General introduction to DYNAMO – HIA project and tool Wilma Nusselder & Stefan Lhachimi

1. General introduction to DYNAMO – HIA project and tool Wilma Nusselder & Stefan Lhachimi On behalf of the Coordinating Center Expert meeting Dynamo-HIA, Rotterdam, May 23th, 2008

2. A joint project of: Erasmus Medical Centre RIVM National Inst of Public Health IASO Int Assoc for Study of Obesity Instituto Nationale dei Tumori, IRCCS London School of Hyg and Trop Med Catalan Institute of Oncology, IDIBEL Haughton Institute, HAUGH

3. What is the health impact of Decrease tax on healthy foods Ban alcohol advertising Ban smoking in pubs

4. This presentation • HIA has become an EU interest • What is HIA? • HIA at the European level • Importance and lack of quantification in HIA • Need for “off- the- shelf” quantitative HIA tool • DYNAMO-HIA tool and project • Challenge of today

5. EU interest in health matters Art. 152 of. EC Treaty TITLE XIII PUBLIC HEALTH Article 152 1.   A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities. Community action, which shall complement national policies, shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to human health.

6. Recent EU interest in health matters Examples of health proposals: • White paper “Together for Health:A Strategic Approach for the EU 2008-2013” • White paper “Strategy for Europe on Nutrition, overweight and Obesity related issues” (30 May 2007) • “An EU alcohol to support Member States in reducing alcohol harm” (October 2006) • Green paper “Towards a Europe free from tobacco smoke: policy options at the EU level” (January 2007) Hence, impact assessments for health policies

7. EU interest 1in health matters beyond health policies • 15 June 2005 Health is incorporated in the “Commission’s integrated impact assessment guidelines” • 30 November 2006: Health States of Affaires Council adopted “Council Conclusions on Health in All Policies” HIAP aim to raise the visibility of health in the development of the Community legislation and policies • Hence, HIAs for non-health proposals, e.g. • Phasing out of tobacco subsidies • Wine reform policy

8. What is HIA? “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, 1999, Gothenburg Consensus paper on HIA)

9. More definitions “a multidisciplinary process within which a range of evidence about the health effects of a proposal is considered in a structured framework,… based on a broad model of health which proposes that economic, political, social, psychological, and environmental factors determine population health. (Northern and York Public Health Observatory in Great Britain)

10. 5 key characteristics of HIA 1. a focus on specific policy or project proposals 2. a comprehensive consideration of potential health impacts 3. a broad, population-based perspective that incorporates multiple determinants and dimensions of health 4. a multidisciplinary systems-based analytical approach 5. a process that is highly structured but maintains flexibility (Cole, Fielding 2007, S. 396)

11. Several HIA definitions: common characteristics • To predict future consequences of health of possible decisions • To inform decision making (Kehm, 2003) 3. To allow participation of stakeholders

12. Several HIA definitions: 5 stages • Screening Deciding whether to undertake HIA • Scoping Deciding how to undertake HIA in given context • Effect analysis also known as appraisal or assessment 4. Interaction with policy process Further engagement with decision-makers to encourage adoption of recommendations or adaptation in the proposal 5. Monitoring and evaluation Ongoing monitoring and evaluation to assess if the HIA recommendations were implemented, if they contributed to positive effects on health and equity; and if not, why not.

13. 2 types of Assessment: • Descriptive: • Describing relevant evidence existing health in the affected population and assessing the evidence on the causal pathways linking the policy with eventual health outcomes • As many significant impacts cannot be quantified, evidence on these impact will be assessed and described qualitatively • Predictive: • Predicting the magnitude and likelihood of potential health impacts • Information on some effects can be quantified and combined in a model to estimate health impact

14. Different approaches to HIA • Quantitative/analytic approach: • Strong focus on estimation of potential health impact from a policy combining effect estimates and descriptive information on the target population • Participation approach • Strong emphasis on stakeholders input • Procedural approach • Strong emphasis on procedural concerns • Combines elements of quantitative and participation approach

15. Quantitative approach fits EU level Each approach has advantages and disadvantages Also a matter of taste More advantages and less disadvantages of quantitative approach at EU level or MS level

