Improving the focus on health inequities in public health practice:

The OAHPP experience with equity lens development

Brian Hyndman MHScIngrid Tyler MD MHSc MEd FRCPC

Objectives

• To summarize work to date on the development of an OAHPP equity lens;

• To describe the application of the equity lens by the Smoke-Free Ontario Scientific Advisory Committee;

• To present a proposed equity lens for use by public health units in implementing the OPHS Foundational Standard;

• To give participants an opportunity to apply the proposed lens (using hypothetical scenarios) and provide feedback on the lens.

Health Equity• The absence of systematic and potentially remediable differences in one or more aspects

of health across populations or population groups defined socially, economically, demographically, or geographically.

Health Inequalities• Differences in health status experienced by various individuals or groups in society.

These can be the result of genetic and biological factors, choices made or by chance, but often they are because of unequal access to key factors that influence health like income, education, employment and social supports.

Health Inequities• Health inequities are differences in health which are not only unnecessary and avoidable,

but in addition are considered unfair and unjust.

Other Considerations of Health and Equity

Health Equity and Political Philosophy• John Rawls: Each person is to have an equal right to the most extensive basic liberty

compatible with a similar liberty for others.• Amartya Sen: Rules to guide society towards greater justice, rather than what a just

society would look like in its entirety• Thomas Pogge: Implicates priviledged groups in undermining the health of

disenfranchised groups

Health Equity and Public Health Ethics• Childress: Discuss social justice and human rights as part of operational

considerations• Kass: Looks briefly at distributive justice, focusing on burdens and benefits

Health Equity and Economics• Decision-analysis has particularly helped in combining values and evidence.

Economists frame this as weighing equity and efficiencyo Equity-Efficiency tradeoffso Equity-Equity tradeoffs

Source: Pinto A .Equity in public health: Theoretical Foundations. Presentation. February 04th, 2010

OAHPP Commitment to Equity

As stated in its founding legislation, Object (a) of the OAHPP is to provide scientific and technical advice and support to the Government of Ontario and the health care system to protect and promote the health of Ontarians and reduce health inequities.

In the 2010-2013 Strategic Plan OAHPP committed to developing and applying a population health equity lens (p.20)

OAHPP Mandate: Scientific and Technical Advice

The OAHPP provides scientific and technical advice to Ministries, local public health units and other partners. – OAHPP core activities include: surveillance, data analysis, the

production of results and reports, research, the development of tools and educational programming, field response and emergency planning

– OAHPP does not directly: …Operate public health programs, apart from the provincial public

health labs. …Create provincial policy, although it can and does inform the policy

process through scientific and technical advice.

OAHPP

LOCAL PUBLIC HEALTH

PRIMARY CARE

HEA LTH

CARE SYSTEM

GOVERNMENT

OAHPP

Developing an OAHPP Equity Lens

What is an Equity Lens?

• An equity lens refers to ‘a metaphorical pair of glasses that ensures people ask ‘who will benefit?’ 1

• An equity lens can raise awareness and consideration of equity issues in service planning and delivery.2

• Most equity lenses consist of 3-5 questions, some include as many as 20 questions

1. Signal, L. (2002) Tackling inequalities through health promotion action. Health Promotion Forum of New Zealand Newsletter 56 10 2. Gardner, B. Health Equity Impact Assessment: Potential for LHINs. Presented October 19th, 2009

Health Impact Assessment (HIA) – a tool to gauge the potential impacts of a policy or project and the distribution of those impacts within affected populations. Include the classic steps of screening, scoping, impact identification, assessment of impacts, recommendations, monitoring and evaluation

Health Equity Impact Assessment (HEIA) – include the classic steps of an HIA, however, focus on the potential impacts of service initiatives/policies on disadvantaged populations, access barriers and related equity issues.

Health Equity Assessment Tool (HEAT) – a simplified equity assessment consisting of 10 questions which can be used to provide a quick overview of potential equity issues and gaps, or a more in depth responses.

