hia a guide for service providers - qh australia - 2003

8/14/2019 HIA a Guide for Service Providers - QH Australia - 2003

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Health ImpactAssessment:

AGuide

ForService Providers


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The State of Queensland

Queensland Health, 2003

ISBN: 0 7345 2915 5

Copyright protects this publication. However, Queensland Health has no objection to thismaterial being reproduced with acknowledgment, except for commercial purposes.Permission to reproduce for commercial purposes should be sought from the Policy andQuality 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 HealthServices, Queensland Health. Brisbane 2003

Acknowledgments

Special acknowledgment needs to be given to the service providers who participated in thefocus group and developmental processes for this resource. Without their dedication, effortand 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 UnitPO Box 73Ipswich Qld 4305Australia

Ph: 07 3810 1500 Fax: 07 3810 1155Email: [email protected]


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Health Impact Assessment: A Guide for Service Providers

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Health Impact Assessment (HIA)

offers the opportunity to

support sustainable communities,

predict, reduce or avoid potential

negative health impacts,

enhance positive impactsand deliver sound and accountable

decision-making


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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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Glossary of terms

Community profile: this is the process of establishing baseline informationconcerning the characteristics of the community in question (see Appendix 1).

Community participation: means involving the community in an activity suchas planning of projects or carrying out a health impact assessment (HIA).

Disadvantaged/vulnerable/marginalised groups: these terms are appliedto groups of people who, due to factors usually considered outside theircontrol, do not have the same opportunities as other, more fortunate groups insociety.

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 toattain their full health potential and, that no one should be disadvantaged fromachieving this potential lit it can be avoided. HIA is usually underpinned by anupfront value system (see Box 2, p27) in which equity plays a major role sothat both health inequalities and inequities in health are explored andaddressed wherever possible.

Grey literature: generally unpublished documents for example, reportsproduced by agencies that have not been published in peer-review journalsbut none-the-less inform practice.

Health: a state of complete physical, mental and social well being and notmerely the absence of disease and infirmity.

Health determinants: this study included assessments and considered theimpacts of the service integration project on the important determinants ofhealth 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 thesedeterminants affect life expectancy, quality of life, and morbidity and mortalityof communities within the reach of the project1.

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


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Health impact: is a change in health status (or in the determinants of healthstatus) of an individual or group attributable to a project, program or policywithin a boundary as agreed by a HIA projects steering group. Studies haveshown that developmental practices can cause health impacts by initiatingsignificant 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 healthstatus determinants (see Table 2, p18 for Factors Affecting Health and Wellbeing).

Health impact assessment: a combination of procedures or methods bywhich a policy, program or project may be judged as to the effects it may haveon the health of a population. That is, will (or does) a project affect quality oflife issues beyond its intended meaning and as a result affect the health ofthat population.

Health inequality and inequity: health inequalities can be defined as

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

Qualitative and quantitative evidence: basically, quantitative evidence isbased on what can be counted or measured objectively whilst qualitativeevidence cannot be measured in the usual ways and may be more subjective,for example, encompassing peoples perceptions, opinions and views.

Social determinants of health: a somewhat loose term that generally refersto the social, cultural and economic factors in which people live, work and playthat 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 developmentin Australia. An interim literature review and briefing paper. Melbourne: Deakin UniversityFaculty of Health and Behavioural Sciences.3

Mcintyre, L. and Petticrew, M. (1999) Methods of Health Impact Assessment: a literaturereview. Glasgow: University of Glascow, Medical Research Council Social and Public HealthSciences Unit, Occasional Paper, December.


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Introduction

It is now well recognised that many influences act on health. Some of themajor factors include poverty, transport, education and the environment andare 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 haveimportant roles to play in enhancing health.

However, practically speaking, how can communities and other sectorsimprove the health of individuals and communities to reduce healthinequalities? To answer this question it is essential at the outset we ensurethat 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 inaddressing the impact of policies and practices.

This guide will offer service providers and others a useful introduction tohealth impact assessment (HIA). Note there is no single correct method ofconducting HIA as conditions and circumstances vary. As a result this guideoffers those who wish to carry out a HIA the ways and means of developingan 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.5Queensland Health (2001) Social Determinants of Health The Role of Public Health

Services. Brisbane: Public Health Services, Queensland Health.


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What is HIA about?Health impact assessment aids us in determining how a project will affectpeoples health. It is a relatively new approach that offers a route tounderstanding the potential risks and benefits associated with any proposal.

