect the history, culture and politics of those
societies and the dominant academic discourses in them. The concepts associated
with the social determinants are not universal (for example, class, status and religion
mean different things in different societies). Some caution is required, especially in
using concepts originating in high income societies in low and middle income ones.
Second, some data are global in the way that they are collected, meaning that they
operate at a relatively high level of generality. The finer grained detail required to
make things happen on the ground is lost.
1.1.5
Nature of health inequity gradients
The difference in health experiences between the top, middle and bottom of the
socioeconomic hierarchy varies considerably between countries. For example in
Nordic countries there are relatively small disparities in health across the population
compared to the United Kingdom and the United States (Davis et al., 2007). In low
and middle income countries the health differences may be very great with a mix of
relatively good health among the well to do and extremes of low life expectancy and
high infant mortality among the very poor. The policy implications will therefore vary
considerably depending on the nature of the health gradient in particular societies. In
any event reaching the poorest and most disadvantaged requires specific actions
(Tugwell et al., 2006b). More and better cross-cultural studies are required to help
clarify the underlying social and economic differences in different countries and the
ways these map against health disparities, especially beyond high income countries
(European Science Foundation, 2004).
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Constructing the evidence base on the social determinants of health: A guide
1.1.6
Translation of knowledge into action
It is important to acknowledge that there are three distinct activities and three distinct
knowledge bases relating to knowledge translation. There are wide gaps between the
discourses and the personnel engaged in each. First is knowledge generation. This is
the principal scope of science and research. Second is the activity of using
knowledge generated in this way, combining it with other learning and turning it into
policy. Third, policy has to be turned into practice and action. The evidence on its
own does not provide a complete recipe for success,or an imperative for action. The
evidence needs further refinement if it is to be useful in everyday practice. This
requires an understanding of local contexts and circumstances; an understanding of
the knowledge bases, and commitment and engagement of local professions; and a
detailed assessment of the particular population at whom the intervention is aimed
(Kelly et al., 2004). All of this presents a considerable set of challenges for the social
determinants approach.
Generating evidence, turning it into policy and turning policy into action and practice
all involve different actors. The players do not necessarily interrelate at all, and even
if they do it will not be in a linear or even cyclical fashion. They interrelate in iterative
and uneven ways, which involve elements of knowledge transfer, of political process,
of opportunism, of serendipity and of power influence (Petticrew et al., 2004; Pittman
& Almeida, 2006). This is described in more detail in chapter 5, ‘Understanding the
policy-making process’.
1.2
Eight principles for developing the evidence base
In the light of the problems listed above, the MEKN developed a set of principles
(Kelly et al., 2006a). These principles provide some of the ways of dealing with the
challenges just outlined and provide a means of working towards solutions.
Principle 1: A commitment to the value of equity
The Commission on Social Determinants of Health has defined health equity as: ‘the
absence of unfair and avoidable or remediable differences in health among social
groups’ (Solar & Irwin, 2007). This is adapted from Margaret Whitehead’s definition of
health equity (Whitehead, 1992). Health inequity is therefore defined as unfair and
avoidable or remediable differences.
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Constructing the evidence base on the social determinants of health: A guide
The explicit value underpinning the development of a methodology for working on the
social determinants of health is that the health inequities that exist within and
between societies are unfair and unjust. This is not a scientifically or rationally
derived principle; it is a value position which asserts the rights to good health of the
population at large. It stands in contrast particularly to the value position that argues
that differences in health are a consequence (albeit an unfortunate consequence) of
the beneficial effects of the maximization of individual utility in a relatively unfettered
market. It is important to note that individual and collective utilities may be at odds
with the rights to health (Macintyre, 1984).
Therefore there is and will be political opposition to the core value of health equity.
Addressing health inequalities will sooner or later involve trade-offs with those in
positions of power. Scientific argument will be marshalled by opponents in support of
the anti health equity position and even where there is political support for equity
there is still a need to ‘sell’ policies that have been identified as effective (Solar and
Irwin, 2007).
Principle 2: Taking an evidence based approach
The second principle is a commitment to an evidence based approach. As will be
argued, an evidence based approach offers the best hope of tackling the inequities
that arise as a consequence of the operation of the social determinants. We assume
further that the evidence will provide the basis for understanding and the basis for
action (Greenhalgh, 2001).
There are a number of difficulties associated with an evidence based approach.
These are developed further in chapter 2. However, the ways of identifying the best
evidence can be based on well established principles. The means of determining the
best empirical evidence are well rehearsed and formulated within the principles of
evidence based medicine (see e.g. Egger et al., 2001; Gomm & Davies, 2000).
However there are other very important types of evidence which are generally
excluded from evidence based medicine but are vitally important in considering the
social determinants of health. These require different approaches. For example in the
case of non quantitative empirical evidence the issues are highly contested, but
guides such as Dixon-Woods et al. (2004) and Pope et al. (2007) provide useful
discussions of the issues involved. They consider ways of determining what
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Constructing the evidence base on the social determinants of health: A guide
constitutes good evidence drawn from competing qualitative paradigms, and ways to
synthesize different types of evidence.
Theoretical and empirical evidence or propositions are still more difficult to deal with,
not least in the social sciences because of their inherent potential ideological content.
Nonetheless they can be appraised on the basis of their empirical testability and
falsifiability, their internal logic and their fit with evidence and observation from other
sources (for an example see NICE, 2007) (This is developed further in section 8.4).
It is important to note that evidence on its own, derived from whatever source or
method, frequently provides apparently simple answers. The task of those charged
with making sense of the evidence and of drawing up evidence based
recommendations is to determine the overall story the evidence tells and make a
judgement about the certainty with which conclusions can be drawn and how they
might be applied in real world settings. The task is to reach a balanced judgement on
the basis of what is known from the evidence, as opposed to what is uncertain in the
world where the evidence based policy or recommendation is to be implemented
(Kelly et al., 2004; Petticrew et al., 2004; Lomas, 2005).
Principle 3: Methodological diversity
The third principle is of methodological diversity: no single approach to the
generation of evidence or data is to be favoured over others. Evidence should not be
appraised and evaluated on the basis of adherence to a single evidence hierarchy in
which a particular method is given priority. Appraisal of evidence should be on the
basis of whether the research method used is appropriate for the research question
being asked and the knowledge being collected, and the extent to which in terms of
its own methodological canon it is considered to be well executed. Some evidence
will be more useful than others, but all sources of evidence may make a contribution
to understanding how social factors influence health outcomes. This principle is
developed further throughout this guide.
Principle 4: Gradients and gaps
There are conventionally three different ways in which inequities are described:
health disadvantage, health gaps and health gradients (Graham, 2004a, 2004b,
2005; and Graham & Kelly, 2004). Health disadvantage simply focuses on
differences, acknowledging that there are differences between distinct segments of
the population or between societies. The health gaps approach focuses on the
22
Constructing the evidence base on the social determinants of health: A guide
differences between the worst off and everybody else, often assuming that those who
are not the worst off enjoy uniformly good health. The health gradient approach looks
at the health differences across the whole spectrum of the population, acknowledging
a systematically patterned gradient in health inequities.
The fourth principle takes an holistic approach to the question of health equity which
embraces the whole of the socioeconomic gradient within societies or populations. In
general (Graham & Kelly, 2004), an approach which considers the whole of the
gradient in health equity in a society should be the starting point for an analysis of the
structure of health inequities in that society. This is in contrast to considering only the
most disadvantaged groups in the population. While in some circumstances targeting
policy or interventions towards the most disadvantaged groups may be the best and
most appropriate action, a whole system or whole gradient approach is the premise
from which to begin, but not to complete, a discussion of equity. This principle is
developed further in chapter 3.
Principle 5: Causes: determinants and outcomes
The fifth principle is a commitment to attempting to identify the causal pathways
whereby the social determinants operate. The differential patterns of health across
populations and the unequal experience of mortality and morbidity are the
consequence of the operation of social and biological factors interacting with each
other at population and individual levels. As noted above, some parts of the causal
pathways are well understood with respect to some social groups and other parts of
the causal mechanisms are less well defined. Although all the parts of the causal
arrangements cannot be identified with complete certainty, any analysis should seek
to help to explain them.
Principles 6 and 7: Social structure and social dynamics
Principles six and seven are linked together. Principle six lays out the imperative of
seeking to describe social structures adequately and principle seven acknowledges
the dynamic nature of that social structure.
Clearly social structures and systems can be described in a variety of ways. The
ways in which social structures are described are not theory- or value-free. We need
to consider: what is the model of social structure, if any, in the evidence? This means
considering the extent to which the evidence is sensitive to the relations between
groups and individuals and in particular the social variations and differences in the
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Constructing the evidence base on the social determinants of health: A guide
population. The important axes of differentiation include the dimensions of age,
gender, ethnicity, race, caste, religion, education, occupation, income/ assets, place
of residence, mobility, status grouping and class membership and also the dynamics
of the technical and social divisions of labour, the stage of development and the
power structures in given societies. Thus it is very important to build social structure
into any consideration of the evidence and to articulate where possible the value
position which informs the model of social structure embedded in the evidence.
Principle seven states the imperative to ensure that descriptions of social structure
do not become ossified. Societies and their component parts are not static objects.
They are constantly changing and therefore the relationships which give rise to
health inequities and differences are themselves also changing in terms of their force
and their salience at any given moment. Therefore the capture of the evidence needs
to lend itself to that dynamic quality. Social dynamics (that is, how social structures
are changing through time) must be a key part of the analysis.
Principle 8: Explicating bias
The eighth and final principle is about explicating bias. All writing and all science are
socially constructed and therefore subject to bias. Forms of bias stemming from the
particular methodologies used or from the political value position of the writer will be
more or less present in all data and evidence. The solution is to acknowledge this
fact and to seek to make the biases explicit, even if the writer has sought to conceal
their own prejudices. This is an imperfect science, but is workable in two stages. The
first is to describe any political bias that is inherent in the argument, and the second
is to seek to determine whether the political biases have influenced the selection and
interpretation of the evidence. This is not to imply that there is some underlying truth
free of bias which would emerge if we could eliminate the bias. It is instead to
acknowledge that biases and perspectives of many kinds inhere in scientific work.
Our task is to be aware of them as far as we can and to see past them in our efforts
to tackle the inequities deriving from the social determinants.
1.3
Conclusion
The six conceptual challenges and the eight principles for dealing with them provide
the basis for developing models of the way the social determinants of health operate.
They also establish the parameters for this guide. In the chapters which follow, some
24
Constructing the evidence base on the social determinants of health: A guide
of these themes are dealt with explicitly again whereas others provide background
ideas which are used to develop the guide.
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Constructing the evidence base on the social determinants of health: A guide
2
Taking an evidence based approach 1
In this chapter of the guide we argue that the evidence based approach offers the
best hope for tackling health inequity arising as a consequence of the social
determinants of health. The use of evidence is not new in public health. When John
Snow in 1850s London, in perhaps the most famous of all public health interventions,
identified the possibility that cholera was a water borne disease, he was using
observation and evidence in a logical and rational way. Although the understanding
was rudimentary by today’s standards, it nevertheless led to effective preventive
strategies and the handle of the Broad Street pump in Soho found its infamous place
in the annals of public health (Chave, 1958). When the first Medical Officers of Health
in Britain plotted epidemic prevalence and linked it to poor housing (Checkland &
Lamb, 1982), and when Victorian social reformers tracked the relationship between
poverty and poor physical health (Briggs, 1959), they were following a route
prescribed by the evidence. Some of the most important breakthroughs in the
prevention of non-communicable diseases have been made using epidemiological
evidence. The demonstration of the relationship between smoking and lung cancer
(Doll & Hill, 1952), between the lack of exercise and heart attack (Morris et al., 1953)
and between exposure to asbestos and lung cancer (Doll, 1955) are striking
examples of the powerful use of evidence. More recently the relationship between
the wider determinants of health and health inequities have been grounded in very
advanced uses of evidence (Marmot & Wilkinson, 1999; Lynch et al., 2000; Davey
Smith et al., 2002).
However, taking an evidence based approach has come to mean more than simply
using evidence or doing well conducted scientific studies. It now means taking a
scientific approach to the accumulation and understanding of the evidence itself
(Egger et al., 2001; Chalmers et al., 2002). A major impetus in this has been the
development of evidence based medicine (Greenhalgh, 2001) and there are
important implications for the social determinants approach.
1 The introduction to chapter 2 and section 2.1 both draw on Kelly, 2006.
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Constructing the evidence base on the social determinants of health: A guide
2.1
Lessons from evidence based medicine
Evidence based medicine has evolved in the last forty or so years for a variety of
reasons. First, there has been a dramatic escalation in the amount of available
medical evidence. The sheer volume of scientific information has become too vast for
even the most conscientious scientist or doctor to keep pace with. Ways of making
the large volume of evidence easily accessible became a necessity and this in turn
led to more systematic ways of organizing databases of evidence than had
conventionally been the case (Greenhalgh, 2001).
Second, as ways of synthesizing and reviewing the vast amounts of information
generated by medical and other scientists became an urgent priority, this was greatly
assisted by the development of new technologies. Computer databases and powerful
search engines allow much more comprehensive ways of finding information than
was ever possible by manual methods. The existence of the new technologies
means it is possible to gather large amounts of information, on a scale congruent
with the volume of new evidence appearing, and then to search it comprehensively
and rapidly.
Third, bias has been identified as a critical problem in science (Egger et al., 2001).
There are two different aspects to this. Some bias arises as a consequence of the
types of method used. Methodologists had written for decades about the problems of
bias, of the fact that subjects involved in scientific investigations often behave
differently to how they would behave normally, of placebo effects, of failures to
observe and record things accurately, and of recording information to reflect the
prejudices of the researchers. The evidence based approach seeks to minimize
these kinds of bias. The other source of bias is more social in origin. It has been
argued that scientists have tended to be much less systematic towards the
accumulated scientific evidence than they have been to the process of gathering new
evidence in the first place. And worse, they have tended to be very selective in their
approach to their favoured evidence. The history of science is full of examples of
scientists preferring their own pet theories and models, in spite of accumulated
evidence which contradicted them (Kuhn, 1970). Bias, intentional or accidental, is an
endemic hazard of scientific and medical activity (Greenhalgh, 2001).
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Constructing the evidence base on the social determinants of health: a guide
One of the most influential British texts in the history of evidence based medicine
appeared in 1972. This was Archie Cochrane’s essay Effectiveness and Efficiency:
Random Reflections on Health Services. Cochrane, himself an eminent physician,
argued that health services have a tendency towards inefficiency because of
organizational, institutional, demographic and technical factors and a variety of other
things including human failure. His principal concern was that there was no agreed
way to determine what worked or did not work, and therefore it was not possible to
tell whether interventions did more harm than good, or had neutral effects. He also
complained that no one could tell how much anything cost, so there was no way of
telling what was good value for money and what was not. He advocated the use of
the clinical trial and argued that economic appraisal of medical interventions must be
undertaken.
The randomized controlled trial (RCT), as Cochrane realized, was the most precise
way to determine the effectiveness of an intervention. With subjects properly
randomized and with investigators blind to which is the experimental group and which
is the control group, it provides the best way to determine whether something works
and allows bias of various kinds to be controlled to a large extent. Doll (1998) has
argued that 1948 represents the watershed because it was the year that the
streptomycin trial for treating pulmonary tuberculosis reported. The methodological
breakthrough was that effectiveness could be plainly demonstrated. Although in 1948
the clinical trial still had many years to go before it found general acceptance
(Cochrane, 1972; Egger et al., 2001), the fundamental principle was established. It
has been argued that before 1948 clinical medicine was dominated by what today we
would call theories, pet beliefs and political positions (Cochrane, 1972; Doll, 1998). It
is suggested that these favoured theories were sometimes tested empirically by
individual clinicians, but were never subject to the kind of deep rigorous scrutiny
which the clinical trial permits (Greenhalgh, 2001). Clinical effectiveness was in much
more tenuous territory than it is today.
Over the last thirty years the use of the RCT as the means of determining
effectiveness has become the gold standard and is indeed the best available way of
determining clinical effectiveness, despite certain philosophical and medical
discussions around points of detail (Davies & Nutley, 2000). The systematic review of
trials through such organizations as the Cochrane Collaboration has become the
modus operandi of developing the evidence base in clinical activities.
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Constructing the evidence base on the social determinants of health: A guide
The principles of building the evidence base are straightforward. It starts from the
accumulation of evidence. Rather than generalize from one particular study to the
world as a whole, the idea is to increase representativeness of findings by putting
together many studies which will provide a closer approximation to what is really
going on. By increasing representativeness by pooling observations and results, bias
should be reduced (Egger et al., 2001). The assumption is that the more often a
finding occurs in different studies, the more likely it is to be accurate or at least as
close as we can get to a representation of reality. To rely on a single result from a
single study and to generalize to a broader reality is unwise because any single
result may be an outlier in a statistical sense, the result of random chance and/or the
result of biases of various kinds. The greater the number of cases, the greater the
likelihood that statistical aberrations will be nullified and the real effect will be found.
In principle the same logic applies to qualitative as well as quantitative work and to
observations of all kinds. Quantitative researchers have taken up this method more
enthusiastically than others, but the principle of cumulation and synthesis carried out
according to strict and replicable protocols applies whatever the methods involved.
The process of building the evidence base therefore involves finding and gathering
together as many examples of studies of a particular type as possible. Then the
methodologically best studies are identified and poor studies eliminated. This
elimination is important. Studies which do not reach predefined standards of
methodological rigour need to be excluded from the evidence base because if they
are methodologically unreliable so too will be their results. After deciding which
studies have met methodological rigour in terms of design, sampling and control of
bias, the results are summed in some way. The aim is either to detect the general
direction in which the evidence points, or to accumulate the results from multiple
studies into one statistical calculation (this is called meta-analysis in the case of
quantitative evidence). The results of the best studies are then synthesized. It is
possible to synthesize qualitative and quantitative data (Dixon-Woods et al., 2004)
The development of powerful computer search engines to interrogate compiled and
indexed databases, on a scale that scholars who used to have to work by hand and
index card could never have imagined, makes systematic discovery of relevant
papers much more straightforward than it once was. The tools of systematic review
and of meta-analysis make synthesis (as opposed to traditional literature reviewing) a
much more auditable, transparent and exhaustive process. The systematic review,
as the name implies, tries to be open and transparent and can claim greater
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Constructing the evidence base on the social determinants of health: A guide
representativeness by virtue of the ability researchers now have to synthesize large
volumes of data using computer technology. It is of course not perfect, but it is less
likely to be subject to the biases mentioned above. More information on systematic
reviewing and guidance on carrying out evidence synthesis can be found in
section 9.1.
2.2
Applying the evidence based approach to the social
determinants of health
Taking an evidence based approach means finding the best possible evidence about
the social determinants of health (NHMRC, 1999). However, given that randomized
controlled trials about the social determinants are relatively rare and that the
evidence is potentially much broader, the approach requires some modification. The
broad principles can however be applied. The most advanced search strategies and
systematic review procedures should normally be used as a starting point where
appropriate (Glasziou et al., 2004; Jackson & Waters, 2005a, 2005b) along with other
forms of rigorous scholarship and consideration of historical, theoretical and
philosophical texts. As this kind of evidence may not reside in papers which are
searchable electronically, hand searching and working from bibliographies remain
important. Theoretical and philosophical propositions can be appraised on the basis
of their empirical testability and falsifiability, their internal logic and their fit with
evidence drawn from other sources. Given that these propositions have a currency
much longer than empirical data, many relevant papers and manuscripts exist
outside of the time periods covered by electronic databases.
The definition of best evidence and best practice should be made on the basis of
their fitness for purpose and their connectedness to research questions (Glasziou et
al., 2004), not on the basis of a priori notions about the superiority of particular types
of evidence or method or placement in an evidence hierarchy, e.g. that the
randomized trial is the only basis for knowledge generation. In SDH the key is
matching research questions to specific problems and using evidence derived from
an appropriate methodology rather than assuming the superiority of a method or a
theoretical approach (Petticrew & Roberts, 2003). Taking an evidence based
approach does not mean relying on or privileging only one kind of method, such as
the randomized controlled trial. It does not mean that there is only one hierarchy of
30
Constructing the evidence base on the social determinants of health: A guide
evidence, and it does not mean an epistemological rejection of subjective positions or
methods. The evidence based approach to SDH categorically rejects the notion of a
single hierarchy of evidence. There will instead be a number of hierarchies of
evidence, and placement within the hierarchies will be dependent on the rigour,
transparency and potential bias of specific pieces of work.
There remain a number of challenges. There is a rich literature describing health
inequalities and the social determinants of health, especially in high income countries
(Graham, 2000; Marmot & Wilkinson, 1999; Shaw et al., 1999; Solar & Irwin, 2007).
For the most part it exists outside of the literature concerned with effectiveness of
interventions. There is a dearth of good scientific studies explaining what can be
done to reduce health inequalities (Millward et al., 2003). There is a lack of
systematic studies of the effects of policy on inequity. The contours of inequality and
social difference and disadvantage are not well described. The degree to which
changes in inequalities can be measured is ill defined (Killoran & Kelly, 2004). As
was noted earlier, the difference between the determinants of health and the
determinants of inequalities in health is often confused (Graham & Kelly, 2004;
Graham, 2004a, 2004b, 2005). The health of populations and the health of
individuals is frequently elided (Heller, 2005). And finally, the links between the
proximal, intermediate and distal determinants of health are poorly conceptualized
and integrated into research (WHO, 2004).
As outlined in chapter 1, one of the great challenges in the study of the social
determinants is describing the social structure accurately so that the differences in
the population which are the manifestations of the social division of labour are more
easily observed. We must improve our sensitivity in measuring the social
determinants of health inequities and how they are mediated by other determinants,
e.g. how socioeconomic position is mediated by gender, ethnicity and race.
There are also of course some important caveats about the evidence based
approach. First, there will be gaps in this evidence and some parts of it will be more
powerful than other parts. It needs to be recognized that strength of evidence, of
whatever kind, alone is not sufficient as a basis for making policy (NHMRC, 1999).
This will be determined by salience, and the extent to which the evidence is
transferable. It is possible to have very good evidence about unimportant problems
and limited or poor evidence about very important ones. Therefore a distinction must
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Constructing the evidence base on the social determinants of health: A guide
be drawn between absence of evidence, poor evidence and evidence of
ineffectiveness. The two former are not the same as the latter.
Second, it needs to be recognized that the links between scientific knowledge and
policy and practice are not linear and that the scientific evidence base is generally
imperfect in its own methodological, theoretical and empirical terms. Consequently,
the connection between evidence and policy and practice inevitably involves matters
of judgement (Kelly et al., 2004). Therefore the strength of evidence alone should not
drive the strength of policy or practice recommendation (Harbour & Miller, 2001).
Third, linking the evidence base to health policy requires sensitivity to the needs and
circumstances of the groups who are the intended beneficiaries of the policy
(Rawlins, 2005; Briss, 2005). The application of research findings to non research
settings requires an understanding of the local context and of the tacit knowledge
and life worlds of practitioners and end users. It also means that evidence hierarchies
must be used flexibly.
The fourth caveat, the risk of using evidence out of context, was outlined in the
previous chapter (section 1.1.4).
What is clearly needed is a dynamic approach to the issue of social differences in
population and a much clearer theoretical account of the way that the nature of social
differences in a society are linked to economic and social development. Also needed
is a taxonomy of the key variables linked to the structure and the dynamics of social
systems. All of this would permit better informed decision-making about the
relevance, feasibility and scalability of actions taken in different country contexts.
While we have collected lots of evidence, even in high income countries there are still
important observations to be made:
•
Theoretical models of social structure often rely heavily on occupational
structure for measuring equity and other variables. This is helpful up to a
point, but the other axes of social difference should also be routinely
collected and used in theoretical models.
•
Although we can test evidence for heterogeneity, there is a huge amount
of health research that pays no heed to social differences even of the
grossest kind.
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Constructing the evidence base on the social determinants of health: A guide
Illustrative case studies
2.5
The following illustrative case study shows an example of the challenges of an
evidence based approach:
•
No. 1 - United Kingdom: Acheson Inquiry.
The following illustrative case studies give examples of the need for equity proofing:
•
No. 2 - Brazil, Peru, United Republic of Tanzania: Failure to equity proof
programme for childhood illnesses
•
No. 3 - Bolivia: Evaluation of Social Investment Fund.
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Constructing the evidence base on the social determinants of health: A guide
3
Gaps and gradients
In this chapter the significance of health gaps and gradients (introduced in chapter 1)
is examined, initially by considering some important work in this field and then by
looking at the policy implications.
3.1
The pioneering work of Antonovsky and Victora
In what was one of the very earliest attempts to review historical and contemporary
evidence about inequities in health in a systematic way, Antonovsky showed that
inequities were a common feature of all differentiated social systems. Examining data
from more than thirty international studies he argued that the inescapable conclusion
was that social class influenced a person’s chance of staying alive. Historically he
noted a variation of about 2:1 between the extremities of the social classes, although
he saw this differential narrowing in the mid 1960s. This class differential held even
though overall death rates were declining. He noted that whatever the index used, or
however the class system was represented, almost invariably the lowest social
classes had the highest mortality rates (Antonovsky, 1967).
He went on to demonstrate that there was an important characteristic in the historical
differences between the most and the least advantaged across different societies. He
observed that where the overall rates of mortality were high, the differences in
mortality between the best and the worst off tended to be relatively small. This, he
claimed, characterized societies in the early period of industrialization. As rates of
economic growth increased, and particularly as industrialization evolved, the patterns
of mortality began to improve for both the most and the least advantaged, but at
differential rates. The middle and upper classes seemed to derive the health
dividends of industrialization earlier. The mortality rate of the most advantaged
improved at a faster rate than the mortality rate of the least advantaged. The result
was that the differences between the most and least advantaged got bigger.
However, as time went on, the rate of improvement for the middle and upper classes
began to slow, while the rate of improvement for the least advantaged began to
increase, resulting in a narrowing of the difference.
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Constructing the evidence base on the social determinants of health: A guide
This led Antonovsky to suggest that where death rates are relatively high or low, the
difference between the most and the least advantaged will tend to be relatively small,
but where the rates of mortality are mid range the difference between the most and
the least advantaged will be relatively high. Since the publication of these data in the
mid 1960s this pattern seems to have evolved still further. For example the gradient
in countries like the UK seems to have begun to steepen again over the last forty
years or so, and in some countries of the former Soviet block the increase in health
inequalities in recent time has been dramatic. One conclusion to be drawn from
Antonovsky’s earlier work, combined with the more recent data, is that health
inequalities are part of long term social, political and economic trends. They are
linked to the playing out of policies and historical events and underlying changes in
the social structure and the division of labour in society in ways that require an
explanation in their own right.
The interesting thing about this is the shape of the curves Antonovsky described.
Both extremes are close together and the middle much further apart. One conclusion
to draw from this is that it describes a pattern that is linked to some underlying
process of modernization/ industrialization, and there are some compelling biological
(the prevalence of infectious disease, the nature of infant mortality) as well as social
(the nature of the housing stock, the appearance of decent sanitation and safe
drinking water in particular) sets of factors at work. Certainly the chronology of events
would lead one in that direction. The other important conclusion is that these data
demonstrate that inequalities in health are not fixed, but rather are variable at
different historical time periods.
One of the more interesting ways of trying to make sense of global type data is to try
to evaluate it in the context of data from different spheres. One of the most striking
examples of this is in relation to work by Victora and colleagues (2000). They
propose the ‘inverse equity hypothesis’, a public health corollary of the ‘inverse care
law’ on individual medical care, as a way of explaining why at different times the
inequity ratio between rich and poor can improve, remain unchanged, or worsen.
Drawing on data relating to the implementation of child health programmes in Brazil,
they note a very similar, almost identical set of curves to that described by
Antonovsky, although over very much shorter time horizons. They note that
whenever there is a new programme introduced, the children of the better off benefit
sooner and to a greater extent than the children of the poorer sections of society. The
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Constructing the evidence base on the social determinants of health: A guide
improvements do affect the less advantaged but later, and there is an inevitable
catching up process. Critically Victora and colleagues argue for the inevitability of this
process ceteris paribus. It operates at a much shorter time frame than the kinds of
historical epochs which Antonovsky was interested in, but the same pattern emerges.
Victora et al. also note that these effects compound one another in the sense that the
children of the more well-to-do are inevitably always in front since the benefits of the
next new intervention(s) will have already kicked in before the poorer cohorts have
caught up with last one. So although the overall effect is of health improvement, the
constantly repeated cycles tend to reinforce the inequalities, giving the impression of
being constant when in fact they are each the product of successive waves of
differential responses to successive interventions.
The work of Antonovsky and Victora points to two policy approaches to dealing with
health inequalities: health gaps and health gradients. We discuss these next.
3.2
Health gaps
When researchers in high income societies talk about health inequities or inequalities
in health they are drawing on data which show that, when measured by occupation in
particular, there are marked differences in health from top to bottom of the
occupational hierarchy (Acheson, 1998). Similar discrepancies are captured in other
measures of social difference based on education, income, housing tenure, gender,
ethnicity, disability and geography. As noted previously, there are conventionally
three different ways in which health inequities are described: health disadvantage,
health gaps and health gradients (Graham, 2004a, 2004b, 2005; Graham & Kelly,
2004).
Health disadvantage simply focuses on differences, acknowledging that there are
differences between distinct segments of the population, or between societies. The
health gaps approach focuses on the differences between the worst off and
everybody else, often assuming that those who are not the worst off enjoy uniformly
good health. The health gradient approach relates to the health differences across
the whole spectrum of the population, acknowledging a systematically patterned
gradient in health inequities. We recommend using the gradient approach because it
allows for a focus on all members of society and recognizes the importance of
considering and taking a societal wide approach to the issue.
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Constructing the evidence base on the social determinants of health: A guide
Conceptually, narrowing health gaps means raising the health of the poorest, fastest.
It requires both improving the health of the poorest and doing so at a rate which
outstrips that of the wider population. It can be an important policy goal. It focuses
attention on the fact that overall gains in health have been at the cost of persisting
and widening inequalities between socioeconomic groups and areas. It facilitates
target setting. It provides clear criteria for monitoring and evaluation. An effective
policy is one which achieves both an absolute and a relative improvement in the
health of the poorest groups (or in their social conditions and in the prevalence of risk
factors).
Where an approach which links evidence about people’s socioeconomic
circumstances and health gaps has been adopted, the focus is on those in the
poorest circumstances and the poorest health: on the most socially excluded, those
with most risk factors and those most difficult to reach. This focus has been important
in linking health inequalities to the social exclusion agenda in high income societies,
and in targeting policies at local and community level. In policy and intervention terms
this leads to approaches which attempt to lift the worse off out of the extreme
situation in which they find themselves. In high income countries, if effective, such
interventions help only a relatively small part of the population. In low and middle
income countries, and especially where the gap is wide and the numbers of people
who are socially excluded are large, the potential for change is significant. However,
such changes effectively mean transforming the social structures of those societies.
In high income countries, focussing policies on the most socially disadvantaged has
a minimal effect on social structure because it affects relatively few people.The
political significance of health gaps in low and middle income countries is therefore
profound and offers a radical agenda, whereas it is relatively conservative in high
income countries.
3.3
Health gradients
The health gradient is important because the penalties of inequities in health affect
the whole social hierarchy and usually increase from the top to the bottom. Thus, if
policies only address those at the bottom of the social hierarchy, inequalities in health
will still exist and it will also mean that the social determinants still exert their malign
influence. The approach to be adopted should involve a consideration of the whole
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Constructing the evidence base on the social determinants of health: A guide
gradient in health inequities rather than only focusing on the health of the most
disadvantaged. The significant caveat is that where the health gap is both large and
the population numbers in the extreme circumstances are high, a process of
prioritizing action by beginning with the most disadvantaged would be the immediate
concern. Otherwise the whole of the population should be considered.
The gradient approach recognizes that, while those in the poorest circumstances are
in the poorest health, this is part of a broader social gradient in health. It is not only
the poorest groups and communities who have poor health. There are large numbers
of people who, although they could not be described as socially excluded, are
relatively disadvantaged in health terms. Preventive and other interventions could
produce major improvements in their health, and proportionate savings for the health
care system. This approach is in line with international health policy. The founding
principle of the WHO was that the enjoyment of the highest attainable standard of
health is a fundamental human right, and should be within reach of all ‘without
distinction for race, religion, political belief, economic or social condition’ (WHO,
1948). As this implies, the standards of health enjoyed by the best-off should be
attainable by all. The principle is that the effects of policies to tackle health inequities
must therefore extend beyond those in the poorest circumstances and the poorest
health.
Assuming that health and living standards for those at the top of the socioeconomic
hierarchy continue to improve, an effective policy is one that meets two criteria. It is
associated with (a) improvements in health (or a positive change in its underlying
determinants) for all socioeconomic groups up to the highest, and (b) a rate of
improvement which increases at each step down the socioeconomic ladder. In other
words, a differential rate of improvement is required: greatest for the poorest groups,
with the rate of gain progressively decreasing for higher socioeconomic groups. It
locates the causes of health inequity, not in the disadvantaged circumstances and
health-damaging behaviours of the poorest groups, but in the systematic differences
in life chances, living standards and lifestyles associated with people’s unequal
positions in the socioeconomic hierarchy (Graham & Kelly, 2004).
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Constructing the evidence base on the social determinants of health: A guide
Figure 4.1
Framework for developing, implementing, monitoring and evaluating policy
Monitoring
Generating evidence
for policy and
practice
Monitoring
Learning from
practice
Getting social
determinants
on the
policy agenda
Evidence synthesis
and action
Monitoring
Effective
implementation and
evaluation
Monitoring
The framework relies on a commitment both in policy and research terms to build an
evidence base using multi-methods of research which draw on a variety of
disciplines, methods and evaluations designed to accommodate the complex nature
of social interventions and their long term impact.
The framework will allow methodological diversity in the development and
consideration of the evidence base. The framework details a systematic approach to
the generation and utilization of evidence in programmes aiming to address the
social determinants of health. The approach is generic to evidence based public
health but it has been made specific and relevant to the social determinants agenda
by applying the principles set out in chapter 1. Using these principles in this way
ensures that policy-makers and practitioners are challenged at each step in the
process to consider the implications of their programmes on different subsets of the
population, thereby equity proofing all the work they do.
The Measurement and Evidence Network was asked to provide an overview of
existing tools and techniques that are available or need to be developed. Such tools
and techniques are necessary both to assess the impact of social determinant
approaches to reducing health inequalities (primarily through evaluation methods),
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Constructing the evidence base on the social determinants of health: A guide
and to support the development and implementation of programmes to ensure that
they do not exacerbate health inequities (through techniques such as health impact
assessment). Examples of the tools currently available are given in the following
sections (5 to 12). They provide a state of the art summary of the tools that currently
exist to support better decision-making by policy-makers and practitioners working in
this area.
It is important to note however that there was a paucity of tools to draw on,
particularly from middle and low income countries. None were found in languages
other than English. Many of those that we have included in this guide are at different
levels of development and it has therefore not been possible to provide a definite list
of the ‘best tools’. However we hope that the issues raised in this guide for improving
methodological approaches in this field set out an agenda for further work leading to
a more comprehensive set of tools and techniques to support effective action on the
social determinants.
4.2
Using the framework
In general terms, the four phases of the framework set out in Figure 4.1 are
applicable to any evidence based approach to population health. However the
framework highlights the most appropriate use of different tools and approaches
which support the development and review of social approaches to health
development and the reduction of health inequities. In doing so it helps to make
explicit when and how to use different evaluation techniques to answer particular
research questions, avoid the potential misuse of evaluation in certain contexts, and
create knowledge for decision-making when formal evaluation is not possible.
The cyclic nature of the framework allows countries to assess their position so that
they can most effectively build a systematic evidence based approach to the social
determinants of health.
For example in some countries policies required to address the social determinants
of health may not yet be in place and therefore more emphasis will be required on
‘Making the case’. On the other hand, where equity focussed policies already exist
countries will need to equip themselves with an evidence base on how best to
implement these policies and with the necessary structures and systems for
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Constructing the evidence base on the social determinants of health: A guide
successful implementation. It may not however be appropriate to start at the top of
the circle (‘Generating evidence for social action’). A country or region with SDH
already on the policy agenda and with substantial grassroots experience of
implementing programmes may find it more useful to start with ‘Learning from
practice’ It is important to note that all phases are important; they are not mutually
exclusive and all countries will probably already be active in all phases to some
degree or other.
The framework forms the structure for the second part of this guide. The remaining
chapters work their way round the framework, starting in the middle with three
chapters on ‘Getting social determinants on the policy agenda’ and finishing with
‘Monitoring’.
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Constructing the evidence base on the social determinants of health: A guide
5
Getting social determinants on the policy
agenda - understanding the policy-making
process
5.1
Introduction
Policy studies emerged as an academic discipline in the 1950s. This followed the
development of large national public sector policies in education, health, housing,
water supply, sanitation, social welfare, etc, in several countries. Many of these
national programmes faced problems in achieving their goals. Similarly, several
research based public health policies and programmes recommended by WHO and
other United Nations bodies and adopted by member governments also faced
difficulties in achieving their objectives. Control of tuberculosis, water borne diseases,
and malaria and other vector borne diseases are cases in point, although small pox
eradication was an exception. Addressing well known determinants of health such as
provision of safe water and sanitation, under-nutrition, shelter, education and
employment have proved even more difficult.
Problems and gaps in achieving the goals and objectives of national policies and
programmes provided a stimulus for policy research. A substantial proportion of
policy studies available in the English language are based on North America and
western Europe. Health sector studies reveal that, despite explicit policies to reduce
inequalities in health and substantial funding in high income countries, inequalities
persist despite overall progress. This suggests that there is a need to further
understand policy processes. It also suggests the need for an ongoing inbuilt process
of research and evidence gathering to inform and track policy. Political and policy
processes, including achieving health goals with an equity focus, need priority
attention. Studying pathways, processes, enablers and barriers, impacts and
unintended outcomes of policies is critical to realizing people’s aspirations for better
health and well-being, and to reaching national and international goals for health and
development.
In public health and related interventions, culture, human behaviour and social
differences in the population play a greater mediating role than in clinical
interventions. Different forms of data and evidence will be called into play, external
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Constructing the evidence base on the social determinants of health: A guide
validity will be inherently problematic and the time from intervention to outcome will
generally be long term (Briss, 2005). Evidence is an essential but not sufficient basis
for policy action. Several other ingredients besides evidence are involved in the
policy-making process, including:
•
Problem recognition and definition
•
Formulation of solutions, including transferability of evidence into
appropriate social strategies
•
Scalability into different contexts and settings
•
Political will.
To complicate matters, the policy-making process is often poorly understood by
researchers (Petticrew et al., 2004; Whitehead et al., 2004; Lomas et al., 2005) so
the dialogue between the two is sometimes characterized more by mutual
incomprehension than by joint working. Researchers are often low on the list of
people with whom policy-makers and politicians wish to consult.
While there are many examples of national governments developing comprehensive
strategies, programmes and initiatives to tackle inequities (Morgan & Ziglio, 2007;
Benzeval et al., 2000), countries vary in their awareness and commitment to take
action (Mackenbach & Bakker, 2002). It is recognized that in some countries there is
still a job to be done in making the case to policy-makers about the need to tackle
health inequities. Different strategies and actions may be required in different
countries depending on where they are in the process of developing policies aimed at
addressing the social determinants of health.
Getting SDH on the policy agenda will be dealt with in this and the following two
chapters. This chapter looks at the policy-making process in detail. The next chapter
looks at how best to make the case to influence that process. (Those who are more
interested in the practical aspects of getting policy into practice may wish to go
straight to the next chapter.) The third chapter deals with ‘equity-proofing’ - we need
to ensure that those policies which do get on the agenda are equitable in outcome as
well as intent.
This chapter is divided into five main sections. First, the nature of policy and policy-
making is described. Second, the specific challenges which the nature of SDH
presents to policy-makers are examined. Third, the need to consider context is
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Constructing the evidence base on the social determinants of health: A guide
explained. Fourth, a range of conceptual models are described and briefly applied to
SDH. Fifth, a series of conclusions are drawn.
The broad conclusion of this chapter is that a universal approach to designing and
implementing policies to address SDH is neither feasible nor desirable. Policy
makers at all levels need to equip themselves with the knowledge and skills to
interpret and apply lessons from their own experience and elsewhere.
5.2
Understanding policy-making
5.2.1
What is policy?
Policy is an over-used term, carrying multiple meanings, as illustrated by Hogwood
and Gunn (1989:13-19) who argue that policy can be defined as:
•
A label for a field of activity
•
An expression of general purpose or desired state of affairs
•
Specific proposals
•
A decision of government
•
A formal authorization
•
A programme
•
An output
•
An outcome
•
A theory or model
•
A process.
This ambiguity is significant because these uses can imply action and inaction,
decision and non-decisions, means and ends.
A study of policy processes of. the National Tuberculosis Control Programme in India
took a historical perspective spanning several decades. It analysed evolving
programme content and institutional cum system development within a broader
socioeconomic and political context, looking at the role of communities, implementors
and a variety of national and international actors. It defined policy as a series of
related decisions, actions or inaction, around a framework of goals and objectives,
evolved and undertaken over a period of time, by several actors at different levels,
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Constructing the evidence base on the social determinants of health: A guide
explicitly or implicitly impinging directly or indirectly on the problem, with intended and
unintended consequences (Narayan, 1998).
Policy includes the creation of the means to guarantee execution. It affects
institutions, organizations, health personnel, services and funding arrangements
within the health care system (Walt, 1994). Implementation is an integral part of the
policy process, related to political processes, societal structures and values
(Narayan, 1998).
5.2.2
Clarifying policy analysis
A distinction needs to be made between analysis for policy (provision of technical
and economic information for policy-making, monitoring and evaluation) and analysis
of policy (focusing on processes and values affecting origins, intentions,
constructions and conduct of policies). A similar distinction can be made in relation to
research: research for policy and research of policy. This difference is essential to
understanding the contribution that analytical approaches can make. These
differences lie on a spectrum of approaches to studying and analysing policy.
There are several theoretical approaches to policy analysis with varying frameworks
of analysis:
•
A linear, rational, problem solving, prescriptive approach (Majchrzak,
1984) is widely used by biomedical experts in the health sector. Although
the limitations of rational choice approaches are recognized (Grindle &
Thomas, 1991), they continue to be widely used.
•
Epidemiology contributes to understanding the nature, magnitude,
distribution spread and determinants of health or disease problems
(Levine & Lilenfield, 1987).
•
Economic approaches with concepts of efficiency, effectiveness and value
for money to make best use of scarce resources have gained currency in
recent decades, when global wealth and knowledge have also peaked.
However, economic approaches have limitations, especially in coping with
political dimensions and value systems (Ganapathy, 1985).
•
Ethnographic and anthropological studies undertaken for over a decade
have contributed to understanding disease and health care in several new
ways.
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Constructing the evidence base on the social determinants of health, a guide
•
Political science approaches focus on actors, institutions and societal
groups involved in policy-making. For instance, health sector policy
studies have looked at the role of policy elites (Grindle & Thomas, 1991)
epistemic communities and health bureaucracies (Justice, 1986); interest
groups and conflicting interests (Reich, 1993); and economic and class
interest (Navarro, 1994). Political mapping (Reich, 1993) and stakeholder
analysis (Crosby, 1992) study political resources and support for and
opposition to policy. Banerji (1985, 1990) analyses health policy with a
multi-disciplinary approach, a historical perspective and a pro-poor value
base.
*
A political economy approach is used by Walt (1994) and Walt and Gilson
(1994). They suggest an analytical model for health policy analysis
incorporating context (social, political and economic), processes, actors
(international, national and sub-national) and content. Concepts such as
context are open to varying political assumptions and interpretations. In
the general academic discourse, public perspectives and participation in
the policy process - particularly of the socially excluded - is generally
limited or absent.
•
Critical policy analysis includes a critical reflection of social science
methodology, recognizing its values, interests, assumptions and structural
limitations (Ganapathy, 1985). The method is committed to social justice
and recognizes issues of power and conflict. It uses different methods to
generate multiple, divergent perspectives, ensuring public participation. A
dialectical analysis of these multiple perspective leads to a deeper
understanding of reality. It is a reflective, dialogical process of engaging
with policy action and collective social action based on demystification
and repoliticization of policy analysis. It holds that every proposition is true
only up to a point; hence multiple perspectives help overcome individual
limitations.
The dominant influences in public health decision-making at national and
international levels continue to be largely biomedical, epidemiological and
econometric. It is particularly important to keep this in mind when developing
methods to study the impact of policies aimed at reducing inequalities in the social
determinants of health which are deeply embedded in the social, cultural, political
and economic fabric of life.
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Constructing the evidence base on the social determinants of health: A guide
5.2.3
Policy implementation
Studies on policy implementation, although small in number, offer useful insights.
The values, assumptions, perspectives and socialization processes of policy- and
decision-makers, planners and implementers influence the implementation process.
Philip Selznick’s study on the Tennessee Valley Authority in 1949 (cited in Parsons,
1995), is an early analysis of implementation. It indicated that organizations and
bureaucracies responsible for implementation adapted, survived and thrived as
complex organic systems interacting with their environment. Informal organizations
developed within the formal structure. Decisions often followed the interests and
values of the members of these informal groupings and not the formal policy goals of
the organization.
Studies of implementation failure in the 1970s reinforced and strengthened support
for a top down approach. There is an assumption of power at the top and of
significant control over political, organizational and technical factors (Williams, 1982).
This approach is used particularly by hierarchical institutions and organizations, and
those driven by very specific technical or business goals and interests. In this
situation, policy objectives may be met and social, environmental and other costs
may be ignored. Policy goals are assumed to be valid (Hogwood & Gunn, 1984).
However this approach is increasingly being contested as different social
constituencies assert themselves.
Research reveals that policies are altered by the actions of local implementers and
by organizational and inter-organizational factors and dynamics (Hill, 1993).
Implementers coping with changing circumstances and difficult field conditions,
where ‘the problem’ presents itself in different dimensions, often make decisions that
alter the intentions of the original policy-makers. Implementers rarely participate in
the planning, design and analysis of research or of policy. Their views and
perspectives are often interpreted and represented by others.
