Community Health Impact Assessment within the francophone and Acadian Community in the Halifax Regional Municipality

Community Health Impact Assessment within the francophone and Acadian Community in the Halifax Regional Municipality Prepared for: Réseau Santé Nouvelle-Écosse March 2010

Acknowledgements The Réseau Santé Nouvelle-Écosse would like to acknowledge our partners including: Partners who have endorsed our initiatives and continue to do so: o Nova Scotia Department of Health, o Nova Scotia Department of Health Promotion and Protection, o Office of Acadian Affairs, o District Health Authorities and the IWK Health Centre; Our community partners throughout the province and especially the Conseil communautaire du Grand-Havre; Société santé en français; and Health Canada. Pyra Management Consulting Services Inc. i

Executive Summary The francophone and Acadian population of the Halifax Regional Municipality (HRM) constitutes a minority community within the diverse population and geography of the region. The Réseau Santé Nouvelle-Écosse (RSNÉ) has experience developing partnerships among all levels of government and coordinates projects for the purposes of increasing access to French-language health services. In 2009, the RSNÉ, in partnership with a steering committee made up of community stakeholders, leaders and decision makers, was funded by Health Canada through the Société Santé en français (SSF) to develop Community Health Impact Assessment (CHIA) tools for both the urban and rural French-speaking minority populations in Nova Scotia. The RSNÉ contracted Pyra Management Consulting Services Inc. (PMCS) to lead the delivery of the urban portion of the project. The key objective of the urban component of the project was to develop a CHIA framework and to use the framework to assess the operational needs for a francophone health centre within the HRM. Specifically, the scope of the project included: 1. Conducting a brief background literature review to identify best and promising practices in the development of community health impact assessment tools. 2. Drawing from the literature review, and current practice throughout the province (e.g. the People Assessing Their Health PATH Community Health Impact Assessment Tool - CHIAT) to develop a draft framework for community health impact assessment in the HRM. 3. Developing and implementing the necessary data collection tools to allow francophone community stakeholders within Halifax Regional Municipality to develop the health impact assessment for their community. 4. Using the framework to inform the preparation of appropriate input data for future analysis by the Department of Health s for Health Care Human Resources planning. 5. Preparing reusable tools, training materials and best practices information from the project for future use by the RSNÉ, particularly in being able to perform similar assessments for future policy issues facing the Frenchspeaking community of the HRM. Based on the results of the literature review, the project team decided to use the PATH process for the CHIAT development and implementation in the HRM. Pyra Management Consulting Services Inc. ii

A key element of the project was finding a way to engage the hard-to-reach urban francophone community and ensure consideration of their interests and issues without fatiguing them with seeming repetition of previous recent consultative initiatives. To accomplish this, previous community efforts to create a community development plan organized into various areas of impact were used as the basis of the CHIA Tool. Representative community members were then recruited to participate in the facilitated workshop to apply the CHIA Tool to examine the impact on the health of the French-speaking community of establishing a Frenchlanguage community health centre in the Halifax Region. Participants in the workshop conducted an evaluation of the CHIA Tool itself after completing the workshop. Workshop participants also pilot tested a needs assessment survey and provided feedback on that data collection tool to allow it to be used in a future initiative in the community to look at specific needs for a community health centre. Comments from participants and the observations of the facilitator were used to refine the project materials and the final versions were used to develop the reuseable tools, training materials and best practice information for future use by the RSNÉ. An independent evaluator was contracted to conduct an evaluation of the project. The following conclusions were drawn from this project: The CHIA worksheet and materials produced in this project will provide a common framework for the RSNÉ to investigate future policy issues within the HRM French-speaking community. The use of the CHIA Tool to examine the impacts of establishing a French-speaking Community Health Centre indicated that this would have a positive effect on the health of the community although it seemed a foregone conclusion to many of the participants. Since the francophone and Acadian community has no such community health centre today, it would clearly have a positive impact upon them. The overall impact to the larger diverse HRM community was not within the scope of this project and may have yielded a different result. For instance, if limited resources and the potential for competition among various facilities within Capital Health were considered. The place of the community in question within the larger context must therefore be considered because if benefits or positive impacts will be realized by one community and costs or negative impacts borne by another the CHIA Tool will not necessarily consider this and could result in polarizing conflict between the elements within the larger group. Pyra Management Consulting Services Inc. iii

Table of Contents Acknowledgements... i Executive Summary... ii Introduction... 1 Background... 1 The Project... 2 Project Methodology and Approach... 3 Results of the Literature Review... 4 Community Health Impact Assessment... 7 Community Health Impact Assessment in Nova Scotia... 8 CHIA Development Process... 11 Using the CHIAT... 12 Choosing What to Assess... 12 Preparing for the Meeting... 12 Facilitating the CHIA Discussion... 13 Results of the CHIA Process... 13 Identifying Next Steps... 13 Data and Reusable Materials... 14 Data... 14 Reusable Materials... 14 Pilot Needs Assessment Survey... 15 Conclusions... 15 Appendices... 17 Appendix 1 - RSNÉ Community Health Impact Assessment Tool... 18 Appendix 2 - Briefing for CHIA Participants... 34 Appendix 3 Raw Data Report of the CHIA Proceedings... 38 Appendix 4 - HRM French Language Community Health Centre Needs Assessment Survey... 49 Appendix 5 - CHIA Facilitator s Guide... 54 Appendix 6 Participant Evaluation of CHIA Sessions... 55 Appendix 7 - Participant Evaluation of Pilot Test Survey... 57 References... 58 Pyra Management Consulting Services Inc. iv

