Transcript How Equity and Interventions Collide

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 Plan
2009-2014
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
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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
CIHR expenditures on Theme IV-related
Population Health Intervention
Research
5
35
25
3
20
15
2
Number
Expenditures ($ millions)
30
4
10
1
5
0
0
2000 01
2001 02
2002 03
2003 04
2004 05
2005 06
2006 07
2007 08
2008 09
2009 10
Fiscal year
grant $ open
grant $ strategic
grant # open
grant # strategic
12
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
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).
Source: OLD SUN INDIAN RESIDENTIAL SCHOOL (GLEICHEN,
AB), P75-103 S7-184, 1945, General Synod Archives.
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 sociopolitical 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
http://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)
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Widened over time (n=12)
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Similar over time (n=10)
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Premature mortality rate and PYLL
Teen pregnancy
Diabetes
Ischemic heart disease
Cervical cancer screening
Cumulative mental illness (rural only)
Under 5 mortality
Multiple sclerosis
Continuity of care (urban only)
Dementia
Narrowed over time (n=1)
– Breastfeeding (urban only)
Healthy Baby Program
Manitoba Centre for Health Policy
(Martens et al, 2010)
• 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).
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
Percent of Births by Community Support Program
Participation by Receipt of Income Assistance (IA)
2004/05 - 2007/08 (Martens et al, 2010)
24
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)
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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)
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.cihrirsc.gc.ca/e/documents/ipph_strategic_plan_e.pdf
•
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•
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•
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•
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•
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