Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review

OBJECTIVE

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective is to identify implementation strategies and indicators being used to integrate and measure health equity.

INTRODUCTION

To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

INCLUSION CRITERIA

This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were assessed followed by a full-text review. The information extracted consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data have been quantitatively tabulated and presented according to 5 review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings are visually presented in charts and diagrams or presented in tabular format.

RESULTS

Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (113 peer-reviewed, 9 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity and we found that both indicators and strategies were lacking adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

CONCLUSIONS

Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

REVIEW REGISTRATION

Dal Space dalspace.library.dal.ca/handle/10222/80835.

SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE FOR THIS REVIEW

http://links.lww.com/SRX/A45.

Development and implementation of a municipal outdoor play policy for children and youth in Nova Scotia, Canada: a community case study

Background: Children and youth benefit from outdoor play; however, environments and policies to support outdoor play are often limited. The purpose of this paper is to describe a case study of the development of a municipal outdoor play policy in Nova Scotia, Canada. The outdoor play policy was developed by the Town of Truro with support from the UpLift Partnership, a School-Community-University Partnership in Nova Scotia, Canada. UpLift supports the health and well-being of school-aged children and youth using a Health Promoting Schools approach which identifies the important role of municipal government in creating healthy school communities. The UpLift Partnership and the municipality hosted online workshops for municipal staff, community leaders and partners that included content about the importance of outdoor play, barriers and facilitators to outdoor play, best practices for youth engagement, the policy development process, and how policy actions can support outdoor play. Workshop participants developed policy actions for their community of Truro, Nova Scotia to increase opportunities for outdoor play for children and youth. Following the workshops, a small team from the municipality and UpLift drafted an outdoor play policy and submitted it to Truro town council for approval. The outdoor play policy was adopted in Fall 2021 and has since informed recreation and municipal planning decisions. By presenting a case study of the development of this outdoor play policy, we hope other communities may be inspired to develop and adopt their own outdoor play policies to benefit children and youth in their communities.

Process and experience of youth researchers within a Health Promoting Schools study in Nova Scotia, Canada

Youth Participatory Action Research (YPAR) is an approach to research that engages youth across the research process. The peer researcher method is a technique used in YPAR where youth are trained in research and ethics to interview their peers. The purpose of this study was to: (i) describe the process of engaging youth as peer researchers in a Health Promoting Schools (HPS) and student engagement project and (ii) understand the peer researchers' perspectives of their experience throughout the project. Youth from across Nova Scotia, Canada in grades 7-10 (ages 12-16) were recruited as peer researchers in the Summer, 2022. The project included three stages: (i) peer researcher training, (ii) practicing, recruiting and conducting interviews and (iii) data interpretation workshop. To understand the peer researcher's experience, quantitative data were collected from an evaluation questionnaire. Outputs were produced using descriptive statistics. Qualitative data were collected through a focus group and interviews and analyzed using inductive content analysis. A total of 11 youth were recruited and completed peer researcher training. Most youth provided positive feedback on the training with a satisfaction score of 8.7/10. Qualitative analysis indicated benefits to the peer researchers including opportunities to build interview and social skills and learn about other's perspectives. This study provides a detailed overview of how to use a peer researcher method in a YPAR project to involve youth in research related to HPS and student engagement. The research also highlights the benefits of engaging youth in YPAR. Future research will report on the findings from the peer interviews.

Physical Activity Trajectories in Early Childhood: Investigating Personal, Environmental, and Participation Factors

INTRODUCTION/PURPOSE

To determine personal, environmental, and participation factors that predict children's physical activity (PA) trajectories from preschool through to school years.

