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Table 6 Supports and barriers in developing and implementing the SDH-PHN role

From: Swimming against the tide: A Canadian qualitative study examining the implementation of a province-wide public health initiative to address health equity

• Health equity already integrated into the OPHS and the Ontario Public Health Organizational Standards • Availability of MOHLTC funding and ongoing support for SDH-PHN positions (e.g., support for provincial SDH-PHN network teleconference line) • Availability of skilled and knowledgeable SDH-PHNs • PHNs with Masters-level education; PHNs with previous health equity experience • Investing in training SDH PHNs and other staff • Investing time and resources at outset for health equity learning • Access to expertise, both internally and externally, supported competency development and knowledge acquisition • Strong leadership at governance and senior management levels enabled action • Development or expansion of internal organizational structures such as working groups, steering committees or departments provided a centralized position for SDH/health equity priorities within the organization • Structurally embedding health equity concept and role: in planning documents (e.g., strategic plans, health unit vision statements) and in processes (e.g., steering committee, reporting member of management and planning committees) • A flexible and adaptive approach allowed organizations to learn and adapt to changing needs and requirements • Open communication and information flow facilitated SDH-PHN role by providing access to staff in all programs • SDH-PHN involvement in organizational decision-making regarding the priority area was necessary to implement health equity activities • Breaking down siloes as part of the planning process facilitated cross-organizational networking and shifts in organizational structure • Networking among nurses and other stakeholders assisted SDH-PHNs and their organizations to build relationships with those doing similar work, to learn from the experiences of others, and to access information and knowledge • Nurses demonstrated leadership in self-organizing knowledge exchange and network development opportunities (e.g., regular meeting of SDH-PHNs across province) • Ongoing support from provincial government (i.e., MOHLTC) and national organization (i.e., NCCDH) for SDH-PHN provincial network • Partnering with external health and non-health organizations, networks and policy-makers allowed PHUs to identify a focus for the SDH-PHNs and to be responsive to the local context • SDH-PHNs given access to policy makers, where they often exercised policy development and advocacy roles • PHUs with a history of action on SDH and health equity implemented the roles more easily, as these were viewed to support and enhance ongoing work
• Ideological tension between biomedical and behavioural/lifestyle paradigm and shift to public health practice to address health equity • Systemic organizational oppression and power dynamics that are stifling for PHN roles • Some public health staff completed their professional education before health equity concepts were integrated into entry to practice professional programs. This contributed to a tension in terms of the required knowledge, skills and values required to support integration of health equity into public health practice • Public health staff belief that influencing social systems in the service of equity was extremely difficult and too broad-based • In units without pre-existing health equity programs, questioning of the evidence base with which to approach health equity work • Perceived lack of clarity regarding provincial expectations was a stumbling block especially for PHUs in the early phases of health equity action. Despite the existence of the OPHS, data highlighted a lack of clear guidance for early implementation • Staff or management transitions and instability related to the position created uncertainty about continuity of the work and support at different levels of the organization. Some staff changes in the SDH-PHN role were the result of normal turnover while others were related to the skills and competencies of the individual in that position. • Limited knowledge of evidence to support local public health action meant that health units spent time trying to identify what to do and how to do it. This was often pre-empted by the need to make the case for health equity action where this was considered an extra responsibility. • Lack of internal coordination within some PHUs impeded role implementation; role could have been better linked to other related work in PHU to move out of siloes • Discipline-specific funding led to some internal frustration, tension and feelings of exclusion early on. While data showed that staff understood why the funding was PHN-specific, some PHUs would have preferred to focus on the skills and competencies required and have the ability to draw from the multidisciplinary perspectives that are often required for SDH/health equity work.