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

Health equity: A concept analysis

BACKGROUND

Although health equity is critically important for healthcare delivery, there are inconsistencies in its definitions or lack of definitions.

PURPOSE

Develop a comprehensive understanding of health equity to guide nursing practice and healthcare policy.

METHOD

Walker and Avant's concept analysis method was used to establish defining attributes, antecedents, consequences, and empirical referents of health equity.

FINDINGS

Health equity defining attributes are grounded in ethical principles, the absence of unfair and avoidable differences, and fair and just opportunities to attain a person's full health potential. Health equity antecedents are categorized into environmental; financial or economic; law, politics, and policy; societal and structural; research; and digital and technology.

DISCUSSION

Health equity's antecedents are useful to distinguish health disparities from health outcomes resulting from individual preferences. To achieve health equity, organizations need to focus on addressing the antecedents.

"A place to be safe, feel at home and get better": including the experiential knowledge of potential users in the design of the first wet service in Montreal, Canada

Background

The harmful use of alcohol is one of the leading health risk factors for people’s health worldwide, but some populations, like people who experience homelessness, are more vulnerable to its detrimental effects. In the past decades, harm reduction interventions that target these complex issues has been developed. For example, wet services include a wide range of arrangements (wet shelters, drop-in centers, transitory housing, etc.) that allow indoor alcohol use and Managed Alcohol Programs provide regulated doses of alcohol in addition to accommodation and services. Although the positive impacts of these interventions have been reported, little is known about how to integrate the knowledge of people experiencing homelessness and alcohol dependence into the design of such programs. The aim of this study is to present the findings of such an attempt in a first wet service in Montreal, Canada.

Methods

Community based participatory research approach and qualitative methods—including semi-structured interviews and focus groups—were used to collect the knowledge of potential users (n = 34) of the wet service. The data collected was thematically analyzed.

Results

Participants reported experiencing harsh living conditions, poverty, stigmatization and police harassment, which increased their alcohol use. The intersection between participants’ alcohol dependence and homelessness with the high barriers to access public services translated into their exclusion from several of such services. Participants envisioned Montreal’s wet service as a safe space to drink, a place that would provide multiple services, a home, and a site of recovery.

Conclusions

Integrating the knowledge of potential users into the design of harm reduction interventions is essential to develop better and more adapted services to meet complex needs. We propose that it could fosters users’ engagement and contribute to their sense of empower, which is crucial for a group that is typically discriminated against and suffers from marginalization.

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.