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Building Health Equity: The Role of Public Health Dr. Cory Neudorf CMHO, Saskatoon Health Region A. Prof., University of Saskatchewan

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Outline <ul><li>Health Inequity reporting at International, National and local levels </li></ul><ul><li>Statistics: the foundation for building a local response </li></ul><ul><ul><li>The need for robust local data </li></ul></ul><ul><ul><li>Building public and political awareness and will </li></ul></ul><ul><li>What can Public Health do about it? </li></ul><ul><ul><li>Changes to Public Health programs and policies </li></ul></ul><ul><ul><li>Inter-sectoral work (e.g. advocacy for policy change (SDOH); community action plans, data access and monitoring i.e. Saskatoon’s “CommunityView” system) </li></ul></ul><ul><ul><li>Working with the rest of the Health System (embedding the work in quality improvement, Chronic disease management / health care equity audit approach) </li></ul></ul>

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Health Inequity Reporting

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Introduction <ul><li>Long tradition of public health involvement in pointing out inequities and improving conditions that create health </li></ul><ul><li>Less the case in recent decades </li></ul><ul><li>Efforts to re-engage with social justice advocacy not always welcomed…”health equity” vs. “health imperialism”? </li></ul><ul><li>Partnership, coalitions, leadership, media attention, advocacy </li></ul>

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The Saskatoon Health Region timeline <ul><li>Local anti-poverty groups working for years at advocacy and awareness…limited progress, waning public interest </li></ul><ul><li>1998 MHO’s Health Status monitoring by SES shows rates of many health conditions higher in inner city NBs than Northern Sask. </li></ul><ul><li>1999 – present -Work with Regional Intersectoral Committee to build Community View Collaborative </li></ul><ul><li>2006 Published Health Disparities study </li></ul><ul><li>2007 Published Survey results on public attitudes, awareness and support for policy change </li></ul><ul><li>2008 “Analysis to Intervention” research summary and 46 evidence based policy options published and used by RIC to form 3 new priorities </li></ul><ul><li>2009 Saskatoon Poverty Reduction Partnership formed to work on a Poverty Reduction Action Plan </li></ul><ul><li>2011 Launch of Action Plan </li></ul>

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1.02 (no difference) n/s 0.89 ( no difference) n/s Cancer 1.82 (82%) n/s 1.33 (33%) n/s Stroke 1.70 (70%) 1.34 (34%) Coronary Heart Disease 1.53 (53%) n/s 1.38 (38%) n/s COPD 12.86 (1186%) 3.98 (298%) Diabetes 2.46 (146%) 1.54 (54%) Injuries and Poisonings 4.27 (327%) 1.85 (85%) Mental Disorders 15.58 (1458%) 3.75 (275%) Suicide Attempts Hospitalizations Rate Ratio Core : Affluent Rate Ratio Core : Total Saskatoon Health Issue

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Income and Health, selected results <ul><li>In comparison to high income residents, low income residents in Saskatoon are: </li></ul><ul><li>1458% more likely to attempt suicide </li></ul><ul><li>1389% more likely to have chlamydia </li></ul><ul><li>1186% more likely to be hospitalized for diabetes </li></ul><ul><li>3360% more likely to have Hepatitis C </li></ul><ul><li>1549% more likely to have a teen birth </li></ul><ul><li>448% more likely to have an infant die in the first year </li></ul><ul><li>Full immunization 46% vs 95% high income </li></ul>

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Survey Data Summary <ul><li>5000 respondents in and around Saskatoon with representation from Inner city (including interviews with homeless people and those without telephones), rest of Saskatoon, and rural residents. </li></ul><ul><li>Response rate 62%. Representative by age, income, neighborhood, income, cultural status. F slightly > M </li></ul><ul><li>Asked about their knowledge and attitudes towards health disparities, and their degree of support for various policy change options </li></ul>

