Patricia O’Campo

A scoping review of intersectoral action for health equity involving governments

ObjectivesWe carried out a scoping review to identify and describe scholarly and grey literature referring to global cases of intersectoral action for health equity featuring a central role for governments.MethodsThe scoping review process systematically identified articles describing one or more cases of intersectoral action. Each article was then described in terms of the context of initiation, as well as the strategies, actors, tools and structures used to implement these initiatives.Results128 unique articles were found describing intersectoral action across 43 countries. A majority of the cases appear to have initiated in the last decade. A variety of approaches were used to carry out intersectoral action, but articles varied in the richness of information included to describe different aspects of these initiatives.ConclusionWith this examination of cases across multiple countries and contexts, we can begin to clarify how intersectoral approaches to health equity have been used; however, the description of these complex, multi-actor processes in the published documents was generally superficial and sometimes entirely absent and improvements in such documentation in future publications is warranted. Richer sources of information such as interviews may facilitate a more comprehensive understanding from the perspective of multiple sectors involved.

Rethinking Social Epidemiology

concepts need not be vague: abstractions such as temperature, gender, et cetera, are quite concrete and precise. Nor should the notion of abstract be equated with unreality or something residing only in thought − abstractions can and do refer to things that are real (Sayer 1992). “Class,” “status,” “identity,” “neighbourhood,” “context,” “government” and even “society” are all abstractions that identify fundamental dimensions of human existence and have a certain degree of practical adequacy for explaining them. On the other side of things, the concept of “concrete objects” “does not merely concern ‘whatever exists’ but draws attention to the fact that objects are usually constituted by a combination of diverse elements or forces” (Sayer 1992). A person, for instance, combines influences and properties from a wide range of sources (e.g., physique, personality, intelligence, attitudes, etc.), each of which “might be isolated in thought by means of abstraction, as a first step towards conceptualizing their combined effect” (Sayer 1992). As a consequence, understanding concrete events or objects involves a double movement: Concrete => abstract, abstract => concrete. At the outset our concepts of concrete objects are likely to be superficial or chaotic. In order to understand their diverse determinations we must first abstract them systematically. When each of the abstracted aspects has been examined, it is possible to combine the abstractions so as to form concepts which grasp the concreteness of their objects (Sayer 1992). This activity forms the basis for research and, indeed, the relationship between empirical events, mechanisms and structures, on the one hand, and abstract and concrete research on the other, as shown in Fig. 2.1. The figure also shows different types of research and what sorts of activity they are concerned with. Orthodox empirical research operates only at the level of empirical events, seeking to make generalizations (extensive research). Abstract research “deals with the constitution and possible ways of acting of social objects” (Sayer 1992). Concrete research seeks to link abstractions and their concrete referents. Interpretive understanding is “ presupposed in all of these types of research” (Sayer 1992), including the final type, synthesis research. Synthesis research seeks to combine all of these elements in a robust way (and is described more fully in Chap. 11). 2.8 From Qualitative/Quantitative Research to Extensive/Intensive Research The previous section appears to advocate for qualitative research to inform quantitative research, or mixed methods. However, the distinction between qualitative and quantitative is of limited utility, as is the term “mixed methods.” This distinction reflects an unfortunate tendency for people to acquire training and experience in either qualitative or quantitative methods, and then choose their research problems and questions on the basis of how amenable they are to study with the methods they know. Receptivity to mixed methods is a view that is often seen as progressive. This view is sometimes presented as if the mere mixing of methods necessarily produces 35 2 “Explanation,” Philosophy and Theory in Health Inequalities Research... better research outcomes. Instead, the appropriateness of the method depends on the type of object and the question one is asking. According to realism, it is preferable to distinguish between intensive and extensive research rather than qualitative and quantitative research, as intensive and extensive research designs are question driven (rather than method driven) (Sayer 1992; Harré 1979). Intensive research and extensive research differ in a number of their properties (Table 2.1). The chief difference is the kinds of questions that they allow researchers to ask about the phenomena under study. In extensive research, which often involves obtaining relatively superficial information on large numbers of people, questions relating to regularities, common patterns and distinguishing features of a population can be asked. It is also possible to ask how widely certain characteristics or processes are distributed or represented. Often this involves the use of surveys or other kinds of large, quantitative data sets. In extensive research, causal processes cannot be directly observed, as the only relations that can be observed are what Sayer (1992) calls “formal relations of similarity” among “taxonomic groups” (e.g., women under 45 years old). Intensive research, on the other hand, asks questions about how a process works in a small number of cases, often with identifiable people and/or institutions, by identifying substantial relations of connection between such factors as the reasons people give for their actions, their biographies and contingent factors. Fig. 2.1 Types of research (Reprinted from Sayer (1992). With permission from Taylor & Francis Books UK)

