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Unit VII PowerPoint Presentation
Weight: 12% of course grade
Contemporary Public Health Issue
Although the United States is among the wealthiest nations in the world, it is far from being the healthiest. Life expectancy and survival rates in the United States have improved dramatically over the past century, but Americans have shorter lifespans and experience more illness than people in other high-income countries. This assignment gives you an opportunity to put together what you have learned in this course, including, but not limited to:
· public health policy, policymaking process, and law;
· public health and the legal system;
· individual and human rights in public health; and
· social justice, ethics and public health policy.
Choose a contemporary public health issue (e.g., bioterrorism, gun violence, or natural disasters like hurricanes, tornadoes, and wildfires), its impact on public health, and strategies for mitigating and managing it once the issue occurs.
Following APA guidelines, create a PowerPoint presentation of 17-20 slides (plus title and reference slides) on the contemporary public health issue you have chosen and a human rights ethical dilemma. You will present this work to a team of Centers for Disease Control and Prevention (CDC) officials tasked with developing global policies for addressing the impact of contemporary public health issues around the world.
Your presentation should assess:
· the human rights concerns associated with the selected issues in public health policy,
· the conflicts of interest between public health policies and your selected emerging public health issue, and
· the gaps in the current health law that apply to the contemporary public health concern you selected with recommended suitable policy interventions to address the selected contemporary public health issue.
Your assignment must be supported with evidence from three to five peer-reviewed references, two of which must be from the CSU Online Library and no more than five years old.
The following resources may be helpful for you as you search the CSU Online Library for peer-reviewed academic articles:
How to Find Journal Articles tutorial
transcript for the How to Find Journal Articles tutorial
How to Find Peer-Reviewed Resources tutorial
transcript for the How to Find Peer-Reviewed Resources tutorial
All content must follow APA guidelines, including all sources used, which must be cited and referenced according to APA standards found in the APA Style Guide located in your myCSU Student Portal.
Ensure your presentation includes visuals such as images and graphics to supplement your message. These images or graphics must be cited according to APA standards as well. Your title and reference slides do not count toward the total slide requirement.
As a part of the presentation, you are encouraged to use the speaker notes section for the content slides to reinforce your presentation.
714 Bull World Health Organ 2009;87:714–719 | doi:10.2471/BLT.08.058321
Using indicators to determine the contribution of human rights
to public health efforts
Sofia Gruskin a & Laura Ferguson a
Abstract There is general agreement on the need to integrate human rights into health policies and programmes, although there
is still reluctance to go beyond rhetorical acknowledgement of their assumed significance. To determine the actual value of human
rights for the effectiveness of public health efforts requires clarity about what their incorporation looks like in practice and how
to assess their contribution. Despite the pervasive use of indicators in the public health field, indicators that specifically capture
human rights concerns are not well developed and those that exist are inconsistently used. Even though “health and human rights
indicators” are increasingly being constructed, it is often the case that health indicators are used to draw conclusions about some
interaction between human rights and health; or that law and policy or other indicators, traditionally the domain of the human rights
community, are used to make conclusions about health outcomes. To capture the added value that human rights bring to health, the
differences in the contributions offered by these indicators need to be understood. To determine the value of different measures for
advancing programme effectiveness, improving health outcomes and promoting human rights, requires questioning the intended
purpose behind the construction of an indicator, who uses it, the kind of indicator it is, the extent to which it provides information
about vulnerable populations, as well as how the data are collected and used.
Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة.
a Program on International Health and Human Rights, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, United States of America.
Correspondence to Sofia Gruskin (e-mail: [email protected]).
(Submitted: 5 September 2008 – Revised version received: 3 January 2009 – Accepted: 4 January 2009 – Published online: 7 July 2009 )
Despite increasing attention paid to the apparent integration
of human rights into public health policies and programmes,
it is difficult to find concrete examples of the benefits that
have been derived from linking human rights norms and
standards to public health imperatives. There is a need to
identify existing approaches that link human rights and health
concerns and then to determine the best ways to assess their
impact on the effectiveness and outcomes of health policies
and programmes. As basic as it sounds, this approach requires
clarity, not only in defining human rights, but also in recog-
nizing what incorporation of identified norms and standards
should look like in practice.
In the interests of validity and comparability, from a
public health perspective, assessment requires appropriate
quantitative indicators. Implicit in the use of such indica-
tors is a sense that they are both impartial and objective. Yet
a human rights perspective suggests querying the assumed
neutrality of an indicator: we should think about who uses
it, for what purposes and in what ways. What occurs before,
during and after the measurement process itself is equally im-
portant as what is being measured. Thus, the purpose of this
paper is to begin to disentangle the diversity of approaches
to health and human rights indicators and to suggest issues
to consider in determining the value of existing approaches.
Human rights and public health practice
Human rights bring into focus the relationship between the
government, which is the first-line provider and protector of
human rights, and individuals (who hold these rights as hu-
man beings).1 Every country in the world is party to at least
one human rights treaty and all have made rights-related
commitments relevant to health.2 While for many years it was
unclear what the incorporation of human rights principles
meant for public health practice, certain actions are increas-
ingly considered part of a human rights-based approach to
health (Box 1).
Although generally not incorporated so systematically,
many of the interventions implied by the actions named in
Box 1 are familiar to people involved in public health. Those
that are not so familiar, such as ensuring transparency for
how decisions are made, are unique contributions that the
human rights field offers to public health. A difficulty lies in
determining whether, by drawing attention to the human
rights aspects of those actions traditionally in the domain of
public health, the nature of the indicator appropriate for their
measurement should remain the same or change. Addition-
ally, the fact that institutions may engage differently with the
same concepts and even the same indicators has implications
for assessing the ways in which monitoring and evaluation
are done across the fields of health and human rights.
A wide range of actors use indicators to capture human rights
concerns relating to health including international and na-
tional human rights mechanisms, governments, health and
development organizations and civil society.
