'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.     

Use of health impact assessment in incorporating health considerations in decision making

STUDY AIM: The aim of this project is to identify from a range of sources the factors associated with the success of a health impact assessment (HIA) in integrating health considerations into the final decision and implementation of a planned policy, programme, or project. DESIGN: Three methods were adopted: (a) a review of HIA case studies; (b) a review of commentaries, reviews and discussion papers relating to HIA and decision making; and (c) an email survey of a purposive sample of HIA academics, HIA practitioners, and policymakers. Information was captured on the following characteristics: information on the year undertaken; geopolitical level; setting; sector; HIA type; methods and techniques used; identification of assessors. MAIN RESULTS: Two groups of factors were identified relating to the decision making environment and to the technical conduct of the HIA. With regard to the environment, striking a balance between decision maker ownership and HIA credibility; organisational, statutory and policy commitment to HIA, and the provision of realistic, non-controversial recommendations were cited as enablers to the integration of HIA findings into the decision making process. Barriers included a lack of knowledge of the policymaking environment by those conducting HIA. Regarding factors relating to the conduct of the HIA: use of a consistent methodological approach; inclusion of empirical evidence on health impacts; timing of the HIA congruent with the decision making process; involvement of expert HIA assessors; and shaping of recommendations to reflect organisational priorities were cited as enablers while lack of a standardised methodology; lack of resources and use of jargon were cited as barriers. CONCLUSIONS: The findings emphasise the importance of considering the politico-administrative environment in which HIA operates. The extent to which HIA fits the requirements of organisations and decision makers may be as important as the technical methods adopted to undertake it.     

Stochastic Dominance and Medical Decision Making

Stochastic Dominance (SD) criteria are decision making tools which allow us to choose among various strategies with only partial information on the decision makers' preferences. The notion of Stochastic Dominance has been extensively employed and developed in the area of economics, finance, agriculture, statistics, marketing and operation research since the late 1960s. For example, it may tell us which of two medical treatments with uncertain outcomes is preferred in the absence of full information on the patients' preferences. This paper presents a short review of the SD paradigm and demonstrates how the SD criteria may be employed in medical decision making, using the case of small abdominal aortic aneurysms as an illustration. Thus, for instance by assuming risk aversion one can employ second-degree stochastic dominance to divide the set of all possible treatments into the efficient set, from which the decision makers should always choose, and the inefficient (inferior) set. By employing Prospect Stochastic Dominance (PSD) a similar division can be conducted corresponding to all S-shaped utility functions.     

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.     

Health impact assessment as an agent of policy change: improving the health impacts of the mayor of London's draft transport strategy

OBJECTIVE: To increase the positive and mitigate the negative health impacts of the mayor's draft transport strategy for London. DESIGN: A rapid prospective health impact assessment (HIA) of the penultimate draft of the strategy, using a review commissioned by the regional director of public health; an appraisal of congestion charging; and a participatory workshop. Two audits of changes were performed to assess the impact on policy of the HIA process. SETTING: Regional government policy development. INTERVENTION: Recommendations from the rapid HIA were fed back into the drafting process. MAIN OUTCOME MEASURE: Changes (a) between the penultimate draft and the draft for public consultation and (b) between that and the final mayoral strategy. RESULTS: The draft transport strategy published for consultation differed in a number of respects from the previous version. Almost all the recommendations from the HIA were incorporated into the final strategy. Significant changes included promoting sustainable travel plans for workplaces and schools; giving priority to infrastructure and services that benefit London's deprived communities; increased emphasis on promoting walking and cycling and reducing reliance on private cars; and a commitment to track the health impacts of the final strategy and its implementation. Specific additions included re-allocating road space. CONCLUSION: HIA was successful in influencing the transport strategy for London, resulting in several improvements from a health viewpoint. HIA is an effective method both for bringing about significant change in policy proposals and in increasing policy makers' understanding of determinants of health and hence in changing attitudes of policy makers.     

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.     

Family surrogate decision making at the end of life: seeing them through with care and respect

Family surrogate decision makers are pivotal in end-of-life decision-making processes. The author investigated decision-making experiences of 20 surrogates who assisted terminally ill family members for this grounded theory study. Findings describe a basic social process of Seeing Them Through With Care and Respect, during which surrogates continuously synthesized the core values of caring for their family member and respecting their family member's autonomy. Surrogate narratives began with Learning the Diagnosis. The major categories of surrogate decision makers' activities during the process were Standing With and Acting For the ill family member. Events reported in two gating categories, Brokering Information and Working With Family, facilitated or impeded decision making. A final category, Outcomes, reports consequences for the surrogate of having been a decision maker.     

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.     