Introduction According to the 2001 census, self-identified francophone and Acadian people make up approximately 4% of the population of Nova Scotia. All Frenchspeaking people in Nova Scotia are part of minority communities. Part of this population is concentrated into certain Acadian and francophone rural areas (e.g. Cheticamp, Île Madame, Pomquet, Clare and Argyle) however, it also includes a significant number of people in the Halifax urban area as well as French speaking immigrants that are not necessarily easily geographically bounded. 1 Despite this, the francophone and Acadian population of the Halifax Regional Municipality (HRM) constitute a minority community within the diverse population and geography of the region. Background In December 2004, the French-language Services Act was proclaimed, confirming Nova Scotia s commitment towards promoting the development of its Acadian and francophone community and maintaining the French language for future generations. The French-language Services Regulations came into effect December 31, 2006. They clarify the responsibilities of each designated department, office, and agency (designated public institutions) with respect to the Act and ensure that there are substantive and measurable improvements to the French language services offered by the Government of Nova Scotia. The regulations require that provincial government departments and agencies like District Health Authorities (DHAs) must develop and publish a French-language Services Plan to show how they intend to increase or improve their Frenchlanguage services. One of the corporate objectives of the plan is to consult the Acadian and francophone community to become more aware of the community s needs and to be better able to establish and prioritize French language services delivery. Tremendous progress has been made since the formation of the Réseau Santé Nouvelle-Écosse (RSNÉ) in 2004, which has as their mandate to enhance access to French-language health care services in Nova Scotia. The RSNÉ, has experience developing partnerships among all levels of government and coordinates projects for the purposes of increasing access to French language health services including, for example: Setting the Stage: A project that developed a plan for improving primary health care services in French. 1 Primary Health Care in Action: A project that expanded RSNÉ s partnership base; enhanced dialogue among the RSNÉ, government authorities and service providers; implemented the Setting the Stage action plan; and Pyra Management Consulting Services Inc. 1

facilitated knowledge sharing about the health of francophone communities. 2 The Directory of French Speaking Primary Health Care Providers in Nova Scotia: The development and multi-phase implementation of an online directory of French speaking primary health care providers (http://www.gov.ns.ca/health/frhcp/). 3 Involvement with various Primary Health Care Transition Fund projects such as the Youth Health Centres in Arichat, Chéticamp and École du Carrefour (Dartmouth). Carnet de santé pour les personnes âgées de 50 ans et plus (Health Handbook for people 50 +, Nova Scotia Edition) and related Health promotion workshops and conferences. Working collaboratively with health charities (e.g. Self-Help Connection, Caregivers Nova Scotia, Écoles santé (Health promoting schools initiative)) on health promotion projects / programs / materials for the Acadian and francophone population. Continuing to interact with other networks and with the Société santé en français (SSF) on multi-jurisdictional projects and on surveillance and evaluation of project work. The Project In 2009, the RSNÉ, in partnership with a steering committee made up of community stakeholders, leaders and decision makers, was funded by Health Canada through the SSF to carry out a project that would look at the development of community health impact assessment tools for both the urban and rural French-speaking minority populations in Nova Scotia. The project was undertaken in two broad components: one to be based on a rural population in the Guysborough-Antigonish-Strait area, and the other to work within the HRM as the largest urban community in the province. The key objective of this component of the project was to develop a Framework for Community Health Impact Assessment (CHIA) and to use the framework to assess the operational needs for a francophone health centre within the HRM as an application of the framework in an urban area. Specifically, the scope of the project included: 1. Conducting a brief background literature review to identify best and promising practices in the development of community health impact assessment tools. 2. Drawing from the literature review, and current practice throughout the province (e.g. the People Assessing Their Health PATH Community Health Pyra Management Consulting Services Inc. 2

Impact Assessment Tool - CHIAT) to develop a draft framework for community health impact assessment in the HRM. 3. Developing and implementing the necessary data collection tools to allow francophone community stakeholders within Halifax Regional Municipality to develop the health impact assessment for their community. 4. Using the framework to inform the preparation of appropriate input data for future analysis by the Department of Health s for Health Care Human Resources planning. 5. Preparing reusable tools, training materials and best practices information from the project for future use by the RSNÉ, particularly in being able to perform similar assessments for future policy issues facing the Frenchspeaking community of the HRM. The RSNÉ contracted Pyra Management Consulting Services Inc. (PMCS) to lead the delivery of the urban portion of the project. This report presents the results of that HRM based project. Project Methodology and Approach PMCS was the prime contractor for this work with Cottreau Consultants Ltée as a subcontractor. Together with the executive director of the RSNÉ they formed the project team that worked with the steering committee and the community to complete the work. To help guide the development of the framework, a steering committee made up of various representatives from the following government departments, institutions, community organizations and individuals was formed: Health Canada, NS Department of Health (DoH), Capital District Health Authority (CDHA), Conseil Scolaire Acadien Provincial (CSAP), Conseil communautaire du Grand- Havre (CCGH), Le Conseil de développement économique de la Nouvelle-Écosse (CDÉNÉ) and the RSNÉ. The project began with a literature review to establish the context of Community Health Impact Assessment and to determine the best practice starting point for such a project. The project team then led several collaborative meetings with the steering committee to guide the development of the CHIA tool to be used to actually carry out the assessment. A key element of this phase of the work was finding a way to engage the hard-to-reach urban francophone community and ensure consideration of their interests and issues without fatiguing them with seeming repetition of previous recent consultative efforts. Pyra Management Consulting Services Inc. 3

