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PED0010.1177/1757975914568127Original ArticleT. Lang et al.
Original Article A health equity impact assessment umbrella program (AAPRISS) to tackle social inequalities in health: program description Thierry Lang1,2,3, Elsa Bidault1,2, Mélanie Villeval1,2, François Alias4, Benjamin Gandouet5, Martine Servat3, Ivan Theis6, Eric Breton7, Nadine Haschar-Noé2,8 and Pascale Grosclaude1,2,9
Abstract: Background: The failure to simultaneously address two objectives (increasing the average health of the population and reducing health inequalities) may have led to what has been observed in France so far: an overall decrease in mortality and increase in inequality. Objective: The Apprendre et Agir pour Réduire les Inégalités Sociales de Santé (AAPRISS) methodology is to analyze and modify interventions that are already underway in terms of their potential impact on health inequalities. It relies on partnership between researchers and actors in the health field, as well as policy makers. In this paper, we describe the program and discuss its feasibility and acceptability. Methods: This program is not a single intervention, but a process aiming at assessing and reshaping existing health programs, therefore acting as a kind of meta-intervention. The program develops scientific and methodological support stemming from co-construction methods aimed at increasing equity within the programs. Stakeholders from prevention policy-making and the health care system, as well as researchers, collaborate in defining interventions, monitoring their progress, and choosing indicators, methods and evaluation procedures. The target population is mainly the population of the greater Toulouse area. The steps of the process are described: (1) establishment of AAPRISS governance and partnerships; (2) inclusion of projects; and (3) the projects’ process. Discussion: Many partners have rallied around this program, which has been shown to be feasible and acceptable by partners and health actors. A major challenge is understanding each partner’s expectations in terms of temporality of interventions, expected outcomes, assessment methods and indicators. Analyzing the projects has been quite feasible, and some modifications have been implemented in them in order to take inequalities in health into account. Keywords: health impact assessment, determinants of health, equity/social justice, evaluation, qualitative, quantitative, community-based research/participatory research
1. 2. 3. 4. 5. 6. 7. 8. 9.
UMR 1027 Inserm – Université Paul Sabatier, Toulouse, France. Institut Fédératif d’Etudes et de Recherches Interdisciplinaires Santé Société, Toulouse, France. Centre Hospitalo-Universitaire de Toulouse, France. Instance Régionale d’Education et de Promotion de la Santé, Toulouse, France. Oncopole de Toulouse, France. Mairie de Toulouse, France. Ecole des Hautes Etudes en Santé Publique, Rennes, France. EA 4561 Prissmh-Soi, Toulouse III, Toulouse, France. Institut Claudius Régaud, Toulouse, France.
Correspondence to: Thierry Lang, UMR INSERM-UPS 1027, Faculté de Médecine, 37 Allées Jules Guesde, 31062 Toulouse CEDEX 9, France. Email: [email protected] (This manuscript was submitted on 17 March 2014. Following blind peer review, it was accepted for publication on 6 November 2014) Global Health Promotion 1757-9759; Vol 0(0): 1 –9; 568127 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914568127 http://ghp.sagepub.com Downloaded from ped.sagepub.com at UNIV OF LETHBRIDGE on November 14, 2015
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Background A high level of social inequalities in health (SIH) has been observed in France in most age groups (1). Mortality has decreased over the years, contrasting with an increase in health inequalities. For example, from 1970 to 1995, the relative index of inequalities according to educational level has increased from 1.96 to 2.77 in men, and from 1.87 to 2.53 in women (2). No public policy has been explicitly developed in order to reduce the social gradient in health. Policies so far have been focused on extreme poverty (exclusion, homelessness, etc.). The failure to simultaneously address the two objectives, that is, increasing the average health of the population and reducing health inequalities, may have led to what has been observed in France so far: an overall decrease in mortality and increase in inequality. Indeed, it has been shown that interventions and preventive actions that do not take SIH into account often contribute to worsening them (3). Reducing SIH has appeared on the political agenda in France over the past few years. It has been emphasized in the second and third National Cancer Plans (national policies targeting cancer) and is among the top priorities of the Agences Régionales de Santé (regional health agencies). It is thus necessary to develop population health intervention research (4). A multiplicity of risk factors and determinants in the health care system, in the organization of prevention, and also in policies outside the health system, that is, the whole social and societal context, help shape social inequalities in health. It would be more relevant to think of prevention in a health promotion perspective, moving beyond interventions based on individual decisions and behaviors towards structural, regulatory and social changes that facilitate choices considered to be conducive to health (‘healthy choices’). Individual behaviors can also change as a result of the strengthening of resources at the individual and community level (5). These risk factors act throughout life, from birth or even before, and therefore require multiple interventions and diverse approaches (6,7). While the effect of each of these determinants may be partial, their accumulation may lead to the inequalities that we know. The multiplicity of causes (social, economic, cultural, educational, etc.) calls for the involvement of a multiplicity of actors, hence the multi-partnership
approach and complexity of interventions. Actions to reduce the social gradient in health are distinguishable from policies focusing on extreme poverty when the root causes have already taken a heavy toll on population health. Alternative approaches have been proposed, including proportionate universalism (8,9), which still have to be translated into interventions. To reduce health inequalities by taking into account the social gradient does not necessarily lend itself to answering the specific needs and contexts of population groups. For this reason, revisiting each policy within and outside the health sector to appraise its foreseen impact on health inequities may stand as a promising strategy for reducing SIH. Given the high level of SIH in France, equityfocused programs are needed. Apprendre et Agir pour Réduire les Inégalités Sociales de Santé (AAPRISS) is a health equity impact assessment program. Its goal is to reduce social inequalities in health, focusing on interventions that either already exist or are in preparation. The program is related to social inequalities in nutrition in order to prevent social inequalities in the onset of cancer. The role of nutritional practices as protective factors reducing the risk of cancer is becoming better known (10). Obesity is a socially stratified health outcome, to the detriment of more disadvantaged groups; this trend has not abated over time. In children, the latest statistics suggest a decrease in the obesity epidemic, but this change is being accompanied by a widening of social inequalities for this indicator (11). Usually, an intervention targeting the determinants of poor nutrition potentially has positive impacts for a range of diseases (cancer, cardiovascular disease, aging, etc.) (10). The effects of such a program are not evident in the short term. Indeed, changes to the projects are expected to be seen in a time period of about a year. However, the process is also expected to induce a co-construction of knowledge, which may have long term bidirectional consequences on practitioners as well as on academic researchers (12). The AAPRISS methodology is to analyze and modify interventions in terms of their potential impact on health inequalitiesi. It relies on partnership between researchers and actors in the health field, as well as policymakers. In this paper, we describe the program and discuss preliminary findings concerning its feasibility and acceptability.
