Purpose of this section
In section 1 you were asked to clarify the health inequalities and the socio-economic causes of these inequalities that influence the problem you want to focus on. The purpose of section 2 is to make sure that your activity considers how the socio-economic circumstances in which people live and work may act as barriers to your intervention.
Whether you are planning to evaluate an intervention or a new service model, an implementation project, a systematic evidence review or a capacity-building activity, you should explain how and why your work will attempt to reduce health inequalities, by addressing some of the socio-economic causes of inequalities identified in section 15-7.
These types of explanations are sometimes referred to as ‘theories of change’ or ‘logic models’8. You may also want to consider longer-term outcomes relevant to health inequalities. Even though measuring these outcomes may not be within the timeline of your project, it can provide a case to get funding for a longer-term evaluation of the effect of your work on health inequalities. However, if your intervention is a new model of care, you could collect routine data to assess the long-term effect of your interventions (see section 4).
Finally, you need to explain how members of the public have contributed to planning your proposed action.
5 Welch, V., et al. PRISMA-Equity 2012 extension: reporting guidelines for systematic reviews with a focus on health equity. Revista Panamericana de Salud Pública 34, 60-67 (2013).
6 Aldrich, R., Kemp, L., Williams, J.S. & Harris, E. Using socioeconomic evidence in clinical practice guidelines. British Medical Journal 327, 1283 (2003).
7 Tugwell, P., de Savigny, D., Hawker, G. & Robinson, V. Applying clinical epidemiological methods to health equity: the equity effectiveness loop. British Medical Journal 7537, 358 (2006).
8 Whitehead, M. A typology of actions to tackle social inequalities in health. Journal of Epidemiology and Community Health 61, 473-478 (2007).
An example of using the Toolkit: Increasing uptake of Health Checks
Section 2: Reducing socio-economic barriers to uptake of health checks
As a result of the section 1 assessment, the team decided to concentrate on people with South Asian heritage aged 45 to 70, particularly those living in economically disadvantaged circumstances. In their initial proposal, the team had identified three factors that limit the uptake of health checks – poor understanding of the risks of cardiovascular disease (CVD), cultural mistrust of the medical establishment, and poor communication within primary care. To deal with these issues, the team planned to improve knowledge and communication, using health trainers to increase ‘health literacy’ in the target group. This involved creating more culturally appropriate information resources, and training staff to increase cultural awareness.
However, discussions resulting from questions in section 1 and with people of South Asian heritage highlighted other socio-economic barriers to uptake of health checks and which affect whether people act on health advice. These barriers included location and time of appointments and difficulties taking time off work or caring responsibilities.
As a result of these discussions, the team revised their plan, to do the following:
- • Include initial research into people’s experiences of health checks and how they could be redesigned to meet people’s needs and restrictions.
- • Work with primary care to provide health checks in local mosques and other community settings so they are more locally accessible.
- • Training staff on the socio-economic causes of health inequalities and barriers to people using preventive services (such as, institutional racism, lack of appointments at convenient times, and problems with access (for example, people may not have access to a car or reliable public transport).
- • The team also recognized that the health trainers needed to be acceptable to the target group. Ideally they should be from South Asian communities, and the team decided to look into whether it would be possible for the target communities to be involved in choosing the health trainers.
A number of issues arose from the team’s discussion of the possible negative consequences of their plan.
- • Diverting resources for health checks into mosques alone would mean reduced access and lower rates of uptake for people who won’t or can’t go to mosques, so the team decided that they needed to include other locations in the community.
- • The ‘logic model’ linking increased uptake of health checks to reduced risk of CVD and other conditions depended on people identified as ‘at risk’ being able to act on the advice they were given. The team recognized that some socio-economic factors affecting the uptake of health checks could also affect whether people take (and continue with) medication, or take advice about changing their diet or becoming more active (for instance, neighbourhoods may be unsafe, or may not have affordable gyms or accessible pavements and parks). Suggestions for how these risks could be reduced included:
- • providing more support from health trainers for people at risk to help them act on recommendations; and
- • finding wider support and resources for people at risk of CVD or other health problems during the health check.
Graham, H. and M.P. Kelly (2004), Health inequalities: concepts, frameworks and policy. Health Development Agency London.
Aldrich, Rosemary, et al. Using socioeconomic evidence in clinical practice guidelines. BMJ: British Medical Journal 327.7426 (2003): 1283.
Tugwell, P., de Savigny, D., Hawker, G., and Robinson, V. (2006). Applying clinical epidemiological methods to health equity: the equity effectiveness loop. Bmj, 332(7537), 358-361.
O'Neill, J., et al., Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health. Journal of clinical epidemiology, 2014. 67(1): p. 56-64.
Ueffing, E., et al., Equity checklist for systematic review authors. Version 2012-10-04. 2009: Campbell & Cochrane Equity Methods Group.
Welch, V., et al., PRISMA-Equity 2012 extension: reporting guidelines for systematic reviews with a focus on health equity. Revista Panamericana de Salud Pública, 2013. 34(1): p. 60-67.
Welch, Vivian A., et al. (2013) Health equity: evidence synthesis and knowledge translation methods. Systematic reviews 2.11-10.
Hankivsky, O. Christoffersen, A.(2008). Intersectionality and the determinants of health: a Canadian perspective. Critical Public Health 18.3: 271-283.
Hosseinpoor, A.R., et al. (2014) Equity-oriented monitoring in the context of universal health coverage. PLoS medicine. 11(9): p. e1001727.
Lorenc, T., Petticrew, M., Welch, V., & Tugwell, P. (2013). What types of interventions generate inequalities? Evidence from systematic reviews. Journal of epidemiology and community health, 67(2), 190-193.
Yukiko, A. (2010), A framework for measuring health inequity. In Hofrichter, R. and R. Bhatia (Eds.) Tackling health inequities through public health practice: Theory to action. New York, Oxford University Press, pp.112-124.
Videos and illustrations of fundamental concepts on health inequalities - developed by the World Health Organization
Interactive graph "Monitoring health inequality: An essential step for achieving health equity". Geneva and the WHO Health Equity Monitor (2014)
Table 1 illustrating case studies looking at differences in health across PROGRESS factors is a helpful aid to demonstrate examples of effective interventions that reduce the burden of disease. In O'Neill, Jennifer, et al. (2014), Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health. Journal of clinical epidemiology 67(1), p. 59.
Table 1 illustrating exemplary systematic reviews which highlight how equity was considered to assess the effects of the intervention (a) on disadvantaged populations; (b) aimed at reducing the social gradient; (c) not aimed at reducing inequality but where it is important to understand the effects of the intervention on equity. In Welch, Vivian A., et al. (2013) Health equity: evidence synthesis and knowledge translation methods. Systematic reviews 2(1), pp: 3-4.
Public Involvement resources
Example of co-design for developing a support package for carers of patients undergoing chemotherapy – by the Kings Fund.
Brown, P., Popular epidemiology: Community response to toxic waste-induced disease in Woburn, Massachusetts. Science, Technology, and Human Values, 1987: p. 78-85.
Lynn, H. and Ward, D. (2002). Putting Breast Cancer on the Map in Britain. In Cornwall, Andrea, and Alice Welbourn (eds). Realizing Rights. Transforming Approaches to Sexual and Reproductive Well-Being. Zed Books, pp. 49-59.
Real-world HIAT Assessment Examples
STEP Service Evaluation – the service aims to reduce avoidable A&E attendances. Blackburn with Darwen Borough Council
Community Connectors. Sefton CVS
Evaluating the impact of Liverpool Community Care Teams. Liverpool CCG