Liveability as determinant of health: Testing a new approach for health impact assessment of major infrastructure

Major urban infrastructure projects are intended to alter the built, human ecology for the better. Even when they are not labelled as health projects, arguably they should produce public health benefits that are commensurate with their scale, particularly when they are publicly funded. Health impact assessment (HIA) is an established method of evaluating major infrastructure projects using a determinants of health equity lens. HIA explicitly puts health front and centre to ask, ‘How should the proposed infrastructure project be altered to improve the determinants of health equity?’ There are well-established HIA protocols, but few provide a framework for scoping possible impacts. Given interest in the concept of liveability we introduce an exhaustive, evidence-based framework of 11 liveability domains for HIA. We then test the framework by scoping the impacts of the Upfield Level Crossing Removal (LXR) project in Melbourne, Australia to hypothesise its impacts on health. Scoping this case study suggests that many domains will be affected in complex ways, some positively and some negatively, exemplifying the potential for the framework to detect major infrastructures' pervasive impacts on determinants of health. The paper includes a plan to validate the liveability framework with empirical research in the HIA assessment stage. The paper concludes with a discussion of the contribution and usefulness of the liveability domains as a framework for structuring HIA and for building its profile, thus advancing the discipline, and helping to ensure that all major infrastructures constitute a prudent investment in public health.     

Health impact assessment and health equity in sub-Saharan Africa: A scoping review

BackgroundNatural resource extraction projects can have positive but also negative effects on the health of affected communities, governed by demographic, economic, environmental, physical and social changes. Negative effects often prevail and these might widen existing health inequities. Health impact assessment (HIA) is a decision-support tool that aims at maximizing benefits and minimizing negative impacts on people's health. A core value of HIA is equity; yet, little is known about health equity in the frame of HIA, particularly in sub-Saharan Africa.MethodologyWe conducted a scoping review to determine whether and to what extent HIA in sub-Saharan Africa addresses health equity. We included peer-reviewed publications and guidelines pertaining to HIA, environmental impact assessment (EIA) and social impact assessment (SIA). Health equity was investigated by identifying (i) how health considerations were addressed and (ii) whether health was stratified by subgroups of the community.ResultsOut of 1′640 raw hits, we identified 62 articles (16 HIA, 36 EIA, one SIA and nine integrated assessments), 32 of which specifically addressed health. While 20 articles focused on a specific health topic, 12 articles used a more comprehensive approach to address health. In 15 articles there were specific subgroup analyses (e.g. mothers, children or marginalized groups) as a measure of health equity. Another 12 papers referred to the community in a more general way (e.g. affected). Without exception, health was an integral part of the nine included guidelines. HIA guidelines addressed health systematically through environmental health areas, risk assessment matrix or key performance indicators.ConclusionsWe found evidence that previously conducted HIA in sub-Saharan Africa and current guidelines address health equity. However, there is a need to stratify community subgroups more systematically in order to determine health differentials better. Future HIA should consider community heterogeneity in an effort to reduce health inequities by “leaving no one behind”, as suggested by the Sustainable Development Goals.     

The impact and effectiveness of health impact assessment: A conceptual framework

The use of health impact assessment (HIA) has expanded rapidly and there are increasing demands for it to demonstrate its effectiveness. This paper presents a conceptual framework for evaluating HIA and describes its development through (i) a review of the literature, (ii) a review of work undertaken as part of a major HIA capacity building project and (iii) an in-depth study of seven completed HIAs. The framework emphasises context, process and impacts as key domains in understanding and evaluating the effectiveness of an HIA. This new framework builds upon the existing approaches to evaluating HIA and extends them to reflect the broad range of factors that comprise and influence the effectiveness of HIAs. It may be of use in evaluating completed HIAs and in planning HIAs that are yet to be undertaken.     

Validating health impact assessment: Prediction is difficult (especially about the future)

Health impact assessment (HIA) has been recommended as a means of estimating how policies, programmes and projects may impact on public health and on health inequalities. This paper considers the difference between predicting health impacts and measuring those impacts. It draws upon a case study of the building of a new hypermarket in a deprived area of Glasgow, which offered an opportunity to reflect on the issue of the predictive validity of HIA, and to consider the difference between potential and actual impacts. We found that the actual impacts of the new hypermarket on diet differed from that which would have been predicted based on previous studies. Furthermore, they challenge current received wisdom about the impact of food retail outlets in poorer areas. These results are relevant to the validity of HIA as a process and emphasise the importance of further research on the predictive validity of HIA, which should help improve its value to decision-makers.     

