How to Advance Equity through Health Impact Assessments · 1. Ensuring the HIA process and products focus on equity. 2. Ensuring the HIA process builds the capacity of communities

HowtoAdvanceEquitythroughHealthImpactAssessments

APlanningandEvaluationFrameworkbytheSOPHIAEquityWorkingGroup

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TheFrameworkforEquityinHIAPracticeEquityisacorevalueofHealthImpactAssessment(HIA).1ManyHIApractitionersengageintheworktoaddresssystemic,avoidable,unjust,andunfairdifferencesbetweenpopulationgroupsinfactorsimportanttohealth.TheconceptualframeworkandtoolsinthisresourceemphasizebuildingcommunitypowerthroughthepracticeofHIAasakeyprocessforadvancingequity.Buildingcommunitypoweristheprocessbywhichcommunitiesgaincontroloverthefactorsthatshapetheirlives,includingaccesstoinformationandopportunity,decision-makers,andpolicy-making.Atruebalanceofpowerimpliesmorethantheparticipationofcommunities,butrathercommunityownershipofprocesses,planning,andactionsthatseektochangethedeterminantsofhealthequity.

Whyweneedtoemphasizebuildingcommunitypowertoadvanceequity.

Wemustachieveabalanceofpowerandfindwaystosharepowerequitablyinordertoadvancehealthequity,acknowledgingthatexistingpowerstructuresworktomaintainthestatusquoandfavorsomegroupsoverothers.Theunequaldistributionofpower—inallitsforms—isthesourceofinequitiesinsocialconditions.Researchoverthepasttwodecadesrepeatedlyshowstherelationshipbetweeninequitiesinsocioeconomicfactorssuchashousing,employmentandwages,education,andneighborhoodconditionsandinequitiesinhealthoutcomes.2,3,4,5Structural,institutional,interpersonal,andinternalizedformsofoppressionbasedonrace/ethnicity,class,gender,sexualorientation,abilityandothersocialconstructsleadtohealthinequitiesandareusedbythosewhobenefitfromretainingpower.

WhatistheroleoftheHIApractitionerincommunitypowerbuilding?

AnimportantroleoftheHIApractitioneristofacilitateaprocessthatleadstogrowingpoweramongcommunitiesfacinginequities.ConductingHIAwiththisasanexplicitgoalcanhelptobuildagencyincommunitiesfacinginequitiesandcontributetoinstitutionalreform,systemschange,andtheredistributionofpowerindecision-making.

Workingwithcommunityorganizinggroupscanhelpachievecommunityengagement.ItisachallengefortheHIApractitioneralonetoorganizetheengagementoftheimpactedcommunityduringanHIAduetovariousconstraints,includingtimelines,resources,leveloftrust,andgeographicscope.Workingthroughexistinggroupsthatdirectlyengagethosemostimpactedcanbeagoodalternative.Weconsiderworkingwithcommunityorganizinggroupstoreachthosemostimpactedbyadecisiontobeauthenticcommunityengagement.



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Wedefineacommunityorganizinggroupasanorganizationthat6:• Helpsacommunityidentifycommonproblemsorchangetargets,mobilizeresources,

anddevelopandimplementstrategiestoreachtheircollectivegoals.• Bringspeoplewhoidentifyasbeingpartofthecommunitytogethertosolveproblems

thattheythemselvesidentify.• Workstodevelopcivicagencyamongindividualsandcommunitiestotakecontrolover

theirlivesandenvironments.HIAPractitionersmusttakeintoaccountthedecision-makingcontext.BeforebeginninganHIA,apractitionershould:• Understandthefullcontextsurroundingtheproposalunderconsiderationandwhat

othersarealreadydoingtoadvanceequity.• ConsiderthepurposeoftheHIAandtheHIAprocesswithinthiscontext.• Takeadvantageofanyauthenticcommunityengagementandpowerbuildingthatmay

alreadybeoccurringaspartoftheoveralldecision-makingprocess—bygovernmentagenciesleadingtheprocess,communityorganizinggroups,orothers.

Contextandscaleinfluenceapractitioners’approachtoandlevelofcommunityengagement.Thepractitioner’sorganizationalcontextwillinfluencetheirabilitytofocusonbuildingcommunitypowerandadditionalshiftsinpublichealthpracticesmaybenecessarytosupportafocusoncommunitypowerbuilding.Engagingandbuildingpowerincommunitiesmostimpactedbyaproposalgetsincreasinglydifficultastheproposal’sscopeincreasesfromtheneighborhoodtothefederallevel.Forexample: • Practitionersatacommunity-basednon-profitoranacademicinstitutionmayhavethe

leewaytomakebuildingcommunitypowercentraltotheirHIAwork.• PractitionersinalocalpublichealthdepartmentmayfocustheirHIApracticeonlocal

decisionsandmayhaveorbeabletoformrelationshipswithcommunitiesthatwillbemostimpacted—engagingwiththesecommunitiesislikelyalreadyrecognizedtobewithintheirpurview.