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Methods This program is not a single intervention, but a process that therefore acts as a kind of metaintervention. This ‘umbrella program’ addresses concerns raised by a number of local authorities in need of methodological assistance (13). Within the engineering of complex public health interventions, the program develops scientific and methodological support stemming from co-construction methods aiming at increasing equity within the projects. Stakeholders from prevention policy-making and the health care system, as well as researchers, collaborate in defining interventions, monitoring their progress, and choosing indicators, methods and evaluation procedures. The target population is mainly the population of the greater Toulouse area. Here we will describe the steps of the process.
Establishment of AAPRISS governance and partnership The AAPRISS steering committee includes three researchers: one representative of the Toulouse city council, one of the Toulouse University Hospital, one of the regional prevention and health promotion group, one of the Toulouse Cancer Centre, and a project manager. Members of this committee get together twice a month to define strategic targets and coordinate stakeholders. Other institutional partners have joined the research program and signed a public commitment agreement toward reducing health inequalities (see Acknowledgements). The scientific team includes researchers from different disciplines, including sociology, epidemiology, psychology, policy analysis and public health.
Process of change: analysis, modification and evaluation of a project Once the steering committee has decided to integrate a project into the AAPRISS program, several steps follow: 1. First meetings These consist of an initial contact, allowing the project leaders to introduce their project and the steering committee to introduce the AAPRISS program. These are attended by all the people involved in the project, the multidisciplinary group of researchers and the partners. The objective is to question the impact of the project on SIH. From this reflection, many lines of thoughts emerge, from which a first draft of ‘shared findings’ is proposed. 2. Establishment of working group and first working group meetings For each project, a specific working group is then set up, including project leaders and participants, researchers from different disciplines, health promotion referents and the project manager. Each member shares his/her skills and knowledge. The working method is based on co-construction of the analysis and sharing of decisions. Some researchers collect field data, while others only attend the working group meetings. Beyond the development of shared findings, the working group is also in charge of the description of interventions. A distinction is drawn between, on the one hand, the theoretical framework of action that can be generalized and transferred to other contexts, and, on the other hand, the local configuration and context. The methods used are both quantitative and qualitative (epidemiology, sociology, psychology).
Inclusion of projects Projects are eligible for inclusion if their goal is related to nutrition and physical activity, thus participating in cancer prevention. Reducing social inequalities in health may be an explicit or implicit goal, or may not be an objective at all. Projects may be currently running or in preparation, and be run by government agencies, institutions or nongovernmental agencies.
3. Adoption of the shared findings After two or three working group meetings, a final document of shared findings is adopted. This describes the main questions regarding the reduction of SIH to be addressed in the project design and/or implementation. Possible directions for modifications that would improve the capacity of the program to reduce SIH are proposed. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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4. Dynamic and cyclical transformation phase The field research continues in order to better assess the positive and negative impacts of the project on SIH. At the same time, on the basis of the shared findings, some project modifications are implemented by project leaders and observed by researchers. 5. ‘Stabilized’ phase By the time the process reaches this phase, the project has been transformed in line with the shared findings. The objective moves on to the evaluation of these transformations and their impact. Evaluation methods are then co-constructed within the working group and progressively implemented. Diverse methodological approaches may be used, for example: process indicators, intermediate results, qualitative and quantitative approaches, and even experimental designs.
Regulatory and ethical aspects The program steering committee ensures that the opinion of a committee for the protection of human subjects is requested for each project included in the program.
Results Programs currently in progress At the moment, five projects have been included. Their objectives were, respectively, to improve nutrition and physical exercise (projects 1–3), the results of bariatric surgery (project 4) and the control of diabetes (project 5). The goal of AAPRISS was, through modifications to these projects, to contribute to reducing social inequalities in nutrition and thus in cancer and diabetes. Project 1: ‘Ciné-Ma-Santé’ (Toulouse City Hall) Goals: This project takes place under the aegis of a wider community program, the ‘Atelier Santé Ville’ of the North Toulouse neighborhoods. It aims at acting on nutritional imbalance risks within families by making them aware of nutritional issues. The intervention is based on a yearly event in an underprivileged neighborhood.
