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.     

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.     

Equity-focused health impact assessment: A tool to assist policy makers in addressing health inequalities

In Australasia (Australia and New Zealand) the use of health impact assessment (HIA) as a tool for improved policy development is comparatively new. The public health workforce do not routinely assess the potential health and equity impacts of proposed policies or programs. The Australasian Collaboration for Health Equity Impact Assessment was funded to develop a strategic framework for equity-focused HIA (EFHIA) with the intent of strengthening the ways in which equity is addressed in each step of HIA. The collaboration developed a draft framework for EFHIA that mirrored, but modified the commonly accepted steps of HIA; tested the draft framework in six different health service delivery settings; analysed the feedback about application of the draft EFHIA framework and modified it accordingly. The strategic framework shows promise in providing a systematic process for identifying potential differential health impacts and assessing the extent to which these are avoidable and unfair. This paper presents the EFHIA framework and discusses some of the issues that arose in the case study sites undertaking equity-focused HIA.     

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.     

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.     

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.     

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.     

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.     

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.     

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.