Reducing health inequities: the contribution of core public health services in BC

A realist impact evaluation of a tool to strengthen equity in local government policy-making

BACKGROUND

Local governments have a critical role to play in addressing health inequities. Health equity impact assessments are recommended to help governments apply an equity lens to the development and implementation of policies and programs. Despite evidence of equity-positive benefits of such tools, adoption remains limited, prompting calls for evaluations to assess their impact and identify factors that will promote uptake across various contexts.

METHODS

We conducted a mixed method study to evaluate the impact of an equity impact assessment (EIA) tool and process on policies and organisational capacity in a local government in Victoria, Australia, and identify factors that influenced this impact. We analysed 33 documents related to 18 EIAs, and conducted surveys (n = 40) and in-depth interviews (n = 17) with staff involved in EIAs.

RESULTS

Almost all (17 of 18) EIAs resulted in equity-positive changes to policies and programs, most frequently addressing individual-level factors, such as making community communications and consultations more accessible to under-represented or under-served groups. Structural-level recommendations from one EIA, such as increasing diversity in decision-making panels, were found to impact both the current policy and a broad range of future, related projects and services. Improvements in equity-centric organisational culture and capacity (including staff awareness, skills and confidence) and increased engagement with under-represented communities were also reported. Factors perceived to influence the impact of EIA's related to organisational commitment and capacity to prioritise equity, process-level factors related to the type and timing of EIAs, and extent of implementation support.

CONCLUSION

Our study supports wider uptake of health equity impact assessments in local government policies and programs. Legislation, leadership and resources from upper-tiers of government can help increase the adoption of equity tools to reduce disparities in population health.

The Lack of Race and Ethnicity Data in Australia-A Threat to Achieving Health Equity

Collecting meaningful race and ethnicity data must be part of the national agenda and must be one of its primary objectives in order to achieve public good and support public interests. Yet, Australia does not collect data on race and ethnicity, and prefers the use of collective cultural groups, whose information is not consistently collected and reported at all levels of government and service delivery. This paper examines the current discrepancies in race and ethnicity data collection in Australia. The paper begins with examining the current practices related to collecting race and ethnicity data and then moves on to examine the various implications and public health significance of not collecting data on race and ethnicity in Australia. The evidence suggests that (1) race and ethnicity data matter, are imperative to ensuring proper advocacy and to reducing inequities in health and social determinant factors; (2) that White privilege is constructed as realized or unrealized personal and systemic racism; and (3) the use of non-committal collective terminologies makes visible minorities invisible, leads to the distorted allocation of governmental support, and legitimises and institutionalises racism and othering, hence perpetuating exclusion and the risk of victimisation. There is an urgent need for the collection of customized, culturally competent racial and ethnicity data that can be consistently integrated into all policy interventions, service delivery and research funding across all levels of governance in Australia. Reducing and eliminating racial and ethnic disparities is not only an ethical, social, and economic imperative, but must also be a critical item on the national agenda. Bridging the racial and ethnic disparities will require concerted whole-of-government efforts to collect consistent and reliable data that depict racial and ethnic characteristics beyond collective cultural groupings.

Navigating conflicting value systems: a grounded theory of the process of public health equity work in the context of mental health promotion and prevention of harms of substance use

BACKGROUND

Promoting health equity and reducing heath inequities is a foundational aim and ethical imperative in public health. There has been limited attention to and research on the ethical issues inherent in promoting health equity and reducing health inequities that public health practitioners experience in their work. The aim of the study was to explore how public health providers identified and navigated ethical issues and their management related to promoting health equity within services focused on mental health promotion and preventing harms of substance use.

METHODS

Semi-structured individual interviews and focus groups were conducted with 32 public health practitioners who provided public-health oriented services related to mental health promotion and prevention of substance use harms (e.g. harm reduction) in one Canadian province.

RESULTS

Participants engaged in the basic social process of navigating conflicting value systems. In this process, they came to recognize a range of ethically challenging situations related to health equity within a system that held values in conflict with health equity. The extent to which practitioners recognized, made sense of, and acted on these fundamental challenges was dependent on the degree to which they had developed a critical public health consciousness. Ethically challenging situations had impacts for practitioners, most importantly, the experiences of responding emotionally to ethical issues and the experience of living in dissonance when working to navigate ethical issues related to promoting health equity in their practice within a health system based in biomedical values.

CONCLUSIONS

There is an immediate need for practice-oriented tools for recognizing ethical dilemmas and supporting ethical decision making related to health equity in public health practice in the context of mental health promotion and prevention of harms of substance use. An increased focus on understanding public health ethical issues and working collaboratively and reflexively to address the complexity of equity work has the potential to strengthen equity strategies and improve population health.

