Applying a gender impact assessment to the design of a health facility

Name of initiative: Building design for health facility

Policy/program/service: Service

New or up for review: New

Sector: Health

This case study has been drawn from real examples, however the narrative is fictional.

Overview

Mariam works for Ocean Valley Shire. She is conducting a gender impact assessment (GIA) on the design of a new health facility, The Ocean Valley Health clinic. As spaces are experienced differently by people of different genders, the team must analyse the architecture and design of the building with a gender lens. This will ensure that people of all genders feel welcome, safe and included when they enter the clinic.

This is the first GIA that Ocean Valley have conducted on a building. Mariam is pleased the GIA is being incorporated from the beginning of the process. Though, she recognises that a GIA at any stage is better than none at all.

Step 1: Define the issues and challenge assumptions

Defining the issues

Working with the municipality of Ocean Valley, the Department of Health are planning to build an extra community health facility to meet the coming health needs of the growing community. Ocean Valley is located in a high growth area, with significant population increases over the last ten years. A further 40% population increase is predicted over the coming decade.

This health facility will be designed to provide women’s and family health specific services, domestic violence services, mental health services and access to General Practitioners. It will not contain an emergency department or surgical suites, as these are available at a metropolitan hospital in the next LGA.

Challenging assumptions

Mariam and her team initially assume that people of different genders would use the building in the same way. The only difference they can think of would be that the women’s health speciality area may be used more so by women and children than other areas. They also assume that the building design won’t have a great impact on people of different genders.

The GIA allows the team to challenge their assumptions and think critically about the impact of infrastructure design on people of different genders. Applying a gender lens, Mariam and her team broaden the scope of their analysis to consider the following:

What are the gendered differences in how people will use the building?
How do needs and priorities regarding building usage differ for people of different genders?
How might other intersecting factors such as disability, age, sexuality and ethnicity impact people’s use of the building?
What safety needs might people of different genders have in utilising a public building?

Applying a gender lens empowers the group to consider how people of different genders, and with other intersecting attributes, may be differently impacted by the clinic’s design. The team realise that a health facility may not automatically be a safe, welcoming place for people of all genders, ages, abilities, cultural and religious backgrounds and sexual identities. However, conducting a GIA can help reduce barriers and create a safe environment which promotes equality.

Broadening the issues with an intersectional gendered lens

After brainstorming gendered and intersectional differences amongst themselves, the team identify additional issues to consider:

Are there different ways that women, men and gender-diverse people understand concepts of ‘safety’, ‘privacy’ and ‘accessibility’?
What amenities are necessary for inclusion of people of all genders?
Given LGBTIQ+ people have lower health outcomes then cis-gendered heterosexual people, how can the building design promote inclusion and acceptance from the outset?
What architectural and design factors contribute to a safe and inclusive public building, particularly in a health clinic?
Aside from Universal Design principles, what are some additional ways that people with disabilities feel welcome, safe and included?
What do neurodiverse people need for a public building to feel safe and welcoming?
What are the language needs of the community?
What might Aboriginal and Torres Strait Islander people need from a building design to ensure cultural safety?
What do children accessing the building need to feel safe and welcome?
Are there lighting and paint colour considerations that increase welcome, safety or create barriers to such?

These questions provide a useful launching place for a gender analysis of the building design. Mariam and her team recognise they may not find all the answers, and that this is a learning process. However, this means they will conduct insightful research, and their recommendations will be evidence-based, leading to greater inclusion.

Step 2: Understanding the context

As neither Mariam or her team are experts on gender-sensitive building design, they approach their research using three methods – internal data, desktop research and consultations.

To guide their investigations, they consider:

Who is likely to be affected?
What are the lived experiences of these diverse groups?
What are the different, gendered impacts of health facility design?
How does providing an intersectional-gender lens align with council’s strategic plan?

Gathering this information will help the team understand the key needs of health facility users. This will ensure safety and inclusion for all. They start by using information already at hand – internal data.

Internal data

The team know that internal data is a great starting point, as it utilises research already completed either by council or for council. It will also be applicable for other GIAs, which will help with future gender analysis.

