10 Promising practices

As part of a Canadian Health Services Research Foundation Fellowship (Executive Training in Research Application – EXTRA), the Health Unit conducted a review and analysis of the literature for practices to reduce social inequities in health.

These practices are relevant at the local public health level and are “promising” in their potential to“level-up” and reduce health inequities.

This chart depicts the Ten Promising Local Public Health Practices to Reduce Social Inequities in Health. They can be grouped into three sections: lifestyle-focused, policy-focused, and cross-cutting. The practices are: 1. Targeting with universalism, 2. Intersectoral Action, 3. Equity focused health impact assessment, 4. Social marketing, 5. Early child development, 6. Purposeful reporting, 7. Competencies and organizational standards, 8. Contribution to evidence base, 9. Community engagement, and 10. Health equity target setting. Adapted from: Sudbury & District Health Unit. (2010, May). Implementing local public health practices to reduce social inequities in health. EXTRA (Executive Training for Research Application) Intervention Project: Final report.

 

1. Targeting with universalism

Every citizen deserves the opportunity to be healthy and to practise healthy behaviours. Thus, health promotion and protection programs and services endeavour to ensure that everyone has access to programs and services. Services designed for general access — by everyone, in the same way — constitute a universal approach.

However, evidence shows that individuals who benefit most from “universal” health programs and services are often those who have more money, more time, more social support, higher literacy and better preceding health. In some cases, universal programs may increase health inequities such that the health of those who are socially advantaged improves more than the health of those who are socially disadvantaged. In their levelling up discussion papers, Dahlgren and Whitehead explain that a “levelling-up” approach is necessary to disproportionately improve the health of more disadvantaged groups while at the same time improving the health of the entire population.1, 2

Targeting within universal programming can be focused on priority populations within a universal strategy. For example, universal interventions can be adjusted to increase accessibility for certain groups, or specific strategies can be developed to address inequalities in the social determinants of health. This fine-tuning of programs increases the likelihood that those who are at greater risk of adverse health receive the greatest benefit. As a result, the health of the entire population improves, but the health of priority populations improves faster —reducing health inequities.

Example: Sudbury & District Health Unit school health programming

The School Health Promotion Team at the Sudbury & District Health Unit (SDHU) has adopted a new approach to working with area schools. Following recommendations from the EXTRA Research Fellowship, the team implemented a “targeted within universal approach” delivery model. Dahlgren and Whitehead1, 2 describe the need to improve disproportionately the health of more disadvantaged groups through targeting, while at the same time improving the health of the entire population.

In partnership and consultation with local school boards, select schools now receive an intensive level of tailored public health programs beyond the universal programs and services offered to all schools. This programming includes the “Can You Feel It?” youth engagement program. The program provides students with skill building opportunities and supportive relationships with peers, school staff, families and community agencies through extra-curricular networks and activities. The program builds student resilience by focusing on their inherent strengths and resources.

What helps me apply targeting with universalism in practice?

What makes targeting with universalism challenging?

References: Promising practice #1: targeting with universalism

1 Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in health: Levelling up part 1. World Health Organization; 2006.

2 Dahlgren G, Whitehead M. European strategies for tackling social inequalities in health: Levelling up part 2. University of Liverpool: WHO Collaborating Centre for Policy Research on Social Determinants of Health; 2006.

Useful links

Concepts and Principles for Tackling Social Inequities in Health: Levelling Up Part 1. Margaret Whitehead and Göran Dahlgren. 2006

The Inequality Paradox: The Population Approach and Vulnerable Populations. Katherine L. Frolich and Louise Potvin. 2008

Can You Feel It? Sudbury & District Health Unit School Program Resources Priority

2. Purposeful reporting

The World Health Organization, among others, identifies the importance of reporting purposefully on the relationship between health and social inequities in all health status reports. The WHO document The Social Determinants of Health: Developing an evidence base for political actionhighlights the link between sharing knowledge of health inequities and political action.3 Similarly, Closing the Gap in a Generation,4 notes that “ensuring that health inequity is measured . . . is a vital platform for action” (p. 2). Thus, intentional and public presentation of evidence about health inequities can be part of a broad strategy for change.

