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: A comparison of 45 local,national, and international guidelines

This article provides a comparison of health impact assessment (HIA) guidelines from around the world and for multiple geographic scales. We identify commonalities and differences within HIA guides to discuss the plausibility of consensus guidelines and to inform guideline development. The practice of HIA has grown over the last two decades with a concurrent growth of HIA guides. This study expands on earlier review work and includes guides published since 2007 (Mindell, Boltong and Forde, 2008). From April 2010 to October 2011, 45 HIA guides were identified through an internet search and review of previous research. Common characteristics, key features, and the HIA process were analyzed. The 45 documents recommended similar but not identical processes for conducting HIAs. These analyses suggest that guidelines for HIAs are similar in many areas of the world and that new HIA practitioners can use these findings to inform their approach. Further discussion is needed to determine if the approaches established in these guidelines are followed and if one set of common guidelines could be written for use in numerous countries and regions.     

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.     

Building capacity for Health Impact Assessment: Training outcomes from the United States

BackgroundDespite the continued growth of Health Impact Assessment (HIA) in the US, there is little research on HIA capacity-building. A comprehensive study of longer-term training outcomes may reveal opportunities for improving capacity building activities and HIA practice.MethodsWe conducted in-depth interviews with HIA trainees in the United States to assess their outcomes and needs. Using a training evaluation framework, we measured outcomes across a spectrum of reaction, learning, behavior and results.ResultsFrom 2006 to 2012, four organizations trained over 2200 people in at least 75 in-person HIA trainings in 29 states. We interviewed 48 trainees, selected both randomly and purposefully. The mean duration between training and interview was 3.4 years. Trainees reported that their training objectives were met, especially when relevant case-studies were used. They established new collaborations at the trainings and maintained them. Training appeared to catalyze more holistic thinking and practice, including a range of HIA-related activities. Many trainees disseminated what they learned and engaged in components of HIA, even without dedicated funding. Going forward, trainees need assistance with quantitative methods, project management, community engagement, framing recommendations, and evaluation.ConclusionsThe research revealed opportunities for a range of HIA stakeholders to refine and coordinate training resources, apply a competency framework and leverage complimentary workforce development efforts, and sensitize and build the capacity of communities.     

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.     

Community participation in Health Impact Assessment. A scoping review of the literature

Currently, the engagement of local communities in Health Impact Assessment is becoming more and more important. A scoping review was performed to take stock of visions, methods and experiences in this field.A combined Scopus and Medline search yielded 100 articles in scientific journals. The final selection consisted of 43 papers, including case studies, evaluation studies, reviews, and opinion papers. After analysis, consultation of four experts was performed to check preliminary study outcomes. A grey literature web search was performed to check and complement the results.Results show that community participation is generally considered a core element in HIA. Views as expressed in the papers concern, firstly, the need for and value of local knowledge, secondly, the adherence to or application of democratic values and, thirdly, empowerment of communities. Three categories of methods are used in relation to community participation, often in combination: methods to facilitate knowledge elicitation, to ensure the inclusion of communities in the HIA process, and to build community capacity to participate in policy development. However, the theoretical or practical underpinning of the choice for specific methods is mostly not presented. The experiences described in the papers mainly focus on the access to local knowledge and its usability as a source of evidence in the HIA process. Described effects of community participation are (improved) relations between communities and local agencies, policy makers and professionals and the empowerment of community members. Although these effects are ascribed to community participation, many papers do not provide support for this conclusion beyond the retrospective perception of participants. Expert consultation and additional analysis of the grey literature supported the results derived from the scientific literature and provided more in-depth knowledge. In the grey literature theoretical frameworks, methods and tools for community participation in HIA were more extensively reported as compared to the scientific literature.We conclude that the visions, methods and experiences concerning community participation show that a participative approach may contribute to better, context specific knowledge. It appears that participative HIA has health promotion potential as it helps develop responsive policies.To accomplish this, HIA should, firstly, be better embedded in broader health promotion programmes. Secondly, the methods and approaches for community participation applied in HIA should be theory-informed and well described. The grey literature offers entry points. Finally, more robust and systematic evaluation and research is needed to assess the impact of HIAs on communities and policies.     

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.     

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.     

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.     

Blood lead levels, δ-ALAD inhibition, and hemoglobin content in blood of giant toad (Rhinella marina) to asses lead exposure in three areas surrounding an industrial complex in Coatzacoalcos, Veracruz, Mexico

The Coatzacoalcos Region in Veracruz, Mexico houses one of the most important industrial complexes in Mexico and Latin America. Lead is an ubiquitous environmental pollutant which represents a great risk to human health and ecosystems. Amphibian populations have been recognized as biomonitors of changes in environmental conditions. The purpose of this research is to measure exposure to lead and evaluate hematological and biochemical effects in specimens of giant toads (Rhinella marina) taken from three areas surrounding an industrial complex in the Coatzacoalcos River downstream. Lead levels in toads' blood are between 10.8 and 70.6 μg/dL and are significantly higher in industrial sites. We have found a significant decrease in the delta-aminolevulinic acid dehydratase (δ-ALAD) activity in blood from 35.3 to 78 % for the urban–industrial and industrial sites, respectively. In addition, we have identified a strong inverse relationship between the δ-ALAD activity and the blood lead levels (r?=??0.84, p?<?0.001). Hemoglobin and mean corpuscular hemoglobin levels, as well as the condition factor, are found to be lower at industrial sites compared with the reference sites. Our results suggest that the R. marina can be considered a good biomonitor of the δ-ALAD activity inhibition and hematological alterations at low lead concentrations.     

