'Fit for purpose' health impact assessment: a realistic way forward

The UK government is committed to health impact assessment (HIA) as a means of ensuring that health will be a key consideration in policy formulation and other public decision making. However there has been some debate about whether current HIA practice can reliably inform decision making. In particular consultation with stakeholders and literature reviewing, key tools used in HIA, are said to suffer from a number of conceptual and methodological problems, which can undermine the validity of the assessment. In this paper, we argue that the philosophical nature of HIA, its purpose and its contribution to the promotion of public health is still being established. We outline our own HIA practice, which is based on a broad philosophy of 'fit for purpose' i.e. what is this HIA for and what is its spatial, temporal, social and political context. We suggest that it is important to guard against unrealistic expectations and illusions of total objectivity and precision in the HIA process. HIA 'screening' is capable of delivering benefits by making policies, programmes and projects, more health conscious. Once we move beyond this basic expectation and wish to be able to make judgements about the relative health benefits of alternative courses of action, the potential resource intensiveness of the process increases considerably. Even at a high level of resource usage any conclusions reached through the HIA process will always be, in part, subjective and therefore likely to be contested. We must decide what we want, what we are prepared to legislate for and what we are prepared to pay for in the HIA process.     

A Philosophical Analysis of the General Methodology of Qualitative Research: A Critical Rationalist Perspective

Philosophical discussion of the general methodology of qualitative research, such as that used in some health research, has been inductivist or relativist to date, ignoring critical rationalism as a philosophical approach with which to discuss the general methodology of qualitative research. This paper presents a discussion of the general methodology of qualitative research from a critical rationalist perspective (inspired by Popper), using as an example mental health research. The widespread endorsement of induction in qualitative research is positivist and is suspect, if not false, particularly in relation to the context of justification (or rather theory testing) as compared to the context of discovery (or rather theory generation). Relativism is riddled with philosophical weaknesses and hence it is suspect if not false too. Theory testing is compatible with qualitative research, contrary to much writing about and in qualitative research, as theory testing involves learning from trial and error, which is part of qualitative research, and which may be the form of learning most conducive to generalization. Generalization involves comparison, which is a fundamental methodological requirement of any type of research (qualitative or other); hence the traditional grounding of quantitative and experimental research in generalization. Comparison—rather than generalization—is necessary for, and hence compatible with, qualitative research; hence, the common opposition to generalization in qualitative research is misdirected, disregarding whether this opposition’s claims are true or false. In conclusion, qualitative research, similar to quantitative and experimental research, assumes comparison as a general methodological requirement, which is necessary for health research.     

Health impact assessment: the state of the art

Health impact assessment (HIA) is being increasingly used due to governments' growing interest in putting health high on their agendas. HIA provides a structured framework to estimate the potential consequences of non-health sector policies in community health. The ultimate goal of this framework is to maximize health gains and, as far as possible, to reduce health inequalities. HIA is believed to have significant potential to address health determinants and to promote intersectorial action in health. Challenges for the future include the need to strengthen its methodological bases, particularly those concerning the process of impact prediction, and the need to promote its progressive incorporation into decision-making processes, either independently or integrated within other impact assessment tools. The strategic affinity of HIA with the European strategy strengthens current opportunities for the implementation of this tool in Spain, especially in the context of the ongoing debate on the future of public health and the need to give public health higher priority in political-institutional agendas. To move forwards, we should promote debate on HIA, as well as research and the practice of this tool in Spain, where only some pioneer experiences exist. The public health sector should lead the development of HIA pilot studies in order to assess its current contribution to the formulation of healthy public policies. In addition, HIA should be promoted among policy makers and other stakeholders in order to facilitate its adoption and integration into strategic planning and relevant agencies and decision-making structures. The ultimate goal is to find new formats for intersectorial collaboration and new tools for putting the principles of into practice, thus successfully achieving health and public health goals.     

