Health Impact Assessment as a Tool for Population Health Promotion and Public Policy

Production of this resource has been made possible through a financial contribution by Health Canada prior to the announcement of the establishment of the Public Health Agency of Canada on September 24, 2004. Any reference to Health Canada should be assumed to be to the Public Health Agency of Canada.

A Report Submitted to the Health Promotion Development Division of Health Canada

by

Study Team:

C. James Frankish, Ph.D.
Lawrence W. Green, Dr. P.H.
Pamela A. Ratner, Ph.D., R.N.
Treena Chomik, M.P.H.
Craig Larsen, M.H.A.

Institute of Health Promotion Research
University of British Columbia
May 1996

Table Of Contents

Executive Summary

Acknowledgements

Introduction

• Rationale
• Purpose
• Methods

Background

• Key Concepts and Terms
• Health
• Quality of Life
• Health Impacts versus Health Outcomes
• Healthy Public Policy
• A Definition of Health Impact Assessment
• Historical Context
• Healthy Public Policy
• Health Field Concept
• Health Promotion, Population Health, and Population Health Promotion
• Determinants of Health

Results

• Current Approaches to Impact Assessment
• Environmental Impact Assessment
• Health Risk Assessment
• Status of Health Impact Assessment in Canada

Discussion and Analysis

• Measuring the Impact of Public Policy-What Do We Need?
• Health Indicators
• Determinants of Health
• Assessing the Policy Environment
• Health Objectives, Goals and Targets as a Strategy for Health Impact Assessment
• U.S. Healthy People Initiative
• Other Countries' and World Health Organization Initiatives
  in Goals and Targets for Health

Conclusion

Recommendations

References

Appendices

• Appendix A Application Abstracts of Health Impact Assessment
• Appendix B Information Contacts
• Appendix C Health Impact Assessment Study Advisory Committee

Figures

• Figure 1. Programs and Policy Influences on Health
• Figure 2. Potential Impact of Policies & Programs (Health or Non-Health)
• Figure 3. Population Health Promotion Model

Executive Summary

The criteria for evaluation of health, social, environmental and economic policies and programs are changing. This is particularly true within the health sector where many governments are adopting an understanding of health that includes a focus on the social and environmental determinants of health. They recognize that societal structures, attitudes and behaviours influence health profoundly, that prevention is better (or at least more timely) than cure, and that prevention is a way to reduce disability and social dependence. Consequently, how social, environmental and economic policies influence health and the prevention or production of illness, disability or death needs systematic monitoring at all levels of government.

With increasing official commitment to decentralization and community participation in decision making and growing consideration of the social determinants of health, some ambiguity, and perhaps controversy, prevails about what impact on health these new perspectives will have. Several important questions remain to be answered. Which strategies will work to achieve beneficial outcomes? What criteria should be applied to judging health impact? How can health impact assessment work to produce better decisions? And, how will the new perspectives ultimately influence policy and program decisions? Most calls for evidence-based decision making offer little indication as to how the use of health impact assessments can lead to "better" health decisions. Without tools and methods that can be used to assess the health impact of policies and programs, these questions cannot be answered. Without the implementation of such tools and methods, health impact cannot be known.

The purpose of this study is to report on the status of the use of health impact assessment as a tool for public policy and a strategy for population health promotion. For this study, health impact assessment is defined as any combination of procedures or methods by which a proposed policy or program may be judged as to the effects it may have on the health of a population.

The report presents and describes:

• approaches developed for health impact assessment;
• approaches developed for similar purposes such as environmental impact assessment;
• specific tools and models used to link proposed programs and policies to their health impact;
• a description of health impact assessment as a means to develop public policy and to facilitate choices among program options;
• a situational analysis of the use of health impact assessment in the provinces and territories of Canada;
• selected Federal level experiences and examples of impact assessment;
• selected national level experiences and examples from other countries;
• selected municipal examples;

• common themes and observations; and
• recommendations and suggestions for future development.

The methods for this study included: (a) a comprehensive literature search, (b) an extensive call for information and case reports pertaining to, or related to, health impact assessment, and (c) the establishment of an advisory committee to provide information sources and to review the draft report.

