Welcome to Fireside Chat # 298

October 17, 2012 1:00 – 2:30 PM Eastern Time (Teleconference open for participants at 12:45 PM ET)

Part 2 Health Equity Tools Health Equity Impact Assessment Tools

Advisors on Tap: April MacInnes, HEIA Project Lead, Health System Strategy and Policy Division, Ontario

Ministry of Health and Long-Term Care Dr. Ingrid Tyler, Physician, Public Health Ontario

Dr. Ninh Tran, Associate Medical Officer of Health, Public Health Services , City of Hamilton Jo Ann Salci, Public Health Nurse, Social Determinants of Health, Public Health Services, City

of Hamilton

www.chnet-works.ca

A project of Population Health Improvement Research Network University of Ottawa

On Twitter? #heia12

Step #1 : Backup PowerPoint Presentation

Access, download, print… www.chnet-works.ca

Step #2 : Teleconference

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For assistance: animateur@chnet-works.ca

Housekeeping :

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Where are you located? Où habitez-vous? For those on Bridgit: √ on your province/territory √ sur votre province ou territoire

What Sector are you from? Put a √ on your answer (or RSVP via email)

/

Public Health Education/Research

Faculty/Staff/Student

Provincial /Territorial

Government/Ministry

Municipality

Health Practitioner Other

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Have you ever used a health/health equity impact assessment tool or audit?

Put a √ on your answer (or RSVP via email)

• Yes • No • Maybe?

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About the National Collaborating Centre

for Determinants of Health

• Our focus – Social determinants of health (SDH) & health equity

• Our audience – All organizations that make up the public health sector in

Canada

– The practitioners, decision makers and researchers who

work within public health

• Our work – Translate and share evidence to influence interrelated

determinants and advance health equity

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Visit us at www.nccdh.ca

@NCCDH_CCNDS

• Resource Library

• Health Equity Clicks: Community

• Health Equity Clicks: Organizations

• Networking events & workshops

nccdh@stfx.ca

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National Collaborating Centre for

Methods and Tools

• dedicated to improving access to, and use of, methods and tools that support moving research evidence into decisions related to public health practice, programs, and policy in Canada.

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How can NCCMT help you?

• Registry of Methods and Tools • Find over 100 resources related to knowledge translation

• Webinars • Learn more about the methods and tools available

• Online learning modules • Increase your understanding of Evidence-Informed Decision

Making (EIDM), practise you skills, earn a certificate

• Webcasts • Watch a video about an NCCMT product or a user story

• Workshops • Attend and learn more about EIDM with an NCCMT

facilitator

www.nccmt.ca 10

For more information about the NCCMT

or to access any of the resources noted

in these slides :

NCCMT website www.nccmt.ca

Contact: info@nccmt.ca

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Objectives of today’s webinar

• Provide you with background, rationale, relevancy and context of health equity impact assessments (HEIA)

• Demonstrate how the Ontario HEIA tool works

• Highlight the use of a health equity impact assessment tool at Hamilton Public Health Services

• Identify opportunities to integrate HEIA into your work and practice

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On Twitter? #heia12

Advisors on Tap

• April MacInnes, HEIA Project Lead, Health System Strategy and Policy Division, Ontario Ministry of Health and Long-Term Care

• Dr. Ingrid Tyler, Physician, Public Health Ontario

• Dr. Ninh Tran, Associate Medical Officer of Health, Public Health Services , City of Hamilton

• Jo Ann Salci, Public Health Nurse, Social Determinants of Health, Public Health Services, City of Hamilton

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On Twitter? #heia12

What is health equity?

April MacInnes, Senior Policy Advisor, Health Protection Policy Unit

Ontario Ministry of Health and Long-Term Care

Health equity is most often defined by the absence

of health inequities or disparities.

Health inequities or disparities are differences in the health outcomes of

specific populations that are “systemic, patterned, unfair, unjust, and

actionable, as opposed to random or caused by those who become

ill.”*

- Margaret Whitehead

*Margaret M. Whitehead, “The Concepts and Principles of Equity and Health,” 22(3) International Journal of Health

Services (1992): 429-445.

