Operationalising Sens Capability Approach An application in public

Operationalising Sen's Capability Approach: An application in public health Dr Paula Lorgelly Health Economics Appraisal Team (HEAT) Public Health and Health Policy

Outline of seminar • Economic evaluations of public health interventions – An example • Sen’s Capability Approach • Operationalising the approach as a means of measuring outcome • Remaining challenges and future research

Cost effective public health • UK background, Wanless (2004) recommended using “a consistent framework … to evaluated the cost effectiveness of interventions initiatives across health care and public health” • 2005 NICE’s remit expanded, now considers public health interventions

Amended NICE reference case • Their approach to methods states: – … resources available in the health service and other available public funds – Cost consequence analysis to supplement cost utility analysis where appropriate

Challenges of producing NICE PH guidance • • Measuring benefit Population based interventions Equity vs. efficiency Economic perspective Time horizons Quality of evidence Cost effectiveness threshold – Chalkidou et al (2008) Health Economics

Challenges of applying standard approaches • Methodological challenges of – – Attributing outcomes to interventions Measuring and valuing outcomes Incorporating equity considerations Identifying intersectoral costs and consequences – Public Health Research Consortium, York

Measuring and valuing outcomes • QALYs are the reference case – Preference for using the EQ 5 D • No adjustment for equity • QALYs have their benefits – Public health vs health care interventions • But does the QALY framework (or descriptive system) capture all relevant outcomes

My (HEAT’s) involvement • Section of Public Health and Health Policy • Strong collaborations with the Medical Research Council Social and Public Health Sciences Unit (MRC SPHSU) – Including a joint appointment (Liz Fenwick) • Involved in evaluating a range of social and public health interventions – Majority of which are complex

Complex Public Health Interventions • Complex interventions – developing overtime – heterogeneous – “made up of various interconnecting parts” • Complex outcomes • Complex evaluation – Comparator group – Randomisation – Perspectives • Timescales

An Example: Go. Well • Glasgow Community Health and Wellbeing Research and Learning Programme • Multi-site, prospective study • Multi-intervention – – Core stock refurbishment Area transformation Special areas Peripheral estates • Baseline survey + follow-ups till 2013

Go. Well – outcomes • Individuals’ health and well-being – – – Physical health Mental health Health behaviours Use of health services Sense of ‘control’ and self-esteem • Neighbourhoods and communities – social participation, personal social networks – neighbourhood outcomes

Go. Well – economic evaluation • Cost-effectiveness (utility) – Which outcome? • Cost consequences – Implicit decision making

Key question • How best to measure and value the outcomes of social and public health interventions?

Capability Approach • Amartya Sen (1979, 1985) • Rejects normative evaluations based exclusively on commodities, income, or material resources • Resources are the means to enhance people’s well-being • Resource-based theories do not acknowledge that people differ in their abilities to convert resources into capabilities

• Wellbeing should be measured not according to what individuals actually do (functioning) but what they can do (capability)

Benefits of using the CA • Evaluative space – Richer set of dimensions – QALYs have one dimension – health • Focus of evaluation – Equality of capability – Equity, rather than health maximisation

Challenges of using the CA • How to operationalise a highly theoretical approach? • What is the set of ‘capabilities’? • How to estimate an index of capability? • How to value this index?

Operationalising the CA • Literature largely conceptual • No gold standard with which to operationalise the CA • Value in operationalising • Issues – How can we choose relevant capabilities? – How can evaluations be sensitive to cultures?

Nussbaum’s Central Human Capabilities Life Practical reason Bodily health Affiliation Bodily integrity Other species Senses, imagination and thought Play Emotions Control over one’s environment

Nussbaum’s Central Human Capabilities Life Being able to live to the end of a Practical human life of normal length. reason. . ; not dying prematurely. . . Bodily health Affiliation Bodily integrity Other species Senses, imagination and thought Play Emotions Control over one’s environment

Nussbaum’s Central Human Capabilities Life Practical reason Bodily health Affiliation Bodily integrity Other species Being able to move freely from place to Senses, imagination place; being able to be secure against Play and thought violent assault, including sexual assault. . . ; having opportunities for sexual Emotionssatisfaction and for. Control over one’s choice in matters of environment reproduction

Nussbaum’s Central Human Capabilities Life Practical reason Bodily health Affiliation Being able to live for and in relation to others, to Bodily integrity Other species recognize and show concern for other human beings, to engage. Senses, in variousimagination forms of social interaction; being able Play to imagine the situation of another and to have and thought compassion for that situation; having the capability for both justice and friendship. . Being able to be treated Emotions Control over one’s as a dignified being whose worth is equal to that of environment others.

