Health Impact Assessment

what it is, why do it, when to use it, how to do it, how to commission it

LSBU MSc in Public Health 7th April 2008

Dr Salim Vohra
Centre for Health Impact Assessment, Institute of Occupational Medicine
What is health?

health
wellbei
ng

diseas
e
 Environment & health in context:
housing
a complex web of factors conditions

housing employment
tenure status
disability sexual smoking
ethnicity behaviour alcohol family working
personality
relationships Personal condition
Biological
genetic leisure circumstances
factors Lifestyle medication
factors activities income

diet illegal personal

sex age transport education
substances

noise soil
smell quality water
quality
public & community
social
environmental air social participation
support
health services quality contact
Environment Determinants of peer
Health & Wellbeing Social influences
pressure

natural land use & fear of

hazards planning discrimination crime &
green natural fear of crime &
resources anti-social
waste space discrimination anti-social
behaviour
management behaviour
research & technological
development
community
business job voluntary & childcare facilities
activity creation charity groups leisure
Economic
facilities
conditions
distribution of
health & social
availability and incomes Availability & access housing
care services
quality of availability
employment and quality of
education
training shops and banking & training
services public advice
transport services

Adapted from ‘Rapid Health Impact Assessment: a guide to research’ by Amanda Harris, 2002
 Or put another way!

Since I came to the

White House
I got two hearing aids,
a colon operation,
skin cancer, a prostate
operation
and I was shot.
The damn thing is,
I never felt better in my
 Or even another way!

“Health is a state of complete

physical, mental and social wellbeing
and not merely the absence of
disease or infirmity…

…Health is therefore a resource for

everyday life, not the objective of
living; it is a positive concept
emphasizing social and personal
resources, as well as physical
capacities.”
World Health Organization, 1947 and 1984.
 Health impact assessment

HIA is:
 a combination of procedures, methods and
tools

 by which a policy, program or project may be

judged

 as to its potential effects on the health of a

population,

 and the distribution of those effects within the

population.
Gothenberg Consensus Document 1991
 Health impact assessment
 HIA as the key systematic approach to identifying
the differential health and wellbeing impacts of
proposed and implemented plans, programmes and
projects
 within a democratic, equitable, sustainable and
ethical use of evidence framework
 so that positive health impacts are maximised and
negative health impacts minimised (within a given
population).
 It uses a range of structured and evaluated sources
of qualitative and quantitative evidence that includes
public and other stakeholders' perceptions and
experiences as well as public health,
epidemiological, toxicological and medical
knowledge.
 Social Model of Health

adapted from Whitehead, M. "Tackling inequalities in health: a review of policy initiatives" in

Tackling inequalities in health: an agenda for action eds. Benzeval, M., Judge, K. et al. London,
King's Fund Publishing. 1995: pp.22-52.
 The Social Model of Health
Diagram

Adapted by Salim Vohra and Dean Biddlecombe from Dahlgren, G. and Whitehead, M. (1991).
Policies and strategies to promote social equity in health. Stockholm, Institute for Future Studies.
What is Environmental Impact Assessment?

 Socio-economic  Built heritage and

archaeology
 Policy context
 Hydrology and water
resources
 Visual & landscape

 Traffic and access

 Geology

 Waste
 Air quality

 Ecology
 Noise and vibration
Town and Country Planning (Environmental Impact Assessment)
(England and Wales) Regulations 1999.
 What is healthy public policy?

 Canada in the 1970’s

 Health is more than health care policy and

practice

 Non-health policies have an equal and greater

infuence on health and wellbeing
Health Impacts vs. Health Needs

health needs assessment

POPULATION PROPOSAL

health impact assessment

 Key Characteristics of HIA

Broad perspective Tight

Perspective
Definition Social - Holistic Medical -
Measurable
of health
Roots Sociology Medicine -
Epidemiology
Values Democratic - Inclusive Expert
- Technocratic
Evidence Qualitative Quantitative

Precision Not aimed for Aimed for

National Assembly for Wales. Developing health impact assessment in Wales. 1999.
available at http://www.wales.gov.uk/polinifo/health/keypubs/healthimpact/pdf/healthimp_e.pdf
 Types of HIA

 Prospective conducted before the implementation of a

proposal

 Concurrent conducted during the implementation of a

proposal

 Retrospective conducted some time after a proposal has

been implemented

 Rapid a short quick assessment or one focussed on

a specific aspect

 Comprehensive a longer detailed assessment looking at all the

health issues
 What is Evidence?

“Where is the life we have lost

in living

Where is the wisdom we have lost

in knowledge

Where is the knowledge we have

lost
in information.”
 Types of Evidence

 Quantitative vs Qualitative

 Strengths and limitations of randomised controlled

trials, toxicology and epidemiology

 Strengths and limitations of interviews, focus groups

and observation

 Criteria for evaluating quantitative evidence

 Criteria for evaluating qualitative evidence

 Nature of Knowledge
“What sociologists of science say is that of course
the world is real
and independent of our observations

but that accounts of the world are produced by observers and

are therefore relative to their capacities, education, training,
etc.

