Enhancing Capacity in the Assessment and Application of Health Equity Tools  Kathleen Perkin, Wanda Martin, Bernie Pauly, Marjorie MacDonald, Warren O’Briain, Trevor Hancock, Bruce Wallace, Samantha Tong (ELPH Research Project) My name is Kathleen Perkin and I’m here all the way from Victoria BC. My presentation today is about enhancing our capacity to assess and apply health equity tools.

Equity Lens in Public Health Purpose: guide and inform learning about the integration of an equity lens in public health and to contribute knowledge of health inequities reduction. www.uvic.ca/elph This project is part of a program of research funded by CIHR and the public health agency of canada. It’s called Equity Lens in Public Health and is based at the university of victoria. This program of research is all about health equity. Health inequities are differences in health that are potentially avoidable, remediable and a consequence of structural injustices that shape the social conditions in ways that disadvantage some groups in the population more than others. We are studying the public health system. Part of a larger program of public health research in bc, some connections to Ont A health inequity is a difference in health between people or groups that is the result of the way society is organized rather than something like random chance or unavoidable inherited susceptibility to illness. For example, people with more money might be able to afford better food and housing, which contributes to better health relative to people with lower income. People who experience discrimination based on identity factors like gender or race may, as a result, be at an unfair disadvantage when it comes to health. So, health equity is when opportunities for good health are evenly distributed in a population, and health is not affected by things like income, place of birth, or identity.

Partners Fraser Health We partner with 6 of BC’s health authorities, as well as BC’s ministry of health, and other provincial and national partners. BC has regional health authorities, and their areas are shown on the map. PHABC, PHAC, NCCDH and Ontario Public Health. Researchers are located at the University of Victoria and University of British Columbia. BC has a system of regional health authorities, and those are shown on the map. The focus of this presentation is one component of the ELPH program of research: creating practical criteria to assess health equity tools. Fraser Health

Health Equity Tools www.uvic.ca/elph A health equity tool is a set of steps or instructions for measuring health equity, assessing health equity in a policy or program, or supporting the inclusion of health equity in policies and institutional practices. There are growing number of health equity lenses, gauges, frameworks, and tools have been created to assist public health policy makers and practitioners to think about and incorporate health equity in their work. However, there has been little critical analysis of these tools in terms of their practical usefulness and theoretical relevance, leaving public health policy makers and practitioners with little guidance on which tools might be applicable for which situations and goals. We did a literature review of available health equity tools up until 2011, and a summary is published on our website. We found that very few tools have been evaluated. As part of this project, we will create criteria for assessing health equity tools for practical relevance, as well as separate criteria for assessing theoretical relevance. To create the practical criteria, we used a collaborative research method called concept mapping. www.uvic.ca/elph

Concept Mapping To be useful, a health equity tool should… We used Concept Mapping to start to develop practical criteria to assess health equity tools. Concept mapping is a way of combining ideas from many different people about one topic, grouping, rating and displaying the results as maps or graphs. The first step is to ask participants to respond to a prompt with short statements (brainstorming)

Have a clear feedback loop to improve practice Have a clear intended outcome Assist program planners to improve the equity of their programs Lead to the identification of areas for improvement in policy/program Here are some examples of statements people submitted online. (brainstorming) Next, statements are sorted and rated. (Sorting and rating) Each participant sorts all the statements into categories. Then participants rate each statement for importance and feasibility. These are some examples of the highest rated statements. Brainstorming: 48 participants, 67 statements generated Sorting: 19 participants Rating (importance) 30 participants, (feasibility) 27 participants

Based on how participants sorted the statements, statements are positioned through a multidimensional scaling in two dimensions. Each number represents a statement. Statements near each other are more related, according to participant sorting. They were sorted into the same category more often. Brainstorming: 48 participants, 67 statements generated Sorting: 19 participants Rating (importance) 30 participants, (feasibility) 27 participants

Then, the program clusters the statements together based on how often participants sorted them into the same category. The analysis does not suggest how many clusters there should be, but provides a best solution for any number of clusters indicated by the analyst. To decide on the number of clusters, we started with a large number of clusters and combined the most closely related clusters until we had a set that seemed to reflect the best fit with the statements. That is, combining further would put statements together that did not seem closely related. A working group of researchers and knowledge users decided on the number of clusters – six clusters in this case. Brainstorming: 48 participants, 67 statements generated Sorting: 19 participants Rating (importance) 30 participants, (feasibility) 27 participants

This is what the results look like This is what the results look like. The positions of the statements are the same, but now they are grouped together in clusters. The next step is to name the clusters. We did this recently at a team meeting. Approximately 30 team members, researchers and people from our partner organizations, participated in naming the clusters.

Reflexive Institutional, Cultural and Public Health Lens Explicit Theoretical Foundations Reflexive Practice These names reflect the general meaning or theme of the statements in each cluster. The large red one, Evaluation for Improvement, contains statements about using the tool for evaluating programs and policies and guiding activities to improve those programs and policies. The purple one at the bottom, User Friendly, contains statements about how the tool should be presented – clear, concise, easy to understand. The lighter blue cluster is about including things to help a user apply the tool – check-lists, instructions, questions, templates. The small dark blue cluster has to do with including a definition of health equity and generally making the theoretical foundations of a tool clear to the user. The large pink cluster, Reflexive Institutional, Cultural and Public Health Lens, is mainly about the institutional environment or culture in which the tool will be applied. Even a well-thought out and appropriate tool will not produce the desired results if the institutional culture is not receptive. These statements get at the importance of having an a culture that supports critical reflection on institutional practices. The last cluster, the dark red Reflexive Practice grouping, is closely related but has more to do with the individual tool user’s orientation to health equity and critical reflection. Practical Resources To Guide Use Evaluation for Improvement User Friendly

Recommendations Health equity tools should Be meaningful and guide action Be clear and concise Contain resources to support use Context matters: Understanding of health equity and institutional environments are as important as the use of tools Next Steps: Practical and Theoretical Criteria At this stage we can make some early recommendations for health equity tools. Based on our analysis, we can say that a health equity tool should provide meaningful results that guide improvements to the policy, program or other process under review. They should be clear and concise, and contain resources like templates and checklists to support use. Two of the clusters relate specifically to reflexive practice and the importance of having an environment supportive to the use of the tool and application of the recommendations. The next steps in this research will be to use this analysis to develop criteria for practical relevance, which we will use to assess health equity tools. We are also working on criteria for theoretical relevance. Our criteria are intended to enhance the capacity of public health practitioners and policy makers to ask and answer the question: What tools for what purpose and in what situation?

www.uvic.ca/elph elph@uvic.ca @ELPH_UVic Thank you! www.uvic.ca/elph elph@uvic.ca @ELPH_UVic