[Application of conceptual mapping in the regulation of access to public health services in the Federal District, Brazil]

Health regulation in the pursuit of equity is the goal of management and requires evaluation methods that improve work processes. The scope of this article is to analyze the application of conceptual mapping in the regulation of access to public health services. It is an exploratory and descriptive study, using a mixed approach, carried out at the Health Regulatory Complex of the Federal District. The data were collected between August and October 2019 and analyzed with the assistance of IRaMuTeQ and Concept Systems® software. There is a convergence of the 25 statements generated by the 71 participants, grouped into 4 clusters, on regulation towards the principle of equity. The healthcare priority level was presented as the focus of regulation and management, the driving force behind the integration of processes. Conceptual mapping is a tool that can support regulation planning and evaluation, as it makes it possible to identify priority points to be worked on by management in improving the regulatory processes identified in this study. These include the training of professionals, the transparency of information and the level of priority healthcare, for effective, equitable, rational and timely access for users of the health system.

"The health equity curse": ethical tensions in promoting health equity

BACKGROUND

Public health (PH) practitioners have a strong moral commitment to health equity and social justice. However, PH values often do not align with health systems values, making it challenging for PH practitioners to promote health equity. In spite of a growing range of PH ethics frameworks and theories, little is known about ethical concerns related to promotion of health equity in PH practice. The purpose of this paper is to examine the ethical concerns of PH practitioners in promoting health equity in the context of mental health promotion and prevention of harms of substance use.

METHODS

As part of a broader program of public health systems and services research, we interviewed 32 PH practitioners.

RESULTS

Using constant comparative analysis, we identified four systemic ethical tensions: [1] biomedical versus social determinants of health agenda; [2] systems driven agendas versus situational care; [3] stigma and discrimination versus respect for persons; and [4] trust and autonomy versus surveillance and social control.

CONCLUSIONS

Naming these tensions provides insights into the daily ethical challenges of PH practitioners and an opportunity to reflect on the relevance of PH frameworks. These findings highlight the value of relational ethics as a promising approach for developing ethical frameworks for PH practice.

Values are not enough: qualitative study identifying critical elements for prioritization of health equity in health systems

Background

Health system policies and programs that reduce health inequities and improve health outcomes are essential to address unjust social gradients in health. Prioritization of health equity is fundamental to addressing health inequities but challenging to enact in health systems. Strategies are needed to support effective prioritization of health equity.

Methods

Following provincial policy recommendations to apply a health equity lens in all public health programs, we examined health equity prioritization within British Columbia health authorities during early implementation. We conducted semi-structured qualitative interviews and focus groups with 55 senior executives, public health directors, regional directors, and medical health officers from six health authorities and the Ministry of Health. We used an inductive constant comparative approach to analysis guided by complexity theory to determine critical elements for prioritization.

Results

We identified seven critical elements necessary for two fundamental shifts within health systems. 1) Prioritization through informal organization includes creating a systems value for health equity and engaging health equity champions. 2) Prioritization through formal organization requires explicit naming of health equity as a priority, designating resources for health equity, requiring health equity in decision making, building capacity and competency, and coordinating a comprehensive approach across levels of the health system and government.

Conclusions

Although creating a shared value for health equity is essential, health equity - underpinned by social justice - needs to be embedded at the structural level to support effective prioritization. Prioritization within government and ministries is necessary to facilitate prioritization at other levels. All levels within health systems should be accountable for explicitly including health equity in strategic plans and goals. Dedicated resources are needed for health equity initiatives including adequate resourcing of public health infrastructure, training, and hiring of staff with equity expertise to develop competencies and system capacity.

Adapting a health equity tool to meet professional needs (Québec, Canada)

While numerous tools are available to better incorporate equity into population health actions, they are limited mainly by their lack of adaptation to professional practices and organizational realities. A study was conducted in Québec to identify and understand, from the perspective of future users, conditions that would facilitate use of a tool (Reflex-ISS) targeted at supporting collaborative action to improve consideration of social inequalities in health (SIH) within population health actions. Concept mapping and focus groups were implemented as complementary methods for investigating the conditions. Significant results that emerged were strong participant interest in the tool and the need for resources to better take SIH into account. The conditions for use that were identified referred to the tool itself (user-friendliness and literacy) and to resources for appropriating the tool, competency development, as well as the role and responsibilities of organizations and policies in promoting use of the tool in daily activities and more fundamentally in acting against SIH in general. Models for organizational innovation give an idea of the dimensions that need to be considered to strengthen the integration of equity into organizations and to support the changes in practice that result from using the tool. They provide a reminder that a health equity tool cannot be the cornerstone of an organizational strategy to fight against SIH; rather, it must be incorporated as part of a systemic strategy of professional and organizational development.

