Iom Chia Hia Reader 2005-2007

Health Impact
Assessment
- a training reader -
what is it
why do it
when to use it
how to do it
how to commission it
Written by Dr Salim Vohra, Director, Centre for Health Impact Assessment 2003-05
Contents
1. Introduction ...................................................................................... 1
2. Health Impact Assessment..................................................................... 2
3. Health, Determinants and Inequalities ...................................................... 9
4. Evidence and Evidence Gathering .......................................................... 14
5. Evaluating Evidence .......................................................................... 19
6. Dealing with Uncertainty: insufficient and contradictory evidence ................. 23
7. Stakeholder Involvement .................................................................... 26
8. Analysis ......................................................................................... 31
8. Commissioning and Scrutinising a HIA ..................................................... 34
9 The Wider Context: political, economic and social factors............................ 37
10. Monitoring and Evaluation of Impacts.................................................... 40
11. Conclusion..................................................................................... 46
Sources of Further Information ................................................................ 47
References......................................................................................... 50
1 . I n t r o d u c t i o n
1. Introduction
There are three core aims of this reader on health impact assessment:
1. To develop in readers a good understanding and appreciation of the value of health impact
assessment (HIA) in identifying the actual and potential negative and positive effects of
policies, plans, programmes, projects, developments and services.
2. To enable readers to undertake a rapid health impact assessment on their own policies, plans,
programmes, projects, developments and services.
3. To enable readers to commission rapid and comprehensive health impact assessments and
critically evaluate the strengths and limitations of health impact assessment statements and
reports.
This reader forms part of the training material that Living Knowledge gives to training participants
so that they achieve these three key learning outcomes:
Understanding of health impact assessment

To develop participants understanding of: what health impact assessment is; its rationale, its
values and structure; when it can be done; where it can be done; why it should be done; the
different approaches; their strengths and limitations; how to use and evaluate evidence on health
impacts; the value of stakeholder consultation and the need to build in monitoring and evaluation.
Undertake a rapid health impact assessment

To show participants how they can integrate health impact assessment and their understanding of
HIA into their own professional work by giving them the skills and experience to screen, scope,
appraise and make recommendations on the potential health impacts of policies, plans,
programmes, projects, developments and services that they are currently working on and might
work on in the future. This includes understanding the need for building in monitoring and
evaluation.
Commission and critically evaluate health impact assessment reports

To develop the participants’ confidence in HIA by providing them with knowledge and information
on HIA – the general framework, the key approaches and their strengths and limitations – that will
allow them to evaluate and understand a tender for a HIA and HIA reports produced by other
people and other organisations.
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2 . H e a l t h I m p a c t A s s e s s m e n t
2. Health Impact Assessment
“Go to the people, live among them

Build on what they know, but of the best practitioners
When their task is accomplished, their work is done
The people all remark, we have done this ourselves”
The New Public Health by John Ashton
2.1 What it is
Health impact assessment (HIA) is a relatively new impact assessment methodology. Its roots lie in
environmental impact assessment and the healthy public policy movement. Legislation in the UK
requires an environmental impact assessment (EIA) to be commissioned as part of the planning
process and lays down what areas must be covered in an EIA. EIAs focus largely on key physical
environmental factors such as impact on plants and wildlife, air quality, noise, hydrology and
archaeology. In contrast, HIA is currently commissioned voluntarily; the methodology is not
prescribed but informed by international best practice and the focus determined by the nature of
the policy, plan, programme, project, development or service (initiative) which is being assessed.
Boxes 1 and 2 at the end of this chapter describe the international context of HIA.
The widely accepted Gothenberg consensus definition of health impact assessment is:
… 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.
WHO European Centre for Health Policy (1999)
HIA is the key systematic approach to identifying the health impacts of proposed and
implemented policies, plans, programmes, projects and services (initiatives) within a
democratic, equitable, sustainable and ethical framework, so that negative health impacts are
reduced and positive health impacts increased (within a given population). It uses a range of
structured and evaluated sources of evidence that includes public and other stakeholders'
perceptions and experiences as well as public health, epidemiological, toxicological and medical
knowledges.
Other impact assessment approaches include social impact assessment, environmental health
impact assessment, technology assessment, strategic environment assessment, sustainability
appraisal and health impact analysis. There are also newer forms of impact assessment such as
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equalities impact assessment, regulatory impact assessment and integrated impact assessment. It is
not in the scope of this reader to discuss their similarities and differences.
There are several key points to note in the definitions given above many of which have a
counterpart in EIA:
• HIA draws on many different techniques and sources of evidence;
• HIA looks at the potential effects of an initiative i.e. it tends to be carried out while the
initiative is at the design or draft stage;
• HIA identifies the potential for positive and negative effects;
• HIA is concerned with the distribution of effects within a population as different groups are
likely to be affected in different ways and therefore looks at how health and other social
inequalities might be exacerbated by the proposed project, service, programme, policy or
development.
In order to examine the ways in which the proposed project, service, programme, policy or
development (initiative) may be expected to affect the health of particular populations it is
important to have a clear understanding of:
• the context within which the initiative is proposed and
• the aims and objectives of the initiative.
HIA tends to draw on knowledge and information which already exists about a proposed initiative
and the communities that are likely to be affected i.e. it tends not to undertake specific new
research on health impacts during the assessment.
As with other forms of impact assessment, including EIA, HIA identifies the potential for unintended
side-effects and suggests ways to avoid negative impacts. It is important to appraise an initiative
and examine the ways in which it might affect people's health and also to consider mitigation and
enhancement measures. Mitigation measures help to reduce the negative health effects and
enhancement measures aim to increase the positive health effects of a given initiative.
HIA also contributes to the development of a monitoring and evaluation strategy for an initiative.
This can ensure that the negative health effects are indeed reduced and the positive effects
increased for any given project, service, programme, policy or development. It can also enable
stakeholders to develop their own milestones and indicators for evaluating the health positives and
negatives of an initiative once it is in operation (Cave, Curtis et al, 2001).
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2.2 Why do it
HIA can help to deliver better and improved policies, plans, programmes, projects, developments
and services (initiatives). It can be used to:
• support the planning and decision-making process by providing timely, relevant and
highly credible health information and analysis.
• improve project design, construction, operation and decommissioning.
• improve plan design, implementation and effectiveness.
• help increase community support and reduces community concerns.
• reduce costs and liabilities further down the project and planning cycle.
• enhance reputation by feeding into corporate social responsibility.
2.3 What it doesn’t do

At the moment it does not give numerical estimates of the negative and positive health impacts.
There is no approach at present that allows us to do this accurately.
This is because:
• many of the effects on an individual’s or community’s health are not easily measurable,
• many health effects are indirect and take many years to manifest themselves,
• the methodology to collect quantifiable health impact evidence and make judgements
based upon it is currently not well developed, and finally
• there is argument about the tendency for quantifiable estimates developed for HIAs to give
a false sense of reassurance and precision to what are a range of complex interactions
between a range of social, cultural, economic, political, environmental and personal
determinants of health.
2.4 How is it done

There are a range of different models for undertaking HIA and an even wider set of HIA Tools
Merseyside British Columbia

Equity-focused HIA (Australia) Swedish County Council
Health Inequality Impact Assessment (Wales)
They are named after the areas and countries where they were first developed and used.
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They are different in that:

Some provide a quick, simple and broad way of thinking through health impacts while others have
structured and precise steps by which health impacts are identified and assessed in detail.
They are similar in that they have 5 core procedural steps (see IOM CHIA’s Comprehensive HIA
Toolbox for more details about how to do each of these steps):
Screening:
In this step policies, plans, programmes, projects, developments and services (developments) are
systematically assessed to see whether a HIA needs to be done on them. A quick assessment is made
on their potential to impact on a community’s health. A HIA may not need to be done either
because the development has very little impact on health or the health impacts are well known and
the mechanisms to reduce them are already in place. Screening helps ensure that time, effort and
resources are targeted appropriately. The type of HIA that needs to be undertaken is also
determined at this stage.
Scoping:
In this step the ‘terms of reference’ for the HIA are set i.e. what aspects will be considered, what
areas and groups might need particular focus, what will be excluded from the HIA and how the HIA
process will be managed.
Analysis:
In this step a systematic review of the potential impacts is undertaken and evidence for these
impacts collected. An assessment of the likely impacts, the size and significance of the effects and
the groups that are likely to be most affected is carried out and described in detail.
Mitigation and Enhancement:

In this step a report, called a health impact statement, is written and recommendations made on
the best way forward including options to reduce the potential negative health impacts (mitigation
measures) and increase the potential positive impacts (enhancement measures).
HIA report/ Health statement:

Development of a written report or statement.
Follow up (monitoring & evaluation):

In this step ways of monitoring the potential health losses (effects of the negative impacts) and
health gains (effects of the positive impacts) as well as mechanisms to evaluate the development as
a whole are developed. The HIA is also evaluated to assess the accuracy and appropriateness of the
health predictions and recommendations made.
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2.5 When is it done