Steps completed: The first meeting, the plenary analysis and four working group meetings have taken place. The dynamic and cyclical transformation phase is underway. Shared findings: These focus on the participation of the target population, which is not well characterized and should be improved. Population participation is a lever of reduction of SIH, as it constitutes a means to improve population empowerment so that people can act on their environment. The participation of the local partners is not organized enough and is not formally based on shared foundations. The lack of structure may result in a lack of relevance and consistency with regard to SIH. The sustainability of the action may be compromised by the precariousness of partner associations, while the fight against SIH involves sustainable public health actions. Modifications: Some transformations have been realized in line with the shared findings. Population participation has been characterized with Arnstein’s ladder (14). Some community members were included in the AAPRISS working group. A frame of shared values about community work was made explicit and written down. Henceforth, each partner has to join this frame. Articles have been written in the health promotion press. The result has been an increase in description of the action, methods, theory and values that are the program’s foundation. This work was seen as a step toward transferability. The program also stimulated reflection on new evaluation methods. Project 2: ‘Quatre repas par jour’ (‘Four meals a day’) in elementary schools (Toulouse City Hall) Goals: This project’s objective is to promote a sequence of four meals a day by avoiding snacking during school time. Steps completed: The first meeting and the plenary analysis have been carried out. A working group has been created and field research began in early 2012. Shared findings: Some shared findings were proposed but have not yet been discussed. This municipality-driven project targets every school in the area, but some of them did not join in. The schools that have not responded are likely to be those located in more deprived areas. Furthermore, parents are not included in the intervention logic, which may result in
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a lack of equity by not taking into account the family context around children. Some parents also resisted the city’s four-meals-a-day drive by providing their children with snacks, which generated racketeering within schools. It is important not to overlook the fact that an action to support healthy eating may impact others’ health and SIH determinants such as day to day conditions at school. Modifications: Some transformations have been proposed. A study is underway using a deprivation index (15) to characterize the neighborhood of the ‘silent schools’. School actors are also involved. The next step is to produce educational material for parents that takes into account cultural, social and religious aspects of their lifestyles. Project 3: ‘Bien manger et bouger dès l’école maternelle!’ (Caisse Primaire d’Assurance Maladie de la Haute-Garonne) Goals: This project aims to educate children in primary schools, in the Haute-Garonne area to address the increased prevalence of obesity and sedentary lifestyle. Steps completed: The first meeting, the plenary analysis and five working group meetings have taken place. The working group was created concurrently and field research work has begun. The dynamic and cyclical transformation phase is underway; modifications have been decided on. The next step is the evaluation of these modifications. Shared findings: Project leaders acknowledged the fact that the objective of reducing SIH was not explicitly stated in the goals of the program. Equity was thus not included in the logic of the intervention. The choice of schools included within the project depends on several criteria (number of children, number of classrooms, teachers’ availability, type of areas, etc.). Due to the lack of an explicit goal of addressing the SIH issue, the selection of the schools did not take into account social environment and, thus, the schools most in need. This project is based on a health education strategy that could increase SIH by benefiting the more advantaged groups of the population more than deprived ones. Modifications: Modifications made to the program so far are related to making the objective of reducing SIH more explicit. A deprivation index is also being used in order to map schools to improve
school selection with regard to SIH reduction. New tools aiming at better acknowledging the diversity of children are in development. Project 4: Therapeutic education for patients undergoing bariatric surgery (Toulouse University Hospitals) Goals: This project aims at making patients feel more autonomous in the management of their chronic diseases. Steps completed: The first meeting, the plenary analysis and two working group meetings have taken place. Shared findings: The shared findings are still being debated before a final document is produced. The methods of accessing the program may induce selection effects that could lead to increased SIH. Not all patients have the same capacities required to engage in such voluntary processes. Caregivers’ teams adapt the project content on the basis of several criteria. These criteria are not explicit, and are thus subjective. This could lead to increased SIH, as it relies on caregivers’ social representations of the social status of patients and is not formalized. The patient education session takes place before the bariatric surgery, and nothing is planned afterwards. The lack of follow-up after surgery could also increase SIH, as patients’ life context does not allow everyone to benefit equitably from the surgery. Modifications: Three transformations have been proposed. They focus on formalization of the adaptation of the therapeutic education program. Furthermore, therapeutic education could be additionally proposed after the surgery. Further reflection on evaluation methods regarding the success or failure of surgery is also underway. Project 5: Patient education on Type 2 diabetes (Toulouse University Hospitals) Goals: This project aims at making patients feel more autonomous in the management of their chronic diseases. Steps completed: The first meeting, the plenary analysis and a working group meeting have taken place. The next working group meeting will allow participants to start developing on the initial findings. Shared findings: These have not been established yet. However, some preliminary reflections were drawn from the discussions, focusing mostly on the IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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difficulty of accessing the program and on the adaptation of the program content and the follow-up in the context of patient life.
Preliminary results on feasibility and acceptability Among the projects that were eligible and invited to participate, no refusal was observed, and the program is ongoing in each project. The attendance at the various committees was found to be high, including that of researchers and practitioners. The result of the process of co-construction was the production of tools; their description and validation is in process. The production of ‘shared findings’ coming out from the meetings, which were meaningful for researchers as well as for practitioners, was found to be quite acceptable by the partners. A period of explanation and discussion was necessary to gain confidence from the partners, since this step implied a critical review of the project. In each project, shared findings were agreed upon by the partners, thus assessing the feasibility of the program. Similarly, preliminary results show that some modifications of the programs were observed.
Discussion Facing the challenge of reducing SIH, this program is an attempt to cope with the fact that determinants of health inequalities are numerous, act from the beginning of life, and are present within and outside the health sector. The goal is thus to experiment with an umbrella program approach aiming at revisiting health interventions. One major challenge of the program is to bring together researchers and actors in the same health equity impact assessment program (16). The second challenge relates to the fact that intervention and evaluation cannot be disentangled from each other (17). Applying a health equity impact assessment approach to health prevention programs in order to reduce SIH is relevant in France, where the level of SIH is the highest in Western Europe (18). It has been emphasized that more sensitive, participatory methods are required in the development of health equity impact assessment (19). For each of the projects, the AAPRISS program follows the main steps of the methodology developed for health equity impact assessment: screening, scoping, data
