Advancing Efforts to Achieve Health Equity: Equity Metrics for Health Impact Assessment Practice
- Equity—“emphasizing that HIA is not only interested in the aggregate impact of the assessed policy on the health of a population but also on the distribution of the impact within the population, in terms of gender, age, ethnic background and socio-economic status, [or other attributes];”
- Democracy—“emphasizing the right of people to participate in a transparent process for the formulation, implementation and evaluation of policies that affect their life, both directly and through the elected political decision-makers.”
- The HIA process and products focused on equity.
- The HIA process built the capacity and ability of communities facing health inequities to engage in future HIAs and in decision-making more generally.
- The HIA resulted in a shift in power benefiting communities facing inequities.
- The HIA contributed to changes that reduced health inequities and inequities in the social and environmental determinants of health.
2. Experimental Section
3. Results and Discussion
- Three rated the level of difficulty as “very easy” or “just right”; two felt that the tool was “somewhat difficult” to use.
- Four respondents either “strongly agree” or “agree” with the statement that the metrics were useful for evaluating equity in HIA and/or proactively thinking about how to include equity considerations in HIA. One disagreed with the statement.
- Two respondents sought outside input from other team members or stakeholders when completing the metrics, and the same respondents also stated that they felt that too much time was involved in using the metrics.
- On average, it took respondents 1.9 h to evaluate an HIA using the metrics.
- our stated that they would use the metrics again. Three would recommend this tool to other HIA practitioners.
- Several projects were not able to score the more distal metrics, outcomes 3 and 4, which generally require more time to measure following the completion of an HIA.
- One reviewer felt that the metrics’ outcomes were multifactorial and unclear, and the tool privileged procedural approaches (community capacity building, consultation, and engagement).
- Another reviewer shared that the metrics were very specific to a comprehensive HIA, rather than other forms of HIA or Health in All Policies (HiAP) approaches.
- The potential uses of the Equity Metrics were expanded, as noted below;
- A paragraph was added to the introduction to the metrics describing the Working Group’s understanding of why community empowerment and power redistribution are critical for advancing equity through HIA practice; and
- Two metrics were revised to increase HIA practitioners’ understanding of the context of how the proposal came about and the implications for equity.
- Comprehensively evaluate the degree to which an HIA successfully incorporated equity, using all of the metrics and the many sources of data available (including document review and interviews with other stakeholders);
- Employ the entire set of metrics as a self-reflective exercise, taking a more cursory approach with limited or no consideration of additional sources of data;
- Compare several HIAs using a subset of the metrics to evaluate how those HIAs addressed specific aspects of equity;
- Evaluate an HIA in a group discussion, using the metrics as a discussion guide;
- Advance equity through meaningful engagement and improved dialogue between stakeholders and decision-makers;
- Aid in planning an approach (at the start of an HIA, during screening and scoping) to advancing equity;
- Push HIA practitioners to achieve process and outcome objectives and to validate the multiple benefits of an HIA outside of solely impacting the decision outcomes; and
- Create benchmarks in legislation related to HIA and HiAP.
