Integrating human health into environmental impact assessment: an unrealized opportunity for environmental health and justice

OBJECTIVES: The National Environmental Policy Act and related state laws require many public agencies to analyze and disclose potentially significant environmental effects of agency actions, including effects on human health. In this paper we review the purpose and procedures of environmental impact assessment (EIA), existing regulatory requirements for health effects analysis, and potential barriers to and opportunities for improving integration of human health concerns within the EIA process. DATA SOURCES: We use statutes, regulations, guidelines, court opinions, and empirical research on EIA along with recent case examples of integrated health impact assessment (HIA)/EIA at both the state and federal level. DATA SYNTHESIS: We extract lessons and recommendations for integrated HIA/EIA practice from both existing practices as well as case studies. CONCLUSIONS: The case studies demonstrate the adequacy, scope, and power of existing statutory requirements for health analysis within EIA. The following support the success of integrated HIA/EIA: a proponent recognizing EIA as an available regulatory strategy for public health; the openness of the agency conducting the EIA; involvement of public health institutions; and complementary objectives among community stakeholders and health practitioners. We recommend greater collaboration among institutions responsible for EIA, public health institutions, and affected stakeholders along with guidance, resources, and training for integrated HIA/EIA practice.     

Integrated environmental impact assessment: a Canadian example

The Canadian federal process for environmental impact assessment (EIA) integrates health, social, and environmental aspects into either a screening, comprehensive study, or a review by a public panel, depending on the expected severity of potential adverse environmental effects. In this example, a Public Review Panel considered a proposed diamond mining project in Canada's northern territories, where 50% of the population are Aboriginals. The Panel specifically instructed the project proposer to determine how to incorporate traditional knowledge into the gathering of baseline information, preparing impact prediction, and planning mitigation and monitoring. Traditional knowledge is defined as the knowledge, innovations and practices of indigenous and/or local communities developed from experience gained over the centuries and adapted to local culture and environment. The mining company was asked to consider in its EIA: health, demographics, social and cultural patterns; services and infrastructure; local, regional and territorial economy; land and resource use; employment, education and training; government; and other matters. Cooperative efforts between government, industry and the community led to a project that coordinated the concerns of all interested stakeholders and the needs of present and future generations, thereby meeting the goals of sustainable development. The mitigation measures that were implemented take into account: income and social status, social support networks, education, employment and working conditions, physical environments, personal health practices and coping skills, and health services.     

Uncertainty in environmental health impact assessment: Quantitative methods and perspectives

Environmental health impact assessment models are subjected to great uncertainty due to the complex associations between environmental exposures and health. Quantifying the impact of uncertainty is important if the models are used to support health policy decisions. We conducted a systematic review to identify and appraise current methods used to quantify the uncertainty in environmental health impact assessment. In the 19 studies meeting the inclusion criteria, several methods were identified. These were grouped into random sampling methods, second-order probability methods, Bayesian methods, fuzzy sets, and deterministic sensitivity analysis methods. All 19 studies addressed the uncertainty in the parameter values but only 5 of the studies also addressed theuncertainty in the structure of the models. None of the articles reviewed considered conceptual sources of uncertainty associated with the framing assumptions or the conceptualisation of the model. Future research should attempt to broaden the way uncertainty is taken into account in environmental health impact assessments.     

Community health policy and provision in Hong Kong: challenges for 1997 and beyond

As 1997 approaches, and Hong Kong faces reunification with China, the need for a clearly defined health policy that addresses Hong Kong's community health concerns is increasingly apparent. The health consequences of rapid industrialization have highlighted the importance of shifting the present biomedical emphasis in health care towards a primary health care approach. However, unless government responsibility for new policy concerns such as community health is better defined by the current administration, priorities are likely to change after 1997. Analysis of community health policy and provision in the short period remaining before handover is therefore important to chart progress and identify the issues yet to be addressed. By drawing on the experiences of one established community health programme in the non-government sector, attempts to meet the changing health needs of Hong Kong's population are discussed and issues that have implications for the effective delivery of community health programmes in newly industrialized countries are identified.     