collection, impact appraisal, recommendations and monitoring/evaluation (19). In line with participatory research methods, AAPRISS developed a strong emphasis on participatory aspects. This dynamic process should lead ultimately to a collaborative learning network. The AAPRISS program is an attempt to create connections between communities that do not usually work together or interact. It includes interdisciplinary work within the academic field and exchanges between public health practitioners and researchers. Its chosen process is the co-construction of knowledge of interventions that aim at reducing SIH, which fully recognizes the legitimacy of practitioners, and the provision of cognitive, strategic and logistic activities (12). The originality of the AAPRISS program is that it brings together researchers, actors in the health sector and local authorities. A challenge thus follows: how to combine different time constraints, types of evaluations and criteria, suitability and local adaptation for the actors, and reproducibility and generalizability for researchers. Another challenge is related to the acceptability of the co-construction process by the funders. By definition, the research project announces that the interventions and their evaluations will be discussed among stakeholders. It is thus not quite defined a priori, as is usually the case in clinical research and public health with randomized experiments or quasiexperiments, which leads to difficulties in getting funded and published. Some obstacles to the AAPRISS program can be identified. Institutional context is indeed important. For instance, it was difficult to set up working group meetings for the hospital-based projects, as caregivers were very busy and staff turnover frequent. The highly hierarchical culture of some institutions impeded the capacity of the project leaders to express their views in the presence of their bosses. This also impacted the capacity to bring about changes to the intervention, as the project leaders preferred to faithfully respect the initial intervention logic. Cross-sectorality led to some misunderstandings linked to social representations of ‘researchers’ and ‘practitioners’ by each other. Researchers could be viewed as removed from the reality of the field and only interested in getting data to conduct their research. Cross-sectorality also raises the question of temporality differences, the
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question of reciprocity of interests, and the question of balance in relationships. Multidisciplinarity implies different epistemological postures that bring about misunderstandings and competing visions of the AAPRISS program objectives. The process of critical reading of interventions could endanger the projects’ sustainability, as they are financially precarious and isolated. Therefore, the question of the evaluation is especially sensitive. Furthermore, the lack of financial resources to support action transformations can be considered as an important limitation. During the process of analysis and identification of ways of improving the actions’ efficacy in reducing SIH, some main findings emerged. Most often, the goal of reducing SIH was not made explicit in the presentation of the actions, either orally or in writing. Absence of procedures for reducing selection bias and for access to interventions was constantly observed. Either access to the interventions was left to the initiative of the individuals, or their institutions (schools) were not selected despite their clear needs or their location in deprived neighborhoods. Even in the community program, little attention was paid to the selection process in the population. In the two hospital programs, the capacity of the patients to comply with the program was assessed based on implicit criteria, raising the possibility that subjective and social criteria were used. The question of the social, cultural and linguistic diversity of the population was rarely addressed upfront. Mainly due to financial constraints, follow-ups on the individuals targeted by the programs, following the end of the intervention, were rarely performed. Lack of contact and networking with possible partners within and outside the health sector was identified in most projects. Participation of the population was not the rule, and this was identified as an avenue for improvement. In the AAPRISS steering committee, the population is not directly involved, since this program is run by institutional representatives. However, involving the public in projects is one aspect of the analysis and possible modification. The population can be included in working groups when it is relevant to a project’s logic. It is indeed necessary to anticipate whether a program will promote values shared by the targeted community, or whether it will impose the values of one social group on another (20). Lastly, in one project, unexpected effects were observed that had an impact on perceived health
and social relationships within some schools located in poor neighborhoods, thus potentially increasing health inequalities. Developing interventions is closely related to evaluation methodologies. In public health research, a broad consensus supports the hierarchical level of evidence of randomized clinical trials. However, randomized clinical trials and experimental trials in public health have major limitations (21). Our project also addresses the need for critical reflection on evaluation methods. In countries where inequalities in health are addressed, current evaluation methods have proven to be largely inappropriate for capturing the complexity of multiple interventions, be they concurrent, evolving over time, multi-partner, or on different timescales. For interventions, a distinction should be made between the concepts used for transferability and the local concrete implementation of the intervention (22). We suggest that this first step is a key element both for providing shared findings and pathways for improvement, and for preparing evaluation. The AAPRISS methodology was found to be feasible and acceptable in this respect.
Conclusion Many partners are involved and have rallied around this program on reducing health inequalities, including the health research sector, the voluntary sector and institutions, and political as well as economic actors. The program has been shown to be feasible and acceptable by partners and health actors. A major challenge of this aspect of the program is to understand each partner’s expectations in terms of temporality of interventions, expected outcomes, assessment methods and indicators. Analyzing the projects has been quite feasible, and some modifications have been implemented in the projects in order to take into account inequalities in health. Beyond projects’ concrete reorientations, a major AAPRISS program outcome has been to introduce reflection on SIH and on the unintended impact of interventions among project leaders and their institutions. An ongoing effort is also necessary to raise awareness on the concept of the social gradient of health within the whole population, and the possible contribution of curative and preventive activities to increasing or reducing SIH. The role of social determinants acting outside the health care IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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system has not yet been clearly recognized. Widening the scope of our approach to all policies will be the next step, and will be accomplished by conducting Health Impact Assessment of policies outside the health sector in France (19,23). Acknowledgements The AAPRISS (Apprendre et Agir pour Réduire les Inégalités Sociales de Santé) program involves the following partners in addition to the authors: B Almudever, JC Basson, L Birelichie, A Bulle, F Cayla, C Delpierre, P Ducourneau, E Gaborit, JP Genolini, T Ginsbourger, M Kelly-Irving, A Lacouture, A Guichard, F Lequerrec, P Manuello, C Martin, A Mayere, MT Munoz-Sastre, I Poirot-Mazeres, V Ridde, F Sicot, and F Sordes-Ader. The program would not have been possible without the following partnerships: Agence régionale de santé MidiPyrénées, Cancéropôle Grand Sud-Ouest, Communauté urbaine du Grand Toulouse, Caisse Primaire d’Assurance Maladie de la Haute Garonne, Département Sciences humaines, sociales et des comportements de santé de l’Ecole des Hautes Etudes en Santé Publique, Institut Claudius Regaud, Institut National de Prévention et d’Education pour la Santé, Ligue nationale contre le cancer, comité de Haute-Garonne, Mutualité Française Midi-Pyrénées, Réseau Oncomip, Conseil Régional de l’Ordre des pharmaciens, Observatoire Régional de la Santé de Midi-Pyrénées, Pôle Cancer-Bio-Santé, Académie de Toulouse. We would like to thank the Scientific Committee: Franco Berrino, Pierre Blaise, Pierre Chauvin, Hercberg Serge, France Lert, Louise Potvin, Alfred Spira for their useful advice and comments as well as the leaders and the teams of the project involved in AAPRISS.
Conflict of interest None declared.
Funding This research received funding from Institut National du Cancer (INCA N° 2011-009), Agence Nationale de la Recherche (ANR- 11-INEG -0003 “EVALISS”), and Agence Régionale de Santé Midi-Pyrénées.
Note i. A website with many documents relating to the program is available at: http://www.iferiss.org/
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research-article2015
PED0010.1177/1757975914568127Original ArticleT. Lang et al.
