The Use of Evidence in
Health Impact
p
Assessment
Dolores Acevedo-Garcia, PhD, MPA-URP
Li d
Lindsay
E
E. R
Rosenfeld,
f ld S
ScD,
D S
ScM
M
Bouve College of Health Sciences
Institute on Urban Health Research
June 29, 2010
With funding from W.K. Kellogg Foundation
O tli
Outline
• Role of evidence in HIA
• Types of evidence used in HIA
• Evidence on effectiveness of HIA
Health Impact Assessment (HIA)
To stem the rising tide of chronic disease
and create safe, thriving communities,
health needs to be regularly factored into
policy and program decisions in sectors
that do not traditionally
traditionall foc
focus
s on health
outcomes.
The Health Impact Project
http://www healthimpactproject org/hia
http://www.healthimpactproject.org/hia
Features of HIA that influence
role of evidence
• Focuses on complex interventions/policy and their
diverse effects on social determinants of health.
• Includes multiple research questions
• Overview of health effects through multiple pathways
(e.g. pollution, housing, open space)
• Involves diversity of evidence (disciplines, study
designs, quality criteria)
Mindell et al., 2004, Enhancing the evidence base for health impact assessment.
Journal of Epidemiology and Community Health
Features of HIA that influence
role of evidence
• Involves a broad range of stakeholders
• Often required within short timescales and limited
resources
• Involves pragmatism to assemble information for
decision makers regardless of the quality of the
evidence.
Mindell et al., 2004, Enhancing the evidence base for health impact assessment.
Journal of Epidemiology and Community Health
What is evidence
evidence-based
based
decision making?
Use of evidence in medicine
Evidence-based
Evidence
based medicine is the
conscientious, explicit and judicious use of
current best evidence in making decisions
about the care of individual patients. The
practice of evidence
evidence-based
based medicine
means integrating individual clinical
expertise with the best available external
clinical evidence from systematic
research.
research
The Cochrane Collaboration
Use of evidence in public health
Evidence-based approaches (those
explicitly
li itl lilinked
k d tto th
the b
bestt available
il bl
scientific evidence and reflecting
community preferences and feasibility) are
increasingly used to inform health policy
decision making on the burden of a
disease attributable to particular causes,
policies that might
g work
interventions and p
to confront those causes, and issues of
community fit and feasibility.
Fielding & Briss, 2006, Promoting evidence-based public health policy: can we have better
evidence and more action? Health Affairs
F d l guidelines
Federal
id li
- OMB
… we
we’re
re using a similar
similar, two
two-tiered
tiered approach
approach.
First, we’re providing more money to programs
that generate results backed up by strong
evidence.
id
Th t’ the
That’s
th ttop ti
tier. Then,
Th
ffor an
additional group of programs, with some
supportive evidence but not as much, we’ve
we ve said:
Let’s try those too, but rigorously evaluate them
and see whether they work. Over time, we hope
th t some off those
that
th
programs will
ill move iinto
t th
the
top tier — but, if not, we’ll redirect their funds to
other,, more promising
p
g efforts.
OMB, June 8 and October 7, 2009 Memoranda
Stages of HIA: How is evidence used?
• Screening (establish health relevance of policy/program)
• Scoping (identifies key health issues; exclusion criteria; public concerns)
(
,p
,
• Assessment (establish baseline, prediction, significance, mitigation; review of evidence)
Communication of HIA findings and
• Communication of HIA findings and recommendations
• Evaluation and monitoring (can produce Evaluation and monitoring (can produce
further evidence)
St
Stages
off HIA:
HIA How
H
is
i evidence
id
used?
d?
•
Screening
•
Emerging selection criteria
criteria, e
e.g.
g Human
Impact Partners, 2009, Considerations
for the Selection of Appropriate Policies
Policies,
Plans, or Projects for Analysis using
Health Impact Assessment
St
Stages
off HIA:
HIA How
H
is
i evidence
id
used?
d?
•
Scoping
•
•
•
•
•
What health impacts are considered?
What
health impacts are considered?
Exclusion criteria
Logic model? Sources?
Likely size of effect?
Less direct impacts?
Inputs
p
Activities
Outputs
p
Revise
D l
Development
t
review process
Inclusion of
HIA review
process
Safe
Sidewalks
Health
Dept.
Public
Outcomes
Ai P
Air
Pollution
ll ti
Traffic
Volume
Recreation
Facilities
Xeriscaping
Political
Entities
Impacts
p
Green Space
D l
Developers
Planning
Dept.
Components
p
Pedestrian
safety
Pedestrian
– vehicle
collisions
Connectivity
Implementation of
HIA design
recommendation
Proximity to
Activity
Center
Proximity
to Schools
Radon Resistant
Construction
Walkability
Ob it
Obesity
CVD
Physical
Activity
Mi d Use
Mixed
U
Zoning
Revise Land
Development
Code
Health
Effects
Lung
Disease
Noise
Healthy
ea t y
Design
Community
Stress
HBP
Expedited
permitting
p
g
Development of a Health Impact Assessment (HIA) Protocol For Polk County, Florida 2005-2006
Stages of HIA: How is evidence used?
