1. Health impact assessment explained

2. Health Impact Assessment (HIA)
A combination of procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population
WHO, European Centre for Health Policy. Gothenburg Consensus Paper, Health Impact Assessment- main concepts and suggested approach. Brussels, 1999.

3. Why use HIA?
We have to think about the effects policies have on health, and in particular, how they can alter the health of all people in the population. Non-health sector proposals, where health is not the main objective, may have major effects on the health and well-being of people, particularly vulnerable groups.

4. HIA explained
HIA is an approach that gets people to think about what they are doing, and how it may alter people’s health. It promotes health – and in the long term contributes to the health of local people
Imagine someone was planning to build a new motorway. An HIA would answer ‘How would this new development affect people’s health?’

5. An HIA would ask….
Would the motorway increase or decrease noise, air or light pollution?
How would the motorway affect local businesses and jobs?
Would the new motorway reduce or increase the stress for local people?
How would a new motorway change the local infrastructure needs - and would this be good or bad for local people?

6. The purpose/function of HIA is to:
Inform and influence the decision maker
Help address inequalities in health.
Promote joined-up working.
Place public health on the agenda
Reduce conflict between stakeholders
Encourage sustainable development
Inform and influence the decision maker
The overarching aim of HIA is to create conditions that encourage and support the protection and improvement of people’s health and wellbeing. The purpose of all HIA is to inform and influence decision making associated with either the development of healthy public policy, healthy strategy development or planning; the undertaking of programmes and projects; or other developments.
HIA is a practical approach that can inform and influence decision makers about how a proposal (or variations) would impact on people’s health (and provide information to stakeholders and the public). It provides the decision maker with recommendations to mitigate or negate possible risks to health, and opportunities to improve people’s health.
Decisions are not taken within the HIA; they are taken by the decision-makers who are typically politically accountable. To influence a proposal, an assessment of the proposals decision making context is required to identify opportunities and barriers that may be encountered for the presentation of recommendations. Obviously, there is no point in carrying out an HIA where a decision is not open to influence. Finally, there is often multiple decision points along the proposals process because the development is often incremental and so there are many opportunities for HIA to influence decisions – but at each stage the questions addressed by the HIA may be different.
Help address inequalities in health
A major purpose for many HIAs to be undertaken is a desire to tackle inequalities. HIA attempts to reduce inequity that results from avoidable and unjust differences in health status between different peoples.To achieve this, HIA outlines inequalities that may arise from a proposal by determining whether health impacts are likely to be distributed unevenly within a population, or between groups, rather than just predicting the impact on the whole population. Because of this, HIA is able to identify both the ‘winners’ and ‘losers’ of a proposal, and recommend how the distribution of impacts can be changed, or how ‘losers’ may be compensated.
Promote joined up working
Because of the broad nature of the determinants of health – HIA usually requires a broad range of stakeholders to participate. This sets the stage for joined up working within and between agencies. In some cases, agencies are already involved in interagency and multidisciplinary working before the HIA begins, but often with HIA ‘unusual links are formed’. Public health staff are able to build coalitions and links with policy makers and planners, and these have the potential to influence future work beyond the end of a single HIA.
Place public health on the agenda
A further benefit to joined up working is that HIA can place public health issues on the agenda of many different agencies and individuals, and introduces the wider determinants of health to them. Tying HIA into a systematic process that promotes the determinants of health is recommended. HIA performs an educational role for policy makers, planners and developers (and vice versa for public health staff learning about how policy makers, planners and developers think and work). It is difficult to determine how important this is, but suffice to say this is considered to be a key component of building healthy communities, as recommended by the Ottawa Charter (First International Conference on Health Promotion, 1986) and Jakarta Declaration (Fourth International Conference on Health Promotion, 1997). Policy process research suggests that a network of actors are instrumental for developing sound policy and influencing decisions. Similarly, implementing decisions often requires the action of multiple actors.
Reduce conflict between stakeholders
An advantage of stakeholder participation is that there is the opportunity for the airing of different views on a proposal, and sometimes conflicts can be resolved
Encourage sustainable development
Undertaking HIA is one way to provide information and recommendations that can be used to pursue the goal of sustainability.

