1. www.cpha.ca
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. www.cpha.ca
Canadian Public Health
Association (CPHA) Sexually
Transmitted and Blood Born
Infections (STBBIs) Health
Equity Impact Assessment
Tool

3. www.cpha.ca
• 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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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

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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. www.cpha.ca
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. www.cpha.ca
When do you conduct an HEIA?

17. www.cpha.ca
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. www.cpha.ca
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

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• 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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
DOH/SDoH FIV
Population-
specific FIV
STBBI HEIA
All health issues
All populations
HIV STBBI specific
All populations
HIV STBBI specific
Population specific

24. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
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. www.cpha.ca
Other HEIA Resources
• Equity Lens in Public Health: Health Equity Tools 2013. Victoria, BC: University of
Victoria. Available from www.uvic.ca/elph
• Health Equity On-Line Course:
http://knowledgex.camh.net/health_equity/Pages/healthEquityImpactAssessment%28
HEIA%29OnlineCourse.aspx
• National Collaborating Centre for Determinants of Health: www.nccdh.ca
• Ontario Ministry of Health and Long Term Care; Health Equity Tool:
www.health.gov.on.ca/pro/programs/heia
• Wellesley Institute: www.wellesleyinstitute.com
The above links are examples of some Health Equity Tools available in Canada

34. www.cpha.ca
Thank You
To access the
tools go to
www.cpha.ca
For more
information
contact:
info@cpha.ca