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Health Impact

Assessment:

A
Guide
For
Service Providers
The State of Queensland

© Queensland Health, 2003

ISBN: 0 7345 2915 5

Copyright protects this publication. However, Queensland Health has no objection to this
material being reproduced with acknowledgment, except for commercial purposes.
Permission to reproduce for commercial purposes should be sought from the Policy and
Quality Officer, Queensland Health, GPO Box 48, Brisbane Q 4001.

This document is available on the Queensland Health Internet site at:


http://www.health.qld.gov.au/HealthyLiving/social_determinants_HP.htm.

Suggested citation
Queensland Health. Health Impact Assessment: A Guide for Service Providers. Public Health
Services, Queensland Health. Brisbane 2003

Acknowledgments

Special acknowledgment needs to be given to the service providers who participated in the
focus group and developmental processes for this resource. Without their dedication, effort
and constructive comments this document could not have been produced.

For further information and copies, please contact:

Southern Public Health Unit Network


West Moreton Public Health Unit
PO Box 73
Ipswich Qld 4305
Australia

Ph: 07 3810 1500 Fax: 07 3810 1155


Email: wmphu@health.qld.gov.au
Health Impact Assessment: A Guide for Service Providers

Health Impact Assessment (HIA)


offers the opportunity to
support sustainable communities,
predict, reduce or avoid potential
negative health impacts,
enhance positive impacts
and deliver sound and accountable
decision-making

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Health Impact Assessment: A Guide for Service Providers

Contents

Glossary of terms .............................................................................................3


Introduction ......................................................................................................5
What this resource will do …............................................................................7
What is Health Impact Assessment? ...............................................................8
Six simple steps … ..........................................................................................9
Step 1: Screening........................................................................................................... 10
Step 2: Scoping............................................................................................................... 12
Step 3: Appraisal and assessment .................................................................................. 15
Step 4: Developing recommendations ............................................................................. 18
Step 5: Negotiate favoured options.................................................................................. 20
Step 6: Monitoring and evaluation ................................................................................... 21
Getting started: Rapid appraisal.....................................................................23
Where to from here? ......................................................................................24
Further information.........................................................................................26
Appendix 1: Community profile categories.....................................................27
Appendix 2: Case Study: Goodna Service Integration Project ......................28
Appendix 3: An example of an assessment matrix ........................................30

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Health Impact Assessment: A Guide for Service Providers

Glossary of terms

Community profile: this is the process of establishing baseline information


concerning the characteristics of the community in question (see Appendix 1).

Community participation: means involving the community in an activity such


as planning of projects or carrying out a health impact assessment (HIA).

Disadvantaged/vulnerable/marginalised groups: these terms are applied


to groups of people who, due to factors usually considered outside their
control, do not have the same opportunities as other, more fortunate groups in
society.

Equity in health: inequity, as opposed to inequality, has a moral and ethical


dimension, resulting from avoidable and unjust differentials in health status.
Equity in health implies that ideally everyone should have a fair opportunity to
attain their full health potential and, that no one should be disadvantaged from
achieving this potential lit it can be avoided. HIA is usually underpinned by an
upfront value system (see Box 2, p27) in which equity plays a major role so
that both health inequalities and inequities in health are explored and
addressed wherever possible.

Grey literature: generally unpublished documents for example, reports


produced by agencies that have not been published in peer-review journals
but none-the-less inform practice.

Health: a state of complete physical, mental and social well being and not
merely the absence of disease and infirmity.

Health determinants: this study included assessments and considered the


impacts of the service integration project on the important determinants of
health such as biological factors, personal/family circumstances and lifestyle,
social environment, physical environment, public services, and public policy.
The determinants model of health influences suggests that these
determinants affect life expectancy, quality of life, and morbidity and mortality
of communities within the reach of the project1.

1
Queensland Health (2001) Social Determinants of Health: The Role of Public Health
Services – Summary Document. Brisbane: Public Health Services, Queensland Health.

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Health Impact Assessment: A Guide for Service Providers

Health impact: is a change in health status (or in the determinants of health


status) of an individual or group attributable to a project, program or policy
within a boundary as agreed by a HIA project’s steering group. Studies have
shown that developmental practices can cause health impacts by initiating
significant changes in the health status of local communities.2,3 As a result a
HIA study should include assessments of those factors that are known health
status determinants (see Table 2, p18 for Factors Affecting Health and Well
being).

Health impact assessment: a combination of procedures or methods by


which a policy, program or project may be judged as to the effects it may have
on the health of a population. That is, will (or does) a project affect quality of
life issues beyond its intended meaning and as a result affect the health of
that population.

Health inequality and inequity: health inequalities can be defined as


differences in health status or in the distribution of health determinants
between different population groups. Inequity refers to the uneven distribution
in health status that may be unnecessary and avoidable as well as unjust and
unfair.

Qualitative and quantitative evidence: basically, quantitative evidence is


based on what can be counted or measured objectively whilst qualitative
evidence cannot be measured in the usual ways and may be more subjective,
for example, encompassing people’s perceptions, opinions and views.