HIA and pollution prevention control: What they can learn from each other

Following the implementation of the Pollution Prevention and Control (England and Wales) Regulations on 1st August 2000, health authorities (now Primary Care Trusts) became statutory consultees for permits issued to industry by the environmental regulators (the Environmental Agency, Local Authorities). The aims of this paper are to review the process of providing public health input in the light of its similarities to and differences from HIA and to identify the opportunities for both HIA and PPC to learn from each other's practice. We emphasise the challenges that are encountered by public health professionals who provide the public health input in the PPC. We use both our own experience of providing this input on behalf of health authorities and our expertise in HIA, environmental epidemiology and contaminated land.     

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.     

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.     

HIA, the next step: Defining models and roles

If HIA is to be an effective instrument for optimising health interests in the policy making process it has to recognise the different contests in which policy is made and the relevance of both technical rationality and political rationality. Policy making may adopt a rational perspective in which there is a systematic and orderly progression from problem formulation to solution or a network perspective in which there are multiple interdependencies, extensive negotiation and compromise, and the steps from problem to formulation are not followed sequentially or in any particular order. Policy problems may be simple with clear causal pathways and responsibilities or complex with unclear causal pathways and disputed responsibilities. Network analysis is required to show which stakeholders are involved, their support for health issues and the degree of consensus.From this analysis three models of HIA emerge. The first is the phases model which is fitted to simple problems and a rational perspective of policymaking. This model involves following structured steps. The second model is the rounds (Echternach) model that is fitted to complex problems and a network perspective of policymaking. This model is dynamic and concentrates on network solutions taking these steps in no particular order. The final model is the “garbage can” model fitted to contexts which combine simple and complex problems. In this model HIA functions as a problem solver and signpost keeping all possible solutions and stakeholders in play and allowing solutions to emerge over time. HIA models should be the beginning rather than the conclusion of discussion the worlds of HIA and policymaking.     

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.     

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.     

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.     

Effects of roads on terrestrial vertebrate species in Latin America

Biodiversity in Latin America is at risk today due to habitat loss, land conversion to agriculture and urbanization. To grow their economies the developing countries of Latin America have begun to invest heavily in new road construction. An assessment of research on the impacts of roads on wildlife in Latin America will help define science-based conservation strategies aimed at mitigating road expansion. The aim of this review was to qualitatively and quantitatively assess scientific research papers addressing road impacts on vertebrate species in Latin America. We searched for scientific papers published as early as 1990 to 2017. We reviewed a total of 197 papers. Published research showed an increasing trend in the last decade with a strong geographic bias with a majority of papers from Brazil. Mammals were the most studied taxa followed by birds, reptiles and amphibians. The majority of studies focused on road mortality and at the individual species level. Studies documented an increase in deforestation rates, in land conversion to agriculture, illegal activities (hunting, logging) and the establishment of human settlements. The effects of roads on species richness and populations abundance varied among taxa with no apparent pattern within taxa. Forest-dependent species tended to avoid crossing roads. Amphibians had the highest median road-kill rate, followed by reptiles, mammals and birds. Our results suggest that there is an urgent need for more research, particularly in Central America and to employ predictive tools for difficult-to-sample or understudied species and critical conservation areas. We recommend a two-speed approach to guide future research: one focusing on quantifying individual species responses towards roads and their implications on population viability; a second consisting of regional or continental-scale analyses and modelling of road risks to species and populations to inform road planning immediately.     

Quantitative health impact assessment methodology for societal initiatives: A scoping review

Health initiatives are increasingly situated outside the institutionalised public health sector. The intersectoral character of societal initiatives, along with indirect relationships between initiatives and health, makes making projections of reach, impact and goal achievement complex. This scoping review of the peer-reviewed literature searches for appropriate methods to conduct quantitative health impact assessment for such initiatives. Database searches were done in PubMed and Web of Science, as well as a reference list search. Studies were then selected in a systematic manner. The review includes 64 studies. Most studies made estimates using simulation methods, notably with Monte Carlo, Markov and system dynamics modelling. Inputs for the models such as transition probabilities and price elasticities were taken from census, register and survey data, evidence from previous (scientific) studies and sometimes outcomes from stakeholder participation. Of different health outcome measures, the number of deaths was most frequently used, followed by QALYs and DALYs and life years. Health effect distribution is frequently mentioned, but not often estimated. Scientific methodological publications on HIAs focusing on civil society initiatives are relatively sparse, indicating possibilities for further methodological advancement. Estimating health effect distributions and incorporating stakeholder participation could make meaningful additions to standard practice.     

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.