HIAs can be done on policies, plans, programmes, projects, developments and services.
They can be done at the:

beginning .................during the development or pre-development stage.
middle ..................... during the implementation stage.
end ........................at the operation or closure stage to look back and evaluate.
In HIA terminology:
Prospective HIA ..........means the impact assessment starts as early as possible in the design or
draft stage of an initiative and recommendations made on how to
maximise the positive and minimise the negative impacts of the design or
draft.
Concurrent HIA ...........means the impact assessment starts when the initiative is underway and
makes recommendations to the planning and delivery team about how the
implementation and operation phase can be modified to reduce the
negative and enhance the positive health effects.
Retrospective HIA........means the impact assessment is carried out when the intervention is
complete. It is too late for this initiative to be changed but lessons can be
learnt about how other similar initiatives should be designed and
implemented.
Some researchers and practitioners suggest that concurrent impact assessment is really monitoring,
retrospective impact assessment is closer to evaluation and that the only true kind of health impact
assessment is prospective (Morgan, 2001).
You can also do quick and broad-brush ones and longer and more detailed ones. In HIA terminology
you can do a rapid, intermediate or comprehensive HIAs.
The most important thing to do is to choose a model and approach that makes sense to you and
get going.
Key questions to consider when planning a health impact assessment are:

does the impact assessment look at the intended outcomes or unanticipated effects of the
initiative?
how can or should the public be part of or involved in the process?
do other people, groups and organisations agree or disagree about the nature and significance
of the health impacts?
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There is a lot of activity in health impact assessment around the world. The Sources of Further
Information section starting on page 40 provides a range of World Wide Web and other resources for
you to explore HIA issues in more detail.
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Box 2.1 How HIA was developed for policies and plans
In the 1980s within international health promotion circles there was considerable
interest in ‘healthy public policy’.
In British Columbia, Canada, HIA was a requirement in the preparation of policy and
guidance was published on how to do this (see the British Columbia model).
In Holland the government examined how health consequences of policies could be

assessed and developed procedures to undertake this.
In Sweden the focus fell on local rather than national agencies and guidance was
published on how to assess the health impacts of policies (see the Swedish County
Council model).
Meanwhile in Europe and particularly in the UK development of HIA encouraged a series

of supra-national and national government statements. In England the green paper ‘Our
healthier nation: a contract for the nation’ stated ‘the Government will apply health
impact assessments to its relevant key policies, so that when they are being developed
and implemented, the consequences of those policies for our health is considered’. This
commitment was renewed in the subsequent white paper ‘Saving lives: our healthier
nation’. Governments in Scotland, Wales and Northern Ireland made similar
commitments. In the 1990s the UK Government acknowledged the existence of
‘Inequalities in Health’ and adopted their reduction as an overarching policy goal. The
Greater London Assembly has developed a system for assessing the health impacts of all
its strategies.
WHO Europe said that, ‘Member states should have established mechanisms for health
impact assessment and ensured that all sectors become accountable for the effects of
their policies and actions on health’ as one of its Health 21 targets. The High Level
Committee on Health of the European Union has also recommended the development of
an easy-to-use checklist of steps in policy appraisal of health impact to be used for policy
development.
Health impact assessment edited by Kemm J, Parry J and Palmer S; 2004
Box 2.2 How HIA was developed for projects
Health impacts especially environmental health impacts were first assessed in developing
countries. This interest moved to more developed countries and major development
projects.
In New Zealand the Resource Management Act 1991 required authorities to make an
‘assessment of any actual or potential effects on the environment’, which includes ‘any
effects on those in the neighbourhood or wider community including socio-economic and
cultural effects’. A guide to health impact assessment was published in 1995 to assist
authorities with this task.
In Australia development planning and resource issues are regulated by the individual
states but the national government produced a report to guide states on how they could
involve impact assessment in their planning and development. Tasmania has gone further
and made HIAs a legal requirement.
In Germany health aspects are considered in the context of environmental impact

assessment (see Bielefeld model). In Holland various large development projects have
been the subject of assessments that covered health and environmental impacts.
In Canada, projects requiring environmental impacts were scrutinised for possible health
impacts and those with greatest potential subjected to a fuller health assessment. In the
United Kingdom an HIA was submitted as evidence to the planning enquiry on a third
runway for Manchester airport and the British Medical Association published a guide to
linked health and environmental impact assessment (see the Merseyside model).
Health impact assessment edited by Kemm J, Parry J and Palmer S; 2004
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3 . H e a l t h , D e t e r m i n a n t s a n d I n e q u a l i t i e s
3. Health, Determinants and Inequalities
“What is spoken of as a clinical picture is not just a photograph of a [wo]man sick in bed
it is an impressionistic painting of the person surrounded by their home, their work, their
relations, their friends, their joys, their sorrows, hopes and fears.”
Dr Francis Peabody
3.1 What is health

Having a clear definition of what we mean by ‘health’ and what definition of health we want to use
when undertaking or commissioning a health impact assessment is crucial as the definition will, to a
large extent, determine what kind of evidence will need to be collected and the kinds of health and
disease factors that should be considered.
Some people understand health as meaning curing diseases, more health services and new medical
technologies and procedures. HIA works with a broad model of health which includes, but does not
stop at, this medical model (Cave and Penner, 2001). It encompasses other wider determinants of
health such as housing, employment, social support, crime and community safety and education.
3.2 Definitions of health

Health is not easy to define and ways of thinking about it have changed over the years and are still
changing. Three key models of health are the "medical model", the "holistic model", and the
"wellness model or social model”: In its basic form, the “medical model” views the body as a
machine that can be fixed when it does not work as it should. Its focus is on diagnosing and treating
specific physical conditions (diseases), and therefore tends to be reactive in dealing with actual
health problems as they occur rather than attempting to prevent them occurring in the first place.
In this model health is defined as the absence of disease and the presence of high levels of normal
physical functioning.
The holistic model of health is exemplified by the 1947 World Health Organisation (WHO)
definition, "a state of complete physical, mental and social wellbeing and not merely the absence of
disease or infirmity". This model uses a broader definition of what health is and also brings in the
idea of the positive aspects of health by introducing the concept of wellbeing. This WHO definition
is seen by some as vague, difficult to measure and subjective as wellbeing can only be measured by
asking a person to tell us how they feel.
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The social model was developed through the WHO’s health promotion initiatives. The definition
argues that "[Health is]1 the extent to which an individual or group is able to realise aspirations and
satisfy needs, and to change or cope with the environment. Health is therefore a resource for
everyday life, not the objective of living; it is a positive concept, emphasizing social and personal
resources, as well as physical capacities." (Health promotion: a discussion document. Copenhagen,
WHO, 1984.)
Other definitions see health in terms of resilience for example, "…the capability of individuals,
families, groups and communities to cope successfully in the face of significant adversity or risk."
(Vingilis and Sarkella, 1997) and in ecological terms, health can be seen as "a state in which
humans, and other living creatures with which they interact, can coexist indefinitely." (Last, 1995:
73).
The advantage of the medical model is that disease states tend to be relatively easily diagnosed and
measured. But this approach is narrow, seeing health as simply about physical disease, its
symptoms and consequences. The holistic and wellness models incorporate broader ideas of
wellbeing that take into account an individual’s subjective feelings of healthiness and wellness.
They allow for people with stable impairments to be seen as healthy e.g. a deaf or blind person or
someone who needs the aid of a wheelchair. They also argue that it is not simply an outcome but
also a resource i.e. that healthiness tends to lead to greater healthiness as it allows and enables
individuals and groups to take up more opportunities. However, these conceptualisations are very
broad and, arguably, vague. It is also difficult to distinguish causality between a given health status
and the determinants of health, for example, has a person’s unemployment led to their ill-health or
has their ill-health (acting imperceptibly over a period of time) led to their unemployment (From
University of Ottawa, 2003).
1
Words in square brackets have been added.
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Figure 3.1: The main determinants of health
Source: Dahlgren and Whitehead (1991)
3.3 Determinants of health

Health is affected by a range of factors, from what we eat and drink, to where we live and work as
well as the social relationships and connections we have with other people and organisations. Below
are two diagrams visually describing the key determinants of health (see Figure 3.1 and Table 3.1).
Figure 3.1, on the previous page, shows the Dahlgren and Whitehead ‘Model of health’. Both
highlight the importance of social, cultural, spiritual and community factors in affecting individual,
family and community health and wellbeing alongside genetic, lifestyle and personal factors such
as age, gender and ethnicity.
Table 3.1 describes some key health impacts, the determinants of health through which these
health impacts occur and the types of policies, plans, programmes, projects, developments and
services (initiatives) that can produce them.
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Table 3.1 Examples of health impacts, determinants of health and initiatives that can produce
them
(Department of Health and the Neighbourhood Renewal Unit, 2002)
Health Impact Known positive/ negative Examples of initiatives that can affect
determinants of health these influencing factors
Cardiovascular disease Smoking Local transport plans
Exercise Healthy living centres
Nutrition Land use and land planning
Being over-weight Smoking cessation programmes
Air pollution Access to affordable fresh foods
Access to affordable physical recreation
Cancer Smoking Land use and land planning
Nutrition Access to affordable fresh foods
Exercise Healthy school meals
Chemical exposures Smoking cessation programmes
Health screening for early Access to screening programmes

detection
Accidents Transport Local transport and waterway plans
Workplace Housing policies, programmes and projects
Home Safety equipment loan schemes
Environment Occupational health
Mental Health Self esteem Education policies, programmes and

services
Social networks
Employment schemes
Social pressures
Crime prevention initiatives
Fear of crime
Sustainable communities
Noise
Transport & housing policies and
programmes
Health Inequalities Poverty Economic regeneration initiatives
Housing Initiatives to improve education,

employment and health for those in most
Access to services need.
Education Welfare reform
Work Housing, transport and planning policies
Access to retail services and other

amenities
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3.4 Health inequalities

Each of us is affected by the determinants of health described in the previous section. However, the
influence of these determinants is different on each of us with some playing a greater or lesser role
depending on the specific personal, social and cultural factors that impinge upon us. These
differences in affect lead to differences in health status (regardless of how we define health) so
that we each possess varying degrees of health and wellbeing. This creates a range of ‘health
inequalities’ between different individuals and different groups within a given society or
population. These inequalities in health due to personal circumstances such as gender, ethnicity,
disability, financial resources, housing, social support networks and self esteem can be exacerbated
by a new or revised policy, plan, programme, project, development or service (initiative).
HIA considers how an initiative could potentially heighten or reduce these health inequalities and
hence how different groups will be affected compared to the affected population as a whole.
To analyse and understand these inequalities individuals and community groups are categorised by
some key characteristics. These include:
Age – e.g. children, elderly people.

