The basics of health impact assessment (HIA): Part 2

1. The basics of health impact assessment (HIA): Part 2 Erica Ison Specialist Practitioner in HIA and HiAP Expert Adviser in HIA, WHO Network of European Healthy Cities, Phase IV

2. Commission on the Social Determinants of Health “The inequities in how society is organized mean that the freedom to lead a flourishing life and to enjoy good health is unequally distributed between and within societies. This inequity is seen in the conditions of early childhood, schooling, the nature of employment and working conditions, the physical form of the built environment, and the quality of the natural environment in which they reside. Depending on the nature of these environments, different groups will have different experiences of material conditions, psychosocial support, and behavioural options which make them more or less vulnerable to poor health. Social stratification likewise determines differential access to and utilization of health care, with consequences for the inequitable promotion of health and well-being, disease prevention, and illness recovery and survival.”

3. Commission on the Social Determinants of Health Overarching recommendations • Improve daily living conditions, i.e. the circumstances in which people grow, live and age • Tackle the inequitable distribution of power, money and resources – i.e. the structural drivers of the conditions of daily life – globally, nationally locally • Measure and understand the problem and assess the impact of action – expand knowledge base, develop a workforce trained in social determinants of health, raise public awareness and evaluate action

4. Classic process of HIA

5. Classic process of HIA

6. HIA: levels or depths of appraisal • Rapid– using the best available information, i.e. no “new” information is collected • Comprehensive – primary research is conducted, i.e. “new” information is generated

7. Methods supporting appraisal Undertaken by assessor(s) • Literature review • Review of HIA case-studies • Profiling (population or individual communities) • Desk-top appraisal Undertaken with stakeholders • Interactive: stakeholder workshops, focus groups, Delphi exercises, citizen’s juries • Non-interactive: surveys (postal or face to face), interviews

8. HIA: What are the hallmarks? • Specificity • Enhancement as well as mitigation • Flexibility • Adaptability

9. Basic Tasks in HIA Screening the proposal Proposal analysis – what are the deliverables of the proposal? Identifying a governance and accountability framework for the HIA Setting the boundaries for the study Setting the management arrangements for the HIA Profiling the community/population using routine and non-routine data Review of published literature – “evidence base” Review of HIA case-studies Identification of potential impacts on health Identification of ways to change the proposal and/or its implementation based on the potential health impacts Writing a report of the results of appraisal Presenting the results to decision-makers responsible for the proposal Process evaluation Effectiveness (impact) evaluation

10. HIA of London’s Mayoral Strategies • Previous Mayor of London made a political commitment to conducting HIA on all major mayoral strategies • HIAs were undertaken by the London Health Commission, an independent body, on behalf of Mayor • London Health Commission submitted HIA results to: • Mayor; • Greater London Assembly; • team responsible for the strategy being assessed

11. London’s Mayoral Strategies • Transport • Economic development • Spatial development • Waste management • Noise • Energy • Biodiversity • Air quality • Culture • Older people

12. Process for HIA on London’s Mayoral Strategies • Scoping main topic areas of the strategy for the HIA to focus on • Literature review of potential impacts on health and effective interventions relating to the strategy • Rapid appraisal techniques used: • HIA stakeholder workshop before public consultation period • Stakeholders from the private, public and voluntary sectors were invited • No members of the public were included • Reporting the results

13. HIA on London’s Mayoral Strategies

14. HIA on London’s Mayoral Strategies Questions for the stakeholder workshop on Noise Strategy • What parts of the strategy need to be kept on the basis of the impacts on people’s health and well-being? How can we increase those positive effects? • What parts of the strategy need to be changed because of their impacts on health and well-being? How can we change the proposal to reduce/avoid those negative effects? • What could be added to the strategy to promote health and well-being?

