If you want to conduct a health impact assessment, or even if you’re just interested in learning more, the case studies below can help.
The RNs and health experts in the following scenarios have made a difference by acting on the deep-rooted causes of health problems. They looked at the strengths and weaknesses of individuals, families and communities and used that information to influence decision-makers. They helped create a more unified vision of health, particularly in response to complex problems (like obesity, poverty, delinquency, homelessness, and health literacy).
Does lowering speed limits improve health?
Speed limits in a Hamilton neighbourhood were reduced to 30 km/h in an effort to make the residential area safer and more child- and family-friendly. Data before and after the reduction was collected to see what impact it had and whether it should be applied to other areas in the city.
The city added a public health nurse to the multidisciplinary team that was evaluating the data. The nurse took part in an introductory health-impact assessment session and reported on health concerns, particularly those related to physical activity and chronic diseases.
Sharon Mackinnon, public health RN
Case study title:
An “adapted” HIA in Hamilton
Location and facility/organization:
Hamilton, Ontario, Public Health Services Chronic Disease Prevention Team
The Public Health Services Chronic Disease Prevention Team in Hamilton, Ontario, is involved in monitoring the impacts of a measure of the transportation plan in one of the city’s neighbourhoods alongside the other municipal services.
On August 12, 2013, the North End neighbourhood of Hamilton implemented one of the measures of its traffic management plan to foster a child- and family-friendly environment. Under this plan, the speed limit was set at 30 km/h for all residential roads in the neighbourhood.
The North End Traffic Management Plan was proposed as a pilot project during which a series of indicators would be monitored to assess the effects of this measure and the pertinence of expanding it to other neighbourhoods of the city.
To this end, the public works department put together a multidisciplinary and intersectoral committee to monitor and analyze the impacts of this new measure. The Chronic Disease Prevention Team of Public Health Services saw an opportunity to incorporate a health concern into a municipal policy. Members of the team are part of the multidisciplinary committee and are responsible for monitoring three determinants of health included in the list of aspects to evaluate: road traumas, physical activity and social cohesion (social connectivity). For the Chronic Disease Prevention Team, the objective is to be able to make recommendations to decision makers that are founded on relevant data that is likely to support the adoption of health-promoting municipal projects.
The team, made up of a public health nurse and a physical activity specialist, participated in an introductory session on health-impact assessment given by the National Collaborating Centre for Healthy Public Policy, and they use the health-impact assessment framework, adapting it to the particular context of a monitoring type of assessment. For the speed limit-reduction measure, data were collected before implementation in order to compare the situation at the start and after five years. The qualitative data were obtained using a summary investigation conducted with representatives of various groups in the neighbourhood.
By incorporating the municipality’s multidisciplinary team, the nurse was able to report on the health concerns, in this case the importance of physical activity and chronic diseases and voice these concerns. Besides these, the committee also discussed various issues associated with vehicular traffic and access to services such as security, parking, emergency measures, and so on.
This initiative enabled the Chronic Disease Prevention Team to include health in the city’s transportation plan, strengthen intersectoral ties with the municipality’s other sectors as well as learn more about the issues and obligations that shape municipal decisions. For health unit representative Sharon Mackinnon, nurses are very well positioned to have an impact in this type of situation. Generally speaking, they have good basic health knowledge combined with a holistic vision of health; they have varied experience as well as methodological skills and relationship skills. They can therefore rely on these assets to guide stakeholders and communities and properly support decision making based on concrete information.
Expand ‘positive parenting program’: is it the right thing to do?
In 2010, the government of Manitoba was considering expanding its “positive parenting program” to benefit children from a wider age range. Before the expansion, a nurse researcher studied the program to ensure it was equitable — that the families who most needed the program had access to it.
Research was conducted and included 14 focus groups and interviews with high-level program administrators. Recommendations were formulated to help ensure that certain groups and families with special needs would be able to benefit from an expansion of the program.