The Steering Committee intended the project to assess the need for a francophone health centre within HRM; however, significant effort was spent on reaching consensus with the steering committee on the wording of the issue or policy question to be used for the CHIA. Representative community members were then recruited to participate in the facilitated workshop to apply the CHIA Tool to examine the impact on the health of the French-speaking community of establishing a French-language community health centre in the Halifax Region. Participants in the workshop conducted an evaluation of the CHIA tool itself after completing the workshop. Workshop participants also pilot tested a needs assessment survey and provided feedback on that data collection tool to allow it to be used in a future initiative in the community to look at specific needs for a community health centre. The project team worked collaboratively together with the steering committee and other stakeholders throughout the course of the project, working both in French and English to take advantage of the expertise of team members and their comfort with the appropriate technical language of the health system. Multiple iterations of review and feedback with the steering committee were used to develop the project tools and materials. Final versions of materials were professionally translated and the facilitated workshops with community members were held in French to maximize cultural relevance and the value of the French-speaking community s input. Comments from participants and the observations of the facilitator were used to refine the project materials and the final versions were used to develop the reuseable tools, training materials and best practice information for future use by the RSNÉ. An independent evaluator was contracted to conduct an evaluation of the project. Results of the Literature Review Health Impact Assessment (HIA) is commonly defined as a combination of procedures, methods, and tools by which a policy, program or project may be judged in terms of its potential effects on the health of a population, and the distribution of those effects within the population. 4-8 Its aim is to inform the decision-making process in favour of health and health equity to maximize potential positive health impacts and minimize potential negative health impacts of a proposal. 9 Its primary output is a set of evidence-informed recommendations that will inform decision-making. 10,11 Pyra Management Consulting Services Inc. 4

HIA is a relatively young field that evolved out of the Environmental Impact Assessment (EIA) process when it was recognized that projects, programs and policies have not only environmental and social impacts, but also impact on the health of a population. 5,7,12-16 While HIA may still be one small component of an EIA, HIA has developed into its own comprehensive, stand-alone assessment of the impact of a project, policy or program on the health of a population. 5,15 HIAs are typically conducted in a staged manner. Different sources in the formal and grey literature describe a process involving anywhere from four to seven steps, depending on how each step is defined. Many sources, however, point to five main steps that are common to the HIA process. 5,8,9,14,16,17 They include: 1. Screening Assessing the policy or project to determine whether or not an HIA is necessary and/or the depth of HIA that is required; 2. Scoping Determining the various issues that must be addressed in the HIA, what information is needed to conduct the HIA, who should be involved in the process; 3. Assessment Gathering and considering the evidence, which is ideally gathered from a number of sources. Assessment can involve a variety of methods such as community profiling, policy analysis, literature review, stakeholder engagement through interviews, focus groups, and workshops for example; 4. Reporting - Development of the HIA report and recommendations; and 5. Monitoring and Evaluation Assessment of the HIA process itself (process evaluation), whether or not the recommendations were accepted/implemented (impact evaluation) and whether or not the implemented decision/policy had an impact on health outcomes (outcomes). The HIA process is guided by four principles or values that are commonly identified in the literature. 4,8,9,11,14,15 These include: Democracy - the right of people to participate in the formulation of and decisions related to projects, programs, policies that affect their lives ; Equity - the desire to reduce inequities that result from differences in the health determinants and/or the health status within and between different population groups ; Sustainability - recognizing that development meets the needs of the present generation without compromising the ability of future generations to meet their own needs ; and Ethical use of evidence transparent and rigorous processes are used to synthesize and interpret the evidence, that the best available evidence from Pyra Management Consulting Services Inc. 5

different disciplines and methodologies is utilized, that all evidence is valued, and that recommendations are developed impartially. The North American HIA Practice Standards Working Group and the International Association for Impact Assessment also identify comprehensive approach to health as a fifth principle, recognizing the broad range of factors that affect health and the need for the HIA process to be guided by the broad determinants of health. 11,14 The HIA process may vary in depth or level of comprehensiveness. A desk-top HIA is conducted very quickly, uses few resources and considers only evidence that is very easily available. 9 Rapid HIA involves a broader range of evidence but still uses limited resources and is completed within a short timeline. 9 Comprehensive HIA is in-depth and takes a longer period of time and more resources to conduct. 18 What is most important is that the type of HIA conducted desk-top, rapid or comprehensive corresponds to the complexity of the project, policy or program at hand, the potential scale and severity of the possible health impacts, the quality of evidence available for consideration, the resources available to conduct the HIA and locally determined health priorities and targets. 9 The HIA process can also take place at varying times throughout a project, program or policies development. Prospective HIA is conducted when a proposal is being developed. It has the potential to influence decisions that will be made. 8,9,15,16 Concurrent HIA takes place while the project, program or policy is being implemented and is useful in informing a review process. 8,9,15,16 Retrospective HIA is carried out after implementation and is useful when planning similar programs or policies. 8,9,15,16 Therefore, in determining the timing of an HIA, it is important to understand the intended purpose of the HIA. 8,9,15,16 Even though each has its place and value within the HIA process, the literature indicates prospective HIA as the preferred type of HIA. 8,9,14,15,19,20 The North American HIA Practice Standards Working Group summarizes the general practice standards for HIA as follows. The HIA process should: include, at a minimum, the five stages outlined above; start with explicit goals and should be evaluated against those goals; respect the needs and timing of the decision-making process; provide meaningful and inclusive stakeholder participation at each stage; be prospective, ideally; and when feasible, be part of an integrated assessment process (i.e. environmental assessment) to avoid redundancy. 14 Pyra Management Consulting Services Inc. 6

