Focusing urban policies on health equity: the role of evidence in stakeholder engagement in an Italian urban setting

ABSTRACT

Health equity in All Policies requires decision makers to face the health impact of their decisions and its distribution among different population groups. Since the evidence policy gap often prevents them from using the evidence provided by experts, appropriate mechanisms of governance are needed to overcome this barrier. In Turin (Italy, pop. 900,000) a community of experts, policymakers and stakeholders was engaged in a participatory evidence-based decision-making process to raise awareness and foster intersectoral actions to tackle social health inequalities. This health equity assessment of urban policymaking was based on the action-research model and moved through three steps: i) co-investigation into the mechanisms responsible for generating health inequalities, ii) co-decision of priorities, iii) co-creation and implementation of actions. The two-years process was continuously fed with new evidence from the Turin Longitudinal Study, linking health, resident and socioeconomic stories of individuals and families. Overall, the equity lens is an effective criterion to identify potential health gains as achievable targets for policymaking, a useful metric for comparative analysis of the impact of different policies and a mean to foster stakeholder’ to cooperate. The case-study shows that a systematic cooperative effort with stakeholders is needed to ensure effectiveness and participation in change and innovation.

KEYWORDS:

• Stakeholder
• engagement
• policymaking
• evidence
• health inequalities
• urban health

This article is related to:

Research for city practice

Acknowledgments

We wish to thank Annalisa Magone, Tatiana Mazali, Roberta De Bonis Patrignani and Paola Mussinatto from Torino Nord Ovest social enterprise for their contribution to set up the first step of the stakeholders’ engagement process. This study was supported by the European Union Horizon2020 Programme under Grant Agreement n° 667661 (Promoting mental wellbeing in the ageing population – MINDMAP) and Grant Agreement n° 643398 (Shaping EUROpean policies to promote HEALTH equitY – Euro-Healthy) to NZ, GC, MM, MS, AS, FB, RD, SP. The study does not necessarily reflect the Commission’s views and in no way anticipates the Commission’s future policy in this area.

Disclosure statement

No potential conflict of interest was reported by the authors.

Key messages

• The city is considered an “umbrella” setting under which all other settings (school, workplace, local community) converge and may be coordinated towards attaining common targets for health promotion and prevention.

• Health is a useful metric for the comparative analysis of the impact of policies by stakeholders and a means to foster their attitude to cooperate. The equity lens is an effective criterion to identify potential health gains as achievable targets for policymaking.

• A local, epidemiologic longitudinal infrastructure may provide factual evidence for raising awareness with good storytelling, while facilitating the health inequalities impact assessment and the results/impact evaluation.

• A systematic cooperative effort of the action-research approach with stakeholders is needed to ensure effectiveness and participation in change and innovation.

Notes

1. TLS is a specific project within the Italian National Statistical Programme that is proposed by the National Statistical System and is yearly approved by law by the Italian Parliament and the national Authority for the Privacy.

2. According to the World health organisation, the Social determinants of health are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.

3. To assess the independent impact of each social determinant (SD), we estimated the attributable fractions as follows: first, relative risks of death (RR) for each SD indicator were estimated by means of multivariate Poisson regression models, adjusting for age and mutually adjusting all the SD indicators for each other. The attributable number of deaths associated with each SD was then estimated by scaling the RRs obtained using the population attributable fraction equation (Eikemo et al. 2014). This metric illustrates the proportion of mortality“attributable” to each of the eight SDs. As such, it shows the percentage of premature deaths that could be averted if all Turin residents had the same risk as the most advantaged groups in each SD.

4. The overall score for each policy (= Global score) was calculated summarizing the single score of each policy\intervention obtained by the judgments on benefit (Fig.2), multiplied by the percentage of the attributable risks of death of each SD (Fig.3) “affected” by the policy under analysis. The final score is reported on a scale of 1-100.