Supporting health impact assessment in practice

Health impact assessment (HIA) is a process that aims to predict potential positive and negative effects of project, programme or policy proposals on health and health inequalities. It is recommended by national government and internationally. Supporting health impact assessment is one of the roles of English Public Health Observatories. The few centres in England with accredited health impact training centres have inadequate resources to meet demand. Currently, the London Health Observatory is providing the bulk of the training nationally. Some Public Health Observatories are currently investigating the preferences for support of those commissioning or conducting health impact assessment within their regions. The availability of published guidance on how to conduct health impact assessments has increased substantially over the past few years. The Department of Health has funded a research project led by the London Health Observatory to develop advice for reviewing evidence for use in health impact assessment. Completed health impact assessments can be useful resources. Evaluation of the process and impact of health impact assessment is important in order to demonstrate its usefulness and to learn lessons for the future. The focus for Public Health Observatories is to train and support others to conduct health impact assessment according to good practice, rather than undertaking health impact assessments themselves. The aim is to create sufficient skilled capacity around the country to undertake health impact assessments. The London Health Observatory plans to share its support models and to roll out a train the trainer programme nationally to enable effective local delivery of their national health impact assessment programme.     

Mini-symposium — Public Health Observatories: Supporting health impact assessment in practice

Health impact assessment (HIA) is a process that aims to predict potential positive and negative effects of project, programme or policy proposals on health and health inequalities. It is recommended by national government and internationally. Supporting health impact assessment is one of the roles of English Public Health Observatories. The few centres in England with accredited health impact training centres have inadequate resources to meet demand. Currently, the London Health Observatory is providing the bulk of the training nationally. Some Public Health Observatories are currently investigating the preferences for support of those commissioning or conducting health impact assessment within their regions. The availability of published guidance on how to conduct health impact assessments has increased substantially over the past few years. The Department of Health has funded a research project led by the London Health Observatory to develop advice for reviewing evidence for use in health impact assessment. Completed health impact assessments can be useful resources. Evaluation of the process and impact of health impact assessment is important in order to demonstrate its usefulness and to learn lessons for the future. The focus for Public Health Observatories is to train and support others to conduct health impact assessment according to good practice, rather than undertaking health impact assessments themselves. The aim is to create sufficient skilled capacity around the country to undertake health impact assessments. The London Health Observatory plans to share its support models and to roll out a train the trainer programme nationally to enable effective local delivery of their national health impact assessment programme.     

A prospective health impact assessment of the Merseyside Integrated Transport Strategy (MerITS)

BACKGROUND: Prospective health impact assessment is a new approach to predicting potential health impacts of policies, programmes or projects. It has been widely recognized that public policies have important impacts on health. In 1997, the Liverpool Public Health Observatory was commissioned to carry out a health impact assessment of the Merseyside Integrated Transport Strategy (MerITS). A secondary aim was to pilot a method for health impact assessment at the strategic level. METHODS: The methods used drew on previous health impact assessments of projects, on strategic environmental assessment, and on policy research. They included policy analysis, semi-structured interviews with key informants and literature searches. RESULTS: Four priority impact areas of MerITS were identified: establishing road hierarchies, economic viability, air quality, and public transport. Potential health impacts in each of these areas were estimated, and recommendations were made to minimize the effects of negative impacts and to enhance positive ones. CONCLUSION: This health impact assessment prospectively identified the key health impacts of a strategy on a defined population and made recommendations to maximize potential positive and minimize potential negative health impacts. The methods employed are generally applicable to prospective health impact assessments of public policies and strategies.     

