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Frequently Asked Questions About Health Impact Assessment

What is health impact assessment?

There are many definitions of health impact assessment (HIA), however the most widely accepted one is from the Gothenburg Consensus Paper:

A combination of procedures, methods and tools by which a policy, program or project may be assessed and judged for its potential effects on the health of the population and the distribution of these impacts within the population.

European Centre for Health Policy, 1999

This definition highlights several of the key features of HIA that should be considered when undertaking HIA:

  • HIA can be undertaken on policies, programs or projects. It can also be undertaken on plans or other detailed strategic proposals.
  • HIA should be undertaken when it will add value to decision-making processes and where there is a commitment to acting on the HIA's recommendations.
  • HIA should be undertaken prior to the implementation of the policy, program and project that is being assessed.
  • HIA should assess the potential positive and negative impacts on health. This should seek to identify any unintended or previously unidentified potential impacts.
  • Health should be broadly defined to include assessments of health hazards and risks as well as ways in which health and wellbeing could be promoted and the social forces that impact negatively on health reduced.
  • HIA should look at the impacts on populations both directly and indirectly affected by the proposal.
  • HIA should include equity as a central concern. For more information see the Equity Focused HIA page.
  • HIA should engage key stakeholders in the formulation of recommendations.
  • HIA should be solution-focused, i.e. it

What are the key steps in health impact assessment?

There are many methods by which potential impacts on health can be examined, including:

  • Evaluation
  • Needs Assessment
  • Monitoring
  • Health impact assessment -
  • Other tools such as the New South Wales Aboriginal Health Impact Statement (Australia)

Knowing when to use a health impact assessment to answer the question as opposed to a needs assessment is important.  Having an understanding of what's involved in a HIA, is one way of knowing when to use HIA and when to use other approaches.  The five steps that "define" a HIA are:


  1. Screening
  2. Scoping
  3. Identification and Assessment of the potential health impacts
  4. NegotiaThursday, November 16, 2006 16:41htm">Monitoring and evaluation

These five steps do not have to be undertaken in the same way and different proposals will require different methods as part of each step - the "socket set" approach.   It is essential, however, that these five steps are understood as integral to any health impact assessment - they "define" HIA.

How is health impact assessment different from other kinds of impact assessment?

Impact assessment:

. is a process whereby predictions are made about the future consequences or impacts of changes being made or considered.  The concept is general, . Within a specific context, such as health effects, there may be a wide range of outcomes for which impacts could be assessed, such as death . GP visits, . absence from work . Different contexts may emphasise different outcome measures, but the constant theme is future prediction, and in particular prediction of differences in outcomes under different scenarios of change against the status quo.
(Miller & Hurley, 2003, p.200)


Health impact assessment is only one type of impact assessment and the other kinds of impact assessment include:

  • Environmental impact assessment
  • Social impact assessment
  • Integrated impact assessment

Environmental and social impact assessment are the specific contexts within which the impact assessment takes place.  Social impact assessment prospectively assesses the potential social impacts of a specific policy or program initiative (where government is usually the proponent).  For example, Area Health Services in NSW are often asked to report on the social impacts of the introduction of a new gaming (alcohol & gambling) venue within their area.  The impacts addressed in an environmental impact assessment are wide ranging with "health effects" forming just one component.  For example, an EIA of a major development project will look at the impact(s) on the socio-economic environment, human health, aboriginal archaeology, non-indigenous heritage, noise and vibration, air quality, greenhouse gas emissions, transport and recreation and amenity with the intent of assessing the overall impact on the environment. 

Health impact assessment has its origins in EIA. The main differences between HIA as a standalone process (as opposed to HIA in EIA) and other forms of impact assessment include:

  • A different context - HIA (outside of EIA) specifically assesses the potential impacts on human health including impact of the social determinants of health on outcomes such as life expectancy, well-being, mental health and other morbidity measures.  The impact of the physical environment on health will be addressed as part of this;
  • Prospective impact assessment of a proposed policy, plan, program or project/development - HIA is not limited to the potential impacts of a major development such as the development of a new landfill site but might assess the potential impacts of a proposed new taxation policy or a new chronic disease initiative on the health of a population.
  • A core principle of HIA is equity - a HIA considers how potential health impacts are distributed in the population, differential health impacts and whether these impacts are potentially inequitable.

