Methodologies for realizing the potential of health impact assessment

Use of Genomic Information in Health Impact Assessment is Yet to Come: A Systematic Review

Information generated by genetic epidemiology and genomics studies has been accumulating at fast pace, and this knowledge opens new vistas in public health, allowing for the understanding of gene-environment interactions. However, the translation of genome-based knowledge and technologies to the practice of healthcare, and especially of public health, is challenging. Because health impact assessment (HIA) proved to be an effective tool to assist consideration of health issues is sectoral policymaking, this study aimed at exploring its role in the translational process by a systematic literature review on the use of genetic information provided by genetic epidemiology and genomics studies in HIA. PubMed, Scopus, and Web of Science electronic databases were searched and the findings systematically reviewed and reported by the PRISMA guidelines. The review found eight studies that met the inclusion criteria, most of them theoretically discussing the use of HIA for introducing genome-based technologies in healthcare practice, and only two articles considered, in short, the possibility for a generic application of genomic information in HIA. The findings indicate that HIA should be more extensively utilized in the translation of genome-based knowledge to public health practice, and the use of genomic information should be facilitated in the HIA process.

Systematic Literature Review of Health Impact Assessments in Low and Middle-Income Countries

Health Impact Assessments (HIAs) motivate effective measures for safeguarding public health. There is consensus that HIAs in low and middle-income countries (LMICs) are lacking, but no study systematically focuses on those that have been successfully conducted across all regions of the world, nor do they highlight factors that may enable or hinder their implementation. Our objectives are to (1) systematically review, geographically map, and characterize HIA activity in LMICs; and (2) apply a process evaluation method to identify factors which are important to improve HIA implementation in LMICs. A systematic review of peer-reviewed HIAs in 156 LMICs was performed in Scopus, Medline, Web of Science, Sociological abstracts, and LILACs (Latin American and Caribbean Health Sciences) databases. The search used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and covered HIAs across all type of interventions, topics, and health outcomes. HIAs were included if they reported a clear intervention and health outcome to be assessed. No time restriction was applied, and grey literature was not included. The eligible studies were subjected to six process evaluation criteria. The search yielded 3178 hits and 57 studies were retained. HIAs were conducted in 26 out of 156 countries. There was an unequal distribution of HIAs across regions and within LMICs countries. The leading topics of HIA in LMICs were air pollution, development projects, and urban transport planning. Most of the HIAs reported quantitative approaches (72%), focused on air pollution (46%), appraised policies (60%), and were conducted at the city level (36%). The process evaluation showed important variations in the way HIAs have been conducted and low uniformity in the reporting of six criteria. No study reported the time, money, and staff used to perform HIAs. Only 12% of HIAs were based on participatory approaches; 92% of HIAs considered multiple outcomes; and 61% of HIAs provided recommendations and fostered cross-national collaboration. The limited transparency in process, weak participation, and inconsistent delivery of recommendations were potential limitations to HIA implementation in low and middle-income countries. Scaling and improving HIA implementation in low and middle-income countries in the upcoming years will depend on expanding geographically by increasing HIA governance, adapting models and tools in quantitative methods, and adopting better reporting practices.

[An innovative approach to local development of health promotion to reduce social inequalities in health]

INTRODUCTION

The city of Villeurbanne has made the political choice to reduce social inequalities in health (SIH). The Public Health Department wanted to assess the health impact in the context of this project. The main objective was to analyse the links between urban development and health in order to identify the impact of the urban project on health and to make recommendations to reduce physical inactivity of children. Attention was focused on a neighbourhood of 6,000 inhabitants in the process of urban renewal. A high rate of adults on antidiabetic treatment was observed in this relatively deprived neighbourhood. School medicine also noted a high proportion of overweight children in schools in the neighbourhood, higher than in all schools of the city. The objective of this HIA was therefore to identify the impact of the renovation project on children's mobility and to make recommendations in order to combat their physical inactivity by encouraging spontaneous physical activity.

METHODS

The selected determinants were grouped into four categories: outdoor environment, use of open spaces, adapted sports facilities/equipment, roads. The evaluation was based on analysis of urban planning documents, environmental analysis reports, ad hoc surveys, individual interviews with the various partners and target actors. A bibliographic review confirmed the positive or negative impacts of various aspects of the project on health.

RESULTS

Although some aspects of the project had a positive impact on the health of the inhabitants, others have a negative impact on children's mobility, well-being and social capital. About 30 recommendations were proposed and prioritized according to their political support and their technical, economic and temporal feasibility.

