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Developing principles for health impact assessment

Authors:
  • Public Health Scotland

Abstract

Policies and practice in many sectors affect health. Health impact assessment (HIA) is a way to predict these health impacts, in order to recommend improvements in policies to improve health. There has been debate about appropriate methods for this work. The Scottish Executive funded the Scottish Needs Assessment Programme to conduct two pilot HIAs and from these to develop guidance on HIA. Case study 1 compared three possible future scenarios for developing transport in Edinburgh, based on funding levels. It used a literature review, analysis of local data and the knowledge and opinions of key informants. Impacts borne by different population groups.were compared using grids. Case study 2 assessed the health impacts of housing investment in a disadvantaged part of Edinburgh, using published literature, focus groups with community groups and interviews with professionals. Disadvantaged communities bore more detrimental effects from the low transport investment scenario, in the areas of: accidents; pollution; access to amenities, jobs and social contacts; physical activity; and impacts on community networks. The housing investment had greatest impact on residents' mental health, by reducing overcrowding, noise pollution, stigma and fear of crime. Although there is no single 'blueprint' for HIA that will be appropriate for all circumstances, key principles to inform future HIA were defined. HIA should be systematic; involve decision-makers and affected communities; take into account local factors; use evidence and methods appropriate to the impacts identified and the importance and scope of the policy; and make practical recommendations.
Abstract
Background Policies and practice in many sectors affect
health. Health impact assessment (HIA) is a way to predict
these health impacts, in order to recommend improvements
in policies to improve health. There has been debate about
appropriate methods for this work. The Scottish Executive
funded the Scottish Needs Assessment Programme to con-
duct two pilot HIAs and from these to develop guidance on
HIA.
Methods Case study 1 compared three possible future
scenarios for developing transport in Edinburgh, based on
funding levels. It used a literature review, analysis of local
data and the knowledge and opinions of key informants.
Impacts borne by different population groups were com-
pared using grids. Case study 2 assessed the health impacts
of housing investment in a disadvantaged part of Edinburgh,
using published literature, focus groups with community
groups and interviews with professionals.
Results Disadvantaged communities bore more detrimental
effects from the low transport investment scenario, in the
areas of: accidents; pollution; access to amenities, jobs and
social contacts; physical activity; and impacts on community
networks. The housing investment had greatest impact on
residents’ mental health, by reducing overcrowding, noise
pollution, stigma and fear of crime.
Conclusion Although there is no single ‘blueprint’ for HIA
that will be appropriate for all circumstances, key principles
to inform future HIA were defined. HIA should be systematic;
involve decision-makers and affected communities; take into
account local factors; use evidence and methods appropriate
to the impacts identified and the importance and scope of the
policy; and make practical recommendations.
Keywords: health impact assessment, transport policy,
housing policy
Introduction
The health of individuals and populations is created or
destroyed by a complex set of factors that interact over the
whole life course.
1,2
Consequently, if the determinants of health
are multiple and interactive, actions to improve health rely on
interventions from many agencies other than the National
Health Service, including housing, education, transport, indus-
try and many others.
2
Therefore to improve health we need to
influence policies and practice in all these sectors. Equally, it is
important to detect policies or activities in these areas that
might have detrimental and perhaps unanticipated effects on
health.
3,4
An evidence-based approach to these tasks requires an
assessment of: the ways that each policy might have an impact
on health, how to improve this impact, and how to ensure that
the combined effects of diverse policies avoid contradictory
effects and create synergistic benefits.
5
Health impact assess-
ment (HIA) is a method of doing this and has been defined as
‘a combination of procedures, methods and tools by which a
policy, programme 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’.
6
In this context, health
impacts have been defined as the ‘overall effects, direct and indi-
rect, of a policy, strategy, programme or project on the health of
a population’ and include impacts on health determinants.
6
In the United Kingdom, the Government expressed commit-
ment to HIA in its recent public health White Papers
7,8
and the
Acheson report recommended that health inequalities impact
assessment (HIIA) should also be carried out.
9
In Europe, HIA
is seen as a way to meet the commitment made in Article 152 of
the European Union Amsterdam Treaty, that ‘a high level of
human health protection shall be ensured in the definition and
implementation of all Community policies and activities’.
10,11
The WHO strategy for Europe, Health 21, identifies HIA as a
way to achieve accountability for health and sets a target that all
member states should establish mechanisms for HIA by 2020.
12
Developing principles for health impact
assessment
Margaret J. Douglas, Lynn Conway, Dermot Gorman, Saskia Gavin and
Phil Hanlon
Journal of Public Health Medicine Vol. 23, No. 2, pp. 148–154
Printed in Great Britain
© Faculty of Public Health Medicine 2001
Common Services Agency, Trinity Park House, Edinburgh EH5 3SQ.
Margaret J. Douglas, Senior Registrar in Public Health Medicine
Scottish Needs Assessment Programme, University of Glasgow, Glasgow G12 8RZ
.
Lynn Conway, Research Assistant
Lothian Health, 148 Pleasance, Edinburgh EH8 9RS.
Dermot Gorman, Consultant in Public Health Medicine
Saskia Gavin, Public Health Epidemiologist
Public Health Institute of Scotland, Glasgow G3 7LS.
