acting on social determinants and health equity: an equity toolkit for public health

Acting on Social Determinants and Health Equity: An Equity

Toolkit for Public Health

Bob GardnerWindsor-Essex County Public Health

November 29, 2013

Problem to Solve: Systemic Health Inequities in Ontario

clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health however measured -- by conditions, quality of life, life expectancy

the gap between the health of the best off and most disadvantaged can be huge – and damaging

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Towards Health Equity Solutionswill set out a toolkit of 18 ideas, directions and techniques• to build equity into public health

planning and delivery• and well beyond health system --

tackling the underlying roots of health inequality in the wider social determinants of health

• solidly based in research evidence and years of best practices

• action-orientated and manageable• measureable – so can monitor and

assess progress• adaptable to specific organizational and

local contextsthe particularly good news = don’t need to start from scratch

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Todaykey message: • health inequities are pervasive, damaging and deep-rooted• but can be addressed through comprehensive health equity strategy

and concerted action

will set out a multi-facetted equity toolkit on how• ideas and directions, tools and techniques, you could adapt• will also highlight a few unintended consequences and challenges to

watch for

two exercises to test out these directions and tools at your tableslots of chance for discussion

will start by looking at underlying social determinants of health4

Gradient of Health Across Many Conditions

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High Blood Pressure Arthritis Rates Diabetes Rates0

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Windsor-Essex County Blood Pressure, Arthritis and Diabetes Rates by Income Quintile, 2007-2012

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Impact of Health Inequities on How We Live Our Lives

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Impact of Health Inequities II

• not just inequitable differences in quality of life• inequality in how long people live

• difference btwn life expectancy of top and bottom income decile = 7.4 years for men and 4.5 for women

• more sophisticated analyses add the pronounced gradient in morbidity to mortality → taking account of quality of life and developing data on health adjusted life expectancy

• even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women

Statistics Canada Health Reports Dec 09

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Acting on Social Determinants of Health

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Canadians With Chronic Conditions Who Also Report Food Insecurity

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SDoH As a Complex ProblemDeterminants interact and intersect with each other → reinforcing and cumulative effect on:

• individuals throughout their lives; and

• on particular communities and populations

In constantly changing and dynamic social and policy environments

In fact, through multiple interacting and inter-dependent economic, social, environmental and health systems

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Acting Across Systems and Sectors

even though roots of health inequities lie in social and economic inequalityneed to also look at how these other systems shape the impact of SDoH:

•access to health services can mediate harshest impact of SDoH to some degree•so too can responsive social services•structure, resources and resilience of communities shape impact and dynamics of inequalities

POWER Study: Gender andEquity Health Indicator Framework


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WHO Model Again: Focusing on the Right Policy Levels


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Three Cumulative and Inter-Dependent Levels Shape Health Inequities → Different Opportunities for Public Health Action

1. because of inequitable access to wealth, income, education and other fundamental determinants of health

→ gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions

2. also because of broader social and economic inequality and exclusion

→ some communities and populations have less infrastructure, resources and resilience to cope with the impact of poor health

3. because of all this, disadvantaged and vulnerable populations have more complex needs, but face systemic barriers within the healthcare and other systems

→ these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need

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Think Big, But Get Going• contradictions of SDoH analysis:

• health inequities can seem so overwhelming and their underlying determinants so intractable → can be paralyzing

• a classic ‘wicked’ policy problem – meaning long-term action is needed across many govts, depts and sectors

• can't do everything at once• don’t wait for perfect strategy or evidence that connects and understands

everything• keep the fundamentals of SDoH in mind, but get going:

• make best judgement from available evidence and experience• identify actionable and manageable initiatives that will make a difference• innovate and evaluate → learn lessons and adapt

• start from where you are – and focus here is on building equity into public health practice


Health Equity = Reducing Unfair Differences

• Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage

• This concept:• is clear, understandable and actionable• identifies the problem that policies will try to solve• is also tied to widely accepted notions of fairness and social justice

• The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes

• A positive and forward-looking definition = equal opportunities for good health

• Equity is a broad goal, including diversity in background, culture, race and identity