Social determinants of health: a somewhat loose term that generally refers


to the social, cultural and economic factors in which people live, work and play
that affect health.

Stakeholders: people concerned with, or affected by, the proposal or project.

2
Mahoney, M. and Wright, J. (2002) Health Impact Assessment: a tool for policy development
in Australia. An interim literature review and briefing paper. Melbourne: Deakin University
Faculty of Health and Behavioural Sciences.
3
Mcintyre, L. and Petticrew, M. (1999) Methods of Health Impact Assessment: a literature
review. Glasgow: University of Glascow, Medical Research Council Social and Public Health
Sciences Unit, Occasional Paper, December.

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Health Impact Assessment: A Guide for Service Providers

Introduction

It is now well recognised that many influences act on health. Some of the
major factors include poverty, transport, education and the environment and
are outside the jurisdiction of health services.4,5

Many other sectors such as local government, other government departments,


the voluntary sector and the community as well as the health sector have
important roles to play in enhancing health.

However, practically speaking, how can communities and other sectors


improve the health of individuals and communities to reduce health
inequalities? To answer this question it is essential at the outset we ensure
that all policies and practices across the range of sectors be properly
assessed for the impact they have on health.

This resource introduces you to the concept of Health Impact Assessment


(HIA)… an approach, which has come to be seen as a useful starting point in
addressing the impact of policies and practices.

This guide will offer service providers and others a useful introduction to
health impact assessment (HIA). Note there is no single correct method of
conducting HIA as conditions and circumstances vary. As a result this guide
offers those who wish to carry out a HIA the ways and means of developing
an approach which will be effective and easy to follow.

4
Acheson, D. (1998) Report of the independent inquiry into inequalities in health. London:
Stationary Office.
5
Queensland Health (2001) Social Determinants of Health – The Role of Public Health
Services. Brisbane: Public Health Services, Queensland Health.

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Health Impact Assessment: A Guide for Service Providers

What is HIA about?


Health impact assessment aids us in determining how a project will affect
people’s health. It is a relatively new approach that offers a route to
understanding the potential risks and benefits associated with any proposal.

A core strength of HIA as a tool is that its recommendations can be based on


the participation of a wide range of stakeholders.

It is useful for public, not-for-profit and private sectors interested in:


• preparation of funding submissions
• community development and planning
• resource allocation and capital investment
• community participation
• service delivery
• strategic development and planning
• policy development and analysis.

Why it is important6
Responding to public concern about health. The organisation carrying out the
HIA as part of its work program can clearly indicate that it cares about the
community and is able to respond to public health concerns.

Demonstrating health gain as added value. Organisations can ensure that


their policies and practices do not actively damage health. In addition, HIA
can be used to promote health gain for the local population and to reduce
health inequalities. HIA can be used where public sector services are
provided on a basis of value for money and health gain from non-health
policies and practices represents added value from the resources invested.

Making public policy healthy. By bringing public health issues into the
foreground of policy-making and decision-making.

Responding to Government priorities. HIA has been recognised by


Queensland Health7 as a pivotal strategy in improving the health of
Queenslanders.

Developing effective partnerships. The core activity of HIA ie working


together for a common purpose with people from different backgrounds and
with different perspective’s – gives rise to significant opportunities for joint
learning and co-operation.

6
National Health Strategy (2000) A Short Guide to Health Impact Assessment: Informing
Healthy Decisions. NHS: London.
7
Queensland Health (2002) Smart State: Health 2020 A Vision for the Future – Directions
Statement. Queensland Health p 44.

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Health Impact Assessment: A Guide for Service Providers

What this resource will do …

This resource will introduce you to the main elements of HIA. It enables all
sectors, public and private and their policy and decision-makers to:

• in partnership with other stakeholders in the community, to identify the


potential health impacts of particular policies, programs or projects

• further explore existing knowledge about particular developments and


associated health impacts

• make informed decisions concerning the impact that these developments


will have on the health of the local community.

This resource has grown out of the recognition by Public Health Services,
Queensland Health of the importance of assessing the possible impact on
health and health inequalities of policies and practices and the need to ensure
that improving health is seen as the responsibility of all of us.8

As an approach, HIA has potential contributions to make in many areas,


including:

• community renewal
• local strategic partnerships
• community strategies
• local/regional transport plans and/or land use plans
• integration of services
• equity audits
• ability of councils to promote the wellbeing of communities.

8
Queensland Health (2001) Social Determinants of Health – The Role of Public Health
Services. Brisbane: Public Health Services, Queensland Health.

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Health Impact Assessment: A Guide for Service Providers

What is Health Impact Assessment?

Health impact assessment is a relatively new approach attracting huge


interest internationally and nationally.

