CDE Appendix 1 Literature Review - Central East Local Health ...

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The Culture, Diversity and Equity Project: Literature Review Noting the variety of definitions of health equity in use in various jurisdictions across Ontario, Lettner (2008a) stresses the importance of crafting “consensus on a working description of health equity to inform the development and implementation of programs, services and projects by both government and communities, as well as community engagement strategies.” Most definitions of health equity/parity/equality vary in accord with, and contradistinction to, how authors have variously defined health inequity/inequality/disparity. Health equity is more often than not defined as a negative goal to be striven after - the reduction or elimination of health inequities or disparities/inequalities that are deemed unjust, unfair and avoidable. Rachlis (2007) explores some of the definitions of health equity in currency in the Ontario context: “[The goal of] reduc[ing] disparities in the health of those groups who may be disadvantaged by social or economic status, age, gender, ethnicity, geography, or language” (Ontario Health Quality Council 2006). or “The goal of…minimiz[ing] systematic and remedial disparities in health and social well-being between groups of people who have different levels of underlying social advantage” (The Ontario Project; cited in Rachlis 2007; see Table 3.1 for more definitions of health equity) Healthy equity definitions and approaches also vary in the scope of groups targeted (see Policy section 3.1 under the ‘scope’ subsection). Other definitions of health equity are framed in more positive terms. Examples include Gardner’s (2008a) definition of health equity as “ensuring equal opportunities for good health for all” and Lettner’s (2008a) definition of health equity as “equal opportunity for good health”. The Ontario Health Equity Council has more recently (2007) and positively defined the goal of health equity in plain language terms as follows: “People should get the same quality of care regardless of who they are and where they live.” This definition, unlike the former two, however restricts the purview of health equity to healthcare services, as is common in the US (where healthcare equity is more often than not the explicit focus of attention, rather than health equity per se, as discussed in the framework section below). The varying terms, premises and definitions of health in/equity discussed above find fuller expression and divergence in the varying frameworks that have been developed in the literature and among health policy-makers and practitioners interested in tackling health disparities. 2.0 FRAMEWORKS FOR TACKLING HEALTH DISPARITIES Health Equity-related frameworks for public policy-making may be divided into two main conceptual camps. The first, here termed ‘Health Equity’, take a broader view of the challenge to be confronted by healthcare systems and agencies – that is disparities in health status, relating to the full spectrum of health determinants, including those beyond the healthcare system. The second approach, here termed ‘Health care Equity’, is more narrowly concerned with examining disparities that have origins, and thus solutions, within healthcare services more specifically. Cultural Competence frameworks may be situated within this latter stream of approaches. In between these two framework approaches is ‘Health Equity in Healthcare Frameworks’, which begin with a fundamental concern with inequities in health status, yet frame solutions more specifically within the context, and from the perspective, of the healthcare system. These frameworks each have particular ways of diagnosing the problem to be confronted and solution to be pursued by governmental healthcare authorities, in a manner significantly shaping the policy and strategic options pursued 16
The Culture, Diversity and Equity Project: Literature Review by those operating within their respective purviews. Health equity and healthcare equity frameworks, nonetheless, need not be, and should not be seen, as necessarily mutually exclusive. The diagram below depicts two different genealogies of approaches tackling inequities in health and social services, and recent attempts to bridge these two approaches in healthcare (see Janzen & Ochocka, 2006 for more on the genealogy and synthesis of these approaches). The distinction drawn between power-oriented and culture-oriented approaches maps partially onto the distinction drawn in this review between health equity and healthcare equity (cultural competence in specific) approaches. Figure 2.1: Contending diagnoses of the sources of inequitable healthcare service Source: Janzen & Ochocka, 2006. Health Equity approaches are generally more power-oriented, focusing much more directly on structural inequities in power in society as these impact upon health status among disadvantaged population groups. Margot Lettner’s (2008a) analysis of the roots of health inequity is exemplary of this power-oriented approach. As she argues: The clear research consensus is that the roots of health disparities lie in broader social and economic inequality and exclusion. The most effective conceptual framework for health disparities is therefore grounded in a determinants of health approach, i.e., it looks beyond the traditional definitions of health, as well as beyond the historical analyses of the causes of illness and injury, and focuses on a broad range of socio-economic influences and outcomes that affect both individual and community or population health, such as income/wealth distribution and poverty, early child development, education, employment and working conditions, housing, gender, race and ethnicity, citizenship and immigration status, language, ability, sexual orientation, age, racism and discrimination, social exclusion, and natural and built environments. Most researchers and policy-makers working within a health determinant, health equity framework, nevertheless, also recognize the important, albeit less determining role, of healthcare services in mitigating the effects of health inequities (healthcare itself being one determinant of health among others).   17
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REFERENCES ACAS [Advisory Conciliat
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