Equity focused Health Impact Assessment (EFHIA) is a framework of health impact evaluation strategy to determine the possible differences or unequal aspects of policy on the health and welfare of a particular population or group within that particular population. EFHIA determines whether these different impacts are inequitable. EFHIA helps to strengthen the HIA in terms of identification and assessment of diffenrial health impact as inequitable. EFHIA mainly assess impact of policy on the different groups within the groups, characteristics of these impacts, whether these impacts are inequitable and recommendations are made to reduce these inequities (Harris-Roxas et al., 2014; Signal and Durham, 2000). Although, health impact assessment (HIA) should reflect on health equity, susceptibility and the division of prospective impacts, in reality this objective has been complicated to recognize, often because it is a complex process. EFHIA is a specific form of HIA to present a structured process for assessing health equity impacts (Povall et al., 2014; Gagnon et al., 2007). There were around 36 tools established for the assessing the equity in the healthcare, however HIA and EFHIA were the best rated among all for assessing the equity in healthcare issues.
HIAs’ suggestions can have following impact on the health policy to be implemented:
Well designed HIA policy has the ability to identify the negative health impacts and lessen these impacts.
Accurate implementation of the HIA policy has potential to improve the positive health impacts.
HIA improves positive health impacts by distributing the positive health impacts to the groups, subgroups and every members of the community. HIA make sure that each and every person comes under policy should get benefit from the positive health impact and improve the health and wellbeing of oneself and the society.
HIA has the potential to identify the similar type of alternative approaches and proceed with these approaches to get the similar type of positive impact as that of the original approach.
HIA has the ability to identify the approaches with very less success rate in the policy implementation and recommend not to proceed with these approaches (Vohra et al., 2003; Douglas and Scott-Samuel, 2001; Harris-Roxas et al., 2012; Simpson et al., 2004 ).
Child nutrition is a global epidemic and it is the need of the hour to give serious attention to this problem. Adequate child nutrition is important because it is the foundation of the life of the children. Future life of the children is a completely depends of the quality of food children are consuming and amount of nutrition children are getting from the consumed food. All the essential components to be formed for the entire life of the child like blood and bone are essentially depend on the food consumed by the children. Child nutrition is not only the cause of worry because of malnutrion, however in recent times excess amount food consumption of low quality and low nutritive value is also a cause of concern globally (Hurley, 2016; Wuehler and Nadjilem, 2011).
The aim of the child nutrition EFHIA is to assess the impact of this policy on the outcome in terms of equality and inequality high and low socioeconomic children. In this programme attention was given to meet the basis needs of malnourished children with low socioeconomic status and to control and monitor the less nutritive food consumption in the high socioeconomic status children mainly obese children. More focus was given to reduce the inequity in both malnourished and obese children.
Aspect assessed in the programme:
In this child nutrition HIA impact of policies and programmes, intentional and unintentionally on child nutrition were assessed. Based on the evidences, plan was developed to implement best strategy for the child nutrition. These strategies were developed based on the experiences of the nutritionist, parents, NGOs, government organizations and stakeholders in the child healthcare. More input was gathered from the conferences, workshops and seminars related to the child nutrition. These strategies were established in the childcare centers, schools and playgrounds. Different type of media like posters, audio-visual advertisements and personnel training to parents and school teachers were provided. Social marketing was effectively implemented for this programme. At the end, effect of all these strategies on the positive and negative outcome of the child nutrition programme was assessed.
HIA programme for child nutrition was designed for the period of one year. This programme started off with the preparation of plan and strategy and a working group was formed which included management, expert members and volunteers. Next step was training to all the stakeholders. After completion of the training these plans and strategies were implemented in the schools, child healthcare centres and playgrounds. Outcome of these plan and strategies were evaluated in regular intervals and progress was discussed and required modifications were made in the plan to get better outcome.
Steps in child nutrition HIA:
Child nutrition HIA was designed on the basis of established steps for the EFHIA. These steps include screening, scoping, identification and assessment (Mahoney et al., 2004). This HIA process was particularly targeted at assessing equality and inequality of malnutrition and obesity within the child nutrition in high and low socioeconomic population. Community-based participatory plan and strategy was applied in the scoping and assessment and steps of the HIA (Israel et al., 2006; Minkler and Wallerstein, 2003; Wallerstein and Duran, 2006 ).