In general terms, an indicator is “a variable with charac-
teristics of quality, quantity and time used to measure, directly
or indirectly, changes in a situation and to appreciate the
progress made in addressing it”.4 Table 1 lays out definitions
and examples of the two types of indicators used to capture
health and human rights concerns.
715Bull World Health Organ 2009;87:714–719 | doi:10.2471/BLT.08.058321
Policy & practice
Indicators of human rights and public health effortsSofia Gruskin & Laura Ferguson
It is immediately apparent that
many of the human rights indicators
constitute measures that fall outside
the traditional definition of a health
indicator. To assess the degree to which
human rights are respected, protected
and fulfilled in the area of health is to
expand the notion of what constitutes
an indicator in this field. Inevitably this
brings with it complications, some of
which are explored in this paper.
Human rights indicators to
measure health
For those involved in monitoring the
human rights compliance of States,
indicators are primarily used to en-
hance the practice of accountability for
health-related rights issues. In this con-
text, interest in health arises primarily
from its relevance to a range of rights,
in particular when non-fulfilment of
health-related rights is thought to im-
pede fulfilment of a range of human
rights. For example, human rights or-
ganizations may quantify violations in
specific areas to highlight governmental
failure to protect human rights relevant
to health, e.g. sexual violence in con-
flict situations.8 Further, some treaty
monitoring bodies ask governments
to show the kind of legislation that ex-
ists to protect population groups from
discrimination in their access to health
care,9 while others ask for such infor-
mation as disaggregation by ethnicity of
the reported number of births attended
by skilled health personnel.10
Attention to the use of such human
rights indicators by actors in the health
arena is rapidly increasing. To ensure a
shared understanding of why and how
they are being used, as well as transpar-
ency, it is important to make explicit
the justification for the assumption that
these indicators are grounded in inter-
national human rights law and they are
linked to the field of health. Highlight-
ing the legal bases from which such
indicators are derived can also help to
minimize bias in how they are used.
Health indicators to measure
human rights
Within the human rights field, com-
pliance with human rights norms and
standards and assessment of government
accountability is often done through use
of “traditional” health indicators. An ex-
ample is infant mortality rates, which are
Box 1. Actions suggested to constitute a rights-based approach to health
• Considering the legal and policy context within which interventions occur.
• Supporting the participation of affected groups, especially vulnerable groups, in all efforts
that concern them.
• Working to ensure discrimination does not occur in the delivery of services nor in the health
outcomes experienced among different population groups.
• Using human rights standards to deliver services in particular with respect to ensuring their
availability, accessibility, acceptability and quality.
• Ensuring transparency and accountability both for how relevant decisions are made and their
ultimate impact.3
used as a measure of State Party compli-
ance with their obligation to respect the
child’s right to life, survival and develop-
ment, even though they were created as
an indicator of population health.10
For those involved in health, the fact
that health indicators draw attention to
rights issues is generally a by-product of
efforts to determine the appropriateness
and effectiveness of policies and pro-
grammes. As one example, disaggregation
of data on the basis of sex and age may
be used to gauge usage of available health
services,11 but may also draw attention
to larger underlying concerns related to
inequities in access. In other instances,
attention to human rights may be driven
by a genuine, but nebulous, desire to “do
good” and thus give insufficient attention
to why a particular health indicator, or
set of indicators, is assumed to measure
human rights.
Even as indicators are frequently
used for purposes beyond those for which
they were originally intended, it is useful
to consider whether health indicators
ostensibly used to measure human rights
would have been constructed differently if
human rights considerations had formed
part of their design, and also to consider
the criteria that are or should be used
to determine how health indicators are
linked to specific human rights for valid
inferences to be made.
Indicators of health and human
With regard to the capture of infor-
mation at the intersection of health
and human rights, increasingly a third
category of indicators exists – those
created in the health field to capture in-
formation specifically relating to human
rights issues in the design and delivery
of health policies and programmes.12–15
This can most plainly be seen in rela-
tion to the components noted previ-
ously as key aspects of a human rights
approach. Some examples follow.
Assessment of laws that may present
obstacles to effective HIV prevention and
care for vulnerable populations provide a
useful example of an indicator that brings
to light issues equally of interest to both
fields.16 Laws that criminalize injecting
drug use, sex work or consensual sex
between men may deter people who
engage in these behaviours from seeking
HIV-related services even if they are avail-
able. Knowledge of the existence of such
laws provides context within which the
public health community can plan and
implement programmatic activities, and
can help the human rights community to
inform advocacy and push for any legal
reform necessary. These indicators could
be improved by capturing not simply the
existence of a law but also its quality, as well
as the degree to which it is implemented.
Indicators relating to the par-
ticipation of vulnerable groups bring
several concerns relevant for both
health and rights. For example, the
Greater Involvement of People Living
with or Affected by HIV/AIDS (GIPA)
principle draws its strength and legal
grounding in the right to participation
and has also been recognized as critical
to effective HIV programming.17 It is
crucial that appropriate participation
be sought from affected communities
to ensure the acceptability of interven-
tions to the population for whom they
are intended. Additional thought is
required on the way to determine in
each instance which populations are
considered vulnerable. This determines
not only whose participation is so-
licited and measured, but also which
populations are acknowledged to exist.
Linguistic challenges
Semantics pose challenges as there are
differences in understanding across the
716 Bull World Health Organ 2009;87:714–719 | doi:10.2471/BLT.08.058321
Policy & practice
Indicators of human rights and public health efforts Sofia Gruskin & Laura Ferguson
Table 1. The two types of indicators used to capture health and human rights concerns
Definition Examples
A health indicator has been defined
as a ”variable that helps to measure
changes in a health situation directly
or indirectly and to assess the extent
to which the objectives and targets of
a programme are being attained”.5
The number of maternal deaths is a raw statistic that takes on greater meaning when
converted into an indicator of number of maternal deaths/live births/year, which can be
tracked over time alongside programmatic activities. Other examples include: the percentage
of the population that has sustained access to improved drinking water sources, the
percentage of children aged less than 5 who sleep under insecticide-treated bed-nets, and
total expenditure on health as a percentage of gross domestic product.
