EVIDENCE BASED MEDICINE:

Health Inequalitees Incorporatnn the Findinne into: clinical

decieion makinns and implementnn channe
CLS 603

Lecture 7 & 8
Dr Samyah Alanazi
saalanazi@KSU.EDU.SA
 Outline

• Thie lecture will be covered by eplitnn it into

two parte :
• 1- Health Inequalites
• 2- Incorporatng the Findings into: clinical
decision making, and implementng change
PART 1 : HEALTH INEQUALITIES
 Health Inequalitee important queetone
• 1- What is meant by the term ‘social
determinants of health

• 2- How these determinants are linked to

inequality in health outcomes between
different social groups

• 3- What potental exists to do something

positve about these inequalites
Health is not just the outcome of genetc or
biological processes but is also infuenced
by the social and economic conditons in
which we live. These infuences have
become known as the ‘social determinants
of health’. Inequalites in social conditons
give rise to unequal and unjust health
outcomes for different social groups
 KEY DEFINITIONS
• Social determinante of health These refer to the
social, economic, and politcal situatons that affect
the health of individuals, communites, and
populatons.
• Abeolute and relatve inequalitee in health Inequality
in health is an empirical noton and refers to
Differences in health status between different groups. It
is a multdimensional concept, consistng of technical
and normatve judgments in the choice of appropriate
metrics.
*Reducing health disparities requires an understanding of the
mechanisms that generate disparities.
• Inequity in health and health care Inequity in health is a
normatve concept and refers to those inequalites that
are judged to be unjust or unfair because they reeult
from eocially derived proceeeee.
• Equity in health care requires actve engagement in
planning, implementaton, and regulaton of health
systems to make unbiaeed and accountable
arrangements that address the needs of all members of
society.

• Health system and health-systems performance The

health system as defned by WHO describes “all the
actvites whose primary purpose is to promote, restore,
or maintain health.
 Social Determinants
• The social conditons in which people live powerfully infuence
their chances to be healthy. Indeed factors such as poverty,
food insecurity, social exclusion and discriminaton, poor
housing, unhealthy early childhood conditons and low
occupatonal status are important determinants of most
diseases, deaths and health inequalites between and within
countries’
(WHO 2004)
 Social Determinants
The social determinants of health are those factors which are outside
of the individual; they are beyond genetc endowment and beyond
individual behaviors. They are the context in which individual
behaviors arise and in which individual behaviors convey risk. The
social determinants of health include
individual resources, neighborhood (place-based) or community
(group-based) resources, hazards and toxic exposures, and
opportunity structures.

– Camara Jones, CDC, 2010

 Social Determinants
Health is infuenced, either positvely or negatvely, by a variety of factors.
Some of these factors are genetc or biological and are relatvely fxed.

‘Social determinante of health’ ariee from the eocial and economic

conditone in which we live and are not eo fied.
• The kind of housing and environments we live in, the health or
educaton services we have access to, the incomes we can
generate and the type of work we do, for instance, can all
infuence our health, and the lifestyle decisions we make.
 Social Determinants
A range of factors has been identfed as
of health and these generally include:
-the wider socioeconomic context;
inequality; poverty; social exclusion;
socio-economic positon; income;
public policies; health services;

.
 Social Determinants
A range of factors has been identfed as
of health and these generally include:

Employment; educaton; housing;

transport; the built environment;
health behaviours or lifestyles; social
and community support networks and
stress.

.
 Social Determinants/Health
1.Social determinants contribute to health inequalites between
social groups. This is because the effects of social determinants
of health are not distributed equally or fairly across society.
2. Social determinants can infuence health both directly and
indirectly. For example educatonal disadvantage can limit
access to employment, raising the risk of poverty and its adverse
impact on health.
3. Social determinants of health are interconnected e.g poverty is
linked to poor housing, access to health services or diet, all of
which are in turn linked to health.
4. Social determinants operate at different levels
 Multple Causes
A range of factors contribute to health Inequalites:
• Socio-economic or material factors such as government social
spending and the distributon of income and other resources in
society which infuence the social and built environment.
• Psychosocial factors such as stress, isolaton, social
relatonships and social support.
• Behavioural or lifestyle factors.
 Measuring Health Inequalites
• Adequate baseline data is necessary to help us understand health
inequalites more fully and to help identfy appropriate targets and
interventons to reduce them.

1.Informaton about death, illness, health and health service use.

2.Informaton about how these health indicators are paterned

across different demographic or socio-economic groups and across
different geographical areas
 Working for Health Equity
• Health equity is defned as the ‘absence of unfair and
avoidable or remediable differences in health’ among
social groups (Solar and Irwin 2007).
• Health equity is therefore about the values of fairness
and justce.
• A focus on health equity means valuing health as an
essental and valuable resource for human development,
helping people reach their potental and contribute
positvely to society.
• Health also represents an important public good, an
investment in human, societal and economic
development.
 Approaches and Principles
1. Focueinn on the moet dieadvantaned nroupe: This targets the worst
off or poorest groups and aims to improve their health through
specifc measures. This approach can improve the health of those
who are worst off, even if the health gap between rich and poor is
unchanged.

