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APA Style Essentials (5th edition)

APA Style Essentials
http://www.vanguard.edu/faculty/ddegelman/index.cfm?doc_id=796
Last modified August 9, 2002

Douglas Degelman, Ph.D., and Martin Lorenzo Harris, Ph.D. 
Vanguard University of Southern California

General Guidelines	Abstract	Text Citations	References
Title Page	Body	Quotations	Tables and Figures

The Publication Manual of the American Psychological Association  (5th ed., 2001) provides a comprehensive reference guide to writing using APA style, organization, and content. To order a copy of the Publication Manual online, go to http://www.apa.org/books/4200060.html. The purpose of this document is to provide a common core of elements of APA style that all members of a department can adopt as minimal standards for any assignment that specifies APA style. Instructors will specify in writing when any of the following elements do not apply to a specific assignment that specifies APA style (e.g., when an abstract is not required) or when additional APA style elements must be observed.
This Web document is itself not a model of APA style. For an example of a complete article formatted according to APA style, go to http://www.vanguard.edu/psychology/prayer.pdf. For an example of an undergraduate research proposal, go to http://www.vanguard.edu/emplibrary/files/psychproposal.pdf. To view this and other PDF documents referenced on this page, you need Adobe Acrobat Reader. To download the free Acrobat Reader, go to http://www.adobe.com/products/acrobat/readstep2.html. To download a Microsoft Word template of an APA-style paper, go to http://www.vanguard.edu/emplibrary/files/psychapa.doc.

1. General Document Guidelines 
1. Margins: One inch on all sides (top, bottom, left, right)         
2. Font Size and Type: 12-pt. font (Times Roman or Courier are acceptable typefaces)         
3. Spacing: Double-space throughout the paper, including the title page, abstract, body of the document, and references.         
4. Alignment: Flush left (creating uneven right margin)         
5. Paragraph Indentation: 5-7 spaces         
6. Pagination: The page number appears one inch from the right edge of the paper on the first line of every page, beginning with the title page. The only pages that are not numbered are pages of artwork.         
7. Manuscript Page Header: The first two or three words of the paper title appear five spaces to the left of the page number on every page, beginning with the title page. Manuscript page headers are used to identify manuscript pages during the editorial process. Using most word processors, the manuscript page header and page number can be inserted into a header, which then automatically appears on all pages.
2. Title Page 
1. Pagination: The Title Page is page 1.         
2. Key Elements: Paper title, author(s), and author(s) affiliation(s).         
3. Article Title: Uppercase and lowercase letters, centered on the page.         
4. Author(s): Uppercase and lowercase letters, centered on the line following the title.         
5. Institutional affiliation: Uppercase and lowercase letters, centered on the line following the author(s).         
6. Running head: The running head is typed flush left (all uppercase) following the words "Running head:" on the line below the manuscript page header. It should not exceed 50 characters, including punctuation and spacing. The running head is a short title that appears at the top of pages of published articles.         
7. Example of APA-formatted Title Page:  http://www.vanguard.edu/psychology/titlepage.pdf
3. Abstract: The abstract is a one-paragraph, self-contained summary of the most important elements of the paper.
1. Pagination: The abstract begins on a new page (page 2).         
2. Heading: Abstract (centered on the first line below the manuscript page header)         
3. Format: The abstract (in block format) begins on the line following the Abstract heading. The abstract should not exceed 120 words. All numbers in the abstract (except those beginning a sentence) should be typed as digits rather than words.         
4. Example of APA-formatted Abstract:  http://www.vanguard.edu/psychology/abstract.pdf
4. Body 
1. Pagination: The body of the paper begins on a new page (page 3). Subsections of the body of the paper do not begin on new pages.         
2. Title: The title of the paper (in uppercase and lowercase letters) is centered on the first line below the manuscript page header.         
3. Introduction: The introduction (which is not labeled) begins on the line following the paper title.         
4. Headings: Headings are used to organize the document and reflect the relative importance of sections. For example, many empirical research articles utilize Method, Results, Discussion, and References headings. In turn, the Method section often has subheadings of Participants, Apparatus, and Procedure. For an example of APA-formatted headings, go to http://www.vanguard.edu/psychology/headings.pdf 
1. Main headings (when the paper has either one or two levels of headings) use centered uppercase and lowercase letters (e.g., Method, Results, Discussion, and References).
2. Subheadings (when the paper has two levels of headings) are italicized and use flush left, uppercase and lowercase letters (e.g., Participants, Apparatus, and Procedure as subsections of the Method section).
5. Text citations: Source material must be documented in the body of the paper by citing the author(s) and date(s) of the sources. The underlying principle here is that ideas and words of others must be formally acknowledged. The reader can obtain the full source citation from the list of references that follows the body of the paper.
1. When the names of the authors of a source are part of the formal structure of the sentence, the year of publication appears in parentheses following the identification of the authors. Consider the following example:

Wirth and Mitchell (1994) found that although there was a reduction in insulin dosage over a period of two weeks in the treatment condition compared to the control condition, the difference was not statistically significant.     [Note: and is used when multiple authors are identified as part of the formal structure of the sentence. Compare this to the example in the following section.] 

