This paper focuses on equity in health, one of the key principles of the Ottawa Charter. It aims at analysing and discussing how the concept was defined, applied, and integrated in health-promotion articles by authors with a Nordic affiliation.
Abstracts were first identified by the search word ''health promotion'' as a key word. The search was limited to 1986-2008 and abstracts written in English by authors with a Nordic affiliation. Abstracts/articles for the present study were subsequently selected from these abstracts using the search word ''equity'' and analysed by quantitative and qualitative content analysis.
A majority of the 18 articles in the study did not include any proper definition of the term ''equity in health''. Most articles dealt with health in general or ''Health for All'' aspects and did not focus on specific strategies for vulnerable individuals or groups. The theoretical papers had a clear focus on equity aspects even though the concept of equity was sometimes included in an implicit way. In contrast, most papers reporting empirical studies did not specifically target equity aspects. Instead, the analysis gave the impression that many authors used the term ''equity'' synonymously with ''equality in health''.
The findings may indicate that the concept of ''equity in health'' has been attenuated or even forgotten by Nordic health-promotion researchers and needs to be re-established as a strong concern within health promotion.
This commentary argues that contextual influences on health inequities need to be more thoroughly interrogated in future studies of population health interventions.
Case examples were chosen to illustrate several aspects of context: its historical, global, and dynamic nature; its multidimensional character; and its macro- and micro-level influences. These criteria were selected based on findings from an extensive literature review undertaken for the Public Health Agency of Canada and from two invitational symposia on multiple intervention programmes, one with a focus on equity, the other with a focus on context.
Contextual influences are pervasive yet specific, and diffuse yet structurally embedded. Historical contexts that have produced inequities have contemporary influences. The global forces of context cross jurisdictional boundaries. A complex set of social actors intersect with socio-political structures to dynamically co-create contextual influences.
These contextual influences raise critical challenges for the field of population health intervention research. These challenges must be addressed if we are going to succeed in the calls for action to reduce health inequities. Implications for future public health research and research-funding agencies must be carefully considered.
The intimate interdependence of human health and the ecosystems in which we are embedded is now a commonplace observation. For much of the history of public health, this was not so obvious. After over a century of focus on diseases, their biologic causes and the correction of exposures (clean water and air) and facilitation of responses (immunizations and nutrition), public health discourse shifted to embrace the concept of determinants of health as extending to social, economic and environmental realms. This moved the discourse and science of public health into an unprecedented level of complexity just as public concern about the environment heightened. To address multifactorial, dynamic impacts on health, a new paradigm was needed which would overcome the separation of humans and ecosystems. Ecosystem approaches to health arose in the 1990s from a rich background of intellectual ferment as Canada wrestled with diverse problems ranging from Great Lakes contamination to zoonotic diseases. Canada's International Development Research Centre (IDRC) played a lead role in supporting an international community of scientists and scholars who advanced ecosystem approaches to health. These collective efforts have enabled a shift to a research paradigm that embraces transdisciplinarity, social justice, gender equity, multi-stakeholder participation and sustainability.
Increasingly, specialized 'forensic' mental health services are being developed to address the criminogenic and clinical needs of people with mental illness who are involved in the criminal justice system. Theoretically, the construction of such specialized services can produce simultaneous positive benefits and negative consequences. This mixed methods study examined and compared the level of self-stigma that was experienced by people who receive compulsory community-based treatment services in the forensic (n=52) and civil (n=39) mental health systems of British Columbia, Canada. The quantitative findings indicate that 'forensic' labelling was not associated with elevated levels of self-stigma. Quantitative level of self-stigma was significantly associated with psychiatric symptom severity, history of incarceration, and history of homelessness. The qualitative findings suggest that access to high-quality, well-resourced forensic mental health services may, for some service users, come at the risk of increased exposure to social and structural stigma. Together, these findings reveal some of the strengths and weaknesses that are associated with organizing forensic mental health services using a specialized service delivery model.
Concern has been growing in the academic literature and popular media about the licensing, introduction and adoption of surgical devices before full effectiveness and safety evidence is available to inform clinical practice. Our research will seek empirical survey evidence about the roles, responsibilities, and information and policy needs of the key stakeholders in the introduction into clinical practice of new surgical devices for pelvic floor surgery, in terms of the underlying ethical principals involved in the economic decision-making process, using the example of pelvic floor procedures.
Our study involves three linked case studies using, as examples, selected pelvic floor surgery devices representing Health Canada device safety risk classes: low, medium and high risk. Data collection will focus on stakeholder roles and responsibilities, information and policy needs, and perceptions of those of other key stakeholders, in seeking and using evidence about new surgical devices when licensing and adopting them into practice. For each class of device, interviews will be used to seek the opinions of stakeholders. The following stakeholders and ethical and economic principles provide the theoretical framework for the study: Stakeholders--federal regulatory body, device manufacturers, clinicians, patients, health care institutions, provincial health departments, and professional societies. Clinical settings in two centres (in different provinces) will be included. Ethics--beneficence, non-maleficence, autonomy, justice. Economics--scarcity of resources, choices, opportunity costs.For each class of device, responses will be analysed to compare and contrast between stakeholders. Applied ethics and economic theory, analysis and critical interpretation will be used to further illuminate the case study material.
The significance of our research in this new area of ethics will lie in providing recommendations for regulatory bodies, device manufacturers, clinicians, health care institutions, policy makers and professional societies, to ensure surgical patients receive sufficient information before providing consent for pelvic floor surgery. In addition, we shall provide a wealth of information for future study in other areas of surgery and clinical management, and provide suggestions for changes to health policy.