Study design and sampling in the Veterans Health Study

There are numerous choices to be made in the design of studies examining the impact of healthcare on patient-reported outcomes. We describe considerations in the design of the Veterans Health Study (VHS), a large-scale longitudinal observational study of healthcare in the Veterans Health Administration (VA). We also consider sampling issues, and discuss the broader theoretical and practical implications of our choices. The VHS was an observational study with a prospective longitudinal design. Subjects were recruited from a cross-sectional sample of the VA patient population, and identified when they came to ambulatory care clinics for a medical visit. Participating patients were contacted by telephone, and scheduled for an interview conducted at the clinic. Prior to the interview they completed a mailed questionnaire. The clinic interview included brief clinical assessments of selected study medical conditions, a medical history interview, limited health examination, and assessments of health status, health-related quality of life, process-of-care measures related to utilization of services, and other patient characteristics. Patients were empaneled and followed over time. Their health was monitored with brief mailed questionnaires completed at 3-month intervals, and with annual patient reassessments at 12 and 24 months. This design had several strengths. Its comprehensiveness and observational nature allowed for examination of a broad range of outcomes and processes of care as they occur in routine practice in the VA system. Study effects on outcomes should be minimal and the longitudinal design permitted the examination of changes in health status and evaluation of the extent to which changes in patients' illnesses and their treatments were associated with changes in outcomes. Many aspects of this study's design were innovative, reflecting careful consideration of design choices and lessons learned from previous outcomes research studies. Choices made in the design of the VHS can serve as models for future studies of the effects of healthcare on patient-reported outcomes.     

Providing General and Preconception Health Care to Low Income Women in Family Planning Settings: Perception of Providers and Clients

This study examines both provider and client perceptions of the extent to which general health concerns are addressed in the context of publicly supported family planning care. A mail survey of family planning providers (n = 459) accepting Medicaid-covered clients in Arkansas and Alabama gathered data on reported actions and resource referral availability for ten categories of non-contraceptive health concerns. A telephone survey of recent family planning clients of these providers (n = 1991) gathered data on the presence of 16 health concerns and whether and how they were addressed by the family planning provider. Data were collected in 2006–2007. More than half (56%) of clients reported having one or more general health concerns. While 43% of those concerns had been discussed with the family planning providers, only 8% had been originally identified by these providers. Women with higher trust in physicians and usual sources of general health care were more likely to discuss their concerns. Of those concerns discussed, 39% were reportedly treated by the family planning provider. Similarly, over half of responding providers reported providing treatment for acute and chronic health conditions and counseling on health behaviors during family planning visits. Lack of familiarity with referral resources for uninsured clients was identified as a significant concern in the provision of care to these clients. Greater engagement by providers in identifying client health concerns and better integration of publicly supported family planning with other sources of health care for low income women could expand the existing potential for delivering preconception or general health care in these settings.     

Empirical science meets moral panic: an analysis of the politics of needle exchange

The paper presents an analysis of the policy advocacy strategies used by both proponents and opponents of needle exchange programs in the US, drawing on the analytic framework developed by Stone. Based on a case study of the politics of needle exchange in Massachusetts, we argue that proponents of needle exchange have relied almost exclusively on empirical scientific arguments to build their case, while opponents have generally resorted to normative ethical arguments. Since the frames of argument are unrelated, the two sides talk past one another, bypassing progress towards resolution or consensus. By failing to address the ethical concerns raised by opponents, public health advocates of needle exchange are losing the larger public debate. The paper concludes with specific recommendations for how public health advocates should respond to the normative dimensions of this public policy issue.     

In search of a healing place: Aboriginal women in Vancouver's Downtown Eastside

Research on general health service delivery in urban areas of Canada shows that Aboriginal people face formidable barriers in accessing culturally appropriate and timely care. Over the past decade, Urban Aboriginal Health Centres (UAHCs) have emerged to address the unmet health concerns of Aboriginal people living in metropolitan areas of the country. The purpose of this research was to address the gap in social science literature on how the health care concerns of Aboriginal women are being met by UAHCs. The research aimed to give voice to Aboriginal women by asking them whether the appropriate professional services and educational programs they need to address their health care needs were being provided in the inner city. A case-study approach was used whereby three separate focus groups were conducted with Aboriginal women who were clients of the Vancouver Native Health Society (VNHS), its sister organization, Sheway, or residents of Vancouver's Downtown Eastside (DTES). In addition, twenty-five semi-structured interviews were conducted with VNHS staff, health providers, government representatives, and community leaders in health care (total n=61). The findings indicate that despite efforts from various quarters to articulate the health and social concerns of the country's marginalized populations, such has not been the case for Aboriginal women living in one of Canada's most prosperous cities. Many Aboriginal women expressed a strong desire for a Healing Place, based on a model of care where their health concerns are addressed in an integrated manner, where they are respected and given the opportunity to shape and influence decision-making about services that impact their own healing.     

