Implementation of the Health Equity Impact Assessment (HEIA) tool in a local public health setting: challenges, facilitators, and impacts.

SETTING: The Simcoe Muskoka District Health Unit (SMDHU) is a local public health agency in Ontario, serving the County of Simcoe and District of Muskoka's population of over 540,000 people in a mixed urban-rural environment. SMDHU has had a strategic focus on the determinants of health since 2007. INTERVENTION: The use of the Health Equity Impact Assessment (HEIA) tool was encouraged throughout SMDHU. An online survey was conducted to assess the implementation of mitigation strategies identified through the HEIAs; in particular, the facilitators and barriers/challenges, and the impacts at both the program level and the level of priority populations, themselves, were assessed. OUTCOMES: Agency programs reported 40 HEIAs conducted between 2013 and 2017. While three of the 40 HEIAs were at an early stage, the remaining 37 were at an advanced stage of implementing mitigation strategies, or beyond. Reports from these 37 advanced-stage HEIAs indicated that 30 of them observed or measured impacts on their programs, services, and/or policies (i.e., program-level impacts), following the implementation of HEIA mitigation strategies. These impacts included improved collaboration with external partners, development of more accessible and inclusive communication, increased availability of information and population health data, increased access to services for priority populations, reduced financial barriers for accessing services, and increased staff training on health equity and priority populations. However, few respondents had measured or purposefully assessed impacts on target populations themselves (i.e., population-level impacts); therefore, such impacts are unknown. Key facilitators to the implementation of mitigation strategies were availability of staff, collaboration and support from other areas of the organization, sufficient time, collaboration with community partners, and the inclusion of HEIAs in program operational plans. Absence of these facilitators was identified as a barrier to implementation of mitigation strategies. IMPLICATIONS FOR POLICY AND PRACTICE: The use of HEIAs served as a catalyst for change in this local public health agency, leading to equity-oriented impacts on public health programming, planning, service delivery, and organizational policy. Support and capacity-building for measuring and evaluating impacts of mitigation strategies on intended priority populations themselves are recommended, to ensure more robust learning and improvement.