Original Article A health equity impact assessment umbrella program (AAPRISS) to tackle social inequalities in health: program description Thierry Lang1,2,3, Elsa Bidault1,2, Mélanie Villeval1,2, François Alias4, Benjamin Gandouet5, Martine Servat3, Ivan Theis6, Eric Breton7, Nadine Haschar-Noé2,8 and Pascale Grosclaude1,2,9
Abstract: Background: The failure to simultaneously address two objectives (increasing the average health of the population and reducing health inequalities) may have led to what has been observed in France so far: an overall decrease in mortality and increase in inequality. Objective: The Apprendre et Agir pour Réduire les Inégalités Sociales de Santé (AAPRISS) methodology is to analyze and modify interventions that are already underway in terms of their potential impact on health inequalities. It relies on partnership between researchers and actors in the health field, as well as policy makers. In this paper, we describe the program and discuss its feasibility and acceptability. Methods: This program is not a single intervention, but a process aiming at assessing and reshaping existing health programs, therefore acting as a kind of meta-intervention. The program develops scientific and methodological support stemming from co-construction methods aimed at increasing equity within the programs. Stakeholders from prevention policy-making and the health care system, as well as researchers, collaborate in defining interventions, monitoring their progress, and choosing indicators, methods and evaluation procedures. The target population is mainly the population of the greater Toulouse area. The steps of the process are described: (1) establishment of AAPRISS governance and partnerships; (2) inclusion of projects; and (3) the projects’ process. Discussion: Many partners have rallied around this program, which has been shown to be feasible and acceptable by partners and health actors. A major challenge is understanding each partner’s expectations in terms of temporality of interventions, expected outcomes, assessment methods and indicators. Analyzing the projects has been quite feasible, and some modifications have been implemented in them in order to take inequalities in health into account. Keywords: health impact assessment, determinants of health, equity/social justice, evaluation, qualitative, quantitative, community-based research/participatory research
1. 2. 3. 4. 5. 6. 7. 8. 9.
UMR 1027 Inserm – Université Paul Sabatier, Toulouse, France. Institut Fédératif d’Etudes et de Recherches Interdisciplinaires Santé Société, Toulouse, France. Centre Hospitalo-Universitaire de Toulouse, France. Instance Régionale d’Education et de Promotion de la Santé, Toulouse, France. Oncopole de Toulouse, France. Mairie de Toulouse, France. Ecole des Hautes Etudes en Santé Publique, Rennes, France. EA 4561 Prissmh-Soi, Toulouse III, Toulouse, France. Institut Claudius Régaud, Toulouse, France.
Correspondence to: Thierry Lang, UMR INSERM-UPS 1027, Faculté de Médecine, 37 Allées Jules Guesde, 31062 Toulouse CEDEX 9, France. Email: [email protected] (This manuscript was submitted on 17 March 2014. Following blind peer review, it was accepted for publication on 6 November 2014) Global Health Promotion 1757-9759; Vol 0(0): 1 –9; 568127 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914568127 http://ghp.sagepub.com Downloaded from ped.sagepub.com at UNIV OF LETHBRIDGE on November 14, 2015
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Background A high level of social inequalities in health (SIH) has been observed in France in most age groups (1). Mortality has decreased over the years, contrasting with an increase in health inequalities. For example, from 1970 to 1995, the relative index of inequalities according to educational level has increased from 1.96 to 2.77 in men, and from 1.87 to 2.53 in women (2). No public policy has been explicitly developed in order to reduce the social gradient in health. Policies so far have been focused on extreme poverty (exclusion, homelessness, etc.). The failure to simultaneously address the two objectives, that is, increasing the average health of the population and reducing health inequalities, may have led to what has been observed in France so far: an overall decrease in mortality and increase in inequality. Indeed, it has been shown that interventions and preventive actions that do not take SIH into account often contribute to worsening them (3). Reducing SIH has appeared on the political agenda in France over the past few years. It has been emphasized in the second and third National Cancer Plans (national policies targeting cancer) and is among the top priorities of the Agences Régionales de Santé (regional health agencies). It is thus necessary to develop population health intervention research (4). A multiplicity of risk factors and determinants in the health care system, in the organization of prevention, and also in policies outside the health system, that is, the whole social and societal context, help shape social inequalities in health. It would be more relevant to think of prevention in a health promotion perspective, moving beyond interventions based on individual decisions and behaviors towards structural, regulatory and social changes that facilitate choices considered to be conducive to health (‘healthy choices’). Individual behaviors can also change as a result of the strengthening of resources at the individual and community level (5). These risk factors act throughout life, from birth or even before, and therefore require multiple interventions and diverse approaches (6,7). While the effect of each of these determinants may be partial, their accumulation may lead to the inequalities that we know. The multiplicity of causes (social, economic, cultural, educational, etc.) calls for the involvement of a multiplicity of actors, hence the multi-partnership
approach and complexity of interventions. Actions to reduce the social gradient in health are distinguishable from policies focusing on extreme poverty when the root causes have already taken a heavy toll on population health. Alternative approaches have been proposed, including proportionate universalism (8,9), which still have to be translated into interventions. To reduce health inequalities by taking into account the social gradient does not necessarily lend itself to answering the specific needs and contexts of population groups. For this reason, revisiting each policy within and outside the health sector to appraise its foreseen impact on health inequities may stand as a promising strategy for reducing SIH. Given the high level of SIH in France, equityfocused programs are needed. Apprendre et Agir pour Réduire les Inégalités Sociales de Santé (AAPRISS) is a health equity impact assessment program. Its goal is to reduce social inequalities in health, focusing on interventions that either already exist or are in preparation. The program is related to social inequalities in nutrition in order to prevent social inequalities in the onset of cancer. The role of nutritional practices as protective factors reducing the risk of cancer is becoming better known (10). Obesity is a socially stratified health outcome, to the detriment of more disadvantaged groups; this trend has not abated over time. In children, the latest statistics suggest a decrease in the obesity epidemic, but this change is being accompanied by a widening of social inequalities for this indicator (11). Usually, an intervention targeting the determinants of poor nutrition potentially has positive impacts for a range of diseases (cancer, cardiovascular disease, aging, etc.) (10). The effects of such a program are not evident in the short term. Indeed, changes to the projects are expected to be seen in a time period of about a year. However, the process is also expected to induce a co-construction of knowledge, which may have long term bidirectional consequences on practitioners as well as on academic researchers (12). The AAPRISS methodology is to analyze and modify interventions in terms of their potential impact on health inequalitiesi. It relies on partnership between researchers and actors in the health field, as well as policymakers. In this paper, we describe the program and discuss preliminary findings concerning its feasibility and acceptability.
