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STBBI Health Equity Impact Assessment Tool


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  • 1. Welcome to the CPHA Webinar Sexually Transmitted and Blood Born Infections (STBBIs) Health Equity Impact Assessment We will be starting shortly. To connect to the Audio portion of the webinar: Toll Free: 1-877-394-5901 Local (Toronto only): 416-548-6023 Access Code: 741-9512
  • 2. Canadian Public Health Association (CPHA) Sexually Transmitted and Blood Born Infections (STBBIs) Health Equity Impact Assessment Tool
  • 3. • This webinar introduces the user to the STBBI Health Equity Impact Assessment Tool (HEIA) developed by the Canadian Public Health Association (CPHA) • This tool was developed as part of the larger project “ Core Competencies for STBBI Prevention” • Other Webinars are available to access the STBBI Core Competencies and associated tools About this webinar
  • 4. Overview • Project Overview and STBBIs in Canada • Overview of Health Equity • Development Process • STBBI HEIA Tool • Factors that Impact Vulnerability • Example Scenario • Tools • Other resources
  • 5. STBBIs in Canada • HIV is different than in most countries - in Canada HIV is not a generalized epidemic; rather it is concentrated in specific populations • HIV rates have been collected since 1985 with significant fluctuations but since 2008 rates have steadily been decreasing in the general population • In 2008 ; 2,619 positive tests were recorded compared to 2012 only 2,062 were reported (PHAC, 2012) • Conversely rates in certain populations and regions are rising (ie. First Nations in SK. People who inject drugs in Ottawa) • While HIV rates are decreasing, sexually transmitted infection data shows that rates have been increasing since 1997 ; chlamydia, gonorrhea and syphilis (PHAC, 2009) • Data collection for HIV in most regions includes a variety of demographic questions this is not the case for other STBBIs making it difficult to develop prevention strategies for targeted populations and regions
  • 6. STBBIs in Canada • In Canada, reported rates of chlamydia, gonorrhea and infectious syphilis have increased significantly among middle-aged adults (40-59 years) over the past decade • The lack of awareness about sexually transmitted infections(STIs) and their prevention may be contributing to the increasing reported rates • Chlamydia continues to be the most commonly reported STI in Canada. Reported rates of chlamydia infections have increased by 71.3% since 2000 • Example – Alberta - Chlamydia rates increased by 207% from 1999 to 2009, with over 13,000 cases reported in 2009. Many of those cases occurred in females with many younger than 25 years of age • Example - Ottawa - The incidence of chlamydia has more than doubled over 10 years in Ottawa and Ontario. Between 2009 and 2010 alone, the number of cases increased by 14% (from 2023 to 2314). Young people 15–29 years had the highest incidence of infection, particularly young women, who accounted for 54% (n=1242) of all reported cases in 2010
  • 7. Project Overview • In 2010 CPHA undertook a project: Preparing Health for New HIV Prevention Technologies: A Roadmap for Comprehensive Action in Canada • This project at looked public health's’ knowledge, information needs roles, opportunities, challenges and capacity to introduce and deliver NPTs in Canada • The project uncovered that front-line providers require and recommended more training and ongoing opportunities to address STBBIs • This in turn led to an online course – with an attempt to link the content to the original Public Health Core Competencies • Individual and organizational capacity to deliver STBBI prevention interventions in Canada to priority populations remains a challenge
  • 8. Project overview • Effective STBBI prevention requires engagement of many disciplines and sectors (public health, social services, mental health services, police services, social housing, youth services, shelters, etc.) • This led to the project “Developing STBBI Core Competencies” • A number of prevention tools currently exist but the STBBI Core Competencies are unique as they are infection specific not profession specific as other competencies are • During the course of the project no other such STBBI have been uncovered
  • 9. Project overview • Similarly, existing Health Equity Impact Assessments (HEIAs) are generic meant to be applied to any proposed policy, legislation or initiative and there was a need to develop a targeted tool for organizations • While many populations may face challenges or barriers to health some groups are significantly impacted by systemic factors that have a deeper impact on their opportunities to achieve equitable health and as a consequence may increase risk of STBBIs • The STBBI Health Equity Impact Assessment Tool has been designed as a practical tool with the goal of helping to ensure that front-line initiatives do their utmost to prevent any increase in existing health inequities and vulnerability to HIV/STBBIs
  • 10. Health Equity Health equity has been defined as: “ A means to reducing barriers in access to quality health care for all by addressing the health needs of people along the social gradient, including those most health disadvantaged…Health inequities or disparities are differences in heath outcomes that are avoidable, unfair and are related to social inequality and marginalization. Roots of disparities lie in the broader social and economic inequality and exclusion…” • Most equity or health equity approaches to health take into account the fact that social determinants of health (SDoH) have an impact on ones’ health and well being • What if anything is different for sexual health?