Gender – e.g. male, female.
Socio-economic status – e.g. unskilled, skilled, professional, income levels, education levels, other.
Ethnicity – e.g. White, Black, Asian, other.
Culture (including religion) – e.g. Buddhist, Christian, Hindu, Muslim, Sikh, other
Sexual orientation – i.e. heterosexual, homosexual, bisexual.
Disability – e.g. physical, mental, other.
Disease vulnerability/ susceptibility – e.g. thallassaemia, cystic fibrosis, sickle cell anaemia,
diabetes.
It is important to recognise that individuals and groups can and do fall into more than one of these
categories. We have multiple identities and fit within multiple categories. The categories are
therefore useful rules of thumb but do not define and encompass what we and other individuals and
communities are.
However, categorising individuals and communities like this provides a systematic way of examining
the potential health impacts, and importantly the health inequalities that result from them, by
ensuring that important characteristics of both individuals and groups are taken into account in
appraising the actual and potential positive and negative health effects of a given initiative.
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4 . E v i d e n c e a n d E v i d e n c e G a t h e r i n g
4. Evidence and Evidence Gathering
"Only daring speculation can lead us further, and not [just] the accumulation of facts."
Albert Einstein
4.1 What is evidence

Health impact assessment is an evidenced-based approach to understanding the health effects of
policies, plans, programmes, projects, developments and services (initiatives). As discussed in the
previous chapter the definition or model of health that is used to frame the assessment will strongly
determine what is seen as good evidence.
Health impact evidence can comes from a variety of sources and therefore in HIAs there can be
concerns, issues and conflicts about what evidence is considered valid.
All forms of data, information, knowledge and research have limitations. The important thing is not
to differentiate between good data, information or knowledge and bad but to understand in what
contexts a particular form of knowledge is appropriately applied. To do that we need to know how
the knowledge was discovered or created, the strengths and limitations of the methods used to
uncover or generate that knowledge and most importantly in what context or contexts it applies.
To understand evidence and the nature of evidence we first need to broadly understand the
philosophical basis of science and scientific knowledge. There are four key paradigms or
philosophies of science: positivist, post-positivist, critical and constructivist.
Positivists
“Reality is there. Look! You can see, hear, touch and measure it.”
The positivist perspective is based on the idea that there is one true reality out there that we can
all collectively comprehend. This real single reality is independent of human thought and action and
can be fully, truly and completely captured by science and the scientific method. Hence, we can
collect facts that are independent, universal, true, objective and value-neutral.
Post-positivists
“Reality is there, but we can only see, hear, touch and measure a bit of it.”
The post-positivist perspective recognises that while there is a real single reality out there we can
only comprehend it imperfectly. We, as observers, mediate and interpret this reality. Hence our
understanding of the real world is always partial and subject to revisions that lead us closer and
closer to what is real and true.
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Criticalists
“Reality is a product of our time and place in history.”
The critical perspective argues that there is no single reality but that reality is socially constructed
and is shaped by historical, social, and cultural factors that include ethnicity and gender. Hence, it
is the different social and cultural structures and institutions, alongside different historical forces
and processes that determine what we see as knowledge, what knowledge we collect and how that
knowledge is discovered/ created.
Constructivists
“Everyone sees the world differently. We share overlapping realities.”
The constructivist perspective argues even more strongly than criticalists that there is no ‘real’
reality out there. Instead there are a diverse set of ‘socially constructed’ realities that depend on
the perspective and situation of the person or observer concerned. Hence, our understandings of
both the natural and social worlds are socially constructed knowledges that have more to do with us
being social organisms, with language, at a certain place in time, than to some objective, value-
neutral and independent reality. Table 4.1 describes the ontology (nature of reality), epistemology
(nature of knowledge) and methodology (the techniques and approaches used to investigate reality
and generate knowledge) of each of the perspectives in more detail.
Table 4.1 Key philosophical assumptions of the four paradigms (from Guba and Lincoln, 1994)
Positivism Post positivism Critical Theory et al Constructivism
Ontology ‘Naïve’ realism – Critical realism – Historical realism – Relativism –
(nature of the there is one real there is one real reality reality is virtual and there are a range of local,
world and reality) reality that we can but we can only shaped by social, specific and overlapping
all apprehend understand it imperfectly political, cultural, realities that we each
and probabilistically economic, ethnic, and have constructed
gender values that have
developed over time
Epistemology Objectivist – Modified objectivist – Subjectivist – Subjectivist –
(nature of findings true findings probably true findings are affected by findings are created and
knowledge and the values we hold constructed
what can be
known about universal universal contextual contextual
reality)
Methodology Experimental – Modified Experimental – Dialogic – Interpretative –
(approach used to verifying specific falsification of Hypothesis generation Hypothesis generation and
understand and hypotheses hypotheses, and testing testing
make sense of
chiefly quantitative
reality)
methods may include qualitative chiefly qualitative chiefly qualitative
methods methods methods
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Tables 4.1 and 4.2 shown to give a flavour of the terminology and words used by academic
researchers and the critical thinking that has gone into creating robust quantitative and qualitative
investigative approaches and knowledges.
Each of the four perspectives (paradigms) have a distinctive orientation in terms of what knowledge
is seen as acceptable, what methodologies are seen as appropriate, their criteria for validity and so
on. Table 4.2 shows in greater detail what the key differences between the four perspectives are in
terms of inquiry aim, nature of knowledge, how knowledge is accumulated, criteria for judging the
quality of research, research values, the role of the researcher, accommodation of other
perspectives, and its social power.
Table 4.2 Position of each perspective with respect to practical research issues (Guba and
Lincoln, 1994)
Issue Positivism Post-Positivism Critical Theory Constructivism
Inquiry aim prediction and control critique and understanding and

transformation reconstruction
Nature of verified hypotheses non-falsified structural and individual

knowledge hypotheses historical insights reconstructions
coalescing around
established as facts or laws probable facts or laws
consensus
Knowledge accretion – building blocks adding to the edifice of historical revisionism, more informed and
accumulation knowledge; sophisticated
reconstruction;
generalisations and cause-effect linkages generalisation by lived experience

similarity
Goodness or conventional benchmarks of “rigour”: internal and historical trustworthiness and

external validity, reliability and objectivity situatedness; erosion authenticity
quality criteria
of ignorance and
action stimulus
Values excluded – influence denied included – formative
Ethics extrinsic – tilt towards ‘deception’ intrinsic: tilt toward intrinsic: tilt towards
‘revelation’ ‘revelation’
Voice “disinterested scientist” as informer of decision “transformative “passionate

makers, policy makers, and change agents intellectual” as participant” as
advocate and activist facilitator of multi-
voice reconstruction
Training technical and quantitative technical; resocialisation; qualitative and quantitative;

quantitative and
qualitative
substantive theories history; values altruism and empowerment
substantive theories
Accommodation commensurable incommensurable
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Hegemony In control of publication, funding, promotion, and Seeking recognition and input
tenure
The positivist perspective emphasises three key aspects in terms of study design: rigour, structure
and the anticipation of problems e.g. bias, confounding, etc. Non-positivist – post-positivist,
criticalist and constructivist - perspectives are much less structured and pursue an emergent
approach where the process of discovery is an important and inherent element of the research
process.
4.2 Gathering evidence?

Evidence can come from a range of sources and can be quantitative and qualitative in nature.
Quantitative evidence is in the form of numbers and statistical analysis of those numbers while
qualitative evidence is in the form of detailed descriptions and logical analysis of those
descriptions.
Importantly, evidence gathering needs to be systematic and why certain evidence is included or
excluded needs to be explicitly justified so that others will find the logic of the approach
understandable, appropriate and transparent.
Some sources of evidence are listed in Table 4.3 on the next page.
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Table 4.3 Some key sources of evidence (in no order of preference)
Type Source
Academic research Evidence gathered from academic research studies

funded by educational institutions, national and local
government and international bodies like the World
Health Organisation, and are carried out by
professional and academically-qualified researchers
and reviewed by their peers.
Census and other routine Evidence gathered by local and national institutions
sources of information whose sole responsibility is to collect accurate and
reliable data on a range of health, social, economic
and environmental issues either through quantitative
questionnaire surveys or through qualitative
interviews and focus groups, as for example, the
British Household Survey and the British Crime
Survey.
Specific local research evidence Research and reports undertaken by local authorities
where the research is carried out by expert-
professionals delivering the service as part of their
work.
Local sources of routine information Local sources of routine information gathered by local
authorities, local educational institutions and the
voluntary sector.
Views, perspectives and judgements of These can be from professional stakeholders

stakeholders delivering or potentially working alongside an
initiative and/or the views of local residents and
potential users of an initiative.
Policies and guidelines Policies and guidelines are increasingly being based
on direct evidence of their value and effectiveness.
Therefore policy guidance can also be treated as a
form of evidence.
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5 . E v a l u a t i n g E v i d e n c e
5. Evaluating Evidence
"Science is perhaps the only human activity in which

errors are systematically criticised and ... in time corrected." Karl Popper
5.1 Evaluating evidence

The key thing to remember is that evidence should be evaluated systematically and the criteria
used for its evaluation is explicitly stated i.e. clear reasons should be given as to why some types of
evidence have been included and others excluded. Quantitative and qualitative research evidence
can be evaluated in a number of ways. This chapter will show how both quantitative and qualitative
perspectives use broadly similar criteria to evaluate the quality of health evidence. However it is
worth noting that these criteria are quite difficult to apply and use with the range of evidence
available to health impact assessment.
5.2 Evaluating quantitative evidence
5.2.1 Four basic criteria

Internal or construct validity
A measure of how representative a research study’s participants are when compared to the wider
population group from which they are drawn. If the participants are not representative then this
can lead to ‘selection bias’ meaning that the study results cannot be applied to the wider
population group from which the participants are chosen. In terms of questionnaire surveys it also
relates to how the questions used to investigate a specific issue, for example measuring quality of
life, accurately measure the issue the researcher is interested in.
External validity or generalisability

A measure of how generalisable the findings from a specific study on specific participants taken
from a specific population can be applied to other communities and societies.
Reliability
A measure of the extent to which a particular study and approach can be repeated to give similar
results in similar contexts i.e. the degree to which the same study on a different population with
similar characteristics to the original population will give rise to findings similar to the original
study.
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Objectivity
A measure of the extent to which emotion and subjective values have been removed from a
research study by, for example, having a clear hypothesis and a pre-agreed study and analysis
methodology.
5.3 Evaluating Qualitative Evidence
5.3.1 Four basic criteria

Credibility (comparable to internal validity )
Whether the study participants recognise the ‘truth’ of the research findings in the context of the
social and cultural factors present when the research was originally carried out.
Transferability (comparable to generalisibility)

The degree to which the research findings can be transferred to other similar contexts and
situations.
Dependability (comparable to reliability)

The degree to which other investigators would be able to reproduce similar findings which are
consistent with this research in a similar research context.
Confirmability (comparable to objectivity)

The degree to which there is evidence for the research findings from the actual field data as
opposed to the biases and perspectives of the researcher i.e. whether another researcher would
generate the same conclusions from analysing the original field data.
5.3.2 Other qualitative criteria
Reflexivity and reflection