DISCUSSION

The HIA created a dynamic cross-working between sectors other than health and provided an opportunity to educate and inform stakeholders on different concepts and their roles in promoting positive health behaviours. The HIA, as a tool to promote health, contributes to implementation of strategies designed to transform living conditions responsible for social inequalities in health.

Challenges and Opportunities of Integrating Human Health into the Environmental Assessment Process: The Canadian Experience Contextualised to International Efforts

A scoping review of the literature was conducted to identify the most pressing issues pertaining to the application of Health Impact Assessment (HIA) and the integration of health concerns into the Environmental Assessment (EA) process in Canada and internationally. The issues identified include the need for government intervention, gaps in methodology and tools, limitations of capacity and expertise, poor intersectoral, disciplinary and public collaboration/participation, challenges of data quantification and analytic complexity, and the need for process efficiency. The issues presented were also contextualised to the status quo practice of EA in Canada and the Canadian Environmental Assessment Act (CEAA 2012). Recommendations were proposed as a starting point for improved integration. First, a commitment by the actors involved to the protection of human health — aligned with the core mandate of the CEAA. Second, the achievement of intersectoral, disciplinary and public collaboration, led by government, ideally the health sector. The case is made for a new era of Canadian leadership and innovation at the interface of health and EA.

[Utilization of tacit knowledge by maternal healthcare providers: a systematic mapping of the literature]

INTRODUCTION

The search for efficient answers to strengthen maternal health care has included various sources of evidence for decision making. In this article, we present a systematic mapping of the scientific literature on the use of tacit knowledge in relation to maternal healthcare.

METHODS

A systematic mapping was conducted of scientific articles published in Spanish and English between 1971 and 2014 following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

Of 793 articles, 30 met the inclusion criteria; 60% were from high-income countries and 66.7% were focused on health professionals. We identified a predominance of qualitative methodologies (62%). Four categories regarding the use of tacit knowledge were generated: proposals to improve the organization of the maternal care system (30%) and to improve the care provided to women during the continuum of pregnancy, childbirth and postpartum (26.7%), determination of health workers' perception and skill levels (26.7%) and the interactions between tacit and explicit knowledge in clinical decision making (16.7%).

CONCLUSIONS

This mapping shows that tacit knowledge is an emerging, innovative and versatile research approach used primarily in high-income countries and that includes interesting possibilities for its use as evidence to improve maternal healthcare, particularly in middle- and low-income countries, where it needs to be strengthened.

Health impact assessments for environmental restoration: the case of Caño Martín Peña

BACKGROUND

Health Impact Assessment (HIA) is a methodology for predicting the effects of a proposed policy or plan on health. A proposed environmental restoration and development plan presented an opportunity for an HIA in an environmental justice community surrounding the Martín Peña channel in San Juan, Puerto Rico. The HIA focused on the dredging of the channel, debris removal, road, sewer, and storm water infrastructure improvements, housing demolition, and resident relocation.

OBJECTIVE

The aim of this study was to determine the potential effects of the proposed plan on the community's health to inform the funding decision by the Puerto Rican legislature. As the first HIA in Puerto Rico, a secondary objective was to build HIA capacity in Puerto Rico.

METHODS

This HIA used community training, literature reviews, existing local studies, focus groups, interviews, and disease surveillance data to assess baseline health, determine expected effects, and build capacity.

FINDINGS

The Martín Peña community is experiencing deteriorating environmental conditions. Flooding and negative environmental exposures, such as mold, limits to physical activity, stress, chemical toxicants, pathogenic bacteria, and pests, are worsening. The higher rates of diseases, such as asthma and diarrhea, in the community compared with elsewhere in Puerto Rico appear to be largely attributable to these factors. Overall, the proposed plan is expected to improve many of these health disparities but the successful implementation depends on continued community acceptance and participation, particularly with the relocation process. Recommendations are for full financing and several mitigation efforts to avoid negative and preserve beneficial health consequences.

CONCLUSIONS

As the first HIA in Puerto Rico, this assessment provided specific recommendations to benefit the health of the community affected by an environmental restoration and development plan and also capacity building for a larger audience in Puerto Rico. This approach could be generalized to other Latino environmental justice communities in Puerto Rico and abroad.

Health impact assessment in Mongolia: current situation, directions, and challenges

Many developing countries have limited capacity to adequately assess and manage health impacts associated with environmental change. In Mongolia, methodologies to introduce health impact assessment (HIA) as part of the environmental impact assessment (EIA) process have been investigated, and a mechanism to incorporate HIA into the current EIA process is proposed. Some challenges to the implementation of HIA are discussed. The country is now in a position to incorporate HIA as part of the approvals process for development projects. Given the recent growth in population, industrial development, and urbanization together with the interest from international mining companies in the resources of the country, it is important for Mongolia to have such tools in place in order to take advantage of economic growth while improving health and well-being outcomes for the population.