Powerful Starting Point = Equity Is a Priority Within Public Health

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+ Promising Strategic Environment

can bring tradition, expertise and local strengths to key system challenges:• Excellent Care for All Act enshrines

equity and population health as fundamental principles

• Action Plan emphasizes keeping people healthier -- preventing chronic and other conditions, childhood obesity, screening, smoke-free

→ opportunity to demonstrate that these challenges can be met – and howPH has more experience than acute sector:• building necessary cross-sectoral

collaborations• up-stream interventions to sustain

healthier communities → opportunity for public health leadership


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Starting Point: Solid Commitment + Strategic Opening + Community Engagement

• can’t just be ‘experts’, planners or professionals who define issues and drive system transformation• have to build diverse voices and perspectives into planning• not just as occasional community engagement, but to identify

fundamental service needs and priorities, and opportunities for creating healthier community structures and resources

• and to evaluate how we are doing→ need to start from communities and residents

• involving all types of people – diverse cultures, backgrounds and perspectives, and unequal social and economic conditions?

• specifically, how to involve and empower those not normally included• adapt different and innovative methods – e.g. principles of inclusion

research, go where people are, build trust


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1. Operationalizing Commitment: Build Health Equity into All Planning and Delivery

• doesn’t mean all programs are all about equity• but equity is built into working culture and routine

planning → all programs take equity into account in planning their services and outreach• obvious example – given inequitable gradient of prevalence and

impact of chronic diseases + impact of living conditions → CDPM programs have to take social determinants and community conditions into account

• not so obvious example – from acute side• concern about reducing hospital re-admission rates → need to

understand living and social conditions into which people are being discharged → need to ensure more intensive discharge planning and web of community-based support


2. Into Practice Through Equity-Focused Planning

• addressing impact of health disparities at system level requires a solid understanding of:• the needs of health-disadvantaged populations• gaps in available services for these populations• key barriers to equitable access to high quality care

• at delivery level:• considering equity in all program planning means drilling

down on above questions to identify specific needs and barriers for that particular service

• requires an array of effective and practical equity-focused planning tools

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Always Plan through a Health Equity Lens

Providers should apply this type of basic equity lens routinely – from strategic to service planning

if we don’t know → find out• highlights importance of collecting

better equity-relevant data across the system and by every provider

• can use proxy data from postal code = neighbourhood characteristics from census data

• can use case studies and draw on provider experience and community perceptions

•if evidence indicates there could be inequitable impact → then drill down using fuller HEIA


Could this program or policy have a differential and inequitable impact on some populations or communities?

How do we need to take the specific needs of disadvantaged individuals and communities into account in planning and delivering this service?

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First Exercise: Using a Health Equity Lens

At your tables, quickly apply this basic equity lens to a program you are working on

We’ll then share the possible barriers, gaps and inequitable impacts you identified.

And the innovations underway to address them.


Could this program or policy have a differential and inequitable impact on some populations or communities?

How do we need to take the specific needs of disadvantaged individuals and communities into account in planning and delivering this service?

• analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations

• using HEIA can help • uncover unintended consequences or nuances easily missed in program planning• embed equity into routine planning processes and working culture• ensure that projects not specifically about equity or particular populations, will take

language, diversity, local community conditions, etc. into account• especially important for health service providers who are not experienced with

equity and for non-health organizations to take the population health impact of their policies into account

• growing, if uneven, use:• across LHINs -- Toronto Central has required HEIA within recent funding application

processes, and refreshing hospital equity plans → some hospitals have built HEIA into their routine planning processes

• adaptation geared to public health settings and standards been developed and promoted by Public Health Ontario

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3. Collect SDoH/Equity Data

need solid equity-orientated data• to identify gaps and needs of

disadvantaged patients• to measure and monitor progress

pilot project in 3 Toronto hospitals (and Toronto Public Health) to collect patient SDoH type data scaled up to all hospitals in Toronto Central LHIN valuable website of resources on how to collect and use this data

Action idea = adapt and use framework in Windsor• at best, across public health settings and

whole health system27

Make That Data Actionable

promising practice = Public Health Observatories

• consistent and coherent collection and analysis of pop’n health data

• UK has system of observatories specializing in different spheres – London on inequities

