Improving Health in the United States The Role of Health Impact Assessment (2011) / Chapter Skim
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3 Elements of a Health Impact Assessment
3 Elements of a Health Impact Assessment
Pages 43-89
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This chapter describes the types, structure, and content of HIAs and summarizes the HIA process, methodologic approaches, and variations in practice. It is informed by a review of U.S.
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HIAs are also differentiated according to whether they are integrated into an environmental impact assessment or done independently. Another categorization is based on the breadth of the HIA and distinguishes HIAs that have a tight
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DEFINITION OF HEALTH IMPACT ASSESSMENT The committee proposes on the basis of its review the following adaptation of the current working definition of the International Association of Impact Assessment (Quigley et al.
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WHO CONDUCTS HEALTH IMPACT ASSESSMENTS? HIAs can be conducted by a variety of agencies, organizations, or individuals.
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involved in conducting an HIA. PROCESS FOR HEALTH IMPACT ASSESSMENT The tasks or elements that are described as part of an HIA are fairly consistent in the peer-reviewed literature and guides reviewed by the committee.
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Some decisions to conduct HIA may depend on a specific statutory requirement or mandated procedure. For example, in the context of NEPA, the lead federal agency must consider "the degree to which the proposed action affects public health or safety" to determine whether a proposal is likely to have "significant" effects and therefore require an environmental impact statement (40 CFR 1 Under NEPA, a federal agency must determine whether a federal environmental decision is likely to have significant effects, and if so, the level of analysis required (40 C.F.R.
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Because any actions taken on the basis of HIA recommendations need to be implemented within a specific legal and policy context, screening needs to establish a clear description of the decision-making process and context. It should also identify the points at which there is an opportunity for information from the HIA to influence decisions.
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A preliminary opinion regarding the potential importance of the proposal for health. The expected resource requirements of the HIA and the ability of the HIA team to meet them.
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Poorly selected proposals may result in HIAs that add little new information and consume considerable time and resources of the HIA team to complete and of recipients to review. HIA should not be assumed to be the best approach to every health-policy question but should instead be seen as part of a spectrum of public-health and policyoriented approaches, some of which will be more appropriate than others, depending on the specific application.
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Scoping Scoping establishes the boundaries of the HIA and identifies the health effects to be evaluated, the populations affected, the HIA team, sources of data, methods to be used, and any alternatives to be assessed. Well-executed scoping saves time, work, and resources in the later stages of the HIA (Harris et al.
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During scoping, the HIA team may produce an initial list, refine it on the basis of stakeholder input, and then make it final through research and analysis in the assessment phase. In other cases, the initial scope is generated by stakeholders and then refined through research and input from advisory or steering committees.
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54 FIGURE 3-1 Example of a logic framework that maps out the possible causal pathways by which health effects might occur. Source: SFDPH 2011.
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Infrastructure Need for new roads and transit, water, or sanitation systems Demand on existing infrastructure Services New services as a direct result of proposal Drain on existing services resulting from proposed action Demographics Community composition Traffic volume Residential or commercial use patterns Other
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The HIA team was assisted by an advisory committee, but it appears that the com mittee was not involved in the scoping. The HIA report states that scoping was done by the HIA team and involved desk-based research and a web and postal survey.
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In some cases, the team may draw on outside consultants who have expertise in a specific health issue or method. Furthermore, HIA teams commonly rely on analyses by such experts as traffic-safety engineers or air-quality analysts who provide information on the links between the proposal and changes in health determinants.
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However, where practical, the HIA team should aim to evaluate a variety of alternatives or, minimally, to identify the characteristics of proposed actions that would be health-protective or detrimental to health. For example, although an HIA may not be able to incorporate engineering or economic specifications for alternate routes for a proposed highway, it could discuss factors that would influence health outcomes, such as indicating that a desirable route would be, for example, 100 m from any school or elderly facility or would not be proximate to high-population-density areas with a number of vulnerable people.
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Committee Conclusions Regarding Scoping The credibility and relevance of HIA to the decision-making process rest on a balanced and complete examination of the health risks, benefits, and tradeoffs presented by the project, policy, program, or plan being assessed. For that reason, it is important that scoping begin with a systematic consideration of all potential effects rather than limiting consideration to a subset of issues predetermined by the team's research interests or regulatory requirements.
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Assessing the baseline health status of the affected population provides a reference point with which the predicted changes in health status may be compared; it identifies any groups that could be more vulnerable than the general population to the impacts of the proposal; and it provides an understanding of the factors that are responsible for determining health in the affected communities, and this, in turn, allows for a better understanding of how any changes in those factors may affect health. In general, the baseline profile focuses on health issues and health determinants that may be affected by the proposal rather than on attempting to provide a complete assessment of community health.
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Sources of information used in a baseline profile might include census data, hospital-discharge records, disease registries, and population and behavior surveys, such as the Behavioral Risk Factor Surveillance Survey, in which information is collected on different geographic scales. The baseline profile also generally draws on data that describe the social, economic, and environmental conditions important to health, such as labor or housing reports, environmental impact assessments, and gray or unpublished data specific to the decision context.
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between various groups has been seen as a core task of HIA, although HIA practice has sometimes been criticized for a lack of attention to health equity (ScottSamuel 1996; WHO 1999; Harris et al.
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impact occur High High High Health Outcome Infectious disease Chronic disease Nutritional disorders Injury Mental health and well-being Health Determinant Individual/ Physiological family Behaviour Socio-economic circumstances Environmental Physical Social Economic Institutional Organization of health care Other institutions Policies Source: ICMM 2010. Reprinted with permission; copyright 2010, International Council on Mining and Metals.
