The power of people and systems - An interview with Dr. Benita Cohen
On December 3rd, we will be hosting an interactive webinar about the people and systems that support equity-oriented approaches in public health practice.
Help us create the content for this celebrity-interview-style webinar.
- Consider the question posed each week by Hannah Moffatt while reading an excerpt interview from Public Health Speaks: Organizational standards as a promising practice to advance health equity
- Join us in an online conversation held from November 26th to December 3rd in our Health Equity Clicks: community
Consider this question when reading the below excerpt:
How does the Organizational Capacity for Public Health Equity Action conceptual framework increase our understanding of effective public health leadership ?
Public Health Speaks: Developing a Conceptual Framework for Organizational Capacity for Public Health Equity Action. A conversation with Dr. Benita Cohen, RN, PhD, Associate Professor, Faculty of Nursing, University of Manitoba.
Hannah Moffatt, Knowledge Translation Specialist at the National Collaborating Centre for Determinants of Health (NCCDH) spoke with Dr. Benita Cohen, Associate Professor with the Faculty of Nursing at the University of Manitoba on September 29, 2012 about the interdisciplinary team research project to develop the conceptual framework for Organizational Capacity for Public Health Equity Action (OC-PHEA). While this research project does not focus on organizational standards explicitly, it was selected as an important example to highlight a tool available to support public health capacity development. Specifically, this tool can be used to facilitate discussions and planning efforts, both within and outside of public health organizations, to support strategies for health equity action. This project is part of Benita’s larger program of research, which focuses on building public health capacity to address and reduce inequities using a social justice lens.
Hannah Moffatt: Could you tell us about the conceptualization of the Organizational Capacity for Public Health Equity Action research project?
Dr. Benita Cohen: The motivation for this research stemmed from my former experience as a public health nurse, and the shared passion among the research team to address social injustice and health inequities. It was also influenced by the final report released by the World Health Organization’s Commission on Social Determinants of Health in 2008 Closing the Gap in a Generation. One of the Commission’s main conclusions was that addressing growing inequities in health— both between and within countries— was an ethical imperative and a matter of social justice. That really spoke to me. Since this report, I think there’s been widespread recognition of the need to address the growing inequities and, similarly, there is recognition about the potential role of public health to engage in activities that advance health equity. There has also been a lot of emphasis on developing effective public health interventions to support practitioners in achieving this goal. However, there is also evidence, such as what was put forward in the NCCDH’s environmental scan in 2010, that the capacity of public health organizations to engage in health equity action is quite variable across Canada.
A few years ago, I identified an interdisciplinary team of academic researchers with a shared interest in promoting social justice and equity to form the Organizational Capacity for Public Health Equity Action (OC-PHEA) project team. We also involved some non-academic collaborators with similar interests, and we were successful in securing a Health Equity Catalyst Grant from the Canadian Institutes of Health Research. Our first objective was to develop a conceptual framework to ground our OC-PHEA work, which could eventually inform capacity-building research initiatives. A literature review yielded a number of conceptual frameworks related to
organizational capacity; however, there really wasn’t one specific to equity action and particularly not in the Canadian context. So, based on our review of the literature, and our knowledge of the public health system, our research team decided to develop a framework that was grounded in the experience of health equity champions within the Canadian public health sector.
Hannah Moffatt: How were these health equity champions identified and what was their role in the project?
Dr. Benita Cohen: We identified and interviewed ten individuals with strong reputations as equity champions in the public health community. We also asked the interviewees to suggest others from their networks who they considered to be health equity champions, which led to interviews with a total of 16 individuals (including, senior public health administrators, public health practitioners, and program managers) from seven provinces across Canada. We used the information obtained in these interviews, combined with key themes from our literature review, to develop a draft conceptual framework. The interviewees were invited to provide feedback on the framework to ensure that what they had talked about was reflected in the draft, and to provide an opportunity to elicit suggestions for improvement.
Hannah Moffatt: What were the main findings of this interview process and what surprised you?
Dr. Benita Cohen: We asked the health equity champions to describe the context of their work. The interviewees identified factors that enabled and constrained their work in the area of health equity. These identified facilitators and barriers were especially pertinent to the development of the conceptual framework, and formed the main findings of our qualitative research. For example, many of the interviewees spoke to the multiple dimensions of organizational capacity required for health equity work. This observation was supported by the literature. Factors identified that affect organizational capacity included motivation and commitment to action, presence of leadership, access to knowledge, and training to develop skills and attitudes of practitioners. The need for sufficient infrastructure, including access to resources as well as supportive policies and processes, was also identified. Many interviewees also described the central role of partnerships, collaborative relationships, and networks occurring among health organizations and between health organizations and other government sectors, all with the purpose of addressing social and, even more importantly, structural determinants of health and health inequities.