METHODS

Two hundred seventy-nine children (4.5 ± 0.9 yr, 52% boys) were included in this study. Physical activity was collected via accelerometry at six different timepoints over 6.3 ± 0.6 yr. Time-stable variables were collected at baseline and included child's sex and ethnicity. Time-dependent variables were collected at six timepoints (age, years) and included household income (CAD), parental total PA, parental influence on PA, and parent-reported child's quality of life, child's sleep, and child's amount of weekend outdoor PA. Group-based trajectory modeling was applied to identify trajectories of moderate-to-vigorous PA (MVPA) and total PA (TPA). Multivariable regression analysis identified personal, environmental, and participation factors associated with trajectory membership.

RESULTS

Three trajectories were identified for each of MVPA and TPA. Group 3 in MVPA and TPA expressed the most PA over time, with increased activity from timepoints 1 to 3, and then declining from timepoints 4 to 6. For the group 3 MVPA trajectory, male sex (β estimate, 3.437; P = 0.001) and quality of life (β estimate, 0.513; P < 0.001) were the only significant correlates for group membership. For the group 3 TPA trajectory, male sex (β estimate, 1.970; P = 0.035), greater household income (β estimate, 94.615; P < 0.001), and greater parental total PA (β estimate, 0.574; P = 0.023) increased the probability of belonging to this trajectory group.

CONCLUSIONS

These findings suggest a need for interventions and public health campaigns to increase opportunities for PA engagement in girls starting in the early years. Policies and programs to address financial inequities, positive parental modeling, and improving quality of life are also warranted.

Impact of an outdoor loose parts play intervention on Nova Scotian preschoolers' physical literacy: a mixed-methods randomized controlled trial

BACKGROUND

Physical activity participation among preschoolers in childcare settings are low, and interventions to increase physical activity levels have produced mixed results. The Physical Literacy in the Early Years (PLEY) project implemented a six-month childcare-based outdoor loose parts play intervention in childcare centres in Nova Scotia, Canada. The purpose of this study was to examine the impact of the PLEY project on the development of domains of physical literacy (physical activity, physical competence, confidence and motivation, knowledge and understanding) in preschoolers attending childcare centres using mixed-methods.

METHODS

Preschoolers (3-5 years) were recruited from 19 childcare centres in Nova Scotia and centres were randomized (parallel design) to the outdoor loose parts play intervention group (n = 11) or control (n = 8) group for 6 months. Participants, early childhood educators, and assessors were not blinded to group assignment. Quantitative and qualitative measures were used to comprehensively assess the impact of the PLEY project on all domains of physical literacy. At 3- and 6-months, early childhood educators participated in focus groups to assess how the intervention supported the development of 4 physical literacy domains: physical activity, physical competence, confidence and motivation, and knowledge and understanding. Physical activity and physical competence were also assessed with accelerometry and the Test of Gross Motor Development-3, respectively.

RESULTS

Two hundred and nine preschoolers participated in the study (intervention group: n = 115; control group: n = 94). Accelerometer data showed that while baseline physical activity was similar between groups, children in the intervention group had higher physical activity at 3- (F(1,187) = 8.30, p = 0.004) and 6-months (F(1,187) = 9.90, p = 0.002) post-intervention. There was no intervention effect on physical competence scores. Thematic analysis of focus group data revealed that outdoor loose parts play contributed to development in all 4 physical literacy domains, including increased movement repertoires, social development, and enjoyment of physical activity. No adverse events or side effects of the intervention were reported.

CONCLUSIONS

Participation in the PLEY project was associated with increased development of various domains of physical literacy and perceived physical literacy among preschoolers, and outdoor loose parts play may be encouraged as an effective strategy to increase physical literacy in early learning settings.

TRIAL REGISTRATION

Biomed Central (ISRCTN14058106), 20/10/2017.

Regional differences in movement behaviours of children and youth during the second wave of the COVID-19 pandemic in Canada: follow-up from a national study

Objectives

Public health restrictions varied by region during the COVID-19 pandemic and reduced opportunities for children to be physically active. The purpose of this study was to assess regional differences in movement behaviours of Canadian children and youth during the second wave of the COVID-19 pandemic.