2. When the authors of a source are not part of the formal structure of the sentence, both the authors and years of publication appear in parentheses, separated by semicolons. Consider the following example:

Reviews of research on religion and health have concluded that at least some types of religious behaviors are related to higher levels of physical and mental health (Gartner, Larson, & Allen, 1991; Koenig, 1990; Levin & Vanderpool, 1991; Maton & Pargament, 1987; Paloma & Pendleton, 1991; Payne, Bergin, Bielema, & Jenkins, 1991).      [Note: & is used when multiple authors are identified in parenthetical material. Note also that when several sources are cited parenthetically, they are ordered alphabetically by first authors' surnames.] 

3. When a source that has two authors is cited, both authors are included every time the source is cited.
            
4. When a source that has three, four, or five authors is cited, all authors are included the first time the source is cited. When that source is cited again, the first author's surname and "et al." are used. Consider the following example:

Reviews of research on religion and health have concluded that at least some types of religious behaviors are related to higher levels of physical and mental health (Payne, Bergin, Bielema, & Jenkins, 1991).

Payne et al. (1991) showed that ... 

5. When a source that has six or more authors is cited, the first author's surname and "et al." are used every time the source is cited (including the first time).
    
6. Every effort should be made to cite only sources that you have actually read. When it is necessary to cite a source that you have not read ("Grayson" in the following example) that is cited in a source that you have read ("Murzynski & Degelman" in the following example), use the following format for the text citation and list only the source you have read in the References list:

Grayson (as cited in Murzynski & Degelman, 1996) identified four components of body language that were related to judgments of vulnerability. 

7. To cite a personal communication (including letters, emails, and telephone interviews), include initials, surname, and as exact a date as possible. Because a personal communication is not "recoverable" information, it is not included in the References section. For the text citation, use the following format:

B. F. Skinner (personal communication, February 12, 1978) claimed ... 

6. Quotations: When a direct quotation is used, always include the author, year, and page number as part of the citation.
1. A quotation of fewer than 40 words should be enclosed in double quotation marks and should be incorporated into the formal structure of the sentence. Example:

Patients receiving prayer had "less congestive heart failure, required less diuretic and antibiotic therapy, had fewer episodes of pneumonia, had fewer cardiac arrests, and were less frequently intubated and ventilated" (Byrd, 1988, p. 829). 

2. A lengthier quotation of 40 or more words should appear (without quotation marks) apart from the surrounding text, in block format, with each line indented five spaces from the left margin.
    
6. References 
1. Pagination: The References section begins on a new page.         
2. Heading: References (centered on the first line below the manuscript page header)         
3. Format: The references (with hanging indent) begin on the line following the References heading. Entries are organized alphabetically by surnames of first authors. Most reference entries have three components:
1. Authors: Authors are listed in the same order as specified in the source, using surnames and initials. Commas separate all authors. When there are seven or more authors, list the first six and then use "et al." for remaining authors. If no author is identified, the title of the document begins the reference.         
2. Year of Publication: In parentheses following authors, with a period following the closing parenthesis. If no publication date is identified, use "n.d."  in parentheses following the authors.         
3. Source Reference: Includes title, journal, volume, pages (for journal article) or title, city of publication, publisher (for book). Italicize titles of books, titles of periodicals, and periodical volume numbers.
4. Example of APA-formatted References: Go to http://www.vanguard.edu/psychology/references.pdf         
5. Official APA "Electronic Reference Formats" document: Go to http://www.apastyle.org/elecref.html         
6. Examples of sources
1. Journal article

Murzynski, J., & Degelman, D. (1996). Body language of women and judgments of vulnerability to sexual assault. Journal of Applied Social Psychology, 26,  1617-1626.         

2. Book

Paloutzian, R. F. (1996). Invitation to the psychology of religion  (2nd ed.). Boston: Allyn and Bacon.         