Evaluating the impact of HIA on urban reconstruction decision-making. Who manages whose risks?

Practitioners and academic researchers increasingly look to evaluation of health impact assessment (HIA) to improve its practice, its efficiency and its legitimacy. Evaluation is also used to account to policy-makers, who express doubts that the benefits of HIA justify its costs. Until recently evaluation of HIA focused on instrument design and procedures but now the focus needs to shift to analysis of the interaction of HIA and decision-making. Multiple case studies have been applied to identify the conditions in which HIA produces the desired benefits. These studies used analytical concepts derived from the literature on evaluation, knowledge utilization, science of sociology and knowledge management.This paper describes a case study in which the strategic motives of the decision-makers affected the impact of an HIA. This HIA comprised of a quantitative environmental model ‘City & Environment’ that was used to assess environmental health impacts of an urban reconstruction plan in a Dutch city. The evaluation of the HIA shows that the decision to follow the recommendations of the HIA was part of a damage control strategy. The more HIA goals deviate from the policy problem and the less HIA is embedded in institutional procedures, then the more HIA impact will be subject to strategic decision-making behaviour. Appropriate cognitive and social strategies are needed to avoid ‘negative learning’ in those the HIA seeks to influence.     

Advancing the practice of health impact assessment in Canada: Obstacles and opportunities

Health Impact Assessment (HIA) is recognized as a useful tool that can identify potential health impacts resulting from projects or policy initiatives. Although HIA has become an established practice in some countries, it is not yet an established practice in Canada. In order to enable broader support for HIA, this study provides a comprehensive review and analysis of the peer-reviewed and gray literature on the state of HIA practice. The results of this review revealed that, although there is an abundance of publications relating to HIA, there remains a lack of transparent, consistent and reproducible approaches and methods throughout the process. Findings indicate a need for further research and development on a number of fronts, including: 1) the nature of HIA triggers; 2) consistent scoping and stakeholder engagement approaches; 3) use of evidence and transparency of decision-making; 4) reproducibility of assessment methods; 5) monitoring and evaluation protocols; and, 6) integration within existing regulatory frameworks. Addressing these issues will aid in advancing the more widespread use of HIA in Canada.     

The role of Health Impact Assessment in the setting of air quality standards: An Australian perspective

The approaches used for setting or reviewing air quality standards vary from country to country. The purpose of this research was to consider the potential to improve decision-making through integration of HIA into the processes to review and set air quality standards used in Australia.To assess the value of HIA in this policy process, its strengths and weaknesses were evaluated aligned with review of international processes for setting air quality standards.Air quality standard setting programmes elsewhere have either used HIA or have amalgamated and incorporated factors normally found within HIA frameworks. They clearly demonstrate the value of a formalised HIA process for setting air quality standards in Australia.The following elements should be taken into consideration when using HIA in standard setting. (a) The adequacy of a mainly technical approach in current standard setting procedures to consider social determinants of health. (b) The importance of risk assessment criteria and information within the HIA process. The assessment of risk should consider equity, the distribution of variations in air quality in different locations and the potential impacts on health. (c) The uncertainties in extrapolating evidence from one population to another or to subpopulations, especially the more vulnerable, due to differing environmental factors and population variables. (d) The significance of communication with all potential stakeholders on issues associated with the management of air quality.In Australia there is also an opportunity for HIA to be used in conjunction with the NEPM to develop local air quality standard measures. The outcomes of this research indicated that the use of HIA for air quality standard setting at the national and local levels would prove advantageous.     

A prospective health impact review of the redevelopment of Central Manchester Hospitals

Health Impact Assessment (HIA) is increasingly being acknowledged as an important tool for considering the health implications of projects and programmes of activity at local, national and international levels. However, standard HIA tools can be difficult to apply when the policy of programme under consideration is particularly complex and intertwined or where significant time, resource and skill constraints are involved. This paper describes a Health Impact Review (HIR) of the plans for a major redevelopment of Central Manchester Hospitals (England). This approach to HIA drew not only from HIR but also from Integrated Impact Assessment (IIA) in order to produce a summary of the most significant health impacts of a policy, programme or project in a more timely and cost-effective way. This example highlights the potential for involving Local Authority Overview and Scrutiny Committees in the HIA process as a way of ensuring that the recommendations of HIA are mainstreamed as part of the ongoing development of projects.     