Benita Cohen, RN, PhD
Case study title:
Nursing research using the equity-focused health impact assessment approach (EFHIA)
Location and facility/organization:
University of Manitoba and Manitoba provincial government
A research nurse affiliated with the department of nursing at the University of Manitoba conducted the first study in Canada on the equity-focused HIA (EFHIA). Between 2011 and 2013, Dr. Benita Cohen, supported by a multidisciplinary team, conducted a study to assess the potential effects of a new provincial program aimed at families with adolescents. The Teen Triple P program is the continuation of the efforts put forth by the Manitoba government in 2005 to support and develop parenting skills with its Triple P program (Positive Parenting Program). The government program was originally created for families with children under six, and was then extended to families with children under 12. In 2010, the government considered the possibility of extending this program even further to include families with adolescents between the ages of 12 and 16. Given its universal scope and the fact that it was not mandatory, the program raised questions about equity. Would the information resources and services offered to families, in particular to those dealing with behavioural or development issues, be accessible to all the families that need them? Was there a risk that groups or families that could benefit from this program would not be reached? These were the questions that the researchers attempted to answer. The study was conducted in two steps. The first consisted in applying the equity-focused health impact assessment (EFHIA) approach using the ACHEIA guide developed in Australia (Mahoney et al, 2004). The second was aimed at assessing the impact of the equity-focused HIA approach on government decisions.
The study was launched with the approval of government decision-makers and the support of the Public Health Agency of Canada. Fourteen focus groups were conducted in four areas of the province and several interviews were conducted with directors of programs geared toward adolescents, making it possible to identify the potential risks of inequality created by the government program and to formulate recommendations to mitigate those risks. For example, low-income groups, parents with children suffering from mental health issues, marginalized groups and single-parent families were identified as being more at risk of not benefitting from the provincial program. Twelve recommendations were formulated by the research team. They were well received by the authorities, who claimed to have become much more aware of inequality issues, not only for the Teen Triple P program, but also for other universal program for which they were responsible.
Nurses host workshops to promote physical activity
Public health nurses worked with municipalities to help promote physical activity. The nurses conducted a literature review to show that even moderate exercise can reduce health risks. They then held a series of workshops with municipal officials.
The workshops helped build ties between the municipal and health sectors and fostered better understanding of the link between health and physical activity, particularly “active transportation” (e.g., cycling, walking). Several of the municipalities said they would continue their commitment to active transport policies.
Brittney Hillier, public health nurse
Case study title:
Nurses in support of municipal decisions that promote health
Location and facility/organization:
Ontario, Simcoe Muskoka District Health Unit
In Ontario, public health nurses from the Simcoe Muskoka District Health Unit ran a project in partnership with the municipalities in their territory with a view to encouraging the adoption of municipal policies that promote physical activity.
For the Chronic Disease Prevention Healthy Lifestyle Service (CDP-HL) team of the Simcoe Muskoka District Health Unit, physical inactivity is one of the key factors in chronic illnesses, and the promotion of healthy habits begins with the creation of environments that promote healthy choices. This direction has been part of the Healthy Lifestyle team’s long-term strategic planning since 2005, and has led it to work on both individual behaviours and the environments that promote healthy choices.
Based on the results of a literature review that confirmed that regular physical activity, even moderate activity, can considerably reduce the risk factor, as well as results of public surveys on barriers to physical activity, the nurses and other members of the Healthy Lifestyle team decided to approach municipal decision-makers. The partnership project, entitled Active Transportation Municipal Partnership Project, was created in 2010 with support from the Healthy Communities Fund of the Ontario Ministry of Health and Long-Term Care, whose purpose, among other things, is to develop policies and programs that facilitate the adoption of a healthy lifestyle.
The unit sent out an invitation to the municipalities on its territory to hold workshops that could support the development of a municipal action plan on active transportation (cycling, walking). In total, nine municipalities answered the call and seven were selected. The workshops took place between October 2010 and March 2011 and featured representatives from the health sector, the municipal sector and several other stakeholders who were likely to contribute to discussions and the development of an action plan. The contribution of the Healthy Lifestyle Service was essential not only in the preparation of workshops but also in terms of providing knowledge about health, physical activity and active transportation. Focusing discussions on a municipal project rather than on determinants of health encouraged the active participation of the municipal sector.
