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

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The Culture, Diversity and Equity Project: Literature Review challenges due to the sectoral frameworks within which governments are designed and accustomed to operating in (see WHO, 2008, p.111; PHAC, 2007; PHAC & WHO, 2008). Such whole-of-government approaches, moreover, where these do exist in practice, most often require coordination at the highest levels of government. Another challenge of the more ‘evidence-based’ health equity models and frameworks employing causal models of health in/equity revolves around the contested nature of ‘causes’ and ‘evidence’ in the literature. As the WHO reports in the former respect: By their nature many of the social determinants considered by the Commission are relatively distant, spatially and temporally, from individuals and health experience. This is challenging, both conceptually and empirically, when trying to attribute causality and demonstrate effectiveness of action on health equity (2008, p. 42). Part of the challenge of evidence-based approaches in this respect is what kinds of evidence are considered to ‘count’ in the scientific literature (too often, critics argue, only experimental quantitative evidence that can be counted). Many ‘upstream’ determinants of health, such as global or national economic arrangements and social policies, however, do not lend themselves to randomized controlled trials etc. Applying overly strict and narrow rules of evidence in this respect could lead to many of the most important health determinants falling off the analytical radar. When it comes to suggesting appropriate intervention strategies, moreover, health equity frameworks and models have less of an evidence-base to stand on. This is in no small part due to the dearth of existing research evaluating the impact and effectiveness of various kinds of health equity interventions on the ground (Exworthy et al., 2006; Gardner, 2008a; Mackenbach et al., 2002a). 15 Theoretically informed, evidence-based health equity models and frameworks, moreover, have to guard against being too complex for policy-makers to understand, as this will inhibit effective translation into policy interventions. Those health equity frameworks complementing their theoretical causal models with corresponding practical intervention frameworks, in this respect (e.g. WHO 2008; New Zealand Min of Health, 2002), hold out the most promise and potential, since they already provide guidance on this translation from theoretical models to sites for policy intervention. Many of the identified causes of health inequity in such frameworks and models, moreover, are of a more politically contentious nature, since they ultimately rely on normative theories of differentiating just from unjust social arrangements and health outcomes. Scientific ‘evidence’, in this respect, is no substitute for ethics. Some of the health equity frameworks are thin on the ethical bases of their commitments. Finally, many of the health equity frameworks encountered in the literature focus near exclusively on socioeconomic status as a bases for health in/equity, failing to take adequate stock of intersecting dimensions of social exclusion and health inequity such as race, ethnicity, gender, and sexual orientation (Galabuzi & Labonte, 2002). 15  Mackenbach et al.’s (2002a) survey of the field of health inequalities remains very much true to this day in this respect: most publications about socioeconomic inequalities in health have focused on the description of socioeconomic inequalities in health in countries, comparisons between countries and the explanation of these inequalities. From these studies we have learnt much about the different factors which influence socioeconomic inequalities in health. However, in practice it seems hard to translate these factors into interventions in health. 50
The Culture, Diversity and Equity Project: Literature Review The (2004) Discussion paper of the Health Disparities Task Group for Public Health Canada, for instance, commendably recommends examining the health status of Aboriginal peoples, single mothers in poverty, women, homeless people, and refugees, but lacks a more explicit ethno-racial lens of analyses. Health Equity in Healthcare Frameworks Strengths Forming a bridge between health equity and healthcare equity frameworks, health equity in healthcare framework have the benefit of keeping within their analytical and strategic purview determinants of health and health inequity that lie beyond the healthcare system, and employing such analyses to effectively and creatively inform appropriate (holistic, prevention-based) strategies to address such inequities within the healthcare system (as illustrated in Gardner’s many recommendations which share a holistic, community-empowerment perspective focusing ‘upstream’ on prevention and health promotion). In concerning themselves with the broad determinants of health status, yet from the situated standpoint of the healthcare system, and what it can do to reduce inequities in health status, health equity in healthcare frameworks have the added appeal and benefit of being more easily operationalized within local/regional healthcare contexts and settings such as the LHINs. Limitations The two health equity in healthcare frameworks engaged in this literature review did not explicitly base themselves upon any etiological model or evidence-base of the causes of health in/equity and the most effective solutions. While these frameworks (e.g. Gardner, 2008a) offer many concrete recommendations for LHINs action, it would be useful to more explicitly wed such intervention frameworks to a more self-consciously elaborated, evidence-based, conceptual framework and model. Healthcare Equity Frameworks Strengths Healthcare equity frameworks taking a more narrow and focused approach on healthcare inequities have, as a particular strength, their ‘do-ability’ and ‘translatability’ into action in and by the healthcare sector. Cultural competence frameworks – the main form of healthcare equity frameworks discussed in this review - are particularly commendable for their close attention to the ways in which cross-cultural dynamics within healthcare settings can seriously and negatively impact upon the accessibility and quality of healthcare services received by cultural minorities (Registered Nurses Association of Ontario, 2007; Stampino, 2007; Simich et al., 2006; Basok, 2007). Cultural competence frameworks have as a particular strength their close attention to the cultural ingredients of successful interpersonal relations, exchanges, and communication, all of which are critical to successful, patientcentred, health outcomes in healthcare contexts. In plural, immigrant-based, multicultural societies such as Ontario, where there is a significant level of ethnocultural diversity, cultural competence frameworks may be of particular use, given their focus on inter-ethnic relations. Limitations Healthcare equity frameworks have been critiqued for failing to consider and engage the most important and consequential determinants of health that are situated ‘upstream’ from the healthcare sector. Though not within the direct control of the healthcare sector, critics argue that the healthcare sector can play a lead role in advancing and advocating a more holistic approach to health that better addresses and accounts for the broader social determinants 51
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