Basically, HIA offers a way of understanding the potential risks and benefits to
health that are contained within any proposal, and doing so rigorously.
Having said this however, HIA is not a rigid approach,
rather it is characterised by its adaptability. It is HIA has been
sufficiently flexible to suit both the resources available defined as a
9
and the responsibilities of the decision-makers. (See combination of
appendix 2 for a sample case study in HIA). procedures or
methods by which a
HIA can provide a valuable tool to help inform policy, program or
decision-making processes at a number of levels and project may be
contexts: judged for the
effects it may have
• policy development and analysis on the health of a
• strategic development and planning population.
• program and/or project development
• commissioning or providing services.

9
National Health Executive (2001) A Short Guide to Health Impact Assessment-Informing
Healthy Decisions. London: National Health Executive.

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Health Impact Assessment: A Guide for Service Providers

Six simple steps …

In undertaking a Health Impact Assessment six simple steps are involved


(Figure 2 on page 25 provides a summary framework for the HIA process)10:

Step 1: Screening
Decide what proposals or projects require assessment.

Step 2: Scoping
Decide the parameters for carrying out the HIA.

Step 3: Appraisal and assessment


Identify and consider the evidence for potential impacts
the proposal or project may have on health.

Step 4: Developing recommendations


Develop specific recommendations for the decision-
makers to improve the proposal. This includes
recommendations for addressing inequalities.

Step 5: Negotiating favoured options


Negotiate with decision-makers for adoption of
recommendations.

Step 6: Monitoring and evaluation


Monitor and evaluate the impact of the adopted
recommendations for achievement of a positive impact
on health.

10
There are various models of HIA but they exhibit commonalities with the Merseyside model
in Figure 2. For example, Queensland Health’s Environmental Health Unit is currently
drafting a HIA framework to capture their current focus. See the section on Further
Information for resources relating to other models.

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Health Impact Assessment: A Guide for Service Providers

Step 1: Screening

In order to make the most efficient use of This step applies to the
available expertise it is important to be selective selection of a project or
about what assessment work is undertaken. practice for their potential
Screening is about rapidly assessing likely to affect the health of a
population. It helps
projects for HIA in relation to a number of issues
determine whether a HIA
and can give a useful indication of resource is worth doing. Issues to
requirements. Issues to consider include:11 cover include economic,
outcome, epidemiological
and strategic issues.

Table 1: Issues to consider during the HIA screening process

Issues Examples of specific issues


Economic • the size of the project and of the population (s) affected
• the costs of the project and their distribution.
Outcome • the nature of potential health impacts of the project (crudely
estimated)
• the likely nature and extent of disruption caused to communities
by the project
• the existence of potentially cumulative impacts.
Epidemiological • the degree of certainty (risk) of health impacts
• the likely frequency (incidence/prevalence rates) of potential
health impacts
• the likely severity of potential health impacts
• the size of any probable health service impacts
• the likely consistency of ‘expert’ and ‘community’ perceptions of
probability (ie risk), frequency and severity of important impacts.
This could be described by a simple matrix. The greater the likely
consistency ie the greater the likely agreement between expert
and lay perceptions of important impacts the greater the need for
a HIA.
Strategic • the need to give greater priority to policies than to programs, and
to programs than to projects, all other things being equal. (This
results from the broader scope and hence potential impact of
policies as compared to programs and to projects)
• timeliness: regarding ensuring that HIA is prospective wherever
possible, and regarding Planning Regulations and other statutory
frameworks
• whether the project requires an Environmental Impact
Assessment12 in addition to HIA; and relevance to local decision
making.

11
Scott-Samuel, A.; Birley, M. and Ardern, K. (2001) The Merseyside Guidelines for Health
Impact Assessment. Merseyside Health Impact Assessment Steering Group.
12
See National Public Health Partnership (2001) Health Impact Assessment Guidelines.
NPHP

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Health Impact Assessment: A Guide for Service Providers

A key function of this stage is to filter out proposals that are unlikely to benefit
from HIA. For example, if:

• a proposal is seen as having little potential impact on health and equity


issues
• there are likely to be impacts but the evidence for these is already well
documented. If so, it may be possible to develop evidence-based
recommendations without resorting to a more comprehensive HIA
• decision-makers are unlikely to be receptive to considering any evidence-
based recommendations.

Who should screen?


While in principle the process of screening may be undertaken by anyone, it is
likely to have more influence if it is done in the context of a wider multi-
sectoral process. This underlines an important element of HIA, that is, the
utilisation of an integrated approach working with a range of stakeholders. In
addition, while it may not always be possible to engage the project’s decision-
makers during this stage, the potential for any HIA to inform subsequent
decision-making is likely to be enhanced if they can be engaged early.

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Health Impact Assessment: A Guide for Service Providers

Step 2: Scoping

If, during the screening step, you decide that further


investigation of health impacts is necessary, then it
Scoping means deciding
is time to establish a firm foundation for the
how to undertake an HIA
appraisal. Owing to the complexities of the social
in a given context. This
determinants it is recommended that a Steering
may mean working in
Group be established to agree on the Terms of
partnership by setting up
Reference (ToR) of the HIA and to provide advice,
a steering group for
guidance and support for the process.
managing the HIA
Representatives should include all major
process.
stakeholders including the community affected,
project proponents and relevant expertise. Key
tasks involved in this stage may include identifying

• How and by whom will the HIA process be overseen?


