CDE Appendix 1 Literature Review - Central East Local Health ...

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The Culture, Diversity and Equity Project: Literature Review Cultural competence approaches - the dominant framework of healthcare equity found in the literature - derive from a longer genealogy of culture-oriented approaches (as mapped out in Figure 2.1) which share a focus on the role of cultural bias and misunderstanding in explaining healthcare inequities. The genealogy of cultural competence is discussed in Section 2.4. Nothing prevents such approaches from also considering and acknowledging the formative role of broader (power inequity-related) determinants of health. Below I discuss some of the more notable and salient examples of health equity and healthcare equity frameworks fashioned and pursued by governmental bodies seeking to tackle health disparities. This discussion of frameworks helps to set the stage for the review of international health equity policies in subsequent sections, enabling the reader to better understand and situate health equity policy interventions in the context of contending, overarching frameworks. 2.1 HEALTH EQUITY FRAMEWORKS Health Equity Frameworks are most distinguished by their fundamental concern with inequities in health status. Such frameworks define the problem to be confronted (‘health inequity’) in broad terms to include all possible (social, political, environmental etc.) determinants of health/health inequity, including many which are beyond the healthcare sector proper. Most such frameworks depict the root sources of health inequity as lying in unjust sociopolitical relations in society. Health Equity Frameworks are also distinguished by their focus on health, as opposed to merely the treatment and eradication of disease. Figure 2.2 below describes the nature of the proposed shift from an illness orientation to a wellness orientation often advocated for in health equity frameworks. Figure 2.2: Towards a Wellness Orientation - Ontario’s Chronic Disease Prevention and Management Framework Source: Meera Jain (2007). Ontario’s Chronic Disease Prevention and Management Framework. 18
The Culture, Diversity and Equity Project: Literature Review The broad and positive understanding of health in health equity approaches is frequently informed by the positive definition of health employed by the World Health Organization (WHO), which remains widely adopted as a working standard in the health equity frameworks and approaches reviewed here: [Health is] a state of compete physical, mental and social well being, and not merely the absence of disease or infirmity. It is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. (WHO, Alma Ata, 1978) This paradigm-shifting definition challenges the more traditional, conventional modern western definition of health, as merely the absence of disease. The health equity frameworks reviewed here can be further subdivided between those that explicitly base themselves on theoretical causal models of the determinants of health/health inequity and those (here dubbed ‘Strategic Intervention Frameworks’) that focus instead on intervention strategies, without explicitly linking such strategies up to a theoretical model or evidence-based framework A. Health Determinant Frameworks Etiological 2 Health Determinant Frameworks provide a theoretical model of the determinants and causes of health and health in/equity, on the basis of assessments of the empirical evidence. They moreover use such causal models to aid and inform the development of policy/intervention strategies. Some examples include the Canadian Institute of Health Research’s (2002) Population Health Framework, New Zealand’s (2002) Framework for Reducing Inequalities in Health, and the WHO’s (2008) Closing the Gap Framework. Rather than elaborate in detail the theoretical bases and underpinnings of these framework models (which is beyond the scope of this literature review), some of the more common theoretical approaches to explaining inequalities in health in the literature are outlined below. All of these perspectives find expression, to greater and lesser degrees, in the frameworks discussed below. Mackenbach et al. (2002a) distinguish four theoretical perspectives in particular: • Selection versus causation perspectives which “imply that health determines socioeconomic position, instead of socioeconomic position determining health”. This perspective focuses on the ways in which poor health results in downward socio-economic mobility which in turn has further negative consequences for health (See for instance van de Mheen et al., 1999; Wadsworth, 1986; Stern, 1983; Illsley, 1955). • Specific determinants perspectives which view various socio-economic factors as directly and indirectly shaping health inequities, in the latter case, mediated through a range of individual health-related behaviours. Such perspectives vary in emphasis on causes of health inequities, emphasizing, to differing degrees, (a) material factors (e.g. low income), (b) psycho-social factors and stressors (which are more and less related to material factors) and (c) health-related behaviours such as smoking, diet, alcohol consumption and physical exercise, which are related to (a) and (b) as proximal determinants of inequalities in health. • Life-course perspectives which pay much more attention to the cumulative effect of disadvantage on individual health over the life-course, often stressing or identifying particular ‘windows of susceptibility’ - “those periods of life when the individual is more susceptible to the effects of certain exposures, malnutrition and infections [for example] during the fetal period, emotional attachment during infancy, and so on.” Lifecourse perspectives have the advantage of bringing into view the 'co-evolution' of social position and health in a manner “taking away the sharp contradiction between 'selection' and 'causation' explanations” (citing van de Mheen et al., 1998; Vigero & Illsley 1995). 2 Etiology refers to the study of causation, in this context, the study of causes and determinants of health and illness, health equity and health inequity. 19
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