A human rights indicator has been
defined as a measure that provides
information on the extent to which
human rights norms and standards
are addressed in a given situation.6
Indicators of fulfilment of human rights would include, for example, the extent to which
international human rights obligations are incorporated into national laws and policies
relevant to maternal health. Human rights indicators also include indicators of violations such
as quantitative summaries of human rights violations, legal audits and determination as to the
existence and use of mechanisms for challenge and redress if violations are alleged to occur.7
fields even when using the same terminol-
ogy. For example, stigma and discrimina-
tion have precise definitions such that, in
relation to health, “stigma” means being
devalued by individuals or communities
on the basis of real or perceived health
status. “Discrimination” refers to the
legal, institutional and procedural ways
that people are denied access to their
rights because of their real or perceived
health status.18,19 In public health, these
terms are increasingly used but often
without distinction. For example, several
instruments ostensibly assess both stigma
and discrimination within the context of
HIV/AIDS.20–23 While presumably excel-
lent for their own purposes, most mix the
definitions and concepts of stigma and
discrimination, thereby detracting from
the ultimate utility of the data from a hu-
man rights perspective for both advocacy
and accountability purposes.
Along similar lines, in 2003 the
United Nations Special Rapporteur
on the Right to Health suggested that
the categories of structural, process and
outcome indicators be introduced into the
monitoring of health-related human
rights,24 and the validity of this approach
for a wide range of rights is increasingly
under discussion in the human rights
community.6 While, to those working
in the health field, this would seem to be
a familiar delineation of indicators and
an important step in bringing together
the human rights and health fields, the
differences in how these categories are
defined is worthy of note. In human rights
terms, “structural indicators” capture the
existence of laws, policies and regulations
considered key to the functioning of
health systems 24 as opposed to variables
reflecting the system in which care is de-
livered.25 “Process indicators” are defined
as measuring “programmes, activities and
interventions”,24 which is different from
the traditional public health definition
of measuring the mechanisms through
which interventions have an impact.25 The
fields more or less come together in their
definition of “outcome indicators”, which
aim to capture the impact of programmes,
activities and interventions on health.24,25
Thus even when the same termi-
nology is used, unless recognized and
addressed, definitional differences be-
tween the health and human rights
fields can lead to confusion and limita-
tions in the presentation and use of the
information collected.
Using existing indicators
It is clearly preferable to first determine
the concept that is to be assessed and then
find an appropriate measure. However,
given the veritable plethora of indicators
already in existence, one should look
at how existing indicators can be better
understood and used to capture issues
relevant to both health and human rights
before giving consideration to the creation
of any new indicators. For an indicator to
be valid from both a health and human
rights perspective, irrespective of why it
was initially constructed, it is essential to
determine the extent of its human rights
sensitivity and its validity in public health
terms. We propose a series of questions to
help guide determination of the health
and human rights appropriateness of any
given indicator.
Why was it designed?
The design of every indicator is influ-
enced by the priorities shaping its use.
An indicator will look quite different
if its intended purpose is to inform
strategy and programme development
as opposed to monitoring targets and
holding specific actors accountable.
While in the end the issues of concern
may be similar, decisions relating to
such issues as specificity, comparabil-
ity and cost will, to a large extent, be
determined by the intended purpose of
the indicator as well the interests of the
entity funding its construction. Care-
ful consideration and due attention to
transparency are obviously required as
to whose values are incorporated and
the extent to which the indicator was
designed with both health and human
rights concerns in mind.
Who is using it?
Beyond the question of whether an
organization’s primary area of focus is
health, human rights or both, the use of
an indicator is likely to look different in
the hands of a nongovernmental organi-
zation, a donor, a national government
institution or an international organiza-
tion. If the indicator is designed by one
actor but used by others, it is unclear
the extent to which all actors need to be
aware of its original purpose in order
for their efforts, including the interpre-
tation and use of any data, to be valid.
What kind of indicator?
Within the public health community,
statistical significance achieved through
use of quantitative indicators has long
been seen as the gold standard for re-
search and evaluation.26 Attention to
human rights concerns sheds light on
the inadequacy of quantitative indica-
tors alone for fully understanding and
addressing a situation. Likewise, surveys
of client perceptions of the availability,
accessibility, acceptability and quality
of health services (key aspects of the
right to health) are useful for raising
human rights concerns, but they too
are inadequate in painting a full pic-
ture. In an ideal world, not only would
717Bull World Health Organ 2009;87:714–719 | doi:10.2471/BLT.08.058321
Policy & practice
Indicators of human rights and public health effortsSofia Gruskin & Laura Ferguson
indicators be constructed to take into
account both health and human rights
considerations, but quantitative and
qualitative indicators would be consid-
ered together to allow for interventions
shaped by a more complete picture of
the issues at hand.
Does it provide information on
vulnerable populations?
Disaggregation of information to reflect
where the needs are most acute is un-
disputed. The question ultimately boils
down to what disaggregation criteria
are applied and in response to whose
demand. In light of the acknowledged
importance of nondiscrimination and
the recognized need for appropriately
targeted interventions, at first glance it
is problematic that most indicators do
not capture information about specific
population subgroups. An inherent ten-
sion between public health and human
rights concerns surfaces here. Statisti-
cal validity requires carefully planned
sampling strategies, which become in-
creasingly costly, time-consuming and
complicated as categories of disaggrega-
tion are added. Conversely, attention to
human rights concerns would seem to
suggest that disaggregation needs to go
beyond sex and geographical location to
include such factors as race, language,
sexual orientation, and civil, political,
social or other status.27 Determining
the appropriate level of disaggregation
for any given setting requires conscious
attention to both public health and
human rights considerations to ensure
the situation of vulnerable populations
with respect to specific health issues is
appropriately addressed without inad-
vertent exacerbation of discrimination.
