From inequalities to equity

Citation

McKenzie, K. (2012), "From inequalities to equity", Ethnicity and Inequalities in Health and Social Care, Vol. 5 No. 3. https://doi.org/10.1108/eihsc.2012.54505caa.001

From inequalities to equity

Article Type: Editorial From: Ethnicity and Inequalities in Health and Social Care, Volume 5, Issue 3

Towards equity

Ethnicity and Inequalities in Health and Social Care is one of the first journals to explicitly attempt to promote race equality in health and social care and allied fields. The journal’s primary aim is knowledge translation and to try to get research to change practice. The journal aims at a wide variety of different professionals important in the health and social care fields (www.emeraldinsight.com/products/journals/journals.htm?id=eihsc).

From its inception the journal has critiqued and explored what is currently known about discrimination and disadvantage internationally with a particular focus on understanding issues that influence the health of populations (Sallah, 2008). Over the 16 issues it has continued to push the envelope with groundbreaking articles covering fields as diverse as masculinity (McKeown et al., 2008), cultural competence (McKenzie, 2008), the links between martial arts and resiliency (Bell, 2008), lesbian gay and bisexual issues (Carr, 2010) and global health (Timimi, 2011). The populations discussed have been as diverse as the issues and the international experts that have graced the journal.

The aim of the journal is not simply to document disparities, but to present positive solutions to combating them. However, this can be difficult in health and social care because although we talk about health services, we usually set up illness services and social care is often reserved for people who are having difficulties. Rather than trying to promote positive health we are pre-occupied with illnesses and problems. We often do not document solutions, especially when they are service innovations as opposed to research projects. But many believe that there are answers to the inequalities in health and social care within communities if only we looked. They take an approach that is akin to positive deviance (www.positivedeviance.org/).

Positive deviance is an approach to behavioral and social change that is based on the observations that in any group or community there are people who buck the trend. Even when there are problems for many, there are some individuals who do not suffer despite having the same challenges. Positive deviance approaches are based on the belief that those people who have been able to buck the trend have successful behaviors or strategies that their peers could learn from. In it is essence positive deviance is a strengths based approach built on an idea that there may be knowledge within communities that will help. In theory, this could lead to more sustainable change than ideas brought from outside.

The concept is said to have its origins in nutrition. Researchers were trying to work out a way to decrease malnourishment in low-income countries and through using a new approach they brought the rate of malnourishment in Vietnam down hugely (Pascale et al., 2010). They had observed that parents who fed their children more regularly, were careful with hand-washing and sought out atypical foods like shrimps and crab that were usually not given to kids had children who were better nourished than parents who did not. They set up nutrition groups where they fed children but they only allowed them in if their parents brought a new food for the group to try. Peer learning led to diversity of food intake. This improved nourishment of all the children in the group and the learning led to improved nourishment of younger children in the same family who had not attended the groups (Pascale et al., 2010). The approach was so successful that dozens of other international problems have used the same methodology of defining the problem, detecting positive deviance individuals, finding out what they do that is effective and uncommon, designing a program to prove that doing what they do makes a difference, monitoring and evaluation and then scaling up (http://en.wikipedia.org/wiki/Positive_Deviance).

From preventing infections in hospitals (Awad et al., 2009) to improving postnatal care (Marsh et al., 2002), positive deviance has proved effective. Not surprisingly it has caught on in business (Hamel, 2007).

Positive deviance is a good idea and particularly attractive to policy makers. Like much of the current discourse around the world (for instance the UK’s big society strategy, www.thebigsociety.co.uk/about-us/) it asks communities to mend themselves. It is not surprising that some communities buy into it. But it is also not surprising that others are more skeptical. They argue that the factors that are causing problems are external, such as increased exposure to the social determinants of health and a lack of adequate funding for preventive interventions or health and social care interventions (www.independent.co.uk/voices/commentators/ed-miliband-the-big-society-a-cloak-for-the-small-state-2213011.html). They see positive deviance approaches as policy makers abdicating responsibility for communities.

Discussions can quickly move to pitched battles between the individual responsibility and social responsibility camps with agreement difficult because these camps represent differing worldviews. And, of course, both are right.

Perhaps we need to move away from the view that we have to choose one path or the other. Perhaps we can choose both. If we take a multi-level view of what happens in society we could build a conceptual model where we need individual, group and environmental interventions if we are to change a behavior or outcome. Individual behaviors are based in a social context. Both may need to change in order to produce movement forwards. We may be happy to accept that, if we want to decrease the impact of smoking on health we can decrease the amount of tar in cigarettes, work on an individual to either decrease their smoking or increase their incentives and support to stop smoking but we can also decrease the availability of cigarettes. Many smoking policies include all three strategies (www.who.int/tobacco/en/). Similarly, a recent meta-analysis of the link between perceived racism and health found that there may be a direct toxic effect of experiencing racism but the impacts on health were also mediated by the way an individual responds to racism (Pascoe and Richman, 2009). The increased risk of poor health of people who are victims of racism are, in part, linked to more risky health behaviors in that group. A strategy to decrease the impact of racism may need anti-racist policy and enforcement but could include increasing individual resiliency or changing individual reactions (United Nations High Commissioner for Refugees, 2009). Communities may have answers to their problems and positive deviance may be helpful in identifying behaviors that promote resilience and change reactions but government or policy level action is likely to also be required.

Multi-level theories have helped our understanding of causation and the need for action in a number of different ways to produce change. These insights have developed over time as have thoughts about the utility of the concept of inequality. Inequality refers primarily to being unequal but it is not clear that this is the issue that many people are concerned about. In a health service based on need it is reasonable for some people to have more service than others. Treating people who have greater need unequally may be needed so that they can have equitable outcomes. The concept of equity, which is linked to justice and fairness, is actually usually what we are aiming for in health services. Rather than considering health inequalities, governments around the world are considering how we promote health equity (www.cdc.gov/healthycommunitiesprogram/overview/healthequity.htm and www.health-inequalities.eu/).

Ethnicity and Inequalities in Health and Social Care wants to document the differences between groups in health and health outcomes but wants to be more active in considering how we can close the gap. In a recent issue from 2011 we started the process of documenting global stories about what people are doing to promote equity even in low income countries and it would be great to have more of your papers on how you and others have been able to change the world.

Kwame McKenzie