Operationalising Sens Capability Approach: An application in public health

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

12. 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

13. GoWell � economic evaluation Cost-effectiveness (utility) Which outcome? Cost consequences Implicit decision making

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

15. 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

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

17. 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

18. 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?

19. 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?

20. Nussbaum�s Central Human Capabilities

25. 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

31. 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

32. 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

33. Phase I, Stage I findings Focus Groups Issues of: Question interpretation Ambiguous questions Answer/response options Question ordering �Questionnaire refinement�

34. 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�

35. 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

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

37. 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

38. 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

39. 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)

40. Deprivation of sample

41. 1: Life Until what age do you expect to live, given your family history, dietary habits, lifestyle and health status?

42. 1: Life II Deviations in life expectancy

43. 2: Bodily Health Does your health in any way limit your daily activities compared to most people of your age?

44. 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)?

45. 4: Senses, imagination & thought I am free to express my views, including political and religious views

46. 5: Emotions In the past 4 weeks, how often have you lost much sleep over worry?

47. 6: Practical reason I am free to decide for myself how to live my life

48. 7: Affiliation Outside any employment, in your everyday life, how likely do you think it is that you will experience discrimination

49. 8: Species I am able to appreciate and value plants, animals and the world of nature

50. 9: Play In the past 4 weeks, how often have you been able to enjoy your recreational activities?

51. 10: Control over one�s environment I am able to influence decisions affecting my local area

53. Aggregation How to develop an index given multi-dimensionality and the incompatible nature of the dimensions? Not uncharted water, Human Development Index has its foundations in the capability approach Ideally, should consider the relative importance of each domain and preferences/tradeoffs for each dimension

54. Preference elicitation Range of techniques available Standard gamble Time trade off (TTO) Rating scale Discrete choice experiments (DCE) Preference weights allow economic evaluations to consider technical and allocative efficiency But who�s preferences? Issues of adaptation and expert opinion

55. (gross) Estimate of capability Give each capability equal weight (that is each question not each domain) Maximum possible score of 18 Mean = 12.44, range: 3 � 17.75

56. Index of capability

57. Health/Wellbeing vs Capability

58. Inequalities and Capability

60. Capability vs Functioning

61. Implementing the approach Questionnaire/instrument appears valid and sensitive More appreciative evaluation space (for public health interventions) Issues of aggregation Valuation approaches Whose preferences Anchoring Acceptability to decision makers QALYs (EQ5D) are the norm

62. Future research ESRC/TSG studentship More participatory approach Consult with key stakeholders (public, academics and govt advisors) Core set of capabilities Test a range of valuation methodologies Validation of instrument in a number of nested GoWell studies

63. Discussion points Weighting dimensions, preference or otherwise? More detailed quantitative analysis, latent class? further reduction? (in)Compatibility of the dimensions problematic? Super-QALY? Or a WALY?

64. Contact details: p.lorgelly@clinmed.gla.ac.uk Final report available at: www.gcph.co.uk