2. Narrowinn health nape :This aims to improve the health of those

who are poorest or most disadvantaged by raising their health
outcomes closer to those who are most advantaged. This usually
involves target setng to reduce the disparity in health outcomes
between the most advantaged and most disadvantaged groups.

3. Reducinn the eocial nradient :Tackling the social gradient in health

involves reducing differences and equalising health all along the
income ladder
 Guiding Principles
Whitehead and Dahlgren (2006) identfed ten guiding principles:
1. Health equity policies should strive to level up, not level down.
2. The three main approaches to reducing social inequites in
health are interdependent and should build on one another.
3. Populaton health policies should have the dual purpose of
promotng health gain in the populaton as a whole and
reducing health inequites.
4. Actons should be concerned with tackling the social
determinants of health inequalites.
5. Stated policy intentons are not enough: the possibility of
actons doing harm must be monitored and assessed (through
health equity impact assessment
 Guiding Principles
6. Appropriate tools are needed to measure the extent of inequites and the
progress towards goals.

7. Concerted efforts must be made to give a voice to the voiceless.

8. Wherever possible, social inequites in health should be described and

analysed separately for men and women.

9. Differences in health based on socio-economic positon should be linked to

ethnicity and geography.

10. Health systems should be built on equity principles – public health services
should be provided according to need, not ability to pay, they should not be
driven by proft, and should offer the highest standards of care to all.
 Key Social Determinants of Health
1. Poverty and Inequality.
2. Social Exclusion and Discriminaton.
3. A Life Course Perspectve
4. Public Policies and Services
5. The Built Environment
6. Work and Employment
7. Community and Social Partcipaton
8. Health Behaviours
9. Stress
 Well established inequalites

• Income
• Poverty
• Educaton
• Health
 1. Poverty and Inequality.

• Both poverty and economic inequality are bad

for health. Poverty is an important risk factor for
illness and premature death. It affects health
directly and indirectly, in many ways, e.g.
fnancial strain, poor housing, poorer living
environments and poorer diet, and limited
access to employment, other resources, services
and opportunites. Poor health can also cause
poverty.
 Policy issues
- Policy ieeuee to coneider:

• Strategies to reduce poverty and inequality are fundamental to reducing health inequalites.

• Long-term targets for greater health equity and the reducton of health inequalites need to
become novernment prioritees and need to be championeds reeourceds reviewed and
supported by medium and shorter term goals, actons.

• Policies and actons to address poverty, social exclusion and health inequalites need to be
mainstreamed into all policy areas.

• Working for health equity requires a joined-up approach acroee novernment departmente and
cross sectoral partnerships between and within sectors.

• Health Impact Assessment could usefully inform this process as it enables policy makers to assess
the health implicatons of a wide range of public policy decisions.
2. Social Exclusion and Discriminaton

Social exclusion is the process by which groups and

Individuals are prevented from partcipatng fully in
society as a result of a range of factors including
poverty, unemployment, caring\responsibilites, poor
educaton or lack of skills, women, older people,
people with disabilites or homeless people, for
example, may experience social exclusion. Social
exclusion therefore is about more than poverty. It is
about isolaton from partcipaton in social life, and
from power and decision-making.
 Social exclusion
• Social exclusion is ofen compounded by discriminaton, which
can arise on the basis of a person’s gender, race or ethnicity,
disability, marital, family or caring status, age, religion etc.
• Equality legislaton has an important role to play in tackling
these forms of discriminaton and promotng greater equality,
inclusion, and diversity.
 Gender
• Gender differences in health and mortality are complex and not
yet fully understood.

• The social determinants of health have both similar and

different effects on men and women.

• Women seem to have a biological advantage over men in terms

of life expectancy.

• Men tend to die younger than women, and research suggests

that the work they do and issues like job security and
unemployment ofen affect men’s health.
 Policy Issues
• Addressing social exclusion, promotnn eocial
inclueion and reepectnn divereity need to be key
public policy priorites.
• Data collecton strategies need to ensure that
adequate informaton about the social and spatal
paterning of populaton health is made routnely
available.
• Public service delivery should be equitables
culturally eeneitve and appropriate to diverse needs
and accessible to people with disabilites and other
vulnerable groups and communites.
 A life course perspectve
• -A life course perspectve is an approach that provides a framework for
understanding how theee eocial determinante of health ehape and infuence an
individual’e health from birth to old ane.

