iom chia hia reader 2005-2007

8/14/2019 Iom Chia Hia Reader 2005-2007

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


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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, economicand 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 . I n t r o d u c t i o n

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 . H e a l t h I m p a c t A s s e s s m e n t

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, developmentsand services (initiatives). It can be used to:

support the planning and decision-making process by providing timely, relevantand 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 doesnt 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 individuals or communitys 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 CHIAs 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 communitys 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 thehealth 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

Informationsection 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 considerableinterest in healthy public policy.

In British Columbia, Canada, HIA was a requirement in the preparation of policy andguidance was published on how to do this (see the British Columbia model).

In Holland the government examined how health consequences of policies could beassessed and developed procedures to undertake this.

In Sweden the focus fell on local rather than national agencies and guidance waspublished on how to assess the health impacts of policies (see the Swedish CountyCouncil model).

Meanwhile in Europe and particularly in the UK development of HIA encouraged aseries of supra-national and national government statements. In England the greenpaper Our healthier nation: a contract for the nation stated the Government willapply health impact assessments to its relevant key policies, so that when they arebeing developed and implemented, the consequences of those policies for our healthis considered. This commitment was renewed in the subsequent white paper Savinglives: our healthier nation. Governments in Scotland, Wales and Northern Irelandmade similar commitments. In the 1990s the UK Government acknowledged theexistence of Inequalities in Health and adopted their reduction as an overarchingpolicy goal. The Greater London Assembly has developed a system for assessing thehealth impacts of all its strategies.

WHO Europe said that, Member states should have established mechanisms for healthimpact assessment and ensured that all sectors become accountable for the effects oftheir policies and actions on health as one of its Health 21 targets. The High LevelCommittee on Health of the European Union has also recommended the developmentof an easy-to-use checklist of steps in policy appraisal of health impact to be used forpolicy 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 indeveloping countries. This interest moved to more developed countries and majordevelopment projects.

In New Zealand the Resource Management Act 1991 required authorities to make anassessment of any actual or potential effects on the environment, which includesany effects on those in the neighbourhood or wider community including socio-economic and cultural effects. A guide to health impact assessment was published in1995 to assist authorities with this task.

In Australia development planning and resource issues are regulated by the individualstates but the national government produced a report to guide states on how theycould involve impact assessment in their planning and development. Tasmania hasgone further and made HIAs a legal requirement.

In Germany health aspects are considered in the context of environmental impactassessment (see Bielefeld model). In Holland various large development projects havebeen the subject of assessments that covered health and environmental impacts.

In Canada, projects requiring environmental impacts were scrutinised for possiblehealth impacts and those with greatest potential subjected to a fuller healthassessment. In the United Kingdom an HIA was submitted as evidence to the planningenquiry on a third runway for Manchester airport and the British Medical Associationpublished 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 . H e a l t h , D e t e r m i n a n t s a n d I n e q u a l i t i e s

The social model was developed through the WHOs 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 individuals 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 persons 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

1Words 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 producethem

(Department of Health and the Neighbourhood Renewal Unit, 2002)

Health Impact Known positive/ negativedeterminants of health

Examples of initiatives that can affectthese influencing factors

Cardiovascular disease Smoking

Exercise

Nutrition

Being over-weight

Air pollution

Local transport plans

Healthy living centres

Land use and land planning

Smoking cessation programmes

Access to affordable fresh foods

Access to affordable physical recreation

Cancer Smoking

Nutrition

Exercise

Chemical exposures

Health screening for earlydetection

Land use and land planning

Access to affordable fresh foods

Healthy school meals

Smoking cessation programmes

Access to screening programmes

Accidents Transport

Workplace

Home

Environment

Local transport and waterway plans

Housing policies, programmes and projects

Safety equipment loan schemes

Occupational health

Mental Health Self esteem

Social networks

Social pressures

Fear of crime

Noise

Education policies, programmes andservices

Employment schemes

Crime prevention initiatives

Sustainable communities

Transport & housing policies andprogrammes

Health Inequalities Poverty

Housing

Access to services

Education

Work

Economic regeneration initiatives

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

Welfare reform

Housing, transport and planning policies

Access to retail services and otheramenities

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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 . E v i d e n c e a n d E v i d e n c e G a t h e r i n g