Validity of predictions in health impact assessment

BACKGROUND: An essential characteristic of health impact assessment (HIA) is that it seeks to predict the future consequences of possible decisions for health. These predictions have to be valid, but as yet it is unclear how validity should be defined in HIA. AIMS: To examine the philosophical basis for predictions and the relevance of different forms of validity to HIA. CONCLUSIONS: HIA is valid if formal validity, plausibility and predictive validity are in order. Both formal validity and plausibility can usually be established, but establishing predictive validity implies outcome evaluation of HIA. This is seldom feasible owing to long time lags, migration, measurement problems, a lack of data and sensitive indicators, and the fact that predictions may influence subsequent events. Predictive validity most often is not attainable in HIA and we have to make do with formal validity and plausibility. However, in political science, this is by no means exceptional.     

Avenues of Influence: the Relationship between Health Impact Assessment and Determinants of Health and Health Equity

This study aims to identify perceived impacts of Health Impact Assessment (HIA) on decision-making, determinants of health, and determinants of health equity and outline the mechanisms through which these impacts can occur. The research team conducted a mixed-methods study of HIAs in the USA. First, investigators collected data regarding perceived HIA impacts through an online questionnaire, which was completed by 149 stakeholders representing 126 unique HIAs. To explore in greater depth the themes that arose from the online survey, investigators conducted semi-structured interviews with 46 stakeholders involved with 27 HIAs related to the built environment. This preliminary study suggests that HIAs can strengthen relationships and build trust between community and government institutions. In addition, this study suggests that HIA recommendations can inform policy and decision-making systems that determine the distribution of health-promoting resources and health risks. HIA outcomes may in turn lead to more equitable access to health resources and reduce exposure to environmental harms among at-risk populations. Future research should further explore associations between HIAs and changes in determinants of health and health equity by corroborating findings with other data sources and documenting potential impacts and outcomes of HIAs in other sectors.     

Pathways to the Use of Health Services Research in Policy

Objective. To apply social science theory so as to define more explicitly the pathways that influence policy makers' use of health services research.
Methods. The analysis builds on a literature review and the author's observations. It identifies important social science concepts relevant to use of research in policy and organizational decision making. It integrates and expands upon existing frameworks to differentiate and analyze 10 pathways that can lead to the use of health services research by policy makers.
Principal Findings. The process through which research is applied involves many factors, only some of which are amenable to influence by researchers. Within these constraints, multiple pathways can drive research use; no one of these is likely to perform better in all circumstances. Successful uptake is more likely when these pathways cause findings to be converted into messages meaningful to policy makers. Various intermediaries play an important role in creating effective pathways, while users also can influence them.
Conclusions. The pathways open up what too often is an unexplored "black box" that mediates between health services research and its use by policy makers. Such pathways can help stakeholders to bridge different perspectives in ways that strengthen the possibility that effective research will be supported and used.     

Rapid health impact appraisal of eviction versus a housing project in a colony-dwelling Roma community

BACKGROUND: During implementation of a community development project involving a severely disadvantaged Roma community, the community was threatened with eviction. Two scenarios, eviction with placement on the waiting list for social housing versus a replacement housing development, were identified and specified. A health impact assessment (HIA) was carried out to inform subsequent negotiations. AIMS: To assess the health effects of eviction in comparison with that of a housing project for a Roma community; to make recommendations on short-term and long-term benefits of the two scenarios in order to inform the local government; and to develop a demonstration HIA that can act as a model for other disadvantaged Roma populations. METHOD: A prospective assessment, based on a broad model of health, was carried out to assess health effects of a housing project compared with eviction. By design, it ensured full involvement of members of the community, local decision makers and relevant stakeholders. RESULTS AND CONCLUSION: This HIA identified numerous positive and some probable negative health effects of a housing project. Despite the uncertainty around some of its predicted effects, the overall health benefit of a housing project clearly outweighed that of eviction. Although the immediate financial advantages of eviction for the municipal government are clear, this example provides further evidence to support the adoption of a statutory requirement to assess both economic and health outcomes. It also provides an example that other Roma communities can emulate.     

Understanding the determinants of health: key decision makers in Saskatchewan Health districts and Saskatchewan Health, 1998

This research inquiry used qualitative and quantitative methods to examine how key decision makers from Saskatchewan health districts and Saskatchewan Health understand the determinants of health. The inquiry was based on the premise that key decision makers' understanding of the determinants of health, and the consensus regarding these understandings, hinder or facilitate dialogue, choice of effective strategies, and achievement of health promotion goals. Interviews indicated variation in perspective and emphasis regarding how key decision makers understand the determinants of health. A survey of key decision makers found: 1) inconsistencies in respondents' understanding of the determinants of health, particularly between stated beliefs and priorities for actions; and 2) that the degree of consensus among decision makers was higher for stated beliefs and lower for choices of action. Results indicate a need for clarification and consensus-building processes concerning the determinants of health, as well as for clear policies that foster consistency between beliefs and actions and minimize inappropriate or undesirable differences in interpretations.     

