mobilising evidence for action on ethnic inequalities
TRANSCRIPT
Mobilising evidence for action on ethnic inequalities
Background
• Increasingly evidence-based culture of healthcare practice and policy. This can inadvertently undermine attention to ethnic diversity and inequality; people struggle to find and present 'good evidence'.
• Advocates need support to:
- compile data/evidence around ethnic inequalities
- present this information persuasively to different audiences.
Objectives
To highlight the importance of:
- Describing and understanding ethnic inequalities adequately, in order to identify appropriate responses, and
- Packaging and presenting evidence effectively to get key stakeholders to support action
To suggest some ways to :- Improve understanding of issues and how can be addressed
- Overcome common data/evidence gaps - Prompt appropriate action even when knowledge incomplete
Types of evidence use: a view from the EEiC project
Interviewer: So, tell me a bit about how you go about getting the evidence and information you need to improve services
Respondent: Well, there's the information you need to work out what needs to be done; and then of course there's the information you need to convince people to let you get on and do it
Working out what needs to be done: beyond description
Ethnicity ???Health –related outcome
Describe ►Explain ►Prescribe
Ethnicity
'Culture' ‘Ways of being & doing’
Access to/exclusion from resources
Genotypic/biological factors
Health –related outcome
Describe ►Explain ►Prescribe
Ethnicity
'Culture' ‘Ways of being & doing’
Access to/exclusion from resources
Genotypic/biological factors
Health –related outcome
risks, exposures, protective
factors
recognition, responses
quantity & quality of
healthcare
Describe ►Explain ►Prescribe
Ethnicity
'Culture' ‘Ways of being & doing’
Access to/exclusion from resources
Genotypic/biological factors
Health –related outcome
risks, exposures, protective
factors
recognition, responses
quantity & quality of
healthcare
Possible interventions
Varied sources of evidence needed
Describing: What? Patterns/differentials across groups.local data analyses; JSNA; equity audits; expert opinion; other
Explaining: Why? Underlying causes, pathways of effect.published research; user feedback; local insight;
third sector reports; expert opinion
Prescribing: How? Interventions that can tackle issues.NICE/other national guidance; published research; good practice
examples; local innovations (pilot & evaluate)
National guidance lacks detail on ethnicity; general statements only
Few 'blue prints'
'How to' evidence limited
Reluctance to transfer learning across settings
Little cost effectiveness data
Describing
JSNAs lack detail on ethnicity
Local data on health needs of minority ethnic populations lacking
Ethnic monitoring in service settings remains poor
Equity Audits rare
No national/regional benchmarking on equalities outcomes
Patient/carer satisfaction rarely stratified by ethnicity
Community consultation variable
Large distance between decision-makers and minority ethnic communities
Insight/evidence from voluntary/community sector contested
Front line staff distant from decision-makers
Research studies not accessed by commissioners
Explaining Prescribing
Challenges to finding/generating evidence on minority ethnic health
Willingness to take risks, pilot & learn
Documentation/sharing good practice (networks)
Co-production of solutions with communities
Theory-driven systematic reviews focused on minority ethnic needs
'Reading across' service contexts to identify commonalities and areas of learning
DescribingAuditing work that takes an equity focus
Service level Key Performance Indicators reported by ethnicity
Creative use of national and local data to highlight likely inequities
Special surveys to fill important gaps
Models of joint provider-commissioner reviews of service from (in)equalities perspective
Peer reviews
Engagement of community members in service review work
Special studies to understand issues behind inequalities (qualitative; insight work)
Deliberative exercises with varied stakeholders to review and synthesise knowledge
Explaining Prescribing
Enablers & Solutions
Some principles for mobilising evidence to understand ethnic inequalities
• Use varied and complementary sources.
• Identify local assets and resources; useful partnerships.
• Appraise all sources of evidence, data and insight.
• Use process as an opportunity to engage stakeholders.
