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.     

Equity and the Social Determinants of Health in European Cities

Equity in health has been the underlying value of the World Health Organization’s (WHO) Health for All policy for 30 years. This article examines how cities have translated this principle into action. Using information designed to help evaluate phase IV (2003–2008) of the WHO European Healthy Cities Network (WHO-EHCN) plus documentation from city programs and websites, an attempt is made to assess how far the concept of equity in health is understood, the political will to tackle the issue, and types of action taken. Results show that although cities continue to focus considerable support on vulnerable groups, rather than the full social gradient, most are now making the necessary shift towards more upstream policies to tackle determinants of health such as poverty, unemployment, education, housing, and the environment, without neglecting access to care. Although local level data reflecting inequalities in health is improving, there is still a long way to go in some cities. The Healthy Cities Project is becoming an integral part of structures for long-term planning and intersectoral action for health in cities, and Health Impact Assessment is gradually being developed. Participation in the WHO-EHCN appears to allow new members to leap-frog ahead established cities. However, this evaluation also exposes barriers to effective local policies and processes to reduce health inequalities. Armed with locally generated evidence of critical success factors, the WHO-EHCN has embarked on a more rigorous and determined effort to achieve the prerequisites for equity in health. More attention will be given to evaluating the effectiveness of action taken and to dealing not only with the most vulnerable but a greater part of the gradient in socioeconomic health inequalities.     

Urban HEART Detroit: the Application of a Health Equity Assessment Tool

The Urban Health Assessment Response Tool (Urban HEART) was developed by the World Health Organization. In 2016, the Urban HEART was adapted and used by the Healthy Environments Partnership, a long-standing community-based participatory research partnership focused on addressing social determinants of health in Detroit, Michigan, to identify health equity gaps in the city. This paper uses the tool to: (1) examine the geographic distributions of key determinants of health in Detroit, across the five Urban HEART specified domains: physical environment and infrastructure, social and human development, economics, governance, and population health, and (2) determine whether these indicators are associated with the population health indicators at the neighborhood level. In addition to the Urban HEART matrix, we developed various tools including graphs and maps to further examine Detroit’s health equity gaps. Although not required by Urban HEART, we statistically analyzed the associations between each indicator with the health outcomes. Our results showed that all the domains contained one or more indicators associated with one or more health outcomes, making this an effective tool to study health equity in Detroit. The Urban HEART Detroit project comes at a critical time where the nation is focusing on health equity and understanding underlying determinants of health inequities in urban areas. A tool like Urban HEART can help identify these areas for rapid intervention to prevent unnecessary burden from disease. We recommend the application of the Urban HEART, in active dialog with community groups, organizations, and leaders, to promote health equity.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-020-00503-0.     

Changes Not for the Fainthearted: Reorienting Health Care Systems Toward Health Equity Through Action on the Social Determinants of Health

Entrenched poor health and health inequity are important public health problems. Conventionally, solutions to such problems originate from the health care sector, a conception reinforced by the dominant biomedical imagination of health. By contrast, attention to the social determinants of health has recently been given new force in the fight against health inequity. The health care sector is a vital determinant of health in itself and a key resource in improving health in an equitable manner. Actors in the health care sector must recognize and reverse the sector''s propensity to generate health inequity. The sector must also strengthen its role in working with other sectors of government to act collectively on the deep-rooted causes of poor and inequitable health.The production of better population health outcomes is usually equated with improvements in health care. But this is a somewhat crude equation. All too often, health care sectors, firmly rooted in medicine, do not demonstrate active engagement with the wide determinants of patients'' health; do not ensure, through a nuanced understanding of social determinants, that care services are made available and accessible to all social groups equitably; and have not been as proactive as one might expect, given the evidence on social determinants of health, in engaging and working with other government sectors (as a kind of steward in support of those sectors'' own activities) to ensure that all government entities appreciate their potential to affect health and health equity.This situation must change. As a first step toward change, some questions need to be answered. How are we as a global community performing with respect to health and health equity, both within countries and between them? What are key obstacles to improving integrated action by health care sectors on the social determinants of health? And what might a reoriented health care sector—one that takes health equity as a central goal and, in so doing, engages with the entire range of social determinants of health—look like? We first offer some definitions of key terms to clarify our discussion.We follow the lead of the Commission on Social Determinants of Health (CSDH) in viewing social determinants as the social, political, economic, and cultural conditions in which people live and work and the structural drivers of these conditions. We define the health care sector as the sector typically responsible for hospital- and community-based health services, public health surveillance, health promotion and workforce planning, standard setting, and regulation of public and private health care services.We use the term stewardship to describe the various roles that can be taken by actors in the health care sector in collaboration with their counterparts in other government sectors. We selected this term deliberately to recognize and minimize the risk of health imperialism (the domination of the health care sector over agendas shared with other sectors). Stewardship implies the general duty of care for a population''s health borne by government as a whole; it involves a nuanced balance of leadership and facilitation in the relationship between the health care sector and other government sectors, ranging from education through infrastructure and urban planning to trade. We define inequity as unjust and avoidable inequalities.     