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Survey Data Summary <ul><li>80% of people agree that the poor are more likely to suffer from poor health </li></ul><ul><li>However, they tend to assume it is only in areas such as suicide attempts, diabetes, HIV/STI’s, while they feel there would be no difference for mental illness, injury, heart disease, breathing problems, stroke and cancer </li></ul><ul><li>If health status does differ by income, they believe an “acceptable level” would be: </li></ul><ul><ul><li>0% 49% of people </li></ul></ul><ul><ul><li>10% 12% of people </li></ul></ul><ul><ul><li>25% 17% of people </li></ul></ul><ul><ul><li>50% 20% of people </li></ul></ul><ul><ul><li>>100% 4% of people </li></ul></ul><ul><li>High level of support for many policy options that have been shown to decrease disparity in health, education, employment, education etc. </li></ul>

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Public Release of Initial study <ul><li>Fall 2006 – Large media event with several days of front page coverage and mini-documentaries on the issue and potential solutions. </li></ul><ul><li>Many partners participated with us, showing their solidarity, and announcing immediate and planned program and policy change </li></ul><ul><li>SHR pledge to study the issue in more detail, compare ourselves to other centres, and provide evidence based policy and program solutions with our partners in the coming years </li></ul>

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Public Health Follow up and Research grants <ul><li>Reducing Health Disparity in Saskatoon (major focus on middle school aged children) 2007 - 2010 </li></ul><ul><li>Improving childhood immunization coverage rates in inner city neighborhoods 2007-2010 </li></ul><ul><li>UPHN / CPHI Urban Health Disparity report 2008 </li></ul><ul><li>From Analysis to Intervention policy options report 2008 </li></ul>

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School based intervention research <ul><li>Survey results conveyed to school division leaders, teachers and students. Priority areas for intervention chosen: </li></ul><ul><ul><li>Physical activity promotion </li></ul></ul><ul><ul><li>Mental Health treatment and promotion </li></ul></ul><ul><ul><li>Bullying and violence prevention </li></ul></ul>

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<ul><li>46 Evidence – based policy options listed in areas such as: </li></ul><ul><ul><li>Income distribution </li></ul></ul><ul><ul><li>Housing </li></ul></ul><ul><ul><li>Social policy </li></ul></ul><ul><ul><li>Education </li></ul></ul><ul><ul><li>Health </li></ul></ul><ul><ul><li>Aboriginal self – governance </li></ul></ul><ul><li>Aimed at local, provincial and federal levels </li></ul>Evidence – Based Policy Options

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Credits Research Team Ushasri Nannapaneni, Christina Scott, Tanis Kershaw, Wendy Sharpe, Norman Bennett, Josh Marko, Lynne Warren, Terry Dunlop and Gary Beaudin Funding The Canadian Institutes for Health Research for their grant titled: “Reducing Health Disparity in Saskatoon”

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Saskatoon Health Region Life expectancy in years, 1998-2004

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Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada Nov. 2008 A collaboration between the Canadian Population Health Initiative and the Urban Public Health Network

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Saskatoon Analysis of Dissemination Areas by Deprivation Index Quintiles

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Pan-Canadian, Regina, Saskatoon and Winnipeg Comparison

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Ratio of Age Standardized Hospitalization Rates Between Low and High SES Groups, Pan-Canadian, Regina, Saskatoon and Winnipeg Source: RQHR presentation on CPHI study

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Ratio of Age Standardized Self-Reported Health Percentages Between Low and High SES Groups, Pan-Canadian, Regina, Saskatoon and Winnipeg Source: RQHR presentation on CPHI study

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Moving Beyond Reports to Reducing the Gaps <ul><li>2009 - 2011 </li></ul><ul><ul><li>Regional Intersectoral Committee facilitated the development / adoption of a Community Action Plan on Social Determinants of Health </li></ul></ul><ul><ul><li>Held multiple public forums, focus groups with diverse interest groups to get their perspectives and ideas, and arrive at consensus on things we can do immediately, or advocate for collectively </li></ul></ul><ul><ul><li>Knowledge translation opportunities to build public awareness and support </li></ul></ul><ul><ul><li>Community Coalition formed, with a leadership committee and working groups to flesh out a community action plan in 2011 </li></ul></ul>

