Strategies for knowledge exchange for action to address place-based determinants of health inequalities: an umbrella review

BACKGROUND

Place-based health inequalities persist despite decades of academics and other stakeholders generating ideas and evidence on how to reduce them. This may in part reflect a failure in effective knowledge exchange (KE). We aim to understand what KE strategies are effective in supporting actions on place-based determinants and the barriers and facilitators to this KE.

METHODS

An umbrella review was undertaken to identify relevant KE strategies. Systematic reviews were identified by searching academic databases (Medline, Embase, Scopus, Web of Science) and handsearching. Synthesis involved charting and thematic analysis.

RESULTS

Fourteen systematic reviews were included comprising 105 unique, relevant studies. Four approaches to KE were identified: improving access to knowledge, collaborative approaches, participatory models and KE as part of advocacy. While barriers and facilitators were reported, KE approaches were rarely evaluated for their effectiveness.

CONCLUSIONS

Based on these four approaches, our review produced a framework, which may support planning of future KE strategies. The findings also suggest the importance of attending to political context, including the ways in which this may impede a more upstream place-based focus in favour of behavioural interventions and the extent that researchers are willing to engage with politicized agendas.

The role of social capital in participatory arts for wellbeing: findings from a qualitative systematic review

BACKGROUND

Social capital is often cited as shaping impacts of participatory arts, although the concept has not been systematically mapped in arts, health and wellbeing contexts. In wider health inequalities research, complex, differential, and sometimes negative impacts of social capital have been recognised.

METHODS

This paper maps of social capital concepts in qualitative research as part of the UK What Works for Wellbeing evidence review programme on culture, sport and wellbeing.

RESULTS

Studies often cite positive impacts of bonding and, to a lesser extent, bridging social capital. However, reported challenges suggest the need for a critical approach. Forms of linking social capital, such as reframing and political engagement to address social divisions, are less often cited but may be important in participatory arts and wellbeing.

CONCLUSIONS

Future research should further specify dimensions of social capital as well as their nuanced effects in arts, and wellbeing contexts.

Homelessness, health and the policy process: A literature review

Homelessness has serious consequences for the health of people experiencing homelessness, and presents a challenge to the provision of quality care by health services. Policymaking to address homelessness, as with other social determinants of health (SDH), is complicated by issues of complex causation, intersectoral working and the dominance of biomedicine within health policy. This paper investigates how policies addressing homelessness have been explored using formal policy process theories (PPT). It also examines how health (as an actor and an idea) has intersected with the issue of homelessness reaching policy agendas and in policy implementation. A systematised search of academic databases for peer-reviewed literature from 1986 to 2018 identified six studies of homelessness policy change from Australia, Canada, France and the United States. PPT were able to articulate the interplay of actors, ideas and structures in homelessness policymaking. When the health sector was involved, it tended to be in terms of healthcare service utilisation rather than a broader public health framework emphasising structural social determinants of homelessness. Tensions between differing the priorities of local homelessness actors and a biomedical evidence-based policy paradigm were noted. Future policy action on homelessness requires new models of intersectoral governance that account for the complexity of health determinants, a health workforce enabled to engage with the SDH, and meaningful inclusion of those with lived and living experience of homelessness in policy formulation.

How much evidence is there that political factors are related to population health outcomes? An internationally comparative systematic review

OBJECTIVES

To provide a 7-year update of the most recent systematic review about the relationships between political features and population health outcomes.

SETTING

Internationally comparative scholarly literature.

DATA SOURCES

Ten scholarly bibliographic databases plus supplementary searches in bibliographies and Google Scholar were used to update a previous systematic review. The final search was conducted in November 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

Any population health outcome measure, apart from healthcare spending.

RESULTS

73 unique publications were identified from the previous systematic review. The database searches to update the literature identified 45 356 raw records with 35 207 remaining following de-duplication. 55 publications were identified from supplementary searches. In total, 258 publications proceeded to full-text review and 176 were included in narrative synthesis. 85 studies were assessed at low risk of bias, 89 at moderate risk of bias and none at high risk of bias. Assessment could not be conducted for two studies that had only book chapters. No meta-analysis was conducted. 102 studies assessed welfare state generosity and 79 found a positive association. Of the 17 studies that assessed political tradition, 15 were found to show a positive association with the left-of-centre tradition. 44 studies assessed democracy and 34 found a positive association. 28 studies assessed globalisation and 14 found a negative association, while seven were positive and seven inconclusive.

CONCLUSIONS

This review concludes that welfare state generosity, left-of-centre democratic political tradition and democracy are generally positively associated with population health. Globalisation may be negatively associated with population health, but the results are less conclusive. It is important for the academic public health community to engage with the political evidence base in its research as well as in stakeholder engagement, in order to facilitate positive outcomes for population health.

Examining intersectional inequalities in access to health (enabling) resources in disadvantaged communities in Scotland: advancing the participatory paradigm

Background

Multiple structural, contextual and individual factors determine social disadvantage and affect health experience. There is limited understanding, however, of how this complex system works to shape access to health enabling resources (HER), especially for most marginalised or hard-to-reach populations. As a result, planning continues to be bereft of voices and lived realities of those in the margins. This paper reports on key findings and experience of a participatory action research (PAR) that aimed to deepen understanding of how multiple disadvantages (and structures of oppression) interact to produce difference in access to resources affecting well-being in disadvantaged communities in Edinburgh.