Health Equity Audit (HEA) – an evaluative assessment tool with 3 steps to systematically review health inequities, ensure required actions to reduce inequities are incorporated into local plans and evaluation the impact of the actions

Equity Lens – a simple tool consisting of 3-5 questions to ensures awareness and some consideration of equity issues in service delivery/planning

Commission of the European Communities. European Policy Health Impact Assessment Guide (2004). Accessed March 16th, 2010 from: http://www.liv.ac.uk/ihia/IMPACT%20Reports/EPHIA_A_Guide.pdf

MethodsLibrarian-Assisted Literature Search• Databases :Medline (both Ovid and PubMed platforms); Academic Search Premier, CINAHL, Health Business Elite, Nursing &

Allied Health Comprehensive; Policy Reference Center and Scopus• Keywords (and matching subject headings): equity, health equity, health technology assessment, health services access, tools,

planning, assessment, public health, public health practice ,"equity lens" (phrase) in a variety of combinations.

Environmental Scan and Librarian-Assisted Web Search• Used terms above + “effectiveness” and “evaluation” (to avoid accessing login pages)• Web searches were also done in specific jurisdictions(i.e. "equity lens" and then limit to Australia: "equity lens" site:.au.)

Key Informant Interviews• J. Millar (PHSA), MOHTLC Equity Unit, L.A. Mulrooney (RNAO), B. Gardner (Wellesley Institute). P. Sutcliffe (SDHU), D.

Patychuck and D. Seskar-Hencic (OPHS First Steps to Equity)

Identification and Assessment of Key Equity Planning Tools• Identification according to: 1) Tools which are most commonly used/described/evaluated ;2) Tools that are Ontario or Canada

based; 3) Tools that have been highly recommended (see next slide)• Assessment according to: assessment template developed to take into consideration unique OAHPP needs (see next slide)

Compilation and Modification of OAHPP-relevant Equity Tool Components• Given no one tool was directly applicable to OAHPP knowledge products and services, concepts, structures and approaches from

various tools were applied to the development of a unique OAHPP Equity Lens

Equity-focused Planning Tools ConsideredCriteria #1- Tools which are most commonly used/described/evaluated:

Mahoney M. Simpson S, Harris E, Aldrich R, Stewart Williams J .(2004). Equity Focused Health Impact Assessment Framework, the Australasian Collaboration for Health Equity Impact AssessmentSignal L, Martin J, Cram F, Robson B. (2008). Health Equity Assessment Tool (HEAT): A Users Guide . Wellington: Ministry of Health ; New Zealand Hamer L, Jacobson B, Flowers J, Johnstone F. (2003) Health Equity Audit Made Simple: A briefing for Primary Care Trusts and Local Strategic partnerships. Health Development Agency, National Health Service

Criteria #2- Canadian tools:Mihevc J. (2006). Utilization of an equity lens and an equity impact statement, Roundtable on Access, Equity and Human Rights, Policy and Finance Committee, City of Toronto.Patuchuck D and Seskar-Hencic D. (2008). First Steps to Equity. Ideas and Strategies for Health Equity inOntario 2008-2010. TorontoMOHTLC/Toronto Central LHIN. (2009). Health Equity Impact Assessment Tool and Workbook. Ottawa Equity Gauge - Tugwell P, de Savigny D, Hawker G, Robinson V. Equity-effectiveness loop: working against the odds: the application of clinical epidemiologic methods to health equity. BMJ 2005;332:358-61T. Hancock . (2008). Interior Health’s Health Equity Assessment Tool. Health Equity: Introduction and Overview Presentation

Criteria #3- Tools that have been highly recommended:Whanu Ora Health Impact Assessment (2008). Wellington: Ministry of Health; New Zealand Health Inequalities Impact Assessment (aka Bro Taf Guidelines) (2004). National Public Health Service for Wales

Survey and Focus GroupsSurvey• to identify staffs’ conceptualization of equity • to gauge interpretations of OAHPPs’ role in “….reducing health inequities”

(Object A)• to address high level issues relating to application of a population health

equity lens to OAHPP’s scientific and technical advice, and other OAHPP operations.

