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Practical Lessons on Dealing With Inequalities in HIA - NICE England - 2005

Practical Lessons on Dealing With Inequalities in HIA - NICE England - 2005

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Practical lessons for dealingwith inequalities in healthimpact assessment
This publication is a companion to
 Addressing inequalitiesthrough health impact assessment 
et al 
., 2003a),which described what a focus on inequalities couldachieve, offered case study examples, and outlinedpromising practice. This bulletin discusses recentpublications and presents a further two case studies thatattempt to address health inequalities through the use ofHIA.
Inequalities and health 
A key focus of HIA is to reduce inequalities that resultfrom unnecessary, avoidable and unjust differences inhealth status between different people (Woodward andKawachi, 2000; Kawachi
et al 
., 2002). This moral andethical dimension that underpins HIA stems from thevalues of the World Health Organization’s programmeof health in the 21st century, which advocates tacklingsocial injustices globally, nationally and locally. The primeminister expressed the importance of inequalities inthe report
Tackling health inequalities: a programmefor action
(DH, 2003): ‘Our society remains scarred byinequalities. Whole communities remain cut off from thegreater wealth and opportunities that others take forgranted. This, in turn, fuels avoidable health inequalities.Tackling such entrenched and enduring health inequalitiesis, of course, a daunting challenge. But nor can we anylonger ignore these problems.’There are four main arguments for tackling inequalities:Inequalities are unjustConditions that lead to marked inequalities affect allmembers of societyInequalities are avoidableInterventions to reduce health inequalities are effective.(Woodward and Kawachi, 2000)Kawachi
et al 
.’s 2002 glossary for health inequalities ishelpful background in the context of HIA.
Why address inequalities in HIA? 
The Gothenburg consensus paper (ECHP, 1999) describesequity as one of the four underpinning values of HIA– ‘where HIA is not only interested in the aggregateimpact of the assessment policy on the health of apopulation but also on the distribution of the impactwithin the population, for instance in terms of gender,age, ethnic background and socio-economic status.’ Thisis supported by HIA practitioners, who have describedaddressing inequalities as ‘the heart of HIA’ (OpinionLeader Research, 2003) and as central to undertaking HIA(Douglas and Scott-Samuel, 2001).The government-commissioned Acheson Report (1998)also notes the important role HIA can play in addressinghealth inequalities, by recommending ‘that as part ofhealth impact assessment, all policies likely to have animpact on health should be evaluated in terms of theirimpact on health inequalities, and formulated in such away that by favouring the less well off they will, whereverpossible, reduce such inequalities.’ The Acheson Reportalso makes the important point that inequalities will onlybe reduced if ‘all policies’ are subject to assessment.This is because ‘policies’ from nearly all sectors havean impact on the health of people, as described in thesocial model of health (Dahlgren, 1995). Governmentsin the Netherlands, Sweden and New Zealand have alsoproposed HIA as a method of dealing with inequalities
This document presents two HIA case studies focusing on health inequalities. This work was undertaken by the Health Development Agency (HDA)but published after its functions were transferred to NICE on 1 April 2005. Neither this document nor the summary version represents NICE guidance.
Practical lessons for dealing with inequalities in HIA
within similar national policy documents (Ostlin andDiderichsen, 2000; Mackenbach and Stronks, 2002;Public Health Advisory Committee, 2004).A further UK policy link is the
Priorities and planningframework 
, where primary care trusts are required tocarry out health equity audit (HEA) (DH, 2002, 2004).Partnership work within HEA can support HIA work, andmany of the steps in the HEA approach can be usefullyinformed by an HIA.As described by Taylor
et al 
. (2003a), addressinginequalities within HIA can result in better decisionmaking by supporting decision makers in assessingproposals on the grounds of equity. It may also createbetter awareness of the political dimensions of health,particularly of how the wider determinants of health(Dahlgren and Whitehead, 1991) could affect healthinequalities. Taking an inequalities focus with HIAmay also lead to better outcomes for communities– addressing inequalities often requires a participatoryapproach with the affected population, and this processmay contribute to better health for the population. Finally,equity itself is a determinant of health (of all people, not just those most disadvantaged), and without a focus oninequalities HIA may miss an opportunity to improve thehealth and wellbeing of all people.
The two case studies identied here (page 5) wereselected for use at the former HDA’s 2003 Conference,where a workshop was held to discuss how practitionerswere attempting to tackle inequalities within HIA. A callfor abstracts, asking for examples of HIA practice, wasalso made to registered users of the HIA Gateway website(www.hiagateway.org.uk) and members of the EuropeanCentre for Health Policy’s HIA Electronic DiscussionNetwork (www.euro.who.int/eprise/main/WHO/Progs/ HPA/HealthImpact/20020320_2%20). A requirementwas that the case studies should demonstrate how theyhad attempted to address inequalities at each stage ofthe process. The case studies were to be presented at theworkshop as examples, and the presenters were availableto answer questions about their work.Submitted abstracts were read by two people, and thosedisplaying the clearest attempts to address inequalitieswithin HIA practice were chosen. It is important tonote that this selection was not based on a systematicsearch of all examples of HIA that attempted to addressinequalities – other examples, both better and worse, arelikely to exist.
Approaches to addressing inequalitieswithin HIA