Nussbaum’s Central Human Capabilities Life Practical reason (A) Political: being able to participate effectively in Bodily health Affiliation political choices that govern one’s life; having the rights of political participation, free speech and freedom of Bodily integrity association. . . (B) Material: being able. Other to holdspecies property (both land movable goods); having the right to seek Senses, imagination employment on an equal basis with others Play. . . and thought Emotions Control over one’s environment

Anand colleagues • Programme of work operationalising the capability approach • Sought to exploit secondary collected data, specifically the BHPS • Addition of further indicators • List of some 60+ capabilities aligned with Nussbaum’s ten (referred to as the OCAP) • Research explores links between life satisfaction/ happiness/wellbeing and capability

Capabilities “What you can do, not what you actually do” Questions – Version 1 Life Being able to live to the end of a human life of normal length. . . ; not dying prematurely. . . Given your family history, dietary habits, lifestyle and health status until what age do you expect to live? Bodily Health Being able to have good health, including reproductive health; being adequately nourished. . . ; being able to have adequate shelter. . . Does you health in any way limit your daily activities, compared to most people of your age? Do you eat fresh meat, chicken or fist at least twice a week? If not, why not? Are you able to have children? If not why not? Is you current accommodation adequately or inadequate for your current needs? Are you prevented from moving home? Bodily Integrity Being able to move freely from place to place; being able to be secure against violent assault, including sexual assault. . . ; having opportunities for sexual satisfaction and for choice in matters of reproduction Are you prohibited from using any of the following: contraception, abortion, fertility treatment? Do you have sufficient opportunities to satisfy your sexual needs/desires? Please indicate how safe you feel walking alone in the area near your home (daylight and after dark): Have you ever been a victim of sexual/domestic/violent assault? How vulnerable do you feel to sexual /domestic/ violent assault in the future Senses, Imagination and Thought Being able to use the senses; being able to imagine, to think, and to reason--and to do these things in. . . a way informed and cultivated by an adequate education. . . ; being able to use imagination and thought in connection with experiencing, and producing expressive works and events of one's own choice. . . ; being able to use one's mind in ways protected by guarantees of freedom of expression with respect to both political and artistic speech and freedom of religious exercise; being able to have pleasurable experiences and to avoid nonbeneficial pain I am free to express my political views I am free to practice my religion How often do you use your imagination/reasoning ? Have you been able to enjoy your normal day to day activities? What is the highest educational or work related qualification you have? Emotions Being able to have attachments to things and persons outside ourselves; being able to love those who love and care for us; being able to grieve at their absence, to experience longing, gratitude, and justified anger; not having one's emotional developing blighted by fear or anxiety. . How easy/difficult do you find it to enjoy the love, care and support of you immediate family? Do you fine it easy/difficult to express feelings of love, grief, long, gratitude and anger? How difficult do you find it to make friends? Have you recently lost much sleep over worry? Have you recently felt under constant stain? Practical Reason Being able to form a conception of the good and to engage in critical reflection about the planning of one's own life. (This entails protection for liberty of conscience. ) My idea of a good life is based on my own judgement. I have a clear plan of how I would like my life to be. How often do you evaluate how you lead your life and where you are going in life? Outside of work, have you recently felt that you were playing a useful part in things? Affiliation Being able to live for and in relation to others, to recognize and show concern for other human beings, to engage in various forms of social interaction; being able to imagine the situation of another and to have compassion for that situation; having the capability for both justice and friendship. . Being able to be treated as a dignified being whose worth is equal to that of others. I respect, value and appreciate other people. Do you tend to find it easy or difficult to imagine the situation of other people? Have you recently been thinking of yourself as a worthless person? Do you normally have at least one week’s holiday away from home? If not, why not? Do you normally meet up with friends/family for a drink or a meal at least once a month? If not, why not? Outside of work, have you ever experienced discrimination because of your: Race; Sexual orientation; Gender; Religion; Age Outside of work, how likely do you think it is that you will experience discrimination because of your: Race; Sexual orientation; Gender; Religion; Age Species Being able to live with concern for and in relation to animals, plants, and the world of nature. I appreciate and value plants, animals and the world of nature. Play Being able to laugh, to play, to enjoy recreational activities. Have you recently been enjoying your recreational activities? Control over one’s environment (A) Political: being able to participate effectively in political choices that govern one's life; having the rights of political participation, free speech and freedom of association. . . (B) Material: being able to hold property (both land movable goods); having the right to seek employment on an equal basis with others. . . I am able to participate in the political activities that affect my life if I want to. At work, have you recently felt that you were playing a useful part in things? Which of these applies to your home? Why have you not bought your home? How likely do you think it is that you will be stopped and searched by the police? When seeking work in the past, have you ever experienced discrimination because of your: Race; Sexual orientation; Gender; Religion; Age When seeking work in the future, how likely do you think it is that you will experience discrimination because of your: Race; Sexual orientation; Gender; Religion; Age To what extent does your work make use of your skills and talents? Do you tend to find it easy or difficult to relate to your colleagues at work?