Bottom-up research approaches starting with ‘street implementers’ were used by
Lipsky in 1971. Others (Howlett & Ramesh, 1995) found that the personal motivation,
goals and strategies of local actors and their reinterpretation of programmes, along
with their developing local network of contacts, substantially altered policies. Formal
and informal relationships constitute policy networks and sub-systems, strongly
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Constructing the evidence base on the social determinants of health: A guide
influencing policy processes. Policy is not the only or major influence on the behavior
of implementers (Elmore, 1982). Negotiation, bargaining, conflict, compromise and
consensus building are integral to the policy process and implementation (Grindle &
Tomas, 1991).
Implementation is referred to as the ‘Achilles’ heel of social policy’. Lack of interest or
naivety about implementation of policies in the real world is a major impediment in
the policy process (Williams, 1982). Despite rigorous plan formulation, setting up of
organizational structures, substantial investment of resources, etc, gaps between
intent and implementation are common (Hogwood & Gunn, 1984). A more inclusive,
participatory and decentralized approach may perhaps be necessary.
The research process itself may also be affected. Peer reviewed literature may
reflect the discourse of the dominant. Grey literature, campaign material and a
growing academic and analytic stream provide subaltern perspectives and ‘reality
bytes’ from the perspective of the poor. These may not meet the inclusion criteria of
rigorous research methodologies such as systematic reviews and meta-analysis.
5.2.4
The policy process
Many see the policy process as a linear, rational process from policy formulation
(design of policies) to policy implementation (their enactment). This linear approach
may be characterized thus:
•
•
Politicians identify a priority and the broad outlines of a solution...;
Policy-makers... design a policy to put this into effect, assembling the right
collection of tools: legislation, funding, incentives, new institutions, directives;
•
The job of implementation is then handed over to a different group of staff, an
agency or local government;
•
...The goal is (hopefully) achieved. (Cabinet Office, 2001:5)
This is a simplistic view for several reasons. The distinction between policy
formulation and implementation is rarely clear. Intentions and actions are sometimes
difficult to distinguish, especially in welfare services where service professionals
invariably have a high degree of discretion or autonomy. Their daily decisions
effectively become the de facto policy of the organization, irrespective of the formally
stated intentions to be found in strategic plans, for example. There is often no start or
end point to the policy process - only a middle (John, 2000). Most policies are
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Constructing the evidence base on the social determinants of health: A guide
devised to fit into a pre-existing situation in which previous decisions define the
parameters of any new policy. The historical impact of decisions creates a set of
conditions from which policy-makers may find it difficult to diverge. This ‘path
dependency’ effectively limits their range of alternative options. Most resource
decisions, for example, only consider marginal changes rather than making a
fundamental re-assessment. This can limit the scope of policy-makers and decision
makers to undertake radical changes of direction, at least in the short-term, a feature
described as ‘incrementalism’ (Lindblom, 1959). This perspective also contends that
the policy process can often be static for relatively long periods, only to be disturbed
by moments of change - 'disjointed incrementalism’. As a result, the policy process is
characterized by positive and negative feedback loops and rarely reaches
completion. Hence it is important to consider not just the objective of the policy
process as stated, but also the unintended consequences for different stakeholders.
5.2.5
Analysing the policy process
As a result, a set of challenges faces anyone wishing to analyse the policy process.
First, policy or organizational decisions do not always take place at a single point in
time and can be protracted over months or even years. As such, it is sometimes
difficult to discern when a specific decision was made.
Second, these decisions rarely take place in public settings. Instead, they are usually
taken behind closed doors away from the public gaze, despite attempts by some to
make the decision-making process more transparent.
Third, outcomes of the policy process that involve no decisions or non-decisions are
difficult to discern. The lack of (observable) action or outcome may, in fact, signify a
complex set of forces that have stifled a decision or prevented proposals from being
enacted.
Fourth, partly as a result of the above factors, rigorous, in-depth empirical policy
studies can be difficult to conduct. Where such research has been undertaken, case
studies are often a favoured approach (Ferlie et al., 2003).
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Constructing the evidence base on the social determinants of health: A guide
5.3
SDH and the policy-making process
If they do not recognize the specific nuances of SDH, policy-makers are liable to
design and implement policies that are ill-conceived, poorly designed and, as a
result, liable to implementation failure (Graham, 2004a). This in turn has longer-term
consequences for building and sustaining the coalition of support that often
underpins policies. The importance of careful policy development is underlined by
Wanless who commented on the United Kingdom: ‘What is striking is that there has
been much written often covering similar ground... but rigorous implementation of
identified solutions has often been sadly lacking.’ (Wanless, 2004:3). Raphael also
notes the disjuncture between evidence and action in Canadian policy: ‘In spite of an
accumulated body of evidence and Canada’s own expertise on the topic, there is
currently a policy vacuum on social determinants of health, as the costs and delivery
of health care services have come to dominate the public debate’ (Raphael,
2003:35).
It is possible to identify several distinguishing features of SDH that might affect the
ways in which policies towards SDH are formulated and implemented (see also
Kirby, 2002). These features may not necessarily be apparent in all policies in all
countries; rather, they need to be applied and interpreted in specific contexts.
Collectively, these make the SDH a ‘wicked problem’ (Rittel & Webber, 1973) - one
which is not easily resolved (if at all) through the traditional policy infrastructure.
Some of these issues have been identified elsewhere in this guide but are repeated
here because of their particular relevance to the policy process.
First, SDH are multi-faceted phenomena with multiple causes. While conceptual
models of SDH such as the Dahlgren and Whitehead model (1991) (among others)
are useful, they do not necessarily provide policy-makers with a clear pathway
towards policy development and implementation. As specific policy initiatives tend to
be targeted to a specific population group in certain circumstances and for prescribed
time-periods, they can neglect the wider context within which SDH are generated and
re-generated. Some policy-makers believe that the lack of a simple problem hinders
the development of simple policy solutions. There is no ‘smoking gun’ (Exworthy et
al., 2006), social inequities in health are ‘invisible’ (Dahlgren & Whitehead, 2006),
and so the policy response tends to be diffuse.
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Constructing the evidence base on the social determinants of health: A guide
Second, recent studies of SDH have emphasized the significance of the life course
perspective (Blane, 1999). The health effects starting in utero and in early childhood
are thought to be profoundly entrenched inter-generationally. Such a perspective
poses serious challenges to policy-making processes whose timescales are rarely
measured over such long periods. The tenure of elected or appointed officials is
measured in months and years rather than decades, the electoral cycles in
parliamentary or presidential democracies are usually 5 to 7 years, and even
reporting cycles (for budgetary purposes, for example) tend to be much shorter
(usually annually). Moreover, coalitions of interests in support of the SDH policy may
be unsustainable over the time periods necessary to witness significant change. The
attention of the public (often supported by the media) has tended to reflect and
magnify such short-term timescales. There have been some exceptions to this
especially in the field of public pension policies, but the general problem of
timescales remains important
Third, SDH necessarily implies policy action across a range of different sectors. It is
increasingly recognized that action beyond healthcare is essential and, as such,
intersectoral partnerships are critical to formulating and implementing policy towards
SDH. However, there is a significant body of evidence which shows that partnerships
are hampered by cultural, organizational and financial issues (Sullivan & Skelcher,
2002). Whether at central, regional or local level or sectorally (say, between the
healthcare sector and the education sector), collaborating organizations operate
according to different values, have different accountabilities and performance
measures/ criteria, and different reasons for collaborating. For instance, government
agencies have traditionally been organized vertically according to service delivery
(Bogdanor, 2005; Ling, 2002). However, such ‘silo’ or ‘chimney’ approaches are not
well equipped to tackle issues that cut across traditional structures and processes.
The health agenda may be quite marginal to the activities of some collaborating
agencies. Even in organizations with apparently similar interests, this is further
complicated by conflicting performance regimes (indicators, timeframes, incentives,
etc). There is also an argument that SDH action is required beyond the state or
government, in civil society including voluntary or even private sector agencies.
Given the differences between these and state agencies, policy collaboration on SDH
can be highly problematic.
Fourth, policy towards SDH must be viewed as one of several competing priorities for
policy-makers’ attention and resources. Economic policy or foreign policy might at
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Constructing the evidence base on the social determinants of health: A guide
different times take precedence over SDH. More specifically, SDH may be
overshadowed in the policy-making process by healthcare itself. However, this
healthcare focus is often to the neglect of health and SDH perse. This focus reflects
the medicalization of (western) society with its emphasis on the medical model of
care, heroic interventions, and the application of the rescue principle. As a result,
attention tends to be on the short-term rather than the long-term and on discrete
interventions rather than coordinated, collaborative ones.
Fifth, the cause-effect relationships within some aspects of SDH are not readily
apparent. Knowing and understanding causal pathways is a first step in devising
appropriate policies but the question of attribution remains. As Deaton (2002) argues:
‘Policy cannot be intelligently conducted without an understanding of mechanisms;
correlations are not enough’ (p.15). In circumstances where a clear cause-effect
relationship cannot be linked with a discrete policy intervention, there may be a case
for relying more heavily on a value-based approach.
Sixth, in order to identify, monitor and analyse epidemiological changes over time,
routine data needs to be available. In many countries, these data are not available, of
poor quality or have been collected over insufficient periods to aid policy-making with
sufficient sensitivity. Just as one cannot fly a modern aeroplane without a large
number of sensors and measurements (dials and meters), one should not expect to
manage a nation’s population health, including the variety of disparities therein,
without a comprehensive health information system.
Seventh, processes of globalization have been undermining the role of the nation
state in policy-making. Powers have been relocated to supranational organizations
such as the European Union, World Trade Organization, International Monetary Fund
and World Bank. In particular, some of the supranational institutions have promoted a
neo-liberal agenda. Raphael argues: ‘The decline of the social welfare state is driving
neo-liberal approaches to policy-making that fundamentally conflict with
strengthening the social determinants of health’ (Raphael 2003:37).
Governments’ ability to shape and mould the SDH with the goal of improving their
population’s health is becoming limited as many of the ‘causes of the causes’ no
longer fall within their responsibility. They therefore need to rely on influence and
leverage in multinational networks. There is a parallel argument that decentralization
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Constructing the evidence base on the social determinants of health: A guide
processes to regions and cities have had a similar effect on the policy-making
capacity of national governments.
The seven factors and their impact on policy are summarized in table 5.1.
Table 5.1
Link between SDH features and the impact on policy-making
Features of SDH
Impact on policy-making
Multifaceted phenomena with multiple causes
Coordinated strategies are difficult to achieve
Life course perspective
Long-term approach do not match policy
timetables
Intersectoral collaboration and partnership
Partnerships are problematic
Dominance of other priorities
SDH often neglected
Cause-effect relationships are complex
Attribution problems hamper policy
Data
Routine data of high quality and in timely
availability, is often lacking
Globalization (and decentralization)
Policy-making involves more stakeholders at
multiple level, hampering governmental
action
The questions which emerge as a result (see table 5.2) are perplexing for policy
makers seeking to incorporate SDH.
Table 5.2
Priority
Time lag
Emergent policy questions
•
Which health inequities are amenable to policy intervention and
by how much?
•
How to shift the focus of policy from healthcare to health/SDH?
•
What is a suitable balance between programmes?
•
How to maintain momentum of policy before outcomes are
demonstrated?
Attribution
How to link policy interventions and observed outcomes?
Accountability
How to hold individuals and agencies responsible for progress?
Measurement
How to monitor progress, with what data and how often?
How to avoid unintended consequences?
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Constructing the evidence base on the social determinants of health: a guide
5.4
Policy-making in context
Policy-making needs not only to be sensitive to the types of issues being addressed
but also to the social, economic and spatial context within which those policies are
introduced.
A number of conceptual approaches aid in the analysis of the role of context.
‘Realistic evaluation’ has been widely adopted as a way of describing and explaining
the interaction between context and policy interventions (‘mechanism’) in generating
outcomes (Pawson & Tilley, 1997). While the model can be simplified as C+M=0
(context + mechanism = outcome), Pawson and Tilley argue that the interaction
between the three components should be viewed as a specific configuration that
reflects the unique combination of factors involved.
5.4.1
Policy description
Part of specifying the precise contextual environment is accurately describing the
policy. A simple comparative mechanism can help enumerate the policy’s
characteristics (see table 5.3).
Table 5.3
Policy characteristics
Degree of
innovation
Traditional
1
2
3
4
5
Innovative
Degree of
controversy
Consensual
1
2
3
4
5
Highly
controversial
Structural or
systemic
impact
Marginal
1
2
3
4
5
Fundamental
Public visibility
Very low
1
2
3
4
5
Very high
Transferability
Strongly system
dependent
1
2
3
4
5
System neutral
Source: Health Policy Monitor (www.hpm.org).
Further description can be made of the policy process:
1. Approach of idea: new / old / recycled
2.
Innovation or pilot project
3.
Stakeholder positions
4. Adoption and implementation: sponsoring departments
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Constructing the evidence base on the social determinants of health: A guide
5. Monitoring and evaluation
6. Review mechanisms: mid-term review or evaluation, final evaluation
(external)
7. Dimensions of evaluation: process / outcome (www.hpm.org).
5.4.2
Levels in the policy-making process
Distinctions are often made about the level at which policy-making takes place. A
common distinction is between top-down and bottom-up. Much of the normative
accounts of the policy process tend to assume a top-down process - from policy
formulation at the centre to local implementation.
Hudson and Lowe (2004) refer to micro, meso and macro levels:
1. Micro level: individual and group activity which contributes to policy
activity
2. Meso level: the way in which micro-level contributions are shaped by
historical precedents, routines and values
3. Macro level: socioeconomic and political trends and patterns.
Frenk (1994) adopts four levels in his health policy analysis:
1. Systemic: institutional arrangements for regulation, finance and service
delivery
2. Programmatic: intermediate level defining the specific priorities of the
system
3. Organizational: actual production of services through a focus on quality
assurance and technical efficiency
4. Instrumental: institutional intelligence for improving system performance
through information, research, technological innovation and human
resource development.
The implications for SDH rest crucially at which level SDH interventions should be
directed. For example, Turrell and colleagues (1999) argue that although policies
implemented at the macro level are supposed to tackle the most fundamental
determinants of inequalities in health, such policies are difficult to achieve. If however
the social determinants are only amenable to locally-based policies, this would
suggest a minimal role for central government/ states. It might be hypothesized that
the leverage points for SDH are at all levels - however defined - thereby offering a
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Constructing the evidence base on the social determinants of health: A guide
potential contribution from all agencies and agents. It does of course make the
coordination of such multilevel policy development highly complex.
Reflecting the need for a multi-level perspective, in recent years there has been a
shift towards multi-level governance in which the interaction between and within
levels has become more interdependent, differentiated and plural (Newman, 2001;
Rhodes, 1997). This new form of governance poses substantial challenges for
governments and local public service organizations which have traditionally been
poor at steering networks of loosely affiliated agencies and agents with differing and
often competing interests.
5.4.3
Uncertainty and ambiguity in the policy-making
process
Given all the above, it is inevitable that the policy-making process will be
characterized by uncertainty and ambiguity. For example, policy objectives may have
been written in sufficiently vague language to allow numerous interpretations. This
may be due to three reasons:
•
Technical incompetence (an inability to define precisely the policy goals or
objectives) and/or
•
Political device to provide room for manoeuvre among stakeholders,
and/or
•
Equivocal evidence (concerning, say, SDH) about the appropriate policy
strategies.
Uncertainty may also be apparent in the policy means or mechanisms. Stakeholders
might for example support the policy objectives but disagree about the means.
The tension between means and ends on the one hand, and certainty and
uncertainty on the other, is captured well by Thompson (2003) who provides a simple
yet powerful categorization of policy approaches for each of the four policy types (see
table 5.4).
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Constructing the evidence base on the social determinants of health: A guide
Relationships between policy means/ ends and degree of certainty
Table 5.4
Ends
Means
Certain
Uncertain
Certain
Tame problems —»evidence
based policy-making
Political/leadership crisis —»
policy/political debate
Uncertain
Wicked problems —» policy
learning
Wicked problems —> ‘muddling
through’
Source: Thompson (2003).
5.5
Models to inform policy-making
As well as providing greater insight into the mechanisms by which policy is
formulated and implemented, conceptual models can afford lessons in different
contexts and can aid transferability. Six models are described here.
5.5.1
‘Policy streams’ model
This model proposed by Kingdon (1995) is concerned with how issues get onto the
policy agenda and how proposals are translated into policy. This is the prelude to
implementation. Kingdon uses the notion of policy streams to explore the ways in
which opportunities for implementation are created. He argues that policy ‘windows’
open (and close) by the coupling (or de-coupling) of three ‘streams’: problems,
policies and politics.
•
Problem stream: Conditions or issues only become defined as problems
when they are perceived as such. Often, only problems which are
amenable to policy remedies are recognized.
•
Policy stream: Insofar as there are multiple potential issues (which may or
may not become defined as policy problems), there are also multiple
strategies and policies proposed not just by civil servants or professionals
but also by interest groups. However, for such strategies to be enacted,
they need to meet a minimum threshold relating to: (a) technical
feasibility, (b) congruence with dominant sociopolitical values, and (c)
anticipation of future constraints on the strategy being proposed. In terms
of SDH, many policy proposals may fail to reach the threshold. For
example, desirable policies may not be feasible or may not have been
proven effective. Moreover, dominant values may run counter to
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Constructing the evidence base on the social determinants of health: A guide
addressing health inequalities and shifting political values may also
threaten this criterion.
•
Politics stream: This stream refers to the lobbying, negotiation, coalition
building and compromise of local, national and international interest
groups and power bases. In terms of SDH, such political debates can be
vociferous, as they often challenge existing social, economic and political
systems or practices.
These three streams may remain separate until they are coupled by chance factors,
such as political (e.g. elections) or organizational cycles (e.g. staff turnover), or by
the actions of a ‘policy entrepreneur’. The ‘policy entrepreneur’ facilitates the coupling
process by investing their own personal resources (namely, reputation, status, time).
This streams model has wide relevance but has been specifically applied to health
inequalities and SDH by Exworthy et al. (2002) and Sihto et al. (2006). Exworthy and
Powell (2004) extended this policy streams model to argue that effective SDH policy
development (across sectors) needs to be advanced at all levels. In short, ‘policy
windows’ need to be opened at national and local levels.
Other similar models have been proposed by Webb and Wistow (1986) and Challis et
al. (1988). The general argument is that three streams - policy, process and
resource - need to be conjoined to make policy formulation and implementation
effective.
•
Policy stream is concerned with policy means - aims and objectives
•
Process stream is concerned with policy ends - the instruments or
mechanisms to achieve the policy ends
•
Resource stream is concerned with the human, financial and material
resources need to facilitate the process stream.
A ‘successful’ policy, therefore, is likely to comprise clear objectives, a mechanism
that achieves those objectives and the resources to facilitate the process (Powell &
Exworthy, 2001). Failure to connect these streams will lead to failure of the policy.
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Constructing the evidence base on the social determinants of health: A guide
5.5.2
Network models
Given that the policy process is a pluralistic activity which involves multiple
stakeholders, each with their own interests and motivation, it is recognized that policy
development rarely operates in isolation but in networks of these stakeholders.
These networks involve interactions between communities of interest.
While networks might develop high degrees of trust and dependence, they can
equally exclude others from the decision-making process. Close network relations
can also foster learning and development as they are grounded in practical
experience. As such, networks can foster bottom-up policy developments.
From these broad principles emerge two main network models: policy and issue
networks, and th^ advocacy coalition framework (Hudson & Lowe, 2004).
Policy and issue networks
The distinction between policy networks and issue networks revolves around the
degree to which stakeholders are directly involved in the policy process. Policy
networks comprise civil servants, politicians and co-opted members (for example,
academic experts). These networks involve stable relationships among a limited
group of stakeholders with shared responsibility and high degree of integration. By
contrast, issue networks are oriented around specific concerns (such as specific
aspects of SDH) and tend to comprise loose, open connections amongst a shifting
group of stakeholders.
There have often been issue networks in the field of SDH, seeking to raise attention
to the problem, promoting solutions and lobbying policy-makers. The SDH policy
network, by contrast, has traditionally been less well developed as it implies crossdepartmental working - which has not typically been the modus operandi of
governments. Across any government, there are potentially several policy networks
relating to SDH. These networks will inevitably involve trade-offs, say between public
health and health-care, between ministries, between SDH programmes and routine
service delivery, and between equity and other principles. There are signs that such
networks are becoming more established as some governments are beginning to
take action on SDH (e.g. Judge et al., 2005), partly in response to issue networks
and to supranational institutions (such as the EU and WHO).
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Constructing the evidence base on the social determinants of health: A guide
Advocacy coalition framework (ACF)
Sabatier’s (1991) ACF model views the policy process as a series of networks which
are composed of all the organizations and stakeholders with a particular interest in
that policy sphere. These networks comprise a ‘coalition of advocates’ and are
termed ‘sub-systems’. They are defined by a set of core values and beliefs which are
resistant to changing ideas and new policies. Although sub-systems are constantly
involved in examining and learning about their policy environment, change is only
likely to occur when a significant number of those values are challenged successfully.
Over the last decade or so, coalitions of advocates have been forming in many
countries around a set of core beliefs relating to SDH, which are challenging existing
dominant values. According to Sabatier, the impact of such core beliefs might only be
apparent after a decade or more.
5.5.3
Policy failure model
Wolman (1981) offers a 1O-part model which seeks to explain why policies might fail
(table 5.5). Rather than assuming that implementation is the most likely outcome, he
argues that policy failure is common and needs to be analysed. His work is useful in
highlighting the multiple locations of policy process and the potential causes of failure
(Exworthy & Powell, 2000).
Table 5.5
Wolman’s ‘policy failure’ model
Policy formulation
1.
2.
3.
4.
5.
Problem conceptualization
Theory selection and evaluation
Specification of objectives
Programme design
Programme structure
Policy implementation
6. Resource adequacy
7. Management and control structure
8. Bureaucratic rules and regulation
9. Political effectiveness
10. Feedback and evaluation.
Source: Wolman, 1981.
Dahlgren and Whitehead (2006) offer an account of potential policy failure in relation
to SDH. They argue that:
There is often a significant gap between policy statements to reduce social inequities
in health and the actions needed to reach this objective. Very few in-depth analyses
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Constructing the evidence base on the social determinants of health: A guide
have been carried out to identify the main reasons for this gap. The following
constraints are worth analysing further, however:
•
Lack of political will
•
Lack of knowledge
•
Lack of financial resources
•
Lack of coordination and management capacity
•
Lack of ownership, and
®
Lack of policy audit and evaluation. (Dahlgren & Whitehead, 2006: 96-97)
Gwatkin (2006) describes policy failure in relation to the Integrated Management of
Childhood Illness (IMCI). Based on the work carried out by Victora and colleagues
(2006) (see case study 4 in appendix I), he argues that ‘the strategy seemed to be
implemented least energetically in the areas where it was most needed’. Three
implications for the ‘design of initiatives to reach disadvantaged groups’ are evident:
•
A distinction between developing interventions that address the needs of
the poor and reaching the poor with those interventions
•
Vertical initiatives (such as oral rehydration) seemed to be more effective
than horizontal efforts to strengthen health systems
•
A ‘distributional element to the assessment of programme effectiveness
increases the challenges that health planners face’ (Gwatkin, 2006:768).
The sober conclusion is that traditional approaches may not be able to overcome
these challenges.
5.5.4
‘Perfect implementation’
There has often been a search for normative conditions which, if achieved, would
guarantee successful implementation. Much of this literature emerged from the policy
efforts in the 1960s and 1970s in some western democracies to implement poverty
reduction programmes (e.g. Pressman & Wildavsky, 1973). Problems with their
implementation raised concerns about how best this might be achieved. While such a
view has largely been discounted in recent years, many practice-oriented documents
often contain a prescriptive, normative dimension, such as examples of‘best’
practice as the only route to improved outcomes. It is, therefore, apt to review the
evidence on ‘perfect implementation’.
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Constructing the evidence base on the social determinants of health: A guide
Arguably, the most well-known account of ‘perfect implementation’ is by Gunn
(1978). Gunn cited 10 conditions:
1.
External factors do not impose crippling constraints
2. Adequate time and resources are available
3.
At all stages, the combination of resources required is available
4.
Policy is based on a valid theory of cause and effect
5.
There is a direct connection between cause and effect, with few (if any)
intervening variables
6.
Only one agency has responsibility for implementation
7.
There is a shared agreement about the policy’s objectives
8.
The order of tasks to meet objectives is specified
9.
Communication between stakeholders is perfect
10. Persons in authority can guarantee compliance of subordinates.
A parallel account by Mazmanian and Sabatier (1981) shows some similarity:
1.
Clarity in defining objectives
2.
Legally enforceable procedure for obtaining compliance by street-level
workers (if needs be)
3.
Insider support from the centre of political power
4.
Clear conceptual basis to the means of promoting change.
In both accounts, there are heroic assumptions about the ability of organizations to
achieve such conditions. Applied to the SDH, these perfect conditions are manifestly
impossible. Notwithstanding these concerns, some commentators have offered their
conditions for effective implementation in the field of SDH. For example, Dahlgren
and Whitehead proposed four ‘general requirements’:
1.
The availability of relevant and good descriptive data on the magnitude and
trends of social inequities in health and their main determinants
2.
The existence of explicitly equity-oriented objectives and targets that are directly
linked to policies, actions and financial resources needed for the implementation
3.
A realistic assessment of possibilities and constraints, with special attention given
to external unhealthy policies and actions that generate inequities in health, and
4.
An adequate management capacity for implementation including efficient
mechanisms for intersectoral collaboration and coordination at national and local
levels. (Dahlgren & Whitehead, 2006:94)
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Constructing the evidence base on the social determinants of health: A guide
Stages of policy development
5.5.5
Some commentators have offered analyses which identify stages of the policy
process. While it is often difficult to identify a linear progression through these stages,
they can help us to understand the evolution of policy. An interesting use of stages
has been by Health Policy Monitor (www.hpm.org) which has been used in
international health policy comparisons, whereby each policy is located on a policy
spectrum (see table 5.6).
Table 5.6
Idea
Policy spectrum
Pilot
Policy
paper
Legislation
Implementation
Change
Evaluation
Source: Health Policy Monitor.
For example, Health Policy Monitor analysed the French ‘public health law’ of 2004,
which outlines the ‘role and the responsibility of the State in public health policy’
including specific objectives for 2004-08. In addition to some analytical comment,
Health Policy Monitor offers a schematic assessment of progress, indicating that at
the time of writing, legislation had been passed but implementation was slow and
incomplete (Paris, 2005) - see table 5.7.
Table 5.7
Idea
Progress in French public health policy
Pilot
Policy
paper
Legislation
Implementation
Evaluation
Change
Source: Paris, 2005.
As of spring 2007, Health Policy Monitor offers two other assessments relating to
SDH: public health goals in Canada and health inequalities targets in England.
The most common example of stages in relation to SDH is by Dahlgren and
Whitehead (2006) (see also Whitehead, 1998). This is illustrated in figure 5.1.
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Constructing the evidence base on the social determinants of health: A guide
Figure 5.1
Action spectrum in health
Measurement
I
A
I
Awareness raising
Recognition
Denial/indifference
Concern
Mental block
Will to take action
I
Isolated initiatives
More structured developments
Comprehensive coordinated policy
Source: Dahlgren & Whitehead, 2006.
5.5.6
Steering at a distance
‘Steering at a distance’ describes changes in the ways in which governments govern,
principally through the separation of strategic and operational functions. The analogy
commonly used is that of a boat, which separates steering and rowing (Osbourne &
Gaebler, 1993). Steering mechanisms have variously included collaborative
arrangements, market-based mechanisms (such as the purchaser-provider system of
quasi-markets) and performance management (including targets and performance
indicators). Equally, and especially in terms of SDH, evidence-based interventions
have been promoted. However, as has been outlined above, governments have
traditionally been weak in steering networks and in operating horizontally across
functional divisions such as government departments.
5.6
Conclusions
A number of conclusions can be drawn from this chapter. For each conclusion the
implications for SDH are highlighted.
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Constructing the evidence base on the social determinants of health: A guide
Conclusion 1: Policy-making is not a simple, linear process
(a) Policy does not move simply from formulation to implementation; there is
no start or end, just a middle.
(b) It operates in networks over multiple levels, with an increasing number of
stakeholders, and is ‘inherently fluid’ (Nutbeam, 2004).
The implication is that getting SDH onto the policy agenda is not simply a task of
generating more or better evidence about the nature of the problem. SDH policy does
however need to be based on plausible evidence, match the current political vision
and be practically feasible (Nutbeam, 2004).
Conclusion 2: Conceptual models can help describe, understand and explain
policy-making processes in different contexts
(a) Policy models can be used to evaluate the outcomes of the policy
process. This aids theoretical generalization and policy learning
(b) No single analytical model will suffice
(c) Local context will continue to play a significant factor in shaping policy
approaches; hence, policy convergence is unlikely
(d) Recognizing the need to adapt policy strategies to local context helps
move the debate beyond the merits of single/ specific interventions.
The implication for SDH is that a conceptual framework is essential to guide and
inform current and future policy development as well as to aid comparison and
learning. ‘Without an overall framework forjudging improvements in well-being, the
choice of measure of the steepness of the gradient is arbitrary, and the policy
implications of targeting it are obscure.’ (Deaton, 2002:26)
Policy interventions need to take account of contextual variables in their design and
implementation. Policy divergence will result not simply because of the variety of
contextual environments but also because of the multiple entry points to SDH for
public policy.
Conclusion 3: SDH presents policy-makers with specific challenges and
opportunities
(a) Policy strategies for SDH will need to be complex, integrated, multifaceted
and long-term
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Constructing the evidence base on the social determinants of health: A guide
(b) These features must be addressed if SDH policy is to be feasible.
The implication for SDH is that policy-makers need to recognize and incorporate the
nuances of SDH throughout the policy-making process (Nutbeam, 2004). 'Given the
pervasive effects of socioeconomic status, no single policy, or even one domain of
policy, can eliminate health disparities.’ (Adler & Newman, 2002:61)
Policies will need to be as diverse as the SDH they seek to address: ‘Addressing
issues of equity in health requires looking at a hierarchy of approaches, from up
stream broad socioeconomic and cultural influences on health, to health systems
policies.’ (WHO, 1998, quoted in Turrell et al., 1999:275)
Conclusion 4: Policy-makers and practitioners need to develop policy-making
skills appropriate to SDH
(a) Policy-makers need to learn about SDH and practitioners need to learn
about policy-making. There needs to be a forum between the two groups
to exchange knowledge
(b) Such learning might take place via case studies, worked examples,
learning sets or exchange visits with similar individuals from parallel
countries.
The implication for SDH is that researchers need to become skilled in policy analysis
and policy-makers need to be sensitized to the implications of emergent research
findings (Nutbeam, 2004). In particular, in policy-making there are often capacity
problems in terms of skilled individuals, numerous disruptive organizational changes
and perverse incentives associated with poorly designed performance measures
(Wanless, 2004). These deficiencies must be overcome.
Illustrative case studies
5.7
See the following illustrative case studies for examples of the policy-making process:
•
No. 5 - Canada: National children’s policies
•
No. 6 - Mexico: Reform of national health system
•
No. 7 - Thailand: Introduction of universal health coverage
•
No. 8 - Various countries - Linking research and evidence to policymaking
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Constructing the evidence base on the social determinants of health: A guide
Getting social determinants on the policy
6
agenda - making the case for change
Having outlined in the previous chapter the policy process and the policy challenges
specifically affecting SDH, we need to consider how interested parties can go about
making the case for change. Some pointers for approaching policy-making are
outlined, followed by some practical steps to help practitioners make the case for
SDH. Although the pointers are targeted at policy-makers, practitioners and social
policy oriented researchers may find them useful in deciding how to gather evidence
and present their case. A key theme in this chapter is that every policy needs to be
adapted and applied sensitively to local contexts. A number of case studies illustrate
the ideas in this chapter.
6,1
Policy pointers
Although writing in the UK context, Wanless (2004) offers a succinct assessment of
the failures in public health policy which have a wider applicability:
•
Lack of evidence base for public health interventions
•
Capacity problems
•
Disruptive impact of organizational change
•
Lack of alignment of performance management measures
•
Poor specification of policy objectives.
The solution, Wanless argued, consists of better monitoring through annual reports
on population health, economic evaluation of interventions, consensus-building
towards SDH objectives, organizational reform and better information systems.
These provide the basis for the following policy pointers.
6.1.1
Better specification of policy ends and means
As Sassi (2005) noted, poorly specified objectives can have serious consequences
for the overall effectiveness of SDH policy programmes. Not only are the declared
objectives not achieved but there is also a danger of losing long-term support from
coalitions of interested stakeholders.
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Constructing the evidence base on the social determinants of health: a guide
Key aspects of improved clarity in policy objectives include:
•
Definition: disadvantage, gap and/or gradient?
•
Site of intervention: downstream and/or upstream?
•
Coverage: universal and/or targeted approaches?
•
Scope, behavioural and/or structural solutions?
6.1.2
Better use of extant evidence
There is a reasonable consensus that extant evidence on SDH is not being applied
sufficiently (Kelly et al., 2004). While this does not imply that better dissemination
alone will ensure uptake of evidence (Whitehead, 1998), it is a crucial part of policy
development from dissemination through adoption and implementation to
maintenance (Rogers, 1995).
Although in the context of the British social care field, Nutley and colleagues offer
recommendations for better use of research evidence in policy:
•
Ensuring a relevant research base
•
Ensuring access to research
•
Making research comprehensible
•
Drawing out the practical implications of research
•
Developing best practice models
•
Requiring research-informed practice
•
Developing a culture that supports research. (Nutley et al., 2007:128,
adapted from Walter et al., 2004,)
A future research programme should comprise conceptual approaches and case
studies, using comparative examples. It should also be informed by (a) a social
ecological approach, (b) targeted approaches, (c) an intersectoral approach involving
community participation, and (d) a multi-entry approach to policy (Turrell et al., 1999).
6.1.3
Better measurement and monitoring
There has been a growing interest in the use of performance management
(especially targets) in developing and sustaining SDH policy. Given the uncertain
attribution between policy and outcome, SDH targets may be viewed as symbolic in
certain circumstances and their purpose may become aspirational rather than
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Constructing the evidence base on the social determinants of health: A guide
necessarily achievable. However, unless supported by an effective set of incentives,
there is a danger that symbolic or aspirational targets wither, lose their meaning and
become ineffectual. Targets should typically be SMART: specific, measurable,
available, relevant, and timely.
The British experience shows some of the problems associated with setting targets.
Targets for reducing health inequalities were introduced in 2001. The Department of
Health published a set of indicators designed to support the targets, but few are
oriented specifically around inequality and most relate to healthcare interventions
(Exworthy et al., 2006). There has been significant criticism of these indicators as a
means to measure complex and dynamic phenomena. They have been accused of
reflecting a reductionist and mechanicist approach to understanding health
inequalities (Hunter, 2003).
Targets for SDH policies need to be placed within a wider approach to measurement
and monitoring. Targets can often remain too narrowly defined with consequent
problems of non-measured aspects and perverse incentives. Exworthy et al. (2006)
suggest three ways in which measurement and monitoring regarding SDH could be
developed:
•
Locally relevant data and research evidence concerning disparities in
health and health care is made available
•
Ways are developed for measurement mechanisms to support the overall
policy
•
Measurement mechanisms provide the data by which rewards for
progress or penalties for the lack of it are implemented.
From these, the authors develop a number of principles underpinning SDH policy
measurement (see table 6.1).
These principles accord well with the points made by Hunter (2003), Wanless (2003)
and Walker (2002):
•
Broad-brush quantitative measures are not sufficiently sensitive
•
Government wants tangible progress but has capacity problems
•
Process measures may help
•
More rounded approach is required
•
Need to experiment with different approaches and to evaluate them
•
Degree of local discretion is required.
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Constructing the evidence base on the social determinants of health: A guide
Principles to consider when designing and managing measurement
mechanisms
Table 6.1
Principle
Interpretation and application
Acceptability/
Sustainability
A small number of indicators should be manageable and understood
by policymakers and practitioners.
Accountability
Individuals or organizations should be held responsible for
implementing relevant policies
Attribution
Indicator changes should be attributed to policy interventions.
Availability
Data should be locally and/or nationally available.
Coverage
All stages of the life course and health care system should be
measured.
Detection / Reliability
Indicators should be able to detect change in disparities and
inequalities (over specified time periods).
Equity dimension
Data should report a distribution across social groups rather than in
the aggregate.
Wider determinants
Measures should address health and/or health care, but neither set of
measures should be medically dominated.
Timing
Data should be collected at regular intervals to inform policy.
Source: Exworthy et al., 2006.
Making the case for change
6.2
6.2.1
Successful policy development
Frenk and Sihto et al. suggest two approaches to successful policy development.
Dr Julio Frenk was Minister of Health in the Mexican government from 2001-07. He
offers advice for successful reform, what he calls the ‘ABCDE agenda’:
A. Agenda: promoting the health agenda amidst competition for attention and
public resources. He suggests that
health officials can make use of global evidence showing that a well
performing health system contributes to the overall welfare of society by
relieving poverty, improving productivity, increasing educational abilities,
developing human capital, generating employment, protecting savings and
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Constructing the evidence base on the social determinants of health: A guide
assets, enhancing competitiveness, and directly stimulating economic growth
with a fairer distribution of wealth.
B. Budget: making health a priority enhances the negotiating power of ministers
in search of increased budgetary support. ‘Use of evidence on the value of
health for development can help convince policy-makers to mobilize more
money for health, but the capacity to deliver more health for the money must
also be demonstrated.’
C. Capacity: developing capacity in the health system and research
infrastructure. ‘The first refers to health-service delivery, through investments
in physical infrastructure and, most importantly, in human resources. The
second has to do with the development of institutions that can undertake the
necessary research to generate sound evidence for policy.’
D. Deliverables: identifying and communicating specific benefits through a focus
on priority disease and risk factors. ‘In this way, the public can link abstract
financial and managerial notions to concrete deliverables.’
E. Evidence: creating and diffusing knowledge is one of the main driving forces
for health progress.
First, and most obviously, knowledge gets translated into new and better
technologies, such as drugs, vaccines, and diagnostic methods. Second,
knowledge is also gained by individuals, who use it to structure their everyday
behaviour in key domains like personal hygiene, feeding habits, sexual
behaviour, and child-rearing practices... Third, knowledge becomes
translated into Evidence that provides a scientific foundation for decision
making both in the delivery of health services and in the formulation of public
policies. (Frenk, 2006:959)
Sihto and colleagues suggest the following minimum criteria for policy development.
1. Compatible interests: ‘In sectors where health interests are compatible with
main sectoral interests such as often in environmental, social or educational
policies, gaining common ground is not problematic’ (Sihto et al., 2006:13). In
sectors where interests conflict, policy development will be more challenging
and long-term.
2. Intersectoral collaboration: This is vital and will be more effective if there is
the possibility of discrete interventions. ‘Success in implementation is limited
by the extent to which health policies or intersectoral action of selected
sectors can address improvement of health determinants of their own’ (Sihto
et al., 2006:13). Childhood nutrition at home and school might exemplify this.
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Constructing the evidence base on the social determinants of health: a guide
3. Resources: As with policy advice in other sectors, resources are crucial. ‘The
costs of the strategies are important and any health policy measures that
negatively influence the cost structure of any public policy area will face
further problems in implementation’ (Sihto et al., 2006:13). Resources should
not be considered simply in financial terms but also in human terms, such as
staff time.
4. Public engagement. Involvement with civil society is essential at all stages of
policy development. ‘Local policies are not meaningful unless scope for
implementation at local level is given at national, regional or global levels.
This implies that the promotion of local health agendas and measures will
only have a limited impact if determinants of other policies are set at national,
regional and global levels’ (Sihto et al., 2006:14). This echoes the ‘fully
engaged scenario’ proposed by Wanless (2004) in the United Kingdom where the level of public engagement in relation to health is high, people are
confident in the health system and demand high quality health care, the health
service is responsive with high rates of technology uptake particularly in
relation to disease prevention, and resources are used efficiently. It also
underlines the need for a policy programme that is fully integrated between
national and local levels, and arguably internationally too.
5
Long-term: While there may be some quick wins which will help secure on
going support for policy programme, the long timescales must be recognized.
This has implications for measurement and monitoring as well.
Some issues are tackled more easily than others and some will require
constant and long-term attention. The importance of continuity and follow-up
needs to be highlighted... this implies first that maintaining a long-term policy
perspective and educational basis is important; second, that in some issues,
legal and broader policy measures are more important than campaigns; and
third, that broader policies are rarely changed with one-off measures. (Sihto
et al., 2006:14)
The success of sustaining the policy momentum over long timescales will, to a large
extent, shape the overall policy impact.
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Constructing the evidence base on the social determinants of health: A guide
6.2.2
Three practical steps to get SDH on the policy
agenda
The Measurement and Evidence Knowledge Network considered the following three
practical steps to be useful in helping stakeholders to get social determinants on the
agenda of policy-makers where such policies do not exist (MEKN, 2006).
Carry out a situation analysis
Different strategies and actions will be required in different country contexts
depending on where they are in the process of developing policies aimed at
addressing SDH. A situation analysis is useful to understand what strategies need to
be employed. For example, the strategies required to get the issue of health
inequities on the agenda will be different to those which are required to overcome the
barriers to making existing policies work in practice.
A situation analysis could include:
•
Mapping the policy picture, focusing on both the macro and micro policy
•
Analysis of resources
•
Making explicit the drivers for policy
•
Assessment of the current political willingness to act, which provides the
gap
context for the most implementable actions
•
Mapping of the public health systems within which action can take place
so that the roles and responsibilities of different actors can be made
explicit.
•
Stakeholder analysis and mapping.
Identify entry points
Getting a better understanding of the policy-making processes allows the
identification of opportunities to influence the policy process (entry points).
Identifying these entry points may involve:
•
Identifying the chain of actors (often with different motives) who take part
in the policy-making process
•
Analysing the resource flows to understand how to optimize the
opportunities for implementation success. For example: what percentage
of resources goes to different levels? Does resource allocation include
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Constructing the evidence base on the social determinants of health: A guide
funds for training and human resource development? What are the
decision-making capacities and autonomy at different levels?
•
Identifying policy windows of opportunity. What opportunities exist to
combine these windows? Who are the national and local policy
entrepreneurs who could facilitate this? What factors threaten to close the
window of opportunity?
Develop a communication strategy including use of the media
Evidence is usually only one ingredient in the policy-making process. Stakeholders
also need to develop effective communication strategies.
Such strategies could include:
•
Use of experiences of civil society in creating stories about successful
programmes and initiatives
•
Reinforcing the need for civil society to be involved in partnership
•
Mobilizing stakeholders for intersectoral action and community
involvement
•
Developing provocative statements which can highlight the costs of doing
nothing
•
Working with and training journalists to promote public health messages
(including use of graphics and photographs to translate research into plain
language).
6.3
Illustrative case studies
The following case studies show some approaches to making the case for SDH in
different contexts. It should be kept in mind that not every approach has been or will
be completely successful.
No. 4 - Brazil: Infant mortality in Cear£ state
No. 5 - Canada: National children’s policies
No. 6 - Mexico: Reform of national health system
No. 7 - Thailand: Introduction of universal health coverage
No. 9 - Thailand: Use of locally-defined health determinants to push for
change, Mun River dam
No. 10 - Brazil & Chile - National conferences
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Constructing the evidence base on the social determinants of health: A guide
Getting social determinants on the policy
7
agenda - equity proofing
Part of getting social determinants on the policy agenda is ensuring that the right kind
of action gets on the agenda. Programmes designed to reduce inequalities often fail
due to the time and resources available to carry them out and/or a lack of evidence
about what works across different segments of the population. There is a range of
tools for introducing an equity focus into effective policy and programme
development at different points in time - ex ante, during or ex post- including:
•
Equity filter/ lens
•
Equity audits/ health equity audits
•
Equity-effectiveness loop
•
Equity gauge
•
Equity-focused health impact assessment.
These are outlined below. More detail is given of equity-focused health impact
assessment as it is felt likely to be the most useful tool for readers of this guide.
7.7
Equity filter/ lens
The ‘equity lens’ is a way of looking at society that goes beyond average numbers to
identify the differences between more or less advantaged social groups. The Global
Equity Gauge Alliance (GEGA) understands an equity lens as a
vision which is certainly not easy to achieve. In addition, many of the inequities in
our society remain masked rather than obvious to those who administer or
manage the health services, and those who use them. It is important therefore to
establish ways of looking at existing data and service provision in such a way that
inequities become apparent. This is done by adopting what has been called an
Equity Lens or perspective. (GEGA, 2004)
Although this may seem obvious, the work by Victors et al. (2006) demonstrates how
even strategies which are intended to improve the health of the most vulnerable
populations (e.g. IMCI) still lack in their original design specific ‘equity lens’ criteria
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Constructing the evidence base on the social determinants of health: A guide
(see chapter 3 and case study 2). This absence represents the blind spot of many
global health strategies.
Recent work by Gwatkin (2001,2005, 2006) draws attention to the absence of this
equity lens in the major global initiatives of the 20th century (Gwatkin, 2001) and
makes a vigorous call to include it in one of the major initiatives of this century, the
Millenium Development Goals:
The health objectives set out in the United Nations Millennium Development Goals
(MDGs) do not share the focus on poor people that typifies the MDGs overall. Rather,
they call for improvements in national averages that can be achieved through gains in
both advantaged and disadvantaged groups. As a result, any reduction in society
wide average rates of death or illness can provide a wide range of outcomes for poor
people. Since expanded health services typically reach better-off groups before
disadvantaged ones, poor people are unlikely to be the principal beneficiaries of
efforts to accelerate progress towards the MDGs by providing additional resources to
the health sector, as presently constituted. More plausible is faster progress among
privileged groups and a rise in poor-rich health disparities. Such an outcome is not
inevitable; but achieving faster progress for poor populations will need reorientation in
addition to expansion of health activities. (Gwatkin, 2005)
This proposal would imply rephrasing the goals with an equity lens, for example by
not only reporting on overall vaccine coverage but also on coverage among those
below the poverty line (Victora, personal communication, 2007). Some countries may
already include an equity lens in their national millennium development goals (e.g.
Chile and the Netherlands) (see Mackenbach & Stronks, 2002 and case study 21).
