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

The Culture, Diversity and Equity Project: Literature Review
Use of Evidence
Health Equity policies can be distinguished by the extent to which they use and incorporate evidence into their
policies and policy-making processes. Global momentum has grown considerably in recent years for evidencedbased
policymaking and evaluation (see Exworthy et al., 2006; Whitley, 2007; Davies, Nutley, and Smith, 2000;
Walshe and Rundall, 2001). Among national governments, the UK government has come closest to living by its
motto of ‘what counts is what works’ (Exworthy and Berney, 2000).
Exworthy et al. (2006) emphasize the importance of prioritizing interventions and policies on the basis of evidence
of their potential effectiveness in reducing health inequalities. Mackenbach et al., (2002b) stress the importance of
two types of evidence more specifically:
[1] evidence that the determinant addressed by the intervention or policy plays a key role in the causation
of socioeconomic inequalities in health; [and]
[2] evidence that the proposed intervention or policy can be expected to effectively reduce exposure to
that determinant in the lower socio-economic groups (or to reduce socioeconomic inequalities in
exposure to that determinant) (p.32).
This is where choice of framework is important, as discussed earlier, since it can more or less provide an evidencebased
theoretical model and framework for intervention.
Both of the above two types of ‘evidence’ discussed by Mackenbach et al. (2002b) can be difficult to definitively
obtain (see Section 2.4). Mackenbach et al. (2002b) and Gardner (2008a) recommend a certain degree of measured
pragmatism in advancing health equity policy and practice in areas where evidence may not be readily established or
forthcoming. 17
Evidence alone, moreover, as earlier discussed, cannot singlehandedly determine health equity policies since the
goals and objectives of such policies also presuppose and require staking out particular normative/ethical positions
(which may be more or less compelling).
The WHO (2008) Closing the Gap report suggests the need to expand conventional definitions and conceptions of
what constitutes ‘evidence’ beyond experimental designs and randomized controlled trials etc. (for instance by
including qualitative measures, community accounts etc.).
Judge and Mackenzie (2002) also elaborate the important potential role of theory-based evaluations when dealing
with broad determinants of health that do not lend themselves to experimental manipulation. (For more on some of
the difficulties in furnishing ‘evidence’ for policies and their impact also see Exworthy et al., 2006 and Judge &
Mackenzie, 2002).
17 Mackenbach et al. argues in this respect:
it may take decades to build up a reasonably extensive evidence base. It is therefore better to be pragmatic and to be prepared to decide for the
implementation of policies and interventions in the absence of full documentation of their effectiveness. Sometimes, effectiveness can reasonably
be expected on the basis of experience in another setting, or evidence of effects on intermediate outcomes. In such cases it is all the more
important that while the policies or interventions are being implemented, evaluations are carried out so that their effectiveness can be determined
at a later stage, and changes made if effectiveness remains below expectations. In reality, all this implies that it will usually be difficult to
prioritize policies and interventions on the basis of scientific evidence only. Other considerations, for example, on the (political) feasibility of
certain strategic options, are likely to have a profound influence on priority setting in this area (2002b, p.33).
59