First and foremost part of the screening is to identity the nature of policy. In this case policy is to implement good child nutrition policy in the low as well as high socioeconomic class. In the society, 50 % population is children and this policy could impact this large population. This child nutrition policy not only impacts in terms of number of population but also it impacts population in terms of duration also. This policy has very high impact on the society because this problem of child nutrition has long term impact on the future of society. If children didn’t get proper nutrition in the childhood, it would definitely affect their future growth. In this policy mainly, children of low socioeconomic status and children of high socioeconomic status were affected. Stakeholders involved in this policy include parents, school teachers, trainers at playground, childcare specialists and other government and non government organizations directly or indirectly involved in the childcare.
In the screening programme gaps were identified between the policy and the child nutrition. Also, corrective measures were established to fill these gaps and to improve outcome of child nutrition policy. In case of malnourished children, identified gaps were knowledge of the parents about the healthy food of the children and economic insufficiency to provide adequate food to the children. To improve on these gaps, parents were given training about the importance of the nutritional food for the children and its impact on the future growth of the children both physical and social terms. To solve the problem of economic insuffiecncy of the parents, arrangements were made to provide subsidized food to the children, policies were implemented in the school to provide nutritious mid-day food to the children so that there would be less burden on the parents in economic terms.
Focus was also given on finding the equality and inequality of child nutrition among children of different socioeconomic status of the same society. In this study, it has been established that there is the unequal distribution of the food habits among the children of the same socioeconomic status. Children in the low socioeconomic status constitute both healthy and malnourished children. This is due to the negligence of parents, school children and other stakeholders of the society and not understanding of the importance of the healthy food for the children. In the same way, in high socioeconomic status children also there is the unequal distribution of the children as obese children and healthy children. One of the main causes identified for the obesity in school going children is consumption of the junk food which mainly includes sweetened beverages, fast foods, refined grains, processed meats, desserts, pizza, fries potatoes and sweets. It has been observed that there is the positive relation between the obesity and the low nutrient, high energy, low fibre, and high glycemic load food (Fox et al., 2009; Datar and Nicosia, 2012). In high socioeconomic status also not all the children were obese, few children were with good health. This inequality in the normal and obese children in high economic status is due to differences in the family culture about the food and negligence towards the long term adverse effects of junk food. To address this equality and inequality in both the malnourished and obese children, strategies were suggested. These strategies include teaching to the parents and teachers about the healthy food and importance of healthy food in the children, supplementation of healthy food in the school, ban of the junk food at school premises and at playgrounds.
Screening tool for the child nutrition:
To get the insight of the child nutrition a survey was conducted by asking questions to the stakeholders like parents, teachers and child care practitioners. Following were the questions asked to them :
1. Whether this policy has prospective to have positive impact on selection of food and nutrition for the children?
2. Whether this policy has prospective to have negative impact on selection of food and nutrition for the children?
3. Whether this policy has prospective to maintain equality in child nutrition?
4. Whether this policy has prospective to maintain ineuqility in child nutrition?
5. Whether policy has prospective to have improvement in the overall health and well being of the society in long term?
6. Whether this policy has potential to impact social, cultural and emotional aspects of the children.
Child nutrition policy in the HIA has both positive and negative impacts on the different groups of the society. In this policy mainly two groups were involved i.e. low economic status group and high economic status group. It has been observed that there is the negative impact on the low economic group and positive impact on the high economic group. It makes clear that implementation of EFHIA in the low economic status children were not going to be changed with this policy. This policy was not going to change the choice of food and nutrition in the low economic status children. On the other side, this policy has the potential to change the selection of food and nutrition in the high economic status children.
Scoping is the process of establishing the framework of the policy in terms of completing the policy in designated time, with designed procedure and making aware of the all the stakeholders about their assigned tacks related to the policy (Birley, 1999).