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 forcesand 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, value-

neutral 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

(nature of the

world and reality)

Nave realism

there is one real

reality that we can

all apprehend

Critical realism

there is one real reality

but we can only

understand it imperfectly

and probabilistically

Historical realism

reality is virtual and

shaped by social,

political, cultural,

economic, ethnic, and

gender values that have

developed over time

Relativism

there are a range of local,

specific and overlapping

realities that we each

have constructed

Epistemology

(nature of

knowledge and

what can be

known about

reality)

Objectivist

findings true

universal

Modified objectivist

findings probably true

universal

Subjectivist

findings are affected by

the values we hold

contextual

Subjectivist

findings are created and

constructed

contextual

Methodology

(approach used to

understand and

make sense of

reality)

Experimental

verifying specific

hypotheses

chiefly quantitative

methods

Modified Experimental

falsification of

hypotheses,

may include qualitative

methods

Dialogic

Hypothesis generation

and testing

chiefly qualitative

methods

Interpretative

Hypothesis generation and

testing

chiefly qualitative

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 knowledgeis 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 Post-Positivism Critical Theory Constructivism

Inquiry aim prediction and control critique and

transformation

understanding and

reconstruction

Nature of

knowledge

verified hypotheses

established as facts or laws

non-falsified

hypotheses

probable facts or laws

structural and

historical insights

individual

reconstructions

coalescing around

consensus

Knowledge

accumulation

accretion building blocks adding to the edifice of

knowledge;

generalisations and cause-effect linkages

historical revisionism,

generalisation by

similarity

more informed and

sophisticated

reconstruction;

lived experience

Goodness or

quality criteria

conventional benchmarks of rigour: internal and

external validity, reliability and objectivity

historical

situatedness; erosion

of ignorance and

action stimulus

trustworthiness and

authenticity

Values excluded influence denied included formative

Ethics extrinsic tilt towards deception intrinsic: tilt toward

revelation

intrinsic: tilt towards

revelation

Voice disinterested scientist as informer of decision

makers, policy makers, and change agents

transformative

intellectual as

advocate and activist

passionate

participant as

facilitator of multi-

voice reconstruction

Training technical and quantitative

substantive theories

technical;

quantitative and

qualitative

substantive theories

resocialisation; qualitative and quantitative;

history; values altruism and empowerment

Accommodation commensurable incommensurable

Hegemony In control of publication, funding, promotion, and

tenure

Seeking recognition and input

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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 researchprocess.

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

sources of information

Evidence gathered by local and national institutions

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 expert-

professionals 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

stakeholders

These can be from professional 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 . E v a l u a t i n g E v i d e n c e

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 studys 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 researchs 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, exposureto 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 highlevels 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 &

Short Time Periods

Toxicological experiments rely on experiments on

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 non-

representative 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 . 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

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 knowledgeThe 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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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 havedetailed 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 publicprovided 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 theissues 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 others 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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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 ourignorance .

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

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Low LEVEL OF UNCERTAIHigh

AppliedNormalScience

Expert-ProfessionalJudgement

Post-NormalScience

High

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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 tomake 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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7 . S t a k e h o l d e r 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 togenerate 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 residents 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 Arnsteins 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 viewsand at worst an attempt to keep residents quiet.

Figure 7.1 Diagram of Sherry Arnsteins Ladder of Citizen Participation

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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Citizen control

Delegated power

8

7

Partnership6

Placation5

Consultation4

Informing3

Therapy2

Manipulation1

Degrees of

Citizen Power

Degrees of

Tokenism

Non

Participation

Better

and

more

genuine

stake-

holder

involve

ment


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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 believingthat 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 window-

dressing 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 thelevel 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 peoples 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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8 . 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 practitioners 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 Schn

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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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 dont 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 beingcoerced 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 lifes 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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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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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 meetsyour 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 staff-

practitioners 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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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 HIAs 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 andservices (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 ininfluencing 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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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)

A. HIGH importance / LOW influence

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

B. HIGH importance / HIGH influence

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

School of Community Health (2)

D. LOW importance/ HIGH influence

Local newspaper (4)GLA (3)

Judiciary (3)

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

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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, cost-

effective 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 ofImpacts

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

iom chia hia reader 2005-2007

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