Phil Hanlon, Director
Address correspondence to Dr Margaret Douglas, Consultant in Public Health
Medicine, Lothian Health, 148 Pleasance, Edinburgh EH8 9RS.
E-mail: margaret.douglas@lhb.scot.nhs.uk
DEVELOPING PRINCIPLES FOR HEALTH IMPACT ASSESSMENT
149
Despite this commitment, sceptics doubt whether methods
exist that can fulfil these ambitious aims. Among practitioners
involved in HIA there remains uncertainty over appropriate
methods
13
and different approaches have been proposed.
14–20
In
particular, there is debate about the relative merits of quantita-
tive and qualitative methods in HIA, and about whether health
inequalities should be considered to be integral to HIA or must
be considered separately as HIIA.
The Scottish Needs Assessment Programme was funded by
the Scottish Executive to conduct two pilot HIAs, to inform
future HIA in Scotland. This paper reports some of the lessons
learnt from these and suggests principles for conducting HIA.
Case study 1: HIA of the City of Edinburgh
Council’s Urban Transport Strategy
21
The City of Edinburgh Council (CEC) has been concerned about
traffic congestion in Edinburgh for many years and has insti-
tuted policies designed to reduce private car use by encouraging
the alternatives such as cycling, walking and public transport,
and by restricting parking. However, car use continues to rise,
causing concern that increasing congestion will undermine
Edinburgh’s economy and reduce the quality of the urban
environment. This led to the development of a new local trans-
port strategy. One of the most contentious issues was a proposal
for road tolling to increase the funding available for transport
infrastructure. To aid decision-making, three possible transport
scenarios were developed, based on different levels of available
funding. This study compared the health impacts under each of
these scenarios so as to inform the strategy.
The study had three stages. First, the main areas of health
impact were identified from a literature review of the effects
of transport on health. Second, a profile of the population of
Edinburgh and recent trends in traffic and areas of impact was
compiled from routine data. From this profile, two main popu-
lation groups were described: (1) middle class, affluent, pre-
dominantly car owning; and (2) disadvantaged, predominantly
non-car owning. Within these groups the following subgroups
were identified: young children; adolescents; the elderly; work-
ing people; and the unemployed. Finally, two meetings were
held with a group of ‘key informants’, people living and working
in Edinburgh with interests in transport and/or health. At these
meetings the group discussed the findings and constructed six
grids to record the health impacts for each group within each of
the three scenarios. The group agreed ‘scores’ for each impact
and each population group using available evidence and their
own local knowledge. The grids used a simple ordinal scale to
aid comparison of impacts borne by different population groups
under the three funding assumptions. Where group members
disagreed on the appropriate score, this was resolved by dis-
cussion or an average score awarded. Table 1 summarizes the
grids presenting health impacts under scenario 1 (low spend)
and scenario 3 (high spend).
The main areas of health impact identified were: accidents;
pollution; access to amenities, jobs and social contacts; oppor-
tunities for physical activity in walking and cycling; and impacts
on community networks. Most detrimental impacts differen-
tially affected more disadvantaged communities. Pollution
affected all groups but people who spend a lot of time in cars
(young children and working people) are exposed to poorer air
quality than those using other modes of transport.
22,23
The
Table 1 Matrix showing health impacts to different population groups under transport policy scenario 1
(low spend) and scenario 3 (high spend)
Physical Access to goods Community
Accidents Pollution activity and services network
1313131313
Young children
Affluent  
Deprived 
Adolescents
Affluent   
Deprived   
Elderly
Affluent   
Deprived   
Working people
Affluent 0 
Deprived   
Unemployed
Deprived  
Key: , very positive impact; , positive impact; 0, no impact; –, negative impact; —, very negative impact.
150
JOURNAL OF PUBLIC HEALTH MEDICINE
scenario with the greatest funding would produce the greatest
health gain, whereas scenarios with lower funding would have
detrimental effects on health and health inequalities. The high
spend option was also favourable to local business interests,
especially in financial and tourism sectors.
Case study 2: HIA of the North Edinburgh Area Renewal
housing strategy
24
This study assessed the health impacts of housing investment in
a disadvantaged part of Edinburgh, so as to inform a review of
the housing strategy.
Information for the study was gathered from a review of the
published evidence, focus group sessions involving community
groups and interviews with professionals working in the area.
Participants of the focus groups ranked the elements of the
housing strategy in order of importance in terms of impact on
health. The ranked list was used as the starting point for discus-
sion of the impacts on health. As the top rankings of all the
groups were broadly similar, they were combined to produce an
overall composite ranking. The literature review focused on the
seven highest ranked elements.
Table 2 summarizes the health impacts of the seven highest
ranked elements of the strategy, as perceived by participants of
focus groups. Both physical and mental health impacts were
identified. Overall, the housing strategy was perceived to have
greatest impact on mental health, especially stress and depres-
sion. Elements of the strategy reported to have a positive impact
on mental health included the following: central heating allows
all parts of the home to be warm, thus increasing living space
and reducing overcrowding; double glazing helps to reduce
noise pollution; security entry and window locks reduce the fear
of crime; a suitable size of home reduces overcrowding; having a
sense of control over your life by actively participating in the
renewal programme brings a sense of achievement. Also, the
redevelopment helped to reduce the stigma associated with
living there and created higher self-esteem among residents. The
physical impacts were due to central heating and double glazing,
with reported improvements in cold and damp-related illnesses.