7. HIA does this by: Using a broad understanding of health.
Using a participatory approach that considers which stakeholders need to be involved
Helping involve local people in decisions and responding to their concerns about health.
Considering different types of evidence - from local views to scientific information.
Assessing how the proposal will affect all members of the community – particularly the most vulnerable.
Assisting with sustainable development by considering short and long term impacts.
Using a broad understanding of health
Described in detail in next slide
Using a participatory approach that considers which stakeholders need to be involved
HIA should involve and engage stakeholders such as experts, proposers/developers, other key players and the community. Where there is any deviation from this situation, the rationale for the decision must be documented and made explicit. While this is not ideal, such a situation may occur where there are inappropriate skills and resources available to carry out consultation well. Therefore, decisions regarding whether stakeholders are merely informed about the proposal, whether they participate in the HIA, or whether they participate in the decision making itself, must be made before the stakeholders are approached, and clearly explained to all. Finally, if participation is required, agreeing the boundaries of useful public participation is important.
Involving local people in decisions and responding to community concerns about health
The advantages of stakeholder participation is that it can lay a platform for inclusion of community voices in the decision making process. This will ensure the value of democracy is upheld, provides an opportunity for the airing of different views on a proposal and adds transparency to the process.
When asked, communities typically rate a a healthy population as one of their highest priorities. HIA helps to address this concern for health – and places health alongside other important outcomes such as environment, economic and social.
Considering different types of evidence
HIA uses evidence to predict impacts and inform recommendations. This evidence should be collected in a methodologically rigorous manner from a broad range of sources, all with their appropriate validity. The best available evidence is aimed for, but compromise is often required to deliver the HIA within available resource and time constraints. Again, stakeholders must decide at the beginning of each HIA what level and type of evidence is required to make the HIA acceptable and usable. The evidence should be able to assist with answering questions about how the proposal may affect the determinants of health, and with questions about potential affects on direct health outcomes. Ideally, part of this evidence - that outlining the chain of causation between proposals and health outcomes would be available in an ‘off the shelf’ format for practitioners to use, as such a rigorous process is difficult for small and rapid HIAs.
Assessing how the proposal will affect all members of the community
HIA attempts to reduce inequity that results from avoidable and unjust differences in health status between different peoples.To achieve this, HIA outlines inequalities that may arise from a proposal by determining whether health impacts are likely to be distributed unevenly within a population, or between groups, rather than just predicting the impact on the whole populatio. Because of this, HIA is able to identify both the ‘winners’ and ‘losers’ of a proposal, and recommend how the distribution of impacts can be changed, or how ‘losers’ may be compensated.
Sustainable development
Undertaking HIA is one way to provide information and recommendations that can be used to pursue the goal of sustainability. An HIA seeks to predict both the short and long-term impacts of a proposal, and consider the human health dimension of sustainability. The definition of ‘long term’ needs to be set by those undertaking the HIA, but it is worth noting that the definition of sustainability describes ‘the needs of future generations’, and so covers periods of at least 40 years or more.
To pursue the value of sustainability, and predict future impacts, HIA must be prospective. A prospective HIA can provide decision makers with information about how a proposal will impact on the health and wellbeing of people in the future.

