Defining equity, its determinants, and the foundations of equity science

Advancing equity as a priority is increasingly declared in response to decades of evidence showing the association between poorer health outcomes and the unfair distribution of resources, power, and wealth across all levels of society. Quandries present, however, through incongruence, vagueness and disparate interpretations of the meaning of equity dilute and fragment efforts across research, policy and practice. Progress on reducing health inequities is, in this context, unsurprisingly irresolute. In this article, we make a case for equity science that reimagines the ways in which we (as researchers, as systems leaders, as teachers and mentors, and as citizens in society) engage in this work. We offer a definition of equity, its determinants, and the paradigmatic foundations of equity science, including the assumptions, values, and processes., and methods of this science. We argue for an equity science that can more meaningfully promote coherent alignment between intention, knowledge and action within and beyond the health sciences to spark a more equitable future.

Five ways 'health scholars' are complicit in upholding health inequities, and how to stop

Health scholars have been enthusiastic in critique of health inequities, but comparatively silent on the ways in which our own institutions, and our actions within them, recreate and retrench systems of oppression. The behaviour of health scholars within academic institutions have far reaching influences on the health-related workforce, the nature of evidence, and the policy solutions within our collective imaginations. Progress on health equity requires moving beyond platitudes like 'equity, diversity and inclusion' statements and trainings towards actually being and doing differently within our day-to-day practices. Applying complex systems change theory to identify, examine and shift mental models, or habits of thought (and action), that are keeping us stuck in our efforts to advance health equity is a promising approach. This paper introduces five common mental models that are preventing meaningful equity-oriented systems transformation within academia and offers ideas for shifting them towards progressively more productive, and authentic, actions by health scholars to advance health equity across systems.

Promoting "Zest for Life": A Systematic Literature Review of Resiliency Factors to Prevent Youth Suicide

Suicide is a leading cause of death among youth globally. In this critical interpretive synthesis, we examined literature on resiliency factors and suicidality. Systematic searches identified 474 articles, 37 of which were included. Results revealed internal (positive self-appraisal, zest for life, personal traits, and coping skills) and external factors (social support system and inclusive environments) contribute to resilience among youth, with age, sex and gender, and Indigenous identity as important intersecting considerations. Findings validated fostering resilience as primary suicide prevention among youth, with little explanation for how these factors may work to protect youth from suicidality. Continued research in this area requires a focus on how to promote resilience at the community and systems levels.

Applying a health equity tool to assess a public health nursing guideline for practice in sexually transmitted infection assessment in British Columbia

SETTING

There is a multitude of health equity tools but little guidance on how to effectively use these tools in public health nursing practice. In BC, public health nurses who are certified in sexually transmitted infection care utilize guidelines authorized by the nursing regulatory body.

INTERVENTION

As part of the Equity Lens in Public Health (ELPH) research project, an assessment of the nursing guideline, Sexually Transmitted Infection (STI) Assessment Decision Support Tool, was undertaken using the Assessing Equity in Clinical Practice Guidelines health equity assessment tool. The chosen tool is intended for use by health care providers, is broadly applicable to clinical practice guidelines, can be used retrospectively, and falls within the category of equity checklists and audits.

OUTCOMES

Overall, the tool was useful in assessing the inclusion and omission of an equity focus in the guideline. However, there were several challenges: the identification of an appropriate health equity tool; the absence of an evaluation of the chosen tool; the tool's focus on chronic disease versus communicable disease; and the difficulty of obtaining client perspectives.

IMPLICATIONS

For an improved equity lens in the STI Assessment Decision Support Tool, future revisions should be equity focused and include perspectives from affected populations, an emphasis on the determinants of health that perpetuate inequities for populations who experience a disproportionate burden of STI, information on provincially available resources, and service delivery models that improve timely and equitable access to treatment and care.

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.

Mapping the social determinants of substance use for pregnant-involved young Aboriginal women

There is a dearth of knowledge about the social determinants of substance use among young pregnant-involved Indigenous women in Canada from their perspectives. As part of life history interviews, 17 young pregnant-involved Indigenous women with experiences with substances completed a participant-generated mapping activity CIRCLES (Charting Intersectional Relationships in the Context of Life). As women created their maps, they discussed how different social determinants impacted their experiences with pregnancy and substance use. The social determinants identified and used by women to explain determinants of their substance use were grouped into 10 themes: traumatic life histories; socioeconomic status; culture, identity and spirituality; shame and guilt; mental wellness; family connections; romantic and platonic relationships; strength and hope; mothering; and the intersections of determinants. We conclude that understanding the context and social determinants of substance use from a woman-informed perspective is paramount to informing effective and appropriate programs to support young Indigenous women who use substances.

The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada

BACKGROUND

Indigenous women in Canada have been hyper-visible in research, policy and intervention related to substance use during pregnancy; however, little is known about how the social determinants of health and substance use prior to, during, and after pregnancy intersect. The objectives of this study were to describe the social contexts of pregnant-involved young Indigenous women who use substances and to explore if an Indigenous-Specific Determinants of Health Model can predict substance use among this population.

METHODS

Using descriptive statistics and hierarchical logistic regression guided by mediation analysis, the social contexts of pregnant-involved young Indigenous women who use illicit drugs' lives were explored and the Integrated Life Course and Social Determinants Model of Aboriginal Health's ability to predict heavy versus light substance use in this group was tested (N = 291).

RESULTS

Important distal determinants of substance use were identified including residential school histories, as well as protective factors, such as sex abuse reporting and empirical evidence for including Indigenous-specific determinants of health as important considerations in understanding young Indigenous women's experiences with pregnancy and substance use was provided.

CONCLUSIONS

This analysis provided important insight into the social contexts of women who have experiences with pregnancy as well as drug and/or alcohol use and highlighted the need to include Indigenous-specific determinants of health when examining young Indigenous women's social, political and historical contexts in relation to their experiences with pregnancy and substance use.

Understanding the Life Histories of Pregnant-Involved Young Aboriginal Women With Substance Use Experiences in Three Canadian Cities

Despite attention paid to substance use during pregnancy, understandings of young Aboriginal women's experiences based on their perspectives have been virtually absent in the published literature. This study's objective was to understand the life experiences of pregnant-involved young Aboriginal women with alcohol and drugs. Semi-structured interviews to gather life histories were conducted with 23 young Aboriginal women who had experiences with pregnancy, and alcohol and drug use. Transcribed interviews were analyzed for themes to describe the social and historical contexts of women's experiences and their self-representations. The findings detail women's strategies for survival, inner strength, and capacities for love, healing, and resilience. Themes included the following: intersectional identities, life histories of trauma (abuse, violence, and neglect; intergenerational trauma; separations and connections), the ever-presence of alcohol and drugs, and the highs and lows of pregnancy and mothering. The findings have implications for guiding policy and interventions for supporting women and their families.