Methods

An innovative approach combining intersectionality and PAR was adopted and operationalised in three overlapping phases. A preparatory phase helped establish relationships with participant groups and policy stakeholders, and challenge assumptions underlying the study design. Field-work and analysis was conducted iteratively in two phases: with a range of participants working in policy and community roles (or ‘bridge’ populations), followed by residents of one Edinburgh locality with relatively high levels of deprivation (As measured by the Scottish Index of Multiple Deprivation, a geographically-based indicator. See http://www.gov.scot/Topics/Statistics/SIMD/DataAnalysis/SPconstituencyprofile/EdinburghNorthern-Leith). Traditional qualitative methods (interviews, focus groups) alongside participatory methods (health resource mapping, spider-grams, photovoice) were employed to facilitate action-oriented knowledge production among multiply disadvantaged groups.

Results

There was considerable agreement across groups and communities as to what healthful living (in general) means. This entailed a combination of material, environmental, socio-cultural and affective resources including: a sense of belonging and of purpose, feeling valued, self-esteem, safe/secure housing, reliable income, and access to responsive and sensitive health care when needed. Differences emerge in the value placed by people at different social locations on these resources. The conditions/aspects of their living environment that affected their access to and ability to translate these resources into improved health also appeared to vary with social location.

Conclusion

Integrating intersectionality with PAR enables the generation of a fuller understanding of disparities in the distribution of, and access to, HER, notably from the standpoint of those excluded from mainstream policy and planning processes. Employing an intersectionality lens helped illuminate links between individual subjectivities and wider social structures and power relations. PAR on the other hand offered the potential to engage multiply disadvantaged groups in a process to collectively build local knowledge for action to develop healthier communities and towards positive community-led social change.

Using evaluability assessment to assess local community development health programmes: a Scottish case-study

BACKGROUND

Evaluation of the potential effectiveness of a programme's objectives (health or otherwise) is important in demonstrating how programmes work. However, evaluations are expensive and can focus on unrealistic outcomes not grounded in strong theory, especially where there is pressure to show effectiveness. The aim of this research was to demonstrate that the evaluability assessment (a cost-effective pre-evaluation tool that primarily gives quick, constructive feedback) can be used to help develop programme and outcome objectives to improve programmes while they run and to assist in producing more effective evaluations. This was done using the example of a community development programme aiming to improve health and reduce health inequalities in its target population.

METHODS

The setting was Glasgow, Scotland, UK and focused on the Health Issues in the Community programme. Data were collected from documents and nine individual stakeholder interviews. Thematic analysis and a realist approach were used to analyse both datasets and, in conjunction with a workshop with stakeholders, produce a logic model of the programme theory and related evaluation options to explore further.

RESULTS

Five main themes emerged from the analysis: History; Framework; Structure and Delivery of the Course; Theory of Action; and Barriers to Delivery and Successful Outcomes. These themes aided in drafting the logic model which revealed they key programme activities (e.g. facilitating group learning) and 23 potential outcomes. The majority of these outcomes (16) were deemed to be short-term outcomes (more easily measured within the timeframe of an individual being involved in the programme) e.g. increased self-esteem or awareness of individual/community health. The remaining 6 outcomes were deemed longer-term and included outcomes such as increased social capital and individual mental health and wellbeing.

CONCLUSIONS

We have shown that the evaluability assessment tool can be applied to the evaluation of community health programmes, providing short- and long-term outcomes that could be evaluated to demonstrate effectiveness and avoid unnecessary or poorly designed full-scale evaluations. This type of pre-evaluation method is already a useful resource for national policy evaluations, but could be a valuable evaluation tool for other regional or community health programmes.

Does public health advocacy seek to redress health inequities? A scoping review

The public health (PH) sector is ideally situated to take a lead advocacy role in catalysing and guiding multi-sectoral action to address social determinants of health inequities, but evidence suggests that PH's advocacy role has not been fully realised. The purpose of this review was to determine the extent to which the PH advocacy literature addresses the goal of reducing health and social inequities, and to increase understanding of contextual factors shaping the discourse and practice of PH advocacy. We employed scoping review methods to systematically examine and chart peer-reviewed and grey literature on PH advocacy published from January 1, 2000 to June 30, 2015. Databases and search engines used included: PubMed, CINAHL, PsycINFO, Social Sciences Citation Index, Google Scholar, Google, Google Books, ProQuest Dissertations and Theses, Grey Literature Report. A total of 183 documents were charted, and included in the final analysis. Thematic analysis was both inductive and deductive according to the objectives. Although PH advocacy to address root causes of health inequities is supported theoretically and through professional practice standards, the empirical literature does not reflect that this is occurring widely in PH practice. Tensions within the discourse were noted and multiple barriers to engaging in PH advocacy for health equity were identified, including a preoccupation with individual responsibilities for healthy lifestyles and behaviours, consistent with the emergence of neoliberal governance. If the PH sector is to fulfil its advocacy role in catalysing action to reduce health inequities, it will be necessary to address advocacy barriers at multiple levels, promote multi-sectoral efforts that implicate the state and corporations in the production of health inequities, and rally state involvement to redress these injustices.