Andy Pennington

Group-based microfinance for collective empowerment: a systematic review of health impacts

Abstract Objective To assess the impact on health-related outcomes, of group microfinance schemes based on collective empowerment. Methods We searched the databases Social Sciences Citation Index, Embase, MEDLINE, MEDLINE In-Process, PsycINFO, Social Policy & Practice and Conference Proceedings Citation Index for articles published between 1 January 1980 and 29 February 2016. Articles reporting on health impacts associated with group-based microfinance were included in a narrative synthesis. Findings We identified one cluster-randomized control trial and 22 quasi-experimental studies. All of the included interventions targeted poor women living in low- or middle-income countries. Some included a health-promotion component. The results of the higher quality studies indicated an association between membership of a microfinance scheme and improvements in the health of women and their children. The observed improvements included reduced maternal and infant mortality, better sexual health and, in some cases, lower levels of interpersonal violence. According to the results of the few studies in which changes in empowerment were measured, membership of the relatively large and well-established microfinance schemes generally led to increased empowerment but this did not necessarily translate into improved health outcomes. Qualitative evidence suggested that increased empowerment may have contributed to observed improvements in contraceptive use and mental well-being and reductions in the risk of violence from an intimate partner. Conclusion Membership of the larger, well-established group-based microfinance schemes is associated with improvements in some health outcomes. Future studies need to be designed to cope better with bias and to assess negative as well as positive social and health impacts.

Development of an Urban Health Impact Assessment methodology: indicating the health equity impacts of urban policies

Background An overarching recommendation of the global Commission on Social Determinants of Health was to measure and understand health inequalities and assess the impact of action. In a rapidly urbanising world, now is the time for Urban HIA. This article describes the development of robust and easy-to-use HIA tools to identify and address health inequalities from new urban policies. Rapid reviews and consultation with experts identified existing HIA screening tools and methodologies which were then analyzed against predefined selection criteria. A draft Urban HIA Screening Tool (UrHIST) and Urban HIA methodology (UrHIA) were synthesised. The draft tools were tested and refined using a modified Delphi approach that included input from urban and public health experts, practitioners and policy makers. The outputs were two easy-to-use stand-alone urban HIA tools. The reviews and consultations identified an underpinning conceptual framework. The screening tool is used to determine whether a full HIA is required, or for a brief assessment. Urban health indicators are a readily available and efficient means of identifying variations in the health of populations potentially affected by policies. Indicators are, however, currently underutilised in HIA practice. This may limit the identification of health inequalities by HIA and production of recommendations. The new tools utilise health indicator data more fully. UrHIA also incorporates a hierarchy of evidence for use during impact analysis. The new urban HIA tools have the potential to enhance the rigour of HIAs and improve the identification and amelioration of health inequalities generated by urban policies.

The health impacts of women's low control in their living environment: A theory-based systematic review of observational studies in societies with profound gender discrimination.

Abstract We conducted a systematic review of observational evidence on the health impacts of womens low control/autonomy in the living environment in societies with profound gender discrimination and gender bias. Thirty observational studies of varying methodological quality were included. Overall, the evidence suggests that womens lower control or autonomy (for example lack of freedom of movement outside the home, lack of authority to access healthcare for sick children) was associated with poorer mental and physical health for women and higher morbidity and mortality for their children, after adjusting for their socioeconomic circumstances. Further studies are needed to disentangle and understand the pathways between low control and health outcomes in contexts of profound gender discrimination. This systematic review has highlighted the general low quality of the evidence base on this research question. It identifies the pressing need for high quality, longitudinal studies in the future. HighlightsTheory posits that restricted autonomy of women in societies with profound gender discrimination may lead to poorer health.Lower control over health determinants in their living environment may lead to poorer health outcomes for women and children.This theory‐based systematic review examined the impact of womens low control in the living environment on health outcomes.The evidence suggests that womens low control in their living environment is associated with adverse health outcomes.There are adverse effects on the health of women and their children in societies with profound gender discrimination.Further high quality longitudinal studies are needed to disentangle and understand these pathways in greater depth.