3. Web document on university program or department Web site

Degelman, D., & Harris, M. L. (2000). APA style essentials. Retrieved May 18, 2000, from Vanguard University, Department of Psychology Web site: http://www.vanguard.edu/faculty/ddegelman/index.cfm?doc_id=796         

4. Stand-alone Web document (no date)

Nielsen, M. E. (n.d.). Notable people in psychology of religion. Retrieved August 3, 2001, from  http://www.psywww.com/psyrelig/psyrelpr.htm         

5. Stand-alone Web document (no author, no date)

Gender and society. (n.d.). Retrieved December 3, 2001, from http://www.trinity.edu/~mkearl/gender.html

6. Journal article from database

Hien, D., & Honeyman, T. (2000). A closer look at the drug abuse-maternal aggression link. Journal of Interpersonal Violence, 15, 503-522. Retrieved May 20, 2000, from ProQuest database.  

7. Abstract from secondary database

Garrity, K., & Degelman, D. (1990). Effect of server introduction on restaurant tipping. Journal of Applied Social Psychology, 20, 168-172. Abstract retrieved July 23, 2001, from PsycINFO database.

8. Article or chapter in an edited book

Shea, J. D. (1992). Religion and sexual adjustment. In J. F. Schumaker (Ed.), Religion and Mental Health (pp. 70-84). New York: Oxford University Press. 

9. Diagnostic and Statistical Manual of Mental Disorders

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

8. Tables and Figures: The Publication Manual (2001, pp. 301-302) provides detailed instructions on the formatting of tables and figures. For an example of an APA-formatted table, go to http://www.vanguard.edu/psychology/table.pdf. For an example of an APA-formatted figure, go to http://www.vanguard.edu/emplibrary/files/psychfigure.pdf. Note that pages with figures do not have page numbers or manuscript page headers.

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Copyright © 2000-2002 Douglas Degelman and Martin Harris

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E-mail questions or comments to Douglas Degelman at ddegelman@vanguard.edu

An analysis of the concept of equity

Written by Nyi Nyi Htay

May 2010

1.     Introduction

Equity is a fundamental right for people to develop a healthy and productive society. It is widely used as a powerful term in the field of economy, health and social science for a long period of time; although there is no adequate operational definition based on the results of concept analysis studies.

In recent years, the concept of equity becomes a major interest of health policy makers and administrators as it is the only key to achieve “health for all” goal. To achieve equitable distribution of health care is one of the principles of primary health care and all categories of health care providers have a responsibility for providing health services to reduce gap between rural and urban areas, lower and higher social classes, or so forth. 

According to the Universal Declaration of Human Rights (UDHR), everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. The UDHR also states that everyone is entitled to all the rights and freedoms set forth in this declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status (PAHO/WHO, 1999).

Indeed the meaning of equity is very subtle, thoughtful and imaginable. However, several definitions of equity appear in the literatures, from different points of view.  In order to provide effective services, all health care providers must have clear understanding about the concept of equity and its abstract attributes. Therefore, it is very important to analyse the concept of equity to develop clear and concise operational definition.

 

2.     Literature Review

2.1.  Concept and concept analysis

Concepts are the backbone of theory. Neither of theory can be built without having clear and validated concepts. Wuest’s diary (as cited in Ducan, Cloutier, & Bailey, 2007) mentioned that concepts have become the cornerstone of nursing curriculum at both undergraduate and graduate levels. They are the respiratory of nursing knowledge and hence the lenses through which students view praxis. According to Kaplan’s diary (as cited in Walker & Avant, 2005), a concept is a mental image of a phenomenon, an idea, or a construct in the mind about a thing or an action.

Concept analysis is a formal, linguistic exercise to determine defining attributes of a concept (Walker & Avant, 2005).  Ducan, Cloutier, and Bailey (2007) stated that concepts have changed over time and the process of concept analysis works towards ‘the truth’ about a concept, from a ‘probable truth’ (immature concepts) towards ‘fixed truth’ (more mature concepts) through research. The purpose of concept analysis is to examine the basic elements (structure and function) of a concept (Walker & Avant, 2005). Hupcey, Morse, Lenz, and Tason (1996) stated that the ultimate purpose of concept inquiry is to enable the researcher to delineate the phenomenon and transform it to an operationalization of the phenomenon.

2.2.   Equity theory

Equity originates from the Latin and French words, which mean equal (Almond, 2002). Equity theory attempts to explain the relations and perceptions of fairness in distributions of resources within social and professional situations. It was first developed in 1963 by John Stacey Adams, a workplace and behavioral psychologist, who asserted that employees seek to maintain equity between the inputs that bring to a job and the outcomes that they receive from it against the perceived inputs and outcomes of others. The belief is that people value equal right, benefits and opportunities which cause them to be motivated to keep the fairness maintained within the relationships of their co-workers and the organization (Adam, 1963; Wikipedia).

