Benita Cohen

Community health clinical education in Canada: part 2--developing competencies to address social justice, equity, and the social determinants of health.

Recently, several Canadian professional nursing associations have highlighted the expectations that community health nurses (CHNs) should address the social determinants of health and promote social justice and equity. These developments have important implications for (pre-licensure) CHN clinical education. This article reports the findings of a qualitative descriptive study that explored how baccalaureate nursing programs in Canada address the development of competencies related to social justice, equity, and the social determinants of health in their community health clinical courses. Focus group interviews were held with community health clinical course leaders in selected Canadian baccalaureate nursing programs. The findings foster understanding of key enablers and challenges when providing students with clinical opportunities to develop the CHN role related to social injustice, inequity, and the social determinants of health. The findings may also have implications for nursing programs internationally that are addressing these concepts in their community health clinical courses.

A Conceptual Framework of Organizational Capacity for Public Health Equity Action (OC-PHEA).

The Canadian public health sector’s foundational values of social justice and equity, and its mandate to promote population health, make it ideally situated to take a strong lead in addressing persistent and unacceptable inequities in health between socially disadvantaged, marginalized or excluded groups and the general population. There is currently much attention paid to improving understanding of pathways to health equity and development of effective population health interventions to reduce health inequities. Strengthening the capacity of the public health sector to develop, implement and sustain equity-focused population health initiatives - including readiness to engage in a social justice-based equity framework for public health - is an equally essential area that has received less attention. Unfortunately, there is evidence that current capacity of the Canadian public health sector to address inequities is highly variable. The first step in developing a sustained approach to improving capacity for health equity action is the identification of what this type of capacity entails. This paper outlines a Conceptual Framework of Organizational Capacity for Public Health Equity Action (OC-PHEA), grounded in the experience of Canadian public health equity champions, that can guide research, dialogue, reflection and action on public health capacity development to achieve health equity goals.RésuméLe secteur canadien de la santé publique, avec ses valeurs fondamentales de justice sociale et d’équité et son mandat de promotion de la santé des populations, est idéalement situé pour jouer un rôle de premier plan face aux iniquités en santé persistantes et inacceptables entre les groupes socialement défavorisés, marginalisés ou exclus et la population générale. On essaie beaucoup, en ce moment, de mieux comprendre les voies de l’équité en santé et d’élaborer des interventions efficaces en santé des populations pour réduire les iniquités en santé. Une mesure tout aussi essentielle et pourtant moins reconnue est de renforcer les capacités du secteur de la santé publique à élaborer, à mettre en oeuvre et à soutenir des initiatives de santé des populations axées sur l’équité - y compris la volonté d’employer en santé publique une grille d’équité basée sur la justice sociale. Malheureusement, il semble que la capacité actuelle du secteur canadien de la santé publique d’aborder les iniquités varie considérablement. La première étape, si l’on veut mettre au point une approche soutenue en vue d’améliorer les capacités d’agir sur l’équité en santé, est de déterminer ce qu’une telle capacité implique. Notre article définit un « cadre conceptuel de la capacité organisationnelle pour une action de la santé publique en matière d’équité », ancré dans l’expérience des champions de la santé publique canadienne sur la question de l’équité, pour orienter la recherche, le dialogue, la réflexion et l’action sur le renforcement des capacités en santé publique et atteindre les objectifs d’équité en santé.

Does public health advocacy seek to redress health inequities? A scoping review

The public health (PH) sector is ideally situated to take a lead advocacy role in catalysing and guiding multi-sectoral action to address social determinants of health inequities, but evidence suggests that PHs advocacy role has not been fully realised. The purpose of this review was to determine the extent to which the PH advocacy literature addresses the goal of reducing health and social inequities, and to increase understanding of contextual factors shaping the discourse and practice of PH advocacy. We employed scoping review methods to systematically examine and chart peer-reviewed and grey literature on PH advocacy published from January 1, 2000 to June 30, 2015. Databases and search engines used included: PubMed, CINAHL, PsycINFO, Social Sciences Citation Index, Google Scholar, Google, Google Books, ProQuest Dissertations and Theses, Grey Literature Report. A total of 183 documents were charted, and included in the final analysis. Thematic analysis was both inductive and deductive according to the objectives. Although PH advocacy to address root causes of health inequities is supported theoretically and through professional practice standards, the empirical literature does not reflect that this is occurring widely in PH practice. Tensions within the discourse were noted and multiple barriers to engaging in PH advocacy for health equity were identified, including a preoccupation with individual responsibilities for healthy lifestyles and behaviours, consistent with the emergence of neoliberal governance. If the PH sector is to fulfil its advocacy role in catalysing action to reduce health inequities, it will be necessary to address advocacy barriers at multiple levels, promote multi-sectoral efforts that implicate the state and corporations in the production of health inequities, and rally state involvement to redress these injustices.