论卫生服务公平性与特需医疗服务之关系

公立医院要不忘自身的职责，承担起卫生服务公平性的重任，又要根据自身发展的需要，适度地开展特需医疗服务，要普通医疗服务与特需医疗服务公抓并举，使医院在激烈的医疗市场竞争中抢占制高点，不断地发展壮大。     

选用不同的健康指标对健康公平指数的影响

目的 本文利用98年卫生服务总调查城市部分的资料研究了健康指标对健康公平研究结果的影响。并对这种影响的产生原因进行了探讨。方法 本文分别采用两周患病率、慢病率和失能残障率等指标作为健康指标，统一用集中指数来衡量硅康公平。结果 研究结果显示，由于指标自身的原因和不同社会经济状况人群间疾病谱的差异，用失能率和残障率等较为客观的指标以及用传染病患病率等对健康公平更为敏感的指标作为研究指标所得到的结果更为客观、可信。结论在研究硅康公平时，用失能率、残障率和传染病患病率等对健康公平敏感的指标作为研究指标得到的结果更为客观、可信。     

Addressing the Social and Environmental Determinants of Urban Health Equity: Evidence for Action and a Research Agenda

Urban living is the new reality for the majority of the world’s population. Urban change is taking place in a context of other global challenges—economic globalization, climate change, financial crises, energy and food insecurity, old and emerging armed conflicts, as well as the changing patterns of communicable and noncommunicable diseases. These health and social problems, in countries with different levels of infrastructure and health system preparedness, pose significant development challenges in the 21st century. In all countries, rich and poor, the move to urban living has been both good and bad for population health, and has contributed to the unequal distribution of health both within countries (the urban–rural divide) and within cities (the rich–poor divide). In this series of papers, we demonstrate that urban planning and design and urban social conditions can be good or bad for human health and health equity depending on how they are set up. We argue that climate change mitigation and adaptation need to go hand-in-hand with efforts to achieve health equity through action in the social determinants. And we highlight how different forms of governance can shape agendas, policies, and programs in ways that are inclusive and health-promoting or perpetuate social exclusion, inequitable distribution of resources, and the inequities in health associated with that. While today we can describe many of the features of a healthy and sustainable city, and the governance and planning processes needed to achieve these ends, there is still much to learn, especially with respect to tailoring these concepts and applying them in the cities of lower- and middle-income countries. By outlining an integrated research agenda, we aim to assist researchers, policy makers, service providers, and funding bodies/donors to better support, coordinate, and undertake research that is organized around a conceptual framework that positions health, equity, and sustainability as central policy goals for urban management.     

卫生领域中的公平性和筹资公平性

卫生服务中的“公平性”不同于“平等”,它包括卫生服务资源分配的公平、卫生服务利用的公平和卫生服务筹资的公平。而卫生服务的筹资其实是社会再分配体系的一部分,它的含义主要受功利主义观点的影响,即效用最大化理论。要达到卫生服务筹资的公平性,则必须满足3条原则。     

Correction to: Randomized Controlled Trial of Doula-Home-Visiting Services: Impact on Maternal and Infant Health