Community Health Impact Assessment Despite the North American HIA Practice Standards Working Group s standard related to meaningful and inclusive stakeholder participation at each stage in the HIA process, a 2008 systematic review and comparison of HIA frameworks identified that there is significant variation among HIAs with respect to the extent of community participation. 13 The extent of participation ranges from providing input through focus groups or workshops, to actually leading the HIA process. 13 The Community Tool Box, a recognized global resource for free information on essential skills for building healthy communities, notes that a truly participatory process is one in which all stakeholders are represented, and in which their role is significant, rather than just symbolic. That means that they actually take part in the planning and monitoring of the HIA, as well as in helping to formulate recommendations. 8 By its definition, stakeholders include: Those who are directly affected by the proposed action or policies; Those who are involved in carrying out the proposed action of policies; No profit and non-governmental organizations (NGOs) concerned with the issued and;/or the population affected; Advocacy groups; The decision makers themselves; Government agencies that have responsibility for the issues and/or populations in question; Representatives of other sectors that are affected by the proposal; Health workers at local, national or international levels; Employers and unions; Those who commission and/or fund HIA; and Those who conduct the HIA. 8 At the end of the spectrum where the community actually leads the HIA process is Community Health Impact Assessment (CHIA), which is a facilitated process that engages a community in developing its own unique assessment tool (CHIAT) and empowers that community to initiate its own impact assessment. Both the assessment tool and the assessment process reflect that community s values, beliefs and vision of what a healthy community should look like it brings the community s perspective, through the priority and value lens of the community members themselves. 21 The process of CHIA is not used to determine if a policy or program is right or wrong for a community, rather it is used to identify how a particular program, policy or activity will improve or diminish the factors that a community believes Pyra Management Consulting Services Inc. 7

are important to its health. 22 Similar to general HIA, CHIA is felt to be most effective if it takes place prior to program, policy or activity implementation. 22 While typically used by a community or a community-level organization or authority, the process may be used by any organization that is concerned about the impact of a policy, program or activity on the health of a particular community. 22 It should be noted as well that the CHIA process may result in the development of a community health impact assessment tool (CHIAT) or resources that can be used to assess policies, programs and activities. 22 It is the process of increasing community awareness of the many factors that affect their health and the possible role of the community on creating healthy public policy is seen as the most important outcome of the process as compared to the development of a CHIAT. 22 There is no one correct way to conduct a CHIA. However, the limited literature that points to CHIA specifically, as compared to HIA in general, often identifies Nova Scotian efforts at CHIA as a successful model. 12,21,23 These experiences have typically involved six basic steps that include: 1. Answering the question What does it take to make and keep our community healthy? ; 2. Developing a Vision of a Healthy Community ; 3. Indentifying the factors that contribute to the vision; 4. Designing the tool; 5. Testing the CHIAT and make revisions; and 6. Making a plan to use the CHIAT. 22,23 Community Health Impact Assessment in Nova Scotia Nova Scotian efforts at CHIA have largely involved the People Assessing Their Health (PATH) process. The PATH process was designed to increase the capacity of people at the community level to become informed and active participants in planning and decision-making related to health and to the wide variety of supports and services that are necessary to ensure the well-being of individuals and communities. 21 Originally begun in the late 1990s when health planning was devolved to the regional and local levels in Nova Scotia, the original PATH I project involved three communities in northeastern Nova Scotia using a structured dialogue approach to identify factors influencing their health and envision the kind of communities in which they wanted to live. 21,23 The communities also developed tools to assess the impact of programs and policies on the health of their communities. 22 This project raised awareness about the determinants of health and engaged citizens in the creation of healthy public policy at the community level. 22 An important aspect of PATH I was its Advisory Committee, which, in 1997, evolved into the PATH Network, an informal association of people from community-based organizations, health boards and Pyra Management Consulting Services Inc. 8

universities whose shared vision was to build healthier communities and increase understanding of the determinants of health. 22 In 2000-2002, PATH II s goal was to increase the capacity of people at the community level by developing processes and tools for community health impact assessment that would enable informed decision-making in community level health planning. 22 As such, PATH II used a facilitated process to engage communities in developing their own unique CHIAT. In 2003 and 2006, the PATH process was used in two rural communities in West Bengal, India, broadening its application to other venues and cultures. 23 In 2008, the PATH Network collaborated with the National Collaborating Centre for Healthy Public Policy to identify the conditions necessary to support community-driven health impact assessment and ways to move forward in this area. 22 As part of this work, three workshops were hosted over an eleven month period. 22 One of the outcomes of the workshops was, based on Nova Scotia s twelve years of experience, the identification of several lessons learned related to using the PATH CHIA process. These lessons learned are key considerations for informing future CHIA efforts in Nova Scotia. They include: People are the main assets at the community level; Everyone can play a role in assessing their health; CHIA allows people to look at different sides of an issue without conflict; The PATH Process can work anywhere - it is adaptable to different cultures and contexts; PATH allows people to use their own words to define what determines their health and to use their own priorities to look at the impact things will have on health; Providing support for local facilitation is a priority and this should be seen as an investment in the community; The process is empowering and builds community capacity; In developing the tool, it is important to ensure representation from every sector of the community; A participatory evaluation process should be built in to every project; Community-driven health impact assessment is a way for decision-makers to gather community input; CHIA is an effective advocacy tool; The PATH Process and CHIA help people to develop a broad understanding of health; Pyra Management Consulting Services Inc. 9