Blending integrated knowledge translation with global health governance: an approach for advancing action on a wicked problem

BACKGROUND

The persistence of health inequities is a wicked problem for which there is strong evidence of causal roots in the maldistribution of power, resources and money within and between countries. Though the evidence is clear, the solutions are far from straightforward. Integrated knowledge translation (IKT) ought to be well suited for designing evidence-informed solutions, yet current frameworks are limited in their capacity to navigate complexity. Global health governance (GHG) also ought to be well suited to advance action, but a lack of accountability, inclusion and integration of evidence gives rise to politically driven action. Recognising a persistent struggle for meaningful action, we invite contemplation about how blending IKT with GHG could leverage the strengths of both processes to advance health equity.

DISCUSSION

Action on root causes of health inequities implicates disruption of structures and systems that shape how society is organised. This infinitely complex work demands sophisticated examination of drivers and disrupters of inequities and a vast imagination for who (and what) should be engaged. Yet, underlying tendencies toward reductionism seem to drive superficial responses. Where IKT models lack consideration of issues of power and provide little direction for how to support cohesive efforts toward a common goal, recent calls from the field of GHG may provide insight into these issues. Additionally, though GHG is criticised for its lack of attention to using evidence, IKT offers approaches and strategies for collaborative processes of generating and refining knowledge. Contemplating the inclusion of governance in IKT requires re-examining roles, responsibilities, power and voice in processes of connecting knowledge with action. We argue for expanding IKT models to include GHG as a means of considering the complexity of issues and opening new possibilities for evidence-informed action on wicked problems.

CONCLUSION

Integrated learning between these two fields, adopting principles of GHG alongside the strategies of IKT, is a promising opportunity to strengthen leadership for health equity action.

[Adaptation and conditions of use of a health equity tool: The Reflex-ISS tool]

Although actions to reduce social inequalities in health cannot be considered the exclusive responsibility of public health actors, they should at least make sure their interventions account for these inequalities. However, the actors involved in these interventions have few tools to support them in this process. Therefore, building on a study conducted in France, we have adapted, tested, and developed in Quebec a tool intended to help actors take into account social inequalities in health. The article presents the approach that led to the adaptation of the tool to the Quebec context, to describe the tool, and then to discuss some issues for inclusion in professional practices. A participatory and constructive process between researchers, managers and practitioners led to a useful and useable tool. It is composed of five aspects of intervention (planning, implementation, evaluation, sustainability, and empowerment) and 44 items for discussion presented as questions. A user guide, a glossary, and some practical examples accompany the tool. It follows a reflexive and constructive process wherein a third party facilitator can assist actors involved in an intervention to analyze how they take social inequalities in health into account. This assessment can help generate collective recommendations for improvements, which can be monitored over time, to improve consideration of equity in public health interventions. The article concludes on some issues related to its integration into professional practices.

Embracing complexity and uncertainty to create impact: exploring the processes and transformative potential of co-produced research through development of a social impact model

The potential use, influence and impact of health research is seldom fully realised. This stubborn problem has caused burgeoning global interest in research aiming to address the implementation ‘gap’ and factors inhibiting the uptake of scientific evidence. Scholars and practitioners have questioned the nature of evidence used and required for healthcare, highlighting the complex ways in which knowledge is formed, shared and modified in practice and policy. This has led to rapid expansion, expertise and innovation in the field of knowledge mobilisation and funding for experimentation into the effectiveness of different knowledge mobilisation models. One approach gaining prominence involves stakeholders (e.g. researchers, practitioners, service users, policy-makers, managers and carers) in the co-production, and application, of knowledge for practice, policy and research (frequently termed integrated knowledge translation in Canada). Its popularity stems largely from its potential to address dilemmas inherent in the implementation of knowledge generated using more reductionist methods. However, despite increasing recognition, demands for co-produced research to illustrate its worth are becoming pressing while the means to do so remain challenging. This is due not only to the diversity of approaches to co-production and their application, but also to the ways through which different stakeholders conceptualise, measure, reward and use research. While research co-production can lead to demonstrable benefits such as policy or practice change, it may also have more diffuse and subtle impact on relationships, knowledge sharing, and in engendering culture shifts and research capacity-building. These relatively intangible outcomes are harder to measure and require new emphases and tools. This opinion paper uses six Canadian and United Kingdom case studies to explore the principles and practice of co-production and illustrate how it can influence interactions between research, policy and practice, and benefit diverse stakeholders. In doing so, we identify a continuum of co-production processes. We propose and illustrate the use of a new ‘social model of impact’ and framework to capture multi-layered and potentially transformative impacts of co-produced research. We make recommendations for future directions in research co-production and impact measurement.

