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Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health
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Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health

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This presentation looks at the opportunities and practices that establish an effective public health system. …

This presentation looks at the opportunities and practices that establish an effective public health system.

Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI

Published in: Health & Medicine, Technology
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  • POWER data age-standardized % of adults 2005overall patterns – 3 X as many low income as high report health to be only fair or poor self-reported = good proxy for clinical outcomes but exactly the point here, capturing people’s experience of their health
  • don’t know local scenes – you will know best how to adapt across provbut do want to set out fairly full repertoire of strategies and programs – 15 ideas
  • In: SDoH lead to gradient of health in chronic conditionsplus affect how people can deal with the conditions= big constraint on strategy to dealing with chronicOut: complex and reinforcing nature of social determinants on health disparities
  • idea of inter-sectionality – reflecting the fact that personal identities and group dynamics do not reflect a single line of oppression/identity such as gender, race or class, but their reinforcing and interacting natureimportant elaboration in SDoH analysis – recognizing that:the effect of determinants varies across people’s livesand that impact of inequalities is cumulativee.g. for children, research shows that:pre-natal and early years are especially sensitive to social conditions and can have a major impact on future healthintervening in early years to counteract adverse effects of wider social and economic inequalities has great potentialgrowing up in inadequate and inequitable social and family circumstances can store up a life-time of health problems
  • need to make sense of SDoH to be able to act making pubic health and other healthcare more equitable can be crucialalso highlights the crucial importance of social context for acting on equity – where PH emphasis on local collaborations, building healthy communities and overall community development is a key part of the equation for action
  • common themes in lit can be linked into this framework:many see this level as being about inequitable risk and exposure due to SD of health inequitiesmany also see inequitable vulnerability, often in terms of social capital and community resources and resilienceemphasize how all these lines of inequality come together -> cumulative and reinforcing impactbut something can be done -> need policy and community action at all these levelsneed to specify different levels in which SDoH and structured inequality affect health -> different policy solutionsimplications for pub health:need for macro policy changes – role of pop’n health research and policy advocacycommunity health profiles and working on the ground in many partnerships to address foundations of healthier communitiesensuring equitable access to ph services and paying particular attention to priority populations
  • Out – will set out a number of promising directions, tools and ideas on howthese fit nicely with NCCDH’s four key roles for ph in advancing equity
  • In: start from strategybroad-based strategic consensus and commitment on equitymajor priority within PHO, OPHA, working groupkey role of NCCDH,collaborations among urban PHUs across Canada, etc.a number of Public Health Units have been pioneering equity strategies and social determinants approachesSudbury’s 10 promising practicesSMN has developed comprehensive strategyWaterloo has focused especially on food insecurityPeterborough has been much involved in poverty reduction collaborationsToronto has emphasized health impact of increasing income inequality, racism and other determinantswide range of promising approaches, programs and interventions -> potential to share and build on all this local innovation
  • one of my themes throughout is alignment – that equity has a better chance of being institutionalized when aligned with – and essential to – key system prioritiesnot going to be easy = system is fragmented – LHINs, primary care, provincial programs, acute and up-stream, public health – let alone beyond health
  • but need to add to these promising starting points = equity strategy + strategic opportunities + community engagement
  • hospital readmissions = also is common interest/leverto enable better community-based service coordination need to match tools to purpose
  • some PHUs have used version of this kind of lens for years
  • increasing attention to this potential – from WHO, through most European strategies, PHAC, to Ontarioquandary: don't reify planning tools do want this to contribute to better equity-focused planningbut better to think of as a process – as a tool to facilitate conversations and analysis about equityless worried about documentation that resultssecond practical quandary:people in the field say it is too difficult to do thoroughlyit is difficult to find consistent data on all the population categories and determinants to be considereddon’t be paralyzed by lack of data – draw on local community and practice leaders also for evidence of potential impactincreasing emphasis on rapid desk-top assessmentsagain, think facilitating tool rather than producing solid evidence
  • quandary again: don’t get paralyzed by inconsistent/inadequate datastart to collectthink of base of data that will be available in 5 yearsPH as leaders here:strong epi resourcesmany PH have developed community health profilese.g. Waterloo partnered with LHIN – opportunity to embed epi and community traditions within wider system
  • hospitals in Toronto Central and Central LHINs – just refreshed 2nd generation in TCand other providers in CentralCHCs have developed a sector-wide plan in GTAfor public health, provincial standards offer a key leverPHU do need to report on SDoH nurses and other activitiesbut thinking more broadly, could develop health equity plans showing how they are putting population health standards and requirements into practice detailing how equity and population-specific expectations and targets are being built into routine PHU performance management and accountabilities