The length of time it takes to go through the PATH Process, as well as the time it takes to conduct a CHIA sometimes presents a challenge for communities; Although it is possible to adapt a CHIAT developed by another group or community, the biggest value comes from going through the process of building your own CHIAT; and A CHIAT does not have to be used for every issue that a community faces, just for the big issues. 22 With respect to the conditions that support community-driven health impact assessment, lessons learned included: CHIA requires a good facilitator; someone who is seen as objective; There needs to be some common desire or predisposition to achieve community ends; Timing is important; the process is best used at the beginning of policy development or when a project or service is not fully defined; The process requires some financial support; Decision-makers needs to understand the value of community input; The process requires a significant time commitment of the part of the participants; It is important to know who it is that should be influenced if CHIA is to have an impact on decision-making; and The community needs to have some common goals. 22 Many of the above noted lessons learned were also identified in the conference proceedings of the 29 th Annual Conference of the International Association of Impact Assessment. It should be noted that while PATH is a recognized process for CHIA in the literature, it is not a system-wide funded process in Nova Scotia. The PATH Network, has, from time to time, received funding from various federal and other sources to undertake the specific PATH activities. Based on the results of this literature review, the project team decided to use the PATH process for the CHIAT development and implementation in the HRM. Pyra Management Consulting Services Inc. 10

CHIA Development Process Using the PATH process and considering the lessons learned by past implementations, the project team engaged the steering committee to identify the best approach to CHIAT development, as well as the appropriate mechanisms to reach stakeholders and the best means of engaging them both in the CHIAT development and in the application of the tool to the test case. The Dartmouth Community Health Board of Capital Health recently held community consultations with respect to the healthcare needs of the urban francophone community 24, and these results, as well as those of the RSNÈs own recent community consultations 25 were considered inputs to the process. The steering committee was particularly interested in conduct of a needs assessment rather than a CHIA, however an understanding of the use and value of both approaches was developed resulting in an effective plan to engage the community without fatiguing them. The facilitator drew upon past experience within the community with the efforts made in the early days of developing the Conseil Scolaire Acadien Provincial (CSAP) system using the appropriate tools and approach for health impact assessment. Recent efforts within the community to conduct a broad consultation in order to develop a Community Development Plan 26 served to provide the Steering committee with considerable food for thought as that plan presents the community s own vision of a healthy and robust francophone community in HRM. The project team outlined the purpose and approach to the CHIA process and explained the broad determinants of health. 27 The Steering Committee quickly determined that not only was there some similarity in the effort undertaken to build the Community Development Plan but in fact that the Community Development Plan itself would serve as a blueprint for the CHIA framework to be developed since it already addressed many of the same underlying factors of a healthy community. The project team constructed a draft CHIA tool based on the structure and areas of impact documented in the Community Development Plan and reviewed it with the steering committee to collaboratively develop their CHIA Tool, representing the broad community point of view without requiring a separate consultation series. The results of the review/discussion were then incorporated into the draft CHIAT and a final version produced in English and French, ready to conduct the assessment (see Appendix 1). The four basic steps of the CHIA process were then undertaken: 1. Choosing what to assess. 2. Preparing for the meeting. Pyra Management Consulting Services Inc. 11

3. Facilitating the CHIA discussion using the CHIAT by working through the assessment worksheet and completing the summary worksheet. 4. Identifying next steps. Using the CHIAT Choosing What to Assess After considerable dialogue the specific question was developed for assessment using the CHIAT. The debate around the impact question to be assessed centred on whether the impact assessment should only look at development of a community health centre, or whether it should more broadly consider various potential mechanisms to improve access to healthcare services for francophones and Acadians within HRM. It was agreed, in keeping with the guidelines of the PATH process 28 constrain the question being reviewed to be specific rather than general and therefore focus on development of a community health centre. It was also agreed that the CHIA and a needs assessment were two separate activities. Therefore the project team would build on previous work of select steering committee members and lessons learned from a Community Health Centre needs assessment conducted in Lemecque, N.B. 29 to construct a needs assessment survey that would be pilot tested as a data collection instrument in support of planning for a future Community Health Centre after the CHIA session was completed. The CHIAT was populated with the question Will establishing a French-language community health centre in the Halifax region have an impact on the following areas? Preparing for the Meeting The facilitator was intimately familiar with eth CHIAT, having been engaged in the process of its development with the Steering Committee and having previously been involved in the development of the Community Development Plan. A review of all the CHIAT materials was conducted to prepare a briefing presentation for participants (see Appendix 2). Participants were recruited collaboratively starting with the suggestions of the Steering committee and the contact information provided by both the RSNÉ and the CCGH for community representatives spanning a broad cross section of the French-speaking community. Part of the challenge of the process was the lack of a well defined community to engage and that challenge was reflected in the participant group. There was little representation from French-speaking recent immigrants, although it did include, youth, seniors, women, family members, professionals and both French speaking people from outside of Nova Scotia as well as Acadians and francophones. Pyra Management Consulting Services Inc. 12

Facilitating the CHIA Discussion Once the participants arrived for the CHIA Session, the project team provided a brief background presentation to introduce the process, explain the concept of healthy community and to set the context in terms of the broad determinants of health and the specific question to be considered. The facilitator then worked through the assessment worksheet with a note taker recording comments in real time and projecting them so that all participants could ensure that the record accurately captured their input. The session was conducted in French and resulted in the completion of the summary worksheet. The results of the session were summarized in a raw data report of the proceedings (see Appendix 3). Results of the CHIA Process The results of completing the CHIA worksheet support that the community views establishment of a community health centre as an overwhelming positive step towards improved health of the community. The participants felt that such a centre would enhance community identity, bringing people together and providing new members of the community an avenue to increased engagement and a sense of belonging. It was also viewed as a potential catalyst to strengthen interactions among francophone organizations within the community. Finally, participants indicated that establishing such a centre would better position the French-speaking community within and alongside its predominantly Anglophone environment, increasing recognition, equality and political voice for the francophone community. Some of the comments from participants after the session suggested that they felt the tool itself leaned toward identifying positive impacts; however since the tool only lists a broad collection of potential impacts, it is more likely a result of the nature of the bias of participants some of whom have been advocating such a health centre for years. One participant commented on the importance of coming together to obtain our health centre, suggesting that bias. Identifying Next Steps The participants in the CHIA session identified the following next steps based on their discussions: that the community be kept up to date on the evolution of the project; that there be further research into community needs and interests; that there be research among military families(to identify needs); and that the Steering Committee prioritize impacts based on the CHIA, and then use that prioritization in planning any implementation of services. Pyra Management Consulting Services Inc. 13