Stratifying data by socioeconomic status (SES), rather than controlling for the effect of SES as many analyses do, is one approach to highlight inequities. Through stratification, the effect of income on health status becomes apparent. Similar analyses could be undertaken for links between health and unemployment, social exclusion, education, deprivation, and other variables.

An additional benefit to reporting in a way that presents, rather than masks, the effect of social inequities in health, is that evidence of progress, or lack thereof, can be revealed and can guide future interventions.

Example: Using a deprivation index to report on community health outcomes

Using a deprivation index developed by the Institut national de santé publique du Québec (INSPQ),5 the Sudbury & District Health Unit is analyzing the relationships between the level of “deprivation” existing in Greater Sudbury neighbourhoods and several commonly reported health outcomes. The INSPQ deprivation index divides socio-economic status into two components, material and social, which together form the deprivation scores for given geographic areas. Reporting health data in this way has highlighted that, among other measures of overall health, more deprived areas suffer higher rates of premature death, hospitalizations and emergency room visits.

Deprivation indices are one tool that health units can use to examine the links between socio-economic status and health outcomes in their communities. In the Sudbury & District Health Unit area, strategic reporting of this information to community leaders and decision makers has prompted both dialogue and action to address health inequities, including two pilots of Equity-focused Health Impact Assessment with community agencies.

What helps me apply purposeful reporting in practice?

What makes purposeful reporting challenging?

References

3 Kelly M, Morgan A, Bonnefoy J, Butt J, Bergman V. The social determinants of health: Developing an evidence base for political action. Measurement and Evidence Knowledge Network, WHO Commission on Social Determinants of Health; October 2007.

4 WHO Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.

5 Pampalon, R., Hamel, D., Gamache, P., Raymond, G. A deprivation index for health planning in Canada. Chronic Diseases 2009; 29(4):178-191.

Useful links

First Steps to Equity: Ideas and Strategies for Health Equity in Ontario, 2008-2010, Diane Patychuk and Daniela Seskar-Hencic, 2008

The Unequal City: Income and Health Inequalities in Toronto, Toronto Public Health, 2008

Ontario Public Health Standards, 2008: Population Health Assessment and Surveillance Protocol Priority

Exploring Urban Environments and Inequalities in Health:Greater Sudbury Census Metropolitan Area, Canadian Institute for Health Information, 2010

3. Social marketing

Social marketing is “the systematic application of marketing alongside other concepts and techniques,to achieve specific behavioural goals, for a social good.” (p. 451)6 Social marketing involves defining and understanding target audiences so that interventions and health communications can be tailored to audience needs and preferences.

With the objective of reducing health inequities, social marketing interventions for local public health practice can create positive social change and improve the health of vulnerable populations by two approaches. The first tailors behaviour change interventions to more disadvantaged populations (with the goal of levelling-up). The second, less conventional approach, uses social marketing to change the understanding and ultimate behaviour of decision makers and the public to take or support action to improve the social determinants of health inequities.7

Example: Let’s Start a Conversation About Health . . . (video and user guide)

Created in June 2011 by the Sudbury & District Health Unit, Let’s Start a Conversation About Health . . . and Not Talk About Health Care at All is a five-minute video highlighting that health is about much more than access to medical care. Along with its accompanying User Guide, the video highlights that everyone has different opportunities for health, largely influenced by their social and economic conditions. It describes actions that various non-health sectors can take and encourages everyone—teachers, builders, dads, nurses, business women, students, politicians—to start a conversation about health . . . and not talk about health care at all.

All SDHU staff have engaged in internal discussion sessions to build their own awareness and understanding of these tools and to explore ways to use them throughout our communities. The video has been shared widely among community decisions makers, agencies, and citizen groups and has sparked both conversation and action towards healthy public policy and the reduction of health inequities. Based on audience feedback and evaluations, the video has been adapted to reflect the diversity of languages, cultures and literacy levels that make up our community.

What helps me apply social marketing in practice?

What makes social marketing challenging?

References

6 Farr M, Wardlaw J, Jones C. Tackling health inequalities using geodemographics: A social marketing approach. International Journal of Market Research 2008; 50(4):449.

