We are a group of summer students who are part of the Patient Partnered Diagnostic Center of Excellence under the Patient-Oriented Research team at Michael Garron Hospital and the University of Toronto. Every week, our team engages in activities led by the team’s scientists, aimed at fostering curiosity, building teamwork, and reflecting on what we have learned. One activity prompted us to examine the merits and shortcomings of a widely recognized image used to illustrate the differences between equity and equality (Figure 1). Our passion for the topic led us to deconstruct and redesign this popular image to focus on healthcare, drawing on our diverse backgrounds in engineering, medicine, nursing, business, and health science. Here we describe our process and the final design of an image depicting health equality, health equity, and health justice. 

Figure 1

 

Original Equity and Equality Image

The original graphic (Figure 1) illustrates the concepts of equality and equity using individuals of different heights attempting to watch a baseball game over a fence. The image shows that providing the same stepping boxes to everyone may still result in some people being unable to watch the game. The purpose of the image is to promote understanding that shifting toward an equity-focused approach can lead to fairer outcomes, such as ensuring that everyone behind the fence has a better view.

While the image is easy to understand, it misrepresents equity in a potentially harmful way. The photo lacks diversity and representation; for example, it excludes women and individuals living with disabilities. Additionally, by choosing height as the single focus, it emphasizes individual physical traits as the cause of disparities, ignoring system-level inequities that are represented by the fence. For example, socioeconomic status; the three men behind the fence, perhaps, were unable to purchase tickets to the game or afford cable. 

The presented solution to the height disparity is similarly problematic. The image portrays only one solution (i.e., a stepping box) which simplifies equity as a “one and done” approach, rather than recognizing the holistic, whole person approach where equity considerations are specialized to meet individual’s needs. It portrays equity as “only” redistributing resources by taking a box away from the taller person and giving it to the shorter individual, and not providing additional support to meet each person’s specific needs. Lastly, the image does not include key concepts beyond equity and equality, such as justice. Previous modifications to the original image include justice or liberation, where the barrier (i.e., the fence) is completely removed. Other adaptations have focused on accessibility, such as incorporating a ramp for wheelchair users or auditory aids for those with visual impairment. 

We aimed to build on these adaptations by developing images that illustrate health equality, equity, and justice, by incorporating structural and individual complexities common in health and social care systems.

We started by creating an image that illustrates health equality (Figure 2) by replacing the baseball game with a healthcare facility and a hedge maze, instead of a fence, to symbolize the complex barriers individuals face when accessing the healthcare system. To illustrate equality, all individuals were given the same map to help them navigate the hedge maze. 

Figure 2

 

Health Equality- Everyone is provided with the same resource (a map) to access and navigate the care system.

We enhanced representation by adding women; individuals of different races and cultures; and people living with disabilities. Structural barriers that could impact access to care, for example, the river were added, along with areas of inaccessibility, such as the narrow maze entrance which is not accessible to those using wheelchairs, and the map (depicted as blurry) which is not accessible to individuals with visual impairments or low health literacy. While not exhaustive, we aimed to visualize some individual-level characteristics and systemic barriers that impact individual’s abilities to access care that we have encountered personally or within our research experiences this summer working with our patient-partnered communities. 

When reimagining the health equity image (Figure 3), we had one main goal. We aimed to ensure redistribution is not the only approach to address health inequities. As such, we illustrated how individual’s needs, depicted in the equality image, can be addressed in different ways, unique to the individuals. To do this, we made sure that everyone kept their map to help them navigate the hedge maze but added a bridge to address the barrier caused by the river; widened the maze entrance, improving accessibility for the person using a wheelchair; and gave an assisted device to the individual who previously had difficulties reading the map. 

Figure 3

 

Health Equity- Everyone is provided with additional support to access care.

Figure 3 shows that even when inequities are decreased, there are still barriers to access. For example, the hedge maze still exists, and all individuals must navigate the maze to access care.

As a result, we introduced the concept of health justice (Figure 4) by removing the maze. Health justice builds on the concept of health equity but goes a step further by emphasizing the broader societal and systemic changes needed to achieve equitable health outcomes. It’s about addressing the root causes of health inequities, such as structural racism, discrimination, and inequality, through systemic change and advocacy. We realize that, in reality, it may be impossible to remove all barriers to accessing care. Removing barriers requires policy reform (for example integration of health and social care and addressing income disparities) and a shift in power led by the community for the community. However, removing the unnecessary barriers that complicate care navigation for patients and their families is a step toward health justice for all. 

Figure 4

  

Health Justice- Some obstacles to access care removed.

The original image (Figure 1) is valuable for illustrating the simple differences between equity and equality. However, it focuses exclusively on a physical trait, lacks inclusivity of various barriers, emphasizes redistribution as the only solution to achieve equity, and does not visualize removing barriers to attain justice. We aimed to address these gaps (Figure 5) while shifting the application of these ideas to healthcare. 

Figure 5

 
Full Equality, Equity and Justice Poster  

We wish that our version will be used over the original in public health settings. We hope it can promote more inclusive/equitable practices and help everyone to better understand the key differences among equality, equity and justice. We recognize no model is a perfect representation, and we encourage future improvements and analysis to be made to better educate everyone on equity and justice.   

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