Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 https://doi.org/10.1186/s12961-020-00559-z RESEARCH Open Access A novel conceptual model and heuristic tool to strengthen understanding and capacities for health inequalities research Lucinda Cash-Gibson1,2*, Matthew Harris3, Germán Guerra4 and Joan Benach1,2,5 Abstract Background: Despite increasing evidence on health inequalities over the past decades, further efforts to strengthen capacities to produce research on this topic are still urgently needed to inform effective interventions aiming to address these inequalities. To strengthen these research capacities, an initial comprehensive understanding of the health inequalities research production process is vital. However, most existing research and models are focused on understanding the relationship between health inequalities research and policy, with less focus on the health inequalities research production process itself. Existing conceptual frameworks provide valuable, yet limited, advancements on this topic; for example, they lack the capacity to comprehensively explain the health (and more specifically the health inequalities) research production process at the local level, including the potential pathways, components and determinants as well as the dynamics that might be involved. This therefore reduces their ability to be empirically tested and to provide practical guidance on how to strengthen the health inequalities research process and research capacities in different settings. Several scholars have also highlighted the need for further understanding and guidance in this area to inform effective action. Methods: Through a critical review, we developed a novel conceptual model that integrates the social determinants of health and political economy perspectives to provide a comprehensive understanding of how health inequalities research and the related research capacities are likely to be produced (or inhibited) at local level. Results: Our model represents a global hypothesis on the fundamental processes involved, and can serve as a heuristic tool to guide local level assessments of the determinants, dynamics and relations that might be relevant to better understand the health inequalities research production process and the related research capacities. (Continued on next page) * Correspondence: lucinda.cashgibson01@estudiant.upf.edu 1 Research Group on Health Inequalities, Environment and Employment Conditions Knowledge Network (GREDS-EMCONET), Department of Political and Social Sciences, Universitat Pompeu Fabra, Mercè Rodoreda 24 Building, Campus Ciutadella UPF, Ramon Trias Fargas, 25-27, 08003 Barcelona, Catalonia, Spain 2 Johns Hopkins University - Pompeu Fabra University Public Policy Center, Barcelona, Catalonia, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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Health Research Policy and Systems (2020) 18:42 Page 2 of 12 (Continued from previous page) Conclusions: This type of knowledge can assist researchers and decision-makers to identify any information gaps or barriers to be addressed, and establish new entry points to effectively strengthen these research capacities. This can lead to the production of a stronger evidence base, both locally and globally, which can be used to inform strategic efforts aimed at achieving health equity. Keywords: Research capacity-building, research capacity strengthening, research systems, conceptual model, health equity, health inequalities Introduction most of the current research and models focus on un- The social, economic and political contexts in which we live derstanding the interplay or relationship between HI generate and maintain the social hierarchies of power and research and HI policy and action [8, 9], with less em- access to resources that are embedded in institutional set- phasis being placed on understanding how HI research tings and policies that create socioeconomic positions [1]; itself is produced. Nevertheless, research on HI research these upstream social mechanisms, or the so-called ‘struc- has been growing in interest over the past few of de- tural determinants’ operate through intermediary (e.g. so- cades, particularly in trying to establish the necessary cial, occupational) determinants that shape the distribution capacities to produce HI research at the local level in of risk factor exposures and social vulnerabilities in a popu- different global settings [10–16]. This interest was en- lation [1]. These processes, which are generated and main- couraged by the final report of the WHO’s Commission tained by “unjust social arrangements” [2], then become on Social Determinants of Health (SDH), entitled ‘Clos- embodied by individuals, and can lead to avoidable and un- ing a Gap in a Generation’ [17], which presented a num- fair systematic differences in health, within and between ber of recommendations to achieve health equity, communities and countries (i.e. health inequalities (HI)) [1, including strengthening the global and local SDH and 3, 4]. In this article, we use the term ‘health inequalities’ to HI evidence base and research capacities. refer to all of the following terms: HI, health disparities, Scientific production is considered to be a good proxy health inequities and social inequalities in health. indicator of research capacity; within the HI research Over the past several decades, HI have increased, field itself, substantial inequalities have been found to along with a global awareness and evidence about this exist between countries and world regions, in terms of complex phenomena [5], provoking the formulation of the volume of production and collaborative dynamics recurring questions concerning their potential explana- [5]. These findings raise further questions that need to