5. For this exercise, we used the data from the 2013 Health Interview Survey (HIS), conducted by the Italian National Institute of Statistics. The HIS collects both, information about health outcomes and socioeconomic information at the individual level. Stratifying the analysis in two age groups (adults 30 to 74 years old and young adults 18 to 35 years old), we calculated the attributable fraction of each SD on the risk to have poor mental health, poor physical health (collected by the SF-12 questionnaire included in the HIS [Ware et al. 1996]) and poor self-perceived health. The estimates were obtained applying the same statistical method used for calculating the Attributable fraction of deaths due to inequalities shown in Fig 3.

Additional information

Funding

This work was supported by the European Union Horizon2020 Programme under Grant Agreement n° 667661 (Promoting mental wellbeing in the ageing population – MINDMAP) and Grant Agreement n° 643398 (Shaping EUROpean policies to promote HEALTH equitY – Euro-Healthy).

Notes on contributors

Nicolás Zengarini

Nicolás Zengarini is a sociologist with an Advanced Degree in Epidemiology. In the last 15 years he participated in numerous European projects focused on epidemiological research and social determinants of health. Currently he performs research activities in the Epidemiology service of ASL TO3 (Turin, Italy) where several projects of social epidemiology are carried out, mainly in the field of oncology and on the evaluation of policies to tackle social inequalities in health. Since 2013 he is the coordinator of the working group of the Longitudinal Study of Turin.

Silvia Pilutti

Silvia Pilutti is a psycho-sociologist, after various experiences in coordinating research structures and projects in the social and labour area, she founded and directs Prospettive Ricerca socio-economic S.A.S. of Turin, a company which deals with analysis and consultancy in the area of policies and services for sustainable innovation, the promotion of community development, welfare and health, with attention to gender inequalities.

Michele Marra

Michele Marra, MA in Epidemiology and MA in Health Promotion and Prevention, is a social epidemiologist actually working as a consultant at the WHO European Office for Investment for Health and Development (Venice Office). His research interests include social inequalities in health as well as the impact on health and health inequalities of policies acting on the distribution of the social determinants of health.

Alice Scavarda

Alice Scavarda, PhD, sociologist, is Research Fellow at the Department of Culture, Politics and Society,  University of Turin. She is also Adjunt Professor in Sociology and Sociology of Organizations at the Department of Clinical and Biological Sciences, University of Turin. Her research interests revolve around chronic illness, disability studies, health promotion and addiction.

Morena Stroscia

Morena Stroscia is a Public Health MD. She works at the Turin Public Health Office – Urban and Environmental Hygiene Service. Her main research interests are health inequalities, environment and built environment impact on health, healthcare system performance evaluation and stakeholder engagement.

Roberto Di Monaco

Roberto Di Monaco teaches sociology of organization and leadership, networks and organizational processes at the University of Turin and is Senior Consultant for Innovation and Organizational Development at LabNET, Applied Network Science Laboratory of the SAA School of Management of the University of Turin. He directed research and consultancy institutions and companies from 1994 to 2007, dealing with work, organization, local development, social inequalities and health. He has directed and coordinated numerous international projects and territorial initiatives.

Franca Beccaria

Franca Beccaria, PhD, is a sociologist, partner in Eclectica, a research institute in Torino (Italy), vice-director at the EMDAS, European Master on Drug and Alcohol Studies, University of Torino (Italy) and Associate professor (title of docent), Faculty of Social Sciences, University of Helsinki. Affiliate: University of Helsinki Centre for Research on Addiction, Control and Governance (CEACG). Her main research interests are drinking cultures, drugs, gambling, addictions, health promotion and health policies, stakeholders and community engagement, and sociology of health.

Giuseppe Costa

Giuseppe Costa MD, epidemiologist since the 1979.  Full professor of public health at the University of Turin. Head of the Regional Health Observatory of the Piedmont Region. Main fields of research are health service evaluation and social determinants of health. Co-leader of the new European Joint Action on health inequalities JAHEE, aiming to promote progress in policy response to health inequalities among 24 member states and the European Commission.