Exploring health equity integration among health service and delivery systems in Nova Scotia: perspectives of health system partners
Authors: Yusuf Joshua , D’Souza Ninoshka J. , A.T. Caldwell Hilary , Meaghan Sim Sarah , Embrett Mark , F.L. Kirk Sara 
Published: August 2024

Abstract
Background
Achieving health equity is important to improve population health; however, health equity is not typically well defined, integrated, or measured within health service and delivery systems. To improve population health, it is necessary to understand barriers and facilitators to health equity integration within health service and delivery systems. This study aimed to explore health equity integration among health systems workers and identify key barriers and facilitators to implementing health equity strategies within the health service and delivery system in Nova Scotia, ahead of the release of a Health Equity Framework, focused on addressing inequities within publicly funded institutions.

Methods
Purposive sampling was used to recruit individuals working on health equity initiatives including those in high-level leadership positions within the Nova Scotia health system. Individual interviews and a joint interview session were conducted. Topics of discussion included current integration of health equity through existing strategies and perceptions within participant roles. The Consolidated Framework for Implementation Research (CFIR) was used to guide coding and analysis, with interviews transcribed and deductively analyzed in NVivo. Qualitative description was employed to describe study findings as barriers and facilitators to health equity integration.

Results
Eleven individual interviews and one joint interview (n = 5 participants) were conducted, a total of 16 participants. Half (n = 8) of the participants were High-level Leaders (i.e., manager or higher) within the health system. We found that existing strategies within the health system were inadequate to address inequities, and variation in the use of indicators of health equity was indicative of a lack of health equity integration. Applying the CFIR allowed us to identify barriers to and facilitators of health equity integration, with the power of legislation to implement a Health Equity Framework, alongside the value of partnerships and engagement both being seen as key facilitators to support health equity integration. Barriers to health equity integration included inadequate resources devoted to health equity work, a lack of diversity among senior system leaders and concerns that existing efforts to integrate health equity were siloed.

Conclusion
Our findings suggest that health equity integration needs to be prioritized within the health service and delivery system within Nova Scotia and identifies possible strategies for implementation. Appropriate measures, resources and partnerships need to be put in place to support health equity integration following the introduction of the Health Equity Framework, which was viewed as a key driver for action. Greater diversity within health system leadership was also identified as an important strategy to support integration. Our findings have implications for other jurisdictions seeking to advance health equity across health service and delivery systems.