tions – questions that all countries should answer to be be answered; for example, why do some countries (and able to develop effective solutions to tackle HI [6]. For potentially also certain regions and institutions within example, why are there considerable inequalities in the countries) produce more HI research than others, par- opportunities to be healthy, between and across soci- ticularly when HI exist everywhere? Why do some coun- eties? What are the causes and conditions that lead to tries, despite similar level of financial resources, seem to HI? Where and how can we intervene to improve health be more ‘productive’ in this research field than others? and well-being for all? What determines the capacity to produce HI research at A prerequisite for answering these questions is invest- the local level, in different settings? What mechanisms ment in local capacities for HI research to be able to are involved in this process? How can local HI research produce a strong evidence base to potentially inform ef- capacities be strengthened? To attempt to answer these fective policies and interventions aiming to address HI. questions, the HI research production process itself Although the claiming of this need goes back in time, a needs to be better understood. particular emphasis was placed in the 1990 report by the The health research systems (HRS) and policy field has Independent Commission on Health Research for Devel- been driving the thinking on how health research is pro- opment [7], which showed major gaps in global health duced, which is a useful starting point to try to analyse research and in the monitoring and evaluation of public how HI research is produced. Several definitions and health needs, particularly in low- and middle-income conceptual frameworks on national HRS and how to countries, and advocated for the examination of the strengthen health research capacities have been pro- health scientific production process itself to expand posed. Deciding which explanatory frameworks to use country-specific health research and its usage to improve can have important implications for how one envisions health and health equity. the practical possibilities to proceed [18]. The HI research production and usage processes are For example, the work by Pang et al. (on behalf of important to support effective action to address HI, yet WHO) [19] was an important step forward in trying to Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 Page 3 of 12 simplify the complex systems and processes through focused on strengthening health research capacities ac- which health research is produced to improve popula- knowledge that different levels of research, and research tion health and health equity, and to establish the attri- capacities, are involved in the health (and HI) research butes, functions and goals of HRS, to guide the production process [3, 31–33]; however, these concep- development of further operational work. Pang et al. tual frameworks also present similar, limited specifica- define an HRS as “[t]he people, institutions, and activities tions of how these research capacities are created, what whose primary purpose in relation to research is to gener- factors shape or condition them, and how these different ate high-quality knowledge that can be used to promote, levels of research and capacities connect and interact to restore, and/or maintain the health status of popula- produce health (and HI) research at the local level, thus tions” ([19]. p. 816). limiting their ability to be empirically tested in the de- However, the related conceptual framework [19] pre- sign of integral strategies aiming to strengthen these sents an oversimplification of HRS, and lacks the cap- capacities in different settings. Furthermore, a systematic acity to comprehensively explain the health (and HI) review assessed the main approaches used in the health research production process at the local level, thereby research capacity strengthening field and found insuffi- providing limited resources to be able to comprehen- cient insights on how sustainable national HRS are sively assess these research capacities at the local level. formed, limited guidance on how to address research Specifically, it fails to sufficiently account for the essen- capacity gaps and persistent ineffective strengthening tial components, pathways, determinants and dynamics strategies being utilised [34]. that are likely to be involved in creating and producing These challenges, both in developing comprehensive this type of research, nor does this conceptual frame- HRS analyses and effective strategies to strengthening work consider the vital role of context and its different health (and HI) research capacities, seem partially due to levels (i.e. historical, socio-cultural and eco-political a limited conceptual understanding of HRS and the re- choices, decisions and actions, as well as institutions search production process(es). This has likely reduced within countries and regions that have shaped how HRS the scope of knowledge necessary to make progress in have emerged and developed) [1, 20]. strengthening these research capacities but also in devel- Since Pang et al.’s [19] initial work, “understanding oping effective multisectoral interventions to promote local context” has been recognised as a key component health equity. of research capacity assessments and strengthening ini- The additional challenge with HI research is that HI tiatives [21]. Furthermore, a study in Guinea Bissau [22] are theoretical, empirical and practically complex [12]; assessed how the national HRS has developed and therefore, to establish in-depth causal explanations, HI evolved over time, and highlights a number of import- research often requires going beyond the use of trad- ant, yet often