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
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.”
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
Classic process of HIA
Stage of HIA
Key questions to answer
Do we undertake an HIA on this proposal or not?
What are the boundaries for the HIA study? What are the
management arrangements? What are the overall governance
and accountability arrangements?
What are the proposal’s effects on health, for the whole
population and for vulnerable groups? How can we achieve
health gain through health protection, health improvement and
reducing health inequalities?
How do we present the information about health impacts, and
suggestions to address those impacts, in an ethically responsible
way that is useful to and usable by decision-makers?
How do we support decision-makers to understand the HIA
results in relation to other information about the proposal?
Monitoring and
Process evaluation: Did the HIA process go well? Could it be
improved? Effectiveness evaluation: What effect did the HIA
have on the proposal? Outcome evaluation: What effect did the
amended proposal have on health?
Classic process of HIA
Stage of HIA
Screening –
potential exit
Use a screening tool appropriate to your locality and/or
population; if there is no screening tool, use an agreed set of
Use a checklist to ensure that all aspects of the HIA study and its
governance and accountability are covered
Use an appraisal tool that includes the relevant determinants of
health; identify methods that are appropriate to the timescale
and budget available for the particular HIA
Use all types of information as equal but being aware that they
reveal different facets of the issues and the ways to address them
Be sensitive to the type of report likely to support decisionmakers, without compromising the ethical treatment of the HIA’s
Monitoring and
Conduct a process evaluation, preferably using a pre-agreed set of
criteria, and an effectiveness evaluation – identify not only which
HIA suggestions were accepted but also which were implemented
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
Methods supporting appraisal
Undertaken by
• Literature review
• Review of HIA casestudies
• Profiling (population or
• Desk-top appraisal
Undertaken with
• Interactive: stakeholder
workshops, focus
groups, Delphi
exercises, citizen’s
• Non-interactive:
surveys (postal or face
to face), interviews
HIA: What are the hallmarks?
• Specificity
• Enhancement as
well as mitigation
• Flexibility
• Adaptability
Basic Tasks in HIA
Screening the proposal
Proposal analysis – what are the deliverables of the proposal?
Identifying a governance and accountability framework for the
Setting the boundaries for the study
Setting the management arrangements for the HIA
Profiling the community/population using routine and nonroutine 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
Process evaluation
Effectiveness (impact) evaluation
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
• London Health Commission submitted HIA results
– Mayor;
– Greater London Assembly;
– team responsible for the strategy being assessed
London’s Mayoral Strategies
 Transport
 Economic development
 Spatial development
 Waste management
 Noise
 Energy
 Biodiversity
 Air quality
 Culture
 Older people
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
 Stakeholders from the private, public and voluntary
sectors were invited
 No members of the public were included
 Reporting the results
HIA on London’s Mayoral Strategies
All major strategies were
subject to HIA
Main topics in strategy
Rapid literature review
Stakeholder workshop
Reporting & Supporting Mayor, Greater London
Assembly & relevant
strategy team given
Monitoring & evaluation Process evaluation
Impact evaluation
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 wellbeing? 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?
Evaluation of HIA on London’s Mayoral
“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
HIA of the Redevelopment &
Regeneration of the Lower Shankill
• 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
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
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
• Suffering from severe health and other inequalities,
some of which are a result of the “Troubles” and
the later “Shankill feuds”
HIA of the Redevelopment & Regeneration
of the Lower Shankill
• Based on 11 options in the Economic Appraisal,
from minor refurbishment to complete
• 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
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
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
Which of the 11 options is best for
health and well-being?
Options 1 & 2
Will not redress either the causes or effects of multiple
deprivation on health
Options 3, 4 & 5
Offer little to social residents apart from small
environmental improvements, but do increase the
availability of social housing
Options 6, 8 & 10
Offer improved housing and environmental conditions
for social residents – good for health – and increase
availability of social housing
Option 7
Offers improved housing and environmental conditions
for social residents – good for health – but increases
mixed tenure with displacement of 20-30 social
Which of the 11 options is best for
health and well-being?
Option 9
Large increase in private housing and major
environmental improvements – gentrification, with
displacement of ~100 social households
Option 11
Complete demolition of estate, requiring decanting
of ~500 social households, which could mean
displacement for some; mixed tenure with almost
half the estate private housing, a reduction in
availability of social housing and a new built
environment; potential for gentrification
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
Which option gets chosen?
The decision also depends on political priorities
support and
Do you want physical or social renewal?
Do you want to support the existing
community or provide housing for new
residents with the potential for
Supply of tenure Do you want to increase the availability of
social housing or of private sector housing?
In option 9, the supply of social housing
would be decreased with the displacement
of social households
Mix of tenures
What balance do you want of social housing
to owner-occupier housing?
HIA: Benefits for stakeholder
• Demonstrating a commitment to health and wellbeing of local people
• Health as an added value for organisations not in
the health sector
• Potential for organisational development and
• Potential to improve partnership working among
agencies and among sectors
• Potential to shift from services that solve problems
to services that prevent problems arising
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
 Planning and design of services that better meet the
needs of the local community

Part 2 - East End Quality of Life Initiative