Adopting a reflexive and self-reflexive attitude. Reflexive in the sense that researchers are aware of
and continually assessing and reflecting on the effect of their presence on the community and the
participants of the research study. Self-reflexive in the sense that researchers should always have at
the fore-front of their minds the effect of their personal characteristics, attitudes and perspectives
on the study, the participants, data collection and data analysis.
Coherence
Coherence in the findings and the conclusions of a study i.e. the ‘fit’ between the purpose of the
research and the methodology used and the research’s relationship to the wider literature (Inui and
Frankel, 1991)
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5.4 Further criteria for epidemiological evidence
5.4.1 Bradford-Hill criteria (using the association between tobacco smoke and cancer as an
example)
Temporal sequence
The cause or exposure always precedes the effect/impact. In the case of tobacco smoke, exposure
to tobacco smoke always precedes the presence of cancer
Strength of association
Low as well as high levels of exposure are associated with the effect/impact. In the case of tobacco
smoke passive as well as active exposure is associated with getting cancer.
Consistency of association
Repeated studies produce similar associations between an exposure and an effect. In the case of
tobacco smoke repeated studies and diagnoses in a range of people around the world provides
consistent evidence of a link between tobacco smoke and cancer.
Specificity of association
The exposure is associated with a very specific measurable effect. Tobacco smoke exposure is
predominantly associated with cancer of the lung.
Biological gradient (dose-response or exposure-effect relationship)

Low levels of exposure give rise to low levels of effect and high levels of exposure give rise to high
levels of effect/impact. Low levels of tobacco smoke exposure give rise to little disease with higher
levels leading to greater and greater associations with cancer.
Plausibility of association
The biological plausibility of the relationship between an exposure and effect. With tobacco smoke
the various chemicals including nicotine have specific measurable negative effects on the lung and
the circulatory system.
Coherence of association
The way the association found in a particular study or assessment between the exposure and effect/
impact fits into the wider health literature. The action of tobacco smoke fits with existing medical
and biological principles of how health and disease occur in human beings.
Experimental evidence
Experimental exposure of animals to an exposure give rise to the effect/ impact. In the case of
tobacco smoke animals exposed to tobacco smoke also develop cancer.
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Analogy to other organisms

Whether other animals also suffer from similar types of disease when exposed. See above.
5.2.3 Limitations of toxicological and epidemiological evidence
Toxicology
Issue Limitation
Animal Models While mice and rats provide a relatively close biological
model to humans they do not always work. One
important example was the trials on Thalidomide which
in rats produced no congenital abnormalities but in
humans led to children being born with limb
deformations.
Small Numbers, High Exposure & Toxicological experiments rely on experiments on

Short Time Periods relatively small numbers of animals and giving them very
high doses of exposure over very short periods of time.
Extrapolation The data collected from these experiments are then

used to extrapolate effects at the lower levels of
exposure and the longer time-scales which face human
communities e.g. effects of air pollution.
Other epidemiological issues to consider:
Issue Meaning
Chance The likelihood that an association between an exposure

and a health outcome could arise purely by chance.
Bias The degree to which the study is affected by a non-

representative study population (selection bias), errors
in eliciting the data (recall bias), researchers
investigating certain things and ignoring others (observer
bias) and the difficulty of measuring the exposure or
effect (ascertainment and measurement bias).
Confounding The degree to which other factors that influence both

the exposure and the health outcome under
consideration are not accounted for in the design and
analysis of the research e.g. socio-economic status,
lifestyle factors, etc.
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6 . D e a l i n g w i t h U n c e r t a i n t y : i n s u f f i c i e n t a n d c o n t r a d i c t o r y e v i d e n c e
6. Dealing with Uncertainty: insufficient and

contradictory evidence
" When one admits that nothing is certain one must, I think, also add that some
things are more nearly certain than others."
Bertrand Russell
6.1 Dealing with lack of evidence and uncertainty of impacts

Being systematic and thorough in gathering evidence is crucial but there are still many areas where
we have little, weak or no evidence for health impacts and the mechanisms by which these impacts
act on human communities e.g. low level chemical releases into the environment.
In these situations the question arises of how to decide and make recommendations when there is
little reliable and robust evidence on the actual and potential health impacts of policies, plans,
programmes, projects, developments and services (initiatives).
The answer is to use both professional and lay experiential knowledges to help contextualise the
evidence from research studies, routine data sources and elsewhere. The views, perspectives and
experiences of local professionals and local residents can be used as another source of evidence as
suggested at the end of Chapter 4.
The next two sections of this chapter show the value of integrating professional and lay experiential
knowledges in helping to create better initiatives as well as a philosophical perspective that
provides a robust and scientific approach to systematically incorporating lay evidence alongside
other types of quantitative and qualitative evidence.
6.2 Value of experiential knowledge

The experiential knowledge of lay people can be both important and valuable in assessing the
potential health effects of initiatives. The two case studies below demonstrate the value and
validity of the experiential knowledge of lay publics.
Herbicide 2,4,5-T controversy in the UK

The scientific Pesticides Advisory Committee in its recommendations on the potential negative
health effects of herbicide use implicitly adopted an idealised model of the ‘social’ world where the
toxicology lab and its controls were taken to be a direct and accurate reflection of real world
conditions of pesticide usage. Furthermore, the Committee assumed that conditions of manufacture
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and transport would be consistent with its social model where there were no accidents, errors in
manufacturing or mistakes in correct usage.
Hence, they dismissed labour union arguments that the herbicide caused health problems because
in practice farmers and farm workers, due to the inconvenience of protective equipment and
clothing, did not to follow the usage instructions. So while farm and forestry workers did not have
detailed scientific knowledge about pesticides they had empirical experiential knowledge of
pesticides, their use and the side-effects of use. In the end, after much debate, the Committee
qualified their recommendations with the words “…pure 2,4,5-T offers no hazards to users nor to
the general public…provided that the product is used as directed” (Wynne, 1989: 285. Italics in
original).
Chernobyl radiation and sheep farmers in the UK

When the UK government realised that radiation from Chernobyl was falling on grazing land in
Wales. Scientists were dispatched to analyse the impact of this on the grass, the sheep eating this
grass and the potential human health implications of eating these sheep.
Government scientists using general models of radiation uptake by plants and animals assumed that
the radiation would decay and disperse in a matter of weeks. However, farmers who observed the
work of these scientists were sceptical because they felt that the scientists were not taking into
account local and contextual information about the type of soil, vegetation and climate. The
farmers raised these concerns but the scientists dismissed them as irrelevant assuming that they
had the more reliable knowledge. It was only when the radiation did not decay and disperse but
seemed to be concentrating that the scientists became more open-minded and followed up the
issues raised by the farmers.
In both the above examples, each group felt that they had the better knowledge but only from a
perspective outside of both sets of groups can it be seen that each perspective was partial and had
usefulness within a certain domain where it had been tried and tested. It would have been of great
value if both sets of knowledges had been integrated from the beginning. This integration would
have occurred sooner if both sides had been willing to understand the rationality and legitimacy of
each other’s perspectives and worldviews (Wynne, 1996).
6.3 Post-normal science

The post-normal science perspective (paradigm) argues that there are three levels of uncertainty:
technical, methodological and epistemological, see Figure 6.1.
Technical uncertainty is about inexactness and can be managed through the use of statistics and
normal science.
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Methodological uncertainty is about unreliability and occurs in more complex situations such as
those found in medicine, engineering and professional consultancy where expert judgement is used
to overcome the uncertainty.
Epistemological uncertainty is about a ‘true’ lack of knowledge where we are ignorant of our
ignorance (Funtowicz and Ravetz, 1992).
Figure 6.1 Diagram of the three levels of uncertainty as described by Funtowicz and Ravetz
High
Epistemological
‘Post-Normal’ Science border with ignorance
(uncertain facts, disputed values,
high stakes, decisions urgent)
DECISION Methodological
unreliability
STAKES
Expert-Professional
Judgement
(use of judgement and good practice)
Technical
inexactness
Applied
‘Normal’ Science
(traditional notions of science)
Low LEVEL OF UNCERTAINTY High
This approach argues that for complex societal issues there is a need for an ‘extended peer
community’ made up of all the affected and interested stakeholders – whether they have scientific
qualifications or not – who assess and examine the issues as well as develop a range of ‘extended
evidence’ that includes anecdotal and experiential knowledge as well as scientific evidence to
make a socially, culturally and scientifically acceptable decision.
In HIA (and we would argue in any other impact assessment) what is important is to be explicit
about whose perspective and views are being used, whose views have not been collected or
excluded and how this relates to the individuals and groups who are likely to be affected by any
actual or proposed policy, plan, programme, project, development or service.
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7 . S t a k e h o l d e r I n v o l v e m e n t
7. Stakeholder Involvement
“Consult: to seek the opinion or advice of another; to take counsel; to deliberate together; to confer.”
die.net
“Consult: to seek approval for a course of action already decided upon.”
Ambrose Bierce
7.1 Why stakeholder involvement

Firstly, involving stakeholders is a crucial part of a health impact assessment and its ethos of equity,
democracy, accountability and sustainability. Secondly, as discussed in Chapter 6, only by talking to
the individuals and groups who are or are likely to be affected by an initiative will we get a rounded
picture of the actual and potential impacts on health and wellbeing. Thirdly, actively listening to
and involving the people who are likely to be affected by an initiative is much more likely to
generate acceptance and support for an initiative and reduce actual and potential conflict, distrust
and anger.
There are five key reasons why we would want to get stakeholders involved in a HIA:
• a preference survey eliciting the likes and dislikes of local people and others about an
initiative;
• residents both existing and new will face the direct positive and negative health consequences
of the initiative;
• residents and other stakeholders have valuable experiential knowledge that they have built up
over the years about the locality in which they live and work and the impacts of past
initiatives;
• not adequately and appropriately addressing resident’s concerns can and does lead to residents
experiencing social and psychological distress; and
• allowing residents and others to have a voice and influence in community processes and
thereby reducing the sense of social exclusion, democratic deficit and inequity.
Central to the development of any stakeholder involvement and participation strategy – including
that within an HIA - is the need to be clear about why stakeholder involvement is being sought and
how these stakeholders views and perspectives will be incorporated into any resulting assessment
report, policy, plan, programme, project, development or service.
7.2 Levels of stakeholder involvement