The study provided qualitative data exploring the impacts
perceived by residents and the value they placed on these
impacts. The ranked lists showed the perceived importance to
health of different elements of the strategy to different groups in
the community.
Discussion
Qualitative and quantitative evidence
Both these examples assessed a broad policy rather than a more
specific project. The aim of this approach to HIA is to make
the health impacts of policies explicit and thereby to provide
evidence to inform better policy-making.
13
This will not satisfy
those who will only admit high-quality evidence that ‘proves’
cause and effect links, but in the practical world of policy-
making, the real challenge is to employ methods that are robust
(being explicit in their strengths and weaknesses) but also practi-
cal and timely. HIA is usually a way to apply existing evidence
to a local situation and policy, to inform policy-making, rather
than being research that generates new evidence.
In these case studies, we used a range of sources to identify
and describe health impacts. These included: published litera-
ture, routinely available data, interviews with key informants,
focus group discussions with community members, and group
meetings. These approaches created an understanding of the
possible or probable impacts of policy on many of the broad
determinants of health and, so by implication, on health status.
The views of local people and other stakeholders also provided
information on the relative importance of each of a variety of
possible consequences of the policies.
There is often a demand for quantitative data to support
decision-making.
15
But we found that qualitative and quantita-
tive data were both useful, giving different perspectives. Many
impacts are best explored using qualitative methods. In the
housing HIA the qualitative data gave insights into the strength
of feeling people had for each impact, and the priority placed on
them. For example, it was more important for people to feel safe
inside their homes than in the street. They also demonstrated
that some impacts were dependent on other factors. For exam-
ple, money saved from cost-efficient heating could only be spent
on ‘healthy’ foods if there were also better shopping facilities.
We found that a combination of methods gave a picture of
the health impacts and produced different kinds of evidence.
The appropriate kinds of evidence to inform policy develop-
ment will vary in different circumstances.
The scope of health impacts
Both case studies used a broad model of health to identify health
impacts. Some impacts were not immediately obvious and were
identified later in the process. Flexibility of process is needed to
ensure these are included in the assessment.
More positive than negative impacts were identified. If HIA
was concentrated on policies that might be health damaging,
it might help prevent health damage. But HIA can also find
opportunities to maximize health gain and be a positive way
to work across sectors to define and to promote healthy public
policy. This is an important difference from Environmental
Assessments, where the priority is to reduce damage.
14
Unresolved debates include the time-scale over which to pre-
dict impacts in prospective HIA and how direct an association
between the policy and the impacts should be recognized. Some
important impacts may arise indirectly or in the long term, but
we can predict with greater certainty direct impacts that occur in
the short term.
Defining the policy and local context
The case studies used detailed information on the relevant poli-
cies, and needed expertise from outside the health sector. It was
difficult to consider the policies in isolation of other relevant
DEVELOPING PRINCIPLES FOR HEALTH IMPACT ASSESSMENT
151
Table 2 Seven highest ranked elements of the housing strategy: health impacts identified by residents
Positive health impact Negative health impact
Central heating and double glazing
Mental health – reduces worries about bills; increases overall sense of Physical health – can aggravate asthma as air too dry,
well-being: reduces depression, degradation, stress, anger, anxiety, can cause more colds and snuffles
embarrassment; better sleepless irritable
Physical health – improves circulation, chest, recovery from operations,
reduces hypothermia, fevers, pneumonia, asthma, coughs, colds, stiffness,
aches and pains, passing out from epilepsy, angina, bronchitis, sore throats,
arthritis, cramp
Family functioning – children can go to own rooms, relieves strain on
parents; people less grumpy, more calm
Income – increases incomemore to spend on foodpotential for improved
diet, more to spend on socializing
Social networks and isolation – increases social life as feel better about
inviting friends roundreduces isolation
Physical environment – reduces dampless illness; reduces noiseless
stress
Education – increased ability to concentrate (because of less noise from
double glazing and heating in children’s bedrooms, etc.)better school
performance
Security entry system and improved window locks
Mental health – reduces distress and anxiety from fear of burglary or
unwelcome visitorsimproved mental health; improved asthma because of
less stress
Social environment – increased confidence to go out and socialize without
fear of burglary
Improvements to inside of house (including sound proofing)
Mental health – less stress/anxiety and better sleep because of decrease Mental health – jealousy and resentment between those
in noise (fear from noise disruptions leading to feelings of panic) who have had improvements and those who have not
Family functioning – more control over immediate environment if less
affected by noise
A choice of house size and type
Social environment – easier to get in and out with children if not in block of
flats – less exposure to racist attacks in own house compared with blocks
of flatsless fearbetter sleepless use of sleeping tablets
Family functioning – improved sleep and family relationships in larger
houseless stress and reduction in feelings of tiredness and sluggishness;
less affected by noise in own house compared with block of flatsbetter
sleep, fewer panic attacks
Physical health – less spread of illness in own house compared with block
of flats with shared stairs, etc.; fewer accidents
Resident input into choice of neighbour
Mental health – less stress if no noisy or annoying neighbours; less fear of Mental health – If this limited consultation does not lead
violence and racist attacks; less anger caused by nuisance children to a reduction in nuisance neighbours, there could be
coming into stair; less vandalism; less worry re drug users becoming role increased frustration that tenant voice is not being heard
models for children
Physical health – reduced threat of injury and spread of diseases via dirty
needles; less injury from racist attacks and other violent incidents
Social environment – better communication, improved social network
Tenant and resident participation
Mental health – sense of control Mental health – if consultation with tenants and
residents is not meaningful, and they feel their views
are not being taken into account, frustration and
increased stress levels could result
152
JOURNAL OF PUBLIC HEALTH MEDICINE
policies; for example, transport policy is interdependent with,
and arguably part of, land use policy. In a retrospective assess-
ment it may be difficult to distinguish the differential impacts of
these related policies. In a prospective assessment that seeks to
inform decision-making, it is necessary to define the policy pro-
posal being assessed, but the recommendations may be directed
to other related policies and other sectors.