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Canada recognizes a number of key determinants

of health

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Why does Health Equity

Matter?

What does it mean to you?

Why Health Equity Matters: This map illustrates a 20 year

difference in life expectancy resulting from socio-

economic circumstances and poor access to healthcare

Within Hamilton,

the average age at

death is 67 years

of age in a lower

income

neighbourhood

and as high as 86

in a higher income

neighbourhood.

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Why Health Equity Matters - Incidence of Chronic Disease

increases as income decreases, regardless of disease and

age

The Power Study Social Determinants of Health and Populations at Risk

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Why Health Equity Matters: Average Household Income,

Toronto

Source: Glaizer, RH et. al. (eds.), Neighbourhood Environments and Resources for Healthy Living –A Focus on

Diabetes in Toronto: ICES Atlas.Toronto: Institute for Clinical Evaluative Sciences; 2007.

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Why Health Equity Matters: Concentration of Visible

Minority Populations, Toronto

Source: Glaizer, RH et. al. (eds.), Neighbourhood Environments and Resources for Healthy Living –A Focus on

Diabetes in Toronto: ICES Atlas.Toronto: Institute for Clinical Evaluative Sciences; 2007.

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Why Health Equity Matters: Age-Sex-Adjusted Diabetes

Rates, Toronto

Source: Glaizer, RH et. al. (eds.), Neighbourhood Environments and Resources for Healthy Living –A Focus on

Diabetes in Toronto: ICES Atlas.Toronto: Institute for Clinical Evaluative Sciences; 2007.

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Cost Implications of Inequity in Ontario

The impact of health inequities is large. If all Ontarians had the same health as Ontarians

with higher income… we estimated that 30 percent of hospitalizations for four

common ambulatory care sensitive conditions (ACSCs) (heart failure, chronic

obstructive pulmonary disease, diabetes, and asthma)— could potentially be avoided

if the hospitalization rates observed among adults living in the highest-income

neighbourhoods could be achieved across all neighbourhood income levels. These

findings illustrate the enormous opportunities to improve overall population health while

reducing health inequities in Ontario.

Source: Bierman AS, Shack AR, Johns A, for the POWER Study. Achieving Health Equity in Ontario: Opportunities for Intervention

and Improvement. In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 2: Toronto; 2012.

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How governments are addressing their legal and ethical

responsibility to integrate equity considerations into

planning and decision making

In Ontario, for example:

• In the Excellent Care for All Act, 2010 (ECFA) preamble, equity is defined as a

critical component of quality health care.

• The Ontario Public Health Standards (OPHS) 2008, explicitly acknowledges the work of public health in reducing health inequities. Specifically, the OPHS Foundational Standard directs boards of health to plan and deliver focused interventions to meet the needs of priority populations.

Addressing health equity can make a critical contribution to health system sustainability by reducing the incidence of costly and preventable illnesses

and related treatments

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How do we Improve Equity in the Health

System?

• Ensure equitable provision of high quality healthcare regardless of

circumstances and make sure that all individuals and communities get the

care they need

• We can do this by:

1. Building health equity into all health planning and delivery

doesn’t mean all programs are all about equity

but all take equity into account in planning their services and

outreach

2. Targeting resources or programs specifically to addressing

disadvantaged populations or key access barriers

looking for investments and interventions that will have the highest

impact on reducing health disparities or enhancing the opportunities

for good health of the most vulnerable

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What is Health Equity Impact Assessment

(HEIA)?

A User-Friendly Tool for the Integration of Equity

Considerations into Health System Delivery and Policy

HEIA provides an evidence-based, systematic method

to embed equity in planning and decision making

• HEIA is a practical tool for assessment and decision support

• It helps to address and anticipate any unintended health impacts that a

plan, policy or program might have on vulnerable or marginalized groups

within the general population.