• Assessment (review of evidence)
Broad definition of evidence
Taking an e
evidence
idence based approach does not
mean relying on or privileging only one kind of
method such as the randomized controlled trial
method,
trial.
It does not mean that there is only one hierarchy
of evidence, and it does not mean an
epistemological rejection of subjective positions
or methods. The evidence based approach to
SDH categorically
t
i ll rejects
j t th
the notion
ti off a single
i l
hierarchy of evidence.
Kelley and Bonnefoy, 2007, The social determinants of health: Developing an evidence
base for political action, Report for WHO Comission on Social Determinants of Health
Broad definition of evidence
•
Use of evidence in HIA may be different than use of evidence in health care (e.g. Cochrane Collaborative), education, policy (e.g. Coalition for Evidence‐based Policy)
•
Those disciplines tend to give more weight to evidence from studies with an experimental design. But “rigorous evidence” can be used in HIA
• How to aggregate evidence?
•
Types of evidence used in HIA
• (Systematic) reviews
• Is review method specified?
• Meta analysis?
• Simulations (decision analysis)
• Input from stakeholders (community survey, g p)
y
focus groups)—may have elements of Community‐based Participatory Research (
(CBPR).
)
• Other, e.g. field observations
St
Stages
off HIA:
HIA How
H
is
i evidence
id
used?
d?
•
Communication of HIA findings and recommendations
Grey literature
Grey
literature
• Peer reviewed
• Political process
•
St
Stages
off HIA:
HIA How
H
is
i evidence
id
used?
d?
•
EEvaluation and monitoring (can produce l ti
d
it i (
d
further evidence)
• HIA is not an evaluation (often prospective).
• An evaluation may be conducted to assess health effects of selected alternative (i.e actual course of action)—but time frame may be a barrier.
• HIA predictions could be assessed against p
g
actual outcomes—very rarely done.
HIA of Concord Naval Weapons Station Re
Reuse Project (Human Impact Partners, 2009)
•
5,028-acre site owned by the Navy for over 60 years
Property will be redeveloped to include residential and
commercial development, and parks/open space
•
7 different alternatives, each proposing a unique
mix of land uses
•
HIP partnered with Community Coalition for a
Sustainable Concord (CCSC)
•
While there are obvious environmental health implications related to
the CNWS Site’s former use as a military ammunitions storage site,
HIP and CCSC decided during
g the scoping
p g stage
g that residual
chemical contamination in groundwater and soil contamination
would not be included in the HIA. We absolutely believe that these
potential health concerns are important and are to be considered as
additive effects to the other health impacts discussed in this report.
However, this type of analysis is outside of the technical expertise of
the HIA team, project timeline and budget. Environmental
i
investigation
ti ti and
d remediation
di ti off th
the site
it iis subject
bj t tto ffederal
d l
regulatory oversight (…) This assessment also excludes
comprehensive air quality and noise analyses. Air quality and noise
issues were not near the top of the community’s
community s list of concerns
concerns, and
are discussed but not focused on. We suggest that these topics be
covered more extensively in the final Environmental Impact Report.
Human Impact Partners, January 2009, Concord Naval Weapons Station
Reuse Project Health Impact Assessment
Piecing evidence together
• Concord Naval Weapons Station Reuse
Project Health Impact Assessment
• Simulated effects on jobs/incomes
• Compared with availability of affordable
housing
• Discussed possible health implications of
limited availability of affordable housing
• qualitative
lit ti narrative
ti nott a simulation
i l ti off h
health
lth
effects
A Child Health Impact Assessment of
Energy Costs and the Low Income Home Energy
Assistance Program (Child HIA Working Group, 2007)
• HIA of federal Low-Income Energy
Assistance Program
g
– Gap in 2007 in Massachusetts due to
decrease in benefit levels
• Literature review (method?); interviews
with stakeholders; qualitative assessment
of impacts
Evidence on effectiveness of HIA
• Effecti
Effectiveness
eness defined as
as: ‘If and ho
how the HIA
approach informs the decision making process
and in particular
and,
particular, if it improves health and
reduces health inequalities.’
• 2002 review: cast wide net for literature search
but onlyy one studyy met critical appraisal
pp
criteria:
– McIntyre, L. and Petticrew M. (1999). Methods of Health
Impact Assessment: a literature review
Taylor & Quigley, 2002, HIA: A review of reviews, UK, Health Development Agency
Evidence on effectiveness of HIA
There is currentlyy no review-level evidence
available to demonstrate if and how the HIA
approach informs the decision making
process and,
d iin particular,
ti l if it iimproves
health and reduces health inequalities.
Taylor & Quigley, 2002, HIA: A review of reviews, UK, Health Development Agency
Evidence on effectiveness of HIA
• Analysis of HIA 1999-2009
• HIA defined as “directly effective” if decisions
were modified and decision-makers
acknowledged health issues.
• Of 35 HIA, 25 “changed the project” and 9
“educated the decision maker”.
Wendel et al. In preparation.
Fi l points
Final
i t
• HIA requires
q
summarizing
g evidence but review
methods have not been formalized.
• There is room for considering different types of
evidence and for different methods to review
each type.
• How different types of evidence are
aggregated/weighted is often not made
explicit qualitative judgment?
explicit—qualitative
• Each step of HIA could benefit from defining
methods that can be used to assess evidence