Fiona Haigh

The effectiveness of health impact assessment in influencing decision-making in Australia and New Zealand 2005–2009

BackgroundHealth Impact Assessment (HIA) involves assessing how proposals may alter the determinants of health prior to implementation and recommends changes to enhance positive and mitigate negative impacts. HIAs growing use needs to be supported by a strong evidence base, both to validate the value of its application and to make its application more robust. We have carried out the first systematic empirical study of the influence of HIA on decision-making and implementation of proposals in Australia and New Zealand. This paper focuses on identifying whether and how HIAs changed decision-making and implementation and impacts that participants report following involvement in HIAs.MethodsWe used a two-step process first surveying 55 HIAs followed by 11 in-depth case studies. Data gathering methods included questionnaires with follow-up interview, semi-structured interviews and document collation. We carried out deductive and inductive qualitative content analyses of interview transcripts and documents as well as simple descriptive statistics.ResultsWe found that most HIAs are effective in some way. HIAs are often directly effective in changing, influencing, broadening areas considered and in some cases having immediate impact on decisions. Even when HIAs are reported to have no direct effect on a decision they are often still effective in influencing decision-making processes and the stakeholders involved in them. HIA participants identify changes in relationships, improved understanding of the determinants of health and positive working relationships as major and sustainable impacts of their involvement.ConclusionsThis study clearly demonstrates direct and indirect effectiveness of HIA influencing decision making in Australia and New Zealand. We recommend that public health leaders and policy makers should be confident in promoting the use of HIA and investing in building capacity to undertake high quality HIAs. New findings about the value HIA stakeholders put on indirect impacts such as learning and relationship building suggest HIA has a role both as a technical tool that makes predictions of potential impacts of a policy, program or project and as a mechanism for developing relationships with and influencing other sectors. Accordingly when evaluating the effectiveness of HIAs we need to look beyond the direct impacts on decisions.

Characteristics of health impact assessments reported in Australia and New Zealand 2005-2009

Objective: To describe the use and reporting of Health Impact Assessment (HIA) in Australia and New Zealand between 2005 and 2009.

Health Impact Assessment in New South Wales & Health in All Policies in South Australia: differences, similarities and connections

BackgroundPolicy decisions made within all sectors have the potential to influence population health and equity. Recognition of this provides impetus for the health sector to engage with other sectors to facilitate the development of policies that recognise, and aim to improve, population outcomes. This paper compares the approaches implemented to facilitate such engagement in two Australian jurisdictions. These are Health Impact Assessment (HIA) in New South Wales (NSW) and Health in All Policies (HiAP) in South Australia (SA).MethodsThe comparisons presented in this paper emerged through collaborative activities between stakeholders in both jurisdictions, including critical reflection on HIA and HiAP practice, joint participation in a workshop, and the preparation of a discussion paper written to inform a conference plenary session. The plenary provided an opportunity for the incorporation of additional insights from policy practitioners and academics.ResultsComparison of the approaches indicates that their overall intent is similar. Differences exist, however, in the underpinning principles, technical processes and tactical strategies applied. These differences appear to stem mainly from the organisational positioning of the work in each state and the extent to which each approach is linked to government systems.ConclusionsThe alignment of the HiAP approach with the systems of the SA Government increases the likelihood of influence within the policy cycle. However, the political priorities and sensitivities of the SA Government limit the scope of HiAP work. The implementation of the HIA approach from outside government in NSW means greater freedom to collaborate with a range of partners and to assess policy issues in any area, regardless of government priorities. However, the comparative distance of HIA from NSW Government systems may reduce the potential for impact on government policy. The diversity in the technical and tactical strategies that are applied within each approach provides insight into how the approaches have been tailored to suit the particular contexts in which they have been implemented.