Sherry Arnstein’s ‘A Ladder of Citizen Participation’ (Arnstein, 1969) is an internationally recognised
framework for understanding and classifying approaches to public participation. At the bottom of
her scale, participation is simply non- or contrived participation where the aim is to appear to be
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involving and consulting a wide range of stakeholders. At the other end is citizen power-sharing
where communities and residents have varying degrees of control and influence throughout the
whole process of developing a policy, plan, programme, project, development or service. In-
between there is tokenistic power-sharing where participation is at best simply informing local
people about a course of action or listening to them without making an explicit commitment to use
their views and at worst an attempt to keep residents quiet.
Figure 7.1 Diagram of Sherry Arnstein’s ‘Ladder of Citizen Participation’
8 Citizen control
7 Delegated power Degrees of

Better
Citizen Power
and
6 Partnership
more
5 Placation genuine
Degrees of stake-
4 Consultation holder
Tokenism
involve
3 Informing ment
2 Therapy
Non
1 Manipulation
Participation
Manipulative consultation is aimed at manipulating and coercing stakeholders and communities

(citizens) involved in the consultation to the point of view of those undertaking the consultation.
Those undertaking the consultation do not care about the other stakeholders and have no
compunction using any and all means to push other stakeholders to their point of view.
Therapeutic consultation is aimed at educating or ‘curing’ stakeholders and communities involved

in the consultation to the point of view of those undertaking the consultation. Those undertaking
the consultation believe in a paternalistic way that they know best and that other stakeholders are
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ignorant and do not know what is best for them and so must be educated away from their views
towards those they hold.
Informative consultation is the first step in legitimate stakeholder and community participation.
The flow of information and informing is one-way with those undertaking the consultation believing
that there is no discussion or debate needed on the information being communicated. This is the
minimum form of consultation.
Consultative consultation is the second step in legitimate stakeholder and community participation.
Those undertaking the consultation undertake the consultation either because they are forced to
undertake it because it is a legal requirement or required by others more powerful stakeholders.
Those undertaking the consultation have the discretion of acting on or ignoring the views,
comments and suggestions voiced by other stakeholders. Often this is and can be seen as ‘window-
dressing’ and tokenistic.
Placative consultation is the third step in legitimate stakeholder and community participation.
Those undertaking the consultation recognise that other stakeholders have a right to voice their
views and feelings but their aim is to address and implement those issues and comments that do not
conflict with their objectives whilst asking for more time and details on the other issues and
comments. Those undertaking the consultation, as in informative and consultative consultations,
retain all the power of decision-making.
Partnership consultation is the fourth step legitimate stakeholder and community participation and
the first level in real power-sharing. There is two-way communication and those undertaking the
consultation allow and enable other stakeholders to share in the decision-making process and
meaningfully influence the final decision.
Delegated consultation is the fifth step in legitimate stakeholder and community participation and
the second level in real power-sharing. Those undertaking the consultation have given community
representatives delegated powers to make decisions by giving them a majority of places on key
decision-making committees. Communities and the public have the power to assure accountability
and adequacy of the consultation, the decision-making process and the resulting decision.
Citizen controlled consultation is the sixth and final step in legitimate stakeholder and community
participation and the third level in power-sharing. Communities control the entire consultation and
decision-making process.
It is therefore critical to work out and be explicit with stakeholders and the community about the
level at which you are involving them so that there is no misunderstanding about the level of
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influence and power-sharing that will be taking place. There are times when involvement is about
informing or listening to other people’s views whilst being explicit about being unable to make a
commitment to incorporate those views and other times when there is a two-way partnership and
considerable power-sharing and influence being given to the views, perspectives and judgements of
those being involved in the HIA or initiative.
7.3 Approaches to stakeholder involvement

There are a range of methods of involving stakeholders including:
1. Public/community meetings
These tend to be the easiest to setup but the hardest to manage. Public meetings involve
organising a venue and meeting time that is accessible and convenient for all relevant
stakeholders. Having a meeting agenda agreed to by key stakeholders beforehand along with
allocated times for speakers and a Chair who will be firm with hecklers is crucial to running a
good public meeting.
2. Street interviews
These are informal interviews conducted in busy areas such as community centres, social clubs,
shopping centres and other venues where key stakeholders may be found. They tend to be held
standing up and follow a structured approach using a standard set of questions.
3. Survey questionnaires
These tend to be sent out by post with a couple of reminders for people who do not return the
questionnaire by a set time. Questionnaires sent out to named individuals tend to have a higher
response rate than those that are mailed to a general person such as ‘The Occupier’. Even
named questionnaires tend to have a low response rate with a response rate of over 10% for
unnamed and 30% for named questionnaires being considered very good.
4. Focus groups
This is where small groups of key stakeholders are brought together in small groups usually
between six-twelve people to discuss an issue or concern in-depth. They require considerable
preparation and a facilitator as well as note-taker.
5. Key informant interviews

These are one-to-one interviews with key professionals and community representatives, e.g.
community centre coordinator, Chair of a local residents’ association, and usually last an hour
with a single interviewer tape-recording the interview and then typing it up later.
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6. Community involvement/consultation groups

These are more long term ‘focus groups’ where key stakeholders are asked to form a
consultation group that will feed its views during the design, implementation and operation of
an initiative usually over a period of months and years.
7. Citizen panels/juries
These are similar to consultation groups but tend to be formed around specific national or local
themes of concern and involve a representative sample of people from an area, region or
society to enable a representative view to be gained e.g. genetically modified crops, human
embryo research, etc.
The best approach is to use a range of methods and then see which ones work and follow these up.
This is because what works in one community today may not work in other communities or in the
same community a few years later.
The accompanying training participants booklet ‘An Introductory Guide: how to consult your
users’ produced by The Cabinet Office provides more detail on each of the methods listed above
along with their strengths, limitations and costs in terms of time, effort and money.
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8 . C o m m i s s i o n i n g a n d S c r u t i n i s i n g a H I A
8. Analysis
“In a practitioner’s reflective conversation with a situation [an initiative]…she functions as agent/experient.
Through her transaction with the situation, she shapes it and makes herself part of it.”
The Reflective Practitioner by Donald Schön
8.1 Chains of inference and chains of causation

Analysis is the critical step of all impact assessments and health impact assessment is no exception.
Analysis is the systematic identification and assessment of the significance of:

• the potential consequences that will arise from a given initiative;
• the individuals, groups and communities that are likely to be affected by those consequences
(intentionally or unintentionally),;
• the potential positive and negative health effects that these consequences may give rise to in
the individuals, groups and communities that are likely to be affected; and
• the options available to minimise the negative health effects and maximise the positive health
effects.
Analysis involves the ability to imagine a virtual world where the proposed initiative is implemented
and thinking through the implications of the initiative from implementation, operation and closure.
Through this imaginative process chains of inferential reasoning are developed to show that:
• the identified consequences could actually occur and how they are likely to occur;
• they could actually occur on the identified individuals, groups and communities;
Once this is accomplished chains of causation are formally developed for the positive and negative
health impacts by examining the health evidence for these health impacts from scientific research.
The evidence is reflectively applied to the specific initiative being assessed to show that:
• the identified consequences could actually lead to the identified positive and negative health
effects;
• there are possible pathways by which these health impacts could occur; and
• there are options to minimise the negative and maximise the positive health effects
Finally, a qualitative and/or quantitative assessment is made of the significance of the identified
consequences of the initiative and the health impacts arising from them.
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Written down like this the analysis step sounds simple, logical and linear however it is complex,
logical, reflective, imaginative and iterative.
8.2 Putting all the evidence together

As discussed previously the pathways of health impact (the determinants of health) through which
initiatives affect individuals, groups and communities have not been fully mapped out and the
strength of evidence for the causation of many health effects is weak or non-existent.
In this uncertain context, the assessors’ direct experiential knowledge, the experiential knowledge
gained from previous health impact assessments and their evaluation, the experiential and expert
knowledge of the professionals involved or affected by the initiative as well as the experiential and
expert knowledges of the individuals, groups and communities who are likely to be affected must be
taken into account to create a holistic assessment.
8.3 Focussing on the significant and the likely

Finally, it is very difficult and time-consuming and highly unlikely that all the consequences of a
proposed initiative and their health effects can be identified accurately. Therefore the focus of the
analysis must always be to identify the potentially most significant and likely negative and positive
health impacts.
This ensures that the final assessment will be relevant both to decision-makers and to those who are
likely to be affected by a proposed initiative.
8.4 Some examples

An organisational anti-smoking policy aimed at helping staff quit smoking is likely to have positive
benefits in terms of supporting those smokers who want to stop. However it could have negative
health effects on those smokers who don’t want to or try and fail to give up by them feeling like
social outcasts and ‘bad’ people who lack willpower. Some may also feel that they are being
coerced and put under pressure to stop something that they enjoy and makes them feel good by
relieving their stress or being a treat or reward for coping with life’s daily stresses.
A green transport and education programme encouraging young people to cycle and appreciate
the health benefits of cycling and being outdoors by providing them with free cycles will have
positive benefits for those young people who take up cycling. However, some young people can see
this as negative and denigrating because, socially and culturally, owning and driving a car,
especially an expensive one, is a way of showing and enhancing our social status.
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A housing development with affordable housing in an area with a housing shortage will have
positive benefits in terms of increasing the availability of good quality housing but can have
negative effects during construction, through increasing traffic, pushing local people out as new
people from outside the area buy the new houses, create a sense of ‘us and them’ between
residents of the new houses and those of the old and put pressures on existing health and social
care services and other retail and leisure amenities.
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8. Commissioning and Scrutinising a HIA
“Consultant: a specialist who gives expert advice or information.” Collins English Dictionary
“Consultant: someone who borrows your watch, tells you the time and then charges you for the privilege.”
The Times
8.1 Commissioning
Health impact assessments (HIAs) are commissioned for a range of different reasons and this tends
to lead to different ways in which they are taken forward.
A HIA can be commissioned because:

