Reduction of inequalities in health: assessing evidence-based tools

The Cochrane [7] and Campbell [8] collaborations were established to prepare, maintain and promote access to systematic reviews thereby helping consumers, policy-makers and clinicians make well-informed decisions. The Cochrane Collaboration reviews studies of the effects of health and health care policies and the Campbell Collaboration reviews the studies of educational, legal and social interventions.

Most reviews present information on effectiveness in terms of averages, without providing any indication of the effectiveness of interventions stratified by socio-economic gradients. If inequalities are present, the recommendation typically carries out statistical adjustment to remove the effect.

Plans to identify interventions that improve the status of the poor and reduce health inequities through a series of systematic reviews are now underway within the Cochrane and Campbell Collaborations. A Cochrane Equity Field has successfully been registered to help deal with the methodological issues that arise from incorporating equity into systematic reviews. Equity gradients relevant to informing policy and decision makers on the effectiveness of interventions include not only socioeconomic gradients but also gender, race, workforce, rural-urban, education and social capital gradients. Examples include those impacting on infections such as peer support for HIV, insecticide treated bed-nets, direct observation of therapy for TB, risk factors such as school nutrition programs, smoking prevention, and chronic conditions such as joint reconstructive surgery.

'Health Coaches' is an equity-oriented strategy designed to help disadvantaged populations to become better decision makers, negotiators, and navigators of the health system for their own health benefit. In a CIDA funded project in Chile, in partnership with the Pontifica Universidad Catolica de Chile (PUC) School of Nursing and the municipality of La Pintana, a proof-of-concept decision support program for disadvantaged women is being implemented to enhance women's evidence-based decision-making capacity in managing their own health and the health of their families [9]. Nursing students, primary care health professionals and individuals from the community receive training in 'coaching' rather than 'advising' to develop decision-making capacities rather than to create dependant relationships. Health coaches have access to evidence-based health information and decision aids. They provide information, clarify values, and develop skills in deliberation, communication, and behaviour change. Delivery of coaching and decision support can take the form of self-care manuals, online health information and decision aids, individual and group patient education and coaching sessions, skills training of primary care professionals, and population-based telephone call centres (Table 2). This program has recently received funding from a technology-transfer funder in Chile (FONDEF) to develop a call-centre in collaboration with a large telecommunications company in Chile.

Potential decision making capacity development applications include:

Policy-makers can access a generic decision aid at the Ottawa Patient Decision Aids Website [10]as well as a compendium of quality-assessed, evidence-based decision aids [11].

The CIET cycles and methods are a tool used to support local evidence-based planning, that is available from CIET [12]. In the 1980s, at least partly in response to the difficulties being experienced in setting priorities and acting to achieve them, CIET developed its population-based applications of modern epidemiology in health planning [13]. Combining an adapted cluster survey technique with qualitative methods for discussing evidence with communities and health workers, the CIET methods are intended to support evidence-based decision making at local and national level. Buy-in from stakeholders centred on the formulation of what to measure (impact, coverage and costs). Consistent with the Triple-A approach, it introduced reiterative cycles of uptake and sharing of evidence, supplemented by a capacity building approach including transfer of measurement skills and community capacity building (Figure 1). This approach introduced formal epidemiological analysis to identify actionable risk and resilience factors, and also incorporated the community voice in a structured way, through focus groups and community meetings. The 1990s saw CIET methods applied in 47 countries worldwide, addressing issues such as access to health care services, gender gap in education, food security, prevention of sexual violence and corruption. CIDA supports application of the CIET methods in Pakistan as a governance support mechanism, emphasizing the community building and equity implications of the methods.

The popularization of geographic information systems (GIS) opens a new horizon for evidence-based health planning. More complex data can be portrayed attractively and, as a consequence, more people can participate in evidence-based decision making. Planners need to identify the mix of circumstances under which a health intervention is effective, to quantify the gaps between the intended and the actual, and to present alternatives for closing them. CIETmap is a free geomatics and epidemiology software developed by the CIET group [14]. Figure 2 shows an application of the CIET map tool to illustrate geographic differences in responses to questions regarding sexual violence and HIV/AIDS in South Africa. The push-button mapping and analysis software allows users to generate maps as evidence-based decision aids directly from survey or routine institutional data. It combines raster and vector mapping techniques with epidemiological analysis tools. While no hardware or software can replace a solid practical training in epidemiology – and no technical training can replace a commitment to equity – customized epidemiological mapping software can provide an important tool for studying and comparing health indicators among and between different population groups.

CIET runs regular international training courses in the use of CIET methods. Interested users can inquire about these courses and training materials by contacting CIET International [15].