Rising unemployment and increasing spatial health inequalities in England: further extension of the North–South divide

BACKGROUND Unemployment negatively affects health. In this study, we quantify the impact of current and rising levels of unemployment on limiting long-term illness (LLTI), mental health problems and mortality in North and South England. METHODS Excess cases of LLTI and mental health problems in the unemployed were calculated as the difference in the prevalence between the employed and unemployed using data from large population surveys for England. Mortality due to unemployment was calculated using the formula for the population-attributable fraction. RESULTS Current levels of unemployment were estimated to be causing 1145 deaths per year and a total of 221 020 cases of mental health problems and 275 409 cases of LLTI in England. Rates of mortality, mental health problems and LLTI due to unemployment were distinctively higher in the North compared with the South. Considering hidden unemployment in the calculations considerably increased the proportion of women suffering from ill health due to unemployment. CONCLUSIONS Our study quantifies the detrimental effect of unemployment on health in England. There is a clear difference between North and South England highlighting the contribution of unemployment to spatial health inequalities. A public health priority should be to (i) prevent unemployment in the first place and (ii) provide support for the unemployed.

Is health impact assessment useful in the context of trade negotiations? A case study of the Trans Pacific Partnership Agreement

Objective The Trans Pacific Partnership Agreement (TPP) is a recently concluded free trade agreement involving Australia and 11 other Pacific-rim nations, which has the potential for far-reaching impacts on public health. A health impact assessment (HIA) was carried out during the negotiations to determine the potential future public health impact in Australia and to provide recommendations to mitigate potential harms. This paper explores the findings and outcomes of the HIA, and how this approach can be used to provide evidence for public health advocacy. Design A modified version of the standard HIA process was followed. The HIA was led by technical experts in HIA, trade policy, and health policy, in collaboration with advocacy organisations concerned with the TPP and health. The HIA reviewed the provisions in leaked TPP text in order to determine their potential impact on future health policy. As part of this process, researchers developed policy scenarios in order to examine how TPP provisions may affect health policies and their subsequent impact to health for both the general and vulnerable populations. The four policy areas assessed were the cost of medicines, tobacco control, alcohol control and food labelling. Results In all areas assessed, the HIA found that proposed TPP provisions were likely to adversely affect health. These provisions are also likely to more adversely affect the health of vulnerable populations. Conclusions The HIA produced relevant evidence that was useful in advocacy efforts by stakeholders, and engaging the public through various media platforms.

Including health in environmental impact assessments: is an institutional approach useful for practice?

Internationally the inclusion of health within environmental impact assessment (EIA) has been shown to be limited. While health-focused research has focused on the technical provision of health information, policy analysis theory may enable description and explanation of the institutional conditions surrounding health inclusion in EIA. However, whether this framework is considered useful by practitioners has yet to be tested. To investigate this, data were collected via a workshop (n = 22) and the results were analysed using ‘Institutionalist’ units of analysis (ideas, actors, organisations and institutions). These results were then emailed to participants who were asked to undertake a follow-up survey about the analysis and approach (n = 9). The workshop results suggested various influences on how and why health is considered or not in EIAs. Overall the survey respondents agreed that the approach was conceptually and practically useful but that the framework alone is insufficient and further work is needed to convince potential users of the value of health in EIA. The findings support the need for more detailed research.

What makes health impact assessments successful? Factors contributing to effectiveness in Australia and New Zealand

BackgroundWhile many guidelines explain how to conduct Health Impact Assessments (HIAs), less is known about the factors that determine the extent to which HIAs affect health considerations in the decision making process. We investigated which factors are associated with increased or reduced effectiveness of HIAs in changing decisions and in the implementation of policies, programs or projects. This study builds on and tests the Harris and Harris-Roxas’ conceptual framework for evaluating HIA effectiveness, which emphasises context, process and output as key domains.MethodsWe reviewed 55 HIA reports in Australia and New Zealand from 2005 to 2009 and conducted surveys and interviews for 48 of these HIAs. Eleven detailed case studies were undertaken using document review and stakeholder interviews. Case study participants were selected through purposeful and snowball sampling. The data were analysed by thematic content analysis. Findings were synthesised and mapped against the conceptual framework. A stakeholder forum was utilised to test face validity and practical adequacy of the findings.ResultsWe found that some features of HIA are essential, such as the stepwise but flexible process, and evidence based approach. Non-essential features that can enhance the impact of HIAs include capacity and experience; ‘right person right level’; involvement of decision-makers and communities; and relationships and partnerships. There are contextual factors outside of HIA such as fit with planning and decision making context, broader global context and unanticipated events, and shared values and goals that may influence a HIA. Crosscutting factors include proactive positioning, and time and timeliness. These all operate within complex open systems, involving multiple decision-makers, levels of decision-making, and points of influence. The Harris and Harris-Roxas framework was generally supported.ConclusionWe have confirmed previously identified factors influencing effectiveness of HIA and identified new factors such as proactive positioning. Our findings challenge some presumptions about ‘right’ timing for HIA and the rationality and linearity of decision-making processes. The influence of right timing on decision making needs to be seen within the context of other factors such as proactive positioning. This research can help HIA practitioners and researchers understand and identify what can be enhanced within the HIA process. Practitioners can adapt the flexible HIA process to accommodate the external contextual factors identified in this report.

