Influence of revised public health standards on health equity action: a qualitative study in Ontario, Canada

Abstract

BackgroundIn 2008, a revised set of public health standards was released in the province of Ontario, Canada. The updated Ontario Public Health Standards (OPHS) introduced a new policy mandate that required local public health units (PHUs) to identify “priority populations” for public health programs and services. The aim of this study was to understand how this Priority Populations Mandate (PPM) facilitated or hindered action on health equity or the social determinants of health through PHUs in Ontario.MethodsThis study used two sets of qualitative data that were part of a larger study. The first set of data was 16 semi-structured key informant interviews with policymakers involved in developing the OPHS and public health practitioners. The second set of data was the qualitative component of a role-based survey sent out to all the 36 PHUs in Ontario. Thematic content analysis was conducted to iteratively develop themes to answer the research question.ResultsWe identified six factors that both facilitated and hindered action on health equity and social determinants of health action in the province resulting from the OPHS and PPM. These six factors were grouped into three categories or themes: OPHS policy attributes (1. introducing new terminology, 2. allowing flexibility in implementation and 3. ensuring evidence-informed decision-making), health sector context into which the PPM was introduced (4. different understandings of health equity and 5. variability in existing partnerships) and implementation by PHUs (6. requirement to address the PPM).ConclusionsAlthough the revised OPHS and the PPM facilitated action on health equity and the social determinants of health, on the whole, this objective could have been better met. The mandate within the OPHS could have been strengthened with respect to promoting action on health equity and the social determinants of health through more clearly defined terminology, conveying a guiding health equity vision and uniting different PHU approaches to addressing health equity.

Searching for justice (and evidence) in public health: Exploring health equity in Canadian public health discourse and practice

“…In similarity to other studies in this review, Hassen and Tyler's (2017) research also shows how those working in Ontario public health units (PHUs) in accordance with OPHS apply a health equity lens in their work exclusively by identifying priority populations. The researchers conducted interviews with policy makers and used survey data collected from 36 PHUs to examine how the newly introduced term, 'priority populations' is applied by those working in public health.…”

“…Studies analysing public health policy documents provided me with insights into how and to what extent the idea of equity and related values such as social justice inform the content and direction of concrete actions (See Giacomini et al, 2003;Edwards and Davison, 2008;Giacomini et al, 2009;Pinto et al, 2012). Other empirical literature centres on how the idea and operationalization of health equity is understood from the perspectives of public health professionals in the context of their daily work (Rizzi, 2014;McPherson et al, 2016;Smith, 2016;Cheff, 2017;Hassen and Tyler, 2017;Pauly et al, 2017;Anne et al, 2018).…”

“…Thought of in another way, equity's flexibility and wide adoptability allows for its successful extension (within a chain of equivalences) across a range of actions and actors. Several studies investigating the experience and perspectives of public health staff applying a health equity lens highlight how the flexibility afforded to health equity and its proxies in provincial standards impedes progress on health equity and SDOH (Rizzi, 2014;Hassen and Tyler, 2017;Pauly et al, 2017). But, as I will show further in Chapters Six and beyond, the language of health equity and its proxies do not only create confusion and impede action.…”

“…as a core value in PHAC Core Competencies document) while at others, it plays a 'scaffolding' role (e.g. in provincial public health policy documents) by generating an orientation or 'equity lens' without specifying a specific course of action to achieving some morally worthy end (Pinto et al, 2012;Tyler and Hassen, 2015;Hassen and Tyler, 2017;McPherson at al., 2017;Pauly et al, 2017). In some provincial documents, the concept of health equity offers an orientation coupled with actionable language around identifying vulnerable or priority populations, however it is unclear how the prescribed actions lead to more equity.…”

“…In Ontario, a lack of strong guidance combined with ample flexibility afforded by the language of priority populations in the OPHS has been found to hinder action on health equity and SDOH (Rizzi, 2014;Tyler and Hassen, 2015;Hassen and Tyler, 2017). Public health leaders find the priority populations mandate (PPM) lacks specificity with respect to how the new language of priority populations are related to SDOH, what constitutes a priority population, and what kinds of action should be taken (Hassen and Tyler, 2017). The upshot of the new language was a de-emphasis on social justice and advocacy as some policy makers did not understand how health equity and SDOH are related to priority populations (5).…”