Health Equity Matters: How Equity and Interventions Collide

Nancy Edwards, RN, PhD, FCAHS

Scientific Director,

CIHR Institute of Population and Public Health Symposium

Toronto, November 29th, 2010

Our Sponsors

• Public Health Agency of Canada

• Canadian Institutes of Health Research

• CIHR Institute of Nutrition, Metabolism and Diabetes

• Thanks to the planning committee: – Alan Shiell, Beth Jackson, Jean-Pierre

Voyer, John Millar, Louise Potvin, Marie DesMeules, Robin Buckland

• Thanks to the IPPH team: – Erica Di Ruggiero, Ashley Page, Emma

Cohen, Sarah Viehbeck, Kim Gaudreau

Overview

• How did we get here?

• The collision of health equity and population health interventions– Some Canadian examples

• Symposium objectives

“Health Equity Matters”IPPH Strategic Plan2009-2014

IPPH Strategic Research Priorities

• Pathways to health equity

• Population health interventions

• Implementation systems for population health interventions in public health and other sectors

• Theoretical and methodological innovations

Funder’s Forum, 2009 Objectives

• Increase understanding and awareness of potential impact of population health intervention research

• Identify challenges and opportunities for enabling population health intervention research and knowledge exchange from a funder’s perspective

• Explore opportunities for organizational alignment and strategic investment in population health intervention research and knowledge exchange in Canada

Structural Impediments to Population Health Intervention

Research and its Use

• Dominant culture of scientific inquiry

• Lack of diversity of funding instruments

• Lack of infrastructure

• Limited incentives and drivers

• Lack of a forum for generating the “Big Questions”

Challenges• Population health research is a “team sport” in which many

players are needed for success (CPHO).

• Telling strong causal stories with large routinely collected data sets that represent multiple policy and program exposures across time

• Implementing and replicating interventions from one context and setting to another

• Scaling-up (more equitable access to more people)

• Understanding and reducing the historical tendency for some interventions to amplify underlying health disparities in the population

Examples of Questions Envisioned

• How can you create health to sustain the economy?

• How do complex social interventions affect “nested” contexts and sectors?

• Which interventions can redistribute resources (financial and material) and modify circumstances that have an effect on health?

IPPH - The Past Year

• Panel presentations at CPHA, IUHPE and EUPHA Conferences to profile population health research of funded Chairs and Strategic Training Research Initiatives in Health

• Launch of population health intervention RFAs (natural experiments and programmatic research)

• Development and pilot testing of peer review guidelines

• Development of a case book on population health intervention research

0

1

2

3

4

5

2000 01 2001 02 2002 03 2003 04 2004 05 2005 06 2006 07 2007 08 2008 09 2009 10

Fiscal year

Exp

endi

ture

s ($

mill

ions

)

0

5

10

15

20

25

30

35

Num

ber

grant $ open grant $ strategic grant # open grant # strategic

12

CIHR expenditures on Theme IV-related Population Health Intervention

Research

Health Equity and Population Health Interventions

• Health Equity• What’s behind the

gradient?• Cumulative effects

across life course• Exposure to risk

conditions that generate and perpetuate risks

• Concentration of risks due to social position

• Population Health Interventions

• Shift the distribution of risk by altering what causes risk conditions

• “Superficial versus radical” strategies

• Inherently intersectoral• Program, policy and

resource redistribution approaches

Hurricane Katrina: Minority communities are less likely to

evacuate in a disaster

Source: OLD SUN INDIAN RESIDENTIAL SCHOOL (GLEICHEN, AB), P75-103 S7-184, 1945, General Synod Archives.

The Indian Act precipitated colonizing policies such as residential schools and the ‘60’s scoop’ that decimated Aboriginal cultural heritage, values, and beliefs (Aboriginal Healing Foundation, 2002).

Context and InterventionsEdwards & Di Ruggiero, Scan J Public Health, 2011

• Contextual influences are pervasive yet specific, and diffuse yet structurally embedded.

• Historical contexts that have produced inequities have contemporary influences.

• The global forces of context cross jurisdictional boundaries.

• A complex set of social actors intersect with socio-political structures to dynamically co-create contextual influences.

Some Canadian ExamplesHealth Equity and Population Health

Interventions• Human early learning partnership in B.C. (Clyde

Hertzman)– mapping complex causal pathways that link structural

impediments to relative disadvantage

• Manitoba Centre for Health Policy (Pat Martens and Marni Brownwell)– documenting inequities and examining population health

interventions

• Modeling diabetes in Ontario (Doug Manuel)– testing Rose’s theorem

Human Early Learning Partnershiphttp://www.earlylearning.ubc.ca/

• Mapping disparities in the social, language, cognitive and physical development of children on a provincial scale