7 Grier S, Bryant CA. Social marketing in public health. Annual Review of Public Health 2005; 26:319-39.

Useful links

Community-Based Social Marketing: Fostering Sustainable Behavior

Let’s Start a Conversation About Health . . . and Not Talk About Health Care at All. Video & User Guide. Sudbury & District Health Unit. 2011

4. Health equity target setting

As understood by the National Health Service in the United Kingdom, “targets are a way of ensuring that resources and effort are directed at tackling health inequalities in an explicit and measurable way.” (p. 9)8 Many countries have incorporated target setting into their intersectoral work on social inequities in health. However, as the World Health Organization highlights, the exact nature of the targets appears to be important, since some targets may be more enabling of progress than others.9

Although target setting is not universally supported in the literature, it appears to hold some promise as part of a strategy for reducing health inequities and may have a role at the local public health level. Examples of target setting suggest it is important to focus on targets in areas shown to be remediable, as opposed to setting lofty but perhaps unattainable targets. Target setting as part of a community engagement process with multiple sectors connects target setting to other identified aspects of health inequity practice.

Example: Priority setting for the Saskatoon Regional Intersectoral Committee

In 2008, the Saskatoon Health Region published the report, Health Disparity in Saskatoon: Analysis to Intervention. This work highlighted some stark health inequities experienced by Saskatoon residents and presented an analysis of community support for policy or initiative options aimed at reducing those inequities.

Informed by that report, the existing Saskatoon Regional Intersectoral Committee (SRIC) identified three priorities for its work: a community action plan for poverty reduction, sustainable housing and employment for Indigenous people. These priority action areas included consideration of specific targets such as “Indigenous employment in the workforce should increase to 15% of full-time service jobs, 15% of management positions and 15% of professional workplaces within 10 years; or by 2017.” (p. 23)10

Supporting community accountability for the SRIC priorities and targets, they further recommended that there be “organizational sponsors for each of the options or initiatives, responsible for seeing that actions are defined and implemented.” (p 20)10

What helps me apply health equity target setting in practice?

What makes health equity target setting challenging?

References

8 Bull J, Hamer L. Closing the gap: Setting local targets to reduce health inequalities. Health Development Agency; 2007.

9 Public Health Agency of Canada, World Health Organization. Health equity through intersectoral action: An analysis of 18 country case studies. Canada: World Health Organization; 2008.

10 Saskatoon Regional Intersectoral Committee. Follow-up to policy or initiative options in the Health Disparity in Saskatoon Report: Recommendations for action in our community – working document. Saskatoon Regional Intersectoral Committee; 2009.

Useful links

From Poverty to Possibility . . . and Prosperity. Saskatoon Poverty Reduction Partnership. 2011

Healthy Lives, Healthy People: Improving Outcomes and Supporting Transparency. Department of Health. 2012

5. Equity-focused health impact assessment

Health impact assessment (HIA) is a structured method to assess the potential health impacts of proposed policies and practices. HIA enables decision makers to highlight and enhance the positive elements of a proposal, and minimize the aspects that may result in negative health outcomes.11 By evaluating a broad range of evidence, HIAs are a useful way to assess the impact of proposals (either policy or specific practice) at the general population level. However, they are also recognized as a promising method to address the underlying social and economic determinants of health and resulting health inequities.12

Equity-focused health impact assessment (EfHIA) specifically includes questions such as “Is this proposal likely to affect those who are already disadvantaged? Is it likely to impose new health burdens on specific groups? Is it likely to change exposure to, and/or distribution of, risk factors or specific determinants of health (for example, living conditions, access to services)?”12 By applying an equity lens to HIAs, it becomes clear that virtually every policy has winners and losers — some groups benefiting more than others.

With the goal of reducing social inequities in health, this knowledge can assist decision makers to minimize negative health outcomes, compensate those affected with other benefits, and ensure that those affected are not already disadvantaged.13 Furthermore, increasing awareness of the determinants of social inequities in health among decision makers and other stakeholders has the potential of influencing both immediate and long-term policy decisions.12,13 Finally, a truly participatory approach to conducting EfHIAs can build the capacity of individuals and communities and foster social networks among diverse community members.