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Methods This program is not a single intervention, but a process that therefore acts as a kind of metaintervention. This ‘umbrella program’ addresses concerns raised by a number of local authorities in need of methodological assistance (13). Within the engineering of complex public health interventions, the program develops scientific and methodological support stemming from co-construction methods aiming at increasing equity within the projects. Stakeholders from prevention policy-making and the health care system, as well as researchers, collaborate in defining interventions, monitoring their progress, and choosing indicators, methods and evaluation procedures. The target population is mainly the population of the greater Toulouse area. Here we will describe the steps of the process.
Establishment of AAPRISS governance and partnership The AAPRISS steering committee includes three researchers: one representative of the Toulouse city council, one of the Toulouse University Hospital, one of the regional prevention and health promotion group, one of the Toulouse Cancer Centre, and a project manager. Members of this committee get together twice a month to define strategic targets and coordinate stakeholders. Other institutional partners have joined the research program and signed a public commitment agreement toward reducing health inequalities (see Acknowledgements). The scientific team includes researchers from different disciplines, including sociology, epidemiology, psychology, policy analysis and public health.
Process of change: analysis, modification and evaluation of a project Once the steering committee has decided to integrate a project into the AAPRISS program, several steps follow: 1. First meetings These consist of an initial contact, allowing the project leaders to introduce their project and the steering committee to introduce the AAPRISS program. These are attended by all the people involved in the project, the multidisciplinary group of researchers and the partners. The objective is to question the impact of the project on SIH. From this reflection, many lines of thoughts emerge, from which a first draft of ‘shared findings’ is proposed. 2. Establishment of working group and first working group meetings For each project, a specific working group is then set up, including project leaders and participants, researchers from different disciplines, health promotion referents and the project manager. Each member shares his/her skills and knowledge. The working method is based on co-construction of the analysis and sharing of decisions. Some researchers collect field data, while others only attend the working group meetings. Beyond the development of shared findings, the working group is also in charge of the description of interventions. A distinction is drawn between, on the one hand, the theoretical framework of action that can be generalized and transferred to other contexts, and, on the other hand, the local configuration and context. The methods used are both quantitative and qualitative (epidemiology, sociology, psychology).
Inclusion of projects Projects are eligible for inclusion if their goal is related to nutrition and physical activity, thus participating in cancer prevention. Reducing social inequalities in health may be an explicit or implicit goal, or may not be an objective at all. Projects may be currently running or in preparation, and be run by government agencies, institutions or nongovernmental agencies.
3. Adoption of the shared findings After two or three working group meetings, a final document of shared findings is adopted. This describes the main questions regarding the reduction of SIH to be addressed in the project design and/or implementation. Possible directions for modifications that would improve the capacity of the program to reduce SIH are proposed. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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4. Dynamic and cyclical transformation phase The field research continues in order to better assess the positive and negative impacts of the project on SIH. At the same time, on the basis of the shared findings, some project modifications are implemented by project leaders and observed by researchers. 5. ‘Stabilized’ phase By the time the process reaches this phase, the project has been transformed in line with the shared findings. The objective moves on to the evaluation of these transformations and their impact. Evaluation methods are then co-constructed within the working group and progressively implemented. Diverse methodological approaches may be used, for example: process indicators, intermediate results, qualitative and quantitative approaches, and even experimental designs.
Regulatory and ethical aspects The program steering committee ensures that the opinion of a committee for the protection of human subjects is requested for each project included in the program.
Results Programs currently in progress At the moment, five projects have been included. Their objectives were, respectively, to improve nutrition and physical exercise (projects 1–3), the results of bariatric surgery (project 4) and the control of diabetes (project 5). The goal of AAPRISS was, through modifications to these projects, to contribute to reducing social inequalities in nutrition and thus in cancer and diabetes. Project 1: ‘Ciné-Ma-Santé’ (Toulouse City Hall) Goals: This project takes place under the aegis of a wider community program, the ‘Atelier Santé Ville’ of the North Toulouse neighborhoods. It aims at acting on nutritional imbalance risks within families by making them aware of nutritional issues. The intervention is based on a yearly event in an underprivileged neighborhood.
