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

The Culture, Diversity and Equity Project: Literature Review
challenges due to the sectoral frameworks within which governments are designed and accustomed to operating in
(see WHO, 2008, p.111; PHAC, 2007; PHAC & WHO, 2008). Such whole-of-government approaches, moreover,
where these do exist in practice, most often require coordination at the highest levels of government.
Another challenge of the more ‘evidence-based’ health equity models and frameworks employing causal models of
health in/equity revolves around the contested nature of ‘causes’ and ‘evidence’ in the literature. As the WHO
reports in the former respect:
By their nature many of the social determinants considered by the Commission are relatively distant,
spatially and temporally, from individuals and health experience. This is challenging, both conceptually
and empirically, when trying to attribute causality and demonstrate effectiveness of action on health equity
(2008, p. 42).
Part of the challenge of evidence-based approaches in this respect is what kinds of evidence are considered to
‘count’ in the scientific literature (too often, critics argue, only experimental quantitative evidence that can be
counted). Many ‘upstream’ determinants of health, such as global or national economic arrangements and social
policies, however, do not lend themselves to randomized controlled trials etc. Applying overly strict and narrow
rules of evidence in this respect could lead to many of the most important health determinants falling off the
analytical radar.
When it comes to suggesting appropriate intervention strategies, moreover, health equity frameworks and models
have less of an evidence-base to stand on. This is in no small part due to the dearth of existing research evaluating
the impact and effectiveness of various kinds of health equity interventions on the ground (Exworthy et al., 2006;
Gardner, 2008a; Mackenbach et al., 2002a). 15
Theoretically informed, evidence-based health equity models and frameworks, moreover, have to guard against
being too complex for policy-makers to understand, as this will inhibit effective translation into policy interventions.
Those health equity frameworks complementing their theoretical causal models with corresponding practical
intervention frameworks, in this respect (e.g. WHO 2008; New Zealand Min of Health, 2002), hold out the most
promise and potential, since they already provide guidance on this translation from theoretical models to sites for
policy intervention.
Many of the identified causes of health inequity in such frameworks and models, moreover, are of a more politically
contentious nature, since they ultimately rely on normative theories of differentiating just from unjust social
arrangements and health outcomes. Scientific ‘evidence’, in this respect, is no substitute for ethics. Some of the
health equity frameworks are thin on the ethical bases of their commitments.
Finally, many of the health equity frameworks encountered in the literature focus near exclusively on socioeconomic
status as a bases for health in/equity, failing to take adequate stock of intersecting dimensions of social
exclusion and health inequity such as race, ethnicity, gender, and sexual orientation (Galabuzi & Labonte, 2002).
15 
Mackenbach et al.’s (2002a) survey of the field of health inequalities remains very much true to this day in this respect:
most publications about socioeconomic inequalities in health have focused on the description of socioeconomic inequalities in health in
countries, comparisons between countries and the explanation of these inequalities. From these studies we have learnt much about
the different factors which influence socioeconomic inequalities in health. However, in practice it seems hard to translate these factors
into interventions in health.
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