overlooked, factors that assist to provide itional (bio)medical models of health and disease, context to the current capacity of the national HRS. For discipline-specific theories, concepts and methods [35], example, the authors highlight the role of history, polit- and specific risks factor analyses as well as traditional ics and power struggles, as well as war and conflict, hierarchies of evidence, all of which produce useful, but international development and epidemics, amongst often ‘fragmented’ or partial, assessment of the complex others. Such contextual factors are likely to be highly problem(s) [36–38]. Instead, the development and appli- relevant to consider when trying to understand and cation of integrated, transdisciplinary approaches are evaluate the current capacity to produce heath and HI needed [12, 35], which include innovative methodo- research, in other post-colonial and post-conflict set- logical and theoretical approaches [12, 35, 39] and tings, for example. “jointly developed” conceptual models and frameworks In addition, a study in Palestine [23] found that the that synthesise discipline-specific perspectives from the conceptual understanding of national HRS amongst na- socio-political to the biological level and from the macro tional stakeholders varied, and was not fully aligned to to the micro level [18, 35]. the work of Pang et al. [19], concluding that clearer con- As such, in order to attempt to address the HI re- ceptualisation and definitions (and awareness of them) search production process knowledge gap, we present a are needed to potentially improve the understanding of novel conceptual model that comprises an intertwined, national HRS and facilitate progress in strengthening comprehensive approach to understand how HI research these research system capacities. Another study in the (and research capacities) are produced; by using the Eastern Mediterranean region found similar results [24]. SDH and political economy perspectives, we build an in- Subsequent tools that build on the work by Pang et al. tricate theoretical understanding of HRS, the HI re- [19] have been developed [25–30], which share similar search production process and research capacities at the shortcomings in terms of guiding the development of local level. This model incorporates a number of add- further operational work. Other conceptual frameworks itional aspects that have not been included in existing Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 Page 4 of 12 models/frameworks and can serve as a heuristic tool to the status quo of the distribution of resources and power guide HI research assessments at the local level. in HI research structures and practices, and to explore Our aim is to provide the basis for new understanding potential ways to modify these conditions [6]. and more focused empirical questions on how to Our conceptual model describes the potential compo- strengthen the HI research production process, related nents, determinants and pathways through which HI research capacities and HRS in different settings, which research is created and aims to achieve a better under- in turn might eventually lead to breakthroughs in action standing of the context within which HI research is pro- towards achieving health equity. duced at the local level; the main determinants and components of HRS and capacities for HI research; the Materials and methods relationship between these main determinants and com- We conducted a critical review [40] to evaluate the sci- ponents, and the production of HI research, clarifying entific and grey literature related to capacity-building/ the pathways that may lead to improvements in health strengthening, HRS and HI research to develop our con- equity; use of the model for evaluating local capacities ceptual model. Whilst reviewing the selected literature, for HI research; and identification of entry points for in- snow-balling search techniques were also used to iden- terventions aiming to strengthen capacities for HI tify any additional literature that may provide further research. critical reflections on these topics. The public health analysis under the lens of political Results economy is a potent approach useful to understand HI Figure 1 depicts our conceptual model of a local HRS and how people’s opportunities for health are condi- along with the potential processes involved in creating tioned by social, eco-political and power structures, be- and producing HI research and HI research capacities as yond control of the individuals affected [3, 6] and can well as how this relates to HI research usage and action; provide useful knowledge to improve the effectiveness of however, this latter process is not the focus of our study. global public health policy analyses and action [41]. Arrows indicate the pathways involved and the direction Analogously, it is also useful to understand how the of activity. opportunities and access to resources to produce HI re- Just as it is recognised that there are sets of structural search are conditioned in a given context. This perspec- determinants that condition people’s health opportun- tive can prompt novel research questions to challenge ities [1], our conceptual model proposes that there are Fig. 1 Conceptual model of a local health research system, with a focus on how health inequalities research and research capacities are produced Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 Page 5 of 12 also (different) sets of structural determinants which op- power struggles that manifest and impact people’s health erate through (different) sets of intermediary determi- and well-being [6]. nants to condition and shape HI research practices and However, several scholars have mentioned the “limited HRS opportunities to produce HI research, and