Staff Focus Groups• to get direct feedback on the proposed Equity Lens and accompanying

workbook, • To explore facilitators and barriers to the implementation of an Equity Lens

OAHPP-wide.

OAHPP Equity Lens

• STEP 1: Assess health inequities which can occur in relation to the scientific or technical issue being addressed

• STEP 2: a) Identify pathways leading to health inequitiesb) Identify potential interventions, actions and best practices to reduce

inequities identified abovec) Ensure these considerations have been incorporated into the OAHPP

project under consideration

• STEP 3: Identify further research/data needs/policy modifications necessary to decrease health inequities as a result of this work.

Lessons Learned

Equity Lens Development• Tools need to be adapted for local and organizational relevance and

flexibility• Need for education and capacity building in the area of applying the equity

lens• For maximal uptake, equity lens needs to be incorporated into

organizational structures and processes• Overall agreement to equity lens in principle, but resistance due to

perception of increased workload

Applying the OAHPP Equity Lens

Scientific Advice to Ontario’s Tobacco Control Strategy

Smoke Free Ontario - Scientific Advisory Committee

• Background– OAHPP asked to convene a scientific advisory committee to bring

advice and recommendations to inform the renewal of Ontario’s tobacco control strategy

– Previous strategies had not explicitly addressed tobacco-related disparities and equity

Applying the Equity Lens – Tobacco Control

• STEP 1: Assess health inequities which can occur in relation to the scientific or technical issue being addressed– Established sub-populations, based on existing understandings of

tobacco-related disparities and available information– Reviewed surveillance data disaggregated by SES, educational level

and other relevant variables– Identified population groups at risk more likely to use or be exposed to

tobacco products

Applying the Equity Lens – Tobacco Control

• STEP 2a: Identify pathways leading to health inequities– Identified groups that might be “left behind”

• STEP 2b: Identify potential interventions, actions and best practices to reduce the health inequities identified– Reviewed evidence, systematic reviews and seminal reports from

other jurisdictions (e.g. Australia, UK)

• STEP 2c: Ensure these considerations have been incorporated intothe OAHPP project under consideration.– Smoke-Free Ontario Scientific Advisory Committee Report

Applying the Equity Lens – Tobacco Control

• STEP 3: Identify further research/data needs/policy modifications necessary to decrease health inequities as a result of this work.– Ensure that monitoring and surveillance systems of tobacco-related

disparities, and the evaluation of policies and services, capture the differential impact on sub-populations

SFO-SAC Application• Equity Lens is reasonably straight forward to apply, especially with the

support of the Workbook• Using Equity Lens tool provided framework for applying equity to

comprehensive tobacco control• Existing organizational structure within OAHPP facilitated successful use

of the Equity Lens• Leadership vision enabled application of equity tool to SFO-SAC example• Presence of data disaggregated by SDOH was helpful, although there

was a lack of multivariate data and limitations of the evidence base for intervention

• Need to build evaluation of tool into piloting process

Lessons Learned

Proposed Equity Assessment Tool for Ontario Public Health

Units

Rationale: Why an Equity Tool for Health Units?Why Now?

• With introduction of OPHS in 2008, steps to address health inequities, including the identification and public reporting of health inequities, were integrated into the mandate of Boards of Health

• OPHS Foundational Standard directs Boards of Health to plan and deliver focused interventions and tailor strategies to meet the needs of priority populations (including those at greater risk of health inequities)

• These initiatives are to be guided by the principles of need, impact, capacity for response and improving local capacity to meet community health needs through partnership and collaboration.

Integration of Health Inequity Reduction into OPHS Foundational Standard

• “Public health interventions shall acknowledge and aim to reduce existing health inequities. Furthermore, Boards of Health shall not only examine the accessibility of their programs and services to address barriers (e.g., physical, geographic, social and economic), but also assess, plan, deliver manage and evaluate programs to reduce inequities in health while at the same time maximizing the health gain for the whole population.”