The present study examined whether there are differences in job-related attitudes and well-being among physicians working in private sector and public sector. In addition, we examined whether psychosocial factors (organizational justice and job control) could mediate these possible differences in different sectors.
Cross-sectional survey data from the Finnish Health Professional Study was used. A random sample of Finnish physicians included 1522 women and 1047 men aged 25-65 years. Outcome variables were job satisfaction, organizational commitment, psychological distress, work ability and sleeping problems. Job control and organizational justice were measured using established questionnaires. Series of regression analyses were performed and the mediational effects were tested following the procedures outlined by Baron and Kenny.
Physicians working in private sector had higher levels of job satisfaction and organizational commitment and lower levels of psychological distress and sleeping problems when compared with physicians working in public sector. Private physicians also had higher levels of organizational justice, which acted as a mediator behind more positive attitudes and better well-being in private sector. Private physicians had higher levels of job control but it did not act as a mediator.
Private physicians feel better than public physicians and this is partly due to higher organizational justice in private sector. Public health care organizations should invest effort to increase the fairness in their organizations and management and pay more attention in improving the well-being of their employees, which could possibly increase the attractiveness of public sector as a career option.
This exploratory study examines the effects of patriarchy on police and individual attitudes toward the enforcement of protective court orders for battered women. Police officers (N = 13) and justice officials (N = 8) in the Municipality of Delta were interviewed for their opinions on the efficacy of both Criminal Code peace bonds and Family Relations Act (R.S.B.C., amended 1986) civil restraining orders. Interview data suggest that both protective orders are rarely treated seriously by the police or the courts. It is argued that the occupational culture of the police leads to exaggerated patriarchal notions of women, marriage, and family that are conservative; blame the victim; point finger at other institutions; foster images of women as manipulative; and produce a fictitious narrative of battered women.
The aim of this study is to analyse if low justice at work, analysed as aggregated workplace means, increases the risk of depression.
A total of 4237 non-depressed Danish public employees within 378 different work units were enrolled in 2007. Mean levels of procedural and relational justice were computed for each work unit to obtain exposure measures that were robust to reporting bias related to depression. Two years later in 2009, 3047 (72%) participated at follow-up. Those reporting high levels of depressive, burn-out or stress symptoms were assigned to a psychiatric diagnostic interview. In the interview 58 cases of new onset depression were identified. Depression ORs by work unit level of procedural and relational justice were estimated by multivariable logistic regression accounting for established risk factors for depression.
Working in a work unit with low procedural justice (adjusted ORs of 2.50, 95% CI 1.06 to 5.88) and low relational justice (3.14, 95% CI 1.37 to 7.19) predicted onset of depression.
Our results indicate that a work environment characterised by low levels of justice is a risk factor for depression.
The present study examined whether job resources (job control, social support, and distributive justice) moderate the associations of high job demands induced by physical and mental workload with musculoskeletal symptoms among geriatric nurses. The data were drawn in Finland from 975 female nurses working in 152 geriatric units who responded to a survey questionnaire. Information on the objective workload in terms of resident characteristics and structural factors was also collected at the unit level. After adjusting for the objective workload, multilevel logistic regression analyses showed that self-reported physical workload was associated with higher risk of musculoskeletal symptoms (OR = 1.93, 95 % CI [1.38, 2.72]) among nurses with low social support. In addition, mental workload was associated with higher risk of musculoskeletal symptoms (OR = 1.72, 95% CI [1.12, 2.62]) for those with low distributive justice. The results suggest that social support and fair reward systems may help to buffer against the detrimental effects of heavy job demands on nurses' musculoskeletal symptoms.
In many countries, public sector has major difficulties in recruiting and retaining physicians to work as general practitioners (GPs). We examined the effects of taking up a public sector GP position and leaving public sector GP work on the changes of job satisfaction, job involvement and turnover intentions. In addition, we examined whether organizational justice in the new position would moderate these associations. This was a four-year prospective questionnaire study including two measurements among 1581 (948 women, 60%) Finnish physicians. A change to work as a public GP was associated with a substantial decrease in job satisfaction and job involvement when new GPs experienced that their primary care organization was unfair. However, high organizational justice was able to buffer against these negative effects. Those who changed to work as public GPs had 2.8 times and those who stayed as public GPs had 1.6 times higher likelihood of having turnover intentions compared to those who worked in other positions. Organizational justice was not able to buffer against this effect. Primary care organizations should pay more attention to their GPs - especially to newcomers - and to the fairness how management behaves towards employees, how processes are determined, and how rewards are distributed.
Social accountability in healthcare requires physicians and medical institutions to direct their research, services and education activities to adequately address health inequities. The need for greater social accountability has been addressed in numerous national and international healthcare reviews of health disparities and medical education.
The aim of this work is to better understand how to identify underserved populations and address their specific needs and also to provide physicians and medical institutions with a means by which to cultivate social accountability.
The authors reviewed existing literature and prominent models focusing on social accountability, as well as medical education frameworks, and identified the need to engage underserved stakeholders and incorporate education that includes knowledge translation and reciprocity. The AIDER model was developed to satisfy the need in medical education and practice that is not explicitly addressed in previous models.
The AIDER model (Assess, Inquire, Deliver, Educate, Respond) is a continuous monitoring process that explicitly incorporates reciprocal education and continuous collaboration with underserved stakeholders.
This model is an incremental step forward in helping physicians and medical institutions foster a culture of social accountability both in individual practice and throughout the continuum of medical education.