• Practitionersinstateorfederalpublichealthagenciesmaybeabletoengagedirectlywithcommunitiesfacinginequities,butarelesslikelytohavedirectorsustainedrelationshipswiththemduetotheroletheseagenciesplayandthegeographicscaletheycover.Theymayhavemoredirectandsustainedrelationshipswithadvocacygroupswhorepresentcommunities.

Stateandfederalagenciescansupportcommunitypowerbuilding.WhilesomestateorfederalhealthagenciesmaybeabletobuildcommunitypowerthroughtheHIAprocess,othersmaynotbeabletodothisandcanplayalternaterolesby:• Providingtechnicalassistancetolocalhealthdepartmentsonhowtoengagethe

community.• ProvidingfundingtocommunityorganizinggroupstoengageinHIA.• Targetingresourcestoplacesorpopulationsfacingthegreatestinequities.• Strengtheninglanguageinpoliciesandfundingopportunitiesabouttherequireddegree

ofcommunityengagementforHIA.



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ComponentsofthePlanningandEvaluationFramework

Wehaveorganizedtheframeworkintofourequity-relatedcomponents:

1. EnsuringtheHIAprocessandproductsfocusonequity.2. EnsuringtheHIAprocessbuildsthecapacityofcommunitiesfacinghealthinequitiesto

engageinfutureHIAsandindecision-makingmoregenerally.3. UsingtheHIAprocesstoshiftpowertothebenefitofcommunitiesfacinginequities.4. UsingtheHIAtoreducedhealthinequitiesandinequitiesinthesocialand

environmentaldeterminantsofhealth.ThefollowingtoolscanhelpyouplanandevaluateanHIAwiththesefourcomponentsinmindfrombeginningtoend.

WaystoUsetheFramework

WeencourageHIApractitionerstoadvancethisconceptualframeworkbyusingtheHIAEquityPlanningToolandtheHIAEquityEvaluationTool:

• UsetheHIAEquityPlanningToolthroughouttheHIAprocess,tohelpplanyourapproachtoaddressingequity.

• EvaluateacompletedHIAusingtheHIAEquityEvaluationToolasaself-reflectiveexercisetoassesshowwellyourHIAbuiltcommunitypowerandimprovedhealthinequities.

• UsetheHIAEquityEvaluationToolaspartofamorethoroughHIAevaluationprocesswithmultipledatapoints.

• UsetheHIAEquityEvaluationTooltoinformpoliciesorlegislationrelatedtoHIA.[ForPolicymakers]

TheconceptsandpracticesreflectedintheHIAEquityPlanningToolandtheHIAEquityEvaluationToolwilllikelybeusefultoadvanceequityinotherprocesses,policies,andpracticesbeyondHIA—includingHealthinAllPolicies.WeencouragethoseoutsideoftheHIAfieldtoconsiderhowthesetoolscanbeadaptedfortheiruse.

NotesManyofthemetricsintheHIAEquityEvaluationToolcanbeevaluatedsoonaftercompletionofanHIAanddecision-makingontheissueinformedbytheHIA.However,itislikelythattheanalysisofthelattermetricswillrequireadditionaltime;itoftentakestimetorealizeshiftsinpowerorreductionsininequities.Inaddition,thelastmetric—improvementsinhealthoutcomes—isaspirationalgiventhatmanydiseasesaremultifactorialandthatcausallinksbetweentheHIA,policychange,andhealthoutcomesaredifficulttovalidate.

SeeGuidanceandBestPracticesforStakeholderParticipationinHealthImpactAssessments7formanyexamplesofmeaningfulengagementateachstep.

Screening

Todo Tips

q Partnerwithcommuni/esfacinginequi/estoiden/fytheproposalonwhichyouwillconductyourHIA.

Ifyoucan’tdothis,makesuretheproposalonwhichyouchoosetoconductyourHIAisrelevanttocommuni/esfacinginequi/es.

•  Askcommuni/esfacinginequi/eswhatissues,policiesand/orplansareaffec/ngtheirlivesandhealth.

•  Analyzethepower,policy,andhistoricalcontextoftheprac/ceorpolicyupforanHIA,tounderstanditsrelevancetoequity.

q Meaningfullyengagecommuni/esfacinginequi/esinScreening.

•  StructuretheScreeningprocesssothatcommunitymembershavetheopportunitytosubstan/allyshapedecisionsabouttheHIAtopic(e.g.,communitymembersholddecision-makingauthority).

Scoping

Todo Tips

q  Includeequity-specificgoalsinyourHIAScope.•  Includeatleastoneequity-specificgoal.•  Developresearchques/onsandmethodsthatwillreveal

thesizeandnatureofinequi/es.

q  Includeequity-specificresearchques/onsinyourHIAScope.

q  Includeequity-specificmethodsinyourHIAScope.

q Meaningfullyengagecommuni/esfacinginequi/esinScoping.

•  StructuretheScopingprocesssothatcommunitymembershavetheopportunitytosubstan/allyshapetheHIAgoals,researchques/ons,andmethods(e.g.,communitymembersholddecision-makingauthority).