Example: Sudbury’s Community Door Working Group, shared space concept

Sudbury’s Shared Space Working Group, including representatives from social services, mental health, business, and education, engaged the support of the Sudbury & District Health Unit to conduct an equity focused health impact assessment of a proposed “shared space concept” within the City of Greater Sudbury. This model would bring together diverse non-profit service providers into one location to share services, reduce costs, and potentially serve clients better.

Over 50 diverse community stakeholders provided their perspectives on the potential impacts of the shared space model. This helped ensure that the needs of all members of our community were represented and explored. In addition, it guided further research and assessment conducted by Health Unit staff in collaboration with the Sudbury Shared Space Working Group.

The final report of this EfHIA included a summary of the most significant potential health impacts identified by community stakeholders, a brief review of the evidence related to those impacts and recommendations for the Sudbury Shared Space Working Group as they explore the implementation of the “shared space model”.

What helps me promote and conduct an equity-focused health impact assessment?

What makes equity-focused health impact assessments challenging?

References

11 Taylor L, Quigley R J. Health impact assessment: A review of reviews. Health Development Agency; October 2002.

12 Taylor L, Gowman N, Quigley R. Addressing inequalities through health impact assessment. Health Development Agency; 2003.

13 Kemm J. Health impact assessment and health in all policies. In: M. Stahl, M. Wismar, E. Ollila, E. Lahtinen, K. Leppo, editors. Health in all policies: Prospects and potentials. Finland: Ministry of Social Affairs and Health, Finland; 2006.

Useful links

Health Impact Assessment as a Tool to Reduce Health Inequalities. National Collaborating Centre – Healthy Public Policy (NCCHPP). 2008

Health Impact Assessment – Fact Sheet. NCCHPP. 2009

Health Impact Assessment – Inventory of Resources. NCCHPP. 2009

6. Competencies/organizational standards

Competencies and organizational standards guide our daily practice. The Public Health Agency of Canada14 identifies 36 core competencies for public health encompassing essential knowledge, attitudes, and skills. Most importantly, these competencies were developed for practice within the context of the values of public health and include, for example, equity, social justice, community participation, and determinants of health. The core competencies for public heath offer a solid foundation for local public health staff recruitment and skill development.

As building blocks for effective public health practice, organizational standards provide benchmarks for public health units. They help promote organizational excellence and establish the foundation for effective and efficient program and service delivery.15 Organizational standards that are rooted in health equity enable public health organizations to build a workforce and allocate resources to prioritize work to reduce social inequities in health.

Example: Ontario Public Health Standards, 2008

The efforts of Ontario’s public health units are guided by the province’s Ontario Public Health Standards, 2008 (OPHS). These standards provide a framework for public health activities and outline specific goals and requirements for local boards of health. The OPHS include overarching principles such as “Public health interventions shall acknowledge and aim to reduce existing health inequities. Furthermore, boards of health shall not only examine the accessibility of their programs and services to address barriers (e.g. physical, social, geographic, cultural, and economic), but also assess, plan, deliver, manage, and evaluate programs to reduce inequities in health while at the same time maximizing the health gain for the whole.” (p. 13)15 They also specifically direct public health units in areas of programming and services for priority populations, population health assessment, surveillance, research, and knowledge exchange.

Public health standards that acknowledge and direct public health units to address the social determinants of health guide decisions made by boards of health as they consider resource allocation and staff capacity to reduce health inequities.

What helps me promote competencies and organizational standards?

What makes the development of competencies and organizational standards challenging?

References

14 Public Health Agency of Canada. Core competencies for public health in Canada: Release 1.0. Ottawa, ON: Public Health Agency of Canada; 2008.

15 Ministry of Health and Long-Term Care. (2008). Ontario Public Health Standards 2008. Toronto: Queen’s Printer for Ontario.

Useful links

Core Competencies for Public Health in Canada.Public Health Agency of Canada. 2008

Ontario Public Health Standards, 2008

Sudbury & District Health Unit Strategic Plan 2013–2017

7. Contribution to the evidence base

When public health staff are asked about their capacity to address social inequities in health, a frequent issue that emerges is a lack of “best practices” to guide their interventions. The EXTRA Research Fellowship was carried out, in part, to help address these staff needs. However, it confirmed the existence of a gap in the evidence base with respect to effective local public health practice to reduce social inequities in health.