Work has already been undertaken exploring the ways in which an equity lens could
be applied in monitoring and evaluating the MDGs (Wirth et al., 2006, 2006b; Balk et
al., 2006).
An equity lens may be also applied to a variety of specific health issues, ranging from
child health (Victora et al., 2003; Scott et al., 2003), through lifestyle related policies,
e.g. tobacco control, alcohol misuse, nutrition, physical activity, obesity (Dahlgren &
Whitehead, 2006), to sport (Sport England, 2004). It implies addressing the diversity
of the whole social gradient and overcoming the ‘average’ blind spot through the use
of measures that account for social differences.
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Constructing the evidence base on the social determinants of health: A guide
7.2
Equity audits/ health equity audits
Health needs assessment is a systematic process of identifying priority health issues,
targeting the populations with most need and taking action in the most cost effective
and efficient way. A health equity audit (HEA) ‘identifies how fairly services or other
resources are distributed in relation to the health needs of different groups and areas,
[and] the priority action required to provide services in relation to need’ (Department
of Health, 2003 cited in Quigley et al., 2005), For example, health equity auditing was
introduced in England to ensure that local community plans for health and
development prioritized those with greatest need (Department of Health, 2002).
Health equity audit provides a framework for systematic action. It highlights the need
to think about inequalities in terms of age, gender, disability, and geography as well
as socioeconomic status. A health equity audit will consider the health needs of
particular groups taking account of at least one of these dimensions against the
provision of services and resources for good health.
Unlike some needs assessments, an HEA goes beyond the description of inequities
and is not complete until changes to reduce avoidable inequalities have been
implemented, for example resource allocation, commissioning, service provision or
health outcomes.
An HEA normally consists of a six-step approach:
1. Agreeing partners and issues for the audit
2. Undertaking an equity profile
3. Identifying high-impact local action to narrow key inequities identified
4. Agreeing priorities for action
5. Securing changes in investment and service delivery
6. Reviewing progress and assessing impact. (Department of Health, 2003;
Hamer et al., 2006)
This is outlined in Figure 7.1.
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Constructing the evidence base on the social determinants of health: A guide
Figure 7.1
The Cycle of Health Equity Audit
1. Agree
priorities and
partners
6. Review
progress and
impacts against
targets
2. Do an equity
profile
t
4
5. Secure
changes in
investment and
service delivery
3. Identify
effective local
action to tackle
inequities
4. Agree local
targets with
partners
Source: Hamer et al., 2003.
Examples of audit topics are smoking, child and adult mental health services, cervical
screening services, teenage pregnancy, coronary heart disease prevention and
treatment services, etc. The most common equity dimensions included in HEAs are
geography, sex, age, ethnicity and some measure of deprivation (Hamer et al.,
2006).
The overall process of health equity auditing is not dissimilar to the process of a ‘gold
standard’ needs assessment. Some argue it is just a new fashionable way of
describing needs assessment processes with a particular emphasis on health
inequalities. Referring to the experience in the United Kingdom, Hamer et al. (2003)
admit that health equity audit is not new and that National Health Service (NHS)
organizations, local authorities and other agencies have been working for many
years to identify and reduce inequalities in the health and wellbeing of different
groups in their communities. She stresses that the difference now is that tackling
health inequalities is integrated into mainstream planning and service delivery within
the NHS and partner agencies (Hamer et al., 2003) and has become mandatory in
England.
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Constructing the evidence base on the social determinants of health: A guide
There are a number of ways in which a health equity audit can assess equity in
service delivery across sectors. This can include a review of:
•
Equal access for equal need: such as greater availability of free fruit in
schools in the most deprived areas
•
Equal use for equal need: such as greater use of smoking cessation
services among low-income smokers
•
Equal quality of care for all: such as culturally appropriate and relevant
maternity services for black and minority ethnic communities
•
Equal outcomes for equal need: such as greater reductions in coronary
heart disease mortality among lower socioeconomic groups.
7.3
Equity-effectiveness loop
The equity effectiveness loop builds on the fact that social and health interventions
affect the population along the social gradient in different ways. Therefore its purpose
is to measure the ‘impact of various factors in the effectiveness of interventions
across socioeconomic gradients’ (Tugwell et al., 2006c).
This tool has been specifically designed to measure interventions that have an
explicit equity objective.
The loop is based on six iterative steps (Tugwell et al., 2006c):
1. Burden of illness and etiology - Determine health status by
socioeconomic status: (a) measurement of health gaps and (b) causes of
health gap.
2. Equity effectiveness - Efficacy modified by access/ coverage, diagnostic
accuracy, provider and patient adherence, by socioeconomic status.
3. Economic evaluation - Determine relationships between costs and effects
of options by socioeconomic status.
4. Knowledge translation and implementation - Integration of feasibility,
impact and efficiency to make decisions using targeted packaging and
communication by socioeconomic status.
5. Monitoring of programme - Ongoing monitoring of process indicators to
gauge implementation progress by socioeconomic status.
6. Reassessment.
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Constructing the evidence base on the social determinants of health: a guide
This is shown in Figure 7.2.
Figure 7.2
Equity Effectiveness Loop
5
MONITORING OF PROGRAM
Ongoing monitoring using markers
to indicate success by SES
1
BURDEN OF ILLNESS and
ETIOLOGY
Determine health status by
SES:Measure Health gap
Causes of Health Gap
Step 6: REASSESSMENT
Equity
Effectiveness
Loop
4
KNOWLEDGE TRANSLATION &
IMPLEMENTATION
Integration of feasibility, impact and
efficiency to make decisions using
targeted packaging and
communication
By SES
2
EQUITY EFFECTIVENESS
Efficacy x Access/coverage x diagnostic
accuracy x provider compliance and
consumer adherence by SES
\
3
ECONOMIC EVALUATION
Determine relationships between costs and
effects of options by SES.
Source: Tugwell et al., 2006c.
Although it has been designed for analysis based on the socioeconomic gradients,
the authors argue that it may also be used with other social stratifiers, e.g. place of
residence, ethnicity, race, gender, etc.
7.4
Equity gauge
An equity gauge is an action-oriented project aimed at bridging research and action.
It is conceived as a catalyst for equity which: strengthens the work of existing groups
by providing evidence of inequities; strengthens community voices; strengthens the
link between community groups and decision-makers; and directly supports the role
of decision-makers (GEGA, 2003).
The Global Equity Gauge Alliance (GEGA) was created in 2000 and at present has
member teams in ten low and middle income countries. GEGA’s Equity Gauge
Strategy is based on three ‘pillars of action’ (GEGA, 2004) (see Figure 7.3):
88
Constructing the evidence base on the social determinants of health: A guide
•
Assessment and monitoring: to analyse, understand, measure and
document inequities
•
Advocacy: to promote changes in policy, programmes and planning
•
Community empowerment and participation: to support the role of poor
and marginalized people as active participants in change, rather than
passive recipients of aid or help.
The three-pillar design considers all pillars to be equally important and essential to a
successful outcome. They are interconnected and overlapping and therefore do not
necessarily follow a temporal sequence. In an equity gauge, the actions of all three of
its pillars should be interconnected and happen concurrently.
Figure 7.3
Three pillars of action
Action to reduce unjust disparities
Equity gauge
o
E
<D
o
E
•a
CD
£
3o
■O
<D
E
U)
tn
CD
tn
tn
<
5
E
<D
>»
'E
E
E
o
O
Source: GEGA, 2003.
Though gauges may vary according to countries’ realities, GEGA has proposed a
basic set of variables which should be monitored and acted upon. These variables
are grouped under the acronym PROGRESS developed by Evans and Brown (2003)
for measuring disadvantage:
89
Constructing the evidence base on the social determinants of health: A guide
Place of residence
Race/ ethnicity
Occupation
Gender
Religion
Education
SES (income or composite measures)
Social capital.
The Ottawa Equity Gauge has recently been created and is applying the Global
Equity Gauge Alliance framework to an industrialized country setting. They have
added a fourth ‘interventions’ pillar, based on the Cochrane and Campbell systematic
reviews of interventions. The Ottawa Equity Gauge project has brought together
researchers, community leaders and stakeholders to work on measuring, monitoring
and addressing health inequities in accidents, exercise, nutrition and smoking in
Ottawa (Tugwell et al., 2006a).
Figure 7.4
Ottawa Equity Gauge
Ottawa Equity Gauge
4 Pillars
Equity Needs:
Monitoring/
Data Analysis
[‘Progress
Indicators!
•RRFSS - Rapid
Risk Factor
Surveillance System.
•CCHS - Canadian
Community Health
Survey
•Health Equity
monitoring-Toolkit
•Community needs
assessment
Neighbourhood QOL
Observatory
Interventions
What works and
in which
settings?
•Food insecurity
•School meals
•Anti smoking
•Physical activity
strategy
•Obesity
Community
empowerment
Community
Participation
Advocacy
Advocacy and
Dissemination
•Catalogue of
organizations
•Participatory
research
•Community studies
•Strategic alliances
•Consensus building
•Social Marketing
•Interactive
Community Forum
•Press analysis
•Strategic alliances
•Dissemination
•Interactive
workshops
Source: Tugwell et al., 2006a.
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Constructing the evidence base on the social determinants of health: A guide
Figure 7.4 shows the four pillars strategy of the Ottawa Equity Gauge, highlighting
specific issues and activities in each pillar as a way of illustrating that an equity
gauge
does not merely describe health disparities but rather couples data collection with
coordinated community-driven actions and advocacy efforts to reduce disparities and
help members of the community to reach their full health potential (Tugwell, 2006a).
For example, one of the most recent interests is food security and nutrition issues.
This has included participatory action research and systematic reviews of published
and unpublished literature, a survey on food insecurity in vulnerable populations in
Ottawa, and an assessment of spatial inequalities in food insecurity though the use of
geographical information systems. All these activities contribute to build up the
evidence base which will then be used for advocacy as well as for community
empowerment and capacity building.
7.5
Equity-focused health impact assessment
7.5.1
Objectives
Health impact assessment (HIA) is a tool for decision-makers to address health
inequalities in local populations. It is a structured process which combines
procedures, methods and tools for assessing the potential impacts of a policy,
programme, project or proposal on the health of a population. The purpose of HIA is
to identify the potential health consequences of a proposal on a given population and
to maximize the positive health benefits and minimize the potential adverse effects
on health and inequalities (Taylor & Blair-Stevens, 2002). An HIA looks for the
positive and negative, intended and unintended health effects and makes
recommendations for improving the policy, programme, project or proposal (ECHP,
1999; Harris-Roxas et al., 2006; Quigley et al., 2005).
In one of the first international position statements on health impact assessment,
WHO states that the purpose of HIA is to measure the potential impacts of policy
decisions in one sector on another sector. The paper argues that social, economic
and other policies in both the public and private sectors are so closely interrelated
that proposed decisions in one sector may impact on the objectives of other sectors.
HIA provides a useful means therefore of improving knowledge about the potential
impact of a policy or programme, which can inform decision-makers and those who
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Constructing the evidence base on the social determinants of health: A guide
might be affected. It can facilitate adjustment of the proposed policy in order to
mitigate the negative and maximize the positive impacts (ECHP, 1999).
An equity-focused HIA (EFHIA) provides a systematic approach to consideration of
equity in each step of an HIA (Simpson et al., 2005; Mahoney et al., 2004; HarrisRoxas et al., 2004). Nonetheless, a necessary caveat to bear in mind is that an
‘EFHIA will not necessarily result in policies to reduce inequalities as it is a proposal
specific process. It may simply end up ensuring that a proposal does not exacerbate
existing inequalities’ in programmes that do not have equity among their objectives
(Harris-Roxas, personal communication, 2007).
HIAs and equity-focused HIAs provide the opportunity to stop, reflect and change a
proposal - an ‘amber light’ principle (Griffiths, 2003). Proponents or decision-makers
have the opportunity to examine the proposal for its health equity impacts in a
structured and considered way prior to implementation. Often what emerges is not
radically new or astounding - in fact those involved in the experience are often
surprised by how obvious the potential impacts are once time is taken to reflect.
Some have described it more as a case of common sense (Harris et al., 2006). What
is important is the opportunity to stop and revisit either the explicit intent (where we
are often blinded by our good intentions) and or to identify how to avoid potential
problems that might arise from major initiatives with no explicit equity focus. The
latter issue is particularly important given that the policy and programme
development context does not usually include automatic consideration of health
impacts and or health equity impacts.
Mindell et al. (2004) distinguish HIA from other tools used to aid decision-making as:
•
It focuses on complex interventions or policy and their diverse effects on
determinants of health
•
It requires evidence on the reversibility of adverse factors damaging to
health
•
It involves a diversity of evidence in terms of relevant disciplines, study
designs, quality criteria and sources of information
•
It involves a broad range of stakeholders
•
It is often required within short timescalesand limited resources
•
It involves a degree of pragmatism to assemble information to inform
decision-makers regardless of the quality of the evidence.
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Constructing the evidence base on the social determinants of health: A guide
In this approach, in addition to promoting the maximum health of the population, four
values are particularly important for HIA:
Democracy: emphasizing the right of people to participate in a transparent
•
process for the formulation, implementation and evaluation of policies that
affect their life, both directly and through elected political decision-makers
•
Equity: emphasizing that HIA is not only interested in the aggregate mpact
of the assessed policy on the health of a population but also on the
distribution of the impact within the population, in terms of gender, age,
ethnic background and socioeconomic status
•
Sustainable development, emphasizing that both short-term and long-term
as well as more and less direct impacts are taken into consideration
•
Ethical use of evidence: emphasizing that the use of quantitative and
qualitative evidence has to be rigorous, and based on different scientific
disciplines and methodologies to get as comprehensive assessment as
possible.
7.5.2
Timing
An equity-focused HIA ideally takes place at the stage when a policy or programme
proposal can be reviewed for its potential health equity impacts and issues can be
addressed prior to implementation. It provides the opportunity to check: (a) if the
stated intentions of the proposed policy or programme will be fulfilled - particularly
important if the stated intention is to improve health equity; and (b) whether there will
be any unintended impacts (positive and/or negative) such as a widening of the gap
by faster improvement among population groups which are more advantaged than
others.
7.5.3
Key factors to consider
Experience shows (Simpson et al., 2005; Mahoney et al., 2004; Harris et al., 2006)
that when undertaking an EFHIA the following issues should be born in mind:
1. Timing of the equity proofing process. It is important that equity proofing
takes place when (a) the proposal is well developed enough to assess the
potential health equity impacts but not so advanced or fixed that there is
no opportunity to amend the proposal before implementation; and (b)
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Constructing the evidence base on the social determinants of health: A guide
enough information relating to the scope and implementation of the
proposal (e.g. coverage, proposed timeframes, phased or immediate
rollout, etc) is available to assess the potential health equity impacts.
2. Buy-in from key stakeholders including relevant Minister(s), senior
decision-makers, etc. Is there a real opportunity to amend the proposal
based on the findings of the equity proofing process and will the findings
be used to amend the proposal? There needs to be a genuine
commitment to consider the results of the process and to amend the
proposal accordingly. Without such a commitment the process will have
minimal impact and possibly disenfranchize those involved even further,
particularly where the process has involved community stakeholders.
3.
Time taken to do the equity proofing. An Australasian experience with six
initial case study sites found that equity-focused HIA would have
potentially greater value if it took less time (Harris et al., 2006). Equity
proofing need not take as long as or longer than the process for
developing the proposal. It is therefore recommended that proponents
give consideration to undertaking a ‘rapid’ equity-focused HIA which might
take 4-6 weeks or an even more rapid equity filter (for instance 1-2
workshops, 1-2 telemeetings and reporting within 7-10 days).
4. Use of ‘experts’ and presentation of the findings as ‘expert knowledge’.
The knowledge necessary to assess potential health equity impacts may
not be considered ‘scientific’.
5.
The need to have evidence to hand or off-the-shelf evidence. Evidence
from activities undertaken beforehand or experience from HIAs
undertaken elsewhere are useful, such as completed health equity audits,
completed evidence developed through the equity gauge approach or
evidence collected as part of the health equity effectiveness feedback
loop.
6. Dissemination, evaluation and consideration of the impact of the equity
proofing process. A key challenge of the field of HIA and equity-focused
HIA has been demonstrating the difference that the process has made,
both in terms of (a) changing the proposal and (b) the benefits of these
changes as reflected in longer term outcomes of the policy or programme
(Quigley & Taylor, 2003). Those undertaking an equity-focused HIA have
a responsibility to report on the impact of the findings on the proposal as
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Constructing the evidence base on the social determinants of health: A guide
well as a longer term evaluation of the impact of the ‘improved’ policy or
programme. A recent study on the cost benefits of HIA (York Health
Economics Consortium, 2006) indicated that the benefits of the HIAs
included in the study outweighed the costs.
Quigley et al. (2005) compare the similarities and differences of health equity auditing
and health impact assessment along with other techniques such as integrated impact
assessment and race equality impact assessment. In doing so, they attempt to
highlight the unique contribution of these techniques to assessing health needs,
informing decisions and assessing impact. The commonality between these
approaches is that they are all used as planning tools to promote decision-making to
ensure effective public health services, in both the health and non health sectors, and
that they all work best when they involve a wide variety of stakeholders, building new
ways of working together and ensuring joined-up planning - at a project, programme,
strategy or policy level (Quigley et al., 2005).
7.6
Conclusion
The need for equity proofing is evidenced even in initiatives which by their essence
are expected to reduce health inequities within and between countries. The example
of the Integrated Management of Childhood Illness (IMCI) programme of WHO and
UNICEF is a case in point - see case study 2 in appendix I.
Ideally and in the longer term equity proofing of policy and programme proposals
should be undertaken as a matter of course - in other words, equity proofing should
be mainstreamed. Equity proofing should also be seen as part of an overall process
for improving how equity is considered and addressed in the policy and programme
development processes of a country. It should be used as an opportunity to stop and
double-check that the intended outcomes will be achieved and there will not be any
worsening of health inequities (unintentional or otherwise). Equity proofing should be
an amber or yellow light before proceeding to green, and implementation.
7.7
Illustrative case studies
The following illustrative case studies give examples of the need for equity proofing:
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Constructing the evidence base on the social determinants of health: A guide
No. 2 - Brazil, Peru, United Republic of Tanzania: Failure to equity proof
programme for childhood illnesses
No. 3 - Bolivia: Evaluation of Social Investment Fund.
No. 21 - The Netherlands: Multilevel surveillance system.
The following illustrative case studies contain examples of health impact assessment:
•
No. 9 - Thailand: Use of locally-defined health determinants to push for
change, Mun River dam
•
No. 15 - Slovenia: HIA of national agricultural policy
•
No. 16 - United Kingdom: HIA of housing redevelopment
7.8
Specific tools
Health Equity Audit: a guide for the NHS
http://www.dh.qov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicvAnd
Guidance/DH 4084138
Canadian Handbook on Health Impact Assessment
http://www.hc-sc.qc.ca/ewh-semt/pubs/eval/handbook-quide/vol 1/index e.html
Introducing health impact assessment (HIA): Informing the decision-making
process
http://www.phel.qov.uk/hiadocs/Full copy of HDA short quide.pdf
WHO web site on health impact assessment (only available in English)
http://www.who.int/hia/en/
Of particular interest: tools and methods section
http://www.who.int/hia/tools/en/
An idea whose time has come: New opportunities for Health Impact
Assessment in New Zealand public policy and planning
http://www.nhc.qovt.nz/phac/publications/an-idea-whose-time-has-come.pdf
Equity Focused Health Impact Assessment:
Harris E, Harris P, Kemp L. (2006). Rapid Equity Focused Health Impact Assessment
of the Australia Better Health Initiative: Assessing the NSW components of priorities
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Constructing the evidence base on the social determinants of health: A guide
1 and 3. Sydney:UNSW Research Centre for Primary Health Care and Equity.
Available from: http://hiaconnect.edu.au/files/Rapid EFHIA of ABHI.pdf.
Harris-Roxas B, Simpson S, Harris E. (2004). Equity Focused Health Impact
Assessment: a Literature Review. Sydney: Centre for Health Equity Training
Research and Evaluation (CHETRE) on behalf of the Australasian Collaboration for
Health Equity Impact Assessment (ACHEIA). Available from:
http://hiaconnect.edu.au/files/Harris-Roxas B (2004) Equity Focused HIA.pdf.
Mahoney M. (2006). An introduction to Equity-focused Health Impact Assessment.
PowerPoint presentation. HIA Research Unit, Deakin University, Australia. Available
from: http://www.nceta.flinders.edu.au/events/documents/MaryMahoneyEFHIAIntroslides.pdf
Mahoney M, Simpson S, Harris E, Aldrich R, Stewart Williams J. (2004). EquityFocused Health Impact Assessment Framework. Sydney: The Australasian
Collaboration for Health Equity Impact Assessment (ACHEIA). Available from:
http://www.hiaconnect.edu.au/files/EFHIA Framework.pdf
Equity-Oriented Tool Kit for Health Technology Assessment
WHO Collaborating Center for Knowledge Translation and Health Technology
Assessment in Health Equity, Institute of Population Health at the University of
Ottawa
http://www.intermed.med.uottawa.ca/research/qlobalhealth/whocc/proiects/eo toolkit/
index.htm
Monitoring Millennium Development Goals with an Equity Lens
Wirth ME, Delamonica E, Sacks E, Balk D, Storeygard A, Minujin A. (2006).
Monitoring Health Equity in the MDGs: a Practical Guide. New York: CIESIN and
UNICEF. Available from:
httD://sedac.ciesin.orq/povmap/downloads/analYsis/Health equity Guidelines.pdf
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Constructing the evidence base on the social determinants of health: A guide
8
Generating evidence for policy and practice
8.1
Status of the evidence base on the social
determinants of health
Decades of primary research have accumulated a strong evidence base to confirm
that social factors, which are shaped by an individual’s relative position in society,
account for the bulk of health inequities that exist between and within countries (Solar
& Irwin, 2007). There are also many examples at an international and national level
of syntheses of this evidence to highlight the role that public policy can have in
shaping the social environment in ways that are conducive to health (Acheson, 1998;
King, 2000; Marmot & Wilkinson, 2003). There is therefore enough evidence
available for all countries to take some action to address the social determinants of
health (see recommendations from other themed knowledge networks).
However, as has already been outlined in chapters 1 and 2, there are two main
deficiencies with this evidence base. Firstly, some authors argue (Graham, 2003)
that the evidence base available to policy-makers is largely based on an
understanding of the social determinants of health rather than the social
determinants of health inequities. This distinction is important at a policy level since
the actions required to address the social determinants of health are not the same as
the actions required to address the social determinants of health inequities.
Secondly, it is well recognized that while there is much evidence available to help us
describe the inequities that exist in different country contexts, there is much less
available to tell us what to do about them.
In part, overcoming these deficiencies requires investment in large scale research
using new approaches which take account of the complexity of interventions aiming
to address the social determinants. However, there is a job to be done at national
and local level in different country contexts to maximize what we already know. This
can be achieved by ensuring that:
•
The key questions that need answering are made explicit, particularly
being clear about who is asking them and for what purpose
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Constructing the evidence base on the social determinants of health: A guide
•
Methodological diversity is achieved by matching the key questions to the
most appropriate research method (Pettigrew & Roberts, 2003)
•
The evidence is generated based on the same principles as those used in
evidence based public health to assess the quality and rigour of research
appropriate to the design and methods being used (Des Jarlais et al.,
2004; Victora et al., 2004).
These three points are developed below.
8.2
Getting the questions right
Generating evidence for effective action involves bringing together knowledge which
is useful both in formulating policy and in understanding how best to implement it.
Whitehead et al. (2004) identify this multi-faceted evidence base as the ‘jigsaw’
required to build a coherent picture of the most effective policies, the most
appropriate interventions and the most cost effective solutions. This jigsaw
recognizes that evidence is produced for different purposes, including mobilizing
political will, getting buy-in from the public, demonstrating success, predicting
outcomes and monitoring progress.
In this context the framework aims to help maximize the evidence that is available by
drawing on a wide range of evidence. In doing so, it promotes a move away from
ranking the quality of evidence based on study design (e.g. hierarchies of evidence
based on the randomized controlled trial) towards asking ‘what is the appropriate
evidence given the question being asked?’ (Glasziou et al., 2004). It recognizes that
the definition of evidence must refer to any type of observation, whether gathered
through qualitative or quantitative methods, and that in reality evidence alone is an
essential but not sufficient basis for policy action. As previously indicated, other
ingredients include political will, transferability of evidence into appropriate social
strategies, and scalability into different contexts and settings (Kawachi, 2005).
In general terms, the evaluation framework proposed by Wimbush and Watson
(2000) is helpful in making explicit the specific needs and perspectives of a full range
of stakeholders involved in the development and implementation of programmes
aiming to address the social determinants of health. The framework helps to
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Constructing the evidence base on the social determinants of health: A guide
determine the types of question to be asked and the appropriate methods to answer
them.
For example, policy-makers and strategic planners are more interested in higher
level questions of what works (questions of effectiveness) and what are the best buys
(questions of cost effectiveness), in order to be able to make decisions about the
most efficient and effective deployment of resources. In relation to the social
determinants, they may also ask additional questions such as ‘What are the benefits
of investing in a social determinants approach?’, ‘Is there a particular social factor
that will give the biggest impact on reducing health inequities?’ or ‘What is the
relative impact of implementing macro level policies compared with efforts that can
be made by local practitioners?’. Impact evaluations of this sort need to be large
scale and take account of the long term nature of social interventions, measuring a
range of short-, medium- and long-term outcomes. They are also likely to be carried
out by professional evaluators.
On the other hand, practitioners who are responsible for the operation and running of
community projects need to understand the practicalities of implementing
interventions in real life situations. They might ask ‘What are the biggest barriers to
implementation and how can these barriers be overcome?’ or ‘What are the best
ways of building effective partnerships to take action on the social determinants of
health?’ These are process evaluations. Those implementing social interventions
need to be clear about the roles and responsibilities of particular sectors.
In addition the population likely to benefit from the service or programme will be
concerned with the quality of service provision, the extent to which it meets their
needs, and the extent to which the process has been participatory or consultative
(experience evaluations).
The framework requires all evaluations to adhere to the principle of ‘commitment to
equity’. All questions developed through this process should therefore take account
of the variations in the target community according to age, gender, ethnicity and
social circumstance and other dimensions of health inequities.
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8.3
Achieving methodological diversity
By nature, addressing the social determinants of health involves a wide range of
stakeholders and actions which cut across sectors. Generating the evidence required
to build the knowledge base about the most effective ways of taking action is also a
multidisciplinary concern (Alleyne et al., 2002). In collating the evidence base,
researchers will draw upon work from sociological, psychological, anthropological
and medical traditions, to name but some. Within each of these areas there are
various epistemological positions, many of which will be in direct philosophical
conflict with others in generating the evidence base on the social determinants of
health. Some of the gaps in the evidence base on how best to tackle the social
determinants of health are in part due to the disagreements among researchers
about the most appropriate research methods and designs for building a robust
evidence base. For example, there are long standing arguments within this field
about the role of the randomized controlled trial - whether it is inappropriate or
impractical, or only provides part of the picture in a multi-level intervention.
Getting the questions right will help to ensure that various sources can be brought
together in such a way as to create the ‘evidence jigsaw’ described by Whitehead et
al. (2004), which helps policy-makers take appropriate action on the social
determinants of health based on the best available evidence. By drawing on a broad
range of evidence (including quantitative and qualitative research, grey literature,
case studies) we are more likely to be able to find out not only what works to address
the social determinants of health, but also how and in what circumstances.
It is not possible or desirable in this guide to provide a comprehensive list of all the
different types of study which could be used to generate a multidisciplinary, multi
method evidence base on the social determinants of health. The framework
recommends that policy-makers, researchers and practitioners assess the
appropriateness of particular methods and evaluation techniques in their own country
contexts. There are many standard text books to help them in this task.
However, with respect to policy-making, the five types of evidence put forward by
Whitehead et al. (2004) are recommended as a useful starting point. These are:
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Constructing the evidence base on the social determinants of health: A guide
•
Observational evidence showing the existence of a problem. This is
most useful when the intervention to tackle the issue is then fairly obvious.
However this type of evidence becomes more complicated when there are
multiple causes of the problem (Diez-Roux, 2004).
•
Narrative accounts of the impacts of policies from the household
perspective. These might include a combination of descriptive studies
(reporting on household budgets and analysing expenditure on the
prerequisites for health for families living in different socioeconomic
circumstances) and qualitative studies of decision-making in families -
exploring why one course of action was chosen over another.
•
Controlled evaluations. Whitehead helps to dispel the myth that
controlled experiments are inappropriate all of the time by identifying
examples of studies that have had a direct effect on policy-making. An
example is in Africa where rigorous evaluations were made of the effects
of Vitamin A on mortality and of rehydration for diarrhoeal diseases. This
research led to changes in worldwide policy and practice after
recommendations from WHO. It is important to note however that much
could be done to improve the design of randomized controlled trials
(RCTs) to take account of the social determinants of health (Oakley et al.,
2006). Current designs generally fail to incorporate the necessary
variables to assess the effectiveness of social approaches and the
random allocation of whole populations is often difficult and/or unethical
(Chaulk & Kazandijian, 2004).
•
Natural policy experiments. Petticrew et al. (2005) put forward solid
arguments for the use of ‘natural experiments’ as a source of evidence for
both investigating the determinants of health inequities and for identifying
effective interventions. Such ‘experiments’ may overcome the barriers of
executing RCTs in the field of social determinants and can offer ‘good
enough’ evidence on how best to act to tackle health inequities. Natural
experiments go some way towards overcoming the issue of attribution
when random allocation is not possible. Whitehead et al. (2004) also
suggest that evidence from other countries or regions could inform debate
if it provided concrete information on what happens when a particular
policy currently under consideration in one place has already been
introduced elsewhere.
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•
Historical evidence. Evidence from the past can be influential in the
process of policy-making. Whitehead et al. (2005) give the example of the
Rowntree Poverty Surveys of 1901 and onwards which painted a vivid
picture of life in the slums of Britain’s industrial cities. This was shocking
to the general public, changed attitudes to poverty and underpinned the
building of the post-war welfare system.
Chapter 9 describes some of the ways in which these different types of evidence can
be brought together to give an understanding of how best to act on the social
determinants of health. However there is a need to ensure that future attempts to
generate this evidence base use mixed method approaches in primary research.
There is also a need to redress the balance and ensure that studies embed process
evaluation into research design to provide meaningful information on outcomes.
One promising advance which combines process and outcome is the ‘realistic
evaluation’ approach, which attempts to provide answers not only about what
interventions work to address SDH, but also how they work and in what context.
These types of evaluations can help us to understand the mechanisms of change
and can make explicit the underpinning theories upon which programmes are based.
Rawson and Tilley’s (1997) notion of realistic evaluation is helpful as it promotes
theory-driven evaluations which help to capture the linkages between the context (the
necessary conditions for an intervention to trigger mechanisms), the mechanisms
(what it is about a particular intervention that leads to a particular outcome in a given
context) and the outcomes (the practical effects produced by causal mechanisms
being triggered in a given context).
8.4
Assessing the quality of the diverse evidence base
Expanding the scope of‘admissible’ evidence in the field of the social determinants
does not mean sacrificing rigour (Kawachi, 2005). It is important that all knowledge
used to generate evidence should be assessed for quality, particularly making clear
any biases that might affect the knowledge used. This follows the principle of
‘explicating bias’ set out in chapter 1. The methodological task is then to find a
means of evaluating research from whatever tradition it comes, according to agreed
criteria of acceptability, and regardless of its theoretical or methodological origins.
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The work of the Cochrane Collaboration is often dismissed by those working in the
social determinants field as the methods and processes used to construct evidence
seem too narrowly focused on the field of bio-medics. In fact, much of the Cochrane
Collaboration’s work is relevant to assessing the quality of the study designs required
to develop the social determinants evidence base. The criteria have been developed
primarily for the production of systematic reviews, which synthesize large amounts of
material to reach a consensus about the most effective approaches to promoting
health and tackling health inequities. However, the more the principles set out in the
guidelines produced by this organization are used at the primary research stage, the
more likely it is that this research can be used at the appraisal and synthesis stage
by organizations collating the best available evidence (Jackson & Waters, 2005b).
While the checklists have primarily been used to assess the quality of individual
research designs, it is possible to use them to derive common quality standards to
apply to all study types and methodologies relevant to the development of the social
determinants evidence base. All studies attempting to answer questions about the
social determinants of health should adhere to the following criteria (usually used to
assess the quality of studies during evidence synthesis):
•
Reporting of what the researchers did and why and how they did it
(transparency)
•
Applying a consistent and comprehensive approach (systematicity)
•
Assessing how applicable the study is to different populations and in
different contexts (relevance).
(Swann et al., 2003)
These criteria are described in more detail below. Combining them with the principles
described in chapter 1 can help to improve the quality of the evidence base on the
social determinants of health.
Transparency
It is important to assess whether there is sufficient information about what the
researchers did and why they did it. Greater transparency of method means a higher
quality piece of work. In relation to the social determinants agenda, it is particularly
important that all the forms of bias that might be present in the study are made
explicit, either those stemming from the particular methodologies used or from the
political value position of the writer.
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Constructing the evidence base on the social determinants of health: A guide
Systematicity
It is important that a consistent methodological approach is applied to all aspects of a
study. Given the complex nature of interventions required to address the social
determinants of health, it is not possible for any one research study to answer all the
questions relevant to this endeavour - it is therefore important for studies to
contextualize their research in a broader theoretical framework (causes,
determinants and outcomes). This allows the reader to understand which aspects of
the social determinants agenda are being investigated and what aspects of the
‘jigsaw’ the research hopes to complete.
Relevance
The context (social structures and social dynamics) within which the study is being
carried out should be stated along with a view on how generalizable the findings
might be to population groups across the dimensions of inequity.
This is not to say that any study which does not meet the three criteria above should
immediately be discarded. Rather, policy-makers and practitioners need to make a
judgement about when the evidence can be used for decision-making, keeping in
mind that the conclusions of a poor quality study are less likely to be reliable than
those of a higher quality work.
Conclusion
8.5
Countries which are just starting to construct this evidence base have an opportunity
to ensure that the richest evidence possible is gleaned from multimethod and
multidisciplinary primary research and that by following the principles and criteria set
out in this guide the quality of that research can be improved. The next chapter looks
at what can be done with the evidence once it has been gathered.
Illustrative case studies
8.6
The following illustrative case studies give examples of generating evidence:
•
No. 4 - Brazil: Infant mortality in Cear£ state
•
No. 6 - Mexico: Reform of national health system
•
No. 7 - Thailand: Introduction of universal health coverage
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Constructing the evidence base on the social determinants of health: A guide
No. 9 - Thailand: Use of locally-defined health determinants to push for
change, Mun River dam
No. 11 - Uganda: Community-based monitoring
8.7
Related reading
Alleyne G.A., Castillo-Salgado C., Schneider MC., Loyola E., and Vidaurre M.
Overview of social inequalities in health in the Region of the Americas, using various
methodological approaches. Rev Panam Salud Publica/Pan Am J Public Health
2002;12(6):388-397.
Center for Global Development -Washington (2006), When Will We Ever Learn?
Improving Lives Through Impact Evaluation, SPRU Electronic Working Paper
Series, Paper No. 145 - February 2006, Partner at The Knowledge Bridge The
.Freeman Centre, University of Sussex, UK
Chaulk C, Kazandjiart V (2004), “Moving beyond randomized controlled trials”,
American Journal of Public Health; Sep 2004; 94, 9; ABI/INFORM Global
Des Jarlais D C, Lyles C, Crepaz N, Abbasi K et al, (2004), “Improving the reporting
quality of nonrandomized evaluations of behavioral and public health interventions:
The Trend statement”, American Journal of Public Health; Mar 2004; 94, 3;
ABI/INFORM Global, pg. 361
Diez-Roux A, (2004), “The Study of Group-Level Factors in Epidemiology: Rethinking
Variables, Study Designs, and Analytical Approaches”, Epidemiologic Reviews, Vol.
26, 2004, DOI: 10.1093/epirev/mxh006
Diez-Roux A, (1998), “Bringing context back into epidemiology: Variables and
fallacies in multilevel analysis”, American Journal of Public Health; Feb 1998; 88, 2;
ABI/INFORM Global, pg. 216
Habicht J, Victoria C and Vaughan J,(1999),’’Evaluation designs for adequacy,
plausibility and probability of public health programme performance and impact”,
International Journal of Epidemiology, 1999; 28: 10-18
Pawson R, Greenhalgh T, Harvey G, Walshe K, (July 2005), ‘Realist review - a new
method of systematic review designed for complex policy interventions’ J Health Serv
Res Policy Vol 10 Suppl 1 July 2005
Petticrew M, Roberts H, (2003), “Evidence, hierarchies, and typologies: horses for
courses” J Epidemiol Community Health 2003;57:527-529
Victora C G, Habicht JP & Bryce J (2004), ‘Evidence-Based Public Health: Moving
Beyond Randomized Trials’, American Journal of Public Health, March 2004, 400 |
Public Health Matters | Peer Reviewed | Victora et al. Vol 94, No. 3
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Constructing the evidence base on the social determinants of health: A guide
8.8
Specific tools
The Bias Free Framework: a practical tool for identifying and eliminating social
biases in health research
Burke M & Eichler M (2006),Global Forum for Health Research, Geneva.
Available from:
http://www.qlobalforumhealth.orq/Site/002 What%20we%20do/005 Publications/O
10 BIAS%20FREE.php
Evaluation in health promotion: principles and perspectives
Available from www.phac-aspc.qc.ca
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Constructing the evidence base on the social determinants of health: A guide
Evidence synthesis and action
9
Creating evidence based guidance is one way of helping to prioritize actions to
address the social determinants and improve the standards of professionals working
in this area. It represents the second phase in the framework outlined in chapter 4
and involves two main stages: synthesizing the available evidence and then turning
that evidence into prioritized recommendations, i.e. evidence based guidance. There
are a number of national and international organizations who are engaged in one or
both of these tasks (see for example www.cochrane.org ; www.campbell.org ;
www.cdc.gov ; www.nice.org.uk). The synthesis of evidence and production of
evidence based guidance is resource intensive. There is therefore a need to
collaborate at an international level to ensure that the task of producing evidence
based guidance is not duplicated unnecessarily. The Cochrane Collaboration has
already begun by setting up a project to assess global priorities for systematic
reviews (Tugwell et al., 2006b). Some areas relevant to the social determinants of
health have already been identified. They include:
•
Community building interventions (designed to build a sense of
community connectedness, cultural revival and social capital) to improve
social and mental health
•
Transport schemes to increase use of maternal and newborn health
services, and increase community support and action for maternal and
newborn health populations.
These topics reflect the shift in emphasis of the Cochrane Collaboration and are an
example of where systematic reviewing can include topics of relevance to the social
determinants agenda.
Countries should judge the relevance of products like these and assess whether they
can use and /or adapt them to develop effective programmes for action in their own
country contexts.
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9J
Synthesizing complex and diverse data
Synthesizing data from diverse sources enables it to be combined in a way that is of
optimum value for policy-making and managerial decision-making. National policy
makers, commissioners of research, and local managers and practitioners look for
answers to questions about health care services and delivery, and look for ways of
improving population health and reducing health inequalities (Kelly et al., 2002;
Ogilvie et al., 2005; Oliver et al., 2003). Some of the methods for synthesizing
various kinds of evidence are detailed in this section in an attempt to bridge the gap
between evidence and policy.
The questions decision-makers ask are complex, questions that go beyond ‘What
works?’ and include ‘When?’ ‘How?’ and ‘Why?’, as well as ‘For which people in
which circumstances?’ Often the answers to these questions are located in a variety
of research and non-research sources, and some of the answers may come from
unpublished as well as published materials. Review and synthesis offer a way of
understanding and using these diverse sources of evidence. Many of the methods
discussed here have been designed to synthesize published qualitative and
quantitative research findings, but some could, potentially at least, be extended to
synthesize other kinds of evidence.
Evidence synthesis encourages broadening the scope of what ‘counts’ as evidence
in the kind of reviews and reports which are designed to inform decision-making.
Evidence can be quantitative and qualitative research findings, as well as data from
stakeholder surveys or the views and values of experts and users. The inclusion of
diverse sources of evidence in reviews does not mean abandoning the rigour of
systematic reviews, but it does mean judging the quality of evidence in context and
defining evidence as relevant to answering specific questions, rather than defining
some forms of evidence as intrinsically and universally of lower quality than others.
Policy-makers are more likely to take note of evidence presented from a robust and
transparent synthesis that gathers evidence from multiple studies, rather than results
from reviews of single interventions. Systematic reviews are seen to be particularly
helpful in this process because they bring together in one place the findings from
many studies and attempt to ascertain what the collected knowledge means to
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Constructing the evidence base on the social determinants of health: A guide
people who do not have the time or expertise to cope with what are often vast and
confusing bodies of evidence.
Many methods for the synthesis of diverse data are still in their formative stages and
most were developed for the synthesis of either qualitative or quantitative data, rather
than synthesis of the two. This section looks briefly at practical ways that synthesis of
different types of evidence can be carried out. The information presented
summarizes material from the book by Pope, Mays and Popay, Synthesising
qualitative and quantitative health evidence. A guide to methods (Buckingham: Open
University Press, 2007) which was developed from an overview of methods for
synthesizing qualitative and quantitative evidence (Mays et al., 2005).
Reviewing evidence
9.1.1
The role of the literature review
Traditionally literature reviews have been used to try to bring together evidence that
has been accumulated on specific areas of research. A literature review remains an
essential precursor to research - a way of identifying current thinking, identifying
gaps and proposing a way forward. However the traditional format of the literature
review does not comment on or judge the quality of the research being summarized.
The range of quantitative and qualitative methodologies under review, together with
the amount of information needing to be extracted, makes the appraisal of study
quality difficult.
Systematic reviews of effectiveness
Systematic reviews are an attempt at a more rigorous and sophisticated tool than the
literature review. Such a review has an explicit, transparent and therefore
reproducible method, less open to research bias or subjectivity. A systematic review
generally has to meet the following criteria:
•
Has a review protocol to guide the review process
•
Has a comprehensive pre-defined literature search strategy
•
Includes a critical appraisal of studies and grading of evidence
•
Has explicit (transparent) inclusion and exclusion criteria
•
Has explicit (transparent) methods of data extraction and (statistical) analysis.
*1
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Constructing the evidence base on the social determinants of health: A guide
Systematic reviews, pioneered by organizations such as the Cochrane Collaboration,
have gained increasing importance in assessing effectiveness of clinical practice.
Systematic reviews initially advocated a strict hierarchy of evidence with randomized
controlled trials (RCTs) at the top. There is however a growing consensus that
evidence from a wide range of sources must be sought to address the complex
questions being asked. As a result evidence is increasingly sought from qualitative as
well as quantitative research, on the grounds that the two can be complementary or
‘developmental’, with the findings of one prompting questions or lines of analysis for
the other (O’Cathain & Thomas, 2006).
The objectives of reviews: ‘knowledge support’ or ‘decision support’
In order to decide what type of evidence to include in a systematic review it is
necessary to know what questions you want the review to answer. Two broad
categories of review have been identified (Dowie, 2001; Mays et al., 2005):
•
Reviews that synthesize and summarize existing knowledge: ‘knowledge
support’. This includes both reviews which focus on the cumulation or
generalization of evidence on the one hand, and those which focus on the
extent to which different sources of information reinforce each other
(examples of this may be found in the Cochrane and Campbell
collaborations).
•
Reviews that will potentially facilitate decision-making through the
provision of further analytical evidence: ‘decision support’. These reviews
may generate new theory or explanations (Hammersley, 2006:240-1).
This type of review may use more than one synthesis method. For
example, a systematic review may include quantitative evidence of the
effectiveness of different interventions using statistical meta-analysis,
alongside a synthesis of the qualitative research evidence of their
acceptability.
The function of a review will influence the research questions and is likely to lead to a
differing emphasis on qualitative and quantitative evidence; the more a review aims
to contribute directly to a specific decision, the more likely it is that it will include non
research evidence as well as methods of modeling and simulation.
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9.1.2
What is synthesis?
Synthesis is the point at which findings from the review process are combined and
conclusions are drawn. Many of the methods for the synthesis of complex data are
still in their formative stages and most were developed for the synthesis of either
qualitative or quantitative data, rather than synthesis of the two. More work still needs
to be done identifying and adapting rigorous methods for combining and integrating
evidence, which will then be of value to policy- and decision-makers.
The process entails organizing and summarizing relevant evidence from a range of
selected studies and then finding some way of bringing it together. Reviews designed
to support policy-making and management decision-making will typically adopt a
broad narrative based approach: they will tell a story.
This chapter looks at three broad techniques for synthesizing evidence:
•
Quantitative synthesis, involving transforming evidence into numbers
which can be represented numerically or statistically
•
Qualitative or interpretative synthesis
•
Mixed approaches which incorporate diverse evidence to inform policymaking and management decision-making, including the combination of
separate syntheses.
We will concentrate more on the latter as this is felt to be most useful to readers of
this guide, as well as being less detailed in the existing literature. While quantitative
approaches are useful for indicating the overall effectiveness of a specific
intervention, qualitative studies add insight, offering deeper understanding into the
reasons why individuals may react in particular ways or hold certain opinions which
impact on effectiveness.
Before looking at the specific techniques for synthesizing evidence we will look at the
stages involved in reviewing evidence systematically.
9.1.3
Stages in reviewing evidence systematically
To help overcome criticisms of bias, inability to replicate results or lack of rigour,
systematic reviewing and synthesis attempt to be as rigorous and transparent as
possible. Important steps towards ensuring that this is achieved include:
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Constructing the evidence base on the social determinants of health: A guide
At theoutset of the review, drafting a protocol setting out the questions
•
an<
lethods of the review, including how studies will be assessed,
------- -
~
~
iXi
searched for and summarized
Being clear about why the review is being carried out. What do you want
•
to achieve?
Being flexible! The review process is seldom linear, with some elements
•
taking place in parallel and others being revisited and further developed
as the review process progresses. The process should include
opportunities to backtrack, revisit review questions and to continue to test
and develop theories. An iterative model demonstrating the stages
characteristic of a systematic review process is illustrated in Figure 9.1
(below)
Involving policy-makers in the review team to help ensure that the right
questions are being asked.