• Saskatoon Observatory is innovative example

opportunity: public health to use its analytical capacity/expertise to support wider health system

• partnering in community health profiles

action idea = adapt observatory model regionally or provincially

• role for PHO?28

4. Build Knowledge We Can Act Onneed broad research base and expansive view of knowledge:• epidemiological – scale of

disparities, disadvantaged communities/groups

• population level linked datasets• community-based research = unique

understanding of needs and interests of marginalized populations

• evaluation – need to know what works and why, for which populations, in varying contexts

systematic data collection + capacity to measure/monitor /evaluate + rich research evidence = knowledge to guide/ground action

5. Beyond Planning: Embed Equity in Targets, Deliverables, and Performance Management

• clear consensus from research and policy literature, and consistent feature in comprehensive policies on health equity from other jurisdictions: • setting targets for reducing access barriers, improving

health outcomes of particular populations, etc• developing realistic and actionable indicators for more

equitable service delivery and health outcomes• tying funding and resource allocation to performance• closely monitoring progress against the targets and

indicators• disseminating the results widely for public scrutiny

= embedding equity into comprehensive performance measurement and management strategy

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Effective Public Health Equity Targets

• various national projects underway to develop equity indicators• can also build equity into indicators already being collected → equity angle is

to reduce inequitable differences faced by particular populations or communities on these indicators

• reducing impact of diabetes is prov priority• equity target = reduce differences in prevalence, complications and

hospitalization rates by income, ethno-cultural backgrounds, etc. and among neighbourhoods or regions

• achieving that will require targeted programming and proactive engagement with under-served communities

• also good reform driver = can only be achieved through coordinated action• similarly, common goal is increasing rates of childhood immunization

• equity target = reduce the differentials in % of kids immunized by neighbourhood, gender, ethno-cultural background, etc.

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Challenges: Equity Indicators and Targets• can’t just measure activity, like number or % of priority pop’n that participated in

program• if theory of change for particular health program begins with enabling more

exercise or healthier eating – then we measure change in that initial step• need to measure contribution to health outcomes – even when impact only

shows up in long-term• need to assess reach

• differentiate those with greatest need who need program/support most• are these populations signing up? • who stuck with program and what impact did it have on their health – and

how this varies by sub-pop’n• then adapt incentives and drivers

• develop weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into funding and incentive system

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6. Use Effective Levers to Institutionalize Equity

• public health standards have been effective way to prioritize and embed equity:• as foundational element of high-performing public health• assessing needs, identifying priority populations, underlying SDoH

• interesting work underway to help implement:• PHO on how to assess and identify priority populations • alPHa/OPHA Health Equity Working Group is also an effective

forum • some lessons to be learned from acute side:• following equity standards arose out of WHO Health Promoting

Hospitals project• adapted to Canadian context, starting with hospitals


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Promising Practice: Actionable Equity Standards


7. Align Equity in Public Health With Key System Priorities

• showing how equity will be critical to achieving system goals and linking equity into central priorities will enhance uptake and success

• one overarching system priority is sustainability:• powerful case to be made for preventative programs and health

promotion as key to reducing avoidable acute care use/costs • another priority is chronic disease prevention and management

• long been key focus of PH health promotion efforts• a challenge for health reform is finding cross-cutting goals/projects that

can address a key issue and help to transform the wider health care system

• reducing prevalence and impact of chronic disease could be such a common goal to integrate upstream health promotion, primary care and chronic care

• and it necessarily involves cross-sectoral collaboration

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Always Drill Down: For Diabetes and Other Conditions, What Are Key Dimensions of Inequities? What Determinants and

Barriers Underlie These Inequities?


