II Literature Review Methodology
VI Next Steps
VII Key Resources
--Submitted by Chase Simms, Graduate Student, The University of Victoria, Masters of Public Health, Social Policy Specialization
Health Nexus is a bilingual organization that supports individuals, organizations and communities as they strengthen their capacity to promote health and to create healthy, equitable and vibrant communities. Recently the organization developed a Health Equity Strategy which aims to increase its capacity to address health inequities. To support the implementation of the strategy, a graduate student conducted a literature review on health equity. The objective of this literature review was to provide evidence on how to embed health equity into organizational capacity.
Currently, there is a lack of cohesive, comprehensive resources that health promoters can utilize to increase their capacity for health equity work. A scan of the academic research found limited resources that offer health promoters detailed actions that were specific to embedding health equity into organizational capacity. In a needs assessment, Health Nexus staff echoed the need for a resource to translate theory into action specifically asking, ‘what can I do to promote health equity?’ Therefore, the research question developed for the literature review is "What strategies/approaches are used by organizations in Canada or Ontario to increase their health equity capacity?"
It is imperative for readers to possess a common understanding of basic health equity terms, including the following definitions:
- The absence of unfair and avoidable or modifiable differences in health among population groups defined socially, economically, demographically or geographically. (Solar & Irwin, 2007)
- Equity in health means that peoples’ needs guide the distribution of opportunities for well-being. Equity in health is not the same as equality in health status. Inequalities in health status between individuals and populations are inevitable consequences of genetic differences and various social and economic conditions, or a result of personal lifestyle choices. Inequities occur as a consequence of differences in opportunity, which result in unequal access to health services, nutritious food or adequate housing etc. In such cases, inequalities in health status arise as a consequence of inequities in opportunities in life. (PHAC, 2010)
- NOTE: Different countries and jurisdictions may use the terms ‘equity’ and ‘equality’ interchangeably. In addition, there may be slight differences when translated into different languages.
- The process of enabling people to increase control over, and to improve their health. It not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental, political and economic conditions so as to alleviate their impact on public and individual health. The Ottawa Charter for Health Promotion describes five key strategies for health promotion: build healthy public policy; create supportive environments; strengthen community action; develop personal skills; and re-orient health services. (PHAC, 2010)
- The ability of an organization to facilitate, support and fulfill an initiative, program, mandate or common goal. (Carlson, Donahue, and Foster, 2011)
Social Determinants of Health (SDOH)
- The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. (WHO, 2017).
- Mikkonen & Raphael (2010) outline the following 14 SDOH: stress, bodies, and illness; income and income distribution; education; unemployment and job security; employment and working conditions; early childhood development; food insecurity; housing; social exclusion; social safety net; health services; aboriginal status; gender; race; and disability.
II Literature Review Methodology
The initial, structured search was conducted within the following databases: Summons 2.0; Web of Science; EBSCOHost; and Google Scholar. The search terms included “health equity,” “organization,” “capacity,” “strategy,” “framework,” “approach,” “Canada” OR “Ontario”; the following terms were excluded, “business*," “econ*,” “primary health care,” OR “primary healthcare.” Additional research was conducted in the grey literature.
Grey Literature Search
Health Nexus’ "Using Evidence Tool" lists a number of databases, the following were explored for relevant grey literature, PHAC Canadian Best Practices Portal (CBPP); CHNet-Works! Researchers-Practitioners Webinars; Health Evidence; and Turning Evidence into Practice (TRIP). Following this a Google search was conducted, which produced thousands of results. The first five pages (equating to 50 results) were screened and analyzed based on the research parameters, because the relevancy to the topic dropped drastically after this point.
Specific health promotion websites that appeared often in this initial Google search were explored further. This entailed searching multiple websites of health promotion organizations across Canada (with a focus on Ontario): the National Collaborating Centre for Determinants of Health (NCCDH); the National Collaborating Centre for Methods and Tools (NCCMT); Peterborough County-City Health Unit; Public Health Ontario (PHO); Sudbury & District Health Unit; the Wellesley Institute; and the BC Centre for Disease Control (BCCDC). Following the screening and eligibility phases, 45 articles (rated strong evidence), and one article (rated moderate evidence) were included. The searches are current as of February 2017.
