The social determinants of health: Developing an evidence base for political action
Final Report from Measurement and Evidence Knowledge Network
Michael P. Kelly (Co-chair) - Josiane Bonnefoy (Co-chair)
World Health Organization - Commission on the Social Determinants of Health, 2007
Available online as PDf file [165p.] at: http://www.who.int/social_determinants/resources/mekn_report_10oct07.pdf
“……This report begins by identifying six problems which make developing the evidence base on the social determinants of health potentially difficult.
These are:
- lack of precision in specifying causal pathways;
- merging the causes of health improvement with the causes of health inequities;
- lack of clarity about health gradients and health gaps;
- inadequacies in the descriptions of the axes of social differentiation in populations;
- the impact of context on interpreting evidence and on the concepts used to gather evidence; and
- the problems of getting knowledge into action.
In order to overcome these difficulties a number of principles are described which help move the measurement of the social determinants forward. These relate to defining equity as a value; taking an evidence based approach; being methodologically diverse; differentiating between health differences, health gaps and health gradients; clarifying the causal pathways; taking both a structural and a dynamic approach to understanding social systems; and explicating potential bias.
The report proceeds by describing in detail what the evidence based approach entails including reference to equity proofing. The implications of methodological diversity are also explored. A framework for developing, implementing, monitoring and evaluating policy is outlined.
At the centre of the framework is the policy-making process which is described beginning with a consideration of the challenges of policies relating to the social determinants. These include the multi-causal nature of the social determinants themselves, the fact that social determinants operate over the whole of the life
course which is a considerably longer time frame than most political initiatives, the need to work intersectorally, and the removal of the nation state as the major locus of policy-making in many parts of the world.
The ways to make the case for policies are described and appropriate entry points and communications strategies are identified.
The next four elements of the framework are outlined in turn:
(a) evidence generation,
(b) evidence synthesis and guidance development,
(c) implementation and evaluation, and
(d) learning from practice. Finally the report describes the principal ways in which policies relating to the social determinants may be monitored….”
Contents
1 The challenge of measurement and evidence about the social determinants of health
1.1 Conceptual and theoretical issues
1.1.1 Causal pathways
1.1.2 The difference between the causes of health and the causes of health inequities
1.1.3 Accuracy of descriptions of the social structure
1.1.4 Context
1.1.5 Nature of health inequity gradients
1.1.6 Translation of knowledge into action
1.2 Eight principles for developing the evidence base
2 Taking an evidence based approach
2.1 The evidence based approach
2.2 ‘Equity proofing’
3 Gaps and gradients
3.1 Health gaps
3.2 Health gradients
3.3 Shape of health gradients...25
4 Framework for policy development, implementation, monitoring and evaluation
5 Getting social determinants on the policy agenda – making the case
5.1 SDH and the policy-making process
5.2 Conceptual models to inform policy-making
5.2.1 ‘Policy streams’ model
5.2.2 Network models
5.2.3 Policy failure model
5.2.4 Stages of policy development
5.3 Making the case
6 Generating evidence for policy and practice
7 Evidence synthesis and action
7.1 Synthesizing complex and diverse data
7.1.1 Systematic reviews of effectiveness
7.1.2 Evidence synthesis
7.1.3 Quantitative approaches to evidence synthesis
7.1.4 Qualitative approaches to evidence synthesis
7.1.5 Mixed approaches to evidence synthesis
7.1.6 Combining separate syntheses: the EPPI approach
7.2 Producing guidance for action
8 Effective implementation and evaluation
8.1 Health equity auditing, needs assessment and impact assessment
8.1.1 Health equity auditing
8.1.2 Health impact assessment
8.2 Organizational development and change management
8.3 Readiness for intersectoral action
8.4 Effective ways of involving local communities
8.5 Evaluation
9 Learning from practice
9.1 Why do we need to collect knowledge from practice?
9.2 What do we know about the features of an effective system for learning from practice?
9.3 What sorts of information should be collected?
10 Monitoring
10.1 Use of data to monitor health inequities
10.1.1 Measuring the magnitude of health inequities
10.2 Sources of health data
10.2.1 Vital statistics
10.2.2 Censuses
10.2.3 Population-based surveys
10.2.4 Health records
10.3 Issues in interpreting key equity stratifiers
10.3.1 Education
10.3.2 Occupation
10.3.3 Income
10.3.4 Gender
10.3.5 Ethnicity/ race/ caste/ tribe/ religion
10.3.6 Place of residence
10.4 Special issues in low and middle income countries
10.4.1 Measuring socioeconomic position and other social constructs
10.4.2 Sources of data on social inequalities in health
10.4.3 Interpreting data on social inequalities in health
10.5 Improvements in monitoring systems
11 Further issues for consideration
11.1 Attribution of effects and outcomes
11.1.1 General theories
11.1.2 Theories of change
11.1.3 Micro theories or programme theories
11.1.4 Tacit knowledge theories
11.1.5 Priorities for action
11.2 The challenge of policy
11.3 Hierarchies of evidence
11.4 Equity: relative or absolute?
11.5 Where further research and development is required
12 Conclusion
13 Recommendations for policy makers and practitioners
14 References
APPENDICES
I Measurement and Evidence Knowledge Network (MEKN) and its methods 113
II Illustrative case studies
Lead authors of final report:
Michael P. Kelly,
With Johan Mackenbach, Mark Exworthy, Jennie Popay, Peter Tugwell, Vivian Robinson, Sarah Simpson, Thelma Narayan, Landon Myer,
Tanja Houweling, Liliana Jadue, Francisca Florenzano
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