Methods

A national sample of Canadian parents (n=1568; 58% women) of children and youth (5–17 years of age) completed an online survey. Participants were classified based on region of residence (British Columbia, Prairies, Ontario, Quebec, or Atlantic Canada). Differences in movement and play behaviours (physical activity, outdoor play, sleep, screen time) between children and youth living in different regions were examined.

Results

Compared to children and youth in Quebec (the region with the highest COVID-19 prevalence), children and youth in the Prairies (F_(1,1563)=9.0, p=0.01) and Atlantic Canada (F_(1,1563)=17.1, p<0.001) participated in more moderate-to-vigorous physical activity (MVPA). Compared to Quebec, living in Atlantic Canada increased the odds of meeting the MVPA guideline (odds ratio (OR)=2.1, p=0.02), living in Ontario decreased the odds of meeting the sleep guideline (OR=0.6, p=0.01), and living in Ontario (OR=0.7, p=0.04) or Atlantic Canada (OR=0.6, p=0.049) decreased the odds of meeting the screen time guideline. Children and youth in Atlantic Canada demonstrated smaller declines in outdoor play than their counterparts in Quebec.

Conclusion

Movement and play behaviours varied between regions of Canada where the highest COVID-19 prevalence corresponded to lower odds of meeting the physical activity guidelines. Low compliance with 24-hour movement guidelines suggests that regional pandemic recovery plans need to prioritize opportunities for healthy movement.

Peering in: youth perspectives on Health Promoting Schools and youth engagement in Nova Scotia, Canada

Health Promoting Schools (HPS) is a whole-school approach that shapes the conditions necessary to support student health and well-being. Youth engagement is recognized as key to HPS implementation, yet research related to the involvement of youth voice in school health promotion initiatives is limited. The purpose of this study was to understand youth perspectives on HPS and school youth engagement. Ten youth (grades 9–10, ages 14–16) were trained as peer researchers using a Youth Participatory Action Research approach. The peer researchers interviewed 23 of their peers (grades 7–10, ages 12–16) on perspectives related to HPS and school youth engagement. All interviews were audio-recorded, transcribed and data were analysed using inductive ‘codebook’ thematic analysis. Themes related to a healthy school community were mapped onto the pillars of HPS: (i) Social and Physical Environment, (ii) Teaching and Learning, (iii) Partnerships and Services and (iv) School Policies. Participants placed more importance on the social and physical environment of the school including respect, inclusivity, supportive relationships and the design of spaces. Key factors for youth engagement were: (i) safe and supportive spaces, (ii) passion and interest, (iii) using their voice, (iv) power dynamics, (v) accessibility and (vi) awareness. With recognition that youth engagement is a crucial part of HPS, this work provides relevant and applicable information on areas of the healthy school community that are important to youth, and if/how they are meaningfully engaged in school decision-making.

Barriers to and strategies to address COVID-19 testing hesitancy: a rapid scoping review

Background

Testing is a foundational component of any COVID-19 management strategy; however, emerging evidence suggests that barriers and hesitancy to COVID-19 testing may affect uptake or participation and often these are multiple and intersecting factors that may vary across population groups. To this end, Health Canada’s COVID-19 Testing and Screening Expert Advisory Panel commissioned this rapid review in January 2021 to explore the available evidence in this area. The aim of this rapid review was to identify barriers to COVID-19 testing and strategies used to mitigate these barriers.

Methods

Searches (completed January 8, 2021) were conducted in MEDLINE, Scopus, medRxiv/bioRxiv, Cochrane and online grey literature sources to identify publications that described barriers and strategies related to COVID-19 testing.

Results

From 1294 academic and 97 grey literature search results, 31 academic and 31 grey literature sources were included. Data were extracted from the relevant papers. The most cited barriers were cost of testing; low health literacy; low trust in the healthcare system; availability and accessibility of testing sites; and stigma and consequences of testing positive. Strategies to mitigate barriers to COVID-19 testing included: free testing; promoting awareness of importance to testing; presenting various testing options and types of testing centres (i.e., drive-thru, walk-up, home testing); providing transportation to testing centres; and offering support for self-isolation (e.g., salary support or housing).