Information from the appraised articles was arranged into nine broad themes, which were then organized by ‘implications’, barriers’, and ‘actions.’ This produced five key themes to create a framework for increasing health equity work for health promotion organizations:
- Theme 1: Establish Strong and Effective Leadership
- Theme 2: Continuously Expand the Evidence Base to Support Best Practices and Foster Knowledge Translation and Exchange
- Theme 3: Collaborate and Partner with Intersectoral Stakeholders and Communities
- Theme 4: Demonstrate and Increase Competencies
- Theme 5: Embed Equity into the Organization’s Mandate, Policies and Procedures.
After reviewing the articles in this literature review, it is clear that strong and sustained leadership at all levels within an organization is essential to building organizational capacity for health equity action. Therefore, strong and effective leadership (Theme 1) serves as the core foundation of the framework. This leadership can exhibit itself in a number of different ways; for example, a staff member may be designated as a health equity champion, whereas others may be motivated to pursue these efforts based on their own accord.
Theme 2 involves strengthening the existing evidence base, and expanding it through best practices. Communication and collaboration is imperative for knowledge translation and exchange. The Wellesley Institute (2016) contends that evidence-informed planning and decision-making is supported when the availability and quality of data collected and reported on health inequities is increased, and regular monitoring performance takes place.
Theme 3 calls for intersectoral collaboration and partnerships with stakeholders and communities. The Wellesley Institute (2016) asserts that community empowerment can occur through health inequity and disparity reduction initiatives, as well as generating data on these inequities. In addition, collaboration, engagement and multi-sectoral actions require joint commitments from all stakeholders involved.
Demonstrating and increasing competencies (Theme 4) entails that all staff encompass various competencies, including public health, professional, cultural, and linguistic. Betker and Ndumbe-Eyoh (2013) argue that essential knowledge, skills, and attitudes are required to advocate for health equity. The Wellesley Institute (2016) emphasizes that staff members need to be supported with competency training, and organizations need to diversity their workforce.
Finally, Theme 5 necessitates that equity is embedded into the organization’s mandate, policies and procedures. The BCCDC (2016) reasons that an equity lens be applied within the organization’s mandate to ensure clear roles and expectations are outlined so equity considerations can be factored into discretionary decision-making. Furthermore, McPherson et al. (2016) found that advisory bodies or working groups related to SDOH and health equity commonly had broad organizational representation, which provided a direct link to senior decision-makers and multidisciplinary staff and created legitimacy for the ongoing SDOH work.
The findings of this literature review closely align with themes outlined by the NCCDH. It clearly identified four key roles for public health action on health determinants to reduce health inequities: assess and report on the health of populations to address health inequities; modify public health interventions; engage in community and multi-sectoral collaboration; and lead/participate to support other stakeholders in policy analysis, development and advocacy to improve health determinants/inequities (NCCDH, 2014). Participants in an environmental scan conducted by the NCCDH shared a number of elements that are necessary for these roles to be undertaken most effectively: leadership (that is collaborative); organizational and system development (within and outside the health sector); development and application of information and evidence, education and awareness raising for public health staff and the general public; skill development based on participatory learning; and partnership development inter- and intra-sectorally (2010). These roles and elements are all in line with the findings of this literature review, and can be applied to health promotion organizations. On the other hand, the literature review findings also highlighted the importance of increasing competencies, and embedding equity into the organization’s mandate, policies and procedures especially for role clarification.
Numerous potential actions for health promotion organizations and practitioners to address the five themes were identified. These actions reflect the steps required for health promotion organizations to increase their capacity for health equity work. Distinct best practices that presented themselves across all five themes was integrating equity into evaluation and reporting. Below these thematic actions are listed:
Theme 1 (Establish Strong and Effective Leadership):
- Possess a clear organizational mandate.