A core strength of HIA as a tool is that its recommendations can be based onthe 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 theHIA as part of its work program can clearly indicate that it cares about thecommunity and is able to respond to public health concerns.

Demonstrating health gain as added value. Organisations can ensure thattheir policies and practices do not actively damage health. In addition, HIAcan be used to promote health gain for the local population and to reduce

health inequalities. HIA can be used where public sector services areprovided on a basis of value for money and health gain from non-healthpolicies and practices represents added value from the resources invested.

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

Responding to Government priorities. HIA has been recognised byQueensland Health7 as a pivotal strategy in improving the health ofQueenslanders.

Developing effective partnerships. The core activity of HIA ie workingtogether for a common purpose with people from different backgrounds andwith different perspectives gives rise to significant opportunities for jointlearning and co-operation.

6

National Health Strategy (2000) A Short Guide to Health Impact Assessment: Informing

Healthy Decisions. NHS: London.7Queensland Health (2002) Smart State: Health 2020 A Vision for the Future Directions

Statement. Queensland Health p 44.


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What this resource will do

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

in partnership with other stakeholders in the community, to identify thepotential health impacts of particular policies, programs or projects

further explore existing knowledge about particular developments andassociated health impacts

make informed decisions concerning the impact that these developmentswill 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 onhealth and health inequalities of policies and practices and the need to ensurethat 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 HealthServices. Brisbane: Public Health Services, Queensland Health.


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HIA has beendefined as a

combination ofprocedures or

methods by which apolicy, program or

project may bejudged for theeffects it may haveon the health of a

population.

What is Health Impact Assessment?

Health impact assessment is a relatively new approach attracting hugeinterest internationally and nationally.

Basically, HIA offers a way of understanding the potential risks and benefits tohealth 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 issufficiently flexible to suit both the resources availableand the responsibilities of the decision-makers.9 (Seeappendix 2 for a sample case study in HIA).

HIA can provide a valuable tool to help inform

decision-making processes at a number of levels andcontexts:

policy development and analysis strategic development and planning

program and/or project development

commissioning or providing services.

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


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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: ScreeningDecide what proposals or projects require assessment.

Step 2: ScopingDecide the parameters for carrying out the HIA.

Step 3: Appraisal and assessment

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

Step 4: Developing recommendationsDevelop specific recommendations for the decision-makers to improve the proposal. This includesrecommendations for addressing inequalities.

Step 5: Negotiating favoured optionsNegotiate with decision-makers for adoption ofrecommendations.

Step 6: Monitoring and evaluationMonitor and evaluate the impact of the adoptedrecommendations for achievement of a positive impacton health.

10

There are various models of HIA but they exhibit commonalities with the Merseyside model

in Figure 2. For example, Queensland Healths Environmental Health Unit is currentlydrafting a HIA framework to capture their current focus. See the section on FurtherInformation for resources relating to other models.


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Step 1: Screening

In order to make the most efficient use ofavailable expertise it is important to be selectiveabout what assessment work is undertaken.Screening is about rapidly assessing likelyprojects for HIA in relation to a number of issuesand can give a useful indication of resourcerequirements. Issues to consider include:11

Table 1: Issues to consider during the HIA screening process

Issues Examples of specific issuesEconomic 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 communitiesby the project

the existence of potentially cumulative impacts.Epidemiological the degree of certainty (risk) of health impacts

the likely frequency (incidence/prevalence rates) of potentialhealth impacts

the likely severity of potential health impacts the size of any probable health service impacts

the likely consistency of expert and community perceptions ofprobability (ie risk), frequency and severity of important impacts.This could be described by a simple matrix. The greater the likelyconsistency ie the greater the likely agreement between expertand lay perceptions of important impacts the greater the need fora HIA.

Strategic the need to give greater priority to policies than to programs, andto programs than to projects, all other things being equal. (Thisresults from the broader scope and hence potential impact ofpolicies as compared to programs and to projects)

timeliness: regarding ensuring that HIA is prospective whereverpossible, and regarding Planning Regulations and other statutory

frameworks whether the project requires an Environmental ImpactAssessment

12 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.12See National Public Health Partnership (2001) Health Impact Assessment Guidelines.

NPHP

This step applies to theselection of a project or

practice for their potentialto affect the health of apopulation. It helpsdetermine whether a HIAis worth doing. Issues tocover include economic,outcome, epidemiologicaland strategic issues.


