Health Equity Talk: Understandings of Health Equity among Health Leaders

Abstract

IntroductionReducing health inequities is a stated goal of health systems worldwide. There is widespread commitment to health equity among public health leaders and calls for reorientation of health systems towards health equity. As part of the Equity Lens in Public Health (ELPH) program of research, public health decision makers and researchers in British Columbia collaborated to study the application of a health equity lens in a time of health system renewal. We drew on intersectionality, complexity and critical social justice theories to understand how participants construct health equity and apply a health equity lens as part of public health renewal.Methods15 focus groups and 16 individual semi-structured qualitative interviews were conducted with 55 health system leaders. Data were analyzed using constant comparative analysis to explore how health equity was constructed in relation to understandings and actions.ResultsFour main themes were identified in terms of how health care leaders construct health equity and actions to reduce health inequities: (1) population health, (2) determinants of health, and (3) accessibility and (4) challenges of health equity talk. The first three aspects of health equity talk reflect different understandings of health equity rooted in vulnerability (individual versus structural), determinants of health (material versus social determinants), and appropriate health system responses (targeted versus universal responses). Participants identified that talking about health equity in the health care system, either inside or outside of public health, is a ‘challenging conversation’ because health equity is understood in diverse ways and there is little guidance available to apply a health equity lens.ConclusionsThese findings reflect the importance of creating a shared understanding of health equity within public health systems, and providing guidance and clarity as to the meaning and application of a health equity lens. A health equity lens for public health should capture both the production and distribution of health inequities and link to social justice to inform action.

Searching for justice (and evidence) in public health: Exploring health equity in Canadian public health discourse and practice

“…Studies analysing public health policy documents provided me with insights into how and to what extent the idea of equity and related values such as social justice inform the content and direction of concrete actions (See Giacomini et al, 2003;Edwards and Davison, 2008;Giacomini et al, 2009;Pinto et al, 2012). Other empirical literature centres on how the idea and operationalization of health equity is understood from the perspectives of public health professionals in the context of their daily work (Rizzi, 2014;McPherson et al, 2016;Smith, 2016;Cheff, 2017;Hassen and Tyler, 2017;Pauly et al, 2017;Anne et al, 2018).…”

“…With few exceptions (e.g. Smith, 2016;Pauly et al, 2017;Anne et al, 2018), existing research does not attempt to make sense of their data in relation to other relevant literature. Nor do they attempt to make sense of findings through relevant theoretical perspectives.…”

“…Thought of in another way, equity's flexibility and wide adoptability allows for its successful extension (within a chain of equivalences) across a range of actions and actors. Several studies investigating the experience and perspectives of public health staff applying a health equity lens highlight how the flexibility afforded to health equity and its proxies in provincial standards impedes progress on health equity and SDOH (Rizzi, 2014;Hassen and Tyler, 2017;Pauly et al, 2017). But, as I will show further in Chapters Six and beyond, the language of health equity and its proxies do not only create confusion and impede action.…”

“…as a core value in PHAC Core Competencies document) while at others, it plays a 'scaffolding' role (e.g. in provincial public health policy documents) by generating an orientation or 'equity lens' without specifying a specific course of action to achieving some morally worthy end (Pinto et al, 2012;Tyler and Hassen, 2015;Hassen and Tyler, 2017;McPherson at al., 2017;Pauly et al, 2017). In some provincial documents, the concept of health equity offers an orientation coupled with actionable language around identifying vulnerable or priority populations, however it is unclear how the prescribed actions lead to more equity.…”

“…Ontario documents only focus on identifying priority populations where priority populations may be based on SDOH or burden of disease while BC policy documents direct public health organizations to measure priority populations using with a consideration of material SDOH. Despite any regional contrasts between these sets of organizational directives, research examining how public health leaders and frontline staff in both provinces actually apply a health equity lens shows that priority populations are often identified based on burden of disease or some need that can be met within existing organizational capacities, and for which actions can produce and be supported by epidemiological evidence (Rizzi, 2014;Tyler and Hassen, 2015;2017;Pauly et al, 2017).…”