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What Can Public Health Do? Advocacy <ul><li>Recommend an All-of-Government approach to this issue. Work to make “Reducing the Gap” or “Equity Till 18” a foundational goal. </li></ul><ul><ul><li>E.g. 3 priority areas for action in UK: </li></ul></ul><ul><ul><ul><li>Increase social and economic supports (income, education, etc) </li></ul></ul></ul><ul><ul><ul><li>Improve access to health services for the poor (esp. primary care and targeted interventions on lifestyle related issues) </li></ul></ul></ul><ul><ul><ul><li>Support people to improve their lifestyles (make it easier for people to make healthy choices) Allen Johnson (UK Sec of State) Nov 2008 </li></ul></ul></ul><ul><li>Make it clear that it is a political choice to set the poverty rate in a jurisdiction. </li></ul><ul><ul><li>E.g.“The Min of Finance can choose what level of poverty we will live with” M.Marmot 2008 </li></ul></ul><ul><li>Don’t let special interest groups sway resolve by claiming “now is not the time” </li></ul><ul><ul><li>Largest gains in Life expectancy in UK came in the 2 decades of world war (social solidarity leading to the welfare state) therefore there is opportunity in our current economic crisis. M.Marmot 2008 </li></ul></ul><ul><li>Become aware, and educate politicians about the causes and solutions </li></ul><ul><li>Take part in National and North American planning in response to WHO Commission report </li></ul>

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What Can Public Health Do? Build Broad-based community support <ul><li>Need 2 things to effect change on health inequities: </li></ul><ul><ul><li>Community support </li></ul></ul><ul><ul><li>Political will </li></ul></ul><ul><li>Reducing the Gap is an ethical imperative, not a partisan issue, but it needs to be translated into whatever language is understood by the various sectors to which you are speaking. Different ideologies may support different elements within an overall strategy. E.g. </li></ul><ul><ul><li>Business sector – how will they benefit economically (reduced costs overall), morally/ethically, workforce stability and productivity, labour availability </li></ul></ul><ul><ul><li>Religious community – poverty and social justice issues in 2000+ verses in the Bible, historical role of the church in solutions </li></ul></ul><ul><ul><li>Gov’t – cross ministerial approaches, overall decrease in costs to government over time. Healthy Public Policy approach (Health Impact Assessment (QC), Health Equity Audit (UK), Equity Impact Review (USA) Needs to be a plank in all party platforms as an overarching strategy, not individual solutions advanced in silos </li></ul></ul><ul><ul><li>Aboriginal government issues – discrimination is underlying contributor, self governance helps. </li></ul></ul>

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What Can Public Health Do? Effect change where we can <ul><li>Support ongoing Public Health research - e.g. costs of poverty vs. interventions, relative contributions of various determinants, identifying disparities in urban and rural areas and in specific risk groups, monitor public support </li></ul><ul><li>Implement evidence based public health interventions to reduce health inequities and evaluate new ideas for program change (for sufficiency and effectiveness) </li></ul><ul><li>Promote regular reporting on progress – report cards, repeated health disparities reports to monitor situation </li></ul><ul><li>Promote mechanisms that allow or encourage inter-ministerial solutions (coalition building, change the mandate of your health promotion department toward reducing health inequity, help build local action plans) </li></ul><ul><li>Work with the rest of the health system to reduce health disparity </li></ul>

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Saskatoon Action Plan to Reduce Poverty <ul><li>shared understanding of poverty in Saskatoon </li></ul><ul><li>shared leadership across sectors </li></ul><ul><li>integrates history of poverty reduction work </li></ul><ul><li>broad goals with multi-year commitment by community partners </li></ul><ul><li>updated on an ongoing basis </li></ul><ul><li>input and commitment from community stakeholders </li></ul><ul><li>Progress report on actions to date with gap analysis </li></ul><ul><li>Follow up with a detailed data report, using 15 years of data, stronger methods, to analyze trends and focus on key drivers and prioritize actions </li></ul>

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Community Roundtables Leadership Group Coordinating Group Community Action Plan Action Groups Measurement & Evaluation Child Care Health Resources Education Housing Income Assistance Welfare to Work Aboriginal Employment