Revealing the wood and the trees: reporting qualitative research

Qualitative research methodologies, which are oriented to better understanding of the context, meaning and experiences of people's lives, have much to contribute to health promotion. For researchers trained in quantitative methods, writing up qualitative research for a peer‐reviewed journal can be a challenge, especially keeping within the prescribed word limits. How well you explain and disseminate your research will influence how others evaluate its quality; this has implications not only for what you write and the terminology you use but for how you structure your article. This paper provides a general guide to presenting qualitative research for publication in a way that has meaning for authors and readers, is acceptable to editors and reviewers, and meets criteria for high standards of qualitative research reporting across the board. We discuss the writing of all sections of an article, placing particular emphasis on how you might best present your findings, illustrating our points with examples drawn from previous issues of this Journal. Overall, we emphasise that reporting qualitative research involves sharing both the process and the findings, that is, revealing both the wood and the trees.     

Lessons in applying health impact assessment to regeneration schemes: the Victorian experience

The value of health impact assessment (HIA) to sectors outside the health domain is increasingly being recognised. A Victorian study explored the application of HIA within a regeneration context. What emerged is a complex analysis of the practical dimensions of applying HIA in this context.     

Evaluating health impact assessment

Health impact assessment (HIA) is a developing approach that assesses the health impacts of a proposal on a population, and produces a practical set of recommendations to inform the decision-making process of the proposal. The purpose is to influence decision makers to increase positive health impacts of a proposal and decrease negative impacts. Most work within the HIA field to date has focused on methodological development and actually carrying out HIAs. Little attention has been paid to the formal evaluation of the HIA approach and whether or not HIA works (if and how the HIA approach informs the decision-making process and, in particular, if it contributes to improving health and reducing inequalities). With the drive towards evidence-informed policy, HIA also needs to show whether it adds value to the decision-making process, given the significant resources often involved in carrying out an HIA. A suggested approach to evaluating HIAs is presented, as well as its relationship with monitoring, drawing on the significant public health evaluation literature that already exists. Methodologies appropriate for use, and examples of indicators suitable for HIA evaluation, are provided. We suggest that typical HIA evaluations should focus on the process of the HIA and the impact that it has on the decision-making process, rather than attempting to evaluate long-term health outcomes or whether predicted impacts actually occurred.     

Qualitative methods for intervention research

Intervention research takes place in field settings and requires understanding of social meanings and social processes. These are tasks for which qualitative research methods are well suited. The purpose of this paper is to provide a starting point for those who would like to learn more about the qualitative research methods used in disciplines where the study of social phenomena in naturalistic settings is common—particularly sociology, cultural anthropology, and human services program evaluation. The paper discusses some ways that qualitative and quantitative methodologies can usefully work together, outlines four key differences in the initial premises of quantitative and qualitative research approaches, briefly reviews some methodological techniques useful in gathering and analyzing qualitative data, and provides suggestions for further reading on various aspects of qualitative research. © 1996 Wiley-Liss, Inc.     

Health Impact Assessment in a Network of European Cities

The methodology of health impact assessment (HIA) was introduced as one of four core themes for Phase IV (2003–2008) of the World Health Organization European Healthy Cities Network (WHO-EHCN). Four objectives for HIA were set at the beginning of the phase. We report on the results of the evaluation of introducing and implementing this methodology in cities from countries across Europe with widely differing economies and sociopolitical contexts. Two main sources of data were used: a general questionnaire designed for the Phase IV evaluation and the annual reporting template for 2007–2008. Sources of bias included the proportion of non-responders and the requirement to communicate in English. Main barriers to the introduction and implementation of HIA were a lack of skill, knowledge and experience of HIA, the newness of the concept, the lack of a legal basis for implementation and a lack of political support. Main facilitating factors were political support, training in HIA, collaboration with an academic/public health institution or local health agency, a pre-existing culture of intersectoral working, a supportive national policy context, access to WHO materials about or expertise in HIA and membership of the WHO-EHCN, HIA Sub-Network or a National Network. The majority of respondents did not feel that they had had the resources, knowledge or experience to achieve all of the objectives set for HIA in Phase IV. The cities that appear to have been most successful at introducing and implementing HIA had pre-existing experience of HIA, came from a country with a history of applying HIA, were HIA Sub-Network members or had made a commitment to implementing HIA during successive years of Phase IV. Although HIA was recognised as an important component of Healthy Cities’ work, the experience in the WHO-EHCN underscores the need for political buy-in, capacity building and adequate resourcing for the introduction and implementation of HIA to be successful.     