Childhood development, education and inequalities

(Dyson, Hertzman et al., 2010)• “Children’s policy has to embrace not only measures

directly targeted at children but also measures which support and encourage families, communities and neighbourhoods. Single-strand policies, short-term programs and one-off interventions may have their place as part of a wide-ranging strategy of this kind. However, on their own, they do not offer an adequate basis for an approach to reducing health inequalities.” (p. iii)

Socioeconomic Health Inequalities in Rural and Urban Manitoba

(Martens et al, 2010)

• Documented trends in inequities in rural and urban communities

Socioeconomic Health Inequalities in Rural and Urban Manitoba

(Martens et al, 2010)• Widened over time (n=12)

– Premature mortality rate and PYLL– Teen pregnancy– Diabetes– Ischemic heart disease– Cervical cancer screening– Cumulative mental illness (rural only)

• Similar over time (n=10)– Under 5 mortality– Multiple sclerosis– Continuity of care (urban only)– Dementia

• Narrowed over time (n=1)– Breastfeeding (urban only)

• Do outcomes differ among those participating in both components of the Healthy Baby Program (prenatal benefits (income supplement of up to $81.41/month) and community support)

• Program coverage – approx 75% of those on income assistance received income supplement; 22% of those receiving income supplement attended community support program (less than 6% overall).

Healthy Baby Program Manitoba Centre for Health Policy

(Martens et al, 2010)

23

Percent of Births by Healthy Baby Prenatal Benefit Application Type by Rural and Urban Income Quintile,

2004/05-2007/08 (Martens et al, 2010)

23

24

Percent of Births by Community Support Program Participation by Receipt of Income Assistance (IA)

2004/05 - 2007/08 (Martens et al, 2010)

24

25

Percent of Births by Community Support Program Participation, by Rural and Urban Income Quintile,

2004/05 - 2007/08 (Martens et al, 2010)

25

Promising Health Outcomes (Martens et al, 2010)

• Prenatal income supplement was associated with a reduction in low birth weight babies and a reduction in premature births.

• Women participating in both parts of the program reported longer breastfeeding.

Datasets used in report (Martens et al, 2010)

• Hospital discharge abstracts• Physician claims• Population-based research registry• Manitoba immunization monitoring system• Vital statistics• Social assistance management information network• Child and family services information system• Families first screening program• Manitoba healthy baby prenatal benefit• Manitoba health baby community support program

participation• Canada census

Revisiting Rose’s TheoremDoug Manuel

• Strategies for coronary heart disease– Population health strategies– Single raised risk factor strategy– High baseline risk strategy

• Modeling diabetes prevalence rates in Ontario

Revisiting Rose(Manuel and Rosella, IJE, 2010)

• “Too often, advocates of a particular population strategy quote Rose’s principal that shifting the curve is the best approach, without this required caveat “when risk is diffused in the population”.

• Too often we assume that risk is widely distributed without actually assessing it.”

Population Health InterventionsResearch Streams

• Discovery research

• Impact research

• Implementation research

Discovery Research

• Methods, theories and tools that are required to measure, examine and understand pathways to health equity and how these intersect with population health interventions

Impact Research

• Examine what works, how it works, under what conditions and for whom

• Determine whether population health interventions successfully reduce inequalities while improving overall health gains?

Implementation Research

• Identify common implementation problems and what hinders effective and equitable access to population health interventions

• Examine intended and unintended intersection of programs and policies as they are scaled-up

• Identify strategies to get “health in all policies”

Building multisectoral partnerships for population health and health equity.

Fawcett, et al., Prev Chronic Dis 7(6), 2010

• “Poor performance in achieving population health goals is well-noted — approximately 10% of public health measures tracked are met.”

• Contributing factors:– lack of shared responsibility for outcomes– lack of cooperation and collaboration– challenges engaging stakeholders at multiple

ecologic levels in building collaborative partnerships for population health

Our Key Conundrums• What data infrastructure is needed for research in this

field and how can we best stimulate its development?

• What funding partnerships would best support advances in this field?

• How can we best support this research through strategic and open grants competitions?

• How can we best stimulate and support innovation across all research streams?

• How do we attract the interdisciplinary mix of scientists needed to advance this field?

Symposium Objectives• Create a forum to identify issues relevant to

advancing the science of population health intervention research

• Identify emergent population health intervention priorities and the data infrastructure that is needed to support related research

• Showcase examples from Canada and other countries of how population health intervention research can add value to policy and practice.