  • 11. Approach: “STBBIs for Core Competencies” resulted in the development of three tools: 1) STBBI Core Competencies 2) STBBI Health Equity Impact Assessment 3) Factors that Impact Vulnerability • CPHA worked with communities across the country and a national reference group to help inform the development of the tools • Core Competencies focus on individual skills ultimately enhancing organizational strengths; the STBBI HEIA is a practical organizational tool to embed equity into planning and programming and prevent an increase of existing inequities in populations that may be at risk of infections • FIV can be used as a stand alone document that provides examples of factors that impact STBBI vulnerability but is to be the companion resource for the HEIA to assess a proposed initiative
  • 12. Approach continued • An extensive literature was conducted to identify existing Health Equity tools, equity and health equity literature as well as participation in health equity webinars and attendance at the International Health Equity Conference in Quebec City in 2012 • Upon final review of the collected information ,for purposes of the project the most relevant tool to be used as a starting point was the Ontario Ministry of Health and Long Term Care’s Health Equity Impact Assessment Tool • The initial STBBI HEIA was loosely predicated on the Ontario tool, literature review and combination of existing tools • Initial edits were completed by an external editor and guided by project staff
  • 13. Approach continued The initial STBBI HEIA was introduced during community consultations and a table top exercise was conducted using a hypothetical proposed policy, program or service ( initiative) The goal of the exercise was to determine if organizations: - Found it useful - Found it was relevant - Found it user friendly The revised STBBI Tool was work shopped: - At the CPHA Conference - In a community partner organization with staff Further iterations of the Tool occurred and the Tool was translated for plain language and a final external edit occurred
  • 14. Responses Initial response was favourable and organizations and individuals felt that it was a Tool that could be incorporated into their work Examples of use: - work planning ; - evaluation and assessment plans to strengthen program and policy development; - guide strategic planning and strengthen internal capacity through team building; - Assist to develop and strengthen external community partnerships Clarifications: - It is not mandatory - It is to be used by organizations and individuals and adapted as necessary
  • 15. STBBI HEIA Tool For Today’s webinar we are highlighting the key sections of the STBBI HEIA The complete STBBI HEIA Tool consists of: - Introduction and background of Health Equity - HEIA principles - STBBI HEIA and Objectives - Factors that Impact Vulnerability (FIV) - Populations and Intersections - Detailed instructions to complete the STBBI HEIA, an adaptable template - An example scenario using FIV - Other Resources
  • 16. When do you conduct an HEIA?
  • 17. Types of HEIA’s There are three main levels of assessment 1. Rapid or desk top HEIA 2. Standard HEIA 3. Comprehensive HEIA Most assessments typically fall between the rapid or desk-top level and the standard level. The organization needs to determine what type will best suit their needs.
  • 18. STBBI HEIA Main Objectives • Support an organization’s assessment and decision-making during the development of STBBI prevention initiatives • The STBBI HEIA is a practical organizational tool to embed equity into planning and programming • The HEIA STBBI can assist to prevent an increase of existing inequities in populations that may be at risk of infections • The STBBI HEIA can assist organizations to develop equitable prevention programs, services or initiatives • The STBBI HEIA can support organizations to identify individuals that may be hidden in their communities
  • 19. • The STBBI HEIA provides specific examples of factors that impact one’s general risk of infection and also in specific populations • Lastly it can strengthen future work around the factors that may impact vulnerability to STBBIs
  • 20. Priority populations and Intersections • There are 8 priority populations considered most at risk of infection to HIV:  Aboriginal peoples (First Nations, Inuit, and Métis peoples)  Gay, bi sexual, 2-spirit, and other men who have sex with men  People who use substances including injection drugs (modified from people who use injection drugs)  People who have been or are currently in prison ( modified from People in prison)  Youth at risk  Women at risk  People from African, Caribbean, Black (ACB) countries, newcomers and other countries where HIV is endemic (modified from people from countries where HIV is endemic)  People living with HIV/AIDS  Other population groups, such as those without legal status in Canada or without health insurance; people without a family doctor.
