Critical considerations for the practical utility of health equity tools: a concept mapping study

The Ottawa Charter for Health Promotion explicitly identified equity and social justice as essential prerequisites for health, and equity in health as an important outcome of health promotion [1]. Since the Ottawa Charter, promoting health equity has been a priority for public health systems worldwide [2‐4]. Starfield [5] described inequities in health as “systematic differences in one or more aspects of health status across socially, demographically, or geographically defined populations or subgroups” (p.546). Health inequities are unfair, avoidable, and potentially remediable; removing barriers to resources for health is essential for achieving health potential [6]. Health inequities are understood to be a consequence of unjust social structures that disadvantage some groups more than others [7].

There is support for, and agreement on, the need to improve health equity and strengthen the implementation and integration of health equity considerations in health care systems internationally [8‐10]. Public health leaders have identified the use of health equity tools and resources as one promising strategy for doing this [11, 12]. Health equity tools have a range of purposes; they can help public health professionals assess the degree to which health equity considerations are included in policies or programs, or to measure health equity. Tools can also aid in choosing actions to address specific health inequities [13‐15]. They can be used to: a) guide the conduct and interpretation of systematic reviews [16‐18], b) incorporate cultural and gender considerations [19, 20], and c) conduct equity audits [21] or equity focused health impact assessments [22‐26].

While health equity tools are meant to strengthen and integrate health equity considerations into public health policies, programs, and practices, there are challenges related to identifying, selecting, appraising and applying health equity tools [27]. Public health practitioners and decision makers struggle to apply a health equity lens in their work [28]. They identify that a lack of shared understanding of health equity and lack of guidance for applying health equity tools makes the use of tools challenging [29, 30]. Tyler et al. [28] found that when implementing an equity focused health impact assessment tool, factors at the system, organizational and operational level made using the tool a challenge. The main barriers to use of this tool include competing priorities; lack of organizational commitment, readiness and resources; and lack of shared understanding about health equity. In Canada, the National Collaborating Centre on Determinants of Health identified that the two most common challenges to health equity action were “getting support to take action on social justice issues in a health system based on biomedical principles” and “not being sure of what to do or what tools are available to help address health equity” [31].

So, despite the growing number of equity-focused resources, lenses, gauges, frameworks, and tools that span a range of purposes [27], there is little guidance in the literature to help practitioners and decision makers choose the appropriate tools, and we know little about the resources and supports that are needed to apply and use these tools. For example, conducting an equity-focused health impact assessment requires significant time and resources compared to using other tools that consist of brief checklists. To our knowledge no specific criteria have been developed for assessing health equity tools in relation to their practical utility. We sought to address this knowledge gap in this study.

As part of the ELPH program of research, we sought to identify available health equity tools and to develop theoretical and practical criteria for assessing them [32]. To date, we have developed an inventory of the health equity tools (see http://​www.​uvic.​ca/​elph), and identified a range of equity theories underlying approaches to health equity action through a review of the literature [33]. The identification of equity theories will guide us in developing the theoretical criteria which will be the focus of a subsequent paper.

We define a health equity tool as a document or resource that clearly identifies improving health equity as a goal and provides a set of steps, questions, or a framework that people can follow to achieve this goal [27]. In this paper, we identify key elements and themes that public health practitioners and leaders deem important in making health equity tools both practical and useful. These findings will inform the development of a set of criteria for judging practical utility of health equity tools. Developing both the practical and theoretical criteria, constitute the next stage of our project. In the study reported in this paper, we used concept mapping [34] to explore the ideas of public health practitioners about what makes a health equity tool both practical and useful, and to determine the feasibility and importance of the ideas generated.

