Learn how organizations are applying the HEIA tool.
Developing Ontario’s Dementia Strategy with a Health Equity Lens
Health Nexus' Best Start Resource Centre (BSRC)
York Region Public Health
Nucleus Independent Living
Health Nexus’ Health Leadership Award
The 2017 Ontario Budget announced a new dementia strategy, along with an investment of more than $100 million over three years. The strategy improves access to high quality care for the more than 194,000 people living with dementia in Ontario and their care partners.
One of the guiding principles of the dementia strategy is to help people live well with dementia, regardless of their social circumstances. This principle guided us to consider carefully the array of needs of people with dementia—from community to community. To deliver truly better services to Ontario’s diverse population, we recognized we needed a framework to approach the multiple and intersecting needs of people with dementia. We decided on the Health Equity Impact Assessment (HEIA).
How was the HEIA done?
The HEIA workbook was a useful resource for mapping out the team’s work on the dementia strategy during the engagement and the strategic development stages. Once the team developed the engagement plan and timelines using a health equity lens, the guidance in the workbook was equally valuable for enabling the team to think thorough how the proposed strategy would impact people with dementia. We considered the intersection of having dementia with the social determinants of health and mapped our proposed strategic pillars against potential impacts of our strategy. We also thought about how to mitigate barriers and provide added support to vulnerable and hard to reach populations.
What was the influence of the HEIA work?
The HEIA tool includes five steps. Step 1 (scoping) helped us consider how dementia intersects with populations (e.g. urban Indigenous, LGBTQ seniors, rural Francophone communities, etc.). Step 2 (potential impacts) broadened our thinking on whom we could reach with our services and who would remain out of reach if we didn’t consider barriers to access, such as lack of information, mono-lingual supports, stigma, and social isolation. Step 3 (mitigation) brought us closer to creating a single strategy that was flexible enough to support many different communities, while Steps 4 and 5 (monitoring, and dissemination) allowed us to keep our stakeholders engaged throughout the process and know the value of their feedback from start to finish.
The HEIA process established equity as a critical component of the dementia strategy development from the start. Its more long-lasting impact was to put a consistent health equity lens on our day-to-day work. Rather than a one-off, HEIA helped us embed health equity as a principle to guide our thinking through each stage of our project.
Best Start Resource Centre (BSRC) is a maternal, newborn and early child development resource centre run by Health Nexus in Ontario. It supports service providers across the province to enhance the health of expectant and new parents, newborns, and young children.
A Healthy Start for Baby and Me is a prenatal and postpartum resource created by the centre. It’s based on a resource developed by Toronto Public Health and is designed for pregnant women and new parents who have difficulty reading due to literacy level or language. Public health nurses and other prenatal educators provide Healthy Start to participants in prenatal classes. It’s available in English and French.
BSRC completed a HEIA on Healthy Start to identify and address unintended positive and negative health impacts of the resource. This HEIA was developed by a student as a placement project under the supervision and assistance of Health Nexus staff.
How was the HEIA done?
The centre interviewed staff and performed a population group analysis to identify priority populations for the HEIA. Based on this analysis, four key population groups were chosen as the focus of the HEIA among the pregnant women, partners and new parents who are the target audience of the resource. The priority populations were people:
- with low incomes (e.g. unemployed or under-employed)
- living in rural, remote or inner-urban areas (e.g. parents or families living in geographic isolation, under-serviced areas, and etc.)
- who are not heterosexual (e.g. who identify as lesbian, gay, bisexual, etc.) or not cis- gender (e.g. trans, genderqueer, etc.)
- who lack social supports.
BSRC then conducted interviews and an online survey with health intermediaries in Ontario, such as public health nurses and prenatal educators, to identify unintended positive and negative health impacts of the resource.
What was learned?
The HEIA identified several unintended positive impacts of the resource, including that clients shared knowledge from the resource with their friends and family and, thereby, felt more empowered. Unintended negative impacts of the resource included potential for further marginalization and that it may compromise participants’ likelihood to seek additional care.
What mitigation strategies were identified?
Using the HEIA, the centre identified three categories of mitigation strategies:
- creating alternative formats of the resource (such as a video version, a mobile-friendly version, or a change in layout)
- translating the resource into additional languages
- increasing inclusivity of content (e.g. more representative pictures)
As a result, BSRC revised the resource to update the layout and content. For example, new pictures were included that increased representation of lower income populations and a diversity of sexual orientations.
HEIA is a valuable and practical framework for identifying ways to revise a resource to improve its health equity impacts. The process of completing a HEIA is straightforward. As in this case, a student can feasibly, develop a HEIA as a placement project, provided that the student has enough access to staff in the program.
York Region Public Health is one of Ontario’s 36 public health units. It delivers a range of programs and services to prevent disease, protect the health and safety of residents, and promote healthy lifestyles and environments.
The health unit completed a Health Equity Impact Assessment (HEIA) during the planning stage of a promotional campaign for their First Dental Visit initiative. This initiative promoted the recommendation that children have their first dental visit by age 1.
Why and how was the HEIA carried out?
The planning team for the First Dental Visit initiative carried out a HEIA to identify potential unintended health equity impacts of the campaign. They thought it was critical because poor oral health outcomes are associated with lower socioeconomic status and oral health care is not publicly funded in Ontario.
