Rapid Evidence Narratives
Brief narratives of current evidence for select, frequently encountered topics in social accountability.
The SAFE for Health Institutions Rapid Evidence Narratives provide evidence-based context for the SAFE for Health Institutions Evaluation Tool.
Each Rapid Evidence Narrative Includes:
- Key Points
- Narrative Summary
- Narrative Review of Current Evidence
- Applications at the micro (patient/institutional), meso (community) and macro (political and/or health policy) levels
Current Rapid Evidence Narratives:
- Racism as a Determinant of Health and Healthcare
- Cultural Continuity: Practicing Cultural Safety in Healthcare
- Community Engagement: the Foundation for Community-Centred Care
- Environmental Accountability of Health Institutions: Why it Matters
- Interventions Targeting the Social Determinants of Health
Racism as a Determinant of Health and Healthcare
Race is an identified determinant of health. However, it is actually racism, not race, that is the determinant of health. Racism is known to negatively impact physical, mental and emotional health. It is also the root cause of fatalities at the hands of healthcare providers and health institutions. Racism also impacts access to healthcare for racialized populations and the quality of healthcare that they receive. The prevalence of racism in healthcare can be understood as both a continuum of racism that exists in health research, health professional education, and standards of practice where there has historically been and remains a lack of diversity, equity and inclusiveness in curriculums, educational materials, and research studies; and, as a manifestation of broader societal beliefs.
Racism can be interpersonal and/or systemic. Both, are prevalent in healthcare and can be described at micro, meso and macro levels. Interpersonal racism is largely manifested at the micro-level as conscious, but more commonly unconscious expressions of bias between a healthcare provider and a racialized patient. Systemic racism is also experienced at the micro-level by individual patients on the receiving end of institutional policies and accepted practices (intentional or unintentional) that racially discriminate against them. Systemic racism is further reflected at the meso-level or community level when broad and wide spread health and social service institutions share policies and accepted practices that perpetuate the racialization of minority ethnic populations. At the macro-level, systemic racism is further reflected in politics and the health policies that further marginalize racialized populations’ access to the health services, social services and basic necessities required to acheive the right to health.
A health institution is at risk of perpetuating racism in healthcare unless they are actively implementing anti-racist standards of care. To be actively anti-racist is to acknowledge that racism exists, that racism is primarily driven by unconscious bias, and that there is a need for continual self-reflection and reform across the micro, meso and macro levels to ensure that anti-racist standards of care are normalized.
Cultural Continuity: Practicing Cultural Safety in Healthcare
Racial and ethnic minority populations suffer from health inequities linked to historic colonization, discrimination and systemic racism within healthcare systems. Cultural safety emphasizes decolonization and challenges the traditional power imbalance held by healthcare providers and health institutions over patients.
Health institutions can create culturally safe environments by adopting a cultural competence continuum. This includes practicing cultural awareness, competency and humility. The sum of these actions can create a culturally safe environment where cultural continuity is possible and acknowledged as a determinant of health. Cultural continuity is achieved when ethnic minority populations can access healthcare services and freely practice and express their culture, continuously and unabated, throughout their interactions with healthcare providers, the health institution and the healthcare system.
In health institutions, cultural safety is largely exercised at micro level. At the micro level, cultural safety would be prioritized by healthcare providers when interacting with ethnically diverse patients at the point of care. Additionally, all of the health institution’s activities and standards of practice would incorporate the cultural context of those the institution serves. At the meso-level, a health institution would further advocate for culturally safe access to community based health and social services. Actions at the micro and meso levels can lead to greater cultural safety and help to achieve better health equity and health outcomes for ethnically diverse peoples.
Community Engagement: the Foundation for Community-Centred Care
Community can be understood in two ways: a collection of people in a geographically defined area and by the relationships that bind people together. Health institutions typically serve a geographically defined region. Within these geographic boundaries are multiple diverse communities that include urban centres, neighbourhoods and diverse population groups. All of these can be considered communities in their own right, even if they are not confined within geographic boundaries.
