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Considering equity in public health and health systems: An example from northwestern Ontario

Considering equity in public health and health systems: An example from northwestern Ontario

By Brianne Wood on December 19, 2018

Image: Kakabeka Falls, Thunder Bay District, Ontario


Author Brianne Wood is an epidemiologist with at the North West Local Health Integration Network. The views mentioned here are her own. For this post, she consulted epidemiologist Erica Sawula of the Thunder Bay District Health Unit.


In epidemiology — the science of counting in public health [1] — we measure and report on the socio-economic characteristics of a population, such as income, education and job status. While the connection between these socioeconomic characteristics and health is clear, translating these numbers into policies and practice that can improve the wellness of a population is more challenging.

Local SDH profiles: A northern, rural and remote community context

The Thunder Bay District Health Unit (TBDHU) makes its epidemiological data available to community partners to use with a local profile [i] of demographic and economic data, using the Public Health Agency of Canada’s determinants of health list. This profile highlights two important differences between the TBDHU and the rest of Ontario:

  1. The TBDHU population faces unique socioeconomic challenges compared to other regions in the province.
  2. These differences are associated with a lower life expectancy (two years lower than the Ontario average) and an increased likelihood of dying of preventable causes. [2]

Mobilizing social determinants data

These reports offer a glimpse into the context of our region in northwestern Ontario — the social, demographic, economic, political and geographic make-up that contributes to our health and overall well-being. Public health professionals rely on these population-level statistics to understand our residents.
These details are particularly important when identifying public health priorities.

For example, the TBDHU profile highlighted a higher prevalence of food insecurity than the province at large. The TBDHU Nutrition program used this gap to prioritize innovative ideas to improve individuals’ and communities’ access to healthy foods.

The Food Action Network’s Gleaning Project facilitates visits to local farms for individuals facing socioeconomic challenges to gather crops that would otherwise be left in the field after harvesting. 

Understanding local communities through data

Erica Sawula (left) and Brianne Wood, epidemiologists in Northern Ontario

In northwestern Ontario, having a better understanding of our population has changed our strategy regarding, for example, food options at public events (i.e., having traditional options including wild game) or conducting water inspections in remote areas (i.e., accessing such areas via canoe). To learn more about public health in unorganized areas, click here.
At the TBDHU, data on the social determinants also helps programs tailor a public health intervention to local communities, whether these communities are defined by geographic or social characteristics. For example, understanding the population segments that aren’t getting flu shots or are more likely to binge drink will highlight opportunities for partnerships or campaigns to work with that particular community. 

We can also use social determinants data to assess whether participation in programs and evaluations (like the infant feeding survey, to be reported on next year) to examine is reflective of the broader population, in terms of factors such as income, ethnicity and education.

While mobilizing something that we would love to do more of, challenges with small area estimation make it hard for us to get down to the neighbourhood level. Sample sizes are small and these surveys systematically miss Indigenous people and communities. [3] With these considerations in mind, it is difficult for us to fully understand our community’s strengths and challenges in relation to public health.

SDH data informs health system planning

Our social profiles of local populations quickly caught the attention of health system planning tables of our Local Health Integration Network (the North West LHIN), the regional health network that plans, funds and integrates local health systems for the area.

The North West LHIN’s jurisdiction includes both the TBDHU and the Northwestern Health Unit (NWHU), and covers almost half of Ontario’s land mass (bigger than Sweden!). Having information about the SDH, as well as measures of the health system performance, helps the transdisciplinary “planning tables” determine their local health priorities to direct funding. For example, planning tables will consider how technology programs can support diabetes patients in remote communities, or how primary care teams can support patients who face socio-economic challenges and health challenges.

Expanding our reporting

This cross-sector appetite for SDH data solidified the need for continued work looking at the SDH and health equity in our populations. The North West LHIN, the TBDHU and the NWHU epidemiologists are now collaborating to produce a joint health Equity Report for Northwestern Ontario (expected publication in summer 2019).

Building upon the Northern Health Equity Strategy by Health Quality Ontario, this report aims to accomplish two main goals:

  1. Determine a common description of health equity and population health for the North West LHIN, the TBDHU and the NWHU.
  2. Measure relationships between social determinants and population health outcomes for LHIN sub-regions, the NWHU, the TBDHU and the LHIN itself.

While only a starting point, this information is vital to describe the “know-do” [4] gap in health equity for northwestern Ontario. The next step is action. Stay tuned!



[i] Check out the latest version of the profile here. The TBDHU’s neighbouring public health agency — the Northwestern Health Unit (NWHU) — reported similar findings in their communities. Check out their report here.


[1] Galea S. Making epidemiology matter. Int J Epidemiol. 2017 Aug 1 [cited 2018 Dec 19];46(4):1083-5.

[2] Buajitti E, Chiodo S, Watson T, Kornas K, Bornbaum C, Henry D, et al. Ontario atlas of adult mortality, 1992-2015, Version 2.0: trends in public health units. Toronto (ON): Population Health Analytics Lab; 2018.

[3] Rotondi MA, O'Campo P, O'Brien K, Firestone M, Wolfe SH, Bourgeois C, et al. Our health counts Toronto: using respondent-driven sampling to unmask census undercounts of an urban indigenous population in Toronto, Canada. BMJ Open. 2017 [cited 2018 Dec 19];7(12), e018936.

[4] Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: time for a map?. J Contin Educ Health Prof. 2006 [cited 2018 Dec 19];26(1):13-24.


Photo credit 1: Erica Sawula

Photo credit 2: Ashley Cerqueira


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