Health equity tools have been identified as one strategy to increase health equity considerations in public health programs and the health sector more broadly. Despite a proliferation of health equity tools, there has been limited critical analysis of these tools, or assessment of their practical utility. Here we used concept mapping to understand what public health practitioners see as important characteristics of a useful health equity tool. This resulted in the construction of six clusters for consideration when developing, selecting and using health equity tools. Ratings of the importance and feasibility of the characteristics in these clusters showed that participants considered all clusters to be important and comparatively feasible to implement, and that targeting the most feasible of the clusters would be strategic because they were also rated as highly important.

A key aspect of these findings is the importance of having tools that have clear and actionable objectives and cycles for evaluation, explicit theoretical foundations, are user friendly, and have supporting guidance documents available (Clusters 1–4). Although some of the statements in these clusters are specific to health equity, these higher level themes demonstrate understanding of what is needed for successful development and delivery of programs in general. Some of these findings are similar to those of Guichard, et al. [40], who used concept mapping to prioritize and identify important conditions for implementing a specific health equity tool (GAALISS tool) in public health practice. These conditions included specifying necessary characteristics of the tool being implemented such as: the tool should be short, have simple terminology, be accompanied by examples, and have a user guide. Their work, and that of Tyler et al. [28], highlighted the importance of leadership, organizational priorities and readiness, and intersectoral partnerships as important conditions for implementing both the GAALISS and Health Equity Impact Assessment (HEIA) health equity tools. That these conditions did not emerge in our work is likely a result of our focus prompt. Participants may have assumed that conditions were already in place, with our participants focusing on the process of implementing a tool as part of their practice and within their sphere of influence. As well, in our work, we identified the importance of having tools that have explicit and coherent theoretical foundations.

Our findings do speak to the value of community engagement and empowerment, as well as the importance of reflexivity and specific knowledge of the root determinants of health inequities in the process of implementing health equity tools (Cluster 5). Others, examining the use of knowledge to action frameworks as important strategies for improving action on health equity [41, 42], have highlighted similar findings. Masuda et al. [43] specifically stress the importance of critical inquiry and reflexive practice as part of the third wave of knowledge translation in terms of moving from ‘what we know’ to ‘how we know’, and recognizing the underlying power relations that shape knowledge in order to promote a more fair and just world within our spheres of influence. McCalman et al. [44] reviewed Indigenous health promotion tools, and these authors also emphasize the importance of cultural competency, community engagement and empowerment, and capacity development as well as partnerships, holism, best practice, and sustainability as key elements.

Our participants identified that to be useful equity tools should encourage the development and use of equity competencies as important to practicality. Some might argue that these elements go beyond the characteristics of the tool itself. It is important to remember, however, that our focus prompt did not ask specifically for characteristics of tools. Rather, it asked “To be useful, a health equity tool should……”. This prompt essentially asked participants about what a health equity tool should be or do in order to be useful. In the view of our participants, a useful tool is not just one that is easy to use, or has a clear purpose or objectives. It is one that encourages practitioners to think in a particular way, and to have a way of being that reflects the values and principles of health equity.

In relation to Cluster 5 (equity competencies), participants specifically highlighted the importance of being aware of stigma and the importance of harm reduction as key elements that make a health equity tool useful. This is not surprising given that 2/3 of participants reported working in public health programs related to mental health promotion and preventing the harms of substance use. Harm reduction is an evidence based non-judgmental approach that focuses on preventing harms of substance use while emphasizing respect, dignity, compassion and meaningful inclusion without expecting cessation of use [45]. Such an approach is clearly consistent with principles of health equity in relation to substance use programs [46].

Cluster 6, which focuses on client engagement in the use and application of health equity tools, highlights key social justice perspectives [47] that call for meaningful involvement and participation of those affected by health inequities in the application and use of health equity tools. Community participation is a central plank in health promotion [1]. In fact, the very naming of that cluster, Nothing about Me without Me- Client Engaged, reflects a popular and well known saying, both in Canada and elsewhere, that builds on original work in disability studies involving people with lived experience in issues that impact their lives [48].