State health care reforms: How they affect children and adolescents with emotional disorders and their families

This article reports on the Health Care Reform Tracking Project, a national study designed to describe and analyze state health care reforms and their impact on children and adolescents with emotional disorders and their families. It summarizes the results of the baseline survey of states conducted in 1995, exploring the nature and extent of the reforms in which states are engaged, most of which involve applying managed care technologies to their Medicaid programs. Trends across states are identified with respect to mental health service delivery, particularly with respect to children and adolescents. The article concludes with a discussion of issues and concerns related not only to mental health service delivery for children and adolescents with emotional disorders and their families but also to the systems of care that have been developing over the past decade to serve them. Some of these concerns include the lack of pilots or demonstrations, limited mental health coverage in some reforms, the lack of integration between mental health and substance abuse systems, the lack of special provisions for children, the need for more reliable bases for deriving capitation rates, the limited incorporation of systems of care, the need to incorporate interagency treatment planning and service delivery approaches, the lack of outcome measures specific to and appropriate for children, and the need for greater family involvement in the planning and implementation of these reforms.     

Use of MMT in Canadian gasoline: health and environment issues

BACKGROUND: Methylcyclopentadienyl manganese tricarbonyl (MMT) is an organic derivative of manganese (Mn) used in Canadian gasoline since 1976 as an antiknock agent and to improve octane rating. Combustion products of MMT are mainly a mixture of Mn phosphate and Mn sulfate. In 1997, the Canadian federal government adopted a law (C-29) which banned both the interprovincial trade and the importation for commercial purposes of manganese-based substances, including MMT. However, the government reworded this law in July 1998 so that manganese-based fuel additives were not included in the restrictions. MMT is now approved for use in Argentina, Australia, Bulgaria, the United States, France, Russia, and conditionally in New Zealand. Nevertheless, these countries are not using MMT intensively and they are waiting for strong evidence of the absence of effects on human health. Even after several years of use of MMT in Canada, many uncertainties remain. METHODS: Different methods were used in order to assess (1) environmental contamination and human exposure to the parental form of MMT, (2) nitrogen oxides (NO(x)) and carbon monoxide (CO) emissions associated with the use of MMT, and (3) qualitative and quantitative assessments of Mn emissions to the environment. RESULTS: The results provide timely information with regard to the impact of MMT on environmental/ecosystem Mn contamination in abiotic and biotic systems as well as on human exposure. Moreover, results raise major concerns with regard to public health effects related to exposure to Mn. CONCLUSIONS: Obviously, there is still an important lack of adequate toxicological information and further studies are needed to provide successful implementation of evidence-based risk assessment approaches.     

Australian federal,state and territory policy on the health and wellbeing of young people: A scoping review

BackgroundThe health and wellbeing of young people are critical for the future of society but the extent to which they are addressed by overarching Australian Federal, State and Territory health policy is difficult to determine. Analysing high-level youth health policy will help establish how Australian governments are articulating and prioritising issues and may guide local and international health agendas.MethodsThis scoping review aimed to determine the extent, range and nature of Australian high-level government policy focused on the general health and wellbeing of the general population of young people. Policies published by Australian Federal, State, or Territory government departments between 2008 and 2019 were thematically analysed employing Braun and Clark's six-step recursive framework.FindingsTwelve policy documents met inclusion criteria. Three meta-themes emerged, comprising policy development, youth health challenges, and policy goals. Policy goals fell into three ubiquitous and overarching categories focused on supporting public health, promoting equity, and improving the health system for young people.ConclusionsA number of youth-specific health policies have been developed by Australian governments in recent years. Whilst goals and strategies are clearly articulated, more can be done to ensure a youth voice in policy development. The policy goals of supporting public health, promoting equity and improving the health system deserve consideration from other countries developing youth health policies.     

Do interventions to increase income improve the health of the poor in developed economies and are such policies cost effective?