For further information about other types of impact assessment see:

Mindell J, Ison E & Joffe M (2003)

A Glossary for Health Impact Assessment. Journal of Epidemiology and Community Health, 57; 647-651.

Where does HIA sit in the planning or policy development cycle?

There are many methods by which health impact can be measured, including:

  • Evaluation
  • Needs Assessment
  • Monitoring during implementation
  • Health impact assessment - rapid/comprehensive/medium and prospective/concurrent/retrospective
  • Using tools such as the Aboriginal Health Impact Statement, audits, checklists etc

Knowing where HIA sits in relation to other methods for measuring health impact should assist in identifying when it is appropriate to use HIA. 

The following diagram outlines where HIA sits in relation to other methods for measuring health impact:



Adapted from Simpson S, Harris E & Harris-Roxas B (2003) Health Impact Assessment:
An introduction to the what, why and how, Health Promotion Journal of Australia,
15(2): 162-167.

HIA should not be used in place of sound needs assessment or planning but can be used to test a draft policy/plan/program that has been developed as a result of needs assessment and planning.  The HIA's recommendations can then be used to strengthen the proposal as well as informing the development of indicators for monitoring and evaluation.

How is health impact assessment different from needs assessment?

Health impact assessment (HIA) is different from needs assessment in that it seeks to assess the potential health impacts of an actual proposal (policy, program, plan, or project) - there is something tangible to assess.  In contrast a needs assessment is conducted to develop a comprehensive picture of key (health) issues in a particular community, population group or geographic area.  The findings of a needs assessment are usually used to inform the development and/or revision of a policy, program, project or plan - ie. to develop a proposal.  HIA might then be used to assess the potential health impacts of the proposal developed in response to the "needs" or issues identified through the needs assessment.  In essence, needs assessment is something to be done before HIA.

See also Where does HIA sit in the planning or policy development cycle.

How is health impact assessment different from monitoring?

Health impact assessment (HIA) is different from monitoring in that it seeks to assess the potential health impacts of an actual proposal (policy, program, plan, or project).  In contrast monitoring is usually undertaken during and following implementation and the results of monitoring may be used to inform evaluation of an initiative. HIA's recommendations might be used to inform the monitoring process, e.g. recommending the types of information that need to be collected to measure whether the potential health impacts eventuated.   In terms of the planning or policy development cycle, monitoring is something that is done after HIA.

See also Where does HIA sit in the planning or policy development cycle?

How is health impact assessment different from evaluation?

Health impact assessment (HIA) is undertaken prospectively - before the policy, program or project is implemented; unlike evaluation which is retrospective.  The value add of HIA is that it assists in the identification of negative and/or unintended consequences in advance of implementation.  This provides an opportunity to ameliorate or amend the policy, program or project before implementation, saving not only resources but also maximizing the positive impacts from the proposed initiative.

Another key difference between HIA and evaluation is that it looks at the differential impact of the proposed policy, program or project (initiative) within the population.  This includes (but is not limited to) looking at the distribution of impact in terms of socioeconomic status, gender, age, and ethnic background (ECHP, 1999). In contrast, the equity of impacts is not necessarily a principle that is considered in evaluation.

While Health impact assessment and evaluation are different it is important to recognise they are also linked.  Evaluations of existing policy, programs or projects can contribute to the literature that is then used to form the basis of the information that informs a HIA.   An evaluation of an existing initiative might include scenarios that are used to predict what the consequences might be of amending or changing the initiative, enabling the incorporation of an HIA approach.  Also a HIA can provide information about the types of indicators that should be monitored during implementation and considered as part of the evaluation of an initiative.

When should we do a health impact assessment?