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.

Health impact assessment of the Atlanta BeltLine

BACKGROUND

Although a health impact assessment (HIA) is a tool that can provide decision makers with recommendations to promote positive health impacts and mitigate adverse health impacts of proposed projects and policies, it is not routinely conducted on most major projects or policies.

PURPOSE

To make health a decision criterion for the Atlanta BeltLine, a multibillion-dollar transit, trails, parks, and redevelopment project.

METHODS

An HIA was conducted in 2005-2007 to anticipate and influence the BeltLine's effect on health determinants.

RESULTS

Changes in access and equity, environmental quality, safety, social capital, and physical activity were forecast, and steps to maximize health benefits and reduce negative effects were recommended. Key recommendations included giving priority to the construction of trails and greenspace rather than residential and retail construction, making health an explicit goal in project priority setting, adding a public health professional to decision-making boards, increasing the connectivity between the BeltLine and civic spaces, and ensuring that affordable housing is built. BeltLine project decision makers have incorporated most of the HIA recommendations into the planning process. The HIA was cited in the awarding of additional funds of $7,000,000 for brownfield clean-up and greenspace development. The project is expected to promote the health of local residents more than in the absence of the HIA.

CONCLUSIONS

This report is one of the first HIAs to tie specific assessment findings to specific recommendations and to identifiable impacts from those recommendations. The lessons learned from this project may help others engaged in similar efforts.

Health impact assessment as a strategy for intersectoral collaboration

OBJECTIVES

This study examined the use of health impact assessment (HIA) as a tool for intersectoral collaboration using the case of an HIA project conducted in Gwang Myeong City, Korea.

METHODS

A typical procedure for rapid HIA was used. In the screening step, the Aegi-Neung Waterside Park Plan was chosen as the target of the HIA. In the scoping step, the specific methods and tools to assess potential health impacts were chosen. A participatory workshop was held in the assessment step. Various interest groups, including the Department of Parks and Greenspace, the Department of Culture and Sports, the Department of Environment and Cleansing, civil societies, and residents, discussed previously reviewed literature on the potential health impacts of the Aegi-Neung Waterside Park Plan.

RESULTS

Potential health impacts and inequality issues were elicited from the workshop, and measures to maximize positive health impacts and minimize negative health impacts were recommended. The priorities among the recommendations were decided by voting. A report on the HIA was submitted to the Department of Parks and Greenspace for their consideration.

CONCLUSIONS

Although this study examined only one case, it shows the potential usefulness of HIA as a tool for enhancing intersectoral collaboration. Some strategies to formally implement HIA are discussed.

Estimating the potential health impact and costs of implementing a local policy for food procurement to reduce the consumption of sodium in the county of Los Angeles

OBJECTIVES

We examined approaches to reduce sodium content of food served in settings operated or funded by the government of the County of Los Angeles, California.

METHODS

We adapted health impact assessment methods to mathematically simulate various levels of reduction in the sodium content of food served by the County of Los Angeles and to estimate the reductions' potential impacts on mean systolic blood pressure (SBP) among food-service customers. We used data provided by county government food-service vendors to generate these simulations.

RESULTS

Our analysis predicted that if the postulated sodium-reduction strategies were implemented, adults would consume, on average, 233 fewer milligrams of sodium each day. This would correspond to an average decrease of 0.71 millimeters of mercury in SBP among adult hypertensives, 388 fewer cases of uncontrolled hypertension in the study population, and an annual decrease of $629,724 in direct health care costs.

CONCLUSIONS

Our findings suggest that a food-procurement policy can contribute to positive health and economic effects at the local level. Our approach may serve as an example of sodium-reduction analysis for other jurisdictions to follow.

A rapid equity focused health impact assessment of a policy implementation plan: An Australian case study and impact evaluation

BACKGROUND

Equity focused health impact assessments (EFHIAs), or health equity impact assessments, are being increasingly promoted internationally as a mechanism for enhancing the consideration of health equity in the development of policies, programs and projects. Despite this there are relatively few examples of examples of completed EFHIAs available. This paper presents a case study of a rapid EFHIA that was conducted in Australia on a health promotion policy implementation plan. It briefly describes the process and findings of the EFHIA and evaluates the impact on decision-making and implementation.

