On December 3rd, we will be hosting an interactive webinar about the people and systems that support equity-oriented approaches in public health practice.
Help us create the content for this celebrity-interview-style webinar.
- Consider the question posed each week by Hannah Moffatt while reading an excerpt interview from Public Health Speaks: Organizational standards as a promising practice to advance health equity
- Join us in an online conversation held from November 26th to December 3rd in our Health Equity Clicks: community
Consider this question when reading the below excerpt:
What are the elements that support or restrain organizational change in public health systems?
Public health speaks: developing Nova Scotia’s public health standards. A conversation with Janet Braunstein Moody, MPH, PnP, bSn, Senior Director, Public Health Renewal, Department of Health and Wellness, Government of Nova Scotia.
Connie Clement, Scientific Director of the National Collaborating Centre for Determinants of Health (NCCDH) sat down on December 27, 2012 with Janet Braunstein Moody, Senior Director of Public Health Renewal with the Nova Scotia Department of Health and Wellness to speak about her experience of working on the collaborative initiative to develop the Nova Scotia (NS) Public Health Standards and about the state of public health renewal in Nova Scotia more broadly. Janet is also an adjunct faculty member with the School of Nursing and Community Health and Epidemiology at Dalhousie University.
Connie Clement: Could you tell us about the renewal process for public health in Nova Scotia?
Janet Braunstein Moody: The review of our public health system followed the release of the National Advisory Committee on SARS and Public Health’s report, Learning from SARS in 2003, and the multiple royal commissions that proceeded. Nova Scotia wanted to conduct an external review of its public health system to see how we stacked up in terms of being an effective, efficient, comprehensive, and responsive public health system. In 2005, we hired a public health consultant to conduct this external review. The review resulted in a document called, The RenewalThe Renewal of Public Health in NS: Building a Public Health System to Meet the Needs of Nova Scotians. This report put forward 21 recommendations or actions for system renewal. What the report generally found was that Nova Scotia was in the shallow end of the swimming pool in terms of effective system design and the ability to be responsive and effective.
The 21 recommendations were divided into five main categories: (1) improve the structure and function of the provincial level system; (2) improve the structure and function of the local level of the system (i.e., district health authorities); (3) strengthen how those two bodies work together; (4) improve how public health works across the continuum of care within the health care system; and (5) improve infrastructure (i.e., people, structure, information). The first specific recommendation was to establish a common vision for public health. And that started us on our strategic planning journey, which is really the foundation of our standards and subsequent protocols.
Connie Clement: How are you using those standards and priorities in Nova Scotia at this time?
Janet Braunstein Moody: Recommendation 11 of our renewal document identifies the establishment of evidence-based standards for our system, for the provincial and local levels. That has always been an intention of ours, but it required a clarified vision. Through the strategic planning process it became very evident that public health had a unique role in understanding population health assessment, surveillance as well as the qualitative elements of our communities. This process and understanding helped to clarify our vision and role.
Over a two-year strategic planning process, we engaged 60 individuals; conducted interviews; and held five to seven stakeholder events involving more than 500 people. We asked people to tell us about their understanding of public health and what they wanted from us. We heard a lot about the complexity of the public health system; we heard some really hard things, but we also heard some really good things. This process allowed us to hear what we needed to hear – public health has a really unique position in the health system.
Public health is largely the only group that is well-poised to understand community health andTherefore, a huge role of public health should be to shine the light on health equity issues and to encourage others to do the same. After the strategic planning process, we made a commitment through six stakes; one of which is the importance of understanding what was labelled ‘social justice’ in the document, but we’re moving more to health equity language as a core consideration in all of our work.
Connie Clement: That’s great . During your strategic planning process, how much did you reach out to sectors outside of public health?
Janet Braunstein Moody: I would say that most of our interviews reached out beyond the public health sector. We interviewed people that we had not previously talked to or really thought were necessary to involve in the strategic planning process before. We talked to people who work in: municipalities (including mayors); the prison system; housing; child development; resource centres; NGOs; and government departments, including environment and agriculture, economic development, and finance. We also spoke to people experiencing homelessness, librarians, and teachers.
Connie Clement: Could you tell us about how social justice, or health equity, is conceptualized within the Nova Scotia standards? What does it mean that one of those six priorities is around
social justice?
Janet Braunstein Moody: I think health equity or social justice was included as part of our six stakes to remind us that it is a core consideration in how we do our work. It was the foundation of our standards. During our discussions about focusing our programmatic areas, or areas of focus, we asked the question, ‘should social justice be one of our programs or areas of focus?’ There were lively debates among our leadership team in response to this question. Where we landed was that health equity was not something that stood alone as a separate program, but that if you did not have health equity incorporated into all of your program areas, we were not achieving our public health purpose. There were tears at that meeting, there was passion, and people were really wound up about it. We ultimately decided to keep our four programmatic areas as they were, but to then highlight health equity as the basis and common thread through all of them.
Connie Clement: How do you determine successful execution of the standards? Specifically, what indicators have been identified for foundational versus program standards?
Janet Braunstein Moody: That’s a very good question and we don’t have the answer to that yet. Right now our standards do not have any indicators. We are working on the first draft of the protocols, which is the next level of detail. However, we’re having a lively debate about where the indicators best fit; either within the protocols or through an accountability framework. We want to ensure the indicators we select align with what Nova Scotia is doing across the rest of the health system; however, we also appreciate that the indicators used by the rest of the health system, and the indicators that public health would need, are different. We also have a specific health equity protocol in our draft and then in each subsequent protocol, there is a reflection of how the foundational standard of health equity needs to be considered in each programmatic area. One of the key questions we’re asking in the protocol review process is, ‘does our understanding and commitment to health equity come out strongly in the protocols?’ I think they do. I’m quite excited about them.
