NIHR CLAHRC North West Coast
Health Inequalities Assessment Toolkit

Section 1 - Clarifying what aspects of health inequalities and their socio-economic causes influence the problem your proposed work plans to address.

  • Purpose
  • Questions
  • Working Example
  • Resources
  • Purpose of this section

    This section is designed to help you:

    (a) clarify how health inequalities influence the problem you want to tackle; and
    (b) identify the socio-economic causes of these inequalities.

    If you are using the toolkit to prepare an application for support from us, you can consider health inequalities associated with gender, ethnic background, age, disability and so on. However, we give priority to applications that show the potential to reduce inequalities in health resulting from socio-economic inequalities.

    So whatever the specific focus of your application, you should explain how the problem is influenced by inequalities in people’s social circumstances. Your application should also highlight plans to address some of these socio-economic causes of health inequalities. For example, if the problem relates to uptake of services or outcomes of treatment for a particular group (for example, women, people with disabilities, or a minority ethnic group) you will need to consider:

    • whether the problem is unequally distributed within the socio-economic group you are focusing on, and if so how; and
    • what particular socio-economic factors may contribute to these inequalities in the problem you want to focus on (for example, low income or poor-quality housing).

    If you are proposing an evidence review or a capacity-building initiative, it will also need to focus on the socio-economic causes of health inequalities. Capacity-building activities might focus, fully or partly, on increasing understanding about health inequalities and their socio-economic causes among those taking part. Also, all applications submitted to us should consider more involvement from public advisers from underrepresented social groups.

    The questions below will help you think about these issues and explain in your proposal how the work you want to do will tackle them. It is difficult to frame questions in language that applies to the broad range of activities we are involved in. If a particular question does not seem relevant to your activity, adapt it to suit the purpose of the exercise.

    As you work through the questions, it might be helpful to look at the hypothetical example provided. This shows how you can use the toolkit to evaluate an activity aimed at increasing the uptake of health checks. This example is designed to help you see how considering the questions below can strengthen the focus on socio-economic causes of health inequalities in your proposed work.

  • Questions to help you clarify the health inequality issue to be addressed

    Clarifying the health-inequality issues

    1.1 What is the problem you plan to address and which groups do you want to work with?

    1.2 What evidence is there that this health problem is unequally distributed across people living in different socio-economic circumstances?

    1.3 What particular socio-economic causes of health inequalities would you expect to influence this problem?

    Making sure the public are involved in an appropriate way

    1.4 Have you involved relevant members of the public (for example, service users or carers, particularly those experiencing socio-economic disadvantage, or people living in disadvantaged neighbourhoods) in helping to identify the problem you want to tackle?

    1.5 How have you involved them?

    1.6 What effect did they have on your understanding of the problem you want to tackle?

  • An example of using the Toolkit: Increasing uptake of health checks

    Section 1: Clarifying what aspects of health inequalities and their socio-economic causes influence low uptake of health checks in primary care

    In this hypothetical proposal, the problem was originally set out as a low uptake of health checks among adults aged 40 to 75 from black and minority ethnic (BME) groups. The proposal argued that increasing the uptake of these checks would reduce the relatively high risk of cardiovascular disease (CVD) and other conditions in these groups.

    The initial proposal considered factors that may influence whether people decide to have these health checks. These included lack of education about the benefits of health checks, cultural distrust of the medical establishment, and the ways in which information about health checks is communicated. In response to the questions in section 1, the team looked at evidence on the socio-economic causes of the low uptake of health checks. The team identified three ways in which socio-economic circumstances might act as barriers to uptake of health checks.

    • The evidence on rates of uptake among BME groups is limited. However, there is strong evidence of lower rates in groups who are experiencing socio-economic problems, regardless of their ethnic background. This suggests that socio-economic circumstances can create barriers to accessing health checks.
    • The location and timing of health checks can make it difficult for people to attend, especially if they cannot access reliable and affordable public transport or take time off from work or caring responsibilities.
    • The content of the health checks, the way they are carried out and the professionals carrying them out (in terms of their gender, or professional or ethnic background) can put people off attending. People who work long hours in poor conditions, or whose jobs are not secure, may put providing for their family ahead of going for health checks.
    People who work long hours under poor working conditions, including job insecurity, may prioritise providing for their families over attendance at health-checks.