They first seek to understand gender-disaggregated data of the predicted users of the health facility. They also look for projected demographics of these users according to age, socioeconomic status and primary language. To do this, they look at:

Regional demographics and relevant survey data
Previously commissioned reports and policy submissions
Business cases and proposals for the development of the health facility

Finding this information helps provide additional context for the community, and identifies areas which can be further explored with desktop research.

Data, statistics and desktop research

The Commission for Gender Equality in the Public Sector (the Commission) have put together useful starting points for collecting external data for GIAs. Miriam and her team search the Commission’s website, where they find sources that help Mariam and her team better understand the lived experiences of women, men and gender-diverse people. They also provide resources on intersectionality, explaining how personal factors, such as ethnicity, disability, sexuality and gender presentation, might further impact experiences of discrimination.

The team also consider the following sources:

Australian Bureau of Statistics (ABS)
HILDA Survey Data
Australian and Torres Strait Islander Data Archive (ATSIDA)
World Bank Open Data
World Health Organisation (WHO) – Open data repository

Mariam is particularly keen for her team to gain an understanding of gendered use and needs of space in building design. They use search engines, libraries and open-source repositories to find research that might facilitate some deeper thinking about perceptions of safety and space.

For more information on the importance of desktop research, please see this Victorian Government resource.

Stakeholder engagement

One of the most important steps to this project is understanding actual lived experience. Consulting with prospective stakeholders shows the team what is needed to help building to feel safe and inclusive. Combining the questions generated in Step 1 with the research findings from Step 2, the team consult with several groups:

LGBTIQ+ advocacy groups
Aboriginal and Torres Strait Islander community groups and Elders
Groups dedicated to supporting mental health for different genders
Local women’s shelters
Community groups for culturally and linguistically diverse (CALD) people and those of non-English speaking backgrounds
Disability services
Older people’s advocacy groups
Parent’s groups
Youth services
Groups dedicated to supporting those affected by poverty and rough sleeping

These groups provide valuable insight to the experiences of people of all genders, as well as the way intersectional factors can compound with gender to cause further harm. Engaging with advocacy groups, particularly for LGBTIQ+ communities, creates additional layers of safety for people who want to contribute but don’t feel comfortable sharing their identity.

Evidence collected by Mariam and her team

The evidence provides a comprehensive overview of the gendered implications of building design in a health setting. The team found their assumptions were challenged and many of their questions were answered. The exercise was useful for critically considering not only the needs of different genders, but the way intersecting identity factors can contribute to inclusion or exclusion.