Figure 9.1
An iterative view of the review process
Define the question or questions with input from users
Develop a protocol
Literature search
Apply inclusion criteria to the studies identified
THEORY TESTING
AND/OR DEVELOPMENT
Appraise the quality of evidence
Extract data
Synthesise evidence
LOOK FOR PATTERNS
GENERALISE/GENERATE THEORY
Write up
Source: Pope et al., 2007.
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Constructing the evidence base on the social determinants of health: A guide
The review process can be broken down into these steps:
•
Defining the review question
•
Developing a review protocol
•
Searching for studies across a range of bibliographic sources
•
Applying inclusion and exclusion criteria
•
Assessing methodological quality
•
Extracting data
•
Synthesizing findings.
Defining the research questions
The review question has to be relevant to potential users of the review and, in theory
at least, answerable. Questions may be developed with an advisory group including
relevant policy-makers, commissioners, funders and service users and should allow
for the flexibility of new or different questions as new evidence emerges. The initial
process of mapping the research should give a feel for the time and resources
needed. In considering appropriate research questions it is suggested (Booth & Fry-
Smith, 2004) that attention should be focused on four key components, identified by
the acronym PICO:
•
People (or participants who are the focus of the intervention)
•
Interventions
•
Comparisons
•
Outcomes.
Examples of review questions from recent reviews include:
•
What is known about the barriers to, and facilitators of, health and health
behaviours among young people? (Shepherd et al., 2006)
•
What does the qualitative and quantitative research literature tell us about
access to health care by vulnerable, socioeconomically disadvantaged
people in the UK? (Dixon-Woods et al., 2006)
The search for studies
This will be wide ranging and is likely to involve a variety of electronic databases
relevant to the topic of the review. Other sources may also be searched, including
conference proceedings, web sites, personal contact with researchers in the field,
searching of specialist journals, databases, scanning of reference lists from studies
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Constructing the evidence base on the social determinants of health: A guide
already identified, internet search engines such as Google Scholar or Scielo
(Spanish and Portuguese), and abstracts of theses and dissertations. In order to
generate relevant information, in manageable quantities, it is important to be precise
and clear when generating key words for the search. Reviewers should have a
———————■
.
--------------------------------------------------------------------------------------- ----------------------------- - -----------------------*
thorough knowledge of the subject area in order to ensure that all relevant search
terms are included and to avoid locating large amounts of irrelevant material. Advice
from information scientists and librarians is advisable. Once the precise review
questions have been defined the preliminary search can be extended and/or refined.
In most reviews, particularly those including qualitative research, a significant amount
of information may be located in the ‘grey’ literature of unpublished reports.
Moreover, recording of qualitative studies on electronic databases is not as
sophisticated or thorough as the indexing of quantitative studies and advice from
appropriate information specialists should be sought.
Determining the study types to be included
In order to produce a review which is both transparent and replicable, the criteria for
including studies in the review must be explicit and clearly stated. For example, if the
review is focused on unintentional injuries in children, the research criteria could
state whether studies will be included which look at:
•
Children of all age groups
•
Children in specific groups, e.g. only those at high risk or from particular
ethnic groups
•
Type of intervention (e.g. multi-faceted community interventions or single
setting such as schools)
•
Which factors/processes could affect the intervention?
•
What is the specific impact on the intervention of organizational structure,
professional competencies, sense of community cohesion, etc?
•
Evidence from ‘beneficiaries’ of the service
•
What are the outcomes of interest? How is a successful intervention
measured?
The final list of factors will be unique to each review and will reflect the nature of the
review question(s) to be answered. Decisions relating to inclusion must be clearly
linked to the review_questions posed.
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Reviews that involve the transformation of raw data or that include large numbers of
studies require greater resources, and where the review question and/or range of
evidence are very broad, it may be necessary to select a representative sample.
Where large quantities of evidence are being analysed it may be appropriate to group
similar studies together; in this way common generalized features of the effect of
interventions are noted and small differences may not be of crucial importance.
Whether or not to include a study on the basis of quality appraisal remains a
controversial and difficult area. In systematic reviews of effectiveness, attempts to
assess quality and internal validity of the work are common. While quality
assessment may be more appropriate for randomized controlled trials than for
qualitative studies, problems remain as to how to select criteria forjudging studies
which are both transparent and rigorous. Even where clear rigorous study design has
been used, this is not always adequately described in the research reports.
Quality appraisal/ validity assessment
The assessment of quality is important for the conclusions of the synthesis. If poorly
designed studies are given too much weight, conclusions reached by the synthesis
may not be substantiated. However quality in general, and validity in particular, are
defined differently for different types of study design and research traditions.
In an effectiveness review quality is primarily judged in terms of internal validity, i.e.
checking that the study is comparing like with like. Criteria used to judge the quality
of quantitative studies are well rehearsed and include study of selection bias, drop
out rates, ‘contamination’ between cases and controls, and observer bias (Chalmers
et al., 1981; Downs & Black, 1998; Jadad, 1998; NHS Centre for Reviews and
Dissemination, 2001).
Arguments about assessing the quality of qualitative studies are more complex and
often strongly contested. There are two central issues:
•
Should the concepts and criteria for methodological quality be broadly
similar or quite different to those used in quantitative research?
•
Should assessment of quality be made during or after the synthesis has
taken place?
There is little consensus identifying criteria against which qualitative research should
be assessed. It is difficult to prescribe a single approach because of the presence of
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multiple, different checklists (see the useful review of these by Spencer et al., 2003)
and because of the lack of agreement about which quality criteria to use, how cut off
points are to be applied, and whether to exclude studies judged to be
methodologically weak. The more diverse the evidence to be scrutinized the harder it
is to develop appropriate methods. Details of the two currently most useful quality
appraisal frameworks for qualitative research - those described in Spencer et al.
(2003) and on the web site of the Public Health Resource Unit, University of Salford are listed in the further reading.
Whatever the approach taken, clear records must be kept and a lack of bias must be
demonstrated (ideally by involving two researchers). The strengths and weaknesses
of the research under study should be reported to allow for this information to be
used during synthesis and interpretation.
Data extraction
Because of the need to be able to replicate the results and the need to standardize
and compare data across researchers and teams, the recording process must be
both transparent and follow a clear process. There are various computer software
programs to support the process, ranging from the commonly used (spreadsheets
and databases such as Microsoft Excel and Microsoft Access) to those specifically
designed for the process such as RevMan and SUMARI.
The type of data recorded as part of the synthesis will be influenced both by the
specific nature of the research question and by the research methodology. In the
context of a systematic review of effectiveness, for example, the data to be extracted
should include details on:
•
The participants
•
The interventions (including content, format and timing)
•
The comparisons
•
The outcomes
•
The study design
•
Factors affecting the interpretation of study results
•
Information relating to applicability across different population groups and
settings.
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Constructing the evidence base on the social determinants of health: A guide
For quantitative studies, the above factors will be relevant but more emphasis may
be put on outcome data (presented as it is in the original paper, or in a form that will
allow the actual impact to be assessed).
Data extraction from qualitative surveys, or more mixed sources of evidence,
involves a possibly greater level of complexity and challenge and tends to take two
main directions: interpret
analysis by---------------------the author, typically
wive
. synthesis--(interpretative
--------- -
in the form of analytical concepts, metaphors or themes) or realist synthesis
(overarching themes, theories and explanations).
9.1.4
Quantitative approaches to evidence synthesis
Quantitative methods of synthesis all involve the conversion of data, whether
qualitative or quantitative, into quantitative (i.e. numerical) form. This can then be
used either for simple counts or more sophisticated statistical analyses, as well as for
use in logical (Boolean) analysis. Qualitative findings are transformed into numbers
by identifying themes, which can then become variables that can be quantified, either
as frequency counts or in binary form. The method allows data from different points
in time to be summarized and compared. It can also provide supporting evidence
when it is deemed unfeasible to repeat original research. The danger however is that
the depth and meaning of the original research can be easily lost.
There are six main quantitative approaches:
•
Content analysis. Categorization of data into themes or categories and
counting how often each category occurs
•
Quantitative case survey. Statistical comparisons are drawn across a
range of discrete case studies (Yin & Heald, 1975; Larsson, 1993)
•
Cross-design synthesis. Data from studies with different quantitative
research designs are pooled (e.g. RCTs and non-randomized
experiments)
•
Bayesian approaches which enable the pooling and statistical analysis of
quantitative studies
•
Qualitative comparative analysis (Ragin, 1987) where data from multiple
studies are summarized and compared using a set of algorithms based on
Boolean logic
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Constructing the evidence base on the social determinants of health: A guide
•
Meta-analysis. Statistical pooling of the results of quantitative studies with
the same or very similar designs (Cooper & Hedges, 1994).
9.1.5
Qualitative approaches to evidence synthesis
Qualitative research takes on a number of forms and is guided by a range of
theoretical perspectives: phenomenology, hermeneutics, ethno-methodology,
grounded theory, etc. The different theoretical perspectives draw on different
disciplines and approaches to research such as anthropology, sociology, social
policy, political science, psychology, history and economics. Studies tend to be small
and are not concerned with statistical generalizability but with conceptual and
theoretical development and the explanation of phenomena. Data produced from
such studies tend to be contextually rich and provide analytical depth.
The synthesis of qualitative research and especially the synthesis of qualitative with
quantitative evidence are relatively recent endeavours. Most of the methods used for
this type of synthesis are at a developmental stage and there are few examples of
their application. In particular there are few examples of the application of interpretive
synthesis methods to the synthesis of qualitative with quantitative findings.
The term ‘interpretive synthesis’ is used to denote methods which share qualitative
methodology and have a particular focus on interpretation. The task is to bring
together, juxtapose, re-analyse and combine the studies from several findings into a
whole that ideally provides some theoretical or conceptual development that moves
beyond the findings of any individual study included in the synthesis (i.e. a new
interpretation).
There are two principal interpretive approaches:
•
Grounded theory (Glaser & Strauss, 1967). Using the ‘constant
comparative method’ to generate theory from data in a systematic fashion
•
Meta-ethnography. Re-interpretation and transformation (translation) of
concepts provided by individual studies into one another.
The techniques employed in both of these methods can be complex and are not best
suited to the novice. To date there has only been one attempt to synthesize
qualitative and quantitative research using a variant of meta-ethnography. This
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method, developed by Dixon-Woods et al. (2005, 2006b) in a study exploring access
to health care by vulnerable groups in the UK, has been called ‘critical interpretive
synthesis’.
9.1.6
Mixed method approaches to evidence synthesis
The methods outlined in this section are able to accommodate diverse evidence:
quantitative and qualitative, research and non-research, etc. They can be less
codified and make fewer pre-specified demands on the reviewer. While this gives
flexibility and freedom, it demands high levels of skills to produce a robust,
transparent piece of research. Moreover, the newness of the methodologies and
shortage of good case studies means that these methods are to some extent still in
development.
Thematic analysis
Thematic analysis is one of the most common methods for synthesis adopted in
approaches to evidence review. It consists of identifying the main, recurrent or most
important issues or themes arising in a body of literature. It is common for thematic
analysis to be developed at least partially in an inductive manner, i.e. without a
complete set of a priori themes to guide data extraction and analysis from the outset.
Thematic analysis tends to attach more importance to working with and reflecting
directly on the main ideas and conclusions which have already been drawn across
bodies of evidence, rather than producing new explanations and theories.
Themes are identified by a comparative process of reading and re-reading studies
which are then coded. Software programs are used to help handle large quantities of
data. Matrix based techniques may also be useful to help present and analyse
between and across themes. The level of sophistication can vary, ranging from
simple descriptions of all the themes identified, through to analysis of how different
themes relate to each other.
Strengths and limitations of thematic analysis
•
A key strength is the ability to handle a diverse body of research, including
qualitative and quantitative data
•
The flexibility of the thematic approach is associated with a lack of
transparency. It can be hard to ascertain how and at what stage the
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themes were identified. This uncertainty reflects the fact that the thematic
analysis can be undertaken in different ways (i.e. quantitatively or
qualitatively, inductively or deductively, theoretically driven or
descriptively)
•
It is unclear whether findings should reflect the frequency with which each
theme is reported or its explanatory significance.
Realist synthesis
Realist synthesis focuses primarily on testing the causal mechanisms or ‘theories of
change’ that underlie a particular type of intervention or programme. A realist review
aims to test the explanatory power of the underlying theories of change shared by
different interventions and programmes, asking whether and why these interventions/
programmes work (or not) for particular groups in particular contexts.
Like other approaches to evidence synthesis, the realist approach extracts data from
various sources of evidence (including research or non-research sources such as
newspapers or official reports.) The purpose of data extraction is to identify the
explanations offered for change across different policy domains and any underlying
patterns of success and failure that occur. The ultimate aim of the review is to use
the data to develop a theory about the conditions (or contextual factors) that
determine the success or otherwise of a particular programme mechanism.
Strengths and weaknesses of realist synthesis
•
Realist synthesis can accommodate an enormous diversity of evidence
•
It can produce compelling ‘stories’ which may have particular resonance
with policy-makers and practitioners
•
This method may add rigour and structure to the traditional literature
review
•
There are few worked examples from which experience can be drawn and
generalizations made.
Narrative synthesis
Narrative synthesis adopts a textual approach to the process of synthesis. It has
been suggested (Dixon-Woods et al., 2004) that the method lies on a continuum, in
between quantitative approaches to synthesis (e.g. meta-analysis) and purely
qualitative approaches (e.g. meta-ethnography). It involves not only the simple
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Constructing the evidence base on the social determinants of health: A guide
juxtaposition of findings from a diverse range of studies, but also, where evidence
allows, it involves some element of integration or interpretation.
In an effort to improve the quality of the methodology and cognisant of criticisms
relating to lack of rigour and transparency, Popay et al. (2006) produced more
detailed guidance on the conduct of narrative synthesis. The guidance offers a
framework composed of four elements:
•
Theory development
•
Development of preliminary synthesis
•
Exploring relationships in the data
•
Testing the robustness of the synthesis model.
Strengths and limitations of narrative synthesis
•
The approach retains the flexibility of literature reviews and is appropriate
for a wide range of review questions and disparate forms of evidence
•
The use of multiple and mixed tools in the synthesis has the potential to
offer novel insights into the evidence being reviewed
•
There is the possibility of bias which may generate unsound conclusions
leading to harmful decisions
•
The use of multiple approaches to the analysis may result in ‘data
dredging’, i.e. over-interpreting data
•
Examples of the application of narrative synthesis methods are in short
supply.
9.1.7
Combining separate syntheses: the EPPI approach
The approach developed by the Evidence for Policy and Practice Information and
Coordinating Centre (EPPI) at the Institute of Education in the United Kingdom
typically involves a very broad review question from which separate sub-questions
are developed. These then form the focus of two or more parallel systematic
syntheses. These parallel syntheses may, for example, focus on sub-questions about
effectiveness, appropriateness, barriers and enablers to implementation, and the
perspectives of the group targeted by the intervention. The results of the separate
syntheses are then combined into a so called ‘meta-synthesis’, aiming to address the
review question in its entirety. It is argued that because the EPPI approach aims to
address review questions that include, but are not restricted to, the effectiveness of a
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specific intervention or programme, they are more appropriate to the needs of policy
makers and managers than the conventional Cochrane-style effectiveness reviews.
The EPPI approach includes all of the standard stages of a systematic review (see
section 9.1.1) but has two innovative features. Firstly, rather than a tightly structured
search strategy, the EPPI approach begins with a comprehensive mapping and
quality screening exercise to identify and describe all studies falling within the broad
remit of the overall review question. Results from this mapping are then used with
stakeholders (including funders) to look again at and check the appropriateness of
the review question. Secondly, at the final ‘meta-synthesis’ stage results from the
parallel syntheses are juxtaposed on a matrix rather than integrated.
Strengths and limitations of the EPPI approach
•
The EPPI approach has the capacity to use evidence from a diverse
range of sources
It has the potential to help answer broad based review questions and is
•
therefore more likely to be relevant to some of the complex concerns of
policy-makers and managers
•
It can involve any number of linked strands of synthesis, each addressing
different questions (e.g. subjective perceptions of need, intervention
design and development, acceptability and feasibility as well as (cost)
effectiveness)
•
It provides a transparent path from evidence synthesis to
recommendations
•
It is a time consuming, labour intensive and therefore expensive method.
9.1.8
Choosing different methods and considering quality
Choosing appropriate methods
Given the complex nature of the questions that reviews seek to answer, a number of
different approaches (running either in parallel or tandem) are often adopted to tackle
different aspects of the review question. Table 9.1 presents an overview,
demonstrating which techniques may be appropriate in the light of different types of
question and the evidence available.
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Table 9.1
Choosing a suitable approach to synthesis given the aim, questions and
evidence of the review
Review aim
and/or policy
management
question
Relevant types
of evidence (if
available)
Likely
approach(es) to
synthesis
Strengths of the
approach
Limits to the
approach
Knowledge
support
All types, but
mostly research
based because of
focus on what the
research says
All bar decision
analysis, etc.
Generalizability
Does not directly
help with a
specific decision
in a particular
context
Decision support
All types,
including research
and non-research
(i.e. need to know
evidence, values
and preferences
of stakeholders
and decision
makers)
Bayesian metaanalysis, decision
analysis, modeling
and simulation of
various types and
possibly narrative
synthesis
Focuses on the
specifics of a
particular decision
in a particular
context
Has to be
modified to be
relevant to
another context;
utility depends on
its being used by
decision-makers,
not generalizable
Is this a problem?
All types,
including research
and non-research
(e.g. qualitative
and quantitative
research, public
and stakeholder
views, opinion
polls, focus
groups)
Narrative
synthesis or, for
qualitative studies,
meta-ethnography
Narrative
synthesis is
flexible, relatively
easy to
understand and
applicable to a
range of situations
and sources of
evidence; metaethnography has
principally been
used for
qualitative
synthesis
Have to work hard
to make sure
methods and
judgements are
explicit, free of
bias and
replicable;
defining
something as a
‘problem’ is value
laden
How big is the
problem? Which
groups does it
affect? Is it
changing over
time?
Quantitative
research and
routine data
analysis.
Qualitative data
on subjective
impact.
Quantitative
research and
routine data
analysis
Quantitative
synthesis plus
meta-ethnography
of qualitative
studies.
Quantitative
synthesis
What can be done
about it (what may
work)? How much
is responding
likely to cost in
general?
Mostly
quantitative
research on
effectiveness and
cost-effectiveness
Meta-analysis of
intervention
studies
Meta-analysis is
well developed for
effectiveness and
reasonably well
developed for
cost-effectiveness
data
How do the
seemingly
effective policies
or interventions
work?
Mostly qualitative
research from
interviews and
observation on
users’ and
providers’
experiences
Various forms of
interpretive
synthesis (e.g.
qualitative cross
case analysis or
meta
ethnography), but
also realist
synthesis
Rich picture of
how policies or
interventions work
in practice as
opposed to
preconceptions of
their architects
Meta-ethnography
is labour
intensive, requires
considerable
qualitative
research
experience
Qualitative studies
may not have
been undertaken
in relevant
settings so
findings may be
hard to apply
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Review aim
and/or policy
management
question
Relevant types
of evidence (if
available)
Likely
approach(es) to
synthesis
Strengths of the
approach
Limits to the
approach
What works for
whom in what
circumstances?
Which factors may
moderate the
impact of this
policy?
Wide range of
research and non
research data
Realist synthesis;
narrative
synthesis; case
survey
Helps with
understanding
mechanisms
underlying
interventions (i.e.
how they work)
Will not
necessarily
produce specific
answers to
particular decision
needs
Will intervention/
policy x work here
with what cost and
benefit
consequence?
Cost-effectiveness
data from
research;
modeling related
to specific
circumstances
including non
research data
Bayesian meta
analysis and cost
effectiveness
modeling;
decision analysis
Makes research
evidence relevant
to specific
circumstances of
a particular
decision
Dependent on
validity of expert
opinion where
research is
lacking and on
specific value
trade-offs of
decision-makers;
decision-makers
may be reluctant
to follow ‘verdict’
of the analysis;
Bayesian meta
analysis can be
hard to explain
How acceptable
will intervention/
policy X be? Will it
be implemented
successfully?
What will the
reaction be here?
Largely qualitative
research and non
research data
(e.g. focus
groups, opinion
polls, stakeholder
analysis)
Interpretive
synthesis (e.g.
meta
ethnography,
qualitative cross
case analysis, etc)
Essential
information for
policy-makers and
managers even
though tricky to
interpret
‘Softness’ and/or
transitory nature
of opinions and
views
Source: Pope et al., 2007.
Assessing the quality of a review of qualitative and quantitative evidence
Given that methods for synthesis are still in development, there are as yet no formally
developed criteria to assess the quality of reviews which synthesize both quantitative
and qualitative evidence. Knowing that the individual components are of good quality
does not itself indicate that the overall review meets quality criteria. Key questions to
ask either at the start or finish (or both) of the review include:
Is the aim clear?
•
Are the review questions relevant to policy-makers?
•
Is the work context specific?
•
Is the methodology transparent and clearly laid out?
•
Is each step in the review and adaptation of the protocol clearly justified?
•
Are the searches carried out comprehensive?
•
Does the review include a sufficiently wide scope of evidence?
•
Are individual studies appraised for quality and relevance?
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Constructing the evidence base on the social determinants of health: A guide
•
Are appropriate exclusion and inclusion criteria used?
•
Is the choice of synthesis method appropriate?
•
How is non-research evidence integrated into the analysis?
•
Does the review generate new knowledge and insights?
•
If more than one method to synthesize is used how is the resultant
analysis handled? How are divergences and contradictions handled?
•
Are the conclusions consistent with the evidence synthesized?
•
Is the final review clearly presented in straightforward language?
•
Can the recommendations be acted on?
•
Does the review team include the appropriate mix of expertise, skills and
experience?
9.2
Producing guidance for action
Developers of guidance in public health attempt to identify, appraise and collate the
best evidence to ensure that the highest quality information is available to a range of
health professionals with responsibility for improving health and reducing health
inequities (Bowen & Zwi, 2005). An essential part of producing this guidance is the
distillation of the most important findings from the scientific evidence base into a set
of implementable actions. This involves assessing the strength of the evidence
(certainty of ‘what works’); its generalizability and transferability; whether change is
realistic; whether the actions identified are amenable to change in the long, medium
or short term; whether it is cost effective; and what impact it will have on health
inequities (NICE, 2006b; Oxman et al., 2006; Sheldon, 2005).
Detailed processes and methods for producing evidence based guidance are
available from a number of well known agencies to ensure that guidance is
appropriate, supported and effective. For example, the National Institute of Health
and Clinical Excellence (NICE) in England and the Centre for Disease Control and
Prevention (CDC) in Atlanta, USA, have developed robust methodologies to ensure
guidance is based on the best available evidence (NICE, 2006b; CDC, 2005) and
that it is tested by a range of stakeholders responsible for implementing it.
While these processes and methods have not specifically been designed to address
the social determinants of health, adhering to their principles can ensure that
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Constructing the evidence base on the social determinants of health: A guide
recommendations produced have a specific equity focus. For instance, NICE
attempts to ensure that its public health guidance is ‘equity proofed’ by collating
evidence not only on what works but how it works and in what circumstances. It
draws its evidence base from a range of disciplines including clinical medicine,
epidemiology, health economics, health psychology, medical anthropology, sports .
science, nursing, education and health promotion.
An essential part of producing guidance is the distillation of the most important
findings from the scientific evidence base into a set of implementable actions. This
involves assessing the strength of the evidence (the degree of certainty about ‘what
works’); its generalizability and transferability; whether change is realistic; whether
the actions identified are amenable to change in the long, medium or short term;
whether it is cost effective; and what impact it will have on health inequities (NICE,
2006b).
In particular a guidance production process should:
•
Support the further development of the evidence ‘jigsaw’ by bringing in other
types of evidence not already retrieved by the formal synthesis of published
research. These should be combined with contextual information about the
country or area and the structures and systems in place to support the
implementation of guidance.
•
Further assess the evidence from synthesis to understand the strength of
evidence, in particular by distinguishing between absence of evidence, poor
evidence and evidence of ineffectiveness (Rawlins, 2005; Briss, 2005). This is
important for prioritizing action as it is possible to have good evidence about
unimportant problems and limited or poor evidence about important ones. It
may not therefore be appropriate to act based on strength of evidence alone.
•
Ensure that prioritized actions are based on a full assessment of the needs of
particular groups across the dimensions of inequities described earlier in this
guide.
Ultimately, producers of guidance aim to move from isolated examples of best
practice to improved standards of practice for all those engaged in improving the
health of populations. Applying the principles proposed by the MEKN and set out in
chapter 1 will ensure that guidance prioritizes actions which can have the greatest
impact on health inequities by addressing SDH.
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Constructing the evidence base on the social determinants of health: A guide
The National Institute for Health and Clinical Excellence (NICE) in the United
Kingdom applies the MEKN principles by ensuring that it draws its public health
evidence base from a range of disciplines including clinical medicine, epidemiology,
health economics, health psychology, medical anthropology, sports science, nursing,
education and health promotion. It also questions the evidence base to seek to
understand not just what works but also how it works and in what circumstances.
Equity proofing is a central component of the public health guidance production
process to ensure that it prioritizes actions for disadvantaged groups based on the
burden of ill health. In the public health work at NICE this is done by involving a wide
range of stakeholders who have an opportunity to engage with all stages of the
process. Stakeholders work with NICE to test the transferability of draft
recommendations into practice, in particular testing them to ensure they do not
disadvantage those population groups who suffer worst health. Working together in
this way helps to ensure that solutions to potential problems are identified at the
guidance production stage and that ownership of the guidance is established with all
those it aims to benefit.
The methods NICE uses to identify, assess and synthesize the evidence are based
on the need to demonstrate the quality and appropriateness of the research and not
of the research design. The strength of evidence is assessed in part on the
appropriateness of the study design to answer specific research questions. For
example:
•
The most robust evidence to answer questions of efficacy (‘what works’) is
generally considered to come from randomized controlled trials. However this
type of study is generally less useful for answering questions about effective
implementation (including the views of the target population)
•
Qualitative research better allows an understanding of the particular
processes and conditions that are required to ensure that interventions are
successful in different contexts.
Case study 14 has more information about NICE’S approach.
The Centre for Disease Control and Prevention (CDC) uses a ‘logic framework’ to
illustrate the broad links between the social, environmental and biological
determinants of a particular issue. This is then used to develop an analytic framework
to demonstrate the relationship between particular interventions and their intended
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Constructing the evidence base on the social determinants of health: A guide
outcomes. The development of logic models allows a more systematic approach to
developing the most appropriate research questions and therefore the best research
design to answer those questions.
In middle income countries (e.g. Brazil) evidence based guidance is largely
generated by national academics interacting with the Ministry of Health (or other
ministries), with a subsidiary role played by WHO, UNICEF and other international
(but not bilateral) agencies. In low income countries this role is primarily played by
WHO, UNICEF, the World Bank or bilateral agencies that invest in programmes of
their choice. Thus the development of evidence based guidance may depend on who
is paying for implementation, and on what their priorities are. This may also affect
equity if an organization prefers to direct its funds to a particular area, regardless of
whether or not this is the most equitable approach (Victora, personal communication,
2007).
Robust, evidence based guidance on the scale of NICE or CDC may not be available
and/or it may not be appropriate to attempt to produce such guidance. Stakeholders
could use guidance from sources such as NICE or CDC and adapt it to their own
country context. Such guidance is normally freely available on the internet. There are
risks to this approach as it may not be obvious to what extent the particulars of the
guidance are country or situation specific. Alternatively stakeholders may find it more
relevant to use the less formal approaches to gathering and assessing evidence
outlined in chapter 11 on ‘Learning from practice’.
While the experience of producing evidence based guidance is heavily dominated by
high income countries, the principles outlined by NICE and CDC provide a useful
starting point for more contextualized guidance produced in different country
contexts.
Illustrative case studies
9.3
The following illustrative case studies give examples of evidence synthesis:
•
No. 12 - Various countries: Synthesis of qualitative data on treatment of
tuberculosis
No. 13 - Various countries - Synthesis of data on school feeding
programmes.
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Constructing the evidence base on the social determinants of health: A guide
The following illustrative case study gives an example of producing evidence based
guidance:
•
No. 14 - United Kingdom: National Institute for Health and Clinical
Excellence.
9.4
Related reading
Aldrich R, Kemp L, Stewart Williams J, Harris E, Simpson S, Wilson A, McGill K,
Byles J, Lowe J and Terri Jackson (2003), ‘Using socioeconomic evidence in clinical
practice guidelines’ 8MJ2003;327; 1283-1285
Alleyne G.A., Castillo-Salgado C., Schneider MC., Loyola E., and Vidaurre M.
Overview of social inequalities in health in the Region of the Americas, using various
methodological approaches. Rev Panam Salud Publica/Pan Am J Public Health
2002;12(6):388-397
Bartley M, Blane D, and Montgomery S (1997), “Socioeconomic determinants of
health: Health and the life course: why safety nets matter”. British Medical Journal
1997;314:1194.
Bowen S. and Zwi A, (2005), “Pathways to "evidence-informed" policy and practice:
a framework for action”. PLoS Medicine 2005;2(7):e166.
Burke M & Eichler M, (2006), “The Bias Free Framework: a practical tool for
identifying and eliminating social biases in health research” Global Forum for Health
Research, Geneva, Switzerland, 2006. Available from:
http://www.qlobalforumhealth.orq/Site/002 What%20we%20do/005 Publications/O
10 BIAS%20FREE.php
Center for Global Development -Washington (2006), When Will We Ever Learn?
Improving Lives Through Impact Evaluation, SPRU Electronic Working Paper
Series, Paper No. 145 - February 2006, Partner at The Knowledge Bridge The
Freeman Centre, University of Sussex, UK
Chaulk C, Kazandjian V (2004), “Moving beyond randomized controlled trials”,
American Journal of Public Health', Sep 2004; 94, 9; ABI/INFORM Global
Commission on the Social Determinants of Health Measurement and Evidence
Knowledge Network, Report on the MEKN “evaluation” Working Group, 6-8 April
2006, Santiago, Chile
Des Jarlais D C, Lyles C, Crepaz N, Abbasi K et al, (2004), “Improving the reporting
quality of nonrandomized evaluations of behavioral and public health interventions:
The Trend statement”, American Journal of Public Health', Mar 2004; 94, 3;
ABI/INFORM Global, pg. 361
Diez-Roux A, (2004), “The Study of Group-Level Factors in Epidemiology: Rethinking
Variables, Study Designs, and Analytical Approaches”, Epidemiologic Reviews, Vol.
26, 2004, DOI: 10.1093/epirev/mxh006
130
Constructing the evidence base on the social determinants of health: A guide
Diez-Roux A, (1998), “Bringing context back into epidemiology: Variables and
fallacies in multilevel analysis”, American Journal of Public Health', Feb 1998; 88, 2;
ABI/INFORM Global, pg. 216
Dixon-Woods M et al. (2005) Integrative approaches qualitative and quantitative
evidence. London: Health Development Agency.
http://www.nice.org.uk/paqe.aspx?o=508055
Elliott H. and Popay J (2000), “How are policy makers using evidence? Models of
research utilisation and local NHS policy making” Journal of Epidemiology and
Community Health 2000;54:461-468.
GRADE Working Group (2004), ‘Grading quality of evidence and strength of
recommendations’ BMJ Volume 328 19 June 2004 bmj.com
Grypdonck M H F (2006), “Qualitative Health Research in the Era of Evidence-Based
Practice”, Qualitative Health Research, Vol. 16 No. 10, December 2006 1371-1385
Available from: http://qhr.saqepub.com/cqi/reprint/16/10/1371.pdf
Habicht J, Victoria C and Vaughan J,(1999),’’Evaluation designs for adequacy,
plausibility and probability of public health programme performance and impact”,
International Journal of Epidemiology, 1999; 28: 10-18
Johanneson M. and Gerdtham UG (1996), “A note on the estimation of the equity
efficiency trade-off for QALYs”. Journal of Health Economics 1996;15(3):359-36
Kelly M, Swann C, Killoran A, Naidoo B, Barnett-Paige E, Morgan M (August
2002), Methodological Problems in Constructing the Evidence Base in Public Health,
Health Development Agency, London
National Health and Medical Research Council ( November 2002), Using
socioeconomic evidence in clinical practice guidelines, ISBN Print: 1864962232
Online: 1864961163
National Institute for Health and Clinical Excellence (NICE) (2006), The public health
guidance development process. An overview for stakeholders including public health
practitioner, policy makers and the public. London, NICE 2006
Ogilvie D, Egan M, Hamilton V, Petticrew M (2005), ” Systematic reviews of health
effects of social interventions^. Best available evidence: how low should you go?”, J.
Epidemiol. Community Health 2005;59;886-892, doi:10.1136/jech.2005.034199
Oliver S et al (2003). An emerging framework for integrating different types of
evidence in systematic reviews for public policy. Available at:
http://www.nice.orq.uk/paqe.aspx?o=508223
Oxman A, Schunemann H, Fretheim A (2006, draft), ‘Improving the use of research
evidence in guideline development: 12. Incorporating considerations of equity’,
Norwegian Knowledge Centre for the Health Services
Popay J., Rogers A. and Williams G, (1998)., “Rationale and standards for the
systematic review of qualitative literature in health services research”. Qualitative
Health Research 1998;8(3):341-351.
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Constructing the evidence base on the social determinants of health: A guide
Pope C, Mays N, Popay J. (2007). Synthesising Qualitative and Quantitative Health
Research. Buckingham: Open University Press.
Rychetnik L, Frommer M, Hawe P, and Shiell A, (2002), “Criteria for evaluating
evidence on public health interventions”. Journal of Epidemiology and Community
Health 2002;56:119-127
Schwartz S; Carpenter K M, (1999), “The right answer for the wrong question:
Consequences of type III error for public health research”, American Journal of Public
Health; Aug 1999; 89, 8; ABI/INFORM Global, pg. 1175
Sheldon T (July 2005) “Making evidence synthesis more useful for management and
policy-making” J Health Serv Res Policy Vol 10 Suppl 1 July 2005
Tugwell P, Petticrew M, Robinson V, Kristjansson E, Maxwell L, (April 2006),
‘Cochrane and Campbell Collaborations, and health equity’ The Lancet Vol 367 April
8, 2006
Weightman A, Ellis S, Cullum A, Sander L, Turley R (2005), ‘Grading evidence and
recommendations for public health interventions: developing and piloting a
framework’ Health Development Agency
Weightman A., Ellis S., Cullum A., Sander L, Turley R, (2005). Grading evidence
and recommendations for public health interventions: developing and piloting a
framework. London: Health Development Agency
Specific tools
9.5
More advice on searching procedures can be found in chapter 4 of Petticrew and
Roberts (2006).
Quality appraisal frameworks:
•
Spencer et al. (2003), (http://www.policyhub.gov.uk/evaluatinq policy/
qua! eval.asp; accessed 17.04.07)
•
Critical Appraisal Tool for qualitative research studies developed by the
Public Health Resource Unit at the University of Salford,
•
http://www.phru. nhs. uk/casp/critical appraisal tools, htmttqualitative
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Constructing the evidence base on the social determinants of health: A guide
10
Effective implementation and evaluation
It has already been established in this guide and by the work of the CSDH knowledge
networks that effective solutions to addressing the social determinants of health and
reducing health inequities need to cut across sectors to take account of the broader
social, cultural, economic, political and physical environments which shape people’s
experience of health and well-being.
It is also recognized that whether governments are applying a health gap or health
gradient approach to reduce health inequities, some of the biggest impacts will be
seen by taking action at the macro level of policy. Often well intentioned policies fail
because of an under-emphasis on redistributory macroeconomic policies and an
over-emphasis on community based initiatives (Mitchell et al., 2000). Nonetheless,
locally based solutions can make a significant contribution to the implementation of
policies on SDH. If these contributions are to be realized, concrete action plans are
required which support individuals, workplaces, structures and systems to develop
and change in ways that make a social determinant approach to health a normal
everyday occurrence.
Generating evidence and producing good practice guidelines and policy is not
sufficient to ensure that well-intentioned policies effectively address the social
determinants of health. (CIHR, 2006; Victora et al., 2006). Policy-makers must
ensure that individuals, workplaces, structures and systems are supported to develop
and change in ways that are conducive to taking action. A lack of attention to followthrough in well intentioned policies and programmes with sophisticated action plans
for implementation often leads to the expectations of governments, professionals and
the general public being undermined (Morgan & Ziglio, 2007).
Action plans may fail which:
•
Do not pay attention to the need for adequate performance management
•
Show insufficient integration between policy sectors
•
Contain contradictions between health inequities and other policy
imperatives. (Exworthy et al., 2002)
Successful action plans at a minimum must:
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Constructing the evidence base on the social determinants of health: A guide
•
Pay attention to the need for adequate performance monitoring and
review (health equity auditing and needs assessment)
•
Support effective integration between policy sectors at national and local
level, to avoid contradictions between health inequities and other policy
imperatives (Exworthy et al., 2002) (health impact assessment)
•
Foster effective leadership and management to ensure there is
organizational capacity to support local implementation (organizational
development and change management)
•
Identify the different sectors involved and plan for their involvement
(readiness for intersectoral action)
•
Provide for appropriate involvement of local communities in the decision
making processes that lead to action (Gillies, 1998) (involvement of local
communities)
•
Support effective evaluation to ensure that learning from practice
happens, in particular learning about the barriers and solutions to effective
implementation (programme evaluation).
These points are dealt with in more detail below.
10.1
Health equity auditing, needs assessment and impact
assessment
Programmes designed to reduce inequalities often fail due to the time and resources
available to carry them out and a lack of evidence about what works across different
segments of the population. Increased policy commitment internationally to tackle
health inequalities has led some governments to introduce mandatory systems for
assessing need against all aspects of health inequalities. The main ways of
assessing whether a programme is meeting expectations in terms of reducing
inequities were outlined in chapter 7. Although presented there as being appropriate
for use before a programme has been implemented, they can be equally valuable if
applied during or at the end of a project. If they identify unintended adverse
consequences of a programme, it may be possible to rectify these before it is too
late. If they cannot be corrected, at least the learning can be applied to future
programmes to help ensure they meet their health equity goals.
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Constructing the evidence base on the social determinants of health: A guide
10.2
Organizational development and change
management
Creating the supporting conditions that are required for effective implementation is a
complex endeavour. We know that the solutions required for reductions in health
inequities need to cut across sectors, involve a range of macro and micro
interventions, and involve a wide range of professionals working together to effect
change in the short, medium and longer term.
Evidence based guidance provides us with the starting point for change but alone will
not improve the practice of individual professionals, nor will it secure the necessary
structural and systems change required to overcome some of the inevitable barriers
to implementing effective programmes and initiatives.
Kelly and colleagues (2004) identify a number of steps to support individual
professionals take effective action derived from evidence based guidance. These
are:
•
Translating knowledge from research about the most effective and
implementable action
•
Providing policy advice to support effective practice
•
Increasing access to quality-assured information on what to do and how to
do it
•
Creating and sustaining networks for knowledge transfer
•
Finding ways of supporting changes in practice at local, regional and
national levels.
(Kelly et al., 2004)
Organizations also need to be supported to set the necessary conditions for effective
implementation. Equipping managers with the skills they need to operate in the
challenging social determinants agenda is essential if they are to balance multi
stakeholder interests, understand complex accountabilities and manage for social
outcomes (Hunter & Killoran, 2004). There is much to be learned from the business
sector to help to manage change in this complex environment (Ackerman, 1997;
Weick & Quinn, 1999).
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Constructing the evidence base on the social determinants of health: A guide
The New South Wales (NSW Health, 2001) capacity building framework provides a
useful model of the complex system changes that are required to secure effective
implementation. They propose five areas that need to be considered in order to
ensure that evidence from research can be effectively translated into action and can
be sustained. These are workforce development, organizational development,
resource allocation, partnerships and leadership.
Some of the key questions that should be asked against the five areas are:
1. Workforce development: Who are the front line practitioners? Do such
‘practitioners’ think of themselves as such? What are the key irritations
experienced by front line staff in getting the work done? Are there
examples of good local practice where problems have been solved on the
ground either because of or in spite of policies and initiatives? Are there
local initiatives, which are the products of local development accessible to
others, such as examples of local training sessions? Are front line
staff/providers able to identify negative but unintended consequences of
recent policy initiatives and management strategies in the field?
2. Organizational development: How are current services provided? What is
the organizational framework that defines the delivery of services? What
are the typical structures and are they universal nationally or do they vary
locally?
3. Resource allocation: Who organizes it? Who manages it? Who funds it? Is
there any statutory framework that governs the activity or aspects of it?
4. Partnerships: Are there networks of practitioners that have been/ could be
utilized? What are the links to other sectors and other professionals?
5. Leadership: Is local leadership important? Do local champions have a
role?
The answers to these questions should provide an initial mapping of the territory
where the barriers and conduits to change are readily identified. It is also effective in
identifying the roles and responsibilities of the key actors required to take action on
the social determinants of health.
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Constructing the evidence base on the social determinants of health: A guide
10.3
Readiness for intersectoral action
Sustainable strategies for reducing health inequities can only be brought about if
there is a recognition that policies need to be long term and that intersectoral action
is required. There needs to be less of an expectation that outcome measures can be
generated in the short term. Without policies in place that outline the importance of a
multi-faceted approach to tackling health inequities, little is likely to change.
Many of the solutions to addressing the social determinants lie outside the health
sector. The ability of stakeholders to reduce health inequities therefore relies on
building strong and durable partnerships with a range of other sectors and agencies.
These include health care, social security, education, housing, security, labour
market, environment, transport, agriculture, industry and energy.
Intersectoral collaboration will only be brought about if there is a political commitment
to ensure that health is everybody’s business (Stewart, 2002). Even when integrated
decision-making processes have been signed up to, health champions will still need
to help other sectors understand why they should get involved in health and health
inequities action (see also the chapter on ‘Making the case’). It is helpful to provide
support to other sectors on actions they can take that will have a positive impact on
health.
Policy champions can help to ensure long term sustainable action on the social
determinants of health. Stakeholders nationally, regionally and locally should identify,
nurture and support a critical mass of policy champions who can act as catalysts and
provide linkages with the chain of actors responsible for the policy-making process
and who can support the process of effective implementation (MEKN, 2006a)
There is also a need for the health sector to look at its own practices in employment,
estates strategies, effects of cross border agreements, etc.
Stakeholders should find ways of:
•
Ensuring that the health care system sets a good example as an employer
and purchaser of services and contributes to the development of local
healthy communities and local economies
137
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Constructing the evidence base on the social determinants of health: A guide
•
Enabling the health sector to support other sectors to address healthrelated issues (e.g. integrated health impact assessment)
•
Measuring the impact of health sector policies and initiatives on health
and health inequities
•
Ensuring that other sectors develop policies which are the most beneficial
to health development, particularly for disadvantaged groups
•
Measuring and evaluating intersectoral programmes, partnerships or
experiences. (WHO, 2005)
Effective ways of involving local communities 2
10.4
It is well recognized and increasingly accepted that successful implementation is
more likely through the use of participatory processes in health development.
Although there is a dearth of rigorous evaluations of social interventions aimed at
reducing health inequalities, reviews have identified certain characteristics of
successful approaches (Gillies, 1998; NHS Centre for Reviews and Dissemination,
1999):
•
Local assessment of needs, especially involving local people in the
research process itself
•
Representation of local people within planning and management
arrangements - the greater the level of involvement, the larger the impact
9
Design of specific initiatives with target groups to ensure that they are
acceptable (i.e. culturally and educationally appropriate), and that they
work through settings that are accessible and appropriate
•
Training and support for volunteers, peer educators and local networks,
thus ensuring maximum benefit from community-based initiatives
•
Visibility of political support and commitment
•
Re-orientation of resource allocation to enable systematic investment in
community-based programmes
•
Policy development and implementation that brings about wider changes
in organizational priorities and policies, driven by community-based
approaches
2 Based on extracts from Morgan, 2006.
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Constructing the evidence base on the social determinants of health: A guide
•
Increased flexibility of organizations, so supporting increased delegation
and a more responsive approach.
Most people working with local populations realize that good community capacity is a
necessary condition for the development, implementation and maintenance of
effective interventions and this is reflected in an increasing number of strategy
documents setting out a social determinants approach to reducing health inequities.
However, Jordan et al (1998) argue that while the nature and extent of public
involvement in determining health needs has increased, the quality of consultation
remains questionable. One reason for this is that policy-makers under heavy
pressure to achieve very specific national policy targets may feel that the involvement
of the community is time consuming and that they can suffer a loss of control. This
can lead to community involvement activities becoming tokenistic and separated from
the main decision-making processes of professionals.
Another problem associated with poor community involvement is that professionals
tend to define communities by their needs. These needs are often translated into
deficiency-orientated policies and programmes which rightly identify the problems
and try to address them. A possible downside to this approach is highlighted by
Kretzmann & McKnight (1993), who claim from their work with communities that
many low-income urban neighbourhoods have become environments of service
where behaviours are affected because residents come to believe that their well
being depends upon being a client. They therefore suggest that rather than focus on
deficits an alternative approach would be to develop policies and activities based on
the assets, capabilities and skills of people and their neighbourhoods.
10.5
Evaluation
Chapter 6 has already described the importance of a range of evaluative approaches
to generate the evidence required to develop equity focused policy, and to provide
answers to broad questions of effectiveness. The latter is supportive of producing
evidence base guidance to improve practice. Wimbush and Watson (2000)
distinguish this evaluation as that done by ‘professional evaluators’ who tend to
engage with evaluation as a knowledge building exercise to improve understanding
of the relationship between an intervention and its effects. Implementation-level
evaluations tend to be carried out by local practitioners (sometimes supported by
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Constructing the evidence base on the social determinants of health: A guide
professional evaluators) to gain a more in-depth understanding of how to strengthen
programmes and a deeper understanding of how things work.
The distinction is made here to illustrate the different types of evaluation required at
different points in the cycle of policy development, implementation, monitoring and
evaluation. However these evaluation efforts are not mutually exclusive. There is a
need for better integration and understanding of the relationship the two and better
collaboration to ensure that efforts are not duplicated. This is particularly important as
practitioners may sometimes feel they are being asked to evaluate everything, when
this is not always required.
