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

Bob GardnerOntario Public Health Association Webinar

July 25, 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: particular 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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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

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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 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 health5

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Planning For Complexity

even though roots of health disparities 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

April 12, 2023 | www.wellesleyinstitute.com

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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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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


1. Powerful Starting Point = Equity As 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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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


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

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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?

• 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. 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

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4. Use Available Levers: Potential of Equity Plans


• 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

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

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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

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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 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

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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

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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

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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


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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

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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


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 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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Inequitable Access to Preventative Care: Pap Smears

Toronto Public Health: health status indicator series Sept 2011

Gradient of Health Across Many Conditions

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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


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

• 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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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

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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.

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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


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

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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/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

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 realizedneed forums to share and build innovation• NCCDH bringing together SDoH PHNs• another advantage of local equity forum • role for PHO or OPHA? 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

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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


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

© The Wellesley Institutewww.wellesleyinstitute.com 40

15. 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 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’

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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

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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

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Health & Medicine

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