• it is seen as a way of providing information to help with designing and developing a policy,
plan, programme, project, development or service (initiative),
• it is a way of bringing key stakeholders together to discuss and decide on an initiative,
• it is a legal duty to carry out a HIA (e.g. in Tasmania)
• it is seen as good practice,
• it is seen to help build trust among other stakeholders, especially communities, by showing
that their concerns are being taken seriously,
• it is seen as providing credible evidence in legal settings, for example, planning inquiries
and other judicial hearings,
• a mixture of the above.
It is important to be clear and explicit about why a HIA is being commissioned so that internal
HIA staff or external consultants have a clear understanding of what they are required to do. It
will also help later when the report and its recommendations are being judged by others to see
how well these objectives have been met.
The key questions to ask in framing any proposed health impact assessment include:
• What is the purpose of the health impact assessment?
• How will the findings be used – will it guide design, assist implementation, reduce negative
effects and/or improve the positive health effects of an initiative?
Setting up a HIA steering or working group that either advises on or project manages the HIA can be
a useful way to ensure that all stakeholders understand and are clear about the scope and limits of
the HIA. Creating a group like this with all the key stakeholders represented ensures that the
findings and recommendations of the HIA are credible and used to inform the design and
implementation of the policy, plan, programme, project, development or service being assessed.
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However, steering groups need a lot of time and resources to set up and maintain and so are
difficult to do well when time is short and resources lacking.
For external consultant-practitioners, references from previous clients are very useful in assessing
the quality of their work but the best way is to review actual copies of previous HIA statements that
they have produced as this will provide a more detailed insight into whether their approach meets
your needs and expectations.
As for costs, a good rule of thumb is that, a rapid HIA is likely to cost between £5-10,000, an
intermediate HIA requiring a community consultation between £15-20,000 and a comprehensive HIA
with a wide stakeholder consultation between £20-30,000.
Clear lines of supervision and communication between external consultants or internal HIA staff-
practitioners are vital.
A clear HIA plan and timetable can ensure that the HIA runs to deadline and is within budget.
Getting other colleagues or another HIA practitioner to critically review the final HIA report can
throw up errors of fact, especially about local context issues, as well as identify where judgements
might be seen as unjustified because they are based on weak, controversial or little evidence.
Finally, a good understanding of the strengths and limitations of HIA in general will ensure that
commissioners are realistic about what HIA can deliver and achieve and what it cannot.
8.2 Scrutinising
The issues considered in evaluating evidence are also important when scrutinising and evaluating a
HIA statement-report.
Key questions to ask are:

• What is the scope of the HIA and the definition of health used?
• Was the methodology used appropriate, explicit and logical?
• What evidence and sources of evidence were included and excluded and was the justification
given explicit, reasonable and appropriate?
• Was there any stakeholder involvement and were a range of stakeholder consulted?
• Was the justification for not consulting stakeholders and/ or involving only certain stakeholders
explicit, reasonable and appropriate?
• Was the analysis of impacts systematic and the reasons for judging the significance and the
extent of the positive and negative health effects explicit, appropriate and justified?
• Do the recommendations, including mitigation and enhancement measures, follow on from the
key issues emerging from the analysis?
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• Is the report as a whole clear, coherent and understandable?

• Does the HIA statement-report achieve the HIA’s aims and objectives?
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9 . T h e W i d e r C o n t e x t : p o l i t i c a l , e c o n o m i c a n d s o c i a l f a c t o r s
9 The Wider Context: political, economic

and social factors
“The primary determinants of disease are mainly economic and social,
therefore its remedies must also be economic and social.”
‘The Strategy of Preventative Medicine’ by Geoffrey Rose
9.1 Why the wider context

Health impact assessments (HIAs) and reports are not developed in a vacuum. All HIAs are set within
particular social, cultural and political contexts. There are social, political, economic and historical
factors that can play a big part in whether a health impact assessment gets commissioned and
implemented and, in turn, whether policies, plans, programmes, projects, developments and
services (initiatives) lead to improvements in the health of individuals and communities.
There are five important factors that can influence how, and to what extent, the findings of a HIA
report influence a given initiative. These are: influential stakeholders, the complexity of the
proposed initiative, the diversity of stakeholders involved, degree of clarity about what the
initiative is aiming to achieve and the wider socio-cultural and political environment.
9.2 Influential stakeholders

Professional groups, politicians and businesses are powerful and organised stakeholders who can and
do have an important influence on whether initiatives are implemented. It is therefore vital for
these groups to be involved in the HIA process so that there is consensus and support for the
recommendations that arise from a HIA report.
One of the key methods for identifying key stakeholders is stakeholder analysis or mapping. This
involves the creation of a grid (see Figure 9.1) where stakeholders are placed by a researcher,
policy analyst, HIA practitioner or local stakeholder in relation to the power they are judged to have
in influencing an initiative and the importance that the initiative has for that stakeholder group.
In the example below, seven local residents were asked which stakeholders they thought had the
most power and influence (measured on the horizontal axis) and how important it was to each of
these stakeholders (measured on the vertical axis). Residents felt that though the initiative was
equally important to them, the developer and the local council they were much less influential. In
contrast, the stakeholder map created by professional stakeholders from the council and the
developer (not shown) showed that they thought that residents had an equal if not greater influence
on the planning and implementation of the local initiative.
Page 37
Figure 9.1: Stakeholder mapping by local residents for a local initiative

(figures in brackets give the number of residents who placed the stakeholder in that category –
7 residents undertook this exercise)
A. HIGH importance / LOW influence B. HIGH importance / HIGH influence

High
Residents (7) Developer (6)

Residents’ Association (7) Planning Dept. (5)
Local Shops & Businesses (7) EIA Consultants (paid by council) (5)
ISCA (6) Councillors (4)
FoE/ Greenpeace (4) NLWA (4)
IMPORTANCE Environmental Health Dept (3) PH Dept (3)
EIA Consultants (paid by developer) (3)
C. LOW importance / LOW influence D. LOW importance/ HIGH influence
School of Community Health (2) Local newspaper (4)

GLA (3)
Judiciary (3)
Low High
INFLUENCE
(in terms of the planning and implementation of the initiative)
9.3 Complexity of proposed initiative

The more radical and complex the design and implementation of an initiative the more difficult and
more easily disrupted it is likely to be. Here again, support by as many stakeholders as possible as
well as a phased and monitored approach to design and implementation are crucial.
9.4 Diversity of stakeholders that need to be involved

Involving a range of stakeholders is important but it also needs to be recognised that there will be a
range and diversity of views within a stakeholder group, e.g. between health professionals as well
as between health professionals and local residents. This diversity itself will create differing
expectations, perspectives, desires, priorities and so on which can lead to conflict and opposition.
This is one of the reasons why these stakeholders and their views need to be incorporated into any
initiative (including the HIA itself) so that as many voices as possible are included in the assessment,
design and implementation process.
9.5 Lack of clarity about the initiative

Lack of a clear vision and rationale for the proposed initiative can be a significant stumbling block
to achieving real and lasting improvements. It is therefore better to have a small number of clear
Page 38
and achievable objectives and a realistic vision than unrealistic, vague and over-ambitious
objectives.
9.6 Changing environment – social, cultural, political, economic

New social, cultural, political and economic issues in the wider society and local community need to
be incorporated into the assessment process. This is one of the strengths of the HIA approach in that
it provides a considerable degree of flexibility and adaptability to changing needs and
circumstances.
These wider contextual factors include recessions, local and national elections, changes in local
employment, demographic changes e.g. new communities entering the area, or cultural ideas
endorsed by celebrities who can influence community lifestyles and life choices. All of these are
difficult to capture at a single point in time.
Shell, the multinational oil company, has developed and continues to use a scenario-based
approach, (see their website for models of this approach), to brainstorm and map out potential
social, economic and political factors that might affect a given policy, plan, programme, project,
development or service (Initiative).
HIAs need to incorporate an outline form of this scenario-based approach by being specific, cost-
effective and feasible about the recommendations that are presented so that they have a high
likelihood of being incorporated into the design and implementation of a new or revised initiative.
Page 39
1 0 . M o n i t o r i n g a n d E v a l u a t i o n o f I m p a c t s
10. Monitoring and Evaluation of Impacts

“We shall not cease from exploration, and the end of all our exploring
will be to arrive where we started and know the place for the first time.”
T. S. Eliot
10.1 Why monitor and evaluate