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<ul><li>Held 2-3 times per year </li></ul><ul><li>Open invitation </li></ul><ul><li>Link to broader community re: poverty </li></ul>Community Roundtables

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<ul><li>Primary purpose to inform Action Plan development on issue area: </li></ul><ul><ul><ul><li>inventory what is already happening on the issue </li></ul></ul></ul><ul><ul><ul><li>identify gaps that need to be addressed </li></ul></ul></ul><ul><ul><ul><li>outline steps needed to achieve desired outcomes </li></ul></ul></ul><ul><li>Work within accountability & coordination mechanisms established by Leadership Group </li></ul><ul><li>One partner takes a lead role to act as the fiscal and accountable authority </li></ul>Action Groups

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<ul><li>Overall decision-making & direction setting </li></ul><ul><li>Key influencers and organizations, lived experience, credibility in orgs/community </li></ul><ul><li>Meets every 2-3 months </li></ul><ul><li>Membership: </li></ul><ul><ul><li>Business </li></ul></ul><ul><ul><li>CBO </li></ul></ul><ul><ul><li>City of Saskatoon </li></ul></ul><ul><ul><li>CUISR </li></ul></ul><ul><ul><li>Faith </li></ul></ul><ul><ul><li>First Nations/Métis Groups </li></ul></ul><ul><ul><li>First Voice </li></ul></ul><ul><ul><li>Leaders from Action Groups </li></ul></ul><ul><ul><li>Provincial Government </li></ul></ul><ul><ul><li>Saskatoon Anti-Poverty Coalition </li></ul></ul><ul><ul><li>Saskatoon Health Region </li></ul></ul><ul><ul><li>United Way of Saskatoon & Area </li></ul></ul>Leadership Group

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<ul><li>Acts on behalf of the Leadership Group re: day-to-day activities </li></ul><ul><li>Meets every six weeks </li></ul><ul><li>Membership: </li></ul><ul><ul><li>City of Saskatoon </li></ul></ul><ul><ul><li>Co-chairs of Leadership Group </li></ul></ul><ul><ul><li>CUISR </li></ul></ul><ul><ul><li>First Voice </li></ul></ul><ul><ul><li>Saskatoon Anti-Poverty Coalition </li></ul></ul><ul><ul><li>Saskatoon Health Region </li></ul></ul><ul><ul><li>SRIC </li></ul></ul><ul><ul><li>United Way of Saskatoon & Area </li></ul></ul>Coordinating Group

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Business sector, Faith sector <ul><li>Speaking at Mayor’s Prayer Breakfast, speaking at churches, preparing materials for use in services, Sunday school, bullitens </li></ul><ul><li>Planning workshop / idea incubator / Dragon’s Den for 2012 with both sectors </li></ul><ul><li>Housing First forum with business leaders </li></ul><ul><li>Planning business leader event with keynote speaker from business world for education, support, ideas </li></ul>

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The Health System Response Source : Dahlgreen, G. & Whitehead, M. (2006). European strategies for tackling social inequities in health: Levelling up Part 2. World Health Organization.

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Reorient local Public Health Services <ul><li>Examples: </li></ul><ul><ul><li>“ Building Health Equity” program </li></ul></ul><ul><ul><li>School Health interventions: </li></ul></ul><ul><ul><ul><li>Mental health promotion </li></ul></ul></ul><ul><ul><ul><li>Physical activity promotion </li></ul></ul></ul><ul><ul><ul><li>Violence prevention </li></ul></ul></ul><ul><ul><li>Immunization coverage enhancements </li></ul></ul>

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Work within the rest of the health system <ul><li>Health Care equity audits </li></ul><ul><ul><li>In public health </li></ul></ul><ul><ul><ul><li>progress to date from immunization initiatives </li></ul></ul></ul><ul><ul><li>In a medical area </li></ul></ul><ul><ul><ul><li>Data from diabetes audit, and plans for interventions with specialists, primary care, CDM&P, public health </li></ul></ul></ul><ul><ul><li>In a surgical area </li></ul></ul><ul><ul><ul><li>Data from surgical audit and plans for further analysis and intervention </li></ul></ul></ul>