This Project • This project aimed to: – further develop and refine the survey instrument as proposed by Anand et al – validate the instrument for use in public health evaluations – propose how future evaluations might employ the capability approach

Phases/Stages • Phase I, Stage I – FG group discussions – Analysis of the You. Gov questionnaire • Phase I, Stage II – Semi-structured interviews – Pilot postal survey • Phase II – Interviews and postal survey (for validation) • Phase III (now a Ph. D studentship) – Develop an index

Phase I, Stage I findings • Focus Groups • Issues of: – – Question interpretation Ambiguous questions Answer/response options Question ordering • ‘Questionnaire refinement’

Phase I, Stage I findings (cont. ) • • Factor analysis (You. Gov questionnaire) Factor loadings onto Nussbaum’s list Correlations amongst multiple measures Raised issues of measuring this so-called capability – yes or no, i. e. does or does not have the capability – or is there a degree of capability • ‘Questionnaire reduction’

Item Reduction/Refinement • Key changes included: – – – Change option responses Merged questions Removed multiple questions, Used more established questions Refined the wording Changed the ordering of the question • 64 specific capability questions to 43 specific capability questions

Phase I, Stage II findings • Semi-structured interviews – Further clarification – Insight into respondents understanding of capabilities • Pilot postal survey + interview – Analysed quantitatively

Further reduction/refinement • • Ordering Understanding and interpretation Face validity for retention Measured capability rather than functioning e. g. I appreciate and value plants, animals and the world of nature I am able to appreciate and value plants, animals and the world of nature

Phase II • 64 capability questions 43 capability questions 18 capability questions • 27 questionnaire (24 questions on capability and demographics + 3 validation questions) • Sent to 1000 Glaswegian homes + 400 invites for interviews

Final version • Postal and interview survey, N=198 • Characteristics of the sample – – – – – white (97%), female (62%), employed full-time (50%), some form of higher education (45%) or no qualifications (24%), married (30%), never married (34%), no dependent children (69%), no religion (35%), Presbyterian (26%), Catholic (28%), household income of under £ 30, 000 per year (61%), average 46 years old (range 19 to 91 years)

Deprivation of sample Deprivation decile 1 2 3 4 5 6 7 8 9 10 Population share 0. 06 4. 83 0. 00 5. 00 4. 13 5. 08 7. 91 5. 20 13. 70 54. 10 Percentage Sampled 0. 04 2. 88 0. 00 2. 98 2. 46 3. 03 4. 71 3. 10 16. 33 64. 48 Percentage responded 0. 5 6. 7 0. 0 3. 1 3. 6 8. 2 4. 6 17. 9 52. 3

1: Life • Until what age do you expect to live, given your family history, dietary habits, lifestyle and health status?

1: Life II • Deviations in life expectancy

2: Bodily Health • Does your health in any way limit your daily activities compared to most people of your age?

3: Bodily integrity • Please indicate how likely you believe it to be that you will be assaulted in the future (including sexual and domestic assault)?

4: Senses, imagination & thought • I am free to express my views, including political and religious views

5: Emotions • In the past 4 weeks, how often have you lost much sleep over worry?

6: Practical reason • I am free to decide for myself how to live my life

7: Affiliation • Outside any employment, in your everyday life, how likely do you think it is that you will experience discrimination

8: Species • I am able to appreciate and value plants, animals and the world of nature

9: Play • In the past 4 weeks, how often have you been able to enjoy your recreational activities?