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HIAEquityPlanningToolHowtoAdvanceEquitythroughHealthImpactAssessments

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Assessment

Todo Tips

q Analyzethedistribu/onofopportuni/esforhealthylivingandhealthoutcomesacrosspopula/ons.

•  Quan/ta/velyassessdispropor/onateimpactsandpoten/alcumula/veimpactsoncommuni/esfacinginequi/es.

•  Conductfocusgroupsand/orsurveyswithcommuni/esfacinginequi/es.

q Usethecommunityknowledgeandexperienceasevidence.

q Meaningfullyengagecommuni/esfacinginequi/es.•  Usecommunitypar/cipatorymethodstoinclude

membersofcommuni/esfacinginequi/esindatacollec/on,forexample.

Recommenda@ons

Todo Tips

q Ensureyourrecommenda/onsfocusonmi/ga/ngnega/veimpactsandmaximizingposi/veimpactsoncommuni/esfacinginequi/es.

•  Recommenda/onsshouldtargetimpactsoncommuni/esfacinginequi/esatthesame/measpromo/nghealthimprovementsfortheen/regreatercommunity.

•  Communitypriori/esshouldbereflectedintherecommenda/ons.

q Ensureyourrecommenda/onsareresponsivetotheconcernsofcommuni/esfacinginequi/es.

q Meaningfullyengagecommuni/esfacinginequi/es.

•  Structuretheprocessofdevelopingrecommenda/onssothatcommunitymembershavetheopportunitytosubstan/allyshaperecommenda/onsandpriori/es(e.g.,communitymembersholddecision-makingauthority).

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Repor@ng

Todo Tips

q Disseminatethefindingsandrecommenda/onsincommuni/esfacinginequi/es. •  Translatefindingsandrecommenda/onsintorelevant

languagesandmediaformats(e.g.,socialmedia).•  Traincommunityleaderstocommunicatefindingsand

recommenda/onsontheirownbehalftopolicymakersandothercommunitymembers.

q Supportmembersofcommuni/esfacinginequi/estodisseminatethefindingsandrecommenda/ons.

q Usearangeofculturallyandlinguis/callyappropriatemediaandplaUormstodisseminatefindingsandrecommenda/ons.

q Meaningfullyengagecommuni/esfacinginequi/es.•  Membersofcommuni/esfacinginequi/esshouldpresent

HIAfindingstothemediaanddecision-makers,forexample.

MonitoringandEvalua@on

Todo Tips

q Ensurethemonitoringandevalua/onplanassessequityimpacts. •  Iden/fythosewithposi/onalpowerwhomusttakeac/on,be

heldaccountable,andreportbacktothecommunityifnega/veequityimpactsarefoundduringmonitoringandevalua/on.

q Ensurethemonitoringandevalua/onplanincludeaccountabilitymechanisms.

q Meaningfullyengagecommuni/esfacinginequi/es.

•  Promotecommunitymemberdecision-makingauthorityandresponsibilityformonitoring.

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Opportuni@esforIncreasingHealthEquityinHIAPurposeandIntent

Opportuni@es Tips

q UsetheHIAprocesstobuildknowledgeandawarenessofdecision-makingprocessesamongcommuni/esfacinginequi/es.

•  Provideleadershiptrainingformembersofcommuni/esfacinginequi/esaspartoftheHIAprocess.

•  Buildunderstandingamongmembersofcommuni/esfacinginequi/esofac/onresearchandhowitcanbeusedtomakechange.

•  Buildtheskillsofcommunitymemberstoanalyzethepower,policy,andhistoricalcontextofdecisions.

q UsetheHIAprocesstobuildthecapacityofcommuni/esfacinginequi/estoinfluencedecision-makingprocesses,suchastheabilitytoplan,fundraise,andtakeac/onwithinthedecision-makingcontext.

q UsetheHIAprocesstoincreasetheinfluencecommuni/esfacinginequi/eshaveoverdecisions,policies,partnerships,ins/tu/ons,andsystemsthataffecttheirlives.

UsetheHIAprocessto:•  ShiYtheculturewithinins/tu/onsandamong

communi/essothattheyconsidercommunitydataandknowledgeasevidence.

•  Buildorstrengthenalliancesbetweenorganiza/onsthatareaddressinginequi/esintheirwork.

•  Createopportuni/esformembersofcommuni/esfacinginequi/estohaveaseatatdecision-makingtables.

q UsetheHIAprocesstochangegovernmentagenciesandotherins/tu/onssotheyaremoreawareofinequi/esandmoretransparent,inclusive,responsive,and/orcollabora/ve.

UsetheHIAprocessto:•  Changeagencyoversight,forexampletoincludea

CommunityAdvisoryBoard.•  Createnewgovernmentoffices,suchasanOfficeof

HealthEquity.•  Changethemissionofagovernmentagency.


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Outcome1:TheHIAprocessandproductfocusonequity

Metric1.a DataCollec@onMethods InterviewQues@ons

ProposalanalyzedintheHIAwasiden@fiedand/orrelevanttocommuni@esfacinginequi@es.

