Policy Statement: Health Equity Impact Assessment

January 2020

INTRODUCTION

As a component of its 2016-2020 Strategic Plan,¹ CPHA committed to inspiring and motivating change in support of health equity, with the desired outcomes of having all policy alternatives and project activities founded on the principle of health equity, and that the Association become a leader in promoting policies and programs that address it. These outcomes are to be achieved by:

• applying an appropriate health equity impact assessment (HEIA) tool;
• addressing structural barriers to health equity in Canada; and
• applying the principles of health equity to its operations.

To meet the first output, CPHA staff and volunteers conducted an extensive search to identify a tool that could be adapted to the Association’s work. That search led to the Canadian Nurse’s Association (CNA) document entitled Social Justice … a means to an end, an end in itself (2nd Edition, 2010).² The CNA document was considered alongside the on-going work of the National Collaborating Centre for the Determinants of Health, a tool developed by CPHA to evaluate programs concerning sexually transmitted and blood-borne infections (STBBI),³ and the health equity impact assessment (HEIA) tool developed by the Ontario Ministry of Health and Long-term Care.⁴ Together, all of these resources were considered in the development of the methodology described here.

This tool has been developed to meet the requirements of CPHA, however it will remain in the public domain and accessible to those who wish to use it.  

The Association thanks all those volunteers who have contributed to the evaluation and selection of the tools that are foundational to this document.

CONTEXT

The World Health Organization describes health equity by noting that:

Others have explained that:

A distinction must be made between equality and equity. Equality indicates that all people receive the same level of support when faced by a situation, while equity directs that those most affected by the situation, and least able to overcome it, receive the bulk of the available resources for improvement, as they will have greater challenges in meeting their full health potential. This concept is also known as proportionate universalism.⁷ Further descriptions of the implications of health equity have been prepared by the National Collaborating Centre for Determinants of Health (NCCDH),^7,8 and Equip Health Care⁹ among others.

Core to health equity are the social determinants of health (SDH) and the influence that income, housing, adequate nutritious food, education, etc. have on one’s health status. As such, a HEIA on a public health challenge will often have to address issues that are beyond the confines of public health, and focus “upstream” on an array of socio-economic influences and outcomes that affect individuals, communities and populations.

Health inequities are more often observed among Indigenous Peoples, sexual and racial minorities, immigrants, people living with functional limitations when compared to the general population, and as a gradient of inequalities resulting from socio-economic status.¹⁰ Intersections exist among the affected populations, and their status may change through the life-course.

The result of these inequities include, among others:

• Reduced life expectancy and adjusted life expectancy;
• Increased infant mortality;
• Increased unintentional injury mortality;
• Increasing suicide mortality for those of lower economic and educational attainment and greater material and social deprivation;
• Lower self-rated mental health;
• Increasing mental illness hospitalizations for each decrease in neighbourhood income and education;
• Increased prevalence of smoking and exposure to second-hand smoke at lower socioeconomic status; and
• Increased household food insecurity for those of low socioeconomic status.

Health equity, social justice,* and the social and environmental determinants of health, are foundational to public health,¹¹ and can be found at various levels of society, including:

• Individual as demonstrated by individual circumstances and health characteristics, coupled with individual health literacy and practices;
• Community as demonstrated by the cultural and social context of the community and a person’s participation in them; and
• Systemic where political, social and economic environments, and health systems and services affect health equity.

Actions to address inequities can be taken at all three levels and are not mutually exclusive.

The topics on which the Association chooses to conduct policy analyses may or may not be directly linked to health equity.^† However, the Association is committed to developing policy alternatives, advocacy and programs that do not contribute to health inequities and, preferably, help alleviate them. As such, the following points should be considered at the onset of the analysis:

• Is the analysis being undertaken to address or develop options for addressing an inequitable situation?
• Are the steps being proposed or taken causing unintended positive or negative effects?
• If negative effects are being identified, what actions can be taken to remediate them?

The goal of improving health equity will be accomplished, in part, by routinely applying an appropriate HEIA tool during the development of policy alternatives and programs to assess their possible effects on health equity.