When designing a space comfortable for all women, men and gender-diverse people, gendered experiences should be considered for the following (Croghan et al. 2015; Terraza et al. 2020):
- Seating size and location, and height and accessibility of information and services
- Colour scheme and textures, visibility and ability to navigate the space
- Inclusion of gender-neutral bathrooms and change rooms, and ensuring parents of all genders have equitable access to baby change tables
- Access to all areas inclusive of mobility aids and double prams
- Break out areas for young children, and child and family-friendly waiting areas and wards
- Entrances and exits should be well-lit and ensure protection from bad weather
- Access to transport and financially accessible parking options
Informed through consultation (based on real data, source confidential):
- Women experiencing family violence need to have access to private amenities within the service
- Family violence services should have a separate exit with child-friendly, fenced outdoor play spaces
- Perceptions of safety are lower for women and gender-diverse people in the area than for men, with almost twice as many saying they don’t feel safe at all
- Women feel safe when streets are well-maintained, pathways are safe, navigating is easy and clear exits are in sight
- Women tend to not feel safe when there is poor lighting, hard to see ahead, there aren’t others around, and poor maintenance
- Fear and experience of sexual harassment hinders women’s participation in night-time and public physical activities (Plan International n.d.)
Statistical and demographic data for Ocean Valley (based on real data, source confidential):
- The region is comprised of more lone parent households than Greater Melbourne, and the majority of lone parents are women
- Women are more likely than men to have low English proficiency in this area
- Women are more likely than men to provide daily primary care to children and other family members, including those who are older or who have a disability
- Women report higher levels of psychological distress and mental ill-health than men in the area, and are more likely to be hospitalised due to self-harm
- The area has higher rates of family violence than Greater Melbourne
- Women are significantly more likely to experience family violence, sexual assault, stalking, harassment and threatening behaviours in this area
- Women are less likely than men to be in full-time employment in this area, and are more likely to be in lower paid and uncertain employment than men
Statistical and demographic data for Ocean Valley (based on real data, source confidential):
- Within the region, men are more likely to be the primary income earners for households
- Men are more likely to have access to a motor vehicle than women
Desktop review:
- Research tells us that mental ill health is reported less amongst men (AIHW 2022a)
- Notions of masculine stereotypes may delay help-seeking for health problems in men, and reduces the likelihood that they will seek help (Galdas et al. 2005)
- “Toxic masculinity” leads to increased rates of risk taking behaviours in men, such as violence, higher rates of substance abuse and gambling (Flood 2018; JSS n.d.)
- Younger men are more often involved in car accidents within the region (Fitzgibbins 2021).
- Gender-diverse people avoid seeking preventative, primary health and emergency care when they need it, largely due to fear of transphobic harassment (Kerr et al. 2019)
- Gender-diverse people often face high levels of discrimination for not conforming to the traditional gender-binary model, often resulting in marginalisation, social and political isolation, and higher prevalence of mental health issues (Larkin 2019)
- LGBTIQ+ people commonly report physical and cultural barriers to accessing universal services including discrimination and stigma, lack of knowledge and understanding, and infrastructure that fails to meet access needs (including safe spaces and gender neutral facilities) (WHO n.d.)
- Women with disabilities are more likely to experience sexual and/or family violence than women without disabilities (AIHW 2022b; Royal Commission 2021)
- Aboriginal and Torres Strait Islander people may face barriers accessing government care systems due to fear of racism, disrespect, judgement, and a historical pattern of negative government interventions (Nolan-Isles et al. 2021)
- Women from culturally and linguistically diverse (CALD) backgrounds are more likely to experience social isolation and financial insecurity, with discrimination and racism affecting their ability to be financially independent and leaving them vulnerable to family violence (NIFVS n.d.)
- People from CALD backgrounds are at greater risk due to stigma surrounding mental health issues, and barriers they may face in accessing culturally safe services and support (Life in Mind n.d.)
- Refugees and humanitarian migrants experience high rates of mental ill health, poor mental health literacy and mixed cultural understanding of mental health. (AIFS 2022)
- There are currently inadequate services for children and young people experiencing family violence (FVRIM 2022)
- LGBTIQ+ people are two and a half times more likely to have been diagnosed or treated for a mental health condition in the last 12 months (LGBTIQ+ Health Australia 2021)
- People who identify as LGBTIQ+ are more likely than other Victorians to have low household income, be unable to raise emergency funds, and to experience food insecurity (VAHI 2017)
- AIFS (Australian Institute of Family Studies) (2022), Understanding the mental health and help-seeking behaviours of refugees, Australian Institute of Family Studies, accessed 15 April 2023.
- AIHW (Australian Institute of Health and Welfare) (2022a) Mental health: prevalence and impact, Australian Institute of Health and Welfare, accessed 21 April 2023.
- AIHW (Australian Institute of Health and Welfare) (2022b) People with disability in Australia, Australian Institute of Health and Welfare, accessed 24 April 2023.
- Croghan CF, Moone RP and Olson AM (2015) ‘Working With LGBT Baby Boomers and Older Adults: Factors That Signal a Welcoming Service Environment’, Journal of Gerontological Social Work, 58(6):637-651.
- DFFH (Department of Families, Fairness and Housing) (2022) Pride in our future – Victoria’s LGBTIQ+ strategy 2022-32, Victorian Government website, accessed 22 April 2023.
- Fitzgibbins M (2021) Why are 17-25 year olds over-represented in road fatalities?, Road Sense Australia, accessed 19 April 2023.
- Flood M (2018) Australian study reveals the dangers of ‘toxic masculinity’ to men and those around them, The Conversation, accessed 23 April 2023.
- FVRIM (Family Violence Reform Implementation Monitor) (2022) Early identification of family violence within universal services, Victorian Government website, accessed 13 December 2021.
- [GLH(1] Galdas PM, Cheater F and Marshall P (2005) ‘Men and health help-seeking behaviour: literature review’, Journal of Advanced Nursing, 49(6):616-23.
- JSS (Jesuit Social Services) (n.d.) The Man Box, Jesuit Social Services, accessed 22 April 2023.
- Kerr L, Fisher CM, Jones T (2019) TRANScending Discrimination in Health & Cancer Care: A Study of Trans & Gender Diverse Australians, Zoe Bell Gender Collective, accessed 14 April 2023.
- LGBTIQ+ Health Australia (2021) Snapshot of Mental Health and Suicide Prevention Statistics for LGBTIQ+ People, LGBTIQ+ Health Australia, accessed 17 April 2023.
- Life in Mind (n.d.) Culturally and linguistically diverse communities, Life in Mind website, accessed 15 December 2022.
- Nolan-Isles D, Macniven R, Hunter K, Gwynn J, Lincoln M, Moir R, Dimitropoulos Y, Taylor D, Agius T, Finlayson H, Martin R, Ward K, Tobin S and Gwynne K (2021), ‘Enablers and Barriers to Accessing Healthcare Services for Aboriginal People in New South Wales’, International Journal of Environmental Research and Public Health, 18(6):3014. doi: 10.3390/ijerph18063014.
- NIFVS (Northern Integrated Family Violence Services Partnerships) (n.d.) Overcoming Barriers (CALD Resource), NIFVS website, accessed 14 December 2022.
- O’Donnell K, Jenkinson R, Prattley J, Quinn B, Rowland B, Tajin R and Wong, C (2022) Recent natural disasters in Australia: Exploring the association with men’s mental health and access to healthcare, AIFS website, accessed 13 December 2022.
- Plan International (n.d.) Safer cities for girls, Plan International website, accessed 12 April 2023.
- Royal Commission (Royal Commission into Violence, Abuse, Neglect, and Exploitation of People with Disability) (2021) Alarming rates of family, domestic and sexual violence of women and girls with disability to be examined in hearing, Royal Commission, accessed 19 April 2023.
- Terraza H, Orlando MB, Lakovits C, Lopes Janik V and Kalashyan A (2020) Handbook for Gender-Inclusive Urban Planning and Design, World Bank, accessed 16 April 2023.
- VAHI (Victorian Agency for Health Information) (2017) The health and wellbeing of the lesbian, gay, bisexual, transgender, intersex and queer population in Victoria – Findings from the Victorian Population Health Survey 2017, Victorian Agency for Health Information, accessed 14 April 2023.
- WHO (World Health Organisation (n.d.) Improving the health and well-being of LGBTIQ+ people, World Health Organisation, accessed 20 April 2023.