Better coordination of evaluation efforts at the national and local level, and between
professional researchers and local practitioners, can go some way to ensuring the
often limited resources available for evaluation are maximized. Policy-makers have a
key responsibility to provide sustained investment in a wide range of evaluation
efforts and to provide theoretical frameworks for evaluation which make explicit what
types of evaluation need to be carried out by whom and for what purpose.
It has been argued that evaluating complex social interventions is hard because of
their size and their need to address multiple problems, often with shifting political
environments (Coote et al., 2004). Given the importance of evaluation in the
implementation of programmes, Hill (2004) offers pointers that should be considered
for improving the quality of evaluations of community initiatives and gaining credibility
with researchers and policy-makers:
1. Their utility is made explicit. E.g.: Who is asking the question and for what
purpose? Have the views of the community have been taken into
account?
2.
Their overall feasibility. E.g.: Are the resources available commensurate
with the expectations of all stakeholders? Has the methodology taken
context into account?
3. An explicit propriety. E.g.: Has the evaluation strategy got a similar value
base to the programme being evaluated?
4. The methodology promotes quality and transparency of process. E.g.:
Where and by whom should the quality criteria for non experimental
methods be debated?
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Constructing the evidence base on the social determinants of health: A guide
5. The expectations of evaluation commissioners is realistic. E.g.: Bridging
the gap between impossible questions and complex interventions.
6. Dissemination and utilization of results. E.g.: Increasing more published
research in this area.
There are many text books which provide detailed instructions on the basic principles
of evaluation and the range of evaluative approaches which are useful in the field of
SDH. Two well established approaches to evaluation are worthy of mention here, to
illustrate the possibilities of producing quality knowledge about local programmes of
action which can improve the evidence base.
The first is ‘realistic evaluation’ (already briefly described in sections 5.4 and 8.3)
developed by Pawson and Tilley (1997) and described by them as:
trying to break down the lazy linguist habit of basing evaluation on the question of
whether 'programmes’ work. In fact it is not programmes that work but the resources
they offer to enable their subjects to make them work. This process of how subjects
interpret the intervention strategy is known as the programme 'mechanism' and it is
the pivot around which realistic evaluation revolves.
The second, 'Program Evaluation’ (PE) developed by CDC, is a systematic set of
practices to improve and account for public health actions and to forecast a range of
‘plausible futures’ stemming from policies (Kawachi, 2005). The foundation of PE
consists of a well described sequence of steps:
•
Engaging stakeholders
•
Describing the programme, including the use of logic models
•
Focusing the evaluation design
•
Gathering credible evidence
•
Justifying the conclusions
•
Ensuring the use and sharing of lessons learned.
Further details of the Program Evaluation framework can be found at
http:Z/ctb. I si. u ka ns. ed u/ctb/c30/proq E va I. htm I.
These two examples are particularly important for supporting evaluation of local
programmes as they follow a number of the principles set out in chapter 1. In
particular they encourage the use of a wide range of methods, they take account of
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Constructing the evidence base on the social determinants of health: A guide
context by trying to understand the systems and structures within which programmes
are being implemented, and importantly they embed the values of ‘commitment to
equity’ in their approach.
10.6
Illustrative case studies
The following illustrative case study contains an example of effective implementation:
•
No. 4 - Brazil: Infant mortality in Ceara state
The following illustrative case studies give examples of health impact assessments:
•
No. 9 - Thailand: Use of locally-defined health determinants to push for
change, Mun River dam
•
No. 15 - Slovenia: HIA of national agricultural policy
•
No. 16 - United Kingdom: HIA of housing redevelopment
The following illustrative case study shows an example of intersectoral action:
•
No. 18 - Sweden: Intersectoral action
The following illustrative case studies give examples of evaluation:
•
No. 2 - Brazil, Peru, United Republic of Tanzania: Integrated
Management of Childhood Illness programme
10.7
•
No. 3 - Bolivia: Evaluation of Social Investment Fund
•
No. 11 - Uganda: Community-based monitoring
•
No. 17 - Mexico: Oportunidades programme
•
No. 19 - Bangladesh: Evaluation of Food for Education programme
Related reading
Alimeida C & Bascolo E (2006), ‘Use of research results in policy decision-making,
formulation, and implementation: a review of the literature’, Cad. Saude Publica, Rio
de Janeiro, 22 Sup:S7-S33, 2006
Blarney A et al (2002). Theory-based evaluation of complex community-based health
initiatives Available at http://www.nice.orq.uk/paqe.aspx?o=508187
Burns A, (2005), “Recognizing the needs and roles of the key actors”, J Health Serv
Res Policy Vol 10 Suppl 1 July 2005
142
Constructing the evidence base on the social determinants of health: A guide
Canadian Institutes of Health Research. Moving population and public health
knowledge into action. CIHR Institute of Population and Public Health Canadian
Population Health Initiative 2006
Commission on the Social Determinants of Health Measurement and Evidence
Knowledge Network, Report on the MEKN “Implementation” Working Group, 6-8 April
2006, Santiago, Chile
Current thinking and approaches among agencies supporting Civil Society
Organisations, Overseas Development Institute, Available from:
http://www.odi.orq.uk/publications/workinq papers/wp260.pdf
Exworthy M, Berney L & Powell M (2002), ‘How great expectations in Westminster
may be dashed locally’: the local implementation of national policy on health
inequalities’, Policy & Politics vol 30 no 1 79-96 ISSN 0305 5736
Kelly M, Speller V, Meyrick J (2004), Getting evidence into practice in public health,
Health Development Agency, London
Kelly M, Swann C, Killoran A, Naidoo B, Barnett-Paige E, Morgan M (August
2002), Methodological Problems in Constructing the Evidence Base in Public Health,
Health Development Agency, London
Michie M, Johnston M, Abraham C, Lawton R, Parker D, Walker D, on behalf of the
“Psychological Theory” Group, (2005), “Making psychological theory useful for
implementing evidence based practice: a consensus approach”, Qual Saf Health
Care 2005;14:26-33. doi: 10.1136/qshc.2004.011155
Michie S and Lester K, (2005), “Words matter: increasing the implementation of
clinical guidelines”, Qual. Saf. Health Care 2005;14;367-370,
doi:10.1136/qshc.2005.014100
Stewart M (2002) Systems governance: towards effective partnership working.
http://www.nice.orq.uk/paqe.aspx?o=508213
Victora CG, Huicho L, Amaral J J, Armstrong-Schellenberg J, Manzi F, Mason E, &
Scherpbier R (2006), ‘Are health interventions implemented where they are most
needed? District uptake of the Integrated Management of Childhood Illness strategy
in Brazil, Peru and the United Republic of Tanzania’, Bulletin of the World Health
Organization | October 2006, 84 (10)
World Health Organization. Meeting on Knowledge Translation in Global Health IQ12 October 2005. Final Report. Geneva: WHO, Departments of Knowledge
Management and Sharing Research Policy and Cooperation 2005.
10.8
Specific tools
Intersectoral action toolkit: The cloverleaf model for success
http://www.phac-aspc.qc.ca/canada/reqions/ab-nwt/pdf/proqrams/isatoolkit.pdf
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Constructing the evidence base on the social determinants of health: A guide
Guide to project evaluation: a participatory approach
http://www.phac-aspc.qc.ca/ph-sp/phdd/resources/quide/index.htm
Working partnership
Book 1 - Introduction http://www.nice.org■uk/paqe.aspx?o=502563
Book 2 - Short assessment http://www.nice.orq.uk/paqe.aspx?o=502565
Book 3 - In-depth assessment http://www.nice.org.uk/paqe.aspx?o=502567
Looseleaf worksheets http://www.nice.orq.uk/paqe.aspx?o=502569
Participation and social assessment: tools and techniques
Rietbergen-McCracken J and Narayan D (1998) World Bank
http://siteresources.worldbank.Org/INTPCENG/11433311116505657479/20509228/Toolkit.pdf
Australian development Gateway: Sustainable development through sharing
knowledge
This web site provides a comprehensive collection of resources and links on applied
social research methods for practitioners involved in applied social research and
evaluation - see http://www.developmentqatewaY com.au/jahia/Jahia/pid/4624
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Constructing the evidence base on the social determinants of health: A guide
11
Learning from practice
Mainstream evidence based practice does not currently make best use of ‘non
scientific’ knowledge that does not find its way into the published literature (El Ansari
et al., 2002; Popay et al., 1998). Often the richest sources of data on how things work
in the real world can be found by tapping into the tacit knowledge of those working
most closely with the targeted communities, and the tacit knowledge of the
communities themselves. Indeed, if it were made more widely available, some of the
tacit knowledge found in community based programmes in low and middle income
countries could be helpful for those countries where social determinants are already
on the policy agenda. It could help them understand the essential ingredients for the
successful implementation of their policies.
By definition tacit knowledge is knowledge which is held in people’s minds and is
difficult to access. There are many ways in which tacit knowledge can be used to
inform policy development and to ensure that evidence based guidance is rooted in
real life circumstances. For example, communicating local experiences of successful
programmes and initiatives through the media can provide a powerful impetus for
policy action in areas where policy does not exist. Also, as was described in section
9.2, involving stakeholders in developing and testing evidence based guidance helps
to elicit knowledge about the transferability and generalizability of recommendations
and helps improve the take up of guidance once produced.
The learning from practice phase in this framework is an explicit attempt to document
some of the tacit knowledge about how best to intervene to address the social
determinants of health. Otherwise when people eventually leave the systems set up
to sustain action on the social determinants of health, their knowledge is lost and the
evidence base remains poor.
It is important to note, however, that it will never be possible or desirable to
systematize all knowledge. The approach set out here focuses on ways of
mainstreaming tacit knowledge so that it becomes part of the evidence base and
hence improves our understanding not only of what works but also of how it works in
different circumstances.
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Constructing the evidence base on the social determinants of health: A guide
This phase of the development of the evidence base is necessary to fill some of the
gaps in the published evidence base and to help better inform future research,
particularly in relation to ensuring the success of policies. In addition insights can be
gained into the sorts of things that do not work and where well intentioned policies
have actually done harm.
It is rather ironic that this chapter, about the need not to lose tacit knowledge about
effective local interventions, is not illustrated by any case studies. The authors were
unable to find relevant examples relating to SDH in the published literature.
11.1
Why do we need to collect knowledge from practice?
Without policies in place that outline the importance of a multi-faceted approach to
tackling health inequities, little is likely to change. However, policies that do not invest
substantial time and effort to understand what is required to work in practice might at
best have no effect on inequities or at worst contribute to increasing the gradients in
health experience that already exist (Kelly et al., 2004; Speller et al., 2005).
Evidence generated through well-resourced experiments can only provide a guide or
signpost towards the kinds of things that might be successful in real life. It is crucial
therefore to add information that comes from practice both to understand the barriers
to effective implementation and to create innovative ways of overcoming them
(Glasgow, 2003).
However, many practitioners do not follow systematic planning processes when
designing and delivering interventions. This is often because they lack the necessary
training and because there is no recognized system or standard for accumulating
knowledge from practice that matches the principles of organizations such as the
Cochrane and Campbell collaborations which are responsible for collecting, collating
and synthesizing knowledge from published research. As Hill (2004) argues in her
review of community level interventions, ‘there was a failure of many evaluation
reports to include sufficient information for the reader to make an informed judgement
about the intervention being evaluated or how it might be replicated’. While this
finding calls for improved processes and methods of formal evaluation (see the
previous chapter), much can be gleaned from the tacit knowledge of practitioners
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Constructing the evidence base on the social determinants of health: A guide
about how things work by supporting them to document the processes that lead to
effective delivery of social interventions.
Given that most of the examples of what appear to be effective local interventions are
never written up or published in academic journals, the tacit knowledge of
practitioners needs to be captured and shared in a systematic way so that it can be
combined with scientific research to improve the chances of policy goals being
delivered effectively.
A key goal of learning from practice systems is to provide policy-makers, planners
and practitioners with guidance that is as robust as possible. Given the incomplete
and often patchy state of the formal evidence base that can be derived from reviews
of published accounts of interventions, such systems can help to fill in some of the
gaps in our knowledge. Until such time as quality research and evaluation projects
have derived unambiguous results to inform decision-making, these systems can
provide complementary streams of intelligence gathering in a systematic way. This
practical experience and knowledge can inform how resources should be used.
Learning from practice systems can be used to:
•
Improve practice locally, regionally and nationally by sharing experience
of innovations that have been seen to have impact but have not been
written up in a formal way
•
Build a network of practitioners who are working in similar areas who can
learn from others’ experience, either by finding similar practitioners who
are working with similar populations and contexts and/or by using the
principles of effective practice and adapting it to specific contexts
•
Encourage better quality reporting and serve to train local practitioners
about the principles of research methodology
•
Improve the scientific evidence base in the longer term by feeding into the
future design and evaluation of larger scale studies
•
Support the ‘making the case’ phase of the cycle by ‘story telling’ about
local successes and the potential impact of community based projects.
There is no consensus on the models or tools that can be used to provide a logical
and relevant framework for quality assurance in health promotion. However there are
some examples of international projects (Gillies, 1998; Aro et al., 2005; WHO, 2004)
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Constructing the evidence base on the social determinants of health: A guide
which provide ideas as to how the systematic collection and collation of evidence
from practice can be achieved.
Collecting evidence from practice can play a significant role in the production of
guidance on the best ways of addressing the social determinants of health in three
ways. First, it can be used to supplement the evidence base derived from the
scientific literature and to produce guidance on best practice. Second, it can be used
with different stakeholders to inform implementation processes. Third, it can be used
to inform revised guidance and support better informed primary research.
What do we know about the features of an effective
11.2
system for learning from practice?
A number of attempts have been made to establish comprehensive and effective
practice collections of health promotion and public health interventions. However
these attempts have often failed due to the lack of clarity about the boundaries of
what is collected, insufficient resources required to sustain them over long periods of
time, and no attempts made to synthesize general conclusions about the evidence
held within the practice collections (Marks, 2002).
This experience has provided useful learning about the essential features of a
learning from practice system:
•
The effort needed to maintain the accuracy of the data in the collections
should not be underestimated. Piloting of systems is therefore essential to
ensure that the resources available match the requirements of the system
in terms of its ongoing maintenance
•
Collections of effective practice will not of themselves change practice,
unless commitment is given to the ongoing training of local practitioners
and to the building of the infrastructures required to support them
•
Effort is required to market the system to ensure that effective networks of
practitioners can be built
•
The requirements for synthesis should be well articulated up front to
ensure that appropriate information is collected from projects
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Constructing the evidence base on the social determinants of health: A guide
•
Collecting data from projects should not just be seen as a paper exercise
and should be complemented by workshops, conferences and other
means of face to face exchange
•
Longer terms goals should be to encourage the writing up of individual or
groups of projects to share information in peer reviewed journal articles or
through web communications
•
The general principles of research methodologies should be used to
ensure the credibility of the projects as they are written up
•
Systems should aim to evolve so that they can improve the standards for
collecting evidence of effective practice
•
Creating change in practice in complex areas is most successful when it
involves creating ownership of the problem and active involvement in
finding solutions
•
The collection of examples of effective practice should not be seen as an
end in itself and should be linked to other ways of improving and
promoting best practice. The goal is for this best practice to be
mainstreamed eventually
•
More effective ‘learning from practice’ systems tend to be those which are
broad enough to give good coverage of key variables but are small
enough to allow for rapid collation and synthesis. Limiting the number of
examples and having a time-limited lifespan are more likely to succeed
than trying to be more comprehensive and ongoing (French, 2003).
11.3
What sorts of information shouid be collected?
Criteria can be developed to select and generate knowledge from known successful
projects to ensure that this knowledge can be utilized by others and be synthesized
to produce transparent and explicit evidence about how that success was achieved.
The following criteria for gathering information have been derived from what is known
already about the characteristics of effective interventions aiming to address the
social determinants of health (French, 2003). These criteria can be used to select
projects for a learning from practice database. They can also be used to revisit
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Constructing the evidence base on the social determinants of health: A guide
projects that are known to be successful but require support in order to understand
what made them a success:
1. Whether a prior local assessment of need was carried out using such
techniques as health equity auditing and therefore whether examples from
practice can be defined in terms of the dimension of inequality being
addressed (e.g. age, gender, socioeconomic group, etc.)
2. Details of the methods used to ensure effective engagement of local
communities in needs assessment, target setting, delivery and evaluation
3. Where multifaceted interventions were carried out, details of how these
interventions worked together to produce the desired outcome
4. How practitioners were trained and supported to deliver the intervention
5
How ownership of the goals of the projects was built up between the
deliverers and the community receiving support
6. What political and managerial commitment existed that contributed to the
success of the project
7. Whether there is a clear theoretical perspective that is congruent with the
form and focus of the intervention
8. How success was measured and through what forms of evaluation (this
could include story telling).
A learning from practice system completes the cycle by improving the reporting of
local experience so that it feeds back into the evidence generation phase. This allows
us to continually improve the quality, breadth and depth of the evidence base on how
best to act to address the social determinants of health.
Having considered the four parts of the tools and techniques framework we now turn
to monitoring, which underpins the whole framework.
11.4
Related reading
Blagescu M & Young J (January 2006), “Capacity Development for Policy Advocacy”
El Ansari W., Phillips CJ. and Zwi AB, (2002), “Narrowing the gap between academic
professional wisdom and community lay knowledge: perceptions from partnerships”.
Public Health 2002; 116:151 -159.
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Constructing the evidence base on the social determinants of health: A guide
Harden A, Garcia J, Oliver S, Rees R, Shepherd J, Brunton G, Oakley A, (2004),
“Applying systematic review methods to studies of people’s views: an example from
public health research”, Journal of Epidemiology and Community Health
2004;58:794-800.
Popay J., Williams G., Thomas C. and Gatrell A, (1998), "Theorising inequalities in
health: the place of lay knowledge”. Sociology of Health & Illness 1998;20(5):619645.
Popay J. and Williams G (1996),.’’Public health research and lay knowledge”. Social
Science & Medicine 1996;42(5):759-768.
11.5
Specific tools
Handbook for evidence-based working and case study writing 2005
http://www.euro.who.int/document/ENI/Handbook case study.pdf
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Constructing the evidence base on the social determinants of health: A guide
12
Monitoring
12.1
Introduction
The purpose of this chapter is to help countries in all stages of development make
optimal use of their data and also consider improving their health information
systems. We draw on recent European experience, particularly on guidelines for
monitoring health inequities which were developed for the European Commission
(Kunst et al., 2001). We also look at issues particular to low and middle income
countries (LMIC).There is an extensive list of related reading at the end.
Monitoring of health inequities using routinely collected data is important for a
number of reasons:
•
These data can be used to attract policymakers’ attention, for example by
benchmarking exercises. Showing that problems are larger than
elsewhere is often an important stimulus to policy-making. Countries with
inadequate data usually also lag behind in policy development on health
inequities
•
These data can be used to identify entry points for policy. For example,
inequities in health determinants provide clues as to underlying factors
which could be addressed by interventions and policies
•
These data can be used to assess the impact of policies. If policies
change over time - if for instance policies which have an adverse effect
on health inequities are implemented - routine data on how inequities in
health and health determinants change over time will provide information
on the impact of the policies.
Countries around the world are in different stages of development of health
monitoring systems. Some countries have very little routinely collected health data.
Other countries have routine health information systems, but these do not monitor
health inequities. Still other countries measure health inequities routinely, but lack
data on the determinants of health inequities so that entry-points for policies cannot
be detected.
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We understand ‘monitoring’ to be a policy-oriented process based on the analysis of
current patterns and trends in health outcomes, their social determinants and health
equity. Consequently, this chapter is oriented to policy-makers, health practitioners
and policy-oriented researchers. The chapter is in seven parts:
1. Guidelines on how to use data to monitor health inequities
2. Explanation of different sources of health data
3. Outline of issues in interpreting key equity stratifiers
4. Special issues in low and middle income countries
5. Special issues in high income countries
6. Suggestions for improvements in monitoring systems
7. Related reading.
In addition illustrative case studies are listed at the end and can be found in
appendix I.
12.2
Use of data to monitor health inequities
12.2.1
Identifying sources of health information
Data sources exist in every country and can often be used for monitoring health
inequalities. Table 12.1 gives an overview of the data sources which are available in
many middle and high income countries. These sources are often also available in
low income countries but may be less reliable, less comprehensive and/or updated
less frequently. Table 12.2 provides a checklist to evaluate the usefulness of these
data sources for monitoring health inequities.
Table 12.1
Overview of potential sources of data for monitoring inequities in health
Data source
Health status indicators covered
Vital registry (births, deaths)
Mortality, length of life
Cause-of-death registry
Mortality from specific causes of death
Level of living surveys and multipurpose
surveys
Disability, symptoms, general health and
quality of life
Health interview surveys
As above, plus self reported prevalence of
diseases and disability
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Constructing the evidence base on the social determinants of health: A guide
Health examination surveys
As above, plus functional impairments and
biological precursors of diseases
Health care utilization registries, e.g. hospital
admissions, general practitioners
consultations
Incidence, case fatality and prevalence of
several diseases leading to utilization of
health services
Disease registers, e.g. cancer, congenital
anomalies, mental health
Incidence, case fatality and prevalence of
specific diseases
Surveillance systems, e.g. on infectious
diseases, injuries
Incidence, case fatality and prevalence of
injuries or specific (acute) diseases
Social security registries, e.g. on sickness
absence, long-term work disability
Incidence and prevalence of several diseases
leading to work disability
Source: Kunst et al., 2001.
Table 12.2
A checklist for the evaluation of data sources
1. Relevance and
timeliness
2. Population
coverage and
representativeness
3. Reliability
4. Precision, power
5. Usefulness for
monitoring trends
a.
Do the data cover at least two of the core socioeconomic indicators
(occupation, education, income)?
b.
In mortality studies, can a distinction be made by cause of death?
c.
In health interview or similar surveys, are different health status
indicators included?
d.
Do the data refer to a recent period (less than 5 years ago)?
a.
Are both men and women included?
b.
Do the data cover all age groups or at least a substantial part of the
entire age range (e.g. 15-74 years)?
c.
Are you sure that the data are not restricted to a specific city/area
or to another sub-population (e g. employees of a company)?
d.
Do the data include the institutionalized population and other
specific groups such as foreigners?
e.
Are you reasonably sure that, if the data come from a survey,
problems with non-response do not strongly bias the results?
a.
Are socioeconomic indicators linked to health indicators at the
individual or household level (instead of the area level)?
b.
If education is used as the socioeconomic indicator, can a
distinction be made between lower educational levels (e.g.
elementary and lower secondary, or <7 and 7-8 years)?
c.
If occupational class is used, can this indicator be determined for
people who are economically inactive (e.g. housewives and
retired)?
d.
If income is used, are data available to estimate household
equivalent income? Are there no serious problems such as income
unknown for many people (say, more than 20%)?
a.
In interview or examination surveys, is the sample size fairly large
(more than 5,000 respondents)?
b.
In mortality studies, is the number of deaths fairly large (more than
1,000 deaths)?
a.
Can three or more periods be compared?
b.
Do these periods together cover a sufficiently long span (about ten
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Constructing the evidence base on the social determinants of health: A guide
years or more)?
c. In interview or examination surveys, are exactly the same health
indicators used in the subsequent surveys?
d.
Is the measurement of socioeconomic indicators comparable over
time? Can the same classification be applied to each period?
Source: Kunst et al., 2001.
In many countries, three types of data will form the core of a health monitoring
system for health inequities:
•
Nationally representative, individual-level data on mortality according to
socioeconomic indicators, to monitor socioeconomic inequalities in
mortality
•
Nationally representative data from health interview, multi-purpose and
similar surveys, to monitor socioeconomic inequalities in self-reported
morbidity and access to and utilization of health care.
•
Nationally representative data from routine health records.
Sometimes, additional data sources are available for monitoring inequities in specific
health problems, such as the incidence or prevalence of particular diseases (e.g.
cancer) or disabilities (e.g. work disability).
When nationally representative data on mortality or self-reported morbidity are not
available, regional or local studies may be used as long as the restriction to specific
regions or areas is recognized explicitly, and extrapolation to the country as a whole
is done only if representativeness has been confirmed. Another alternative is to use
'ecological’ studies in which mortality or morbidity indicators can be linked to
socioeconomic indicators at the level of small areas. These data can be subject to
bias if they are used to infer individual-level relationships between socioeconomic
status and morbidity or mortality (the ecological fallacy), but can nevertheless be
useful as long as the potential for bias is recognized.
12.2.2
Measuring socioeconomic status
Table 12.3 gives an overview of indicators that can be used to measure
socioeconomic status (SES). Some measures may be preferred over others for
theoretical reasons - for instance a class perspective on health inequities would lead
one to prefer occupational class over educational level. Since there is no general
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Constructing the evidence base on the social determinants of health: A guide
consensus on this we recommend using at least two of the three core indicators of
socioeconomic status (education, occupation or income) if data sources permit.
An important additional consideration for choosing between socioeconomic status
indicators is the appropriateness of a particular measure for the whole population.
For instance, level of education can be used readily for both men and women,
including those not currently employed, whereas occupational class can often only be
measured forthose currently employed, which in many countries excludes a large
number of women and elderly persons.
Educational level can be measured by means of a hierarchical classification of the
population according to their completed educational level. Part-time education and
vocational training are preferably taken into account. A distinction can be made
between at least five categories similar to: none, elementary, lower secondary, upper
secondary and tertiary.
Table 12.3
Overview of possible socioeconomic indicators
Measured
at individual level
Measured
at household level
Measured
at area level
Education
highest level completed
number of years of
schooling
literacy
idem, of head of
household, partner
or parent
% low educated
% illiterate
ratio female/male literacy
Occupation
current occupational
class
(idem, but lifetime
based)
(score on social
distance scale)
idem, of
head of household
% low class
% underemployed
% informal sector
% unemployed
% female population in the
labour force
household per
capita income
consumption /
expenditure
(quintiles or poverty
line)
Own production...
% low income
(quintiles or poverty line)
average income
ratio female/male income
10/10 share of income
20/20 share of income
income distribution
total amount of
assets or capital
household per
capita wealth
(quintiles or poverty
line)
% low wealth/assets
(quintiles or poverty line)
average wealth
10/10 share of income
20/20 share of income
wealth/assets gradient
Core indicator
Income
Wealth/assets
household members
personal income
(work, subsidies, /
consumption /
expenditure
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Constructing the evidence base on the social determinants of health: A guide
housing material
conditions (walls,
floor and roof)
housing amenities
(electricity, radio,
bycicle, fuel used)
housing tenure
or facilities
Composite
combination of above indices
% ‘bad’ housing
combination of above
indices
Source: Adapted from Kunst et al., 2001.
Income level can be measured by classifying the population according to household
equivalent autonomous income. This implies that, where possible, (a) the income of
all household members is summed, (b) their net (instead of gross) income is
measured, and (c) an adjustment is made for household size. Households are then
classified into groups of equal number, such as income quintiles or deciles.
Information on occupation can be used to classify subjects into ‘occupational
classes’. A distinction should at least be made between non-manual classes, manual
classes, farmers and other self employed. If possible, a further distinction can be
made between e.g. upper and lower non-manual classes, and between skilled and
unskilled manual classes. The occupational class can be determined on the basis of
the individual’s current or last occupation. However, if many persons are not
economically active, a classification on the basis of the occupation of the head of
household may be considered.
Composite measures (combining e.g. education and occupation) are not
recommended for routine use in individual-level data, although they may be used for
the identification of disadvantaged groups of particular interest, such as poor lone
mothers or disadvantaged migrant groups.
These three key socioeconomic indicators are discussed in greater detail in
section 12.4.
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Constructing the evidence base on the social determinants of health: A guide
12.2.3
Tabulating health indicators by socioeconomic group
The first step in making sense of data is to create insightful tabulations. One possible
format is in table 12.4. This format is intended to be used for analysing trends in
health inequities over time, but can also be used for other purposes such as
analysing variations in health inequities between countries (replace ‘period’ by
‘country’). Although it focuses on socioeconomic variables, it may also be applied to
other equity stratifiers.
The health indicator can be expressed as the rate or probability of occurrence of
negative health problems. In some cases, however, measures of positive health may
be preferred. Where possible, mortality and morbidity rates should be presented by
gender and broad age group, in order to assess whether patterns apply across the
whole population.
Health measures should be standardized for age in such a way that comparisons can
be made not only between socioeconomic groups, but also between periods and
countries if applicable. There are some country or region specific age standardization
measures (e.g. the European Standard Population). When neither countries nor their
reference region use specific standardization, formats such as the World Standard
Population or the World Health Organization Standard Population are recommended.
Table 12.4 Basic scheme for tabulating and analysing trends in socioeconomic
inequities in health
Step 1: Population size
Share in total population (%)
SE indicator
Period 1
Period 2
Period 3
100
100
100
______ Trend
Absolute
Relative
change
change
Group 1 (highest)
Group 2_______
Group 3_______
Group 4_______
Group 5 (lowest)
Total
Step 2: Health
Occurrence of health problem (rate)
SE indicator
Period 1
Period 2
Period 3
______ Trend
Absolute
Relative
change
change
Group 1 (highest)
Group 2_______
Group 3_______
Group 4
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Constructing the evidence base on the social determinants of health: A guide
Group 5 (lowest)
Total
Step 3: Magnitude of health differences
____________________________ Inequity index
Period 1
Period 2
Relative version________
Absolute version
Period 3
Absolute change
from period 1 to 3
Source: Kunst et al., 2001
Measures of mortality can be summarized in terms of life expectancies, and
measures of mortality and self-reported morbidity can be combined into measures
such as disability-free life expectancy.
It is important not only to look at rates of health problems but also at the distribution
of the population over socioeconomic groups, as the size of the relatively
disadvantaged groups will determine the population health impact of health
inequities.
12.2.4
Measuring the magnitude of health inequities
When the purpose of the analysis is to determine whether the magnitude of health
inequities has changed over time, or differs between countries, the tabulated data
needs to be summarized in one or more indices. It is important however to always
check the summary indices against the patterns that are visible in the basic
tabulations.
Table 12.5 outlines the most commonly used summary indices of the magnitude of
health inequities. The choice of whether to use absolute or relative measures can
affect the assessment of whether a health inequity exists and its magnitude.
Sometimes a disparity on the relative scale (i.e. the rate ratio of a health outcome
between a low and a high socioeconomic status group) may not appear to be a
disparity on the absolute scale (i.e. the rate difference between the two groups). It is
critical that researchers and policy-makers are clear about which type of measure
they are using. The choice of measure is also relevant for the discussion about the
distinction between health gaps and health gradient (see chapter 3).
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Constructing the evidence base on the social determinants of health: A guide
We recommend, where possible, using both relative and absolute measures of health
inequities (i.e. both rate ratios and rate differences comparing two contrasting
groups) to ensure that inequities are identified. Other more sophisticated measures
can also be used to gain more insight into the patterns of health inequities.
Regression-based measures have been developed to take the ‘gradient’ nature of
health inequalities into account. Some measures also take into account the
distribution of the population over socioeconomic groups. This sometimes leads to
interesting insights, for instance when the size of relatively disadvantaged groups has
diminished overtime so that the population health impact has also diminished,
perhaps despite rising relative and/or absolute differences between groups.
Table 12.5
Overview of summary indices of the magnitude of health inequities
Summary index description
Indices that
compare two
contrasting
groups
Compare
extreme
groups
Compare
broad groups
Regression
based indices
that take into
account all
groups
separately
Based on
absolute SES
Total impact
indices that
explicitly take
into account
population
distributions
The PAR
perspective
(equality by
levelling up)
Based on
relative SES
The ID
perspective
(equality by
redistribution
)
Summary index
_________ (with example of an interpretation)
On the absolute occurrence
On the relative
of health problems
occurrence of health
______ problems_______
Rate Difference
Rate Ratio
e.g. the absolute difference in
idem, but the proportional
mortality between
mortality difference
professionals and unskilled
manual workers____________
Rate Difference
Rate Ratio
e.g. the absolute difference in
idem, but the proportional
mortality between non-manual mortality difference
and manual classes_________
Absolute effect index
Relative effect index
e.g. the absolute increase in
idem, but the proportional
health associated with an
increase in health
income increase of 1000 US
dollars.____________________
Slope Index of Inequity (Sil)
Relative Index of
e.g. the health difference
Inequity (RII)
between the top and bottom of idem, but the proportional
the income hierarchy________ health difference________
Population Attributable Risk PAR (%)
(PAR)
e.g. the total number of cases
idem, but as a proportion
that would be avoided if
of all cases (of death,
everyone had tertiary
disease, etc.) in the total
education__________________ population____________
Index of Dissimilarity (ID)
ID (%)
e.g. the total number of cases
idem, but as a proportion
to be redistributed between
of all cases (of death,
groups in order to obtain the
disease, etc.) in the total
same average rate for all
population
groups
Source-. Kunst et al., 2001.
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The best measure will depend on its fitness for purpose, just like the choice of
evidence methodology. At the beginning of the 1990s Wagstaff and colleagues
(1991) warned researchers and policy-makers that conclusions on health inequalities
depended on the measure chosen. Since then there have been numerous works
revising different measures, broadening the range of measures, and incorporating
measures beyond the classical epidemiological ones (Regidor, 2004a, 2004b).
Table 12.6 Advantages and disadvantages of summary indices most frequently used
to measure health inequities
Summary index
1.
Rate ratio of highest
versus lowest
socioeconomic status
groups
2.
Rate difference between
highest versus lowest
socioeconomic status
groups
3.
Advantages
Disadvantages
Easy to calculate and to
interpret
Only takes into account
extreme groups, ignoring
inequalities within groups or
between intermediate
groups.
Regression-based
relative effect index
Takes into account all social
groups and allows the
inclusion of other variables in
the model.
More complex to calculate
and needs statistical
packages to do so.
Needs verifying regression
assumptions, e.g. lineality.
4.
Population-attributable
risk - percent
5.
Population-attributable
risk - absolute
Easy to calculate and to
interpret. Takes into account
the variation between groups
as well as the population
size.
It does not consent
association between SES
and group morbidity and
mortality.
6.
Regression-based
population-attributable
risk - percent
Requires statistical packages
and statistical knowledge to
interpret it.
7.
Regression-based
population-attributable
risk - absolute
Consents association
between SES and group
morbidity and mortality of the
whole social gradient.
8.
Index of dissimilarity percent
Easy to calculate and to
interpret.
9.
Index of dissimilarity absolute
It does not take into account
the health variable and the
SE variable.
10. Relative index of
inequality
11. Slope index of inequality
12. Gini coefficient and
Lorenz curve
The distribution assumption
is not applicable to morbidity
or mortality.
Takes into account the
population size and the
relative groups’ SES.
Sensitive to the population
average health status.
Requires statistical packages
and statistical knowledge to
interpret it.
Comprises data from all
groups; it does not
population SES stratification.
It does not take into account
the socioeconomic
dimension.
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Constructing the evidence base on the social determinants of health: A guide
On its own, it does not
provide information on the
way inequality is distributed.
13. Concentration index and
concentration curve
Includes the social
dimension in the analysis
and uses information from
the whole population.
Geographic and trend
analysis varies little when
analysing morbidity or
mortality over 15 years old.
On its own, this index does
not discriminate the way in
which inequality is
distributed.
Source: Schneider et al., 2002b.
Given the diversity of advantages and disadvantages, it is recommended to use more
than one index to depict the multi-dimensional nature of health inequities, as well as
selecting the indices based on the objective pursued. Ideally complementary indices
should be used. Furthermore, just as there are no ‘correct’ measures, neither are
there ‘correct’ reference groups (Harper & Lynch, 2004). This is another decision to
make together with the summary index/ indices. Fitness for purpose also includes the
final audience. Sophisticated measures may only be appropriate within a research
context, and simpler measures may be more appropriate for addressing policy
makers.
12.2.5
Evaluating and interpreting the results
Several data problems may bias estimates of the magnitude of health inequities. The
effect of data problems that cannot be avoided in the selection or analysis of data
should be thoroughly evaluated wherever possible, for example using the checklist in
table 12.7. These problems should be evaluated for their possible effect on the
results. Sometimes these effects can be quantified by means of sensitivity analyses.
Further problems in analysing data due to difficulties in interpreting the key equity
stratifiers are outlined in section 12.4.
Table 12.7
Area
Delimitation
and
representative
-ness of study
population
Checklist of potential data problems
Affecting the measurement of
inequities in health at one moment in
______________ time_____________
Exclusion from the study of specific sub
populations, e.g.
- non respondents to surveys
- specific SES groups, e.g. self employed
- others, e.g. institutionalized, foreigners
Affecting the measurement of
time trends in these inequities
Changes in delimitation of the
population, e.g.
- different age groups
- different geography
- different survey samples_____
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Constructing the evidence base on the social determinants of health: A guide
Measurement
and
classification
of health
indicators
Exclusion from analysis of those with
missing values due to, e.g.
- unknown SES, e.g. inactive men
- health status unknown, e.g. cause of
death____________________________
Misclassification due to, e.g.
- problems with self-reports
- inaccurate registry of causes of death
- incomplete coverage by e.g. hospital
registries
Failure to measure all aspects of health
that were aimed to be studied, e.g.
- restriction of moderate instead of severe
levels of ill health
- incomplete selections of diseases or
disability items
Measurement
and
classification
of socio
economic
indicators
Confounding
Power,
precision
Misclassification due to, e.g.
- lack of detailed basic data
- the numerator/ denominator bias
- use of crude social class schemes, e.g.
ISCO based schemes
- inaccurate measurement of e.g. income
Failure to measure all relevant groups
separately, e.g.
- those with elementary education only
- non-manual workers with lowest status
Confounding inherent to a specific
indicator of SES or health, e.g.
- insurance coverage as a proxy for
income
- facility-based measures of health
Wide confidence intervals to inequity
estimates
Changes in problems with
representativeness
(see cell to the left)
Changes in the measurement
and classification, e.g.
- different health questionnaires
- different classifications of
diseases
Changes in problems with
measurement and classification
(see cell to the left)
Changes in population health not
taken into account, e.g. changing
mix of diseases_______________
Changes in data, indicators and
classifications
Changes in problems with
measurement and classification
(see cell to the left)
Social changes not taken into
account, e.g. changes in
- educational systems
- income structure
- position of specific occupations
Changes in the effect of
confounding
Overlap in the confidence
intervals to inequity estimates for
different periods
Source-. Kunst et al., 2001
Measuring the magnitude of health inequities is usually only the first step and will not
in itself be able to inform policy-making. Although health monitoring systems are not
designed for scientific research into the causes of health inequities, they can often be
used to get a first idea of these possible causes. There are three general
approaches, each of which can be feasible with data collected in health monitoring
systems or other statistical systems:
•
Carrying out in-depth descriptions of health inequities (e.g. by looking at
causes of death in addition to total mortality)
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Constructing the evidence base on the social determinants of health: A guide
•
Comparing inequities in health outcomes to inequities in health
determinants (e.g. by looking at inequalities in smoking and other
behavioural risk factors)
•
Relating inequities in health to contextual factors (e.g. by looking at
implementation of welfare policies.
12.3
Sources of health data
The basic instruments of any health information system are vital statistics, censuses,
population-based surveys and health records. These are found in all countries
although they differ greatly in their coverage, quality and frequency. The last two
sources include a variety of instruments, such as health and multipurpose surveys,
health interview surveys, health care utilization registries, surveillance systems, small
areas, epidemiological studies and longitudinal studies. All of them provide
information for monitoring health outcomes and health equity.
In this section different sources of data are examined and strengths and weaknesses
in monitoring health inequities are identified.
12.3.1
Vital statistics
Vital registries are core instruments of a health monitoring system, providing
continuous information on births and deaths by age and sex, and with attribution of
cause of death. They are present in all countries but they are of varying coverage
and quality. For example, a recent study in Latin America proposed three categories
based on countries’ coverage and quality of vital and health statistics (see table
12.8).
Table 12.8 Latin America: Typology of countries according to vital, morbidity and
resources statistics characteristics
Country
typology
Group 1
Argentina
Chile
Costa Rica
Cuba
Vital statistics
Morbidity & resources
• High coverage: over 90 per cent
• Tendency to greater coverage in
birth and general mortality registries
than in infant mortality
• Greater level of coverage than
• Greater problem analysis
• Little time series and geographical
analysis
• Important regional differences,
when there is analysis
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Constructing the evidence base on the social determinants of health: A guide
Uruguay
quality
• Differences in system perceptions
among producers.
• Regional differences either in
coverage or in quality
• Positive perception of the system
among data producers and users.
Group 2
Brazil
Colombia
Ecuador
Mexico
Panama
Venezuela
• Middle coverage: between 70 and
80 per cent
• Greater problem analysis, but
erratic.
• Important differences according to
estimation sources
• Lower time series and
geographical analysis.
• Greater level of coverage than
quality
• Important regional differences,
where analysis is being done.
• Important regional differences
either in coverage or in quality
• Differences in system perceptions
among producers.
• Differences in system perceptions
between data producers and users.
Group 3
Bolivia
Dominican
Republic
El Salvador
Guatemala
Honduras
Nicaragua
Paraguay
Peru
• Low coverage level: less than 70
per cent and sometimes less than
50 per cent
• Almost no analysis on the national
level, and even less geographical
or time series.
• Greater level of coverage than
quality, but scarce application of
evaluation techniques
• Greater uniformity in negative
perceptions of the system.
• Little responSe to evaluation.
• Important regional differences
either in coverage or in quality
• Greater uniformity in negative
perceptions of the system.
Source-. Elaborated upon information from Giusti (2006).
Birth registries
Birth registries give us information on such diverse health indicators as birth weight,
delivery assistance, teenage fertility, and health relevant indicators like mother’s
educational level. They also provide data on live births, which are used to calculate
infant mortality rates. Therefore problems in coverage of birth registration not only
affect fertility statistics but also have an effect on recorded infant mortality rates.
According to a recent UNICEF study (2005) on birth registration, there are enormous
disparities within and between regions of the world (see table 12.9).
Table 12.9
Proportion of unregistered births by region
Regional summaries
Sub-Saharan Africa
Percentage of
unregistered
children (born 2003)
55
Middle East and North Africa
16
South Asia
63
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Constructing the evidence base on the social determinants of health: A guide
East Asia and Pacific
19
Latin America and Caribbean
15
CEE/CIS and Baltic States
23
Industrialized countries
2
Developing countries
40
Least developed countries
71
World
36
Source: UNICEF, 2005.
If non-registration occurred in similar proportions across populations, it would not be
difficult to extrapolate to the whole population. However non-registration is itself
biased since the children most likely to be unregistered are precisely those most
vulnerable. The UNICEF study drew up a profile of under-five non-registered
children, affirming that these children
tend to be poor, live in rural areas, have limited access to health care, are not
attending early childhood education, have higher levels of malnutrition and have
higher mortality rates. They are likely to have been born without the support of a
health professional or midwife, and their mothers have low levels of formal education
and are less likely to have adequate knowledge of signs of some child illnesses and
of HIV/AIDS transmission. (UNICEF, 2005:23)
Death registries
Together with birth data, death registries are an essential part of any vital statistics
system. Death registries provide useful information on gender, age, education,
occupation, and place of residence. In the case of infants under one year old,
information on the mother and father is collected in most countries. Moreover, cause
of death registries enable monitoring of age-specific and age standardized death
rates for total and cause-specific mortality, allowing calculation of specific rates
according to social stratifiers such as education, occupation, gender, ethnicity or
place of residence.
However, in LMIC there are significant problems in coverage, especially with infant
mortality. As well as coverage there are other relevant issues to consider for
monitoring: (a) the existence of a cause of death register; (b) the use of the Xth
revision of the International Illness Classification (CM); (c) the proportion of medically
certified deaths; and (d) the proportion of ill defined deaths in the country.
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For the purpose of monitoring health equity, when there is no full coverage at least
representativeness of different subgroups must be assured (e.g. ethnic groups)
(Braveman, 1998). On the other hand, there are countries (e.g. China and India)
which do not have national vital statistics but have a system based on selected areas
with full coverage.
12.3.2
Population and housing censuses
A population census is defined as the total process of collecting, compiling,
evaluating, analysing and publishing or otherwise disseminating demographic,
economic and social data pertaining, at a specific time, to all persons in a country or
in a well delimited part of a country (United Nations, 1997). During the last century
population-only censuses increasingly became population and housing censuses.
The combination represents a rich source of data about the social determinants of
health, through information on sex, age, family composition and education, linked to
housing and community living conditions.
Population and housing censuses provide useful information on most stratifiers (age,
gender, education, occupation, ethnicity, residence) although by and large they do
not gather information on health or income. Nonetheless, they enable the
construction of wealth indices based on assets or housing characteristics. Since
censuses provide information on fertility, mortality and migration, they are the basis
for (a) population projections, vital for mortality rate calculations as they provide the
rate’s denominator, and (b) life tables, which permit life expectancy to be calculated
and therefore represent a key component of monitoring systems.
Although they are not the preferred way of monitoring mortality, in many low and
middle income countries with vital registries coverage below 90%, censuses are an
essential instrument in measuring mortality, especially infant and child mortality
(Vapattanawong et al., 2007), and even maternal mortality in some countries
(Stanton et al., 2001). They also represent a key tool for the analysis of under
representation in vital statistics, both births and deaths, by allowing the measurement
of non-registration both at national level and among specific population groups, e.g.
ethnic groups.
An additional value for a social determinants of health approach is that they provide
information for contextual variables to be used when monitoring small areas.
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Just as vital registration varies greatly between countries, censuses also vary in the
quality of data collection, frequency, timeliness and later accessibility. Nonetheless,
censuses are becoming more frequent and increasingly supported by national and
international initiatives, e.g. PARIS21 (Partnership in Statistics for Development in
the 21st Century) (see table in appendix II for details of which countries carry out
censuses and other surveys). In addition some regions are harmonizing the
preparation process for the census round in 2010 by coordinating the census
questionnaire in terms of common definitions (e.g. ethnicity), themes and questions.
This will enable comparisons between countries (ECLAC, 2005, 2007; Farah, 2005).
12.3.3
Population-based surveys
Population based surveys including health interview surveys, epidemiological
studies, longitudinal studies and small areas studies can provide information for
monitoring health outcomes and health equity.