Using Win-Win Strategies to Implement Health in All Policies: A Cross-Case Analysis

Background In spite of increasing research into intersections of public policy and health, little evidence shows how policy processes impact the implementation of Health in All Policies (HiAP) initiatives. Our research sought to understand how and why strategies for engaging partners from diverse policy sectors in the implementation of HiAP succeed or fail in order to uncover the underlying social mechanisms contributing to sustainable implementation of HiAP. Methods In this explanatory multiple case study, we analyzed grey and peer-review literature and key informant interviews to identify mechanisms leading to implementation successes and failures in relation to different strategies for engagement across three case studies (Sweden, Quebec and South Australia), after accounting for the role of different contextual conditions. Findings Our results yielded no support for the use of awareness-raising or directive strategies as standalone approaches for engaging partners to implement HiAP. However, we found strong evidence that mechanisms related to “win-win” strategies facilitated implementation by increasing perceived acceptability (or buy-in) and feasibility of HiAP implementation across sectors. Win-win strategies were facilitated by mechanisms related to several activities, including: the development of a shared language to facilitate communication between actors from different sectors; integrating health into other policy agendas (eg., sustainability) and use of dual outcomes to appeal to the interests of diverse policy sectors; use of scientific evidence to demonstrate the effectiveness of HiAP; and using health impact assessment to make policy coordination for public health outcomes more feasible and to give credibility to policies being developed by diverse policy sectors. Conclusion Our findings enrich theoretical understanding in an under-unexplored area of intersectoral action. They also provide policy makers with examples of HiAP across wealthy welfare regimes, and improve understanding of successful HiAP implementation practices, including the win-win approach.

The Effect of Social Isolation on Depressive Symptoms Varies by Neighborhood Characteristics: A Study of an Urban Sample of Women with Pre-School Aged Children

ObjectivesTo examine how individual characteristics, social isolation, and neighborhood context affect depressive symptoms in a socio-economically diverse population of women with young children.MethodsInterviews were conducted with 261 mothers from 68 neighborhoods in Baltimore between 1998 and 2000. Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression scale (CES-D). Neighborhood context was characterized using police and Census data. Multilevel regression was performed.ResultsSocially isolated women reported on average 73% (95% CI, 48 and 92%) more depressive symptoms than women who were not socially isolated; however, the association of social isolation and depressive symptoms varied by level of crime in the neighborhood. Social isolation was associated with an average increase in depressive symptoms of 128% (95% CI, 115 and 138%) for women in low-crime neighborhoods but with no change for those in high-crime neighborhoods. The interaction remained significant after controlling for individual- and neighborhood-level socio-demographic characteristics.

Population-Based Data and Community Empowerment

This chapter focuses on the transformation of population-based data and data systems into social resources that actively contribute to social, economic and political solutions to reduce health inequities. Our first underlying premise is that current systems of population health data collection, management, analysis and use are too often disconnected from the communities being described and whose data are being collected. Our second and related premise is that, in order for data to become a tool for social empowerment and social change, the social structuring of data governance and management must change from systems that reinforce social exclusion by marginalizing communities from their data to systems in which communities are fully and centrally involved in data decision making. The first part of this chapter rationalizes these premises by providing examples of the ways in which existing data systems undermine the broader mission of social epidemiology to identify effective interventions that alleviate conditions of social marginalization and poverty. The remainder of the chapter focuses on strategies for transformation in health and social data and data systems.

Oral health, oral pain, and visits to the dentist: neighborhood influences among a large diverse urban sample of adults.

The objective of this study was to assess the association between oral health and individual-level characteristics as well as both socioeconomic position (SEP) and service provision characteristics at the neighborhood level. Multilevel logistic analysis was undertaken of data from the Neighbourhood Effects on Health and Well-being Study in Toronto comprising 2,412 participants living in 47 neighborhoods and 87 census tracts. Three oral health outcomes were investigated: last dental visit, self-rated oral health, and self-rated oral pain. Results indicated that SEP was significantly associated with no dental visits in the last year, poor self-rated oral health, and experiencing oral pain after adjusting for age, gender, and immigrant status. Lack of dental insurance was associated with no visits to the dentist in the last year and poor self-rated oral health; however, no association was observed with oral pain. In adjusted regression models, few neighborhood level variables were significantly associated with dental visits and self-rated oral health and no neighborhood variables were associated with oral pain. Based on these results, SEP appears to be important in evaluating oral health outcomes. While insignificant in this study, neighborhood factors are important when considering the impact of service provision on oral health.