Health impact assessments are a snapshot of the health status of a defined population and the
potential impacts of policies, plans, programmes, projects, developments and services (initiative)
on this population.
Therefore, it is important to build in measures and methods of monitoring whether, to what extent
and in what way the potential health impacts actually manifest themselves. It is also worthwhile
evaluating the overall value and influence a given health impact assessment has had on the
subsequent design, implementation and operation of an initiative.
However, it can be difficult to identify and track the changes in health brought about by a given
initiative because they tend:
• not to have health improvement as a primary goal;
• to be implemented in tandem with other initiatives;
• to have shorter timescales of operation than the determinants of health which may
take decades to manifest themselves as positive or negative changes in health status;
and
• to change, develop and grow and it becomes difficult and complex to assess how
these changes are changing the positive and negative health impacts originally
envisioned.
10.2 Monitoring
Monitoring is the ongoing assessment of a policy, plan, programme, project, development or service
(initiative) while it is active and operational.
Most monitoring involves collecting information on direct visible outputs of an initiative. Monitoring
measures outputs such as the number of people positively and negatively affected by an initiative
while evaluation measures outcomes such as how and in what ways these people have been
affected. To give an example consider a policy to create advice and guidance centres for
unemployed people. We can measure outputs such as whether the policy was implemented, how
many centres were built, how many people use the service, what social and ethnic background they
are from and their gender. However, the outcomes we are ultimately interested in are whether
Page 40
these users have been helped by the service to access further education, training or employment;
whether crime and disorder have been reduced; whether young people feel they are doing
meaningful and worthwhile things and whether these unemployed people feel valued and part of
the wider society.
The key approach to monitoring changes in health has been to develop indicators which give an
indirect measure of the health status of a given community. This is due to the difficulty of directly
assessing individual health changes attributable to a given initiative. A range of health indicators
have been developed by the World Health Organisation based on the DPSEEA framework, see Table
10.1, made up of eight broad environmental health indicator themes and specific indicators within
each theme. In the UK, the key health indicators include: unemployment, ethnicity and
unemployment, educational attainment, proportion of homes judged unfit to live in, domestic
burglary rate, air quality, road traffic accidents, life expectancy at birth, infant mortality rate
and the proportion of people with self-assessed good health.
However, it can be difficult to get information covering populations at a small area level as routine
sources of information, for example census data, generally cover larger areas. Measures of health
service use and activity, which are routinely collected or gathered in a survey, can be used to
estimate population health status however they are indirect (proxy) measures; it is important to be
aware of the different influences on the data and the different and incompatible ways in which the
information might have been collected. Information from NHS trusts or primary care trusts may be
available at ward level, or street level, but there is as yet no standardised approach to collecting
this type of data (from Bardsley, Cave et al: source 2001).
Most health indicators measure illness and the treatment of disease. Mortality (numbers of deaths)
and morbidity (numbers of ill people) information is commonly used. However, trying to capture
health impacts through changes in the patterns of mortality and morbidity are not always relevant
to many initiatives and does not capture quality of life or episodes of illness which are not
presented to health care agencies. Finally, some health effects occur over many years and these
impacts are difficult to monitor.
Routine health data can be supported with specially commissioned surveys of self-perceived health
status and quality of life. These should ideally use items from national surveys so that local results
are comparable to national ones. A prospective design will follow individuals and allow more
detailed analysis of the reasons for changes in health. These surveys are resource intensive and it is
advisable to invest in specialist help.
Indicators from non-health sectors can also be used as part of a composite set of health indicators
to show changes in the determinants of health e.g. unemployment rates and levels of car
ownership.
Page 41
10.2 Evaluation
Evaluation and monitoring though closely intertwined are separate processes. There are two forms
of evaluation to be considered here: an evaluation of the policy, plan, programme, project,
development or service (initiative) and an evaluation of the HIA itself. Both are important.
An evaluation of an initiative involves asking whether the initiative achieved its overall aims and
objectives. Was health, wealth, social relationships improved and jobs and goods created. An
evaluation of an HIA involves asking whether the predictions and recommendations made by the HIA
turn out to be accurate and did the implementation of the HIA recommendations lead to
improvements in health outcomes. Other aspects that can be evaluated include whether the HIA
process was robust and were a range of stakeholders, including decision-makers, fully engaged with
the HIA.
One important perspective on evaluation called ‘realistic evaluation’ argues that there are three
aspects to consider when undertaking an evaluation: the context, the mechanism and the outcome.
The context within which an initiative is implemented and a HIA undertaken has a profound
influence on the outcomes that are generated. A close study and explicit description of the social,
cultural, political, economic and environmental factors that contributed to the success or failure of
an initiative or HIA are vital for any good evaluation.
The mechanism is the actual means used to implement and deliver an initiative (or HIA) to the
target individuals and communities and how the mechanism of implementation was affected by the
context. A close study and explicit assessment of the mechanism will highlight the barriers that
occurred to prevent the initiative (or HIA) from being successfully implemented and fully realised.
Finally, the outcome is the actual results of an initiative and what it has achieved. Here again an
assessment of how close or divergent these outcomes were to the original vision, aims and
objectives of the initiative will identify how and in what ways issues emerged and interactions took
place that resulted in the initiative being less successful than it might otherwise have been.
There are three aspects of an initiative (or HIA) that can be evaluated: its process, its impact (short
term successes) and its outcomes (long term successes).
Process evaluation is concerned with evaluating how an initiative (or HIA) was designed and
implemented and whether the process followed key values: transparency, democracy, equity and
inclusivity. By showing that an initiative was designed, implemented and operated in keeping with
these values we can say that the outcomes are also likely to be transparent, democratic, equitable
and inclusive and therefore likely to be positive for health.
Page 42
Impact evaluation is concerned with evaluating the implementation stage of an initiative or HIA i.e.
whether it achieved its objectives in the short term and whether recommendations and feedback
from an impact assessment, consultation exercise and/or feedback from users/affected groups are
used to modify and improve the initiative and its effects.
Outcome evaluation is concerned with evaluating whether an initiative (or HIA) has achieved its
long term objectives (and outcomes).
Page 43
Table 10.1 WHO environmental health indicators (P=population)
Information Needed Formula Unit

socio-demographic context
poverty Jarman/ Carstairs/ Townsend Index/ Index Multiple Deprivation (IMD) See individual indexes individual ranking scales
2
population density No. of residents, Land Area (km ) Population (P)/Area (A) no. of residents per km2
age structure No. under 16 years, no. over 65 years, total population 100 x [(P0-15 + P65+)/Ptot ] percentage (%)
infant mortality Death rate of infants under 1 yr of age, per 1000 live births, over time Deaths<1yr/Live births in a deaths per 1000 live
period year births
life expectancy at birth Age-specific and gender-specific death rates Average expected lifespan years
air pollution
outdoor air pollution Mean annual conc. of ozone, CO, PM10, PM25, SPM, SO2, NO2, O3 and Pb Particle concentration in air mg/m3
respiratory illness - morbidity No. of acute respiratory infections in children under 5years, 1000 x (Rc /Pc) no. per 1000 under 5's
total no. of children under 5yrs, over a year
respiratory illness - mortality Annual mortality rate due to ARI in children under 5yrs, total no. of children 1000 x (Mc /Pc) no. per 1000 under 5's
under 5yrs, over a year
air quality management Management Capabilities Assessment Index - management capability, Qualitative assessment not applicable
standards, controls
availability of lead-free petrol % of lead-free petrol consumption as % of total consumption (U/T) x 100 percentage (%)
sanitation
excreta disposal No. with access to basic sanitation, total population 100 x (Pe/ Pt) percentage (%)
unsafe housing % population living in substandard housing P in substandard/P in all percentage (%)
housing x 100
home accidents Accidents in home, total population 1000 x (Accidents/Population) no. accidents per 1000
head of population
Page 44
Information Needed Formula Unit

urban planning Land use planning, building regulations - evidence of existence, Qualitative assessment not applicable
implementation and enforcement
drinking water
water supply - access & connection No. with access to mains connection, continuous and sufficient, total (Pwith/ Ptotal) x 100 percentage (%)
population
water quality monitoring (Conc. of NO3-N; no. of faecal coliforms, total population) no. of valid 1000 x (sum M1/P) various
measurements in 1 year, total population
solid waste management
waste disposal Proportion of hazardous material in domestic waste, amount of waste Mw/P tonnes per capita
disposed, total population
waste management Hazardous waste policy and regulations and enforcement Qualitative assessment not applicable
hazardous/ toxic substances
blood lead % of children under 5 yrs with blood lead levels over 10micrograms/dl 100 x (Nh/Nt) percentage (%)
poisonings No. of poisonings, total population N/P no. per 1000 head of
population
contaminated land management Formal definitions, Register, Legal Liability, Development Controls, Qualitative assessment not applicable
Contaminated Land Agency
non-occupational risks
motor vehicle accidents Death rate due to motor vehicle accidents, total resident population 1000 x (Mt/P) no. per 1000 head of
population
o
injuries to children Incidence of physical injury to children under 5 years of age, total n . of 1000 x (Ic/ Pc) no. per 1000 under 5's
children under 5yrs
poisonings of children No. of cases of poisoning in children under 5yrs, total no. of children under 1000 x (Pc/Nc) no. per 1000 under 5's
5yrs
adapted from DPSEEA (Varty, 2002)
Page 45
1 1 . C o n c l u s i o n
11. Conclusion
“The journey of a thousand miles begins with a single step”
Chinese proverb
This reader has explored a number of key aspects of health impact assessment including what it is,
why it’s done, how it’s done, when it’s used and how it should be commissioned.
Health impact assessment is a flexible methodology for understanding the varying health impacts
both positive and negative, that policies, plans, programmes, projects, developments and services
(initiatives) can have on the individuals and communities that they are targeted at as well as on
those that are not the specific targets of the initiative in question.
Health impact assessment is a relatively new approach that is still evolving and there are different
ways of doing it depending on the particular initiative, the local context, the perspective of the
assessor and the time and resources available.
In HIA, using a range of evidence from a variety of sources is important as is highlighting gaps,
contradictions and weaknesses in our evidence base and the limitations of our assessment.
Involving and including as many stakeholders as possible is crucial in ensuring that key priorities and
concerns are not overlooked. Involvement also ensures that there is support and ‘ownership’ of
initiatives by those who will be affected by the initiative as well as ensuring that negative health
effects are reduced and positive ones enhanced.
It is also vital to understand and take account of the wider social, cultural, economic, political and
environmental factors that can help or hinder the implementation of an initiative as well as an HIA
and its recommendations. Doing this will ensure that the recommendations from an HIA are timely,
feasible, practical and likely to be implemented.
Finally, monitoring and evaluation are useful ways of ensuring that the findings and work that have
gone into an initiative and an HIA are successful in improving individual and overall population
health and wellbeing over the short and long terms.
We hope this reader and the accompanying training course have given you enough knowledge,
understanding and experience to enable you to undertake and commission your own health impact
assessments. We hope that we have given you the springboard to start your own HIA adventure and
journey…
Good luck and bon voyage!
Page 46
S o u r c e s o f F u r t h e r I n f o r m a t i o n
Sources of Further Information
The following are useful sources of information that will deepen your knowledge about health
impact assessment and act as a resource for your future work. Websites have been listed where
appropriate.
Books
London's Health: developing a vision together. Resource for health impact assessment. Volumes 1 & 2
Ison, E. 2000. London, commissioned by NHS Executive.
A FREE detailed resource. Volume 1 covers the methodology behind HIA and provides an overview of all the
important approaches to doing a HIA. Volume 2 provides an overview of a range of case studies of HIA.
http://www.londonshealth.gov.uk/allpubs.htm#hia
Health impact assessment: concepts, theory, techniques and applications

Edited by J Kemm, J Parry, S Palmer, Oxford University Press, Oxford, 2004
A up-to-date look at HIA, its history, strengths, weaknesses, areas of debate and future directions.
Health and environmental impact assessment: an integrated approach.