Introduction Although home-visiting programs typically engage families during pregnancy, few studies have examined maternal and child health outcomes during the antenatal and newborn period and fewer have demonstrated intervention impacts. Illinois has developed an innovative model in which programs utilizing evidence-based home-visiting models incorporate community doulas who focus on childbirth education, breastfeeding, pregnancy health, and newborn care. This randomized controlled trial (RCT) examines the impact of doula-home-visiting on birth outcomes, postpartum maternal and infant health, and newborn care practices. Methods 312 young (M = 18.4 years), pregnant women across four communities were randomly assigned to receive doula-home-visiting services or case management. Women were African American (45%), Latina (38%), white (8%), and multiracial/other (9%). They were interviewed during pregnancy and at 3-weeks and 3-months postpartum. Results Intervention-group mothers were more likely to attend childbirth-preparation classes (50 vs. 10%, OR = 9.82, p < .01), but there were no differences on Caesarean delivery, birthweight, prematurity, or postpartum depression. Intervention-group mothers were less likely to use epidural/pain medication during labor (72 vs. 83%; OR = 0.49, p < .01) and more likely to initiate breastfeeding (81 vs. 74%; OR = 1.72, p < .05), although the breastfeeding impact was not sustained over time. Intervention-group mothers were more likely to put infants on their backs to sleep (70 vs. 61%; OR = 1.64, p < .05) and utilize car-seats at three weeks (97 vs. 93%; OR = 3.16, p < .05). Conclusions for practices The doula-home-visiting intervention was associated with positive infant-care behaviors. Since few evidence-based home-visiting programs have shown health impacts in the postpartum months after birth, incorporating doula services may confer additional health benefits to families.

     

社会资本与健康公平关系的实证研究

目的：探讨社会资本对我国城市居民健康公平的影响。方法：分析方法包括单因素和logistic回归分析。主要测量指标包括自评健康指标和因子分析得到的5个社会资本因子。结果：邻里关系、互惠与社会支持高分组的人群自评健康差的概率只有低分组的1．37倍和1.32倍。但是引入社会资本变量后，贫困对自评健康的影响并没有很明显的减少。结论：在消除贫困所带来的影响的前提下，推动贫困人口社会资本的发展，对健康公平的改善会更有意义。     

Epidemiologic Health Impact Assessment: Estimation of Attributable Cases and Application to Decision Making

Objectives:The epidemiologic Health Impact Assessment (eHIA) process is receiving growing attention in Italy. In the context of such an approach, the present paper has three objectives: to review the computational aspects of eHIA for stressing strengths and weaknesses of methods and formulas; to discuss which rate at baseline could be used for the estimation of attributable cases; how to use the results of eHIA to make decisions regarding the realization of industrial projects.Methods and Results:Using a linear formulation of the relationship between exposure and disease occurrence: a) formulas have been derived to compute attributable cases (AC) using both Relative Risk (RR) and Excess Risk (ER) approaches; b) a discussion is made of the use as baseline rate of the rate that is caused by all the risk factors for a particular disease and a suggestion is made to use the rate that is caused simply by the risk factors that are under evaluation; c) under assumptions and approximations that must be validated in any specific situation, formulas are derived to compute Incremental Lifetime Cumulative Risk (ILCR), an indicator that can be used to compare the results coming from the eHIA approach with the levels of action used by USEPA and others (10⁻⁶, 10⁻⁵, 10⁻⁴).Conclusion:In this paper, the methodology and the formulas commonly used in eHIA have been enlarged to consider the case in which the baseline rate is equal to zero, suggesting to use Excess Risk (ER) estimates instead of Relative Risk (RR) estimates. Using different baseline rates produces very different estimates of AC, and work needs to be done on this topic. Lastly, due to assumptions, approximations, and uncertainty of eHIA computations, prudence and caution should be exercised in using eHIA results in decision making, particularly if hard decisions have to be made.     

对WHO卫生系统绩效公平性评价的几点疑问

文章从理论框架、内容到结论等方面对《2 0 0 0年世界卫生报告》中卫生系统绩效的公平性评价提出不同意见 ,认为 WHO制定的评价框架并没有真实反映出卫生系统的公平性 ,数据来源有限 ,可信度较差 ,存在较大偏倚 ,结论并没有比较出各国卫生系统的公平性差异 ,整个评价体系在理论上存在一定的缺陷。建议在确定和测量公平性评价指标方面还需要做更深入的研究     

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.