Understanding the concept of fairness is essential to understanding the theory of equity. Fairness rules are culturally bound and indicating that generally one of three rules of fairness can be applied: proportionality, equality, or need. Rules based upon proportionality mean that individuals receive "equal relative gains from the relationship" or “gains that are in proportion to what they have put into the relationship”. The equality rule, on the other hand, means that regardless of how much each person has put into the relationship, they should each reap equal rewards. Finally, the need-based rule indicates that need should be the determining factor in what partners get from a relationship, regardless of their individual contributions to it (Deutsch, 1985).

The International Development Research Centre (2005) pointed that the basic concept of equity includes: equalizing individual net benefits or opportunities for such benefits; providing for distribution (of goods or services) according to entitlement; providing a decent minimum standard or level (of goods and services); utilitarianism, or maximizing aggregate gain with resources; maximizing the position of the least well-off; and providing for envy-free allocations.

Marjorie Cohen stated that equity is not identical with equality. To people who believe that everything is truly fair when laws treat everyone equally, equity is a sufficient concept. Equity does not require that people be equal - only that they are treated in the same fair way.

2.3.   Equity and People with HIV/AIDS

The widespread abuse of human rights and fundamental freedoms associated with HIV has emerged in all parts of the world in the wake of the epidemic. In response to this situation, the International Guidelines on HIV/AIDS and Human Rights mentioned that all governments and health authorities should take measures necessary to ensure for all persons, on a sustained and equal basis, the availability and accessibility of quality goods, services and information for HIV prevention, treatment, care and support, including antiretroviral and other safe and effective medicines, diagnostics and related technologies for preventive, curative and palliative care of HIV and related opportunistic infections and conditions (UNAIDS/OHCHR, 2006).

Because of the terrible nature of disease, and negative public image towards HIV infected person, many people with HIV/AIDS are pushed automatically to the marginal area of health care. A WHO survey conducted in Nigeria indicated that one in 10 doctors and nurses refused to care for the patients with HIV/AIDS or had denied them to be admitted to hospital (WHO/UNAIDS, 2003). In a study conducted in India, all people with HIV/AIDS said that they experienced discrimination in health care facilities once the diagnosis was confirmed (Larson & Narain, 2001).  WHO (2003) also pointed that almost 50% of people with HIV/AIDS had experienced discrimination at the hands of health care workers in Philippine, while in Thailand, 11% of respondents reported they had denied medical care because of their seropositive status.

Nurses should have a genuine attitude and desire to give care to any patient with any health problem. As the patient has a right to claim and receive appropriate care regardless of his or her diagnosis, nurses must provide the needed care to the patient who is diagnosed with AIDS, and the nurse manager should not allow any staff member refuses to provide care for a HIV-positive patient (Sheridan, 1994).

2.4.   Previous research findings

Almond (2002) conducted a study to analyse the concept of equity and its application to health visiting. The results of in-depth analysis of the literatures delivered three critical attributes of the concept of equity. These are equal opportunity of access to services; a high standard of service for everyone, and unequal distribution of services to meet unequal need. 

Swoney and Barr (2004) conducted a concept analysis study: Equity of access to health care for people with learning disabilities. The results of this study suggested six defining attributes of equity of access to health care: the opportunity to seek or gain access to a service; the right to avail equally of the service; a sense of fairness; confidence in service provider; within a time frame; and being/feeling empowered.

Ridde (2008) conducted a study on equity and health policy in Africa using concept mapping as a research method. The results of study indicated nine basic attributes of social justice: good governance; justice and social peace; equitable and rational management of resources; rational and efficacious management of aid; community participation; fight against poverty; social security; equity of access to basic social services; and respect of human rights.

Poverty is a primary cause of inequity. Global Poverty Guide (2010) described that although the governments of the world have taken commitment to achieve eight Millennium Development Goals (MDGs) with targets to be met by 2015; current projections suggest that 800 million people remain in extreme poverty in 2015, making barriers in equity of access to health care services.

Whitehead (1992) described seven principles of action for addressing global health inequities. They are improving living and working conditions; enabling healthier lifestyles; decentralizing power and decision-making and encouraging citizen participation in policy-making; conducting health impact assessments of multisectoral actions; keeping equity on the global health agenda; assuring that health services are of high quality and accessible to all; and basing equity policies on appropriate research, monitoring and evaluation.

3.     Procedures for Concept Analysis

In this study, eight steps of concept analysis method, developed by Walker and Avant (2005) were applied to analyse the concept of equity.

Step-1  Selecting a concept

Selecting the appropriate concept is the foundation of concept analysis. Walker and Avant (2005) suggested some criteria to choose a concept which include interested one, associated with work and experiences, manageable and applicable in academic research, and avoidance of “primitive terms” and “umbrella terms”.  

