We define âadvocacy for health equityâ as âa deliberate attempt to influence decision makers and other stakeholders to support or implement policies that ...
Appendix 4. Selective Glossary of Terms
Advocacy for Health Equity We define “advocacy for health equity” as “a deliberate attempt to influence decision makers and other stakeholders to support or implement policies that contribute to improving health equity using evidence.” This stands in contrast to other kinds of advocacy, such as patient advocacy, which aims to ensure patients obtain the necessary care they are entitled to, or mental health advocacy, which aims to challenge discrimination faced by past and present users of mental health services. (See also Effectiveness, Evidence, Health Equity, Knowledge Transfer and Translation.)
Evidence “Evidence” is commonly understood as knowledge derived from qualitative and quantitative research and intended to be used to support a conclusion. A conclusion, in turn, may be composed of many different pieces of evidence arrived at by different research methods. There are disagreements over the qualities of evidence arising from different research methods, to the extent that “the value of evidence is in the eye of the beholder.”1 While the “hierarchy of evidence” can be a useful tool for assessing the strength of evidence, policymakers and other decision makers also value “lower standards of evidence” in making decisions.2,3,4 (See also Knowledge Transfer and Translation, Hierarchy of Evidence.)
Effective (Advocacy for Health Equity)
By “effective” we mean the likelihood that an advocacy effort will have the intended effect(s) and expected outcome(s). These could include having research evidence understood by decision makers, obtaining the support of politicians or businesses for a policy proposal, and changing the terms of a debate about the allocation of resources. Whether or not an advocacy effort is likely to be effective should be gauged against evidence derived from research examining advocacy. Because advocacy is so dependent on context, it may be difficult to derive useful lessons from the research methods that produce the very highest standards of evidence. (See also Advocacy for Health Equity, Evidence, Hierarchy of Evidence.)
Health Equity “Health equity” refers to the absence of systematic inequalities in health and to “an ethical concept, grounded in the principle of distributive justice.”5 It usually is used in aspirational terms, because inequalities are so pervasive and relate to many different factors (eg, biological, physical/environmental, behavioral, and social). The policy goal of moving toward equity in health therefore implies attempts to reduce health inequalities to a minimal level, though this minimal level may not be defined. (See also Health Inequalities.)
Health Inequalities “Health inequalities” are differences in the distribution of various measures of health among defined population groups. Some health inequalities are attributable to biological variations or behavioral choices, and others are attributable to the external environment or conditions that are mainly outside the control of the individuals concerned. Many others are more likely to result
from interplay of the environment, social stratification, and human behavior. This leads some scholars to talk about the “causes of the causes” of health inequalities. In contrast to disparities in health, which usually refer to racial or ethnic differences in health, health inequalities are measured across population groups rather than being concerned with comparisons between specific socially defined groups.6,7 (See also Health Equity.)
Hierarchy of Evidence A “hierarchy” is said to reflect the relative authority and strength of different types of biomedical research. Randomized controlled trials (RCTs) generally rank above cohort studies, and casecontrolled studies rank above cross-sectional surveys. There is debate about how useful the hierarchy of evidence is in health inequalities research, as many of the social determinants of health (SDHs) are not amenable to study using RCTs. Instead, the “lowest standards” of evidence often provide information about practices, perceptions, cultural contexts, and the reasons why interventions work, and they can generate hypotheses that can be tested using research methods associated with higher standards of evidence. As a result, researchers have found that filtering out all but the “highest standards of evidence” can result in useful studies— and evidence—being missed. A helpful way to organize and evaluate public health evidence might be to consider methodological appropriateness, that is, whether the research method can convincingly answer the question being asked.8,2,9,10 (See also Evidence.)
Knowledge Transfer and Translation Knowledge transfer (KT) is a term used to describe the one-way flow of evidence from researchers to potential users of the evidence, who includes policymakers, clinicians, and clients.
Lomas categorized three types of transfer activities: (1) diffusion—promoting general awareness via journals, newsletters, websites, and mass media; (2) dissemination—sharing research findings with particular stakeholders, for example, in workshops or seminars; (3) implementation—discussing barriers to implementation, for example, through face-to-face meetings with experts. Concerns have been raised about the effectiveness of KT because researchers, policymakers, and clinicians inhabit “different cultural worlds” and knowing the evidence does not necessarily lead to its being used in making decisions. Attention has thus shifted to bridging this “cultural gap” by translating knowledge so that it “resonates” with the target audience’s culture. Translation activities include consideration of (1) the message, (2) the target audience, (3) the messenger, (4) the knowledge transfer process and infrastructure, and 5) evaluation of success and effectiveness. We term both sets of practices “knowledge transfer and translation.11, 12, 13 (See also Evidence.)
Leveling Up Leveling up is a policy strategy to reduce health inequalities by improving the health status of disadvantaged groups to the level enjoyed by non-disadvantaged groups. The term is partly a response to criticism that policy strategies to reduce health inequalities can worsen the health of those who enjoy better health. Leveling up suggests instead that health inequalities can be reduced by improving the health of the worst off rather than by reducing the health of those who (currently) enjoy better health. Some scholars argue that leveling up should be a part of all local,
national, and international policies to increase the population’s health.14,15,16 (See also Socioeconomic Gradient in Health.)
Socioeconomic Gradient in Health The social gradient in health is the pervasive and linear increase in health that comes with a higher social position, as measured by class, economics, education, and so forth. Over time, the gradient as a whole tends to shift upward because the overall health of most groups is improving. The degree of improvement, however, tends to be greater the higher up the social gradient that one goes. This means that health can improve and health inequalities can become greater at the same time.17 (See also Inequalities in Health, Leveling Up.)
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10. Ogilvie D, Egan M, Hamilton V, Petticrew M. Systematic reviews of health effects of social interventions: 2. best available evidence: how low should you go? J Epidemiol Community Health. 2005;59(10):886-892. 11. Johnson LS. From knowledge transfer to knowledge translation: applying research to practice. OT Now. 2005;July/August:11-14. 12. Lomas J. Diffusion, dissemination, and implementation: who should do what? Ann NY Acad Sci. 1993;703:226-235; discussion 235-227. 13. Shonkoff JP. Science, policy, and practice: three cultures in search of a shared mission. Child Dev. 2000;71(1):181-187. 14. Whitehead M, Dahlgren G. Concepts and Principles for Tackling Social Inequities in Health: Levelling Up Part 1. Copenhagen: World Health Organization, Regional Office for Europe; 2006. http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf. Accessed February 7, 2014. 15. Dahlgren G, Whitehead M. Concepts and principles for tackling social inequities in health: Levelling Up Part 2. Copenhagen: World Health Organization, Regional Office for Europe; 2006. http://www.euro.who.int/_data/assets/pdf_file/0018/103824/E89384.pdf. Accessed February 7, 2014. 16. Davis JK, Sherriff N. The gradient evaluation framework (GEF): A European framework for designing and evaluating policies and actions to level-up the gradient in health inequalities among children, young people and their families. Brighton: University of Brighton; 2012. http://health-gradient.eu/wpcontent/uploads/2012/12/GEF_GefDocFinal.zip. Accessed 18/09/2014. 17. Marmot M, Allen J, Goldblatt P, et al. Fair Society, Healthy Lives. United Kingdom: Strategic Review of Health Inequalities in England post-2010; 2010. http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmotreview/fair-society-healthy-lives-full-report. Accessed February 6, 2014.