The evidence that does exist is often produced by practitioners working in a service delivery context in which publishing is not a priority. The evidence produced is often preliminary, small scale and specific to a particular context. Therefore, practice-based evidence might not be accepted for publication in traditional academic outlets. Grey literature (reports and evaluations) form part of the knowledge base for local public health interventions, but even these do not represent a complete picture of existing practice knowledge. Grey literature is often difficult to access.

It is important that practitioners consistently undertake evaluations of interventions aimed at reducing health inequities. Such evaluations should explicitly capture the impact of activities on different populations. In addition, the burgeoning knowledge base on addressing social inequities through local public health action can be strengthened by intentional dissemination of knowledge. Knowledge exchange can occur through conventional mechanisms such as journal publications and reports, or through communities of practice.

Example: The National Collaborating Centre for Determinants of Health

The National Collaborating Centre for Determinants of Health (NCCDH) focuses on the social and economic factors that influence the health of Canadians. The Centre translates and shares information and evidence about the social determinants of health with front-line public health practitioners, policy makers and researchers—the individuals who need this information to make evidence-informed decisions for practice, planning, policy and research.

The objectives of the NCCDH are to:

What helps me contribute to the evidence base?

What makes contributing to the evidence base challenging?

Useful links

Databases of health equity initiatives:

Inequalities in Health System Performance and Social Determinants in Europe – Tools for Assessment and Information Sharing. World Health Organization

European Portal for Action on Health Inequalities

The Prevention Institute

Health Equity & Social Justice Toolkit. National Association of County & City Health Officials. 2012

8. Early childhood development

Early child experiences establish the foundational building blocks for development across the life stages.16 Furthermore, with the greatest gains experienced by the most deprived children,investments in early child development have been referred to as powerful equalizers.16

Early child experiences influence language, physical, social, emotional and cognitive development, which in turn, and throughout the life course, affect learning, educational, economic and social success and health.16, 17, 18 Early childhood development (ECD), nurturing environments and quality childhood experiences are important for positive human development and health. Early child experiences contribute to positive developmental outcomes, and subsequently health, through a number of pathways,including psychological, behavioural and physical.19

Some of the specific early childhood interventions noted in the literature and familiar to public health practice include prevention of fetal alcohol spectrum disorder, promotion and support of breastfeeding, home visiting and positive parenting practices. Areas of policy and program focus that have been demonstrated to be effective include those related to housing quality, childcare and early learning, food security, youth sexual education and consultation, promotion of equity between rural and urban areas and elimination of child poverty.

Example: Triple P Positive Parenting Program of Sudbury and Manitoulin districts

Community partners from across Sudbury and Manitoulin districts have embraced the Triple P Positive Parenting Program as a valuable resource for every parent. Providers from health, education and social services agencies have been trained to assist parents with interventions ranging from providing advice by telephone, in-person consultations and parenting support.

By working collaboratively to provide area parents with the resources and support they need, Triple P partners are working to enhance early childhood development by, promoting development, growth, health and social competencies, promoting the development of non-violent, protective and nurturing environments, promoting the independence and health of families by enhancing parenting skills and reducing the incidence of child abuse, mental illness, behavioural problems, delinquency and homelessness.

What helps me promote positive early childhood development?

What makes the promotion of positive early childhood development challenging?

References

16 CSDH. Closing the gap in a generation: Health equity through action on the social determinants of health: Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.

17 Irwin L, Siddiqi A, Hertzman C. Early child development: A powerful equalizer. World Health Organization’s Commission on Social Determinants of Health; June 2007.

17 Pascal CE. With our future in mind: Implementing early learning in Ontario; 2009.

19 McCain MN, Mustard F. Reversing the brain drain: Early years study: Final report. Toronto: Ontario Children’s Secretariat; 1999.