• A life cycle or life course perspectve provides a useful framework for

understanding how social determinants nenerate health inequalitee and to
identfy entry pointe for interventone.

• Briefy a ‘life course’ perspectve explores how different social determinants

operate or accumulate as advantages or disadvantages over different stages of the
lifecycle.
 3. A Life Course Perspectve
• Interest in a life course perspectve emerged in the 1980s in relaton to
chronic diseases
• the individual life course is shaped by multple trajectoriee
• it emphasizes the importance of understanding the interactons
between biological change and social change at the individual level.

A life course approach recognizes the role of tme in shaping health

outcomes and incorporates tme into models explaining health outcomes.
 3. A Life Course Perspectve
How the tme maters ?
• Individuals’ health changes over tme.
• Determinants of health vary over tme.
• Relatons between determinants and health can change over tme.
• Relaton between determinants and health may depend on tme.

• This life cycle is affected by either

• Protectve factors improve health and contribute to healthy
development.
• Risk factors diminish health and make it more difcult to reach one’s full
potental.
• Factors are not limited to individual behavior or access to health, but
can include family, neighborhood, community, and social policy.
 3. A Life Course Perspectve

• The infuence of wider social conditons on health is signifcant

at different points the lifecycles partcularly when people are
moet dependent or vulnerables e.n. childhoods prennancy
and older ane.
• Recent research shows how accumulated social disadvantage
or advantage over the lifecycle infuences health and well-
being, the likelihood of illness and of premature death.
• These infuences occur across the life course, from ‘womb to
tomb’.
 3. A Life Course Perspectve
Early Programming
Early experiences can program an
individual’s future health and development.
This includes prenatal programming as well
as intergeneratonal programming (i.e. the
health of the mother prior to concepton)
that impact disease or conditon, or make
and individual more vulnerable or
susceptble to developing a disease or
conditon in the future.
– Fine and Kotelchuck, Rethinking MCH: The Life Course Model
as an Organizing Framework, Concept Paper, DHHS, HRSA, October 2010.
 3. A Life Course Perspectve

Cumulatve Impact
While individual episodes of etreee may have minimal impact in an otherwise positve
trajectory, the cumulatve impact of multple stresses over tme may have a profound
direct impact on health and development, as well as an indirect impact via associated
behavioral or health services seeking changes.

– Fine and Kotelchuck, Rethinking MCH: The Life

Course Model
as an Organizing Framework, Concept Paper,
DHHS, HRSA, October 2010.
 4. Public Policies and Services
• Although individuals can make choices in everyday life that
may improve and protect their health, they are not
completely in control of the social conditons in which they
live and work.

• Public policy exerts a powerful infuence on these external

conditons, and can play an important role in supportng
individuals by creatng conditons conducive to good health.

• Public policy also has an important role to play in encouraging

other sectors to contribute to greater health equity.
 Health Services
• In the case of both primary care and hospital services, access based on
need rather than on the ability to pay is important for health equity.

• Compreheneive and equitable primary health care is vital to

supportng healthy lives and to the identfcaton and care of health
problems as they arise within the community.

• Access to primary health care also has the potental to reduce the need
for more costly acute hospital care in the longer term.

• When people become ill, access to equitable and appropriate care and
treatment from specialist or hospital services becomes fundamental
 Educaton
• The foundatons for life-long health are set down in childhood.
Childhood poverty casts a long shadow over the health of an
individual.

• Poverty is an underlying determinant of ill health and educaton

ie renarded ae a very important route out of poverty.

• Research on health inequalites has frequently shown that those

with poorer levele of educaton eiperience poorer health.

• This may well be because level of educaton is a strong indicator

of a person’s socio-economic status
 Policy issues
• More equitable and adequately resourced public
services will contribute to greater social inclusion
and a fairer distributon of resources and
opportunites in society.

• Access to health services should be based on need

rather than on ability to pay.

• The opportunity to live in a healthy neighbourhood

environment and to live indecent, warm, affordable
housing or accommodaton is important for health.
 Conceptual framework for
understanding health inequalites
 Towards equity in Health
• The heterogeneity in the scale and interplay of the substantal
challenges to health care in the states and districts needs
contextually relevant solutons.

• India has made much progress in the past few years, with several
innovatve pilot programmes and initatves in the public and
private sectors, and the establishment of the Natonal Rural
Health Mission in 2005 being the most noteworthy government-
led initatve.
 Some suggestons..
1. Equity metrices as applied to data for health and health
systems, needs to be integrated into all health-system policies
and implementaton strategies, and at every stage of any reform
process.

2. An equity-focueed approach is needed to gather, use, and apply

data for health outcomes and processes of health care, and
during monitoring and assessment of health-systems
performance
3. An intelligence system should be created that
works across the health-system network,
epanninn the public and private eectore, and
allopathic and non allopathic medicine
(ayurveda, yoga and naturopathy, unani, siddha,
and homoeopathy), and that is aligned with
internatonal principles and standards for health
metrics.
4. Although India has good sources of data,
these could be beter applied to monitoring
the changing equity gaps and quantfcaton of
progress among disadvantaged groups of
people.