METHODS

The rapid EFHIA was undertaken in four days, drawing on an expert panel and limited review of the literature. A process evaluation was undertaken by email one month after the EFHIA was completed. An impact evaluation was undertaken two years later based on five semi-structured interviews with members of the EFHIA working group and policy officers and managers responsible for implementing the plan. A cost estimation was conducted by the EFHIA working group.

FINDINGS

The EFHIA made both general and specific recommendations about how the health equity impacts of the policy implementation plan could be improved. The impact evaluation identified changes to development and implementation that occurred as a result of the EFHIA, though there was disagreement about the extent to which changes could be attributed solely to the EFHIA. Those responsible considered the recommendations of the EFHIA in the next versions of their ABHI implementation plans. Factors that influenced the impact of the EFHIA included consolidating understandings of equity, enabling discussion of alternatives, and differing understandings of the purpose of the EFHIA. The EFHIA cost US$4,036 to undertake.

CONCLUSIONS

This EFHIA was conducted in a short timeframe using relatively few resources. It had some reported impacts on the development of the implementation plan and enhanced overall consideration of health equity. This case highlights some of the factors and preconditions that may maximise the impact of future EFHIAs on decision-making and implementation.

Standard tool for quantification in health impact assessment a review

BACKGROUND

The health impact assessment (HIA) of policy proposals is becoming common practice. HIA represents a broad approach with quantification of the impact of policy options at its core. However, no standard tool is available and it remains unclear whether any current model can serve as a standard for the field.

PURPOSE

The aim of this study is to assess whether already existing models can be used as a standard tool for the quantification step in an HIA.

METHODS

A search in 2008 identified 20 models for HIA, of which six are sufficiently generic to allow for various and multiple diseases and different risk factors: Age-Related Morbidity and Death Analysis, Global Burden of Disease, Population Health Modeling, PREVENT, Proportional Life Table Method, and the National Institute for Public Health and the Environment (the Netherlands) Chronic Disease Model. These were evaluated along three proposed model structure criteria (real-life population, dynamic projection, explicit risk-factor states) and three usability criteria (modest data requirements, rich model output, generally accessible) developed to address the needs and requirements of the HIA framework.

RESULTS

Of the six generic models investigated, none fulfills all the proposed criteria as a standard HIA tool. The models are either technically advanced with no or limited accessibility, or they are accessible but oversimplified.

CONCLUSIONS

Further work on models for HIA with equal emphasis on technical appropriateness, availability of data, and end-user-friendly implementation is warranted if the field is to move forward.

The built environment and health: introducing individual space-time behavior

Many studies have examined the relationship between the built environment and health. Yet, the question of how and why the environment influences health behavior remains largely unexplored. As health promotion interventions work through the individuals in a targeted population, an explicit understanding of individual behavior is required to formulate and evaluate intervention strategies. Bringing in concepts from various fields, this paper proposes the use of an activity-based modeling approach for understanding and predicting, from the bottom up, how individuals interact with their environment and each other in space and time, and how their behaviors aggregate to population-level health outcomes.

A model for probabilistic health impact assessment of exposure to food chemicals

A statistical model is presented extending the integrated probabilistic risk assessment (IPRA) model of van der Voet and Slob [van der Voet, H., Slob, W., 2007. Integration of probabilistic exposure assessment and probabilistic hazard characterisation. Risk Analysis, 27, 351-371]. The aim is to characterise the health impact due to one or more chemicals present in food causing one or more health effects. For chemicals with hardly any measurable safety problems we propose health impact characterisation by margins of exposure. In this probabilistic model not one margin of exposure is calculated, but rather a distribution of individual margins of exposure (IMoE) which allows quantifying the health impact for small parts of the population. A simple bar chart is proposed to represent the IMoE distribution and a lower bound (IMoEL) quantifies uncertainties in this distribution. It is described how IMoE distributions can be combined for dose-additive compounds and for different health effects. Health impact assessment critically depends on a subjective valuation of the health impact of a given health effect, and possibilities to implement this health impact valuation step are discussed. Examples show the possibilities of health impact characterisation and of integrating IMoE distributions. The paper also includes new proposals for modelling variable and uncertain factors describing food processing effects and intraspecies variation in sensitivity.

A review of health impact assessment frameworks

BACKGROUND

Consideration of health impacts of non-health sector policies has been encouraged in many countries, with health impact assessment (HIA) increasingly used worldwide for this purpose. HIA aims to assess the potential impacts of a proposal and make recommendations to improve the potential health outcomes and minimize inequalities. Although many of the same techniques can be used, such as community consultation, engagement or profiling, HIA differs from other community health approaches in its starting point, purpose and relationship to interventions. Many frameworks have been produced to aid practitioners in conducting HIA.