Health policy has shifted towards placing a greater emphasis on the role of lifestyle and life circumstances in improving health. The factors that are associated with poor health status are known, but the comparative effectiveness of specific policy interventions in improving health and reducing inequalities in health is unclear. For example, there is little evidence that specific policies aimed at providing income support or poverty eradication have any measurable impact on health. Two previous reviews have addressed the evidence in this area but in a fairly restrictive way. One considered only randomised trials and the other excluded non-cash benefits. This article builds on the previous reviews in three ways: a broader scope of study designs and types of intervention is considered; more recent literature is reviewed; and it considers the extent to which an economic evaluation framework has been applied. A systematic search of electronic databases was carried out for literature published since 1980 and in the English language. Each study was appraised in terms of its relevance to the question of interest, and the quality of the study design was appraised in terms of its capacity to provide robust answers. Few studies were found with health outcomes as their main focus. Most of the studies that used secondary data sources or survey data were of poor quality. Where economic evaluations were reported, these tended to be restricted to financial assessments. Different types of interventions were evaluated. In studies of cash benefits, there was limited evidence that they had a positive effect on some health domains, mainly psychosocial. Studies in welfare-to-work interventions produced mixed results in terms of impact on either income or health; there was no consistent relationship between income gains and health improvements. Five welfare-to-work studies included 'benefit-cost analysis', but these were essentially financial assessments. Studies of benefits in kind did not meet the quality criteria for inclusion in this article. Overall, we found no evidence of the potential cost effectiveness of income support or anti-poverty initiatives in improving health, nor is there a strong effectiveness literature on which to build such analysis. However, the hypothesis that increased income may improve health cannot be said to have been properly tested. Studies generally analyse the incremental effect of changes to the welfare system and do not estimate the health effects of current provisions. The production function for good health is complex. Increasing income may be a necessary, but not a sufficient, condition for the creation of better health in those with low incomes.     

Health and safety problems associated with long working hours: a review of the current position.

The European Community Directive on Working Time, which should have been implemented in member states of the European Community by November 1996, contains several requirements related to working hours, including the right of employees to refuse to work more than 48 hours a week. The United Kingdom government attempted to oppose the Directive, arguing that there is no convincing evidence that hours of work should be limited on health and safety grounds. Much of the research in this area has focused on the problems of shiftworking and previous reviews have therefore tended to emphasise this aspect of working hours. However, there is much less information about the effects of overtime work, which is a central element of the terms of the Directive. This paper reviews the current evidence relating to the potential effects on health and performance of extensions to the normal working day. Several gaps in the literature are identified. Research to date has been restricted to a limited range of health outcomes--namely, mental health and cardiovascular disorders. Other potential effects which are normally associated with stress--for example, gastrointestinal disorders, musculoskeletal disorders, and problems associated with depression of the immune system, have received little attention. Also, there have been few systematic investigations of performance effects, and little consideration of the implications for occupational exposure limits of extensions to the working day. Existing data relate largely to situations where working hours exceed 50 a week and there is a lack of information on hours below this level, which is of direct relevance to the European Community proposal. Finally, it is clear from investigations relating to shiftwork that a range of modifying factors are likely to influence the level and nature of health and performance outcomes. These include the attitudes and motivation of the people concerned, the job requirements, and other aspects of the organisational and cultural climate. It is concluded that there is currently sufficient evidence to raise concerns about the risks to health and safety of long working hours. However, much more work is required to define the level and nature of those risks.     

Lessons from San Francisco: health impact assessments have advanced political conditions for improving population health

Health impact assessment is a structured decision support tool used to systematically characterize the anticipated health effects, both adverse and beneficial, of societal decisions. In San Francisco, the use of health impact assessments has not only produced evidence to inform health policy decision making but has also contributed to the political conditions needed to achieve optimal population health. Health impact assessments have helped increase public awareness of the determinants of health, routine monitoring of these determinants, cooperation among institutions, health-protective laws and regulations, and organizational networks for health advocacy and accountability. Drawing on more than a decade of local experience, we identify the direct and indirect effects of the assessments on the politics of governance as well as on health. We demonstrate that health impact assessment is both an analytic tool and a process that helps build the social institutions that can improve health.     