. resource constraints mean that it will not always be possible to conduct an HIA, and therefore it will be necessary to prioritise inquiries. (Nilunger et al, 2002, p.32)

In order to make the most efficient use of available expert resources, it is necessary to be selective about what work is undertaken.  (Scott-Samuel et al, 1998, p.7)

Not everybody who is developing a policy/program/plan or project needs to do health impact assessment.  Although the decision to undertake an HIA should not be solely based on whether resources are available, this aspect does need to be taken into account.  The decision to undertake an HIA or not and the level of HIA (rapid, intermediate or comprehensive) should be undertaken as part of the screening process - which is the first step in the HIA process and the process where projects, policies or programs are selected for HIA (Scott-Samuel et al, 1998).

The Merseyside Guidelines recommend that the following issues should inform whether or not an HIA is required:

  • economic issues eg. what is the cost of the initiative and its distribution
  • outcome issues eg. an estimate of the potential health impacts of the initiative
  • epidemiological issues eg. the degree of certainty (risk) of health impacts
  • strategic issues eg. the need to give greater priority to HIA of policies than to programs and to programs than to projects given the wider scope and potential impact of policies and then programs  (Scott-Samuel et al, 1998, p.8)

The Federation of Swedish County Councils also recommend that before commencing any type of HIA, consideration should be given to ". whether there is any point in applying HIA to the proposal in question." (1998, p.15).

Therefore application of HIA will need to give due consideration to these types of issues.  What this question highlights is that HIA is a value driven process, a process that involves trade-offs and that in deciding to undertake an HIA it is always important to ask - what will the added value be of undertaking an HIA and will it add value to the decision-making process?  As highlighted by the Merseyside Guidelines, a number of issues (ranging from economic to strategic) need to inform the answer to this question.

In New South Wales, Australia, a number of developmental HIA sites have been established as part of the NSW HIA Project. One of the aims of the sites has been to better identify the "triggers" for when HIA should be used.


What's the rationale for undertaking health impact assessment?

There are broadly four reasons that are given for undertaking HIAs:

  • To identify hazards to health from the proposed development;
  • To reduce or eliminate potential risks to health arising from these hazards and/or undertake risk communication as part of this process;
  • To identify, and where feasible strengthen, the ways in which the proposed development can promote health; and
  • To identify and address underlying social, environmental and economic impacts of the development that will have both direct and indirect impacts on health.

The first two reasons would generally fit more easily within a risk assessment/health protection focus while the last two build onto these approaches to identify ways in which health can be enhanced and underlying determinants of health addressed.

The "value add" of HIA is that it enables decision makers to enhance the potentially positive aspects and/or ameliorate the potentially negative aspects of the proposed policy, program, plan or project prior to implementation.

For more information about the rationale and potential "value add" of prospective HIA see:

Kemm JR.(2000)

Can Health Impact Assessment fulfil the expectations it raises? Public Health, 114:431-433.

References

ECHP (1999)

Gothenberg Consensus Paper on Health Impact Assessment: main concepts and suggested approach, European Centre for Health Policy, WHO Regional Office for Europe: Brussels.
http://www.who.dk/document/PAE/Gothenburgpaper.pdf

Federation of Swedish County Councils (1998)

Focusing on Health: How can the health impact of policy decisions be assessed? Landstrings Forbundet & Svenska Kommunforbundet: Stockholm
Review

Miller B Hurley J (2003)

Life Table methods for Quantitative Impact Assessments in Chronic Mortality,  Journal of Epidemiology and Community Health, 57, p 200-206

Nilunger L, Schafer Elinder L & Pettersson B (2002)

Health Impact Assessment: screening of Swedish governmental inquiries.  Health Policy, 8(5), p 30-32.

Scott-Samuel, Birley & Arden (1998)

The Merseyside Guidelines for Health Impact Assessment.  Liverpool Public Health Observatory: Liverpool.
Read Review

Simpson S, Harris E & Harris-Roxas B (2003)

Health Impact Assessment: An introduction to the what, why and how, Health Promotion Journal of Australia, 15(2): 162-167




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