The ethics of social risk reduction in the era of the biological brain

Downing the Master's Tools? New Research Strategies to Address Social Determinants of Health Inequalities

A dramatic increase in the volume of research literature referencing social determinants of health (SDH) since the report of the World Health Organization Commission on the topic in 2008 has not been matched by expansion of policies and interventions to reduce health inequalities by way of SDH. This article argues that familiar hierarchies of evidence that privilege clinical epidemiology as used in evidence-based medicine are inappropriate to address SDH. They misunderstand both the range of relevant evidence and the value-based nature of standards of proof. A richer conceptual armamentarium is available; it includes several applications of the concepts of epidemiological worlds and the lifecourse, which are explained in the article. A more appropriate evidentiary approach to SDH and health inequalities requires "downing the master's tools," to adapt Audre Lorde's phrase, and instead applying a multidisciplinary approach to assessing the evidence that adequately reflects the complexity of the relevant causal pathways. Doing so is made more difficult by the power structures that shape research priorities, yet it is essential.

Can health equity survive epidemiology? Standards of proof and social determinants of health

OBJECTIVE

This article examines how epidemiological evidence is and should be used in the context of increasing concern for health equity and for social determinants of health.

METHOD

A research literature on use of scientific evidence of "environmental risks" is outlined, and key issues compared with those that arise with respect to social determinants of health.

RESULTS

The issue sets are very similar. Both involve the choice of a standard of proof, and the corollary need to make value judgments about how to address uncertainty in the context of "the inevitability of being wrong," at least some of the time, and to consider evidence from multiple kinds of research design. The nature of such value judgments and the need for methodological pluralism are incompletely understood.

CONCLUSION

Responsible policy analysis and interpretation of scientific evidence require explicit consideration of the ethical issues involved in choosing a standard of proof. Because of the stakes involved, such choices often become contested political terrain. Comparative research on how those choices are made will be valuable.

Integrating knowledge generation with knowledge diffusion and utilization: a case study analysis of the Consortium for Applied Research and Evaluation in Mental Health

OBJECTIVE

Knowledge diffusion and utilization (KDU) have become a key focus in the health research community because of the limited success to date of research findings to inform health policies, programs and services. Yet, evidence indicates that successful KDU is often predicated on the early involvement of potential knowledge users in the conceptualization and conduct of the research and on the development of a "partnership culture". This study describes the integration of KDU theory with practice via a case study analysis of the Consortium for Applied Research and Evaluation in Mental Health (CAREMH).

METHODS

This qualitative study, using a single-case design, included a number of data sources: proposals, meeting minutes, presentations, publications, reports and curricula vitae of CAREMH members.

RESULTS

CAREMH has adopted the following operational strategies to increase KDU capacity: 1) viewing research as a means and not as an end; 2) bringing the university and researcher to the community; 3) using participatory research methods; 4) embracing transdisciplinary research and interactions; and 5) using connectors. Examples of the iterative process between researchers and potential knowledge users in their contribution to knowledge generation, diffusion and utilization are provided.

CONCLUSIONS

This case study supports the importance of early and ongoing involvement of relevant potential knowledge users in research to enhance its utilization potential. It also highlights the need for re-thinking research funding approaches.