Ontario Public Health Standards (2008), p. 13.

To assist health units with:

• implementing the requirements of the OPHS Foundational Standard

• the planning and implementation of programs and services designed to reduce health inequities among priority populations

• assessing the extent to which current programs and policies may be contributing to the reduction or exacerbation of health inequities

Purpose of Equity Assessment Tool

Proposed Equity Assessment Tool for PHUs

STEP 1• Identify health inequities related to the public health issues(s) addressed through the

planning and implementation of specific programs or policies (including OPHS requirements).

STEP 2a) Assess the causal pathways leading to these health inequities.b) Determine potential actions (including interventions and best practices) to reduce the

health inequities identified above.c) To the extent possible, modify the program or policy through incorporation of these

actions.STEP 3• Evaluate the impact of the above work on the reduction of health inequities to guide

further modification to the programs/policies under consideration

Equity Assessment Tool Relevant OPHS FoundationalStandard Principle

Relevant OPHS FoundationalStandard Requirements

STEP 1: 

Identify health inequities related to the public health issues(s) addressed through the planning and implementation of specific programs or policies (including OPHS requirements).

NeedImpact

Population Health AssessmentSurveillanceResearch and Knowledge Exchange

STEP 2:

a)  Assess the causal pathways leading to these health inequities.

b)Determin

e potential actions (including interventions and best practices) to reduce the health inequities identified above.

c) To the extent possible, modify the program or policy through incorporation of these actions.

NeedImpactImpactCapacityPartnerships

Research and Knowledge Exchange

STEP 3:

Evaluate the impact of the above work on the reduction of health inequities to guide further modification to the programs/policies under consideration

ImpactCapacityPartnerships

Program EvaluationResearch and Knowledge Exchange

Links Between Health Unit Equity Assessment Tool and OPHS Foundational Standard

EQUITY ASSESSMENT TOOL STEP 1

Identify health inequities related to the public health issue(s) addressed through the planning and implementation of specific programs or policies (including those related to OPHS requirements).

EQUITY ASSESSMENT TOOL STEP 1 Referring back to Tables 1 and 2 (same as OAHPP equity lens):

1. What health inequities exist in relation to the issue(s) addressed in the program or policy under consideration

a) Who is most advantaged in relation to the health issue under consideration and how?b) Who is most disadvantaged in relation to the health issue under consideration and how?c) Who has the potential to benefit most from the programs or policies in place to address

the health issue?d) Who has the potential to realize the least amount of benefit from the programs or policies

in place to address the health issue?e) What is the magnitude of difference that already exists between advantaged and

disadvantaged groups (assessed subjectively or quantitatively, depending on available data and resources?

EQUITY ASSESSMENT TOOL STEP 12. How can the health inequities identified be measured qualitatively or quantitatively?

a) Who are the missing populations for whom little or no data are available?

b) Why do we have missing data, what are the barriers to collecting the information needed to assess inequities in this case?

c) What new data collection, systems and/or indicators would be necessary to get the information you need above?

d) What indicators might be used?

EQUITY ASSESSMENT TOOL STEP 2

a) Assess the causal pathways leading to these health inequities

b) Determine potential actions (including interventions and best practices) to reduce the health inequities identified above

c) To the extent possible, modify the program or policy through incorporation of these actions.

EQUITY ASSESSMENT TOOL STEP 2 AASSESS THE CAUSAL PATHWAYS LEADING TO THESE HEALTH INEQUALITIES

1. How do the determinants of health affect individual vulnerability to negative health outcomes related to the issues addressed by yourprogram or policy?

2. What other potential pathways can be identified?

3. List the ways in which your program or policy could potentially affect these pathways.

EQUITY ASSESSMENT TOOL STEP 2 BDETERMINE POTENTIAL ACTIONS TO REDUCE THE HEALTH INEQUITIES IDENTIFIED ABOVE

1. Based on the pathways above, what are some interventions to reduce health inequities?

2. What additional initiatives already exist that might help to reduce health inequities related to the issue(s) addressed by your program/policy (at local, provincial and national levels)?