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* The goal of social justice is to develop the ability of people to realize their potential in the society in which they live. Classically, “justice” refers to ensuring that individuals both fulfil their societal roles and receive their due from society, while “social justice” generally refers to justice in terms of the distribution of wealth, opportunities and privileges within a society.
† The approach to identifying issues for development of policy alternatives, and the Association’s process for evaluating them can be found on CPHA’s website. Underlying the assessment are a series of questions that include: Does the topic fit within CPHA’s mission and vision? Does it align with the values and ethics of public health professionals? Is there an alignment with the functions and core competencies of public health? and Is there an evidence-base to support the work?

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DEVELOPING CPHA’s HEIA TOOL

The purpose of a HEIA tool is to:

• Help identify unintended health effects of decision-making;
• Support equity-based improvements in policy and programs;
• Embed equity into decision-making; and
• Build capacity to address and increase awareness of the issues.

A number of tools exist that meet these criteria.¹² The challenge was to identify and subsequently adapt a tool to meet the needs of CPHA. The methodology used for identifying and developing this tool is presented in Appendix 1.

As a result of the analysis, two tools that were developed by Canadian organizations were considered further.  These included:

• Ontario Ministry of Health and Long-Term Care (MOHLTC). The Health Equity Impact Assessment Tool and Workbook.¹³ This tool was developed for application to the health sector and provides a public health workbook, forms and detailed explanations of how to complete an assessment.
• Canadian Nurses Association. Social Justice … a means to an end, an end in itself.² This social justice gauge was developed to meet the needs of a non-governmental organization with interests that are similar, in part, to those of CPHA, places the discussion within a social justice perspective (a foundational consideration of public health), and provides a degree of flexibility and simplicity that better addresses the needs of CPHA.

The Canadian Nurses Association document was chosen as the basis on which to develop CPHA’s approach, but components of the OMHLC methodology were integrated as well, as were components of a CPHA-developed HEIA tool for the STBBI prevention community.³ 

In adapting a tool for CPHA’s purposes, the Association recognizes the role of public health in truth and reconciliation and is committed to fulfilling our commitments to Indigenous Peoples. This effort is both complimentary and integral to our health equity activities.

CANADIAN PUBLIC HEALTH ASSOCIATION’s HEALTH EQUITY IMPACT ASSESSMENT TOOL

Purpose

This HEIA tool should be used to inform the design and implementation of CPHA’s policy analyses and programmatic activities. It is not meant to determine whether an action is right or wrong, but rather to provide information concerning the effect of the current or proposed action on health equity. It provides a determinants of health lens with which to identify and mitigate negative effects of policy recommendations, while maximizing positive effects that align with a public health approach. It should:

• Support the assessment and decision-making process for an initiative;
• Identify and address unintended effects on populations;
• Enhance the consistency and transparency of CPHA’s work;
• Strengthen work that addresses the factors that may affect vulnerability; and
• Catalogue the decision-making process in a systematic way to assist with future initiatives.

Types of Analysis

Three levels of complexity are available, with the choice of level based on the scope and intent of the project. Each level of analysis will require research to identify the problems and possible methods of mitigating them, identify possible indicators to measure the effect, and possibly evaluate the effect to determine success. They include:

• Rapid or desktop HEIA – This form of assessment uses information that might be at hand or is collectable through searches of the grey and academic literature, and known service users based on existing interactions, interviews and usage statistics.
• Standard HEIA – This assessment builds on the desktop HEIA by incorporating greater outreach and sourcing of information from (scoping and systematic) literature reviews and community participation.
• Comprehensive HEIA – This assessment expands on the work required for the previous two forms by including more intensive and possibly original research, including engagement with communities and different sectors through consultations.

It is anticipated that most policy analyses will require a rapid/desktop approach, while project activities could benefit from a standard HEIA. The analysis should be conducted throughout the policy development/project lifecycle.

The Tool

The analysis consists of a five-step process, that is summarized in the framework presented in Appendix Two.

