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Welcome to the CPHA Webinar STBBI/HIV Community Partner

webinar

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Local (Toronto only): 416-548-6023 Access Code: 741-9512

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The Canadian Public Health Association Community Partner

Webinar Core Competencies for STBBI

Prevention, STBBI Health Equity Impact Assessment Tool and

Factors that Impact Vulnerability (FIV)

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Project Overview The Project Core Competencies resulted in three documents: • Core Competencies for STBBI Prevention • STBBI Health Equity Impact Assessment • Factors that Impact Vulnerability (FIV) Companion resource to the HEIA

• Overall there were consultations/and or focus groups in 6 locations • In addition key informant interviews were held with individuals whom work in

sexual health, STBBI prevention, research, treatment and care, core competency experts and public health

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Community partners Vancouver: AIDS Vancouver, 3 focus groups Saskatoon: Saskatchewan HIV/AIDS Research Endeavour Ottawa: AIDS Committee of Ottawa Montreal:COQ-SIDA Halifax: AIDS Coalition of Nova Scotia & AIDS Commission of Nova Scotia Renfrew County: Ottawa Valley Health and Wellness Centre West Champlain Healthy Community Corporation Yellowknife: Aurora College

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Approach • Each location and partner was responsible for specific task and duties and

worked with the project leads to effectively coordinate the community visits

• All of the consultations followed the same format with semi structured sessions throughout the day facilitated by the project team and consultant

• Competency development consisted of an analysis of the data collected in the skills, knowledge, attitudes and behaviours large group discussions and break out sessions and also informed the HEIA and FIV tool

• Information collected through the guided focus groups with people most at risk of STBB’s or living with an STBBI as proved to be critical to identify specific skills for front line workers to be effective

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Approach cont • While the STBBI tool was loosely modeled on the Ontario Health Equity

Impact Assessment Tool with significant modifications to ensure it was STBBI Specific

• HEIA incorporated suggestions and feedback from participants at the consultations, national reference group and key informants

• The tool was further refined and the HEIA was first piloted at the CPHA conference and then in community with a partner organization to assess future as well as current initiatives

• The practical opportunity to pilot the HEIA with a group provided critical feedback both for tool content as well as facilitation style

• The FIV companion resource was also created as a parallel process

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Approach Cont • The FIV tool was initially formulated based on a literature review and further

developed based on participant feedback and suggestions during the flip chart rank and sort exercise and breakout sessions during consultations

• The FIV tool is not meant to be a definitive document

• It highlights some of the factors that have an impact on an individuals’ risk of STBBIs

• Can be used to highlight factors that impact risk for all populations as well as specific populations

• The FIV document can be used as a stand alone tool but was primarily created to be used as a companion resource to the STBBI HEIA

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STBBI Core Competencies • The STBBI Core Competencies are based on the broader Core

Competencies for Public Health • These Competencies provide public health practitioners with the knowledge,

skills, and attitudes required to be effective in their work

• In order to best address the increasing rates of STBBIs; a targeted approach is required

• As a result the STBBI Core Competencies have been created for front-line

providers. They are not profession specific; they are STBBI prevention specific and focus on HIV and other sexually transmitted and blood-borne infections

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STBBI Core Competencies Competencies will:

• Core competencies address the need for common language, skills and approaches for front-line providers across disciplines and sectors so that clients receive consistent HIV prevention, health and well-being messages, programs and services

• Increase the capacity of front-line providers to address Factors that Impact Vulnerability (FIV) to STBBIs

• Encourage service delivery that is evidence-based, population-focused, ethical, equitable, standardized and client-centred

• Act as an adaptable set of skills, knowledge and practices that can be used in all prevention strategies

• At an organizational level, core competencies provide a framework and common understanding for integrated action in tackling the complex social factors at play when dealing with the social determinants of health that increase vulnerability to HIV infection and other communicable diseases

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Development Process • CPHA worked with communities across Canada to identify the knowledge,

skills, attitudes, and behaviours which enhance the prevention activities

• The competencies were then refined by external experts and reviewed for plain language