5. Furthermore, equity-based targets need to be

fully integrated into the natonal, state, and
local goals.
6. A concerted effort is needed to improve the knowledge
base of health-systems research and health-equity
research.

7. The decieion-makinn proceee for the achievement of

health equity needs more thought and development

8. The challenge of how to prioritie and implement health

policiee for the achievement of equity when reeourcee
are ecarce requires a deliberatve process—ie, assessment
of the implicatons and risks of those decisions, with
monitoring of how such decisions will affect health equity
• Epidemiolonical diferencee and the emerninn
burden of chronic dieeaeee mean that choices
are needed for the allocaton of resources
between subpopulatons with different disease
paterns.

• Furthermore, with India’s aneinn populaton,

deliberaton of intergeneratonal equity is
needed in the allocaton of scarce resources
between different age groups.
• Multlateral organisatons, natonal and local
governments, non-governmental
organisatons, private sector, pharmaceutcal
industry, civil society, and research and
academic insttutons all have responsibilites
and parts to play in ensuring the successful
achievement of equity in health and improved
health governance
• Accountability, transparency, and improved
leadership and partnerships are needed within
the health system, with systematc assessment
and analysis of health-system governance.

• The role of civil society, and the need to

engage, empower, and build capacity within
this group to atain equity in health and
improved quality health care at reasonable
costs
Part 2: Incorporatnn the Findinne into: clinical decieion
makinns and implementnn channe
 WHY implement Evidence Baeed
Practce?
• To achieve a meaeurable improvement in:
• Quality of patent care
• Consistency of patent care
• Patent outcomes
• Cost containment
• EBP is the accepted standard in modern healthcare systems and increasingly
recognised as a core clinical competency. Internatonally, several regulatory
agencies have emphasised the importance of using scientfc evidence to
guide clinical decisions as a means of improving patent outcomes. To
improve patent outcomes, healthcare professionals need to do more than
acquire and appraise best evidence: implementng evidence into practce is
also required. Implementng the evidence is a complex and actve process
involving individuals, teams, systems and organisatons, and requires careful
planning.
 How to Facilitate the implementaton of Evidence Baeed Practce

• Several models have been developed to guide healthcare

professionals in the successful implementaton of evidence into
practce.
Table : Models for Implementation of EBP
• Another common theme among implementaton models is
the challenge of realising change within the social or
organisatonal constraints of a given clinical setng.

• Strategies that have been successfully applied in healthcare

organisatons include the involvement of EBP mentors, the
use of clinical library services and journal clubs, and the
provision of educaton and promoton through in-service
training, email bulletns, newsleters, etc.

• Muir Gray also identfes the support of a librarian or

informaton scientst and access to electronic resources as
necessary support structures to the implementaton of EBP.
• Hospital or health service administrators must agree that best evidence
should at each stage inform and underpin patent care, and provide
fnancial and other resources to support EBP, such as:

• Access to ICT and adequately resourced library services for the purposes
of acquiring reliable evidence .

• Allocaton of healthcare professionals to provide in-service educaton

sessions and mentoring programmes .

• Time allocated to release clinicians to work with a librarian in

accumulatng and synthesising the evidence and/or atend educaton
sessions .

• funding to permit all of the above points.

• Strong clinical leadership is essental to encourage and sustain a culture of

enquiry, collegiality and evidence-based practce.
 Facilitatore and Barriere to the Implementaton of EBP

Table : Facilitators and Barriers to the Implementation of EBP

 Sample implementaton workfow
• The template on the next slide sets out a series of steps - based
on the fve steps of EBP - that may be used to successfully
implement an evidence-based practce change. Not all of the
steps are required for each change in practce.
Table : Implementation Checklist
Aeeeee outcomee and make channee to
practce ae neceeeary
• Afer an evidence-based practce change has been
implemented, the fnal step in the EBP cycle involves
assessing outcomes, disseminatng results and making
further changes to practce as necessary or as prompted by
new evidence.

• Rengerink et al.: “Tools measuring EBP behaviour of

healthcare professionals should assess the use of EBP steps
in practce, the performance of evidence-based clinical
[procedures] and/or the effect of EBP on patent
outcomes.”20 All fve steps in the EBP process should be
considered as part of any assessment.
Dieeeminatnn the reeulte of an EBP interventon may be accompliehed in eeveral waye:
 ASSESS YOUR OWN EBP
PERFORMANCE
• Self-assessment should be an integral part of
the contnuous cycle of EBP. The checklist
below sets out some of the questons you
might consider:
Table : Self Assessment checklist