Step One – Scoping
This step includes a review of the policy, advocacy or program to determine if the current status has been considered from the perspective of its possible effect on the various components of the population. A guiding question for the analysis is:

“Does the policy/advocacy/program acknowledge that different individuals or groups occupy different positions of social advantage in society?”

Some of the groups or characteristics to consider include:

• Indigenous Peoples;
• Seniors and children;
• People living with functional limitations compared to the general population;
• Ethno-cultural differences;
• Newcomers and racialized communities;
• Homeless, marginally housed, and under-housed individuals;
• Linguistic considerations;
• Low income, under-employed, and unemployed;
• Rural, remote and inner urban communities;
• Sex and gender; and
• Sexual orientation (LGBTQ2S+).

Consideration may be required at the individual, community and systemic levels.

Step Two – Potential Impact
Efforts should be made to evaluate the possible effects that the proposals may have on the communities and individuals identified above. A guiding question for this assessment is:

“Does the proposal etc. acknowledge that unfair differences (inequities) exist in the opportunities or outcomes that are presented to different individuals or groups? Are these differences at the individual, community or systemic levels?”

Points to be considered include:

• The probability of an effect occurring;
• The nature and quality of evidence available for the assessment;
• The severity and scale of the difference; and
• Whether the effect(s) is/are immediate or latent.

Step Three – Mitigation
The purpose of this section is to identify whether efforts have been made to mitigate possible unintended negative effects or develop other approaches that may address any differences that are present. A question that could guide this analysis is:

“Are the root causes of the inequities recognized and are attempts made to address them?”

Factors to consider in this assessment include:

• Social factors;
• Environmental factors;
• Living environments;
• Availability of community and health services; and
• Structural and systemic factors.

Considerations to incorporate into this analysis include:

• How can barriers or inequitable situations be reduced or eliminated?
• How can the positive effects or benefits be maximized?
• What specific changes are required to meet the needs of vulnerable or marginalized people or communities?
• Can the population (key stakeholders) be engaged in the design and planning of the changes?
• How should systemic barriers to equitable access be addressed?
• How can recommendations be made to decision-makers?

Actions that might be considered include:

• Increasing participation of health seeking populations in planning and development of the initiative; and
• Determining whether the proposed work aligns with complementary projects of partners and stakeholders, both inside and out of the health sector.

Step Four – Monitoring
The purpose of this section is to identify short- and long-term indicators and evaluation protocols that permit analysis of the level of success resulting from the HEIA. Questions to consider include:

Short Term

• Has the proposal/policy etc. been accepted by the target organizations?
• Have any proposals concerning health equity been accepted?

Long Term

• Are indicators defined, and data collection methodologies developed and implemented that can be used to determine if the proposed mitigation strategies respond to the original need?

Step Five – Dissemination
Once the assessment is complete, efforts should be made to share the information with those most affected. A focusing question for this work is:

“Are the results of the HEIA to be made available?”

Points to consider include:

• Are the documents at an appropriate reading and comprehension level?
• Are the communications culturally appropriate?

For the majority of CPHA’s policy analysis and advocacy activities, the assessment might be limited to the first three steps. The Association, as a developer of policy alternatives and advocacy, does not have an implementation function, although it may monitor advocacy to determine its success and the effect on the health of the general population. However, project work may directly benefit from the inclusion of the latter two components of the assessment. In general, the overarching discussion should address the following considerations:

• How does or does not the proposal affect the health of individuals, communities or the population?
• Will the proposal negatively affect other people, communities and populations?
• What responsible actions are taken to mitigate harmful effects?
• Are the potential effects monitored and evaluated?
• Are the results disseminated?