3. What further action could be taken by your health unit in reducing health inequities related to the issue(s) addressed by your program/policy?

– … in regards to population health assessment– … in regards to surveillance– … in regards to research and knowledge exchange– … in regards to program evaluation– … in regards to other OPHS Standards and requirements (not directly related to your

program/policy)– … in regards to staff education and professional development– … in regards to communications– … in regards to your internal policies and procedures– …other

EQUITY ASSESSMENT TOOL STEP 2 CTO THE EXTENT POSSIBLE, MODIFY THE PROGRAM/POLICY THROUGH INCORPORATION OF THESE ACTIONS

1. How can your program or policy be modified to further support or supplement reduction in health inequities (including inequities that may be inadvertently resulting from your program/policy)?

• … in terms of access to programs/services• ….in terms of priority group participation in program/policy development• … in terms of program delivery or policy implementation• … in terms of reducing barriers to benefiting from the program/policy• …in terms of additional supports• … in terms of communication • … in terms of internal health unit policies and procedures• …other2. For the modifications listed above, what is the:

– Strength of evidence?– Likely impact?– Contextual probability for change?– Time scale for achieving change?– Measurement option to know if health inequities have been reduced?

EQUITY ASSESSMENT TOOL STEP 3EVALUATE THE IMPACT OF THE ABOVE WORK ON THE REDUCTION OF HEALTHINEQUITIES TO GUIDE FURTHER MODIFICATION TO THE PROGRAMS/POLICIES UNDER CONSIDERATION

1. What modifications were made to your program/policy to further support or supplement reduction in health inequities (including inequities that were inadvertently resulting from your program/policy)?

• … in terms of access to programs/services• … in terms of priority group participation in program/policy development• … in terms of program delivery or policy implementation• … in terms of reducing barriers to benefiting from the program/policy• …in terms of additional supports• … in terms of communication • … in terms of internal health unit policies and procedures• …other

EQUITY ASSESSMENT TOOL STEP 3EVALUATE THE IMPACT OF THE ABOVE WORK ON THE REDUCTION OF HEALTHINEQUITIES TO GUIDE FURTHER MODIFICATION TO THE PROGRAMS/POLICIES UNDER CONSIDERATION

2. What (if any) further action was be taken by your health unit in reducing health inequities related to the issue(s) addressed by your program/policy?

– … in regards to population health assessment– … in regards to surveillance– … in regards to research and knowledge exchange– … in regards to program evaluation– … in regards to other OPHS Standards and requirements (not directly related to your

program/policy)– … in regards to staff education and professional development– … in regards to communications– … in regards to your internal policies and procedures– … other

3. How have these modifications impacted health inequities related to the public health issue(s) addressed through your program policy?

4. What further modifications to your program/policy are needed in order to reduce health inequities?

Next Steps – Equity Assessment Tool for PHUs

• Modification of tool based on feedback received from APHEO workshop participants

• Further consultations on draft tool with public health professional associations and other key stakeholder groups

• Launch of final tool at 2011 OAHPP/OPHA/aLPHa conference

Acknowledgements• Heather Manson, Director, Health Promotion, Chronic Disease and Injury

Prevention, OAHPP• Andrew Pinto, Medical Resident, Dalla Lana School of Public Health, University

of Toronto• Susan Bondy, Dalla Lana School of Public Health, University of Toronto• Paul McDonald, Department of Health Studies and Gerontology, University of

Waterloo• Daniela Seskar-Hancic, Population Health Planning and Evaluation, Region of

Waterloo Public Health• Caroline Murphy, Project Staff, SFO-SAC, OAHPP• Phat Ha, Project Staff, SFO-SAC, OAHPP• Jas Chana, Senior Policy Analyst, OAHPP• HPCDIP Team, OAHPP

Group Discussion

Application of Equity Assessment Tool & Critical Reflection