How are data collected?
The public health community’s inter-
est in the process of collecting data
is to a large extent centred around
determining ways to ensure reported
results are valid,28 whereas a human
rights perspective is concerned with the
processes of why and how data are col-
lected. Egregious examples within the
public health field, such as Nazi human
experimentation 29 and the Tuskegee
Syphilis Study,30 have drawn attention
to ethical concerns but a human rights
perspective highlights the responsibil-
ity of the researcher, policy-maker and
health programmer to know the source
of data in all instances. This helps to
ensure not only that efforts are appro-
priately informed but also, if necessary,
that data collection efforts be amended
to ensure human rights violations do
not inadvertently occur in the process.
How are data used?
Once data are collected, there are issues
to consider with respect to whether the
information is made publicly available,
released to the affected community with
proper education or only known to a
small subset of actors; concerns may exist
in each of these scenarios. Transparency
in how this decision is reached will help
ensure legitimacy and accountability
for any problems that may occur from
Table 2. Using HIV to highlight the issues raised by questioning indicators
Question Example
Why was this indicator designed? Tracking the total number of people on antiretroviral therapy (ART) might suffice for monitoring
governmental accountability and progress towards achieving universal access targets. However, to
inform the provision of ART, a detailed breakdown of which populations are (and are not) accessing ART
would be more useful.
Who is using the indicator? Designed by international organizations, early indicators of the number of people on ART included
women who were given prophylaxis to prevent vertical transmission of HIV to their infants. These
numbers were initially used by other organizations who were unaware that data which appeared to
show some degree of gender equity in access to ART were in fact masking the low numbers of women
accessing ART outside the context of preventing vertical HIV transmission.
What kind of indicator is it? The number of people who have been tested for HIV is a quantitative indicator often used in the field of
HIV. However, this does not capture the quality of the HIV testing process such as the type of counselling,
ensured confidentiality and appropriate referral, all of which are critical to people’s ability to process the
information presented both for behaviour change and to promote long-term connection with HIV-related
services. Bringing together qualitative and quantitative indicators can not only improve use of services but
provide a more accurate picture of the long-term impact of HIV testing on communities and more broadly.
Does the indicator provide appropriate
information with regard to vulnerable
Access to services for the prevention of mother-to-child transmission of HIV is often used as an indicator of
coverage of HIV services. However, an aggregate figure can hide under-served populations: disaggregation
by age, for example, might highlight adolescents as an under-recognized population; or disaggregation by
locality might draw attention to the need to improve these services for remote rural populations.
How are data collected? Estimates of prevalence of HIV infection among sex workers and intravenous drug users are sometimes
presented as evidence of commitment to vulnerable populations. These estimates could be modelled
from data collected from sex workers or drug users who voluntarily came forward for HIV counselling and
testing, but the information equally could be collected at centres for rehabilitation where people are pulled
off the streets, detained, tested without their consent and given no access either to their test results or to
adequate care.
How are data used? The withholding of information by government officials in the context of HIV, for example when
governments refuse(d) to report accurately the numbers of people estimated to be living with HIV in
their borders, is well known. Equally troubling have been documented instances of the inappropriate
use of data fuelling stigma, discrimination and human rights violations such as occurred for people from
communities identified in government statistical reports as having high rates of HIV infection including
immigrants, sex workers and drug users.31
718 Bull World Health Organ 2009;87:714–719 | doi:10.2471/BLT.08.058321
Policy & practice
Indicators of human rights and public health efforts Sofia Gruskin & Laura Ferguson
rights-based approach, indicators which
genuinely capture both sets of con-
cerns will ultimately help to determine
whether policies and programmes that
are the most effective in health terms
are also those that have achieved the
greatest level of compliance with hu-
man rights principles. Even as clarifying
these links is important, all of this will
remain purely academic unless the data
are used to improve support for affected
communities. Although still young
and fairly amorphous, the potential of
health and human rights indicators for
informing evidence-based policies and
programmes underscores the need for
their further development. ■
Competing interests: None declared.
subsequent use of the data. Attention
to human rights considerations can also
make an important contribution to the
use of purportedly neutral health data
and help to ensure these data do not
end up unintentionally fostering stigma,
discrimination or further violations of
human rights. Table 2 draws on examples
from HIV to highlight the sorts of issues
raised by previous questions.
Different types of indicators capture
different sorts of data through diverse
mechanisms. Consequently, effective
assessment of health and human rights
concerns may require innovative ap-
plication of proven monitoring and
evaluation methodologies, such as tri-
angulation across different data sources.
Such an approach would promote
pioneering use of existing indicators
thereby maximizing the potential use of
existing data without further burdening
monitoring and evaluation systems with
new indicators.
The value of what can genuinely
be called health and human rights in-
dicators is not only to show progress,
disparities and gaps within countries
and globally: the process of measure-
ment matters as much as the data
themselves. Health and human rights
indicators can show the extent to
which governments and other entities
are meeting their health-related human
rights obligations, highlight areas where
further efforts might lead to increased
fulfilment of these obligations and, by
extension, improve health outcomes.