The assessment carried out by the Healthy Lifestyle Service at the conclusion of this project highlighted some important gains from the project, in particular the development of new relationships between the municipal sector and the health sector and a better understanding of how a transport plan may be related to health determinants. Several municipalities involved in this program have continued their commitments to active transport, seeing the advantages it offers in terms of sustainable communities. The participating nurses said that the entire process helped them to better understand the interrelations between municipal decisions and the health sector and to identify the potential synergies in addressing determinants of health. The success of this project and the long-term connections that were created has led the health unit to consider similar projects for other issues, such as food safety.
Nurses’ perspective informs public health project
In 2011, two nurses joined a public health team in Sudbury, Ontario, to bring a social determinants of health perspective to the team’s work. The goal was to bring together several community organizations and investigate the potential for a new model of services for vulnerable people.
47 people representing various community groups shared their experiences with the project and 13 recommendations were made. The nurses used their knowledge of the community to inform the health impact assessment process while strengthening relationships with the other team members.
Martha Andrews and Stephanie Lefebvre
Case study title:
An Equity-focused Health Impact Assessment (EFHIA)1
Location and facility/organization:
Sudbury, Ontario, Sudbury & District Health Unit
Two nurses have been part of the multidisciplinary team of the Sudbury & District Health Unit (SDHU) that undertook the first Equity-focused Health Impact Assessment (EFHIA) in 2011.
Equity-focused HIA is among ten practices retained by the Sudbury & District Health Unit as promising practices for responding to social inequities in health, following an in-depth literature review2. It is a central component of the Sudbury & District Health Unit’s approach that is taking shape notably through the work of local, non-health sector partners who can have an impact on social determinants of health. Following efforts to raise awareness among their partners, the board of directors of the Sudbury & District Health Unit was interested in trying out an equity-focused HIA, and a project to create a shared space for non-profit organizations that offer services in the community was chosen as the subject for that EFHIA.
The purpose of the project, called Shared Space Model for Sudbury Community Service Agencies, was to establish a new model of services for vulnerable people by bringing together several community organizations under one roof to share the costs and services and thereby better serve their respective clienteles. The project was carried out by the Sudbury Shared Space Working Group (SSSWG).
The team of the SDHU Health Equity Office was the main project manager for the HIA approach, but worked closely with SSSWG, which also includes the representatives of the main proponents of the project. Together, they made up the HIA project team.
This multidisciplinary team, which included the two nurses appointed to focus on the social determinants of health, followed the classic steps of an HIA. The screening and scoping steps were carried out during a single event where 47 people representing various community groups were invited to contribute by identifying the project’s potential impacts based on their own experiences. They recommended looking at some of the positive effects expected from the service consolidation project, such as improved consistency among the various services offered to vulnerable populations, the possibility of users making more use of lesser-known services, and the creation of jobs due to the consolidation and the expected increase in activities. Furthermore, they asked to investigate the risk of stigmatization for various groups given the nature of the services offered.
The more in-depth analysis was undertaken by the Health Equity Office and involved establishing the population profile, performing a literature review and conducting semi-structured interviews with key local informants.
Following this analysis process and discussions with the SSSWG, thirteen recommendations were made by the team in charge of the equity-focused HIA to respond to the various issues that were uncovered during the process.
For the Public Health Nurses at SDHU, participating in an EFHIA project provides an advantageous opportunity to meet their objective of working on social determinants of health and health equity. They feel that nurses have much to bring into an EFHIA multidisciplinary team. They know the community as well as their needs and assets, detain specific knowledge in health, and have developed relationships of trust which facilitate liaisons with partners.
1 Andrews, M. & Lefebvre, S. (2012) Equity-Focused Health Impact Assessment – A Community Pilot. An Assessment of a Shared Space Model for Sudbury Community Service Agencies. http://www.sdhu.com/uploads/content/listings/EfHIAPilot-SharedSpace-FINAL.pdf