It is not the world or its properties but the vocabularies in whose

terms we know them that are socially constructed
i.e. fashioned by human beings - which is why our understanding
of those properties is continually changing.”

Stanley Fish quoted in The Wilson Quarterly, Autumn 2001, pg60 Wittgenstein's Curse, by Jay Tolson
 Factors to Consider
 Difficult to rank and depends on the types of
information you are looking for

 Depends on the expertise of the person

gathering and using the evidence

 Pay attention to the source – who, what, where,

when, how and why?

 Find as many different sources of evidence as

possible – the more sources that say the same
thing the stronger the evidence
Appraising Impacts - rapid
Appraising Impacts - rapid
Appraising Impacts - detailed
Impacts are like an elephant

Spain, M. Kings Fund newsletter 1998. .

 Some models of HIA

 UK - Merseyside

 Canada – British Columbia

 Sweden – Swedish County

Councils

 Australia – Equity focused HIA

 Merseyside … key areas influencing health

influences on examples of specific influences

health
biological Age, sex and genetic factors
factors
personal/family Family structure and functioning
circumstances Primary/secondary/adult education,
and lifestyle Occupation, unemployment, income,
Risk-taking behaviour, diet, smoking, alcohol, substance
misuse
Peer pressures, discrimination,
social
environment Social support neighbourliness, social networks/isolation
Community/cultural/spiritual participation.
physical Air, water, noise, smell, view,
environment Housing conditions, working conditions, amenities, civic
design,
Land
Accessuse, waste
to and disposal,
quality energy,
of health local environmental
care
public services features.
Childcare, social services, housing/leisure/employment
services
Public transport, policing, other health relevant public
services, non-statutory agencies and services.
Economic-social-environmental-health trends
public policy
local and national priorities, policies, programmes, projects.
 Merseyside … identification of impacts

Categories/ Project Predicted Risk of impact

specific development/ health impacts
influences on operation nature?
health activity size?
how measurable?

qualitative Q definite D
estimable E probable P
calculable C speculative S

+
ve -
ve
Merseyside …
stages in the process
 Health impact pathways
Context
young, mobile, ethnically diverse population,
high levels of deprivation, poor housing conditions
Mechanisms
Housing company
Outcomes
residents feel more positively about building works
area renovation process
the area will become more attractive some people might have to move to
to tenants who want permanent new accommodation outside
homes and are able to pay higher programme area
rents in the private market Health outcomes
strengthen social capital mental stresses, increased pollution
positive health outcomes from & accident hazards from building
improved housing works
improve average measures of health negative health outcomes associated
but will not reduce health with continuing problems with
inequalities housing and possibly homelessness
From A practical guide: Vol 1 HIA for regeneration
for some
projectsgroups
 Gathering the Evidence
 Disease based … lots of ALSO … websites …
agencies … Consultant
for Communicable take note of where you
Diseases visit so that you do not get
lost and do not get
 Crime … Police … victim swamped by the detail …
support
government departments
 Employment … Learning are useful as are
& Skills Council, Training organisations in other
& Workforce regions …
Confederation …
Economic Development - Office of National
officer Statistics

 Transport … Department - Regional Health

of Transport Observatories
Dealing with uncertainty – facts and values

 Scientific vs. Experiential Knowledge

 ‘Hard’ Facts vs. ‘Soft’ Values

 ‘Hard’ Decisions vs. ‘Soft’ Science

 Quality Assurance – technical, environmental,

societal, ethical

 Post-normal science involves an ongoing dialogue between as many

stakeholders as possible, regardless of their qualifications and
affiliations, to create an extended peer community that assesses,
evaluates and uses extended facts which include anecdotal evidence
as well as statistics gathered by the affected community
 Dealing with uncertainty – a
framework
High
IGNORANCE
‘Post-Normal’ Epistemological
border with
Science ignorance
(uncertain facts,
disputed values, Methodolo
high stakes, decisions
gical
DECISI urgent)
unreliabilit
ON Expert-Professional y
STAKE Judgement
S of judgement and good practice)
(use
Technic
al
inexactn
ess

Applied
‘Normal’ Science
(traditional notions of science)

Low LEVEL OF UNCERTAINTY High

 Key Points

 Health is a multi-dimensional concept and hence the definition of health

used in an HIA shapes the kind of impacts assessed and the evidence
sought for those impacts.

 Most models of HIA follow similar steps: screening, scoping, appraisal,

mitigation and enhancement and recommendations.

 Evidence for many health impacts that have a complex and indirect effect
on people’s health are difficult to apply directly to specific local populations
and even more difficult to use to give quantitative estimates of impact.

 All types of evidence have strengths and limitations and therefore explicit
criteria for how evidence is evaluated is important in HIA.

