Health Equity for Healthy Minds

Health Equity for Healthy Minds

The focus of acute health care always seems to be in a reactive state. The demands shift and change from one area to the next, in regards to what our sight is set on. Over the past two years it seems as though everything has been put on hold as all of health care has turned towards battling the Covid-19 pandemic. While the streets lined with chants for health care heroes and pots and pans were clapped together, one thing remained evident within our field. Health inequity gave us a glaring insight as to why it is important to focus on the social determinants of health to help truly define a healthy population. The focus of this blog will be to examine the Health Equity Framework (HEF) and to discuss the importance of health equity within our communities, specifically in regards to mental health quality of care.

The Health Equity Framework (HEF) is used within research to show that health outcomes for individuals involve complex interactions between people and their environment (Peterson et al., 2021). The HEF focuses on three foundational concepts: “Equity at the core of health outcomes; multiple, interacting spheres of influence; and a historical and life-course perspective” (Peterson et al., 2021). Equity will occur when all of the citizens of Ontario have equal access to health care (Woodward et al., 2021). The HEF looks at the individual as a whole. It empowers each individual to have access to resources that help them achieve their best possible physical, emotional and social well-being (Peterson et al., 2021). According to the Ministry of Health and Long Term Care (2017), “health equity means that all people can reach their full health potential and are not disadvantaged from attaining it because of their race, ethnicity, religion, gender, age, social class, socioeconomic status or other socially determined circumstance.”

Traditionally when health care providers look at a health care issue they tend to look at the individual. They do assessments based on the individual’s history and habits and what brought them into the hospital setting at that moment. The “issue” is treated, the patient is discharged, and the health care provider does not look much past this interaction and instead waits for the bed to be filled with the next patient from the emergency department. By only treating the individual we fail to identify the importance of the social determinants of health (SDoH) and how these circumstances can affect the individual’s overall health. Using the HEF, health care practitioners would think beyond the individual and identify the gaps that we are missing from multiple spheres of influence for the patient (Peterson et al., 2021).

The HEF came to fruition because research started to show that the impact of the social determinants of health on health outcomes was “more significant than areas such as the health care system, biology/genetic endowment, and the physical environment” (Middlesex London Health Unit, n.d.). The framework was thought to have a more encompassing view than other frameworks of the SDoH and importance of health care utilization (Dover & Belon, 2019). As pictured below, Figure 1 is a visual depiction of the impact the social determinants of health have on the health status of a population.

Figure 1. (Middlesex London Health Unit, n.d.)

When the HEF, which this paper is focusing on, was created the researchers used “four interacting spheres of influence that represent both categories of risk and protective factors for health outcomes, as well as opportunities for strategies and interventions that address those factors” (Peterson et al., 2021). The framework was built to support that individuals’ health outcomes are “influenced by complex interactions between people and their environment” (Peterson et al., 2021).

In Figure 2 you can see the four interacting spheres with health equity at the center.

Figure 2. (Peterson et al., 2021).

Health equity is at the core of the framework and it is defined as “having the personal agency and fair access to resources and opportunities needed to achieve the best possible physical, emotional and social well-being” (Peterson et al., 2021). As mentioned earlier, traditionally health care focuses on the individual and their own illness. When focus is just on the barriers for the individual, we fail to see the impact on any upstream actions for the social determinants of health and what could be preventing an individual from achieving their best health outcome (Peterson et al., 2021). According to the Middlesex London Health Unit (n.d.), “upstream actions advocate for greater fairness in power structures and income; they are about decreasing the causes-of-the-causes, whereas downstream actions address immediate health needs at an individual or family level; they are about changing the effect of the causes.”

The HEF identifies the importance of not only individuals, but also communities, having fair access to resources and opportunities such as education, health services and housing. Some communities are recognized as not having equal distributions of opportunities. This could be based on biases such as racism, homophobia or socioeconomic status. If this difference of resources continues between communities then there is a larger issue of health inequity.

Another key characteristic of the HEF is the design. The framework is “designed to highlight the explicit and implicit interactions of multilevel influences on outcomes” (Peterson et al., 2021). Looking at Figure 2, the four spheres of influence are described below, each with their pro and con listed:

Systems of Power. This sphere refers to policies, processes, and practice. These are the individuals or groups of people who decide the distribution of resources and opportunities for a community (think Government and institutions). Think of this sphere as an upstream approach in regards to promoting health equity through fair access to funds and opportunities. On the other hand, the worry with this sphere is that it could intensify health inequities if policies are created for one group to have an advantage over another.

