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Using a rigorous modified Delphi process, a series of technical expert panels identified a comprehensive set of valid and reliable health indicators, that are amenable to action, comparable, and address equity issues. The indicators assess both population health and clinical care. Stakeholders from a range of community organizations, government, and health care settings across the province were instrumental in shaping the indicator selection and in helping to define priority reporting areas.
The reported indicators are first stratified by sex and then by important social determinants of health including—when possible—income level, educational level, ethnicity, and geography. Thus we are documenting essential information about differences between women and men, and also between subgroups of women and men, depending on their age, income level, education, ethnicity and where they live.
Each Report chapter will be sequentially released beginning in 2009 as follows:
From its inception, a diverse group of stakeholders-including community-based organizations, health advocates, providers, consumers, and policymakers have been integral to shaping the report. Their perspectives helped identify priorities for reporting and indicators for inclusion. Stakeholders contributed invaluable suggestions for how to make the report and the presentation of information in it most helpful to users. They also helped develop ideas and partnerships for strategic dissemination of findings.
Input from stakeholders was also used to develop the POWER Study Gender and Equity Framework.
POWER Study Gender and Equity Health Indicator Framework
The POWER Study Gender and Equity Health Indicator Framework recognizes the pathways through which non-medical determinants of health are the primary determinants of health status, and that population and individual health outcomes are mediated by community and health system characteristics as well as by health system performance. This framework also recognizes that sex and gender influence how all these factors impact on women’s experiences with care and on their health outcomes.
The Burden of Illness in Ontario
On June 23, 2009 we released the Burden of Illness Chapter. In this chapter we reported on the burden of illness experienced by Ontarians and how it differs by sex, socioeconomic status and geographical area of residence. In doing so, we identify opportunities for improvement, present objective evidence to inform priority setting, and provide a baseline from which to measure progress. The Burden of Illness chapter is divided into five sections: Health and functional status, Chronic disease risk factors, Chronic conditions, Sexually-transmitted infections, Mortality. The full report as well as a highlights document can be downloaded from our website www.powerstudy.ca .
Much of the morbidity and premature mortality we report is preventable through: public health and clinical interventions; health system redesign aimed at chronic disease prevention and management; community engagement and empowerment; and social policy aimed at addressing the social determinants of health. Given an aging population, a concerted effort to reduce the illness burden among Ontarians can contribute to the sustainability of the health system by reducing demand for health care services. This could be accomplished by preventing chronic disease and its complications and thus reducing rates of preventable emergency department visits, hospitalizations and the need for long-term care. It can also diminish the financial burden associated with the substantial direct and indirect costs of illness and disability.
We found sizable and modifiable inequities in health in Ontario on multiple measures associated with gender, income, education, ethnicity and geography. Ontarians of lower socioeconomic position experienced much higher levels of chronic disease and disability than those who were more advantaged. They were also more likely to die prematurely. We identify many opportunities for improvement, present objective evidence to inform priority setting, and provide a baseline from which to measure progress.
The impact of these inequities was substantial. If all Ontarians had the same health as Ontarians with higher incomes, an estimated 318,000 fewer people (166,000 women and 152,000 men) would be in fair or poor health; an estimated 238,000 fewer people (110,000 women and 121,000 men) would be disabled; and there would be an estimated 3,373 fewer deaths each year (947 women and 2,426 men) among Ontarians living in metropolitan areas.
Gender matters. There were large differences in health associated with income, education, and ethnicity among both women and men. The differences between subgroups of women associated with income, education and ethnicity were often larger than the overall differences between women and men For example, while 13 percent of women and men in Ontario reported their health as being fair or poor, 26 percent of low-income women versus only eight percent of higher-income women reported their health as fair or poor. The social determinants of health influenced women and men differently. For example, disadvantaged women (i.e., low income) were particularly at risk for disability and chronic pain and disadvantaged men were particularly at risk for early death. Women were more likely to report comorbidity and disability than men, and men had higher rates of potentially avoidable mortality and premature death. In addition, women were more likely to be poor than men, adding greatly to the high burden of illness that they experienced.
Ethnicity and language were also associated with health and functional status. In particular Aboriginal women and men (living off-reserve) were more likely to report fair or poor health and activity limitations than other ethnic groups. Aboriginal women were more likely to report fair or poor health and activity limitations than Aboriginal men. Ontarians who spoke French only or who spoke neither French nor English also reported worse health than those who spoke English only or were bilingual (French and English).
Geography also matters. There were important differences across Ontario Local Health Integration Networks (LHINs) in the health and functional status of their residents, as well as the distribution of risk factors for chronic disease (smoking, obesity, and sedentary lifestyles).
It is not surprising that we found health inequities in the province—health inequities associated with socioeconomic position have been well-documented in many societies. What is surprising and of great concern is the size of these health inequalities. This may be a reflection of growing income inequality and rates of poverty. In the mid 1990’s in Canada, levels of income inequality and poverty began to climb (following a period of two decades when these levels were on the decline). In fact, inequality and poverty rates in Canada were recently reported to exceed the average of the member countries of the Organization for Economic Co-Operation and Development (OECD) countries.