• It builds on existing work and creates greater consistency and

transparency in the way that equity is being considered across the health

system.

• The end goal of HEIA is to achieve health equity and eliminate disparities in

health.

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Health Equity Impact Assessment (HEIA) helps users to align

services/policies/programs with need—enabling better health

outcomes

Source: Health Equity Audit: A Guide for the NHS, UK Department of Health 29

In this simplified example, there is a match between need and high

services/programs: a desirable situation

Source: Health Equity Audit: A Guide for the NHS, UK Department of Health 30

In this simplified example, those with the most need experience the

wrong type of service/policy: the undesirable “inverse care law”

Source: Health Equity Audit: A Guide for the NHS, UK Department of Health 31

HEIA tools have been adopted in a number of

jurisdictions

• Including Australia, New Zealand, the United Kingdom.

• HEIA is also used and advocated by the WHO.

• The Ontario HEIA tool was developed by MOHLTC in collaboration with the

province’s Local Health Integration Networks (LHINs) and a second edition

was recently launched with Public Health Ontario. It incorporates

international evidence as well as input gathered during regional pilots and

conversations with health service providers.

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The HEIA tool includes a template and a workbook, which provides

step-by-step instructions on how to complete the HEIA template.

Template & Workbook – core components of HEIA

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Using the HEIA 2.0 Tool

In collaboration with:

Dr. Ingrid Tyler, Public Health Physician

Public Health Ontario

Getting started…

• HEIA is typically conducted by the planning, policy or program team or staff person

(not an external/third-party)

• HEIA should be conducted as early as possible in all planning or policy

development to enable adjustments to the initiative before opportunities for change

become more limited.

• It should be a living document, with health equity impacts identified as the design of

the initiative evolves.

• HEIA can also be introduced retrospectively as a valuable evaluation tool to

examine whether individual initiatives are capitalizing on available opportunities to

improve equity or whether they may potentially result in widening health disparities.

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Where does HEIA fit?

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How long will it take me to apply the tool?

Among impact assessment methodologies there are

usually three broad categories of assessment,: • Desktop Assessment

– Information is gathered by the user from existing data and resources.

– Generally completed within a few days. • Rapid Assessment

– More detailed and involves more outreach and sourcing of information.

– Generally completed in a few weeks. • Comprehensive Assessment

– Involves more extensive research such as community and sector consultation.

– Complete assessment can take months. – Typically used for large scale, very complex

projects.

For additional information on

depth and scope of impact

assessment tools please see

these useful resources:

Center for Disease Control and

Prevention:

• “Health Impact Assessment”.

Available at http://www.cdc.gov/healthyplaces/hia.

htm and

• “Health Impact Assessment

Fact Sheet”. Available at http://www.cdc.gov/healthyplaces/fact

sheets/Health_Impact_Assessment_fa

ctsheet_Final.pdf

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Describe the initiative or decision that the HEIA is being applied to:

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Defining the Issue

• Be specific

• Clear objective for initiative

• Have project details available

• (eg. include a straw dog, process map, template, P&Ps)

• Articulate the change proposed (if any)

• (eg. person, place, time)

• Consider breaking down equity assessments into process,

access, materials

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Step 1. Scoping Consider and identify affected populations, including intersecting populations and

relevant SDOH

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Gathering the Information

• Consider a range of evidence sources, integrating mainstream

research evidence (such as a literature review) with broader

streams (such as community consultations and the working

experiences of program planners).

• Populations (those who are at risk and for whom public health

interventions may have a substantial impact at the population

level) may be identified through surveillance, epidemiological ,

research studies and experience

• Remember: Track your sources (eg. (author, date); (personal

communication; J. Doe (collegue/client));(program stats 2008-

2012); (personal/program experience); (assumption))

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Identifying Determinants of Health (DOH) and

Inequities

• Consider:

• Inequities in access to the fundamental determinants of

health (eg. income, housing, nutritious food, clean water…)

• Inequities in health status (eg. burden of disease, mortality,

quality of life)

• Inequities in the incidence of high risk behaviours

• Inequities in the access to and utilization of programs and

services

• Understanding the known or likely pathways that lead to the

inequities identified can assist in determining potential impacts

and mitigation measures.

