CARRFS eNews spoke with Dr. Cory Neudorf, Medical Officer of Health, Saskatoon Health Region, about Surveillance and Health Inequity.
Saskatoon Health Region has been widely credited for the 2008 report Health Disparity in Saskatoon - what was the main reason for this initiative?
The background really started with some of the disease monitoring that was going on at that time where the province would put out a report indicating that Saskatoon Health Region had teen pregnancy, diabetes or other rates to be around the provincial average. As the Medical Officer of Health for the Saskatoon Health Region I knew that we had pockets with problems within our region that were large and yet being ignored in these reports.
A report in 2006 looked at neighbourhood income combined with a variety of hospitalizations, mortality, physician visits and health status indicators. What we saw was that health disparity by income was a lot higher in various areas around Saskatoon for most of the indicators than what we had expected. And more importantly, it was across many different conditions.
Our health board suggested that it was not enough for us to report on this but to give examples of how the health system as well as other sectors of influence on health determinants can respond to improving health equity. So the 2008 Health Disparity in Saskatoon report was a collection of analysis we did with our first CIHR (Canadian Institute for Health Research) grant. It was an attempt to drill down into some of the causes for the health disparity and where these pockets were in the Saskatoon Health Region.
“Our health board has measures within their performance monitoring dash-board for improving health equity.”
The Public Health Observatory has continued with the work. We have developed a few different types of analysis and interventions as well as developed a health equity surveillance system and equity audit tools for the health care system with the purpose of improving health equity. Where we find inequity, whether it is by economic status, gender, age, rural/urban etc. we work with the relevant department(s) to drill down to find out what the driving force for health inequity is and assist them in thinking about ways to improve health equity.
Looking back, are you satisfied with what came out of the work?
I am very satisfied with the processes that were put in place. We are starting to see positive outcomes. I am obviously not satisfied with the improvements that have been made up to date, as we have not reduced poverty or reduced the health equity gap to zero. But what we have done is to raise the initiative to a level of importance that is now self-sustaining. There are many different leaders in the community as well as in the health sector that are now integrating a health equity approach into their planning and program delivery, so that has become high priority. Even at the provincial level, within the provincial health plan, there is a goal of reducing health inequalities. Our health board has measures within their performance monitoring dashboard for improving health equity. And we are starting to see departments within the health system choosing initiatives for improving health equity. I’m satisfied with the momentum it’s gained, but obviously there is still a lot of work to be done to reduce those gaps.
The forward thinking for us is to refining the surveillance activities to be able to better inform and prioritize the work. The next report that we are working on will show how health equity has developed over time. We are using a lot more advanced methodologies, looking at 15 years worth of data and doing statistical modeling to be able to look at trends over time to see which of the equity gaps are narrowing or broadening, getting worse or staying the same.
Dealing with determinants of health, going beyond the health sector to get data, you run into “data silos” - various sectors collect the data differently - how did you deal with that?
This involves trust and building relationships. When we started looking at teen pregnancy and infant mortality, I tried to build a health status report using publicly available data. What I found was that the data I needed to develop a comprehensive health status report for our region was going beyond health data and into the other determinants areas. But when I went to get publicly available data from education, social services, justice, police - they were all using different time periods, geography, age breakdowns and publication timeframes. There was never a point in time when everybody’s data was available at the same time. We couldn’t layer the data because it was all too disparate.
What we did was to work with the Saskatoon Regional Intersectoral Committee to come up with a shared data infrastructure. Over the years, this has come to be called the Community View Collaboration, which is now a publicly accessible website with a GIS interface, tables and charts and a wide variety of data sets from the contributing partners.
We started with a base - the census data that everybody wanted and added on health data, data from municipal governments including police, as well as social services and education. Many other partners have now started to contribute including researchers at the university. Over time, the database has grown - not only the numbers of data sets, but also in years of available data. No agency around the table could have built this on their own. But by pooling resources, we were able to create data sets which everyone could use and we built it in such a way that it had a flexible interface for choosing geography, age groups, gender, socio-economic status etc.
