When quality meets quantity: the role of qualitative data in framing health inequalities

policyChris Carmona, Catherine Swann

and Mike KellyNational Institute for Health and

Clinical Excellence (NICE).

Summary

• A brief overview of work undertaken by CPHE and the HDA that is aimed at integrating qualitative data into the evidence base

A case study in the rational model of policy making

• Health inequalities in England 1997 to the present day!!

A rational approach would involve…..

• Review of policy options

• Political considerations

• Data, evidence

• Political possibilities

• The art of persuasion

The evidence based approach to health

inequalities

• Pre-1997 Inequalities in Health Debates

• The Acheson Report

• The Our Healthier Nation White Paper

NHS R&D Strategy

• Systematic approach to using scientific evidence in public health

• knowledge base to be brought together• identifying gaps• underpin OHN and NHS Plan• make the evidence base accessible• provide high quality evidence to reduce

inequalities in health

Questions

• Did this mean quantitative data only?

• Did this favour one kind of methodological approach?

Commitment to multiple methods, including

qualitative approaches

Immersion in the key debates

• The primacy of the RCT

• The complexity of the field

• Effectiveness is the wrong question

• etc.

A limited evidence base

• Evidence about what works to reduce inequalities very limited

• About 0.4% of published scientific papers discuss interventions which might reduce inequalities

• About the same percentage of funded research concerned with interventions

• Rich in description, weak on solution.• But it is possible to identify effective

interventions.

Starting Point

• First stage to synthesise review level work in public health priority areas

• Second stage to bring in other forms of scientific evidence

• Third stage to work towards the synthesis of evidence from different research traditions

Products

• Evidence Briefings

• Evidence Reviews

• Systematic Reviews

• Rapid Reviews

• Discussion papers

• Teenage pregnancy• HIV/AIDS• STIs• Smoking• Alcohol X2• Drugs X3• Obesity• Low birth weight• Breastfeeding X3• Youth Suicide• Life course• Infant nutrition• Public health economics• Work, job satisfaction and

psychological health• Grading evidence• Qualitative evidence

synthesis

• Social support in pregnancy

• Physical activity X3• Mental health• Accidental injury• Health Impact

Assessment• Transport• Gradients and gaps• Health Impact

Assessment• Housing• Work and worklessness• Chronic illness• Second hand smoke• Systematic review

definitions• Smoking and inequalities

• Public Health Intervention Guidance

• Public Health Programme Guidance

Interventions Programmes

• Physical activity

• Smoking cessation

• STIs & teen conception

• Substance misuse

• Physical activity & environment

• Smoking

• Behaviour change

• Maternal & child nutrition

• Community engagement

• Obesity

Qualitative evidence useful as data when:

• It addresses key research questions for guidance development

• It gives access to hard-to-reach or under-researched populations

• It is well conducted

Qualitative techniques useful in the production of guidance:

• For field-testing draft recommendations

• For developing implementation tools and processes

• Innovative techniques may be needed to optimise the process

What has the process demonstrated?

Empirically

• Importance of tailored and targeted approaches

• Multi level and multifaceted approaches often effective

• Theoretically well informed works best

• Can develop guidance on the basis of the existing evidence

Theoretically

• The precise nature of the causal pathways and the different dimensions of inequality is under-investigated

• The health interaction between different aspects of inequalities not highly developed.

• The ways in which interventions work in different segments of the population not well understood

• The implications of the demographic and social structure not linked to health data

Gaps in the evidence

• Gaps in the initial formulation of primary research studies.

• Gap between evidence and practice

• How to do it

• Process data

• Implementation problems

• Local infrastructures data

• Better evidence about downstream rather than upstream interventions

• Morbidity data much less secure than mortality data

• Extremely limited evidence about major policy initiatives

• Lack of good cost effectiveness data

Methodologically

• The evidence as a framework of plausible possibilities

• The evidence as a starting point for intervention not an imperative or a recipe

• The need to use multiple methods

Where quantity meets quality

Thresholds of qualitative data• Contested

• Qualitative approaches highly heterogeneous in themselves

• Require different criteria to determine what would constitute a fatal flaw

• Horses for courses

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