16. Quantitative approach: advantages • Apparent objectivity of the approach • Its fit with prevalent paradigms in health, environmental, and policy science • Potential impacts can be easily compared across policy alternatives and scenarios (Cole, Fielding 2007, S. 400)

17. Quantitative approach: advantages • Apparent objectivity of the approach • Its fit with prevalent paradigms in health, environmental, and policy science • Potential impacts can be easily compared across policy alternatives and scenarios (Cole, Fielding 2007, S. 400) EU level: more need to compare potential impacts across policy options and scenarios than in HIA of specific project at local level

18. Quantitative approach: disadvantages • May be infeasible because of limited data on the effect estimates and baseline characteristics of the population • Is highly time- and cost-intensive • Incorporates numerous value- and model-based assumptions that are not always explicit • May give an unwarranted patina of robust science • May omit or de-emphasize stakeholder participation (Cole, Fielding 2007, S. 400)

19. Quantitative approach: disadvantages • may be infeasible because of limited data on the effect estimates and baseline characteristics of the population • is highly time- and cost-intensive • incorporates numerous value- and model-based assumptions that are not always explicit • may give an unwarranted patina of robust science • may omit or de-emphasize stakeholder participation (Cole, Fielding 2007, S. 400) EU level: • More data available on effect estimates and baseline characteristics • More economics of scale and “off- the- shelf” models could be used • Stakeholder participation is less feasible anyway

20. HIA methodology for EU policy development - European Policy Health Impact Assessment (EPHIA)to develop andtest a HIA methodology for use by the European Community and its institutions in EU policy development - Gives key concepts and principles • Gives procedures and methods

21. EPHIA: key concepts and principles EPHIA uses broad, population-based perspective of health that incorporates multiple determinants and dimensions of health • Health is more than absence of illness or disease • Health is affected by complex interaction between social and economic factors, the physical environment and individual behaviors, as well as hereditary factors = the determinants of health Determinants of health as layers of influence

22. EPHIA: Determinants of health Core layer is: individual life style factors

23. EPHIA Procedure and methods Stages

24. EPHIA: Impact analysis (assessment) Impact analysis is using all the information gathered, to analyze the expected health impacts Strong emphasis on describing conditions and associations: • ”the purpose of impact analysis is to identify and characterize potential impacts” • “impact analysis involves organizing evidence of impacts from different data sources, qualitative and quantitative” But includes also predictive assessment: - explicit mentioning of scenarios applied to quantitative models

25. EPHIA: scenarios to compare policy options 1. To compare the potential health impacts due to different policy options: - min. 2 scenarios: basic scenario without policy and a second scenario with the policy 2. The scenarios could be applied to quantitative models identified in the data collection stage 3. The modeling provides an estimation of the magnitude and direction of the potential health impacts: by using alternative scenarios the effect of different policy options can be estimated.

26. EPHIA: Quantitative models EPHIA: “The quantitative models should be identified in the data collection stage” • EPHIA gives no further guidelines on quantitative HIA models Hence, EPHIA suggests to use existing models in the HIA to predict effects of policies

27. But still great challenge to predict policy options 2003 • “HIA has come a long way in the past 10 years, but if it is to go further it has to concentrate on its two key tasks predicting the future and assisting decision-makers” John Kehm (2003) 2007 • “Quantification is comparatively rare in HIA and there is little uniformity between HIA studies in the conduct and reporting of predictions” Lennert Veerman (2007)

28. Solution: using “off the shell quantitative HIA-model” • Prediction of the effects of health policies is useful for policy makers, the more so for EU policy making • Such predictions using a quantitative model are still rare in HIA • It takes time (cost) to prepare a model • If suitable “off the shell models” are available the HIA analyst can focus on assessing the effect of the proposed policy on exposure to determinants.