Increasing decision-makers' access to economic evaluations: alternative methods of communicating the information

OBJECTIVES: Although the importance of economic evaluations is recognized, research suggests the ways in which studies are summarized may not be optimal for a busy decision maker with little training in economics methodology. Therefore, the objective of this study was to seek decision makers' views on different summary formats, including a score, short summary, and structured abstracts of different degrees of detail. METHODS: We contacted 2,400 people, of which 84 decision makers volunteered and were presented, cumulatively, with different formats and asked whether these provided sufficient detail on the methodology and results of an economic study. RESULTS: From the fifty decision makers who responded to the questionnaire, it was found that the preferred combination was a very short summary, plus a more detailed structured abstract. It was also found that decision makers with economics training preferred the most detailed format, partly reflecting their reasons for consulting economic evaluations. CONCLUSIONS: Decision makers require both an initial screen of study content, plus more detail should they find the study relevant or interesting.     

Characteristics of health impact assessments reported in Australia and New Zealand 2005–2009

Objective : To describe the use and reporting of Health Impact Assessment (HIA) in Australia and New Zealand between 2005 and 2009. Methods : We identified 115 HIAs undertaken in Australia and New Zealand between 2005 and 2009. We reviewed 55 HIAs meeting the study's inclusion criteria to identify characteristics and appraise the quality of the reports. Results : Of the 55 HIAs, 31 were undertaken in Australia and 24 in New Zealand. The HIAs were undertaken on plans (31), projects (12), programs (6) and policies (6). Compared to Australia, a higher proportion of New Zealand HIAs were on policies and plans and were rapid assessments done voluntarily to support decision‐making. In both countries, most HIAs were on land use planning proposals. Overall, 65% of HIA reports were judged to be adequate. Conclusion : This study is the first attempt to empirically investigate the nature of the broad range of HIAs done in Australia and New Zealand and has highlighted the emergence of HIA as a growing area of public health practice. It identifies areas where current practice could be improved and provides a baseline against which future HIA developments can be assessed. Implications: There is evidence that HIA is becoming a part of public health practice in Australia and New Zealand across a wide range of policies, plans and projects. The assessment of quality of reports allows the development of practical suggestions on ways current practice may be improved. The growth of HIA will depend on ongoing organisation and workforce development in both countries.     

The early childhood educator in the emperor's new clothes: A powerful moral decision maker in action

The construction of moral decision within a socially ambiguous situation is not exclusive to Andersen's emperor, but rather is shared by many early childhood educators as powerful decision makers within the day care center. Based on Andersen's perceptive analysis, this paper suggests a cognitive model (Argyris and Schon 1974, Schon 1983) which explains the gap between these decision makers' hypothetical and actual moral knowledge (Damon 1980).     

Page Avenue health impact assessment: building on diverse partnerships and evidence to promote a healthy community

The Page Avenue health impact assessment (HIA) was focused on a redevelopment in Missouri. This case study describes a comprehensive HIA led by an interdisciplinary academic team with community partners, as well as compliance with North American HIA Practice Standards. Some of the key lessons learned included: (1) interdisciplinary teams are valuable but they require flexibility and organization; (2) engaging community stakeholders and decision-makers prior to, during, and following the HIA is critical to a successful HIA; and (3) HIA teams should not be too closely affiliated with decision-makers. It is hoped that this case study will inform future HIAs.     

An integrated approach to data management, risk assessment, and decision making

This paper describes a methodology called Risk Analysis, Communication, Evaluation, and Reduction (RACER) that converts environmental data directly to human health risk to enhance decision making and communication. The methodology was developed and implemented following the Cerro Grande fire in New Mexico that burned approximately 7,500 acres of Los Alamos National Laboratory in May 2000. The absence of a coordinated and comprehensive approach to managing and understanding environmental data was a major weakness in the responding agencies' ability to make and communicate decisions. RACER consists of three basic elements: managing information, converting information to knowledge, and communicating knowledge to decision makers and stakeholders. Data are maintained in a web-accessible database that accepts data as they are validated and uploaded. The user can select data for evaluation and convert them to knowledge using human health risk as a benchmark for ranking radionuclides, chemicals, pathways, or other criteria needed to make decisions. Knowledge about risk is communicated using graphic and tabular formats. The process is transparent, flexible, and rapid, which enhances credibility and trust among decision makers and stakeholders. The fundamental principles used in RACER can be applied anywhere radionuclides or chemicals are present in the environment.     

What health care services does the public want and who should decide? Ask them!

Most of the parties involved in healthcare decisions – governments, politicians, healthcare professionals, pharmaceutical companies, special interest groups – actively work to make their desires known. In Israel the public is part of the decision committee; in Germany health care decision are made more or less without the public being involved. In a recently published IJHPR article, Giora Kaplan and Orna Baron-Epel raise the question of how well acquainted senior decision makers in the Israeli health system are with the public’s priorities regarding the services being considered for inclusion in the public funding list. This commentary speculates about the reasons for the discrepancies found in that article between the decision makers’ and the public’s view. Furthermore, it reports on survey results from Germany about who should be part of the decision making committee and briefly touches upon the situation in other OECD countries. While public opinion may not be the determining factor, all authors advocate a strengthening of the public’s contribution to the health care decision making process, including steps to make decision makers aware of public priorities on an ongoing basis.     

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.