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

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

there are likely to be impacts but the evidence for these is already welldocumented. If so, it may be possible to develop evidence-basedrecommendations 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 islikely 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, theutilisation of an integrated approach working with a range of stakeholders. Inaddition, while it may not always be possible to engage the projects decision-makers during this stage, the potential for any HIA to inform subsequentdecision-making is likely to be enhanced if they can be engaged early.


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Identifying the scale andsignificance of the proposal orproject and resource availabilitywill help to determine the level ofdetail required for the HIA. HIAcan be undertaken at differentlevels: rapid, intermediate orcomprehensive levels (see Box 1below).

Step 2: Scoping

If, during the screening step, you decide that furtherinvestigation of health impacts is necessary, then itis time to establish a firm foundation for theappraisal. Owing to the complexities of the socialdeterminants it is recommended that a SteeringGroup be established to agree on the Terms ofReference (ToR) of the HIA and to provide advice,guidance and support for the process.Representatives should include all majorstakeholders including the community affected,project proponents and relevant expertise. Keytasks 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 projects key decision points and what time is available to undertakethe HIA?

The specialists and practitioners who could be useful to the process.

Resource issues (eg skills and human and financial resources are requiredand available).

The scope of the work in terms of time, place and relevant populationgroup 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.

Scoping means decidinghow to undertake an HIAin a given context. Thismay mean working inpartnership by setting upa steering group formanaging the HIAprocess.


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Figure 1: Rapid/Intermediate/Comprehensive appraisal

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

Box 1: Health impact assessment levels of detail

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

Intermediate: this is a more detailed investigation of health impacts over alonger period of time than a rapid appraisal but less than a comprehensiveappraisal. It usually involves a review of the available evidence and anysimilar HIAs; the perception, knowledge and experience of stakeholders

(people concerned with, or affected by, the proposal or project); and insome cases the collection and analysis of new information. Duration:weeks.

Comprehensive: this consists of a more systematic, intensiveinvestigation of health impacts undertaken over an extended period oftime. It usually involves a review of the available evidence base along withthe other elements mentioned under Intermediate HIA. A ComprehensiveHIA would usually also involve the gathering and analysis of newinformation. 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 theassessment process. Representatives should include all major stakeholdersincluding 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)

Rapid Intermediate Comprehensive


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the scope of the work including geographical and time boundaries, what toinclude and exclude, range and extent of the potential impacts, specifichealth determinants affected

program outline, eg timelines

budget/funding issues.

Different types of partnerships will expect different input from members of thesteering group. With some extended projects a relatively hands-off steeringgroup may be the most appropriate only meeting at three-monthly intervalsand focusing attention on key review points. With other projects the steeringgroup 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 andmanage the HIA. The group will plan and allocate responsibility for tasks andoutputs, while also identifying the skills required and who should be involvedduring the appraisal.


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Step 3: Appraisal and assessment

In this stage the process moves along towardspractical outputs. It involves investigating,appraising and reporting on how the proposalsimplementation is likely to affect the health ofpopulations. It involves the following steps

Examining the proposal to identify keyelements and give consideration of theirrelationship to the range of wider determinantsof health and health inequality. It often startswith considering the potential positive andnegative impacts of the proposal against

factors that affect health and well being (see Table 2 below).

Collecting and collating the best available qualitative and quantitativeevidence using a range of methods. This may involve deciding to go aheadwith the best available information at the time. The range of methods thatcan 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 identifyingand describing the nature and magnitude of the potential or actual,beneficial and harmful health impacts associated with the proposal orproject. (See Appendix 3 for an example of an assessment matrix).

Because of the complex interrelationships between the socialdeterminants, it is important to consider how they collectively impact onhealth. This needs to be achieved through considering a range ofevidence.

Reporting on the impacts needs to be done in a way that helps peopleunderstand how the proposal or project may affect the different groups andcommunities and to focus constructively on the most important health andequity aspects. That is, it is necessary to prioritise the impacts.

Appraisal and assessment:This is the method ofconducting the actualassessment and includesidentifying and givingconsideration to a range ofevidence for potentialimpacts on health and equity.


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Table 2: Factors affecting health and well being 13

Categories ofInfluences onHealth

Examples of specific influences

Biological factors age, sex, genetic factorsPersonal/family

circumstances andlifestyle

family structure and functioning

primary, secondary, adult education 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/communityenvironment

culture and peer pressures

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).Physicalenvironment

air 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 forHealth Impact Assessment. Merseyside Health Impact Assessment Steering Group, p11.


