Evidence & Policy
A journal of research, debate and practice

Promoting action on structural drivers of health inequity: principles for policy evaluation

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  • 1 Australian National University, Australia
  • | 2 Flinders University, Australia
  • | 3 University of New South Wales, Australia
  • | 4 University of Liverpool, UK
  • | 5 Flinders University, Australia
  • | 6 University of Adelaide, Australia
  • | 7 Australian National University, Australia
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Background:

Insufficient progress has been made towards reducing health inequities, due in part to a lack of action on the root causes of health inequities. At present, there is a limited evidence base to guide policy decision making in this space.

Key points for discussion:

This paper proposes new principles for researchers to conduct health equity policy evaluation. Four key principles are presented: (1) where to evaluate – shifting from familiar to unfamiliar terrain; (2) who to evaluate – shifting from structures of vulnerability to structures of privilege; (3) what to evaluate – shifting from simple figures to complex constructs; and (4) how to evaluate – shifting from ‘gold standard’ to more appropriate ‘fit-for-purpose’ designs. These four principles translate to modifying the policy domains investigated, the populations targeted, the indicators selected, and the methods employed during health equity policy evaluation. The development and implementation of these principles over a five-year programme of work is demonstrated through case studies which reflect the principles in practice.

Conclusions and implications:

The principles are shared to encourage other researchers to develop evaluation designs of sufficient complexity that they can advance the contribution of health equity policy evaluation to structural policy reforms. As a result, policies and actions on the social determinants of health might be better oriented to achieve the redistribution of power and resources needed to address the root causes of health inequities.

  • Alkin, M.C. (2013) A tribute to Carol Weiss and her vision, American Journal of Evaluation, 34(3): 44244. doi: 10.1177/1098214013490226

    • Search Google Scholar
    • Export Citation
  • Anaf, J., Baum, F.E., Fisher, M., Harris, E. and Friel, S. (2017) Assessing the health impact of transnational corporations: a case study on McDonald’s Australia, Globalization and Health, 13(7): 116. doi: 10.1186/s12992-016-0230-4

    • Search Google Scholar
    • Export Citation
  • Baciu, A., Negussie, Y., Geller, A. and Weinstein, J.N. (2017) The root causes of health inequity, in A. Baciu, Y. Negussie, A. Geller and J.N. Weinstein (eds) Communities in Action: Pathways to Health Equity, Washington, DC: National Academies Press.

    • Search Google Scholar
    • Export Citation
  • Baker, P., Friel, S., Gleeson, D., Thow, A.M. and Labonte, R. (2019) Trade and nutrition policy coherence: a framing analysis and Australian case study, Public Health Nutrition, 22(12): 232937. doi: 10.1017/S1368980019000752

    • Search Google Scholar
    • Export Citation
  • Baum, F. (2005) Wealth and health: the need for more strategic public health research, Journal of Epidemiology and Community Health, 59(7): 54245, doi: 10.1136/jech.2004.021147.

    • Search Google Scholar
    • Export Citation
  • Baum, F. (2016) The New Public Health, 4th edn, Melbourne: Oxford University Press.

  • Baum, F. and Fisher, M. (2014) Why behavioural health promotion endures despite its failure to reduce health inequities, Sociology of Health and Illness, 36(2): 21325. doi: 10.1111/1467-9566.12112

    • Search Google Scholar
    • Export Citation
  • Baum, F., Lawless, A. and Williams, C. (2013) Health in all policies from international ideas to local implementation: policies, systems and organizations, in C. Clavier and E.de Leeuw, Health Promotion and the Policy Process, London: Oxford University Press, ch 10.

    • Search Google Scholar
    • Export Citation
  • Baum, F., Newman, L. and Biedrzycki, K. (2012) Vicious cycles: digital technologies and determinants of health in Australia, Health Promotion International, 29(2): 34960. doi: 10.1093/heapro/das062

    • Search Google Scholar
    • Export Citation
  • Bowen, S., Zwi, A.B., Sainsbury, P. and Whitehead, M. (2009) Killer facts, politics and other influences: what evidence triggered early childhood intervention policies in Australia? Evidence & Policy, 5(1): 532, doi: 10.1332/174426409X395394.