• Which decision-makers need to be engaged?
• The project’s key decision points and what time is available to undertake
the HIA?
• The specialists and practitioners who could be useful to the process.
• Resource issues (eg skills and human and financial resources are required
and available).
• The scope of the work in terms of time, place and relevant population
group and geographical boundaries.
• Which potential health impacts need further consideration with regard to
population and/or geographical area?
• Details of assessment methods to be used, given the resources available,
to gather the evidence base necessary to conduct the HIA.
• The responsibilities for the different assessment tasks.
• The monitoring and evaluation of the HIA processes.

Identifying the scale and


significance of the proposal or
project and resource availability
will help to determine the level of
detail required for the HIA. HIA
can be undertaken at different
levels: rapid, intermediate or
comprehensive levels (see Box 1
below).

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Health Impact Assessment: A Guide for Service Providers

Figure 1: Rapid/Intermediate/Comprehensive appraisal

Rapid Intermediate Comprehensive

Note:
Rapid appraisal is considered by many organisations as an entry point for
Health Impact Assessment. There are no clear boundaries around the three
levels – you may wish to adopt elements from all three if necessary and
appropriate for your needs.

Box 1: Health impact assessment – levels of detail

• Rapid: this entails a ‘quick and dirty’ investigation of the health impacts of
a project. It usually involves an exchange of existing knowledge and
expertise, and research from previous HIAs. Rapid HIA is usually carried
out quickly and with relatively minimal resources. Duration: days.

• Intermediate: this is a more detailed investigation of health impacts over a


longer period of time than a rapid appraisal but less than a comprehensive
appraisal. It usually involves a review of the available evidence and any
similar HIAs; the perception, knowledge and experience of stakeholders
(people concerned with, or affected by, the proposal or project); and in
some cases the collection and analysis of new information. Duration:
weeks.

• Comprehensive: this consists of a more systematic, intensive


investigation of health impacts undertaken over an extended period of
time. It usually involves a review of the available evidence base along with
the other elements mentioned under Intermediate HIA. A Comprehensive
HIA would usually also involve the gathering and analysis of new
information. Duration: months.

It is recommended that the steering group agree on the Terms of Reference


(ToR) of the HIA and to provide advice, guidance and support for the
assessment process. Representatives should include all major stakeholders
including the community affected, project proponents and relevant expertise.
The ToR are project specific, but should include:

• steering group membership and their roles


• feedback to steering group (its nature and frequency)
• details of assessment methods to be used
• form and content of HIA outputs including reporting issues (eg
confidentiality, ownership)

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Health Impact Assessment: A Guide for Service Providers

• the scope of the work including geographical and time boundaries, what to
include and exclude, range and extent of the potential impacts, specific
health determinants affected
• program outline, eg timelines
• budget/funding issues.

Different types of partnerships will expect different input from members of the
steering group. With some extended projects a relatively hands-off steering
group may be the most appropriate only meeting at three-monthly intervals
and focusing attention on key review points. With other projects the steering
group may be more hands-on with members committing time to the day-to-
day tasks of the HIA.

Who should scope?


It is helpful at this stage to set up a steering group to help oversee and
manage the HIA. The group will plan and allocate responsibility for tasks and
outputs, while also identifying the skills required and who should be involved
during the appraisal.

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Health Impact Assessment: A Guide for Service Providers

Step 3: Appraisal and assessment

In this stage the process moves along towards


practical outputs. It involves investigating,
Appraisal and assessment:
appraising and reporting on how the proposal’s
implementation is likely to affect the health of This is the method of
populations. It involves the following steps conducting the actual
assessment and includes
identifying and giving
• Examining the proposal to identify key
consideration to a range of
elements and give consideration of their
evidence for potential
relationship to the range of wider determinants
impacts on health and equity.
of health and health inequality. It often starts
with considering the potential positive and
negative impacts of the proposal against
factors that affect health and well being (see Table 2 below).

• Collecting and collating the best available qualitative and quantitative


evidence using a range of methods. This may involve deciding to go ahead
with the best available information at the time. The range of methods that
can be utilised and the associated evidence include:

• in-depth interviews with key informants


• focus group discussions
• equity audits
• surveys, questionnaires
• secondary analysis of existing data
• community profiling
• health needs assessment
• expert opinion
• documentary source (including grey literature).

• Considering the evidence and appraising the impacts, including identifying


and describing the nature and magnitude of the potential or actual,
beneficial and harmful health impacts associated with the proposal or
project. (See Appendix 3 for an example of an assessment matrix).
Because of the complex interrelationships between the social
determinants, it is important to consider how they collectively impact on
health. This needs to be achieved through considering a range of
evidence.

• Reporting on the impacts needs to be done in a way that helps people


understand how the proposal or project may affect the different groups and
communities and to focus constructively on the most important health and
equity aspects. That is, it is necessary to prioritise the impacts.