In scoping, initial attention was given to make decision on the nature and scope of the policy. This child nutrition policy is related to the health of the children both in the low and high socioeconomic status. This policy was designed for the children below ten years and these children include both school going and those which were not going to the school. As it is difficult to evaluate the children by visiting every house in the society, children were targeted those were going to the school, visiting the playground and childcare centers. Data was collected for the children about their eating habits in terms of amount of food, quality of food, whether it is a homemade food or outside food, if outside what is the frequency of outside food, interest and disinterest of children on food consumption. This information was collected mainly from the parents and teachers in one month time period of the total policy duration. Stakeholders form the different profession, communities and expertise were designated to implement this policy. Policy makers group included management, expert committee, nutritionist, healthcare providers, community members and people from different government and non-government organization related to the field. Stake holders from the group on which policy was going to be implemented included children, parents, teachers and childcare health professionals. Others aspects required for the successful completion of the policy implementation project were also decided like budget of the project and source of financing, time duration of the project i.e. it should be completed in the 1 year period. All the plans were decided to implement the policy and it was recommended that intermediate reporting should be there to the management and expert team about the status and progress of the project. Management and expert team discussed and debated about the outcomes of the policy with all the stakeholders and made recommendations. Timely recommendations from them were incorporated in the plan of the policy to improve the outcome of the project.
Tools applied in the child nutrition HIA were :
1. Based on the screening process whether there is the significant health impact.
2. What is the interest of community and government in the policy?
3. What is the capability in terms of expertise, financial and other resources for implementing the policy ?
Implementation of this well structured plan, definitely helped to save time and resources in conducting the project. In this way a very clear and well designed project plan was implemented so that it would make easy way to the subsequent HIA step of the EFHIA.
Impact identification step of HIA was the most extensive step, in which most of the work related to the policy was carried out. In this prospective impacts of the policy were identified. Some of these prospective impacts were known from the earlier evidence and some were unknown. Later, these impacts were evaluated for the equality or inequality and positive or negative impacts. Known impacts identified in this process were : there was more influence of parents and family members on the food and nutrition habits of the children, also the community in which they were staying had impact on their food and nutrition habits, policies of the school. There were differences in the understanding of the policy between low and high socioeconomic status community. People with high socioeconomic status understood the policy and followed it, on the other side, it was difficult to make understand the policy to the people with low economic status. Educated parents were more efficient in implementation of the policy as compared to the uneducated parents. Parents were more efficient in implementation of the policy as compared to the teachers and other stakeholders involved in this process. Unknown impact identified was, there was no clear distinction in terms of geography among the low and high socioeconomic status people. These two groups were evenly spread throughout the community.
Data was collected from parents, teachers and childcare health professional to understand the impact of this policy on the low and high economic status population. This data was collected by arranging a workshop, so that all the data could be collected at the same time. Data was collected by preparing questionnaire and these stakeholders should respond to these questions. These questions were decided by the expert committee based on the evidences available for the child nutrition in the low and high economic status community. At the time of data collection, these stakeholders were advised to give suggestions on the current draft of the policy. Suggestions from these stakeholders were helpful in the redesigning of the project proposal in better way. This consultation form the stakeholders are very important because it was based on the actual evidence and it had high level impact on overall outcome of the project. In this way, these stakeholders were directly or indirectly involved in the future design of the project. At the same time, members of the expert committee and working group of the project were from the same communities of the low and high socioeconomic status. Hence it was easy for them to understand the issues and suggestions of the community stakeholders. Hence, they incorporated and implemented these suggestions in more effective way. This strategy was based on the recommendation of HIA over the epidemiology. Risk factors, observations and motivation were not taken same as that of its existence in HIA. However, these factors were based on the cause of its origin (Joffe and Mindell, 2002). This criteria of HIA was satisfied in better way by incorporation of suggestions of stakeholders from the community in the policy designing
Working group of the project made sure that this policy was reaching to the each and every child, parent and teacher of the selected community those were within the scope of this project. Gaps were identified in the implementation of the policy like understanding of the policy by people in the low socioeconomic status and less education. Corrective actions were taken to make these people understand importance of the policy of the child nutrition HIA. There were slightly different strategies made for people with low socioeconomic status. Being working group of the policy from the same community, it helped to prepare modified strategy for the people in low socioeconomic status and with less education. Modifications or amendments made in the existing policy included, teaching them about the importance of child nutrition with direct communication instead of seminars or workshops. Also, priorities were decided on the certain tasks like giving more attention to make understand people in the low socioeconomic status and with less education about the policy.