    • Search Google Scholar
    • Export Citation
  • Chan, M. (2013) WHO Director-general addresses health promotion conference: opening address at the 8th Global Conference on Health Promotion, https://www.who.int/director-general/speeches/detail/who-director-general-addresses-health-promotion-conference. doi:

  • Commission on Social Determinants of Health (2008) Closing the Gap in A Generation: Health Equity Through Action on the Social Determinants of Health, Final Report of the Commission on Social Determinants of Health, Geneva, Switzerland: World Health Organization.

    • Search Google Scholar
    • Export Citation
  • Deravin, L., Francis, K. and Anderson, J. (2018) Closing the gap in Indigenous health inequity: is it making a difference?, International Nursing Review, 65(4): 47783. doi: 10.1111/inr.12436

    • Search Google Scholar
    • Export Citation
  • Fisher, M., Freeman, T., Schram, A., Baum, F. and Friel, S. (2020) Implementing policy on next-generation broadband networks and implications for equity of access to high speed broadband: a case study of Australia’s NBN, Telecommunications Policy, 44(7): 101911, doi: 10.1016/j.telpol.2020.101911.

    • Search Google Scholar
    • Export Citation
  • Friel, S., Townsend, B., Fisher, M., Harris, P., Freeman, T. and Baum, F. (2021) Power and the people’s health, Social Science and Medicine, 282: 112, https://www.sciencedirect.com/science/article/abs/pii/S0277953621005050?via%3Dihub. doi: 10.1016/j.socscimed.2021.114173

    • Search Google Scholar
    • Export Citation
  • Gray, S. (2015) The Northern Territory Intervention: An Evaluation, Melbourne: Caastan Centre for Human Rights Law.

  • Harris, P., Baum F., Friel, S., Mackean, T., Schram, A., and Townsend, B. (2020) A glossary of theories for understanding power and policy for health equity, Journal of Epidemiology and Community Health, 74(6): 54852.

    • Search Google Scholar
    • Export Citation
  • Kelly, M.P., Morgan, A., Bonnefoy, J., Butt, J. and Bergman, V. (2007) The Social Determinants of Health: Developing An Evidence Base for Political Action, Final Report to World Health Organization Commission on the Social Determinants of Health from Measurement and Evidence Knowledge Network, Chile and London: Universidad del Desarrollo and National Institute for Health and Clinical Excellence.

    • Search Google Scholar
    • Export Citation
  • Kelly, Y., Sacker, A., Del Bono, E., Francesconi, M. and Marmot, M. (2011) What role for the home learning environment and parenting in reducing the socioeconomic gradient in child development? Findings from the Millennium Cohort Study, Archives of Disease in Childhood, 96(9): 83237. doi: 10.1136/adc.2010.195917

    • Search Google Scholar
    • Export Citation
  • Kickbusch, I. (2009) Policy Innovations for Health, New York: Springer.

  • Knai, C., Petticrew, M., Douglas, N., Durand, M.A., Eastmure, E., Nolte, E. and Mays, N. (2018) The public health responsibility deal: using a Systems-level analysis to understand the lack of impact on alcohol, food, physical activity, and workplace health sub-systems, International Journal of Environmental Research and Public Health, 15(12): 2895, doi: 10.3390/ijerph15122895.

    • Search Google Scholar
    • Export Citation
  • Kunst, A.E. (2017) Evaluation of health equity impact of structural policies, International Journal of Health Services, 47(3): 43239, doi: 10.1177/0020731417709960.

    • Search Google Scholar
    • Export Citation
  • Lasswell, H.D. and Kaplan, A. (2013) Power and Society: A Framework for Political Inquiry, New Jersey: Transaction.

  • Lee, J., Schram, A., Riley, E., Harris, P., Baum, F., Fisher, M., Freeman, T. and Friel, S. (2018) Addressing health equity through action on the social determinants of health: a global review of policy outcome evaluation methods, International Journal of Health Policy and Management, 7(7): 58192. doi: 10.15171/ijhpm.2018.04

    • Search Google Scholar
    • Export Citation
  • Link, B. and Phelan, J. (2005) Fundamental sources of health inequalities, in L.B. Rogut, J.R. Knickman, D. Mechanic and D. Colby (eds) Policy Challenges in Modern Health Care, Chapel Hill, NC: Rutgers University Press.

