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

Systemic health inequities, which are differences in health that are “unnecessary, avoidable and considered unfair and unjust” [1], are a prominent problem in Canada that require attention and action [2, 3]. In recent years, health equity has increasingly been seen as a goal of public health systems in Canada, with a number of initiatives arising to assist in addressing this issue across the health sector [2, 4, 5]. In Canada, health is provincially regulated and in the province of Ontario, the Ministry of Health and Long-Term Care (MOHLTC) oversees policies and direction of health care and public health. The MOHLTC sets out the minimal standards for public health programs and services in Ontario through the Ontario Public Health Standards (OPHS). There are 36 local Public Health Units (PHUs) within the province of Ontario that provide health promotion, protection and disease prevention programs to distinct geographic regions. Each PHU is an independent unit that reports to a Board of Health (BOH), which is required to comply with the OPHS [6]. The OPHS was revised in 2008 by the MOHLTC to replace the previous 1997 Mandatory Health Programs and Services Guidelines (MHPSG) [6]. As summarized by Pinto et al. [3], the revised public health standards had to be: 1) revenue- neutral 2) focused on evidence 3) focused on short-and long-term outcomes and performance and 4) less prescriptive to provide PHUs with the ability to tailor public health interventions to local needs.

The revised OPHS addressed health equity though introducing the term ‘priority populations’ and this new language was used predominantly throughout the 2008 OPHS [6] (p.1). The OPHS mandated that PHUs “assess the needs of the local population, including the identification of populations at risk, to determine those groups that would benefit most from public health programs and services (i.e., priority populations)” [6] (p.24). As the standards required local PHUs to “consider the determinants of health when identifying priority populations”, the link to health equity was inferred [6] (p.24), [4, 7, 8]. This mandate to identify priority populations, which we have called the Priority Population Mandate (PPM), was seen as enabling of action on health equity or the social determinants of health (SDOH) through the PHUs. However, with the revised public health standards, Pinto et al. [3] states that the term ‘priority populations’ was used as a proxy for health equity and that accordingly, the OPHS has a “lack of specificity” on health equity [3] (p.8). Throughout this paper, we use Priority Populations Mandate (PPM) to refer to the fact that the OPHS policy required PHUs to identify and take action on ‘priority populations’. Thus, the PPM is one component of the OPHS policy. To support implementation of the PPM within PHUs in Ontario, we undertook the Priority Populations Project [9], which had the following objectives:

This study is a sub-analysis of that larger project. This work builds on the paper by Pinto et al. [3] to understand how the OPHS facilitated or hindered health equity practice in the field [2]. The purpose of this study was to understand how the Priority Populations Mandate facilitated action on health equity (HE) or the social determinants of health (SDOH)¹ through the Ontario Public Health Units (PHUs).

Methods of the Priority Populations Project are provided in more detail in the Priority Populations Project Technical Report [9]. The project was approved by the Public Health Ontario (PHO) Research Ethics Board and used an Integrated Knowledge Translation strategy through collaboration with knowledge users, the alPHa-OPHA Health Equity Working Group. This sub-study draws on two of the three sets of data, namely the key informant interviews and the role-based survey, to answer the specific research question and does not triangulate data.

The first set of data was 16 semi-structured key informant interviews with policymakers involved in developing the OPHS and public health practitioners. They were identified through snowball sampling. Our aim was to gain an understanding of how the term ‘priority populations’ was intended to be used as written in the OPHS, as well as how the term is being applied by public health practitioners in the field. Since some practitioners who were implementing the mandate in the field were also involved in developing the OPHS, the 16 key informants fell into three key groups:

Each of the three groups had their own semi-structured interview guide (which can be found in the Technical Report) [9]. Informed consent was obtained and the interviews were conducted, recorded and transcribed in July and August 2013 by one interviewer to ensure consistency. The interviewer (NH) also recorded notes and impressions directly after each interview and referred to these notes through the analysis process.

The second set of data was the qualitative component of a role-based survey sent out to all the 36 PHUs in Ontario. The online survey was developed with FluidSurveys and required active consent to access the survey [10]. The anonymous survey was distributed through institutional and professional listservs.

The survey was completed in October and November of 2013 by Medical Officers of Health and Associate Medical Officers of Health (MOH/AMOHs), Social Determinants of Health (SDOH) Nurses and PHU Epidemiologists. Individuals were not asked to identify their PHUs. The survey included multiple choice questions and free-text options; however only the free-text components of the survey were included in this study.

For the purposes of this study, we (NH and IT) went back to the transcripts of the key informant interviews and the free-text fields of the surveys that had previously been identified as a part of the Priority Populations Project. From our previous analysis of the transcripts, we had identified key statements. These key statements took the form of sentences and encompassed broad ideas rather than small phrases or words that were out of context. As such, it was possible to recode these key statements keeping in mind our research question for the sub-analysis (i.e., “How did the Priority Populations Mandate facilitate health equity or social determinants of health (SDOH) practice in Ontario Public Health Units (PHUs)?” We applied thematic content analysis to these key statements and inductively identified repeating themes related to what elements of the PPM facilitated or hindered HE/SDOH practice in PHUs. We did not conduct member checking with this sub-analysis.

