Original Article
Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health

https://doi.org/10.1016/j.jclinepi.2013.08.005Get rights and content

Abstract

Objectives

To assess the utility of an acronym, place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital (“PROGRESS”), in identifying factors that stratify health opportunities and outcomes. We explored the value of PROGRESS as an equity lens to assess effects of interventions on health equity.

Study Design and Setting

We assessed the utility of PROGRESS by using it in 11 systematic reviews and methodological studies published between 2008 and 2013. To develop the justification for each of the PROGRESS elements, we consulted experts to identify examples of unfair differences in disease burden and an intervention that can effectively address these health inequities.

Results

Each PROGRESS factor can be justified on the basis of unfair differences in disease burden and the potential for interventions to reduce these differential effects. We have not provided a rationale for why the difference exists but have attempted to explain why these differences may contribute to disadvantage and argue for their consideration in new evaluations, systematic reviews, and intervention implementation.

Conclusion

The acronym PROGRESS is a framework and aide-memoire that is useful in ensuring that an equity lens is applied in the conduct, reporting, and use of research.

Introduction

What is new?

  • PROGRESS refers to place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital.

  • This article provides examples of unfair differences in disease burden and an intervention that can effectively address these health inequities for each of the PROGRESS factors.

  • The acronym PROGRESS can be used as an aide-memoire, a framework to guide data extraction, and a tool to guide equity analyses for researchers to ensure explicit consideration of equity in the design of new intervention studies and in systematic reviews.

Many factors contribute to whether a population is described as “disadvantaged.” Globally, populations are, on average, living longer and healthier lives than at any other time in history. The average life expectancy at birth in 1955 was 48 years. By 1995, it was 65 years, and by 2025, it is predicted to reach 73 years. There are now more than 5 billion people with life expectancy of more than 60 years [1]. However, these improvements do not reach all groups of the world's population equally. Just as there are inequalities in access to natural resources that affect well-being, there are also inequalities in health status, which are not coincidental. Rather, they are driven by socially stratifying forces that are systemic in societies.

The World Health Organization has defined health inequalities as “differences in health status or in the distribution of health determinants between different population groups” [2] (e.g., racial, ethnic, sexual orientation, or socioeconomic groups). Some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions that are mainly outside of an individual's control. In the first case, it may be impossible, or in the second case, ethically unacceptable, to change the underlying factor that is driving the inequity, and thus, it can be deemed unavoidable. However, in the third case, the uneven distribution of health may be avoidable, as well as unjust and unfair [4]. These differences have been described as disparities [3] or as “health inequities” [4]. It is the context in which one is born, lives, and works that causes underlying inequities in health. These inequities may result in differences across a population in terms of incidence of disease, health outcomes, and access to health care. Inequities in health are therefore linked to income, occupation, place of residence, and gender among other factors. Unlike the individual behavioral-based determinants of health (downstream factors), these upstream factors are ones over which individuals have little or no direct control but which can only be altered through social and economic policies and political processes [5]. To understand and act on health inequities, both upstream and downstream factors must be considered [6]. Depending on the context, particular factors may be more or less important for a certain population.

Although much of the literature has focused on inequities between countries, unfair differences in health are prevalent within countries as well. For example, in China, rates of childhood stunting are three times higher in rural areas than in urban areas [7], and maternal mortality is higher in poorer provinces than in richer provinces [8]. In India, immunization rates vary by caste and certain castes have low rates [9]. These differential health outcomes are not coincidental but rather are grouped according to socially stratifying forces such as place of residence and level of income [10]. There are also many significant differences in health outcomes among countries, regions, or continents [5] such as differences in child mortality in high-income countries (HICs) compared with low- or middle-income countries (LMICs). In 2010, neonatal mortality in Africa was 34 per 1,000 live births compared with just 9 per 1,000 live births in the Americas [11].

Section snippets

Background

Programs and policies may be successful in reducing the gradient in health between the most and the least disadvantaged groups within a population. However, in some cases, these interventions inadvertently contribute to increasing inequities in health and ultimately may even increase the gap between the most and the least disadvantaged [12]. Increasing the availability of an effective intervention within a country or region is not necessarily enough to reduce inequities. The intervention has to

Exploration of the justification of the elements of PROGRESS

This article provides an explanation for each of the PROGRESS components. Each element of PROGRESS is justified on the basis of differences in effects. We have not described why the difference exists but have attempted to explain why these differences may contribute to disadvantage and argue for their consideration in new evaluations and systematic reviews. Variations in health are evident across a number of socially stratifying forces captured by PROGRESS.