The team collected evidence for their HEIA from various sources, including:
- World Health Organization,
- Public Health Agency of Canada, and
- journal articles.
In addition, the health unit’s staff also contributed their practice knowledge and observations to the evidence.
What was the influence of the HEIA?
From the start, the planning team recognized that variations in health literacy would be key to potential health equity impacts because their project was a public health promotional campaign. By initiating a HEIA early, they were able to embed health equity considerations into the project’s foundation. The evidence they gathered indicated that lower health literacy was associated with lower socioeconomic status in Canada. The team, therefore, identified low income families as a priority population in their HEIA.
In steps two and three of the HEIA tool, the planning team looked at how the promotional campaign could positively or negatively impact the health literacy of low income families in regards to the First Dental Visit initiative. They came up with strategies for mitigating potential negative health equity impacts on their priority population. In each of their working group meetings, they considered how their campaign could help this population understand and act on the oral health information that the campaign would present. The planning team decided to develop promotional material to reduce barriers associated with low health literacy and to create a dissemination strategy tailored to reach low income families.
The planning team found that their HEIA was an opportunity to learn more about health equity and health literacy. In addition, the HEIA was completed through a consultation with the Health Equity Program. Health equity staff guided the process, while the dental program provided content knowledge. The planning group thought this collaborative process made their HEIA a rich and rewarding experience.
Nucleus Independent Living, which helps adults live at home independently in Toronto, Mississauga and Halton, conducted a HEIA on its Supports for Daily Living (SDL) Program. This program assists seniors who want, and are able, to continue living in their own homes. It provides 24-hour practical assistance with essential activities that a senior cannot perform because of physical limitations or health conditions.
Nucleus conducted the HEIA on their SDL program because it is their largest program and the seniors it serves are at high risk. It saw the HEIA as a good way to dig deeper and explore potential equity barriers in the program and, if they were found, come up with methods to address them.
How was the HEIA carried out?
To complete the HEIA, Nucleus formed a multidisciplinary committee, which met monthly. This committee went through the HEIA template and answered the questions in the columns under the determinants of health. It then selected two determinants in the tool to focus on: “income and social status” and “personal health practices and coping skills”. The committee explored the unintended consequences of the program and identified indicators that the organization could monitor. The discussion at each meeting was also an opportunity to learn more about health equity.
What was the influence of the HEIA?
After completing the HEIA, Nucleus implemented health equity awareness training as part of its orientation for new hires and at staff meetings. Using the HEIA tool also increased awareness of the social determinants of health among staff and impacted service delivery at the individual level. Nucleus implemented the eight core health equity questions within the Supports for Daily Living program, as well as its Attendant Outreach program. Next, Nucleus aims to analyze the monitoring data and use the findings to address additional equity barriers.
Although its initial aim was just to complete the tool, the Nucleus HEIA committee soon found that the HEIA could be a framework for learning more about health equity and for sharing this learning with teams within the organization. “I would suggest that it’s not only about the outcome (that is, a completed tool or template), but more importantly it’s about the process,” said Carole Beauvais, Executive Director of Nucleus. This process at Nucleus helped increase awareness of the social determinants of health among team members who interact with clients on a daily basis in their homes. Frontline staff can now use this awareness to recognize more how the social determinants of health impact Nucleus’s clients and, then, take action.
Health Nexus’ Health Leadership Award honours leaders who have an impact on the health and wellbeing of their community. It seeks to: increase the profile and exposure of leaders and their work; increase opportunities to learn from innovative work; and increase awareness about the importance of the determinants of health. An HEIA was conducted on the Communications Stream of the program.
Data for the HEIA was gathered through:
- Interviews with Team Leads
- Focus groups with the Leadership Award team
- Interviews with key informants representing the population groups identified in Step 1 of HEIA
Populations of concern and unintended impacts:
Although many population groups were identified by the team members at Health Nexus, due to limitations on time, the following three population groups were chosen as a the focus of the HEIA:
- Aboriginal people (outside of Ontario)
- Canadians with disabilities
- Low income groups
Potential positive unintended consequences that were identified include: raised profile for the award recipient; building connections with diverse communities; and intersectoral reach and collaboration. Potential negative unintended consequences include: populations groups not represented are not being heard from, risking of the Award creating an “echo chamber” of like groups; minimal contact with non-successful applicants could have negative implications.
- Offer different application methods or platforms such as interviews and video submissions. Consider accessibility for those who are Deaf/hard-of-hearing, who have mobility issues, who are visually impaired, or who lack Internet access.
- Use targeted communication strategies to reach different populations (for example, reaching youth through a Facebook campaign).
- Build relationships with priority groups.
One mitigation strategy implemented:
The language used on the nomination form was simplified. The forms were edited for plain language and for appearance. A telephone call from the Award screening team to all nominators was added to the nomination process. During this call nominators were surveyed about their experience with the nomination process and were asked to offer ideas for further improvement.
This case study demonstrated that a modified approach to HEIA – converting the formal tool to focused interview questions – can work well in some circumstances. Discussing the interview questions provided participants in the process with an opportunity to consider larger issues than can be considered within the confines of the table in HEIA template. As an awareness tool, HEIA process was useful: the discussions did broaden the conversation and raise awareness of potential barriers and inequities even internally among very experienced people. This modified approach was likely successful because HEIA was limited to a small, defined piece – the Communications Stream – rather than the entirety of the Award.