Competencies were then selected on: Measurabilty STBBI Specific Based on Public Health Competencies but does not duplicate them

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STBBI Core Competencies The STBBI Core Competencies Tool is comprised of 8 Sections: 1.Why Competencies were developed 2. The Competency Statements 3. Factors that Impact Vulnerability 4. Individual level factors

5. Community level factors 6.System level factors 7. How the Competencies were developed 8. Self Assessment Tool

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STBBI Core Competencies 1. Knowledge of STBBI transmission modes, disease and infection progression, and treatment options .

a) Can demonstrate consistent use of universal precautions

b) Can identify, share, and contextualize best practices in prevention of STBBI transmission

c) An understanding that the presence of one STBBI may increase risk of other infections

d) Demonstrates knowledge of bio-medical risks associated with sexual practices (including insertive, receptive, anal, vaginal)

e) Recognizes the complex factors, including the need for intimacy and pleasure, involved in assessing a person for risk in sexual and non - sexual decision-making.

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2. Respect for the diverse range of beliefs, practices, and values that influence sexual practices and decision-making

a) Can recognize how the determinants of health influence STBBI risk for specific populations b) Can see how culture shapes an individual’s sexual health and decision-making c) Understands how stigma and discrimination can lead to further exclusion and isolation d) Knows and appreciates the Factors that Impact Vulnerability

e) Understands how a person’s experiences affect decisions about accessing services, getting tested, and having treatment

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3. Effective use of interventions to modify risk of STBBIs a) Creates and maintains appropriate boundaries within the client–service

provider relationship b) Can identify and apply harm reduction strategies c) Applies approaches that meet the STBBI prevention needs of the client

(such as motivational interviewing and active listening) d) Supports clients in making informed decisions while acknowledging they

are experts in their own lives e) Can comfortably discuss sexual practices, related risks, and prevention

of STBBI f) Can put situations in context in order to effectively meet the needs of

those at increased risk of STBBIs

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4. Advocacy on behalf of those at risk of STBBIs and living with HIV.

a) Demonstrates awareness of the impact that organizational policies and practices have on access to STBBI prevention services

b) Ensures a safe and respectful environment that does not isolate or

marginalize client c) Identifies appropriate referral options for clients whose complex health

needs may impact their risk of STBBI d) Acknowledges own limitations and be able to support clients’ navigation

of systems

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5. Planning, implementation, adaptation, and evaluation of STBBI programs and policies

a) Can apply a health equity lens to inform programs, services, and interventions

b) Can contextualize disparity and adapt programs to ensure inequities are

not increased c) Knows the laws and organizational policies surrounding disclosure and

confidentiality d) Demonstrates an understanding and ability to adapt as necessary with

people from diverse backgrounds e) Ensures that programs and services are not only culturally relevant but

also culturally safe for populations most at risk of infections

f) Can apply organizational procedures, protocols and standards to the delivery of STBBI services

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Attitudes and Factors that Impact Vulnerability Factors that Impact Vulnerability : Individual Community System • It is important to note that the FIV have been linked to populations but also

at which level of impact they may reside

• So a FIV may be linked to a specific population but also identified as an individual impact

• This helps develop and design interventions on a population as well as an impact level

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FIV and Attitudes of Front-line Workers • Service providers need confidence and a level of comfort to address the

complex needs of those at risk in an unbiased, non-judgmental, and inclusive manner

• The Factors that Impact Vulnerability (FIV) provide an initial list of factors that can challenge the attitudes and beliefs of those working with people at risk of STBBIs.

• They need to understand their own role in shaping a client’s experience

• Service providers should consider their personal attitudes toward the people they work with and choices as well as the factors that impact vulnerability

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• An understanding of the FIV is essential for front-line workers if they are going to understand a client’s risk of STBBIs.

