Participation for health equity: a comparison of citizens’ juries and health impact assessment

Abstract

Despite research demonstrating that the social determinants of health are the primary cause of health inequities, policy efforts in high-income countries have largely failed to produce more equitable health outcomes. Recent initiatives have aimed to create ‘healthier’ policies by incorporating public perspectives into their design, and scholarship has focused on improving participatory technologies. Yet how participation can improve health equity through policymaking for the social determinants of health remains unclear. The thesis addresses this gap by examining how two examples of participatory technologies implemented in Australia and the UK -- citizens’ juries and health impact assessment -- affected health equity. I found that the intersection between context, positionality and process generated a range of direct and distal outcomes for health equity.

I conducted a qualitative comparative analysis of four case studies of participatory processes, including interviews and document analysis. In doing so, I examine how processes were contextually designed and delivered, personally experienced, and how their adaptive and interpretive nature produced outcomes relevant to health equity.

Though participatory technologies were often designed and promoted as uniform tools, the context in which they were employed profoundly affected their implementation. Processes were embedded within different participatory ecologies -- histories, spaces and practices – that shaped their aims, design and delivery. Similarly, individual characteristics of participants (especially their positionality) affected how they interpreted the process: what the process could achieve and how they should participate. In turn, participants’ experiences resulted from (in)congruence between their expectations and outcomes.

The participatory experience led to various personal outcomes, including civic skills, social capital and empowerment, which can benefit health equity. ‘Having a say’ was often described as the vital ingredient for why participants experienced empowerment. Yet what mattered most for generating this outcome was whether or not participants ‘felt heard.’ This dialogic process between participants ‘voicing’ and decision-makers ‘listening’ was core to the experience of empowerment.

The processes also led to governance outcomes. The level of impact on the intended decision ranged, with some processes creating direct effects, but more commonly, by being situated in participatory ecologies, the processes affected change through non-linear or diffuse channels. Though public participation is often structured to achieve a technocratic goal, the processes accomplished other participatory, epistemic and institutional aims. These non-technocratic outcomes, combined with decision-making changes, could improve governance for the social determinants of health.

Power acted as a mechanism that underpinned other elements of the processes. Public health theories have begun to focus on the role of power as a fundamental determinant of health inequities, and this thesis contributes to this emerging body of evidence by examining how instrumental, structural and discursive forms of power were enacted and influenced how processes were implemented, experienced, and what outcomes they produced.

By examining not just what outcomes occurred but how they arose, this research develops a better understanding of the underlying mechanisms that generate outcomes. This shifts evidence from ‘perfecting the form’ toward building an understanding of how to utilise participatory approaches within specific contexts to achieve health equity benefits. The thesis highlights the need for greater consideration of context, positionality and variability of experiences in public participation. If participatory processes seek to achieve specific outcomes (healthy public policy and empowerment) that improve health equity, then consideration must be given to the mechanisms that can produce these effects.