As such, Clusters 5 and 6 specifically highlight public health commitments to social justice, and speak to the importance of developing critical consciousness in relation to structural and systemic injustices that have produced health inequities for those facing structural disadvantages due to gender, ethnicity, sexual orientation, class, ability and how they are positioned within current systems of care [49, 50]. It seems reasonable to us that our participants identified these aspects of public health and social justice as key elements in determining the usefulness and practicality of health equity tools. These are the very foundations of public health [51, 52]. If a tool does not support practitioners to work in practical and meaningful ways with people impacted by health inequities, then practitioners did not view it as useful to their practice. Although these clusters reflect a unique perspective of practitioners focused on health equity work in the area of mental health promotion and preventing harms of substance use, we would argue that these clusters may be applicable to judgements about the usefulness of health equity tools in other areas of public health practice. Specifically, we highlight important practitioner insights about the need for tools that encourage individual reflexivity on power and position and recognition of how stigma embedded in institutional cultures can obscure the structural and social conditions that impact health. We note that the overall sample contained participants in a wide range of roles from each health authority, all with varying levels of responsibility and education. Thus these viewpoints are from people with experience at different levels of authority and from program areas of the organization.

Strategic direction and action planning can occur with the use of Go-Zone maps and ladder graphs [34]. The clusters entitled ‘User Friendliness’ and ‘Templates and Tools’ indicate that having a clear and well defined tool is both highly important and feasible. For designers of tools, ensuring that a tool is clear and concise, with sufficient examples and information to aid in the selection and use of the tool are comparatively simple areas to target that are highly important in ensuring a tool’s utility. We would add that making a tool clear and concise does not necessarily mean that it reflects a sound theoretical understanding of health equity. Given previous research on the lack of shared understanding of health equity among public health leaders and practitioners, and the difficulties in applying a health equity lens to take action on promoting health equity [28‐30], it seems insufficient and restrictive to focus only on the form of the tool, such as making it simple, concise and easy to use.

Statements and clusters ranked as important but less feasible offer areas for reflection and deliberation on ways that guidance in these clusters could be achieved. Participants noted that to be useful, application of health equity tools should be complemented by the development of practitioner competencies related to health equity. These competencies include taking a reflexive position and possessing a compassionate understanding of the broader structural injustices that produce health inequities, and being able to raise practitioner consciousness about the roots of health inequities. Participants also noted the importance of tools that promote inclusion and meaningful involvement of clients to address health inequities. Although these areas may be more difficult to address, these clusters draw attention to important elements of a health equity tool that need to be considered beyond the form of the tool itself in order to make it truly useful and avoid unintentionally perpetuating health inequities and/or harms. A strength of this study is that it directly involved public health leaders and practitioners in considering an issue that is relevant in their work. The fact that all of the clusters had comparatively high importance and feasibility indicates the careful consideration that went into the generation of all the responses as to what makes a useful health equity tool, and that all clusters need to be considered in the development of practical criteria.

Our public health partners identified challenges in identifying and applying a health equity lens and tools, and were lacking guidance on how to work effectively toward reducing health equities. Thus participants were well situated to provide insight into what would make a useful health equity tool from their experience with searching for, selecting, and using such tools. Overall, few studies have addressed the theoretical or practical aspects of selecting and implementing health equity tools as an intervention to promote action on health equity. In this paper, we have identified and described clusters of thematic elements that can inform the development of practical criteria for constructing, selecting and using health equity tools. The findings of this study provide the basis for these yet-to-be developed criteria. In addition to the obvious characteristics of health equity tools that reflect practicality such as being useful in evaluating and informing improvements, being user friendly and including tools and templates to support use, our participants also identified unique aspects of usefulness. That is, to be useful, health equity tools need to have explicit theoretical foundations, promote health equity competencies that are rooted in critical conceptions of social justice and ensure that practitioners engage and participate directly with community members who are experiencing health inequities. These aspects of usefulness have important implications for public health systems in supporting health equity action in organization.