When we put reports out we involve the partners if we are using data from other sectors to ask if we have interpreted it right and if we have understood the data limitations. These relationships need constant attention. And the big issue here is having the Regional Intersectoral Committee with the senior members of each of the major partners sitting around the table multiple times a year working collaboratively on projects.
What role do you think public health has in reducing health equity, poverty and social determinants of health?
Public health is a relatively small force if you look at the overall health system - less than 2% of the health budget is going to public health. But even that small budget is huge compared to many non-governmental organizations or coalitions that are working in the area of social justice improving social determinants of health.
The role that we have played is to coordinate and facilitate. While public health was quite a leader in that area across Canada 100 years ago, it has for decades been relatively absent. We have found that there is a huge need for infrastructure - access to analysts, to data, data sets, and to databases – something that we can do that others don’t have the capacity for. The rigor we have in building infrastructure surveillance can be leveraged for many other groups – taking the data and the reports and building upon them.
The other side is the voice that the public health has – especially the Medical Health Officer’s office. We have a legislative mandate to report on what is driving the health status in the region and to make suggestions for improvements. Early on, we decided that the health status reports should not be dry statistical documents left open to the interpretations of others. We needed to analyze the data and put forward potential implications and suggestions for improvements. We now have recommendations in our health status reports. It started out with recommendations from a health perspective but then increasingly using more of a community development approach to work with other sectors and data owners. Our reports are not just us speaking up – input from other sectors gives us a stronger voice. Likewise, there are things we can say that perhaps others groups can’t - so the message about poverty reduction coming from the Medical Health Officers Office, I think, has been a powerful addition to local advocacy efforts.
Public Health has a strength in using community development and partnership as the model for improvement of social determinants of health and reducing health inequity - moving away from the lifestyle approach in health promotion and more into the causes of the causes. In addition to our Public Health Observatory work and data analysis, we have taken our health promotion department and reoriented it towards action on the social determinants of health as the prime focus rather than exclusively a lifestyle approach, and using all elements of the Ottawa Charter for Health Promotion. Even where we do lifestyle interventions it should be through the lens of the social determinants of health.
“We also need to be brave enough to go out and make recommendations for change.“
What role do you see the profession of epidemiology having in the future?
We need to think about the rigor we use in building surveillance systems for health equity. We need to systematically build up data sets in a way that we can do stratified analysis by various elements of social determinants for the individuals - something we haven’t done a good job at. The traditional ‘person, place and time’ approach takes us only so far. The details of who that person is in an environmental context are how we need to view the data. We need to move away from doing one-off equity reports and to systematically apply a surveillance approach to health equity data and beef up our analytical methods.
The epidemiologist needs to be conversant in specialized statistics needed for this type of analysis. When was the last time our public health epidemiologists got involved with, for example. the Gini-coefficient or concentration indices? Are we comfortable with Poisson regression and modeling necessary for looking at effects over time and looking at the root cause of some of those differences over time? Getting beyond the simplistic descriptive analysis that we tend to do for basic outbreak analysis and health status reports into more complex methods are essential. We need to look at the causes of the causes. That is what is needed for the future of chronic disease epidemiologists.
The analysis must go beyond the numerical impact to looking at what the clinical implications are. Diversifying the team to include epidemiologists working with, say, medical epidemiologists, medical health officers and staff from various health and human service sector disciplines, in order to bring more life to the analysis and a better understanding of the implications. We also need to be brave enough to go out and make recommendations for change - always taking the practical relevance to our data and starting to look for program or policy implications. If we are going to improve equity, we need to change our methods and approaches. We need to commit to monitoring and evaluating over time to see if we are making a difference. From this perspective, I think the future is very bright for epidemiology. It is far more interesting using a larger range of skills and to actually be able to see program and policy improvements as a result of the work that we are doing. <>
By Jostein Algroy