Assessing health impacts in complex eco-epidemiological settings in the humid tropics: Modular baseline health surveys

The quantitative assessment of health impacts has been identified as a crucial feature for realising the full potential of health impact assessment (HIA). In settings where demographic and health data are notoriously scarce, but there is a broad range of ascertainable ecological, environmental, epidemiological and socioeconomic information, a diverse toolkit of data collection strategies becomes relevant for the mainly small-area impacts of interest. We present a modular, cross-sectional baseline health survey study design, which has been developed for HIA of industrial development projects in the humid tropics. The modular nature of our toolkit allows our methodology to be readily adapted to the prevailing eco-epidemiological characteristics of a given project setting. Central to our design is a broad set of key performance indicators, covering a multiplicity of health outcomes and determinants at different levels and scales. We present experience and key findings from our modular baseline health survey methodology employed in 14 selected sentinel sites within an iron ore mining project in the Republic of Guinea. We argue that our methodology is a generic example of rapid evidence assembly in difficult-to-reach localities, where improvement of the predictive validity of the assessment and establishment of a benchmark for longitudinal monitoring of project impacts and mitigation efforts is needed.     

A new approach to criteria for health risk assessment

Health Impact Assessment (HIA) is a developing component of the overall impact assessment process and as such needs access to procedures that can enable more consistent approaches to the stepwise process that is now generally accepted in both EIA and HIA. The guidelines developed during this project provide a structured process, based on risk assessment procedures which use consequences and likelihood, as a way of ranking risks to adverse health outcomes from activities subjected to HIA or HIA as part of EIA.The aim is to assess the potential for both acute and chronic health outcomes. The consequences component also identifies a series of consequences for the health care system, depicted as expressions of financial expenditure and the capacity of the health system.These more specific health risk assessment characteristics should provide for a broader consideration of health consequences and a more consistent estimation of the adverse health risks of a proposed development at both the scoping and risk assessment stages of the HIA process.     

Health impact assessment in Latin American countries: Current practice and prospects

BackgroundWith the objective to avoid and mitigate potential adverse health impacts of projects, programmes and policies, health impact assessment (HIA) offers an opportunity for disease prevention and health promotion. Although HIA has gained importance over the past two decades, it is unclear whether and to what extent HIA practice has been established and institutionalised in Latin America. To address this issue, the current practice and prospects of HIA in Latin America was assessed in the peer-reviewed literature and existing guidelines.MethodologyThe peer-reviewed literature was systematically searched using five electronic databases until February 2016. Studies were included on a set of pre-defined criteria. The search was carried out in English, French, Portuguese and Spanish. Additionally, a search for HIA guidelines used in Latin American countries and territories was performed by means of a Google search and on websites of government departments and institutions that may promote HIA.ResultsThe search yielded 167 hits in the peer-reviewed literature of which 17 articles met inclusion criteria. Only four peer-reviewed articles described prospective HIAs and four featured a discussion of the HIA approach. The remaining nine articles presented health impact evaluations. Most studies were published only recently, after 2012 (88%). Seven HIA guideline documents were identified, two of which were country-specific (i.e. Brazil and Mexico) and the remaining five addressed HIA at the regional level.ConclusionsThis study confirmed the paucity of literature pertaining to HIA implementation, as well as HIA guidelines in Latin America. Mexico, Brazil and Cuba have the longest track record in scientific literature and guidelines on HIA. In order to better understand current barriers and limitations to practice and institutionalisation of HIA in Latin American countries, a broad discussion among policy makers, academic institutions and HIA practitioners is warranted nationally and regionally.     