  • Out: recognizing that what gets measured, matters
  • quandary: but don’t take too long in search for perfect indicatortheme of reification of evidence-based nature/ethos of PH – indicators and data to measure them are never going to be perfect
  • this is both strategic and opportunistic
  • a central driver on acute side is quality improvement -> key role for Health Quality Ontario as catalyst in accelerating use of evidence, brokering improvement focusing the system on common quality agendaparallels for Public Health Ontario?role of OPHA in on-the-ground QI partnerships/initiatives?PH will want to be part of any broad Provincial quality strategycollaborations with HQO?fall OPHA conffocus in acute sectors and ECFAA on patient-centred care -> means taking the full range of people’s specific needs into account -> more intensive case management, referral planning and post-discharge follow-up
  • emerging forms:CHCs as hubs of primary care, health promotion and related social servicesnetwork of neighbourhood multi-service centresschools with health and social services acting as hubs for their local communities – remember when PH nurses were in schools
  • probably not much consistency across the systems in how priority pop’n are definedquandary raised by colleague at Waterloo talk:often don’t have comprehensive local and specific datacan bring planning and interventions to a haltalways a question of balance – can’t be rash, but also cant be paralyzed by imperfect databuild on all available sources of local knowledge – incl community-based, practice experiencerationale for whyequity rationale:certain groups within society are most adversely affected by systemic health inequitiesgoal of many strategies is to raise the worst off, fastestnot just a social justice argument, but improving adverse health of worst off can contribute to more effective use of scarce healthcare resources, positively affect social productivity and cohesion, enhance overall population health, etc.health and underlying social disadvantage can be inter-generationalwill persist – if not worsen – if not addressedaccess to quality servicesmost disadvantaged populations have greater and more complex needsuniversal programs can leave vulnerable groups out – and behindspecific at-risk groups need specific interventionsuniversal programs will not be effective unless adapted to specific needs, constraints and dynamics of vulnerable populations
  • good e.g. of double role of PH: part of policy advocacy and developing on–the-ground work-around solutions
  • Drilling down again:vulnerable pop'ns = immigrantswhat could be barriers here?Peel project as innovative example -- local research, partnerships with ethno-cultural gr, go where immigrant women are to encourage screeningToronto Public Health: health status indicator series Sept 2011
  • specifying the problem to solveOnt 2005 age standardized 25>
  • in other words, universalism without targeting – more specifically, without context
  • many of you have done community health profiles for your areas
  • challenge in driving social change on complex issues -- what are key pathways to change? what are levers or enablers to drive change in those directionssuch broad collaboration will be particularly important to Health Links and other system integration initiatives
  • NSM has comprehensive equity framework here Wppg RHA is most recent example from other prov
  • example of clearing house of equity initiatives in Europekey role for OPHA, PHO
  • one of NCCDH’s four rolesPeel planning mechanism as e.g.
  • window hasn’t closed -- we will continue to work with TPH and others on evolution of social assistance policy
  • have done policy orientated HEIAs recently of casinos, cuts of CSUMBworking on fluoridation at suggestion of O?A Eq WG – stay tuned
  • also key to policy change on SDoH is broader public awareness and mobilization lots of work underway on how to popularize and promote SDoH RWJ, NCCDH, videos Ryan Meili book and new collaborative called Upstreamat the same time, what language could help to pull together diverse work PH is doing? could be focus on creating foundations of healthy communities
  • basic ideas of health and social justice can be a powerful vision to drive action
  • Transcript

    • 1. Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health Bob Gardner Ontario Public Health Association Webinar July 25, 2013
    • 2. 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: particular conditions, quality of life, life expectancy the gap between the health of the best off and most disadvantaged can be huge – and damaging 2
    • 3. Outline • health inequities are pervasive and damaging • but these inequities can be addressed through comprehensive health equity strategy and concerted policy and community action • means acting on health equity within the health system • will set out tips, tools and promising ideas on building equity into public health planning and delivery • and acting well beyond healthcare -- tackling the underlying roots of health inequality in the wider social determinants of health • some directions for community-based innovation, cross-sectoral partnerships, and collaborating/advocating for fundamental social and policy change to reduce inequality • again, with examples and opportunities for public health • will also highlight a few unintended consequences and challenges to watch for 3
    • 4. Canadians With Chronic Conditions Who Also Report Food Insecurity 4
    • 5. SDoH As a Complex Problem Determinants interact and intersect with each other in constantly changing and dynamic environments In fact, through multiple interacting and inter-dependent economic, social, environmental and health systems Determinants have a reinforcing and cumulative effect on: • individuals throughout their lives • and on communities and population health 5
    • 6. Planning For Complexity even though roots of health disparities lie in social and economic inequality need 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 and Equity Health Indicator Framework 6July 29, 2013 | www.wellesleyinstitute.com
    • 7. 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 7