In many low and middle income countries such population-based surveys are
conducted at regular intervals to examine trends in health. There is a wide range of
such surveys and the best known are: the Demographic and Health Surveys (from
ORC Macro), the Multiple Indicator Cluster Survey (UNICEF), the World Health
Surveys (WHO), the Demographic Surveillance Systems (INDEPTH) and the Core
Welfare Indicators Questionnaire (World Bank). These surveys provide information
on recent illness episodes in relation to access to care, maternal and child health
practices, health knowledge, reproductive behaviour, anthropometric measures, and
biological testing for HIV, anaemia and malaria. In many countries they also
represent the main source of data on mortality; some of them even provide
information on causes of death through verbal autopsies (a method of ascertaining a
probable cause of death by interviewing the relatives of the deceased) (Soleman et
al., 2006, 2005; Setel et al., 2005; Korenromp, 2003).
In addition, in most countries there are also routine multi-purpose household surveys
which contain health modules. These include Living Standards Measurement
Surveys (LSMS) and household income and expenditure and consumption surveys.
This section looks at the best known surveys. Appendix III gives more detail of their
contents.
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Demographic and Health Surveys (DHS)
The Demographic and Health Surveys (DHS) started as the World Fertility Survey, a
survey on fertility and therefore concentrated on matters such as contraception and
limited to women of reproductive age. Since 1985 it has expanded its population and
topics and has now been undertaken in more than 75 low and middle income
countries around the world (see table in appendix II).
These surveys select nationally representative samples of 5,000 - 20,000 individuals
within each country, and collect detailed data on various aspects of morbidity and
mortality for participating households. Assessment of health outcomes is by
individual report, and DHS data are particularly useful for developing population
based estimates of infant and child mortality, as well as maternal mortality, all
measures which can be difficult to quantify otherwise in settings with limited coverage
of health care services. In many countries the DHS is carried out at 5-yearly intervals
to assist in examining trends in population health. DHS routinely collect data on the
education and employment status of individuals within participating households, as
well as household asset indices. As a result, DHS are a valuable resource for
describing the social inequalities in health within participating countries.
Because these surveys are repeated at regular intervals, they can also provide a
valuable source of information on changes in health inequities through time, including
monitoring the impact of policies and programmes to reduce social inequalities.
Though the DHS is not meant to measure illness prevalence, it provides information
on recent illness episodes in relation to access to care, maternal and child health
practices, health knowledge, sexual behaviour, anthropometric measures, and
biological testing for HIV and anaemia. Appendix III gives more details.
The classic DHS tool has now been complemented by other surveys:
•
AIDS Indicator Survey (AIS) and the Malarian Indicator Survey (MIS), both
standardized tools to obtain indicators for monitoring national HIV/AIDS
and malaria programmes
•
Key Indicators Survey (KIS) which covers areas related to family planning,
maternal health, child health, HIV/AIDS and infectious diseases. It
provides monitoring and evaluation data for population and health
activities in small areas - regions, districts, catchment areas
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Constructing the evidence base on the social determinants of health: A guide
•
Quantitative studies include Biomarker Collection, Geographic Data
Collection (which by geocoding DHS locations makes it possible to
combine analysis with censuses) and Benchmarking Surveys.
•
Qualitative studies which provide informed answers to questions that lie
outside the purview of standard quantitative approaches, looking at the
social and cultural contexts of daily life.
The table in appendix II shows the type and year of all major surveys for LMIC
countries.
Together with censuses, the basic DHS tool has been used to complement vital
registry statistics in countries with low coverage and/or low quality of death registers,
particularly in relation to infant mortality. Some examples are the methods developed
by the Latin American Demographic Centre (CELADE) in the 1980s: Proyecto
Investigacidn Fecundidad Hijos Propios para America Latina (IFHIPAL) (Research
into Fertility Using the Own-Children Method in Latin America) and Investigacion en
Mortalidad Infantil en Amdrica Latina (IMIAL) (Research on Infant Mortality in Latin
America).
Multiple Indicator Cluster Survey (MICS)
Along with the Demographic and Health Surveys, the MICS developed by UNICEF is
a major global source of information designed to enable countries to produce
nationally representative and statistically sound data to monitor national and
international targets. It was initially established in the 1990s to monitor the goals of
the World Summit for Children, and it has now become a key tool for monitoring of
about half of the Millennium Development Goal indicators. It also now incorporates
an asset index enabling analysis of equity in health. At present there are reports and
data files available from 42 countries (see table in appendix II).
The survey has three components: a household questionnaire, a women’s
questionnaire (15-49 years) and a children’s questionnaire (under 5 years). The
household component includes information on education, maternal mortality, child
disability, child labour, water and sanitation, salt iodization and household assets.
The women’s component comprises maternal health, contraceptive use, HIV/AIDS,
tetanus toxoid and child mortality. The children’s component includes data on birth
registration, breastfeeding, care of illness, malaria, immunizations, anthropometry
and consumption of vitamin A. There are more details of the survey in appendix III.
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One valuable aspect is that besides the stand-alone MICS, UNICEF has encouraged
countries to incorporate some of the data collected through MICS modules in their
own national multi-purpose household surveys.
Demographic surveillance systems (DSS)
While the previous surveys have a national remit, the demographic surveillance
systems (DSS) surveys carried out over 60 years by the International Network of
Field Sites with Continuous Demographic Evaluation of Populations and Their Health
(INDEPTH), focus on measuring demographic and health outcomes in small areas.
As opposed to cohort studies which focus on individuals, DSS does a longitudinal
follow up of the entire population of a particular geographic area, the demographic
surveillance area (DSA). There are currently 36 demographic surveillance sites
spread around Africa, Asia and Central America (INDEPTH Network, 2005). More
details of the survey are in appendix III.
Ngom and colleagues (2001) consider that demographic surveillance systems have
represented a crucial research tool for the evaluation of health interventions aimed at
reducing socioeconomic differentials in mortality and morbidity in remote areas of
sub-Saharan Africa. They have also contributed to causes of death studies through
the renewed application of verbal autopsies in their questionnaires in countries with
scarce death register coverage (Soleman et al., 2006, 2005; Setel et al., 2005;
Korenromp, 2003).
Core Welfare Indicators Questionnaire (CWIQ)
The Core Welfare Indicators Questionnaire (CWIQ) was designed jointly by the
World Bank, UNDP and UNICEF for monitoring social indicators in Africa on an
annual basis. The CWIQ was developed to evaluate whether the target groups are
actually accessing and benefiting from interventions designed to improve social and
economic conditions. It was designed as a quick and simple tool for monitoring
changes in key social indicators over time for different population subgroups. It
collects information on household well-being and on access, usage and satisfaction
with basic services by the community. There are more details in appendix III.
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Multi-purpose household surveys
Multipurpose household surveys are increasingly being used to monitor health
inequities since the data from their health modules (e.g. self-reported health status,
out of pocket health expenditure, access and utilization of health care services) may
be analysed according to diverse equity stratifiers.
In LMIC multi-purpose household surveys represent a key instrument for monitoring
health inequities with a social determinants approach since they present three main
advantages over other data sources. First, they include modules on different social
determinants of health, particularly education, occupation, employment conditions,
social security, housing conditions, community facilities, ethnicity, gender, age and
residence. Second, they are unique in providing information on personal and
household income/ consumption/ expenditure alongside the above social
determinants of health. Third, such surveys also provide data on individuals and
populations outside the institutional registries, e.g. populations outside the labour
force, children who are not in school (never enrolled and those who have abandoned
the formal educational system), people who do not access health services, etc.
Data on health status varies greatly between countries, ranging from general
questions on illnesses or accidents during the survey reference period, to more
detailed information on chronic diseases, nutritional status (children and pregnant
women), or health behaviour and attitudes (smoking, alcohol, physical exercise).
Data on out-of-pocket expenditure is relevant for monitoring the differential
magnitude of health expenditures on the household budget as well as the
distributional effect of social policy. It refers to payments for medicines, visits,
examinations and hospitalization. Information on access to health care includes
transportation time to health care facilities, waiting lists, etc.
There is a wide range of multi-purpose household surveys, including the Living
Standards Measurement Surveys (LSMS) developed by the World Bank, along with
many surveys carried out regularly in different countries supported by their own
governments (Dachs, 2002; Dachs et al., 2002; Ferrer, 2000; Sadana et al., 2000)
(see appendices II and III for more information).
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Constructing the evidence base on the social determinants of health: A guide
education, which in turn will affect the child’s income once he/she becomes an adult.
Education influences occupation, rather than the other way around. Gender affects
the educational level attained in the first place and it is also interactive with income
since at the same educational level women and men do not usually receive the same
income. On the other hand, age should be considered as a confounding factor:
younger populations are expected to have more education than older ones since the
highest level of education is constantly increasing. This reveals the dynamic social
nature of education: while its absolute value increases, its relative value decreases
and new generations require greater education for similar occupations.
Finally, education is a variable that permits a gradient approach and a relational
approach. For instance, the social gradient approach would examine infant mortality
according to the mother’s education, while the relational approach relates education
to a particular variable. For example, a relational approach to education from the
point of view of gender would not only examine school enrolment or literacy by
gender but would also use an indicator like the number of illiterate women per
thousand illiterate men.
Thus monitoring health equity through education is more than just classifying health
outcomes or access by educational levels but further, looking at how these factors
interact.
12.4.2
Occupation
There are several ways to classify people by occupation. The main approach in many
European countries is the ‘class structural’ approach. Distinctions are made between
people who have structurally different positions in the labour market and who, as a
result, differ in terms of income, privileges, lifestyles and characteristics like voting
behaviour. The resulting groups of people are usually referred to as ‘occupational
classes’ or ‘social classes’.
However in many low and middle income countries ‘occupation’, as collected in vital
statistics or censuses, is not an adequate stratifier. Firstly, the question is not usually
asked consistently. It generally relies on an open question, and the people recording
the information do not have a clear definition of occupations. Hence the data are
unreliable. Secondly, in LMIC occupation is highly dependent on working conditions:
the same occupation might have quite different income levels and health effects
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Constructing the evidence base on the social determinants of health: A guide
depending on whether the person works in the formal or in the informal sector.
Thirdly, there are significant levels of under- and non-paid employment (e.g. unpaid
family workers), as well as high levels of economic inactivity particularly in the female
population.
‘Occupational classes’ is not a useful alternative concept since there are no studies
where these have been classified taking into account position and income variables.
Nevertheless in LMIC occupation may be used as a measure of vulnerability in
identifying the unemployed, workers without social insurance, the informally
employed, child labour, young people who do not work or study, among others.
12.4.3
Income
The income level of a person can be used in two ways: to indicate the socioeconomic
status of the income recipient, with higher personal income indicating a better labour
market position; or to indicate access to scarce material resources, where
measurement of household equivalent income is more appropriate.
Income level can be measured by classifying the population according to household
per capita autonomous income. This implies that, where possible, (a) the
autonomous income of all household members is summed, (b) their net (instead of
gross) income is measured, and (c) an adjustment is made for household size.
Households are then classified into groups of equal number, such as income
quintiles or deciles.
Information on income level is also aggregated around the poverty/ indigence line. As
opposed to quintiles or deciles, which divide households in groups of equal number,
these lines divide households according to their position above or below the poverty
and/or indigence line.
The poverty line may be defined in absolute or relative terms. In most low and middle
income countries poverty is measured in absolute terms, that is, in relation to the
level necessary to cover feeding and non feeding needs. Usually this measure
considers three categories: ‘very poor’ (indigence), ‘poor’ and ‘non poor’. Households
considered ‘very poor’ are those whose total income is below the minimum level to
purchase for each one of its members a basic basket of food considered necessary
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for subsistence. Households considered ‘poor’ are those which are able to purchase
the basic food basket but are not able to cover non food items such as clothing,
shelter, transport, education and health care. The non poor households are those
which are able to cover the food and non food needs of their members.
On the other hand, in relative terms, the line is defined in relation to the income level
of people living in the same country. A frequently used poverty line in high income
countries is 50 percent of the nation’s median income.
Income may be measured in four ways: income perse, expenditure, consumption or
wealth/assets. All these concepts may be expressed in terms of quintiles or deciles
which aggregate equal number of households according to the household
autonomous per capita income, per capita expenditure, per capita consumption, per
capita wealth/ assets, or in poverty lines.
Although household income is used more often than household expenditure in middle
and high income countries,, Braveman (1998) stresses that household expenditure is
a more suitable measure of socioeconomic status in ‘subsistence or barter
economies, or in economies where a considerable proportion of the population is
employed in the informal sector’ (Braveman,1998: 47). Additionally, Dachs (2002)
argues that total household expenditure is preferable over income since it is
considered to be ‘less biased, less prone to seasonal variations, particularly in rural
areas, and is considered a better indicator of household economic status overall’
(Dachs, 2002: 337).
On the other hand, Wagstaff and Waters (2005) consider that measuring expenditure
is problematic since it is difficult to value durables or self production. They argue in
favour of using consumption, which includes the sum of food or articles produced by
the household as well as those bought or given by others. Although this information
is collected, valued and added to the autonomous household income in some
household surveys (e.g. Encuesta de Caracterizacion Socioecondmica
[Socioeconomic Characterization Survey] in Chile), Szekely and Hilgert (1999) draw
attention to the fact that in LMIC income still has the additional drawback of under
declaration in the richer sectors of society, thus underestimating inequity.
The Wealth Index (Rutstein & Johnson, 2004), introduced by the Demographic and
Health Surveys, provides an important alternative to standard measures (such as
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income, education and occupation) for measuring social inequalities in health in
LMIC. The index is calculated using easy-to-collect data on a household’s ownership
of selected assets, ranging from a fan to televisions, bicycles or a car; materials used
for housing construction such as flooring material; types of drinking water source and
sanitation facilities; and other context specific characteristics related to wealth status.
However, it is important to recognize that the most appropriate measures of
socioeconomic position are context specific. No single measure can be applied
universally in the study of social inequalities in health, especially in countries with
large disparities in wealth and economic opportunity. Policy-makers and researchers
interested in developing monitoring systems to examine social inequalities in health
need to think carefully about the most appropriate measures of socioeconomic
position in their country or region.
12.4.4
Gender
Gender by definition is a relational stratifier and it is highly interactive with other
equity stratifiers such as education, occupation, income or ethnicity.
An important caveat to keep in mind is that not all differences between sexes reflect
gender inequities. For instance, differences in birth weight between girls and boys do
not echo a gender issue since boys universally tend to weigh more than girls at birth.
But it is a gender issue whether there are differences between girls and boys in terms
of immunization coverage or malnutrition.
Gender analysis presupposes the need for distinguishing between sexes when
collecting and processing data. However, since gender is a relational concept,
analysing by gender means more than distinguishing the data between men and
women or boys and girls. It means using indicators that illustrate the relationship
between genders.
One such instrument is the Gender Parity Index (GPI), developed by UNESCO,
which gives the ‘ratio of female-to-male value of a given indicator. A GPI of 1
indicates parity between sexes; a GPI that varies between 0 and 1 means a disparity
in favour of men/ boys; a GPI greater than 1 indicates a disparity in favour of women/
girls’ (UNESCO, 2006). In education, for instance, one could assess literacy in terms
of the ratio between literate women and literate men.
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12.4.5
Ethnicity/ race/ caste/ tribe/ religion
Ethnic groups, race, caste, tribe and religion are also stratifiers that reveal inequities
in health (Anderson et al., 2006; Montenegro & Stephens, 2006; Mowbray, 2007;
Ohenjo et al., 2006; Stephens et al., 2006). These stratifiers show enormous variety
across the world, ranging from Indigenous and Afro-Latino populations in Latin
America and the Caribbean; Hill Tribes and Muslim minorities in the East Asia and
Pacific region; Berbers in the Middle East and Northern Africa; populations other than
the dominant tribe in sub-Saharan Africa; lower castes and tribes in South Asia;
Roma in Eastern Europe (Lewis & Lockheed, 2006).
At first sight, ethnicity might seem simple to identify. Nonetheless there are problems
of under representation and differences within and between groups that need to be
properly addressed in the data sources.
There are two main criteria for identifying ethnicity: self-identification and language.
In some cases self-identification has problems of under representation since the
degree of ethnic awareness may vary between generations (ECLAC, 2006). It is also
potentially unstable in repeated surveys.
Language is considered a key predictor of indigenous health (Montenegro &
Stephens, 2006). When language is used as a marker, as well as identifying the
native language, it is also important to assess whether people are monolingual or
bilingual, since this is a key issue in determining access to and utilization of health
services (ECLAC, 2006).
Another relevant aspect is to distinguish between dominant (primary and secondary)
and not dominant groups such as tribes (Moyo, 2004; Wirth et al., 2006b).
A significant issue to take into account is that for rural and remote populations it is
not ethnicity itself which is the most relevant factor. For instance in some cases the
evidence demonstrates that ‘land’, i.e. dispossession from their land, is a key social
determinant. Experiences in Uganda showed a reduction from 59% to 18% in the
under 5 mortality rate of Twa families who were given land (Balenger et al., 2005).
When people lose their land it adversely affects their family food supply and their
herbal pharmacopeia. For example, forest people like Pygmies elaborate compounds
against diseases like malaria, guinea worm, jaundice, diarrhoea, toothache and
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helminthiasis (Ohenjo et al., 2006). Moreover, dispossession weakens their
traditional culture which usually acts as a protective factor. This frequently goes
hand-in-hand with increasing discrimination, marginalization and poverty, and the
greater health risks of being transient labour.
Furthermore, access and utilization of health care have additional dimensions to be
taken into account, e.g. identity cards, language barriers, culturally appropriate care
services, distance and location of health care facilities, among others.
Finally, as in the case of gender, ethnicity as a stratifier is highly related to other
markers of socioeconomic status as well as to different dimensions in the ‘ethnic’
category, for instance the interrelation between ‘ethnicity’ and ‘race’ (Harris et al.,
2006). Therefore it is necessary to examine SDH between ethnic and non ethnic
groups but also within ethnic groups. Braveman (1998) makes the point that although
routinely public health statistics in the United States have for a long time noted racial/
ethnic distinctions, standard health statistical reports have not routinely included
measures of socioeconomic status. Without information on socioeconomic status,
inappropriate inferences are often made about the nature of apparent racial/ ethnic
differences in health and health care. When this happens, misguided strategies may be
suggested to address the problems (Braveman, 1998: 55).
Along the same lines, Ohenjo and colleagues (2006) draw attention to the argument
raised by the African Commission on Human and Peoples’ Rights in 2005 that
although
all Africans are indigenous as compared to the European colonialists..., if the concept
of indigenous is exclusively linked with a colonial situation, it leaves us without a
suitable concept for analysing the internal structural relationships of inequality that
have persisted from colonial dominance (Ohenjo et al., 2006: 1937).
Kawachi and colleagues (2005) consider the historical, political, and ideological
obstacles that have hindered the analysis of race and class as codeterminants of
disparities in health.
In sum, ethnicity is a complex concept. Monitoring SDH and health equity requires
acknowledging its multidimensional character, paying particular attention to the
historical context, the social dynamisms inherent in its respective definitions and the
interrelationships with other social stratifiers and within the ethnicity category itself.
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12.4.6
Place of residence
As well as the classical rural/ urban distinction, place of residence also implies
administrative units (villages, municipalities, provinces, regions or states) and
geoclimate areas. Disaggregation is needed not only in the interest of following up
inequities as such, but also to allow decision-making at the local level.
Recently, geographic software programs (e.g. geographic information system (GIS)
software and geographic databases such as the Gridded Population of the World
[GPW] or the Digital Chart of the World [DCW]) have enhanced our ability to carry out
spatial analysis. This allows research on the influences of climatic parameters -
rainfall, aridity, farming systems, growing season - and geographic parameters population density, urban proximity, coastal proximity, distance to roads - to explain
differences in health outcomes.
On the one hand, the use of climatic variables makes it possible to consider
environmental factors which affect agricultural production and disease transmission.
On the other, the use of diverse geographic variables has the potential to go beyond
the traditional urban/ rural dichotomy towards analysis based on an ‘urban/ rural
continuum’ (Balk et al., 2003).
Besides GIS software and databases, a third factor contributing to spatial analysis is
the fact that data sources (e.g. censuses and surveys like DHS and WHS) are
increasingly using geocoding, which allows richer analysis with a greater range of
contextual variables. A recent study on mortality in ten West African countries used
geographic parameters like average population density within 30 kilometres and the
distance to the nearest populated settlement of 50,000 persons or more, as well as
climatic parameters like rainfall, aridity, farming systems, length of growing season,
and the stability of malaria transmission, to explain part of the differences in child
mortality within countries (Balk et al., 2003). Another example is the study by Victora
and colleagues which used geographic parameters to assess equity in the access to
and the implementation of health interventions in the Integrated Management of
Childhood Illness strategy in Brazil, Peru and the United Republic of Tanzania
(Victora et al., 2006) (see more information about this in case study 2 in appendix I).
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The expansion of the use of geocoding in censuses, vital registries, population
surveys and health facility records means that geographical location has begun to be
used as a proxy for socioeconomic status, although not in the classical rural/ urban
distinction. This has provided a way of taking into account the increasing
heterogeneity within urban areas - with significant poverty pockets, e.g. urban and
peri-urban slums - as well as the emergence of more developed poles within rural
areas. Braveman (1998) proposes ‘microgeographic markers’ as ‘among the most
useful proxy measures of socioeconomic status’ and defines ‘microgeographic areas’
as
small geographic territories (generally sub-disctrict level) whose characteristics are
often used to describe the people who live or work in them. A microgeographic
marker is a variable (e.g. a unique code assigned to a neighbourhood as in census
data, or a postal code) that identifies a microgeographic area. In order to use a
microgeographic marker as a socioeconomic measure, the area/ territory represented
must be small enough so that there is a high degree of socioeconomic homogeneity
among households within the area (Braveman, 1998: 53).
Although small area analysis is subject to errors due to the assumption that the
area’s characteristics are shared by all its members (the ecological fallacy),
Braveman argues that ‘a poor individual or household is at considerably lower risk of
adverse health outcomes if that individual/ household resides within a neighbourhood
that is predominantly non-poor’ (Braveman, 1998: 54). In this way, small area
analysis assumes that even the cases that might not be typical of the particular area
under analysis are influenced by the area’s characteristics.
The Dutch health equity monitoring system presented in case study 21 (appendix I)
uses a geographical SES indicator based on postcodes as a proxy for socioeconomic
status.
12.5
Special issues in low and middle income countries
Any observer of international health trends will recognize that the global distribution
of premature morbidity and mortality follows a clear gradient according to the wealth
of nations, with low and middle income countries suffering a greater burden of
disease than high income countries. However, the importance of measuring and
understanding social inequalities in healthcare within low and middle income
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countries has received considerably less attention. This section focuses on issues in
the monitoring of social and economic inequalities in health within the resource
limited contexts of Asia, sub-Saharan Africa and Latin America and the Caribbean.
The focus is specifically on the ways in which monitoring social inequalities in health
may be different compared to advanced health information systems in Europe,
Australia and North America. There are three interrelated issues that require
consideration: (a) the measurement of socioeconomic position, (b) the sources of
data that may be used for routine monitoring, and (c) the interpretation of data on
socioeconomic inequalities in health.
12.5.1
Measuring socioeconomic position and other social
constructs
As outlined above, the most commonly used measures of socioeconomic position
focus on individual income/ assets, education and occupation (often combined into
the construct of ‘socioeconomic status’ or SES). At other times, social class
measures (which focus on occupational categories) are used. Both of these
measures are useful in understanding social inequalities in the distribution of health
and disease, but in many settings these standard measures will not provide adequate
sensitivity in quantifying degrees of wealth or poverty. For example, in regions where
many households grow their own food, and/or barter for food and goods, using cash
income as a measure of wealth may be inappropriate. Similarly, in many settings
educational systems are relatively weak (or have been weak in the past, despite
recent development), meaning that many adults have received little formal schooling
regardless of socioeconomic position. And in countries or districts where levels of
formal employment are low, employment status is unlikely to be a specific measure
to distinguish socioeconomic position. These types of problems in measuring
socioeconomic position are likely to affect the poorest and most marginal individuals
in society disproportionately - leading researchers to underestimate social
inequalities in health within a country or region.
In this light, alternative measures of socioeconomic position may be required in
conducting research on social inequalities in health in developing countries. One of
the most commonly used approaches is to examine individual and household wealth
based on ownership of material goods and access to key services. Material goods of
interest may include household appliances (such as a refrigerator, radio or
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television), transport (such as a bicycle or automobile) or agricultural wealth (such as
livestock or land ownership). Key services such as access to running water, toilet
facilities, financial services (such as bank accounts) and proximity to healthcare
facilities can also be useful measures. In studies of health in small geographic areas
(such as within a community or district), one of these measures may be used as a
simple and easily assessed substitute for socioeconomic position. However in most
situations a single measure is not adequate to capture variability in socioeconomic
position. Instead, it is common to combine several into an aggregate index of wealth.
One common format for this is the asset index that is used as part of Demographic
and Health Surveys (see section 12.3.3).
The asset index and related aggregate measures of socioeconomic position provide
an important alternative to standard measures (such as income, education and
occupation) for measuring social inequalities in health in LMIC. However it is
important to recognize that the most appropriate measures of socioeconomic position
are context specific. No single measure can be applied universally in the study of
social inequalities in health, especially in countries with large disparities in wealth and
economic opportunity. Policy-makers and researchers interested in developing
monitoring systems to examine social inequalities in health need to think carefully
about what are the most appropriate measures of socioeconomic position in their
country or region.
There are a number of other measures that can be used as substitutes for
socioeconomic position in the event that more detailed individual-level variables are
not available. Two of the most commonly used alternatives are geographic area and
individual race/ethnicity. These are discussed in more detail below.
12.5.2
Sources of data on social inequalities in health
In many parts of Europe and North America, routinely collected health data contains
variables that can be used specifically to monitor social inequalities in health.
However the situation in many low and middle income countries may be very
different, as routine population-based health statistics, such as mortality or other vital
registration data, are not always available. When these data are available they are
often incomplete, with information regarding the most marginalized groups such as
rural communities or urban slums - precisely those who are of greatest interest in
understanding social inequalities in health - subject to the greatest missing data.
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There are several options which may be used to help overcome the lack of routine
population-based data. As mentioned previously, population-based surveys may be
conducted at regular intervals to examine trends in health. The best-known such
approach is the Demographic and Health Surveys (DHS), which are described
above. In many countries, the DHS is collected at 5-yearly intervals to assist in
examining trends in population health. DHS routinely collect data on the education
and employment status of individuals within participating households, and DHS
analyses frequently use household asset indices. As a result, DHS are a valuable
resource for describing the social inequalities in health within participating countries.
Because these surveys are repeated at regular intervals, they can also provide an
invaluable source of information on changes in social inequalities in health through
time, including monitoring the impact of policies and programmes to reduce social
inequalities.
While DHS and other such surveys can provide evidence about social inequalities in
health, they do not collect detailed information on cause-specific morbidity and
mortality (which can be difficult to assess retrospectively through questionnaires). In
addition, DHS are designed to collect nationally-representative data, and may not be
ideal for examining local variations in health (such as within a single district or
community). In these instances, health facility statistics represent an important
alternative data source that may be of use in collecting information about social
inequalities. Health facility reporting data can be analysed both to examine the
burden of disease in local populations served by particular facilities, and to compare
geographic patterns in morbidity and mortality between communities. Care must be
taken however as data may be confounded by SES and health-seeking behaviour.
In most countries, geographic location captures critical information regarding
socioeconomic inequalities. Rural communities are often systematically poorer than
cities, and within urban centres wealth and poverty cluster within neighbourhoods.
Because of this spatial patterning in socioeconomic position, policy-makers and
researchers can use information about where different forms of morbidity and
mortality occur within a country or region as a useful proxy to reflect social
inequalities.
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12.5.3
Interpreting data on social inequalities in health
Data on social inequalities in health require careful interpretation, particularly in low
and middle income countries where a wide range of measures of socioeconomic
position may be employed by different studies within a single country. In such cases
it is the responsibility of the policy-maker or researcher to synthesize diverse data on
social inequalities and to interpret the data appropriately (see section 9.1 for more
information on evidence synthesis).
One critical point is that many measures of socioeconomic position are proxy
(substitute) measures, used because the ideal measures are not available. As a
result, policy-makers and researchers must be careful to avoid inferring causal
associations in data that simply describe social inequalities in health. For example, a
hypothetical population survey in a low income country could show that households
with electricity have lower rates of childhood mortality than households without
electricity. Such a finding is useful to describe a social inequity in health, where
electricity within the home is a proxy measure for increased socioeconomic position.
However, the inference that electrification is causally linked to child mortality may not
be correct (depending on the common causes of childhood mortality in that context).
Avoiding causal inferences from descriptive data is particularly important when
interpreting associations between health status or health-related behaviours and
race/ ethnicity. It is common both in routine health statistics and in research to collect
and analyse data according to race/ ethnicity, including measures of nationality
(distinguishing native residents of a country from immigrants). Because
socioeconomic position is commonly patterned along racial/ ethnic lines, such an
approach can provide valuable insights into social inequalities in health. But while
race/ ethnicity are useful proxies for socioeconomic position in describing social
inequalities, causal inferences regarding racial/ ethnic variations in health should be
made with caution. The most appropriate causal interpretation of patterns in health
and disease according to race/ ethnicity focus on the role of discrimination - the
systematic placement of certain groups at a socioeconomic disadvantage - in
shaping health, particularly around access to healthcare services and the protective
benefits of social and economic resources. It is generally incorrect to interpret racial/
ethnic differences in health as being due to innate biological or genetic factors,
except in a handful of specific health conditions.
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12.6
Special issues in high income countries
12.6.1
Sources of health data
Over the last few decades, socioeconomic inequalities in morbidity and mortality
have been recognized as an important public health problem in many high income
countries (NIC). Many of these countries have advanced health information systems
which allow at least some health indicators to be broken down by measures of
socioeconomic status. In each country for which such data are available, it has been
shown that citizens who are disadvantaged in income level, occupational status
and/or educational level are also disadvantaged in self-reported health and length of
life. People from lower socioeconomic groups frequently suffer two or three times
more often from chronic illness, disability or other health problems.
Mortality registries are an important source of data. Especially when a link can be
made between individual death certificates and records of the population censuses,
these registries have few or no serious drawbacks. The main advantages are (a) the
possibility of distinguishing causes of death, (b) the availability of data for most age
groups, (c) the coverage of long time periods, and (d) the ‘hard’ nature of this health
indicator. Unlike many other data sources, mortality registries cannot be biased by,
for example, factors affecting self reports of health (a problem with health surveys) or
factors affecting health care utilization (a problem with facility-based registries).
Despite the advantages of mortality registries, it should be recognized that they
provide no data on socioeconomic inequalities in disease prevalence, disability or
other morbidity indicators. In addition, data on socioeconomic inequalities in mortality
are sometimes not available even in high income countries. Therefore,
complementary sources of data should be utilized. Health interview and similar
surveys are a rich and up-to-date source of information on socioeconomic
inequalities in morbidity. Nationally representative surveys have been held over the
last years in many NIC. Information is available from these surveys on several health
indicators and on most or all core indicators of socioeconomic status. This data
source is therefore recommended for monitoring inequalities in morbidity, even
though this monitoring is complicated by problems such as low statistical validity and
the exclusive use of people’s self-reports on their health.
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In many high income countries, mortality registries and health interview surveys form
the core of a monitoring system for health inequities. Despite their complementary
nature however, they do not cover all relevant dimensions of health. Other sources of
data may be needed when there is a particular interest in monitoring the incidence,
prevalence or survival of specific diseases. In this case data may be used from
disease registers such as for cancer or mental health. The limitations and potential
benefits are likely to vary between data sources and should therefore be evaluated in
detail for each source individually.
A few other data sources may also provide data on socioeconomic inequalities in
health. Examples include hospital discharge registries and health examination
surveys. However facility-based data sources may be biased due to socioeconomic
differences in the tendency to use health care.
12.6.2
Methods of linking health to socioeconomic data
In several high income countries, mortality data can be differentiated by
socioeconomic status through linking to census data. In this approach, persons
enumerated during the census (and classified by educational level or occupational
class) are followed over time to determine their risks of dying. This longitudinal
approach is least subject to bias, because the socioeconomic data on deaths
(denominator) come from the same source as the socioeconomic data on person-
years at risk (numerator). In many countries however this superior approach is not
feasible and another approach has to be followed. In this case socioeconomic
information on death certificates is used to classify the denominator, and
socioeconomic information from the census held close to the period in which the
deaths occurred is used to classify the numerator. This ‘unlinked cross-sectional’
approach is more subject to bias but can provide very useful information, as shown
by its almost century-long application in the Decennial Supplements of Occupational
Mortality in England and Wales.
Many HIC have regular health interview or multi-purpose surveys which collect
population-wide data on health indicators and also on socioeconomic status
indicators such as education, occupation and income. As outlined previously,
measurement and classification of these socioeconomic indicators is far from
straightforward.
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For education, we recommend a distinction between elementary, lower secondary,
upper secondary and tertiary education which is based on the International Standard
Classification of Educations (ISCED) of 1997. This classification is summarized in
table 12.10. Elementary education corresponds to ISCED level 1, lower secondary to
level 2, upper/ post secondary to levels 3 and 4, and tertiary to levels 5 and 6. When
no information is available on the level of education that was completed or attended,
a substitute measure is the number of years that a person attended school. This
figure has the attractive property of being a quantitative measure of socioeconomic
status, but in its most simple form it fails to take into account the type and therefore
the level of education that was attended.
The income level of a person can be used in two ways. Income indicates the
socioeconomic status of the income recipient, with higher personal income indicating,
among other things, a better labour market position. Income can also be used as an
indicator of access to scarce material resources, wealth or standard of living, and in
that case measurement by means of household equivalent income is more
appropriate. This is calculated by (a) adding all income components, (b) subtracting
deductions of tax and social contributions, (c) adding the net incomes of all
household members, and (d) adjusting the total household income for the size of the
household (i.e. the number of household members).
Many methods have been developed to take into account the size and, less often,
the age composition of households. For various countries, standard formulae have
been developed. A simple formula that may be used for international overviews
consists of dividing the household income by the square root of the number of
household members. Income is not a perfect indicator of standard of living. For
example, income measures are inadequate when the emphasis of the research is on
lifetime income or long-term wealth. In these cases, other indicators may be more
appropriate. Indicators of house ownership or tenure may be considered in these
cases.
It may finally be noted that, when the household equivalent income of each individual
is assessed, an instrument is available to identify the poor as those who have an
income below the poverty line. Poverty lines can be established in various ways, and
each country has its own lines. A common approach that can easily be used in
international overviews is to define poverty in purely relative terms, that is, in relation
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to the income level of other persons living in the same country. A frequently used
poverty line in advanced systems is 50 percent of the nation’s median income.
Table 12.10 An educational classification based on the International Standard
Classification of Education (ISCED) 1997
ISCED Level
1
2
Primary
education, or
first stage of
basic education
Lower
secondary
education, or
second stage of
basic education
3
(Upper)
secondary
education
4
Post-secondary
non-tertiary
education
5
First stage of
tertiary
education
6
Second stage of
tertiary
education
Main characteristics of educational level
• Entry at the start of compulsory education (where it exists)
• beginning of systematic study of reading, writing and mathematics
• corresponds to first 6 years of ‘basic education’ (where it exists)
• also includes literacy programmes for those too old to enter
elementary school.___________________________________
• Entry after some 6 years of primary education
• full implementation of basic skills, and foundation for lifelong
learning
• several teachers conduct classes in their field of specialization
• end corresponds to the end of compulsory education (where it
exists)
• also includes remedial, special or adult education similar in content.
• Minimum entrance requirements (usually completion of level 2)
• includes both programmes designed to provide access to tertiary
education and programmes designed to lead directly to labour
market
• more specialization than at level 2
• teachers need to be more qualified or specialized than at level 2
• also includes special or adult education similar in content________
• Admittance requires as a rule completion of level 3
• typically, programmes aim to prepare students for studies at level 5,
by broadening the knowledge of those who completed level 3
• more specialization and more complex applications than at level 3
• a typical full-time duration of between 6 months and 2 years
• also includes adult education such as courses during professional
life.___________________________________
• Admittance requires as a rule completion of level 3 or 4
• programmes have a cumulative theoretical duration of at least 2
years
• programmes are theoretically based, research preparatory or give
access to professions with high skill requirements
• completion corresponds to Bachelor’s degree (English speaking
countries), ‘Diplom’ (German) or the Licence (French)
• also includes adult education similar in content.
• Leads to the award of an advanced research qualification
• programmes require the submission of a thesis or other product of
original research.
Source: Kunst et al., 2001 (Table constructed by the authors on the basis of UNESCO, 1997).
There are several ways to classify people by occupation. The main approach in many
European countries is the ‘class structural' approach. In this approach, distinctions
are made between people who have structurally different positions in the labour
market and who, as a result, differ in terms of income, privileges, lifestyles and
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characteristics like voting behaviour. The resulting groups of people are usually
referred to as ‘occupational classes’ or ‘social classes’. One internationally used
class scheme is the EGP (Erikson, Goldthorpe and Portocarero) scheme (see table
12.11).
Table 12.11 An example of a social classification based on occupational information:
the EGP social class scheme
Examples of occupational titles
that are usually assigned to these classes
Occupational class
I
Upper-grade professionals,
administrators and managers;
large employers
II
Lower-grade professionals,
administrators and managers
III
Routine non-manual employees,
sales personnel, service workers
IVa
Self-employed and artisans
(with employees)_________
Self-employed and artisans
(without employees)______
Self-employed farmers and
fishermen
physician
architect
judge, lawyer
university professor
newspaper editor *
head of firm *
insurance agent *
primary teacher
bookkeeper *
salesman *
ticket seller
computer operator
shop owner
automobile dealer
hotel operator
village head
high civil servant
head of large firm
banker
nurse
system analyst
journalist
designer_________
office clerk
receptionist
sales clerk
waiter___________
market vendor
pub keeper
independent artisan
farmer
farm foremen
family farm worker
specialized farmer
V
Lower-grade technicians, foremen
foreman
supervisor
VI
Skilled manual workers
Vila
Semi- and unskilled manual
workers
Vllb
Agricultural workers
cook
miner
butcher
cabinet maker______
mail carrier
nursemaid
watchman
assembly line worker
field crop worker
milker
tractor driver
aircraft worker
goldsmith
printer
carpenter_____
cigarette maker
glazier
driver
porter________
forester
fisherman
hunter
IVb
IVc
★★
★★★
****
*★
★★★
Promoted to occupational class I if more than 10 subordinates
Also includes self-employed persons whose occupations are classified under class II, III,
V, VI or Vila.
Also includes self-employed persons whose occupations are classified under class Vllb
★***
Workers in class VI are promoted to occupational class V if they have more than 10
subordinates.
Source: Kunst et al., 2001 (Table constructed by the authors on the basis of Erikson &
Goldthorpe (1992) and Ganzeboom et al. (1989))
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Y2.7
Improvements in monitoring systems
Low- and middle-income countries urgently need to collect information on the key
equity stratifiers examined above, and in a consistent manner within the country so
that data are comparable. This requires programmes oriented towards improving the
production, dissemination and utilization in policy-making of vital and health statistics.
The aim should be to support countries to improve (a) coverage (including
representation of diverse groups and non registration); (b) quality (consistency,
sampling and estimation methods and statistical techniques); (c) timeliness; (d)
frequency; (e) geographical disaggregation; (f) stratifiers collected: and
(g) accessibility of micro databases.
Although many international agencies have developed data collection instruments as
well as databases on which most LMIC are highly dependent, there is a need for
(a) better coordination among them; (b) greater standardization of definitions,
indicators and sources, between countries and agencies as well as among the
different agencies; and (c) increasing incorporation of social determinants of health
and equity dimensions in these databases.
In middle and high income countries it would be useful if health monitoring systems
could permit a first exploration of the factors and circumstances which contribute to
health inequities. This is a challenge even for high income countries because it
requires a comprehensiveness of data collection systems which is hard to achieve.
We propose the development of ‘multilevel surveillance systems’ of health inequities
which routinely collect information on social determinants, health outcomes and
relevant health determinants in a coherent fashion. The term ‘multilevel’ refers to the
‘layered’ nature of health determinants: social determinants may influence specific
environmental exposures, which may influence behavioural factors or psychosocial
conditions, which may influence biological risk factors, which may ultimately have an
impact on health.
Although such multilevel surveillance systems do not yet exist, there are a number of
recent experiences from which one can learn, including:
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•
WHO’s Global Burden of Disease Study and its sequel, the Comparative
Risk Assessment Study, which have identified, collected and analysed
information on the main health determinants world-wide
•
The Australian Obesity Sentinel Site Surveillance System, which is a
multilevel surveillance system on obesity including information on a wide
range of determinants of obesity on which information is collected on a
regular basis
•
A government advisory committee in the Netherlands that has proposed a
set of quantitative targets for tackling health inequities (e.g. targets on
disparities in income, working conditions, smoking, health care utilization).
These targets have been used for the development of a monitoring
system which covers social determinants, health outcomes and relevant
health determinants (see case study 21 for more details).
In the development of a multilevel surveillance system for monitoring health
inequities a number of steps can be distinguished:
1. Identification of health determinants which should be included in the
monitoring system (in addition to socioeconomic status indicators and
health outcomes)
2. Specification of the data which are necessary to measure these health
determinants (e.g. operational definitions, data collection modes,
classification by socioeconomic status)
3. Identification of sources of population prevalence data (e.g. health or
multipurpose surveys), and final selection of indicators
4. Development of analytical approaches which help to link health
determinants information to information on socioeconomic inequalities in
health (e.g. ecological comparisons, mathematical and simulation
modelling)
5. Testing a pilot system for its usefulness to inform policy-makers.
The Netherlands is developing such an approach, which is outlined in case study 21.
12.8
Illustrative case studies
The following illustrative case studies give examples of monitoring:
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Constructing the evidence base on the social determinants of health: A guide
No. 3 - Bolivia: Evaluation of Social Investment Fund
No. 6 - Mexico: Reform of national health system
No. 7 - Thailand: Introduction of universal health coverage
No. 11 - Uganda: Community-based monitoring
No. 17 - Mexico: Oportunidades programme
No. 18 - Sweden: Intersectoral action
No. 20 - Kenya: Grassroots monitoring
No. 21 - The Netherlands: Multi-level surveillance system.
12.9
Related reading
Baker M G, Fidler D (2006), ‘Global public health surveillance under new
international health regulations’, Emerging Infectious Diseases Journal, US Centers
for Disease Control and Prevention, Volume 12, Number 7 —July 2006, Available
from http://www.cdc.gov/ncidod/EID/vol12no07/05-1497.htm
Blakely T, Hales S, Kieft Ch, Wilson N, and Woodward A (2005), “The global
distribution of risk factors by poverty level”. Bulletin of the World Health Organization
2005;83(2):118-126.
Blakely T, Hales S, Kieft C, Woodward A (2004), “Poverty. Assessing the distribution
of health risks by socioeconomic position at national and local levels”. Environmental
Burden of Disease 2004; Series N°10:1-32. Geneva: World Health Organization.
Blaxter M. A comparison of measures of inequality in morbidity. Health Inequalities in
European Countries 1989; 199-230.
Braveman P (2003), “Monitoring equity in health and healthcare; a conceptual
framework”. J Health Popul Nutr 2003/21 (3): 181 -192.
Carr-Hill R (1990), “The measurement of inequities in health: Lessons from the
British experience” Social Science & Medicine 1990;31(3):393-404
Dachs NS (2002), “Using household surveys and other information sources to study
equity in Latin American and the Caribbean”. Rev Panam Salud Publica/Pan Am J
Public Health 2002;11 (5-6):413-417
Fotso J and Kuate-Defo B (2005), “Measuring socioeconomic status in health
research in developing countries: should we be focusing on households,
communities or both”. Social Indicators Research 2005;72(2):189-237.
Gakidou E, Murray C, Frenk J (2000), ’’Defining and measuring health inequality: an
approach based on the distribution of health expectancy”, Bulletin of the World
Health Organization 2000;78(1):42-54.
Gerdtham U, Johannesson M, Lundberg L, Isacson D (1999), “A note on validating
Wagstaff and van Doorslaer's health measure in the analysis of inequalities in
health”. Journal of Health Economics 1999;18:117-124.
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Constructing the evidence base on the social determinants of health: A guide
Grafni A and Birch S (1991), “ Equity considerations in utility-based measures of
health outcomes in economic appraisals: An adjustment algorithm”. Journal of Health
Economics 1991;10(3):329-342
lllsey R and Le Grand J (1987), “The measurement of inequality in health”. In:
Williams A (ed.). Economics and Health. London: Macmillan 1987:12-36.
Krieger N, Williams D, Moss N (1997), “Measuring social class in us public health
research: concepts, methodologies and guidelines”. Annu. Rev. Public Health 1997;
18:341-78.
Kunst A, Groenhof F, Mackenbach J (1998), “Occupational class and cause specific
mortality in middle aged men in 11 European countries: comparison of population
based studies”. British Medical Journal 1998;316:1636-1641.
Kunst A and Mackenbach J (1994), “Measuring socio-economic inequalities in
health”. World Health Organization Regional Office for Europe Copenhagen 1994:1117.
Lindelow M (2002), “Sometimes more equal than others. How the choice of welfare
indicator can affect the measurement of health inequalities and the incidence of
public spending”. CSAE WPS/2002-15.
Lindholm L and Rosen M (1998), “On the measurement of the nation's equity
adjusted health”. Health Econ. 1998;7:621-628
Macintyre S, Eliaway A, Cummins S (2002), “Place effects on health: how can we
conceptualise,operationalise and measure them?”, Social Science & Medicine 55
(2002) 125-139
Mackenbach J and Kunst A (1997), “Measuring the magnitude of socio-economic
inequalities in health: An overview of available measures illustrated with two
examples from Europe”. Social Science & Medicine 1997;44(6):757-771.
Murray C, Gakidou E, Frenk J (1999), “Health inequalities and social group
differences: what should we measure?” Bulletin of the World Health Organization
1999;77(7):537-543.
Muurinen JM and Le Grand J (1985), “The economic analysis of inequalities in
health”. Social Science & Medicine 1985;20(10):1029-1035.
Najman J (1988), “The measurement of socioeconomic inequality and social class in
Australia: A review of past practices and recent developments”. Community Health
Studies 1988;7(1):31-41.