conse- academic freedom” there is in the health and social sci- quently the opportunities to address HI in a given ence research fields in certain countries due to academic context. institutional structures, ideologies and dependence for We consider the core of HRS and HI research capacity research funding, and the impact this can have on the to be comprised of research infrastructure and research framing of the HI research design and findings [43, 44]. production (indicated by dotted lines in Fig. 1). The HI Critical HI research requires the application of inte- research infrastructure is composed of two multifaceted grated transdisciplinary approaches, such as an eco- subcomponents, namely HI human resources and inte- social lens [45], to consider the social, historical and grated health and socio-demographic information sys- ideological forces and power structures that can main- tems, which can come together within a creative tain and (re)produce HI. Additionally, it requires going intellectual space and interact (as appropriate, depending beyond the privileging of scientific knowledge created in on the research questions proposed), to enable critical certain (often higher-income country) settings [46, 47] HI research to be created and produced. and the adoption of privileged, hegemonic methodo- Furthermore, we consider financing, stewardship and logical (and philosophical) approaches often used in governance to be threads that run throughout the HRS, public health and HI research due to “their perceived each with their own internal dynamics that will shape strength in establishing cause and effect” ([36], p. 252– the opportunities and access to the resources available, 253), which provide only partial accounts of social real- and which can enable or disable the HI research produc- ity, or of a complex social phenomenon [38], resulting in tion process at various points. a limited contribution to the knowledge required to ad- To explain our model, we start from HI research pro- dress HI in a given setting, globally [31]. duction (i.e. the outcome of interest in this study) and At the global scale, efforts aiming to strengthen HI re- elaborate backwards to cover the main pathway(s), com- search capacity need to consider these dynamics so as to ponents and determinants as well as the dynamics po- determine how to develop enabling HI research condi- tentially involved in this overall process. tions and individual research skillsets as well as how to overcome the “epistemic injustices” and deep-seeded “unconscious biases” still prevalent in varying degrees in Research production global health research production and research practices As mentioned, an indication of research capacity is the [46, 48–51] and in particular the HI research field [5, counting of scientific international peer-review journal 38]. publications [30]. Whilst grey literature (e.g. briefs, re- ports) can also be produced, disseminated and used Research infrastructure alongside scientific (HI) research, it is a separate process As existing research highlights, development of HI re- and not the focus of our paper. search infrastructure requires a conducive research en- vironment and the provision of resources such as Creative intellectual space facilities, financial research support, and scientific lead- To create critical HI scientific research, the intellectual ership as well as enabling career structures, good re- and creative autonomy of HI researchers needs to be search management, and access to technical information fostered through a supportive research infrastructure at and equipment [33, 52], amongst other things. A key the systemic and institutional (macro and meso) levels. component of HI research infrastructure is a critical This includes career pathways and (transdisciplinary) re- mass of skilled workforce that, through adequate (ideally search training so that HI researchers are given the op- transdisciplinary) training, mentoring and research infra- portunity and resources, including sufficient time [8], to structural support [53], will have the competences to reflect and pose relevant innovative questions, pursue understand and assess the broader determinants of HI, critical HI research on complex global-societal issues, to design, lead and conduct critical HI research, as well and be in a better position to be able to explore potential as to establish sustainable research institutions, teams, ways to modify these inequitable conditions and out- and networks, and co-develop effective solutions to ad- comes. Such issues include HI and/or the (unequal) dis- dress HI at local level [33]. These have been identified as tribution of resources and power in social structures, pending needs in many countries and regions around between and within countries, which are maintained by the world [12, 31, 54]. contemporary global and societal norms and policies, In addition, the capacity and governance to consist- and ‘privileged’ actors [42] as well as the micro level ently collect, manage and report data at the macro, meso Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 Page 6 of 12 and micro level, across time, are also pending issues in provide and allocate research funding resources, they many countries [5, 55, 56]. However, with the limited also play a role in framing and steering research agendas data that is currently available, the WHO Global Obser- and priorities [68], and in deciding what type of research vatory on Health Research and Development calculates gets supported (or not), where and by whom, as well as that, on average, higher-income countries have 73 times the ‘appropriateness’ of the research frame used, often in more health researchers than low-income countries [57]. line with certain ideologies [32, 33, 47, 52, 69, 70]. By This