Health impact assessment

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Health impact assessment (HIA) is defined as "a combination of procedures, methods, and tools by which a policy, program, 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." ( ECHP 1999 , p. 4)

Population health v

Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population. This concept does not refer to animal or plant populations. It has been described as consisting of three components. These are "health outcomes, patterns of health determinants, and policies and interventions". A priority considered important in achieving the aim of Population Health is to reduce health inequities or disparities among different population groups due to, among other factors, the social determinants of health, SDOH. The SDOH include all the factors that the different populations are born into, grow up and function with throughout their lifetimes which potentially have a measurable impact on the health of human populations. The Population Health concept represents a change in the focus from the individual-level, characteristic of most mainstream medicine. It also seeks to complement the classic efforts of public health agencies by addressing a broader range of factors shown to impact the health of different populations. The World Health Organization's Commission on Social Determinants of Health, reported in 2008, that the SDOH factors were responsible for the bulk of diseases and injuries and these were the major causes of health inequities in all countries. In the US, SDOH were estimated to account for 70% of avoidable mortality.



HIA is intended to produce a set of evidence-based recommendations to inform decision-making ( Taylor & Quigley 2002 , p. 2). HIA seeks to maximise the positive health impacts and minimise the negative health impacts of proposed policies, programs or projects.

Evidence Material supporting an assertion

Evidence, broadly construed, is anything presented in support of an assertion. This support may be strong or weak. The strongest type of evidence is that which provides direct proof of the truth of an assertion. At the other extreme is evidence that is merely consistent with an assertion but does not rule out other, contradictory assertions, as in circumstantial evidence.

Decision-making cognitive process resulting in the selection of a belief or a course of action among several alternative possibilities

In psychology, decision-making is regarded as the cognitive process resulting in the selection of a belief or a course of action among several alternative possibilities. Every decision-making process produces a final choice, which may or may not prompt action.

Health, as defined by the World Health Organization (WHO), is "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." This definition has been subject to controversy, as it may have limited value for implementation. Health may be defined as the ability to adapt and manage physical, mental and social challenges throughout life.

The procedures of HIA are similar to those used in other forms of impact assessment, such as environmental impact assessment or social impact assessment. HIA is usually described as following the steps listed, though many practitioners break these into sub-steps or label them differently:

Policy Impact Assessments (IAs) are formal, evidence-based procedures that assess the economic, social, and environmental effects of public policy. They have been incorporated into policy making in the OECD countries and the European Commission.

Environmental impact assessment

Environmental assessment (EA) is the assessment of the environmental consequences of a plan, policy, program, or actual projects prior to the decision to move forward with the proposed action. In this context, the term "environmental impact assessment" (EIA) is usually used when applied to actual projects by individuals or companies and the term "strategic environmental assessment" (SEA) applies to policies, plans and programmes most often proposed by organs of state. Environmental assessments may be governed by rules of administrative procedure regarding public participation and documentation of decision making, and may be subject to judicial review.

Social impact assessment (SIA) is a methodology to review the social effects of infrastructure projects and other development interventions. Although SIA is usually applied to planned interventions, the same techniques can be used to evaluate the social impact of unplanned events, for example disasters, demographic change and epidemics.

  1. Screening - determining if an HIA is warranted/required
  2. Scoping - determining which impacts will be considered and the plan for the HIA
  3. Identification and assessment of impacts - determining the magnitude, nature, extent and likelihood of potential health impacts, using a variety of different methods and types of information
  4. Decision-making and recommendations - making explicit the trade-offs to be made in decision-making and formulating evidence-informed recommendations
  5. Evaluation, monitoring and follow-up - process and impact evaluation of the HIA and the monitoring and management of health impacts

The main objective of HIA is to apply existing knowledge and evidence about health impacts, to specific social and community contexts, to develop evidence-based recommendations that inform decision-making in order to protect and improve community health and wellbeing. Because of financial and time constraints, HIAs do not generally involve new research or the generation of original scientific knowledge. However, the findings of HIAs, especially where these have been monitored and evaluated over time, can be used to inform other HIAs in contexts that are similar. An HIA's recommendations may focus on both design and operational aspects of a proposal.

Community health is a major field of study within the medical and clinical sciences which focuses on the maintenance, protection, and improvement of the health status of population groups and communities. It is a distinct field of study that may be taught within a separate school of [public health] or [environmental health]. The WHO defines community health as:

environmental, social, and economic resources to sustain emotional and physical well being among people in ways that advance their aspirations and satisfy their needs in their unique environment.

Design can have different connotations in different fields of application, but there are two basic meanings of design: as a verb and as a noun.

HIA has also been identified as a mechanism by which potential health inequalities can be identified and redressed prior to the implementation of proposed policy, program or project ( Acheson 1998 ).

A number of manuals and guidelines for HIA's use have been developed (see further reading).

Determinants of health

The proposition that policies, programs and projects have the potential to change the determinants of health underpins HIA's use. Changes to health determinants then leads to changes in health outcomes or the health status of individuals and communities. The determinants of health are largely environmental and social, so that there are many overlaps with environmental impact assessment and social impact assessment.

Levels of HIA

Three forms of HIA exist:

It has been suggested that HIAs can be prospective (done before a proposal is implemented), concurrent (done while the proposal is being implemented) or retrospective (done after a proposal has been implemented) ( Taylor, Gorman & Quigley 2003 , p. 1). This remains controversial, however, with a number of HIA practitioners suggesting that concurrent HIA is better regarded as a monitoring activity and that retrospective HIA is more akin to evaluation with a health focus, rather than being assessment per se ( Kemm 2003 , p. 387). Prospective HIA is preferred as it allows the maximum practical opportunity to influence decision-making and subsequent health impacts.

HIA practitioners

HIA practitioners can be found in the private and public sectors, but are relatively few in number. There are no universally accepted competency frameworks or certification processes. It is suggested that a lead practitioner should have extensive education and training in a health related field, experience of participating in HIAs, and have attended an HIA training course. It has been suggested and widely accepted that merely having a medical or health degree should not be regarded as an indication of competency.

The International Association for Impact Assessment has an active health section.

A HIA People Directory can be found on the HIA GATEWAY.

HIA worldwide

HIA is currently being used or developed around the world, most notably in Europe, North America, Australia, New Zealand, Africa and Thailand.

The new safeguard policies and standards of the International Finance Corporation (IFC), part of the World Bank, were established in 2006. These contain a requirement for health impact assessment in large projects. The standards have been accepted by most of the leading lending banks who are parties to the Equator Principles. Health impact assessments are becoming routine in many large development projects in both public and private sectors of developing countries. There is also a long history of health impact assessment in the water resource development sector - large dams and irrigation systems.

HIA conferences

The 13th International HIA Conference was held in Geneva in 2013.

The 12th International HIA Conference was held in Québec City in 2012.

See also

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Further reading

Books and edited book chapters

Journal articles

Journal special issues

Manuals and guidelines

Other publications


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HIA resource websites

Government HIA websites

University HIA websites

Professional associations

Other HIA websites

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