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Considering and appraising the evidence can also be undertaken in a varietyof ways such as appointment of an assessor with the necessary skills andknowledge or undertaking workshops or other participatory events to explorethe views of stakeholders. If a workshop is conducted then appointment of acoordinator or facilitator is usual.

Who should appraise and assess?In assessing the impacts of a project on health determinants broadparticipation is essential if a comprehensive picture of potential health impactsis 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 concernsare addressed and for social justice reasons. Participants may include thefollowing stakeholders:

members of affected communities project proponents

relevant experts

health professionals

community organisations

key decision-makers.

The steering groupmay consider it betterfor resource purposesto employ an HIAexpert to collate theavailable evidence,and have a skilledresearcher collect any

additional informationrequired.


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Step 4: Developing recommendations

Owing to the complexity of interrelationshipsbetween the health determinants in mostcases a series of options will require to bedefined and presented. Option appraisal willresult in the steering group agreeing on a setof recommendations for modifying the projectsuch that its health impacts are optimised inthe context of the many and complexconstraints which invariably constitute thesocial, material and political environment inwhich it will be undertaken.

The following characteristics of alternativeoptions or recommendations will requireconsideration:

the stages of project development or operation when the recommendationwill 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 therecommendations

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 appropriatelyaddressed.

It will also be necessary to prioritise the recommendations so that decision-makers are clear about stakeholders views. This is important if resources for

implementing the proposals are limited or there are competing priorities suchas economic or employment issues.

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

Developingrecommendations:Based on the best availableevidence this entailsdeciding on and prioritisingspecific recommendationsfor submission to thedecision-makers. This stepcompletes the main part ofthe HIA process but it isimportant to undertake thefollowing two steps (Steps 5

& 6) for a more completeprocess.


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Who should develop recommendations?As with the Appraisal stage (Step 3) the steps during this phase can beundertaken in a variety of ways, including appointing an assessor to lead thediscussions 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 besought from all those involved based on their experience, expectations andopinions with the final decision reflecting the consensus based on the bestavailable evidence.


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Step 5: Negotiate favoured options

Health impact assessment serves as a supportto decision making and is not a substitute for it.HIA can contribute to informed decisions basedon valid assessment of potential or actualhealth impacts and has the potential to improvethe quality of decision making.

As indicated in the previous step whenconsidering recommendations there are manypotentially conflicting priorities and issues thatcan affect decision making. Therecommendations made should have

considered these factors to ensure that they are not only based on the bestevidence available but also consider the context in which the decision makingoccurs. In this way the recommendations will have the greatest chance ofbeing valued and acted upon. As a result it is important to consider whoactually makes the decisions about specific proposals or projects and to beaware 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 andrecommendations are presented in a concise and succinct format, and thatthey 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 thedecision-making context.

Negotiate favoured

options: Through furtherengagement with thedecision-makersreinforce the merits andvalue of the evidencebased recommendationsand advocate for theiradoption or adaptation inthe proposal or project.


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Step 6: Monitoring and evaluation

It is important to monitor and evaluate theeffect of the HIA on the proposal and theproposals development andimplementation. In assessing whether theHIA made a difference, a good HIA will aimto monitor and evaluate its activities toenable those involved in the process to:

improve HIA processes;

modify future proposals or projects torealise health gains

determine whether the

recommendations were implemented assess the accuracy of predictions

made during appraisal.

Monitoring and evaluation will, by necessity be constrained by financial andhuman resources, and the time available. Types of evaluation include

Process this involves assessing how the HIA was conducted, who wasinvolved, and how useful and valuable was the process.

Impact this entails following how far recommendations were adoptedand implemented by the project proponents and if not, why not?

Outcome evaluation means assessing whether the anticipated positiveeffects on health, well being and equity were in fact enhanced, and anynegative effects minimised and if not, why not, and how can plans befurther adapted?

Who looks after evaluation?The steering group can monitor the acceptance and implementation of theHIA recommendations while resources and skills required and time availableto undertake other monitoring and evaluation activities should have been

identified during the scoping exercise. Some of these activities may need tobe conducted by specialists and experts in the field using appropriate socialindicators such as health outcomes, employment, transport and housingindicators.

Monitoring and evaluation:Subsequent implementationand monitoring of therecommendations providesthe opportunity to evaluateand make changes asindicated. For example, toimprove the HIA process, tomake changes to futureproposals, and to assess theaccuracy of predictions

made during the course ofthe appraisal.