Connie Clement: What do you think some of the key factors or elements were that supported incorporating health equity so centrally within these new standards for Nova Scotia?
Janet Braunstein Moody: I think one of the key elements was the strategic planning process. It was – I have to say – it was probably one of the more profound experiences that I’ve had in public health in terms of really being able to stop, sit, listen, wallow, and not try to fix what you’ve heard, but just let it emerge through a process. We interviewed the usual and unusual suspects and it just became clearer and clearer to us across the health system that there was no one area that really took on health equity. And it became clearer and clearer through our process that this could be a very strong role for public health. We couldn’t walk away from that role.
Connie Clement: How have the local district health authorities responded to the Nova Scotia Public Health Standards? given that the protocols are not available yet, how are you seeing the standards be used at this time?
Janet Braunstein Moody: As the leadership team, we have led this process, of which the district health authorities were all members. They’re not provincial standards, they’re system standards. In engaging the district health authorities from the early stages, we feel we have promoted shared ownership. I think that the devil is in the details and we need to consider what the standards actually mean to the public health nurse on the front line or the nutritionist or the health educator. One step we’re taking to better understand this is conducting dialogue interviews with front-line staff around change implementation and the introduction of the new protocols. One of the themes we’re hearing a lot is around the complexities of public health and the broad scope of our work. For example, while you have some people working on policy issues, you also have people in one-to-one client services. Implementation of the standards will be different for different people based on their unique roles and needs.
Connie Clement: What are some of the barriers you foresee as you move towards implementation? What strategies have you identified or are already using to minimize those barriers?
Janet Braunstein Moody: Those are some of the questions we’re currently asking in our dialogue interviews with front-line staff. A couple of the barriers are related to understanding and tailoring to the complexity of public health. Another barrier is that the background or foundational knowledge that practitioners have when they enter the public health system can sometimes be sparse. Knowledge and awareness of those fundamental principles is important for understanding the purpose and content of the standards and, therefore, that knowledge base among staff affects implementation.
Another barrier is resistance to change. It’s difficult to change practice, that sentiment of, ‘we have been doing this for 25 years, so why are you telling us we need to change now?.’ I think there’s also a barrier around the increasingly common conceptualization that managers and directors need to be good managers and directors as opposed to having content expertise in public health, that tension between content and process experts. But in reality, you have to be both. One of the barriers we had, and will continue to have, is responding to the needs of a broad mix of management with different knowledge and skill sets. This will require a very thoughtful introduction of the standards and tailored training of management in terms of how to mentor and introduce the standards to staff in their varied contexts.
When we’re talking about shifting our work further upstream, there’s this huge overwhelming sense that we’re going to dump more work on to others. The conversation at the local level has been ‘well if public health stops doing that, who’s going to pick it up?.’ A common example we give in response to this concern is around breastfeeding- that public health’s role is going to migrate from individual level breastfeeding support to addressing environmental factors that affect breastfeeding. For example, we can change the environment by promoting babyfriendly hospitals and communities and dispelling public perceptions around disadvantages of breastfeeding. If we [public health] don’t change the environment, the individual breastfeeding mother is not going to be as successful.
Connie Clement: What are some of the lessons you’ve learned moving as far as you have in the implementation of the public health standards in Nova Scotia? What advice do you have for others who are considering developing and implementing standards for their organizations or in their own jurisdictions?
Janet Braunstein Moody: It’s not for the faint of heart. It’s work that requires us to change internally as much as it is about changing a system. There’s a personal change that needs to happen. For me, I needed to be able to understand and believe in the benefits of developing public health standards. I needed to understand it with every fiber of myself to be able to have an impact in the broader system. The magnitude of this effort is comparable to changing the direction of an ocean liner. It is about long-term change and there are going to be challenges along the way. But every little degree makes a difference.
Another lesson learned is around the benefits of getting involved in various activities and on various committees, particularly if they are out of your sector or out of your comfort zone. This becomes more difficult as we have increasing demands, but you never know the impact you may have representing public health and health equity interests at these tables. For example, I represented public health on the Health Services Insurance Work Health Act working group. Every week I came to the committee meeting with two or three questions that we [as a working
group] needed to ask such as, ‘does this impact some groups more than others? If so, why?’. I had the lovely opportunity to keep asking those questions around that table for a year and a half. As a result, “health equity” is now in the preamble of the new act. So it’s about being there, developing relationships with other sectors and within the health system and actively trying to influence the way big system decisions are made. If you don’t embrace that with every fiber of yourself, you’re not going to be able to achieve that. Finally, you need to be patient. Public health sees change in decades. We’re the patient people.
Connie Clement: Based on your experience, to what extent do you think organizational standards are an effective strategy to advance health equity through public health?
Janet Braunstein Moody: I think they’re going to be an essential strategy. Furthermore, I think if you don’t see the words “health equity” throughout the standards, then you’re not going to have that impact. I think they really need to be strong in how they are understood and articulated across the system. It’s fundamental.
Connie Clement: Is there anything else that you’d like to share or add about the development of the standards in Nova Scotia or about organizational standards in general?
Janet Braunstein Moody: I think what we’re learning is that this is a process. It isn’t a roll out and it isn’t an implementation project. It is about being able to understand and integrate health equity
into the way we think and into the culture of our system. And that’s going to take time. We really need to be patient and recognize that there are skill sets that different people have and different people need to develop. That diversity is part of the richness of public health.
Connie Clement: Thank you so much Janet for sharing your thoughts and experiences with the development of the Nova Scotia Public Health Standards and good luck with the next stages of your learning and your implementation. This has been a great conversation.
Next week read the interview with Dr. Rosana Pellizzari.
Each of these interviews can be found in Public Health Speaks: Organizational standards as a promising practice to advance health equity.