Can health impact assessment fulfil the expectations it raises?

The United Kingdom and other European Governments are increasingly calling for Health Impact Assessment (HIA) of policies in order to predict how they will affect the health of populations. Approaches to HIA can be characterised as broad focus (holistic, sociological, qualitative) or tight focus (limited, epidemiological, quantitative). HIA must add value to decision making and lead to better decisions than would have otherwise been made. The quality of HIA will be judged on its utility, its predictive accuracy and its process. HIA must be closely integrated with the decision making process. HIA may be undertaken in combination with Environmental Impact Assessment (EIA) or separately. HIA does not mean that health should take primacy over other policy goals but does ensure that health is considered.     

Shifting discourse on health in Canada: from health promotion to population health

This paper argues that discourse on health are products of the particular social, economic and political context within which they are produced. In the early 1980s, the discourse on health in Canada shifted from a post-Lalonde Report lifestyle behaviour discourse to one shaped by the discourse on the 'social determinants of health'. In Canada, we are currently witnessing the emergence of another discourse on health-'population health'-as a guiding framework for health policy and practice. Grounded in a critical social science perspective on health and health promotion, this paper critiques the population health discourse in terms of its underlying epistemiological assumptions and the theoretical and political implications which follow. Does it matter whether we talk about 'heterogeneities in health' or 'inequities in health'? This paper argues that it does, and concludes that population health is becoming a prevailing discourse on health at this particular historical time in Canada because it provides powerful rhetoric for the retreat of the welfare state. This paper argues further that it is health promotion's alignment with the moral economy of the welfare state that makes it a countervailing discourse on health and its determinants.     

What do we need for robust, quantitative health impact assessment?

Health impact assessment (HIA) aims to make the health consequences of decisions explicit. Decision-makers need to know that the conclusions of HIA are robust. Quantified estimates of potential health impacts may be more influential but there are a number of concerns. First, not everything that can be quantified is important. Second, not everything that is being quantified at present should be, if this cannot be done robustly. Finally, not everything that is important can be quantified: rigorous qualitative HIA will still be needed for a thorough assessment. This paper presents the first published attempt to provide practical guidance on what is required to perform robust, quantitative HIA. Initial steps include profiling the affected populations, obtaining evidence for postulated impacts, and determining how differences in subgroups' exposures and susceptibilities affect impacts. Using epidemiological evidence for HIA is different from carrying out a new study. Key steps in quantifying impacts are mapping the causal pathway, selecting appropriate outcome measures and selecting or developing a statistical model. Evidence from different sources is needed. For many health impacts, evidence of an effect may be scarce and estimates of the size and nature of the relationship may be inadequate. Assumptions and uncertainties must therefore be explicit. Modelled data can sometimes be tested against empirical data but sensitivity analyses are crucial. When scientific problems occur, discontinuing the study is not an option, as HIA is usually intended to inform real decisions. Both qualitative and quantitative elements of HIA must be performed robustly to be of value.     

National risk signatures and human embryonic stem cell research in mainland China