Step 3: Evaluate the options

The team have now learned about the gendered and intersecting needs of the community. Mariam and her team begin to compile some options to recommend for the design of the building. The team aims to contrast the gendered impacts of a standard build with one with a gender equitable focus. This will help ensure the design of the Ocean Valley health facility is inclusive and equitable for women, men and gender-diverse people.

The first option is to design the clinic as normal. This means that some amenities will be included, but the longer-term considerations, such as gender-sensitive layout and outdoor spaces, would not be incorporated.
This option includes the following recommendations:
- Gender-neutral and accessible single stall bathroom amenities will be located in each ward, service and waiting areas
- Gendered bathrooms will also be included in these areas
- Entries and exits will be located in the same area to direct traffic more efficiently, with emergency exits located in appropriate locations according to regulations
Gendered benefits of option 1
- People of all genders can feel safe accessing amenities without fear of judgement for their gender identity
Gendered risks of option 1
- Women and children experiencing family violence may be at a greater risk when using these services as safe and private areas haven’t been integrated into the design
Overall impact
- This option considers some gendered and intersectional needs, such as bathroom accessibility
- However, it doesn’t think about the gendered needs of women and children accessing family violence services
- It also doesn’t consider other forms of inequality, such as creating welcome spaces for gender-diverse community members
- The team rates the overall gender impact of option 1 as negative
This option is a more comprehensive option which attempts to incorporate as much of the feedback and research as possible. This option may cost more to begin with, however it does still fit within the budget. It will also be much more cost efficient than renovating the building to be more gender equitable at a later stage.
This option includes the following recommendations:
- The family violence service will be located with its own, locked entry from the main corridor
- The family violence service will be located on the first floor with secure access to an outdoor, child-friendly, green space
- The family violence service will have a secure entrance/exit, with clear access to well-lit parking and pick up zones
- Many toilets will be a single gender-neutral secure cubicle, with baby change facilities and wheelchair accessible amenities provided within each ward and service
- The gender-neutral toilets will feature a non-gendered pictorial sign
- Design of entrances and exits will incorporate large open doorways with clear directions to a welcome area (to be followed with signage that welcomes people of all backgrounds, genders and language groups)
- Waiting areas will have child friendly play spaces, located away from entry and exit points
- Signage will be provided in English and community language translations
- Indigenous plants and well-lit outdoor walking trail will be incorporated into design
Gendered benefits of the program
- It considers the needs of gender-diverse people through its open and clear welcome space and neutral amenities
- It addresses the sensitive needs of victim-survivors (usually women and children) accessing family violence services
- It recognises that physical spaces carry gendered assumptions which must be actively addressed from the outset of design
- As women are more likely to bring children to the facility, having child-friendly waiting areas will help alleviate stress
- Having gender-neutral bathrooms with baby change facilities will ensure parents of any gender will feel comfortable when tending to their baby
Gendered risks of the program
- The thoughtful design of the building may not be supported unless services, policies and staff adopt inclusive practices
Overall impact
- This option considers and addresses gendered and intersectional needs of people when using a public health facility
- The team rates the overall gender impact of option 2 as positive