Steps completed: The first meeting, the plenary analysis and four working group meetings have taken place. The dynamic and cyclical transformation phase is underway. Shared findings: These focus on the participation of the target population, which is not well characterized and should be improved. Population participation is a lever of reduction of SIH, as it constitutes a means to improve population empowerment so that people can act on their environment. The participation of the local partners is not organized enough and is not formally based on shared foundations. The lack of structure may result in a lack of relevance and consistency with regard to SIH. The sustainability of the action may be compromised by the precariousness of partner associations, while the fight against SIH involves sustainable public health actions. Modifications: Some transformations have been realized in line with the shared findings. Population participation has been characterized with Arnstein’s ladder (14). Some community members were included in the AAPRISS working group. A frame of shared values about community work was made explicit and written down. Henceforth, each partner has to join this frame. Articles have been written in the health promotion press. The result has been an increase in description of the action, methods, theory and values that are the program’s foundation. This work was seen as a step toward transferability. The program also stimulated reflection on new evaluation methods. Project 2: ‘Quatre repas par jour’ (‘Four meals a day’) in elementary schools (Toulouse City Hall) Goals: This project’s objective is to promote a sequence of four meals a day by avoiding snacking during school time. Steps completed: The first meeting and the plenary analysis have been carried out. A working group has been created and field research began in early 2012. Shared findings: Some shared findings were proposed but have not yet been discussed. This municipality-driven project targets every school in the area, but some of them did not join in. The schools that have not responded are likely to be those located in more deprived areas. Furthermore, parents are not included in the intervention logic, which may result in
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a lack of equity by not taking into account the family context around children. Some parents also resisted the city’s four-meals-a-day drive by providing their children with snacks, which generated racketeering within schools. It is important not to overlook the fact that an action to support healthy eating may impact others’ health and SIH determinants such as day to day conditions at school. Modifications: Some transformations have been proposed. A study is underway using a deprivation index (15) to characterize the neighborhood of the ‘silent schools’. School actors are also involved. The next step is to produce educational material for parents that takes into account cultural, social and religious aspects of their lifestyles. Project 3: ‘Bien manger et bouger dès l’école maternelle!’ (Caisse Primaire d’Assurance Maladie de la Haute-Garonne) Goals: This project aims to educate children in primary schools, in the Haute-Garonne area to address the increased prevalence of obesity and sedentary lifestyle. Steps completed: The first meeting, the plenary analysis and five working group meetings have taken place. The working group was created concurrently and field research work has begun. The dynamic and cyclical transformation phase is underway; modifications have been decided on. The next step is the evaluation of these modifications. Shared findings: Project leaders acknowledged the fact that the objective of reducing SIH was not explicitly stated in the goals of the program. Equity was thus not included in the logic of the intervention. The choice of schools included within the project depends on several criteria (number of children, number of classrooms, teachers’ availability, type of areas, etc.). Due to the lack of an explicit goal of addressing the SIH issue, the selection of the schools did not take into account social environment and, thus, the schools most in need. This project is based on a health education strategy that could increase SIH by benefiting the more advantaged groups of the population more than deprived ones. Modifications: Modifications made to the program so far are related to making the objective of reducing SIH more explicit. A deprivation index is also being used in order to map schools to improve
school selection with regard to SIH reduction. New tools aiming at better acknowledging the diversity of children are in development. Project 4: Therapeutic education for patients undergoing bariatric surgery (Toulouse University Hospitals) Goals: This project aims at making patients feel more autonomous in the management of their chronic diseases. Steps completed: The first meeting, the plenary analysis and two working group meetings have taken place. Shared findings: The shared findings are still being debated before a final document is produced. The methods of accessing the program may induce selection effects that could lead to increased SIH. Not all patients have the same capacities required to engage in such voluntary processes. Caregivers’ teams adapt the project content on the basis of several criteria. These criteria are not explicit, and are thus subjective. This could lead to increased SIH, as it relies on caregivers’ social representations of the social status of patients and is not formalized. The patient education session takes place before the bariatric surgery, and nothing is planned afterwards. The lack of follow-up after surgery could also increase SIH, as patients’ life context does not allow everyone to benefit equitably from the surgery. Modifications: Three transformations have been proposed. They focus on formalization of the adaptation of the therapeutic education program. Furthermore, therapeutic education could be additionally proposed after the surgery. Further reflection on evaluation methods regarding the success or failure of surgery is also underway. Project 5: Patient education on Type 2 diabetes (Toulouse University Hospitals) Goals: This project aims at making patients feel more autonomous in the management of their chronic diseases. Steps completed: The first meeting, the plenary analysis and a working group meeting have taken place. The next working group meeting will allow participants to start developing on the initial findings. Shared findings: These have not been established yet. However, some preliminary reflections were drawn from the discussions, focusing mostly on the IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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difficulty of accessing the program and on the adaptation of the program content and the follow-up in the context of patient life.
Preliminary results on feasibility and acceptability Among the projects that were eligible and invited to participate, no refusal was observed, and the program is ongoing in each project. The attendance at the various committees was found to be high, including that of researchers and practitioners. The result of the process of co-construction was the production of tools; their description and validation is in process. The production of ‘shared findings’ coming out from the meetings, which were meaningful for researchers as well as for practitioners, was found to be quite acceptable by the partners. A period of explanation and discussion was necessary to gain confidence from the partners, since this step implied a critical review of the project. In each project, shared findings were agreed upon by the partners, thus assessing the feasibility of the program. Similarly, preliminary results show that some modifications of the programs were observed.
Discussion Facing the challenge of reducing SIH, this program is an attempt to cope with the fact that determinants of health inequalities are numerous, act from the beginning of life, and are present within and outside the health sector. The goal is thus to experiment with an umbrella program approach aiming at revisiting health interventions. One major challenge of the program is to bring together researchers and actors in the same health equity impact assessment program (16). The second challenge relates to the fact that intervention and evaluation cannot be disentangled from each other (17). Applying a health equity impact assessment approach to health prevention programs in order to reduce SIH is relevant in France, where the level of SIH is the highest in Western Europe (18). It has been emphasized that more sensitive, participatory methods are required in the development of health equity impact assessment (19). For each of the projects, the AAPRISS program follows the main steps of the methodology developed for health equity impact assessment: screening, scoping, data