- Ensure organizational commitment and readiness.
- Support health equity champions.
Theme 2 (Continuously Expand the Evidence Base to Support Best Practices and Foster Knowledge Translation and Exchange):
- Create and use a strong knowledge base.
- Sustain theoretical and methodological innovations.
Theme 3 (Collaborate and Partner with Intersectoral Stakeholders and Communities):
- Borrow resources and tools, provide mutual support, network, working groups.
- Engage with communities.
- Establish comprehensive strategies and strategic directions.
Theme 4 (Demonstrate and Increase Competencies):
- Implement ongoing training.
- Foster a supportive learning environment.
- Update competencies regularly.
Theme 5 (Embed Equity into the Organization’s Mandate, Policies and Procedures):
- Possess a clear organizational mandate.
- Create enabling infrastructures.
There was varying terminology based on the research topic of interest. For example, the term ‘health equity’ may be coined ‘health equality’ in other countries or in different languages. Consequently, it was difficult to narrow down terminology to a manageable size that could produce results; some of the terms included ‘strategy,’ ‘framework,’ and ‘approach.’ A large number of article results were related to ‘equity’ in the financial sense, and primary care techniques (such as new surgery techniques, and scientific evidence) therefore the terms “business*,” “econ*,” “primary health care” OR “primary healthcare” were omitted.
The majority of the evidence outlined in the results was found in the grey literature. As a result, limitations include a lack of reproducibility of the review and search engine restrictions. For example, many documents relating to tools and frameworks that measure and increase health equity organizational capacity may be kept confidential within the organization – thus making it impossible for the general public to access online. If the same search was conducted one year from now, there may be a substantial amount of material on the topic that has been published, which would interfere with the replicability of this initial search. Lastly, this literature review does not explore the topic outside of Canada.
VI Next Steps
The purpose of this literature review was to provide Health Nexus staff with concrete evidence to effectively assist them in their health equity activities, both internally and externally. Health promotion organizations can utilize the framework developed, and adopt it as a foundation for their health equity work (see Figure 1). It is hoped that the framework and list of detailed actions ignite and contribute to the overall health equity momentum in the health promotion field.
Figure 1: Framework: Health Equity Organizational Capacity for Health Promotion Organizations
The full literature review is available on Health Nexus’ website http://en.healthnexus.ca/news/increasing-organizational-capacity-health-...
VII Key Resources
Tools and Toolkits
- Achieving the Vision of an Inclusive Peel Region: A Diversity, Equity, and Inclusion Organizational Self-Assessment Tool
- Health Equity Impact Assessment (HEIA) - Ministry Programs - Health Care Professionals - MOHLTC
- Health Equity Tools Inventory
- Overview HEIA – Community of Interest
- Equity-Focused Knowledge Translation Toolkit | Resource Details | National Collaborating Centre for Methods and Tools.
- Health & Health Equity in the GTA.
- The Organizational Capacity Assessment Tool (OCAT)
- Promoting Action on Equity Issues: A Knowledge-to-Action Handbook
- Public health planning toolkit
- Templates and User Guides for Equity-Focused Impact Assessment
- Tools and approaches for assessing and supporting public health action on the social determinants of health and health equity
- Toward Health Equity: A Practice Tool
- Toward Health Equity: A Tool for Developing Equity-Sensitive Public Health Interventions
Health Equity Glossaries and Fact Sheets
- Building Health Equity Capacity in the Mississauga Halton LHIN: Health Equity Glossary.
- “Let’s Talk: Health Equity.” NCCDH, 2013.
- Towards an Understanding of Health Equity: Glossary
- Why Health Equity Matters: Fact Sheet
Collaborations and Partnerships
Examples of Equity Initiatives
- “Equity Focused Health Impact Assessment Framework.” The Australasian Collaboration for Health Equity Impact Assessment (ACHEIA)
- Whānau Ora Health Impact Assessment
Online Learning Opportunities
- Online Courses: Social Determinants of Health & Health Equity
- Recommended Online Learning Opportunities Related to Health Equity and Social Determinants of Health, for Public Health Practitioners in Canada
Webinars and Videos
- “NCCDH Webinar: Intersectionality & Health Equity.”