    • Search Google Scholar
    • Export Citation
  • Lloren, A., Liu, S., Herrin, J., Lin, Z., Zhou, G., Wang, Y., Kuang, M., Zhou, S., Farietta, T. and McCole, K. (2019) Measuring Hospital-specific disparities by dual eligibility and race to reduce health inequities, Health Services Research, 54(Suppl 1): 24354. doi: 10.1111/1475-6773.13108

    • Search Google Scholar
    • Export Citation
  • Mackean, T., Fisher, M., Friel, S. and Baum, F. (2020) A framework to assess cultural safety in Australian public policy, Health Promotion International, 35(2): 34051. doi: 10.1093/heapro/daz011

    • Search Google Scholar
    • Export Citation
  • Malmusi, D., Muntaner, C., Borrell, C. and SOPHIE investigators, S. (2018) Social and economic policies matter for health equity: conclusions of the SOPHIE project, International Journal of Health Services, 48(3): 41734. doi: 10.1177/0020731418779954

    • Search Google Scholar
    • Export Citation
  • Marmot, M. (2017) Social justice, epidemiology and health inequalities, European Journal of Epidemiology, 32(7): 53746. doi: 10.1007/s10654-017-0286-3

    • Search Google Scholar
    • Export Citation
  • National Aboriginal Community Controlled Health Organisation (2017) #NTIntervention: ten years on and what has been achieved?, https://nacchocommunique.com/2017/06/23/naccho-aboriginal-health-ntintervention-ten-years-on-and-what-has-been-achieved/.

    • Search Google Scholar
    • Export Citation
  • Ogilvie, D., Cummins, S., Petticrew, M., White, M., Jones, A. and Wheeler, K. (2011) Assessing the evaluability of complex public health interventions: five questions for researchers, funders, and policymakers, Milbank Quarterly, 89(2): 20625. doi: 10.1111/j.1468-0009.2011.00626.x

    • Search Google Scholar
    • Export Citation
  • Paradies, Y.C. (2006) Defining, conceptualizing and characterizing racism in health research, Critical Public Health, 16(2): 14357, doi: 10.1080/09581590600828881.

    • Search Google Scholar
    • Export Citation
  • Partridge, E. (2013) Caught in the same frame? The language of evidence-based policy in debates about the Australian Government ‘intervention’ into Northern Territory Aboriginal Communities, Social Policy and Administration, 47(4): 399415. doi: 10.1111/spol.12026

    • Search Google Scholar
    • Export Citation
  • Pawson, R. and Tilley, N. (1997) Realistic Evaluation, London: Sage.

  • Popay, J., Williams, G., Thomas, C. and Gatrell, T. (1998) Theorising inequalities in health: the place of lay knowledge, Sociology of Health and Illness, 20(5): 61944, doi: 10.1111/1467–9566.00122.

    • Search Google Scholar
    • Export Citation
  • Ruckert, A., Schram, A., Labonté, R., Friel, S., Gleeson, D. and Thow, A.M. (2017) Policy coherence, health and the sustainable development goals: a health impact assessment of the Trans-Pacific Partnership, Critical Public Health, 27(1): 8696. doi: 10.1080/09581596.2016.1178379

    • Search Google Scholar
    • Export Citation
  • Schram, A., Aisbett, E., Townsend, B., Labonté, R., Baum, F. and Friel, S. (2019) Toxic trade: the impact of preferential trade agreements on alcohol imports from Australia in partner countries, Addiction, 115(7): 127784. doi: 10.1111/add.14925

    • Search Google Scholar
    • Export Citation
  • Schram, A., Friel, S., Freeman, T., Fisher, M., Baum, F. and Harris, P. (2018) Digital infrastructure as a determinant of health equity: an Australian case study of the implementation of the National Broadband Network, Australian Journal of Public Administration, 77(4): 82942. doi: 10.1111/1467-8500.12323

    • Search Google Scholar
    • Export Citation
  • Slama, K. (2010) Tobacco Control and Health Equality, London: Sage.

  • Stepanikova, I. and Oates, G.R. (2017) Perceived discrimination and privilege in health care: the role of socioeconomic status and race, American Journal of Preventive Medicine, 52(1S1): S8694, doi: 10.1016/j.amepre.2016.09.024.