Child nutrition HIA made it clear that one strategy or plan was not applicable to all the groups and subgroups within the community. If one strategy exhibited its potential in identifying equalities or inequalities in one section of the community, it would not be useful in finding the same in other section of the community. It was also established that different approaches were applicable at different levels and circumstances. These different approaches would be useful in identifying equalities and inequalities in overall population with differential population like low and high economic status in the same community.
Assessment of Impacts:
This was the final and most complex step of the child nutrition HIA. In this step recommendations of the previous steps were evaluated and discussed and suggestions during the interim reports were discussed. While making final decision on the recommendation, validity of the evidence behind the recommendation was examined for different stakeholders. This step performed the function of mapping of all the previous observations and evidences from different stakeholders to make final conclusion. Impact of the child nutrition HIA, was positive on the most of the population of the mentioned community. It had positive impact on all the members of the community with high socioeconomic status and 2/3 of the members of the low socioeconomic status community. Very few of the members of low socioeconomic status community were negatively impacted by this policy. Evidences about the impact of the child nutrition HIA were collected from the parents, teachers and childcare health professionals. There were the consistent evidences obtained from the parents and childcare health professionals. However, there was little discrepancy in evidences obtained from teachers as compared to the parents and childcare health professionals. This discrepancy in the evidences about the impact was in the acceptable limit. Hence, these evidences were considered in decision making for the final conclusion of the impact of the policy.
Central topic of the child nutrition HIA policy was to reduce the inequality among the low and high socioeconomic status children. In this case also inequality was observed in implementing child nutrition policy among low and high socioeconomic status population. Inequality observed for the low socioeconomic population in the form of limited understanding of the HIA policy. However, this inequality could be reduced or avoided by implementing training or teaching in the form of direct communication instead of seminars and workshops. This inequality observed was acceptable and reasonable because expecting the same type understanding in both low and high socioeconomic status population was unfair to the low socioeconomic population. At the time of the assessment of the impact of the HIA policy considerations were given to the interests and needs of the stakeholders. These impacts were critically evaluated. Need of the low economic status community stakeholders considered was their inability to provide quality food to their children due to the financial status. These stakeholders were given a fair chance to provide quality food to their children by giving subsidized food and later impact on them was evaluated.
Few of the practices followed in the earlier policy were not successful like teaching to the people in low socioeconomic status. These practices were modified or amended to more friendly to this group of population by teaching them through the face to face communication instead of other media like seminars and workshops. Successful steps implemented in the policy were recommended to carry forward in the next policy and in the actual practice. All the advantages of the steps to be carried forward for the policy implementation in the actual practice were properly documented so that it could be used as evidence. Steps to be carried forward were the implementation of the strategy in the population in the high socioeconomic status population. Because it identifies both equalities and inequalities in this population and inequalities could be reduced with the implementation of this strategy. These recommendations from the child nutrition HIA were presented to the expert committee and management. Expert committee and management examined and disused the feasibility of these recommendations and prepared final response to these recommendations. This response was again presented to the HIA working group and this working group agreed to the responses made by the expert committee and management (Bond, 2004).
In child nutrition HIA, data should be collected from the parents, teachers, play ground centers and child care centers. There should be supplementary education to these stakeholders about the healthy food and long term impact of unhealthy food on the children. Both the online and print based media should be incorporated in the teaching of these stakeholders. This programme should be designed to both the school and non-school going children. Children should be promoted to do physical exercise. Mid-day meal in the school should be nutritious and it should include fruits and milk. Junk food and other unhealthy food should be banned in the school premises. Children should restrict on consuming off-campus food and restaurants. Government should apply heavy taxation on the junk food. Social marketing should be encouraged to supply healthy food to the schools. Government should implement policies to provide healthy food to the children, specifically subsidy should be provided on the healthy child food. There should be regular health check up for the children at schools and child care centre to assess children with both malnutrition and children prone to obesity. Members form the same society should be included the working group of the project. A 24 hr support system should be provided to all the members of the community. There should be involvement of public figures and celebrities for the campaign of the policy. Encourage children by giving prizes for beat performing child.