Engaging with community can be understood in terms of micro, meso and macro levels. Micro level community engagement is what health institutions are most familiar with and refer to as patient-engagement. Micro level or patient-engagement typically produces patient-centred outcomes. Meso level community engagement can be understood as engagement with diverse, identifiable populations or groups of people tied together by their relationships (i.e. people experiencing homelessness). Meso level engagement focuses on specifically defined population-based outcomes. Macro level community engagement widens the depth, breadth and comprehensiveness of engagement to be inclusive of all communities, diverse populations and stakeholders. Macro level engagement shifts the focus to community-centred outcomes. Across the micro, meso and macro levels of community engagement healthcare outcomes evolve from patient-centred, towards population-specific and onto community-centred.
Effective community engagement must be meaningful, give communities ‘stakeholder power’ and empower communities in decision making at the health institution. A health institution should integrate what is learned through community engagement to reshape its healthcare services, policies, processes, procedures and institutional standards. A health institution with meaningful and effective community engagement is able to anticipate community needs and gains the opportunity to explore how the social determinants of health, amongst other factors, impact the patients, populations and communities it serves.
Environmental Accountability of Health Institutions: Why it Matters
The environment is considered a social determinant of health. Existing evidence suggests that environmental accountability in health institutions can contribute to better health outcomes for patients and particularly for populations and communities affected by environmental catastrophes and environmental degradation. Environmental accountability is an important consideration for health institutions who must develop zero-emmision and zero-waste driven delivery of healthcare services as important steps on their paths towards social accountability.
Health institutions must understand that global warming, and the ensuing environmental catastrophes, are the greatest threat to public health in the 21st century. Rising temperatures will cause deadly heat waves. More frequent and more severe natural disasters such as forest fires, hurricanes and flooding will lead to tragic loss of life. There will be more favorable conditions for the spread of communicable diseases and environmental degradation will accelerate. When the natural environment collapses, there will be direct and indirect impacts on health with an increase in respiratory diseases driven by poorer air quality, loss of airable land, food security and nutrition driven by droughts. This will cause further economic hardships that will disproportionately affect already marginalized populations (who ironically contribute the least to global warming and environmental degradation).
Health institutions are 24/7, high volume, resource consuming, waste generating and carbon emitting giants (4.4% of net cardon emissions gloablly). Healthcare institutions can focus their efforts internally at the micro or institutional level through either a top-down or bottom-up approach to environmental accountability. A top-down approach begins at the highest levels of the instituion and involves a high-level assessment of institutional operations, areas of high-consumption, greatest-waste production and highest carbon emissions. A bottom-up approach begins with an assessment of front-line healthcare service delivery to individual patients, and the ‘behind the scenes’ efforts that bring these services forward to patients, to identify practices that lead to high resource consumption and greatest-waste, and to high carbon emissions.
Interventions Targeting the Social Determinants of Health
Social determinants of health include income and income distribution, housing, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, social exclusion/inclusion, social safety network, health services, colonialism (often referenced as Aboriginal status), racism (often referenced as race), gender discrimination (often referenced as gender), and ableism (often referenced as disability). Politics, policies and socially constructed hierarchies govern these determinants of health. Marginalized and disadvantaged populations who are born into, grow, live, work and age under condidtions that are essentially imposed on them are often negatively impacted by the social determinants of health.
Because determinants of health can negatively impact the health of the patients and communities a health institution serves, it is imperative that health institutions target the social determinants of health at micro, meso and macro levels. Micro level interventions can be implemented at the point-of-care with individual patients. Micro level interventions can be further supported at the institutional level by considering the social determinants of health in decision making by using a social justice lens or health-equity impact assessment tools. For example, a person experiencing homelessness and accessing care at the health insitution could be placed in housing as part of their medical interventions. At the meso or community level, an understanding of how the social determinants of health manifest themselves outside of health institution could drive partnerships, intervention and advocacy. At the macro or political levels, larger-scale advocacy and community-level actions through intersectoral partnerships could achieve much broader change.
The most successful interventions that target the social determinants of health have components of both institutionally based targets and partnership-based strategies. The intersectoral nature of successful interventions may be a barrier to action for health institutions who may not perceive a cost-benefit or have limited understanding of other social support services that impact health. Despite these barriers, the evidence shows that properly designed interventions targeting social determinants of health tailored to local populations are successful and should be pursued by health institutions as part of their comprehensive strategy.
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