highlights the average size of the human resource ideology, we mean a system of value judgments and be- capacity gap that is likely to exist between certain groups liefs that shape how research, and policy, is convention- of countries, globally, in being able to undertake health ally developed and carried out [44, 71]. and HI research. Furthermore, substantial gaps in data Furthermore, scholars have pointed out that (research) and human resource capacity are also likely to exist institutions at all different levels, including universities, within countries, which have not been reported. can be deeply ideological, which can sometimes (nega- At the same time, countries and local regions need to tively) impact the HI scientific discourse, and researcher be able to describe and measure the extent of HI and academic careers in the case of those interested in po- their determinants, understand and monitor their evolu- tentially controversial topics such as HI [43, 44]. tion overtime, and use this evidence to design and adjust Applying a political economy perspective and an inte- interventions to maximise the health benefits for all [17, grated transdisciplinary approach to the (HI) knowledge 33, 58]. This requires reliable, disaggregated and inte- production process, for example, allows one to see that grated health and socio-demographic data, information it is not a value-neutral, apolitical and purely scientific systems and routine monitoring mechanisms, supported process [43, 44], rather it is shaped by “...ideological by human resources. Such information systems can as- values, political and power relations, and economic sist researchers and decision-makers to identify entry forces” ([44], p. 916). However, so far, these types of ap- points for HI intervention, evaluate the impact of pol- proaches, reflections and considerations have been limit- icies and prioritise the use of resources to work towards edly applied to HI research [44, 68], and even less so to health equity [59]. the HI research production process and HI research Global efforts have been made to enhance the equity capacities. orientation of national health information systems and to build HI observatories, which have also identified sev- Structural determinants of HI research eral pending challenges to be addressed and which can It is understood that structural determinants of HI exist provide useful learning for other settings [54, 58–63]. within specific political and historical contexts, which For example, an evaluation of the capacity of Mozambi- consist of a number of interacting macro-level factors or que’s national health information systems to monitor determinants (e.g. macroeconomic and public policies, and measure health equity [64] identified significant gaps socio-cultural values and epidemiological conditions, in the availability of disaggregated equity stratifiers to be among others) that change over time, and can generate, able to measure and monitor the targets for United configure and maintain social structures, and exert influ- Nation’s Sustainable Development Goal three, which is ence (and power) at an intermediary (meso) level(s); this, focused on ensuring healthy lives and promoting well- in turn, can be embodied and can condition the subse- being [65, 66]. Such technical gaps, which are likely to quent opportunities to produce certain (health) out- exist in similar low-income country settings, not only in- comes at the individual (micro) level [1]. hibit the monitoring and measuring of HI, health equity Our conceptual model therefore proposes that there are and other related outcomes themselves, but also the po- also sets of structural determinants that operate through tential design and adjustment of much needed multi- intermediary determinants to condition and shape domes- sectoral policy changes in these settings [64, 66]. tic HI research practices, and HRS opportunities to pro- duce HI research, which consequently condition and Intermediary determinants of HI research shape the opportunities and access to resources to be able Local research agendas and prioritises are not always to potentially address HI in a given context. aligned with, and driven by, local population health and Additionally, within and across social contexts, the well-being needs. Institutions also play a key role in the views, values and ideologies around HI differ [1, 44], politics (understood as the exercise of power between which, as mentioned, likely impacts the type and degree groups) of health [67], in the process of HI of action taken to address them [16, 26, 33]. For ex- (re)production, and in the HI research production ample, HI are either seen as ‘natural’ and ‘inevitable’ out- process itself, acting as ‘vectors of power’ that is exer- comes of individual (lifestyle) choices and genetic cised and controlled by hegemonic groups [44, 68]. Re- differences, where the State has less ‘responsibility’ in search funding institutions, for example, do not simply creating the necessary changes [72–74] or as a social Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 Page 7 of 12 injustice that needs to be tackled by all at various social Formal, international research networks, for example, levels [72]. The first perspective is thought to be partly can pool and mobilise international and local resources due to the fact that the public health field has tradition- and capacities, and have become important players in ally been dominated by professionals trained (only) in strengthening research capacities for research, particu- medicine or biology, and who focus on the “biomedical larly in low- and middle-income countries. Examples of models of heath and disease” (rather than the ‘social such types of networks include vertical research projects, models’), where health