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Health Impact Assessment: A Guide for Service Providers

Table 2: Factors affecting health and well being 13


Categories of
Influences on Examples of specific influences
Health
Biological factors age, sex, genetic factors
Personal/family • family structure and functioning
circumstances and • primary, secondary, adult education
lifestyle • occupation or unemployment
• income
• risk taking behaviour
• diet
• smoking; alcohol; substance misuse
• exercise and recreation
• means of transport (cycle, car ownership)
• mental health factors.
Social/community • culture and peer pressures
environment • discrimination
• social support (eg neighbourliness, social networks, isolation)
• community, cultural, spiritual participation, historical context
• sense of control.
Structural factors • housing and working conditions
• public safety
• civic design
• shops (location, range, quality)
• transport systems (road, rail).
Physical • air
environment • water
• noise
• smell
• view
• land use
• developments
• waste disposal
• energy
• local environmental features.
Public services access to (eg location, disabled access, costs) and quality of:
• primary, community, secondary health care
• child care
• social services
• housing
• leisure
• employment
• social security services
• public transport
• policing
• other health-relevant public services
• non-statutory agencies and services.
Public policy • economic
• social
• environmental
• health trends
• local and national priorities, policies, programs and projects.

13
based on Scott-Samuel, A.; Birley, M. and Ardern, K. (2001) The Merseyside Guidelines for
Health Impact Assessment. Merseyside Health Impact Assessment Steering Group, p11.

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Considering and appraising the evidence can also be undertaken in a variety


of ways such as appointment of an assessor with the necessary skills and
knowledge or undertaking workshops or other participatory events to explore
the views of stakeholders. If a workshop is conducted then appointment of a
coordinator or facilitator is usual.

The steering group


may consider it better
for resource purposes
to employ an HIA
expert to collate the
available evidence,
and have a skilled
researcher collect any
additional information
required.

Who should appraise and assess?


In assessing the impacts of a project on health determinants broad
participation is essential if a comprehensive picture of potential health impacts
is to be established. Input from stakeholders and key informants (people with
relevant knowledge of the project and its outcomes) will be required.
Participation of the affected community is essential to ensure local concerns
are addressed and for social justice reasons. Participants may include the
following stakeholders:

• members of affected communities


• project proponents
• relevant experts
• health professionals
• community organisations
• key decision-makers.

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Health Impact Assessment: A Guide for Service Providers

Step 4: Developing recommendations

Owing to the complexity of interrelationships


between the health determinants in most Developing
cases a series of options will require to be recommendations:
defined and presented. Option appraisal will Based on the best available
result in the steering group agreeing on a set evidence this entails
of recommendations for modifying the project deciding on and prioritising
specific recommendations
such that its health impacts are optimised – in
for submission to the
the context of the many and complex decision-makers. This step
constraints which invariably constitute the completes the main part of
social, material and political environment in the HIA process but it is
which it will be undertaken. important to undertake the
following two steps (Steps 5
The following characteristics of alternative & 6) for a more complete
options or recommendations will require process.
consideration:

• the stages of project development or operation when the recommendation


will be implemented
• timing of implementation
• health determinants affected by implementation
• the nature of these effects and probability they will occur
• agencies that will implement and fund the implementation of the
recommendations
• technical adequacy of the recommendation
• the social equity and acceptability of the recommendation
• costs of the recommendation: direct/indirect, capital/revenue,
fixed/variable, financial/economic
• how the implementation of the recommendation will be monitored
• have community concerns been adequately considered and appropriately
addressed.

It will also be necessary to prioritise the recommendations so that decision-


makers are clear about stakeholder’s views. This is important if resources for
implementing the proposals are limited or there are competing priorities such
as economic or employment issues.

Note:
Recommendations are usually produced in a report format. Consideration
should also be given to providing feedback of the findings and
recommendations from the HIA process to the local community involved in
and affected by the project.

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Health Impact Assessment: A Guide for Service Providers

Who should develop recommendations?


As with the Appraisal stage (Step 3) the steps during this phase can be
undertaken in a variety of ways, including appointing an assessor to lead the
discussions and produce the final report with recommendations. Alternatively,
a series of workshop events could be convened. A coordinator or small team
could draw together the outputs from the various groups. Insights could be
sought from all those involved based on their experience, expectations and
opinions with the final decision reflecting the consensus based on the best
available evidence.

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Health Impact Assessment: A Guide for Service Providers

Step 5: Negotiate favoured options

Health impact assessment serves as a support Negotiate favoured


to decision making and is not a substitute for it.
options: Through further
HIA can contribute to informed decisions based
engagement with the
on valid assessment of potential or actual
decision-makers
health impacts and has the potential to improve
reinforce the merits and
the quality of decision making.
value of the evidence
based recommendations
As indicated in the previous step when
and advocate for their
considering recommendations there are many
adoption or adaptation in
potentially conflicting priorities and issues that
the proposal or project.
can affect decision making. The
recommendations made should have
considered these factors to ensure that they are not only based on the best
evidence available but also consider the context in which the decision making
occurs. In this way the recommendations will have the greatest chance of
being valued and acted upon. As a result it is important to consider who
actually makes the decisions about specific proposals or projects and to be
aware that:

• they may or may not have been involved in the assessment process
• the decision-makers may have other priorities to consider besides health.