    • 8. Acting on Complexity • contradictions of SDoH analysis: • health inequities can seem so overwhelming and their underlying determinants so intractable → can be paralyzing • are 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 that connects and understands everything • think big, 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 8July 29, 2013 | www.wellesleyinstitute.com
    • 9. 1. Powerful Starting Point = Equity As a Priority Within Public Health 9
    • 10. + 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 how PH has more experience than acute sector: • building necessary cross-sectoral collaborations • up-stream interventions to sustain healthier communities → opportunity for public health leadership 10July 29, 2013 | www.wellesleyinstitute.com
    • 11. Solid Strategy + 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 community needs into planning • not just as occasional community engagement, but to identify fundamental needs and priorities • and to evaluate how we are doing → need to start from communities and residents + through an equity lens: • how to involve 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 + thinking also about the communities in which they live and the social determinants that shape their opportunities for health 11July 29, 2013 | www.wellesleyinstitute.com
    • 12. 2. Into Practice Through Equity-Focused Planning • addressing impact of health disparities at system level requires a solid understanding of: • the specific 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 • obvious example – given 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 web of community-based support • requires an array of effective and practical equity-focused planning tools 12
    • 13. 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 13July 29, 2013 | www.wellesleyinstitute.com 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?
    • 14. • 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 14
    • 15. 3. Success Condition = Better Social Determinants Data •pilot project in 3 Toronto hospitals to collect patient SDoH type data – scaled up to all hospitals in Toronto Central •Toronto Public Health was part of pilot •action idea = adapt and scale up provincially • begin to consistently collect SDoH data on all programs, across all PHUs • at best across all sectors •promising practices = Public Health Observatories in UK • consistent and coherent collection and analysis of pop’n health data • interest/development in Western Canada -- Saskatoon Observatory 15
    • 16. 4. Use Available Levers: Potential of Equity Plans 16July 29, 2013 | www.wellesleyinstitute.com • lesson from acute health care sector = building equity into provider planning is one crucial lever for operationalizing equity • equity priorities will/can be built into Quality Improvement Plans or accountability agreements with LHINs • a promising direction several LHINs have taken up is to require providers to develop equity plans → • identified data and research gaps → began to address • encouraged and institutionalized equity-driven innovation across the institutions • equity increasingly came to be seen as core business
    • 17. 5. Beyond Planning: Embed Equity in Targets, Deliverables, Performance Management and other System Drivers • clear consensus from research and policy literature, and consistent feature in comprehensive policies on health equity from other countries: • setting targets for reducing access differentials, improving health outcomes of particular populations, etc • developing realistic and actionable indicators for more equitable service delivery and health outcomes • closely monitoring progress against the targets and indicators • tying funding and resource allocation to performance • disseminating the results widely for public scrutiny • all this as part of comprehensive performance measurement and management strategy 17
    • 18. Adapting Public Health Equity Indicators and Targets • OPHA/alPHa Working Group has developed indicators • various national projects underway to develop equity indicators • PH can move quickly to adapt effective and actionable indicators • don’t need to re-invent the wheel -- adapt from other jurisdictions • 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 • e.g. reducing impact of diabetes is prov priority • equity target = reduce differences in prevalence, complications and rates of hospitalization by income, ethno-cultural backgrounds, etc. and among neighbourhoods or regions • also good reform driver = can only be achieved through coordinated action 18
    • 19. 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 assess impact through equity lens • identify those with greatest need = who programs most need to support and keep to have an impact • are those who need program/support most signing up – reach question? • do they stick with program and what impact did it have on their health – and how does this vary within the pop’n? • then adapt incentives and drivers • develop weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into incentive system • need to measure health outcomes – even when impact only shows up in long- term 19
    • 20. 6. Aligning 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 • it necessarily involves community-based programs and cross-sectoral collaboration • 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 a common goal to integrate upstream health promotion, primary care and chronic treatment, and hospital, community-based agencies and public health 20
    • 21. Alignment II: to Quality and Person-Centred Services • taking social context and living conditions into account are part of good service delivery • when people face adverse social determinants of health → can increase risk of mental and physical health illness → fewer resources to cope (from supportive social networks, to good food and being able to afford medication) • providers and programs need to know this to customize and adapt care to SDoH and population needs and contexts • e.g. well-baby care has to be more intensive for poor or homeless women • to get beyond barriers, screening and health promotion has to be delivered in languages and cultures of particular population/community • so focus on priority populations means different types of service mixes to take account of their specific context and needs 21
