The Health Equity Impact Assessment: A Case Study in COVID-19 Visitor Policy

Visitor restriction policies have been common place in hospitals during the COVID-19 pandemic as infection control measures. In many pediatric hospitals, this included limiting to 1 caregiver at a child’s bedside, even in complex circumstances.⁴  In hospitals with infection control measures that include visitor restrictions, rates of nosocomial COVID-19 have been low, although these interventions are grouped with others, so the positive impact of visitor restriction policies alone remains unknown.⁵ 

Although these policies are believed to decrease the spread of disease, they are not without harms. For all families, visitor restriction policies can be a barrier to family-centered care.⁴  Visitors, such as parents, guardians, grandparents, and siblings, can be essential components of the pediatric care team, and their presence can influence physical and mental health outcomes.^6,7  During the COVID-19 pandemic in particular, restricting visitors at the bedside can negatively impact patient and family experiences, safety outcomes, and care quality.⁸ 

In addition, visitor restriction policies may impair family functioning.⁹  They represent an increased barrier to family presence at the bedside. They may cause long-term separation of children from a parent, a caregiver, their siblings, and other sources of support. They create difficulties for parents who must attend to competing needs. Lastly, they may affect clinical teams.⁴  The enforcement of visitor restriction policies by the clinical team can be challenging and can make relationship-building substantially more burdensome.^4,5  In our experience, clinical team members commonly point to their moral distress around visitor restriction policies as one of the most difficult elements of providing care during this pandemic.

Although it was understood that visitor restriction policies had the potential to be burdensome for families, as the COVID-19 visitor restriction policy was deployed in our institution, concerns were quickly raised by patients, families, and clinicians that these burdens were experienced inequitably and disproportionately by families from particular groups. Recognizing this, our institution created a committee to evaluate the policy and its disparate impact.

The committee was composed of a family advisor, experts in health equity, ethics, infection prevention, nursing, facilities, and security; and other stakeholders. The committee included workforce members and clinicians from diverse racial and ethnic groups, genders, and roles within the organization.

Although the original goal of this committee was to reduce bias in the granting of exceptions to the visitor restriction policy, the committee eventually took on the role of overseeing the COVID-19 visitor policy as a whole, maintaining a primary focus on equity. The committee’s goals were to ensure that the visitor restriction policy was implemented in a safe, data-driven, and equitable manner and to ensure that the policy was made transparent to patients, families, and clinical teams. The committee developed and maintained a clear and operationalized process review of visitor exception requests and ongoing evaluation of policy impact. The committee reviewed and revised the content and implementation of the COVID-19 visitor restriction policy in an iterative process. This work was explicitly linked to our institution’s overall focus on antiracism. Other institutional antiracism efforts include robust equity, diversity, and inclusion training; an antiracism discussion series; and a health equity consultation service.

In the committee’s review, inequities were identified in the way that exceptions to the policy were being requested, evaluated, and granted. Although quantitative data were not collected, the committee observed that patients and families to whom the team felt particularly connected or who were able to create the most convincing narrative appeared able to obtain exceptions to the visitor policy at a higher rate. As a fictionalized example, a long-standing patient admitted for sepsis who was well known to the team might have had multiple team members advocate for there to be 2 parents at the bedside. A family new to the institution without established connections whose child was admitted for sepsis might have had no one advocate for a policy exception on their behalf. Those believed to be at particular risk for harm from the COVID-19 visitor restriction policy included families impacted by systemic racism, families with fewer financial or other resources, and families who spoke a language other than English for care.

In addition, the committee noted that families with multiple children and a single caregiver or those with a caregiver with an inflexible job were disproportionately affected by the visitor restriction policy, particularly in the ambulatory setting. Whereas previously a caregiver might have brought their child to an appointment and brought their other children with them, the visitor restriction policy required that caregiver to find child care for their other children or forgo the ambulatory appointment altogether. Finding child care in the context of school closures, day care limitations, and other pandemic-related changes is challenging. Paying for child care in a time when many have reduced or lost employment is further burdensome. To address the challenges, the committee allocated resources toward expanding child care and sibling support, allowing families with multiple children to be accommodated when they could not find child care. Because child care had previously been a part of our organization’s services, we did not have to secure additional funding for this endeavor. Existing space, resources, and volunteers were leveraged. The committee also highlighted the potential disproportionate burdens of this policy on families who spoke a language other than English for care. As a result, the committee worked to ensure policy signage and communications were available and visible in multiple languages. Throughout the iterative committee process, feedback was elicited regarding staff and family satisfaction, any perceived safety concerns, and areas for additional improvement. Quantitative data on the outcome of the policy changes were not collected.

After the committee’s work on the COVID-19 visitor policy, the institution’s Center for Diversity and Health Equity formally established an EIA to be conducted during decision-making processes and before enacting new programs or policies. An EIA is designed to systematically examine how groups that have been, and continue to be, disenfranchised and discriminated against will likely be affected by a proposed decision.¹⁰  In the same way that environmental impact statements, fiscal impact reports, and workplace risk assessments help inform decisions, EIAs can be used to anticipate, eliminate, and prevent adverse consequences in a variety of contexts. EIAs allow policy makers to systematically consider questions such as Which groups are most advantaged and most disadvantaged by this policy? How are they disadvantaged? What evidence do we have for this? The EIA tool was finalized after the visitor policy committee had competed its work, in part on the basis of experience gained through that process. In Table 1, we show how an EIA framework could have been applied to the formation of the COVID-19 visitor restriction policy committee.

The COVID-19 pandemic has caused harm to children and families and has disproportionately affected American Indian, Alaska Native, Black or African American, and immigrant populations, likely as a result of systemic racism and structural inequities.¹¹  In addition, it has disproportionately affected those who are facing poverty.¹¹  Likewise, COVID-19 visitor restriction policies introduce the potential for harm to all children and families, but they may disproportionately do so for particular groups of families.^4,6 

Justice demands that we do all we can to mitigate existing disparities in health care. Hospitals can start by interrogating the role of existing policies in perpetuating or causing disproportionate harms. As an example, here, we discuss one institution’s approach to uncover and address the disproportionate harm of our COVID-19 visitor restriction policy. When implementing any policy, a multidisciplinary and inclusive team ought to carefully weigh known risks and benefits while considering inequitable harms. Performing an EIA when developing or updating policies may help to systematically identify, reduce, eliminate, and prevent discrimination and inequities in access and care. When equity is not intentionally addressed at the start and regularly revisited, disparity is often unconsciously maintained or exacerbated.