is considered as the absence of centres of excellence, and global North–South (and disease (and/or a commodity), and the distribution of more recently, global South–South) research partner- (‘poor’) health and HI are predominantly the result of ships and consortia [34]. (‘poor’) individual choices and behaviours [72]. The bio- medical models do not acknowledge the role of up- Discussion stream structures and (class, gender and race/ethnicity) Firstly, we find that the distinction must be made be- power relations within which individual agency exists tween the processes of producing, and of using, health and can be shaped by [1, 43, 72, 73]. As a result, “socio- or HI research. For example, Pang et al. [19] consider structural violence” is often committed ([74], p. 239), both the ‘research production’ process and ‘research where the victims of HI are often blamed and stigma- usage’ process as the two main processes and goals of tised for their own injuries [43, 74] and political atten- HRS, but then consider ‘producing and using research’ tion and interventions are mainly directed downstream to be one single HRS function. However, this perspective towards promoting (and correcting ‘poor’) individual takes a linear view on how health or HI research is pro- lifestyle choices and behaviours, and improving health- duced, disseminated and incorporated into policy and care services [72] – despite the health system being just practice to improve health and well-being [8, 80]. one of the many intermediary determinants of HI [1]; In reality, as many political and social scientists discuss this has occurred in the United Kingdom, for example, [8, 81], the process of ‘research usage’ is neither linear, during various historical periods [74–76]. nor simultaneous, but rather influenced by a number of Underpinning all of this are not only divergent views other factors and stakeholders that are intertwined with of what action is possible, but also different institutional institutional and individual ideologies, values and inter- and individual ideologies and values about what is con- ests [8, 76, 82]. Therefore, instead, we propose that the sidered to be socio-politically desirable in society (i.e. main goal and function of HRS are to produce health or egalitarian versus individualism) [44], including giving HI research that may or may not be used, and we con- more or less importance to issues related to territory, ceive ‘research usage’ to be a separate process and sec- class, gender, ethnicity, etc. As such, it becomes clear ondary goal (and function) of HRS, which is beyond the that the way HI are considered, and the subsequent ac- scope of our paper. tion taken to address them, is highly political [72]. Secondly, HI and health equity are inseparable from Furthermore, under globalised neoliberalism [77], power and politics [72], which means that action on HI, changes in the roles and regulations of the state, foreign including creating and producing HI research, is a polit- affairs and the market have led to the increasing influ- ical process [26, 83]. Yet, the political determinants of ence of global eco-political conditions in domestic deci- health and HI have been largely neglected and margina- sions and global governance issues, i.e. global political lised from mainstream public health debate and analyses determinants, that impact on health and HI [6, 78]. [31, 34, 72, 84], this includes an absence of questions re- These constitute important dimensions of ‘context’ that lated to politics and power dynamics within and between need to be analysed and considered, alongside the strat- societies and countries [44]. As one study in Ethiopia egies pursued by actors and institutions involved in such highlights [85], if and when politics is referred to in global and local arrangements [1]. mainstream public health research, it is often in regard to whether there is political commitment or not, rather Research networks than going deeper into the political context to consider Our model presents how different types of (local and how politics impacts health, HRS and the related re- international, formal and informal) research networks search practices, or how internal power relations could can interact with HRS to pool and mobilise differential be changed to achieve better health (and related re- individual and institutional resources and capacities to search) outcomes [85, 86]. This is thought to be due, in strengthen research capacities [79]. These networks part, to what we mentioned previously about the two bring new conditions, pathways and relations to the HI main models of health, disease and HI. However, be- research production process as well as new individual tween these two main stances, there are also more nu- behaviours, interests and micro (power) struggles to the anced perspectives. For example, some may consider the research process [8, 76]. topic to be too complex (i.e. a “wicked” problem) or “too Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 Page 8 of 12 political” ([73], p. 115), not covered within their “discip- need to challenge the “enormous disparities of opportun- linary skill set” and/or not in their “own interest” to ity, wealth and power” that exist globally [65, 96]. This question or challenge HI, the status quo or their posi- also requires integrated, interdisciplinary and intersec- tionality [43, 73]. toral collaborations and approaches to understand and Scholarly debates over HI research findings, ultimately inform programmatic action on the various commercial, epidemiological and ontological debates over “causality political, economic, environmental and social determi- and causal relationship” [35, 38] and the relative import- nants of HI [66]. ance of individual behaviour and action and social struc- Fifthly, in