For example, when the response to an impact is yes, establish the priority according to a scale similar to the following: o Major positive impact o Significant positive impact o Weak positive impact o Weak negative impact o Significant negative impact o Major negative impact. The Steering Committee also identified an immediate next step of using the participants of the CHIA session to undertake a pilot test of the Needs Assessment Survey. Feedback from the pilot test participants was used to revise the first draft of the survey and to produce the final version of that survey in English and French (see Appendix 4). As a follow up to the project, the RSNÉ and the CCGH are working with the Steering Committee to roll out the survey to the community. Data and Reusable Materials Data Intended results of the project included the development of data suitable for input to the Department of Health s statistical model of Health Care Human Resources planning. However the nature of the impact assessment conducted did not lead to identification of any particular human resources planning data suitable for input to that model. The Steering Committee is committed to working with the RSNÉ on the ongoing planning of the Health Human Resources needed to improve access to health care for French-speaking people in Nova Scotia, and the RSNÉ remains engaged collaboratively with the Department of health in the planning to meet those needs, including the training and recruitment of French-speaking health care professionals. Reusable Materials Reusable materials that the RSNÈ can further develop for use in the future for specific impact analyses and to build capacity both within its own organization and within the community were developed in the form of the CHIAT worksheet itself (Appendix 1), the briefing presentation for participants (Appendix 2), the facilitator s guide to conducting a CHIA (Appendix 5), and the needs assessment survey that is ready for deployment (Appendix 4). The CHIA worksheet could be fine tuned based on the participant feedback comments. For example, one participant noted that the worksheet seems to exclude child and adolescent respondents suggesting that a revised CHIA tool Pyra Management Consulting Services Inc. 14

may be needed to incorporate any direct engagement of youth. There were several suggestions that the tool could be condensed or simplified by combining some of the impacts. We suggest that the broad set of impacts be left within the tool and that during the CHIA session itself the facilitator use that broad list to engage participants to consider all areas of impacts. Condensing impacts may lead participants to not explicitly think of the potential for affecting particular areas of impact. However, if the tool is customized or fine tuned to meet specific participants expectations there may be a way to balance this. Finally, the RSNÉ did not have the resources available to present the entire background and rationale of the issue under assessment in French. Future sessions should ensure a complete French language presentation. The specific findings of the CHIA session will guide the ongoing planning and development of a business case for a Community Health Centre. Pilot Needs Assessment Survey The needs assessment survey was developed from a previous survey conducted in Lemecque, N.B. 29 The participants in the CHIA session were asked to act as a pilot test group for the survey. The specific feedback from participants is included in Appendix 7. The survey itself was updated based on this feedback and will be used as a follow on to this work. Conclusions The following conclusions were drawn from this project: The CHIA worksheet and materials produced in this project will provide a common framework for the RSNÉ to investigate future policy issues within the HRM French-speaking community. The use of the CHIA Tool to examine the impacts of establishing a French-speaking Community Health Centre indicated that this would have a positive effect on the health of the community although it seemed a foregone conclusion to many of the participants. Since the francophone and Acadian community has no such community health centre today, it would clearly have a positive impact upon them. The overall impact to the larger diverse HRM community was not within the scope of this project and may have yielded a different result. For instance, if limited resources and the potential for competition among various facilities within Capital Health were considered. The place of the community in question within the larger context must therefore be considered because if benefits or positive impacts will be realized by one Pyra Management Consulting Services Inc. 15

community and costs or negative impacts borne by another the CHIA Tool will not necessarily consider this and could result in polarizing conflict between the elements within the larger group. Pyra Management Consulting Services Inc. 16

Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 RSNÉ Community Health Impact Assessment Tool Briefing for CHIA Participants Raw Data Report of the CHIA Proceedings HRM French Language Community Health Centre Needs Assessment Survey CHIA Facilitator s Guide Participant Evaluation of CHIA Sessions Participant Evaluation of Pilot Test Survey Pyra Management Consulting Services Inc. 17