Developing Guidelines for Quality Community Health Nursing Clinical Placements for Baccalaureate Nursing Students

Rapidly increasing enrollment in Canadian schools of nursing has triggered the development of innovative clinical placement sites. There are both opportunities and challenges inherent in the delivery of clinical nursing education in diverse community settings. As part of the Canadian Association of Schools of Nursing’s (CASN) ongoing work to assist its members and ensure baccalaureate graduates are prepared to meet the Canadian Community Health Nursing Standards of Practice at an entry-to-practice level, the CASN Sub-Committee on Public Health (funded by the Public Health Agency of Canada) conducted extensive national consultations with representatives from both academic and practice settings, as well as key national organizations. The resultant Guidelines for Quality Community Health Nursing Clinical Placements, released by CASN in 2010, aim to provide direction to Canadian schools of nursing and practice settings in addressing the challenges and opportunities arising from the changing context of community health nursing student clinical placements.

Preparing the community health nursing workforce: internal and external enablers and challenges influencing undergraduate nursing programs in Canada.

The Canadian Schools of Nursing (CASN) task force on public health was mandated to facilitate Schools of Nursing to provide students with the foundation required to meet the Canadian Community Health Nursing Standards of Practice. This paper reports on an environmental scan that explored barriers and enablers influencing the integration of community health nursing content in baccalaureate education in Canada. Data was collected over three phases including: 1) a pan-Canadian survey of nursing schools, 2) completion of open-ended workbook questions by educators, policy makers, administrators, and community health nursing managers attending a pan-Canadian symposium on community health nursing, and 3) recorded notes from the symposium. The response rate for the survey was 72.5% (n = 61 schools) and approximately 125 stakeholders participated in symposium activities. Internal and external enablers and challenges as well as recommendations for practice and education are presented.

Reorienting Public Health Nurses’ Practice With a Professional Practice Model:

Purpose Documents articulating public health nurses’ (PHNs’) roles, including Canadian standards and competencies, depict a broad focus working at multiple levels to improve population outcomes through the promotion of health equity. Conversely, Canadian experts depict a looming crisis, based on the rising disconnect between daily activities and ideal practice. While perfectly positioned, PHNs’ skills and abilities are under-utilized and largely invisible. The intention of this study was to develop a model to support the full scope of equity-focused PHN practice. Method A participatory action research approach was used. Qualitative data were gathered using semistructured interview guides during audio-recorded meetings. The data were coded into central themes using content analysis and constant comparison. A researcher reflexive journal and field notes were kept. A significant feature was full participant involvement. Results The outcome was a professional practice model to reframe the PHN role to focus on population health and equity. The model was imperative in promoting full scope of practice, dealing with workload pressures, and describing PHNs’ value within the organization and broader health system. Conclusion Professional practice models hold promise as frameworks to depict autonomous practice activities, situated within organizations and healthcare systems, and underpinned by nursing knowledge.

A multiple case study of intersectoral public health networks: experiences and benefits of using research

BackgroundNetwork partnerships between public health and third sector organisations are being used to address the complexities of population level social determinants of health and health equity. An understanding of how these networks use research and knowledge is crucial to effective network design and outcome evaluation. There is, however, a gap in the literature regarding how public health networks use research and knowledge. The purpose of this paper is to report on the qualitative findings from a larger study that explored (1) the experiences of public health networks with using research and knowledge, and (2) the perceived benefits of using research and knowledge.MethodsA multiple case study approach framed this study. Focus group data were collected from participants through a purposive sample of four public health networks. Data were analyzed using Framework Analysis and Nvivo™ software supported data management. Each network had the opportunity to participate in data interpretation.ResultsAll networks used published research studies and other types of knowledge to accomplish their work, although in each network research and knowledge played different but complementary roles. Neither research nor other types of knowledge were privileged, and an approach that blended varied knowledge types was typically used. Network experiences with research and knowledge produced individual and collective benefits. A novel finding was that research and knowledge were both important in shaping network function.ConclusionsThis study shifts the focus in the current literature from public health departments to the community setting where public health collaborates with a broader spectrum of actors to ameliorate health inequities. Both formal research and informal knowledge were found to be important for collaborative public health networks. Examining the benefits of research and knowledge use within public health networks may help us to better understand the relationships among process (the collaborative use of research and knowledge), structure (networks) and outcomes (benefits).