Rational for selecting the term equity for concept analysis

The concept of equity is chosen to be analysed in this study. From the personal point of view, I immersed over ten years of my professional life in the area of public health and recognized many inequitable situations in health care. For example, likes other developing countries, because of stigma and discrimination, people with HIV/AIDS have not received the needed care in their families and health care settings. Even in hospital, they are confronted with insensitivity such as “impatient manner”, “delayed responses” and “reluctant to touch” in the nursing care (Nyi Nyi Htay and Mehm Pho Nyein, 2007). It loses the meaning of equity in health care. At the moment, these experiences make me to consider some questions. What is equity? What are the hindering issues to achieve equity? How do we do to achieve equity in health care?

From the professional point of view, since caring tradition of nursing encompasses both art and science, nurses should give all the patients an utmost and wholehearted care, but not care as a duty. Donaldson (1983) stated that nursing without caring would not be nursing, and nurses have a legal, ethical and professional contract with society to care for all its members. In addition, the concept of equity is widely used in the field of nursing today. Nurses from both hospitals and communities have a due responsibility for providing comprehensive and equitable nature of care to all categories of patients without classifying their socioeconomic background, ethnic identity, gender and demographic location. Nurses need to realize the underpinning attributes and operational definition of equity so that they can contribute more effectively in implementation of primary health care services to prevent and promote health of the individuals, families and communities.  

From another point of view, although there are a number of concept analysis studies relating to the meaning of equity, all these studies focused to analyse multiple worded concept in specific situation. There is no study which focuses to analyse only single worded concept of the term equity. Finally, the concept of equity is manageable to be analyzed and applicable in my academic research which focuses to develop strategies for promoting health status of people with HIV/AIDS in community.     

Step-2  Aim and objectives

Aim

The aim of this concept analysis study is to increase understanding about the concept of equity.

Objectives

1.      To examine the defining attributes of equity.

2.      To identify model case, borderline case, related case and contrary case of equity.

3.      To determine the antecedents and consequences of the concept of equity.

4.      To determine empirical referents of equity.

5.      To develop operational definition of equity.

Step-3  Identification of all uses of the concept of equity

In this step, all uses of the concept of equity are identified and clarified through reviewing and analyzing literatures from various dictionaries, texts, journals and articles including online sources. To illustrate clearly, the uses of the concept of equity are categorized into four general areas – economics, politics and law, social science and health.

Uses in economics

As description in various dictionaries, the uses of equity in economics include: (a) the study of fairness in economics, particularly as to taxation or welfare economics; (b) a right or legal share of something; (c) the value of an ownership interest in property, including shareholders' equity in a business; (d) the difference between the market value of a property and the claims held against it; (e) the market value of a debtor’s property in excess of all debts to which it is liable; and (f) a justifiable share; one likely to be recognized as a fair share in an equity court (Collins English Dictionary, 2003; Oxford English Dictionary, 1989;The Free Dictionary; Veterinary Dictionary; Wikipedia).

Uses in politics and law

There are various dictionary definitions relating to  the uses of equity in politics and law such as (a) a concept encompassing ideas of justice, fairness or equity of opportunity; (b) conformity with rules or standards; (c) right judgement; (d) a justice applied in circumstances covered by law yet influenced by principles of ethics and fairness; (e) a system of jurisprudence founded on principles of natural justice and fair conduct; (f) an equitable right or claim; (g) equity of redemption; (h) principles of justice outside common law or Statue law, used to correct laws when these would apply unfairly in special circumstances; and (i) a body of rules or customs based on general principles of fair play rather than on common law or statutory law (American Heritage Dictionary of English Language; Collins English Dictionary, 2003; Cultural Dictionary, 2005; Oxford Advanced Learner’s Dictionary, 1974; Random House Dictionary; Wikipedia; WordNet).

Uses in social science

According to dictionary definitions, the uses of equity in social science include: (a) fairness in relationships; (b) fairness, impartiality and justice; (c) freedom from bias or favoritism; (d) treating everyone in the same way; (e) a free and reasonable claim or right; (f) equality, conformity, symmetry and fairness; (g) a system based on social justice and equity; (h) fair act or decision; (i) the state, quality or ideal of being just, impartial, and fair; and (j) the principle of treating all persons equally in accordance with the law (American Heritage Dictionary of English Language; Cambridge International Dictionary of English, 1995; Collins English Dictionary, 2003; Collins Thesaurus of the English Language, 2002; Mosby's Dental Dictionary, 2008; Online Etymology Dictionary; Webster’s New World College Dictionary, 2010; Wikipedia).

In addition, literatures from other sources indicate the uses of equity as (a) striving towards equitable inequalities that reflect the needs and strengths of the various groups (b) an ethical principle; (c) consonant with and closely related to human rights principles; (d) an ethical and a philosophical perspective and addresses questions such as what, why and how much. It deals with justice of distribution; and (e) a value judgement (Braveman & Gruskin, 2003; Hill, 2010; International Development Research Centre, 2005; Sanyal, Pettigrew, Ghista, BiauwChi, & Lim, 2010).