• Aim for 'good enough'; avoid being blocked completely
• BUT, identify gaps to be filled; clear improvement plan
Exercise in pairs - Introduction
Scenario:
You are a mid-level public health practitioner
You are aware that smoking rates are higher among sections of the minority ethnic population than in the White British population in your area, and that the representation of BME people in smoking cessation services is low.
The Director of Public Health has agreed that this is an important issue to address, and has tasked you with getting the CCG committed to this issue. He has asked that you compile the relevant evidence to 'make the case'.
Information sources for the exercise
1. Local data on access to cessation services by ethnicity.
2. National level data on smoking patterns by ethnicity.
3. NICE guidance statements.
4. Brief descriptions of good practice interventions.
5. Qualitative study illustrating BME smokers' barriers, and practitioner perspectives.
Exercise1
1. Look at the sources that you have been given and identify the key pieces of information/evidence relating to: - describing ethnic inequality- understanding ethnic inequality- prescribing action on inequality
2. Identify gaps. What else would you like to know?
3. How/where might you get this extra information?
From knowledge to action
Simple direct application of evidence use (instrumental use) is rare in commissioning
Most likely to happen where:• Evidence is non-controversial; problem/issue uncontested• Certainty in the best course of action• Requires limited change or upset to current status quo• Clear responsibility for action• Wider environment is supportive
These are not often the characteristics of evidence on ethnic inequalities.
Using evidence in other ways:
Conceptual: changes understanding; redefines the problems/issues; relocates the causes; suggests alternative places to look for solutions; challenges taken-for-granted assumptions etc.
Influential: reframes issues to increase their perceived importance, urgency, relevance; empowers actors to take action; gives legitimacy; persuades etc.
Identify ways to mobilising evidence/information/insight to increase understanding and prompt action
From knowledge to action
Challenges to mobilising evidence for action on ethnic inequalities
As well as gaps in the data/evidence base, mobilising evidence around ethnic inequalities can be difficult because:
•Ethnicity is complex; people struggle to understand its varied links to health.•Stereotypes and misunderstandings: people pre-judge the issues (e.g. assuming the causes of observed inequalities lie in cultural practices or ignorance).•Decision-makers lack confidence and often demand a higher standard of evidence before committing resource.•Assumption that addressing ethnic inequality will add complexity and cost.•Lack of local good practice: assume inequality is inevitable and progress is impossible.•Prevailing values and norms: decision-makers question whether it is right to focus attention on minority ethnic groups.
Mobilising evidence for action on inequalities
Describing: What? Highlight the unacceptable; urgent.
Explaining: Why? Locate cause within influence/responsibility
Prescribing: How? Identify what should be done. Benchmark.
Aim to align issues with core priorities, engender commitment, empower and leverage resource.
Influential and conceptual uses of evidence are key to success.
Some principles for effective presentation of evidence for action
• Empower (challenge, but also offer support/hope)• Focus on key themes• Remember most people have little time to read• Draw on national/international data and policy• Illustrate with local examples that resonate• Use varied data/evidence types -
statistics + local patient stories can be a powerful combination• Articulate an attractive vision; align that vision with audience's
key priorities• Articulate a clear expectation - what do you want of the
audience?
Exercise 2
Look again at the evidence/information you have. Think about how you would use this evidence to make the case to the
CCG. Think carefully about this audience.
• What are you trying to achieve? What do you want/need them to do (at this stage; later on)?
• What are their key concerns likely to be? • What sort of information/evidence will they respond well to?• How do you think it should be packaged?• How, where, when and by whom should it be delivered?
Exercise 2
Discuss in pairs and jot down your ideas: Outcome wanted:
Key message:
Facts/information to be included:
How will you format and present the information? Think about your audience:
'For change effort to be successful, it has to succeed in attracting new people to 'the cause' '
'Your goals need to be described in language that others will hear. This is not about making false statements or hiding the truth but recognising what is important to others and what will help align them with your goal.' (NHS Institute for Improvement and Innovation)
Evidence gaps should not block all action; be creative; draw on diverse sources; work to improve data; pilot and evaluate.