29. “Off the shelf” quantitative HIA model • As tool to synthesize evidence on target population, exposure to determinants, disease and mortality patterns and their associations with the determinants • Hence translating lots of data into policy relevant information • As a tool to predict and compare future impact of policy options • Translating a description of evidence into a comparison of policy options

30. Quantitative tool to predict change in health status Effect analysis: Description of baseline situation Estimation of change in exposure to determinants of health Quantitative tool Estimation of change in health outcomes

31. Quantitative tool to predict change in health status Effect analysis: Description of baseline situation Estimation of change in exposure to determinants of health Core layer EPHIA: life style factors Quantitative tool Estimation of change in health outcomes

32. Need for quantitative HIA-tool What has more impact? -------------------------------------------------------------------------------------------------- OR: Answer also depends on other factors 20% is exposed Disease risk is 4% RR is 4 2% exposed Reduction in exposure is 50% Disease risk is 2% RR is 2 Reduction in exposure is 60%

33. More need for quantitative HIA-tool • Prediction of health effect due to changes in lifestyle factors is further complicated by fact that: • life style risk factors often affect multiple diseases • life style risk factors often affect mortality, and hence population exposed to the policy So where are policy makers without a quantitative model?

34. Without quantitative model

35. With quantitative model

36. With quantitative model

37. Available quantitative tools • There are a few quantitative tools available • E.g. Prevent, Armada, Proportional MSLT, POHEM, RIVM-CM, Foresight • No existing model does fully comply with all desiderata of HIA (today)

38. DYNAMO – HIA: • Development of “off the shelf” HIA tool to predict health impact of policies that change health

39. 1. Development of a DYNAMO-HIA • Main characteristics :- fits the needs of ‘health impact assessors and users in developing and evaluating health policy’- generic, adaptable- applicable throughout EU- software available through the internet • Uses experience from existing models, IMPACT, POPMOD, PREVENT, POHEM, ARMADA etc

40. DYNAMO-HIA tool starts from lifestyle factors

41. DYNAMO-HIA models multiple risk factors • Model is generic, risk factors can be changed or added by users • Model includes already few example risk factors risk factors can be added by users

42. DYNAMO-HIA models multiple diseases Selected cancers CVD COPD Diabetes Diseases can to be added by users

43. DYNAMO-HIA tool Risk factors (e.g. smoking, BMI, alcohol)  Diseases (e.g. coronary heart disease, diabetes, several cancers)  Morbidity/Mortality/LE/DALE

44. DYNAMO-HIA-tool • “Off the shelf HIA” generic, user-friendly tool to predict health impact of policies that change health • Tool is meant to assist policy makers by synthesizing existing evidence and providing transparent comparisons of the health effects of different policy options

45. Scope of the DYNAMO-HIA • Effect of change in determinants of health on health outcomes (“outcome assessment”) • Generic approach is possible in framework of epidemiological multi sate modeling: risk factor -> health state -> mortality • Effect of policy on determinants (exposure impact assessment) is beyond the scope of the tool • Tailored approach by HIA annalist is needed for translation of each policy into effects on determinants

46. Core activities/objectives of DYNAMO-HIA project • Development of a HIA model in software tool • Compilation of consistent datasets on 3 lifestyle risk factors and 4 chronic diseases • Illustration of HIA tool by assessing health effects of various policy scenario’s

47. 1. Development of a HIA model in software tool (WP 4 and 5) Model specification (WP 4): - this meeting Model construction (WP 5):- mathematical model- implementation in prototype software tool- user manual

48. 2. Compilation consistent datasetsWP 6-10 EU-wide estimates and data-sets for specific countries on smoking, obesity, alcohol consumption, cardiovascular disease, diabetes, cancer and COPD • consistent = consistent throughout Europe and internally consistent • feasible data requirements • Collected where possible according to ECHI guidelines (EUROCADET, EUPHIX, EUROCISS, IMCA etc) • make datasets available for use in model

49. 3. Illustration by evaluation of scenario’s (WP 11 and 2) Estimate potential health gain in the EU for specific policy scenario, in comparison with scenario of all countries having life style of ‘most favorable’ country WP 11: Develop scenario’s Perform HIA applying products of WP 4, 5 and WP 6-10 WP 2: Disseminate in papers, website, conference, training seminar

50. Summary WP’s WP 4 Specification WP 5 Construction WP 6 Smoking WP 7 Obesity WP 8 Alcohol WP 9 CVD/Diabetes WP 10 Cancer WP 11 Scenario dev • Development of the model • Construction of data sets • Illustration by scenario’s WP 1 Coordination WP 2 Dissemination WP 3 Evaluation