8. Many factors impact on your health
the social and economic environment
the physical environment
and the person’s individual characteristics and behaviours.
For example, income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
For example, education – low education levels are linked with poor health, more stress and lower self-confidence.
A broad understanding of health.
Health, determinants of health, pathways, and health impacts.
From a population health perspective, health is defined quite broadly. The World Health Organization (WHO) has, rather ambitiously, defined good health as not merely the absence of disease, but a state of complete physical, mental and social well-being (WHO 1981). While this definition is disputed, it provides a better definition for basing HIA than a disease-based definition. Certainly, there are also different cultural interpretations of health, although the same view is not necessarily held by all members of a particular ethnic group.
HIA considers the many factors that combine together to affect the health of individuals and communities, both positively and negatively. Whether people are healthy or not, is determined by our circumstances and the environment we live in. To a large extent, multiple causal factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact. The determinants of health are presented in a number of ways by different people and countries, but all present a similar concept. One common method for presenting the wider determinants of health is that by the Dahlgren and Whitehead (1991) which displays the many layers of determinants. They include:
Age, sex and hereditary factors (genetics). Individual characteristics that are generally considered to be fixed, but that impact on final health potential.
Individual lifestyle factors. Personal behaviours and ways of life that individuals adopt that have health-damaging or health-promoting potential such as: diet; smoking; exercise; sexual practices; coping skills.
Social and community influences. Interactions between the individual and their friends, family and immediate community around them such as: social support networks; peer pressure; social status; dependence on benefits.
Living and working conditions. Factors in peoples immediate surroundings encountered as part of their daily lives such as: safe water and food; clean air; healthy workplaces, type of employment available and size of local businesses; safe communities and roads; quality and quantity of housing stock; access to essential facilities and services such as health care and schools.
General socioeconomic, cultural and environmental conditions. The conditions prevalent in society as a whole (gross domestic product, mean income levels, environmental conditions, employment rates, deprivation and inequalities, life-supporting eco-systems, standard of living; place of women in society; attitudes to ethnic minorities)
The important point stressed by the model is that these determinants interact, and they are inter-related. A change in one layer may lead to a change in another layer; and a health problem/benefit focussed on one layer may be a symptom of a larger issue in some other layer. There are a great number of social determinants of health and the complexity of the causal networks is considerable. Providing public and private policy makers with information about such complexities is important for them to be able to consider health in their decisions.
The pathways through which a proposal may impact on health are those that are presented in the determinants of health model above. The underlying causes (for example general socio economic conditions affect the other determinant of health layers (living and working conditions, social and community influences and individual lifestyle factors), which in turn affect health status. This simple model shows how a non-health sector proposal could ultimately impact on the health of the community. In effect, HIA is concerned with all of the steps in the causal path from proposal to impact, including the ‘causes of the causes’ of health.
The determinants of health can either directly, or indirectly impact on our health. Determinants that have indirect impacts affect intermediate factors that will ultimately impact on people’s health in the long term (long causal link to impact), whereas determinants that have direct impacts do not have an intermediary step (short causal link to impact). Determinants that have direct impacts are such things as smoking, diet and physical activity, etc. Determinants that have indirect health impacts are such things as social support, the environment, taxation policies on smoking, etc.
A final important point about determinants is that they can also be cumulative and multiplicative – so that when more than one determinant is experienced, the health impact is far more significant than what may be expected from simply ‘adding one determinant to another’. For example, asbestos exposure has a far greater health impact on a smoking population than a non-smoking population.

9. What international policies support HIA?
Article 152 of the Amsterdam Treaty - the European Union (EU) should examine the possible impact of major policies on health.
The new Strategic Environmental Assessment protocol - places a special emphasis on the consideration of human health for Europe
1997 Organisation of African Unity Harare Declaration on Malaria Prevention and Control in the Context of African Economic Recovery and Development - included calls for EIA and HIA of all new developments in Africa.
Health21 – The health for all policy framework - outlines strategies to ensure the use of health impact assessment in Europe.
Article 152 of the Amsterdam Treaty The Treaty calls for the European Union (EU) to examine the possible impact of major policies on health. HIAs are relevant as the treaty states that "A high level of health protection shall be ensured in connection with the formulation and implementation of all Community policies and all Community measures". The European Commissions Health Strategy proposal stresses that policies must ensure that public health aspects are considered in all EU decisions and actions – that is, that the EU should conduct health impact assessments. The new Strategic Environmental Assessment protocol Health effects are generally poorly assessed within Environmental Impact Assessments (EIA), if at all. The establishment of a ‘Strategic Environment Assessment (SEA) Protocol’ – to supplement the UNECE ‘Convention on EIA’ is addressing this problem. Thirty-five Governments of European United Nations members signed the new SEA protocol in May 2003 – a political commitment to the protocol provisions. The protocol places a special emphasis on the consideration of human health, going beyond existing legislation. This reflects the political will of the Governments, and the technical support of the health section including WHO. The protocol also recommends that SEA is undertaken early in the decision-making process of proposals, allowing more time for environmental and health issues to be considered as part of a wider sustainability agenda.
1997 Organisation of African Unity Harare Declaration on Malaria Prevention and Control in the Context of African Economic Recovery and Development The Declaration pledged to support fully the implementation of the Global and Regional Strategies and approaches recommended by WHO to eradicate malaria, and called upon all members to take immediate and sustainable action. This included calls for EIA and HIA of all new developments in Africa.
Health21 – The health for all policy framework The 51 countries comprising WHO's European Region have embraced a common policy framework for health development that outlines strategies to turn national policies into practical operational programmes at a local level. After consultations with all Member States and numerous major organizations in the Region, four main strategies for action were chosen to ensure that scientific, economic, social and political sustainability drive the implementation of Health21. The first of which is ‘that multisectoral strategies tackle the determinants of health, taking into account physical, economic, social, cultural and gender perspectives and ensuring the use of health impact assessment’.