The international development of human embryonic stem cell research has become closely tied to global bioethics, which places moral responsibility on stem cell researchers. This article argues that the development of bioethical regulation of human embryonic stem cell research is better understood by approaching the institutionalisation of bioethics in terms of risk perceptions of stem cell scientists. Eschewing approaches that understand bioethical risk as a mere matter of morality or as a social construct, this article emphasises the materiality and strategic reasoning of bioethical views on risks associated with human embryonic stem cell research. Such an approach allows the identification of forms of risk rooted in the everyday practice of Chinese human embryonic stem cell research, including moral risk (as a violation of cultural values), material risk (in relation to the distribution of material resources and wealth), political risk (in terms of the political economy of bioethics and public debate) and reputational risk (in terms of personal and national honour). Although this analysis builds on Tom Horlick-Jones's concept of risk signatures of new technologies, which emphasise the capacities of different technologies to engender and delimit the particular social and cultural interpretations of the risks they generate, the article reveals the existence of a certain global awareness among stem cell scientists of risk signatures. They display a creative and strategic awareness regarding the possible opportunities and constraints the risk signature of human embryonic stem cell research affords in their particular institutional context compared to those of others abroad and at home in different environments. The existence of this form of reflexivity requires recognition and methodological accommodation.     

A framework for the evidence base to support Health Impact Assessment

OBJECTIVE: To introduce a conceptual structure that can be used to organise the evidence base for Health Impact Assessment (HIA). BACKGROUND: HIA can be used to judge the potential health effects of a policy, programme or project on a population, and the distribution of those effects. Progress has been made in incorporating HIA into routine practice, especially (in the UK) at local level. However, these advances have mainly been restricted to process issues, including policy engagement and community involvement, while the evidence base has been relatively neglected. RELATING POLICIES TO THEIR IMPACT ON HEALTH: The key distinctive feature of HIA is that determinants of health are not taken as given, but rather as factors that themselves have determinants. Nine ways are distinguished in which evidence on health and its determinants can be related to policy, and examples are given from the literature. The most complete of these is an analysis of health effects in the context of a comparison of options. A simple model, the policy/risk assessment model (PRAM), is introduced as a framework that relates changes in levels of exposures or other risk factors to changes in health status. This approach allows a distinction to be made between the technical process of HIA and the political process of decision making, which involves lines of accountability. Extension of the PRAM model to complex policy areas and its adaptation to non-quantitative examples are discussed. ISSUES FOR THE FUTURE: A sound evidence base is essential to the long term reputation of HIA. Research gaps are discussed, especially the need for evidence connecting policy options with changes in determinants of health. It is proposed that policy options could be considered as "exposure" variables in research. The methodology needs to be developed in the course of work on specific issues, concentrated in policy areas that are relatively tractable. CONCLUSIONS: A system of coordination needs to be established, at national or supranational level, building on existing initiatives. The framework suggested in this paper can be used to collate and evaluate what is already known, both to identify gaps where research is required and to enable an informed judgement to be made about the potential health impacts of policy options. These judgements should be made widely available for policy makers and for those undertaking health impact assessment.     

Women's health, men's health, and gender and health: implications of intersectionality

Although intersectionality is now recognized in the context of women's health, men's health, and gender and health, its full implications for research, policy, and practice have not yet been interrogated. This paper investigates, from an intersectionality perspective, the common struggles within each field to confront the complex interplay of factors that shape health inequities. Drawing on developments within intersectionality scholarship and various sources of research and policy evidence (including examples from the field of HIV/AIDS), the paper demonstrates the methodological feasibility of intersectionality and in particular, the wide-ranging benefits of de-centering gender through intersectional analyses.     

Health discourse,sexual slang and ideological contradictions among Mozambican youth: implications for method

Despite the urgency of improving an understanding of sexual cultures in the face of a globally devastating HIV epidemic, methodological reflection and innovation has been conspicuously absent from qualitative research in recent years. Findings from fieldwork on condom use among young people in Mozambique confirm the need to remain alert to the ideological and linguistic bias of applied methods. Interviewing young people about their sexuality using a conventional health discourse resulted in incorrect or socially acceptable answers rather than accurate information about their sexual behaviour. Young people's resistance to enquiry, the paper argues, is due to ideological contradictions between their sexual culture and slang, on the one hand, and Western health discourses associated with colonial and post-colonial opposition to traditional culture and languages, on the other. Mixing colloquial Portuguese and changana sexual slang is constructed around ideas of safedeza and pleasure, while dominant health discourses address sexuality as both ‘risky’ and ‘dangerous’. In order to gain a deeper understanding of sexual cultures and to make HIV prevention efforts relevant to young people, it is suggested that researchers and policy makers approach respondents with a language that is sensitive to the local ideological and linguistic context.     

