Assessing the unintended health impacts of road transport policies and interventions: translating research evidence for use in policy and practice

Background  

Transport and its links to health and health inequalities suggest that it is important to assess both the direct and unintended indirect health and related impacts of transport initiatives and policies. Health Impact Assessment (HIA) provides a framework to assess the possible health impacts of interventions such as transport. Policymakers and practitioners need access to well conducted research syntheses if research evidence is to be used to inform these assessments. The predictive validity of HIA depends heavily on the use and careful interpretation of supporting empirical evidence. Reviewing and digesting the vast volume and diversity of evidence in a field such as transport is likely to be beyond the scope of most HIAs. Collaborations between HIA practitioners and specialist reviewers to develop syntheses of best available evidence applied specifically to HIA could promote the use of evidence in practice.     

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.     

Criteria for use in the evaluation of health impact assessments

This paper reports the conclusions of a recent workshop that was established to discuss how health impact assessments (HIAs) might be evaluated. The main purposes of HIA are: (a) to predict the consequences of different decisions; (b) to make the decision-making process more open by involving stakeholders; and (c) to inform the decision makers. 'Prediction', 'participation' and 'informing decision makers' are thus the three domains in which HIA should be evaluated. In the 'prediction' domain, process criteria scrutinize the methods used to see if it is likely that they would produce reliable predictions. Outcome criteria involve verifying the predictions, but this is frequently impractical and predictions for the counter factual (the option not chosen) can never be verified. In the 'participation' domain, process criteria examine the ways in which stakeholders were involved, while outcome criteria explore the degree to which the stakeholders felt included. In the 'informing decision makers' domain, process criteria are concerned with the communication between decision makers and those doing the HIA, and should reflect upon the relevance of the HIA content to the decision makers' agenda. Outcome criteria explore the degree to which the decision makers considered that they had been informed by the HIA. This paper concludes with suggestions for the types of information that should be included in HIA reports in order to permit the readers to make an assessment of the 'quality' of the HIA using the three domain criteria outlined above.     

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.     

'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.     

Health impact assessment of housing improvements: incorporating research evidence

BACKGROUND: Health impact assessment (HIA) has been widely recommended for future social policies and investment, such as housing improvement. However, concerns have been raised about the utility and predictive value of an HIA. Use of existing research data would add more weight to forecasts by an HIA. METHODS, RESULTS, and CONCLUSIONS: A recent systematic review of housing intervention studies found a lack of research. The authors recommended that a broader evidence base would be needed to support HIA. In response to consultation with policymakers and HIA practitioners this paper presents a way in which research can be used to inform HIA. Based on the systematic review, the authors have developed a table of synthesised findings indicating the expected health effects of specific housing improvements. The authors also reviewed observational data of housing associated health risks to highlight the key impacts to consider when doing a housing HIA. The findings are presented and the authors discuss how they should be used to inform evidence based housing HIA. In addition to considering the existing research, HIA must consider the local relevance of research. Consultation with local stakeholders also needs to be incorporated to the final assessment. The lack of data and the difficulties in gathering and reviewing data mean that not all HIAs will be able to be informed by research evidence. Well conducted prospective validation of HIAs would contribute to the development of healthy housing investment by informing future housing HIA.     

Health impact assessment of agriculture and food policies: lessons learnt from the Republic of Slovenia

The most important public health priority in agricultural policy-making is currently food safety, despite the relatively higher importance of food security, nutrition, and other agricultural-related health issues in terms of global burden of disease. There is limited experience worldwide of using health impact assessment (HIA) during the development of agriculture and food policies, which perhaps reflects the complex nature of this policy sector. This paper presents methods of HIA used in the Republic of Slovenia, which is conducting a HIA of proposed agricultural and food policies due to its accession to the European Union. It is the first time that any government has attempted to assess the health effects of agricultural policy at a national level. The HIA has basically followed a six-stage process: policy analysis; rapid appraisal workshops with stakeholders from a range of backgrounds; review of research evidence relevant to the agricultural policy; analysis of Slovenian data for key health-related indicators; a report on the findings to a key cross-government group; and evaluation. The experience in Slovenia shows that the HIA process has been a useful mechanism for raising broader public health issues on the agricultural policy agenda, and it has already had positive results for policy formation. HIA is one useful approach to more integrated policy-making across sectors, but clearly it is not the only mechanism to achieve this. A comparison of the approach used in Slovenia with HIA methods in other countries and policy contexts shows that there are still many limitations with HIA application at a government level. Lessons can be learnt from these case studies for future development and application of HIA that is more relevant to policy-makers, and assists them in making more healthy policy choices.     