10. What international policies support HIA?
The Strategic Environmental Directive -adopted by the European Commission to ensure that environmental consequences of certain plans and programmes are identified and assessed during their preparation and before their adoption.
Environmental impact assessment - a statutory requirement in many countries. Similar to HIA, EIA explores the effect of policies, programmes and projects on the environment.
The Strategic Environmental Directive The European Commission began negotiations for a Directive on Environmental Assessment of plans and programmes in Several amendments to the proposal were made, on route to the SEA Directive being formally adopted by the European Council on 5 June The purpose of the SEA-Directive is to ensure that environmental consequences of certain plans and programmes are identified and assessed during their preparation and before their adoption. Member states are required to implement the directive into their own legislation by 27 June Again, the assessment of the health effects of proposals is not guaranteed, and when it is – it may be narrowly focused and solely quantitative in nature.
Environmental impact assessment EIA began in the 1970s in America. There is a statutory requirement in many countries to undertake EIA. Similar to HIA, EIA explores the effect of policies, programmes and projects on the environment. There is now a statutory requirement for EIA to be undertaken in many countries in the world. The EIA Directive (EU legislation) on Environmental Impact Assessment of the effects of projects on the environment was introduced in 1985 and was amended in Unfortunately EIA does not typically include an assessment of the health effects of proposals, and when it does – it may be narrowly focused and solely quantitative in nature.

11. When is an HIA undertaken?
Before implementation (prospective) - to allow steps to be taken to change a proposal at the planning stage.
If an HIA is to influence a proposal, it must meet the deadlines of any decisions regarding that proposal. The timing of an HIA is also influenced by the degree of development of the proposal – the HIA cannot be so early that the lack of detail in the proposal hinders good predictions of the health impacts and subsequent difficulty in generating concrete recommendations, but also not too late in the process that little influence is achieved with decision makers. There are examples of HIA that have been undertaken where the recommendations were delivered too late to inform the decision making process
A point of discussion in HIA is the role of retrospective HIA and concurrent HIA. Both of these descriptions are unhelpful and that it is time that we only discussed and used prospective HIA. The majority of the work carried out in the approaches known as Retrospective HIA and Concurrent HIA are adequately covered by the usual terms of evaluation and surveillance, and those typically used in the other impact assessment fields. A further reason for not describing all three as impact assessment is that they involve different thought processes. Retrospective and concurrent work requires observation and induction, whereas prospective HIA uses deduction. It is sometimes considered that evaluation is different from retrospective HIA because evaluation generally ‘monitors the extent to which a proposal’s objectives were achieved’. While this is a critical aspect of evaluation, it reduces evaluation to only a fragment of its potential use – which can ‘construct and provide the best possible information that might bear on the value of whatever is being evaluated’. This allows consideration of intended and unintended impacts to be considered in the evaluation, if the evaluator chooses to consider them.

