Presentation on theme: "Health Equity Matters: How Equity and Interventions Collide Nancy Edwards, RN, PhD, FCAHS Scientific Director, CIHR Institute of Population and Public."— Presentation transcript:
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 29 th, 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 Plan
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
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), P 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 Interventions Edwards & 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 Examples Health 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 Partnership 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/ /08 (Martens et al, 2010) 23
24 Percent of Births by Community Support Program Participation by Receipt of Income Assistance (IA) 2004/ /08 (Martens et al, 2010) 24
25 Percent of Births by Community Support Program Participation, by Rural and Urban Income Quintile, 2004/ /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 Theorem Doug 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 Interventions Research 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)
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