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Windsor-Essex County Diabetes Rates by Immigration Status, 2007-2012

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8. Embed Equity into Quality

• quality improvement is another key transformational driver across the health system

• taking social context and living conditions into account are part of good service delivery• when people face adverse social determinants of health → fewer

resources to cope (from supportive social networks, to good food and being able to afford medication)

• e.g. primary care guidelines on best care for people living in poverty• providers and programs need to know this, to customize and adapt care to

SDoH and specific needs and contexts• e.g. well-baby care has to be more intensive for poor or homeless women• to get beyond barriers, preventative screening and health promotion has

to be delivered in languages and cultures of particular population/community

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Not Just at Individual Level: Build Equity-Driven Service Models

peer programs• CHCs, public health and many community providers have established ‘peer health

ambassadors’ to provide system navigation, outreach and health promotion services to communities facing particular barriers

• Waterloo has had peer program for over 20 years – nutrition, parenting, social support – partnering with community groups

neighbourhood focus of many health promotion initiatives:• not just disease by disease, or lifestyle elements in isolation, but coordinated

programming to meet local needsbeing part of hub-style multi-service centres

• a range of health and employment, child care, language, literacy, training and social services are provided out of single ‘one stop' locations

• based solidly in local communities and responding to local needs and priorities → can become important community ‘space’ and support community capacity building

• from provider and funder points of view = more efficient use of scarce resources and better overall coordination


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9. Priority Populations Target Programs and Resources for Equity Impact

• consistent tradition within PH has been to identify priority populations and target services to:• those facing the harshest disparities – to raise the worst off fastest• or most in need of specific services – e.g. poor young moms• or the worst barriers to equitable access to high-quality services – newcomers,

Aboriginal populations• this requires sophisticated analyses of the bases of inequities:

• which requires good local research and detailed information • community health profiles to identify local disparities, unmet needs and

gaps• community-based research to provide rich and deep local knowledge –

especially for designing effective program solutions• involvement of local communities and stakeholders in planning and priority

setting is critical to understanding the real local problems

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Effective Targeting = Clear Focus

• defining priority populations• not just a general or statistical category – bottom 20 %, all immigrants• but social groups who face particularly poor health or inequitable

determinants of health – and why• these populations could occupy particular positions – precarious workers,

recent immigrants – or may share common backgrounds, identities or other community interests – Aboriginal people, LGBTQ, homeless

• could be people who live in particularly disadvantaged neighbourhoods• get priority populations involved in what matters to them and what

programs will meet their needs• however defined, no population or community is ever homogeneous

• need to drill down further – e.g. youth within Francophone African immigrants have specific needs


10. Not Just Priority Populations: Target Systemic Barriers

in Toronto and other cities: people without health insurance

• immigrants in 3 month wait time, refugees, undocumented

• inequitable access → delayed care and worse outcomes

• TPH staff have played a key role in Scarborough Volunteer Clinic and networks

federal cuts to refugee healthcare→ adverse impact on particularly

vulnerable people→ increased healthcare costs/demands at

prov and provider levelsequity is ‘wicked’ policy problem, but not always = predictable and avoidable results of bad policyaction idea = create local network to improve access for uninsured and/or refugees

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Problem = Newcomers Face Service BarriersOne Solution = Interpretation as a Key Quality and Equity Lever

•access to interpretation underlies wait times, safety and other acute system priorities•requirement that adequate interpretation be available wherever needed → improves quality and equity•equally crucial for health promotion

•action idea = Windsor area LHIN, PH, acute, community health and other providers consider centralized/coordinated interpretation services


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Inequitable Access to Preventative Care: Pap Smears

Toronto Public Health: health status indicator series Sept 2011

Problem = Under-Screened PopulationsSolution = Focused Community Partnerships

lower screening rates in particular ethno-cultural or disadvantaged groups e.g. South Asian women in Peel

→ community-based research to assess why→ broad partnerships of Public Health, providers and trusted community organizations to get beyond barriers→ outreach to diverse community settings where women live, work

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11. Health Promotion Through an Equity Lens

• need to customize and concentrate health promotion programs to be effective for most disadvantaged

• programs have to take account of inequitable resources of vulnerable individuals and communities• advice to manage chronic conditions by exercising depends upon

affording a gym or being close to safe park• diet and nutrition are key – yet high degree of food insecurity

• adjust programs to specific barriers and community needs• deliver in languages and cultures of particular population/community• go where people are -- e.g. CHCs/health promoters into malls• Immigrant Women's’ Health Centre, Sherburne, Aboriginal

communities and other vans in Toronto


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Windsor-Essex County Vegetable and Fruit Consumption Five or More Times a Day, by Income Category, 2009-2010

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Build Equity Upstream: Chronic Disease Prevention and Management

start by identifying populations and communities at greater risk

• South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America

→ design programs to meet specific needs

build in equity target = common goal is reducing childhood obesity → if goal is to increase the % of kids who exercise regularly

• equity target = reduce the differentials in % of kids who exercise by neighbourhood, gender, ethno-cultural background, etc.