    As a result of the discussions, the team decided to concentrate on people of South Asian heritage and consider how socio-economic disadvantage results in inequalities in the uptake of health checks. An alternative approach might have been to focus on increasing uptake in disadvantaged neighbourhoods which have considerable ethnic diversity (and where research shows rates are low). The team did not specifically deal with the question of whether (and how) increased uptake of health checks would reduce risk of CVD or other diseases in the proposal, but it came up in the discussion and they looked at it later in the assessment.

    The team were planning to involve people of South Asian heritage when refining and evaluating the intervention once funding was agreed, but they have not involved them so far in defining the ‘problem’ or the proposed action. They will need to do this before their proposal can be supported.

  • Resources


    Mol, Annemarie (2008): The Logic of Care: Health and the Problem of Patient Choice. London: Routledge (Chapter 5)

    Annandale, E. and K. Hunt, (Eds). Gender inequalities in health. 2000: Open University Press.

    Krieger, N. (2006). Researching critical questions on social justice and public health: an ecosocial perspective. Social injustice and public health, 11, 460.

    Link, B. G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of health and social behavior, 80-94.

    Popay, J., et al., Beyond ‘beer, fags, egg and chips’? Exploring lay understandings of social inequalities in health. Sociology of health & illness, 2003. 25(1): p. 1-23.

    Braveman, P., and Gruskin, S. (2003). Defining equity in health. Journal of epidemiology and community health, 57(4), 254-258.

    Sara Arber’s latest study on inequalities in ageing in England.

    Public Health England handy resource list on Health Inequalities


    The roots of health inequalities - web based course funded by the National Center for Minority Health and Health Disparities, National Institutes of Health (USA).

    Unnatural causes- documentary series produced by California Newsreel and Vital Pictures, Inc.  (USA).


    The Last Straw! A Board Game on the Social Determinants of Health - developed by Kate Rossiter and Kate Reeve (Canada)

    Gender equality and health – video for the SOPHIE project (Spain/EU).

    What is health equity? - short film by the Health Equity Institute (USA)

    How wealth is distributed in the UK - short film by Inequality Briefing (UK).

    Income inequality - short film by Inequality Briefing (UK).

    Why equality is better for everyone - talk by Richard Wilkinson (UK).

    The great leveller –documentary produced by the Channel 4 Equinox series.

    Community factors & how they influence health equity, resources by the Prevention Institute (USA).

    Listen to Professor Jennie Popay talk through the development of the HIAT - NIHR CLAHRC NWC’s website (UK).

    Public Involvement resources

    The Public Involvement Impact Assessment Framework (PiiAF) website provides a wide range of resources to start thinking about what public involvement (PI) involves, and possibilities for research and implementation. It also provides a comprehensive list of resources and published cases of methods and tools that have been used to assess PIThese resources can inspire you to adapt them to involve the public in the context of your intervention.

    The Service User Involvement Best Practice Guide provides a series of short videos to illustrate key issues around user involvement: what it is; why it is important; different methods for different contexts and users; barriers and how to overcome them. Remember that even if you intervention/action doesn’t involve service users you can still use and adapt some of these ideas to develop your own work! 

    Involve, an NHS-funded organisation, and the UK National Coordinating Centre for Public Engagement offer great examples of different ways in which you can involve the public in research and funding applications. provides a compilation of conceptual and practical resources, including methods and case studies, to understand power relations in participatory projects. Be inspired by this case study involving UK citizens as activists and health officials to avoid the closure of a health centre.

    Mind the gap website: Listen To Your Patient And They Will Tell You The Problem – A True Story.

    Real-world HIAT Assessment Examples

    STEP Service Evaluation – the service aims to reduce avoidable A&E attendances. Blackburn with Darwen Borough Council

    Community Connectors. Sefton CVS

    Evaluating the impact of Liverpool Community Care Teams. Liverpool CCG