The literature search included the collection of directly relevant materials by means of an international call for information via telephone, facsimile, mail, e-mail, and the Internet, with subsequent follow-up. An advisory committee was assembled and polled to identify key contact people. These potential resource persons were then contacted for information and examples of the application of health impact assessment. The methods and search efforts were necessarily limited by the two-month time period available for this study.

The background information section highlights the social, political, and environmental contexts within which health impact assessment is evolving. It reviews some conceptual issues, particularly in relation to health, and several pitfalls associated with broadened definitions.

The results section provides a report of past, current, and planned health impact assessment initiatives and comments on the potential value of each in the further development of the field. The analysis primarily covers provincial and territorial initiatives but also includes examples from municipal, federal, and international settings to a more limited extent. Impact assessments in other areas such as the environment are presented and discussed in terms of possible contributions to health impact assessment development. A summary of the application of health impact assessment in the provinces and territories is provided at the end of the results section.

The recommendations section arises from the results to suggest action steps based on common themes emerging from the literature. The recommendations embody the principle that tools such as health impact assessment, with wide-ranging implications, should be developed through a multi-sectoral approach with common goals and objectives developed through a consensus process that can transcend changes in government. The core recommendations are:

1. The federal government should undertake, in collaboration with other major national organizations having a stake or a role in the determinants of population health, a systematic national goal setting process. Such a process should combine the evidence and experience already compiled and developed in the form of goals and objectives in the provinces and territories.
2. Develop objectives and targets in all areas regardless of the availability of data to confirm the estimates of baseline levels for the Canadian population at large or specific populations.
3. Develop monitoring and surveillance systems to track progress toward the objectives, and to provide a source of trend, baseline and follow-up data for assessment of health impact.

Among the appendices are a compilation of application abstracts, a listing of contact persons who provided information or further contact recommendations, and a listing of the advisory committee members.

Acknowledgements

This report was written by a team of researchers from the Institute of Health Promotion Research at the University of British Columbia. Lawrence Green and James Frankish are the Director and Associate Director of the Institute. Pamela Ratner is a Medical Research Council of Canada and Izaak Walton Killam Postdoctoral Research Fellow at the Institute. Treena Chomik is an inter-disciplinary doctoral student in Health Promotion. Craig Larsen served as the Project Coordinator.

We wish to acknowledge the support of our colleagues at the Institute of Health Promotion Research and the British Columbia Consortium for Health Promotion Research. We also consulted with colleagues from the other health promotion research centres across Canada, and additional members of the established Advisory Committee.

This report was funded by the Health Promotion Development Division of Health Canada. We want to thank Dr. Tariq Bhatti and Ms. Nancy Hamilton of Health Canada for their guidance and generous support of this study.

We view this report as a resource for policy makers and planners who are interested in advancing the area of health impact assessment. We hope it will contribute to the development of new knowledge, the building of skills, and meaningful change in the health and quality of life of Canadians.

Introduction

Rationale

The activities, policies, and programs of government are designed to attempt to solve public problems and to serve the public good. With an intractable debt and budgetary deficits, Canadians, perhaps more than ever, demand accountability--they want to know that policies and programs fulfill their objectives. Yet, how can we know that particular policies are beneficial when an effect may have multiple causes and a cause may have a vast array of effects? It may be demonstrated that a desired objective is met, but how do we know that unintended, adverse consequences do not also arise?

Pal (1992) identified four concepts of policy impact that may be included in a policy evaluation: direct impact, economic impact, social impact, and political impact. A policy can be examined in relation to its intended target, the balance between its costs and benefits, its effect on the texture of social life, and the government's political interests (reelection chances). These four concepts have been the underpinnings of most policy analysis debates.

It has been only in recent years that health advocates have recognized that the impact of governmental policies on the population's health has been overlooked or neglected in traditional approaches to policy analysis and evaluation. The Ottawa Charter for Health Promotion (First International Conference on Health Promotion, 1986) identified that health considerations should be relevant to all policy makers in all sectors; they should be aware of the health consequences of their decisions. Stating the "should," however, is the easy part. Stating the "how" and implementing the ideal constitute the challenges. What procedures or methods must be in place to judge a policy or program in relation to the effect(s) it may have on the population's health status?

There was a time when public health could easily track the health impact of its programs or its neglect of programs. The communicable disease reporting systems and the monitoring of outbreaks provided a sentinel warning alarm whenever a controlled disease threatened to become uncontrolled. The short incubation period between infection and symptoms meant that the discovery of symptomatic individuals could be traced quickly back to the probable source of their infections, and that source could then be controlled.

