Do tools catalyze action on health equity?
As part of Public Health 2017 in Halifax, NS, the National Collaborating Centre for Determinants of Health (NCCDH) co-hosted a pre-conference session on June 5th entitled “Public health leadership and capacity: Do tools catalyze action?” We worked closely with the National Collaborating Centre for Methods & Tools (NCCMT), the Equity Lens in Public Health (ELPH) project from the University of Victoria, and the Nova Scotia Healthy Authority (NSHA) to develop this day. We wanted to explore how the structure and leadership of public health can impact action to reduce health inequities, and how the use of tools can influence (and be influenced by) public health practice.
Over 70 participants took part, representing all regions of Canada except for the three territories. The two most common challenges we heard from folks in the room were getting support to take action on social justice issues in a health system based on biomedical principles, and when there was support, not being sure of exactly what to do or what tools are available to help address health equity.
Tools can be a catalyst for having conversations about the role of public health in addressing health equity. For example, using metaphors as a tool to communicate about principles of equity is a powerful way to frame the concepts and make them real to the audience you are working with. Sana Shahram from the ELPH project discussed the importance of embedding values like social justice early in communications about health equity to bring the audience together before talking about solutions — so stakeholders can see how they have a role in the options for change. Metaphors outlining an explanatory chain (cause of the problem, mediating factors, and final consequence) are effective in bringing attention to imbalances of power and resources that effect health outcomes. The ELPH project offers a list of resources including some related to metaphors, which can be used in combination with resources from the FrameWorks Institute on creating and using metaphors.
If tools can be catalysts for important conversations on health equity, in what environments can they be used most effectively? We learned that for tools to actually drive change, an organization’s capacity to actually take action on health equity must be considered. Giovanna Good from Lambton Public Health outlined how characteristics of individual practitioners (knowledge, values, skills, motivation, access to resources) exist within organizational processes and structures (organizational standards, culture, competencies, policies, planning, evaluation, reporting) that are influenced by system governance and decision making (reporting relations, inter-sectoral partnerships, accountability, provision of resources). To assess capacity of the internal environment, it is necessary to consider internal drivers of leadership, formal and informal systems, accountability, resources, partnerships, and governance/decision making. External influences can promote or limit the uptake of health equity as a priority in the wider socio-economic and political systems. A recent case study outlines how the Lambton Public Health framework can be used to assess public health organizational capacity to address health equity.
For an organization to consider its capacity to address health equity on any level means the organization needs to be both ready and willing to change practice. Kristin Read from the NCCMT highlighted models that can assess organizational readiness and resistance to change (some can be found in the NCCMT Registry of Methods & Tools) and influencing factors including the nature of the change, location of the push (top-down or bottom-up), clear outcomes that can also be measured, and nature of the organizational structure (hierarchical or flat). To consider which tool will work for a particular organizational context means attending to barriers and enablers that influence the ability to act on health equity and to using knowledge mobilization tools. Findings from a recent NCCDH co-supervised research project were shared, revealing barriers such as siloed organization structure, poor communication, lack of training, and lack of leadership support along with enablers such as strong relationships, dedicated health equity staff, and strong leadership support. The availability of knowledge mobilization tools was also noted as an enabler, and the ELPH inventory of health equity tools was highlighted. But as Bernie Pauly, one of the ELPH project principal investigators, noted, it is essential to consider whether there is competence on individual and organizational levels, while simultaneously critically assessing the quality of the tool and what type of tool is needed for what purpose in order to use health equity tools effectively.
The NSHA provides a natural experiment to explore how tools and organizational capacity come together as they implement a health equity lens within a centralized provincial public health authority. Carol McKinnon and Catherine Hebb (both of the NSHA) provided some early insights into embedding health equity in provincial public health protocols, the challenges of implementing a health equity lens province-wide, and the creation of a diversity lens toolkit to support cultural competence in public health work. The hope is that by embedding health equity principles within public health mandates, the broader health system can be transformed towards reducing inequities.
So, do tools catalyze action on health equity in public health? Tools can stimulate action within an organization that is ready to change, has the capacity to address equity, has attended to the barriers and facilitators to action, and that has direction based on values of social justice. Sometimes the right tool that has been critically assessed can help facilitate certain tasks or projects, but it is the organizational capacity and leadership that determine if the use of tools will lead to real change in public health practice.
What are you doing to support your organization’s capacity to effectively use tools that address health equity? What is your organization’s capacity to address health equity? Share your story! Send me your thoughts and ideas, or start a conversation in Health Equity Clicks.