Quantitative health impact assessment: current practice and future directions

STUDY OBJECTIVE: To assess what methods are used in quantitative health impact assessment (HIA), and to identify areas for future research and development. DESIGN: HIA reports were assessed for (1) methods used to quantify effects of policy on determinants of health (exposure impact assessment) and (2) methods used to quantify health outcomes resulting from changes in exposure to determinants (outcome assessment). MAIN RESULTS: Of 98 prospective HIA studies, 17 reported quantitative estimates of change in exposure to determinants, and 16 gave quantified health outcomes. Eleven (categories of) determinants were quantified up to the level of health outcomes. Methods for exposure impact assessment were: estimation on the basis of routine data and measurements, and various kinds of modelling of traffic related and environmental factors, supplemented with experts' estimates and author's assumptions. Some studies used estimates from other documents pertaining to the policy. For the calculation of health outcomes, variants of epidemiological and toxicological risk assessment were used, in some cases in mathematical models. CONCLUSIONS: Quantification is comparatively rare in HIA. Methods are available in the areas of environmental health and, to a lesser extent, traffic accidents, infectious diseases, and behavioural factors. The methods are diverse and their reliability and validity are uncertain. Research and development in the following areas could benefit quantitative HIA: methods to quantify the effect of socioeconomic and behavioural determinants; user friendly simulation models; the use of summary measures of public health, expert opinion and scenario building; and empirical research into validity and reliability.     

Introduction of health impact assessment and healthy cities as a tool for tackling health inequality]

In order to reduce the health inequalities within a society changes need to be made in broad health determinants and their distribution in the population. It has been expected that the Health impact assessment(HIA) and Healthy Cities can provide opportunities and useful means for changing social policy and environment related with the broad health determinants in developed countries. HIA is any combination of procedures or methods by which a proposed 4P(policy, plan, program, project) may be judged as to the effects it may have on the health of a population. Healthy city is one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and in developing to their maximum potential. In Korea, social and academic interest regarding the HIA and Healthy Cities has been growing recently but the need of HIA and Healthy Cities in the perspective of reducing health inequality was not introduced adequately. So we reviewed the basic concepts and methods of the HIA and Healthy Cities, and its possible contribution to reducing health inequalities. We concluded that though the concepts and methods of the HIA and Healthy Cities are relatively new and still in need of improvement, they will be useful in approaching the issue of health inequality in Korea.     

Social marketing: Should it be used to promote evidence-based health information?

The implementation of public health knowledge is a complex process; researchers focus on organizational barriers but generally give little attention to the format and validity of relevant information. Primary and secondary papers and practice guidelines should represent valid and relevant sources of knowledge for clinicians and others involved in public health. However, this information is usually targeted at researchers rather than practitioners; it is often not completely intelligible, does not explain what it really adds to existing knowledge or which clinical/organizational context to place it in, and often lacks 'appeal' for those who are less informed. Moreover, this information is sometimes founded on biased research, shaped by sponsors to give scientific plausibility to market-driven messages. A "social marketing" approach can help public health researchers make evidence-based information clear and appealing. The validity and relevance of this information can be explained to target readers in light of their own knowledge levels and in terms of how this information could help their practice. In this paper we analyse the barriers to knowledge transfer that are often inherent in the format of the information, and propose a more user-friendly, enriched and non-research-article format.     

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.     

Soft data,hard effects. Strategies for effective policy on health impact assessment--an example from the Netherlands

Health impact assessment (HIA) on a strategic level focuses on the broad determinants of health. However, the evidence with regard to the health impacts is often necessarily 'soft'. The example of a health impact review on national housing policy in the Netherlands shows that HIA can be effective even in the absence of hard data. Strategies used to overcome the problem of not having hard data are outlined. The authors argue that, for HIA to be effective, it does not necessarily have to be limited to easy-to-measure, easy-to-quantify programmes and health effects.     

