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Strengthening organizational conditions that support the use of health equity tools

March 15, 2017

Left: Nova Scotia Public Health Standards (2011-2016); right: Nova Scotia Health Equity Protocol (2015)


The Nova Scotia Public Health Standards (2011-2016) and cross-cutting Health Equity Protocol (2015) arose out of a dedicated 2-year renewal process. Together they require Public Health staff to “understand the principles of health equity and social justice, develop critical analysis skills, and apply health equity approaches and tools." This requirement spurred groups within NS’s Department of Health & Wellness, the NS Health Authority, and the NCCDH to locate and develop tools that could support staff in taking a health equity approach.

Our project originated in 2015 with a call from the Nova Scotia Health Research Foundation (NSHRF) for project teams interested in exploring knowledge translation approaches to current issues in health services and policy. Our project team (Christine Johnson, NSHA Eastern Zone; Karen Fish, NCCDH; Doris Gillis, St Francis Xavier University Department of Human Nutrition; Lynn Langille, NS Department of Health & Wellness) successfully applied for the mentorship opportunity.

In the early days, our concern was to “fast track” the use of 4 tools in Public Health decision-making:

  1. NCCDH’s Public health roles for improving health equity;
  2. NS’s Health Equity Lens;
  3. NS Public Health’s Shifting the Conversation: A Focus on the Social Determinants of Health & Health Equity; and
  4. PHAC’s Toward Health Equity: A Tool for Developing Equity-Sensitive Public Health Interventions

Each of these tools was designed to help staff identify, understand and respond to inequities in the distribution of good health. 

As our work progressed, however, it became clearer that we had to focus on encouraging a culture shift to one that presumes the use of health equity tools in all its work. We recognized that our ‘tools’–focused goal had to happen within a bigger change: building individual and institutional commitment to the values of social justice and equity. We knew this all along, but we struggled with how to make it an organizational request.

Meanwhile, in the background and foreground for our group members, the health services in Nova Scotia were being centralized; nine district health authorities were merged into one provincial health authority. The structures and staffing of the organization we wanted to affect were in flux. Our work was at a point where we had to bring in more people, but there were too many staffing unknowns to reach out. We had to wait. 
One resource that supported our shift in thinking—from fast tracking tools to shifting organizational culture to support the use of tools—is the equity-focused knowledge translation approach from Jeff Masuda and colleagues (2014). This work—which became our guiding framework—emphasizes relationships, critical inquiry and reflexive practice. Masuda et al. set out to find a knowledge translation approach that accounts “for the critical context of differential views on why social inequalities exist and what should be done to address them.” They determined that in order to achieve “better reasoning” in decision-making, change agents need to investigate who is producing our evidence, how to present the possibility of alternative realities, and how to build pathways for collective action through relationship.
Our work was also influenced by the results of university-driven focus groups held in north eastern NS in 2015. StFX Human Nutrition honours research student Sarah Ngunangwa asked public health practitioners to identify barriers and enablers they experienced in using knowledge-to-action tools. People spoke of a lack of shared understanding of health equity and how to build it in public health practice. They also referred to widely-held and deeply-entrenched attitudes, values, beliefs and perceptions about what determines health and whether public health should engage in upstream action.

While we had been mentored to avoid the “training” solution trap, we knew the work of building institutional commitment demanded that we bring people together to reflect, share and discuss.  Even though each of us had facilitation and workshop design skills, we still felt stretched: we needed someone with extensive knowledge of education for organizational change. Our search led us to Darren C. Brown, a change and education consultant, who offered his services pro bono for a number of meetings. Darren’s expertise enlivened our work; we began to move through our philosophical blockages to start focusing on process and design. With Darren, we started designing a 3-part gathering for NSHA employees: what we called a straw dog. The design concept included inter-workshop projects for participants, projects that would keep them engaged in a reflection, research and action cycle. Our objectives expanded: we want to honour evidence from those with lived experience, make equity a pan-NSHA endeavour, and help staff discriminate in their use of tools and their choices how to engage in this work.

Today, the health sector reorganization dust is settling, and public health has four health equity staff in place. We are poised to move into action: to confirm organizational commitment to do this work, to determine the most strategic organizational approach, to broaden our team of organizers, and to find funds to continue to engage our consultant and to support the costs of bringing staff together.

We welcome your questions and feedback. Please contact Christine Johnson, Health Equity Lead, NSHA.

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