Locating Politics in Social Epidemiology

Recent social epidemiologic research has focused on the impact of politics, expressed as political traditions or parties and welfare state characteristics, on population health. Guided by a political economy of health and welfare regimes framework, this chapter synthesizes this growing body of evidence and locates 73 empirical and comparative studies on politics and health meeting our inclusion criteria. Two major research programs – welfare regimes and democracy – and two emerging programs – political tradition and globalization – are identified. Primary findings include: (1) left and egalitarian political traditions on population health are the most salutary, consistent and substantial; (2) the health impacts of advanced and liberal democracies are also positive and large; (3) welfare regime studies, primarily conducted amongst wealthy countries, find that Social Democratic regimes tend to fare best with absolute health outcomes yet inconsistently in terms of relative health inequalities; and (4) globalization defined as dependency indicators such as trade, foreign investment and national debt is negatively associated with population health.

Retrenched Welfare Regimes Still Lessen Social Class Inequalities in Health: A Longitudinal Analysis of the 2003–2010 EU-SILC in 23 European Countries

This article builds on recent work that has explored how welfare regimes moderate social class inequalities in health. It extends research to date by using longitudinal data from the EU-SILC (2003–2010) and examines how the relationship between social class and self-reported health and chronic conditions varies across 23 countries, which are split into five welfare regimes (Nordic, Anglo-Saxon, Eastern, Southern, and Continental). Our analysis finds that health across all classes was only worse in Eastern Europe (compared with the Nordic countries). In contrast, we find evidence that the social class gradient in both measures of health was significantly wider in the Anglo-Saxon and Southern regimes. We suggest that this evidence supports the notion that welfare regimes continue to explain differences in health according to social class location. We therefore argue that although downward pressures from globalization and neoliberalism have blurred welfare regime typologies, the Nordic model may continue to have an important mediating effect on class-based inequalities in health.

Socioeconomic Position and Factors Associated With Use of a Nonsupine Infant Sleep Position: Findings From the Canadian Maternity Experiences Survey

OBJECTIVES With a focus on socioeconomic position, we examined the association between maternal education and nonsupine infant sleep position, and examined patterns of effect modification with additional sociodemographic, maternal, infant, and health services predictors. METHODS Data were from the Maternity Experiences Survey, a national population-based sample of 76 178 new Canadian mothers (unweighted n = 6421) aged 15 years or older interviewed in 2006-2007. Using logistic regression, we developed multivariate models for 3 maternal education strata. RESULTS Level of maternal education was significantly and inversely related to nonsupine infant sleep position. Stratified analyses revealed different predictive factors for nonsupine infant sleep position across strata of maternal education. Postpartum home visits were not associated with use of this sleep position among new mothers with less than high school completion. Adequacy of postpartum information regarding sudden infant death syndrome was not associated with nonsupine infant sleep position in any of the educational strata. CONCLUSIONS These findings suggest a need to revisit Back to Sleep health promotion strategies and to ensure that these interventions are tailored to match the information needs of all families, including mothers with lower levels of formal education.

Informal employment in high-income countries for a health inequalities research: A scoping review.

BACKGROUND Informal employment (IE) is one of the least studied employment conditions in public health research, mainly due to the difficulty of its conceptualization and its measurement, producing a lack of a unique concept and a common method of measurement. OBJECTIVE The aim of this review is to identify literature on IE in order to improve its definition and methods of measurement, with special attention given to high-income countries, to be able to study the possible impact on health inequalities within and between countries. METHODS A scoping review of definitions and methods of measurement of IE was conducted reviewing relevant databases and grey literature and analyzing selected articles. RESULTS We found a wide spectrum of terms for describing IE as well as definitions and methods of measurement. We provide a definition of IE to be used in health inequalities research in high-income countries. Direct methods such as surveys can capture more information about workers and firms in order to estimate IE. CONCLUSIONS These results can be used in further investigations about the impacts of this IE on health inequalities. Public health research must improve monitoring and analysis of IE in order to know the impacts of this employment condition on health inequalities.