Drawing attention to all elements of a
Utilisation d’indicateurs pour déterminer la contribution des droits de l’homme aux efforts en faveur de la
santé publique
Il existe un consensus sur la nécessité d’intégrer les droits de
l’homme aux politiques et aux programmes sanitaires, malgré
une certaine réticence à aller au-delà de la reconnaissance
rhétorique de leur importance supposée. Pour déterminer ce
qu’apportent réellement les droits de l’homme à l’efficacité des
efforts en faveur de la santé publique, il faut avoir une idée claire
de la forme que prend leur intégration dans la pratique et des
modalités d’évaluation de leur contribution. En dépit de l’usage
envahissant des indicateurs dans le domaine de la santé publique,
on ne dispose pas encore d’indicateur bien au point qui rende
compte spécifiquement des préoccupations liées aux des droits de …
Moving towards a new vision:
implementation of a public health policy
Ruta Valaitis1*, Marjorie MacDonald2, Anita Kothari3, Linda O’Mara1, Sandra Regan4, John Garcia5, Nancy Murray1,
Heather Manson6, Nancy Peroff-Johnston7, Gayle Bursey8 and Jennifer Boyko4
Background: Public health systems in Canada have undergone significant policy renewal over the last decade in
response to threats to the public’s health, such as severe acute respiratory syndrome. There is limited research on
how public health policies have been implemented or what has influenced their implementation. This paper
explores policy implementation in two exemplar public health programs -chronic disease prevention and
sexually-transmitted infection prevention – in Ontario, Canada. It examines public health service providers’ ,
managers’ and senior managements’ perspectives on the process of implementation of the Ontario Public
Health Standards 2008 and factors influencing implementation.
Methods: Public health staff from six health units representing rural, remote, large and small urban settings were
included. We conducted 21 focus groups and 18 interviews between 2010 (manager and staff focus groups) and
2011 (senior management interviews) involving 133 participants. Research assistants coded transcripts and
researchers reviewed these; the research team discussed and resolved discrepancies. To facilitate a breadth of
perspectives, several team members helped interpret the findings. An integrated knowledge translation approach
was used, reflected by the inclusion of academics as well as decision-makers on the team and as co-authors.
Results: Front line service providers often were unaware of the new policies but managers and senior
management incorporated them in operational and program planning. Some participants were involved in policy
development or provided feedback prior to their launch. Implementation was influenced by many factors that
aligned with Greenhalgh and colleagues’ empirically-based Diffusion of Innovations in Service Organizations
Framework. Factors and related components that were most clearly linked to the OPHS policy implementation
were: attributes of the innovation itself; adoption by individuals; diffusion and dissemination; the outer context –
interorganizational networks and collaboration; the inner setting – implementation processes and routinization; and,
linkage at the design and implementation stage.
Conclusions: Multiple factors influenced public health policy implementation. Results provide empirical support for
components of Greenhalgh et al’s framework and suggest two additional components – the role of external
organizational collaborations and partnerships as well as planning processes in influencing implementation. These
are important to consider by government and public health organizations when promoting new or revised public
health policies as they evolve over time. A successful policy implementation process in Ontario has helped to move
public health towards the new vision.
Keywords: Public health, Policy, Health policy, Implementation, Implementation science, Knowledge translation
* Correspondence: [email protected]
1Faculty of Health Sciences, School of Nursing, McMaster University,
1280 Main Street West, Hamilton L9S 4K1, ON, Canada
Full list of author information is available at the end of the article
© 2016 Valaitis et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
( applies to the data made available in this article, unless otherwise stated.
Valaitis et al. BMC Public Health (2016) 16:412
DOI 10.1186/s12889-016-3056-3
mailto:[email protected]
Public health systems in Canada have undergone significant
renewal over the last decade in response to various threats
to the public’s health such as severe acute respiratory syn-
drome (SARS) [1, 2], water contamination [3], and Hepa-
titis C in the blood supply [4]. In Ontario (ON), Canada,
renewal efforts have involved the review and subsequent
revision of public health policies that “establish the mini-
mum requirements for fundamental public health pro-
grams and services…” to be delivered by ON’s 36 boards of
health [5]. There is limited research on how these policies
have been implemented or what has influenced their imple-
mentation. Understanding the process of policy implemen-
tation in practice settings can provide valuable learning for
other jurisdictions undergoing similar public health policy
renewal processes, and is the focus of this paper.
The aim of Renewing Public Health Systems (RePHS) –
a five year program of research – is to study the implemen-
tation and impact of public health renewal in two Canadian
provinces, ON and British Columbia (BC), over time. Two
exemplar programs – chronic disease prevention (CDP)
and sexually-transmitted infection prevention (STIP) – are
being used to explore these topics. These programs were
chosen based on having a similar focus in both provinces
allowing for provincial comparisons, the likelihood of pri-
mary care and public health collaboration on the topic (a
secondary research interest) and expressed interest by our
knowledge user partners. This paper reports on results
from the first two years of data collection (baseline) in
2010–11 in ON. Baseline results from BC are reported in a
parallel paper [6].
OPHS policy development
Five years after the 2003 SARS outbreak, the Ontario
Public Health Standards 2008 (OPHS) [5] were released.
Additional file 1 provides a detailed history of the
process of initiation, development, and roll out of the
policies up to 2010 when this program of research was
initiated. In short, following the 2003 SARS outbreak [7, 8]
a provincial report – Revitalizing Ontario’s Public Health
Capacity [9] – recommended that the Mandatory Health
Programs and Services (MHPSG) [10] policy document
be replaced with renewed provincial public health pro-
gram standards that were to be continually revised, in
other words, part of an ever-greening process. The
Standards were expected to fit within public health’s fis-
cal envelope or public health funding. In addition, there
was to be increased emphasis on accountability, coord-
ination and collaboration across the health system, as
well as financial sustainability. Government and a Tech-
nical Review Committee deliberated on a number of
cross-cutting themes to be included in the new Stan-
dards [11]. These included: balancing the need for pro-
vincial standardization and being responsive to local
contexts; integrating public health functions as part of the
overall framework emphasizing population health assess-
ment and surveillance, as well as the delineation of a Foun-
dational Standard; establishing a logic model approach to
define causal linkages between requirements, board of
health and societal outcomes; and, ensuring that public
health roles and contributions to addressing determinants
of health and reducing health inequities was prominent
within a robust introduction to the standards.