The PROGRESS acronym has been tested

Discussion

The aforementioned examples demonstrate the importance of applying an equity lens to interventions as a strategy for ameliorating the gap between the most and the least disadvantaged. We have indicated a difference in burden of disease and provided an example of an effective intervention to address each difference in health outcomes. Thus, the burden is avoidable, but without a concerted effort, the interventions may not always reach the most disadvantaged population, making these differences

Conclusion

PROGRESS can be used as a tool to help ensure that socially stratifying factors are considered in the conduct, reporting, and the use of research and interventions as they may play a role in contributing to inequities in health outcomes. However, the degree to which the PROGRESS acronym represents disadvantage depends on the context and setting. The context is important in determining which inequalities are likely to drive inequities, remembering that the group at risk for disadvantage in

References (78)

  • M. Whitehead

    The concepts and principles of equity and health

    Int J Health Serv

    (1992)
  • Unequal treatment: confronting racial and ethnic disparities in health care

    (2002)
  • Becerra-Posada F, Serre A, Tristan M, Becerril-Montekio V, Poulain S, Ribeiro A, et al. Multilateral cooperation...
  • F. Diderichsen et al.

    The social basis of disparities in health

  • T. Shen et al.

    Effect of economic reforms on child growth in urban and rural areas of China

    N Engl J Med

    (1996)
  • T. Evans et al.

    Introduction

  • F. Peter et al.

    Ethical dimension of health equity

  • WHO

    World health statistics 2012

    (2012)
  • T. Lorenc et al.

    What types of interventions generate inequalities? Evidence from systematic reviews

    J Epidemiol Community Health

    (2013)
  • R. Wolfe

    Working (in) the gap: a critical examination of the race/culture divide in human services

    (2010)
  • C.M. Borkhoff et al.

    Reaching those most in need: a scoping review of interventions to improve health care quality for disadvantaged populations with osteoarthritis

    Arthritis Care Res (Hoboken)

    (2011)
  • V. Welch et al.

    Does consideration and assessment of effects on health equity affect the conclusions of systematic reviews? A methodology study

    PLoS One

    (2012)
  • V. Welch et al.

    How effects on health equity are assessed in systematic reviews of interventions

    Cochrane Database Syst Rev

    (2010)
  • J. Caird et al.

    Childhood obesity and educational attainment: a systematic review

    (2011)
  • J. Kavanagh et al.

    Inequalities and the mental health of young people: a systematic review of secondary school-based cognitive behavioural interventions

    (2009)
  • Oliver S, Kavanagh J, Caird J, Lorenc T, Oliver K, Harden A. Health promotion, inequalities and young people's health....
  • E. Coren et al.

    Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people

    Cochrane Database Syst Rev

    (2013)
  • V.A. Welch et al.

    Deworming and adjuvant interventions for improving the developmental health and well-being of children in low- and middle-income countries: a systematic review and network meta-analysis (protocol)

    Campbell Library

    (2013)
  • L. Augustincic Polec et al.

    Strategies to increase the ownership and use of insecticide treated bednets to prevent malaria (protocol)

    Cochrane Database Syst Rev

    (2011)
  • T. Evans et al.

    Road traffic crashes: operationalizing equity in the context of health sector reform

    Inj Control Saf Promot

    (2003)
  • D.R. Gwatkin

    10 best resources on… health equity

    Health Policy Plan

    (2007)
  • D. Ogilvie et al.

    The harvest plot: a method for synthesising evidence about the differential effects of interventions

    BMC Med Res Methodol

    (2008)
  • L.A. Mizen et al.

    Clinical guidelines contribute to the health inequities experienced by individuals with intellectual disabilities

    Implement Sci

    (2012)
  • S. Thomas et al.

    Population tobacco control interventions and their effects on social inequalities in smoking: systematic review

    Tob Control

    (2008)
  • V. Welch et al.

    PRISMA-Equity 2012 Extension: reporting guidelines for systematic reviews with a focus on health equity

    PLoS Med

    (2012)
  • P. Tugwell et al.

    Is health equity considered in systematic reviews of the Cochrane Musculoskeletal Group?

    Arthritis Rheum

    (2008)
  • N. Chaudhury et al.

    Missing in action: teacher and health worker absence in developing countries

    J Econ Perspect

    (2006)
  • M.E. Ford et al.

    Conceptualizing and categorizing race and ethnicity in health services research

    Health Serv Res

    (2005)
  • K.J. Mckenzie et al.

    Race, ethnicity, culture, and science

    BMJ

    (1994)
  • Cited by (0)

    Conflict of interest: None.

    Financial disclosure: None.

    View full text