Two major health inequality reports were recently released, one in the UK and the other in the US. This is the final post in a series which seeks to better understand the health perspective of these reports. In the first post we talked about the implications of how researchers frame their studies. In the second post we discussed the challenges to building evidence on the social determinants of health (SDOH). In the third post we presented 8 principles which help overcome these challenges. Using these principles as a framework, we will now evaluate the health perspective of the two reports.
Action on the social determinants of health requires that evidence be generated using sound methodological approaches. These approaches must be appropriate to the research questions being asked which in turn should be derived from a specifically defined problem. We will first look at the background of the two reports to get an idea for their specific aims. We will then look at the reports’ adherence to the 8 principles in hopes of gaining a better understanding of each study’s health perspective.
Background of Reports:
County Health Rankings(CHR): CHR is a major component of the US-based Mobilizing Action Toward Community Health (MATCH) project and a collaborative effort between The Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. The CHR project was developed specifically to fulfill MATCH’s first objective: Increase awareness of the many factors that contribute to the health of communities. Researchers hope this increased awareness will ultimately catalyze multi-sector action that will improve health and reduce health inequalities within America.
The final report presents data for every county in each of the 50 States and ranks them both on measures of health outcomes and health determinants. Outcome data includes measurements of both mortality and morbidity. Specific health determinants were chosen across four broad categories, each weighted for its contribution to health: Health Behaviors (30%), Clinical Care (20%), Socio-economic Factors (40%) and Physical Environment (10%). Specific indicators were chosen “based on a review of the literature, expert opinion, and data analysis”.
Fair Society, Healthy Lives (FSHL): Fair Society, Healthy Lives was commissioned by the UK government to “assemble the evidence and advise on the development of a health inequalities strategy in England”. Enlisting the help of nine task groups, researchers relied on scientific evidence, but also “engaged widely with stakeholders and attempted to learn from their insights and experience”. Chair Commissioner, Michael Marmot, was keen to expose the ideological position behind the work, stating that health inequalities are unfair, and “putting them right is a matter of social justice”.
As can be judged from their backgrounds, both projects seek to reduce health inequalities in their respective countries. Both also emphasize the importance of multi-sector engagement. In a previous post we exposed 8 principles that provide a framework for developing evidence on the social determinants of health. By judging the projects’ adherence to these principles we hope to better understand the health perspective of these studies.
Health Perspectives:
The first principle emphasizes that research on SDOH should assert a commitment to equity and specifically the Right to good health for all populations. While FSHL strongly advocates that equality in health is “a matter of fairness and social justice”, it does not make the explicit claim that health is indeed a human right. CHR makes an even smaller commitment to the idea of equity. It exposes only broad health inequalities that exist across county lines and does so neither through a lens of fairness, social justice nor human rights.
Related to a studies’ degree of commitment to equity is the second principle that specifies the need to ensure that the right types of questions are being asked and that appropriate methods are being used to answer them. Both studies are concerned with the reduction of health inequalities. However, CHR’s lack of commitment to equity has serious implications for its entire methodological approach. For instance, CHR’s framework for compiling data neither expands our conceptualizations of evidence nor does it draw on wide range of research, both key components of the third principle. The report also completely ignores principle four by excluding from its analysis the systematic differences in health outcomes across various social groups. By contrast, FSHL incorporates evidence from a wide variety of stakeholders and focuses entirely on the the health gradient within the UK.
The fifth principle specifies that research should strive to move beyond descriptions of observations to the identification of causal mechanisms. CHR has a comprehensive model that incorporates the influence of programs and policies on health determinants but it is extremely linear and disregards the interplay and interaction of various determinants. Additionally, while CHR accounts for a lag time between determinants and their health impacts, this consideration pales in comparison to the emphasis placed on the lifecourse perspective in FSHL. In sum, while CHR assigns different weights to the health impact of clinical care, behavioral influences, socio-economic conditions, and the physical environment, FSHL explains how socio-economic conditions influence all of these determinants, from access to care to an individual’s choice to engage in unhealthy behaviors. FSHL also demonstrates how specific policies such as taxes and wage laws influence the structural determinants of health, something which is less explicit in CHR.
Excluding the many axes of differentiation in a society from its analysis, CHR also fails to meet both principles 6 and 7 which emphasize the need to accurately describe dynamic social structures. In contrast, FSHL integrates into its report a framework for both reducing and monitoring reductions in health inequalities across time and various axes of differentiation.
The eighth and final principle, highlights the need for bias to be explicated in a way which allows us to understand any political biases inherent in the research. This permits us to determine to what level these biases have influenced the selection and interpretation of the evidence. FSHL’s ideologic premise is eagerly explicated early on the report. However, while CHR does a good job of making it’s scientific methodology transparent and its evidence easily accessible, no political biases are acknowledged.
Understanding variations in how health inequality research is pursued is important because different health perspectives can undermine attention to the broader determinants of health inequalities and hinder the development of healthy public policies.
Implications of Health Perspectives:
There are three main implications of CHR’s health perspective. First, with no acknowledgment of the Universal Right to Health, CHR sets no precedent for health campaigns to approach health as a governmental responsibility.
Second, without highlighting the social gradient in health, the report fails to direct appropriate attention to the upstream decisions and institutions responsible for the unequal distribution of resources necessary for health.
A third implication is that while CHR may catalyze action that improves health on a population level, it is possible that large inequalities across social groups will persist. The social determinants of health are not necessarily the same as the social determinants of health inequalities. Health inequalities are linked to social disadvantage. Social disadvantage is systematically distributed and responsible for the social gradient in health, which remains consistently under reported in CHR.
CHR intends to be a “call to action”, helping “community leaders see that where we live, learn, work, and play influences how healthy we are and how long we live”. Therefore, it may be argued that exposing health inequalities across social gradients was not the intention of the report. Indeed the issue is indirectly addressed in the FAQ section of their website with a question that asks: How do you account for the fact that a number of the measures used may hide disparities that exist in the county? CHR responds by encouraging “communities to use the Rankings as a starting point to delve more deeply into data that may highlight the disparities within counties”.
Community-driven solutions to health inequalities are essential. However, in order to identify and tackle the social determinants of health inequalities, communities must first know what they are and be able to accurately describe them. CHR offers little strategic or comprehensive direction in this regard.
FSHL manages to tackle each of the eight principles. While it doesn’t explicitly acknowledge health as human right, it does show a strong commitment to equity. Like CHR it emphasizes the role communities play in reducing inequalities. Outlined in the UK report however is a much more comprehensive strategy for various communities to work from. One that encourages policies which have a “proportionate effect across the social gradient” as well as the lifecourse.
Conclusion:
The true policy implications of both reports remains to be seen. The differences between the two reports and how health inequalities are approached is however, astounding.
Michael Marmot, Chair of the FSHL project, also chaired the WHO’s Commission on Social Determinants of Health (CSDOH). He had a significant role in the release of CSDOH’s final report: Closing the Gap in a Generation, released in August 2008. Fair Society, Healthy Lives is the UK’s response to this report. It could therefore be argued that his perspective is better aligned with the principals of developing research on health inequalities than researchers of CHR. However, Dr. Gail Wilensky is an advisor to the Robert Wood Johnson Foundation and was also a Commissioner on the WHO’s CSDOH.
Moreover, evidence linking social disadvantage to health is not new. It is widely available and in fact, much of the evidence comes from the US. In a background report CHR even makes reference, albeit scant, to the social gradient and Michael Marmot’s work.
Despite their difference in perspective, both reports deserve attention and discussion.
Excellent post! Principles, not principals
Thanks