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Step 2. Impact Assessment Identify and record the potential unintended (negative/positive) impacts

of the planned policy, program, decision

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Existing Programs

• You are likely to apply HEIA to an existing program, policy or

service perhaps at a time of service expansion, re-alignment or

review. In this case you can consider ways in which your

initiative is “currently affecting” populations and DOH,

including evaluation of the activities deliberately being done to

reduce inequities. In applying the HEIA to a current program

you must also consider potential unintended impacts of the

current program and any changes you may be considering of

implementing at the time of the review.

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Step 3. Mitigation Identify and record the best ways to reduce the potential

negative impacts and amplify the (unintended) positive impacts

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Mitigation Strategy Considerations Intervention Organization Alignment/collaboration

Modifications that support or

supplement a reduction in

health inequities:

Access to

programs/services

Priority group

participation in service

development

Program delivery or

policy implementation

Reducing barriers to

benefit from the

service

Additional supports

Communication plans

Modifications that support or

supplement a reduction in

health inequities:

Population health

assessment

Surveillance

Research and

knowledge exchange

Program evaluation

Staff education and

development

External

communications

Internal policies and

procedures

With complementary

initiatives that might help to

reduce inequities:

Internal to your

organization

Local agencies and/or

services

Local, provincial or

federal stakeholders

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Step 4. Monitoring Articulate how success could be measured for each mitigation

strategy you have identified.

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Initially,

• What are the range of options for measuring any reduction in

health inequities for each mitigation measure identified?

For Planning Purposes:

• What modifications (identified in Step 3) were implemented?

• What impacts, resulting from these modifications can you

observe or measure?

Monitoring

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Step 5. Dissemination Identify and record how results and recommendations for addressing

equity will be shared.

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Within your Unit, Organization and Externally

• Share your literature reviews

• Share evidence and data gaps identified

• Share proposed solutions to missing information

• Share facilitators to HEIA implementation and evaluation identified

• Share barriers to HEIA implementation and evaluation identified

• Share your strategies to overcome barriers

• Share case studies

• Share your evaluation

AND

• Celebrate your impact

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HEIA Website and Contact Information

English Site: www.ontario.ca/healthequity

French Site: www.ontario.ca/equite-sante

For further assistance, advice, questions or if you have comments, contact the HEIA team:

HEIA@ontario.ca

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Equity Impact Assessment: Implementation Considerations Based on: An Overview of the Application and Evaluation of Health Equity Planning and Assessment Tools Prepared by: Henok Amare, MPH Student, University of Toronto, placed at Public Health Ontario, Summer 2012

www.oahpp.ca

Description of Project

Jurisdictional scan of materials relating to the application and evaluation of health equity planning tools; includes case studies on the published and grey literature, as well as key informant interviews; excludes application in developing nations and non-English materials.

Objectives

• Identify factors that facilitate or hinder the application and uptake of health equity planning and assessment tools.

• Describe the current activities related to evaluation of the use of equity planning tools

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www.oahpp.ca

Health Equity Assessment Tool (NZ)

Equity Focused Health Impact Assessment (Aus.)

Tools Associated with Case Studies Found

HIA HEA EFHIA HEAT WOHIA

Health Impact Assessment (EU)

Health Equity Audit (UK)

HEIA

Health Equity Impact Assessment (ON)

Whanau Ora Health Impact Assessment (NZ)

www.oahpp.ca

Facilitators

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System Level Operational Level

- Leadership support

- Mandating the use of tool

- Incorporate into performance

management

- Setting inequality targets

- Availability of data and literature

- The timing of the application of the

tool

- The size and the skill set of

working committee

- Availability of resources and

support

- Prior relationship, trust and

common purpose among working

groups

www.oahpp.ca

Barriers

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System Level Operational Level