• and achieving that won’t be just a question of education and awareness, but proactive empowerment of kids and ensuring equitable access to facilities, space and programs

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Watch for Unintended Consequences

• health promotion that emphasizes individual health behaviour or risks without setting it in wider social context• can lead to ‘blame the victim’ portrayals of disadvantaged who practice ‘risky’

behaviour• focus on individual lifestyle in isolation without understanding wider social forces that

shape choices and opportunities won’t succeed• universal programs that don’t target and/or customize to particular

disadvantaged communities• inequality gap can widen as more affluent/educated take advantage of programs

• programs that focus on most disadvantaged populations without considering gradients of health and specific need• the quintile or group just up the hierarchy may be almost as much in need• e.g. access to medication, dental care, child care and other services for which poorest

on social assistance are eligible do not benefit working poor• supporting the very worst off, while not affecting the ‘almost as worse off’ is unlikely

to be effective overall

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12. Key Lever for Acting on SDoH: Inter-Sectoral Collaboration and Coordination

• equity-driven quality care is not just customizing immediate service delivery, but ensuring networks of community-based care and support• particularly important in less advantaged communities with less resources

• needs good cross-sectoral coordination and planning • can identify community health needs, access barriers, fragmentation, service

gaps, and how to address them• public health units and LHINs are pulling together or participating in cross-

sectoral planning tables• also Local Immigration Partnerships, Social Planning Councils

• and looking beyond vulnerable individuals to the communities in which they live• providing and partnering to provide related services/support such as

settlement, language, child care, literacy, employment training, youth programs, etc.

• a number of PHUs have been pioneering social determinants approaches through broad community collaborations on food security, poverty reduction and other facets of building healthier communities

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Structural Determinants of Health Inequities: and Simultaneously Always Local

poor housing, high levels of poverty and precarious employment can be concentrated in particular neighbourhoods and areas, compounded by racism and other forms of social exclusion

impact and severity of health inequities can also be concentrated in particular populations and neighbourhoods

+ inequitable access to healthcare and other services

+ services can be poorly coordinated and planned

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13. Plan Strategically/Act Locally

• clear benefits of comprehensive national/prov health equity strategy:• but even best national strategy needs to be adapted/implemented locally• and even without national strategy, can still act locally• recent Wellesley comparative survey of local health equity strategies

• many innovative local strategies at LHIN level, RHAs from other prov, PHUs• again, potential of PH:

• many PHUs work closely with local partners in community collaborations, networks and planning forums

• tradition of researching/understanding local health needs and challenges • Manitoba has provincial community health mapping initiative, • many Ontario PHUs have done local health mapping -- Toronto profiles,

Waterloo partnered with LHIN


http://www.wellesleyinstitute.com/publication/driving-location-action-the-potential-of-city-and-regional-health-equity-strategies/

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Realizing the Potential of Collaboration: Equity and Community-Driven Local Planning Forums

pre-condition for coordination = creating effective local cross-sectoral planning forumscrucial to sustaining broad action needed to address deep-seated structural problems

action idea = create Windsor health equity forums with concrete planning mandate• to develop a Windsor health

equity plan?