 Lay people are just ‘experts’ on their day off i.e. they have useful knowledge
and experience to provide on the health effects of initiatives.
Stakeholder Involvement & Engagement
8 Citizen control

Degrees of
7 Delegated power
Citizen Power Better

and
6 Partnership
more

5 Placation genuine

stake-
Degrees of holder
4 Consultation
Tokenism
involve
ment
3 Informing

2 Therapy
Non
Participation
1 Manipulation

Arnstein, S. (1969). A ladder of citizen participation in the USA. Journal of the American Institute of Planners 35, 216-24.
 Reporting Back - writing a HIA report

“My aim is to put down on paper what I see and what I feel
in the best and simplest way.”
Ernest Hemingway

“Those who write clearly have readers, those who write

obscurely have commentators.”
Albert Camus

8. Aim and objectives of HIA

9. Scope of HIA
10. HIA methodology
11. Policy context for HIA
12. Baseline community demographic & health profile
13. Impact analysis
14. Mitigation & enhancement
15. Conclusions & recommendations
 Barriers to Implementing HIA Findings

 Influential stakeholders
 professional groups, politicians, business

 Complexity of proposed change

 radical and complex implementation or change process

 Diversity of stakeholders that need to be involved

 Range of stakeholders with differing interests

 Lack of clarity
 Lack of clear vision and rationale for proposed changes

 Changing environment – social, political, economic

 New aspects emerging which change the wider context
 Commissioning HIA
A HIA can be commissioned because:
 it is seen as a way of providing information to help with
designing and developing a policy, plan, programme, project,
development or service (initiative),
 it is a way of bringing key stakeholders together to discuss
and decide on an initiative,
 it is a legal duty to carry out a HIA
 it is seen as good practice,
 it is seen to help build trust among other stakeholders,
especially communities, by showing that their concerns are
being taken seriously,
 it is seen as providing credible evidence in legal settings, for
example, planning inquiries and other judicial hearings,
 a mixture of the above.
 Commissioning HIA
 HIA Steering/Advisory Group

 For external consultant-practitioners, references from previous clients are very useful in
assessing the quality of their work but the best way is to review actual copies of previous
HIA statements that they have produced as this will provide a more detailed insight into
whether their approach meets your needs and expectations.

 As for costs, a good rule of thumb is that, a rapid HIA is likely to cost between £7-
12,000,an intermediate HIA requiring a community consultation between £20-35,000 and
a comprehensive HIA with a wide stakeholder consultation between £50,000+.

 Clear lines of supervision and communication between external consultants or internal

HIA staff-practitioners are vital.

 A clear HIA plan and timetable can ensure that the HIA runs to deadline and is within
budget.

 Getting other colleagues or another HIA practitioner to critically review the final HIA report
can throw up errors of fact, especially about local context issues, as well as identify where
judgements might be seen as unjustified because they are based on weak, controversial
or little evidence.

 Finally, a good understanding of the strengths and limitations of HIA in general will ensure
that commissioners are realistic about what HIA can deliver and achieve and what it
cannot.
 Scrutinisng a HIA
Key questions to ask are:

 What is the scope of the HIA and the definition of health used?
 Was the methodology used appropriate, explicit and logical?
 What evidence and sources of evidence were included and excluded
and was the justification given explicit, reasonable and appropriate?
 Was there any stakeholder involvement and were a range of
stakeholder consulted?
 Was the justification for not consulting stakeholders and/ or involving
only certain stakeholders explicit, reasonable and appropriate?
 Was the appraisal of impacts systematic and the reasons for judging
the significance and the extent of the positive and negative health
effects explicit, appropriate and justified?
 Do the recommendations, including mitigation and enhancement
measures, follow on from the key issues emerging from the appraisal?
 Is the report as a whole clear, coherent and understandable?
 Does the HIA statement-report achieve the HIA’s aims and objectives?
 Driving forces for change
 International
 Globalisation – interconnectedness and fragility of systems
 Climate change
 Population pressures (growth and migration)

 Europe
 Public concern
 Sustainability
 Public and environmental health

 South Africa
 As above
 Poverty, Development, Inequalities
 Overview of what’s happening
 Internationally
 Canada, Australia and New Zealand – Health and planning
legislation
 USA - interest gathering pace
 World Bank through IMF
 Shell

 European Union
 SEA and EIA Directives
 EC research on health and planning
 Public health agenda - skills, capacity building,
mainstreaming
 Planning agenda – HIA champions, spatial plans
 www.designforhealth.net

USA
 www.sfdph.org/phes/enchia/enchia_HDMT.htm

USA
 www.hiaconnect.edu.au/completed_hia.htm

Australia
Africa
Netherlands
 www.belfasthealthycities.com

Ireland
www.anamai.moph.go.th/6thglobal/Health%20Impact%20Assessment%20in%20Laos!.pdf

Laos
 www.who.int/hia/examples/overview/whohia201/en/index.html

HIA in Thailand
 www.mrcindia.org/MRC_profile/epidemiology/HIA.pdf

India

 ..
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/ENVIRONMENT/EXTENVASS/0,,contentMDK:20486275~pagePK:148956~piPK:216618~theSitePK:407988,00.html

World Bank
 www.ipieca.org/activities/health/health_publications.php

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