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Figure 2: Stages in the HIA process

Procedures Methods

(based on: Scott-Samuel, Birley and Ardern, (2001) The Merseyside Guidelines for

Health Impact Assessment. Merseyside Health Impact Assessment Steering Group,p6.)

STEP 1: APPLY SCREENING

CRITERIA TO SELECTPROJECT OR POLICY

STEP 2: SCOPING.AGREEING HOW BEST TOUNDERTAKE THE HIA.

Agree terms ofreference for

assessment

Select assessor

STEP 3:CONDUCTAPPRAISAL AND

ASSESSMENT

Appraise theassessment

STEP 5: NEGOTIATEFAVOURED OPTIONS

Implement

STEP 6: MONITORING ANDEVALUATION (in relation toboth the overall proposaland benefit of the HIA)

Policy analysis (ifappropriate)

Profiling ofcommunities

Interviewstakeholders andkey informants

Identify healthdeterminants

affected

Assess evidence

Establish priorityimpacts

STEP 4: DEVELOPINGRECOMMENDATIONS

Collect evidence fromprevious reports


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Getting started: Rapid appraisal

HIA has the potential to offer a great deal to the community, to partnershiparrangements, to individual organisations, and to individuals within theorganisations. However, at times, management may be understandablyhesitant about introducing this approach into their organisation, citing anumber 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 toprepare in advance for the introduction for HIA. Part of this process could be

raising peoples awareness of HIA through provision of accurate andinteresting information about the approach, its potential benefits and possiblebarriers.

Rapid appraisal is generally considered the entry point for HIA as it can beundertaken in a relatively short space of time and does not require theintensive use of resources. As such it offers organisations an attractiveopportunity to make a practical start in HIA. It is a systematic study of thehealth 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 orpartnership

the impacts of particular concern are highlighted, especially if relevant toat-risk populations.

Appraisal:

information on the proposal to be appraised, a basic community profile, thehealth impacts of particular concern are circulated to all stakeholders priorto the workshop

during the workshop participants identify health impacts

opportunities for searching current literature for evidence is constrained bytime limitations, therefore, placing more emphasis on knowledge ofassessor and other stakeholders

the recommendations about modifications to the proposal or project maytend to be broad depending on the evidence and/or experience of the

assessor.


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Where to from here?

HIA is a tool designed to support policy- and decision-making. It is well suitedto improving public health by encouraging an awareness of health at everylevel of policy-making and by making it a concern to improve the public healthrouting decision-making.

One of the reasons HIA can be used effectively in this context concerns thevalues-base underpinning its usage and development as a methodology. Thedominant value underpinning the use of HIA is sustainability and it is from thisstarting 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, toreduce disability and social dependence, and to promote empowerment andself-help (for individuals and communities); using limited resources effectivelyto 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 andindirectly, through their elected decision-makers, in a transparent process forthe 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 thehealth of a population, but also the distribution of that impact within thepopulation, for example, in terms of sex, age, ethnic background or socio-economic status, which accords with the aims of reducing inequalities inhealth.

Equality: involving members of the community as full and active stakeholderswhose views are accorded respect; according the same status to allstakeholders irrespective, for example, of source of funding for either the

proposal or the HIA.

Ethical use of evidence: using evidence in a rigorous manner, andemploying a range of disciplines and methodologies, to achieve acomprehensive 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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Actions to promote sustainable development would be expected to promotehealth, and health impact assessment can be used to ensure that health gaindoes indeed arise from sustainable development. Furthermore, using theprinciples of sustainability can extend the process of HIA to ensureconsideration is given to 15:

short-, medium- and long-term health impacts

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

This resource describes an approach to undertaking an assessment of thehealth impact of policy, programs or projects both centrally and locally. Giventhe present state of development of HIA, the methods outlined have theadvantage of having already undergone a degree of field-testing. However,other approaches to HIA can and will be developed and should not be ignoredas possible alternative methodologies.

15

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


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Further information

Readings and internet sites:

Acheson, D. (1998) Report of the independent inquiry into inequalities inhealth. London: Stationary Office.

Cave, B. and Curtis, S. (2001) Health Impact Assessment for RegenerationProjects. 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 aMethodological Seminar [online]http://www.doh.gov.uk/research/documents/rd2/healthimpact.pdf

Ison, E. (2000) Resource for Health Impact Assessment. London: NHSExecutive [online] www.londonshealth.gov.uk

Mcintyre, L. and Petticrew, M. (1999) Methods of Health Impact Assessment:A Literature Review. Medical Research Council: Social & Public HealthSciences Unit [online] http://www.msoc-mrc.gla.ac.uk/

National Public Health Partnership (2001) Health Impact AssessmentGuidelines. 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 PublicHealth Services. Queensland: Public Health Services, Queensland Health.

