Academic journal article Perspectives in Public Health

To What Extent Can Evaluation Frameworks Help NGOs to Address Health Inequalities Caused by Social Exclusion?

Academic journal article Perspectives in Public Health

To What Extent Can Evaluation Frameworks Help NGOs to Address Health Inequalities Caused by Social Exclusion?

Article excerpt

Introduction

This article begins by highlighting some of the central debates around health inequalities and outlining the links between health inequalities and social exclusion. Non-governmental organisations (NGOs) delivering public health services operate within a broad policy context, and this is briefly reviewed. Then, the topic of evaluation is introduced, and the relationship of evaluation frameworks to health inequalities and social exclusion is identified, with particular reference to language and values.

Two concepts are then used to discuss these issues: the concept of 'comparative advantage'1 from the third sector literature and the concept of 'space of access'2 from the health inequalities literature. Bringing these concepts together enables us to address the central question posed within this article: 'to what extent can evaluation frameworks help NGOs to address health inequalities caused by social exclusion?'

For the purposes of this article, NGOs means non-profit organisations, including charities, social enterprises and community interest companies, collectively known in the United Kingdom as 'the third sector'.

Health Inequalities

Health inequalities have been recognised as a major national and international problem for over a decade.3 The literature suggests that three types of factors create health inequalities: individual choices, social determinants, and physical environmental factors.4 Individual choices include lifestyle choices about whether or not to smoke or eat processed foods; social determinants include issues such as educational attainment and employment status; and physical environmental factors could include distance from health services or level of access to green spaces. There are other factors, too, such as psychosocial determinants and the United Kingdom's current climate of austerity, and of course all of these factors interact and are interdependent. Furthermore, there is now extensive evidence that being disadvantaged in one or more of these factors can lead to, and perpetuate, ill health.5-7

One important reason for the perpetuation of inequalities in health is that socioeconomically disadvantaged groups are either harder to engage in, or find it harder to access, health care services. Understanding both accessibility and exclusion is hence seen as key in addressing health inequalities.8,9 In England, primary health care is available to all and is mostly free to patients. However, barriers to access are not only related to financial aspects of care. Apart from structural aspects of care such as availability (volume of services), accommodation (opening hours), and affordability, one must also consider cultural aspects such as what Harris et al.8 call 'appropriateness' and 'acceptability' as important in understanding accessibility of care.

Some people find it more difficult than others to use public health services and the barriers may be due to individual disadvantages or to barriers created by services. Individual disadvantages can include an off-putting experience in the past,10 'transport difficulties; residential instability ... and a lack of understanding of the health care system',11 or a range of other factors such as homelessness, domestic violence, or poor mental health.12 Barriers created by services can include an inconvenient location or opening hours, or the way a service is managed,10 settings which alienate people, or difficulties in communication.12

People experiencing such barriers are often described as 'hard to reach', although this is an ambiguous and contested term10,13 whose understandings and definitions vary between locations and services.12 The term 'hard to reach' can serve to conceal the complexities of people's lives and the factors which cause their disengagement.12 Also, the term places the blame for any difficulty squarely on an individual, family or group, when in fact at least some of the barriers are created by the services themselves. …

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