PP35 How are Health Inequalities Affected by Control in the Living Environment? A Critical Review of Theory

Background Recent public health strategies aim to increase the control, or power, that individuals, communities and populations have over decisions that affect their daily lives. While systematic reviews have revealed the health impact of measures to improve control in the work environment, evidence from the ‘living environment’ has not been synthesised. We conducted a critical review of proposed theories and causal pathways linking control in the living environment and socio-economic inequalities in health. Methods We identified theoretical discourses (published in books, academic papers, reports and policy documents) across a range of diverse fields, including: public health, social determinants of health and health inequalities; sociology/political science; and international development. Initially, seminal works were identified by experts. We then employed a ‘pearl-growing’ approach: hand-searching reference lists and asking key informants to identify additional publications. Theoretical elements were extracted and analytical frameworks developed to elucidate the pathways identified. Results On reviewing a substantial body of literature, we found the relationship between control in the living environment and health inequalities had been conceptualised at three levels: Personal level Low perceived control impacts on health via fatalism and hostility reactions, which are engendered by social position and the cumulative effects of chronic stress across the lifecourse. Micro/Meso level The immediate external environment, determined by social position, dictates opportunities for individuals and communities to exercise autonomy and control over their living conditions. This effect occurs at the individual, household and community levels, and is important for health via control beliefs (as above), people’s abilities to improve their living conditions and avoid disease risks, and through community trust and reciprocity. Macro level Socio-political structures and processes operate at the level of whole societies, stratifying access to resources and opportunities, or power, that people have to achieve good health. This can result in better health outcomes for low-income populations with greater gender equity; and negative outcomes for whole societies in which people lose the opportunity for control over their lives. Conclusion Theories proposed on how control in the living environment could lead to the generation of socio-economic inequalities in mental and physical health reveal a range of processes at individual, micro/meso and macro levels. The findings of this critical review are being used to inform a theory-led systematic review of empirical evidence examining the links between control and health. This will allow us to refine the conceptual pathways, and identify potential intervention points and promising interventions.

OP11 Missing Women? The Health Inequalities Impact of Low Control and Gender Discrimination: A Theory-Led Systematic Review of Observational Studies

Background Increasing control and empowerment are considered central to efforts to reduce health inequalities. From our critical review of theory, low control or powerlessness emerged as a potentially fundamental mechanism underlying social inequalities in health. Amartya Sen’s theories of “freedom” and “capabilities” to live a long and healthy life have been influential: focusing attention on the health consequences of a lack of freedom for women in contexts where there is pervasive gender discrimination. We conducted a systematic review, which addressed the question: what is the empirical evidence of the extent and nature of the relationship between control in the living environment and health-related outcomes, differentiated by gender, socio-economic status or ethnicity? Findings relating to gender inequalities are presented here. Methods Logic models developed from our critical review of theory were used to guide our search strategy and to locate relevant literature. Studies were identified by searching seven bibliographic databases, screening reference lists, consulting key informants and searching organisational websites. Observational studies of any design were included that addressed our review question. Data extraction and quality appraisal of included studies were carried out by two reviewers, with disagreements brought to the wider team for discussion. This was followed by a narrative synthesis. Results We identified 61 studies, 25 of which reported findings on the health-related outcomes of low control/discrimination against women, all but one set in low and middle-income countries. There is some evidence that women with low control have reduced freedom of movement and control over important determinants of health such as access to food and nutrition, household resources, healthcare, education, employment, land and property ownership and reproductive rights. For women, low control or autonomy was associated with increased anxiety, stress and depression, increased childhood malnutrition and mortality, higher fertility, poorer reproductive health and higher levels of violence against women. Son preference, in societies characterised by low female control and discrimination, is associated with poorer health outcomes that include reduced survival of girls and women; resulting in the phenomenon of “missing women”. The effects of gender discrimination on survival begin before birth through selective abortion of female foetuses, leading to distorted population demographics. Conclusion There is empirical evidence of an adverse impact on the health of women and female children living in societies in which they suffer low control and overt gender discrimination. Purposeful measures to improve the economic, social and political position of women in their societies are advocated to improve the situation.