collection, impact appraisal, recommendations and monitoring/evaluation (19). In line with participatory research methods, AAPRISS developed a strong emphasis on participatory aspects. This dynamic process should lead ultimately to a collaborative learning network. The AAPRISS program is an attempt to create connections between communities that do not usually work together or interact. It includes interdisciplinary work within the academic field and exchanges between public health practitioners and researchers. Its chosen process is the co-construction of knowledge of interventions that aim at reducing SIH, which fully recognizes the legitimacy of practitioners, and the provision of cognitive, strategic and logistic activities (12). The originality of the AAPRISS program is that it brings together researchers, actors in the health sector and local authorities. A challenge thus follows: how to combine different time constraints, types of evaluations and criteria, suitability and local adaptation for the actors, and reproducibility and generalizability for researchers. Another challenge is related to the acceptability of the co-construction process by the funders. By definition, the research project announces that the interventions and their evaluations will be discussed among stakeholders. It is thus not quite defined a priori, as is usually the case in clinical research and public health with randomized experiments or quasiexperiments, which leads to difficulties in getting funded and published. Some obstacles to the AAPRISS program can be identified. Institutional context is indeed important. For instance, it was difficult to set up working group meetings for the hospital-based projects, as caregivers were very busy and staff turnover frequent. The highly hierarchical culture of some institutions impeded the capacity of the project leaders to express their views in the presence of their bosses. This also impacted the capacity to bring about changes to the intervention, as the project leaders preferred to faithfully respect the initial intervention logic. Cross-sectorality led to some misunderstandings linked to social representations of ‘researchers’ and ‘practitioners’ by each other. Researchers could be viewed as removed from the reality of the field and only interested in getting data to conduct their research. Cross-sectorality also raises the question of temporality differences, the
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question of reciprocity of interests, and the question of balance in relationships. Multidisciplinarity implies different epistemological postures that bring about misunderstandings and competing visions of the AAPRISS program objectives. The process of critical reading of interventions could endanger the projects’ sustainability, as they are financially precarious and isolated. Therefore, the question of the evaluation is especially sensitive. Furthermore, the lack of financial resources to support action transformations can be considered as an important limitation. During the process of analysis and identification of ways of improving the actions’ efficacy in reducing SIH, some main findings emerged. Most often, the goal of reducing SIH was not made explicit in the presentation of the actions, either orally or in writing. Absence of procedures for reducing selection bias and for access to interventions was constantly observed. Either access to the interventions was left to the initiative of the individuals, or their institutions (schools) were not selected despite their clear needs or their location in deprived neighborhoods. Even in the community program, little attention was paid to the selection process in the population. In the two hospital programs, the capacity of the patients to comply with the program was assessed based on implicit criteria, raising the possibility that subjective and social criteria were used. The question of the social, cultural and linguistic diversity of the population was rarely addressed upfront. Mainly due to financial constraints, follow-ups on the individuals targeted by the programs, following the end of the intervention, were rarely performed. Lack of contact and networking with possible partners within and outside the health sector was identified in most projects. Participation of the population was not the rule, and this was identified as an avenue for improvement. In the AAPRISS steering committee, the population is not directly involved, since this program is run by institutional representatives. However, involving the public in projects is one aspect of the analysis and possible modification. The population can be included in working groups when it is relevant to a project’s logic. It is indeed necessary to anticipate whether a program will promote values shared by the targeted community, or whether it will impose the values of one social group on another (20). Lastly, in one project, unexpected effects were observed that had an impact on perceived health
and social relationships within some schools located in poor neighborhoods, thus potentially increasing health inequalities. Developing interventions is closely related to evaluation methodologies. In public health research, a broad consensus supports the hierarchical level of evidence of randomized clinical trials. However, randomized clinical trials and experimental trials in public health have major limitations (21). Our project also addresses the need for critical reflection on evaluation methods. In countries where inequalities in health are addressed, current evaluation methods have proven to be largely inappropriate for capturing the complexity of multiple interventions, be they concurrent, evolving over time, multi-partner, or on different timescales. For interventions, a distinction should be made between the concepts used for transferability and the local concrete implementation of the intervention (22). We suggest that this first step is a key element both for providing shared findings and pathways for improvement, and for preparing evaluation. The AAPRISS methodology was found to be feasible and acceptable in this respect.
Conclusion Many partners are involved and have rallied around this program on reducing health inequalities, including the health research sector, the voluntary sector and institutions, and political as well as economic actors. The program has been shown to be feasible and acceptable by partners and health actors. A major challenge of this aspect of the program is to understand each partner’s expectations in terms of temporality of interventions, expected outcomes, assessment methods and indicators. Analyzing the projects has been quite feasible, and some modifications have been implemented in the projects in order to take into account inequalities in health. Beyond projects’ concrete reorientations, a major AAPRISS program outcome has been to introduce reflection on SIH and on the unintended impact of interventions among project leaders and their institutions. An ongoing effort is also necessary to raise awareness on the concept of the social gradient of health within the whole population, and the possible contribution of curative and preventive activities to increasing or reducing SIH. The role of social determinants acting outside the health care IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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system has not yet been clearly recognized. Widening the scope of our approach to all policies will be the next step, and will be accomplished by conducting Health Impact Assessment of policies outside the health sector in France (19,23). Acknowledgements The AAPRISS (Apprendre et Agir pour Réduire les Inégalités Sociales de Santé) program involves the following partners in addition to the authors: B Almudever, JC Basson, L Birelichie, A Bulle, F Cayla, C Delpierre, P Ducourneau, E Gaborit, JP Genolini, T Ginsbourger, M Kelly-Irving, A Lacouture, A Guichard, F Lequerrec, P Manuello, C Martin, A Mayere, MT Munoz-Sastre, I Poirot-Mazeres, V Ridde, F Sicot, and F Sordes-Ader. The program would not have been possible without the following partnerships: Agence régionale de santé MidiPyrénées, Cancéropôle Grand Sud-Ouest, Communauté urbaine du Grand Toulouse, Caisse Primaire d’Assurance Maladie de la Haute Garonne, Département Sciences humaines, sociales et des comportements de santé de l’Ecole des Hautes Etudes en Santé Publique, Institut Claudius Regaud, Institut National de Prévention et d’Education pour la Santé, Ligue nationale contre le cancer, comité de Haute-Garonne, Mutualité Française Midi-Pyrénées, Réseau Oncomip, Conseil Régional de l’Ordre des pharmaciens, Observatoire Régional de la Santé de Midi-Pyrénées, Pôle Cancer-Bio-Santé, Académie de Toulouse. We would like to thank the Scientific Committee: Franco Berrino, Pierre Blaise, Pierre Chauvin, Hercberg Serge, France Lert, Louise Potvin, Alfred Spira for their useful advice and comments as well as the leaders and the teams of the project involved in AAPRISS.
Conflict of interest None declared.
Funding This research received funding from Institut National du Cancer (INCA N° 2011-009), Agence Nationale de la Recherche (ANR- 11-INEG -0003 “EVALISS”), and Agence Régionale de Santé Midi-Pyrénées.
Note i. A website with many documents relating to the program is available at: http://www.iferiss.org/
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