The health impacts of transformative infrastructure change: Process matters as much as outcomes

BackgroundMajor infrastructure development is often transformative for society, including its health. In this realm, there is a growing trend to view airports as drivers for health. By linking airport, urban and health planning, airports can become settings for health. Engaging stakeholders and those affected by such major change in health assessments is essential. This paper demonstrates that health and health equity impacts of major infrastructure developments such as airports extend to the planning processes for these developments; it argues that building a Healthy Airport requires greater consideration of how communities are engaged in these processes.MethodsWe carried out a Health Impact Assessment of community engagement practices for the planning processes of a new greenfield airport in Australia. The standard step-wise process for completing an HIA was followed.Results151 stakeholders participated in the study. Overall, participants were dissatisfied with community engagement for the proposed airport. While there were some unanticipated positive community level impacts resulting from the engagement process (community members becoming involved in community activism), by and large community members identified mostly negative impacts including anxiety, disempowerment, poor social connection, lack of trust and aggravation of health inequities.ConclusionPotentially affected individuals and communities may feel disenfranchised by transformative infrastructure change ‘over their heads’. Missed opportunities to achieve benefits of well-executed community engagement not only lead to feelings of disempowerment and frustration among stakeholders but can potentially negatively impact on individual and community health and well-being. Health impact assessments that effectively assess planning and engagement processes can play a role in mitigating these impacts.     

Perception survey on the relevance of main categories of health determinants for conducting health impact assessment

Addressing the characterization of social and economic determinants of health (SDH) properly is a key aspect in conducting a Health Impact Assessment (HIA). This article explores the level of knowledge on HIA environmental and public health professionals have as well as their perception regarding key concepts such as the definition of ‘health’ and the relevance of SDH. With this purpose in mind, a survey was conducted among experts (n = 41) who attended a technical session on HIA within the framework of the most important conference on the Environment on a national level in Spain. A hierarchical cluster analysis was conducted to categorize groups of respondents depending on their working profile and professional expertise and a Friedman test was used to compare mean ranks so as to assess the importance given to SDH according to the target respondents' perception. Strong differences were found in the relevance given to diverse SDH according to their contribution to a good state of health, the block referring to ‘Habits and lifestyle’ being the one perceived as more significant. SDH were ranked in a diverging order from that reported in the scientific evidence regarding the association between SDH and a wide range of health outcomes. Also, some diverging trends were illustrated between groups of respondents according to the relevance given to each block of SDH. However, differences in responses between groups of respondents were not statistically significant. A self-appraisal by respondents also revealed that the practitioner's level of knowledge on HIA ranged between low to medium. Therefore, it is recommended to improve their capacity.     

Theory and practice to integrating health in environmental assessment: Synthesis of an experience with stakeholders to deliver a national HIA guideline

Private or public developers, including local authorities and government agencies, have limited operational guidance to include case-relevant health information in environmental reports. In Italy, the absence of technical indications prompted the Ministry of Health to construct a new model of Health Impact Assessment (HIA) for health integration in Environmental Assessment (EA) processes. A coordinating committee set within an inter-institutional working group was assisted by public and private key stakeholders to deliver guidance on HIA. The three research stages of framing, production and delivery were carried out to: (1) frame the context for HIA guidance implementation; (2) produce the operational guideline and tools; (3) train and disclose the guideline to final users. The guideline and the operational procedures were informed by core criteria to achieve a health standard in environmental reporting. The procedures guide the user to carry out a comprehensive assessment of the population health based on the broad determinants. The environmental reporting integrates health through functional components, divided into levels and supported by related flowcharts and checklists. HIA knowledge and skills were provided to facilitate the guideline utilization within the health departments. The guideline embedded the existing EA national legacy, normative and technical. The entire decisional cycle, from strategic planning to project development was covered in the guideline including the screen of proposals. The experience triggered the definition of an environmental health collaborative platform under the Ministry of Health coordination to fill gaps in competence building, sector operational tools development, methodologies harmonization on the national territory.     

Stakeholder participation in health impact assessment: A multicultural approach

The literature on impact assessment (HIA) registers the importance of stakeholder participation in the assessment process, but still lacks a model for engaging stakeholders of diverse ethnic, professional and sectorial backgrounds. This paper suggests that the multicultural approach can contribute to HIA through a revision of the generic 5-step HIA model, and its implementation in a metropolitan plan in Southern Israel. The health issue scoped by the stakeholders in the HIA is related to land uses in the vicinity of the national hazardous industry and hazardous waste site. The stakeholders were representatives of the diverse populations at stake, including rural Bedouins and Jewish city dwellers, as well as representatives from the public sector, private sector, non-governmental organizations and academia. The case study revealed that a multicultural stakeholder participation process helps to uncover health issues known to the community which were not addressed in the original plan, and provides local knowledge regarding health conditions that is especially valuable when scientific data is uncertain or absent. It enables diverse stakeholders to prioritize the health issues that will be assessed. The case study also reveals ways in which the model needs revisions and improvements such as in recruitment of diverse participants. This paper presents a multicultural model of HIA and discusses some of the challenges that are faced when HIA is implemented in the context of current decision-making culture.     