Appendix 1 - RSNÉ Community Health Impact Assessment Tool COMMUNITY HEALTH IMPACT ASSESSMENT TOOL Community health impact assessment is a way to bring the health concerns of the community forward in discussions of public policy. It allows us to estimate the effect that a particular activity (a policy, program project or service) will have on the health of the community). It suggests things we can do to maximize the benefits (the positive effects) and minimize the harm (the negative effects) of that activity. 1 Community health impact assessment helps to identify how a policy decision will affect the many things that a community considers important for its health and well-being. This community health impact assessment tool has been created to assist the Acadian and francophone community in the Halifax Regional Municipality in assessing the impact of policies and programs upon the health of our community. In 2009, our community participated in an extensive consultation process to develop a Community Development Plan. Through that process, we identified a number of factors that we as a community believe are important for the health and well-being of our community. Additional information about what we believe to be the main factors determining our community s health was gathered through community and youth consultations held by the Réseau Santé Nouvelle-Écosse and a community conversation held by the Capital District Health Authority, both held in 2009, as well as previous work done by the Réseau Santé Nouvelle-Écosse on health services planning for the francophone and Acadian community in Nova Scotia. We used all of this information about what our community views as important for the health and well-being of our community to develop this community health impact assessment tool. The tool lists many factors that must be assessed to determine the impact of a proposed policy or program on our community. The tool will not tell us if a policy decision is right or wrong. But it will give us information about the potential negative and positive impacts of any specific policy decision, and help to contribute to the final decision-making process. It is our hope that this tool can be used to help examine the impact of a wide variety of policy questions on the health and well-being of our community. It may be that not all of the factors listed in the tool are relevant for every policy question. 1 Antigonish Town and County Community Health Board. (2002). Community Health Impact Assessment Tool: Planning for a Healthy Community. http://www.antigonishwomenscentre.com/pdfs/antiognish%20chiat.pdf. The format for the tool was adapted from this resource as well. Pyra Management Consulting Services Inc. 18

Using the Tool For any policy, program or project decision that may have a significant effect on the overall health of the community, a small group made up of community members representing those who will likely be impacted the most by the decision can work together using this tool to assess the overall impact on the community s health. The group should appoint a facilitator for the meetings. The process for facilitating a community health impact assessment process is described in the Appendix. The group should examine each of the factors separately, seeking additional information if required. Once the group has examined all of the factors, they complete step 2 of the tool. This is where the group discusses the overall potential harms and benefits of the policy or program. The process ends with a discussion about next steps. Pyra Management Consulting Services Inc. 19

I. OUR POPULATION: Immigration/migration Will have an impact on the following areas: 1. Migration of French-speaking people into the area 2. Migration of French-speaking people out of the area 3. Retention of French-speaking people who have migrated here 4. The ability to be supportive of other programs aimed at immigrants 5. Orientation services for new arrivals Positive YES Negative NO or Neutral NEED MORE INFO COMMENTS Pyra Management Consulting Services Inc. 20

I. OUR POPULATION: Youth and Young Adults Will have an impact on the following areas: 1. Strengthening the sense of community among youth and young adults 2. Supporting youth in the management of their own health 3. Providing a way of continuing to engage youth 4. Retaining youth within the community (influencing their choice to stay here) 5. Addressing youth health needs in a way that is youth centred 6. Supporting youth programs and services 7. Providing support to parents to communicate with and understand the concerns of youth 8. Providing a safe space to address youth s mental health needs 9. Supporting youth in physical activity programs (not just organized sports) 10. Supporting youth in nutrition programs Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS 11. Empowering youth with the tools to make wise choices 12. Providing support for teen pregnancy needs 13. Providing support for teen addiction needs 14. Providing support for teen sexuality needs Pyra Management Consulting Services Inc. 21

I. OUR POPULATION: Families Will have an impact on the following areas: 1. Bringing families together Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS 2. Attracting French-speaking families to the area 3. Retention of French-speaking families in the area 4. The ability to be supportive of other programs aimed at families 5. Supporting family needs across the life cycle 6. The ability to support families that may be widely spread across the geography 7. Families abilities to manage their own health 8. Coordination with other services e.g. Mental Health Services, IWK etc. 9. Access to mental health services and information 10. Access to health information and health promotion information appropriate for families 11. Access to caregiver support 12. Assisting families with special needs 13. Assisting families with physical disabilities 14. Providing services for early childhood development Pyra Management Consulting Services Inc. 22

15. Providing support for family resource centres 16. Providing support to single parent families II. OUR SPACE: Infrastructure Will have an impact on the use of the following: 1. CCGH facilities Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS 2. Other Francophone organizations facilities, community based agencies, etc. 3. CDHA/IWK facilities 4. Université Ste-Anne 5. Other schools 6. Existing (whether French speaking or not) Youth Health Centres 7. Existing private health care practices/clinics 8. Existing mobile/other outreach services 9. Current projects of other groups 10. Businesses Pyra Management Consulting Services Inc. 23

II. OUR SPACE: Health and well being Will have an impact on the following areas: 1. Building capacity within the community for future health project planning, implementation, management and evaluation 2. Reducing the stigma associated with mental health needs 3. Raising the profile of existing French language health services 4. Strengthening the coordination of planning, delivering and evaluation of French language health services 5. The expansion and ease of maintenance of the directory of French speaking health care professionals 6. Supporting ongoing development of French language service plans as required by government regulations (e.g. for DHAs) 7. The tele-care/tele triage system (811) Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS 8. The Bonjour! Program 9. Accessing health information and health promotion materials 10. Raising awareness among decision makers regarding the needs of the community 11. The ability to hold decision makers accountable for delivery of health and well-being related services 12. Access to health care providers 13. Access to collaborative health care delivery 14. Access to oral health care/services Pyra Management Consulting Services Inc. 24

II. OUR SPACE: Seniors Will have an impact on the following areas: 1. Organized seniors groups Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS 2. Seniors who are not part of an organized group 3. Events (e.g. seniors games) 4. Support services (e.g. VON, meals on wheels) 5. Existing care facilities 6. Providing support for families 7. Other seniors programs 8. Transition services to help move seniors to care facilities 9. French language staffing and services within facilities 10. Support for the planning and implementation of seniors accommodation and assisted living Pyra Management Consulting Services Inc. 25