Scanlan J (2006), ‘Can we actually measure health disparities?’ Chance
2006:19(2):47-51. Available from :
http://www.ipscanlan.com/imaqes/Can We Actually Measure Health Disparities.pd
f
Valkonen T (1993), “.Problems in the measurement and international comparisons of
socio-economic differences in mortality”. Social Science & Medicine 1993;36(4):409418.
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Ver Ploeg M and Perrin E (2004). Eliminating health disparities: Measurement and
data needs. Washington DC: National Academies Press
Wagstaff A, Paci P, Van Doorslaer E (1991), “On the measurement of inequalities in
health”. Social Science and Medicine 1991;33:545-557.
Wagstaff A., Paci P and Van Doorslaer E. On the measurement of inequalities in
health. British Medical Journal 1991;33(5):545-557.
Waters E, Goldfel S and Hopkins S (2002), The 'Best Start' Indicators Project State
of Victoria. Department of Human Services 2002.
Watkins F, Bendel N, Scott-Samuel A and Whitehead M (2002), “Through a glass
darkly: what should public health observatories be observing?” Journal of Public
Health Medicine 2002;24(3):160-164.
Williams R and Doessel D (2006), “Measuring inequality: tools and an illustration”,
International Journal for Equity in Health 2006, 5:5 doi: 10.1186/1475-9276-5-5 May 22, 2006. Available online at: http://www.equitvhealthi.eom/content/5/1/5
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13
Further issues for consideration
This chapter considers some of the issues and technical matters that remain at the
end of the programme of work of the MEKN. While the MEKN carried out its work,
some new issues emerged. In this chapter some of the questions and the future
directions for research and investigation are highlighted.
13.1
Attribution of effects and outcomes
Much has been written in this guide about the causes of health inequities and the
manner in which the social determinants lead directly to health outcomes. There is
another important sense in which cause or attribution is significant. It is linked to, but
is conceptually separate from, the way in which the social determinants’ causal
pathways operate. This is the relation between the intervention, the action or the
policy on the one hand, and the outcome on the other. It is linked to the causal
pathways of the social determinants because an accurate understanding of the
proximal and distal causes of health inequity will in due course demonstrate the links
between the social and the biological.
The critical problem is that in much of the social determinants approach to policy and
interventions, the causal chain is assumed to exist rather than being demonstrated.
Whether it is the assumption that particular policies will have particular outcomes or
that specific interventions will have demonstrable consequences, the link between
the two is assumed to exist, to be self evident or to be a given. Such assumptions are
dangerous because so much of the detail of the causal pathway is unaccounted for.
There are two important contributions which help to articulate these relationships,
both of which originated in the attempt to understand better the process and methods
of evaluating complex interventions, particularly community interventions. These are
the work of Weiss (1995) and Pawson (2006). Weiss (1995) contributed the idea of
theories of change and Pawson (2006) developed the idea of programme theory. At
the heart of both authors’ arguments is the exhortation to be as explicit as possible
about the way actions/ interventions/ activities/ engagement are thought to work. In
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both cases this is what they mean by theory. The theory helps to develop a logic
model or causal pathway between the action and the outcome.
In order to demonstrate this argument we distinguish here between four different
types of theory to help expose these underlying mechanisms: general theories,
theories of change, micro theories or programme theories, and tacit knowledge
theories.
13.1.1
General theories
First there are general theories about the nature of human behaviour and society
which provide broad explanatory principles about humans and their relationship with
society. Disciplines such as sociology, psychology, economics and philosophy all
provide different and competing examples of this type of theory. Such theories are
often highly formal; they may or may not be testable; but they provide broad
epistemological, ontological and often methodological frameworks for organizing
knowledge, actions and learning, and for producing and understanding data and
evidence. Well known examples of such theories are the maximization of utility in
economics, functionalism in sociology, and the transtheoretical model in psychology.
They also include such diverse theories as psychoanalysis, Marxism, positivism, post
modernism, Catholicism, Aristotelian ethics and so on.
13.1.2
Theories of change
Second, and often explicitly or implicitly derived from the first type of theory, are
theories about how a particular action or activity works. These are often causal type
ideas, assumptions or beliefs, in which one set of actions is linked to a set of
outcomes. An example would be: ‘If we introduce a local food cooperative scheme in
a disadvantaged community, it will lead people to eat more healthily’. Another
example would be: ‘If we develop local credit unions for disadvantaged female
workers in particular developing countries, they will enjoy a greater degree of self
determination and this will lead to their greater empowerment which in turn will have
beneficial health effects’. These types of theories are sometimes explicitly used in
helping to frame the objectives of interventions (e.g. ‘To improve dietary outcomes by
introducing a food cooperative’). This type of theory is sometimes, although not
invariably, referred to in the literature on complex community interventions as ‘a
theory of change* (Weiss, 1995). Weiss and others make the point that many
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interventions do not make clear to themselves or others what their theory of change
is, and consequently evaluation of the intervention is difficult. Weiss therefore
recommends making the objectives of an intervention crystal clear, being precise
about the link between actions and outcomes, and making the theoretical link
between them completely explicit. A theory of change is therefore a statement that
describes a direct causal link between an action and an outcome and the reason why
that link should exist.
However the last element - why there should be a link - is often either missed out or
assumed to be self evident. The proponents of the food cooperative might be
drawing on economic ideas of supply and demand by believing that if healthy food is
cheap and easily accessible, people will consume it and benefit from that
consumption. The problem is that neither do they make that theoretical link clear nor
do they consider the complications in the link that they assume exists.
Proponents of the theory of change approach suggest that in complex community
interventions, objectives should define what the action or intervention consisted of,
what its intended measurable outcome was, and what the causal link between the
two was. If articulated a priori such theories provide the basis for planning
interventions and their evaluations. A key problem is often that because theories of
change have not been made explicit at the outset of interventions it is difficult to tell
retrospectively whether or not they have been successful, and if they have not, why
not.
13.1.3
Micro theories or programme theories
To work properly for evaluation or planning purposes, the causal link must be
explored. This is where the third type of theory comes in. For convenience these will
be referred to as micro theories or programme theories. These are the atoms in the
causal chains describing how the different elements in an intervention relate to one
another. Theories of change define the causal link between action and outcome.
Micro theories or programme theories unpick the link still further.
Rawson (2006) makes the point that all interventions, policies or actions are theories.
He argues that as well as being collections of people, resources and equipment,
interventions are conjectures or hypotheses which state that ‘if we deliver a
programme in this way, or we manage services in that way, then it will bring about an
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improved outcome’. In this sense it is similar to a theory of change. Such conjectures
are grounded in assumptions (theories) about what happens and why, and perhaps
suggested remedies to the social arrangements into which the intervention was
originally placed. However in programme theory there is another step. This can be
illustrated by the food cooperative example above.
In the case of the food cooperative and healthy eating in the community, the
programme theory would begin with a series of statements. For example:
•
The best setting for the cooperative is a traditional shop
•
The shop should resemble commercial retail outlets and not charity
provision
•
Its range of goods should be displayed attractively.
•
People will come to the store in preference to their normal way of buying
groceries.
•
The consumers will know what to buy.
•
The consumers will know how to prepare the food that they buy.
•
The people for whom the food is prepared will want to eat the new diet
rather than their habitual one.
•
There will be a sufficient change in the nutritional status as a
consequence to produce beneficial health effects.
Each of these statements must be accompanied by the word ‘because’ in order to
expose the programme theory. Taking the statement ‘People will come to the store in
preference to their normal way of buying groceries’, there is a series of micro theories
in answer to the ‘because’ question: ‘because they will prefer it’, ‘because they will
recognize the potential benefits’, ‘because they will find it attractive’, ‘because it is
accessible’, etc.
In turn each of these statements will have counter reasons why the opposite may be
true and the project may not work in the way intended. Thus ‘People will not come to
the shop’... ‘because they prefer to buy food from the mobile shop which comes to
the front door, is more accessible, offers credit, and sells contraband tobacco and
illegal drugs’.
The aim of the micro theory is both to lay bare the elements in the process and to
help identify the counter arguments in a systematic way. In the programme theory
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one of the critical steps is identifying the mechanisms which are intended to have
effects. Mechanisms are the engines of explanation. So we seek to understand the
mechanisms which supposedly work and ask how they work.
Mechanisms are not universal in their effects. They work under certain conditions or
contexts. A key research and development objective is to describe these conditions
in detail. There are a range of contexts - pre-existing, concurrent and future - which
will affect the mechanisms. Contexts determine and constrain the choices and
opportunities of the people who are the subject of the activity and of the people
implementing it. Knowing how things work involves tracing the limits of when and
where they work. Causal connections are established via three things: context,
mechanisms, and outcomes - or, put more simply, what works for whom and under
what circumstances? (Pawson, 2006)
Programme theories outline the implicit theoretical ideas about the relationships
between things which are usually tacit and taken for granted. Interventions carry
many theories. The success of an intervention depends on the cumulative success of
entire sequences of theories. This is the implementation chain. Most implementation
chains are non linear. This is because along the chain, individual actors reason in
various ways, which makes the change happen. Human volition is touched by the
intervention and through interpretive processes the changes occur. Many actors will
be involved in any one intervention chain, each bringing their own understandings
and interpretations to the situation. Interventions are embedded in complex social
systems. There are several layers of influence - individual capacities, interpersonal
relationships, institutional settings and the wider infrastructural setting. Interventions
will also change the context and in turn will be affected by the changing context
(Pawson, 2006).
13.1.4
Tacit knowledge theories
The people involved in an intervention may or may not be fully aware of the theories
which govern their actions and the expectations they have of the outcomes. This
brings us to the final type of theory. These are the theories or ideas in the heads of
those involved in commissioning, delivering and receiving interventions - sometimes
called tacit knowledge. These usually come in the form of taken for granted
assumptions about the world, which all human beings have in their minds. This is the
territory that social constructionists, phenomenologists, ethnomethodologists and
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grounded theorist practitioners have conventionally been most interested in. Clearly
these link to micro and programme theories, not least because the micro links often
involve trying to determine what is in the mind’s eye of the actors and anticipating
their actions. A phenomenological or grounded theory type of approach would
provide an understanding of these things, and would be better than guessing, but
would be largely meaningless without the theoretical architecture of the other three
types of theory. However in practical terms these theoretical ideas are likely to be
highly varied across all the actors involved.
13.1.5
Priorities for action
It is important to note that these four types of theory are not discrete and distinct.
They merge and overlap and influence each other. An urgent research and
development priority is to get much better at articulating and describing these
theories as they apply to the social determinants. The whole enterprise of arresting
the negative effects of the social determinants of health depends on being able to do
so.
In summary it is important to specify three things with respect to any intervention,
action or policy. First, be as specific as possible about its content in its application on
the ground. Second, clarify what is to be done, to whom, in what social and economic
context, and in what way. Third, articulate the underlying theories which make explicit
the assumed causal links between actions and outcomes (Davidson et al., 2003;
Rawson, 2006; Weiss, 1995). It is very important to be clear about the behaviours
that need to be changed, any relevant contextual changes that need to be made, and
the level at which the intervention will be delivered (individual, community or
population) (NICE, 2007).
In other words it is important to specify the ways in which things are supposed to
work. The logic model or causal pathway is invaluable and is an urgent requirement
for future research and development to underpin the social determinants approach.
As Rawson argues, once such pathways are specified and once such theories are
drawn up, it becomes possible to develop a better understanding of the mechanisms
which make interventions and policies successful or otherwise. It is all too easy to
focus on the characteristics of the population or the characteristics of the intervention
in seeking to understand why it works or the degree to which it is more or less
effective. However, the critical path through which an intervention is implemented is
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as much a part of the equation as the population and the intervention itself. The
configuration of delivery mechanisms, the actions of the individuals who work in
these organisations, and the ways both interact with each other and with the target
populations are absolutely critical. The tacit knowledge of such actors influences the
causal chain. An urgent research and evaluation priority is to articulate these causal
chains in more and precise detail. It is all too easy to blame global capital or distant
shadowy forces as responsible for the general state of inequity which, as we have
said, remains stubbornly resistant to change. Yet the actions of health economies of
different jurisdictions are in the hands of actors who can change them. For various
institutional reasons, systems remain as much a part of the problem as they are
potentially part of the solution.
13.2
The challenge of policy
In chapter 5 above we have outlined the problems attaching to the policy process
and to some extent that chapter prefigures the arguments in the previous section
here. Too often policy is detached from detailed understanding of its implementation
and of the issues we have just argued are significant for understanding attribution. In
addition to that there is another important question: to what degree is there
something specific to health policy and consequently to the social determinants of
health beyond the general issues described in chapter 5?
There are several points. First, health policy is often policy about provision of acute
and chronic care, rather than about prevention and about health improvement.
Second, health equity is affected by a great deal more than policies on the provision
of acute and chronic medical care, although inequity within provision of services is
important. The vexing issue is how to bring these other dimensions of health into the
policy arena and particularly how to get the finance and economic ministries involved.
It is usually difficult because, with some notable exceptions often grounded in very
particular historical circumstances, finance and economic ministries have as their
imperatives very different goals to that of a typical health ministry. They may be still
more distant from concerns about disease prevention and health improvement, let
alone the question of health equity.
Almost all policy initiatives across all levels of government will have health
consequences. Health impact assessment allows some degree of assessing this. We
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strongly argue for the development and use of health impact and equity impact tools
which specifically and explicitly use the stages of change approach and the realistic
evaluation approach outlined elsewhere in this guide. In other words, rather than
simply estimating the likely effect of policy, logic models showing the implementation
chain falling out of policy are urgently required as the basis for health impact and
health equity assessments.
13.3
Hierarchies of evidence
One of the key questions which is left incomplete at the end of this project is how to
use hierarchies of evidence. The idea of a single hierarchy of evidence is a powerful
one. To recap, it is based on the straightforward premise that only the best evidence
should be used to determine whether a clinical intervention is effective. At the top of
the hierarchy sit meta analysis of randomized controlled trials, systematic reviews of
the randomized controlled trials and randomized controlled trials themselves. Then in
descending order come non randomized trials, case control studies, cohort studies,
controlled before and after studies, interrupted time series studies and correlation
studies. Non analytic studies, expert opinion and formal consensus are at the bottom.
There is no place for qualitative or theoretical evidence in such a hierarchy. The
principle is that the further up the hierarchy, the greater the chance of eliminating
bias. The focus on bias relates to the internal validity of the evidence, meaning the
degree of certainty about the evidence presented and conclusions drawn from it. The
principle is a sound one where the question is one of clinical effectiveness. The
development of this method as a way of determining the efficacy and the
effectiveness of clinical interventions has been an important milestone in the
foundation and development of evidence based medicine.
The issue at the heart of this guide however is that in public health and in the social
determinants of health the clinical trial is seldom either available or appropriate. As
this guide has shown, the range of evidence that needs to be considered is extensive
and the questions that the research has sought to answer are much broader than just
those of clinical effectiveness. We have argued that taking an evidence based
approach does not mean relying on, or privileging, only one kind of method, such as
the randomized trial, it does not mean that there is only one hierarchy of evidence,
and it does not mean an epistemological commitment to objectivity above subjective
positions or methods.
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We have argued for multiple methods, diverse epistemologies and a broad church of
data. We have argued for methodological diversity. We have argued that no single
approach to the generation of evidence or data is to be favoured over others.
Evidence should not be appraised and evaluated on the basis of adherence to a
single evidence hierarchy in which a particular method is given priority. Appraisal of
evidence should be on the basis of whether the research method used is appropriate
for the research question being asked and the knowledge being collected, and the
extent to which in terms of its own methodological canon it is considered to be well
executed.
There do not presently exist agreed hierarchies for dealing with the full range of
evidence. Because of this we have used the term ‘fitness for purpose’. This
encapsulates a number of different ideas. We are not in a position at the moment to
point to a hierarchy of evidence for qualitative studies, for theoretical evidence, or for
the many other types of evidence that we argue are potentially admissible. We
believe that the development of such hierarchies is an urgent methodological priority.
Even an organization such as the National Institute for Health and Clinical Excellence
in England, which has made a commitment to taking a very broad approach to the
evidence in its public health work, does not have a complete set of procedures to
deal with all the possible evidence types.
Fitness for purpose therefore means determining the answer to several questions.
First, has the research question been spelled out clearly, or if not, has a hypothesis
been specified or the relationship between two variables clarified? Second, is the
chosen method going to answer the question? Is the tool the right one for the task in
hand? This is vital. So often, research methods are chosen by researchers on the
basis of philosophical predilection rather than fitness for purpose. Third, the appraiser
of the evidence needs to turn their mind to the idea of the fatal flaw. In a randomized
controlled trial for example, if the researchers and the subjects were not blind to the
random allocation and if an intention to treat analysis had not been carried out, one
would have serious concerns about the level of bias that might creep into the results.
The absence of random allocation and intention to treat are fatal flaws in design. It is
difficult to be as prescriptive with other forms of evidence, but in determining fitness
for purpose the appraiser should consider what sort of flaw would lead one to
seriously doubt the reliability of the data and to assume that the strong possibility of
bias should be considered. In a qualitative investigation if the author does not report
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how the respondents were recruited, how they were chosen as informants and how
the particular extracts of the conversations with key informants were selected and on
what grounds, we would have good reason to suppose that the possibility of bias was
high. These would constitute fatal flaws. In an economic model if the parameters
were not known because they were not reported, and thus no sensitivity analysis
could be undertaken, this would constitute a fatal flaw.
13.4
Equity: relative or absolute?
Equity is a political concept and it is used in various ways by a variety of protagonists
to justify and rationalize different political positions. It is also a scientific concept. One
of the vexatious elements of the question of equity concerns absolute and relative
differences between groups and individuals. It is frequently misused politically in this
regard.
We have rehearsed the argument at length in the text and have argued for the use of
both absolute and relative measures of equity. This is important because using one
or the other measure alone can be misleading. When the focus is on the whole
health gradient of the population following an intervention, we might see overall
improvement for the whole population group. In high income countries it is also quite
likely that in such circumstances we will see the uppermost groups improving more
quickly than the rest. The result is that the health inequities measured in relative
terms are getting worse because those at the bottom of the gradient are not
improving at as fast a rate as those at the top. However in absolute terms those at
the bottom may be better off that they were previously and may therefore show
absolute improvement. It could be argued that the issue of equity is less relevant
than the argument in favour of overall improvement. In the case of extreme
disparities this is compelling. Our view is that iMs important to use both sets of
measures in order to reflect the range of societies involved, the variations across and
within societies, and the differential effects of interventions across populations.
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13.5
Where further research and development is required
At the end of this project we know what we do not know more clearly than we did at
the beginning. There are several important areas where more detailed work is
required. The tools to measure the impact of the social determinants based on the
appropriate causal pathway need to be developed. Given the complexities of the
causal pathways from determinants to health outcomes, the best and most sensitive
measures of such outcomes need further attention. Standard epidemiological
measures of mortality and morbidity are clearly a starting point, but robust measures
of quality of life across cultures, of well-being, of social cohesion, of community
integration and of social capital for example require detailed further work. In some of
these areas there are considerable literatures, but the linkages back up the causal
chain to the social determinants and down the chain to specific health indicators
remain a considerable research and development task. Every effort should be made
to support and fund such important developmental work.
We have laid strong emphasis on equity proofing in this guide. But we must
acknowledge that this tool is still in its infancy, compared to what we know about
technologies like the randomized trial. Again there are areas of considerable
development and expertise here but it is still early days. These are very important
tools and once again we would encourage development and support in these areas.
The linkage of equity proofing to questions of absolute and relative equity referred to
above also requires close attention.
Another important area of work which we signaled in the text is the cross cultural
research comparisons between different country and cultural contexts. The health
gradient is made up of two axes, the actual health disparities and the degree of social
inequality in society. Social inequity is itself made up of a number of sub-axes related
to gender, ethnicity, disability, geography, caste, and social class for example. A
programme of research is urgently required to explore the degree to which these
axes of social differentiation overlap, interact and cluster together, and the impact of
these on heath disparities cross culturally.
Another important area for further work is on the synthesis of evidence across the
different research traditions. The multiple potential hierarchies of evidence and the
threshold judgements which may be used to consider them will in time give rise to
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bodies of evidence which will require evidence syntheses. Once again this is an area
where much useful work is already in train. But in scientific terms it is early days -
although we have drawn in this guide on some of the leading work on the synthesis
of data and evidence, there is still quite a long way to go. The Cochrane and the
Campbell Collaborations have moved some things on within part of the evidence
base. But the requirement remains to synthesize theoretical evidence, models and
qualitative and quantitative information.
In the final analysis the guide leaves open detailed questions about the methods and
tools for measuring causes and pathways and linking the material together. This
constitutes a research agenda of its own which should be able to build upon the work
undertaken here and provide future generations of scholars with the tools they will
need to finish the job.
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14
Conclusion
The fact that there are health differences across all societies is a given. There are
enormous amounts of data which show this. The mechanisms of the social
determinants operate in all societies. The conclusion of this guide explores the ways
in which these mechanisms may operate and describe a general causal pathway.
Finally we finish with a plea for action rather than inaction in the face of the
complexity of dealing with the mechanisms of the social determinants.
14.1
Social structure and the operation of the
determinants of health inequities
It is important to conceptualize the issue of health inequities, at least initially, beyond
the immediate context (although as noted previously, context is highly important in
political and policy terms). Much of the data about inequities is country or locality/
region specific. This is not in itself a bad thing, but the question this immediately
raises concerns the transferability of the findings from one context to another and the
transferability of the concepts which describe inequities. This is not simply the
standard question about external validity (whether that which has been observed
under controlled circumstances still applies without strict scientific control). Neither is
the concern with whether replication is possible, although both of these issues are
important for other reasons. What makes the question of transferability still more
problematic is the degree to which the cultural context has generated the conceptual
framework which defines the social structure and in turn the tools to measure
inequity. To what extent does the way that the research questions were initially
posed, as well as the way findings are interpreted, influence what is known?
This is well demonstrated by the overall Eurocentric approach to the question of
inequity. There is a large western European literature on health inequities and to a
lesser extent from the United States, Canada, Australia and New Zealand. This
literature reflects the concerns and preoccupations of those societies. Whether and
the degree to which these preoccupations have broader applicability is an empirical
question and the degree to which they should be the starting point for an analysis of
the social determinants or merely a contribution to it is uncertain at this time, and will
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only be resolved as further research is undertaken in different societies and the
conceptual and methodological frameworks evolve. This subject is outlined in more
detail in section 1.1.4.
So there are a number of conceptual issues requiring further work both to map the
social differences and to link that map to better conceptualizations of social structure.
This in turn would permit a better and more precise analysis of the causal pathways.
There is also a range of linked unresolved empirical and theoretical issues. Even
within the Eurocentric approaches, the evidence relating to reductions in inequalities
is actually very thin. While there is a huge literature describing the problem of
inequity, the proportion of published papers about interventions to reduce inequalities
is much more limited, other than in very general terms (Millward et al 2003a; Kelly
2006a). Even if the empirical grounding of this material were more secure, there is
little agreement either a priori or post hoc as to what changes in inequalities would be
regarded as a success, or what sizes of interventions would be regarded as
desirable. In high income countries the extent of change which represents a
significant enough difference remains largely under explored in the literature. In turn
this means that identifying ‘what works’ is a problem because the meaning of ‘works’
tends to be assumed rather than defined. More troubling still is that even within a
high income country context the conceptual apparatus to describe inequalities in
health is limited. The conceptual basis for most of the data is a measure of
occupation and or socioeconomic status. The more discrete dimensions of social
difference like ethnicity, gender, disability, place, age and geography, while never
explicitly denied as important, as noted above are under developed empirically and
theoretically. Consequently the relationships between the different dimensions of
inequality, and the ways they interact with each other to produce health effects, is
hardly to be found in the extant evidence at all (Graham & Kelly, 2004). As we have
argued, this is vitally important because, as shown above, different segments of the
population respond differently to identical interventions. The differential response to
smoking education among different social classes is a case in point.
It seems clear from the data that the social variation in the population is considerable
and the existing measures of socioeconomic status do not adequately capture these
variegations in the population. A related point is that there is a dearth of studies at
topic level where inequity and measures of inequity are part of the research
questions. Thus evidence about inequalities remains strongest at aggregate
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population mortality level, and much more diffuse at the level of individual topics like
HIV or accidental injury. The epidemiological data clearly show the social class
gradient in many topics, but the researchers seldom address inequities perse
(Killoran & Kelly, 2004).
These perhaps surprising gaps exist for several reasons. Sometimes particular
groups have not been studied, so for example there is very little review level research
on the sexual behaviour of young heterosexual men and its impact on rates of
teenage fertility in Britain. Sometimes the research questions simply sidestep the
issue - there is little work in the UK on social exclusion and the transmission of HIV/
AIDS for example. In some cases particular disciplinary input appears to be absent.
So there is very little evidence about cost effectiveness of interventions more or less
universally. In general the evidence base is much stronger with respect to
downstream than upstream interventions (Kelly, 2006a).
From a methodological point of view, even within the Eurocentric paradigm very few
studies reach an ideal gold standard. This observation is not just the very obvious
and commonplace one that inevitably there will always be practical, resource and
other real world difficulties in conducting research, and that these will reflect
themselves in the way that final results are presented. Nor is the point that bias is an
inevitable part of the scientific endeavour. The observation is more fundamental than
that. The nature of scientific research designs means that critical variables, of vital
interest to practice, are frequently excluded from consideration. In the interest of
increasing the degree of certainty that the observed relationships between two
variables are real, a range of other potential confounding factors are controlled out of
the analysis. To some extent all science inevitably involves abstraction from the
complexities of messy reality in order to make sense of phenomena and the
relationships between them. However in public health this means that the search for
scientific purity, particularly as the evidence hierarchy is ascended, is traded off
against the loss of two sorts of important information. The first is process data, i.e.
material relating to the practical problems associated with doing the research, or of
doing the intervention upon which the research is based, or both. This may well
include all sorts of material relating to the actions, motives and behaviours of people,
including the investigators as well as the subjects who are involved in the study. The
second missing data relate to the mediating effects of variables like the local context
and circumstances.
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In high income societies many solutions have been tried or suggested and have
formed part of various policy initiatives, but in the main they have not been evidence
based and their effects have not been evaluated in ways which would allow policy to
develop in a systematic way towards health improvement. And the grand social
determinants such as fiscal, educational, criminal justice, housing and transport
policies and their effects on health and health inequity have not been subject to the
kind of appraisal which would allow for the development of more equity-led policy.
14.2
Towards a causal hypothesis
There is an urgent need to understand the relationship between the social and the
biological. Some of the best known approaches are described in chapter 1. Why is it
that the molecules and the biochemistry in the human body show such a strong link
with social factors? And what is the pathway from the major social determinants to
individual health outcomes? In this pathway, what constitute the proximal,
intermediate and distal causes?
We have a huge amount of data which would allow for the development of models to
help open up these questions. Biologically, sociologically and psychologically
plausible pathways need to be developed with reference to each other. This will allow
for the development of explanatory systems which cross the traditional discipline
boundaries and the different levels of explanation. Sociology must stop its
explanations ending at the level of the social; psychologists must move beyond a
focus only on the on the individual and on treating social factors (if they do so at all)
as residual characteristics of individuals; and medicine must draw itself away from
the fetishism of the gene and acknowledge the powerful social and psychological
forces impacting on the biology of human life.
Within the extant literature there are many models and theories which help to provide
a potential way of mapping the social to the biological. In this chapter a hypothesis is
developed, based on two sociological-philosophical ideas - the life course and the
life world. Life course sociology and life course epidemiology have accumulated a
significant body of evidence which shows that from the moment of conception to the
moment of death, the human organism accumulates insults and benefits (Kuh et al.,
2003). In health terms these insults and benefits are a kind of profit and loss account
which determines the health state of the individual. Some of these things are
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biological and are determined by the hereditary structure of the organism; others are
environmental and reflect the immediate physical, social, psychological and
emotional environment of the growing child, and then the adult. But the life course
approach also demonstrates that at critical points on life’s journey, which are very
highly socially patterned, benefits and insults can be greatly magnified, past insults
can be cancelled out, and new benefits can come into play. It is also clear that these
changes may be self reinforcing, producing and reproducing patterns of health
advantage and disadvantage. Those critical points on life’s journey are like gateways
or forks in the road, setting in train patterns that may endure and have long lasting
effects.
It is also clear that the life course follows quite distinct patterns for different social
groups. The trajectory through life for the child of a single mother in receipt of state
benefit in public sector housing in Scotland will be very different to that of a child born
to a professional couple in Beverley Hills, California, and both will be quite different to
that of a child born in the Gaza Strip or the slums of Rio de Janeiro. The direction
people go at each gateway has a profound effect on their future. The gateways and
where they lead are markedly determined by social factors.
On life’s journey the experience of benefits and insults to health occurs in what some
philosophers call the life world. The notion of the life world developed in
phenomenological writings and, in the context used here, in the work of Schutz in
particular (Schutz, 1964, 1967, 1970). The argument also draws upon the work of
Mead (1934).
The life world is a social space, partly physical but predominantly cognitive and
subjective. It is the place where we make our own decisions, where we decide upon
our immediate actions, where we judge ourselves and others, where we experience
the social structure first hand in the form of opportunities, barriers, difficulties,
disadvantage, and it is where our emotions are played out and our feelings are
expressed.
Every individual human being subjectively inhabits his or her own personal life world.
At its core is the subjective self, which is experienced as a continuous self existing
though time and space within a more or less familiar world of places and people.
Although the life world is uniquely personal, it is also inhabited by others who are
recognized as physically and subjectively similar to, but separate from, the self.
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These others who inhabit the centre of our life world are those individuals whom we
meet and interact with, or think about and relate to, on a recurring basis. The people
with whom we share our domestic arrangements, some of our workmates and
perhaps friends and family, as well as those who are not intimates or friends but
whom we meet with regularly, make up the life world. It is the interaction, real or
imagined, on a repetitive basis which defines the inner zones of the life world. The
level of intimacy is not the crucial issue. It is the repetitive and routine nature of the
contacts with others that is important.
Schutz (1967,1970) conceptualized the life world as a series of concentric circles.
The innermost circle is the one where the everyday contacts and routines are highly
predictable and are therefore taken for granted. They are salient and immediate and
tend most of the time to be the most important. The more distant parts of the life
world are inhabited by things and people we can recognize even though we do not
know them, and whom we could and would understand were we to meet and interact
with them. We therefore have some sense of these persons and things but their
impact on us is nil or negligible. Schutz described the concentric circles of the life
world as zones of relevance (Schutz, 1970). The closer to the centre, the greater the
relevance of what goes on there to the T. The values and prescriptions of the circles
closest to the centre are important. The stock of knowledge or assumptions that an
individual has of those parts of the life world is a crucial resource for making sense of
things (Schutz, 1967).
It is very important to note that the innermost circle of the life world may not be, and
Schutz never suggested it would be, a place that was benign and cosy. It may be
violent and bullying. It may be cold and unforgiving. It may be unpleasant and
chronically difficult. It will be the place where discrimination and disadvantage are
experienced. However, it constitutes the centre of the existence of the person. Life
worlds change gradually as individuals move through space and time. Groups of
intimates change, children grow up, leave home and move to a more distant part of
the individual’s life world. New people come into our orbit of friends and
acquaintances. The social group in the everyday life world of contacts - direct and
indirect, real, imaginary or virtual - is potentially continually in a state of flux. The
possible variability is enormous.
The key Schutzian point for us here is that the central realities and experiences of
everyday life are the principal focus for sociological analysis of the variations in
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modern societies. This is because life worlds are the building blocks of social life and
individual behaviour originates and is rationalized and explained in the life word. The
experiences and meanings attributed to disadvantage are constructed in the life
world. It is the fulcrum of human existence around which everything else rests and
the prism through which all meaning is refracted. It is the point where social structure
impacts on the individual. It is the highly localized manifestation of the social
structure and is where that social structure is experienced, is made meaningful and
constrains human action in a very direct way. It is in fact where social structure
originates.
The life world is the locus of experience: social, psychological and physical. It is that
social and emotional space which all of us uniquely inhabit. It is the world of the
everyday, it is the world of the immediate experience and the aspects of life that we
take for granted. It is where life is at its most meaningful and its most painful. The life
world is also about the physical space which we inhabit. It is where the social meets
the biological. Life worlds are the point at which stressors are moderated, mediated
or exacerbated. It is the point where insults are parried or where they have their
noxious effects. It is the point where vulnerabilities translate stressors into physical
and emotional damage. It is where immunities - biological, physical or psychological
- work their protective powers. Social disadvantage is characterized by the inability
or lesser ability to control the life world. Social advantage is characterized by the
ability to make control of the life world sustainable.
There are four types of resources that help to control the life world. First, these are
technical things like skills, knowledge, money and access to services and resources.
Second, there are interpersonal resources constituted from the relationships, social
support, safety and ease of communication in our world. Third, there are intra
personal resources - the ability to deal with the emotions of life and its psychological
distresses with equanimity or otherwise. Finally there are the resources of being able
to make sense of the life world, of being able to make it meaningful. If humans can
do that, they seem better able to cope with the ups and downs of human existence.
The argument advanced here is that the trajectory through the life course, mediated
through the life world, is how structural factors determine health. The life world is
where the causal mechanisms of health inequities operate, and the pathways to ill
heath can be described. Disadvantage may be viewed as a differential opportunity
(life chance) to control one’s life world (Weber, 1948). Differences between life
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worlds are the social manifestations of differences in physical life chances. Life
worlds operationalize the differential experiences of power, exploitation and access
to resources. Where life worlds abut, the experience of discrimination and
disadvantage originates and within the life world the experience of pain and suffering
are located. Our contention is that this model provides a promising framework in
which to understand and develop the causal pathways.
14.3
A plea for action
The fact that health inequity is socially determined is one of the most important
problems and challenges for global health policy. In due course precise causal
pathways describing the links between the social factors and the human biology may
be able to be described. This will allow policy to be targeted with a precision we lack
today. It will also help to create ways to bring the macro social and economic
determinants of health into the policy foreground. However, the fact that it is not yet
possible to describe the causal pathways precisely, should not and must not be an
excuse for inaction. Much is known about the social factors which affect health. What
is known is not universal in its applicability. It must therefore be read through a lens
which deals with its salience, meaning and relevance in particular local contexts. It
must also be equity proofed (i.e. a policy or programme needs to identify, assess and
address its potential health equity impacts so as to maximize the potential health
equity outcomes and minimize any potential harm). However, as this guide
demonstrates, it is possible to describe comprehensively what can be known and
how it can be interpreted. It is also clear how it can be linked to policy and what can
be done to get those policies and guidance deriving from them, implemented and
monitored.
There is no such thing as value neutral science. The Commission on Social
Determinants of Health has a specific commitment to equity and to taking action to
reduce socially determined health inequities. Equity is normative; it is based on a
value judgement. This will generate political opposition. The value of equity is not a
universal one in spite of being located in a discourse of human rights - the right to
good health. It is also important not to use the problem of values or the problem of
the complexity which bedevils population health as excuses for inaction. This guide
has identified ways of confronting the difficulties and finding workable solutions with
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the evidence and data that are available now and of being clear and transparent
about values.
The social determinants of health inequities is truly a field which is extensive in its
coverage, diverse in its ways of formulating the problem, full of good ideas and
replete with suggestions as to what might be done to help to improve things along
with various political solutions. And yet the problem of health inequity remains
stubbornly ubiquitous in spite of all these efforts. The world remains an unequal place
in which the damaging effects of the inequity itself and the health consequences of
those inequities remain as sharp as ever. In spite of all this knowledge it sometimes
seems that we are powerless in the face of the problem. This guide takes a
pragmatic approach and shows how it is possible to begin to marshal evidence in
such a way that it may be effective. While it would be foolhardy to suggest that the
work reported here will solve all these problems, the establishment of the WHO
Commission on Social Determinants of Health and the scientific work it has
sponsored mark an important watershed. The work undertaken by the WHO
Commission and the methodological thinking which has informed this has helped to
map the territory. No doubt the map will improve and in due course the
methodological questions will be better defined and formulated than the current
authors have been able to do in this guide.
This guide is a starting point which intellectually establishes the case that an
evidence based approach is the one most likely to offer the hope of success, that the
evidence comes in many shapes and forms, and that we must get smarter about
synthesizing and appraising that evidence. We must move well beyond sterile
debates about the superiority of particular disciplinary or epistemological positions.
The unnecessary suffering and death wrought on the population by inequity is simply
too big a problem to be brought to a standstill by the philosophical indulgences of
academic solipsism. The world of political power needs to be engaged in ways that
will be effective and will produce the necessary changes.
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15
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Appendix I - Illustrative case studies
The following case studies have been chosen to illustrate one or more of the points in
this guide. They feature SDH themes although they do not always describe describ
interventions specifically to address SDH (there is little available in the literature).
These case studies are intended for illustrative purposes only; they have not been
critiqued and may be subject to the biases of the original author(s).
Chapters illustrated:
2 - Evidence based approach
8 - Generating evidence for policy and
practice
3 - Gaps and gradients
9 - Evidence synthesis and action
5 - Understanding the policy-making process
10 - Effective implementation and evaluation
6 - Making the case
12 - Monitoring
7 - Equity proofing
Chapter illustrated
Case study
2^
3
5
6
7
8
9
10
1. United Kingdom - Acheson
Inquiry
x
2. Brazil, Peru, United Republic of
Tanzania - Failure to equity
proof
x
x
3. Bolivia - evaluation of social
investment fund
X
X
4. Brazil - Infant mortality in Ceara
X
X
X
12
X
X
5. Canada - National children’s
policies
X
X
6. Mexico - National health system
X
X
X
X
7. Thailand - Universal health
coverage
X
X
X
X
8. Various countries - Linking
research and evidence to policymaking
X
9. Thailand - Mun river dam
X
10. Brazil & Chile - National
conferences
X
11 .Uganda - Community-based
monitoring
12. Various countries - Synthesis of
data on tuberculosis treatment
X
X
X
X
X
X
x
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Constructing the evidence base on the social determinants of health: A guide
Chapter illustrated
Case study
2
3
5
6
7
8
9
13. Various countries - Synthesis of
data on school feeding
programmes
x
14. United Kingdom - National
Institute for Health and Clinical
Excellence
x
10
15.Slovenia - Health impact
assessment
X
X
16.United Kingdom - Health impact
assessment
X
X
12
17. Mexico - Oportunidades
programme
X
X
18.Sweden - Intersectoral action
X
X
19. Bangladesh - evaluation of
Food for Education programme
X
X
20. Kenya - Grassroots monitoring
21. The Netherlands - Multilevel
surveillance system
X
X
X
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Constructing the evidence base on the social determinants of health. A guide
Case study 1: United Kingdom - Using evidence to inform
health policy: the Acheson Inquiry
Illustrates: Evidence based approach
This case study illustrates the work undertaken by the Evaluation Group of the
Independent Inquiry into Inequalities in Health (the Acheson Inquiry). The Group was
established to help the British government formulate policy to reduce health
inequalities. This case study reports on the quality of the evidence used to support
the Inquiry’s 39 major recommendations.
In 1997, the Minister for Public Health commissioned Donald Acheson, the former
Chief Medical Officer for England, to review the latest available information on health
inequalities and to identify, in the light of scientific and expert evidence, priority areas
for future policy development. The Inquiry reported in 1998. It presented both
evidence about the problem (health-related effects of particular determinants and the
possible link between the health effect and these determinants) and evidence about
the effectiveness of interventions to address the problem.
The members of the Inquiry’s Evaluation Group developed a matrix of criteria against
which they believed policy recommendations should be judged for priority setting
(see box below), but found that they were unable to use the criteria because the
proposals lacked sufficient information. For example, submissions did not adequately
describe methods and there was little empirical evidence of effectiveness. Where
Box 1. Criteria used by the Evaluation Group of the Acheson Inquiry to evaluate policy
recommendations:
Supported by systematic, empirical evidence
Supported by cogent argument
Scale of likely health benefit
Likelihood that the policy would bring benefits other than health benefits
Fit with existing or proposed government policy
Possibility that the policy might do harm
Ease of implementation
Cost of implementation.
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evidence for effectiveness was cited, it was usually clearer for more specific
‘downstream’ proposals such as medical interventions focused on individuals than for
macro level ‘upstream’ proposals such as social, economic or educational
interventions aimed at whole communities.
The Evaluation Group noted that their observation of the lack of empirical evidence
did not mean that they thought the Inquiry should not propose policies formulated on
the basis of logic and common sense or that they thought interventions aimed at
whole communities are not effective. Rather it reflected the paucity of good quality
studies of these more ‘upstream’ interventions.
The Group acknowledged that even their own recommendations for health equity
were ‘quite medical’ in nature because they were the kind of interventions that often
have evidence behind them. For this reason, an editorial in the British Medical
Journal (Davey Smith et al., 2001) criticized the Evaluation Group’s assessment of
the evidence because ‘health differentials between social groups, or between poor
and rich countries, are not primarily generated by medical causes and require
solutions at a different level’.
In 2001 England’s then Health Development Agency examined the approach to
gathering evidence of effectiveness of both the Acheson Inquiry and the country’s
new Social Exclusion Unit. The paper concluded that, given a favourable political
environment, the ‘logic and equity’ used in the Acheson Inquiry are important factors
in decision-making.
While the Social Exclusion Unit draws extensively on research and external
expertise, it also relies on good practice and promising ideas, and members of the
Unit visit and consult widely with local authorities, business, the voluntary sector, faith
groups and other agencies, and people who have a direct experience of social
exclusion. The Health Development Agency concluded that a pragmatic rather than
doctrinaire approach to evidence of effectiveness is key to the process of developing
healthy public policy.
Source: Public Health Agency of Canada, 2001b.
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Case study 2: Brazil, Peru and United Republic of Tanzania Failure to equity proof interventions for children in low and
middle income countries
Illustrates: Equity proofing; Evaluation
The need for equity proofing is evidenced even in initiatives which by their essence
are expected to reduce health inequities within and between countries.
The Integrated Management of Childhood Illness (IMCI) strategy was designed by
WHO and UNICEF to reduce infant mortality and the incidence and seriousness of
illnesses that affect children under five, as well as improving their growth and
development. It is one of the key strategies for meeting the Millennium Development
Goals with greater equity.
Victora and colleagues (2006) looked at the implementation of IMCI in three
countries - Brazil, Peru and the United Republic of Tanzania. The objective was to
assess whether the strategy was implemented in the areas with greatest child health
needs.
The study was carried out through interviews with key stakeholders at the national
and district levels, as well as an ecological study of factors associated with health
worker training in IMCI. The baseline mortality rates in children under five years old
before IMCI implementation were assessed. Also included were district
characteristics (population, distance from the capital or main city, urbanization rate),
environmental variables (water supply), and socioeconomic indicators (literacy,
income and Gross Domestic Product (GDP)). The district Human Development
Index, which combines data on GDP per capita, education (weighted average of
adult literacy rate and gross school enrolment ratio) and life expectancy at birth was
calculated.
In Brazil, IMCI was less likely to be implemented in municipalities with low scores on
the Human Development Index, low per capita income, small populations and located
further away from the state’s capital. Indicators of literacy, urbanization, water supply
and baseline under five mortality rate (U5MR) were not associated with IMCI
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implementation. In Peru, no significant correlations were found between coverage of
training of health workers in IMCI and any of the indicators studied. Though
correlations were weak, IMCI coverage tended to be lower in departments with
higher values of the Human Development Index, larger populations and poorer water
supply. In Tanzania, the only significant correlation was the earlier introduction of
IMCI in districts that were close to Dar es Salaam. None of the other correlations,
including the baseline U5MR, were statistically significant.
Though WHO recommended clear criteria for selecting districts for early
implementation, these did not include equity considerations (e.g. mortality levels).
This incentivized the initial selection of districts that were close to the national capital
or main city, with a strong experience in previous vertical child health programmes,
managed by motivated teams and with sufficient funding available. In the expansion
phase, IMCI tended to be adopted by other districts with similar characteristics.
However, as the authors highlight, ‘these characteristics are likely to be found in
districts where the U5MRs are lower than the national average’.
Nonetheless, the authors stress that IMCI ‘should not be singled out as the only
strategy without explicit pro-equity implementation guidelines... Until recently, equity
considerations were seldom addressed in international child health initiatives aimed
at low and middle income countries... Unless pro-active efforts are made to deploy
interventions where they are most needed, inequalities in child health may widen as
a result of new programmes’.
Source: Victora et al., 2006.
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Case study 3: Bolivia - Evaluating Bolivia’s Social Investment
Fund
Illustrates: Equity proofing; Evaluation; Monitoring
Project description
The Bolivian Social Investment Rund (SIR) was established in 1991 as a financial
institution promoting sustainable investment in the social sectors, notably health,
education and sanitation. The policy goal is to direct investments to areas that have
been historically neglected by public service networks, notably poor communities.
SIP funds are therefore allocated according to a municipal poverty index, but within
municipalities the programme is demand-driven, responding to community requests
for projects at the local level. SIR operations were decentralized in 1994, enhancing
the role of sector ministries and municipal governments in project design and
approval. The Bolivian SIR was the first institution of its kind in the world and has
served as a prototype for similar funds that have since been introduced in Latin
America, Africa and Asia.
Impact evaluation
Despite the widespread implementation of social funds in the 1990s, there have been
few rigorous attempts to assess their impact on poverty reduction. The Bolivian SIR
evaluation, carried out jointly by the World Bank and SIR, began in 1991 and at time
of writing (2002) was ongoing. The study features baseline (1993) and follow-up
(1997) survey data that combine to allow a before-and-after impact assessment. It
includes separate evaluations of education, health and water projects and is unique
in that it applies a range of evaluation techniques and examines the benefits and
drawbacks of these alternative methodologies.
Evaluation design
The evaluation programme includes separate evaluations of education, health and
water projects that assess the effectiveness of the programme’s targeting to the poor.
It also assesses the impact of its social service investments on desired community
outcomes such as improved school enrolment rates, health conditions and water
availability. It illustrates best-practice techniques in evaluation using baseline data in
impact analysis. The evaluation is also innovative in that it applies two alternative
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most efficient in populated areas that already have access to a water system so that
the project can take advantage of economies of scale.