    • 22. 7. 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 • e.g. Waterloo has had peer program for over 20 years – nutrition, parenting, social support – partnering with community groups 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 • from provider and funder points of view = more efficient use of scarce resources and better overall coordination • can provide more ‘wrap-around’ integrated services from person’s point of view • based solidly in local communities and responding to local needs and priorities → can become important community ‘space’ and support community capacity building 22July 29, 2013 | www.wellesleyinstitute.com
    • 23. 23 8. 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 • this requires sophisticated analyses of the bases of disparities: • 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
    • 24. Drilling Down: How to Focus on Particular Populations • 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 • 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 • however defined, no population or community is ever homogeneous • need to drill down – e.g. youth vs. seniors within Francophone African immigrants -- to identify needs and plan interventions 24July 29, 2013 | www.wellesleyinstitute.com
    • 25. 9. Target 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 levels equity is ‘wicked’ policy problem, but not always = predictable and avoidable results of bad policy action idea = create local network to improve access for uninsured and/or refugees 25
    • 26. Inequitable Access to Preventative Care: Pap Smears 26 Toronto Public Health: health status indicator series Sept 2011
    • 27. Gradient of Health Across Many Conditions 27
    • 28. 10. 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 28July 29, 2013 | www.wellesleyinstitute.com
    • 29. 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 29
    • 30. Watch for Unintended Consequences: Health Promotion • 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 30
    • 31. Structural Determinants of Health Inequities -- and 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 31July 29, 2013
    • 32. 11. Key Lever for Acting on SDoH: Cross-Sectoral Collaboration and Coordination • can identify community health needs, access barriers, fragmentation, service gaps, and how to address them • public health departments and LHINs are pulling together or participating in cross-sectoral planning tables • Local Immigration Partnerships, Social Planning Councils • and coordinated services are particularly important in less advantaged communities with less resources • not just about better coordination and planning • a number of public health units have been pioneering social determinants approaches through broad community collaborations on food security, poverty reduction and other facets of building healthier communities • look beyond vulnerable individuals to the communities in which they live → meeting full range of needs means moving beyond healthcare • focus on community development as part of mandate for many PHUs and CHCs • providing and partnering to provide related services/support such as settlement, language, child care, literacy, employment training, youth programs, etc. 32
    • 33. 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: • 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 • PH working closely with local partners in community collaborations, networks and planning forums 34July 29, 2013 | www.wellesleyinstitute.com
    • 34. 12. Realizing the Potential of Collaboration: Equity and Community-Driven Local Planning Forums pre-condition for this kind of coordinated action = creating effective cross-sectoral planning forums institutions are also crucial to sustaining broad action needed to address deep-seated structural problems action idea = create local health equity forums with concrete planning mandate 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/pr ojects/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 35July 29, 2013 | www.wellesleyinstitute.com
    • 35. 13. Realizing the Potential of Community-Based Innovation and Initiatives 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 realized need forums to share and build innovation • NCCDH bringing together SDoH PHNs • another advantage of local equity forum • role for PHO or OPHA? 36
    • 36. 14. Add Public Health Voice: Policy Platforms and Opportunities • long tradition of advocating for healthy public policies • Healthy Cities movement • linking pop’n health into wide ranging issues -- climate change, city design, transportation • key current direction is Health in All Policies • public health has unique position: • part of local govt – often with MOH on senior mgmt team • 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 37
    • 37. Policy Windows to Advance Health Equity II cut to particularly important component of social assistance – in context of shift of resources/responsibilities to municipalities also partnership with community agencies and public health – Peterborough extended to developing an on-line tool to track impact of these cuts interest from PHUs to build into their community work 39July 29, 2013 | www.wellesleyinstitute.com
    • 38. © The Wellesley Institute www.wellesleyinstitute.com 15. Shifting the Frame: Health = Healthy and Equitable Communities Sudbury & other public health videos, flyers, etc. July 29, 2013 | www.wellesleyinstitute.com 40
    • 39. 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 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 vision of different health futures and to organize to achieve them • 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’ 41
    • 40. Health Equity • could be one of those ‘big’ unifying ideas.. • if we see opportunities for good health and well-being as a basic right for all • if we see the damaged health of disadvantaged and marginalized populations as an indictment of an unequal society • and can show that focused initiatives can make a difference • and demonstrate 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 progressive future • and showing that we can get there from here 42
    • 41. Key Messages • health disparities 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 through • 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 43

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