Useful links

Early Child Development: A Powerful Equalizer. Final report for the World Health Organization’s Commission on the Social Determinants of Health. 2007

Childhood/ Early Life Backgrounder. Unnatural Causes Health Equity Database. 2008

Video – “Brain Hero”. Centre on the Developing Child, Harvard University, 2011

9. Community engagement

As a strategy to reduce health inequities, community engagement is the process of involving community stakeholders in the development and implementation of policies, programs and services. In closing the gap in a generation, the World Health Organization highlights the need to “empower all groups in society through fair representation in decision-making about how society operates, particularly in relation to its effect on health equity, and create and maintain a socially inclusive framework for policy-making.”20

Working with community professionals and agency representatives is one approach to engagement. However, building relationships with target populations and service users is also key to identifying community strengths and challenges. Engaging diverse community members in the development and implementation of policies, programs and services builds awareness and skills of participants and increases the likelihood that programs are appropriate and responsive to community needs.

Example: Development of a Greater Sudbury community drug strategy

The ongoing development and implementation of a strategy to reduce the misuse of substances in the City of Greater Sudbury has involved input from a wide variety of community partners including those whose lives have been impacted by substance misuse.

Partners working in the areas of prevention, enforcement, harm reduction, treatment and others whose work is impacted by the substance misuse of others (for example, faith groups, Children’s Aid Society) were called upon to share their knowledge, dreams, and solutions to the challenges of substance misuse at one of five meetings. A person recovering from substance misuse and a current substance user were both present to share their ideas at each of these meetings.

Follow-up meetings to assess the positive and negative impacts of proposed ideas and strategies were held with current substance users and those in various stages of recovery at locations that were convenient and comfortable for them. This process of engagement with both community service providers and users validated and strengthened the proposed drug strategy that was recommended to City Council.

What helps me apply community engagement in practice?

What makes community engagement challenging?

References

20 WHO Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.

Useful links

Building communities from the inside out: A path towardfinding and mobilizing a community’s assets. John Kretzman and John McKnight. 1993. Available in the Sudbury & District Health Unit Resource Centre

The Community Tool Box. A resource of community building guidance and tools

Tamarack Institute for Community Engagement

Health Canada Policy Toolkit for Public Involvement in Decision Making. 2000

Community Engagement and Communication. Module 5.The Health Planner’s Toolkit. Health System Intelligence Project. Government of Ontario. 2006

10. Intersectoral action

A comprehensive strategy to promote health includes health care when individuals are ill and addresses the underlying causes of poor health where people live, work, learn and play. These underlying causes are, in part, the result of social, economic and political actions from different community sectors and all levels of government and industry. Safe and affordable housing, access to parks and recreational activities, quality health care, early childhood education, safe streets, public transportation and opportunities for meaningful employment are just some of the many factors that influence an individual’s opportunities for health and well-being.

Intersectoral action is critical to building health for all because many of the solutions to addressing social inequities in health lie outside of the health sector. Building strong and durable relationships between public health and other sectors (for example, education, municipal, transportation, environment, finance) is necessary for effective action to build healthy communities and reduce social inequities in health.

Example: The Marginalized Populations Coalition for Housing

The presence of mould, poor property maintenance, lack of sanitary facilities and insect infestations are examples of housing and living conditions that may negatively impact a resident’s physical and mental health. These health hazards are related to many factors and addressing them requires actions from many community partners.

In the fall of 2009, the Sudbury & District Health Unit took a lead role in developing a multi-agency coalition to address the housing-related concerns of vulnerable or marginalized residents of our communities. Partnerships have been fostered with community stakeholders including the Homelessness Network, providers of mental health and home nursing services and the City of Greater Sudbury (including by-law enforcement, building services, emergency medical services, police services, fire services and Greater Sudbury Housing Corporation).

The coalition works collaboratively to exchange knowledge and expertise, serves as a point of referral and conducts joint field inspections as necessary. Members meet on a regular basis to discuss current cases and brainstorm solutions to complex scenarios. Several positive and creative resolutions to housing issues have been achieved for vulnerable members of our communities.

What helps me promote intersectoral action?

What makes intersectoral action challenging?

Useful links

The Community Tool Box. A resource of community building guidance and tools

Tamarack Institute for Community Engagement


This item was last modified on August 10, 2016