Ø  InterviewswithHIAprac//oner

Ø  Interviewswithcommunitypar/cipants

Ø  HIAReport

•  Whowasinvolvediniden/fyingtheproposalanalyzedintheHIA?•  Weremembersofthecommunitythatwouldbeimpactedby

theproposalinvolvediniden/fyingthisasapoten/alHIAtopic?•  Ifnot,didthecommunityhaveconcernsaboutissuesthatwere

relevanttothisproposal?•  Ifnot,howwasthisHIArelevanttocommuni/esfacing

inequi/es?Howwasthisdetermined?•  WasthisproposalofinteresttotheleadHIAprac//oner(s)andnot

ofinterestorrelevanttothecommunity?•  Wasananalysisconductedtounderstandhowthedecisionbeing

analyzedforthisHIAfitintothelargerpolicy-makingcontextandhowtheHIAcouldbeusedtoadvanceequitymorebroadly?

•  DidtheHIAprocessandproductsreflectanunderstandingofthepower,policyandhistoricalcontextofthedecisions?

Score(circleone) Examplesofhigh-scoringac@vi@es

NotatallTheproposalisnotofinterestorrelevanttothecommunity.

TosomeextentTheproposalwasiden/fiedbyHIAprac//onerasbeingrelevanttocommuni/esfacinginequi/es.

VeryTheproposalwaspriori/zedbycommuni/esfacinginequi/esasbeingimportantfortheirhealth.

²  HIAprac//oneraskedcommunityfacinginequitywhatpolicyorplantheythoughtwouldhaveanimpactontheirhealthandproceededwiththatastheHIAtopic.

²  HIAprac//oneraskedcommunityfacinginequitywhattheirmainhealthconcernswere,iden/fiedanHIAtopicbasedonthat,andgainedcommunitysupportformovingforwardwiththeHIA.

²  HIAprac//oneranalyzedthepower,policy,andhistoricalcontextofthedecisiontounderstanditsrelevanceforequity.

Notes

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HIAEquityEvalua@onToolHowtoAdvanceEquitythroughHealthImpactAssessments


Metric1.b DataCollec@onMethods InterviewQues@ons

TheHIAscope—includinggoals,researchques@ons,andmethods—clearlyaddressesequity.

Ø  HIAReport

OrØ  InterviewwithHIA

prac//onerandcommunitypar/cipantsifgoals,researchques/ons,andmethodsarenotincludedintheHIAreport

•  WhatweretheHIAgoalsandresearchques/ons?•  IftheHIAgoalsand/orresearchques/onsdon’tmen/onequity:did

thegoalsandresearchques/onsconsiderequity?Whichinequi/eswereaddressed?

•  Didyourresearchmethodsaddressequity?Ifso,how?


NotatallNo.

TosomeextentScopeincludesequity-relatedgoals,ques/ons,ormethods.

VeryScopeincludesequity-relatedgoals,ques/ons,andmethods.

²  AtleastoneoftheprimarygoalsoftheHIAistoassessequityimpacts,whetherornotthetermequityisused.

²  Researchques/onscallforfocusoncommuni/esfacinginequi/es.

Notes

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Metric1.c DataCollec@onMethods

Distribu@onofhealthandequityimpactsacrossthepopula@onwereanalyzed(e.g.,exis@ngcondi@ons,impactsonspecificpopula@onspredicted)[email protected]@lizedcommunityknowledgeandexperienceasevidence.

Ø  HIAReport


NotatallDistribu/onofimpactsnotassessedandcommunityknowledge/experiencenotincluded.

TosomeextentDistribu/onofimpactsassessedorcommunityknowledge/experienceincluded.

VeryDistribu/onofimpactsassessedandcommunityknowledge/experienceincluded.

² Quan/ta/veassessmentofdispropor/onateimpacts(andpoten/alcumula/veimpacts)oncommuni/esfacinginequi/esincludedintheHIA.

²  Focusgroupsand/orsurveysconductedincommuni/esfacinginequi/es.

Notes

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Metric1.d DataCollec@onMethods InterviewQues@ons

Recommenda@onsfocusonimpactstocommuni@esfacinginequi@esandareresponsivetocommunityconcerns.

Ø  HIAReportØ  InterviewswiththeHIA

prac//onerØ  Interviewswithcommunity

par/cipants

•  Didtherecommenda/onsfocusonequityimpactsand/or

impactstocommuni/esfacinginequi/es?Ifso,how?•  Didthecommuni/esfacinginequi/eshaveinputintothe

recommenda/ons?Ifso,canyoudescribetheprocessforcollec/ngandintegra/ngcommunityinput?

•  Doanyoftherecommenda/onsreflectspecificinputfromcommuni/esfacinginequi/es?Ifso,how?


NotatallRecommenda/onsdonotaddressissuesrelatedtoequity.

TosomeextentRecommenda/onsaddressequityimpacts.

VeryRecommenda/onsaddressequityimpactsandareresponsivetocommunityconcerns.