There are few examples of HIA in the published literature,
but one similar assessment of a transport strategy has recently
been published.
25
This identified similar impacts to our HIA of
the transport strategy, but differences in the local context were
also important. For example, the existence of disadvantaged
estates on the outskirts of Edinburgh and the local tourism
industry affected the priority impacts. Evidence must be weighed
for its local relevance as well as its robustness.
Participation
Participation of affected people is crucial in HIA because of
their insight into how a proposal might affect their community,
their well-being and their behaviour.
19
It is also needed to study
the value that affected people place on different health impacts.
Affected communities may also suggest changes to maximize
the health benefit. Participation might be needed at different
stages of the HIA, to identify and describe impacts and to make
recommendations. It is difficult to engage meaningfully with
communities, but the mechanisms used will not be unique to
HIA. Often a range of different methods might be used to gather
community views. Mechanisms might include focus groups,
citizens panels, opinion polls and inviting views from existing
community groups.
Inequalities
Both case studies could be described as health inequalities
impact assessment as they explicitly addressed different impacts
affecting different population groups. For example, in the trans-
port HIA, deprived populations were most disadvantaged by
policies favouring car use. In the housing HIA, different groups
gave priority to different elements of the strategy. These differ-
ences have implications for the recommendations of the HIA.
We found it was an essential part of the HIA to identify the
population groups who would bear each impact. We believe
that HIA and HIIA should not be separate processes. Rather,
all HIA should consider impacts on inequalities.
This has implications for the presentation of findings,
especially if quantitative measures of health impact are used, for
example, the total number of people affected by each impact. If
quantitative measures are used to compare impacts, there might
be a temptation to sum them to reach a ‘bottom line’ value for
the health impacts of a proposal. This might allow easier com-
parison of policy options, but would hide the differences
between impacts borne by different groups. Instead, the health
benefits and costs for each group should be presented separ-
ately. For HIA to help tackle inequalities, it is essential that the
different impacts borne by different groups are made explicit.
Then the recommendations can seek to reduce any health
inequalities that might result from the proposed policy or pro-
ject.
Making recommendations
In making recommendations to prevent any adverse impacts
and enhance positive health impacts, we need to understand
what change to the proposal is possible. This implies working
closely with the policy developer. The recommendations should
be closely connected to the health impacts identified. The
recommended changes may be at the margin but still achieve
important improvements in health. Having made recommenda-
tions, their implementation and the future impacts on the health
of the population should be monitored. It is not clear who
should be responsible for this, and it is likely to vary with indi-
vidual circumstances.
Putting the evidence together
The two studies adopted different procedures to collate the
evidence. The housing HIA used the Merseyside guidelines.
14
The transport HIA adapted guidance circulated by the Scottish
Office.
26
Both groups progressed through the following stages:
(1) collate background information on policy and population;
(2) identify impacts; (3) describe and/or quantify and/or deter-
mine priorities of impacts; (4) make recommendations. How-
ever, these stages were not distinct or self contained, and earlier
stages were revisited in the light of later findings. The case
studies found that health impact assessment was an iterative
process.
We concluded that there is no single ‘blueprint’ for HIA that
will be appropriate for all circumstances. Different approaches
and methods will be required in different situations. However,
we have defined principles that highlight the key issues to con-
sider. These are presented below.
Key principles for health impact assessment
The HIA process should:
Screen. Not all policies can be subjected to HIA; a screening
process
6
should be applied to select and determine priorities
of the topics with important health impacts.
Negotiate. The scope of the HIA and implementation of
recommendations should be agreed with decision-makers.
Share ownership. The HIA should be jointly owned by the
decision-makers, the investigators, the affected community
and other stakeholders.
Be timely. The initial HIA should be carried out when the
policy is clearly defined but it is still possible to influence
decision-making.
Define and analyse the policy. It is important to understand
the policy being assessed, including its rationale, its objec-
tives and evidence of the results of similar policies elsewhere.
This includes consideration of the policy context.