Critical considerations for the practical utility of health equity tools: a concept mapping study

Background

Promoting health equity within health systems is a priority and challenge worldwide. Health equity tools have been identified as one strategy for integrating health equity considerations into health systems. Although there has been a proliferation of health equity tools, there has been limited attention to evaluating these tools for their practicality and thus their likelihood for uptake.

Methods

Within the context of a large program of research, the Equity Lens in Public Health (ELPH), we conducted a concept mapping study to identify key elements and themes related to public health leaders and practitioners’ views about what makes a health equity tool practical and useful. Concept mapping is a participatory mixed-method approach to generating ideas and concepts to address a common concern. Participants brainstormed responses to the prompt “To be useful, a health equity tool should…” After participants sorted responses into groups based on similarity and rated them for importance and feasibility, the statements were analyzed using multidimensional scaling, then grouped using cluster analysis. Pattern matching graphs were constructed to illustrate the relationship between the importance and feasibility of statements, and go-zone maps were created to guide subsequent action.

Results

The process resulted in 67 unique statements that were grouped into six clusters: 1) Evaluation for Improvement; 2) User Friendliness; 3) Explicit Theoretical Background; 4) Templates and Tools 5) Equity Competencies; and 6) Nothing about Me without Me- Client Engaged. The result was a set of concepts and themes describing participants’ views of the practicality and usefulness of health equity tools.

Conclusions

These thematic clusters highlight the importance of user friendliness and having user guides, templates and resources to enhance use of equity tools. Furthermore, participants’ indicated that practicality was not enough for a tool to be useful. In addition to practical characteristics of the tool, a useful tool is one that encourages and supports the development of practitioner competencies to engage in equity work including critical reflections on power and institutional culture as well as strategies for the involvement of community members impacted by health inequities in program planning and delivery. The results of this study will be used to inform the development of practical criteria to assess health equity tools for application in public health.

Death Is a Social Justice Issue: Perspectives on Equity-Informed Palliative Care

All too often, palliative care services are not responsive to the needs of those who are doubly vulnerable, being that they are both in need of palliative care services and experiencing deficits in the social determinants of health that result in complex, intersecting health and social concerns. In this article, we argue for a reorientation of palliative care to explicitly integrate the premises of health equity. We articulate the philosophical, theoretical, and empirical scaffolding required for equity-informed palliative care and draw on a current study to illustrate such an approach to the care of people who experience structural vulnerabilities.

Xpey' Relational Environments: an analytic framework for conceptualizing Indigenous health equity

INTRODUCTION

Both health equity research and Indigenous health research are driven by the goal of promoting equitable health outcomes among marginalized and underserved populations. However, the two fields often operate independently, without collaboration. As a result, Indigenous populations are underrepresented in health equity research relative to the disproportionate burden of health inequities they experience. In this methodological article, we present Xpey' Relational Environments, an analytic framework that maps some of the barriers and facilitators to health equity for Indigenous peoples.

METHODS

Health equity research needs to include a focus on Indigenous populations and Indigenized methodologies, a shift that could fill gaps in knowledge with the potential to contribute to 'closing the gap' in Indigenous health. With this in mind, the Equity Lens in Public Health (ELPH) research program adopted the Xpey' Relational Environments framework to add a focus on Indigenous populations to our research on the prioritization and implementation of health equity. The analytic framework introduced an Indigenized health equity lens to our methodology, which facilitated the identification of social, structural and systemic determinants of Indigenous health. To test the framework, we conducted a pilot case study of one of British Columbia's regional health authorities, which included a review of core policies and plans as well as interviews and focus groups with frontline staff, managers and senior executives.

CONCLUSION

ELPH's application of Xpey' Relational Environments serves as an example of the analytic framework's utility for exploring and conceptualizing Indigenous health equity in BC's public health system. Future applications of the framework should be embedded in Indigenous research methodologies.

Health Equity Talk: Understandings of Health Equity among Health Leaders

INTRODUCTION

Reducing health inequities is a stated goal of health systems worldwide. There is widespread commitment to health equity among public health leaders and calls for reorientation of health systems towards health equity. As part of the Equity Lens in Public Health (ELPH) program of research, public health decision makers and researchers in British Columbia collaborated to study the application of a health equity lens in a time of health system renewal. We drew on intersectionality, complexity and critical social justice theories to understand how participants construct health equity and apply a health equity lens as part of public health renewal.