²  Keyrecommenda/onsfocusonimpactstothosefacinginequi/es,notjustonimprovingoverallpopula/onhealth

²  Recommenda/onsreflectcommunitypriori/es

Notes

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Metric1.e DataCollec@onMethods InterviewQues@ons

Findingsandrecommenda@onsweredisseminatedinandbycommuni@esfacinginequi@esusingarangeofculturallyandlinguis@callyappropriatemediaandplaZorms.

Ø  InterviewswiththeHIAprac//oner


Ø  Reviewofcommunica/ons(e.g.,summarydocuments,resul/ngmedia)

•  Werefindingsdisseminatedtothecommuni/esfacing

inequi/es?Ifso,how?Bywhom/whatformat?Doyouhaveanyideahowmanypeoplereceivedorreadthem?Howdoyouknowpeoplereceived/readthem?

•  Werethefindingscommunicatedinawaythatwasunderstandabletomanypeopleinthecommunity?Howdoyouknow?

•  Werecommuni/esfacinginequi/esinvolvedinthedevelopmentofdissemina/onproducts,ordetermina/onofkeyaudiencesandcommunica/onoutlets?Ifso,how?


NotatallNodissemina/oninorbycommuni/esfacinginequi/es.

TosomeextentDissemina/onoccursinorbycommuni/esfacinginequi/es.

VeryDissemina/onoccursinandbycommuni/esfacinginequi/eswithappropriatemediaandplaUorms.

²  Findingsandrecommenda/onstranslatedintorelevantlanguagesandmediaformats(e.g.,socialmedia)anddistributed

²  Communityleaderscommunicatefindingsontheirownbehalftopolicymakersandothercommunitymembers

Notes

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Metric1.f DataCollec@onMethods

Monitoringandevalua@on(M&E)planincludedcleargoalstomonitorequityimpactsover@meandanaccountabilitymechanism(i.e.,accountabilitytriggers,ac@ons,andresponsiblepar@es)toaddressadverseimpactsthatmayarise.

Ø  HIAreportØ  Monitoringandevalua/onplan(M&Eplan)


NotatallEquityimpactsnotincludedinM&Eplan

TosomeextentEquityimpactsincludedinM&Eplan

VeryEquityimpactsincludedinM&Eplanandaccountabilitymechanismsputinplace.

²  DuringM&E,ifnega/veequityimpactsarefound,decision-makersareresponsibleforimplemen/nganimprovementplanandrepor/ngbacktothecommunity.

Notes

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Outcome2:TheHIAprocessbuiltthecapacityandabilityofcommuni@esfacinghealthinequi@estoengageinfutureHIAsanddecision-makingmoregenerally.


Communi@esfacinginequi@esleadoraremeaningfullyinvolvedineachstepoftheHIA.

Ø  InterviewwithHIAprac//oner

Ø  Interviewwithcommunitypar/cipants

•  Werecommuni/esfacinginequi/esmeaningfullyengagedineachstepoftheHIA?Ifyes,canyoudescribehowforeachstep?Canyoudescribetherangeortypesofcommunitystakeholderswhopar/cipatedineachstepofthisHIA?


NotatallNoinvolvementofcommuni/esfacinginequi/es

TosomeextentCommuni/esfacinginequi/esmeaningfullyengagedinsome,butnotall,HIAsteps

VeryCommuni/esfacinginequi/esmeaningfullyengagedinallHIAsteps

²  SeeGuidanceandBestPrac7cesforStakeholderPar7cipa7oninHealthImpactAssessments(referencedabove)formanyexamplesofmeaningfulengagementateachstep.

²  Forexample,inthescopingstagethiscouldincludecommuni/esfacinginequi/eshavingdecision-makingauthorityoverthefinalScope;intheassessmentstagethiscouldincludeu/lizingcommunitypar/cipatorymethods.

Notes

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Outcome2:TheHIAprocessbuiltthecapacityandabilityofcommuni@esfacinghealthinequi@estoengageinfutureHIAsanddecision-makingmoregenerally.


AsaresultoftheHIA,communi@esfacinginequi@eshaveincreasedknowledgeandawarenessofdecision-makingprocesses,anda\ainedgreatercapacitytoinfluencedecision-makingprocesses,includingabilitytoplan,organize,fundraise,andtakeac@onwithinthedecision-makingcontext

Ø  InterviewwithHIAprac//oner

Ø  Interviewwithcommunitypar/cipants

•  What,ifanything,isdifferentforthecommuni/esfacinginequi/es,asaresultoftheHIA?Forexample,werethere:•  Anychangesinknowledgeorawarenessofdecision-making

processes?Pleasedescribespecifically.Whatdoyouseeorhearthattellsyouthereissuchachange?Specificexamples?

•  Anychangesintheabilityofthecommunitytoplan,organize,fundraise,ortakeac/ononfuturesimilardecisions?Whatdoyouseeorhearthattellsyouthereissuchachange?Specificexamplesofanystepstaken?

•  AsapartoftheHIAprocess,werecommuni/esfacinginequi/esmeaningfullyengagedtounderstandthepower,policy,andhistoricalcontextoftheproposeddecision?