Queensland Health (2003) Social Indicators for Assessing the Impact ofGovernment Policies on Health Inequalities. Queensland: Public HealthServices, Queensland Health.

Scott-Samuel, A.; Birley, M. and Ardern, K. (2001) The MerseysideGuidelines for Health Impact Assessment. Merseyside Health ImpactAssessment Steering Group [online]http://www.liv.ac.uk/PublicHealth/obs/OBS.HTM

World Health Organisation (1998) Social Determinants of Health: The SolidFacts. Denmark: WHO [online] http://www.who.dk/tech/hcp/index.htm


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Appendix 1: Community profile categories

This is the process of establishing baseline information concerning thecharacteristics 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 thecommunity.

Categories of information contributing to community profiles include:16

characteristics of the existing and, where appropriate, new or transientresidents of the region (size, age structure, socio-economic status, groupsat risk)

physical characteristics of the region (eg weather, geography)

existing and proposed land uses (and their compatibility with proposeddevelopments) history of the region (eg land use, institutions, populations)

current environmental quality (eg levels of pollution and environmentaldegradation over time)

current health status of the population (eg morbidity, mortality, social andpsychological 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 carefulconsideration)

existing living conditions of the population, especially in relation to access

to food and water supplies, as well as access to health care facilities andother 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 fora model of service integration the Goodna Service Integration Project thatwas trialled in West Moreton. The West Moreton Public Health Unit,Queensland Health undertook the study in collaboration with the GoodnaService Integration Project Team. In addition, Public Health Services wishedto investigate the utility of this methodology as a tool for assessing serviceintegration.

Aim: the aims of the study were to:

assess the processes and impacts of a model of service integration onhealth determinants and health outcomes of the community affected by theproject

identify and highlight the actual and potential impacts on health and healthdeterminants to the Steering Group and stakeholders including decisionand policy makers, service providers, and representatives of affectedcommunities

provide recommendations based on positive and negative health impactsthat have arisen or may arise so that potential and actual negative effectscan 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 theMerseyside model of HIA which allows the assessor to distinguish betweenprocedures and methods for assessment: procedures providing the context forcommissioning and implementing the HIA while the methods componentbeing the actual process for carrying out the assessment. A steering groupwas central to the studys development and implementation.

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

Six in-depth interviews were held with community representatives, serviceprovider organisations and project proponents. In addition, four focus groupswere conducted with service consumer groups and a service provider groupfor a total of 21 participants.


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

In addition, four key elements have been identified in the literature ascharacterising 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 inclusioninto these four elements to assess the merits of HIA for service integration.

Findings and predicted impacts: positive and negative findings wereidentified 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 andoutcome evaluation will be dependent upon the take-up of therecommendations.

Utility of the methodology: evaluation of the utility of this approach for serviceintegration involved identification of findings within the four elements ofservice integration. Key learning pointswere also identified to contribute tofuture usage of HIA methodologies.


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Appendix 3: An example of an assessment matrix17

Category ofinfluences

Predictedhealth impacts

Nature of impact (brief summaryof impact)

Potentialimpact is it

definite (D),probable (P) orspeculative (S)

Short (S),medium

(M) orlong-term (L)

+ve -veBIOLOGICAL

AgeGenderGeneticfactorsPERSONAL/FAMILY CIRCUMSTANCES AND LIFESTYLE

Familystructure andfunctioning

EducationOccupationIncomeRisk takingbehaviourDietSmokingAlcoholSubstance useExerciseRecreationMeans of

transportSOCIAL ENVIRONMENT

CulturePeerpressuresDiscriminationSocial supportSocialnetworks/isolationCommunityparticipationPHYSICAL ENVIRONMENT

Environmentalimpacts andnuisancesWorkingconditionsTransport,communications andaccessibilityPublic safety

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


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PUBLIC SERVICES

Access to andlocation ofhealth carefacilitiesQuality of

health carefacilitiesChild careSocial servicesHousing andhome servicesEmploymentand socialsecurityPublictransportPolicingNGOsagencies andservicesPUBLIC POLICYEconomic,social,environmentand healthtrendsLocal andnationalprioritiesPolicies

ProgramsProjects

hia a guide for service providers - qh australia - 2003

Documents