Conclusion

Various barriers to COVID-19 testing and strategies for mitigating these barriers were identified. Further research to test the efficacy of these strategies is needed to better support testing for COVID-19 by addressing testing hesitancy as part of the broader COVID-19 public health response.

Strategies and indicators to address health equity in health service and delivery systems: a scoping review protocol

OBJECTIVE

The purpose of this review is to describe how health service and delivery systems support health equity and to identify strategies and indicators being used to measure health equity.

INTRODUCTION

It is widely acknowledged that a population health and equity approach is needed to improve the overall health of the population. The health service and delivery system plays an important role in this approach. Despite this, system transformation to address health inequities has been slow. This is due, in part, to the lack of evidence-based guidance on how health service and delivery systems can address and measure health equity integration. Most studies focus on health equity integration in the public health sector at a provincial or national level, but less is known about integration within the health service and delivery system. More information is needed to understand how that transformation is occurring, or could occur, to make a meaningful contribution toward improving population health outcomes.

INCLUSION CRITERIA

This scoping review will identify studies that describe the strategies and indicators that health service and delivery systems are using to integrate health equity and how progress is measured. Evidence from qualitative, quantitative, mixed method studies, and gray literature will be included.

METHODS

This review will be conducted in accordance with JBI methodology for scoping reviews. A comprehensive search strategy, developed with a librarian scientist, will be used to identify relevant sources. Titles, abstracts, and full texts will be evaluated against inclusion criteria. Information will be extracted by two independent reviewers. Data will be synthesized and presented narratively, with tables and figures where appropriate.

Fare well to Nova Scotia? Public health investments remain chronically underfunded

Inspired by Fiset-Laniel et al.’s (2020) article entitled “Public health investments: neglect or wilful omission? Historical trends in Quebec and implications for Canada”, we assessed public health investments since the establishment of the Nova Scotia provincial health authority in 2015. We analyzed Nova Scotia Department of Health and Wellness budgets from 2015−2016 to 2019–2020 and observed that less than 1% of funding was budgeted for public health annually, an amount well below the recommendation that 5–6% of healthcare funding be spent on public health. Healthcare spending has increased annually since 2015–2016, but proportions of funding to different programs and services have remained static. Specifically, we did not observe a change in investment in public health over time, suggesting that while the government does not necessarily spend too much or too little on healthcare, it spends far too little on public health. This chronic under-funding is problematic given the high rates of non-communicable diseases in Nova Scotia and health inequities experienced within the population. The 2020 COVID-19 pandemic has highlighted the importance of public health work, and the need for a pandemic recovery plan that prioritizes investment in all areas of public health in Nova Scotia.

The Effects of the COVID-19 Pandemic on Health and Well-Being of Children and Youth in Nova Scotia: Youth and Parent Perspectives

Objectives: The COVID-19 pandemic led to school closures, cancellations of major events, and loss of in-person social interactions for children and youth. These restrictions undoubtedly impacted the lives of children and youth. This study describes the well-being of children and youth in Nova Scotia during the COVID-19 pandemic and their thoughts and feelings about the return to school, from the perspectives of both youth and parents. Methods: A province-wide survey was conducted in August 2020 with parents of school-age children and youth and youth to measure youth well-being since the pandemic began. Results: Parents of children and youth in grades pre-primary to 12 (n = 699; 53% girls) and youth in grades 3-12 (n = 279; 69% girls) completed the online survey. Perceptions of parents about children's emotions during the pandemic were: bored, safe, lonely, happy, and anxious. Youth reported feeling bored, relaxed, depressed, safe, and worried. Sixty-three percent of youth and 72% of parents reported that they/their child felt they were missing important life events. Parents reported that being with parents, being physically active and being with friends made their child feel positive. Youth reported that being with friends, pets and watching TV made them feel good during this time. Seventy-six percent of parents and 62% of youth reported they/their child were getting more screen time than before the pandemic. With schools closed, participants most frequently shared that they missed friends and social interactions, in-person learning, and extra-curricular activities. Youth and parents expressed worries about COVID-19 outbreaks and related restrictions when schools re-opened to in-person learning. Conclusion: The well-being of children and youth in Nova Scotia was greatly impacted by the COVID-19 pandemic and related school closures in 2020. It is essential that pandemic recovery plans prioritize the health and well-being of children and youth.