A double-edged sword? Health research and research governance in UK primary care

Contemporary health research is becoming increasingly formalised, regulated and institutionalised. In the UK, this has manifested itself in the development of a framework for ‘governing’ health research. The framework is often presented as a neutral decision-making tool guiding elements of research (such as ethical and peer review) through formal governance processes and approval procedures. We locate the framework as emerging in the wider context of the growth of ‘guidelines’ in healthcare that raises questions about the extent to which formal rationality has taken hold on knowledge production and what this means for health research. We therefore explore if and how the framework prioritises particular approaches to the production of knowledge and the tensions that emerge between managerial requirements and the work of researchers. We employed qualitative telephone interviews to access the accounts of both researchers and administrators across a range of primary healthcare settings in England and to capture a range of experiences and levels of involvement in research and governance. Our analysis revealed the double-edged nature of research governance: on the one hand, the framework provided a valuable aid to decision-making and the formalisation of tacit knowledge about ‘good research practice’; on the other, consequent managerial processes engaged researchers in a series of low-level activities and privileged particular ways of viewing the world. Our findings add to existing knowledge by moving beyond documenting concerns over research governance and show how the reduction of research governance according to a ‘common’ set of principles and procedures facilitates the production (and managerial oversight) of quantitative and clinical, over qualitative and experiential, knowledge.     

The political abuse of medicine and the challenge of opposing it

A fundamental aim of medicine is to protect and promote health. The practice of medicine has, however, been used to promote political aims which may be detrimental to health. The article attempts to isolate the ways in which political abuses may interfere with good medical practice: by allowing health policies to be influenced by undemocratic political considerations; by using health services to reward or punish political supporters or opponents; by direct medical involvement in political acts which contradict accepted medical ethics; and by the support which conventional medical practises give to perpetuating inequalities in health and social services. Each of these is examined with the use of a number of examples. The ways in which medical personnel have opposed the political abuse of medicine is explored by a brief review of the opposition of Chilean doctors to torture, the involvement of South African doctors in opposing the abuse of health services in perpetuating apartheid, and the growing medical movement in opposition to nuclear war. Some comments concerning the monitoring of a multitude of medical disciplines which are open to political abuse are made. The purpose of the paper is primarily to stimulate debate around this important issue and it does not attempt to provide a comprehensive review of the political abuse of medicine.     

Renegotiating Sexuality and Intimacy in the Context of Cancer: The Experiences of Carers

There is a growing body of evidence to show that cancer can result in dramatic changes in sexuality, sexual functioning, and intimate couple relationships, with significant implications for both quality of life and psychological well-being. However, the experiences of intimate partners are often neglected in research on sexuality and intimacy in the context of cancer. This study used a material-discursive framework and a qualitative methodology to investigate the ways in which intimacy and sexuality are renegotiated in the context of cancer, and what factors are associated with successful or unsuccessful renegotiation, from the perspective of partners caring for a person with cancer. Twenty participants were interviewed, across a range of cancer types, stages, and age groups. Eleven participants reported that they were unable to negotiate other ways of being sexually intimate when penetrative sexual intercourse was no longer physiologically possible or desirable. Nine were able to renegotiate sexual intimacy in the context of cancer to include practices previously positioned as secondary to “real sex,” such as mutual masturbation, self masturbation, manual stimulation, oral sex, massage, the use of vibrators, kissing, and hugging. Grounded theory analysis identified two themes associated with renegotiation: “Alternative” sexual practices-redefining sexual intimacy, and couple communication and relationship context. Difficulties in renegotiation were associated with adherence to the coital imperative, sexual relationship or communication problems which existed prior to cancer, and the positioning of the person with cancer as a child or an asexual sick patient rather than a sexual partner. The implications for health professional intervention to ameliorate changes to sexuality in the context of cancer are discussed.