•  Werethereanychangesinorganiza/onalcultureorprac/cesaroundcommunitymemberpar/cipa/onintheproposal/decisionthatwasthetargetofthisHIA?WhataboutfordecisionsbeyondthetargetofthisHIA?


NotatallNoincreaseinknowledgeorawarenessofdecision-makingprocesses

TosomeextentCommuni/esfacinginequi/esacquiredknowledgeandawareness

VeryCommuni/esfacinginequi/esacquiredknowledge,awareness,andgreatercapacitytotakeac/on

²  HIAprocessinvolvedleadershiptrainingformembersofcommuni/esfacinginequi/es

²  HIAconductedinsuchawayastoincreaseunderstandingofac/onresearchasatoolforcommunitychange

²  Communitymembershaveabekerunderstandingofhowtoanalyzethepower,policy,andhistoricalcontextofdecisions.

Notes

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Outcome3:TheHIAresultedinashi^inpowerbenefi@ngcommuni@esfacinginequi@es.


Communi@esthatfaceinequi@eshaveincreasedinfluenceoverdecisions,policies,partnerships,ins@tu@onsandsystemsthataffecttheirlives.

Ø  Interviewswithdecision-makers


Ø  Addi/onalcheck-insforupdatesover/mewithcommunitypar/cipants

•  Didcommunitymembershaveanincreasedinfluenceoverdecisions,policies,partnerships,ins/tu/ons,orsystemsthatwerethetargetofthisHIA?Ifso,howdoyouknow?Canyoudescribethechangeininfluence?•  Hascommunitypar/cipa/onindecision-makingincreased,asaresultofthis

HIA?Ifyes,howdoyouknow?Canyoudescribethatpar/cipa/on?•  Didtheins/tu/onsandcommuni/eschangetheirideasaboutwhatis

consideredvalidevidenceordata?Canyougiveexamples?•  Werecommunitymembersinvitedtopar/cipateinfutureplanningordecision-

makingeffortsonthisissue?•  Wastheremutuallearningthatresultedinaculturechangebothwithin

communi/esandins/tu/onsaboutconsideringcommunityconcernsindecision-making?

•  Didpar/cipa/ngcommuni/eshaveanincreasedabilitytoinfluencedecisions,policies,partnerships,ins/tu/ons,orsystemsthataffecttheirlivesbeyondthetargetofthisHIA?Ifyes,canyougiveexamplesofwheretheyhavebeenabletoincreasetheirsphereofinfluenceandpower?•  Forexample,werecommunitymembersinvitedtositonCommunityAdvisory

Boards,councils,workgroups,orothervenuesthatwouldgivetheminfluenceinotherspheresorsectorsbeyondthespecifictargetofthisHIA?

Score(circleone,ifdataisavailable) Examplesofhigh-scoringac@vi@es

NotatallNoincreasedabilitytoinfluence

TosomeextentIndividualsandgroupshadincreasedinfluenceoverthedecisionthatwasthefocusoftheHIA

VeryIndividualsandgroupshaveincreasedinfluenceoverabroadrangeofdecisionsandsystemsthataffecttheirlives

²  AshiYinculturebothwithinins/tu/onsandamongcommuni/esaboutwhatisconsideredevidence(i.e.,communitydataorknowledgeas"expert"andvalidevidence)

²  Membersofcommuni/esfacinginequi/esgetinvitedtothedecision-makingtable

Notes

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Outcome3:TheHIAresultedinashi^inpowerbenefi@ngcommuni@esfacinginequi@es.


Governmentandins@tu@onsaremoretransparent,inclusive,responsive,and/orcollabora@ve.

Ø  Interviewswithdecision-makers


Ø  Addi/onalcheck-insforupdatesover/mewithcommunitypar/cipants

Ø  Reviewofpublicdocuments

•  What,ifanything,isdifferentforgovernmentandins/tu/ons,asaresultoftheHIA?Werethereanychangesinadministra/veprac/cesthatmakethemmoretransparent,inclusive,responsive,orcollabora/vewiththecommunityfacinginequi/es?Ifyes,canyougivesomeexamples?•  Forexample,isaddressinginequi/esanewpartoftheins/tu/on’s

statedmissionorgoals?•  Wereanynewresourcesassignedtoaddresshealthorequity,suchasa

newoffice,staffperson,orprogram?•  Willtheins/tu/onassessandmonitorthestatusofhealthinequi/es

over/me,measuredbyindicatorscreatedwithinputfromcommuni/esfacinginequi/es?And,ifso,arethererequiredac/onsifinequi/espersist?

•  Wasthereanimprovementinhowaccessibledataistothecommunity?•  Iscommunityoutreachbytheins/tu/onbekernowthanitwasbeforethe

HIA?Whatisdifferent?Whatdoyouseeorhearthattellsyouitisbeker?


NotatallNoincreaseinins/tu/onaltransparencyorinclusiveness

TosomeextentIns/tu/onsmoretransparentandinclusive

VeryAsystems-levelchangehasbeenimplementedthatallowsforsustainedinfluence

²  Changeinins/tu/onaldesign,suchasCommunityAdvisoryBoards,newofficesofHealthEquity,orintegra/onofequityintoallmissions

Notes

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Outcome4:TheHIAcontributedtochangesthatreducedhealthinequi@esandinequi@esinthesocialandenvironmentaldeterminantsofhealth.