- “NCCDH Webinar: Strengthening Organizational & Health System Performance to Report and Act on SDH.”
- Let’s Start a Conversation About Health...and Not Talk About Health Care at All (Voice-Over)
- Sudbury & District Health Unit - 10 Promising practices
- HC Link - Health Equity
- Let’s Start a Conversation About Health . . and Not Talk About Health Care at All: USER GUIDE
- Resources, Principles, and the Practice of Health Equity A compilation of training resources for community health care service providers in the Champlain region
- WCH Women's Xchange | Addressing Issues of Equity in Research
- Building Organizational Capacity to Advance Health Equity
BC Centre for Disease Control. “Equity and EPH Handbook.” Professional Resource. Health Equity & Environmental Health. Accessed February 13, 2017. http://www.bccdc.ca/health-professionals/professional-resources/health-e....
BC Centre for Disease Control. “Taking Action on Equity Using Policy Levers in Environmental Public Health Practice.” BC Centre for Disease Control, 2016. http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/E....
BC Centre for Disease Control. “Taking Action on Health Equity in Environmental Public Health: Five Strategies for Organizational Change.” BC Centre for Disease Control, 2016. http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/E...
Betker, Claire, Louis Sorin, Hannah Moffatt, Kevin Churchill, Stephanie Lefebvre, and Cory Neudorf. “Advancing Health Equity through Public Health: The Power of People and Systems.” Teleconference - CHNET-Works! Fireside Chat #355, December 3, 2013.
Carlson, Marie, Donahue, Stasha, and Foster, Sheri. “Towards an Understanding of Health Equity: Glossary.” Alberta Health Services, 2011.
McPherson, Charmaine, Sume Ndumbe-Eyoh, Claire Betker, Dianne Oickle, and Nancy Peroff-Johnston. “Swimming against the Tide: A Canadian Qualitative Study Examining the Implementation of a Province-Wide Public Health Initiative to Address Health Equity.” International Journal for Equity in Health 15 (2016): 129. doi:10.1186/s12939-016-0419-4.
Mikkonen, Juhavv and Raphael, Dennis. Social Determinants of Health: The Canadian Facts. Toronto: York University, School of Health Policy and Management, 2010. http://www.deslibris.ca/ID/223317.
National Collaborating Centre for Determinants of Health. “Integrating Social Determinants of Health and Health Equity into Canadian Public Health Practice: Environmental Scan 2010.” National Collaborating Centre for Determinants of Health, 2011. http://nccdh.ca/resources/entry/scan.
National Collaborating Centre for Determinants of Health. “Leadership for Health Equity: Working Intersectorally and Engaging the Community in Western Health.” National Collaborating Centre for Determinants of Health, 2014. http://nccdh.ca/resources/entry/Working-intersectorally-and-engaging-the...
National Collaborating Centre for Determinants of Health. “Public Health Speaks: The Power of People and Systems.” National Collaborating Centre for Determinants of Health, 2014. http://nccdh.ca/resources/entry/public-health-speaks-the-power-of-people....
Public Health Agency of Canada. “Glossary of Terms - Public Health Practice - Public Health Agency of Canada.” Glossary of Terms, July 21, 2010. http://www.phac-aspc.gc.ca/php-psp/ccph-cesp/glos-eng.php
Solar O, Irwin A, 2007. A conceptual framework for action on the social determinants of health. World Health Organization.
The Wellesley Institute. “Acting on Social Determinants and Health Equity: Opportunities and Promising Practices for Public Health” July 2013. https://www.slideshare.net/WellesleyInstitute/opha-webinar-july-2013.
World Health Organization. “WHO | Social Determinants of Health.” Social Determinants of Health, 2017. http://www.who.int/social_determinants/en/.