15. Evaluation of HIA on London’s Mayoral Strategies “The HIAs have raised awareness of the social model of health and public health amongst those whose primary roles are not health related … Most importantly [they] have influenced strategy.” Opinion Leader Research, 2002

16. HIA of the Redevelopment & Regeneration of the Lower Shankill Background • The Lower Shankill is a protestant housing estate in the centre of Belfast • Dominated by several protestant paramilitary groups during the 30 years of the “Troubles”, including one of the most violent and notorious led by “Mad Dog Adair” • Feuding among the paramilitaries in the summers of 2000 and 2001 resulted in 7 men being murdered, families were burnt out of their homes and more than 350 people were forced to leave the estate

17. HIA of the Redevelopment & Regeneration of the Lower Shankill Conditions on the estate • Estate managed by the Northern Ireland Housing Executive (NIHE) • About 500 houses built at different times • Large central open space infested with rats • Many voids where empty houses were knocked down (policy during the “Troubles”) • Road infrastructure poor and designed to enable the British Army to apprehend paramilitaries and prevent get-aways

18. HIA of the Redevelopment & Regeneration of the Lower Shankill Community profile for the HIA People on the Lower Shankill are: • Living in the 2nd most deprived community in Northern Ireland • Experiencing multiple deprivation: poor access to services, unemployment, poor-quality environment, low educational attainment, and high levels of crime • Suffering from severe health and other inequalities, some of which are a result of the “Troubles” and the later “Shankill feuds”

19. HIA of the Redevelopment & Regeneration of the Lower Shankill • Based on 11 options in the Economic Appraisal, from minor refurbishment to complete redevelopment • Commissioned by NIHE; project managed by Belfast Healthy Cities • Steering Group of partner organisations, including local government, health, voluntary sector & community representatives • HIA project plan approved by the Steering Group • Training in HIA given to community members and representatives from community organisations, who helped to compile the community profile

20. HIA of the Redevelopment & Regeneration of the Lower Shankill Rapid appraisal methods • Stakeholder workshop • Open event at the local school • Focus groups with the local women’s group, the old people’s home and with the ex-political prisoners • Desk-top appraisal by HIA Assessor Suggestions from all stakeholders and the HIA Assessor were based on the impacts identified and presented to NIHE In addition, there was a poster competition for the schoolchildren (prize was a bicycle), and the children also made maps, models and posters for the open event

21. HIA of the Redevelopment & Regeneration of the Lower Shankill Community responses during the HIA • People said that the “heart had been ripped out of the estate”, and they felt “abandoned” by organisations in the public sector • They wanted redevelopment and a better environment but not complete demolition of the estate because of the need for decanting (option 11), and most people did not want the estate taken over by private housing • They thought redevelopment would give the estate a better image and reputation, which it badly needed • They also wanted people who had left the estate to be able to return Steering Group discussions • Affordability of housing is key to the Shankill redevelopment (and to Belfast as a whole) • It is important to recognise the cultural needs of this protestant community

22. Which of the 11 options is best for health and well-being?

23. Which of the 11 options is best for health and well-being?

24. Which of the 11 options is worst for health and well-being? • For the people living on the Lower Shankill, option 9, with the displacement of ~100 social households, would have serious harmful impacts on mental health and well-being, especially given the community’s previous history of displacement arising from conflict and violence • Option 9 would also damage community cohesion, affecting family cohesion, social contact and the availability of social support (practical, emotional and technical), worsening their already poor health status

25. Which option gets chosen? The decision also depends on political priorities

26. HIA: Benefits for stakeholder organisations • Demonstrating a commitment to health and well-being of local people • Health as an added value for organisations not in the health sector • Potential for organisational development and learning • Potential to improve partnership working among agencies and among sectors • Potential to shift from services that solve problems to services that prevent problems arising

27. HIA: Benefits for the community • Greater involvement in policy- and decision-making • Potential to extend the democratic process, especially to groups in society who feel excluded • Skills development and capacity building • Potential to contribute to increasing social capital • Potential to reduce sources of inequality and disadvantage • Planning and design of services that better meet the needs of the local community