Today's focus on population health is complicated by the facts of multicausality and long latency periods (decades for some) between the causes, sources, or determinants of health. Health impact today becomes a matter of tracing single diseases, disabilities or death back to genetics, living conditions, or environmental exposures. It is further complicated by the fact that most of the leading causes of disease, disability, and death are no longer discretely detected at a point in time. The chronic and degenerative diseases creep up on individuals and populations over their lifetimes. They are not detectable or isolatable as incidences or outbreaks. Population health data consist of prevalence rates rather than incidence rates.

The criteria for evaluation of health, social, environmental and economic policies and programs are changing. This is particularly true within the health sector where many governments are adopting an understanding of health that includes a focus on the social and environmental determinants of health. They recognize that societal structures, attitudes and behaviours influence health profoundly, that prevention is better (at least more timely) than cure, and that prevention is a way to reduce disability and social dependence. Consequently, how social, environmental and economic policies influence health and the prevention or production of illness, disability or death needs systematic monitoring at all levels of government.

With increasing official commitment to decentralization and community participation in decision making and growing consideration of the social determinants of health, some ambiguity, and perhaps controversy, remains about what impact on health this new perspective will have, what strategies will work to achieve beneficial outcomes, what criteria should be applied to judging health impact, how health impact assessment can work to produce better decisions, and what its ultimate influence on policies and program decisions may be. Most calls for evidence-based decision making offer little indication as to how the use of health impact assessments can lead to "better" health decisions. Without tools and methods that can be used to assess the health impact of policies and programs, these questions cannot be answered. Without the implementation of such tools and methods, health impact cannot be known.

Purpose

The Health Promotion Development Division of Health Canada (1995) recently recognized the above stated concerns and acknowledged that developing "healthy" public policy will require concrete activities, particularly those that address the development of health impact assessment tools. To this end, the Division solicited a situational analysis of health impact assessment strategies for public policy development and for population health promotion. The overall objective of this study was to report on the status of health impact assessment, as it currently occurs internationally, nationally, provincially and locally.

Methods

To complete the situational analysis we undertook: (a) a comprehensive literature search, (b) an extensive call for case reports pertaining to, or related to, health impact assessment, and (c) assembly of an advisory committee to recommend additional information sources and to review the draft report.

The literature search employed key phrases such as health impact assessment, environmental impact assessment, health risk assessment, health hazard appraisal, and health policy impact assessment, and was conducted within the Medline database for the years 1980 to early 1996. Little material of direct relevance was obtained from the published literature.

Our call for information about applications of health impact assessment and further contacts was initially directed at individuals and organizations who we knew to be, or suspected might be, acquainted with the topic. This initial contact list included people from across Canada and from several other countries. For both the initial contacts and following up on all leads, the broadcast was conducted via mail, e-mail, facsimile or telephone, as appropriate. In the interest of expedience, leads were contacted by mail only when other modes of communication were not available.

Feedback from the initial and subsequent contacts rapidly led to an extensive network of leads in many countries, regions, and sectors. Some information was obtained for every province and territory of Canada. A full list of respondents is provided in Appendix B. It should be noted that this list does not reflect the full scope of our call for information.

An advisory committee was assembled of willing individuals who had expressed particular interest or familiarity with health impact assessment. The committee members are listed in Appendix C. The two roles of the advisory committee members were to recommend any further contacts beyond our existing roster and to review our draft report and to provide feedback.

The short time line for the study shaped the employed method in several ways: first, follow-up memos to the initial group were issued within the first week; second, communication by e-mail, facsimile, or telephone, rather than mail, was used and encouraged wherever possible; third, some later leads could not be explored; and fourth, some mailed materials of possible relevance to the report were not received in time for us to consider.

We received a significant amount of material in response to our call for information. Those materials or examples that best illustrate the application of health impact assessment have been formulated into Health Impact Assessment (HIA) Application Abstracts. Seventeen HIA Appli-cation Abstracts are included in Appendix A of this report. Each Abstract summarizes the key points of the case study, including the following: abstract number and title, contact person or agency, major approach to HIA, defining features, HIA application considerations, and reference(s). These abstracts are referred to by abstract number throughout the main body of the report.

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