addition to identifying the components, de- tures [3], have stated that these issues are not only of terminants and pathways involved in this process, the scientific interest, but can also be used to push for cer- identification of mechanisms and causal linkages that tain policy responses and, therefore, hold significant pol- are triggered in certain contexts, and which can lead to itical implications [35, 87]. For example, this has been the outcome of interest [97] (i.e. stronger HI research highlighted in the case of the United Kingdom over vari- capacities and increased HI research production in this ous historical and political periods [8, 75, 81, 87]. case) is also crucial. This type of in-depth understanding Thirdly, formal international health research networks about causal explanations can be used to inform the are also shaped and conditioned by underlying historical strategic development of more effective strategies to and contemporary geo-political power relations that strengthen this research process and its related capaci- exist amongst country partners at institutional and indi- ties. This is important since research is more than just a vidual level [47, 70, 88]. These types of networks are tool to generate new knowledge, it can also serve as a often led by external partners (linked to funding sources) strategy to advance population health and social change [20, 28, 42, 47] and are considered to be valid ap- [44]. proaches to enhance local HI research capacities, with As such, scholars have argued for more HI research to potentially mutual benefits for all involved, providing go beyond what can be “observed or measured” via posi- that certain ethical principles are followed and contrac- tivistic quantitative approaches or “perceived” by study tually established [12, 89, 90]. participants via interpretivisitic qualitative approaches However, there are also concerns that, as unantici- which only provide descriptions and partial understand- pated consequences, these new research environments ing of social reality [38]. Broader epistemology and onto- can potentially create research dependence, “intellectual logical approaches, such as realist approaches, are colonialism” [70, 91, 92] and/or establish parallel struc- thought to be useful since they try to consider both tures that bypass domestic research systems [15, 22], structure and agency [38, 98], and to reconcile the ten- which can restrict and/or erode local sovereignty [16] sion between scientific objectivity (which promotes neu- and exasperate the very problems they claim to aim to trality or value-free science) and value judgments [44], solve [33, 93]. Yet, concepts of power (and power strug- amongst other things, to establish more in-depth causal gles) at the meso- and micro-levels within these net- explanations and understanding of the complex issue works are insufficiently recognised, and need to be under study [38]. Realist approaches have started to be addressed to be able to determine to what extent coun- used to evaluate complex health and social issues and in- tries, institutions and researchers have the power, cap- terventions [36, 38, 97]; such approaches should also be acity (including equitable access to opportunities and considered by researchers and decisions-makers in com- resources) and agency to determine if, and what type of, bination with our guiding conceptual model when plan- HI research is produced at local level. This need to ac- ning local HI research capacity assessments and knowledge and address unequal power relations in pub- evaluations. lic health research collaborations has been highlighted in Lastly, critical reviews are useful to develop a hypoth- a study conducted in Zambia [94], and in a systematic esis or model that acts as a starting point for further review on managing (formal, international) health re- evaluation with the aim of critically evaluating the po- search capacity strengthening networks [95]. tential value from the aggregate literature to provide a Fourthly, applying a political economy perspective to new phase of conceptual development and subsequent public health analyses can help to assess the distribution testing. Whilst these critical interpretations are essen- of power and resources within HI research and its devel- tially subjective, emphasis is placed on the conceptual opment [6], despite public health researchers and practi- contribution of each item of the included literature [40], tioners not being typically trained to conduct this serving as a value method for our article. type of analysis [96]. A political economy perspective To conclude, our model was purposefully designed to has been discussed and advocated for in the context of understand the HI research production process at a glo- the Sustainable Development Goals and the ‘leaving no bal level to ensure its relevance for different settings one behind’ agenda [65, 96], which acknowledges the since HI research capacity challenges exist globally [5, Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 Page 9 of 12 63]. An application of our model to a specific country or We encourage researchers and decision-makers work- local setting would require an exhaustively defined ing in this broad area to test and adapt our model to dif- context-based model that exceeds the limits of this ferent local contexts, potentially in combination with a paper. However, it is expected that such application realist approach, to develop more comprehensive assess- should be developed in the future to empirically test and ments of local capacities for HI research as well as to es- analyse our model, and guide further in-depth analyses tablish the potential mechanisms and causal linkages of the HI research production process in different con- involved. Such information