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Operationalising Sen's Capability Approach: An application in public health

This seminar explores the operationalisation of Sen's Capability Approach in measuring outcome in public health interventions. It discusses the challenges and future research in cost-effective public health strategies.

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Operationalising Sen's Capability Approach: An application in public health

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  1. Operationalising Sen's Capability Approach: An application in public health Dr Paula Lorgelly Health Economics Appraisal Team (HEAT) Public Health and Health Policy

  2. Outline of seminar • Economic evaluations of public health interventions • An example • Sen’s Capability Approach • Operationalising the approach as a means of measuring outcome • Remaining challenges and future research

  3. Cost effective public health • UK background, Wanless (2004) recommended using “a consistent framework … to evaluated the cost effectiveness of interventions initiatives across health care and public health” • 2005 NICE’s remit expanded, now considers public health interventions

  4. Amended NICE reference case • Their approach to methods states: • … resources available in the health service and other available public funds • Cost consequence analysis to supplement cost utility analysis where appropriate

  5. Challenges of producing NICE PH guidance • Measuring benefit • Population based interventions • Equity vs. efficiency • Economic perspective • Time horizons • Quality of evidence • Cost effectiveness threshold • Chalkidou et al (2008) Health Economics

  6. Challenges of applying standard approaches • Methodological challenges of • Attributing outcomes to interventions • Measuring and valuing outcomes • Incorporating equity considerations • Identifying intersectoral costs and consequences • Public Health Research Consortium, York

  7. Measuring and valuing outcomes • QALYs are the reference case • Preference for using the EQ5D • No adjustment for equity • QALYs have their benefits • Public health vs health care interventions • But does the QALY framework (or descriptive system) capture all relevant outcomes

  8. My (HEAT’s) involvement • Section of Public Health and Health Policy • Strong collaborations with the Medical Research Council Social and Public Health Sciences Unit (MRC SPHSU) • Including a joint appointment (Liz Fenwick) • Involved in evaluating a range of social and public health interventions • Majority of which are complex

  9. Complex Public Health Interventions • Complex interventions • developing overtime • heterogeneous • “made up of various interconnecting parts” • Complex outcomes • Complex evaluation • Comparator group • Randomisation • Perspectives • Timescales

  10. An Example: GoWell • Glasgow Community Health and Well-being Research and Learning Programme • Multi-site, prospective study • Multi-intervention • Core stock refurbishment • Area transformation • Special areas • Peripheral estates • Baseline survey + follow-ups till 2013

  11. GoWell – outcomes • Individuals’ health and well-being • Physical health • Mental health • Health behaviours • Use of health services • Sense of ‘control’ and self-esteem • Neighbourhoods and communities • social participation, personal social networks • neighbourhood outcomes

  12. GoWell – economic evaluation • Cost-effectiveness (utility) • Which outcome? • Cost consequences • Implicit decision making

  13. Key question • How best to measure and value the outcomes of social and public health interventions?

  14. Capability Approach • Amartya Sen (1979, 1985) • Rejects normative evaluations based exclusively on commodities, income, or material resources • Resources are the means to enhance people’s well-being • Resource-based theories do not acknowledge that people differ in their abilities to convert resources into capabilities

  15. Wellbeing should be measured not according to what individuals actually do (functioning) but what they can do (capability)

  16. Benefits of using the CA • Evaluative space • Richer set of dimensions • QALYs have one dimension – health • Focus of evaluation • Equality of capability • Equity, rather than health maximisation

  17. Challenges of using the CA • How to operationalise a highly theoretical approach? • What is the set of ‘capabilities’? • How to estimate an index of capability? • How to value this index?

  18. Operationalising the CA • Literature largely conceptual • No gold standard with which to operationalise the CA • Value in operationalising • Issues • How can we choose relevant capabilities? • How can evaluations be sensitive to cultures?

  19. Nussbaum’s Central Human Capabilities Life Practical reason Bodily health Affiliation Bodily integrity Other species Senses, imagination and thought Play Emotions Control over one’s environment

  20. Nussbaum’s Central Human Capabilities Being able to live to the end of a human life of normal length . . . ; not dying prematurely . . . Life Practical reason Bodily health Affiliation Bodily integrity Other species Senses, imagination and thought Play Emotions Control over one’s environment

  21. Nussbaum’s Central Human Capabilities Life Practical reason Bodily health Affiliation Bodily integrity Other species Being able to move freely from place to place; being able to be secure against violent assault, including sexual assault . . . ; having opportunities for sexual satisfaction and for choice in matters of reproduction Senses, imagination and thought Play Emotions Control over one’s environment

