Hello and welcome to Research Roundtable. My name is Annette Brown, Principal Economist here at FHI 360. Today, we are talking about the research report titled, “Learning From the World, Global Strategies for Improving Health Equity and Social Determinants of Health.” It’s authored by Dr. Gretchen Thompson and several other co-authors from here at FHI 360. We’re fortunate to have Gretchen here today to tell us more about this interesting report. So, one of the reasons I really wanted to bring this report on to Research Roundtable is because it’s for the United States, but looking at the rest of the world and so it really brings together the ideas that FHI 360 works in the United States as well as globally. So, give us kind of the high-level overview of this study and what the research questions were. [Gretchen] Certainly, um, we set out to help the Robert Wood Johnson Foundation learn from the world, um, and discover initiatives and programs that are advancing health equity. We had a set of three main research objectives, the first one was to identify countries outside the United States that are tackling health equity. Secondly, to outline the relevant historical, social, cultural context in which those programs, initiatives are taking place, and then thirdly, to think about how or analyze ways in which those programs can speak to the foundation’s Culture of Health framework. [Annette] Great. Super interesting, so, I’m gonna kind of skip to the end a little bit because you say in your executive summary, “the current project very much led to insights on learning how to learn from the world.” So, what’s one of those insights? [Gretchen] Well the insight was that we needed a way to learn to learn from the world. I mean we quite literally, you know had to set out a systematic framework to help structure our analysis and our research for this study. [Annette] Alright, and so that’s a great sequitur. What was that framework? What was this, the methodological underpinning for your approach here? [Gretchen] Yeah, so we used macro comparative research, um, sociological research methods and really, that’s um, an umbrella of research methods that uses both quantitative and qualitative approaches to make comparisons across nation states or countries. [Annette] Interesting. So it seems like the first step there then is coming up with a list of nations or countries to do the comparisons, right? And, uh, you had, an interesting, kind of two-stage approach to doing this. Can you tell us a little bit about that? [Gretchen] Definitely, so for our first stage, we had to narrow things down and create some boundaries, um it was kind of like looking for a needle in a haystack. There are 195 sovereign nations. So, we identified some criteria that would help us understand or select countries that would be similar to the US. Demographic composition, democratic governance and then after that, we said okay, how can we identify which countries are making gains in equity or health equity? So, we use readily available data like the Gini coefficient, to look at improvements in equity. [Annette] Interesting, and so, drumroll, [Gretchen] Yeah, [Annette] What are the countries that you selected? [Gretchen] So, once we ranked countries among those indicators that we had used, we settled on, um, Australia, Northern Ireland, the Czech Republic, Indonesia, South Africa, Brazil and Singapore. [Annette] Singapore doesn’t strike me as a good U.S. comparator so much? [Gretchen] Yeah, so, it’s… while it is a nations… a city-state, um, and was introduced into the study because there was some interest around, uh, a housing case study that was done, it actually made a really good comparator for urban areas in the U.S. [Annette] Yeah, that is, that’s very relevant. And I think one of the things that I thought was great about that list is that it is spread across different regions of the world. [Gretchen] Absolutely, we made it a point to get countries from every WHO region. [Annette] Great. Alright, so, I’m going to come back to the countries and into the methods in a second, but I think this is a good place to stop and, remind, to let our viewers know and to remind us, what’s the definition of health equity that the Robert Wood Foundation is using and that we’re using, you were using for this this research. So I’m going to read from the report. “Health equity means that everybody has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments and healthcare.” So, when I read that, I was like, Wow! So, we really are talking about a broad system that determines health equity and not just specific things that we associate with health. [Gretchen] Absolutely, um, we’re just now beginning to wrap our arms around how the social determinants of health really impact health outcomes and health equity. It’s a very important area. [Annette] Great, so let me come back to methods just a little bit. We have these eight countries and we want to compare them, so you used qualitative comparative case study analysis? [Gretchen] Yes. [Annette] Can you tell us a few words about what that is? [Gretchen] That’s a mouthful. Um, so, we essentially used a case study analysis across these countries to take a deeper look under the hood and see, okay what are some of the promising programs, policies, initiatives, that were seen in these countries that have promise for advancing health equity. We built out case studies and then we did a qualitative interpretive analysis to identify patterns and themes that emerged across at least more than one country or program and policy. [Annette] Great, so let’s start first… your data were then kind of policies and programs. Give us an example of one of the kinds of programs that you looked at, maybe one that wasn’t so obviously health? [Gretchen] Absolutely, so right out the gate, we build out the case study for Northern Ireland and identified right away a flax trust initiative that used a trauma-informed, place-based approach to rebuild communities and reclaim spaces that have been marred by political violence and, um, conflict. And this was I think a really compelling and interesting study, even so far as they’re relocating the university in Belfast, to help rebuild that community. [Annette] That’s great, that’s interesting. So, then you said doing this interpretive analysis, you identified common themes and [Gretchen] We did. [Annette] you present them in the report as four strategies that show up as being common across more than one of the countries, and being common across programs, different kinds of programs. [Gretchen] Yeah. [Annette] I thought that was interesting. So tell us what those four strategies are? [Gretchen] So, the four strategies included, um, decolonization and trauma-informed frameworks, also, coordinated multi-sectoral collaboration, participatory approaches, um, and approaches to reducing spacial inequality. [Annette] Which ties back to again, that [Gretchen] absolutely. [Annette] the flex trust program. So, among those four strategies, was there one that was less expected for you, or that you felt was more important than you expected? [Gretchen] Yeah. Um, we were really pleasantly surprised but surprised at how many countries were taking a very explicit step to addressing colonial legacies, and using a decolonization and trauma-informed approach. Um, South Africa, Australia, both of those had programs and policies that directly targeted that. [Annette] Wow! And one of the things that I really learned from reading the report was that there are different kinds of colonialism and so there are some examples that are more relevant for the U.S. than… than others. [Gretchen] Yeah, so we think that settler colonialisms in countries where you have the combination of occupation, um, colonial occupation and subjugation of a population, creates very entrenched and enduring legacies that have inequitable outcomes, including health inequities. [Annette] Including health inequities. [Gretchen] Yep. [Annette] Wow. So this is really interesting. Before we close, what were the recommendations? Where do we go from here? [Gretchen] Well, we set out to learn from the world, and, um, I think learning can be a never-ending process or at least hopefully it should be, so the recommendations we made were really in that spirit. Um. You know, first, we feel like we need to further interrogate settler colonial legacies and how those impact particularly the U.S…Um. Secondly, there wasn’t a U.S.-based scan or survey of health equity programs available. So, we need to see what’s going on here in our own country too, um. [Annette] Yeah. According to this larger definition of health equity, what… what in the U.S. falls under that. Interesting. [Gretchen] Exactly, um, and then among those, have rigorous evaluations that help us know what’s working well and why. [Annette] Right. [Gretchen] Um, and then, finally, keep the conversation going. I think the social determinants of health is sort of new and in our discourse around health and health equity and we need to keep talking about it and how important it is. [Annette] That’s great. That’s great. Well, thank you for starting that conversation and that discourse with us here on Research Roundtable. I want to recommend to our viewers to definitely read this report, the link is available, but also behind this report and available are the eight country case studies with a lot of really valuable information about the programs that you looked at here, um, so people should take a look at those as well. [Gretchen] Yep. [Annette] Thank You Gretchen. [Gretchen] Thank you. [Annette] Thank you for joining us here at Research Roundtable. Feel free to join the discussion in the comments below and I hope that you join us again for another episode.