- Absence of facilitators

- “the nature of public health”

- Different views on heath equity among

working groups

- Conflicting evidence

- Non-objectivity of the tools

- Competing time pressure

- Lack of resources

- Capacity of the health sector

- The timing of application

- Conflicting interest between two health

sectors

- The reality of decision making process

www.oahpp.ca

Acknowledgements

• Brian Hyndman, Senior Planner, Public Health Ontario

• Jo-Ann Salci, Public Health Nurse, Hamilton Public Health

• Henok Amare, MPH Student, University of Toronto

• Christiane Mitchell, Research Assistant, Public Health Ontario

• Heather Manson, Chief, Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario

• MOHTLC HEIA Team

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The Equity Lens Tool Experience

at Hamilton Public Health Services

Dr. Ninh Tran, AMOH & Jo Ann Salci, PHN

General Background • Hamilton population:

520,000

• 18.1% or 89,676 living in poverty

• Hamilton Public Health Services (PHS) has 450 staff divided into 5 divisions

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SDOH Background

• 2009: SDOH Position Statement endorsed by Board of Health (BOH)

• 2009-present: Introductory SDOH Workshops for staff

• Spring 2011: SDOH Committee formed with representatives from each division; one SDOH PHN position filled

• Summer 2011: Process of selecting an Equity Tool began

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Selecting an Equity Tool

• Process completed by the

SDOH Committee

• Reviewed five tools

• Selected Equity Framework

drafted by Public Health

Ontario (PHO)

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Criteria for Selecting Tool

• Linkages to PH & Ontario Public Health Standards

• Preference for a provincial level tool vs. a locally created tool

• Potential for support from PHO in implementing tool

• Adaptability to existing processes in Hamilton PHS

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Adapting the Tool

• SDOH Committee met

over a two month period

to make adaptations

which included:

– format changes e.g.

creating worksheets in

table format

– language simplification

– enhancements, e.g.

glossary

– name: Equity Lens Tool

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Adapting the Tool

• We did not change:

– the overall intent of the original

PHO Framework

– the steps of the process

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Implementing the Pilot

• Four divisions identified a program

within their division to pilot the Equity

Lens Tool and provide feedback

• Pilot programs were asked

– to modify their program as determined

by the Equity Lens Tool, as feasible, and

– to include these modifications in their

operational plans

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Implementing the Pilot

November 2011

Distribution of the

tool and example

December 2011 Introductory session

January 2012

Support session for

managers

March 2012 Mid-term check-in

session

May 2012 Focus group session

June 2012 Debrief session

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Barriers to using the Tool

• Lack of current, local, disaggregated data regarding priority populations

• Time needed to complete the tool

• Pilot was an “add-on”

• The format of the tool

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Facilitators to using the Tool • Provision of an example of a

completed tool

• Consistent staff support from

SDOH Committee

• Support from PH Library

• Sharing at Check-in session

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Lessons Learned

• The process of using the Equity Lens

Tool assisted with the identification of

modifications

• Some modifications were simple and

others were more complex and costly

• The Equity Lens Tool process needs

to be integrated into other existing

processes at PHS

• The tool itself needs to be re-formatted

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Next Steps

• Use feedback from focus

group to modify the

implementation process

and the tool

• Create a toolkit to support

managers and staff with

their various roles

• Work to integrate equity

into existing PHS and City

of Hamilton processes

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QUESTIONS?

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What actions will you take as a result of your involvement in this

Fireside Chat? Here are some options

√ the options that apply to you… X those that you would not use…

1. I gained new information or insights about how I

(my organization) could use HIEA in my work.

2. I feel motivated to further explore this method.

3. I plan on using HEIA in my work.

4. Other

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Contact Us

National Collaborating Centre for Determinants of Health

www.nccdh.ca | www.ccnds.ca

nccdh@stfx.ca

Follow us on Twitter: @NCCDH_CCNDS

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