Community-level action may be a very effective way of reducing health inequalities. Communities have the power and freedom to identify priority health problems, and to use a phased approach to modify the cultural, political, economic and social context in order to effect change.

The Ottawa Equity Gauge project will measure, monitor and address health inequities in accidents, exercise, nutrition and smoking in Ottawa. It is based on the Global Equity Gauge Alliance's framework that has been implemented in 11 low and middle-income countries since 2000 [16]. This framework seeks to reduce health inequities through three broad spheres of action, described as pillars. These pillars are (Figure 3); 1)Assessment and Monitoring, 2)Advocacy, and 3)Community Empowerment. The Ottawa Equity gauge also emphasizes a fourth 'Intervention" pillar based upon Cochrane and Campbell systematic reviews of the interventions. The Ottawa Equity Gauge project brings together researchers, community leaders, and stakeholders. The current focus is on identifying food security and nutrition issues in Ottawa using a mix of participatory action research and systematic reviews of published and unpublished literature. Partners include representatives from non-governmental organizations (eg Ottawa Just Food, Centretown Community Health Centre) as well as policy-makers (City of Ottawa Health Department) and multiple disciplines from the University of Ottawa. The Ottawa Equity Gauge team has recently completed a survey to understand food insecurity in vulnerable populations in Ottawa that is now being used for advocacy. The Ottawa Equity Gauge team is now assessing spatial inequalities in food insecurity, with funding from the Canadian Institutes of Health Research. The Ottawa Equity Gauge has recently been approved as a GEGA associate and has recently co-supervised a Canadian Society of International Health Intern with Antoinette Ntuli of GEGA. The Global Equity Gauge Alliance has reference material on how to set up an Equity Gauge [17].

The Measurement and monitoring pillar involves the analysis, description and understanding of health inequities through the collection and collation of qualitative and quantitative data information [16]. This will identify targets for action and enable later evaluation on whether change has occurred. Some possible sources for data have already been selected including the Ottawa subsets of the 2001/02 Canadian Community Health Survey, the 1996/97 National Population Health Survey, the Canadian Fitness and Lifestyle Research Institute Survey, and the Ottawa Rapid Risk Factor Surveillance System. The Intervention pillar aims to address the lack of evidence that exists on the effectiveness of interventions to reduce health disparities through the accumulation and synthesis of research. Most notably this will involve systematically reviewing the evidence for public health interventions on low socio-economic groups, rather than just that of population averages. The information gained on the effectiveness of interventions as well as the data gathered from the monitoring pillar will improve the capacity for the promotion of pro-equity policies. Advocacy will be combined with a bottom up approach of community empowerment and capacity building. This pillar places importance on working with communities to help them speak more effectively for themselves, and building the capacity of individuals and community groups to improve their own health. An Equity Gauge therefore does not merely describe health disparities but rather couples data collection with coordinated community-driven actions and advocacy efforts to reduce disparities and help members of the community to reach their full health potential.

This toolkit was developed in response to the recommendations from the Ottawa Conference on Exploring Global Interfaces [18]. The Toolkit represents a valuable synthesis of methods to assemble the information on which clinical and health policy decisions about technologies can be based. The Toolkit uses the Technology Assessment Iterative Loop (TAIL) as an overall framework [19] & is accessible on the internet [20].

The toolkit focuses on choosing health interventions based on the health needs of a population, using an iterative approach. The iterative steps are: 1) Health needs assessment; 2) Priority setting and needs-based technology assessment; 3) Community effectiveness; 4) Cost-effectiveness; and 5) Policy, strategy and management. Step 6 involves re-iterating back to needs assessment to monitor the impact of needs-based health technology assessment. The tools in the five steps involve the input from many disciplines, for example; social scientists, health care professionals, biostatisticians, stakeholders and consumers, policy makers and computer specialists. This toolkit has been used as a training tool by the WHO Collaborating Centre for Health Technology Assessment. Furthermore, international research fellows and research interns have worked on chapters of the toolkit as part of their training. The toolkit has been widely disseminated at meetings including ISTAHC, the Global Forum, the Cochrane Collaboration and PAHO conferences.

The tool kit has focused on averages, but is now being expanded to include the above methods for assessing distributional issues so that equity gradients will be detected and included in any indicators. Peter Tugwell and colleagues have developed the equity-effectiveness loop framework to assess the "staircase effect" of reductions in efficacy in disadvantaged populations [21]. Its innovation will also lie in incorporating the new advances in knowledge translation (i.e. the development and evaluation of how these tools are being used and how to make these tools transferable). Case studies will be developed to describe successes and challenges in implementation [22].