Development of the Physical Literacy Environmental Assessment (PLEA) tool

Physical literacy is becoming increasingly popular in sport, recreation, physical education and physical activity settings and programming. We developed an environmental assessment tool to evaluate the extent child and youth activity programs implement physical literacy across four domains: environment, programming, leaders and staff, and values and goals. The Physical Literacy Environmental Assessment (PLEA) tool was developed in 3 phases. First, the PLEA tool was created, content validity established, and physical literacy leaders were consulted. In the second phase, the PLEA tool was completed and tested by 83 child and youth programs and it was validated with individual physical literacy assessments completed on children in programs that scored in the top 10% and bottom 10% on the PLEA tool. Third, a National consultation was conducted, and program leaders provided feedback on the PLEA tool. In Phase 1, the PLEA tool was modified and shortened from 41 to 29 indicators, based on feedback from physical literacy content leaders. In Phase 2, participants in programs that scored in the top 10% had significantly higher scores on the upper body object control domain of PLAYfun (p = 0.018), and significantly higher PLAYself scores (p = 0.04) than participants in programs that scored in the bottom 10%. In Phase 3, over 80% of program leaders identified the PLEA tool was useful, and relevant to their areas of practice. The completed PLEA tool is a 20-item environmental assessment tool to evaluate to what degree child and youth programming implement physical literacy across four domains: environment, programming, leaders and staff, and values and goals. The application and validity of the PLEA tool beyond child and youth physical education, sport, dance and recreation sectors, such as in early years programs, should be investigated.

Tracking of physical activity and fitness during the early years

The early years are characterized by rapid physical growth and the development of behaviours such as physical activity. The objectives of this study were to assess the 12-month changes in and the tracking of physical activity and fitness in 400 preschoolers (201 boys, 4.5 ± 0.9 years of age). Physical activity data, expressed as minutes per day and as the percentage of time spent at various intensities while wearing an accelerometer, were collected in 3-s epochs for 7 days. Short-term muscle power, assessed with a 10-s modified Wingate Anaerobic Test, was expressed as absolute (W) and relative (W/kg) peak power (PP) and mean power (MP). Aerobic fitness, assessed with the Bruce Protocol progressive treadmill test, was expressed as maximal treadmill time and heart rate recovery (HRR). Light physical activity decreased by 3.2 min/day (p < 0.05), whereas vigorous physical activity increased by 3.7 min/day (p < 0.001), from year 1 to year 2. Physical activity exhibited moderate tracking on the basis of Spearman correlations (r = 0.45-0.59, p < 0.001) and fair tracking on the basis of κ statistics (κ = 0.26-0.38). PP and MP increased from year 1 (PP, 94.1 ± 37.3 W; MP, 84.1 ± 30.9 W) to year 2 (PP, 125.6 ± 36.2 W; MP, 112.3 ± 32.2 W) (p < 0.001) and tracked moderately to substantially (PP, r = 0.89, κ = 0.61; MP, r = 0.86, κ = 0.56). Time to exhaustion on the treadmill increased from 9.4 ± 2.3 min to 11.8 ± 2.3 min (p < 0.001) and tracked strongly (r = 0.82, κ = 0.56). HRR was unchanged at 65 ± 14 beats/min (p = 0.297) and tracked fairly (r = 0.52, κ = 0.23). The findings indicate that fitness tracks better than physical activity over a 12-month period during the early years.