British Medical Association, Earthscan, London, 1998.
An important work which created an impetus for public health professionals to be active in ensuring that
health is integrated into development initiatives.
Evidence Bases
NETHERLANDS – NSPH Health impact assessment database

The Netherlands School of Public Health (NSPH), has taken the initiative to start preparing a preliminary HIA
database which can be accessed through the internet and which will, in due time, be part of an international
HIA Information System (HIS)
http://www.hiadatabase.net/
UNITED KINGDOM – Health Development Agency Evidence Base
HDA Evidence Base aims to provide access to the best available information on what works to improve health
and reduce health inequalities via the Internet. This resource is aimed at a wide range of practitioners and
researchers engaged in public health work.
http://www.hda.nhs.uk/evidence/
International
World Health Organisation – Health Impact Assessment

Very useful website bringing an international perspective to HIA policy and practice with some very useful
resources on HIA.
Page 47
http://www.who.int/hia/en
Europe
FINLAND - Stakes
A Finnish website by STAKES (National Research and Development Centre for Welfare and Health) promoting
Human Impact Assessments, with a particular focus on human impacts and sustainable development
http://www.stakes.fi/sva/huia/index.html
UNITED KINGDOM - HIA gateway

UK's Health Development Agency's website provides access to HIA related information, resources, networks and
evidence to assist people participating in the HIA process.
http://www.hiagateway.org.uk/
North America
CANADA - Health Canada Office of Environmental Health Assessment

Health Canada and Canada as a whole has been in the vanguard of incorporating health into policies, plan,
programmes and projects. This site has a range of Canadian resources on HIA.
http://www.hc-sc.gc.ca/hecs-sesc/ehas/index.htm
USA – Minnesota – Department of Health

Some useful resources about HIA from a US perspective
http://www.health.state.mn.us/divs/chs/mhip/
Australasia
Australia - HIA Connect http://chetre.med.unsw.edu.au/hia/

This site contains information on Australian HIA activity.
NEW ZEALAND - Ministry of Health

Guide to facilitate and encourage the integration of health impact assessment into the resource management
process.
http://www.moh.govt.nz/moh.nsf/7004be0c19a98f8a4c25692e007bf833/b96ae86add32e5f94c256671000cd202?OpenDocume
nt
Associations & Societies
IAIA - International Association for Impact Assessment

The International Association for Impact Assessment is the professional body for all impact assessment
practitioners including health impact assessment practitioners.
http://www.iaia.org/
Page 48
Page 49
R e f e r e n c e s
References
(2003). Measurement on health. Epi5251 online course notes.

http://courseweb.edteched.uottawa.ca/epi5251/Index_notes/Definitions%20of%20Health.htm . University of
Ottawa.
Adams, J. (2001). Risk. London: Routledge.
Arnstein, S. (1969). A ladder of citizen participation in the USA. Journal of the American Institute of Planners
35, 216-24.
Bardsley, M., Cave, B., Jacobson, B. et al. (2001). Monitoring regeneration and health: a health indicators
toolbox for practitioners. London, Health of Londoners Programme.
Available: http://www.holp.org.uk
Hill, B.A. (1965). The environment and disease: Association or causation? Proceedings of the Royal Society of
Medicine, 58, 295-300.
Cave, B. and Curtis, S. (2001). Health impact assessment for regeneration projects. Volume I: A practical
guide. London, East London and the City Health Action Zone and Queen Mary, University of London.
Available: http://www.geog.qmul.ac.uk/health/guide.html
Cave, B., Curtis, S., Cooke, A. et al. (2003). How important is public participation for health impact
assessment? draft.
Cave, B., Curtis, S., Coutts, A. et al. (2001). Health impact assessment for regeneration projects. Volumes I-III.
London, East London and the City Health Action Zone and Queen Mary, University of London .
Cave, B. and Penner, S. (2001). Frequently asked questions about HIA. London, Queen Mary, University of
London.
Connell, J. P. and Kubisch, A. C. (1998). "Applying a theory of change approach to the evaluation of
comprehensive community initiatives: progress, prospects, and problems," in New approaches to evaluating
community initiatives. Volume 2 Theory, measurement, and analysis. Edited by K. Fulbright-Anderson, A. C.
Kubisch, and J. P. Connell, Washington DC: The Aspen Institute.
Connell, J. P., Kubisch, A. C., Schorr, L. B. et al. (1995). New approaches to evaluating community initiatives:
concepts, methods & contexts. Washington DC: The Aspen Institute.
Dahlgren, G. and Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm,
Institute for Future Studies.
Devers, K. J. (1999). "How will we know 'good' quality research when we see it?" Beginning the dialogue in
health services research. Health Services Research 34, 1153-88.
Funtowicz, S. O. and Ravetz, J. R. (1992). "Three types of risk assessment and the emergence of post-normal
science," in Social theories of risk. Edited by S. Krimsky and D. Golding, Westport, Conn. ; London: Praeger.
Guba, G. E. and Lincoln, Y. S. (1994). "Competing paradigms in qualitative research," in Handbook of

qualitative research. Edited by N. K. Denzin and Y. S. Lincoln, Thousand Oaks: Sage.
Hancock, T. (1993). Human development and the community ecosystem: three ecological models. Health
Promotion International 8, 41-47.
Inui, T. S., and Frankel, R. M. (1991). Evaluating the quality of qualitative research: a proposal pro-tem.
Journal of General Internal Medicine 6, 485-86.
Page 50
R e f e r e n c e s
Ison, E. (2000). London's Health: developing a vision together. Resource for health impact assessment. London,
commissioned by NHS Executive.
Available: http://www.londonshealth.gov.uk/allpubs.htm#hia
Judge, K., Barnes, M., Bauld, L. et al. (1999). Health Action Zones: learning to make a difference. Findings
from a preliminary review of Health Action Zones and proposals for a national evaluation. A report submitted
to the Department of Health, 1-120. Health Action Zones – The National Evaluation Team.
Available: http://www.ukc.ac.uk/PSSRU/downloads/ddp1546.html
Last, J. M. (1995). A dictionary of epidemiology. New York: Oxford University Press.
Morgan, R. (2001). Impact assessment, monitoring and auditing.
Pawson, R. and Tilley, N. (1997). Realistic evaluation. London; Thousand Oaks, Calif.: Sage.
Statistics Division and Central Health Monitoring Unit. (2001). Technical supplement on target setting for
health improvement. Department of Health.
Available: http://www.ohn.gov.uk/ohn/technical/technical
Varty, S. (2002). Environmental health indicators: framework and methodologies.

http://www.northampton.ac.uk/ncr/who/ . University of Northampton.
Vingilis, E., and Sarkella, J. (1997). Determinants and indicators of health and well-being: tools for educating
society on the sustainability of well-being. Social Indicators Research 6, 1-20.
Weiss, C. H. (1995). "Nothing as practical as good theory: exploring theory-based evaluation for Comprehensive
Community Initiatives for children and families," in New approaches to evaluating community initiatives.
Concepts, methods, and contexts. Edited by J. P. Connell and others, Washington DC: The Aspen Institute.
Whitehead, M. (1995). "Tackling inequalities in health: a review of policy initiatives," in Tackling inequalities in
health: an agenda for action. Edited by M. Benzeval, K. Judge, and M. Whitehead, pp. 22-52. London: King's
Fund Publishing.
WHO European Centre for Health Policy. (1999). Health impact assessment: main concepts and suggested
approach. Gothenburg consensus paper. 1-10. Brussels, WHO Regional Office for Europe, ECHP.
Available: http://www.who.dk/document/PAE/Gothenburgpaper.pdf
Wynne, B. (1989). "Building public concern into risk management," in Environmental threats: perception,
analysis and management. Edited by J. Brown, London: Belhaven.
Wynne, B. (1996). ""May the sheep safely graze?" a reflexive view of the expert-lay knowledge divide," in Risk,
environment and modernity: towards a new ecology. Edited by S. Lash, B. Szersynski, and B. Wynne, London:
Sage.
Page 51
What others have said was worthwhile about this reader
and our HIA training course:
“All aspects – greater awareness that HIA

could be applied to all projects.”
Public Health Worker
“Materials good. The course was stretching (and not patronising as many courses seem to
be). Thought provoking and very useful. Slides good. Discussions very helpful.” YISP Youth
Justice
“Effects of policies on health – looking at evidence

and establishing the links.”
Planning Policy Officer
“HIA – i.e. last afternoon. The packs given on first day – excellent
– have already used. Thanks.”
“Case studies and group work – opened my eyes to much of the health world.”
Housing - Performance & Services Manager
Last session – practical and brought together discussions/

topics of previous sessions. Health Visitor
“The role play as you had a real experience talking with other agencies.”
“Preparation of the HIA report on the last day. Many issues discussed over the entire
course.” Transportation Engineer
Centre for Health Impact Assessment, Institute of Occupational Medicine

Research House Business Centre, Fraser Road, Perivale, Middlesex. UB6 7AQ
Tel: 020 8537 3491/2 Fax: 020 8537 3493
Website: www.iom-world.org

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Health Impact

Understanding of health impact assessment

Undertake a rapid health impact assessment

Commission and critically evaluate health impact assessment reports

2. Health Impact Assessment

“Go to the people, live among them

… a combination of procedures, methods and tools by which a policy, program or project

• improve project design, construction, operation and decommissioning.

• improve plan design, implementation and effectiveness.

• help increase community support and reduces community concerns.

• enhance reputation by feeding into corporate social responsibility.

2.3 What it doesn’t do

2.4 How is it done

Merseyside British Columbia

They are different in that:

Mitigation and Enhancement:

HIA report/ Health statement:

Follow up (monitoring & evaluation):

2.5 When is it done

They can be done at the:

Key questions to consider when planning a health impact assessment are:

In Holland the government examined how health consequences of policies could be

Meanwhile in Europe and particularly in the UK development of HIA encouraged a series

Box 2.2 How HIA was developed for projects

In Germany health aspects are considered in the context of environmental impact

3. Health, Determinants and Inequalities

3.1 What is health

3.2 Definitions of health

Figure 3.1: The main determinants of health

Source: Dahlgren and Whitehead (1991)

3.3 Determinants of health

Cardiovascular disease Smoking Local transport plans

Exercise Healthy living centres

Nutrition Land use and land planning

Being over-weight Smoking cessation programmes

Air pollution Access to affordable fresh foods

Access to affordable physical recreation

Cancer Smoking Land use and land planning

Nutrition Access to affordable fresh foods

Exercise Healthy school meals

Chemical exposures Smoking cessation programmes

Health screening for early Access to screening programmes

Accidents Transport Local transport and waterway plans

Workplace Housing policies, programmes and projects

Home Safety equipment loan schemes

Environment Occupational health

Mental Health Self esteem Education policies, programmes and

Health Inequalities Poverty Economic regeneration initiatives

Housing Initiatives to improve education,

Education Welfare reform

Work Housing, transport and planning policies

Access to retail services and other

3.4 Health inequalities

Age – e.g. children, elderly people.

4. Evidence and Evidence Gathering

4.1 What is evidence

Positivism Post positivism Critical Theory et al Constructivism

Ontology ‘Naïve’ realism – Critical realism – Historical realism – Relativism –

Epistemology Objectivist – Modified objectivist – Subjectivist – Subjectivist –

Methodology Experimental – Modified Experimental – Dialogic – Interpretative –

Issue Positivism Post-Positivism Critical Theory Constructivism

Inquiry aim prediction and control critique and understanding and

Nature of verified hypotheses non-falsified structural and individual