DEVELOPING PRINCIPLES FOR HEALTH IMPACT ASSESSMENT
153
Define and profile the population. The population whose
health is being considered should be defined and its health
status, health problems and capacity should be profiled. This
should include separate identification and profiling of rele-
vant subgroups.
Use an explicit model of health. The scope of the health
impacts to be identified, and the nature of causality assumed
should be clear. This requires a framework to define health
impacts, health determinants, and influences on health and
health determinants.
Be aware of underlying values. HIA is as much art as science.
Judgements must be made in determining priorities of poten-
tial impacts, estimating risks and benefits and making rec-
ommendations. This is necessarily value laden. Investigators
should be explicit about the values or political position from
which HIA is undertaken.
Be systematic. The HIA should be carried out in a systematic
way, using a comprehensive framework to identify all rele-
vant impacts and a transparent, credible approach.
Think broadly. All relevant impacts should be identified and
considered, including indirect and long-term impacts.
Use appropriate evidence. Both quantitative and qualitative
methods may be used in an HIA and the combination of
methods used will vary with circumstances. The evidence
and methods gathered should be appropriate to the impacts
identified and the importance and scope of the policy.
Involve the community. They have unique insights into how
the proposal might affect their lives, their community, and
their health-related behaviour.
Take into account local factors. HIA combines evidence from
elsewhere with consideration of local differences that might
influence how and by whom the impacts are borne locally.
Recognize difference. Communities are not homogeneous.
Different impacts are borne by different sectors of the com-
munity and HIA should make these explicit.
Monitor impacts prospectively. Having carried out an initial
prospective HIA, there should be a procedure for continuous
monitoring of resultant impacts, to identify any unexpected
impacts and inform future prospective HIA of similar poli-
cies.
Make practical recommendations. Recommendations should
seek to mitigate adverse and enhance beneficial impacts, be
practical to implement and should aid the most effective use
of limited budgets.
(Note: ‘policies’ is used here to mean policies, programmes or
projects.)
Acknowledgements
The work was funded by the Scottish Executive Health Depart-
ment. We also thank the members of the Transport HIA
Working Group and the NEAR HIA Working Group, which
undertook the two case studies, and the urban regeneration
HIA group that discussed methods of HIA for urban regenera-
tion projects.
References
1 Wadsworth MEJ. Health inequalities in the life course perspective.
Social Sci Med 1997; 44: 859–869.
2 Marmot M, Wilkinson R. Social determinants of health. Oxford:
Oxford University Press, 1999.
3 Scott-Samuel A. Health impact assessment: an idea whose time has
come. Br Med J 1996; 313: 183–184.
4 Scott-Samuel A. Assessing how public policy impacts on health.
Healthlines 1997; 15–17.
5 Stewart S. The possible Scot: making healthy public policy. Edinburgh:
Scottish Council Foundation, 1998.
6 World Health Organization European Centre for Health Policy.
Health impact assessment: main concepts and suggested approach.
Gothenburg consensus paper, 1999. [On-line.]
http://www.who.dk/hs/ECHP/attach/gothenburg.htm
(16 August 2000, date last accessed).
7 Secretary of State for Health. Saving lives: our healthier nation. Cm
4386. London: The Stationery Office, 1999.
8 Secretary of State for Scotland. Towards a healthier Scotland: a white
paper on health. Cm 4269. Edinburgh: The Stationery Office, 1999.
9 Department of Health. Independent inquiry into inequalities in health.
London: The Stationery Office, 1998.
10 European Communities. Treaty of Amsterdam Amending the Treaty on
European Union, the Treaties Establishing the European Communities
and Certain Related Acts. Luxembourg: Office for Official
Publications of the European Communities, 1997.
11 Hubel M. Evaluating the health impact of policies. A challenge.
Eurohealth 1998; 4: 27–29.
12 World Health Organization Regional Office for Europe.
Health 21 – health for all in the 21st century. Copenhagen: WHO
Regional Office for Europe, 1999.
13 Lock K. Health impact assessment. Br Med J 2000; 320: 1395–1398.
14 British Medical Association. Health & environmental impact
assessment. An integrated approach. London: Earthscan, 1998.
15 Department of Health. Policy appraisal and health. London: HMSO,
1995.
16 Frankish CJ, Green L, Ratner P, Chomik T, Larsen C. Health impact
assessment as a tool for population health promotion and public policy.
Vancouver: Institute of Health Promotion Research, University of
British Columbia, 1996.
17 Health Canada. Canadian handbook on health impact assessment: the
basics. Ottawa, Ont.: Minister of Public Works and Government
Services Canada, 1999.
18 Health Promotion Division. Developing health impact assessment in
Wales. Cardiff: National Assembly for Wales, 1999.
19 Scott-Samuel A, Birley M., Ardern K. The Merseyside guidelines for
health impact assessment. Liverpool: Liverpool Public Health
Observatory, University of Liverpool, 1998.
20 Winters L. Health impact assessment: a literature review. Observatory
Report Series No. 36. Liverpool: Liverpool Public Health
Observatory, University of Liverpool, 1997.
21 Scottish Needs Assessment Programme. Health impact assessment of
the City of Edinburgh Council’s urban transport strategy. Glasgow:
Scottish Needs Assessment Programme, 2000.