Poverty Trajectories Experienced by Persons with Mental Illness

ABSTRACT The present study aimed to better understand the relationship between mental illness and poverty by comparing three groups of individuals with mental illness in Canada: those who see their financial status as improving, worsening, or staying the same. This study used a focused ethnography approach to collect qualitative data from 34 focus group participants. Participants highlighted several facilitators and barriers to financial improvement and often described their financial situation as a cycle that was difficult to escape. Results are discussed in terms of policy implications to facilitate both a movement toward mental health and away from poverty.

Report of an equity-focused health impact assessment of a proposed universal parenting program in Manitoba.

OBJECTIVES: To assess potential inequitable impacts of a proposed Teen Triple P Positive Parenting Program (Teen PPP) in Manitoba to achieve equity of access and outcomes for families of diverse backgrounds; recommend (if required) alternative actions to promote greater equity of access and outcomes for families participating in Teen PPP; and evaluate the influence of recommendations on implementation of the proposed program.INTERVENTION: An equity-focused health impact assessment (EfHIA) of the proposed Teen PPP was conducted, using a standard EfHIA framework. Methods used to assess potential Teen PPP impacts included: a literature review, key informant interviews and 14 community consultations. Evidence was analyzed, summarized and presented to the project Steering Committee (SC), along with draft recommendations for ensuring that equity is considered in Teen PPP planning and rollout.OUTCOMES: The SC prioritized 12 possible inequitable impacts of Teen PPP with potential to prevent certain parents/caregivers either from accessing the proposed program or benefitting adequately from the program, causing them to drop out prematurely. Recommendations for avoiding these impacts were finalized by the SC and presented to provincial government officials responsible for the proposed program. Follow-up interviews with these individuals indicated that the recommendations were well received and raised equity-related issues that will be considered in future program planning decisions.CONCLUSION: EfHIA is a proven planning tool for ensuring that health equity is considered in all policies, which is one of the necessary conditions for reducing inequities and closing the health equity gap throughout Canada within a generation.RésuméOBJECTIFS: Évaluer les effets potentiellement inéquitables d’un projet de programme de pratiques parentales positives (Triple P) pour les parents d’adolescents au Manitoba afin d’offrir un accès et des résultats équitables aux familles de divers milieux; de recommander (au besoin) des mesures de rechange pour promouvoir plus d’équité dans l’accès et les résultats des familles participant à Teen Triple P; et d’évaluer l’influence des recommandations sur la mise en oeuvre du programme proposé.INTERVENTION: Nous avons mené une évaluation d’impact sur la santé axée sur l’équité (ÉISAÉ) du programme Teen Triple P proposé, à l’aide d’un cadre d’ÉISAÉ type. Les méthodes suivantes ont servi à évaluer les effets potentiels de Teen Triple P: une revue de la littérature spécialisée, des entretiens avec des informateurs et 14 consultations communautaires. Les données probantes ont été analysées, résumées et présentées au comité directeur (CD) du projet, accompagnées de recommandations préliminaires pour que l’équité soit prise en compte dans la planification et le déploiement de Teen Triple P.RÉSULTATS: Le CD a priorisé 12 effets inéquitables possibles de Teen Triple P qui risqueraient d’empêcher certains parents ou aidants d’accéder au programme proposé ou d’en bénéficier convenablement, ce qui les ferait abandonner prématurément le programme. Les recommandations pour éviter ces effets ont été parachevées par le CD et présentées aux fonctionnaires provinciaux responsables du programme proposé. Des entretiens de suivi auprès de ces personnes ont indiqué que les recommandations ont été bien accueillies et qu’elles ont soulevé des questions d’équité qui seront prises en compte dans les futures décisions de planification du programme.CONCLUSION: L’ÉISAÉ est un outil de planification éprouvé pour que l’équité en santé soit prise en compte dans toutes les politiques, ce qui est l’une des conditions nécessaires pour réduire les iniquités et combler le fossé de l’équité en santé partout au Canada en une génération.