10: Control over one’s environment • I am able to influence decisions affecting my local area

Life expectancy (deviations) Bodily Health a Daily activities Suitable Accommodation Bodily integrity Neighbourhood safety Potential for assault Senses imagination and thought Freedom of expression Imagination and creativity Emotions Love and support Losing sleep Practical Reason Planning one’s life Affiliation Respect and appreciation a Social networks Discrimination Species Appreciate nature Play Enjoy recreation Control over one’s environment Influence local decisions a Property ownership Employment discrimination Gender Age Deprivation Income 5. 514** 0. 137 0. 352 6. 655** 0. 850 2. 895 11. 655** 3. 906 8. 374* 4. 409 39. 831** 16. 120 8. 559 10. 755* 5. 355 9. 548 29. 991** 8. 202 12. 314 13. 601 4. 535 6. 717 6. 006 14. 895 4. 523 6. 817 14. 734 14. 304 4. 347 3. 244 13. 616 5. 223 14. 859 10. 080 20. 056 21. 750* 5. 947 6. 989 14. 423 12. 382 7. 121 0. 037 2. 586 5. 807 2. 418 18. 569* 0. 764 2. 017 10. 363 12. 133 0. 209 2. 584 11. 447 25. 648* 2. 452 1. 912 2. 218 12. 778 2. 057 3. 302 14. 869 14. 602** 5. 501 31. 934** 55. 575** 10. 039 1. 527 8. 025* 5. 514 14. 450 13. 458** 16. 180

Aggregation • How to develop an index given – multi-dimensionality and – the incompatible nature of the dimensions? • Not uncharted water, Human Development Index has its foundations in the capability approach • Ideally, should consider the relative importance of each domain and preferences/tradeoffs for each dimension

Preference elicitation • Range of techniques available – – Standard gamble Time trade off (TTO) Rating scale Discrete choice experiments (DCE) • Preference weights allow economic evaluations to consider technical and allocative efficiency • But who’s preferences? – Issues of adaptation and expert opinion

(gross) Estimate of capability • Give each capability equal weight (that is each question not each domain) • Maximum possible score of 18 • Mean = 12. 44, range: 3 – 17. 75

Index of capability

Health/Wellbeing vs Capability

Inequalities and Capability Mean Std Dev Minimum Maximum Male 12. 53 2. 41 5. 50 17. 75 Female 12. 40 2. 62 3. 00 17. 25 Under 40 12. 50 3. 00 17. 75 40 to 60 12. 30 2. 65 4. 50 17. 25 Over 60 12. 70 2. 42 6. 50 16. 00 deciles 1 to 6 13. 45 1. 79 8. 50 16. 50 deciles 7 to 9 12. 88 2. 43 4. 50 17. 75 decile 10 11. 92 2. 66 3. 00 17. 25 less than £ 10 k 10. 73 2. 70 4. 50 14. 75 £ 10 k to £ 19 k 11. 85 2. 66 3. 00 17. 25 £ 20 k to £ 40 k 13. 25 1. 95 7. 50 16. 50 more than £ 40 k 13. 94 1. 54 10. 50 17. 75 p-value Gender 0. 761 Age 0. 772 Deprivation 0. 006 Income <0. 001

Capability vs Functioning Interviewee 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Adequately nourished C C F C C C F F C C C C Expressing views C C C C C F Love, care & support C F F F C C C F NOT SURE F C Planning of one's own life C F F C F C C C C C BOTH F Influencing decisions affecting local area F C C C C F

Implementing the approach • Questionnaire/instrument appears valid and sensitive • More appreciative evaluation space (for public health interventions) • Issues of aggregation – Valuation approaches – Whose preferences – Anchoring • Acceptability to decision makers – QALYs (EQ 5 D) are the norm

Future research • ESRC/TSG studentship – More participatory approach – Consult with key stakeholders (public, academics and govt advisors) – Core set of capabilities – Test a range of valuation methodologies – Validation of instrument in a number of nested Go. Well studies

Discussion points • Weighting dimensions, preference or otherwise? • More detailed quantitative analysis, latent class? further reduction? • (in)Compatibility of the dimensions problematic? • Super-QALY? Or a WALY?

• Contact details: • p. lorgelly@clinmed. gla. ac. uk • Final report available at: • www. gcph. co. uk