Uses in the field of health

In the health literatures, the term equity is commonly used to describe equity in health and health services. Braveman and Gruskin (2003) stated that equity is the absence of systematic disparities in health (or in the major determinants of health) between groups with different levels of underlying social advantage/disadvantage – that is, wealth, power, or prestige. Braveman (2006) mentioned that health equity means pursuing the elimination of health disparities or inequalities in which disadvantaged social groups such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination – systematically experience worse health or greater health risks than more advantaged social groups. Macinko and Starfield (2002) also described that equity in health means the absence of potentially remediable, systematic differences on one or more aspects of health across socially, economically, demographically, or geographically defined population groups or subgroups, whereas equity in health services implies that there are no differences in health services where health needs are equal (horizontal equity) or that enhanced health services are provided where greater health needs are present (vertical equity). Whitehead (1992) pointed that equity in health is concerned with creating equal opportunities for health, and with bringing health differentials down to the lowest levels possible.

Whitehead’s diary (as cited in International Development Research Centre, 2005) mentioned that equity in health implies ideally everyone should have a fair opportunity to attain their full health potential and more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided. Zere et al., (2007) stated that equity in health care is defined as equal access to a basic package of services for equal need.

Chang’s diary (as cited in Sanyal, Pettigrew, Ghista, BiauwChi, & Lim, 2010) stated that health equity deals with the chance that an individual gets to realize the full potential of his or her health, and healthcare equity addresses the access component to health and deals with the moral, ethical, and economic debate of ways to balance the factors that are outside an individual’s control and yet impact the status of his or her health. According to Daniels’s diary (as cited in International Development Research Centre, 2005), access to health care is equitable if and only if there are no information barriers, financial barriers, or supply anomalies that prevent access to a reasonable or decent basic minimum of health care services. PAHO/WHO (2000) mentioned that gender equity in health means women and men have equal opportunities to enjoy good health, without becoming ill or dying through causes that are unjust and avoidable.

Two basic types of equity in health

According to the literatures, there are two main types of equity in health care services – horizontal and vertical equity. Horizontal equity proposes that people with equal health needs should have equal access to healthcare. Whereas, vertical equity refers to health care access taking into account the differences that already exist in terms of age, income, gender, and geography. For example, people with higher income have to pay proportionately more for the same access to healthcare. This is to counterbalance the differences in health status that exist between a higher earning individual and a lower earning one. This can also be interpreted as people with unequal health needs being provided with unequal care, so that all achieve equal health status (Chang’s diary, as cited in Sanyal, Pettigrew, Ghista, BiauwChi, & Lim, 2010). PAHO/WHO (1999) also stated that horizontal equity concerns with the allocation of equal or equivalent resources for equal need and vertical equity highlights the allocation of different resources for different levels of need.

Synonyms and Antonyms of equity

Some synonyms of the term equity are fairness, justice, integrity, honesty, fair play, righteousness, impartiality, rectitude, conformity, symmetry, reasonableness, fair-mindedness, uprightness, and equitableness (Collins Thesaurus of the English Language, 2002).

The antonyms of the term equity include bias, inequity, partiality, unfairness, unjustness, injustice, illegality, lawlessness, unethicalness, disproportion, imbalance, dishonesty, instability, wrong, and violation (Collins Thesaurus of the English Language, 2002).

Step-4  Determination of defining attributes

Determining the defining attributes is the heart of concept analysis. Walker and Avant (2005) suggested some guidelines to facilitate development of defining characteristics. First, read through all the definitions and uses you have collected. Second, look for commonly themes – these will be the ‘first cut’ set of defining characteristics or attributes. Third, review the cluster of commonly occurring attributes and reduce the list by eliminating redundancies and collapsing attributes into higher order concept.

Following above suggestions, in this study, four defining attributes of equity were identified.

1.      Having equal right or opportunity to meet specific needs in a situation or relationship;

2.      A sense of being fair, impartial and justifiable;

3.      Be conformity with the rules and standards; and

4.      No disparities across socially, economically, demographically, or geographically defined population groups or subgroups.