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. The available data, however, may not be sufficient, and the HIA team may make a decision to dedicate resources to collection of new data.
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The HIA team identified the pathways in which the expansion would affect the lives of the primarily Iñupiat residents of the area. Activities directly or indi rectly associated with oil and gas -- including aircraft traffic, seismic exploration, influx of nonresident workers, and emissions and discharges -- were identified, and pathways were analyzed to consider their impacts on such problems as diet-related chronic illnesses (for example, diabetes and hypertension)
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Outputs of Assessment Assessment should result in a report that Describes the baseline health status of the affected population with appropriate indicators, including prevalent health problems, health disparities, and social, economic, and environmental factors that affect health. The baseline should be focused on the issues that are likely to be affected by the proposal.
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Decisions are often based on incomplete information and must often be made within a specified time rather than waiting for more complete information. By necessity, therefore, impact assessment is a pragmatic exercise and reflects a balance between scientific rigor and professional judgment.
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. That issue will probably continue to challenge the credibility of HIA practice in the eyes of some audiences and highlights the need for continued research and refinement of methods to improve its value to decision-makers (Petticrew et al.
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An HIA of proposed oil de velopment in Sakhalin Island, Russia, concluded that a large influx of oil and gas workers from outside the region could increase the risk of sexually transmitted ill nesses in workers and the community. The HIA proposed mitigation measures (such as restricting access to the work camp by local residents)
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Because decision-makers must eventually translate health-based recommendations into actionable measures (for example, by modifying legislation, drafting regulations or permit conditions, instituting new zoning requirements, or encouraging voluntary activities) , regular communication between the HIA team and the decision-makers is important for the success of a proposed recommendation (EPA 2009)
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A plan for continuous monitoring, adaptation of mitigation measures, and verification of performance -- although not currently a uniform aspect of HIA practice -- helps to ensure that measures are carried out and achieving their objectives. Such a plan is often referred to as a public-health management plan or a healthaction plan (Quigley et al.
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Committee Conclusions Regarding Recommendations Making recommendations is a well-accepted part of HIA practice, but relatively little attention has been paid to how they should be formulated. The committee notes three considerations that may be particularly important for producing effective, actionable recommendations.
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HIA is meant to assist decision-makers, so although the act of reporting is a formal step in the HIA process, it is also in the interest of decisionmakers and the HIA team to keep in constant communication throughout the HIA process so that emerging results can be incorporated into the policy, plan, program, or project.
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Casey Foundation as an initiative with the potential to encourage long-term strategies and partnerships to strengthen families and communities. Human Impact Partners then worked with groups in other states to extrapolate the findings of the national report to local jurisdictions to analyze the health effects of paid sick days.
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. A number of corporations and professional associations, such as the International Committee on Mining and Metals and the International Association of Oil and Gas Producers, have guidance for HIA, but relatively few completed industry-led HIAs or environmental, social, and health impact assessments are available on the Internet or on public Web sites that catalog HIA activity.
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Furthermore, impact assessments, including HIAs, may rely on proprietary business information whose disclosure is legally barred or could damage a proponent's business edge or competitiveness. Notwithstanding those considerations, the committee considers the public disclosure of HIAs to be an important ideal of practice but recognizes that it may not be realistic to expect widespread disclosure in the absence of requirements or incentives for it.
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Robust and continuing efforts to inform decision-makers of the findings and recommendations of the HIA and efforts by HIA practitioners and other stakeholders to champion choices that will benefit health can be an essential part of an effective HIA. Available studies suggest that efforts to involve and inform decision-makers throughout the HIA process and a strong relationship between the HIA team and decision-makers are often critical for the HIA's effectiveness (Veerman et al.
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Focuses on the changes in health status or health indicators resulting from implementation of the proposal. In practice, most HIAs do not include process, impact, or outcome evaluation; this has been attributed to a lack of interest, time, and resources in the case of process and impact evaluation and to the length of time (often many years)
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In some cases, the impact of the HIA on a decision is clear-cut. For example, in the Alaskan oil and gas HIA mentioned in Box 3-3, the HIA team drafted recommendations in collaboration with the decisionmaker, the Bureau of Land Management, which formally adopted the recommendations as mitigation measures.
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. Outcome evaluation requires a suitable research design, ideally an appropriate comparison group, and data from the monitoring of health outcomes or of changes in health determinants as described above.
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Self-evaluation performed by the HIA team -- for example, against a set of process objectives or practice criteria -- serves quality-assurance aims and can produce insights that will improve the field. Self-evaluation should be considered a valuable step of the HIA process.
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SUMMARY: WHAT CRITERIA DEFINE A HEALTH IMPACT ASSESSMENT? This chapter has described HIA categories, defined HIA, discussed current HIA practice, noted variations in practice, and provided the committee's conclusions regarding each step of the HIA process.
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2010. Minimum Elements and Practice Standards for Health Impact Assessment (HIA)
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2005. Affordable Housing and Child Health: A Child Health Impact Assessment of the Massachusetts Rental Voucher Program.
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2006. Use of health impact assessment in incor porating health considerations in decision making.
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2005. A Guide to Health Impact Assessments in the Oil and Gas Industry.
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2005. Criteria for use in the evaluation of health impact assessments.
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2007. Inupiat health and proposed Alaskan oil development: Results of the first Integrated Health Impact Assessment/Environmental Impact Statement of proposed oil development on Alaska's North Slope.
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89 Elements of a Health Impact Assessment Copenhagen: World Health Organization [online]
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