Based on the themes that arose, factors of the PPM were grouped into either an attribute of the OPHS policy, context into which the PPM was introduced or PHU implementation of the PPM in the field. For example, the following quote by a policymaker was coded as an OPHS policy attribute because it describes the policy itself: “what we were trying to do was give each health unit the flexibility of addressing the health needs, as [identified] by epidemiology, of their communities.” Data were further subcategorized and then considered from the perspective of understanding how the PPM facilitated or hindered action on HE/SDOH. The above statement was then coded a second time as a facilitator of HE/SDOH action. During data analysis, the research team consciously engaged in reflection and challenged personal assumptions [9].

Based on our analysis, a broad understanding of how health equity is facilitated in Ontario emerged and this was depicted in a conceptual model (see Fig. 1). We identified six factors (see Table 1) which influenced how the PPM affected HE/SDOH action in Ontario. These six factors were grouped into three categories or themes: 1) OPHS policy attributes 2) health sector context into which the PPM was introduced and 3) implementation by the PHUs. The conceptual model highlighted the links between the overarching categories/themes and each of the six factors and how they contributed to HE/SDOH action in Ontario.

Each of these six factors had the potential to facilitate or inhibit HE/SDOH action in Ontario. The model depicted how these factors conceptually link to broader action on HE/SDOH while the specific ways in which the factors facilitated or inhibited are summarized in Tables 2 and 3 and discussed in more detail below (see Table 2: facilitators and Table 3: barriers).

We explored how the PPM facilitated or hindered action on HE/SDOH. We found that the PPM both facilitated action on HE/SDOH (by increasing dialogue, raising awareness of capacity issues, organizing practice and directing resources as noted in Table 2) and inhibited action on HE/SDOH (by causing confusion, having little conceptual clarity, focusing on identification of priority populations and not action as noted in Table 3).

The PPM could have been strengthened to guide action on HE/SDOH if it introduced more clearly defined terminology. Although there are ways in which the PPM could drive action on health equity, it appears that overall the PPM was received by practitioners in a way that inhibited immediate action because they got caught up in understanding the term ‘priority populations’. Our study highlights that for health equity policies to be action-oriented, they need to be as clear and explicit as possible about terminology that is used. The National Collaborating Centre for the Determinants of Health (NCCDH) observed that the term ‘priority populations’ has the “risk that without specific inclusion of social justice values, the term can be interpreted too broadly, and be used to identify populations not experiencing disadvantages” [12] (p.4). The terminology is perceived by some as weakening the impact and link to health equity and resulted in confusion about whether the PPM was intended to address health equity at all.

The PPM could have been strengthened to guide action on HE/SDOH if it had a clear guiding health equity vision. The perceived weakening of the link to health equity by introducing the term ‘priority populations’ may have resulted from differences in opinion regarding the term ‘social justice’. As noted in our larger study report, six informants were in agreement that, “the term ‘social justice’ causes divide” [9] (p.25) and warned against its use. We heard that, “by introducing the term ‘social justice’you basically introduced a contentious lightening rod into the discussion” and “words like social justice or health equity could mean to someone [that] you are just trying to raise taxes to create more programs for the public sector” [9] (p.25). However, some participants wanted to push a social justice framework and said, “there is room for us to strengthen, disseminate and acknowledge a public health ethical framework that embeds social justice within it.” Therefore, the OPHS and PPM were perceived to fall short of committing to a clear health equity vision for public health in the province. This inhibited public health action as participants felt that a stronger top-down mandate was necessary to push work on HE/SDOH further and would solidify support from BOH in doing this work.

Finally, the PPM could also have been strengthened to guide action on HE/SDOH if it was able to unite different PHU approaches to addressing health equity. One of the reasons writing an overarching OPHS and PPM may have been difficult is because of the wide range of ways in which health equity has been operationalized in the province. Raphael and Brassolotto [11] discussed three differing approaches to addressing SDOH, 1) service delivery, 2) intersectoral and community, and 3) structural [11]. Pinto et al. [3] identified that the recognition of “how equity is conceptualized” would assist in developing “more explicit, action-oriented and concrete steps” to address health equity (p.8). At the same time, the intention of the OPHS to be flexible and not prescriptive is understandable, as it was meant for PHUs at the local level to adapt the mandate to their needs.

In spite of barriers described above, and without formal evaluation, many respondents felt that overall the PPM was a step in the right direction and that “we can safely say that in some cases work to address the needs of priority populations as prescribed by the mandate has resulted in an increase in direct service provision to priority populations.” However, the PPM seemed to only address health equity from a service-delivery perspective and did not acknowledge that some practitioners and PHUs had intersectoral and community or structural approaches to health equity [11]. To successfully reap the benefits of a flexible policy that can be adapted at the local level, it appears necessary to establish and communicate a complete vision of the ways in which health equity is operationalized.

We found that the revised OPHS and the PPM facilitated action on HE/SDOH (by increasing dialogue, raising awareness of capacity issues, organizing practice and directing resources) but that on the whole, this objective could have been better met. The PPM could have been strengthened to guide action on health equity if 1) it introduced more clearly defined terminology, 2) had a clear guiding health equity vision and 3) was able to unite different PHU approaches to addressing health equity. For a policy to move forward action on health equity there needs to be clear terminology that explicitly articulates a health equity vision.