Basic premises

1. The following slides were presented at a meeting of potential editors and methods advisors for the proposed Cochrane review group in February 2008. The slides were designed to promote discussion rather than represent the views and directions of this group.

2. Basic premises • Public health interventions, culture, human behaviour and social differences in the population play a greater mediating role than in clinical interventions. • Determinants of health are not necessarily the same as the determinants of inequities in health. • Necessary to distinguish between the causes of health improvement and the causes of health inequities. • Factors which improve overall health have differential effects on the population ( → catching up effect)

3. Transferability • External validity • Replicability • Epistemological framework – (cultural context & conceptual structure) • Theory of change • Strength of evidence: • absence of evidence, poor evidence and evidence of ineffectiveness.

4. Applicability • Data necessary to deduce applicability in LMIC. • End user • The evidence into practice process in LMIC is not necessarily similar to HIC. • Policy makers’ characteristics may differ from HIC.

5. Context • Social structures and social dynamics • Social/public policies • universal vs. targeted policies) • Gaps & gradients • Disadvantage • Gaps • Gradients • Suggestion: to individualise countries (not just DCs ot LMIC)

6. Gaps & gradients • Linear inequity - classic gradient (steepness may vary) • Top inequity (majority does not, benefits concentrated in higher socioeconomic groups • Bottom inequity (most have access to interventions, one clear group lags behind

7. Equity stratifiers or axes of differentiation • They intersect, interact, overlap and cluster together in their effects. • Or even change independently of each other. • Their salience varies in different societies at different stages of economic development. Disadvantage (e.g. poverty) or context (e.g. occupation, ethnicity).

8. Education • Dynamic nature: Absolute and relative value (time and space) • Confounders: interaction with other axes

9. Occupation • Reliability – definitions and data collection • Formal or informal sector. • Significant levels of under- and non-paid employment (e.g. unpaid family workers). • High levels of economic inactivity, particularly in the female population. • ‘Occupational classes’ is not a useful alternative concept.

10. Income • Different measures: • Income per se • consumption • expenditure (less biased, less prone to seasonal variations, particularly in rural areas) • wealth/ assets. • Aggregation: poverty/ indigence line or quintiles • Poverty line : absolute or relative terms feeding and non-feeding needs

11. Ethnicity Ethnic groups: ethnic, racial, tribal, caste, religious and national origin groups • Self-identification and language. • Under representation (young people), unstable in repeated surveys. • Language monolingual or bilingual. • Dominant (primary and secondary) and not dominant groups, e.g. Tribes.

12. Place of residence • Villages, municipalities, provinces, regions or states • Geoclimate areas • Climatic parameters (rainfall, aridity, farming systems, length of growing season, the stability of malaria transmission) • Geographic parameters - population density, urban proximity, coastal proximity, distance to roads • Traditional urban/ rural dichotomy & ‘urban/ rural continuum’ .

13. Searching strategies • In LMIC many journals are not indexed by the main electronic databases and often they do not even have a web site. • National governments are a key source. However, not in internet. • Donors (i.e., UN agencies, international banks and NGOs) • Regional Evaluation Associations (Latin America and Africa). • Language barriers • Complex causal chain: not always will be covered in public health journals • Search words for LMIC (individual countries) • Suggestion: Supported by local researchers to generate a register of the main sources at regional level, particularly grey literature.