Metric4.a DataCollec@onMethods

TheHIAinfluencedthesocialandenvironmentaldeterminantsofhealthwithinthecommunityandadecreaseddifferen@alinthesedeterminantsbetweencommuni@esfacinginequi@esandothercommuni@es.

Ø  Monitoringofdatarelatedtothedeterminantsofhealth(e.g.,fromgovernmentagencies)uponcomple/onoftheHIA


NotatallNochangeindeterminants

TosomeextentCommuni/esfacinginequi/esexperienceimprovementsinhealthdeterminants

VeryCommuni/esfacinginequi/esrealizeimprovementsinhealthdeterminantsandclosethegaponinequi/es

²  DeterminantsofhealththatwerethefocusoftheHIAareimprovedincommuni/esfacinginequi/esatafasterratethaninthegeneralpopula/on

Notes

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Outcome4:TheHIAcontributedtochangesthatreducedhealthinequi@esandinequi@esinthesocialandenvironmentaldeterminantsofhealth.

Metric4.b DataCollec@onMethods

TheHIAinfluencedphysical,mental,andsocialhealthissueswithinthecommunityandadecreaseddifferen@alinthesehealthoutcomesbetweencommuni@esfacinginequi@esandothercommuni@es.

Ø  Monitoringofdatarelatedtothedeterminantsofhealth(e.g.,fromgovernmentagencies)uponcomple/onoftheHIA


NotatallNochangeinhealthoutcomes

TosomeextentCommuni/esfacinginequi/esexperienceimprovementsinhealthoutcomes

VeryCommuni/esfacinginequi/esrealizeimprovementsinhealthoutcomesandminimizehealthdispari/es

²  HealthoutcomesthatwerethefocusoftheHIAareimprovedincommuni/esfacinginequi/esatafasterratethaninthegeneralpopula/on

Notes

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KeyDefinitionsEquityAsMargaretWhiteheadwrotein1992:“Equityinhealthimpliesthatideallyeveryoneshouldhaveafairopportunitytoattaintheirfullhealthpotentialand,morepragmatically,thatnoneshouldbedisadvantagedfromachievingthispotential,ifitcanbeavoided.”PaulaBravemanaddsthat“equityinhealthistheabsenceofsystematicdisparitiesinhealth(orinthemajorsocialdeterminantsofhealth)betweengroupswithdifferentlevelsofunderlyingsocialadvantageordisadvantage,namelywealth,powerorprestige.”8

CommunitiesfacinginequitiesThistermwaschosentodescribecommunitiesthatarefacingimpactsofadecisionwithimplicationsforequity,andthatmayhavehistoricallyfacednegativeimpactsfrompreviousdecisions.Manyphraseshavebeenusedtodescribesimilarpopulationssuchasvulnerableorsociallydisadvantaged.Communityadvocateshavepointedoutissueswiththesephrases,includingthatcommunitiesthemselvesmaynotidentifywiththeseterms.HealthInequityvs.HealthDisparityPopulationswithinasocietycanhavedisparatehealthoutcomes.Somedisparitiesaretobeexpected—arthritis,forexample,ismorecommonamongseniors.Thesedifferencesarecommonlycalledhealthdisparities.

Otherdifferences,mostoftenbetweenpopulationsthathavevaryinglevelsofpowerandaccesstoopportunity,maybesystemic,avoidable,unfairorunjust.Forexample,peopleinalow-incomecommunityofcolorinonepartofacitymayhavelowerlifeexpectancythanmoreaffluentpeopleinaseparatepartofthesamecity.Thesedifferencesarecommonlycalledhealthinequities.PowerPowerisdefinedasthepotentialtoshapeourlivesandtheworldaroundus.Therearemultipleformsofpower,9including:

• Influencingdecision-makingdirectlybyorganizingpeopleandresources.• Influencingwhatisonthepoliticalagendabybuildinganinfrastructureof

organizations.• Influencingideologyandworldviewbychangingthepublicnarrative.

CommunityengagementCommunityengagementistheprocessofincludingmembersofcommunitiesfacinginequitiesandothercommunitiesintheHIAprocess.Engagementcantakevariousforms:informing,consulting,involving,collaborating,orempowering.10