Final Thought

• “We need to mobilize the power of ideas in order to influence the ideas of power, that is to say, the ideas of those with the power to make decisions.” (Julio Frenk, Montreux, 2010)

References• Brownell, M. 2010. Using Data from the Manitoba Centre for Health Policy to Help Us Understand Child Health. Moving Child Health Data into Practice, National Child Day Forum,

Pre-conference Workshop, Winnipeg, November 15. Accessed on May 13, 2011 from http://www.gov.mb.ca/healthychild/ncd/ncd2010_brownell_pre.pdf

• Brownell, M; Chartier, M; Au, W; Schultz, J. 2010. Evaluation of the Manitoba Healthy Baby Program. Manitoba Centre for Health Policy. Accessed on May 13, 2011 from http://www.gov.mb.ca/health/phc/pdf/machs/brownell.pdf

• CIHR. 2010. CIHR-Institute of Population and Public Health (IPPH) Strategic Plan 2009-2014. Accessed on May 13, 2011 from http://www.cihr-irsc.gc.ca/e/documents/ipph_strategic_plan_e.pdf

• Dyson, A.; Hertzman, C.; Roberts, H.; Tunstill, J.; Vaghri, Z. 2010. Childhood development, education and health inequalities. Marmot Review. Accessed on May 13, 2011 from http://www.marmotreview.org/AssetLibrary/pdfs/full%20tg%20reports/early%20years%20and%20education%20t.g.%20full%20report.pdf

• Edwards, N; Di Ruggiero, E. 2011. Exploring which context matters in the study of health inequities and their mitigation. Scandinavian Journal of Public Health. 39, 6: 43-49. Accessed on May 13, 2011 from http://sjp.sagepub.com/content/39/6_suppl/43.full.pdf+html

• Erasmus, 2004. Notes on A History of the Indian Residential School System in Canada. Aboriginal Healing Foundation. Prepared for The Tragic Legacy of Residential Schools: Is Reconciliation Possible? A conference Hosted by The Assembly of First Nations, University of Calgary, March 12-13. Accessed on May 13, 2011 from www.ahf.ca/downloads/is-reconciliation-posible.pdf

• Fawcett, S; Schultz, J; Watson-Thompson, J; Fox, M; Bremby, R. 2010. Building Multisectoral Partnerships for Population Health and Health Equity. Preventing Chronic Disease: Public Health Research, Practice, and Policy. 7 (6): 1-7. Accessed on May 13, 2011 from http://ukpmc.ac.uk/backend/ptpmcrender.cgi?accid=PMC2995607&blobtype=pdf

• Frenk, J. 2010. Keynote Speech. Health Systems Research for the 21st Century: The Power of Knowledge in an Interdependent World. First Global Symposium on Health Systems Research. Montreux, Switzerland. November 16-19. Accessed on May 13, 2011 from http://www.hsr-symposium.org/images/stories/frenk_presentation.pdf

• Healthy Baby. 2011. Manitoba Prenatal Benefit & Community Support Program. Accessed on May 13, 2011 from http://www.gov.mb.ca/healthychild/healthybaby/index.html

• Human Early Learning Partnership. 2011. University of British Columbia. Accessed on May 13, 2011 from http://www.earlylearning.ubc.ca/

• Lipscombe, LL; Austin, PC; Manuel, DG; Shah, BR; Hux, JE; Booth, GL. 2009. Income-related differences in mortality among people with diabetes mellitus. Canadian Medical Association Journal. 182. 1: 1-17. Accessed May 13, 2011 from http://www.cmaj.ca/cgi/reprint/182/1/E1

• Manitoba Centre for Health Policy. 2011. Accessed on May 13, 2011 from http://www.umanitoba.ca/faculties/medicine/units/community_health_sciences/departmental_units/mchp/

• Manuel, DG; Lim, J; Tanuseputro, P; Anderson, GM; Alter, DA; Laupacis, A; Mustard, CA. 2006. Revisiting Rose: strategies for reducing coronary heart disease. British Medical Journal. 332: 659-662.Accessed May 13, 2011 from http://www.bmj.com/content/332/7542/659.full.pdf

• Manuel, DG; Rosella, LC. 2010. Commentary: Assessing population (baseline) risk is a cornerstone of population health planning—looking forward to address new challenges. International Journal of Epidemiology. 39: 380-382. Accessed May 13, 2011 from: http://ije.oxfordjournals.org/content/39/2/380.full.pdf+html

• Martens, P.; Brownell, M.; Au, W; et al. 2010. Health Inequalities in Manitoba: Is the Socioeconomic Gap in Health Widening or Narrowing over Time? Manitoba Centre for Health Policy, University of Manitoba. Accessed from: http://mchp-appserv.cpe.umanitoba.ca/reference/Health_Ineq_final_WEB.pdf

• Old Sun Indian Residential School, Gleichen, Alberta. 1945. General Synod Archives. P75-103, S7-184.

• PHAC. 2008. National Meeting on Promotion and Prevention in Acapulco, Guerrero, Mexico. July 5. Accessed on May 13, 2011 from http://www.phac-aspc.gc.ca/cpho-acsp/speeches-discours/nmppmex080705-eng.php

• Reading, J. 2009. A Life Course Approach to the Social Determinants of Health for Aboriginal Peoples. For The Senate Sub-Committee on Population Health, March. Accessed on May 13, 2011 from http://www.parl.gc.ca/Content/SEN/Committee/402/popu/rep/appendixAjun09-e.pdf