For recommendations to be acted upon it is important that the decision-


makers have been involved in the process, that the report and
recommendations are presented in a concise and succinct format, and that
they arrive before key decisions are reached.

Who should negotiate?


Usually it is the task of the steering group to consider the best way to do this.
As part of this process it is essential to have a good understanding of the
decision-making context.

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Health Impact Assessment: A Guide for Service Providers

Step 6: Monitoring and evaluation

It is important to monitor and evaluate the


effect of the HIA on the proposal and the Monitoring and evaluation:
proposals development and Subsequent implementation
implementation. In assessing whether the and monitoring of the
HIA made a difference, a good HIA will aim recommendations provides
to monitor and evaluate its activities to the opportunity to evaluate
enable those involved in the process to: and make changes as
indicated. For example, to
• improve HIA processes; improve the HIA process, to
• modify future proposals or projects to make changes to future
realise health gains proposals, and to assess the
• determine whether the accuracy of predictions
recommendations were implemented made during the course of
• assess the accuracy of predictions the appraisal.
made during appraisal.

Monitoring and evaluation will, by necessity be constrained by financial and


human resources, and the time available. Types of evaluation include

♦ Process – this involves assessing how the HIA was conducted, who was
involved, and how useful and valuable was the process.
♦ Impact – this entails following how far recommendations were adopted
and implemented by the project proponents and if not, why not?
♦ Outcome – evaluation means assessing whether the anticipated positive
effects on health, well being and equity were in fact enhanced, and any
negative effects minimised and if not, why not, and how can plans be
further adapted?

Who looks after evaluation?


The steering group can monitor the acceptance and implementation of the
HIA recommendations while resources and skills required and time available
to undertake other monitoring and evaluation activities should have been
identified during the scoping exercise. Some of these activities may need to
be conducted by specialists and experts in the field using appropriate social
indicators such as health outcomes, employment, transport and housing
indicators.

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Health Impact Assessment: A Guide for Service Providers

Figure 2: Stages in the HIA process

Procedures Methods

STEP 1: APPLY SCREENING


CRITERIA TO SELECT
PROJECT OR POLICY

STEP 2: SCOPING. Policy analysis (if


AGREEING HOW BEST TO appropriate)
UNDERTAKE THE HIA.

Agree terms of Profiling of


reference for communities
assessment

Interview
Select assessor
stakeholders and
key informants

STEP 3: Collect evidence from


CONDUCT Identify health previous reports
APPRAISAL AND determinants
ASSESSMENT affected

Appraise the
assessment Assess evidence

STEP 5: NEGOTIATE
FAVOURED OPTIONS Establish priority
impacts

Implement
STEP 4: DEVELOPING
RECOMMENDATIONS
STEP 6: MONITORING AND
EVALUATION (in relation to
both the overall proposal
and benefit of the HIA)

(based on: Scott-Samuel, Birley and Ardern, (2001) The Merseyside Guidelines for
Health Impact Assessment. Merseyside Health Impact Assessment Steering Group,
p6.)

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Getting started: Rapid appraisal

HIA has the potential to offer a great deal to the community, to partnership
arrangements, to individual organisations, and to individuals within the
organisations. However, at times, management may be understandably
hesitant about introducing this approach into their organisation, citing a
number of issues as possible barriers, namely:

• limited resources (eg time, money, staff, facilities)


• an overcrowded agenda
• minimal community involvement
• a lack of expertise or skills in HIA.

To help reduce risks and maximise tangible outcomes, it is important to


prepare in advance for the introduction for HIA. Part of this process could be
raising people’s awareness of HIA through provision of accurate and
interesting information about the approach, its potential benefits and possible
barriers.

Rapid appraisal is generally considered the entry point for HIA as it can be
undertaken in a relatively short space of time and does not require the
intensive use of resources. As such it offers organisations an attractive
opportunity to make a practical start in HIA. It is a systematic study of the
health impacts based on:

• the knowledge and perceptions of stakeholders and assessors


• the evidence base and experience gained from previous, similar HIAs.

Features of Rapid Appraisal

Scoping:
• all relevant stakeholders are identified
• the assessor is likely to be appointed from within the organisation or
partnership
• the impacts of particular concern are highlighted, especially if relevant to
at-risk populations.

Appraisal:
• information on the proposal to be appraised, a basic community profile, the
health impacts of particular concern are circulated to all stakeholders prior
to the workshop
• during the workshop participants identify health impacts
• opportunities for searching current literature for evidence is constrained by
time limitations, therefore, placing more emphasis on knowledge of
assessor and other stakeholders
• the recommendations about modifications to the proposal or project may
tend to be broad depending on the evidence and/or experience of the
assessor.