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AboutThisFrameworkEquityisacorevalueofHealthImpactAssessment(HIA).11ManyHIApractitionersengageintheworktoaddresssystemic,avoidable,unjust,andunfairdifferencesinfactorsimportanttohealthbetweenpopulationgroups.Therearemanycompellingmoral,economic,andhealthargumentsforprioritizingandincorporatingequityintoHIApractice.HIApractitionersandevaluatorshavefoundthatmanyHIAscouldbeimprovedbytakingamoreintentionalandthoroughapproachtoaddressingequityimpacts12andhavesoughttoremedythisthroughnewtools13andguidance.1415AclearframeworkforplanninganHIAandevaluatingthedegreetowhichanHIAsuccessfullyincorporatedequityhasnotbeenavailable,thoughsuchaframeworkcouldhelpguideHIApractitionersandevaluators,aswellasequityadvocates.SuchaframeworkwouldalsoprovidemoredetailtotheHIAPracticeStandards16regardingtheincorporationofequityintoHIApractice.Withthisinmind,theSOPHIAEquityWorkingGroupcollaboratedinaconsensusprocesstodevelopEquityMetricsforHealthImpactAssessment,Version1,whichwasreleasedin2014.Manyoftheoriginalauthorsreconvenedin2016tosolicitinputfrompractitionersandotherusers,andthenincorporatedthisfeedbacktoevolvetheframeworkpresentedhereasVersion2.Formoreinformationpleasecontactanyoftheauthors:EmilyBourcier:[email protected]:[email protected]:[email protected]:[email protected]:tina@raimiassociates.comHowtoAdvanceEquityThroughHealthImpactAssessments:APlanningandEvaluationFrameworkwasdevelopedwithfundingfromtheHealthImpactProject,acollaborationoftheRobertWoodJohnsonFoundationandThePewCharitableTrusts.



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References1QuigleyR,denBroederL,FuruP,BondA,CaveB,andBosR.(2006).HealthImpactAssessment,InternationalAssociationforImpactAssessment,InternationalBestPracticePrinciples.SpecialpublicationseriesNo.5.Availableat:http://www.iaia.org/publicdocuments/special-publications/SP5.pdf2Krieger,N.(1994).Epidemiologyandthewebofcausation:Hasanyoneseenthespider?SocialScience&Medicine,39(7),887-903.3Marmot,M,&Wilkinson,RG(Eds.).(1999).Socialdeterminantsofhealth.Oxford,U.K.:OxfordUniversityPress.4Williams,DR,Costa,MV,Odunlami,AO,&Mohammed,SA.(2008).Movingupstream:Howinterventionsthataddressthesocialdeterminantsofhealthcanimprovehealthandreducedisparities.JournalofPublicHealthManagementandPractice,14(Suppl),S8-17.5CommissionontheSocialDeterminantsofHealth.(2008).Closingthegapinageneration:Healthequitythroughactiononthesocialdeterminantsofhealth.FinalReportoftheCommissiononSocialDeterminantsofHealth.Geneva,Switzerland:WorldHealthOrganization.6Minkler,M.(2012).CommunityOrganizingandCommunityBuildingforHealthandWelfare.NewJersey:RutgersUniversityPress.7StakeholderParticipationWorkingGroupofthe2010HIAintheAmericasWorkshop.(2011).GuidanceandBestPracticesforStakeholderParticipationinHealthImpactAssessment.Oakland,CA.Availableat:https://sophia.wildapricot.org/resources/Documents/guide-for-stakeholder-participation.pdf8Braveman, P, and Gruskin, S. (2003). Defining equity in health. J Epidemiol Community Health 2003; 57:254–258.9Healey,RandHinson,S.PowerandSocialChange.Availableat:http://www.strategicpractice.org/system/files/power_and_social_change.pdf10InternationalAssociationforPublicParticipation(2007).IAP2SpectrumofPublicParticipation.Availableat:http://c.ymcdn.com/sites/www.iap2.org/resource/resmgr/imported/IAP2%20Spectrum_vertical.pdf11QuigleyR,denBroederL,FuruP,BondA,CaveB,andBosR.(2006).HealthImpactAssessment,InternationalAssociationforImpactAssessment,InternationalBestPracticePrinciples.SpecialpublicationseriesNo.5.Availableat:http://www.iaia.org/publicdocuments/special-publications/SP5.pdf12Harris-RoxasB,SimpsonS,andHarrisE.(2004).EquityFocusedHealthImpactAssessment:Aliteraturereview.Sydney:CHETREonbehalfoftheAustralasianCollaborationforHealthEquityImpactAssessment.Availableat:http://www.healthimpactproject.org/resources/document/Harris-Roxas_B_2004_Equity_Focused_HIA.pdf13See,forexample:Harris-Roxas,BF,HarrisPJ,andKempLA.(2011).Arapidequityfocusedhealthimpactassessmentofapolicyimplementationplan:AnAustraliancasestudyandimpactevaluation.IntJEquityHealth.10:6.14HellerJ,MalekafzaliS,TodmanL,andWierM.(2013).PromotingEquityThroughthePracticeofHealthImpactAssessment.Availableat:http://www.humanimpact.org/component/jdownloads/finish/9/29415TheSOPHIAEquityWorkgroup(2016).CommunicatingAboutEquityinHealthImpactAssessment:AGuideforPractitioners.Availableat:https://sophia.wildapricot.org/resources/Documents/Communicating_Equity_in_HIA_Final.pdf16BhatiaR,FarhangL,HellerJ,LeeM,OrensteinM,RichardsonMandWernhamA.(2014).MinimumElementsandPracticeStandardsforHealthImpactAssessment,Version3.Availableat:https://sophia.wildapricot.org/resources/Documents/HIA-Practice-Standards-September-2014.pdf