Who plans for health improvement? SEA,HIA and the separation of spatial planning and health planning

This study examines whether there is active planning for health improvement in the English spatial planning system and how this varies across two regions using a combination of telephone surveys and focus group interviews in 2005 and 2010. The spatial planning profession was found to be ill-equipped to consider the health and well-being implications of its actions, whilst health professionals are rarely engaged and have limited understanding and aspirations when it comes to influencing spatial planning. Strategic Environmental Assessment was not considered to be successful in integrating health into spatial plans, given it was the responsibility of planners lacking the capacity to do so. For their part, health professionals have insufficient knowledge and understanding of planning and how to engage with it to be able to plan for health gains rather than simply respond to health impacts. HIA practice is patchy and generally undertaken by health professionals outside the statutory planning framework. Thus, whilst appropriate assessment tools exist, they currently lack a coherent context within which they can function effectively and the implementation of the Kiev protocol requiring the engagement of health professionals in SEA is not to likely improve the consideration of health in planning while there continues to be separation of functions between professions and lack of understanding of the other profession.     

Can health feasibly be considered as part of the planning process in Scotland?

The planning system is significant because of its capacity to determine the quality of the built environment as well as the health, well-being and quality of life of the individuals and communities therein. Development planning is especially important because of the long-term impact of the decisions. This paper was developed in response to increasing recognition amongst HIA practitioners in Scotland of the importance of planning for health. It focuses on the relationship between the planning system in Scotland, specifically the Development Planning element of it, and population health and considers how the health impact assessment (HIA) approach can facilitate and support joint working with planners. In particular, consideration is given to the potential impact of the introduction of Strategic Environmental Assessment (SEA) on the linkages between health, HIA and planning.     

Evaluating impacts of marine governance on human communities: Testing aspects of a human impact assessment model

A human impact assessment (HIA) model was developed to guide research to understand how changes in a fishery can impact fishermen and fishing communities. Path analysis demonstrates that job satisfaction is an important variable intervening between marine governance and well-being. Individual-level variables in the demographic latent variable influence aspects of job satisfaction as well as well-being. It is variance in management that influences satisfaction with fishing which has a direct effect on well-being. In the HIA model, the three components of job satisfaction (self-actualization, income, and psycho-social) have the greatest total impact on well-being. The model also indicates complex relationships between management, fishing activity attributes, job satisfaction, and individual and social attributes. Relationships between community context and differences in job satisfaction in the Northeast and Alaska regions confirmed that these factors, also included in the HIA model, are important aspects of impact assessment. Results help to show that changes in ocean governance have impacts on the human communities who use these important resources. To anticipate and ameliorate potential impacts on human well-being as indicated by tools such as the HIA model, research needs to be accomplished to appropriately design and account for these impacts.     

Rethinking human health impact assessment

Most EIA programs around the world require the consideration of human health impacts. Yet relatively few EIA documents adequately address those impacts. This article examines how, why, and to what extent health impacts are analyzed in environmental impact assessments in the U.S. An empirical study of 42 environmental impact statements found that more than half contained no mention of health impacts. In the others, health impacts were analyzed narrowly, if at all, using risk assessment to quantify the carcinogenic potential of a single substance over a single generation. This analytic focus overlooks other significant morbidity and mortality risks, cumulative and intergenerational effects, and broader determinants of health. This article investigates these problems and provides recommendations to improve human health impact assessment, using strategic environmental assessment, qualitative health data, health outcomes in addition to cancer, and a precautionary approach to risk.     

Health impact assessment research and practice: A place for paradigm positioning?

In this article, we provide a critical review of the place of paradigm in health impact assessment (HIA) research and practice. We contend that most HIA practitioners have given insufficient attention to paradigm positioning when developing and applying HIA methodologies and that some concerns about current HIA practice can be attributed to this. We review HIA literature to assess the extent and nature of attention given to paradigm positioning and these related concerns. We then respond to our critique by exploring the implications, opportunities and challenges of adopting a critical realist paradigm, which we believe has the potential to help HIA practitioners to develop HIA methodology in a way that addresses these issues.