TAKING BETTER ACCOUNT OF SOCIAL INEQUALITIES IN HEALTH:
THE RÉFLEX-ISS TOOL

User Manual

Definitions of terms and concepts useful for completing the grid

Social inequalities in health
Social inequalities in health refer to the disparities in health associated with social advantages or disadvantages (e.g., income, schooling, social inclusion). These disparities are unjust and avoidable, and it is possible to mitigate them. Social inequalities in health are distributed according to a social gradient. The terms “social inequalities in health” and “health inequities” are sometimes used interchangeably (http://nccdh.ca/images/uploads/Glossary_EN_Feb_26.pdf). The social gradient implies a continuum, that is, that individuals’ state of health correlates with their socioeconomic status (for example their level of education or of income). Social gradient serves to describe the phenomenon by which those at the top of the social pyramid enjoy better health than those directly beneath them, who in turn are healthier than those below, and so on, all the way to the bottom levels (Guide INPES, 2010 http://www.inpes.sante.fr/CFESBases/catalogue/pdf/1333.pdf).

Target population and target subgroups
An intervention’s target population consists of subgroups that can be distinguished from each other for the purposes of adapting the action to each one. To be effective, an intervention must plan activities for each of the target subgroups. This means notably that not all target subgroups will be addressed in the same way, as they vary by language, level of education, socioeconomic level, etc. For example, an intervention targeting the children in neighbourhood x must address the different needs of the target subgroups identified, such as children 0–5 years old in migrant families, children in single-parent families, or children in families within middle-level socioeconomic groups. Thus, an intervention aiming to reduce social inequalities in health will not try to reach only the poorest, but rather all of the various groups within the concerned population affected by the health issue, all along the social gradient, while modulating the intervention’s intensity according to socioeconomic level and needs.

Social determinants of health
Social determinants of health are interdependent social, political, economic, and cultural factors that generate the conditions in which individuals are born, live, grow up, learn, work, have fun, and grow old. Interaction between social determinants of health transforms and changes them over time and over life periods, affecting the health of individuals and groups in different ways. Inequitable distribution of social determinants of health among social groups is at the root of the establishment and perpetuation of social inequalities in health within a country or between various countries. (http://nccdh.ca/images/uploads/Glossary_EN_Feb_26.pdf).

Empowerment
Empowerment is a process or an approach that aims to help individuals, communities, or organizations have greater power to act and take decisions on the important aspects of their life, and have greater influence on their environment. For the purposes of developing this discussion tool, the framework proposed by Ninacs, outlined below, has been used to define empowerment (Ninacs, W., 2003). Individual empowerment occurs on four levels: participation, competencies, self-esteem, and critical awareness.

• Participation manifests progressively, from silent participation to exercising the right to speak (including the right to refuse to speak), followed by the right to be heard, and culminating in the right to participate in decision-making. Participation also refers to a growing capacity to contribute and to take responsibility for one’s participation, which involves the capacity to act rationally and the willingness to become engaged.
• Competencies include the knowledge and skills necessary for participation, on the one hand, and execution of the action on the other. They can involve both the acquisition of new skills and the re-evaluation of skills already possessed.
• Self-esteem leads individuals to perceive that they have the capacity to act to achieve personal or collective objectives.
• • Critical awareness represents the development of a collective conscience (the individual is not the only one with a problem), a social awareness that assuages individual feelings of guilt through the realization that individual or collective problems are influenced by the way in which society is organized. The culmination of critical awareness is political awareness and the acceptance of personal responsibility for change (the solution to structural problems depends on social change, that is, political action).

Proportionate universalism
This approach consists in offering the entire population a certain number of universal services, and then intensifying action to address the specific needs of persons, depending on the difficulties they are facing (Marmot Review (2012). Fair society, healthy lives: Strategic review of health inequalities in England post-2010). Thus, the approach does not focus on only the poorest people.

Undesirable outcomes
Unforeseen consequences that go against the intended goal, e.g., increasing social inequalities in health, increasing stigmatization, deterioration in the target group(s) state of health, negative change in attitude of the general population or of certain actors with respect to the target subgroup(s).

Best practices
Best practices are activities based on sound scientific evidence, extensive community experience, and cultural knowledge. They also refer to interventions developed based on recognized criteria to increase their potential effectiveness. Health-centred interventions will be more effective if based on established best practices. (http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/ipchls-spimmvs/glossary-glossaire-eng.php)

Health literacy
Health literacy is “the ability to access, comprehend, evaluate, and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course.” According to the Intersectoral Approach to Improving Health Literacy for Canadians, a health literate individual is able to: 1) understand and carry out instructions for self-care, including administering complex daily medical regimens, 2) plan and achieve the lifestyle adjustments required for improved health, 3) make informed positive health-related decisions, 4) know how and when to access health care, 5) share health promoting activities with others, and 6) address health issues in the community and society. (http://www.cpha.ca/uploads/progs/literacy/examples_e.pdf)

Stigmatization
Behaviours, life habits, life conditions, or other personal characteristics are linked to a moral judgment that defines illnesses or ill people as either “good” or “bad”. The stigmatization process is based, among other things, on the idea that persons are responsible for their problem or illness, at least in part, and therefore deserve to be blamed given their behaviour. In this way, individuals who smoke, drink alcohol, eat rich foods, or have unprotected sexual relations are judged negatively and blamed when their health is affected or even just because it could be affected. (http://www.inspq.qc.ca/pdf/publications/1637_DimensionEthiqueStigmatisation_OutilAideReflexion.pdf)

©2015, Anne Guichard, Valéry Ridde, Kareen Nour, Ginette Lafontaine, in collaboration with Catherine Hébert, Magalie Benoît, and Émilie Tardieu.Produced with financial support from the Direction de santé publique de la Montérégie - Centre intégré de santé et des services sociaux de la Montérégie-Centre and the Canadian Institutes of Health Research.