Step-5  Identification of a model case

A model case is an example of the use of the concept that demonstrates all the defining attributes of the concept. That is, the model case should be a pure case of the concept, a paradigmatic example, or a pure exemplar (Walker & Avant, 2005). To clear the concept, the model case of equity is illustrated as follows:-

“One day, a black woman is admitted to a medical ward with prolonged fever and cough. She has five children and her husband died of AIDS in three years ago. She is a poor and uneducated woman. However, she is welcomed warmly by on-duty nurse and is occupied in a common room. The nurse takes detail history and thorough physical assessment. She gets an opportunity to express her problems and needs to the nurse. Because of nurse advocate, she gets approval from the hospital administrator to take required investigations and treatment, supported by the hospital’s cost sharing program. After taking investigations, she is informed that she has HIV infection, following pre-test and post-test counseling. However, care giver – patient relationship is not interrupted because of her HIV-seropositive status. She receives standardized treatment for her diagnosis including ART to control the progress of disease. Likes other patients, she also receives empathetic care from nurses conformity with the hospital’s nursing care standards. She also gets a chance to contact with peer groups and religious men during hospitalization. By the arrangement of nurse in-charge, in addition, all her children get opportunity to take HIV antibody test and care and support by a community health care agency. After discharged from hospital, she is able to take care of herself and actively involves in the activities of peer groups in her community.”

All defining attributes are seen in this model case. First of all, the woman gets equitable right to express her problems and needs to health care provider, and to take required investigations and treatment without worrying about cost of hospitalization. Also, all her children get opportunity to take HIV antibody test and required care and support. Secondly, the provision of service is fair, impartial and justifiable because the woman is welcomed warmly and occupied in a common room, not discriminated. She receives empathetic care and supports from nurses like other patients. She also gets a chance to involve in peer group. Thirdly, the woman has received standardized treatment and care according to the hospital’s standard guidelines. Finally, there is no disparity in health care although the woman is a black ethnic, poor and uneducated person.

Step-6  Identification of borderline, related and contrary cases

Borderline Case

Borderline cases are those examples or instances that contain most of the defining attributes of the concept being examined but not all of them. They may contain most or even all of the defining characteristics but differ substantially in one of them, such as length of time or intensity of occurrence (Walker and Avant, 2005).  A borderline case for the concept of equity is described as follows:-

“On an evening, a community health nurse is requested by a community resident to give birth for a poor multipara woman at their home. According to the clinic record, the nurse has already known that this woman is HIV-positive and does not take regular antepartum care.  In addition, they live in the outskirt of the town, 5 miles away from the clinic. However, the nurse accepts the request and decides to visit immediately. When arriving to the home, the nurse quickly assesses the mother and fetus condition. Because of the contraction is strong enough and fetus’s head is seen, following the principles of universal precaution, the nurse helps the woman’s birth to her baby successfully. The nurse gives the needed care to the baby and mother. In the following days, the nurse also provides follow-up care to this family, but regular visit would not be made because of distant location.”

This case encompasses all of the defining attributes but the third attribute; “be conformity with the rules and standards” is not clear. Firstly, the woman gets an equitable opportunity to give birth by nurse’s home service. Next, although the nurse has already known that the woman is poor and HIV-positive, no rejection or discrimination of health service is seen. She accepts the request, takes necessary assessment, gives the woman’s birth and provides the needed care to both mother and child. So, provision of health care is accepted as fair, impartial and justifiable. In addition, no disparity is seen regardless of HIV-positive status and poor living condition. Finally, it is found that the nurse follows the principles of universal precaution and provides intra-natal and post-natal care. But, because of distant location, she would not make follow-up visit regularly. Therefore it is difficult to decide whether the provision of nursing care is acceptable or not in comparison with nursing care standards.

Related Case

Walker and Avant (2005) stated that related cases are instances of concepts that are related to the concept being studied but that do not contain all the defining attributes. They are similar to the concept being studied; they are in some way connected to the main concept. The related case for the concept of equity is described as follows:-

“An occupational health nurse has given a responsibility for providing health education about HIV/AIDS to the factory employees in a rural area. Then, the nurse prepares an educational program including taking permission from the employers. After that, she gives health education about HIV/AIDS to all employees. She also provides a package of condoms to each employee.”       

It is an example of practice to prevent inequities in health services, but it is not a true and pure example of the concept of equity, rather it is made on the basis of equality. Whitehead (1990) stated that “Equity is not the same as equality. Similarly, not all inequalities are considered inequities.” Baig also suggested that the meaning of equity focuses on similar rights, not same rights. It is not a blind equality. Also, equality equals quantity, whereas equity equals quality (Difference Between.net). In this example, the nurse provides health education to all employees and distributes equal amount of condoms to each of them, instead of giving education based on each employee’s educational needs and providing condoms according to their needs and desires.

Contrary Case

Walker and Avant (2005) stated that contrary cases are clear examples of “not the concept”, but they are very helpful to understand the concept easily by excluding all its defining attributes. The following case is undoubtedly an example of an inequitable, unfair and unjust service, devoid of all critical attributes of equity.

