NIHR CLAHRC North West Coast
Health Inequalities Assessment Toolkit

Section Four - Planning for wider effects on health inequalities and avoiding negative ones

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

    The purpose of this section is to encourage you to consider whether the work you propose could have effects on health inequalities and their socio-economic causes other than those directly associated with it. If you are able to identify any wider effects, think about what action you could take to deliver positive effects or avoid negative ones.

  • Questions to help identify and address wider effects on health inequalities

    4.1 Is there potential to increase understanding of the socio-economic causes of health inequalities among service providers, commissioners and members of the public involved in your proposed work?

    4.2 If so, how might you support and evaluate this?

    4.3 What benefits might there be for the members of the public involved in your work, and how could you avoid any disadvantages? How could you evaluate these benefits?

    4.4 Have you thought about the most effective way you can share what you have learned from your work within the wider social and healthcare communities?

    4.5 Have you developed innovations in methods for evaluating or monitoring the effects of health inequality, and if so how can you share these?

    Making sure you involve the public appropriately

    Throughout this assessment we have advised you to involve relevant members of the public in all stages of your planned activity. This is a requirement of any work we support.

    4.6 Assuming you now have members of the public advising you on the work, have you asked them to think about the possible wider effects on:

    (a) being involved in your activity;
    (b) health inequalities and their socio-economic causes; and
    (c) how any positive or negative effects can be delivered or avoided?
  • An example of using the Toolkit: Increasing uptake of Health Checks

    Section 4: Planning for wider positive effects of your work and avoiding negative effects

    The initial proposal for research to increase uptake of health checks did not consider its possible wider effect on socio-economic inequalities in health or on the members of the public involved in the research.

    However, during discussions prompted by section 4 of the toolkit, the team identified a number of potentially positive wider effects, as follows:

    • Improved relationships between primary-healthcare providers and their South Asian communities. As professionals become more aware of the socio-economic causes of ill-health and the socio-economic causes of stigma associated with consultation and treatment, judgment and respect also grows, increasing people’s trust in health trainers12.
    • In time, health trainers could expand their role and advise people on other health conditions where inequalities exist.
    Health trainers could also help people to access wider social and healthcare services13. These changes could encourage service providers and commissioners to develop ways to help people living in socio-economically disadvantaged conditions deal with wider social problems that increase their risk of cardiovascular disease. Some of this support could be towards accessing good-quality advice about debt and benefits.

    The team were aware that putting in place partnerships and actions to make these changes and assess their effect on health outcomes is challenging. However, they agreed to consider whether it would be practical to extend the evaluation over a longer period to collect research data in one fieldwork area.

    To assess the effects of involving the public in their research, the team also agreed to work through some of the exercises in the Public Involvement Impact Assessment Framework Guidance14 with the public to see what they could gain from involving them, and to put in place an internal evaluation process to assess whether they have achieved this.

    12 Metzl, J.M. & Hansen, H. Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine 103, 126-133 (2014).

    13 Popay, J., Kowarzik, U., Mallinson, S., Mackian, S. & Barker, J. Social problems, primary care and pathways to help and support: addressing health inequalities at the individual level. Part I: the GP perspective. Journal of epidemiology and community health 61, 966-971 (2007).

    14 Popay, J and Collins, M (editors) with the PiiAF Study Group. The Public Involvement Impact Assessment Framework Guidance. (Universities of Lancaster, Liverpool and Exeter, 2014).

  • Resources


    Create a vision exercise - resource developed by the Participatory Impact Pathways Analysis (PIPA) wiki space. The activities proposed can be adapted easily to suit your particular project and timeframe.

    Draw Network Maps- resource developed by the Participatory Impact Pathways Analysis (PIPA) wiki space.

    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