"It's not a food issue; it's an income issue": using Nutritious Food Basket costing for health equity advocacy.

Abstract

Ontario's public health units (PHUs) face considerable challenges in addressing the social determinants of health, even though "reducing health inequities" is a primary population health outcome in the Ontario Public Health Standards (OPHS). Since 1998, the OPHS mandated PHUs to use the Nutritious Food Basket (NFB) protocol to document food costs, a requirement that was removed in 2018. This study examined how the NFB advanced health equity advocacy by Ontario PHUs, and why some have used this tool more strategically than others. Semi-structured qualitative phone interviews were conducted with 18 public health dietitians (PHDs) and three key informants between May and October 2017. Interviews were audio-recorded, transcribed, inductively coded, and analyzed. The PHDs agreed that the NFB tool provides essential localized evidence of inadequate incomes for people living in poverty, and supports the health equity mandate of PHUs in Ontario. Factors that support NFB research and advocacy work include strong PHU leadership regarding health equity, participation in community coalitions, and engagement with Ontario Dietitians in Public Health (ODPH). Interviewees identified lack of support at the PHU level and lack of coordination of food insecurity work at the Ministry of Health as significant barriers to PHUs' use of the NFB to advance health equity mandates. This study offers compelling evidence for reinstating NFB costing in the Ontario Public Health Standards as a mandatory requirement of PHUs. Without this requirement, the already-limited capacity of PHUs to advance health equity in Ontario will be further compromised.