Implementation of the Health Equity Impact Assessment (HEIA) tool in a local public health setting: challenges, facilitators, and impacts

Abstract

Setting

The Simcoe Muskoka District Health Unit (SMDHU) is a local public health agency in Ontario, serving the County of Simcoe and District of Muskoka’s population of over 540,000 people in a mixed urban-rural environment. SMDHU has had a strategic focus on the determinants of health since 2007.

Intervention

The use of the Health Equity Impact Assessment (HEIA) tool was encouraged throughout SMDHU. An online survey was conducted to assess the implementation of mitigation strategies identified through the HEIAs; in particular, the facilitators and barriers/challenges, and the impacts at both the program level and the level of priority populations, themselves, were assessed.

Outcomes

Agency programs reported 40 HEIAs conducted between 2013 and 2017. While three of the 40 HEIAs were at an early stage, the remaining 37 were at an advanced stage of implementing mitigation strategies, or beyond. Reports from these 37 advanced-stage HEIAs indicated that 30 of them observed or measured impacts on their programs, services, and/or policies (i.e., program-level impacts), following the implementation of HEIA mitigation strategies. These impacts included improved collaboration with external partners, development of more accessible and inclusive communication, increased availability of information and population health data, increased access to services for priority populations, reduced financial barriers for accessing services, and increased staff training on health equity and priority populations. However, few respondents had measured or purposefully assessed impacts on target populations themselves (i.e., population-level impacts); therefore, such impacts are unknown. Key facilitators to the implementation of mitigation strategies were availability of staff, collaboration and support from other areas of the organization, sufficient time, collaboration with community partners, and the inclusion of HEIAs in program operational plans. Absence of these facilitators was identified as a barrier to implementation of mitigation strategies.

Implications for policy and practice

The use of HEIAs served as a catalyst for change in this local public health agency, leading to equity-oriented impacts on public health programming, planning, service delivery, and organizational policy. Support and capacity-building for measuring and evaluating impacts of mitigation strategies on intended priority populations themselves are recommended, to ensure more robust learning and improvement.

Résumé

Lieu

Le Bureau de santé du district de Simcoe Muskoka est un organisme de santé publique local de l’Ontario qui sert les plus de 540 000 habitants du comté de Simcoe et du district de Muskoka, un environnement mixte (urbain-rural). Le Bureau est stratégiquement orienté sur les déterminants de la santé depuis 2007.

Intervention

L’utilisation d’un outil d’évaluation de l’impact sur l’équité en matière de santé (EIES) est encouragée dans tout le bassin de ce bureau de santé. Un sondage en ligne a été mené pour évaluer la mise en œuvre des stratégies d’atténuation cernées grâce aux EIES, et en particulier les éléments qui entravent/limitent ou qui favorisent ces stratégies, ainsi que leurs impacts sur les programmes et sur les populations prioritaires.

Résultats

Selon les programmes de l’organisme, 40 EIES ont été menées entre 2013 et 2017. Trois en étaient encore à une étape préliminaire, mais les 37 autres avaient terminé ou presque terminé la mise en œuvre de stratégies d’atténuation. Les rapports des 37 EIES à un stade avancé indiquent que 30 d’entre elles ont observé ou mesuré les impacts sur les programmes, les services et/ou les politiques (« impacts sur les programmes ») après la mise en œuvre des stratégies d’atténuation de l’EIES. Ces impacts étaient la collaboration améliorée avec les partenaires externes, des communications plus accessibles et plus inclusives, la disponibilité accrue d’informations et de données sur la santé des populations, l’accès élargi aux services dans les populations prioritaires, la réduction des obstacles financiers à l’accès aux services, et une augmentation de la formation du personnel sur l’équité en santé et les populations prioritaires. Par contre, peu de répondants avaient mesuré ou délibérément évalué les impacts sur les populations cibles elles-mêmes (« impacts sur les populations »); ces impacts ne sont donc pas connus. Les principaux éléments favorisant la mise en œuvre des stratégies d’atténuation étaient la disponibilité du personnel, la collaboration et le soutien d’autres sections de l’organisme, le temps suffisant, la collaboration avec des partenaires associatifs et l’intégration des EIES dans les plans opérationnels des programmes. L’absence de ces éléments constituait un obstacle à la mise en œuvre des stratégies d’atténuation.

Conséquences pour les politiques et la pratique

L’utilisation des EIES a été un catalyseur de changement dans cet organisme de santé publique local, et elle a eu des impacts sur l’équité dans les programmes de santé publique, la planification, la prestation de services et les politiques organisationnelles. Il est recommandé de soutenir et de renforcer les capacités de mesure et d’évaluation de l’impact des stratégies d’atténuation dans les populations prioritaires elles-mêmes pour consolider les apprentissages et les améliorations.

Appendices

Appendix 1. Survey questions

• 1. What year was your HEIA conducted?

• 2. Please identify your program and the topic of the original HEIA conducted in 2013/14.

• 3. Using the HEIA tool as a guide, please indicate what step of the HEIA you are currently at.

• 4. What were the challenges in not being able to start or complete a full HEIA? Check all that apply.

• 5. Please tell us more about your experience with the challenge(s) identified above.

• 6. Do you intend on going any further with your HEIA at this time or in the future?

• 7. How many mitigation strategies were identified in your HEIA?

• 8. Of the identified mitigation strategy (ies), how many were fully implemented (i.e., the mitigation strategy was completed)?

• 9. What factors contributed to the full implementation of the mitigation strategy (ies)? Check all that apply.

• 10. Please tell us more about your experience with the factors identified above.

• 11. Of the identified mitigation strategies, how many were partially implemented (i.e., the mitigation strategy was started but is not yet fully completed)?

• 12. What are the reasons these mitigation strategies were not fully implemented? Check all that apply.

• 13. Please tell us more about your experience with the factors identified above.

• 14. Of the identified mitigation strategies, how many have not yet started?

• 15. What are the reasons for these mitigation strategies not being started? Check all that apply.

• 16. Please tell us more about your experience with the factors identified above.

• 17. Do you intend to go any further with these mitigation strategies in the future?

• 18. We are interested in learning about any changes or impacts that have occurred as a result of the implementation of the mitigation strategies to: your program, service, policy or initiative; and the priority population(s). If there was no change or impact noticed or observed, indicate why.

Appendix 2. Toronto Central LHIN’s 8 standardized demographic questions

Source – pages 21 to 23 of report at http://torontohealthequity.ca/wp-content/uploads/2013/02/Measuring-Health-Equity-Demographic-Data-Collection-Use-in-TC-LHIN-Hospitals-and-CHCs-2017.pdf

• 1. What language would you feel most comfortable speaking in with your health care provider? Check ONE only.

• 2. Were you born in Canada?

• 3. Which of the following best describes your racial or ethnic group? Check ONE only.

• 4. Do you have any of the following? Check ALL that apply.

  (options include chronic illness, developmental disability, drug/alcohol dependence, learning disability, mental illness, physical disability, sensory disability, none, other, prefer not to answer, do not know).

• 5. What is your gender? Check ONE only.

• 6. What is your sexual orientation? Check ONE only.

• 7. What was your total family income before taxes last year? Check ONE only.

• 8. How many people does this income support?