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Health Impact Assessment: A Guide for Service Providers

Where to from here?

HIA is a tool designed to support policy- and decision-making. It is well suited


to improving public health by encouraging an awareness of health at every
level of policy-making and by making it a concern to improve the public health
routing decision-making.

One of the reasons HIA can be used effectively in this context concerns the
values-base underpinning its usage and development as a methodology. The
dominant value underpinning the use of HIA is sustainability and it is from this
starting point that the others stem (and are outlined in Box 2 below):

Box 2: Values underpinning HIA14

Sustainability: appraising health impacts in both the short- and long- terms,
and those that are direct and indirect; working to prevent negative impacts, to
reduce disability and social dependence, and to promote empowerment and
self-help (for individuals and communities); using limited resources effectively
to achieve health gain that may affect several generations.

Promotion of health: working to attain the maximum gain for the population.

Democracy: fulfilling the right of people to participate, both directly and


indirectly, through their elected decision-makers, in a transparent process for
the development, implementation and evaluation of policies, programs and
projects that affect their lives.

Equity: addressing not only the impact of a policy, program or project on the
health of a population, but also the distribution of that impact within the
population, for example, in terms of sex, age, ethnic background or socio-
economic status, which accords with the aims of reducing inequalities in
health.

Equality: involving members of the community as full and active stakeholders


whose views are accorded respect; according the same status to all
stakeholders irrespective, for example, of source of funding for either the
proposal or the HIA.

Ethical use of evidence: using evidence in a rigorous manner, and


employing a range of disciplines and methodologies, to achieve a
comprehensive assessment of the health impacts.

14
Ison, E. (2000) Resource for Health Impact Assessment. Volume 1: (The Main Resource).
London: NHS Section 3.2 Inset 3.C.

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Health Impact Assessment: A Guide for Service Providers

Actions to promote sustainable development would be expected to promote


health, and health impact assessment can be used to ensure that health gain
does indeed arise from sustainable development. Furthermore, using the
principles of sustainability can extend the process of HIA to ensure
consideration is given to 15:

• short-, medium- and long-term health impacts


• framing recommendations to change proposals such that they may have a
positive effect on the health of not only present but also future generations.

This resource describes an approach to undertaking an assessment of the


health impact of policy, programs or projects both centrally and locally. Given
the present state of development of HIA, the methods outlined have the
advantage of having already undergone a degree of field-testing. However,
other approaches to HIA can and will be developed and should not be ignored
as possible alternative methodologies.

15
Ison, E. (2000) ibid Section 3:9.

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Health Impact Assessment: A Guide for Service Providers

Further information

Readings and internet sites:

Acheson, D. (1998) Report of the independent inquiry into inequalities in


health. London: Stationary Office.

Cave, B. and Curtis, S. (2001) Health Impact Assessment for Regeneration


Projects. East London and the City Health Action Zone [online]
http://www.geog.qmul.ac.uk/health/guide.html

Department of Health (1999) Health Impact Assessment: Report of a


Methodological Seminar [online]
http://www.doh.gov.uk/research/documents/rd2/healthimpact.pdf

Ison, E. (2000) Resource for Health Impact Assessment. London: NHS


Executive [online] www.londonshealth.gov.uk

Mcintyre, L. and Petticrew, M. (1999) Methods of Health Impact Assessment:


A Literature Review. Medical Research Council: Social & Public Health
Sciences Unit [online] http://www.msoc-mrc.gla.ac.uk/

National Public Health Partnership (2001) Health Impact Assessment


Guidelines. Canberra: enHealth Council, National Public Health Partnership
[online] http://enhealth.nphp.gov.au/council/pubs/ecpub.htm

Queensland Health (2001) Social Determinants of Health: The Role of Public


Health Services. Queensland: Public Health Services, Queensland Health.

Queensland Health (2003) Social Indicators for Assessing the Impact of


Government Policies on Health Inequalities. Queensland: Public Health
Services, Queensland Health.

Scott-Samuel, A.; Birley, M. and Ardern, K. (2001) The Merseyside


Guidelines for Health Impact Assessment. Merseyside Health Impact
Assessment Steering Group [online]
http://www.liv.ac.uk/PublicHealth/obs/OBS.HTM

World Health Organisation (1998) Social Determinants of Health: The Solid


Facts. Denmark: WHO [online] http://www.who.dk/tech/hcp/index.htm

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Health Impact Assessment: A Guide for Service Providers

Appendix 1: Community profile categories

This is the process of establishing baseline information concerning the


characteristics of the community in question. Information derived can be used
to predict likely impacts of a policy or practice on a community. Consequently,
profiles can be used to assess and measure any future changes to the
community.