II. OUR SPACE: Education Will have an impact on the following areas: 1. Preschools Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS 2. Schools 3. Universities other than Université Ste-Anne 4. Université Ste-Anne 5. Student societies/unions/councils 6. Other education facilities (e.g. private colleges, training institutes) 7. Nova Scotia Community College 8. Existing health education, schools and programs (primary and continuing) 9. Supporting the organizing of conferences (e.g. mini colloques) 10. Dalhousie Medical School including Continuing Medical Education 11. Other professional education programs including continuing education 12. Continuing and community education programs 13. Health promotion within schools 14. French language education for health professionals (Terminology and conversational) Pyra Management Consulting Services Inc. 26

15. Access to existing or creation of new scholarships and other educational incentives 16. The ability of people to access and understand health information regardless of their level of literacy II. OUR SPACE: Women Will have an impact on the following areas: 1. Access to women`s health services such as menopause, breast health and well woman clinics in French 2. Access to French language screening services such as breast and PAP screening 3. Access to French language pre and post-natal services and information 4. Access to French support groups (e.g. for violence or problems with children) 5. Access to French language healthy lifestyles and nutrition information 6. Tracking and research on francophone women`s health Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS Pyra Management Consulting Services Inc. 27

II. OUR SPACE: Economics Will have an impact on the following areas: 1. Levels of income in the community in general 2. Levels of income for seniors; low income and single parent families, people who are chronically, physically or mentally ill, people with disabilities who require assistance to live independently 3. People s ability to purchase adequate, nutritional food for all members of the household 4. Availability of safe, affordable housing Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS II. OUR SPACE: Employment Will have an impact on the following areas: 1. The quality of work and working conditions (including pay equity) 2. Local employment opportunities for francophones 3. Retention of French speaking professionals 4. Attraction of French speaking professionals 5. Implementation of bilingual position policies (e.g. availability of bilingual staff in health facilities such as nursing homes, pharmacies, etc.) 6. Promoting and supporting French and bilingual employment opportunities Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS Pyra Management Consulting Services Inc. 28

II. OUR SPACE: Environment Will have an impact on the following areas: 1. Environmental regulations and standards Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS 2. Exposure to harmful substances 3. Protection and responsible management of natural resources 4. Air and water quality within the community 5. The ability to support broader environmental initiatives (e.g. carbon trading) 6. Recycling, composting, etc. Pyra Management Consulting Services Inc. 29

III. OUR Culture and Identity Will have an impact on the following areas: 1. Use of or access to the local media by the francophone community 2. Increased francophone media Positive YES Negative NO Or Neutral NEED MORE INFO COMMENTS 3. Access to Internet-based information in French 4. Access to telephone based information in French 5. Reinforcement of the Acadian/francophone cultural identity 6. Support for French language arts and culture programs 7. The ability to address the tendency of Seniors and persons in stressful situations to revert to their mother tongue Pyra Management Consulting Services Inc. 30

IV and V. OUR Leadership and Organizational Capacity Will YES have an impact on the following areas: Positive Negative 1. The development of leadership skills within the community 2. The ability to influence municipal, provincial and federal government policy and decisions 3. The ability to influence DHA policy and decisions 4. Ongoing community development programs and initiatives 5. Future community development programs and initiatives 6. The ability to form and strengthen partnerships 7. Ongoing change management within the health system (e.g. primary care renewal, collaborative practice models, etc.) NO or Neutral NEED MORE INFO COMMENTS Pyra Management Consulting Services Inc. 31

Step Two Once you have considered the impact of the proposed policy or program on all of the factors contributing to the community s health and well being, your group needs to summarize the overall impacts. For each of the sections of the community health impact assessment tool, your group will develop statements of overall impact. This is not just a simple matter of tallying up the number of positive and negative impacts in each section, because your group may consider some of the factors to be more important than others. An example of an overall impact statement is: Generally positive, but special attention needs to be paid to... or Overall there is a negative impact in this area. If the program is implemented as planned it may have a negative effect on this aspect of our community s health. Page Category Overall Impact 3-5 Our population 6-15 Our space 16 Our culture and identity 17 Our leadership and organizational capacity Pyra Management Consulting Services Inc. 32

Next Steps Based on the result of the summary of assessment, your group can now identify next steps. What is going to be done with the results of the community health impact assessment? The table below can help you organize and keep track of your actions steps. Next Step (What are we going to do?) Who Will be Involved? When? Person Responsible for Making Sure it Happens Report Back to Group by When? Pyra Management Consulting Services Inc. 33

Appendix 2 - Briefing for CHIA Participants Évaluation des impacts sur la santé communautaire acadienne et francophone de la RMH La création d un outil, son utilisation et l analyse des résultats! Jim Pyra et George Cottreau Pyra Management Consulting Services Inc. 13 avril 2010 Slide 1 Évaluation des impacts sur la santé communautaire (Community Health Impact Assessment) L évaluation des impacts sur la santé communautaire (EISC) prescrit qu une COMMUNAUTÉ détermine elle-même les éléments qui lui sont importants pour sa santé. Le processus repose sur une approche santé globale de la population ayant comme racines les déterminants de la santé. C est un processus qui fournit l information nécessaire pour arriver aux décisions fondées sur les priorités de la communauté. Slide 2 Déterminants de la santé Santé Canada identifie 12 déterminants de la santé. Ils sont identifiés dans le Plan de développement communautaire de la région de Halifax. 1. le niveau de revenu et le statut social; 2. les réseaux de soutien social; 3. l'éducation et l'alphabétisme; 4. l'emploi et les conditions de travail; Slide 3 Déterminants de la santé 5. les environnements sociaux; 6. les environnements physiques; 7. les habitudes de santé et la capacité d'adaptation personnelles; 8. le développement de la petite enfance; 9. le patrimoine biologique et génétique; 10.les services de santé; 11.le sexe; 12. la culture. Slide 4 Pyra Management Consulting Services Inc. 34