HIA is a practical approach that determines how aproposal will affect people’s health. Recommendations to‘increase the positive’ and ‘decrease the negative’ aspectsof a proposal are produced to inform decision makers.HIA is described as one way to attempt to addressinequalities. Within the peer-reviewed literature, fourpapers provide explicit frameworks (or commentaries onthem) for addressing inequalities within HIA.
et al 
– Lester, C., Grifths, S., Smith, K. andLowe, G. (2001) Priority setting with health inequalityimpact assessment.
Public Health
115: 272-6.
et al 
– Mackenbach, J., LennertVeerman, J., Barendregt, J. and Kunst, A. (2004)Health inequalities in HIA.
Kemm, J., Parry, J. andPalmer, S. (eds).
Health impact assessment: concepts,theory and applications.
Oxford: Oxford UniversityPress, ch. 3.
Parry and Scully
– Parry, J. and Scully, E. (2003)Health impact assessment and the consideration ofhealth inequalities.
 Journal of Public Health Medicine
 25(3): 243-5.
et al 
– Taylor, L., Gowman, N. and Quigley, R.(2003a)
Learning from practice bulletin:
 Addressinginequalities through health impact assessment.
 London: Health Development Agency.It is well recognised that to attempt to addressinequalities through an HIA, it is important to take arigorous and structural approach, and action should betaken at each stage of the HIA process (Taylor
et al 
.,2003a; Mackenbach
., 2004). The majority of HIAsundertaken discuss and consider inequalities and use HIAmodels that are able to address inequalities. But they donot use a structured approach to address inequalities intheir work, or present it in a way that makes it clear thatany impact on health inequalities was assessed (Parry andScully, 2003; Mackenbach
et al.
, 2004). Ideas for morerigorously addressing inequalities in HIA are presented byParry and Scully (2003) and Mackenbach
et al 
. (2004),but both reports note that a lack of available resourcesand time within most HIAs may make such a rigorous andcomplex approach difcult, despite it being appropriate intheory.HIA can attempt to address inequalities in two ways:
Practical lessons for dealing with inequalities in HIA
By outlining the distribution of impacts that are likely tobe experienced across populations – recommendationscan reect this understanding and minimise harm ormaximise benets to vulnerable people. In this case the
outputs and outcomes
of the HIA are importantBy carrying out the HIA – the process can includethe participation of vulnerable groups, and thisinvolvement may be empowering and benecial initself. In this case the
of the HIA is important.
Four approaches to HIA
Parry and Scully (2003)
As a minimum, these authors believe that HIA should‘explicitly set out the estimation of the differentialdistribution of effects arising from a policy … stratied bysex, age, ethnicity and socio-economic status relative tothe whole population.’ Also, they call for clear exclusionand inclusion criteria for relevant subgroups to bedeveloped. This commentary focuses on what the authorsconsidered the most important rst steps required toaddress inequalities, without outlining a more detailedprocess for anyone who may have wanted to stretch theirpractice.
et al 
. (2001)
In contrast, these authors present a detailed process(and a rapid appraisal toolkit) for attempting to addressinequalities when undertaking HIAs. The process wasdeveloped by the Bro Taf Health Authority, drawingon
The Merseyside guidelines for health impact assessment 
et al 
., 2001), and has beenused for carrying out an HIA on a proposed new roaddevelopment (Lester and Temple, 2002, 2004). The toolkitfocuses on the needs of the most disadvantaged in thecommunity when carrying out planning. The basic stepsinclude:Identifying which determinants of health are related tothe planning topicDiscussing the prevalence of these determinants locally,for the whole population and for socio-economicgroupsGathering evidence to support or refute the initialdiscussion on local determinantsIdentifying opportunities for action as a result ofexamining the evidenceRating the opportunities for action in terms of strengthof evidence, size of possible impact, probabilityof achieving change locally, and the timescale forachieving such a change.
et al 
. (2004)
Similarly, these authors outline a four-step process toaddress inequalities in HIA:Identify what health determinants the proposal mayhave an impact on, then estimate their prevalenceLook at the socio-economic distribution of thesedeterminants, and what this contributes to currentinequalities in healthEstimate how the policy will affect the prevalence ofthe health determinants in different socio-economicgroupsEstimate how such changes in the prevalence of thedeterminants of health may affect health inequalitiesamong the different socio-economic groups.
et al 
. (2003a)
These authors present promising practice guidancefor attempting to address inequalities, derived from aworkshop attended by practitioners, leading academics,policy makers and HIA commissioners. The guidanceemphasises the need for action at every stage of the HIAprocess (from screening to reporting) to maintain thefocus on inequalities. The promising practice guidance isgrouped around ve themes:Being clear about purpose and choicesScreening and scopingUsing a participatory approachWorking systematicallyReporting back.
Discussion of approaches 
The frameworks of Lester
et al 
. (2001) and Mackenbach
et al 
. (2004) begin by identifying the determinants ofhealth on which the proposal may have an impact.This demonstrates one of HIA’s strengths: that healthoutcomes affected by the wider determinants of healthare considered. The prevalence of the determinants isconsidered in both frameworks, and each asks questionsabout how these determinants may be distributed amongthe population. Mackenbach
et al 
. (2004) stretch thepractitioner to consider the impact of this distributionon current inequalities in health. This step is a valuableaddition, as it will highlight those determinants that aremost important for addressing inequalities in the localpopulation – but whether the data for such an analysisare available is a pertinent question.Lester
et al 
. (2001) explicitly describe the evidence-gathering step, whereas Mackenbach
et al 
. (2004)describe the need to estimate how the policy will affect

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