Categories of information contributing to community profiles include:16

• characteristics of the existing and, where appropriate, new or transient


residents of the region (size, age structure, socio-economic status, groups
at risk)
• physical characteristics of the region (eg weather, geography)
• existing and proposed land uses (and their compatibility with proposed
developments)
• history of the region (eg land use, institutions, populations)
• current environmental quality (eg levels of pollution and environmental
degradation over time)
• current health status of the population (eg morbidity, mortality, social and
psychological health indicators (eg ABS Census data)
• information from previous studies of similar projects in similar locations
(can be problematic as data reliability needs to be given careful
consideration)
• existing living conditions of the population, especially in relation to access
to food and water supplies, as well as access to health care facilities and
other community-level services.

16
based on Milner, S. (1999) “The Health Impact Assessment of Non-Health Public Policy”.
In, Department of Health, Health Impact Assessment: Report of a Methodological Seminar.
DOH: UK: 42.

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Appendix 2: Case Study: Goodna Service Integration Project

Queensland Health (2003) Assessing the utility of HIA for service integration:
Health impact assessment of the Goodna Service Integration Project – a case
study. Queensland: Public Health Services, Queensland Health.

Background: the study was concerned with the health impact assessment for
a model of service integration – the Goodna Service Integration Project that
was trialled in West Moreton. The West Moreton Public Health Unit,
Queensland Health undertook the study in collaboration with the Goodna
Service Integration Project Team. In addition, Public Health Services wished
to investigate the utility of this methodology as a tool for assessing service
integration.

Aim: the aims of the study were to:


• assess the processes and impacts of a model of service integration on
health determinants and health outcomes of the community affected by the
project
• identify and highlight the actual and potential impacts on health and health
determinants to the Steering Group and stakeholders including decision
and policy makers, service providers, and representatives of affected
communities
• provide recommendations based on positive and negative health impacts
that have arisen or may arise so that potential and actual negative effects
can be avoided or reduced and the positive effects encouraged and
enhanced
• influence the service integration project processes so that it is responsive
to health impact considerations.

Methods: concurrent/retrospective HIA. The assessment followed the


Merseyside model of HIA which allows the assessor to distinguish between
procedures and methods for assessment: procedures providing the context for
commissioning and implementing the HIA while the methods component
being the actual process for carrying out the assessment. A steering group
was central to the study’s development and implementation.

The steering group identified key informants for initial discussion as well as
helping to identify major stakeholders and key informants for interviews and
focus groups. During the course of the interviews and focus groups other
informants were suggested that it was felt could contribute to the assessment
process.

Six in-depth interviews were held with community representatives, service


provider organisations and project proponents. In addition, four focus groups
were conducted with service consumer groups and a service provider group
for a total of 21 participants.

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Health Impact Assessment: A Guide for Service Providers

It was agreed that health outcomes in terms of health impacts from the project
should be based on the model of health determinants identified within the
Merseyside model and assessed according to whether positive or negative
impacts, their potential impact being definite, probable or speculative and
whether in the short, medium and long terms.

In addition, four key elements have been identified in the literature as


characterising a place approach to service integration, namely:
• community participation and equity
• responsibility and accountability
• coordination and integration of service delivery
• flexible governance/partnerships.

The main points and themes from discussions were extracted for inclusion
into these four elements to assess the merits of HIA for service integration.

Findings and predicted impacts: positive and negative findings were


identified and grouped according to:
• personal/family circumstances and lifestyle
• social environment
• physical environment
• public services
• public policy.

Recommendations: were drawn up according to the above groupings.

Evaluation:

HIA of the Service Integration Project: process evaluation only as impact and
outcome evaluation will be dependent upon the take-up of the
recommendations.

Utility of the methodology: evaluation of the utility of this approach for service
integration involved identification of findings within the four elements of
service integration. Key learning points were also identified to contribute to
future usage of HIA methodologies.

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Health Impact Assessment: A Guide for Service Providers

Appendix 3: An example of an assessment matrix17

Category of Predicted Nature of impact (brief summary Potential Short (S),


influences health impacts of impact) impact – is it medium
definite (D), (M) or
probable (P) or long-
speculative (S) term (L)
+’ve -‘ve
BIOLOGICAL
Age
Gender
Genetic
factors
PERSONAL/FAMILY CIRCUMSTANCES AND LIFESTYLE
Family
structure and
functioning
Education
Occupation
Income
Risk taking
behaviour
Diet
Smoking
Alcohol
Substance use
Exercise
Recreation
Means of
transport
SOCIAL ENVIRONMENT
Culture
Peer
pressures
Discrimination
Social support
Social
networks/isolat
ion
Community
participation
PHYSICAL ENVIRONMENT
Environmental
impacts and
nuisances
Working
conditions
Transport,
communicatio
ns and
accessibility
Public safety

17
Note: you may wish to add a column for comments for those responses that need
clarification

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Health Impact Assessment: A Guide for Service Providers

PUBLIC SERVICES
Access to and
location of
health care
facilities
Quality of
health care
facilities
Child care
Social services
Housing and
home services
Employment
and social
security
Public
transport
Policing
NGOs
agencies and
services
PUBLIC POLICY
Economic,
social,
environment
and health
trends
Local and
national
priorities
Policies
Programs
Projects

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