Relationships and Networks. This sphere focuses on the connection with family, friends and the community. Health equity is promoted through this sphere by connections that have positive influences on an individual. The worry with this sphere is that self-harming behaviours could be encouraged through the networks that an individual is a part of.

Individual Factors. This sphere includes an individual’s response to their environment based on their attitudes, skills and behaviours. Attitude, skills and behaviours can be seen as having both a negative and positive impact on an individual.

Physiological Pathways. This sphere refers to a person’s biological, physical, and cognitive ability. This sphere cannot be easily modified by intervention. (Peterson et al., 2021)

As a registered nurse in Ontario, I can recognize the inequities that are shown to a person with lived experience (PWLE) of mental health and addiction. “Equity issues in mental health have a significant and often negative impact on the people, communities and health system of Ontario” (CAMH, May, 2014). There is a significant stigma towards an individual with a mental health condition. When social determinants of health are assessed for an already marginalized group of individuals, it becomes quite evident why the HEF would be beneficial to try and one day meet, the needs of the individual and communities.

When looking at the four spheres of the HEF and social determinants of health from a mental health standpoint, it is obvious that provincially there is a mental health crisis. According to CAMH (December, 2017) “people with mental health issues face discrimination in employment, housing and many other essential and health-promoting areas of life.” We are at a point that the issues are so ingrained into our culture that policies and financial help need to occur.

Systems of Power. Currently we have such a wide range of complex problems within mental health care that action is required at levels higher than the healthcare system. This marginalized group has limited access to the social determinants of health and therefore is being set up to fail in some instances.

Relationships and Networks. The stigma that is unfortunately attached to a mental health diagnosis can affect relationships and networks that you had as a child. “LGBT people face higher rates of depression and anxiety, and LGBT youth are more likely than their heterosexual peers to die by suicide” (CAMH, May, 2014).

Individual Factors. “PWLE, those experiencing a severe and persistent disability, experience unemployment…Only 25% of participants were employed” (CAMH, May 2014). Without employment it is difficult to have a positive attitude and gain any skills.

Physiological Pathways. Individuals who suffer from a mental health condition may have a history of early childhood adversities which could disrupt development of brain architecture and function (Peterson et al., 2021).

Social determinants of health continue to have an impact on an individual’s overall wellbeing. Health equity is a state that every province should aspire to be at for their residents. By examining the HEF and comparing it to individuals who live with a mental health diagnosis, it is evident that we have a lot of work to do to accomplish equity in healthcare.

References

Advancing equity in mental health: An action framework. (n.d.). Retrieved February 28, 2022, from https://ontario.cmha.ca/wp-content/uploads/2016/07/PPE-0001-Advancing-Equity-in-Mental-Health-2.pdf

Advancing equity in Ontario: Understanding key concepts. (n.d.). Retrieved March 1, 2022, from https://ontario.cmha.ca/wp-content/uploads/2016/07/Advancing-Equity-In-Mental-Health-Final1.pdf

DeCamp, M., DeSalvo, K., & Dzeng, E. (2020). Ethics and spheres of influence in addressing social determinants of health. Journal of General Internal Medicine, 35(9), 2743–2745. https://doi.org/10.1007/s11606-020-05973-1

Dover, D.C., & Belon, A. P. (2019). The health equity measurement framework: A comprehensive model to measure social inequities in health. International Journal for Equity in Health 18(36), https://doi.org/10.1186/s12939-019-0935-0

Government of Canada. (n.d.). Achieving health for all: A framework for health promotion. Retrieved February 27, 2022, from https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/achieving-health-framework-health-promotion.html

Health Quality Ontario’s health equity plan. (n.d.). Retrieved February 27, 2022, from https://www.hqontario.ca/Portals/0/documents/health-quality/Health_Equity_Plan_Report_En.pdf

Peterson, A., Charles, V., Yeung, D., & Coyle, K. (2021). The health equity framework: A science- and justice-based model for public health researchers and practitioners. Health Promotion Practice, 22(6), 741–746. https://doi.org/10.1177/1524839920950730

Planning and Evaluation Framework. Middlesex-London Health Unit. (n.d.). Retrieved March 2, 2022, from https://www.healthunit.com/planning-and-evaluation-framework

Woodward, E. N., Singh, R. S., Ndebele-Ngwenya, P., Castillo, A. M., Dickson, K. S., & Kirchner J. E. (2021). A more practical guide to incorporating health equity domains in implementation determinant frameworks. Implement Sci Commun 2(61). doi: 10.1186/s43058-021-00146-5