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Table 7 Recommendations based on the research findings

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

Policy • Local involvement in policy development at the provincial level may help reduce policy implementation gaps. • Increased dialogue and communication about requirements and expectations prior to role creation and funding could enhance clarity across the public health system. • Ongoing engagement through discussion across multiple system levels can also help avoid and address major policy implementation gaps. • Providing guidance to PHUs on how to implement health equity mandates while maintaining flexibility for local adaptation will support implementation. • Clear accountability measures built into accountability agreements can help ensure that positions are used to meet the intended mandate of increasing organizational health equity capacity. • Ongoing feedback mechanisms between provincial and local stakeholders can help ensure that local public health organizations have the support needed to fully implement health equity positions and related activities. • Taking action on the SDH and health equity requires a multidisciplinary approach. Human resource initiatives that draw from a range of disciplines will benefit from diverse skills and perspectives. • Support for knowledge exchange and network development for those in similar roles enhances information sharing and joint planning, and will amplify gains across organizations.
Practice • Including health equity considerations in program planning and delivery supports public health unit staff, including SDH-PHNs, to consistently and explicitly work to address SDH and health equity. This would help to address doubts about the role of public health in addressing SDH/health equity, alleviate tension in the practice environment, and demonstrate organizational and leadership support for the work. It would also underline the need to shift approaches, from a largely behavioural and biomedical to a SDH and health equity focus. • Clearly defined responsibilities for health equity positions (built into accountability agreements that draw explicit links between provincial mandates and locally planned actions) would minimize the disconnect between provincial plan intentions and local health unit interpretations. • Organizations seeking to better address the SDH and health equity must look internally and align their workplace values, culture, and practices with equity and social justice. By doing so, they create an environment for professionals to develop a reflexive public health practice. • Public health organizations that 1) develop and promote cultural attributes (such as a shared vision, mission, and goals) that prioritize health equity and are understood and valued throughout the organization, and 2) foster a culture of creativity and responsiveness, will support PHNs and other staff to practice the full scope of their competencies. • A supportive learning environment in which there is continued development that enables staff to gain the skills required to be effective in their roles. This means cultivating a healthy organizational culture in public health by:  o transforming power relationships within the organization and beyond,  o encouraging access to and free flow of information,  o supporting innovation and new methods, and  o creating an engaged earning environment. • Internal and external activities serve to bolster the work of the organization. Ensuring that internal structures are in place brings public health staff together and helps reduce internal siloes. Given that the SDH lie outside public health, working in collaboration with communities, health partners and non-health partners is an essential part of the health equity role. • Visionary and empowering leadership supports the integration of health equity as part of everyday public health practice. Enhancing these leadership styles will help further organizational action.
Education • All disciplines in public health must receive continuing education and professional development in addressing SDH and health equity to support the development of knowledge and skills. • Competency development across the organization would allay concerns of being siloed, disperse collegial tension, and position health equity specialist roles within a supportive framework. This allows for “leadership from within” on health equity. • Competencies highlighted in this study include:  o knowledge of SDH and health equity  o organizational change/development  o systems change strategies  o program development and evaluation with specific consideration to equity  o advocacy  o policy development  o community engagement  o leadership
Research The critical yet still-emerging area of health equity and addressing SDH would benefit from further research that examines the following: • the relationship between organizational culture (including values and ideology) and an organization’s capacity to work on a health equity agenda • the impact of structurally embedded workplace inequities (e.g., disempowerment of nurses) on health inequity priorities • the activities of SDH-PHN and their influence on their respective organization’s capacity to address health equity work • the disciplines and public health professionals best positioned to effectively advance the health equity agenda and how best to prepare/educate practitioners for these roles • the development of similar public health roles in other jurisdictions to strengthen the science behind public health equity work and to increase the strength of the transferability of the findings reported here