The fact that SIF investments have had no perceptible impact on school attendance
has prompted a restructuring of SIF interventions in this sector. Rather than focusing
solely on providing infrastructure, projects will provide a combination of inputs
designed to enhance school quality. Similarly, disappointing results on water quality
(which showed no improvement resulting from SIF projects compared with the pre
existing source) have generated much attention, and project design in this sector was
changed to include training of personnel.
Lessons learned about evaluation process
Effectiveness of the randomization technique. The randomized research design, in
which a control group is selected at random from among potential programme
beneficiaries, is far more effective at detecting programme impact than the matchedcomparison method of generating a control group. Randomization must be built into
programme design from the outset in determining the process through which
programme beneficiaries will be selected, and random selection is not always
feasible. However, when programme funds are insufficient to cover all beneficiaries,
an argument can be made for random selection from among a larger pool of qualified
beneficiaries.
Importance of institutionalizing the evaluation process. Evaluations can be extremely
complex and time consuming. The Bolivia evaluation was carried out over the course
of seven years in an attempt to rigorously capture project impact, and achieved
important results in this regard. However, the evaluation was difficult to manage over
this length of time and with the range of different actors involved (government
agencies and financing institutions). Management and implementation of an
evaluation effort can be streamlined by incorporating these processes into the normal
course of local ministerial activities from the beginning. Further, extensive evaluation
efforts may be best limited to only a few programmes - for example, large
programmes in which there is extensive uncertainty regarding results - in which
payoffs of the evaluation effort are likely to be greatest.
Evaluation costs and administration
Costs. The total estimated cost of the Bolivia SIF evaluation to date (2002) is
US$ 878,000, which represents 0.5% of the total project cost. Data collection
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represents a relatively high proportion of these costs (69%), with the rest being spent
on travel, World Bank staff time and consultants.
Administration. The evaluation was designed by World Bank staff and financed jointly
by the World Bank, the KfW banking group, and the Dutch, Swedish and Danish
governments. Survey work was conducted by the Bolivian National Statistical
Institute and managed by SIF counterparts for the first round and later the Ministry of
Finance for the second round.
Sources'. Baker, 2002; Newman et al., 2002.
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Case study 4: Brazil - Use of survey data to determine and
refine state-wide policies and programmes; persistent
inequities between rich and poor
Illustrates: Gaps and gradients; Making the case; Generating evidence for policy
and practice; Effective implementation and evaluation
Early in the 1980s the infant mortality rate (IMR) in the state of Ceara, in the poor
northeastern area of Brazil, was higher than 100 per 1000 live births and malnutrition
was very common. In 1986 the new state government requested UNICEF support to
help improve child health and a state-wide survey of child health and nutrition was
commissioned. More than 4,500 children under three years old were surveyed in
8,000 families in forty different municipalities. Based on the survey conclusions, new
health policies were implemented, including Growth monitoring, Oral rehydration,
Breastfeeding promotion, Immunization and vitamin-A supplementation (known as
the GOBI strategy). Since lack of access to health-care facilities was a major
problem, a large new programme for community health workers was established and
another programme for traditional birth attendants was expanded. Responsibility for
health services was decentralized to rural municipalities which were the ones with the
worst health indicators. A social mobilization campaign for child health was
implemented, which included the use of the media and small radio stations to
broadcast educational messages.
Similar surveys were repeated again in 1990 and 1994 and after each one the results
were incorporated into health policy. This process was sustained by four consecutive
state governors who all gave high priority to improving child health. The experience in
Cear£ drew international attention and in 1993 the State received the Maurice Pate
Award, the annual UNICEF prize for successful progress towards child health and
well-being.
Considerable advances in the population coverage of the four GOBI interventions
had been made by 1994. The use of oral rehydration solution had increased to more
than 50% in children with diarrhoea; nearly all children had a growth chart and a half
had been weighed within the previous three months; immunization coverage was
90% or higher; and median breastfeeding duration - a difficult indicator to improve -
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had apparently increased from 4.0 to 6.9 months. Disease frequency and mortality
outcome indicators for the whole population also showed considerable improvement
between 1987 and 1994. The prevalence of low weight-for-age fell from 13% to 9%,
low height-for-age from 27% to 18%, and reported episodes of diarrhoea in children
in the previous two weeks from 26% to 14%.
Infant mortality was estimated at 39 per 1000 live births in 1994, a 37% reduction on
the estimated 63 per 1000 in 1987.
Immunization rates improved remarkably in all income groups, with the inequity gap
between rich and poor closing as the wealthy reached near universal coverage. For
both growth monitoring and use of oral rehydration solution, the inequity gap was
also narrowed. Assessment of breastfeeding duration showed that in 1987 it was
longer among the poorest, whereas by 1994 the gap between rich and poor had
narrowed in favour of the wealthier - an interesting ‘trickle up’ phenomenon, since
health messages had been primarily directed to the poorest people.
Despite the progress achieved in improving coverage for public health interventions,
inequity between rich and poor for disease frequency and infant mortality remained
largely unchanged between 1987 and 1994. The proportions of children in the
extreme categories of family income remained almost the same in both years,
showing that income inequalities had persisted and remained largely unchanged.
Cases of diarrhoea remained about 60% higher among the poor.
In Cearci, despite the implementation of child health interventions for the poorest
families, inequities appeared to remain largely unchanged for four health status
impact indicators - weight, stunted growth, prevalence of diarrhoea, and infant
mortality. Despite an overall improvement in health, the inequity ratio between rich
and poor remained the same. An explanation is that wealthy families had made
greater and earlier use of both public sector and private services to protect their
children’s health.
The conclusions from Cear£ suggest that, even with public-health programmes
targeted at the poorest, it is difficult to close the inequity gap if the rich have not yet
achieved high levels of vaccination coverage and consequently low levels of
morbidity or mortality.
Source: Victora et al., 2000.
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Case study 5: Canada - A decade of children’s policies based
on evidence (1990-2001)
Illustrates: Understanding the policy-making process; Making the case
This case study explores how evidence influenced the development of national
policies to enhance children’s health and well-being in Canada over the previous
decade (1990-2001). The goal of national child development policies in Canada is
optimal well-being for all children while recognizing special needs and disadvantage
when resources are scarce.
Evidence was successfully used to influence policy decisions. Key ingredients in this
success were:
The weight of evidence on healthy child development was compelling
The evidence was consistent with the context and values of the time
The nature of the evidence on the determinants of health helped rally various
stakeholders to create mutually acceptable goals.
Base decisions on evidence
In a population health approach, evidence on health status, the determinants of
health and the effectiveness of interventions is used to assess health, identify
priorities and develop strategies to improve the health of the entire population and
reduce ineguities in health status among population groups. The case study
highlights Canada’s success in presenting the evidence on children’s health status
and the determinants of healthy child development to the public and decision
makers. This success resulted from:
Accurate recording and monitoring of health status through population
based surveys, surveillance and record keeping which showed that
although the majority of Canadian children and youth enjoyed very good
health, disparities existed, such as those related to income. As well,
Aboriginal children and their families fared poorly in almost all health and
social indicators, compared to the general population. The National
Longitudinal Study on Children and Youth (NLSCY), initiated in 1994,
looks at physical and emotional health, behaviour, income, learning, social
well-being, and parental and community involvement. The NLSCY data
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showed that by kindergarten age (age 4-6), a socioeconomic gradient in
readiness for school had emerged in Canada.
•
Credible interdisciplinary research groups, both inside and outside of
government which carried out child development research that took into
account all the determinants of health. For example, investigators in the
Canadian Institute for Advanced Research (CIAR) persuasively
summarized the evidence on brain development from neurobiology and
developmental psychology.
Collaborate across sectors and levels
The weight of evidence on healthy child development helped to answer the question
of who is responsible for making things better. The fact that health, well-being and
competence have essentially the same principal determinants (e.g. a healthy
pregnancy, secure attachment, safe neighbourhoods, stable income, preschool
stimulation) means that the objectives of a wide variety of government departments
and levels of government can be met by working in concert.
Assess contextual conditions, characteristics and trends
In addition to gathering evidence, a population health approach scans the prevailing
context and trends to assess current conditions. As this case study points out,
evidence is only one factor in decision-making. Two other key factors are: the values
that politicians, the public and interest groups hold on any issue; and the policy
context in which the evidence is considered. Important contextual pieces that
underlay the development of child policy work in Canada in the 1990s include:
•
After the fiscal restraint in the early to mid 1990s, the Canadian public was
anxious to re-invest in health and social policy. In a 1998 national opinion
poll, Canadians included ‘better support and nurturing for children’ among
their top priorities for national action
•
The evidence linking a healthy childhood to a healthy, skilled adulthood
resonated with the growing political need to develop a strong knowledge
based economy. It made sense that ‘investing’ in young children now
would lead to a healthy, prosperous and productive society in the future
•
The adoption of a population health framework by many governments in
the mid 1990s set the stage for the acceptance of early childhood
development as a primary determinant of health and prosperity for adults,
as well as for children.
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Increase upstream investments and apply multiple strategies
Research on the determinants of healthy child development showed that investing in
children and youth requires a mix of policies dealing with income, education, health
and the environment. Evidence also showed that all levels of society have an effect
on child development. While parents, caregivers and family have the primary role,
neighbourhoods, communities, governments, private industry and the voluntary
sector all have a part to play. These findings underscored the importance of a multi
level strategy with a focus on upstream investments. The following list of selected
policy initiatives in Canada reflects an integration of economic, social and health
policy at different levels to improve children’s health and well-being.
Table 1:
Year
Some key policy initiatives to enhance the well-being of children in
Canada, 1991-2001
Policy Initiatives
1991
Ratification of the Convention on the Rights of the Child
1992
Community-Based Initiatives : Community Action Program for Children; Aboriginal
Head Start; The Canada Prenatal Nutrition Program; Fetal Alcohol Syndrome/Fetal
Alcohol Effects Initiative
1993
School Net: connects all Canadian public schools and public libraries to the Internet
1998
National Child Benefit: a tax benefit policy to prevent and reduce child poverty
1999
National Children’s Agenda: a cooperative effort by all governments to ensure that
all children have the best opportunity to develop to their fullest potential
1999 Social Union Framework Agreement: a collaborative framework for social policy in
Canada with an emphasis on children in poverty
2000
Health Accord and Early Childhood Development Initiative (ECD): affirmed a
commitment by all governments to invest in early childhood development
2001
Employment Insurance: maternity and paternity benefits doubled from six months
to one year; adoptive leave tripled from 10 weeks to 35 weeks; commitment to
‘family friendly’ workplaces in federal jurisdictions.
Demonstrate accountability for health outcomes
Population health focuses on health outcomes and on determining the degree of
change that can actually be attributed to interventions. In the national policies to
enhance children’s health and well-being in Canada, accountability mechanisms are
built in and agreed to by all levels of government. For example, the Early Childhood
Development Initiative, agreed to at the First Ministers meeting in 2000, commits all
governments to reporting publicly on their efforts and the results.
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Lessons learned
The case study concludes with lessons learned for successfully turning knowledge
into policy. One key strategy recommended is to use credible experts as messengers
and champions For instance Dr. Fraser Mustard, an early development expert and
researcher with the CIAR, managed to gain audiences with key politicians in every
level of government.
Lessons learned were to:
•
Use credible experts as champions
•
Build the weight of the evidence
•
Value evidence from various sources
•
Invest in effective research transfer strategies
•
Popularize research results
•
Form partnerships and formal links between researchers and decision
makers
Share intersectoral data
Find win-win in intersectoral collaboration
•
Support independent interdisciplinary research groups.
Source: Public Health Agency of Canada, 2001a.
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Case study 6: Mexico - Use of evidence to reform national
health system
Illustrates: Understanding the policy-making process; Making the case; Generating
evidence for policy and practice; Monitoring
Since 2000 Mexico has been immersed in a process of transformation of its health
system that may hold important lessons for other developing nations. Mexico is a
heterogeneous middle-income country with a population of more than 100 million. Its
high degree of social ineguality means that it represents the gamut of health
problems affecting the world.
In the design, implementation, and evaluation of its reform, Mexico has made
intensive use of the best available evidence, which has been derived from national
analysis and knowledge-related global public goods, such as systematic
comparisons of the experiences of other countries, measurement methods, and
conceptual frameworks. In particular, Mexico has assimilated lessons from
innovations introduced in many other countries around the world, while making its
own experiences available to other countries.
In Mexico, as in many other developing countries, the health system had been
unable to keep up with growing financial pressures. Although social insurance was
introduced in 1943, it had been limited to salaried employees in private firms or in
public-sector institutions, and to their families. This arrangement excluded the self-
employed, the unemployed, and those who were out of the labour market or worked
in the informal sector of the economy. The net result was that by 2000, half of
Mexican families, most of them poor, had no social protection against the financial
consequences of ill health.
Empowerment through evidence
The reform of the Mexican health system invested heavily in the generation and
application of relevant knowledge, in what the author feels is probably a textbook
case of evidence based policy. For instance, the calculation of national health
accounts showed that more than half the total health expenditure in Mexico was out-
of-pocket since about half the population had no health insurance. Furthermore, out-
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of-pocket expenditures were shown to be regressive, since they represented a higher
proportion of income in poor households than in richer ones.
These findings were unexpected, because the Mexican health system was generally
assumed to be based on public funding. Instead, the analysis for 2000 revealed that
in one trimester almost 1.5 million households had an economic catastrophe, were
driven below the poverty line, or were forced deeper into poverty by out-of-pocket
spending. In this way, sound evidence made the public aware of a reality that had
hitherto been outside the policy debate - namely, that health care itself could
become a direct cause of impoverishment.
The WHO framework for the assessment of health-systems performance also helped
to make the local case for reform. This framework highlighted fairness of financing as
one of the intrinsic goals of health systems. As a result of its high degree of out-of-
pocket spending, Mexico did very poorly on the international comparative analysis of
fair financing. Instead of generating a defensive reaction, this poor result spurred
detailed country-level analysis in 2001 that showed that catastrophic expenditures
were concentrated in poor and uninsured households. Such analysis was based on
data from the national income and expenditure surveys for Mexico. These surveys
are produced by many countries in the world, and provide homogeneous datasets
that are very valuable for cross-national comparisons, but they have not been fully
exploited for health-policy formulation.
From evidence to action
Major legislative reform was undertaken to establish a system of social protection in
health and was approved by a large majority from all political parties in the Mexican
Congress. The new public, voluntary scheme called Popular Health Insurance or
Seguro Popular came into effect on 1 January 2004. It was due to expand at the rate
of 1.7 million families per year until universal coverage is achieved in 2010. The
Seguro Popular has elicited an enthusiastic response from the population, so that by
the end of 2006 it should have enrolled the targeted 5.1 million families (about 22
million people).
The insured are entitled to a specific package of benefits. An antecedent to this
approach was the Oportunidades programme which aimed to enhance the basic
capabilities of families living in extreme poverty (see case study 18 for more details of
this programme).
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Expanded coverage by the Seguro Popular has already offered more financial
protection for poor families. Comparisons between several rounds of the national
income and expenditure surveys show reduction by a third in the number of
households from the poorest 20% of the population affected by catastrophic health
care payments.
Results can also be assessed through two national health and nutrition surveys,
carried out in 2000 and in 2005-06. During the period between the two surveys there
was a major increase in the use of early detection services for several noncommunicable diseases, most notably hypertension (52% increase in blood-pressure
measurement) and breast cancer (71% increase in the use of mammography).
The assessment experience gathered by the Oportunidades programme is being
applied to the current health system reform. In addition to its technical aspects,
rigorous evaluation has political value to assure the continuity of innovations through
changes in administration. In the case of Oportunidades, scientific evidence
persuaded the government not only to continue with the programme, but also to
expand it.
A hallmark of the Mexican experience has been a substantial investment in research
to design the reform, monitor progress towards its implementation, and assess its
results. This is a clear example of the possibility of use of science to promote social
change by harmonizing two core values of research: scientific excellence and
relevance to decision-making.
The path is clear: sound evidence must be the guiding light for designing,
implementing, and evaluating programmes in national governments, bilateral aid
agencies, and multilateral organizations. This is the path that will lead to more
equitable development through better policy-making for health.
Source: Frenk, 2006.
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Case study 7; Thailand - Introduction of universal health
coverage
Illustrates: Understanding the policy-making process; Making the case; Generating
evidence for policy and practice; Monitoring
Use of research to support policy development
By early 2002 Thailand had achieved universal coverage (UC) of healthcare by
introducing a tax-funded health insurance scheme to 47 million people (73% of the
population) who were not already covered by the other schemes available. The UC
programme was characterized by clear policy goals, limited participation, strong
institutional capacity and very rapid implementation (one year).
An important factor in early policy formulation was the extent to which national
research provided evidence to support development of the policy. The effective
interface between the research community and policy-makers was a key factor in
evidence based policy development. While the agenda for UC was set by the Prime
Minister after a landslide electoral victory in January 2001, policy formulation was led
by civil servants supported by key policy entrepreneurs (known as reformists) and
researchers who continuously generated evidence and proposed policy options. This
was possible due to initiatives such as:
•
The Health Systems Research Institute (HSRI) supporting the
development of the National Health Account, a tool for monitoring financial
flows. Researchers were able to maintain and continually update it
•
The International Health Policy Program (IHPP) and its predecessor the
Senior Research Scholar programme continuously building up capacity in
health policy and health systems research through apprenticeships and
long-term fellowships
•
Strong research programmes and institutional collaboration developed
between the Health Planning Division of the Ministry of Public Health,
IHPP and London School of Hygiene and Tropical Medicine
•
Partnership working developed over the last decade between the Ministry
of Public Health and the National Statistics Office.
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Close relationships were observed between politicians and reformists, and between
reformists and researchers, which undoubtedly helped with the speed of
development and implementation of the policy. The reformists had a bridging role
between the technical capacity to produce sound evidence and the political will.
Politicians, reformists and researchers were mostly of the generation of student
activists who protested against the military government in the 1970s. Many student
leaders also became civic movement leaders and civil society was mobilized in '
support of the UC bill.
Use of research to support programme design
Researchers and policy-makers were able to learn from previous experience with
existing non-universal health schemes, in particular the Civil Service Medical Benefit
Scheme (CSMBS) introduced in 1963 and the Social Health Insurance (SHI) scheme
introduced in 1990. Experience with and evaluation of these two schemes directly
affected the design of the UC programme. Notably:
•
Cumulative experience of fee for services in the CMBS resulted in a
consensus between reformists that such a model would not be
appropriate for the UC scheme
•
The capitation payment method and purchaser-provider were adopted
from the SHI scheme
•
The UC scheme has proper referral processes and better use of primary
care than SHI.
Results
Direct taxation was chosen as the funding mechanism for pragmatic reasons
because of the desire for speedy implementation. It has since been assessed as an
equitable funding model in comparison with social insurance or other contributory
schemes.
The National Statistics Office conducted a health and welfare survey in 2004 which
assessed coverage of the UC scheme. This indicated that the beneficiaries of the
scheme are principally in the low income groups, unlike the two other main health
insurance schemes (see Figure 1).
The scheme has also resulted in a reduced incidence of catastrophic health
expenditure from 5.4% to 2.8 - 3.3%.
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Constructing the evidence base on the social determinants of health: A guide
Figure 1
Scheme beneficiaries by income quintiles, 2004
100%
17%
80%
23%
60%
41%
40%
26%
20%
11%
14%
0%
sss
CSMBS
UC
□ Q1 (poorest) BQ2 DOS 004 BOS (richest)]
Source: NSO Health and Welfare Survey 2004, cited in Tangcharoensathien, 2007.
The Ministry of Public Health and the National Statistics Office are working on
developing and deepening the data available from such surveys and intend to use
the data to continue to monitor the impact of the UC scheme on health inequities.
Source: Tangcharoensathien, 2007.
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Case study 8: Various countries - Linking research and
evidence to policy-making
Illustrates: Understanding the policy-making process
There is increasing demand for evidence based public health policy on the social
determinants of health and on the reduction of health inequities. However, turning
evidence into policy requires links between knowledge producers and knowledge
users. These links are not straightforward since there are:
•
Cultural differences between the world of research and the world of politics
•
Language differences, i.e. to what extent is the language of research
compatible with the language of politics?
•
Timescale differences, i.e. ‘a week is a long time in politics’
•
Differences in objectives: solving real life problems or building an academic
reputation.
These differences translate into disconnects between research questions and policy
questions:
3
Research questions answer academic questions
»
Academic research focuses on controlling out key implementation variables
•
Absence of process information
•
Problems of getting evidence into practice.
High income countries
Petticrew, Whitehead and colleagues explored how research evidence influences
public health policy-making and how its utility and relevance could be improved.
Special attention was paid to evidence on the production and reduction of health
inequities. Seven senior policy advisors with a substantive role in policy development
across a range of sectors participated in one focused workshop, and eight senior
research leaders, most of whom were currently involved in evaluations of the health
effects of major policies, participated in another. They were all from English-speaking
high income countries.
Policy-makers highlighted the prevalence of‘policy free evidence’ and identified gaps
in the evidence base on health inequities. They consider that much of the research is
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Constructing the evidence base on the social determinants of health: A guide
descriptive and etiological, rather than evaluative. From their perspective, the key
features of knowledge and evidence should be:
•
simplicity
•
timeliness
relevance
•
clarity.
On the other hand, research leaders identified five types of evidence which is thought
to be particularly effective with policy-makers. These are:
•
Observational studies which have identified a problem
•
Politically timely studies which capture the imagination
•
Controlled evaluations of interventions
•
Natural policy experiments
•
Historical evidence with a long shelf life.
The researchers proposed the following strategies in order to improve the availability
and use of these types of evidence:
•
Assembling the evidence jigsaw
•
Nurturing an ‘evaluation culture’
•
Creating closer engagement between researchers and policy-makers.
Although this study was primarily carried out to identify the different perspectives on
the production and use of evidence on health inequities between policy-makers and
researchers, there was a remarkable similarity between the results of the two
workshops. The most evident similarity was on the types of evidence expected to
have the most powerful impact on policy, and there was a common understanding of
the different types of evidence needed for different types of policy questions.
Mexico
In another part of the world, Trostle and colleagues (1999) discussed the relationship
between Mexican health research and policy. Sixty-seven researchers and policy
makers were interviewed about the factors which promote or impede exchanges
between researchers and policy-makers in four priority health topics: AIDS, family
planning, immunization and cholera.
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Content of research
The quality of the research was mentioned as an important promoting factor. This
was not however measured through the publication and peer review process, but
was largely determined by the identity and fame of the researcher, the reputation of
the journal or book, and the judgement of the policy-maker. Other factors which
promoted the role of research were: the recent importance given to social research
as a source of information despite the fact that more attention is paid to biomedical
research results; and the specificity, concreteness and cost-effectiveness of the
research recommendations. The factors which obstruct interaction between
researchers and policy-makers are differences in vocabulary between researchers
and policy-makers, and the perceived usefulness of each group’s knowledge.
Actors
In terms of individual and collective stakeholders, three promoting factors were
acknowledged: groups of researchers and policy-makers identifying priority
problems, the level of international support for research, and the critical role of official
research organizations in the health sector in Mexico. The interviewees also
mentioned three types of obstacles: the lack of technical background of decision
makers and the mass media, a political culture where decision-making is based on
experience and pressure rather than research results, and the actions of interest
groups (especially commercial ones).
Process
Informal communication was mentioned as a critical channel between researchers
and policy-makers, as well as balanced interests and formal communication
channels, while narrow professional interests are considered an impediment.
Context
The stability of the PRI (Institutional Revolutionary Party) in Mexican government was
recognized as a promoting contextual factor. So were the rotation of researchers into
policy-making positions, the small size and relative homogeneity of the research
community, and the urgency of a health problem. As impeding factors were
mentioned for example the centralization of power and information, restrictions on
funding, and changes in top-level management in the health system.
Apart from the results in common between the four health topics, several differences
were found as well: the extent of reliance on formal communication channels, the role
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Constructing the evidence base on the social determinants of health: A guide
of the mass media in building social consensus or discord, levels of interest group
polarization and social conflict, the role of foreign donors in supporting local research
and policy initiatives, and the level of support for biomedical versus social research.
Further democratic changes in Mexico were mentioned as the most important
incentive to increase the use of research in policy-making. The two major challenges
are: the fact that researchers are but one of many interest groups and research is but
one input among many others to be considered by policy-makers; and the relatively
small role of the public in policy-making in Mexico.
Sources: Bronfman et al., 2000 ; Petticrew et al., 2004; Trostle et al., 1999;
Whitehead et al., 2004
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Constructing the evidence base on the social determinants of health: A guide
Case study 9: Thailand ~ Use of locally-defined health
determinants to push for change, Mun River dam
Illustrates: Making the case; Generating evidence for policy and practice; Health
impact assessment
In 1994, a dam was built on the Mun river in Thailand 5.5 kms before it reaches the
Mae Kong river. This Pak Mun dam obstructs fish migration from the Mae Kong to
the Mun. The fishery resource has thus been greatly reduced, leading to sharp
reductions in income for the local fishery households. A health impact assessment
(HIA) was set up to provide evidence based information to advocate for a change in
public policy in managing the dam, with the support of other related studies.
After long protest and negotiations, the Thai government decided in 2001 to open the
dam gate for four months (later for one year) in order to conduct a study on the
‘Approach to restoration of ecosystem, livelihood and culture’. This provided a good
opportunity to gather evidence based information to be used for public decision
making.
The big debate was about the impact of the dam on fishery resources, income and
compensation. However, other issues also related to the health of the local
population. To avoid too narrow a scope for the HIA, the local definition of health and
determinants of health were identified. For the villagers health was 'living happily and
peacefully together with the family and community, and within the natural
environment, which can ensure their secure livelihoods and community culture’. The
villagers also identified six factors for healthy living: having enough food, secure
livelihood, happy family, healthy body, peaceful spirituality and a generous
community. The local population put great emphasis on: natural resource security,
food security, economic security and social environment. Changes in these things
resulting from opening the dam gates were analysed. Data collection and analysis
were carried out using a participatory approach. Table 1 shows the health impact of
both the dam construction and the opening of its gates.
Although the impact assessment studies recommended the Thai government should
keep the dam gate open as the main way to restore the ecosystem, livelihood, health
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Constructing the evidence base on the social determinants of health: A guide
Table 1
Health
aspects
Physical
health
Mental
health
Social
health
Spiritual
health
Health impacts of dam construction and opening of dam gates, according
to four determinants of health
Effects of dam construction
Effects of opening dam gates
Much better due to improvement in
fishery and other resources.__________
Much better because of better water
quality.____________________________
Better but still anxiety about long-term
Disorders due to high tension.
government decisions._______________
Accidents due to broader river.________ Lower risks but still some incidence.
Pressure due to economic hardship and Much better due to better economic
insecurities.________________________ situation and food security.___________
Better but still anxiety about long-term
Anxiety due to various insecurities.
government decisions._______________
Conflicts based on different standpoints Still exists but people start to join and
about dam issue.___________________ share the same fishing grounds._______
Oppression due to negative response Still exists but people feel more
confident to come up for their own
from government.
rights._____________________________
Loss of togetherness due to the Much better especially for fishery
households.________________________
emigration and hardships.
Weaker supportive relationship due to Still exists but people start to join and
conflict on dam issue.________________ share the same fishing grounds._______
Broader social networks to support their Still the same.
movement._________________________
Losses
of spiritual
infrastructure, The holy places and ceremonies
especially those related to the river and gradually returned.
rapids.____________________________
Loss of shared activities, especially The shared activities gradually return,
but remaining conflict obstructed their
those related to fishing.
progress.__________________________
Deterioration of conducive environment The hardship was reduced. More
donation and spiritual practices were
due to hardship and conflict.
expected, but the remaining conflict
may affect the progress.
Food insecurity, due to the loss of local
food sources.______________________
Skin rashes from low water quality.
and local culture, the government decided to open the dam gate only for a period of
four months a year. The unsuccessful influencing of government decision-making in
this case may have occurred because of incomplete integration of knowledge
management, civic empowerment and political involvement. The process of impact
assessment studies was successful in terms of civic empowerment, since it allowed
both local NGOs and local people to participate. Knowledge management improved
at the local level, although this needs further improvement. However the weak point
in this study was political involvement. Since this was not adequately and properly
designed, the impact assessment studies failed to convince policy-makers to follow
their suggestions. The future of the Mun river and the health of its people are still
insecure.
Source-. Sukkumnoed et al., 2003.
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Constructing the evidence base on the social determinants of health: A guide
Case study 10: Brazil and Chile - Use of national conferences
to bring together policy and evidence
Illustrates: Making the case
Two Latin American countries have developed a tradition of using national
conferences as a bridge between evidence and policy-making.
Chile - National Convention on Women’s Health and women’s health
parliaments
The National Convention on Women’s Health was held in 1994. It was intended to
produce a diagnosis and propositions for women’s health from women and via a
‘citizenship’ approach to health. The convention was an opportunity for women to
discuss their own health, to define their priorities and to draw up proposals for action
and for policy implementation. The process took place in eight of Chile’s regions. It
began on 28 May 1994, International Day of Action for Women’s Health, and lasted
all year, involving some 230 organizations and approximately 3,000 women
throughout the country. The process involved housewives, peasants, adolescents,
fishermen’s wives, sex workers, healthcare providers, indigenous women, women
politicians, elderly women and temporary women workers.
The first priority was quality of care in sexual and reproductive health and the
concept of quality of care in the broader sense. For women the following were
fundamental: treatment, quality of services, the patient-physician relationship,
availability of proper equipment and facilities as well as of suitable health
professionals. Attention continued to focus on quality of care in sexual and
reproductive health through the follow-up and monitoring of the agreements of the
United Nations International Conference on Population and Development in 1994.
A later version of this exercise in civic participation has been the organization since
2002 of four women’s health parliaments, bringing together more than 1,000 women,
which have addressed analysis of health reform and put forward proposals from the
gender perspective.
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Constructing the evidence base on the social determinants of health: A guide
As a result of these efforts, and in line with global progress on women’s rights, in
1994 the Ministry of Health decided to transform the traditional Maternal and
Perinatal Health Programme into a women’s health programme, with the aim of
decentralizing reproductive health care to cover other aspects of women’s life cycles
and to progress towards a concept of comprehensive health, with the gradual
inclusion of the gender perspective.
Source: Nazarit, 2007.
Brazil - National Health Conferences
Brazil’s National Health Conferences began in 1942 but were initially limited to public
health experts. Since 1986 they have been open to a large number of delegates from
social organizations and professionals from all over the country, and are held each
four years. The 13th Conference took place in 2007.
Key participants in the health conferences are the Health Councils. These are
statutorily constituted. They are described in health law 8142:
The Health Council, in a permanent and deliberative capacity, is a collegiate agency
consisting of government representatives, service providers, health workers and
users, acting in the development of strategies and in monitoring the enforcement of
health policy at the specific government level, including in its economic and financial
aspects, where decisions are ratified by the head of the legally constituted power in
each sphere of government.
At present there are approximately 6,000 Health Councils in Brazil.
Participatory health sector activity is supplemented and enriched by the holding of
National Health Conferences each four years and by similar preparatory events
preceding the meetings in each state and county. The latter also provide a forum for
the highly competitive elections to appoint delegates to represent the Health Councils
at the national conferences. Conferences are governed by a strict set of bylaws; their
sessions discuss each topic on the program, vote on each resolution, and then adopt
them for subsequent inclusion in a final report. Numerous other events are held aside
from the conferences, e.g., focus conferences (mental health, indigenous health,
sexually transmitted diseases/AIDS, drugs, human resources, etc.) and various
forums.
Source: Labra & Giovanela, 2007.
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Constructing the evidence base on the social determinants of health: A guide
Case study 11: Uganda - Community-based monitoring and
evaluation of Poverty Action Fund
Illustrates: Generating evidence for policy and practice; Evaluation; Monitoring
The Uganda Debt Network (UDN) is a civil society organization monitoring the
Poverty Action Fund (RAF) set up in 17 districts. The RAF was to be used for five
sectors, including health. In May 2000, the UDN established RAF Monitoring
Committees in each of the 17 districts with the objective of enabling community
members to monitor the functioning of PAFs and to check for corruption. However,
these district level structures were found to be inaccessible by members of the
community.
The UDN then decentralized the monitoring further through a community based
monitoring and evaluation system (CBMES). The CBMES monitors RAF at not only
district level but also sub-county, parish and village levels. The CBMES was piloted,
along with the Kamuli District RAF monitoring committee, in eight villages in two sub
counties. The initial meetings to select participants were held in public spaces
accessible to all, with approximately 33% of the participants being women. Of these
participants, 80 were selected for training, with women constituting nearly 40% of
those selected.
The participants in the training programme identified the following indicators for
monitoring health:
•
Number of medical personnel in health centres, their time of reporting and
hospitality
•
Availability of medicines, syringes, gloves and cotton wool
•
Waiting time for services
•
Distance of health centre
•
Availability of immunization services
•
Number of beds.
The participants were trained in collecting and recording data on these indicators and
in interacting with government officials. The findings were fed back to the district
officials, chairperson and members of the sub-counties, members of the press and
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Constructing the evidence base on the social determinants of health: A guide
local radio, government officials and members of the communities. During these
feedback meetings, the members of the other CBMES committees (beyond the pilot
phase) were selected and the indicators for monitoring were refined.
The following changes were reported in the health services in the pilot area due to
the CBMES:
•
Removal of user fees (one county)
•
Improvement in stock of medicines and supplies (one county)
•
Establishment of immunization outreach services (one country)
•
Increase in beds in general ward and in labour ward (both counties).
However, problems remain:
®
The availability of beds and drugs was far from adequate
•
In one county, treatment for HIV/AIDS continued to be unavailable
•
Corruption and long distances to reach health care services continued to
pose problems.
•
Inadequate resources to cope with increase in demand after the
improvement in infrastructure and removal of user fees led to a slight
deterioration in quality of service.
Lack of adequate resources for travel and other costs incurred by monitors posed
problems in replication.
Source: Murthy, 2007.
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Constructing the evidence base on the social determinants of health: A guide
Case study 16: United Kingdom - Health impact assessment
of a housing estate regeneration project
Illustrates: Health impact assessment
The Ferrier housing estate in south London with 6,800 residents was the subject of a
£10m (US$ 15m) regeneration project as part of a regeneration strategy for the area.
Given the size of the project and the established links between health and housing,
the project wanted to ensure that the potential positive health impacts were
maximized and negative ones diminished. A health impact assessment (HIA) of the
project was therefore commissioned. This case study was written in 2000 when the
HIA was underway.
The aims of the HIA were:
•
to assess the potential health impacts on residents, both positive and
negative, of changes in housing and land use on the Ferrier Estate
•
to highlight the impact of the proposed development on health inequities
•
to make recommendations to enhance the predicted positive impacts and
minimize the negative ones.
The HIA - process and content
The HIA was carried out at a very early stage in the development of the options for
the estate, when there was little detail or clarity about what changes would be made.
This lack of clarity presented considerable challenges in designing and carrying out
the HIA. In fact the HIA became part of the process to formulate and assess the
options. The work started in January 2000 and the first report, which informed the
options for the development of the estate, was in May 2000.
The HIA was led by the local health authority but there was a strong emphasis on
partnership with the local authority (social services, housing and education services)
and community and voluntary groups. All of these organizations were represented on
the project steering group. A working group with local representation was responsible
for the day-to-day work of the HIA. Members of the working group were involved in
shaping the nature of and facilitating community involvement in the project, and
designing and carrying out parts of the research. In addition public participation was
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Constructing the evidence base on the social determinants of health: A guide
key. Community representatives were involved both formally and informally. The aim
was to involve residents in the HIA and ensure its widest possible ownership.
Health determinants and health outcome measures
The WHO definition of health and, in line with this, a social model of health
determinants underpinned the HIA. Examples of these determinants were used in
interviews with key stakeholders to help identify the potential health impacts of the
regeneration project. Established links between health and housing suggest that
improvements in housing design and the environment might lead to a number of
long-term health outcomes:
•
Decrease in accident rates
•
Decrease in respiratory disease
•
Decrease in excess winter deaths
•
Decrease in cardiovascular morbidity and mortality.
In addition several process indicators for long-term changes in health status were
identified from the literature and from discussions with the steering group, the
working group and some key individual stakeholders:
•
Access to better transport routes
•
Access to green spaces
•
Access to better food and nutrition through improved local shopping
facilities
•
Design provision for lifetime homes
•
Enhanced community safety measures, leading to better mental health
•
Energy efficient central heating
•
Good pest infestation control.
Learning points
These relate to the planning and commissioning stages of the HIA.
Planning: A clear understanding of the political processes and structures involved in
policy- and decision-making was necessary to identify and involve key people early
and consistently in the HIA.
Skills: The skills required for an HIA include:
•
Public health, epidemiological and social science research skills
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Constructing the evidence base on the social determinants of health: A guide
•
Experience of community development and involvement
•
Team working
•
Interpersonal and communication skills
•
Influencing and negotiating skills at a range of levels
•
Good project management and organizational skills.
Timing: External political decision-making processes can make it difficult to plan an
HIA and carry it out at the most effective stage of the project. Care needs to be taken
not to develop an extensive database if it is completed too late to be of use.
Support and commitment: Gaining support and commitment from other organizations
and getting them to see health as part of their agenda is crucial to be able to
influence the decision-making process.
Data issues: Some data issues had been identified but not resolved at the time of
writing the case study:
•
How to decide what is or is not important in terms of health determinants
•
How to weight the contributions of the various stakeholders
•
How to balance the qualitative and quantitative data.
Source: Barnes & MacArthur, 2000.
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Constructing the evidence base on the social determinants of health: A guide
Case study 17: Mexico - Use of monitoring and evaluation to
continuously improve the Oportunidades programme
Illustrates: Evaluation; Monitoring
The human development programme Oportunidades (Opportunities) was designed to
improve the educational, health and nutrition conditions of people in extreme poverty
in Mexico. The programme started in 1997 in rural areas; in 2001 it was expanded to
semi-urban areas and in 2002 to urban areas. In 2005 it covered 5 million families or
approximately 25 million people, one fourth of Mexico’s total population.
The programme combines traditional cash transfers with incentives on education,
health and nutrition. These require active family participation in taking care of their
education and health. In order to receive food benefits, family members must
(a) receive a preventive health check; (b) monitor the weight and height of children
under five years old; (c) breastfeeding mothers must take care of their nutrition; and
(d) pregnant women must attend antenatal care. To receive the cash benefits for
education, families must be responsible for their children’s school enrolment and
must ensure a minimum annual attendance of 85%. The subsidy is not given twice
for the same grade, thus it is lost in case of grade repeats.
One of the programme’s salient features is that right from the start it incorporated an
evaluation component to identify and measure the programme’s impacts. This
includes both quantitative and qualitative evaluations, which are carried out by wellknown national and international research and academic institutions.
Rigorous and continuous evaluations have not been a characteristic of Latin
America. The evaluation component of Oportunidades has become a benchmark in
social policy in the region. In the words of the former Mexican Undersecretary for
Social Development, Fernando Medina, ‘there is no turning back after the evaluation
experience of Oportunidades’. Furthermore, the need for evaluation has permeated
the highest decision-making levels. According to Medina, senior officials have
become conscious of the need for valid and timely programme evaluations to follow
up on processes and the impact on the target population.
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Constructing the evidence base on the social determinants of health: A guide
Survey
Population
Stratifiers
Health items
Social determinants
Care for read traffic and other injuries
Health system responsiveness
Seeing health care providers
Outpatient and care at home
Inpatient hospital
Health goals and social capital.
Sources:
DHS: http://www.measuredhs.com/aboutsurveYS/dhs/questionnaire archive.cfm
■
LSMS: http://www.worldbank.orq/LSI\/IS/quide/describe.html
WIICS: http://www.childinfo.orq/MICS2/finques/l\/l2finQ.htm
DSS: http://www.indepth-network.org/dss site profiles/dss sites.htm
CWlQ: http://siteresources.worldbank.orq/INTSTATINAFR/Resources/cwiq.pdf
WHS: http://www.who.int/healthinfo/survey/instruments/en/index.html
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Constructing the evidence base on the social determinants of health: A guide
Appendix IV - Recommendations from MEKN final
report
The following recommendations for policy-makers and practitioners were made in the
MEKN final report, The social determinants of health: Developing an evidence base
for political action (Kelly et al., 2007):
1. Actions to tackle the social determinants of poor health and health
inequities must focus on the causes of health inequities rather than
general health improvement. Attention should be drawn to the difference
between the social determinants of health and the social determinants of
health inequities.
2. Actions to tackle the social determinants of health must focus on the
whole spectrum of the population, taking account of the needs of different
groups. This must be based on accurate descriptions of the social
structure and must recognize the dynamic nature of that social structure.
3. Actions to tackle the social determinants of health must be evidence
based. That evidence may be drawn from a variety of disciplines and
methodological traditions. There should be no hierarchy of evidence - the
quality of the research is more important than the type of research.
4. Where evidence based policies or actions are developed they must be
equity proofed prior to implementation using health equity impact
assessment and during implementation using health equity audits or other
equity proofing tools.
5. Where evidence based policies and actions are to be developed, due
regard must be taken of the difficulties of getting evidence into practice
and into policy; specifically the barriers to the use of evidence need to be
understood.
6. Actions on the social determinants of health must involve sectors other
than health and must involve meaningful partnerships.
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Constructing the evidence base on the social determinants of health: A guide
7. Situation analysis to determine entry points and communication strategies
must precede all interventions and actions.
8
Evaluation and monitoring of the impact of actions must be an integral
part of any intervention or action. This should be informed by a model of
evaluation in which the theoretical causal link between the intervention
and the outcome is articulated in advance and explicitly.
9. It is vital to continue to develop evidence bases about the social
determinants. These should be rich in terms of the methods used. There
are a variety of ways of collecting and synthesizing evidence. Best
practice suited to the method should be used. The evidence base should
include the tacit knowledge of all involved, especially the planned
beneficiaries of the interventions or actions. These data should also
include routine data sets.
10. Cross cultural and cross national research is required to allow
comparisons to be made between the links between social and economic
disadvantage and health disparities.
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Constructing the evidence base on the social determinants of health: A guide
Appendix V - List of abbreviations
ACF
Advocacy coalition framework
CAP
Common Agricultural Policy, EU
CBA
Controlled before-and-after study
CCT
Controlled clinical trial
CBMES
Community Based Monitoring and Evaluation System
CDC
Centre for Disease Control and Prevention (Atlanta, USA)
CELADE
Latin American Demographic Centre
CHIS
California Health Interview Survey, USA.
CIAR
Canadian Institute for Advanced Research
CIHR
Canadian Institutes of Health Research
CSDH
Commission on Social Determinants of Health, WHO
CSMBS
Civil Service Medical Benefit Scheme, Thailand
CWIQ
Core Welfare Indicators Questionnaire
DCW
Digital Chart of the World
DOT(S)
Directly observed therapy (strategy)
DHS
Demographic and Health Surveys
DSS
Demographic Surveillance Systems
ECHP
European Centre for Health Policy
ECLAC
Economic Commission for Latin America and the Caribbean
EFHIA
Equity-focused health impact assessment
EGP
Erikson, Goldthorpe and Portocarero
EPOC
Effective Practice and Organisation of Care Group (Cochrane)
EPPI
Evidence for Policy and Practice Information and Coordinating Centre,
UK
EU
European Union
FFE
Food for Education, Bangladesh
GDP
Gross domestic product
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Constructing the evidence base on the social determinants of health: A guide
GEGA
Global Equity Gauge Alliance
GIS
Geographic information system
GOBI
Growth monitoring, Oral rehydration, Breastfeeding and Immunization
GPI
Gender Parity Index
GPW
Gridded Population of the World
HEA
Health equity audit, health equity auditing
HES
Household Expenditure Survey
HIA
Health impact assessment
HIC
High income countries
HIV/AIDS
Human immunodeficiency virus / acquired immune deficiency
syndrome
HSRI
Health Systems Research Institute, Thailand
HVI
Healthy Villages Initiative, Kenya
IAH
Intersectoral action on health
IFHIPAL
Proyecto Investigacion Fecundidad Hijos Propios para America Latina
(Research into Fertility Using the Own-Children Method in Latin
America)
IHPP
International Health Policy Program, Thailand
IHS
Integrated Household Surveys
IMCI
Integrated Management of Childhood Illness
IMIAL
Investigacitin en Mortalidad Infantil en America Latina (Research on
Infant Mortality in Latin America)
IMR
Infant mortality rate
ISCED
International Standard Classification of Educations
ITS
Interrupted time series
KN, KNs
Knowledge network(s)
KPH
Kenya Partnership for Health
LMIC
Low and middle income countries
LSMS
Living Standards Measurement Surveys
MDG, MDGs Millennium Development Goal(s)
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Constructing the evidence base on the social determinants of health: A guide
M&E
Monitoring and evaluation
MEKN
Measurement and Evidence Knowledge Network, CSDH
MICS
Multiple Indicator Cluster Survey
NGO, NGOs
Non-governmental organization(s)
NHIS
National Health Interview Survey, USA
NHMRC
National Health and Medical Research Council (Canberra, Australia)
NHS
National Health Service, UK
NICE
National Institute for Health and Clinical Evidence, UK
NSW
New South Wales, Australia
NLSCY
National Longitudinal Study on Children and Youth
RAF
Poverty Action Fund, Uganda
PAHO
Pan American Health Organization (WHO)
PARIS21
Partnership in Statistics for Development in the 21st Century
PE
Program Evaluation, CDC
PIMIRA
(Program-linked Information Management by Integrative-participatory
Research Approach), Kenya
RCT, RCTs
Randomized controlled trial(s)
RII
Relative index of inequality
SDH
Social determinants of health
SE
Socioeconomic
SES
Socioeconomic status
SHI
Social Health Insurance, Thailand
SIF
Social Investment Fund, Bolivia
STD
Sexually transmitted disease
TB
Tuberculosis
U5MR
Under five mortality rate
UC
Universal coverage
UCL
University College London, UK
UDD
Universidad del Desarrollo, Chile
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Constructing the evidence base on the social determinants of health: A guide
UDN
Uganda Debt Network
UK
United Kingdom
UNDP
United Nations Development Program
UNESCO
United Nation Educational, Scientific and Cultural Organization
UNICEF
United Nations Children’s Fund
USA
United States of America
WHO
World Health Organization
WHS
World Health Surveys
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