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Equity and EPH consultation

Health Equity and Environmental Public Health Consultations

 

Methods

This project is based on an iterative approach to knowledge building. The primary goal for the first year (2014-15) was to increase knowledge of health inequities related to the natural and built environment and to improve understanding of how these inequities impact environmental public health practice in BC. We built partnerships and assessed needs in order to guide the development of tools and resources in the following years.

We conducted an exploratory focus group with environmental health officers (EHOs) in each of BC's five regional health authorities and in the First Nations Health Authority. Fraser Health Authority served as a pilot site in March 2014; the remaining focus groups were held in March 2015.

Focus groups lasted between one and two hours each. Each focus group included 5 to 13 field and supervisory staff; managers were not included in order to encourage participants to speak freely and to share their thoughts and ideas. EHO participants were recruited with the help of managers from each health authority, but their participation was voluntary and dependent on their ability to attend in person at the designated time and location. Each focus group included EHOs with a range of experience levels, who worked across a variety of service areas (e.g., food, drinking water, built environment, personal services, air quality, general practice, etc.), and who served communities of different sizes.

The loosely structured focus group discussions were designed to help us learn how EHOs view barriers that vulnerable groups may face in complying with environmental health regulations, how EHOs respond to those barriers, and what gaps exist for EHOs when working with populations affected by barriers. These discussions were audio-recorded, transcribed, and analysed using QSR NVivo 10 or ATLAS.ti 7 qualitative data analysis software. Transcripts were first reviewed to identify themes based on the project objectives. Additional themes arose as the analysis progressed and transcripts were re-reviewed.

This needs assessment provided the information needed to start articulating a vision of an equity-integrated EPH practice. The focus groups identified:

  • the major social determinants of health—or barriers to compliance—that EHOs encounter through their practice
  • a variety of strategies EHOs use to respond when barriers are present
  • how inequities intersect with different EPH service areas
  • opportunities to remove systemic barriers that might contribute to inequities and to better support EHOs to respond barriers related to the social determinants of health
Approach

Consultations with environmental public health practitioners in BC and across Canada indicate that there are multiple ways of viewing how health inequities and the social determinants of health relate to practice, and there are different approaches to responding to inequities.

This equity quad can help guide thinking about equity and environmental public health. 

Person-Centred Approach to EPH
Systems Approach to EPH
Practice model

Traditional
Focus on regulation and health protection, using education as a tool.
Emergent
Focus on health promotion and creating supportive environments.
Response
to health inequities



Individual
Respond to socioeconomic barriers
when they arise. Incorporate equity
into practice by providing tools for practitioners who work with individuals who face socioeconomic barriers.

Population
Remove barriers to health in society. Integrate equity into the EPH mandate with policy and collaborative mechanisms across all areas of practice.

The Equity Quad: Moving toward an equity-oriented EPH practice. The top row (green) describes typical EPH practice, which has been gradually shifting from a regulatory compliance approach to one that incorporates health promotion and healthy environments as tools to both improve health and improve compliance. The bottom row (blue) indicates how an equity lens could be applied to either the Traditional or Emerging approaches to EPH practice. 

Health protection and environmental public health have traditionally operated within a regulatory framework, with activities centred on inspection, education, and enforcement. Many regions have begun relying more on health promotion and other population health based activities and less on regulatory activities. Such approaches aim to protect people from environmental health hazards and prevent chronic diseases by creating healthy, supportive environments.

During traditional inspection and licensing activities, the social determinants of health may present as barriers to compliance related to language, education, geographic location, culture, or income, all of which can influence the interaction between a practitioner and individual. Responses to these barriers (see Figure) might involve actions to mitigate or work around existing barriers rather than a punitive response to non-compliance. Incorporating an equity lens to traditional practices is considered a transactional change[i] — it relies on tools and resources that practitioners can use to work more effectively to mitigate the effects of equity-related barriers. Although the explicit recognition of equity may be recent, many approaches that can mitigate health inequities are already used by individual EHOs as tools to better protect the public's health[ii].