  22. Nussbaum’s Central Human Capabilities Life Practical reason Bodily health Affiliation Being able to live for and in relation to others, to recognize and show concern for other human beings, to engage in various forms of social interaction; being able to imagine the situation of another and to have compassion for that situation; having the capability for both justice and friendship. . . . Being able to be treated as a dignified being whose worth is equal to that of others. Bodily integrity Other species Senses, imagination and thought Play Emotions Control over one’s environment

  23. Nussbaum’s Central Human Capabilities Life Practical reason (A) Political: being able to participate effectively in political choices that govern one’s life; having the rights of political participation, free speech and freedom of association . . . (B) Material: being able to hold property (both land and movable goods); having the right to seek employment on an equal basis with others . . . Bodily health Affiliation Bodily integrity Other species Senses, imagination and thought Play Emotions Control over one’s environment

  24. Anand and colleagues • Programme of work operationalising the capability approach • Sought to exploit secondary collected data, specifically the BHPS • Addition of further indicators • List of some 60+ capabilities aligned with Nussbaum’s ten (referred to as the OCAP) • Research explores links between life satisfaction/ happiness/wellbeing and capability

  25. This Project • This project aimed to: • further develop and refine the survey instrument as proposed by Anand et al • validate the instrument for use in public health evaluations • propose how future evaluations might employ the capability approach

  26. Phases/Stages • Phase I, Stage I • FG group discussions • Analysis of the YouGov questionnaire • Phase I, Stage II • Semi-structured interviews • Pilot postal survey • Phase II • Interviews and postal survey (for validation) • Phase III (now a PhD studentship) • Develop an index

  27. Phase I, Stage I findings • Focus Groups • Issues of: • Question interpretation • Ambiguous questions • Answer/response options • Question ordering • ‘Questionnaire refinement’

  28. Phase I, Stage I findings (cont.) • Factor analysis (YouGov questionnaire) • Factor loadings onto Nussbaum’s list • Correlations amongst multiple measures • Raised issues of measuring this so-called capability • yes or no, i.e. does or does not have the capability • or is there a degree of capability • ‘Questionnaire reduction’

  29. Item Reduction/Refinement • Key changes included: • Change option responses • Merged questions • Removed multiple questions, • Used more established questions • Refined the wording • Changed the ordering of the question • 64 specific capability questions to 43 specific capability questions

  30. Phase I, Stage II findings • Semi-structured interviews • Further clarification • Insight into respondents understanding of capabilities • Pilot postal survey + interview • Analysed quantitatively

  31. Further reduction/refinement • Ordering • Understanding and interpretation • Face validity for retention • Measured capability rather than functioning e.g. I appreciate and value plants, animals and the world of nature  I am able to appreciate and value plants, animals and the world of nature

  32. Phase II • 64 capability questions  43 capability questions  18 capability questions • 27 question questionnaire (24 questions on capability and demographics + 3 validation questions) • Sent to 1000 Glaswegian homes + 400 invites for interviews

  33. Final version • Postal and interview survey, N=198 • Characteristics of the sample • white (97%), • female (62%), • employed full-time (50%), • some form of higher education (45%) or no qualifications (24%), • married (30%), never married (34%), • no dependent children (69%), • no religion (35%), Presbyterian (26%), Catholic (28%), • household income of under £30,000 per year (61%), • average age 46 years old (range 19 to 91 years)

  34. Deprivation Population share Percentage Percentage decile Sampled responded 1 0.06 0.04 0.5 2 4. 83 2.88 6.7 3 0.00 0.00 0.0 4 5.00 2.98 3 .1 5 4.13 2.46 3.1 6 5.08 3.03 3.6 7 7.91 4.71 8.2 8 5.20 3.10 4.6 9 13.70 16.33 17.9 10 54.10 64.48 52.3 Deprivation of sample

  35. 1: Life • Until what age do you expect to live, given your family history, dietary habits, lifestyle and health status?

  36. 1: Life II • Deviations in life expectancy

  37. 2: Bodily Health • Does your health in any way limit your daily activities compared to most people of your age?

  38. 3: Bodily integrity • Please indicate how likely you believe it to be that you will be assaulted in the future (including sexual and domestic assault)?

  39. 4: Senses, imagination & thought • I am free to express my views, including political and religious views

  40. 5: Emotions • In the past 4 weeks, how often have you lost much sleep over worry?

  41. 6: Practical reason • I am free to decide for myself how to live my life

  42. 7: Affiliation • Outside any employment, in your everyday life, how likely do you think it is that you will experience discrimination

  43. 8: Species • I am able to appreciate and value plants, animals and the world of nature

  44. 9: Play • In the past 4 weeks, how often have you been able to enjoy your recreational activities?

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