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Health care equity program Objectives <ul><li>Identify The Problem </li></ul><ul><li>To identify systematic inequities in access to and uptake of needed health care services in Saskatoon Health Region. </li></ul><ul><li>To understand the factors which contribute to these inequities in SHR </li></ul><ul><li>And the Solution </li></ul><ul><li>To identify interventions that have been shown to work to address these factors reduce the inequities </li></ul><ul><li>To promote their implementation in SHR </li></ul><ul><li>To evaluate impact of interventions implemented to reduce inequities identified </li></ul><ul><li>Mainstream the Approach </li></ul><ul><li>To develop a health care equity audit tool to form integral part of the quality assurance programs of the health Region </li></ul><ul><ul><li>Audit tools with evidence based guides to intervention options </li></ul></ul>

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Health Care Equity Audit Cycle Problem (inequity ) and causes Intervention to address inequity Measure Impact and Amend intervention Identify Evidence Based Interventions

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Health Care Equity audit Immunisation Problem Low Immunisation rates Core Neighbourhood Implement Phone based reminder system for parents And other service changes Measure Impact and Amend intervention Lit Review – Evidence Based practice for Improving Rates

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Barriers to Quality Healthcare <ul><li>Patient </li></ul><ul><li>Affordability </li></ul><ul><li>Family responsibilities </li></ul><ul><li>Emotional stress </li></ul><ul><li>Demands of work </li></ul><ul><li>Language </li></ul><ul><li>Lack of awareness </li></ul><ul><li>Service </li></ul><ul><li>Availability of service </li></ul><ul><li>Culturally insensitive services </li></ul><ul><li>Complexity of access </li></ul><ul><li>Bad experience of service </li></ul><ul><li>Discrimination </li></ul><ul><li>Clinical practice </li></ul>

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Health Care Equity Audit Surgical procedures ( City Residents) <ul><li>Procedures </li></ul><ul><li>Cataract </li></ul><ul><li>Hysterectomy </li></ul><ul><li>Hip Replacement </li></ul><ul><li>Knee Replacement </li></ul><ul><li>Cardiac revascularization </li></ul><ul><li>Back Surgery </li></ul><ul><li>Caesarean section </li></ul><ul><li>Analysis </li></ul><ul><li>Age specific procedure rates </li></ul><ul><li>Age specific readmission rates </li></ul><ul><li>Waiting times </li></ul><ul><li>Age specific Length of in patient stay </li></ul><ul><li>% day case </li></ul><ul><li>Populations </li></ul><ul><li>Gender </li></ul><ul><li>Area of residence </li></ul><ul><li>Cultural background </li></ul>

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Eg: Cardiovascular Revascularization

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Ischemic Heart Disease Mortality

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Health Equity Audit-Next Steps for SHR <ul><li>Meetings with key health care providers and patients in each of the studied areas to determine modifiable causes of inequity, design interventions and develop a standardized toolkit and surveillance system for health equity </li></ul><ul><li>Equity indicators are being required of all health system departments next year as part of quality improvement activities and performance monitoring </li></ul><ul><li>SLT includes an equity indicator as part of their pay for performance </li></ul>

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Health System Response - Summary <ul><li>While our health is only 20-30% determined by the Health System, we need to do our part in reducing inequity by acting on what is within our power to change – the balance of services we provide, the equity dimension of quality, and providing equal service for equal need </li></ul><ul><li>We also need to support and advocate for policies and programs in other sectors that determine the other 70-80% of people’s health </li></ul><ul><li>Public Health has an ongoing role to monitor the health equity situation and evaluate any policy changes made in response </li></ul>

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Conclusions <ul><li>Public Health has a long history of pointing out the problems associated with inequity </li></ul><ul><li>Increasingly, there is an expectation that we need to be the catalyst for change at the local level to improve health equity as well </li></ul><ul><li>There is ample evidence for us to act within our own programs, but also to assist the rest of the health system in their response, and to support inter-sectoral action </li></ul>