Inequalities and Effectiveness Evidence

1. Inequalitiesand Effectiveness Evidence Andrew Tannahill Head of Evidence for Action NHS Health Scotland

2. Tackling health inequalities: what works? • Do you want the short answer or the long answer?

3. A shorter answer – some pointers • Infant mortality – life circumstances and services • Problem of differential effectiveness of campaigns and individual-focused interventions… • …but some support for targeting and tailoring, eg: • smoking cessation (Bauld et al, 2007) • breastfeeding • Limited evidence from Healthy Living Centres/Initiatives • Environmental protection measures and child accidental injuries • Rehousing from slum areas – self-reported physical and mental health at 18 months (vs 9 months) • WHO Commission on Social Determinants of Health – Interim Statement (2007)….

4. CSDH Interim Statement • Highlights social determinants as ‘the causes of the causes’; refers to material, psychosocial and political empowerment, and ‘flourishing lives’ • Also refers to action on ‘the more immediate influences’ • ‘….social determinants approach bridges the artificial distinction between technical and social interventions… both are necessary aspects of action’ • Spotlights: early child development; education; urban living environment; working environment; contextualising behaviour (tobacco, alcohol, diet); multilevel, intersectoral action; social policy • But very little specific effectiveness evidence presented at this stage • Refers to 9 Knowledge Networks, including one on Measurement and Evidence • Final Report, based on evidence across all workstreams, due May 2008

5. A longer answer – some considerations • Dearth of inequalities-related effectiveness evidence • Multiple dimensions of inequality • Multiple action areas and levels, with interactions between them • Complex relationships between life circumstances, health-related behaviours and ill-health/good health • Compounding effects of adverse circumstances through the lifecourse • Skewing of available effectiveness evidence, in general • Fundamental limitations of a piece-by piece approach to effectiveness evidence • Need for clarity regarding aims and priorities • The place of evidence • Implications for decision making

6. Dearth of evidence on tackling inequalities • Better at describing the inequalities than showing how they can be reduced • Systematic reviews encounter lack of inequalities-related evidence from primary evaluations • Key word search in Cochrane yields few reviews • Books – contents vs covers • More evidence on effectiveness in general populations, but questions regarding applicability or adaptation to equality and diversity groups • Understandable tendency to propose solutions based on extrapolation from evidence linking life circumstances and health (what should or might work) rather than demonstrated effectiveness (what has worked)

7. Multiple dimensions of inequality • Eg: • individual socioeconomic status/educational attainment • area of residence • gender • ethnicity • disabilities • Not all inequality is inequity

8. Multiple action areas • Health topics – eg: cardiovascular health; cancer; healthy weight; mental health; sexual health; general health and wellbeing • Behaviour/lifestyle topics – eg: tobacco; alcohol; drugs; food and nutrition; physical activity • Stages in lifecourse/lifestages – preconception, pregnancy, birth and neonatal period; early years; middle and late childhood; teenage transition; working age and middle years; later life • Settings – schools/educational settings; workplace; health and social care settings; community and voluntary sector settings • Cross-cutting themes – eg: life circumstances/cultural influences; public/community engagement/involvement; partnership working; organisational issues; ‘upstream’ vs ‘downstream’ action in general

9. Multiple action levels: the ‘health improvement onion’, and culture Key to levels • Individuals • Families/groups • Communities • ‘Specific’ aspects of environment (eg tobacco control) • Wider health determinants (socioeconomic etc) • Culture (influenced by 1-5, and influences 1-5) 1 2 3 4 5 6

10. Complex relationships Good health Life circumstances Behaviours Ill-health

11. Skewing of available effectiveness evidence • Conventional approach to evidence reviewing/rating (imported from clinical practice) gives primacy to randomised controlled trials/systematic reviews of RCTs • RCTs have a place, but mainly for clinical/analogous interventions; other study designs are the best available for some types of action, notably including many policies; complex, multifaceted evaluations are needed for complex, multifaceted interventions • Conventional approach has led to skewing of the search for, and supply of, effectiveness evidence towards ‘core’ of onion • The actions/types of action on which there is the most ‘conventional’ evidence are not necessarily the most important • Need more fully fit-for-purpose approaches to effectiveness evidence for health improvement and tackling health inequalities (primary research and reviewing/overviewing)

12. Limitations of a piece-by-piece approach • ‘Unravelling gossamer with boxing gloves’ (Chapman, 1993) • ‘Unravelling gossamer with boxing gloves, blindfolded’ (Tannahill, today) • Even if we can evaluate lots of individual action ‘pieces’ of various sorts, what about the big picture ‘jigsaw’ – or ‘mosaic’? • Need ‘big picture’ comparisons (between populations, between places, between time periods) to assess the combined effectiveness of packages of actions, in relation to health overall and particular subject areas

13. Need for clarity regarding aims and priorities • Tackling the whole gradient or the greatest disadvantage? • Absolute or relative health inequalities, or both? • Overall, and for any given health or risk factor topic, what is the overarching priority? • To gain the maximum overall improvement in the health of the population as a whole? • To reduce health inequalities? (Absolute, relative or both? Whole gradient or greatest disadvantage?) • Is the prime driver health equity or social justice?

14. What is acceptable?

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20. Relative or absolute health inequalities:some evidence 1 • Lynch et al, 2006: ‘Conventional risk factors explain the majority of absolute social inequality in CHD…. However, the role of conventional risk factors in explaining relative social inequality was modest…. If the concern is to reduce the overall population burden of CHD and the disproportionate population health burden associated with the social inequalities in CHD, then reducing conventional risk factors will do the job.’

21. Relative or absolute health inequalities:some evidence 2 • Gruer et al (unpublished): ‘Smokers die younger than never-smokers regardless of sex or social position. As measured by mortality rates, smoking tobacco is a greater source of health inequality in this population than social position.’ • Analysis adds weight to notion that effectively tackling ‘conventional’ risk factors would have a substantial impact on absolute health inequalities, but less of an impact on relative health inequalities.

22. Focusing on ‘conventional’ risk factors:some considerations • Balance between action on life circumstances, specific policy measures, and individual-focused interventions; role of culture(s) • Potential opportunities for rapid impact through interventions with high risk individuals • How to target and tailor individual-focused interventions, and achieve mass reach/sustained engagement • Social justice and ethical dimensions

23. The place of evidence: king or courtier? • Current approaches to effectiveness evidence are not fully fit-for purpose • In any case, there will never be effectiveness evidence on everything • There is a place for theory as well as effectiveness evidence • Even with as much evidence as could realistically be imagined, effectiveness evidence alone would not be a sufficient base for health improvement decision making – eg: • we need to be able to innovate, using plausible theory • action for which there was evidence of effectiveness might not be considered desirable on ethical grounds • A broader base is needed – incorporating theory and ethics as well as evidence (on health issues, causal factors and effectiveness/harm) • We should think of evidence-informed policy and practice, not evidence-based

24. Implications for decision making? • Clarify aims and priorities, and make them explicit • Recognise – and reflect – the complexity • In public health, ‘and’ is usually a better word than ‘or’; notion of a concordant society • Shift focus from applying evidence/translating knowledge to decision making more broadly • Decisions should be based on explicit application of a set of ethical principles, making appropriate use of available evidence and theory to inform judgements