OBJECTIVE

To review the many HIA frameworks in a systematic and comparative way.

STUDY DESIGN

Systematic review.

METHOD

The literature was searched to identify published frameworks giving sufficient guidance for those with the necessary skills to be able to undertake an HIA.

RESULTS

Approaches to HIA reflect their origins, particularly those derived from Environmental Impact Assessment (EIA). Early HIA resources tended to use a biomedical model of health and examine projects. Later developments were designed for use with policy proposals, and tended to use a socio-economic or environmental model of health. There are more similarities than differences in approaches to HIA, with convergence over time, such as the distinction between 'narrow' and 'broad' focus HIA disappearing. Consideration of health disparities is integral to most HIA frameworks but not universal. A few resources focus solely on inequalities. The extent of community participation advocated varies considerably.

CONCLUSION

It is important to select an HIA framework designed for a comparable context, level of proposal and available resources.

The Quality Improvement Demonstration Study: an example of evidence-based policy-making in practice

Background

Randomized trials have long been the gold-standard for evaluating clinical practice. There is growing recognition that rigorous studies are similarly needed to assess the effects of policy. However, these studies are rarely conducted. We report on the Quality Improvement Demonstration Study (QIDS), an example of a large randomized policy experiment, introduced and conducted in a scientific manner to evaluate the impact of large-scale governmental policy interventions.

Methods

In 1999 the Philippine government proposed sweeping reforms in the National Health Sector Reform Agenda. We recognized the unique opportunity to conduct a social experiment. Our ongoing goal has been to generate results that inform health policy. Early on we concentrated on developing a multi-institutional collaborative effort. The QIDS team then developed hypotheses that specifically evaluated the impact of two policy reforms on both the delivery of care and long-term health status in children. We formed an experimental design by randomizing matched blocks of three communities into one of the two policy interventions plus a control group. Based on the reform agenda, one arm of the experiment provided expanded insurance coverage for children; the other introduced performance-based payments to hospitals and physicians. Data were collected in household, hospital-based patient exit, and facility surveys, as well as clinical vignettes, which were used to assess physician practice. Delivery of services and health status were evaluated at baseline and after the interventions were put in place using difference-in-difference estimation.

Results

We found and addressed numerous challenges conducting this study, namely: formalizing the experimental design using the existing health infrastructure; securing funding to do research coincident with the policy reforms; recognizing biases and designing the study to account for these; putting in place a broad data collection effort to account for unanticipated findings; introducing sustainable policy interventions based on the reform agenda; and providing results in real-time to policy makers through a combination of venues.

Conclusion

QIDS demonstrates that a large, prospective, randomized controlled policy experiment can be successfully implemented at a national level as part of sectoral reform. While we believe policy experiments should be used to generate evidence-based health policy, to do this requires opportunity and trust, strong collaborative relationships, and timing. This study nurtures the growing attitude that translation of scientific findings from the bedside to the community can be done successfully and that we should raise the bar on project evaluation and the policy-making process.

[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.

The forest for the trees: a systems approach to human health research

We explore the relationship between current research directions in human health and environmental and public health policy. Specifically, we suggest there is a link between the continuing emphasis in biomedical research on individualized, therapeutic solutions to human disease and the increased reliance on individual choice in response to environmental and/or public health threats. We suggest that continued research emphasis on these traditional approaches to the exclusion of other approaches will impede the discovery of important breakthroughs in human health research necessary to understand the emerging diseases of today. We recommend redirecting research programs to interdisciplinary and population-focused research that would support a systems approach to fully identifying the environmental factors that contribute to disease burden. Such an approach would be able to address the interactions between the social, ecological, and physical aspects of our environment and explicitly include these in the evaluation and management of health risks from environmental exposures.

Growing the field of health impact assessment in the United States: an agenda for research and practice

Health impact assessment (HIA) methods are used to evaluate the impact on health of policies and projects in community design, transportation planning, and other areas outside traditional public health concerns. At an October 2004 workshop, domestic and international experts explored issues associated with advancing the use of HIA methods by local health departments, planning commissions, and other decisionmakers in the United States. Workshop participants recommended conducting pilot tests of existing HIA tools, developing a database of health impacts of common projects and policies, developing resources for HIA use, building workforce capacity to conduct HIAs, and evaluating HIAs. HIA methods can influence decisionmakers to adjust policies and projects to maximize benefits and minimize harm to the public's health.