The draft OPHS were submitted to the Chief Medical
Officer of Health in April, 2007 with an expectation that
“a robust and comprehensive roll-out strategy” would be
included with training supports. On the Technical
Review Committee’s advice, government continued to
develop protocols to support specific requirements
within the OPHS to achieve greater standardization in
province-wide implementation. Figure 1 illustrates the
four pillars (or principles), upon which the Standards
were built, the OPHS Foundational Standard [5] and its
accompanying Population Health Assessment and Sur-
veillance protocol [12], as well as five program standards
and their relevant protocols that existed at the time this
study was conducted. This figure was updated in May
2014 to reflect the addition of the Tanning Beds Compli-
ance Protocol [13].
In 2007, Protocol Development Teams began drafting
protocols, such as a Population Health Assessment and
Surveillance Protocol and Infectious Diseases protocol
[12, 14]. Numerous stakeholders had an opportunity to
comment on drafts in 2008. Guidance documents were
also developed, updated or referenced. The OPHS and
26 protocols were released in October 2008 and came
into effect in January 2009 and continue to be updated,
with the most recent revisions to the 2008 Standards
published in 2014 [15] with an additional protocol.
The OPHS release in 2009 included program specific
workshops and a dedicated website for the OPHS with
additional resources. In support of the OPHS release,
the former Ministry of Health Promotion and Sport re-
leased nine guidance documents in 2010. The content of
these policy documents has been explored in depth by
the RePHS research team from a number of perspectives
including: chronic disease prevention [16], equity [17],
public health human resources [18], and primary care
and public health collaboration [19].
An integrative framework to understand implementation
of a public health policy intervention
A focus on implementation sciences grew in parallel
with the development of the field of knowledge transla-
tion, but this focus was on the knowledge user setting and
understanding how a knowledge product or innovation
could be integrated in everyday practice or policymaking
in a sustainable way. As a result, attention to how
Valaitis et al. BMC Public Health (2016) 16:412 Page 2 of 17
contextual and organizational factors enabled implementa-
tion became important [20, 21]. Greenhalgh and colleagues
wrote a seminal article and book that reported on a sys-
tematic review to address how innovations can be spread
and sustained in health services organizations [22, 23].
They used a meta-narrative technique to synthesize find-
ings from empirical and theoretical works in 13 different
research traditions, such as evidenced-based medicine and
complexity studies. Based on their analysis, the authors put
forth a “unifying conceptual model” of diffusion in service
organizations composed of eight elements: 1) the
innovation, 2) adoption by individuals, 3) assimilation by
the system, 4) diffusion and dissemination, 5) system ante-
cedents for innovation, 6) system readiness for innovation,
7) the outer context: interorganizational networks and col-
laboration, 8) implementation and routinization, and 9)
linkage (at the design and implementation stage). We used
this empirically-based framework [22, 23], to interpret our
data related to the policy implementation. In our analysis
we took the authors’ advice also to pay attention to imple-
mentation adaptations that arose and occurred informally
in addition to those that were spread through official,
planned mechanisms.
The purpose of this paper is to explore public health
service providers’, managers’ and senior managements’
perspectives in six Ontario health units on the process
of implementation of the OPHS and factors influencing
their implementation within two exemplar public health
programs – CDP and STIP. We used Greenhalgh et al’s
Model of Diffusion of Innovations in Service Organiza-
tions as an organizing framework [22, 23] to interpret
the findings. Similar to the parallel paper that explored
policy implementation of BC’s Core Public Health Func-
tions Framework, “knowledge about the implementation
experience and the challenges encountered by practi-
tioners and managers may help inform improvements in
both the policy intervention and the implementation
process” [6] p.4.
This paper reports on baseline results from a longitu-
dinal multiple case study, which incorporated a number
of data collection methods. We drew upon results from
focus groups and interviews to obtain perspectives from
health unit personnel and senior management in relation
to the core program standards. Cases were defined as
the STIP and CDP programs that are directed by policy.
These programs were chosen because they were offered
in both provinces and were likely to involve collabor-
ation with primary care – a cross cutting theme. Six out
of 36 health units in the province of Ontario were re-
cruited to provide a diverse sample that matched the
general demographic makeup (e.g., population density;
ratio of immigrants; urban, rural, remote or mixed) of
the health authorities in BC. One health unit dropped
out due to reduced capacity to participate in research as
a result of multiple staff changes and vacancies; the
health unit was replaced by another in 2011. Service
providers, managers and senior management (i.e., direc-
tors, a Chief Nursing Officer, Medical Officers of Health,
and Associate Medical Officers of Health) were recruited
to participate (Table 1). Service providers and managers
participated in focus groups separately to avoid the in-
fluence of power-over relationships. Focus groups were
Fig. 1 Ontario Public Health Standards 2008. The Ontario Public Health Standards [1] framework is supported by four pillars which are the principles
that underpin the Standards. The foundational Standard and protocol is to be integrated into the 5 program Standards with their relevant
accompanying protocols. This diagram was current at the time of data collection: In May 2014, it was revised and an additional protocol was added.
Valaitis et al. BMC Public Health (2016) 16:412 Page 3 of 17
conducted within homogenous teams (i.e., STIP and
CDP) when relevant. Senior management participated in
interviews. Interviews and focus groups were audio-
taped, transcribed verbatim, cleaned for accuracy and
entered into NVivo10.0 for analysis. Focus groups were
conducted face-to-face at the health units by program
area, and interviews were completed in person or by
phone by researchers. Focus group and interview ques-
tions were tailored to address participant groups, i.e.,
service providers, managers, senior management (See
Additional file 2).
In this study, we used concepts in Greenhalgh’s frame-
work as sensitizing concepts to provide general ideas for
developing our interview questions to ensure that we
covered the broad domain of known influences on suc-
cessful policy and innovation implementation. When it
came time for analysis, we did not use Greenhalgh’s
framework to structure or organize our coding. Rather,
we coded line by line in inductive fashion to develop a
set of empirically-derived codes. To begin, a coding
framework was created by having each researcher from
the team code two or three selected transcripts followed
by a review and discussion in a face-to-face meeting.