    • Search Google Scholar
    • Export Citation
  • Swinburn, B.A. et al (2019) The global syndemic of obesity, undernutrition, and climate change: The Lancet commission report, The Lancet, 393(10173): 791846, doi: 10.1016/S0140-6736(18)32822–8.

    • Search Google Scholar
    • Export Citation
  • Thow, A.M., Snowdon, W., Labonté, R., Gleeson, D., Stuckler, D., Hattersley, L., Schram, A., Kay, A. and Friel, S. (2015) Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases? A prospective policy analysis of the Trans-Pacific Partnership agreement, Health Policy, 119(1): 8896. doi: 10.1016/j.healthpol.2014.08.002

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Friel, S., Baker, P., Baum, F. and Strazdins, L. (2020a) How can multiple frames enable action on social determinants? Lessons from Australia’s paid parental leave, Health Promotion International, 35(5): 97383. doi: 10.1093/heapro/daz086

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Friel, S., Schram, A., Baum, F. and Labonté, R. (2020b) What generates attention to health in trade policymaking? Lessons from success in tobacco control and access to medicines: a qualitative study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership, International Journal of Health Policy and Management, 10(10): 61324. doi: 10.34172/IJHPM.2020.80.

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Schram, A., Baum, F., Labonté, R. and Friel, S. (2020c) How does policy framing enable or constrain inclusion of social determinants of health and health equity on trade policy agendas?, Critical Public Health, 30(1): 11526. doi: 10.1080/09581596.2018.1509059

    • Search Google Scholar
    • Export Citation
  • Townsend, B., Schram, A., Labonté, R., Baum, F. and Friel, S. (2019) How do actors with asymmetrical power assert authority in policy agenda-setting? A study of authority claims by health actors in trade policy, Social Science and Medicine, 236: 19, doi: 10.1016/j.socscimed.2019.112430.

    • Search Google Scholar
    • Export Citation
  • Wardle, J., von Wagner, C., Kralj-Hans, I., Halloran, S.P., Smith, S.G., McGregor, L.M., Vart, G., Howe, R., Snowball, J. and Handley, G. (2016) Effects of evidence-based strategies to reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer Screening Programme (ASCEND): four cluster-randomised controlled trials, The Lancet, 387(10020): 75159. doi: 10.1016/S0140-6736(15)01154-X

    • Search Google Scholar
    • Export Citation
  • Weiss, C.H. (1997) Theory-based evaluation: past, present, and future, New Directions for Evaluation, 76: 4155. doi: 10.1002/ev.1086

  • Weiss, C.H. (1999) The interface between evaluation and public policy, Evaluation, 5(4): 46886. doi: 10.1177/135638909900500408

  • Whitehead, M. (1991) The concepts and principles of equity and health, Health Promotion International, 6(3): 21728. doi: 10.1093/heapro/6.3.217

    • Search Google Scholar
    • Export Citation
  • Whitehead, M. et al. (2015) Natural Policy Experiments and Their Impact On Health Inequalities: A Guide for Evaluation, Liverpool: University of Liverpool and Erasmus Medical Centre.

    • Search Google Scholar
    • Export Citation
  • Whitehead, M. and Dahlgren, G. (2006) Concepts and Principles for Tackling Social Inequities in Health: Levelling up Part 1, Geneva: World Health Organization.

    • Search Google Scholar
    • Export Citation
  • Woolf, S.H. (2019) Necessary but not sufficient: why health care alone cannot improve population health and reduce health inequities, Annals of Family Medicine, 17(3): 19699. doi: 10.1370/afm.2395

    • Search Google Scholar
    • Export Citation
  • Ziegler, T.B. et al. (2019) Shifting from ‘community-placed’ to ‘community-based’ research to advance health equity: a case study of the heatwaves, housing, and health: increasing climate resiliency in Detroit (HHH) Partnership, International Journal of Environmental Research and Public Health, 16(18): 3310. doi: 10.3390/ijerph16183310

    • Search Google Scholar
    • Export Citation
  • 1 Australian National University, Australia
  • | 2 Flinders University, Australia
  • | 3 University of New South Wales, Australia
  • | 4 University of Liverpool, UK
  • | 5 Flinders University, Australia
  • | 6 University of Adelaide, Australia
  • | 7 Australian National University, Australia

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