Discussion and conclusion:
The equity-focused HIA allowed the child nutrition program to evaluate its prospective advantage and disadvantage for low and high socioeconomic children. It can also adopted to maximize the positive impacts and minimize negative impacts. This child nutrition programme assessed strategies to meet the requirements of the low and high economic status community. This child nutrition assessed the equality and inequality gaps in the mentioned community. Management and expert committee were able to made final recommendation due to well structured HIA plan. In conclusion, child nutrition HIA was a helpful tool to develop equity in low and high economic status children. This programme reduced the inequality in this population. This methodology can be used in other communities.
Birley, M. (1999). Procedures and methods for health impact assessment. In: Health impact assessment. Report of a Methodological Seminar. London: Department of Health, 11–33.
Bond, A. (2004). Lessons from EIA. In Health Impact Assessment. Edited by: Kemm J, Parry J, Palmer S. Oxford: Oxford University Press. pp. 131-142.
Datar, A. and Nicosia, N. (2012). Junk Food in Schools and Childhood Obesity. Journal of Policy Analysis and Management, 31(2), pp. 312-337.
Douglas, M.J. and Scott-Samuel, A. (2001). Addressing health inequalities in health impact assessment. Journal of Epidemiology and Community Health , 55(7), pp. 450–451.
Fox, M.K., Dodd, A.H, Wilson, A. and Gleason, P.M. (2009). Association between school food environment and practices and body mass index of US public school children. Journal of the American Dietetic Association, 109(2), pp. S108-17.
Gagnon, F., Turgeon, J. and Dallaire, C. (2007). Healthy public policy: A conceptual cognitive framework. Health Policy, 81(1), pp. 42-55.
Harris-Roxas, B., Viliani, F., Bond, A., et al., (2012). Health Impact Assessment: The state of the
art. Impact Assessment And Project Appraisal, 30(1), pp. 43–52.
Harris-Roxas, B., Haigh, F., Travaglia, J. and Kemp L. (2014). Evaluating the impact of equity focused health impact assessment on health service planning: three case studies. BMC Health Services Research, 5(14), p. 371.
Hurley, K.M., Yousafzai, A.K. and Lopez-Boo, F. (2016). Early child development and nutrition: A review of the benefits and challenges of implementing integrated interventions. Advances in Nutrition , 7, pp. 357-363.
Israel, B.A., et al., eds. (2006). Methods in Community-Based Participatory Research for Health. Jossey Bass Publishers: San Francisco, CA.
Joffe, M. and J. Mindell J. (2002). A framework for the evidence base to support Health Impact
Assessment. Journal of Epidemiology and Community Health , 56, pp. 132-138.
Mahoney, M., Simpson, S., Harris, E., Aldrich, R. and Stewart, W.J. (2004). Equity Focused Health Impact Assessment Framework, the Australasian Collaboration for Health Equity Impact Assessment (ACHEIA). www.apho.org.uk/resource/view.aspx?RID=44801.
Minkler, M. and Wallerstein, N.B. (2003). Community-Based Participatory Research for Health. CA: San Francisco: Jossey-Bass Publishers.
Povall, S.L., Haigh, F.A., Abrahams, D. and Scott-Samuel, A. (2014). Health equity impact assessment. Health Promotion International, 29(4), pp. 621-33.
Signal, L. and Durham, G. (2000). Health Impact Assessment in the New Zealand Policy Context. Social Policy Journal of New Zealand, 15, pp. 11-26.
Simpson, S., Harris, E. and Harris-Roxas, B. (2004). Health Impact Assessment: An introduction to the what, why and how. Health Promotion Journal of Australia, 15(2), pp. 162–167.
Vohra, S., Amo-Danso, G. and Ball, J. (2013). Health impact assessment and its role in shaping government policy-making: the use of health impact assessment at the national policy level in England. In Integrating health impact assessment with the policy process. Edited by O’Mullane M. Oxford: Oxford University Press; pp. 76–87.
Wallerstein, N.B. and Duran, B. (2006). Using community-based participatory research to address health disparities. Health Promotion Practice, 7(3), pp. 312-23.Wuehler, S.E. and Nadjilem, D. (2011). Situational analysis of infant and young child nutrition policies and programmatic activities in Chad. Maternal & Child Nutrition, 7(1), pp. 63-82.