Introduction

The Ontario Ministry of Health has identified health equity as a key component of quality care.1 Health equity involves all people reaching their full health potential without disadvantages caused by social position or circumstances.2 But what does health equity look like in practice, why does it matter, and how does it apply to different roles within healthcare?

Globally, nationally, and provincially there is greater awareness of the need to address social inequities. As Ontario responds to this need, there has been an increased demand for tools and resources to better identify and mitigate health inequities within the healthcare system. Having healthcare leaders mandate health equity training and support its delivery to all staff is a key step in the process of providing more inclusive and equitable services. Once this foundation is created, organizations can engage in dialogues about how health equity can be put into practice. This can include making it a topic at staff meetings, sharing information in internal staff communication, and establishing health equity indicators within the organization.

Health equity training is part of a toolbox of resources that organizations can use to create a consistent baseline understanding and to ensure that all staff are able to implement strategies that provide more equitable healthcare. The implementation of health equity training may look different from one organization to another. However, the principles outlined in this document are valuable elements of effective health equity training. 

Health Equity in Context

Health equity training is one tool among many, and alone it will not be effective. Rather, the effectiveness of health equity training requires a comprehensive effort to address equity within an organization. This effort would include a strategic plan that looks at equity at all levels of an organization. To support the work of equity within an organization, this plan should encompass a range of factors, including leadership and human resource policies and procedures.3 In developing a larger equity strategy, an organization should identify a set of key components and trainings that are needed to create a safe and equitable healthcare setting.

Who We Are

The HEIA Champions group represents a number of Ontario healthcare organizations who are dedicated to championing the use of the Ontario Ministry of Health’s HEIA, a practical tool for identifying and improving the health equity impacts of initiatives. The HEIA Champions group also aims to embed health equity principles throughout the healthcare system. 

How we arrived at these promising practices

In this document, we share what we have learned from our extensive, collective experience developing and implementing health equity training for our own organizations and for other healthcare agencies. However, it’s beyond the scope of this document to provide a review of the literature on health equity training. By sharing what we have learned in our work, we hope to help other healthcare organizations enhance the work they are doing to support the advancement of health equity in the province.

Organizational Climate

Organizations need to support their health equity training for it to be most effective. We recommend that organizations create a health equity training committee comprised of senior leaders and direct-care staff to develop a strategic plan for fostering health equity broadly within the organization. Part of the work of this committee is to establish expectations for health equity-related behaviour within the organization. In turn, these behaviours can lay the foundation for health equity indicators, which may be evaluated or included in employee performance reviews. Mandatory training and tailored training for teams and management are also ways that organization can support a more equitable workplace climate.

Healthy Equity Training in Context

When embarking on health equity training, it is important for leadership to first assess if there is capacity to follow through on the larger aims of the training. This may include having the capacity to coach employees and create an environment that will support equity within the organization.

Health equity training is most effective when it is focused on developing the competencies of participants. There should be a stepped progression in developing these competencies from “Knows,” to “Knows how,” to “Shows,” and ultimately to “Does”.4,5

Health equity training provides the opportunity for the participant to “know” the facts about health equity and to “know how” to apply this knowledge. This allows them to “show” how to apply their learning and finally to apply the knowledge (i.e. the “Does”) within the workplace.

Competency and Evaluation Based Training

Furthermore, to help learners develop these competencies, it’s recommended that the objectives of the training include specific and measurable behaviours that will be changed through the training program.6 This enables an organization to measure the effectiveness of a session and identify potential areas for improvement. The behaviours identified for change can also be measured before training begins to establish a baseline for comparison and then measured again at appropriate intervals after the training. This process allows for follow-up training or support that is specific to any gaps or challenges that participants might face.

Health equity training in context

In addition to evaluating training, organizations should have a plan in place to access their broader equity strategy. This evaluation can be an iterative process in which insights from evaluation can lead to further organizational change

Tailored Curriculum

The content of health equity training is best when it is tailored to the needs of the participants. Training developers can determine these requirements through a needs assessment prior to designing the training. Information for a needs assessment can be gathered through surveys and key informant interviews and include the following:

• Participants’ baseline knowledge of health equity
• The context of participants’ work and how health equity relates to their job
• The participants’ perceived learning needs.

While general health equity principles provide a foundation to build upon, it is essential that training also includes content specific to participants’ workplace roles and responsibilities. This content makes the training more meaningful and engaging, fosters applied learning, and creates an opportunity for team-building and cohesiveness.8,9

However, the following are some important topics that health equity training should include:

• racism
• power and privilege
• intersectionality
• disability.

Moreover, the training should address the following vulnerable and marginalized populations:1

• age specific groups
• Indigenous peoples
• people with disabilities
• Ethno-racial populations
• Francophone communities
• homeless individuals
• linguistic communities
• low income people
• religious and faith communities
• rural and remote populations
• women
• LGBTQ+ people.

Interactive and Applied Approach

Considerations about Safety

Include Follow-up

Conclusion

References

1. Ontario Ministry of Health and Long-Term Care. (2008). Health Equity Impact Assessment. Ontario Ministry of Health and Long-Term Care. 
2.  Ontario Ministry of Health and Long-Term Care. (2018). Health Equity Guideline, 2018. Queen’s Printer of Ontario.
3.  Wyatt R., Laderman M., Botwinick L., Mate K., & Whittington J. (2016). Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.
4. Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic medicine, 65(9), S63-7.
5. Moore, D. E., Green, J. S., & Gallis, H. A. (2009). Achieving desired results and improved outcomes: Integrating planning and assessment throughout learning activities. Journal of Continuing Education in the Health Professions, 29(1), 1-15.
6. For further discussion about developing specific and measurable training objectives, see: Mager, R. F. (1984). Preparing Instructional Objectives. 2nd Edition. Belmont, CA: Pitman Management and Training.
7.  For more information on assessing training needs, see: University of Toronto Faculty of Medicine Continuing Professional Development. (2020). Quick tips: Methods of assessing learning needs (No. 5; Program Design Series). University of Toronto. 
8.  Campbell, C., & Sisler, J. (2019). Supporting Learning and Continuous Practice Improvement for Physicians in Canada: A New Way Forward. Ottawa: The Future of Medical Education in Canada–Continuing Professional Development.
9.  Asher, A., Kondziolka, D., & Selden, N. R. (2009). Addressing deficiencies in American healthcare education: a call for informed instructional design. Neurosurgery, 65(2), 223-9.
10. For a review of the literature on the concept of psychological safety, including with respect to job performance and organizational learning, see: Edmondson, A. C., & Lei, Z. (2014). Psychological safety: The history, renaissance, and future of an interpersonal construct. Annual Review of Organizational Psychology and Organizational Behavior, 1(1), 23–43.