Looking for Ideas : SETO

•arose out of community concern re access•brings together public health, CHCs, shelters, researchers and service providers serving marginalized communities in south-east Toronto•for an overview of SETo’s development see http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx •ongoing collaboration and idea sharing → supports service coordination and problem solving•emphasized concrete demonstration projects → many with lasting impact•advocacy with institutions and governments around key issues such as harm reduction, dental care and access for non-insured people


http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx

http://knowledgex.camh.net/researchers/projects/semh/profiles/Pages/seto.aspx

15. Realizing the Potential of Equity-Driven Innovation

potential:• huge number of initiatives already

addressing equity across province• + equity focused planning will yield useful

information on existing system barriers and the needs of disadvantaged populations

• and we’ll be seeing more and more population-specific program interventions

but• these initiatives and interventions are not

being rigorously assessed• experience and lessons learned are not

being shared systematically• so potential of promising interventions is

not being realizedneed forums to share and build innovation• NCCDH bringing together SDoH PHNs• another advantage of local equity forum • role for PHO or OPHA? 54

16. Add Public Health Voice: Policy Advocacy

• long tradition of advocating for healthy public policies• Healthy Cities movement• linking pop’n health into wide ranging issues -- climate change, city

design, transportation• policy advocacy = one of key roles identified in NCCDH model

• public health has unique position:• part of local govt• protected by provincial mandates and responsibilities• long been solidly based in local communities and collaborations

• can use credible professional/evidence-based voice to intervene in public debates

• need to identify most effective platforms and policy opportunities• and what the key issues are in your communities

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Policy Windows: II

also partnership with community agencies, CHCs and other providers and public health – Peterborough

extended to developing an on-line tool to track impact of these cuts

current focus – again in broad collaborations – is on municipal housing plans to ensure they include this kind of flexible support


http://www.wellesleyinstitute.com/housing/tracking-the-impact-of-cuts-to-housing-and-homelessness-supports/

© The Wellesley Institutewww.wellesleyinstitute.com 58

17. Shifting the Frame: Health = Healthy and Equitable Communities

Sudbury & other public health videos, flyers, etc.


Back to Community Again: Build Momentum and Mobilization

• sophisticated strategy, solid equity-focused research, planning and innovation, and well-targeted investments and services are key

• but in the long run, also need fundamental changes in over-arching social policy and underlying structures of economic and social inequality

• these kinds of huge changes come about not just because of good analysis, but through widespread community mobilization and public pressure

• key to equity-driven reform will also be empowering communities to imagine their own alternative health futures and to organize to achieve them

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Second Exercise

From this equity toolkit, what are two or three ideas or directions that you could develop here?

How would you adapt them to your context?


18. Pull All This Together into a Strategic

Roadmap

• from a large toolkit, develop a roadmap of what you will do – how and when

• can’t be a rigid blueprint, needs to be adapted and implemented flexibly to contexts and circumstances

• but need clear sense of direction and overall goals

• needs to pull various initiatives into a coherent and connected action plan

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Promising Practice: Potential of Equity Plans Demonstrated


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Build a Cycle of Equity-Driven Planning and Innovation

• not just a one-off plan• but building equity into

ongoing cycle of analysis, planning and implementation

• see Saskatoon health equity audit process

• embed equity into routine planning and performance management processes

• build evaluation and learning into continuous innovation

Analysis

Plan and

engage

Implement

Evaluate

Innovation


Health Equity and Community Mobilization

• we need to find ways that governments, providers, community groups, unions, and others can support each others’ campaigns and coalesce around a few ‘big ideas’

• health equity could be one of those ‘big’ unifying ideas..• if we can shift the public and policy frame to see opportunities for good

health and well-being as a basic right for all• if we frame the damaged health of marginalized populations as an

indictment of an unequal society – but also show that focused initiatives can make a difference

• if we recognize that coming together to address the social determinants that underlie health inequalities will also address the roots of so many other social problems

• thinking of what needs to be done to create health equity is a way of imagining and forging a powerful vision of a better future for all

• and showing that we can get there from here

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Key Messages• health inequities are pervasive and deep-seated – but can’t let

that paralyze us• do need a comprehensive and coherent health equity strategy –

but don’t wait for perfect strategy• think big and think strategically – but get going• have set out a roadmap – of strategies, principles and tools -- to

drive equity into action

• there is a solid base of public health evidence, experience, commitment and community connections to build on

• real opportunity within the current health and policy environment for public health to lead the way on equity

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acting on social determinants and health equity: an equity toolkit for public health

Health & Medicine

gradient of health

health systems

health services

poorer health

impact of health inequities

roots of health inequities

systemic health inequities

public health action