 

Addressing barriers with an equity lens. Individual barriers may be manageable, particularly if they exist in isolation, while systemic barriers tend to create challenges that are more difficult to surmount. However, when multiple barriers of any kind are present, their combined challenges are complex and more difficult to address. (Adapted from Dr. B. Nummer.)

 

It is essential that population health activities focus on advocating for or creating environments that are more supportive of health[iii]. This can help address systemic factors (or hurdles; see Figure) that prevent people from living in healthy circumstances, accessing services, or meeting their full health potential. Systemic factors may also hinder a practitioner's ability to provide service to a broad spectrum of the population in a way that meets regulatory requirements or to address underlying factors that affect compliance. Creating more health-supporting environments requires a higher level of transformative organizational change[i] that can lead to better outcomes overall.


[i] Britnell M. Transforming health care takes continuity and consistency. Harvard Business Review. 2015 December 28. Available from: 
https://hbr.org/2015/12/transforming-health-care-takes-continuity-and-consistency?#
[ii] Diez Roux, A. V. (2016). "On the Distinction—or Lack of Distinction—Between Population Health and Public Health." American Journal of Public Health 106(4): 619-620. Available from: http://dx.doi.org/10.2105/AJPH.2016.303097
[iii] First International Conference on Health Promotion (1986). The Ottawa Charter for Health Promotion. Ottawa. Available from:  
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

Resources

Can focus groups be a tool for change? Introducing health equity to environmental public health practice

Rideout K., Oickle, D. and Clement, C., Environmental Health Review 2016, 59(4):113-116

Research article in Environmental Health Review exploring the potential for focus groups to be used as a tool to introduce new concepts into public health practice.


Dec 2016

Integrating equity into environmental health practice: Findings of a pilot study

Rideout K.  and Oickle, D., Environmental Health Review 2016, 59(1):35-39

Research article in Environmental Health Review about how equity intersects with environmental health practice and how practitioners respond, with discussion of how to further support the integration of equity into practice.

Mar 2016



Opportunities for environmental public health action on the social determinants of health and health inequity

Rideout, K., Oickle, D., Scarpino, J., Chang, H., Ness, T., Vecchiarelli, V. Ma, L., Environmental Health Review 2015, 58(4):75-78

Commentary article in Environmental Health Review highlighting how environmental public health practitioners can support health equity — based on workshops held at Canadian Institute of Public Health Inspectors (CIPHI) meetings.

Dec 2015



Determinants of health and environmental health practice: Opportunities for action

Presentation at the Canadian Institute of Public Health Inspectors (CIPHI) Manitoba Branch in Winnipeg — in collaboration with NCCEH and NCCDH and with guest speakers Dr. Heejune Chang (Winnipeg Regional Health Authority), Tim Ness (First Nations and Inuit Health Branch, Health Canada), and Julie Scarpino (Manitoba Health).

(PPT slides)
Oct 2015





Public health inspectors taking action on health equity and the social determinants of health

Presentation at the Canadian Institute of Public Health Inspectors (CIPHI) 81st Annual National Educational Conference in Ottawa — in collaboration with NCCEH and NCCDH and with guest speaker Vittoria Vecchiarelli (Regional Municipality of York).

(PPT slides)
Sep 2015



Equity in environmental health practice: A role for public health inspectors

CHNET-Works Fireside Chat — in collaboration with NCCEH and NCCDH and with guest speakers Ken Shaw (Fraser Health Authority) and Gary O’Toole (NS Department of Health and Wellness).

(audio and
PPT slides available)
May 2015

Addressing health inequities and the social determinants of health in environmental health practice

Presentation at the Canadian Public Health Association based on the pilot study — in collaboration with NCCEH and NCCDH.


Presentation
May 2015

Equity in environmental health practice: Findings of a pilot study

Research report based on the pilot focus group conducted in Fraser Health Authority and Nova Scotia — in collaboration with NCCEH and NCCDH.

Report
PDF
Apr 2015

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