12. Steps in HIA
Identifying if an HIA should occur (screening) - systematically deciding if an HIA necessary.
Identifying what to do and how to do it (scoping) - reviewing the issue in more detail, setting the boundaries for the HIA, and considering how the HIA appraisal stage should be undertaken
Identifying health hazards and considering evidence of impact - considering a range of evidence between the determinants of health and key elements of the proposal.
It is not possible to carry out an HIA on every project, policy or programme. Therefore screening is used to systematically decide when to do an HIA. to as the ‘appraisal or assessment’ stage. This first stage acts as a selection process, where proposals are quickly assessed or ‘screened’ for their potential to affect the population’s health.
Scoping sets the boundaries for, and considers how the HIA appraisal stage should be undertaken.
If a decision is taken that an HIA would be useful, the next task is to consider how it can best be undertaken. This stage involves establishing the practical foundations for the
assessment, and is often referred to as scoping. Key tasks involved in this stage may include
• how and by whom will the HIA process be overseen?
• which decision-makers need to be engaged?
• when are the proposal’s key decision points, and what time is available to undertake the HIA?
• to what extent can those who may be affected by the proposal be involved?
• which specialists and practitioners could usefully be involved?
• what skills and human and financial resources are required and available?
• what are the boundaries for the appraisal of health impacts in terms of time, place and relevant population group and/or geographical area?
• which potential health impacts need further consideration with regard to which population and/or geographical area?
• what range of methods will be used, given the resources available, to gather the evidence base needed to undertake the HIA?
• how will responsibility be divided up for different HIA tasks?
• how will the HIA process be monitored and evaluated?
The third stage involves investigating, appraising and reporting on how the proposal’s implementation is likely to affect the health of the
population/s. This usually involves the following.
Examining the proposal – identifying key elements of the
proposal and considering their relationship to the range of wider determinants of health and inequality. Appraisal often starts with considering potential positive and negative
impacts of the proposal against a set of health determinants.
Collecting and collating the best available qualitative and quantitative evidence – this can involve collating existing sources of evidence, or collecting and collating new data. Evidence sources and data can be collected using a range of qualitative and quantitative methods.
Considering the evidence and appraising impact – this includes identifying and describing the nature and magnitude of the potential – and actual – beneficial and harmful health impacts associated with the proposal. However, considering evidence can be complex because of the interrelationship between different health determinants. Also, it is not always easy to isolate the influences of particular interventions on complex and dynamic social systems. It is therefore important to consider a range of different types of evidence and encourage discussion about their nature, value and potential limitations.
Reporting on the impacts – this needs to be done in a way that helps people understand how the proposal might affect the different groups and communities potentially affected by the proposal, and to focus constructively on the most important health and equity aspects.

13. Steps in HIA
Developing recommendations to reduce hazards and/or improve of health - set of recommended changes to the proposal to the decision makers.
Evaluation and monitoring:
whether the HIA has influenced the decision making process (and the subsequent proposal);
monitoring the implementation of the proposal to ensure that any recommendations that decision- makers agreed to, actually occur;
longer term monitoring of the health of populations is sometimes a component of larger proposals.
Whether or not the steering group has the power to make direct decisions on the proposal, members will be in a position to recommend potential changes to the proposal,
highlighting practical ways to maximise the health gain and to minimise any potentially harmful impacts. Prioritising the recommendations will also be important, so that decision-makers are clear about stakeholders’ views. This is particularly important if resources for implementing the proposal are limited, or there are competing priorities, such as economic or employment considerations. Reaching an agreed set of recommendations may also involve reconciling conflicting impacts. For example, a proposal to
increase physical activity as part of a local transport strategy could lead to some health gain, but may also affect the rate of accidental injuries. In this situation you will not only have to assess the quality of the available evidence, but also consider action to remove or mitigate any potential negative impacts associated with the recommendation.
Recommendations are usually produced in the form of a report. Consideration should also be given to feeding back the findings and recommendations from the HIA process to
the local population affected by the proposal.
It is important to consider both how to monitor and evaluate the proposal’s development and implementation, and the effect of the HIA on the proposal (ie, did it make a
difference?). A good HIA process will aim to monitor and evaluate its activities to help those involved in the assessment to:
• improve the process of HIA
• modify future proposals to achieve health gains
• observe whether the recommendations were implemented
• assess the accuracy of predictions made during appraisal.
This can be undertaken in a number of ways:
• process – assessing how the HIA process was undertaken, who was involved, and how useful and valuable the process was
• impact – tracking how far recommendations are subsequently accepted and implemented by the decision-makers – and if not, why not?
• outcome – assessing whether the anticipated positive effects on health, wellbeing and equity were in fact enhanced, and any negative ones minimised – and if not,
why not, and how can plans be further adapted?

14. HIA tools and guidance
Many different toolkits are available, as are basic guides to carrying out HIA. Find all these at:

15. Some examples of where HIA has been used.
Building a new road near residential areas.
The local village school policy to implement safer routes to school.
Building an out-of-town shopping centre.
Increasing runway & passenger capacity at an airport.
Changing the fuel used in a cement kiln.
Assessing the common agricultural policy.
Rapid, intermediate, comprehensive?
Concurrent, retrospective, prospective?
Who would you involve in the steering group?
Whose responsibility is the HIA? Resources?
There is no right or wrong.

16. Where to from here?
Many examples of HIA are available on website. The site also provides information:
About HIA
Tools and methods to do HIA
How HIA contributes to policy making
The evidence used in HIA
HIA related links and networks.