Disability claim review by non-physicians to meet the legal requirement of Dutch work disability certification laws

The number of assessments of incapacity for work has increased to such an extent in the Netherlands (450,000 per year, of which 150,000 are first assessments) that experiments are now being undertaken to employ non-physicians for these assessments. There is no shortage of insurance physicians however: the number available is underestimated as many of these have resigned their regular jobs to perform the same activities on a freelance or second basis. A problem is certainly that these physicians are hindered by an exceedingly bureaucratic system in which e.g. patients are summoned by the administrative section to be reassessed who have already resumed working. Non-physicians may assist in the assessments, but in most cases there is a relation between psychic, somatic and social factors, which requires the generalist physician's eye. The main problem is that government regulations lead to a steady growth in the number of (re)assessments required. A possible but onorthodox solution is proposed which involves medical certification of incapacity for work. This may discourage long-term absenteeism and at the same time it may draw the physician's attention to the existence of an industrial health care problem.     

Factors influencing milk and milk product consumption in young and elderly women with low calcium intakes

The aim of this research was to investigate factors influencing milk and milk product consumption in young and elderly women consuming less than two-thirds of the RDA for calcium. Semi-structured, open-ended interviews were conducted with 71 women over 70 years and 22 women aged 19–23 years. Questions addressed changes in milk and milk product intake, and reasons for changes; perceptions of the likely effects of an increased intake of milk or milk products on health; reasons for low consumption of milk or milk products; and willingness to increase intake of various calcium-rich foods. The elderly low-calcium consumers were identified from a nutrition and health study of all people over 70 years residing in one New Zealand town. The young women were low-calcium consumers identified from a university class of nutrition students. Older women were most likely to perceive that increasing their milk or milk product intake would have either no effect on their health or adverse effects on conditions such as diabetes, high blood cholesterol or blood pressure, and heart problems. Although young women were more likely to perceive potential health benefits from consuming more milk (and to a lesser extent milk products), an increase in body weight was the reason given by all those who believed an increased intake would be bad for them. Some 13–18% of women had been advised by doctors to eliminate milk or milk products from their diet, usually for inappropriate reasons. For both age groups, dislike was the most important reason for not consuming more milk; however health concerns were the primary reason for not consuming more of the other dairy products. There is need to actively counter misconceptions amongst both women (particularly elderly women) and doctors, concerning adverse effects of milk or milk products on health conditions. For young women, emphasis is needed that weight control does not require the exclusion of milk or milk products from the diet. Programs are required to increase awareness of the wide range of low-fat milks and milk products now available, and of the potential benefits of these for bone health.     

Reporting of skin cancer risks in the house-building industry: alternative approaches to the analysis of categorical data

BACKGROUND: Increasing incidence of skin cancer is of concern to public health. Working predominantly outside, construction workers are at increased risk of sunburn and certain forms of skin cancer. The objective of this paper was to explore these concerns via use of alternative approaches to categorical data analysis by considering the relationship between the size of house-building companies, use of risk assessments and the system for reporting sunburn. METHODS: The survey population was speculative house-building companies. A self-administered questionnaire was sent to health and safety advisors in house-building companies. Questions related to the number of house units built, inclusion of adverse weather in the risk assessment, and the presence or absence of a system for reporting sunburn were analysed. Alternative approaches to conventional chi(2) tests were used in order to investigate a multiway data structure. A loglinear model was employed using Statistical Package for Social Sciences to explain data in three-way tables. RESULTS: The questionnaire achieved a response rate of 31% (n=94). A significant association identified in a two-way study of the mechanisms of reporting sunburn also appeared at the sublevels introduced by the inclusion of a third method of categorization. Finally, correspondence analysis was used to present a graphical insight into the study. CONCLUSIONS: In the two-way analysis, the size of house-building company had a significant impact on the presence of a system for reporting sunburn, although this was not translated into the three-way analysis. The establishment of systems within risk assessments to incorporate exposure of construction workers to ultraviolet radiation, and reporting of incidents of sunburn, is essential if this public health issue is to be addressed.