• At the same time, workers should not assume that the factors are relevant to each person’s experience—they must acknowledge that people are experts in their own lives

Individual: - Factors that impact sexual decision making - The role that intimacy and pleasure may play Community: - Attitudes towards sexual and personal practices front line workers may

posess - Taboos and the stigmatization of certain sexual practices System: -Cultural orientations may influence how people discuss sex in public and in private - Health, legal and education systems are intrinsically adversarial and impact how people engage

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Self Assessment Tool • This tool is for front line providers to perform a self assessment of their

demonstrated knowledge of the Core Competencies

• It can be used in overall performance assessments and in conjunction with learning plans to further develop their skills, knowledge and as a result contribute to enhance organizational capacity and robustness

• The tool is helpful to identify areas where more skill development is needed and opportunities for development

• The tool can provide the opportunity for communication between front line providers and managers, supervisors, directors

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The self assessment tool provides a check list for each competency statement

There are three levels an individual can rate their demonstrated ability: a) Proficient: Expert/Others consult with me b) Knowledgeable: Comfortable; occasionally consult with others c) Aware: Heard of it; regularly consult with others - The tool also provides a not relevant category as some positions will not

require knowledge in all areas nor should people be expected to be experts in all areas

- A learning plan template has also been created as part of the competency

tools but can be used as a stand-alone tool

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Implementation The Core Competencies can be incorporated in a number of ways: • Facilitating workshops internally with one another

• In consultation with supervisors annual learning plans can be developed

that includes ways to strengthen the competencies

• Performance appraisals can include identifying strengths and outline areas for improvement or development

• Based on the competencies self assessment tool a team learning plan could be developed and implemented

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Health Equity Impact Assessment • 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 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.

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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?

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STBBI HEIA • 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

• The STBBI HEIA can assist organizations to develop any prevention programs, services or initiatives and provide specific examples of factors that impact one’s general risk of infection and also in certain population

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Process

• 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

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Process 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

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Development Cycle Optimally organizations would use it at the start of initiative development

It can still be used throughout the various stages but may be not as effective

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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.

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STBBI HEIA Main Objectives • Support an organization’s assessment and decision-making during the

development of STBBI prevention initiatives • Identify and address unintended impacts, positive or negative, on priority

populations and other groups that may face challenges attaining equitable health outcomes

• Build on an organization’s existing prevention work and enhance

consistency and transparency in how equity issues are addressed • Strengthen work around the factors that may impact vulnerability to STBBIs • Systematically catalogue the decision-making process to assist in the

development of future initiatives.

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Populations • 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

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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

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DOH/SDoH FIV Population-specific FIV

STBBI HEIA

All health issues All populations

HIV STBBI specific All populations

HIV STBBI specific Population specific

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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.)

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FIV continued • The examples provided are to highlight the factors that were identified

through the project • They are meant to be used to spark initial discussion • Each organization and region should identify specific FIV and it is important

to record those as well • It is anticipated that the list will evolve and refined over time as information

and research is conducted • Throughout the HEIA it is important to remember FIV are the lens from

which to assess the initiative

For the present completed list you can access it @ www…cpha.ljdljjdsjadlj

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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

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Sample Template Name of Initiative: Target

Population(s):

Intended Outcomes:

Step 1. SCOPING

Step 2. UNINTENTIONAL POTENTIAL IMPACTS

Step 3. MITIGATION

Step 4. MONITORING

Step 5. DISSEMINATION

1. a) Populations that may be impacted by the initiative:

1. b) Factors that Impact Vulnerability:

2. a) Unintended positive or neutral impacts:

2. b) Unintended negative impacts:

2. c) More information needed:

Ways to reduce potential negative impacts and amplify positive impacts:

Ways to measure success for each mitigation strategy:

Ways to share results and recommendations:

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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 have shared that they have

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• 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 localized 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

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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

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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

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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

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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.

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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 the organization and with community partners • Post the results of your STBBI HEIA on your website

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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%28HEIA%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

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Conclusion CPHA would like to thank all of you for significant contributions to the project and ongoing commitment and passion working to reduce rates of new infections. All of the tools can be accessed……..

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Thank you

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