The thing that really stood out for me was that the champions spoke about the complexity of these factors, both internal to their organizations and externally. The complexities create unique organizational contexts, which in turn determine how and which aspects of capacity are developed. For example, tension of organizational priorities, role overload, dominance of acute care on policy agendas, and lack of readily available measurement tools can act to constrain organizational capacity for health equity action. Alternatively, a key facilitator that emerged through analysis is the powerful influence of equity champions, particularly those in senior management and governance positions. Equity champions or those people with credibility, respect, a commitment that is inspiring to others, and who consistently advocate to make health equity a priority, can significantly influence how capacity needs are identified and addressed. Those are some of the key findings that informed the development of the framework.
Hannah Moffatt: As a result of this process, could you describe what the conceptual framework looks like, and how it fits within the context of organizational settings?
Dr. Benita Cohen: We actually have a graphic that depicts the framework components and their interrelationship. Essentially, the framework contains two key domains of organizational capacity for public health equity action: (1) the internal context (i.e., those dimensions of the organization that determine its ability to take action on health equity); and (2) the enabling external environment (i.e., those dimensions of the local community and broader systems that determine the ability of public health as a sector to act). Both the internal and external domains are characterized by similar dimensions, for which there are three: (1) shared beliefs and values; (2) demonstrated commitment and will to act; and (3) supportive infrastructure. For each of the two broad domains, internal context and external environment, we identified an initial set of key elements, which could ultimately serve as capacity indicators.
To illustrate further, the OC-PHEA framework suggests that equity action requires internal capacity in three areas: (1) an identified organizational-level belief that promoting health equity is a priority; (2) a commitment to equity-focused action as expressed in strategic plans; and (3) provision of structures and resources necessary to support equity action, such as health equity champions at all levels of the organization. Elements of organizational infrastructure are factors like access and ability to interpret local data on inequities, advocacy skills among the workforce, and processes to ensure community engagement influences organizational decision-making. Equity action also requires similar capacity within the external environment. For example, if you were to look at the domain of external or community infrastructure, it would include others outside of public health that can access decision makers and resources for equity actions at all jurisdictional levels.
There is an important underlying assumption of the framework, and that is that there must be alignment and key linkages (e.g., coalitions) between the internal and external domains to strive for health equity. In other words, optimal capacity would exist if both the internal and external domains were strong and well supported. But in reality, we do recognize that differing levels of capacity exist within organizations at different points in time. Therefore, even in the absence of optimal capacity, an organization may have some ability to take effective action to address health inequities. We think that’s very important— everyone can do something.
Hannah Moffatt: How do you think this framework could be applied in real world public health settings to help build organizational capacity for taking action on health equity?
Dr. Benita Cohen: In the broadest sense we hope that the conceptual framework will serve as a resource for public health organizations and practitioners. The framework can be used as an opportunity to reflect and to engage in a dialogue on factors that influence, or act as barriers to, health equity actions. Public health organizations could use the constructs presented to identify their own capacity indicators or identify indicators that could be used to measure or monitor
capacity over time. The framework definitely can serve as a discussion and planning tool.
The second capacity in which the framework may be used is as a platform to engage other public health leaders and leaders from other sectors, as they strive to institutionalize their health equity practice. This could advance the health equity discourse and the integration (or mainstreaming) of social justice into public health practice.
We expect that as the framework is applied in various real world settings, the feedback from users will contribute to further revisions that will enhance the framework’s applied use. We’re hoping this will continue to be an iterative development process. We are not presenting the framework as the be-all and end-all; but it is a first jumping off point. Ultimately, we would like to obtain additional funding to identify a specific set of indicators, and then use those indicators to monitor changes in organizational capacity for public health equity action over time. Our team is hoping to engage public health units at the regional-local level to collaborate with us as we move forward.
Hannah Moffatt: What advice would you offer to practitioners or organizations interested in building their capacity to take action on health equity issues?
Dr. Benita Cohen: One piece of advice that really stands out to me is that addressing health inequities needs to be considered as an overall systems performance issue. It cannot be something that is viewed as the sole responsibility of one group, or simply as an additional factor in a list of public health priorities. Health equity action requires its own strategy; its own measurement plan including, the assessment of current capacity to take action; and a sustainability plan to ensure continued action and long-term impacts.
The literature identifies the assessment of organizational capacity as a first step in taking appropriate actions. The conceptual framework of Organizational Capacity for Public Health Equity Action is a tool that can help organizations to conduct this type of assessment. So, my parting words would be that on behalf of my research team, we encourage practitioners to use this framework and adapt it to their own needs. We anticipate it will be an effective tool to support practitioners as they move forward with their health equity work.
Hannah Moffatt: Thank you very much, Benita for sharing your thoughts and your research with us today. Best of luck as you move forward with this very important initiative to develop public health capacity in the area of public health equity action.
Each of these interviews can be found in Public Health Speaks: Organizational standards as a promising practice to advance health equity.
Join us starting next Tuesday, November 26th to December 3rd for a conversation in the Health Equity Clicks: online community for an opportunity to co-create the Dec. 3rd webinar.
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CollaborationCompetencies & organizational standardsHealthy public policy