“A ten year-old boy was born HIV positive. He was placed in a small primary school near their village and everything was fine until someone broke his confidentiality. After that he was forced to seat in the corner of the class room and nobody wanted to study with him in the same place. The parents of some other students screamed at him not to play with their children. Even some of his school teachers showed dislike behaviors and prohibited him to have lunch with other students. The boy felt loneliness in the school and his grading pulled down to the lowest level in comparison with other students. Although inclusive education policy has been implementing in the school system, finally, the boy was not allowed to attend in this school.”

In this case study, the boy lost equitable opportunity to study education when the others knew his real condition. The situation of the boy’s learning environment was unfair and unjustifiable since the boy faced discrimination in education and social relationship by his class-mates, their parents and some school teachers. In addition, it was found that the rule and policy of inclusive education system was meaningless, and a disparity in teaching-learning environment because of HIV positive status was also noted.

 Step-7  Identification of antecedents and consequences

Antecedents

Walker and Avant (2005) suggested that antecedents are those events that must occur prior to the occurrence of the concept. The antecedents for equity that arise from the literature are:-

1.      Unfair distribution of resources and services;

2.      Unsatisfaction in a situation or interpersonal relationship;

3.      A desire to have equitable right or opportunity;

4.      A perceived unmet need and prior conflict between competing needs;

5.      Reactive response to known inequities and proactive to prevent inequities developing;

6.      Intolerance of avoidable inequities (technologically, financially or morally);

7.      Respect for a principle of human right;

8.      A belief of being an equal citizen;

9.      An ability to make comparisons or judge; and

10.  Commitment to egalitarian principles.

Consequences

Walker and Avant (2005) stated that consequences are those events or incidents that occur as a result of the occurrence of the concept. According to the result of literature analysis, the consequences of equity encompass the followings.

1.      Increased access to community resources and services;

2.      Increased satisfaction and motivation;

3.      Decreased avoidable inequities (technologically, financially, morally);

4.      Increased opportunity to experience better standard of living;

5.      An ability to make informed decision;

6.      A feeling of inclusion and acceptance;

7.      Narrower disparities between social advantaged and disadvantaged groups; and

8.      Enforcement to achieve millennium development goals.

Step-8  Determining empirical referents

Determining the empirical referents is extremely useful in instrument development because these are categories of phenomena whose presence demonstrate the occurrence of the concept (Walker & Avant, 2005).  In this study, the empirical referents of equity include:-

1.      Positive perception of people towards the right and opportunity to meet their needs in a situation or relationship

2.      Satisfaction in a situation or relationship 

3.      Fair distribution of resources and services

4.      No conflicting behaviors or responses in a situation or relationship

5.      Following the rules and standards of related field

6.      Feeling of being an equal citizen

Various quantitative and qualitative studies are needed to clarify and validate these empirical referents of equity. Likert scale is useful to analyze the perception and satisfaction of people in a situation or relationship. Observation method is fundamental to determine the behaviors and responses of people in an actual situation. Use of structured questionnaires, observation, interviewing, focus group discussion and record reviewing methods are suitable to determine the clarity and validity of these empirical referents. Evidence based studies and literary analysis method are essential to confirm observability and measurability of these referents. Equity audit and quality assessment using the criteria of acceptability, accessibility, effectiveness, relevance and efficiency are also needed to test the reliability, validity and applicability of the concept of equity.

4.     The Author’s Operational Definition of Equity   

Operational definition is the first most essential tool to test the validity of a concept. Walker and Avant (2005) stated that without operational definition, there is no way to test and validate the theory and its concepts in the ‘real world’.   Based on the defining attributes of equity, the operational definition of equity was synthesized as follows.

“Equity is a subjective concept in which all people have an equitable right or opportunity to meet their needs and have experienced a sense of fairness or justices in a particular situation. It may involve ensuring the standards of practice to guarantee the quality of service for all, regardless of class, position, race, religion, geographic location, health condition, age or gender.”

5.     Limitations

1.  The defining attributes are constructed highly based on dictionary meanings and health literatures. Critically analysis of literatures concerning uses of equity in other field is needed.

2.      All case exemplars are constructed hypothetically since the concept of equity meeting all defining attributes in real situation is difficult to be identified.

3.      It is difficult to prove the measurability of all empirical referents of the concept of equity in real situation.

4.      It is difficult to say that whether the operational definition of the concept of equity can be empirically examined at practice level and whether it can be applicable at a micro-level.

6.     Conclusion

This paper is an attempt to present an analysis of the concept of equity. It is the outcome of exploring the essence of this concept by examining meanings, usages, attributes, antecedents, consequences and empirical referents, including illustration of model case, borderline case, related case and contrary case. Based on the results of analysis, an operational definition of equity was developed. However, it is important to note that this work is only a prerequisite for the term. Further exploration of this concept is certainly needed.

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