might assist in establishing texts. For example, we encourage the development of in- new entry points to strengthen HI research capacities depth case study analyses, using realist approaches, to and the evidence base, which in turn can be used to in- identify key contextual factors and mechanisms involved form more locally relevant interventions aiming to ad- in creating and producing HI research and research cap- dress HI as well as to inspire the praxis and social acities. This knowledge can support more pragmatic transformation necessary to achieve health equity. thinking on what type of intervention could effectively strengthen the HI research production process and HI Abbreviations HI: health inequalities; HRS: health research system; SDH: social determinants research capacities, where, how and for whom. of health Conclusion Acknowledgements Despite increase evidence on HI over the past decades, The authors would like to acknowledge the peer reviewers for their time in efforts are still urgently needed to strengthen capacities reviewing this manuscript, and for their suggestions on how to strengthen it. JB is a recipient of an ICREA Acadèmia (Generalitat de Catalunya). The to produce HI diagnoses, and to establish entry points Department of Primary Care and Public Health at Imperial College London is for interventions aiming to address HI and population grateful for support from the Northwest London National Institute for Health health needs. Comprehensive conceptual understanding Research (NIHR) Collaboration for Leadership in Applied Health Research & Care (CLAHRC), the Imperial NIHR Biomedical Research Centre (BRC), and the of the HI research production process is a vital first step, Imperial Centre for Patient Safety and Service Quality (CPSSQ). However, the yet current research and models have mainly focused on above-mentioned funders had no role in the study design, data collection the HI research utilisation process rather than on the HI and analysis, decision to publish, or preparation of this manuscript. research production process itself. Authors’ contributions A number of existing conceptual frameworks, focused LCG and JB conceived the idea for the study and the methodological on understanding how health research is produced, used approach; LCG drafted the first version of the manuscript and conducted the and strengthened, provide valuable yet limited advance- initial analysis; MH, GG and JB reviewed the draft and made additional substantial contributions to the analysis and manuscript writing. LCG ments in this area. For example, they lack the capacity to reviewed the consistency of the manuscript, the veracity of data, assured the comprehensively explain the potential pathways, compo- approval of all authors, and submitted the paper on behalf of the authors. nents, key determinants and dynamics involved in the health, and more specifically the HI, research production Funding process at the local level, thus limiting their ability to be No research funding was provided to conduct this study. empirically tested and to provide practical guidance on Availability of data and materials how to strengthen the HI research production process Not applicable. and related research capacities in different settings. Sev- eral scholars have also identified insufficient insights in Ethics approval and consent to participate these areas and have highlighted the need for further un- Not applicable. derstanding and guidance in this broad topic. To fill this knowledge gap, we developed a novel con- Consent for publication Not applicable. ceptual model that integrates the SDH and political economy perspectives to provide a comprehensive un- Competing interests derstanding on how HI research is potentially produced The authors declare that they have no competing interests. (or inhibited) at the local level. Our model represents a global hypothesis on the fundamental processes, and key Author details 1 Research Group on Health Inequalities, Environment and Employment components, determinants and dynamics involved, and Conditions Knowledge Network (GREDS-EMCONET), Department of Political can serve as a heuristic tool to guide the assessment of and Social Sciences, Universitat Pompeu Fabra, Mercè Rodoreda 24 Building, the HI research production process and research cap- Campus Ciutadella UPF, Ramon Trias Fargas, 25-27, 08003 Barcelona, Catalonia, Spain. 2Johns Hopkins University - Pompeu Fabra University Public acity at the local level. The application of this Policy Center, Barcelona, Catalonia, Spain. 3The School of Public Health, model could assist to identify information gaps and bar- Imperial College London, London, United Kingdom. 4National Institute of riers, and provide the basis for new understanding and Public Health, Mexico, Av. Universidad No. 655 Colonia Santa Maria Ahuacatitlán, C.P, 62100 Cuernavaca, Morelos, Mexico. 5Transdisciplinary more focused empirical questions on how to strengthen Research Group on Socioecological Transitions (GinTRANS2), Universidad HI research capacities. Autónoma, Madrid, Spain. Cash-Gibson et al. Health Research Policy and Systems (2020) 18:42 Page 10 of 12 Received: 17 June 2019 Accepted: 6 April 2020 Geneva: WHO; 2015. http://www.who.int/tdr/publications/seven-principles/ en/. Accessed 25 Mar 2020. 22. Kok MO, Rodrigues A, Silva AP, de Haan S. The emergence and current performance of a health research system: lessons from Guinea Bissau. References Health Res Policy Syst. 2012;10:5. https://doi.org/10.1186/1478-4505-10-5. 1. Solar O, Irwin A. A Conceptual Framework for Action on the Social 23. Alkhaldi M, Abed Y, Pfeiffer C, Haj-Yahia S, Alkaiyat A, Tanner M. Determinants of Health: Social Determinants of Health Discussion Paper 2. 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