APPENDIX ONE

Selection of a Health Equity Impact Assessment Tool for CPHA

A working group of volunteers from CPHA’s membership was established and assigned the task of reviewing the options available for HEIA tools that were identified in a recent publication¹² with a view to evaluating their applicability to CPHA’s work. Their assessment was guided by the following criteria:

• Is the purpose of the tool clearly defined?
• Does the tool clearly define health equity?
• Has the tool been applied to a public health practice situation or is it conceptual in nature?
• If the tool has been used, has it been formally evaluated?
• Is the intended audience for the tool aligned with CPHA’s activities? Is the tool applicable to the development of a broad spectrum of policy alternatives, programs, and advocacy activities?
• Is the tool easy to use and understand? Are there clear steps that guide its use?
• How much time and effort would be required by an analyst to conduct an assessment using this tool? (A high level of effort would involve collecting additional data and conducting analysis, while a low level would be to qualitatively apply a small number of criteria during the conventional level of analysis.)
• Can the tool be applied to the breadth of social and economic conditions that currently exist in Canada?
• Does the tool have the potential to advance health equity within CPHA’s work? Will the tool contribute to the identification of specific and potential actions to improve health equity?

Following the initial evaluation, the selected tool was reviewed for consistency with the work of the National Collaborating Centre for the Determinants of Health^7,8 and a recent tool developed by CPHA for use within sexually transmitted and blood borne infections (STBBI) activities.³ The tool was then reviewed and evaluated by a core group of staff for applicability to CPHA’s work and efficiency of use, before being submitted to the Public Policy Committee and Board of Directors for concurrence.

APPENDIX TWO

CPHA Health Equity Impact Assessment Tool

Type of Analysis: Desk Top Standard Comprehensive
Description of Initiative:
SCOPING Does the initiative acknowledge that different individuals or groups are affected?
Population			Effect
POTENTIAL IMPACT Does the initiative acknowledge that inequities exist in the opportunities or outcomes that are presented to different individuals or groups?
Unintended Positive Effect		Unintended Negative Effect		More information needed
MITIGATION Are the cause(s) of the inequities recognized and are attempts made to address them?
Factor Considered			Proposed steps to reduce or eliminate barrier
MONITORING Is it reasonable and feasible for CPHA to monitor the proposed actions?
What steps could be taken to monitor progress?
DISSEMINATION Will the results of the HEIA be provided to interested parties?
What steps will be taken to disseminate the information?

REFERENCES

1. CPHA, 2016. Strategic Plan 2016-2020. Canadian Public Health Association, Ottawa. 
2. CNA, 2010. Social Justice … a means to and end, an end in itself. 2^nd Edition – 2010. Canadian Nurses Association, Ottawa. 
3. CPHA, 2014. Sexually Transmitted and Blood-Borne Infections (STBBIs), including HIV, Health Equity Impact Assessment (HEIA) Tool. Canadian Public Health Association, Ottawa. 
4. OMHLC, 2008. Health Equity Impact Assessment (HEIA) Workbook: How to conduct HEIA. Ontario Ministry of Health and Long-Term Care. Toronto, ON.
5. World Health Organization, 2021. Health Topics: Health Equity. 
6. Whitehead, M, and Dahlgren, G. 2006. Concepts and principles for tackling social inequities in health: Levelling up Part 1. Geneva: World Health Organization. As described in: NCCDH 2013. Let’s Talk Health Equity. Antigonish, NS: National Coordinating Centre for the Determinants of Health, St. Francis Xavier University.
7. National Collaborating Centre for Determinants of Health. 2013. Let’s talk: Universal and targeted approaches to health equity. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University.
8. National Collaborating Centre for Determinants of Health. 2013. Let’s Talk Health Equity. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University.
9. EQUIP Health Care, n.d. Research to Equip Health Care for Equity. Toolkit.
10. Public Health Agency of Canada and Pan-Canadian Public Health Network, 2019. Key Health Inequalities in Canada: A National Portrait. Executive Summary.
11. CPHA, 2017. Public Health: A Conceptual Framework. Second Edition. Canadian Public Health Association, Ottawa.
12. Pauly, B., MacDonald, M., Hancock, T., O’Briain, W., Martin, W., Allan, D. et al., 2016. Health Equity Tools 2.0. University of Victoria, Victoria, BC.
13. Ontario Ministry of Health and Long-Term Care. 2013. Health Equity Impact Assessment Tool and Workbook.

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Policy Statement: Health Equity Impact Assessment