Housing, health and master planning: rules of engagement

OBJECTIVES Knowledge about health focussed policy collaboration to date has been either tactical or technical. This article focusses on both technical and tactical issues to describe the experience of cross-sectoral collaboration between health and housing stakeholders across the life of a housing master plan, including but not limited to a health impact assessment (HIA). STUDY DESIGN A single explanatory case study of collaboration on a master plan to regenerate a deprived housing estate in Western Sydney was developed to explain why and how the collaboration worked or did not work. METHODS Data collection included stakeholder interviews, document review, and reflections by the health team. Following a realist approach, data was analysed against established public policy theory dimensions. RESULTS Tactically we did not know what we were doing. Despite our technical knowledge and skills with health focussed processes, particularly HIA, we failed to appreciate complexities inherent in master planning. This limited our ability to provide information at the right points. Eventually however the HIA did provide substantive connections between the master plan and health. We use our analysis to develop technical and tactical rules of engagement for future cross-sectoral collaboration. CONCLUSIONS This case study from the field provides insight for future health focussed policy collaboration. We demonstrate the technical and tactical requirements for future intersectoral policy and planning collaborations, including HIAs, with the housing sector on master planning. The experience also suggested how HIAs can be conducted flexibly alongside policy development rather than at a specific point after a policy is drafted.

Evaluating the impact of equity focused health impact assessment on health service planning: three case studies.

BackgroundHealth impact assessment has been identified internationally as a mechanism to ensure potential health impacts and health equity impacts of proposals are considered before implementation. This paper looks at the impact of three equity focused health impact assessments (EFHIAs) of health service plans on subsequent decision-making and implementation, and then utilises these findings to test and refine an existing conceptual framework for evaluating the impact and effectiveness of health impact assessments for use in relation to EFHIAs.MethodsCase study analysis of three EFHIAs conducted on health sector plans in New South Wales, Australia. Data was drawn from 14 semi-structured interviews and the analysis of seven related documents (draft plans and EFHIA reports).ResultsThe case studies showed that the EFHIAs all had some impact on the decision-making about the plans and their implementation, most clearly in relation to participants’ understandings of equity and in the development of options for modifying service plans to ensure this was addressed. The timing of the EFHIA and individual responses to the EFHIA process and its recommendations were identified as critical factors influencing the impact of the EFHIAs. Several modifications to the conceptual framework are identified, principally adding factors to recognise the role individuals play in influencing the impact and effectiveness of EFHIAs.ConclusionEFHIA has the potential to improve the consideration of health equity in health service planning processes, though a number of contextual and individual factors affect this. Current approaches can be strengthened by taking into account personal and organisational responses to the EFHIA process.

Facilitating interprofessional learning about human rights in public health contexts: challenges and strategies.

Occasions when public health practitioners engage in professional learning increasingly involve them in encounters with (a) concepts that originate from unfamiliar disciplines and that may be multidisciplinary, complex and sometimes contested, (b) colleagues who have different discipline and profession backgrounds, and (c) modes of learning and teaching that are unfamiliar. While these factors can enhance both the processes and products of learning, they can also present significant challenges when those learning occasions are designed and facilitated. Drawing on our own reflected-on experience of working in such contexts and a body of related literature, we elaborate on these interrelated challenges and propose three strategies that can help address them. The strategies entail encouragement and support for establishing common commitments and values, perspective-taking and self-reflexivity, conversation and storytelling. Specific examples of challenges and strategies are derived, in particular, from a learning agenda associated with the mainstreaming of a human rights approach to public health. That agenda requires practitioners to understand the concept of human rights, appreciate its relevance for public health work and be capable of integrating a human right perspective into their day-to-day work.