The good news is that there is a lot we can do to close these gaps in health equity. There is growing evidence for the effectiveness of interventions to reduce overall population risk, improve health outcomes and close the health gaps between the less advantaged and more advantaged members of society. We concluded that the following four key actions can accelerate progress in improving the health of and reducing inequities among all Ontarians:
- Prioritize chronic disease prevention and management;
- Coordinate population health, community and clinical responses for improving health;
- Address the broader determinants of health; and,
- Routinely include gender and equity analysis in health indicator monitoring and reporting.
Prioritize Chronic Disease Prevention and Management
- Because chronic diseases and their risk factors contribute greatly to health inequities, the implementation of a comprehensive and coordinated chronic disease prevention and management strategy—one that addresses the need of at-risk populations—is the key to improving population health and achieving health equity.
- It is especially important to identify specific opportunities to improve quality of life and functional status through both community-based and health care interventions. For example, improved pain management and falls prevention interventions can reduce illness burden and contribute to the goal of helping older Ontarians remain active and independent.
Coordinate Population Health, Community and Clinical Responses
- There are many important ongoing activities aimed at improving health in the province including: targeting population-based health promotion, enhancing the quality and capacity of community-based services, and improving the quality of care delivered in clinical settings. Efforts to integrate and coordinate these activities could produce synergies to accelerate progress in improving health and reducing health inequities among Ontarians.
Address the Broader Social Determinants of Health
- There is a need to address the broader social determinants of health (i.e., income, education, food security, housing and environment) and to integrate these efforts with health policy. Cross-sectoral partnerships are needed to accomplish this.
- To guide these efforts, tools such as Health Impact Assessments (HIAs) are available to assess the health impact of policy—including those in non-health sectors such as education, housing and environment—on both population health and health inequities. Conducting HIAs in key priority areas in Ontario could support efforts to achieve health equity.
Routinely Include Gender and Equity Analysis in Health Indicator Monitoring
- Attention to gender issues is required to improve population health because women and men have different health needs and different social contexts that influence their health. A gender and equity focus should be routinely incorporated into health indicator reporting and monitoring. This provides the needed information to effectively target gender, socioeconomic and ethnic inequities in health. Monitoring these indicators over time will allow us to assess progress in improving health and reducing inequities
- Improvements in data quality, availability and timeliness are needed to support monitoring and reporting strategies. There is especially a need for data on ethnicity, knowledge of official languages and length of residence in Canada to improve the capacity to measure, monitor and improve health for Ontario’s diverse communities.
Cancer
The Cancer Chapter (include hyperlink) released on August 20, 2009 focuses on cancers that are important causes of illness and death among women in Ontario including the two most common cancers affecting both sexes; lung and colorectal as well as the common cancers that occur only in women; breast, cervical, ovarian and uterine. The indicators we include explore the continuum of cancer care from screening, through treatment, surveillance and end of life care. We identify where performance on these indicators differed for women and men and look at whether the experience of cancer care was different for women and men, by income, age and where they live. We identified a number of important and potentially modifiable gaps especially pertaining to screening, where clear benchmarks exist. We also found some differences in care by age, sex, income and region across the province
A Catalyst for Change
The aim is for the findings to serve as a catalyst for action. Because findings for men are included, the report also provides critical information needed to improve men’s health, particularly for socioeconomically disadvantaged men. The products of the POWER Study are designed as tools for knowledge translation to increase the uptake of evidence-based practice and policy in women’s health. It is our intention that the findings from the Study will be used to target areas where inequities exist, develop interventions to reduce these differences and monitor the effectiveness of our efforts to promote equity. We are working to develop a sustainable model for measuring and monitoring changes in access, quality, and outcomes of care to assess the effectiveness of health system reform and integration efforts.
The POWER Study is funded by Echo: Improving Women's Health in Ontario, an agency of the Ministry of Health and Long-Term Care. This report does not necessarily reflect the views of Echo or the Ministry.
The POWER Study is a partnership between the Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital and the Institute for Clinical Evaluative Sciences (ICES) in Toronto.
This article includes excerpts from the following POWER Study Chapters:
Chapter 1: Shiller SK, Bierman AS. Introduction to the POWER Study. In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 2009. http://powerstudy.ca/the-power-report/the-power-report-volume-1/introduction-to-the-power-study
Chapter 2: Clark JP, Bierman AS. The POWER Study Framework. In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 2009. http://powerstudy.ca/the-power-report/the-power-report-volume-1/the-power-study-framework
Chapter 3: Bierman AS, Ahmad F, Angus J, Glazier RH, Vahabi M, Damba C, Dusek J, Shiller SK, Li Y, Ross S, Shapiro G, Manuel D. Burden of Illness. In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 2009. http://powerstudy.ca/the-power-report/the-power-report-volume-1/burden-of-illness
Chapter 4: Krzyzanowska MK, Barbera L, Elit L, Kwon J, Lofters A, Saskin R, Yeritsyan N, Bierman AS. Cancer. In: Bierman AS, editor.Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 2009. http://powerstudy.ca/the-power-report/the-power-report-volume-1/cancer
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