Qualitative and quantitative approaches to health impact assessment: An analysis of the political and philosophical milieu of the multi-method approach

Health Impact Assessment (HIA) is a relatively new, but increasingly important, contributor to both local and national decision-making processes. Adopting a multi-method approach, it incorporates qualitative and quantitative analyses to determine the various health impacts of policies and projects. HIA thus reflects recent developments in sociological theory, which have promoted qualitative techniques and challenged the dominance of quantitative methods. HIA embodies a particular renegotiation of the qualitative/quantitative opposition; each individual HIA represents an empirical instance of this renegotiation. As such, HIA can be conceptualized as a kind of ‘political space’, in which the opposition in question is structured by various social forces and plays out in concrete ways. Moreover, and notwithstanding the supposed methodological rapprochement, an analysis of a number of HIAs claims to expose a continuing, but perhaps unsurprising, privilege in favour of quantitative methods. In the first place, the paper contends that closer examination reveals this privileging to be unjustified, both empirically and theoretically, and alternative methodological and epistemological configurations are suggested accordingly. Specific gestures are made in this respect toward the work of Martin Heidegger and Jacques Derrida. In particular, the paper argues for a broad hermeneutic approach that both encompasses and situates the methodological tensions HIA stages. Second, attention is drawn to the fact that various and particular sociopolitical conditions maintain the characteristic architecture of the opposition. The political importance of HIA across a series of key issues is underscored in support of a more radical interpretation. For once situated within its wider cultural context, HIA ceases to resemble some straightforwardly neutral technology for health protection and delivery. If, instead, one reads it as an indicative micropolitical phenomenon, then one can begin to interrogate this simple policy tool in more complex ways. HIA both reveals, and is implicated in, a more fundamental and diffuse process that is presently resisting, undermining and regenerating traditional power distributions within the administration of health and beyond. The paper implicitly argues that HIA can only be properly understood within this context and, equally, allows one a certain analytical access to this context.     

Greater Granville Regeneration Strategy

An urban regeneration health impact assessment (HIA) was conducted collaboratively with three major government agencies and the local community in 2005 and 2006 to identify health impacts of a major land use strategy outlined in the consultant's report for the Greater Granville Regeneration Plan - Stage 1 (Sydney: Hassall Pty Limited, 2005). Health impacts were identified and agreed recommendations were developed to ameliorate negative impacts, with a formal partnership agreement to progress implementation and monitoring. The Granville HIA has been influential in changing major policy initiatives of Parramatta City Council and the NSW Department of Housing, contributing to positive health outcomes for the Granville community.     

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.     

Bridging health and foreign policy: the role of health impact assessments

Health impact assessment (HIA) is an important tool for exploring the intersection between health and foreign policy, offering a useful analytical approach to increase positive health impacts and minimize negative impacts. Numerous subject areas have brought health and foreign policy together. Yet further opportunities exist for HIA to address a broader range of health impacts that otherwise may not be seen as relevant to foreign policy. HIA may also improve the quality of scientific evidence available to policy-makers. The Framework Convention on Tobacco Control offers lessons for the strategic use of HIA. However, HIA alone is limited in influencing these decision-making processes, notably when issues diverge from other core concerns such as economics and security. In such cases, HIA is an important tool to be used alongside the mobilization of key constituencies and public support.     

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.     

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.     

Health impact assessment, human rights and global public policy: a critical appraisal

Public policy decisions in both the social and economic spheres have enormous impact on global public health. As a result of this, and of the skewed global distribution of power and resources, health impact assessment (HIA) potentially has a key role to play in foreign policy-making and global public policy-making. Governments, multilateral bodies and transnational corporations need to be held to account for the health impacts of their policies and practices. One route towards achieving this objective involves the inclusion of human rights assessments within HIA. International commitments to human rights instruments and standards can be used as a global auditing tool. Methodological issues may limit the effectiveness of HIA in promoting health equity. These issues include the use of procedures that favour those holding power in the policy process or the use of procedures that fail to apply values of equity and participation. The identification and production of evidence that includes the interests of less powerful groups is a priority for HIA and would be furthered if a human rights-based method of HIA were developed. Because HIA considers all types of policies and examines all potential determinants of health, it can play a part when foreign policy is developed and global decisions are made to treat people as rights holders. Since the human right to health is shaped by the determinants of health, developing links between the right to health assessment (that is, an assessment of the impact of policies on the right to health) and HIA--as recently proposed by the United Nations Special Rapporteur on the right to health--could strengthen the development of foreign policy and global decisions. Such links should be pursued and applied to the development of foreign policy and to the operation of multilateral bodies.