|Metric||Description||Examples of High Scoring Activities/ Results|
|Outcome 1: The HIA Process and Product Focused on Equity|
|1.a||Proposal analyzed in the HIA was identified by and/or relevant to communities facing inequities||HIA practitioner asked community facing inequity what policy or plan they thought would have an impact on their health and proceeded with that as the HIA topic; practitioner asked community facing inequity what their main health concerns were, identified an HIA topic based on that, and gained community support for moving forward with the HIA; HIA practitioner analyzed the power, policy, and historical context of the decision to understand its relevance for equity|
|1.b||The HIA scope—including goals, research questions, and methods—clearly addresses equity||At least one of the primary goals of the HIA is to assess equity impacts, whether or not the term equity is used; research questions call for focus on communities facing inequities|
|1.c||Distribution of health and equity impacts across the population were analyzed (e.g., existing conditions, impacts on specific populations predicted) to address inequities; the HIA utilized community knowledge and experience as evidence||Quantitative assessment of disproportionate impacts (and potential cumulative impacts) on communities facing inequities included in the HIA; focus groups and/or surveys conducted in communities facing inequities|
|1.d||Recommendations focus on impacts to communities facing inequities and are responsive to community concerns||Key recommendations focus on impacts to those facing inequities, not just on improving overall population health; recommendations reflect community priorities|
|1.e||Findings and recommendations are disseminated in and by communities facing inequities using a range of culturally and linguistically appropriate media and platforms||Findings and recommendations translated into relevant languages and media formats (e.g., social media) and distributed; community leaders communicate findings on their own behalf to policy-makers and other community members|
|1.f||Monitoring and evaluation (M & E) plan included clear goals to monitor equity impacts over time and an accountability mechanism (i.e., accountability triggers, actions, and responsible parties) to address adverse impacts that may arise||During M & E, if negative equity impacts are found, decision-makers are responsible for implementing an improvement plan and reporting back to the community|
|Outcome 2: The HIA Process Built the Capacity and Ability of Communities Facing Health Inequities to Engage in Future HIA and in Decision-Making More Generally|
|2.a||Communities facing inequities lead or are meaningfully involved in each step of the HIA||For example, in the scoping stage this could include communities facing inequities having decision-making authority over the final Scope; in the assessment stage this could include utilizing community participatory methods|
|2.b||As a result of the HIA, communities facing inequities have increased knowledge and awareness of decision-making processes, and attained greater capacity to influence decision-making processes, including ability to plan, organize, fundraise, and take action within the decision-making context||HIA process involved leadership training for members of communities facing inequities; HIA conducted in such a way as to increase understanding of action research as a tool for community change; community members have a better understanding of how to analyze the power, policy, and historical context of decisions|
|Outcome 3: The HIA Resulted in a Shift in Power Benefiting Communities Facing Inequities|
|3.a||Communities that face inequities have increased influence over decisions, policies, partnerships, institutions and systems that affect their lives||A shift in culture both within institutions and among communities about what is considered evidence (i.e., community data or knowledge as “expert” and valid evidence); members of communities facing inequities get invited to have a seat at the decision-making table|
|3.b||Government and institutions are more transparent, inclusive, responsive, and/or collaborative||Change in institutional design, such as Community Advisory Boards, new offices of Health Equity, or integration of equity into all missions|
|Outcome 4: The HIA Contributed to Changes that Reduced Health Inequities and Inequities in the Social and Environmental Determinants of Health|
|4.a||The HIA influenced the social and environmental determinants of health within the community and a decreased differential in these determinants between communities facing inequities and other communities||Determinants of health that were the focus of the HIA are improved in communities facing inequities at a faster rate than in the general population|
|4.b (aspirational)||The HIA influenced physical, mental, and social health issues within the community and a decreased differential in these health outcomes between communities facing inequities and other communities||Health outcomes that were the focus of the HIA are improved in communities facing inequities at a faster rate than in the general population|
Conflicts of Interest
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© 2014 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/4.0/).
Heller, J.; Givens, M.L.; Yuen, T.K.; Gould, S.; Jandu, M.B.; Bourcier, E.; Choi, T. Advancing Efforts to Achieve Health Equity: Equity Metrics for Health Impact Assessment Practice. Int. J. Environ. Res. Public Health 2014, 11, 11054-11064. https://doi.org/10.3390/ijerph111111054
Heller J, Givens ML, Yuen TK, Gould S, Jandu MB, Bourcier E, Choi T. Advancing Efforts to Achieve Health Equity: Equity Metrics for Health Impact Assessment Practice. International Journal of Environmental Research and Public Health. 2014; 11(11):11054-11064. https://doi.org/10.3390/ijerph111111054Chicago/Turabian Style
Heller, Jonathan, Marjory L. Givens, Tina K. Yuen, Solange Gould, Maria Benkhalti Jandu, Emily Bourcier, and Tim Choi. 2014. "Advancing Efforts to Achieve Health Equity: Equity Metrics for Health Impact Assessment Practice" International Journal of Environmental Research and Public Health 11, no. 11: 11054-11064. https://doi.org/10.3390/ijerph111111054