Health Impact Assessment: A triumph over common sense?

I'm giving a plenary talk at the 4th Asia Pacific Health Impact Assessment Conference in Seoul this week. I've attached the slides, a detailed paper and abstract below. It may be a little niche but hopefully some of you will be interested.

Health Impact Assessment: A triumph over common sense? from Ben Harris-Roxas

Download the detailed paper of the talk (21 pages PDF)

Abstract Evaluations of health impact assessments (HIAs) have highlighted its potential impacts on decision-making, implementation and broader factors such as intersectoral collaboration (Harris-Roxas et al. 2011, Harris-Roxas et al. 2012b, Wismar et al. 2007). Tensions often arise between stakeholders about the outcomes of HIAs however. Studies that have looked at this have found that there are:

• Often disagreements between stakeholders about the perceived purpose of the HIA and what form it should take (Harris-Roxas et al. 2012a, Harris-Roxas & Harris 2011); and
• The perception that an HIA’s recommendations could have been identified through normal planning and implementation processes and that the HIA didn’t necessarily have to be conducted (Harris-Roxas et al. 2011). In other words, that an HIA’s recommendations are “common sense”.

These two issues, about the perceived purpose of HIA and the “common sense” nature of HIAs’ recommendations, lie at the heart of any discussion of the HIA effectiveness. These issues have also been under-explored in the literature to date. This plenary will present initial findings from a study that looked at two decision-support equity-focused HIAs of similar health sector proposals (local health service obesity prevention and treatment service plans) longitudinally. This involved conducting 23 semi-structured interviews with key stakeholders before, during and after the HIAs, and document reviews. One of the HIAs was completed while the other one was screened and determined to be unnecessary. This study is unique in relation to HIA to the authors’ knowledge, because it looks at expectations and perceptions of effectiveness before and after the HIAs were completed. It also compares two similar planning situations, one in which an HIA was conducted and one in which the HIA was screened out.

The study’s findings highlight that while many of the recommendations and distal impacts of an HIA (Harris-Roxas & Harris 2012) could notionally be anticipated through common sense analysis, in practice they are rarely foreseen. A similar phenomenon has been demonstrated in other fields such as organisational psychology and management (Orrell 2007, Watts 2011). This study also highlights the critical role that learning plays in impact assessment practice (Morgan 2012, Bond & Pope 2012). This learning takes three forms: technical, conceptual and participatory (Harris & Harris-Roxas 2010, Glasbergen 1999). Learning may also take place at individual, organisational and social levels. This suggests that “common sense” is anything but common in the real world of planning and decision-making, and for good reasons. What seems obvious in hindsight is rarely apparent in advance. HIA, as a structured process for looking at under-considered impacts, has an important role to play in moving beyond common sense towards broader learning and more nuanced analyses of alternatives.

IAIA 2012 Conference first batch of presentations online

If you didn't manage to get to Porto for the IAIA 2012 conference then you can browse the presentations from the conference which have started to trickle in at:

http://www.iaia.org/conferences/iaia12/proceedings/default.aspx

For those who did attend but haven't yet uploaded their presentations click the link and then go to the upload page and your presentation today (The link is on the right).

The Role of HIA in Promoting Healthy Urban Development

I'll be live blogging a workshop on HIA and healthy planning, which is being held in Sydney and organised by the Public Health Association of Australia, the Australian Health Promotion Association and the UNSW Research Centre for a primary Health Care and Equity. I'll update this post as we go along.
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HIA In the USA
Dr Andrew Dannenberg, formerly of the US CDC, gave an overview of the inks between the built environment and public health. He then moved on to detailing the history of HIA in the US. The first HIA in the US was conducted in 1999 - around 160 have been completed in the USA as of 2012.

In the US, as elsewhere, most HIAs have been voluntary. The regulatory ones are less common and tend to be more contested, though they are still being done. Quantification and modelling ends to be more speculative but is important for reasonable cost-benefit models, which have been important to get traction in major decision-making processes in the US.

Community involvement in HIAs remains a thorny issue, as it does virtually everywhere. Vulnerabilities are important differential impacts to consider but practically challenging (as elsewhere).

There's an interesting distribution in the use of HIAs in the US. Most states have done one or are doing one, but most of the experience is on the west and east coast states. The majority have been conducted on built environment and transport proposals. San Francisco has been a leader in HIA and that work has largely been done using existing resources, i.e. not using special funds. Interesting examples room San Francisco and Boston were discussed. He gave some good examples of where good HIAs were conducted but they didn't change decisions - timing and other factors matter. "Getting the health information into the discussion is the primary purpose of HIAs" - I wonder if many would agree. That seems to be *a* purpose but is it the *only* purpose? And is it enough to justify HIA's use?

Andy mentioned a number of high-level govt documents that mention and support HIA's use. He also mentioned Health in All Policies and the work done to explore this in California. Massachusetts has introduced a requirement that HIA screening has to be done on all transport proposals, but the practicalities of this has still got to be figured out.

Andy mentioned the National Environmental Policy Act and how HIA might be integrated into that requirement (500 national NEPA-mandated EIAs are conducted every year, many more under state "mini-NEPAs"). Alaska has done a lot of work on health in EIA under their regulatory impact assessment procedures.

There's a lot of discussion on the legislative mechanisms that exist in the US, eg laws that are compatible with HIA's use. I wonder if this is a necessary but not sufficient condition for HIA's use, or maybe even not even necessary. Australia has had a lot of policy support for HIA that hasn't converted to activity. An imponderable.

Questions
Evaluation in HIA? Andy says that evaluation of HIA is useful but focusing on the predictive efficacy of HIA can be misguided/difficult. A lot of the evaluations that have been done have been conducted that the case level - there aren't many cross-sites studies of effectiveness (he mentioned the major Australian Research Council-funded study of HIA effectiveness that UNSW is currently completing, which I'm involved in and this is why Andy is here). Also most decisions have many factors that influence them, so it's hard to attribute change solely to HIAs.

Qualitative evidence for HIAs - can they ever give insights into the magnitude of potential impacts? Andy sort of flipped it around, there are lots of limitations to what we can quantitatively model. His point is essentially that we should quantify what we can. "My feeling is that the recommendations from an HIA would be the same without quantitative predictions, though the decision might not be." Well said.

What factors help enhance the uptake of recommendations? Relationships with decision-makers, that you're a known, credible group. Also that recommendations be actionable - where they lead to clear activities and not be motherhood statements.

We're many of the HIAs required by regulation? No, the vast majority are voluntary.

Have you seen many HIAs that are just done to tick a box? No, because most are done voluntarily that means that someone usually wants them done. (my view is that this is a major strength of HIA rather than a limitation - Ben)

Can you comment on the state of the art in qualitative research in HIA? Yes, it's difficult. Is air quality more important than physical activity? Difficulties in trying to prioritise between behaviours/environments/risks. It's hard.

Commentary from Australia: A planning perspective - Susan Thompson and a public health perspective - Peter Sainsbury.

They echoed many of Andy's points. Both identified the need for dedicated resources.

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My iPad ran out of charge so I wasn't able to do justice to Susan and Peter's presentations. I'll add their presentations and the recording to this post in the next few days.