154
JOURNAL OF PUBLIC HEALTH MEDICINE
22 British Medical Association. Road transport and health. London:
Chameleon Press, 1997.
23 Jefferiss P, Rowell A, Fergusson M. The exposure of car drivers and
passengers to vehicle emissions; comparative pollution levels inside and
outside vehicles. A report for Greenpeace by Earth Resources Research.
London: Greenpeace, 1992.
24 Scottish Needs Assessment Programme. Health impact assessment of
the North Edinburgh Area Renewal (NEAR) housing strategy.
Glasgow: Scottish Needs Assessment Programme, 2000.
25 Fleeman N, Scott-Samuel A. A prospective health impact assessment
of the Merseyside Integrated Transport Strategy (MerITS). J Publ
Hlth Med 2000; 22: 268–274.
26 Douglas, M. Health impact assessment: a practical approach.
Glasgow: Office for Public Health in Scotland, 1998.
Accepted on 1 February 2001
... • Noise and other polices and practice in many sectors affect health so a Health Impact Assessment [15] is one of the ways to predict these health impacts, and in order to recommended improvements in policies to improve health. ...
... They must be considered in establishing political practices for planning the healthy growth of any country. Based on the evidence, the approach I will be following in this article to study how urban planning policy impact health and how to improve synergies and positive effects is the health impact assessment (HIA; Douglas et al., 2001). The HIA provides a combination of instruments, procedures, and methods adopted for having potential effects on the healthy condition of the population. ...
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... There are no set procedures for conducting an HIA, though best practices off ered by mining or impact assessment associations and government-issued reports suggest a series of steps including screening, scoping, assessment, recommendations, reporting and possible monitoring, and evaluation (Douglas, Conway, Gorman, Gavin, & Hanlon, 2001;MacNaughton & Hunt, 2009;Parry & Stevens, 2001). The diversity that may exist in practice is countered with more universal agreement on the underlying purpose of conducting an HIA: to improve decision making, empower local communities, and compel diff erent agencies to consider health at a higher level. ...
... Baum (1995) contends that researchers may select from 'a smorgasbord of methods'. Douglas et al (2001) suggest that the different data types are useful in providing 'different perspectives' on the same issues. ...
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This article was migrated. The article was marked as recommended. A national survey (questionnaire) on Cardiology trainees undertaken on behalf of the author by the British Junior Cardiologists Association (BJCA) on training opportunities, needs, attitudes and perceived barriers that exist within “current training” in cardiac devices suggests lack of opportunity for hands on training and poor attitude to training resulting in a perceived lack of competence. The conflict between service commitment and training was a recurring theme.
... Another case study provided examples of contextual knowledge that helped 'rank' the importance of several impacts of a project, e.g. safety at home versus safety in public space (Douglas et al., 2001). Several authors describe experiences where the knowledge of community members is essentially different from expert knowledge and combining these two types of knowledge is challenging. ...
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Currently, the engagement of local communities in Health Impact Assessment is becoming more and more important. A scoping review was performed to take stock of visions, methods and experiences in this field.
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Background Health Impact Assessment (HIA) is a practical tool used to judge the potential health effects of a policy, program, or project on a population. In 2016, China started implementing HIA to promote its nationwide “Health First” political campaign. The central government developed a succession of laws and plans to shape HIA’s political-administrative framework, yet they are too broad to advise how to undertake an HIA at a local level. Since 2017, China has tested HIA pilots in several jurisdictions to institutionalize HIA. However, all HIA pilots are far from completion as of September 2023, moving at a much slower rate than other policy pilots. This raises the question of why HIA has been so slow to grow in the Chinese context. What can China do to further its HIA development? By seeking answers to these questions, this article aims to inform Chinese policymakers and planning researchers whose scholarly interests vary from health impact assessment to governance and institution building in a volatile global economy that now places a high value on planning for public health. Methods In this qualitative study, we conducted 17, one-off, semi-structured, online interviews with Chinese scholars and officials from various disciplines who had direct or indirect experience with HIA. The disciplines include urban planning, public policy, public health, etc. We identified four major themes through a codebook thematic analysis using ATLAS.ti 22. Results Four themes have emerged concerning the delayed growth of HIA in China. They are conceptual differences between EIA and HIA; technical issues associated with environmental hazards and individual health; legislative issues; and cross-sector collaboration issues. Conclusions The delayed growth of China’s HIA prevents the country from widely refining its policies, programs, and projects to achieve public health goals. To address this, the paper offers several recommendations, including emphasizing policies that enact changes and de-emphasizing scientific uncertainty; developing the HIA implementation law, supporting policies, and a practical guideline; and promoting multidisciplinary professional development. We believe that these recommendations will eventually speed up the HIA development in China. We also hope that the recommendations can offer policy guidance to other developing countries as they navigate their public health policies.
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Poor housing is associated with poor health. This suggests that improving housing conditions might lead to improved health for residents. This review searched widely for studies from anywhere in the world which had investigated whether or not investment to improve housing conditions is linked with improvement in health. A huge amount of research on housing and health has been published but very few studies have investigated if improved housing conditions impact on residents' health. Neighbourhood renewal programmes often include housing improvements but a key aim of these programmes is to improve the area by attracting new residents, often those who are better off. In these programmes, improvements in health statistics may simply reflect a change in the population living in an area and the original population may not have benefited from the improved living conditions. This review only looked at studies where changes in health for the original population were being investigated rather than changes for the area. We identified 39 studies which assessed changes in health following housing improvement. The studies covered a wide range of housing improvements. The housing improvements in high income countries, and conducted in the past 30 years, included refurbishment, rehousing, relocation, installation of central heating and insulation. Studies from the developing world included provision of latrines. Older studies (pre‐1965) examined changes in health following rehousing from slums. Overall, it would appear that improvements to housing conditions can lead to improvements in health. Improved health is most likely when the housing improvements are targeted at those with poor health and inadequate housing conditions, in particular inadequate warmth. Area based housing improvement programmes, for example programmes of housing‐led neighbourhood renewal, which improve housing regardless of individual need may not lead to clear improvements in housing conditions for all the houses in a neighbourhood. This may explain why health improvements following these programmes are not always obvious. Improvements in warmth and affordable warmth may be an important reason for improved health. Improved health may also lead to reduced absences from school or work. Improvements in energy efficiency and provision of affordable warmth may allow householders to heat more rooms in the house and increase the amount of usable space in the home. Greater usable living space may lead to more use of the home, allow increased levels of privacy, and help with relationships within the home. An overview of the best available research evidence suggests that housing which promotes good health needs to be an appropriate size to meet household needs, and be affordable to maintain a comfortable indoor temperature. Abstract Background The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow‐up periods. Impacts on socio‐economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts. Objectives To assess the health and social impacts on residents following improvements to the physical fabric of housing. Search methods Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH‐DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In‐Process & Other Non‐Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status. Selection criteria Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross‐sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio‐economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language. Data collection and analysis Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non‐experimental and uncontrolled studies. Health and socio‐economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta‐analysis was not appropriate the data were tabulated and synthesized narratively following a cross‐study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model. Results Thirty‐nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty‐three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non‐experimental studies of warmth improvements, 12 non‐experimental studies of rehousing or retrofitting, three non‐experimental studies of provision of basic improvements in low or middle Income countries (LMIC), and three non‐experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review. Very little quantitative synthesis was possible as the data were not amenable to meta‐analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively. Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing‐led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre‐1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio‐economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced. Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis. Authors' conclusions Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work. While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities. Plain language summary Housing improvement as an investment to improve health Poor housing is associated with poor health. This suggests that improving housing conditions might lead to improved health for residents. This review searched widely for studies from anywhere in the world which had investigated whether or not investment to improve housing conditions is linked with improvement in health. A huge amount of research on housing and health has been published but very few studies have investigated if improved housing conditions impact on residents' health. Neighbourhood renewal programmes often include housing improvements but a key aim of these programmes is to improve the area by attracting new residents, often those who are better off. In these programmes, improvements in health statistics may simply reflect a change in the population living in an area and the original population may not have benefited from the improved living conditions. This review only looked at studies where changes in health for the original population were being investigated rather than changes for the area. We identified 39 studies which assessed changes in health following housing improvement. The studies covered a wide range of housing improvements. The housing improvements in high income countries, and conducted in the past 30 years, included refurbishment, rehousing, relocation, installation of central heating and insulation. Studies from the developing world included provision of latrines. Older studies (pre‐1965) examined changes in health following rehousing from slums. Overall, it would appear that improvements to housing conditions can lead to improvements in health. Improved health is most likely when the housing improvements are targeted at those with poor health and inadequate housing conditions, in particular inadequate warmth. Area based housing improvement programmes, for example programmes of housing‐led neighbourhood renewal, which improve housing regardless of individual need may not lead to clear improvements in housing conditions for all the houses in a neighbourhood. This may explain why health improvements following these programmes are not always obvious. Improvements in warmth and affordable warmth may be an important reason for improved health. Improved health may also lead to reduced absences from school or work. Improvements in energy efficiency and provision of affordable warmth may allow householders to heat more rooms in the house and increase the amount of usable space in the home. Greater usable living space may lead to more use of the home, allow increased levels of privacy, and help with relationships within the home. An overview of the best available research evidence suggests that housing which promotes good health needs to be an appropriate size to meet household needs, and be affordable to maintain a comfortable indoor temperature.
Thesis
Health Impact Assessment (HIA) is an assessment of the health effects, positive or negative, of a project, programme or policy. However, the quality of the evidence base currently available for HIA may limit the soundness and completeness of the conclusions, and consequently the capacity to achieve health gain. I developed a four-stage framework of the information required to quantify health impacts: evidence for causality, magnitude of response, baseline event rate, and change in exposure. The UK National Air Quality Strategy requires local authorities to achieve targets for seven outdoor air pollutants. I conducted systematic literature reviews and evaluated the epidemiological evidence relating ambient particulates and nitrogen dioxide (the pollutants relevant to central London) to various health outcomes. For those assessed as being causal, I considered the shape and magnitude of the relationship. Using local authority air pollution data, I modelled three ways in which pollution could fall to achieve the UK objectives. I wrote spreadsheets to estimate the effects on premature deaths and hospital admissions of reducing pollution to the objectives, combining the exposure-response coefficients with baseline mortality or hospital episode statistics data and modelled falls in pollution. I then performed these calculations for Kensington & Chelsea and Westminster. Air quality management using technical fixes will accomplish only these health gains; traffic reduction would have a broader range of health impacts. I reviewed the availability of evidence for other ways in which transport affects health, particularly community severance and physical activity. Policies that achieve air quality targets by reducing traffic are likely to have substantially greater health benefits than those that rely on technical fixes, but this is unquantifiable at present. I also compared my approach with the rapid literature review in general usage in HIA, and have identified specific gaps in the evidence and research needs.
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Objectives: To determine the association among number of factors influenced by asthma using geographic information system. Methods: The cross-sectional study was conducted in Landhi and Korangi towns of Karachi from 2011 to 2013, and comprised ecological mapping and multi-criteria evaluation techniques to discover the relationship of local environmental settings with asthma. Additionally, exacerbating environment and the root causes within the local settings were assessed. Data was gathered using an extended version of the questionnaire developed by the International Union against Tuberculosis and Lung Disease. Data was analysed by using ArcGIS 10. Results: The findings are very alarming as almost 40% (468,930 estimated pop 1998 census) of the study population lived in high asthma-prone environment, having a very high risk of respiratory disorders, including asthma. Conclusion: The integrated environmental effect in the form of respiratory disorders was appraised, focusing on asthma by using multi-criteria analysis.
Technical Report
Many of those behind the increased international interest in HIA are also promoting a health equity agenda, and there is increasing interest in how the two may be combined. Despite suggestions that equity should be considered in every HIA there is little enabling guidance available. There is a need, particularly in contexts where an explicit commitment to reducing health inequalities does not exist, for clearly structured, practical guidance on how to incorporate equity in HIA.
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Health impact assessment is a structured method for assessing and improving the health consequences of projects and policies in the non-health sector. It is a multidisciplinary process combining a range of qualitative and quantitative evidence in a decision making framework. Applications include national policy appraisal, local urban planning, transport,; and water and agricultural projects. Benefits include improved interagency collaboration and public participation. Limitations include a lack of agreed methods and gaps in the evidence base for health impacts.
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Prospective health impact assessment is a new approach to predicting potential health impacts of policies, programmes or projects. It has been widely recognized that public policies have important impacts on health. In 1997, the Liverpool Public Health Observatory was commissioned to carry out a health impact assessment of the Merseyside Integrated Transport Strategy (MerITS). A secondary aim was to pilot a method for health impact assessment at the strategic level. The methods used drew on previous health impact assessments of projects, on strategic environmental assessment, and on policy research. They included policy analysis, semi-structured interviews with key informants and literature searches. Four priority impact areas of MerITS were identified: establishing road hierarchies, economic viability, air quality, and public transport. Potential health impacts in each of these areas were estimated, and recommendations were made to minimize the effects of negative impacts and to enhance positive ones. This health impact assessment prospectively identified the key health impacts of a strategy on a defined population and made recommendations to maximize potential positive and minimize potential negative health impacts. The methods employed are generally applicable to prospective health impact assessments of public policies and strategies.
Article
Life history approaches to the study of inequalities in health provide evidence that the biological and the social beginnings of life carry important aspects of the child's potential for adult health. Biological programming may set the operational parameters for certain organs and processes. Social factors in childhood influence the processes of biological development, and are the beginnings of socially determined pathways to health in adult life. Life history studies of health are beginning to show the important factors associated with the development of these pathways, and the life stages at which intervention to reduce adult health inequalities may be most effective.
Assessing how public policy impacts on health
  • A Scott-Samuel
Scott-Samuel A. Assessing how public policy impacts on health. Healthlines 1997; 15–17.
British Medical Association. Road transport and health
JOURNAL OF PUBLIC HEALTH MEDICINE 22 British Medical Association. Road transport and health. London: Chameleon Press, 1997.
Health impact assessment: a literature review Observatory Report Series No. 36
  • L Winters
Winters L. Health impact assessment: a literature review. Observatory Report Series No. 36. Liverpool: Liverpool Public Health Observatory, University of Liverpool, 1997.
The possible Scot: making healthy public policy. Edinburgh: Scottish Council Foundation
  • S Stewart
Stewart S. The possible Scot: making healthy public policy. Edinburgh: Scottish Council Foundation, 1998.
Health impact assessment: an idea whose time has come
  • A Scott-Samuel
Scott-Samuel A. Health impact assessment: an idea whose time has come. Br Med J 1996; 313: 183–184.
The exposure of car drivers and passengers to vehicle emissions; comparative pollution levels inside and outside vehicles. A report for Greenpeace by Earth Resources Research
  • P Jefferiss
  • A Rowell
  • M Fergusson
Jefferiss P, Rowell A, Fergusson M. The exposure of car drivers and passengers to vehicle emissions; comparative pollution levels inside and outside vehicles. A report for Greenpeace by Earth Resources Research. London: Greenpeace, 1992.