METHODS

15 focus groups and 16 individual semi-structured qualitative interviews were conducted with 55 health system leaders. Data were analyzed using constant comparative analysis to explore how health equity was constructed in relation to understandings and actions.

RESULTS

Four main themes were identified in terms of how health care leaders construct health equity and actions to reduce health inequities: (1) population health, (2) determinants of health, and (3) accessibility and (4) challenges of health equity talk. The first three aspects of health equity talk reflect different understandings of health equity rooted in vulnerability (individual versus structural), determinants of health (material versus social determinants), and appropriate health system responses (targeted versus universal responses). Participants identified that talking about health equity in the health care system, either inside or outside of public health, is a 'challenging conversation' because health equity is understood in diverse ways and there is little guidance available to apply a health equity lens.

CONCLUSIONS

These findings reflect the importance of creating a shared understanding of health equity within public health systems, and providing guidance and clarity as to the meaning and application of a health equity lens. A health equity lens for public health should capture both the production and distribution of health inequities and link to social justice to inform action.

Swimming against the tide: A Canadian qualitative study examining the implementation of a province-wide public health initiative to address health equity

BACKGROUND

Effectively addressing the social determinants of health and health equity are critical yet still-emerging areas of public health practice. This is significant for contemporary practice as the egregious impacts of health inequities on health outcomes continue to be revealed. More public health organizations seek to augment internal organizational capacity to address health equity while the evidence base to inform such leadership is in its infancy. The purpose of this paper is to report on findings of a study examining key factors influencing the development and implementation of the social determinants of health public health nurse (SDH-PHN) role in Ontario, Canada.

METHODS

A descriptive qualitative case study approach examined the first Canadian province-wide initiative to add SDH-PHNs to each public health unit. Data sources were documents and staff from public health units (i.e., SDH-PHNs, Managers, Directors, Chief Nursing Officers, Medical Officers of Health) as well as external stakeholders. Data were collected through 42 individual interviews and 226 documents. Interview data were analyzed using framework analysis methods; Prior's approach guided document analysis.

RESULTS

Three themes related to the SDH-PHN role implementation were identified: (1) 'Swimming against the tide' to lead change as staff navigated ideological tensions, competency development, and novel collaborations; (2) Shifting organizational practice environments impacted by initial role placement and action to structurally embed health equity priorities; and (3) Bridging policy implementation gaps related to local-provincial implementation and reporting expectations.

CONCLUSIONS

This study extends our understanding of the dynamic interplay among leadership, change management, ideological tensions, and local-provincial public health policy impacting health equity agendas. Given that the social determinants of health lie outside public health, collaboration with communities, health partners and non-health partners is essential to public health practice for health equity. The study findings have implications for increasing our knowledge and capacity for effective system-wide intervention towards health equity as a critical strategic priority for public health and for broader public policy and community engagement. Appropriate and effective public health leadership at multiple levels and by multiple actors is tantamount to adequately making inroads for health equity.

Systems science and systems thinking for public health: a systematic review of the field

OBJECTIVES

This paper reports on findings from a systematic review designed to investigate the state of systems science research in public health. The objectives were to: (1) explore how systems methodologies are being applied within public health and (2) identify fruitful areas of activity.

DESIGN

A systematic review was conducted from existing literature that draws on or uses systems science (in its various forms) and relates to key public health areas of action and concern, including tobacco, alcohol, obesity and the social determinants of health.

DATA ANALYSIS

117 articles were included in the review. An inductive qualitative content analysis was used for data extraction. The following were systematically extracted from the articles: approach, methodology, transparency, strengths and weaknesses. These were then organised according to theme (ie, commonalities between studies within each category), in order to provide an overview of the state of the field as a whole. The assessment of data quality was intrinsic to the goals of the review itself, and therefore, was carried out as part of the analysis.

RESULTS

4 categories of research were identified from the review, ranging from editorial and commentary pieces to complex system dynamic modelling. Our analysis of each of these categories of research highlighted areas of potential for systems science to strengthen public health efforts, while also revealing a number of limitations in the dynamic systems modelling being carried out in public health.

CONCLUSIONS

There is a great deal of interest in how the application of systems concepts and approach might aid public health. Our analysis suggests that soft systems modelling techniques are likely to be the most useful addition to public health, and align well with current debate around knowledge transfer and policy. However, the full range of systems methodologies is yet to be engaged with by public health researchers.