Step 4: Finalise recommendations

As the gender impact is positive, Miriam and the team recommend option 2. It includes simple but comprehensive design elements to ensure that the space is designed for people of all genders. Specifically, the team recommended that:

The family violence service will be located with its own, locked entry from the main corridor.
The family violence service will be located on the first floor with secure access to an outdoor, child-friendly, green space
The family violence service will have a secure entrance/exit, with clear access to well-lit parking and pick up zones
Many toilets will be a single gender-neutral secure cubicle, with baby change facilities and wheelchair accessible amenities provided within each ward and service
The gender-neutral toilets will feature a non-gendered pictorial sign
Design of entrances and exits will incorporate large open doorways with clear directions to a welcome area (to be followed with signage that welcomes people of all backgrounds, genders and language groups)
Waiting areas will have child friendly play spaces, located away from entry and exit points
Signage will be provided in English and community language translations
Indigenous plants and well-lit outdoor walking trail will be incorporated into design

Additionally, they recommend that Mariam is involved throughout every consultation on the building design. This means that as the plan shifts, the gendered considerations remain a priority.

The GIA and recommendations were put to the Project Steering Committee for their endorsement. The Committee were pleased with the analysis and found that the recommendations were reasonable. All of Miriam’s recommendations were approved, and the team is proud of their work to promote gender equality.

Preparing for progress reporting to the Commission

Now that a gender impact assessment has been completed, Mariam and her team need to prepare to report on their progress, as per their obligations under the Gender Equality Act.

The progress report is due every two years, and must be submitted to the Commission for Gender Equality in the Public Sector. Mariam has documented the recommendations and submitted these to a GIA focal point which stores all GIA information in a central location. Follow up actions and outcomes will also be recorded for reporting and accountability. This will save Mariam and others time and effort as the reporting deadline approaches.

The team knows that for the GIA component of the progress report they will need to:

Identify all policies, programs and services that were subject to a gender impact assessment
Report on the actions taken as a result of the gender impact assessment

This information has benefits outside of progress reporting, as well. Miriam knows that the data collected for this GIA will be useful for other GIAs completed by her organisation.

The following actions resulted from the GIA:

The family violence service will be located with its own, locked entry from the main corridor
The family violence service will be located on the first floor with secure access to an outdoor, child-friendly, green space
The family violence service will have a secure entrance/exit, with clear access to well-lit parking and pick up zones
Many toilets will be a single gender-neutral secure cubicle, with baby change facilities and wheelchair accessible amenities provided within each ward and service
The gender-neutral toilets will feature a non-gendered pictorial sign
Design of entrances and exits will incorporate large open doorways with clear directions to a welcome area (to be followed with signage that welcomes people of all backgrounds, genders and language groups)
Waiting areas will have child friendly play spaces, located away from entry and exit points
Signage will be provided in English and community language translations
Indigenous plants and well-lit outdoor walking trail will be incorporated into design

Governance

Updated 20 July 2023

Applying a gender impact assessment to the design of a health facility

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Defining the issues