Agreement was reached on the coding framework and
remaining transcripts were coded by trained staff. After
a few more transcripts were coded, results were reorga-
nized by identifying codes that could be merged or reor-
ganized into higher level thematic codes by researchers.
When all coding was completed, each researcher was
assigned a set of transcripts to review as a peer debrief-
ing strategy: in other words, each transcript was
reviewed by two researchers to increase the credibility of
analysis [24, 25].
In the final step, after thematic higher order codes
were identified, we again turned to Greenhalgh’s frame-
work to help us in interpreting the various categories of
inductive codes and the relationships among them. Our
discussion is therefore framed around relevant concepts
in Greenhalgh’s framework. Nonetheless, we acknow-
ledge that in our coding we were theoretically sensitized
by the Greenhalgh framework. Sensitizing concepts are
central to a grounded theory approach to analysis [26],
but the notion was developed much earlier by Blumer
[27]. A sensitizing concept is one that is not clearly spe-
cified with respect to its attributes. Thus, it does not
allow the researcher to move easily between data iden-
tifying the instance and the attributes of the concept.
Rather, a sensitizing concept provides the researcher
with general suggestions about what to look for in an
empirical instance. Definitive concepts, on the other
hand, provide very specific directions for what to see
[27] p. 7.
Key results were circulated to decision-maker team
members (they were not privy to the raw data) as well as
senior Ministry staff at various meetings for input. Thus
decision-makers provided additional context to help inter-
pret findings and increase credibility of results [28]. An in-
tegrated knowledge translation approach [29] was used
throughout, and is reflected by the inclusion of academics
as well as decision-maker researchers (i.e., government
and public health unit staff) on the RePHS team.
Ethics and consent
Ethics Board approvals were obtained from McMaster
University Hamilton Integrated Research Ethics Board
(HIREB); Public Health Ontario through the University
of Toronto (Office of Research Ethics); Ottawa Public
Health, Ottawa Public Health Research Ethics Board;
Sudbury & District Health Unit, Sudbury & District
Health Unit, Research Ethics Review Committee (RERC);
and Toronto Public Health, Toronto Public Health Re-
search Ethics Board. All participants consented to this
Participant demographics will be presented followed
by results, using illustrative participant quotes, re-
lated to: 1) how the OPHS (policies) were dissemi-
nated; 2) awareness of policies; 3) general opinions
about the policies; 4) processes used for policy imple-
mentation; and 5) internal and external factors influencing
policy implementation.
Participant demographics
A total of 21 focus groups and 18 interviews were con-
ducted throughout October-December 2010 (manager
and staff focus groups) and August 2011 (senior man-
agement interviews) (Table 1). A total of 133 individuals
participated from six participating health units. Of all
participants, there were 74 (55.6 %) nurses; 17 (12.8 %)
Table 1 Number of Participants by Type, Data Collection Strategy and Program (2010–2011)
Participant Type Focus groups (# of FGs) Interviews Total
CDP STIP CDP STIP Mixed Programs
Service providers 40 (6 FGs) 34 (6 FGs) – – – 74
Managers 21 (4 FGs) 20 (5 FGs) 3 1 – 45
Senior managers – – – – 14 14
Total ON 61 54 3 1 14 133
Valaitis et al. BMC Public Health (2016) 16:412 Page 4 of 17
health promoters; 13 (9.8 %) dietitians; 5 (3.8 %) nutri-
tionists; 5 (4.8 %) physicians; 4 (3.0 %) social workers; 1
(0.8 %) community worker; and 9 (6.8 %) ‘other’ [missing
data n = 5 (3.8 %)]. Of all participants: 22 (16.5 %)
worked for under a year in their current positions; 56
(42.1 %) for 1–5 years; 23 (17.3 %) for 6–10 years; 16
(12.0 %) for 11–15 years; and the remaining 11 (8.3 %)
were in their positions for over 15 years [missing data:
n = 5 (3.8)] (see Fig. 2).
Policy dissemination at the health unit level
Policies were most frequently communicated through
formal means by health unit managers to front line ser-
vice providers. This was done through program discus-
sions, new staff orientation, presentations, in-services,
emails and workshops. In some health units, managers
noted that communication “cascaded” from senior
management to service providers and policy analysts,
and in one health unit a designated ‘champion’ was
responsible to ensure policies were communicated
through programs/branches (satellite offices). Some-
times participants were informed about the policies by
external sources such as: external networks, Ministry
of Health and Long-Term Care updates, Ministry
sponsored webinars, and the Ministry’s formal launch.
A director noted: “I think mostly it was in the initial
consultations. So there was that launch of the drafts
and all the health units were asked to provide feedback.”
Often managers and front line staff were involved in
standards development by providing feedback, or con-
tributing to the writing process. This helped to incorp-
orate a variety of perspectives. As described by a service
… I met with the tobacco cessation people [at the
Ministry] as they rewrote those mandatory guidelines
[…]. And from my perspective what was needed as far
as cessation goes in the various communities
throughout Northern Ontario, I guess that’s what we
were representing.
In a few cases policies were reviewed by staff inde-
pendently, staff assisted in the preparation of guidance
documents, or they participated on a provincial planning
Awareness of the new policies
Managers and senior management knew about the new
policies and reported that staff awareness was supported
through discussions at team meetings or regular plan-
ning meetings. As described by one manager:
We were aware of them and used them as a planning
tool before, even before they were passed. So, I think
we were very aware of them and we try to really
encourage our staff to continue to be aware of them.