  • 21. Populations continued • While it is important to be aware of the identified populations that are at increased risk of STBBIs it is also important for organizations to not feel constrained or that they are prescribed • The suggested populations are a starting point from which to examine their community and may raise awareness of people who may be living in the community that they were unaware of • Organizations can use the STBBI HEIA to identify who may be most at risk and how to tailor the initiative to best address the risks or vulnerabilities of people who may be most impacted by factors that may increase their risk • It is important to note that identifying other groups that may be impacted does not mean that an organization should serve all groups; it is to be aware for the potential of impacts within a population that they did not intend
  • 22. Factors that Impact Vulnerability (FIV) • Most HEIA’s examine communities through a DoH lens • While many approaches to STBBI prevention are built on a SDoH approach and is useful many of these tools look at how factors affect overall health and well-being and not their unique impact on risk of STBBIs • In the course of this project Factors that Impact Vulnerability specific to STBBI were identified, they are an evolution of the SDoH • Overarching FIV have been identified that impact all populations and have been further refined to specific populations • The list is a starting point and not meant to be exhaustive or definitive but to be used as companion resource to conduct assessing a proposed initiative
  • 23. DOH/SDoH FIV Population- specific FIV STBBI HEIA All health issues All populations HIV STBBI specific All populations HIV STBBI specific Population specific
  • 24. Examples of some overarching FIV that are applicable to all populations - Culture and faith affect a person’s decisions around prevention, medical care, treatment and intervention - Distrust of systems affects individual decisions to access health services, sexual health services and testing - Poor mental health can influence an individual’s decision to participate in high-risk activities such as substance use - Attitudes towards sexual and personal practices inform discussions between a service provider and service user - Perceptions about who is at risk of STBBIs may have an impact on information provided by service providers and risk triage in the health care system - Lateral violence and internalized homophobia may influence a person’s risk-taking behaviours and how they use community supports - Experiences of violence and trauma can be linked to risk-taking behaviours (Some populations experience higher rates of violence, such as First Nations, Inuit and Metis, refugee women, people with disabilities, sex workers, LBGTQ people)
  • 25. STBBI HEIA at a glance 1. Scoping a) Populations b) Factors that Impact Vulnerability 2. Unintended Impacts a) Positive b) Negative 3. Mitigation 4. Monitoring 5. Dissemination
  • 26. Sample Template NameofInitiative: Target Population(s): IntendedOutcomes: Step1. SCOPING Step2. UNINTENTIONALPOTENTIALIMPACTS Step3. MITIGATION Step4. MONITORING Step5. DISSEMINATION 1.a)Populations thatmaybeimpacted bytheinitiative: 1.b) FactorsthatImpact Vulnerability: 2.a)Unintendedpositive orneutralimpacts: 2.b)Unintended negativeimpacts: 2.c) Moreinformation needed: Waystoreduce potentialnegative impactsand amplifypositive impacts: Waysto measure successfor eachmitigation strategy: Waystoshare resultsand recommendations:
  • 27. Example Scenario • In a small to medium sized coastal town the local AIDS service organization administers and delivers the STBBI programs, services and prevention activities in the community • Local employment is limited and many people fly to the oil patch in Alberta for term work; typically two weeks in two weeks out • Recently the ASO has seen a significant increase of male clients who have tested positive for an STBBI • Some men have disclosed that although in hetero sexual relationships; they have had sex with other men, or with sex trade workers while away and not always practiced safer sex • Staff are concerned about the rising rates and want to determine how to reduce rates and raise awareness in the community about risk • In the past poster campaigns have worked targeting gay men; on buses, storefronts and tv ads. Primarily promoting condom use • The ASO has decided that since it worked in the past it may again and decide to re launch and target hetero men between 25 and 55
  • 28. Scoping 1 a) Populations 1. Male oil patch workers 2. Spouses, monogamous partners 3. LGBQQT 4. Women at risk 5. Youth 1b) Factors that Impact Vulnerability -Lack of confidentiality ( small community) -Possibility of increased use of substances (being far away and isolated from family, friends, new opportunities not available at home) -Unaware of sexual partners’ health/history -Spouses/partners: unaware of risk that may be present and continue to participate in barrierless sexual activity -LGBQQT: marginalized, unaware of risks -Women: unaware of risk, power dynamics -Youth: unaware of risk
  • 29. Unintended Impacts Remember these can also be neutral and more information may be needed Positive Workers: none Spouses/sexual partners: none LGBQQT: none Women: none Youth :none Negative Workers: Possibly fear of stigma of testing positive, fear of disclosing to partner(s) as a result will not get tested, fear of ramifications for relationships Spouses/sexual partners: possible increase of risk LGBQQT: May feel further isolated in the community, uncomfortable accessing services or testing at the ASO due to hetero male focus Women: further false sense of security; campaign doesn’t resonate Youth: Lack of awareness
  • 30. Mitigation • Engage members of the other identified populations to design a campaign that they feel would be relevant and effective • Focus groups, interviews with existing clients are a few examples of gathering feedback • Incorporate (if feasible) recommendations
  • 31. Monitoring examples The organization can: • Use client surveys or questionnaires with members of priority populations and those impacted by the initiative • Rates of new STBBIs • Process evaluation to ensure that frontline service providers, developers, planners, and decision-makers are integrating equity and the FIV into their processes and client interactions • Focus groups or interviews with affected populations to see if their vulnerability has increased or decreased since the implementation of the initiative.
  • 32. Dissemination examples • Present a case study at a conference, In a webinar or through another media vehicle • Do a literature review or evidence summary • Summarize your results for other frontline organizations in your community • Lead a workshop or other professional development activity based on your experience within your organization and with community partners (lunch and learn) • Post the results of your STBBI HEIA on your website
  • 33. Other HEIA Resources • Equity Lens in Public Health: Health Equity Tools 2013. Victoria, BC: University of Victoria. Available from • Health Equity On-Line Course: HEIA%29OnlineCourse.aspx • National Collaborating Centre for Determinants of Health: • Ontario Ministry of Health and Long Term Care; Health Equity Tool: • Wellesley Institute: The above links are examples of some Health Equity Tools available in Canada
  • 34. Thank You To access the tools go to For more information contact: