Iom Chia Hia Reader 2005-2007

Health Impact Assessment - a training reader what is it why do it when to use it how to do it how to commission it

Written by Dr Salim Vohra, Director, Centre for Health Impact Assessment 2003-05

Contents 1. Introduction.............................................................................. ................1 2. Health Impact Assessment.......................................................................2 3. Health, Determinants and Inequalities...................................................10 4. Evidence and Evidence Gathering..........................................................15 5. Evaluating Evidence...............................................................................20 6. Dealing with Uncertainty: insufficient and contradictory evidence.........24 7. Stakeholder Involvement........................................................................28 8. Analysis............................................................................... ...................33 8. Commissioning and Scrutinising a HIA...................................................36 9 The Wider Context: political, economic and social factors.........................................................................................39 10. Monitoring and Evaluation of Impacts..................................................42 11. Conclusion............................................................................... .............48 Sources of Further Information...................................................................49 References................................................................................................. .52

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1. Introduction There are three core aims of this reader on health impact assessment: 1. To develop in readers a good understanding and appreciation of the value of health impact assessment (HIA) in identifying the actual and potential negative and positive effects of policies, plans, programmes, projects, developments and services. 2. To enable readers to undertake a rapid health impact assessment on their own policies, plans, programmes, projects, developments and services. 3. To enable readers to commission rapid and comprehensive health impact assessments and critically evaluate the strengths and limitations of health impact assessment statements and reports.

This reader forms part of the training material that Living Knowledge gives to training participants so that they achieve these three key learning outcomes: Understanding of health impact assessment To develop participants understanding of: what health impact assessment is; its rationale, its values and structure; when it can be done; where it can be done; why it should be done; the different approaches; their strengths and limitations; how to use and evaluate evidence on health impacts; the value of stakeholder consultation and the need to build in monitoring and evaluation. Undertake a rapid health impact assessment To show participants how they can integrate health impact assessment and their understanding of HIA into their own professional work by giving them the skills and experience to screen, scope, appraise and make recommendations on the potential health impacts of policies, plans, programmes, projects, developments and services that they are currently working on and might work on in the future. This includes understanding the need for building in monitoring and evaluation. Commission and critically evaluate health impact assessment reports To develop the participants’ confidence in HIA by providing them with knowledge and information on HIA – the general framework, the key approaches and their strengths and limitations – that will allow them to evaluate and understand a tender for a HIA and HIA reports produced by other people and other organisations.

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2. Health Impact Assessment “Go to the people, live among them Build on what they know, but of the best practitioners When their task is accomplished, their work is done The people all remark, we have done this ourselves” The New Public Health by John Ashton

2.1 What it is Health impact assessment (HIA) is a relatively new impact assessment methodology. Its roots lie in environmental impact assessment and the healthy public policy movement. Legislation in the UK requires an environmental impact assessment (EIA) to be commissioned as part of the planning process and lays down what areas must be covered in an EIA. EIAs focus largely on key physical environmental factors such as impact on plants and wildlife, air quality, noise, hydrology and archaeology. In contrast, HIA is currently commissioned voluntarily; the methodology is not prescribed but informed by international best practice and the focus determined by the nature of the policy, plan, programme, project, development or service (initiative) which is being assessed. Boxes 1 and 2 at the end of this chapter describe the international context of HIA. The widely accepted Gothenberg consensus definition of health impact assessment 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. WHO European Centre for Health Policy

HIA is the key systematic approach to identifying the health impacts of proposed and implemented policies, plans, programmes, projects and services (initiatives) within a democratic, equitable, sustainable and ethical framework, so that negative health impacts are reduced and positive health impacts increased (within a given population). It uses a range of structured and evaluated sources of evidence that includes public and other stakeholders' perceptions and experiences as well as public health, epidemiological, toxicological and medical knowledges.

Other impact assessment approaches include social impact assessment, environmental health impact assessment, technology assessment, strategic environment assessment, sustainability appraisal and health impact analysis. There are also newer forms of impact assessment such as

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equalities impact assessment, regulatory impact assessment and integrated impact assessment. It is not in the scope of this reader to discuss their similarities and differences.

There are several key points to note in the definitions given above many of which have a counterpart in EIA:

•

HIA draws on many different techniques and sources of evidence;

•

HIA looks at the potential effects of an initiative i.e. it tends to be carried out while the initiative is at the design or draft stage;

•

HIA identifies the potential for positive and negative effects;

•

HIA is concerned with the distribution of effects within a population as different groups are likely to be affected in different ways and therefore looks at how health and other social inequalities might be exacerbated by the proposed project, service, programme, policy or development.

In order to examine the ways in which the proposed project, service, programme, policy or development (initiative) may be expected to affect the health of particular populations it is important to have a clear understanding of:

•

the context within which the initiative is proposed and

•

the aims and objectives of the initiative.

HIA tends to draw on knowledge and information which already exists about a proposed initiative and the communities that are likely to be affected i.e. it tends not to undertake specific new research on health impacts during the assessment. As with other forms of impact assessment, including EIA, HIA identifies the potential for unintended side-effects and suggests ways to avoid negative impacts. It is important to appraise an initiative and examine the ways in which it might affect people's health and also to consider mitigation and enhancement measures. Mitigation measures help to reduce the negative health effects and enhancement measures aim to increase the positive health effects of a given initiative. HIA also contributes to the development of a monitoring and evaluation strategy for an initiative. This can ensure that the negative health effects are indeed reduced and the positive effects increased for any given project, service, programme, policy or development. It can also enable stakeholders to develop their own milestones and indicators for evaluating the health positives and negatives of an initiative once it is in operation .

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2.2 Why do it HIA can help to deliver better and improved policies, plans, programmes, projects, developments and services (initiatives). It can be used to: • support the planning and decision-making process by providing timely, relevant and highly credible health information and analysis. •

improve project design, construction, operation and decommissioning.

•

improve plan design, implementation and effectiveness.

•

help increase community support and reduces community concerns.

•

reduce costs and liabilities further down the project and planning cycle.

•

enhance reputation by feeding into corporate social responsibility.

2.3 What it doesn’t do At the moment it does not give numerical estimates of the negative and positive health impacts. There is no approach at present that allows us to do this accurately. This is because:

•

many of the effects on an individual’s or community’s health are not easily measurable,

•

many health effects are indirect and take many years to manifest themselves,

•

the methodology to collect quantifiable health impact evidence and make judgements based upon it is currently not well developed, and finally

•

there is argument about the tendency for quantifiable estimates developed for HIAs to give a false sense of reassurance and precision to what are a range of complex interactions between a range of social, cultural, economic, political, environmental and personal determinants of health.

2.4 How is it done There are a range of different models for undertaking HIA and an even wider set of HIA Tools Merseyside

British Columbia

Equity-focused HIA (Australia)

Swedish County Council

Health Inequality Impact Assessment (Wales) They are named after the areas and countries where they were first developed and used.

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They are different in that: Some provide a quick, simple and broad way of thinking through health impacts while others have structured and precise steps by which health impacts are identified and assessed in detail. They are similar in that they have 5 core procedural steps (see IOM CHIA’s Comprehensive HIA Toolbox for more details about how to do each of these steps): Screening: In this step policies, plans, programmes, projects, developments and services (developments) are systematically assessed to see whether a HIA needs to be done on them. A quick assessment is made on their potential to impact on a community’s health. A HIA may not need to be done either because the development has very little impact on health or the health impacts are well known and the mechanisms to reduce them are already in place. Screening helps ensure that time, effort and resources are targeted appropriately. The type of HIA that needs to be undertaken is also determined at this stage. Scoping: In this step the ‘terms of reference’ for the HIA are set i.e. what aspects will be considered, what areas and groups might need particular focus, what will be excluded from the HIA and how the HIA process will be managed. Analysis: In this step a systematic review of the potential impacts is undertaken and evidence for these impacts collected. An assessment of the likely impacts, the size and significance of the effects and the groups that are likely to be most affected is carried out and described in detail. Mitigation and Enhancement: In this step a report, called a health impact statement, is written and recommendations made on the best way forward including options to reduce the potential negative health impacts (mitigation measures) and increase the potential positive impacts (enhancement measures). HIA report/ Health statement: Development of a written report or statement. Follow up (monitoring & evaluation): In this step ways of monitoring the potential health losses (effects of the negative impacts) and health gains (effects of the positive impacts) as well as mechanisms to evaluate the development as a whole are developed. The HIA is also evaluated to assess the accuracy and appropriateness of the health predictions and recommendations made.

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2.5 When is it done HIAs can be done on policies, plans, programmes, projects, developments and services. They can be done at the: beginning .................during the development or pre-development stage. middle ..................... during the implementation stage. end ........................at the operation or closure stage to look back and evaluate. In HIA terminology: Prospective HIA..........means the impact assessment starts as early as possible in the design or draft stage of an initiative and recommendations made on how to maximise the positive and minimise the negative impacts of the design or draft. Concurrent HIA...........means the impact assessment starts when the initiative is underway and makes recommendations to the planning and delivery team about how the implementation and operation phase can be modified to reduce the negative and enhance the positive health effects. Retrospective HIA........means the impact assessment is carried out when the intervention is complete. It is too late for this initiative to be changed but lessons can be learnt about how other similar initiatives should be designed and implemented. Some researchers and practitioners suggest that concurrent impact assessment is really monitoring, retrospective impact assessment is closer to evaluation and that the only true kind of health impact assessment is prospective . You can also do quick and broad-brush ones and longer and more detailed ones. In HIA terminology you can do a rapid, intermediate or comprehensive HIAs. The most important thing to do is to choose a model and approach that makes sense to you and get going. Key questions to consider when planning a health impact assessment are: 

does the impact assessment look at the intended outcomes or unanticipated effects of the initiative?



how can or should the public be part of or involved in the process?



do other people, groups and organisations agree or disagree about the nature and significance of the health impacts?

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There is a lot of activity in health impact assessment around the world. The Sources of Further Information section starting on page 40 provides a range of World Wide Web and other resources for you to explore HIA issues in more detail.

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Box 2.1 How HIA was developed for policies and plans In the 1980s within international health promotion circles there was considerable interest in ‘healthy public policy’. In British Columbia, Canada, HIA was a requirement in the preparation of policy and guidance was published on how to do this (see the British Columbia model). In Holland the government examined how health consequences of policies could be assessed and developed procedures to undertake this. In Sweden the focus fell on local rather than national agencies and guidance was published on how to assess the health impacts of policies (see the Swedish County Council model). Meanwhile in Europe and particularly in the UK development of HIA encouraged a series of supra-national and national government statements. In England the green paper ‘Our healthier nation: a contract for the nation’ stated ‘the Government will apply health impact assessments to its relevant key policies, so that when they are being developed and implemented, the consequences of those policies for our health is considered’. This commitment was renewed in the subsequent white paper ‘Saving lives: our healthier nation’. Governments in Scotland, Wales and Northern Ireland made similar commitments. In the 1990s the UK Government acknowledged the existence of ‘Inequalities in Health’ and adopted their reduction as an overarching policy goal. The Greater London Assembly has developed a system for assessing the health impacts of all its strategies. WHO Europe said that, ‘Member states should have established mechanisms for health impact assessment and ensured that all sectors become accountable for the effects of their policies and actions on health’ as one of its Health 21 targets. The High Level Committee on Health of the European Union has also recommended the development of an easy-to-use checklist of steps in policy appraisal of health impact to be used for policy development. Health impact assessment edited by Kemm J, Parry J and Palmer S; 2004

Box 2.2 How HIA was developed for projects Health impacts especially environmental health impacts were first assessed in developing countries. This interest moved to more developed countries and major development projects. In New Zealand the Resource Management Act 1991 required authorities to make an ‘assessment of any actual or potential effects on the environment’, which includes ‘any effects on those in the neighbourhood or wider community including socioeconomic and cultural effects’. A guide to health impact assessment was published in 1995 to assist authorities with this task. In Australia development planning and resource issues are regulated by the individual states but the national government produced a report to guide states on how they could involve impact assessment in their planning and development. Tasmania has gone further and made HIAs a legal requirement. In Germany health aspects are considered in the context of environmental impact assessment (see Bielefeld model). In Holland various large development projects have been the subject of assessments that covered health and environmental impacts. In Canada, projects requiring environmental impacts were scrutinised for possible health impacts and those with greatest potential subjected to a fuller health assessment. In the United Kingdom an HIA was submitted as evidence to the planning enquiry on a third runway for Manchester airport and the British Medical Association published a guide to linked health and environmental impact assessment (see the Merseyside model).

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Health impact assessment edited by Kemm J, Parry J and Palmer S; 2004

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3. Health, Determinants and Inequalities “What is spoken of as a clinical picture is not just a photograph of a [wo]man sick in bed it is an impressionistic painting of the person surrounded by their home, their work, their relations, their friends, their joys, their sorrows, hopes and fears.” Dr Francis Peabody

3.1 What is health Having a clear definition of what we mean by ‘health’ and what definition of health we want to use when undertaking or commissioning a health impact assessment is crucial as the definition will, to a large extent, determine what kind of evidence will need to be collected and the kinds of health and disease factors that should be considered. Some people understand health as meaning curing diseases, more health services and new medical technologies and procedures. HIA works with a broad model of health which includes, but does not stop at, this medical model . It encompasses other wider determinants of health such as housing, employment, social support, crime and community safety and education.

3.2 Definitions of health Health is not easy to define and ways of thinking about it have changed over the years and are still changing. Three key models of health are the "medical model", the "holistic model", and the "wellness model or social model”: In its basic form, the “medical model” views the body as a machine that can be fixed when it does not work as it should. Its focus is on diagnosing and treating specific physical conditions (diseases), and therefore tends to be reactive in dealing with actual health problems as they occur rather than attempting to prevent them occurring in the first place. In this model health is defined as the absence of disease and the presence of high levels of normal physical functioning.

The holistic model of health is exemplified by the 1947 World Health Organisation (WHO) definition, "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity". This model uses a broader definition of what health is and also brings in the idea of the positive aspects of health by introducing the concept of wellbeing. This WHO definition is seen by some as vague, difficult to measure and subjective as wellbeing can only be measured by asking a person to tell us how they feel.

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The social model was developed through the WHO’s health promotion initiatives. The definition argues that "[Health is]1 the extent to which an individual or group is able to realise aspirations and satisfy needs, and to change or cope with the environment. 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." (Health promotion: a discussion document. Copenhagen, WHO, 1984.)

Other definitions see health in terms of resilience for example, "…the capability of individuals, families, groups and communities to cope successfully in the face of significant adversity or risk." and in ecological terms, health can be seen as "a state in which humans, and other living creatures with which they interact, can coexist indefinitely." .

The advantage of the medical model is that disease states tend to be relatively easily diagnosed and measured.

But this approach is narrow, seeing health as simply about physical disease, its

symptoms and consequences. The holistic and wellness models incorporate broader ideas of wellbeing that take into account an individual’s subjective feelings of healthiness and wellness. They allow for people with stable impairments to be seen as healthy e.g. a deaf or blind person or someone who needs the aid of a wheelchair. They also argue that it is not simply an outcome but also a resource i.e. that healthiness tends to lead to greater healthiness as it allows and enables individuals and groups to take up more opportunities. However, these conceptualisations are very broad and, arguably, vague. It is also difficult to distinguish causality between a given health status and the determinants of health, for example, has a person’s unemployment led to their ill-health or has their ill-health (acting imperceptibly over a period of time) led to their unemployment (From University of Ottawa, .

Figure 3.1: The main determinants of health 1

Words in square brackets have been added.

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Source: Dahlgren and Whitehead

3.3 Determinants of health Health is affected by a range of factors, from what we eat and drink, to where we live and work as well as the social relationships and connections we have with other people and organisations. Below are two diagrams visually describing the key determinants of health (see Figure 3.1 and Table 3.1). Figure 3.1, on the previous page, shows the Dahlgren and Whitehead ‘Model of health’. Both highlight the importance of social, cultural, spiritual and community factors in affecting individual, family and community health and wellbeing alongside genetic, lifestyle and personal factors such as age, gender and ethnicity. Table 3.1 describes some key health impacts, the determinants of health through which these health impacts occur and the types of policies, plans, programmes, projects, developments and services (initiatives) that can produce them.

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Table 3.1 Examples of health impacts, determinants of health and initiatives that can produce them (Department of Health and the Neighbourhood Renewal Unit, 2002) Health Impact

Known positive/ negative determinants of health

Examples of initiatives that can affect these influencing factors

Cardiovascular disease

Smoking

Local transport plans

Exercise

Healthy living centres

Nutrition

Land use and land planning

Being over-weight

Smoking cessation programmes

Air pollution

Access to affordable fresh foods Access to affordable physical recreation

Cancer

Smoking

Land use and land planning

Nutrition

Access to affordable fresh foods

Exercise

Healthy school meals

Chemical exposures

Smoking cessation programmes

Health screening detection Accidents

Mental Health

for

early

Access to screening programmes

Transport

Local transport and waterway plans

Workplace

Housing policies, programmes and projects

Home

Safety equipment loan schemes

Environment

Occupational health

Self esteem

Education services

Social networks

policies,

and

Employment schemes

Social pressures

Crime prevention initiatives

Fear of crime

Sustainable communities

Noise

Transport & programmes Health Inequalities

programmes

housing

policies

and

Poverty

Economic regeneration initiatives

Housing Access to services

Initiatives to improve education, employment and health for those in most need.

Education

Welfare reform

Work

Housing, transport and planning policies Access to amenities

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retail

services

and

other

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3.4 Health inequalities Each of us is affected by the determinants of health described in the previous section. However, the influence of these determinants is different on each of us with some playing a greater or lesser role depending on the specific personal, social and cultural factors that impinge upon us. These differences in affect lead to differences in health status (regardless of how we define health) so that we each possess varying degrees of health and wellbeing. This creates a range of ‘health inequalities’ between different individuals and different groups within a given society or population. These inequalities in health due to personal circumstances such as gender, ethnicity, disability, financial resources, housing, social support networks and self esteem can be exacerbated by a new or revised policy, plan, programme, project, development or service (initiative). HIA considers how an initiative could potentially heighten or reduce these health inequalities and hence how different groups will be affected compared to the affected population as a whole. To analyse and understand these inequalities individuals and community groups are categorised by some key characteristics. These include: Age – e.g. children, elderly people. Gender – e.g. male, female. Socio-economic status – e.g. unskilled, skilled, professional, income levels, education levels, other. Ethnicity – e.g. White, Black, Asian, other. Culture (including religion) – e.g. Buddhist, Christian, Hindu, Muslim, Sikh, other Sexual orientation – i.e. heterosexual, homosexual, bisexual. Disability – e.g. physical, mental, other. Disease vulnerability/ susceptibility – e.g. thallassaemia, cystic fibrosis, sickle cell anaemia, diabetes. It is important to recognise that individuals and groups can and do fall into more than one of these categories. We have multiple identities and fit within multiple categories. The categories are therefore useful rules of thumb but do not define and encompass what we and other individuals and communities are. However, categorising individuals and communities like this provides a systematic way of examining the potential health impacts, and importantly the health inequalities that result from them, by ensuring that important characteristics of both individuals and groups are taken into account in appraising the actual and potential positive and negative health effects of a given initiative.

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4. Evidence and Evidence Gathering "Only daring speculation can lead us further, and not [just] the accumulation of facts." Albert Einstein

4.1 What is evidence Health impact assessment is an evidenced-based approach to understanding the health effects of policies, plans, programmes, projects, developments and services (initiatives). As discussed in the previous chapter the definition or model of health that is used to frame the assessment will strongly determine what is seen as good evidence. Health impact evidence can comes from a variety of sources and therefore in HIAs there can be concerns, issues and conflicts about what evidence is considered valid. All forms of data, information, knowledge and research have limitations. The important thing is not to differentiate between good data, information or knowledge and bad but to understand in what contexts a particular form of knowledge is appropriately applied. To do that we need to know how the knowledge was discovered or created, the strengths and limitations of the methods used to uncover or generate that knowledge and most importantly in what context or contexts it applies. To understand evidence and the nature of evidence we first need to broadly understand the philosophical basis of science and scientific knowledge. There are four key paradigms or philosophies of science: positivist, post-positivist, critical and constructivist. Positivists “Reality is there. Look! You can see, hear, touch and measure it.” The positivist perspective is based on the idea that there is one true reality out there that we can all collectively comprehend. This real single reality is independent of human thought and action and can be fully, truly and completely captured by science and the scientific method. Hence, we can collect facts that are independent, universal, true, objective and value-neutral. Post-positivists “Reality is there, but we can only see, hear, touch and measure a bit of it.” The post-positivist perspective recognises that while there is a real single reality out there we can only comprehend it imperfectly. We, as observers, mediate and interpret this reality. Hence our understanding of the real world is always partial and subject to revisions that lead us closer and closer to what is real and true.

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Criticalists “Reality is a product of our time and place in history.” The critical perspective argues that there is no single reality but that reality is socially constructed and is shaped by historical, social, and cultural factors that include ethnicity and gender. Hence, it is the different social and cultural structures and institutions, alongside different historical forces and processes that determine what we see as knowledge, what knowledge we collect and how that knowledge is discovered/ created. Constructivists “Everyone sees the world differently. We share overlapping realities.” The constructivist perspective argues even more strongly than criticalists that there is no ‘real’ reality out there. Instead there are a diverse set of ‘socially constructed’ realities that depend on the perspective and situation of the person or observer concerned. Hence, our understandings of both the natural and social worlds are socially constructed knowledges that have more to do with us being social organisms, with language, at a certain place in time, than to some objective, valueneutral and independent reality. Table 4.1 describes the ontology (nature of reality), epistemology (nature of knowledge) and methodology (the techniques and approaches used to investigate reality and generate knowledge) of each of the perspectives in more detail. Table 4.1 Key philosophical assumptions of the four paradigms Positivism

Post positivism

Critical Theory et al

Constructivism

Ontology

‘Naïve’ realism –

Critical realism –

Historical realism –

Relativism –

(nature of the

there is one real

there is one real reality

reality is virtual and

there are a range of local,

world and reality)

reality that we can

but we can only

shaped by social,

specific and overlapping

all apprehend

understand it imperfectly

political, cultural,

realities that we each

and probabilistically

economic, ethnic, and

have constructed

gender values that have developed over time Epistemology

Objectivist –

Modified objectivist –

Subjectivist –

Subjectivist –

(nature of

findings true

findings probably true

findings are affected by

findings are created and

the values we hold

constructed

knowledge and what can be known about

universal

universal

contextual

contextual

Methodology

Experimental –

Modified Experimental –

Dialogic –

Interpretative –

(approach used to

verifying specific

falsification of

Hypothesis generation

Hypothesis generation and

understand and

hypotheses

hypotheses,

and testing

testing

may include qualitative

chiefly qualitative

chiefly qualitative

methods

methods

methods

reality)

make sense of reality)

chiefly quantitative methods

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Tables 4.1 and 4.2 shown to give a flavour of the terminology and words used by academic researchers and the critical thinking that has gone into creating robust quantitative and qualitative investigative approaches and knowledges. Each of the four perspectives (paradigms) have a distinctive orientation in terms of what knowledge is seen as acceptable, what methodologies are seen as appropriate, their criteria for validity and so on. Table 4.2 shows in greater detail what the key differences between the four perspectives are in terms of inquiry aim, nature of knowledge, how knowledge is accumulated, criteria for judging the quality of research, research values, the role of the researcher, accommodation of other perspectives, and its social power. Table 4.2 Position of each perspective with respect to practical research issues Issue

Positivism

Inquiry aim

prediction and control

Nature of

verified hypotheses

knowledge established as facts or laws

Post-Positivism

Critical Theory

Constructivism

critique and

understanding and

transformation

reconstruction

non-falsified

structural and

individual

hypotheses

historical insights

reconstructions coalescing around

probable facts or laws

Knowledge

accretion – building blocks adding to the edifice of

accumulation

knowledge;

consensus historical revisionism,

more informed and sophisticated reconstruction; lived experience

generalisations and cause-effect linkages generalisation by similarity Goodness or quality criteria

conventional benchmarks of “rigour”: internal and

historical

trustworthiness and

external validity, reliability and objectivity

situatedness; erosion

authenticity

of ignorance and action stimulus

Values

excluded – influence denied

included – formative

Ethics

extrinsic – tilt towards ‘deception’

intrinsic: tilt toward

intrinsic: tilt towards

‘revelation’

‘revelation’

“disinterested scientist” as informer of decision

“transformative

“passionate

makers, policy makers, and change agents

intellectual” as

participant” as

advocate and activist

facilitator of multi-

Voice

voice reconstruction Training

technical and quantitative

technical;

resocialisation; qualitative and quantitative;

quantitative and substantive theories

qualitative substantive theories

history; values altruism and empowerment

Accommodation

commensurable

incommensurable

Hegemony

In control of publication, funding, promotion, and

Seeking recognition and input

tenure

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The positivist perspective emphasises three key aspects in terms of study design: rigour, structure and the anticipation of problems e.g. bias, confounding, etc. Non-positivist – post-positivist, criticalist and constructivist - perspectives are much less structured and pursue an emergent approach where the process of discovery is an important and inherent element of the research process.

4.2 Gathering evidence? Evidence can come from a range of sources and can be quantitative and qualitative in nature. Quantitative evidence is in the form of numbers and statistical analysis of those numbers while qualitative evidence is in the form of detailed descriptions and logical analysis of those descriptions. Importantly, evidence gathering needs to be systematic and why certain evidence is included or excluded needs to be explicitly justified so that others will find the logic of the approach understandable, appropriate and transparent. Some sources of evidence are listed in Table 4.3 on the next page.

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Table 4.3 Some key sources of evidence (in no order of preference) Type

Source

Academic research

Evidence gathered from academic research studies funded by educational institutions, national and local government and international bodies like the World Health Organisation, and are carried out by professional and academically-qualified researchers and reviewed by their peers.

Census and other routine

Evidence gathered by local and national institutions

sources of information

whose sole responsibility is to collect accurate and reliable data on a range of health, social, economic and environmental issues either through quantitative questionnaire surveys or through qualitative interviews and focus groups, as for example, the British Household Survey and the British Crime Survey.

Specific local research evidence

Research and reports undertaken by local authorities where the research is carried out by expertprofessionals delivering the service as part of their work.

Local sources of routine information

Local sources of routine information gathered by local authorities, local educational institutions and the voluntary sector.

Views, perspectives and judgements of

These can be from professional stakeholders

stakeholders

delivering or potentially working alongside an initiative and/or the views of local residents and potential users of an initiative.

Policies and guidelines

Policies and guidelines are increasingly being based on direct evidence of their value and effectiveness. Therefore policy guidance can also be treated as a form of evidence.

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5. Evaluating Evidence "Science is perhaps the only human activity in which errors are systematically criticised and ... in time corrected." Karl Popper

5.1 Evaluating evidence The key thing to remember is that evidence should be evaluated systematically and the criteria used for its evaluation is explicitly stated i.e. clear reasons should be given as to why some types of evidence have been included and others excluded. Quantitative and qualitative research evidence can be evaluated in a number of ways. This chapter will show how both quantitative and qualitative perspectives use broadly similar criteria to evaluate the quality of health evidence. However it is worth noting that these criteria are quite difficult to apply and use with the range of evidence available to health impact assessment.

5.2 Evaluating quantitative evidence 5.2.1 Four basic criteria Internal or construct validity A measure of how representative a research study’s participants are when compared to the wider population group from which they are drawn. If the participants are not representative then this can lead to ‘selection bias’ meaning that the study results cannot be applied to the wider population group from which the participants are chosen. In terms of questionnaire surveys it also relates to how the questions used to investigate a specific issue, for example measuring quality of life, accurately measure the issue the researcher is interested in. External validity or generalisability A measure of how generalisable the findings from a specific study on specific participants taken from a specific population can be applied to other communities and societies. Reliability A measure of the extent to which a particular study and approach can be repeated to give similar results in similar contexts i.e. the degree to which the same study on a different population with similar characteristics to the original population will give rise to findings similar to the original study.

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Objectivity A measure of the extent to which emotion and subjective values have been removed from a research study by, for example, having a clear hypothesis and a pre-agreed study and analysis methodology.

5.3 Evaluating Qualitative Evidence 5.3.1 Four basic criteria Credibility (comparable to internal validity ) Whether the study participants recognise the ‘truth’ of the research findings in the context of the social and cultural factors present when the research was originally carried out. Transferability (comparable to generalisibility) The degree to which the research findings can be transferred to other similar contexts and situations. Dependability (comparable to reliability) The degree to which other investigators would be able to reproduce similar findings which are consistent with this research in a similar research context. Confirmability (comparable to objectivity) The degree to which there is evidence for the research findings from the actual field data as opposed to the biases and perspectives of the researcher i.e. whether another researcher would generate the same conclusions from analysing the original field data. 5.3.2 Other qualitative criteria Reflexivity and reflection Adopting a reflexive and self-reflexive attitude. Reflexive in the sense that researchers are aware of and continually assessing and reflecting on the effect of their presence on the community and the participants of the research study. Self-reflexive in the sense that researchers should always have at the fore-front of their minds the effect of their personal characteristics, attitudes and perspectives on the study, the participants, data collection and data analysis. Coherence Coherence in the findings and the conclusions of a study i.e. the ‘fit’ between the purpose of the research and the methodology used and the research’s relationship to the wider literature

5.4 Further criteria for epidemiological evidence

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5.4.1 Bradford-Hill criteria (using the association between tobacco smoke and cancer as an example) Temporal sequence The cause or exposure always precedes the effect/impact. In the case of tobacco smoke, exposure to tobacco smoke always precedes the presence of cancer Strength of association Low as well as high levels of exposure are associated with the effect/impact. In the case of tobacco smoke passive as well as active exposure is associated with getting cancer. Consistency of association Repeated studies produce similar associations between an exposure and an effect. In the case of tobacco smoke repeated studies and diagnoses in a range of people around the world provides consistent evidence of a link between tobacco smoke and cancer. Specificity of association The exposure is associated with a very specific measurable effect. Tobacco smoke exposure is predominantly associated with cancer of the lung. Biological gradient (dose-response or exposure-effect relationship) Low levels of exposure give rise to low levels of effect and high levels of exposure give rise to high levels of effect/impact. Low levels of tobacco smoke exposure give rise to little disease with higher levels leading to greater and greater associations with cancer. Plausibility of association The biological plausibility of the relationship between an exposure and effect. With tobacco smoke the various chemicals including nicotine have specific measurable negative effects on the lung and the circulatory system. Coherence of association The way the association found in a particular study or assessment between the exposure and effect/ impact fits into the wider health literature. The action of tobacco smoke fits with existing medical and biological principles of how health and disease occur in human beings. Experimental evidence Experimental exposure of animals to an exposure give rise to the effect/ impact. In the case of tobacco smoke animals exposed to tobacco smoke also develop cancer. Analogy to other organisms

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Whether other animals also suffer from similar types of disease when exposed. See above. 5.2.3 Limitations of toxicological and epidemiological evidence Toxicology

Issue

Limitation

Animal Models

While mice and rats provide a relatively close biological model to humans they do not always work. One important example was the trials on Thalidomide which in rats produced no congenital abnormalities but in humans

led

to

children

being

born

with

limb

deformations. Small Numbers, High Exposure &

Toxicological

experiments

rely

on

experiments

on

Short Time Periods

relatively small numbers of animals and giving them very high doses of exposure over very short periods of time.

Extrapolation

The data collected from these experiments are then used to extrapolate effects at the lower levels of exposure and the longer time-scales which face human communities e.g. effects of air pollution.

Other epidemiological issues to consider: Issue

Meaning

Chance

The likelihood that an association between an exposure and a health outcome could arise purely by chance.

Bias

The degree to which the study is affected by a nonrepresentative study population (selection bias), errors in

eliciting

the

data

(recall

bias),

researchers

investigating certain things and ignoring others (observer bias) and the difficulty of measuring the exposure or effect (ascertainment and measurement bias). Confounding

The degree to which other factors that influence both the

exposure

and

the

health

outcome

under

consideration are not accounted for in the design and analysis of the research e.g. socio-economic status, lifestyle factors, etc.

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6. Dealing with Uncertainty: insufficient and contradictory evidence " When one admits that nothing is certain one must, I think, also add that some things are more nearly certain than others." Bertrand Russell

6.1 Dealing with lack of evidence and uncertainty of impacts Being systematic and thorough in gathering evidence is crucial but there are still many areas where we have little, weak or no evidence for health impacts and the mechanisms by which these impacts act on human communities e.g. low level chemical releases into the environment. In these situations the question arises of how to decide and make recommendations when there is little reliable and robust evidence on the actual and potential health impacts of policies, plans, programmes, projects, developments and services (initiatives). The answer is to use both professional and lay experiential knowledges to help contextualise the evidence from research studies, routine data sources and elsewhere. The views, perspectives and experiences of local professionals and local residents can be used as another source of evidence as suggested at the end of Chapter 4. The next two sections of this chapter show the value of integrating professional and lay experiential knowledges in helping to create better initiatives as well as a philosophical perspective that provides a robust and scientific approach to systematically incorporating lay evidence alongside other types of quantitative and qualitative evidence.

6.2 Value of experiential knowledge The experiential knowledge of lay people can be both important and valuable in assessing the potential health effects of initiatives. The two case studies below demonstrate the value and validity of the experiential knowledge of lay publics. Herbicide 2,4,5-T controversy in the UK The scientific Pesticides Advisory Committee in its recommendations on the potential negative health effects of herbicide use implicitly adopted an idealised model of the ‘social’ world where the toxicology lab and its controls were taken to be a direct and accurate reflection of real world conditions of pesticide usage. Furthermore, the Committee assumed that conditions of manufacture

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i n s u f f i c i e n t

a n d

c o n t r a d i c t o r y

e v i d e n c e

and transport would be consistent with its social model where there were no accidents, errors in manufacturing or mistakes in correct usage. Hence, they dismissed labour union arguments that the herbicide caused health problems because in practice farmers and farm workers, due to the inconvenience of protective equipment and clothing, did not to follow the usage instructions. So while farm and forestry workers did not have detailed scientific knowledge about pesticides they had empirical experiential knowledge of pesticides, their use and the side-effects of use. In the end, after much debate, the Committee qualified their recommendations with the words “…pure 2,4,5-T offers no hazards to users nor to the general public…provided that the product is used as directed” . Chernobyl radiation and sheep farmers in the UK When the UK government realised that radiation from Chernobyl was falling on grazing land in Wales. Scientists were dispatched to analyse the impact of this on the grass, the sheep eating this grass and the potential human health implications of eating these sheep. Government scientists using general models of radiation uptake by plants and animals assumed that the radiation would decay and disperse in a matter of weeks. However, farmers who observed the work of these scientists were sceptical because they felt that the scientists were not taking into account local and contextual information about the type of soil, vegetation and climate. The farmers raised these concerns but the scientists dismissed them as irrelevant assuming that they had the more reliable knowledge. It was only when the radiation did not decay and disperse but seemed to be concentrating that the scientists became more open-minded and followed up the issues raised by the farmers. In both the above examples, each group felt that they had the better knowledge but only from a perspective outside of both sets of groups can it be seen that each perspective was partial and had usefulness within a certain domain where it had been tried and tested. It would have been of great value if both sets of knowledges had been integrated from the beginning. This integration would have occurred sooner if both sides had been willing to understand the rationality and legitimacy of each other’s perspectives and worldviews .

6.3 Post-normal science The post-normal science perspective (paradigm) argues that there are three levels of uncertainty: technical, methodological and epistemological, see Figure 6.1. Technical uncertainty is about inexactness and can be managed through the use of statistics and normal science.

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U n c e r t a i n t y :

i n s u f f i c i e n t

a n d

c o n t r a d i c t o r y

e v i d e n c e

Methodological uncertainty is about unreliability and occurs in more complex situations such as those found in medicine, engineering and professional consultancy where expert judgement is used to overcome the uncertainty. Epistemological uncertainty is about a ‘true’ lack of knowledge where we are ignorant of our ignorance .

Figure 6.1 Diagram of the three levels of uncertainty as described by Funtowicz and Ravetz

High ‘Post-Normal’ Science (uncertain facts,

DECISI ON

ExpertProfessional Judgement (use of judgement and

Applied ‘Normal’ Science (traditional notions of

Low

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LEVEL OF UNCERTAIN High

6 .

D e a l i n g

w i t h

U n c e r t a i n t y :

i n s u f f i c i e n t

a n d

c o n t r a d i c t o r y

e v i d e n c e

This approach argues that for complex societal issues there is a need for an ‘extended peer community’ made up of all the affected and interested stakeholders – whether they have scientific qualifications or not – who assess and examine the issues as well as develop a range of ‘extended evidence’ that includes anecdotal and experiential knowledge as well as scientific evidence to make a socially, culturally and scientifically acceptable decision. In HIA (and we would argue in any other impact assessment) what is important is to be explicit about whose perspective and views are being used, whose views have not been collected or excluded and how this relates to the individuals and groups who are likely to be affected by any actual or proposed policy, plan, programme, project, development or service.

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I n v o l v e m e n t

7. Stakeholder Involvement “Consult: to seek the opinion or advice of another; to take counsel; to deliberate together; to confer.” die.net “Consult: to seek approval for a course of action already decided upon.” Ambrose Bierce

7.1 Why stakeholder involvement Firstly, involving stakeholders is a crucial part of a health impact assessment and its ethos of equity, democracy, accountability and sustainability. Secondly, as discussed in Chapter 6, only by talking to the individuals and groups who are or are likely to be affected by an initiative will we get a rounded picture of the actual and potential impacts on health and wellbeing. Thirdly, actively listening to and involving the people who are likely to be affected by an initiative is much more likely to generate acceptance and support for an initiative and reduce actual and potential conflict, distrust and anger. There are five key reasons why we would want to get stakeholders involved in a HIA: •

a preference survey eliciting the likes and dislikes of local people and others about an initiative;

•

residents both existing and new will face the direct positive and negative health consequences of the initiative;

•

residents and other stakeholders have valuable experiential knowledge that they have built up over the years about the locality in which they live and work and the impacts of past initiatives;

•

not adequately and appropriately addressing resident’s concerns can and does lead to residents experiencing social and psychological distress; and

•

allowing residents and others to have a voice and influence in community processes and thereby reducing the sense of social exclusion, democratic deficit and inequity.

Central to the development of any stakeholder involvement and participation strategy – including that within an HIA - is the need to be clear about why stakeholder involvement is being sought and how these stakeholders views and perspectives will be incorporated into any resulting assessment report, policy, plan, programme, project, development or service.

7.2 Levels of stakeholder involvement Sherry Arnstein’s ‘A Ladder of Citizen Participation’ is an internationally recognised framework for understanding and classifying approaches to public participation. At the bottom of her scale, participation is simply non- or contrived participation where the aim is to appear to be involving

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and consulting a wide range of stakeholders. At the other end is citizen power-sharing where communities and residents have varying degrees of control and influence throughout the whole process of developing a policy, plan, programme, project, development or service. In-between there is tokenistic power-sharing where participation is at best simply informing local people about a course of action or listening to them without making an explicit commitment to use their views and at worst an attempt to keep residents quiet. Figure 7.1 Diagram of Sherry Arnstein’s ‘Ladder of Citizen Participation’

8

Citizen control

7

Delegated power

6

Degrees of Citizen Power

Partnership

Better and more

5

Placation

4

Consultation

3

Informing

2

Therapy

1

genuine

Degrees of Tokenism

stakeholder involve ment

Non Participation

Manipulation

Manipulative consultation is aimed at manipulating and coercing stakeholders and communities (citizens) involved in the consultation to the point of view of those undertaking the consultation. Those undertaking the consultation do not care about the other stakeholders and have no compunction using any and all means to push other stakeholders to their point of view. Therapeutic consultation is aimed at educating or ‘curing’ stakeholders and communities involved in the consultation to the point of view of those undertaking the consultation. Those undertaking the consultation believe in a paternalistic way that they know best and that other stakeholders are

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ignorant and do not know what is best for them and so must be educated away from their views towards those they hold. Informative consultation is the first step in legitimate stakeholder and community participation. The flow of information and informing is one-way with those undertaking the consultation believing that there is no discussion or debate needed on the information being communicated. This is the minimum form of consultation. Consultative consultation is the second step in legitimate stakeholder and community participation. Those undertaking the consultation undertake the consultation either because they are forced to undertake it because it is a legal requirement or required by others more powerful stakeholders. Those undertaking the consultation have the discretion of acting on or ignoring the views, comments and suggestions voiced by other stakeholders. Often this is and can be seen as ‘windowdressing’ and tokenistic. Placative consultation is the third step in legitimate stakeholder and community participation. Those undertaking the consultation recognise that other stakeholders have a right to voice their views and feelings but their aim is to address and implement those issues and comments that do not conflict with their objectives whilst asking for more time and details on the other issues and comments. Those undertaking the consultation, as in informative and consultative consultations, retain all the power of decision-making. Partnership consultation is the fourth step legitimate stakeholder and community participation and the first level in real power-sharing. There is two-way communication and those undertaking the consultation allow and enable other stakeholders to share in the decision-making process and meaningfully influence the final decision. Delegated consultation is the fifth step in legitimate stakeholder and community participation and the second level in real power-sharing. Those undertaking the consultation have given community representatives delegated powers to make decisions by giving them a majority of places on key decision-making committees. Communities and the public have the power to assure accountability and adequacy of the consultation, the decision-making process and the resulting decision. Citizen controlled consultation is the sixth and final step in legitimate stakeholder and community participation and the third level in power-sharing. Communities control the entire consultation and decision-making process.

It is therefore critical to work out and be explicit with stakeholders and the community about the level at which you are involving them so that there is no misunderstanding about the level of

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influence and power-sharing that will be taking place. There are times when involvement is about informing or listening to other people’s views whilst being explicit about being unable to make a commitment to incorporate those views and other times when there is a two-way partnership and considerable power-sharing and influence being given to the views, perspectives and judgements of those being involved in the HIA or initiative.

7.3 Approaches to stakeholder involvement There are a range of methods of involving stakeholders including: 1. Public/community meetings These tend to be the easiest to setup but the hardest to manage. Public meetings involve organising a venue and meeting time that is accessible and convenient for all relevant stakeholders. Having a meeting agenda agreed to by key stakeholders beforehand along with allocated times for speakers and a Chair who will be firm with hecklers is crucial to running a good public meeting. 2. Street interviews These are informal interviews conducted in busy areas such as community centres, social clubs, shopping centres and other venues where key stakeholders may be found. They tend to be held standing up and follow a structured approach using a standard set of questions. 3. Survey questionnaires These tend to be sent out by post with a couple of reminders for people who do not return the questionnaire by a set time. Questionnaires sent out to named individuals tend to have a higher response rate than those that are mailed to a general person such as ‘The Occupier’. Even named questionnaires tend to have a low response rate with a response rate of over 10% for unnamed and 30% for named questionnaires being considered very good. 4. Focus groups This is where small groups of key stakeholders are brought together in small groups usually between six-twelve people to discuss an issue or concern in-depth. They require considerable preparation and a facilitator as well as note-taker. 5. Key informant interviews These are one-to-one interviews with key professionals and community representatives, e.g. community centre coordinator, Chair of a local residents’ association, and usually last an hour with a single interviewer tape-recording the interview and then typing it up later.

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6. Community involvement/consultation groups These are more long term ‘focus groups’ where key stakeholders are asked to form a consultation group that will feed its views during the design, implementation and operation of an initiative usually over a period of months and years. 7. Citizen panels/juries These are similar to consultation groups but tend to be formed around specific national or local themes of concern and involve a representative sample of people from an area, region or society to enable a representative view to be gained e.g. genetically modified crops, human embryo research, etc. The best approach is to use a range of methods and then see which ones work and follow these up. This is because what works in one community today may not work in other communities or in the same community a few years later. The accompanying training participants booklet ‘An Introductory Guide: how to consult your users’ produced by The Cabinet Office provides more detail on each of the methods listed above along with their strengths, limitations and costs in terms of time, effort and money.

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C o m m i s s i o n i n g

a n d

S c r u t i n i s i n g

a

H I A

8. Analysis “In a practitioner’s reflective conversation with a situation [an initiative]…she functions as agent/experient. Through her transaction with the situation, she shapes it and makes herself part of it.” The Reflective Practitioner by Donald Schön

8.1 Chains of inference and chains of causation Analysis is the critical step of all impact assessments and health impact assessment is no exception. Analysis is the systematic identification and assessment of the significance of: •

the potential consequences that will arise from a given initiative;

•

the individuals, groups and communities that are likely to be affected by those consequences (intentionally or unintentionally),;

•

the potential positive and negative health effects that these consequences may give rise to in the individuals, groups and communities that are likely to be affected; and

•

the options available to minimise the negative health effects and maximise the positive health effects.

Analysis involves the ability to imagine a virtual world where the proposed initiative is implemented and thinking through the implications of the initiative from implementation, operation and closure. Through this imaginative process chains of inferential reasoning are developed to show that: •

the identified consequences could actually occur and how they are likely to occur;

•

they could actually occur on the identified individuals, groups and communities;

Once this is accomplished chains of causation are formally developed for the positive and negative health impacts by examining the health evidence for these health impacts from scientific research. The evidence is reflectively applied to the specific initiative being assessed to show that: •

the identified consequences could actually lead to the identified positive and negative health effects;

•

there are possible pathways by which these health impacts could occur; and

•

there are options to minimise the negative and maximise the positive health effects

Finally, a qualitative and/or quantitative assessment is made of the significance of the identified consequences of the initiative and the health impacts arising from them.

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a

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Written down like this the analysis step sounds simple, logical and linear however it is complex, logical, reflective, imaginative and iterative.

8.2 Putting all the evidence together As discussed previously the pathways of health impact (the determinants of health) through which initiatives affect individuals, groups and communities have not been fully mapped out and the strength of evidence for the causation of many health effects is weak or non-existent. In this uncertain context, the assessors’ direct experiential knowledge, the experiential knowledge gained from previous health impact assessments and their evaluation, the experiential and expert knowledge of the professionals involved or affected by the initiative as well as the experiential and expert knowledges of the individuals, groups and communities who are likely to be affected must be taken into account to create a holistic assessment.

8.3 Focussing on the significant and the likely Finally, it is very difficult and time-consuming and highly unlikely that all the consequences of a proposed initiative and their health effects can be identified accurately. Therefore the focus of the analysis must always be to identify the potentially most significant and likely negative and positive health impacts. This ensures that the final assessment will be relevant both to decision-makers and to those who are likely to be affected by a proposed initiative.

8.4 Some examples An organisational anti-smoking policy aimed at helping staff quit smoking is likely to have positive benefits in terms of supporting those smokers who want to stop. However it could have negative health effects on those smokers who don’t want to or try and fail to give up by them feeling like social outcasts and ‘bad’ people who lack willpower. Some may also feel that they are being coerced and put under pressure to stop something that they enjoy and makes them feel good by relieving their stress or being a treat or reward for coping with life’s daily stresses. A green transport and education programme encouraging young people to cycle and appreciate the health benefits of cycling and being outdoors by providing them with free cycles will have positive benefits for those young people who take up cycling. However, some young people can see this as negative and denigrating because, socially and culturally, owning and driving a car, especially an expensive one, is a way of showing and enhancing our social status.

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A housing development with affordable housing in an area with a housing shortage will have positive benefits in terms of increasing the availability of good quality housing but can have negative effects during construction, through increasing traffic, pushing local people out as new people from outside the area buy the new houses, create a sense of ‘us and them’ between residents of the new houses and those of the old and put pressures on existing health and social care services and other retail and leisure amenities.

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H I A

8. Commissioning and Scrutinising a HIA “Consultant: a specialist who gives expert advice or information.” Collins English Dictionary “Consultant: someone who borrows your watch, tells you the time and then charges you for the privilege.” The Times

8.1 Commissioning Health impact assessments (HIAs) are commissioned for a range of different reasons and this tends to lead to different ways in which they are taken forward. 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 (e.g. in Tasmania)

•

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.

It is important to be clear and explicit about why a HIA is being commissioned so that internal HIA staff or external consultants have a clear understanding of what they are required to do. It will also help later when the report and its recommendations are being judged by others to see how well these objectives have been met. The key questions to ask in framing any proposed health impact assessment include: •

What is the purpose of the health impact assessment?

•

How will the findings be used – will it guide design, assist implementation, reduce negative effects and/or improve the positive health effects of an initiative?

Setting up a HIA steering or working group that either advises on or project manages the HIA can be a useful way to ensure that all stakeholders understand and are clear about the scope and limits of the HIA. Creating a group like this with all the key stakeholders represented ensures that the findings and recommendations of the HIA are credible and used to inform the design and implementation of the policy, plan, programme, project, development or service being assessed.

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a

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However, steering groups need a lot of time and resources to set up and maintain and so are difficult to do well when time is short and resources lacking. 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 £5-10,000, an intermediate HIA requiring a community consultation between £15-20,000 and a comprehensive HIA with a wide stakeholder consultation between £20-30,000. Clear lines of supervision and communication between external consultants or internal HIA staffpractitioners 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.

8.2 Scrutinising The issues considered in evaluating evidence are also important when scrutinising and evaluating a HIA statement-report. 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 analysis of impacts systematic and the reasons for judging the significance and the extent of the positive and negative health effects explicit, appropriate and justified?

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•

C o m m i s s i o n i n g

a n d

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a

H I A

Do the recommendations, including mitigation and enhancement measures, follow on from the key issues emerging from the analysis?

•

Is the report as a whole clear, coherent and understandable?

•

Does the HIA statement-report achieve the HIA’s aims and objectives?

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9 .

T h e

W i d e r

C o n t e x t :

p o l i t i c a l ,

e c o n o m i c

a n d

s o c i a l

f a c t o r s

9 The Wider Context: political, economic and social factors “The primary determinants of disease are mainly economic and social, therefore its remedies must also be economic and social.” ‘The Strategy of Preventative Medicine’ by Geoffrey Rose

9.1 Why the wider context Health impact assessments (HIAs) and reports are not developed in a vacuum. All HIAs are set within particular social, cultural and political contexts. There are social, political, economic and historical factors that can play a big part in whether a health impact assessment gets commissioned and implemented and, in turn, whether policies, plans, programmes, projects, developments and services (initiatives) lead to improvements in the health of individuals and communities. There are five important factors that can influence how, and to what extent, the findings of a HIA report influence a given initiative. These are: influential stakeholders, the complexity of the proposed initiative, the diversity of stakeholders involved, degree of clarity about what the initiative is aiming to achieve and the wider socio-cultural and political environment.

9.2 Influential stakeholders Professional groups, politicians and businesses are powerful and organised stakeholders who can and do have an important influence on whether initiatives are implemented. It is therefore vital for these groups to be involved in the HIA process so that there is consensus and support for the recommendations that arise from a HIA report. One of the key methods for identifying key stakeholders is stakeholder analysis or mapping. This involves the creation of a grid (see Figure 9.1) where stakeholders are placed by a researcher, policy analyst, HIA practitioner or local stakeholder in relation to the power they are judged to have in influencing an initiative and the importance that the initiative has for that stakeholder group. In the example below, seven local residents were asked which stakeholders they thought had the most power and influence (measured on the horizontal axis) and how important it was to each of these stakeholders (measured on the vertical axis). Residents felt that though the initiative was equally important to them, the developer and the local council they were much less influential. In contrast, the stakeholder map created by professional stakeholders from the council and the developer (not shown) showed that they thought that residents had an equal if not greater influence on the planning and implementation of the local initiative.

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T h e

W i d e r

C o n t e x t :

p o l i t i c a l ,

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Figure 9.1: Stakeholder mapping by local residents for a local initiative (figures in brackets give the number of residents who placed the stakeholder in that category – 7 residents undertook this exercise)

High

IMPORTANCE

A. HIGH importance / LOW influence

B. HIGH importance / HIGH influence

Residents (7) Residents’ Association (7) Local Shops & Businesses (7) ISCA (6) FoE/ Greenpeace (4) Environmental Health Dept (3)

Developer (6) Planning Dept. (5) EIA Consultants (paid by council) (5) Councillors (4) NLWA (4) PH Dept (3) EIA Consultants (paid by developer) (3)

C. LOW importance / LOW influence

D. LOW importance/ HIGH influence

School of Community Health (2)

Local newspaper (4) GLA (3) Judiciary (3)

Low

High INFLUENCE (in terms of the planning and implementation of the initiative)

9.3 Complexity of proposed initiative The more radical and complex the design and implementation of an initiative the more difficult and more easily disrupted it is likely to be. Here again, support by as many stakeholders as possible as well as a phased and monitored approach to design and implementation are crucial.

9.4 Diversity of stakeholders that need to be involved Involving a range of stakeholders is important but it also needs to be recognised that there will be a range and diversity of views within a stakeholder group, e.g. between health professionals as well as between health professionals and local residents. This diversity itself will create differing expectations, perspectives, desires, priorities and so on which can lead to conflict and opposition. This is one of the reasons why these stakeholders and their views need to be incorporated into any initiative (including the HIA itself) so that as many voices as possible are included in the assessment, design and implementation process.

9.5 Lack of clarity about the initiative Lack of a clear vision and rationale for the proposed initiative can be a significant stumbling block to achieving real and lasting improvements. It is therefore better to have a small number of clear

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and achievable objectives and a realistic vision than unrealistic, vague and over-ambitious objectives.

9.6 Changing environment – social, cultural, political, economic New social, cultural, political and economic issues in the wider society and local community need to be incorporated into the assessment process. This is one of the strengths of the HIA approach in that it provides a considerable degree of flexibility and adaptability to changing needs and circumstances. These wider contextual factors include recessions, local and national elections, changes in local employment, demographic changes e.g. new communities entering the area, or cultural ideas endorsed by celebrities who can influence community lifestyles and life choices. All of these are difficult to capture at a single point in time. Shell, the multinational oil company, has developed and continues to use a scenario-based approach, (see their website for models of this approach), to brainstorm and map out potential social, economic and political factors that might affect a given policy, plan, programme, project, development or service (Initiative). HIAs need to incorporate an outline form of this scenario-based approach by being specific, costeffective and feasible about the recommendations that are presented so that they have a high likelihood of being incorporated into the design and implementation of a new or revised initiative.

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10. Monitoring and Evaluation of Impacts “We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time.” T. S. Eliot

10.1 Why monitor and evaluate Health impact assessments are a snapshot of the health status of a defined population and the potential impacts of policies, plans, programmes, projects, developments and services (initiative) on this population. Therefore, it is important to build in measures and methods of monitoring whether, to what extent and in what way the potential health impacts actually manifest themselves. It is also worthwhile evaluating the overall value and influence a given health impact assessment has had on the subsequent design, implementation and operation of an initiative. However, it can be difficult to identify and track the changes in health brought about by a given initiative because they tend: •

not to have health improvement as a primary goal;

•

to be implemented in tandem with other initiatives;

•

to have shorter timescales of operation than the determinants of health which may take decades to manifest themselves as positive or negative changes in health status; and

•

to change, develop and grow and it becomes difficult and complex to assess how these changes are changing the positive and negative health impacts originally envisioned.

10.2 Monitoring Monitoring is the ongoing assessment of a policy, plan, programme, project, development or service (initiative) while it is active and operational. Most monitoring involves collecting information on direct visible outputs of an initiative. Monitoring measures outputs such as the number of people positively and negatively affected by an initiative while evaluation measures outcomes such as how and in what ways these people have been affected. To give an example consider a policy to create advice and guidance centres for unemployed people. We can measure outputs such as whether the policy was implemented, how

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many centres were built, how many people use the service, what social and ethnic background they are from and their gender. However, the outcomes we are ultimately interested in are whether these users have been helped by the service to access further education, training or employment; whether crime and disorder have been reduced; whether young people feel they are doing meaningful and worthwhile things and whether these unemployed people feel valued and part of the wider society. The key approach to monitoring changes in health has been to develop indicators which give an indirect measure of the health status of a given community. This is due to the difficulty of directly assessing individual health changes attributable to a given initiative. A range of health indicators have been developed by the World Health Organisation based on the DPSEEA framework, see Table 10.1, made up of eight broad environmental health indicator themes and specific indicators within each theme. In the UK, the key health indicators include: unemployment, ethnicity and unemployment, educational attainment, proportion of homes judged unfit to live in, domestic burglary rate, air quality, road traffic accidents, life expectancy at birth, infant mortality rate and the proportion of people with self-assessed good health. However, it can be difficult to get information covering populations at a small area level as routine sources of information, for example census data, generally cover larger areas. Measures of health service use and activity, which are routinely collected or gathered in a survey, can be used to estimate population health status however they are indirect (proxy) measures; it is important to be aware of the different influences on the data and the different and incompatible ways in which the information might have been collected. Information from NHS trusts or primary care trusts may be available at ward level, or street level, but there is as yet no standardised approach to collecting this type of data . Most health indicators measure illness and the treatment of disease. Mortality (numbers of deaths) and morbidity (numbers of ill people) information is commonly used. However, trying to capture health impacts through changes in the patterns of mortality and morbidity are not always relevant to many initiatives and does not capture quality of life or episodes of illness which are not presented to health care agencies. Finally, some health effects occur over many years and these impacts are difficult to monitor. Routine health data can be supported with specially commissioned surveys of selfperceived health status and quality of life. These should ideally use items from national surveys so that local results are comparable to national ones. A prospective design will follow individuals and allow more detailed analysis of the reasons for changes in health. These surveys are resource intensive and it is advisable to invest in specialist help.

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Indicators from non-health sectors can also be used as part of a composite set of health indicators to show changes in the determinants of health e.g. unemployment rates and levels of car ownership.

10.2 Evaluation Evaluation and monitoring though closely intertwined are separate processes. There are two forms of evaluation to be considered here: an evaluation of the policy, plan, programme, project, development or service (initiative) and an evaluation of the HIA itself. Both are important. An evaluation of an initiative involves asking whether the initiative achieved its overall aims and objectives. Was health, wealth, social relationships improved and jobs and goods created. An evaluation of an HIA involves asking whether the predictions and recommendations made by the HIA turn out to be accurate and did the implementation of the HIA recommendations lead to improvements in health outcomes. Other aspects that can be evaluated include whether the HIA process was robust and were a range of stakeholders, including decision-makers, fully engaged with the HIA. One important perspective on evaluation called ‘realistic evaluation’ argues that there are three aspects to consider when undertaking an evaluation: the context, the mechanism and the outcome. The context within which an initiative is implemented and a HIA undertaken has a profound influence on the outcomes that are generated. A close study and explicit description of the social, cultural, political, economic and environmental factors that contributed to the success or failure of an initiative or HIA are vital for any good evaluation. The mechanism is the actual means used to implement and deliver an initiative (or HIA) to the target individuals and communities and how the mechanism of implementation was affected by the context. A close study and explicit assessment of the mechanism will highlight the barriers that occurred to prevent the initiative (or HIA) from being successfully implemented and fully realised. Finally, the outcome is the actual results of an initiative and what it has achieved. Here again an assessment of how close or divergent these outcomes were to the original vision, aims and objectives of the initiative will identify how and in what ways issues emerged and interactions took place that resulted in the initiative being less successful than it might otherwise have been. There are three aspects of an initiative (or HIA) that can be evaluated: its process, its impact (short term successes) and its outcomes (long term successes).

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Process evaluation is concerned with evaluating how an initiative (or HIA) was designed and implemented and whether the process followed key values: transparency, democracy, equity and inclusivity. By showing that an initiative was designed, implemented and operated in keeping with these values we can say that the outcomes are also likely to be transparent, democratic, equitable and inclusive and therefore likely to be positive for health. Impact evaluation is concerned with evaluating the implementation stage of an initiative or HIA i.e. whether it achieved its objectives in the short term and whether recommendations and feedback from an impact assessment, consultation exercise and/or feedback from users/affected groups are used to modify and improve the initiative and its effects. Outcome evaluation is concerned with evaluating whether an initiative (or HIA) has achieved its long term objectives (and outcomes).

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Table 10.1 WHO environmental health indicators (P=population)

socio-demographic context poverty population density age structure infant mortality life expectancy at birth air pollution outdoor air pollution respiratory illness - morbidity

Information Needed

Formula

Unit

Jarman/ Carstairs/ Townsend Index/ Index Multiple Deprivation (IMD) No. of residents, Land Area (km2) No. under 16 years, no. over 65 years, total population Death rate of infants under 1 yr of age, per 1000 live births, over time

See individual indexes individual ranking scales Population (P)/Area (A) no. of residents per km2 100 x [(P0-15 + P65+)/Ptot ] percentage (%) Deaths<1yr/Live births in a deaths per 1000 live

period Age-specific and gender-specific death rates

year Average expected lifespan

births years

Mean annual conc. of ozone, CO, PM10, PM25, SPM, SO2, NO2, O3 and Pb No. of acute respiratory infections in children under 5years,

Particle concentration in air 1000 x (Rc /Pc)

mg/m3 no. per 1000 under 5's

respiratory illness - mortality

total no. of children under 5yrs, over a year Annual mortality rate due to ARI in children under 5yrs, total no. of children 1000 x (Mc /Pc)

no. per 1000 under 5's

air quality management

under 5yrs, over a year Management Capabilities Assessment Index - management capability,

Qualitative assessment

not applicable

standards, controls % of lead-free petrol consumption as % of total consumption

(U/T) x 100

percentage (%)

No. with access to basic sanitation, total population % population living in substandard housing

100 x (Pe/ Pt) P in substandard/P in

home accidents

Accidents in home, total population

housing x 100 1000 x (Accidents/Population) no. accidents per 1000

urban planning

Land use planning, building regulations - evidence of existence,

Qualitative assessment

head of population not applicable

availability of lead-free petrol sanitation excreta disposal unsafe housing

percentage (%) all percentage (%)

implementation and enforcement drinking water water supply - access & connection

No. with access to mains connection, continuous and sufficient, total

(Pwith/ Ptotal) x 100

percentage (%)

water quality monitoring

population (Conc. of NO3-N; no. of faecal coliforms, total population) no. of valid

1000 x (sum M1/P)

various

measurements in 1 year, total population solid waste management

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waste disposal waste management hazardous/ toxic substances blood lead poisonings contaminated land management

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Information Needed Proportion of hazardous material in domestic waste, amount of waste

Formula Mw/P

Unit tonnes per capita

disposed, total population Hazardous waste policy and regulations and enforcement

Qualitative assessment

not applicable

% of children under 5 yrs with blood lead levels over 10micrograms/dl No. of poisonings, total population

100 x (Nh/Nt) N/P

percentage (%) no. per 1000 head of

Formal definitions, Register, Legal Liability, Development Controls,

Qualitative assessment

population not applicable

Contaminated Land Agency non-occupational risks motor vehicle accidents

Death rate due to motor vehicle accidents, total resident population

1000 x (Mt/P)

no. per 1000 head of

injuries to children

Incidence of physical injury to children under 5 years of age, total no. of

1000 x (Ic/ Pc)

population no. per 1000 under 5's

poisonings of children

children under 5yrs No. of cases of poisoning in children under 5yrs, total no. of children under

1000 x (Pc/Nc)

no. per 1000 under 5's

5yrs adapted from DPSEEA

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11. Conclusion “The journey of a thousand miles begins with a single step” Chinese proverb

This reader has explored a number of key aspects of health impact assessment including what it is, why it’s done, how it’s done, when it’s used and how it should be commissioned. Health impact assessment is a flexible methodology for understanding the varying health impacts both positive and negative, that policies, plans, programmes, projects, developments and services (initiatives) can have on the individuals and communities that they are targeted at as well as on those that are not the specific targets of the initiative in question. Health impact assessment is a relatively new approach that is still evolving and there are different ways of doing it depending on the particular initiative, the local context, the perspective of the assessor and the time and resources available. In HIA, using a range of evidence from a variety of sources is important as is highlighting gaps, contradictions and weaknesses in our evidence base and the limitations of our assessment. Involving and including as many stakeholders as possible is crucial in ensuring that key priorities and concerns are not overlooked. Involvement also ensures that there is support and ‘ownership’ of initiatives by those who will be affected by the initiative as well as ensuring that negative health effects are reduced and positive ones enhanced. It is also vital to understand and take account of the wider social, cultural, economic, political and environmental factors that can help or hinder the implementation of an initiative as well as an HIA and its recommendations. Doing this will ensure that the recommendations from an HIA are timely, feasible, practical and likely to be implemented. Finally, monitoring and evaluation are useful ways of ensuring that the findings and work that have gone into an initiative and an HIA are successful in improving individual and overall population health and wellbeing over the short and long terms. We hope this reader and the accompanying training course have given you enough knowledge, understanding and experience to enable you to undertake and commission your own health impact assessments. We hope that we have given you the springboard to start your own HIA adventure and journey… Good luck and bon voyage!

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Sources of Further Information The following are useful sources of information that will deepen your knowledge about health impact assessment and act as a resource for your future work. Websites have been listed where appropriate. Books London's Health: developing a vision together. Resource for health impact assessment. Volumes 1 & 2 Ison, E. 2000. London, commissioned by NHS Executive. A FREE detailed resource. Volume 1 covers the methodology behind HIA and provides an overview of all the important approaches to doing a HIA. Volume 2 provides an overview of a range of case studies of HIA. http://www.londonshealth.gov.uk/allpubs.htm#hia Health impact assessment: concepts, theory, techniques and applications Edited by J Kemm, J Parry, S Palmer, Oxford University Press, Oxford, 2004 A up-to-date look at HIA, its history, strengths, weaknesses, areas of debate and future directions. Health and environmental impact assessment: an integrated approach. British Medical Association, Earthscan, London, 1998. An important work which created an impetus for public health professionals to be active in ensuring that health is integrated into development initiatives.

Evidence Bases NETHERLANDS – NSPH Health impact assessment database The Netherlands School of Public Health (NSPH), has taken the initiative to start preparing a preliminary HIA database which can be accessed through the internet and which will, in due time, be part of an international HIA Information System (HIS) http://www.hiadatabase.net/ UNITED KINGDOM – Health Development Agency Evidence Base HDA Evidence Base aims to provide access to the best available information on what works to improve health and reduce health inequalities via the Internet. This resource is aimed at a wide range of practitioners and researchers engaged in public health work. http://www.hda.nhs.uk/evidence/

International World Health Organisation – Health Impact Assessment Very useful website bringing an international perspective to HIA policy and practice with some very useful resources on HIA.

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http://www.who.int/hia/en

Europe FINLAND - Stakes A Finnish website by STAKES (National Research and Development Centre for Welfare and Health) promoting Human Impact Assessments, with a particular focus on human impacts and sustainable development http://www.stakes.fi/sva/huia/index.html UNITED KINGDOM - HIA gateway UK's Health Development Agency's website provides access to HIA related information, resources, networks and evidence to assist people participating in the HIA process. http://www.hiagateway.org.uk/

North America CANADA - Health Canada Office of Environmental Health Assessment Health Canada and Canada as a whole has been in the vanguard of incorporating health into policies, plan, programmes and projects. This site has a range of Canadian resources on HIA. http://www.hc-sc.gc.ca/hecs-sesc/ehas/index.htm USA – Minnesota – Department of Health Some useful resources about HIA from a US perspective http://www.health.state.mn.us/divs/chs/mhip/

Australasia Australia - HIA Connect

http://chetre.med.unsw.edu.au/hia/

This site contains information on Australian HIA activity. NEW ZEALAND - Ministry of Health Guide to facilitate and encourage the integration of health impact assessment into the resource management process. http://www.moh.govt.nz/moh.nsf/7004be0c19a98f8a4c25692e007bf833/b96ae86add32e5f94c256671000cd202?OpenDocumen t

Associations & Societies

IAIA - International Association for Impact Assessment The International Association for Impact Assessment is the professional body for all impact assessment practitioners including health impact assessment practitioners. http://www.iaia.org/

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R e f e r e n c e s

References

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What others have said was worthwhile about this reader and our HIA training course: “All aspects – greater awareness that HIA could be applied to all projects.” Public Health Worker

“Materials good. The course was stretching (and not patronising as many courses seem to be). Thought provoking and very useful. Slides good. Discussions very helpful.” YISP Youth Justice

“Effects of policies on health – looking at evidence and establishing the links.” Planning Policy Officer

“HIA – i.e. last afternoon. The packs given on first day – excellent – have already used. Thanks.” “Case studies and group work – opened my eyes to much of the health world.” Housing - Performance & Services Manager

Last session – practical and brought together discussions/ topics of previous sessions. Health Visitor “The role play as you had a real experience talking with other agencies.” “Preparation of the HIA report on the last day. Many issues discussed over the entire course.” Transportation Engineer

Centre for Health Impact Assessment, Institute of Occupational Medicine Research House Business Centre, Fraser Road, Perivale, Middlesex. UB6 7AQ Tel: 020 8537 3491/2

Fax: 020 8537 3493

Website: www.iom-world.org