In a few health units the OPHS were incorporated into
organizational documents, such as strategic plans and
logic models, as a way to identify and align priority
program activities with the government mandate thereby
facilitating policy implementation into services and
Service providers were asked about their knowledge of
the policies. Many were unaware of them, or were only
aware of some aspects of them, such as the accompany-
ing protocols. As noted by one participant: “I’m familiar
with the OPHS but the old ones (referring to MHPSG).
I haven’t seen the new [OPHS], updated ones. They have
not been, in any way that I’m aware of, been shared with
me.” For most front line staff who were aware, they did
not focus on them “… I don’t think about the standards
an awful lot. Like in the clinic here, you are focused on
hands-on work. So it’s not something that we dwell on
too much. We know what we have to do and we do it.”
Despite direct involvement by health unit staff in the de-
velopment of the OPHS and broad health unit commu-
nications around them, awareness was uneven. Overall,
managers were more aware and found ways to incorpor-
ate them into their work processes, whereas most front
line service providers either were unaware or paid little
attention to the OPHS. Having more direct engagement
with the policies through the development and or imple-
mentation phases seems to have influenced the level of
awareness of the policy.
Influences on policy implementation
Themes that indicate influences on policy implementa-
tion are bolded and summarized in Fig. 3.
The OPHS themselves: general opinions about policies
There were mixed views about the OPHS. In general,
some managers and senior management reported that
they were fortunate to have them, describing them as
providing direction and being empowering. As a director
Fig. 2 Number of Participants by Years in Position
Valaitis et al. BMC Public Health (2016) 16:412 Page 5 of 17
noted: “… it does provide direction for us. It is a way
that we have structured our organization somewhat
around the Standards. It’s certainly how we report out
on things.” Others saw the policies as being similar to
the old policies with the same overarching themes or as
an extension of the MHPSG. A few others understood
them as continually emerging and changing, with their
new protocols and guidance documents.
There was a mix of opinions around the degree of
prescriptiveness of the OPHS compared to the
MHPSG. However, most participants felt the OPHS were
generally less prescriptive allowing for more flexibility in
programming, but providing less direction. Exceptions
were related to aspects of infectious disease programs
which were seen as more prescriptive. As a STIP man-
ager described: “It’s not prescriptive as far as the educa-
tion piece, but the clinical and the investigation, that’s
very prescriptive.” There was a need for balance between
having flexibility in implementing the OPHS while also
being prescriptive so that arguments could be made for
some hard to sell programs, such as harm reduction. A
manager explained:
The lack of information [referring to the non-
prescriptive policy] allows us to do what we’d like to
do. However, that same lack of information also
doesn’t give us the permission that we need to do
some of the things that we need to do. So, would we
have liked to have seen more meat? Maybe.
Participants indicated that the non-prescriptive nature
of the policies left decision-making around them open
to outside influences, which will be described later.
Some tension was identified in that the policies called
for evidence-based programming. However, participants
felt that there were times when specific, local commu-
nity needs were not prioritized areas in the OPHS or no
evidence existed in relation to interventions to address
Fig. 3 Factors influencing policy implementation
Valaitis et al. BMC Public Health (2016) 16:412 Page 6 of 17
community needs. Participants also correctly understood
that the policies were to be fiscally neutral – in other
words, staying within the budget. This limitation was
generally accepted by participants as a reality that could
not be changed.
Organizational leadership
Organizational leadership was a significant factor influ-
encing policy implementation. The topic of leadership
was spoken about as both a barrier and facilitator by
staff and managers from most health units. A significant
factor influencing implementation was management
approaches. Some staff in a number of health units said
they felt unsupported and disempowered. Complaints
ranged from challenges to autonomous practice of ser-
vice providers, increased control by senior management,
a lack of staff voice, lack of transparency related to
changes in priorities, limits on innovation, and having to
work through multiple layers of bureaucracy. One staff
member described this latter issue as follows: “…they
have added layers and layers and layers. I used to report
to a manager; now I have a supervisor and I have a
manager. There’s the MOH.” Another staff member
described their lack of control:
You are suddenly doing something that just changes
your […] entire operational plan and allocation of
resources. And we are often not given a reason. It
could be someone’s personal interest: It could be
something they heard on the news. But it just plops
into your assignment and we don’t have a lot of say at
that level.
On the other hand, leadership was seen by many
others as being trusting, supportive, flexible, accessible,
and encouraging creativity. As one staff member put it:
“I met with the supervisor of the population health team
and we talked about the scope of this position as well as
the standards and planning for this upcoming year. So
she was very supportive and just assisting me with that
Capacity building opportunities and resources was
another important factor influencing implementation of
the policies. Staff in most health units expressed the
presence of and value in capacity or career building op-
portunities, as well as access to supportive tools and re-
sources; however, not all staff members shared this
sentiment. One participant said: “I don’t feel supported
in terms of responsibilities with the new policies. They
tell us what we are supposed to do but I don’t think the
process and how we do it is well supported…”
Another leadership factor influencing implementation
that was mentioned in most health units was a sense of
inequity in program support from management
across programs and branches. In particular there was
less support for some topics over others. Topics that did
not explicitly fall under the policies were less valued al-
though they were important to communities, for ex-
ample: “body image: there wasn’t quite a good fit under
OPHS […] Is that mental health? Because, if it’s mental
health, then it doesn’t belong in public health. If it’s
healthy eating, then sure.” Also, health promotion was
less valued by managers than infectious disease control;
and sensitive topics such as harm reduction were valued
less than topics such as healthy weights.
Explicit senior leadership support for the policy
and its implementation was reported to be important
by all. Having a vacant senior leadership position at the
time of the roll out was a barrier for implementation in
some health units, while other health units were influ-
enced by local municipal pressures. A lack of valuing of
OPHS by leadership and lack of leadership to champion
the OPHS were problematic in half of the health units.
As shared by one participant: “The lack of importance
placed on [the policies], from the top down impacted
how they were received by staff.” Another senior man-
ager supported perceptions from some health units that:
“We …

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