Top of Page. Skip directly to search Skip directly to A to Z list Skip directly to navigation Skip directly to page options Skip directly to site content. Healthy Places Accomplishments Why Invest? Health Impact Assessment. Recommend on Facebook Tweet Share Compartir. This website is archived for historical purposes and is no longer being maintained or updated. What Is HIA? The major steps in conducting an HIA include Screening identifying plan, project, or policy decisions for which an HIA would be useful.
Scoping planning the HIA and identifying what health risks and benefits to consider. Assessment identifying affected populations and quantifying health impacts of the decision. Recommendations suggesting practical actions to promote positive health effects and minimize negative health effects. Reporting presenting results to decision makers, affected communities, and other stakeholders. CDC cosponsored the National Research Council report Improving Health in the United States: The Role of Health Impact Assessment , which found that the HIA holds promise for incorporating aspects of health into decision making because of its Applicability to a broad array of policies, programs, plans, and projects.
Consideration of adverse and beneficial health effects. Ability to consider and incorporate various types of evidence. Engagement of communities and stakeholders in a deliberative process. Collins J, Koplan JP. American Public Health Association. Depending on a wide range of applications, the production of technical and methodological HIA guidance and specific tools has grown [ 15 ]. Different criteria can be used to classify existing case studies and a review of national experiences is often a suitable way to define a general standard at the country level [ 3 , 17 , 18 , 19 ].
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The HIA approach, used as a stand-alone impact assessment tool or integrated into procedures for assessing the environmental impact of projects and plans in the environmental setting, i. The ISS is the Italian technical-scientific body of the Ministry of Health responsible for public health, and the Department of Environment and Health of ISS conducts studies on the relationship between environmental contamination and its effects on health. Some critical elements have been identified. In particular, application of the EIA directive has highlighted the complexity of the assessments in reference to the multidisciplinary nature of the experts needed to address the issue of a predictive approach to preventing adverse health and environmental effects.
Very often, the health component in the EIA has been considered only as a description of the health profile of the local population involved, and no prospective assessment has been produced in accordance with the procedures of risk assessment. The lack of specific guidelines as well as the scarce involvement of health-scientific institutions within the evaluation procedures have been major limits for the proper consideration of impact on health.
In recent years, greater collaboration between health and environmental institutions, with various commitments by the Ministry of Health, permitted development of methods and procedures for a more comprehensive approach. The case studies and experiences presented in this paper, selected for their national relevance, demonstrate the results of inter-institutional collaborations.
The paper analyzes cases of HIA or health assessment provided within the EIA and SEA in Italy in order to identify common key points in health impact assessments of policies, plans or projects. The aim is to outline gaps and needs for the definition of a standard model to compare the three approaches and achieve better inclusion of health considerations in strategic planning and project evaluation. The experience of impact assessments presented here both case studies done by the authors or reviews of EIA and SEA reports were chosen because they are representative of the issues relating to the activities of health impact assessment and their effective integration with the components of environmental assessment.
The framework was outlined by a theoretical search within the MonITER Project [ 28 ], which compared existing HIA frameworks developed by other authors [ 20 , 29 ] and covers the seven following aspects: a model of health; b focus of HIA; c application level; d integration with other assessment forms; e participation; f type of evidence g added value to the proposal. To facilitate the review, a set of questions shown in Table 1 was used.
The questions addressed have been discussed in the HIA literature by other authors [ 19 ]. The findings of the review are shown in Table 2 , and key issues are discussed in Section 4. Questions for analyzing case studies regarding the key aspect of health impact assessment. Also, specific methodological issues of HIA practice have been covered to support the definition of a general best practice [ 28 , 31 ].
Specific research action was addressed to define the relevance of HIA at the local level, integrating the view and knowledge of public officials in the Regional administration [ 32 ]. Since there has been an ongoing special collaboration with regions and municipalities implementing the requirements of UN Agenda 21 [ 33 ] to raise awareness in municipalities and citizens regarding HIA foundations. Findings from HIA case studies [ 25 , 26 , 27 ] are shown in Table 2.
A qualitative assessment of impact was also experimented to link the determinants of health to the final outcome through risk factors, using the causal chain approach. A workshop session was carried out as a means of stakeholder consultation to prioritize determinants and sectors for programming focused interventions [ 26 ].
Introduction to Health Impact Assessment
The cases analyzed show how HIA has been handled and emerging issues are discussed. The screening of the proposal and the monitoring of outcomes appear formal to some extent. While the screening process usually determines whether it would be appropriate to conduct an HIA of the chosen policies, in the two cases of assessing the impact of a working waste incinerating plant [ 26 ] and of the proposed project of a new incinerator [ 25 ], it has been finalized to collect available data and provide a report with the likely impacts. Furthermore, an attempt has been made to support the decisional component to judge the HIA opportunity, developing a prototypal screening-scoping tool [ 28 ] subsequently applied within a real setting [ 31 ].
However, its application in several contexts showed that it was always very helpful in the preliminary definition of the main impacts and the identification of cross-issues related to the proposal. Further work is needed to fit the tool for use within specific sectors. Regarding the monitoring phase, it has never been implemented. In one case [ 27 ], indicators of impacts have been developed for future follow-up and monitoring, including a minimum set of recommendations about stakeholder roles. However, a monitoring plan for the implementation was not provided.
The requirements directly related to health were: four epidemiological studies, three analyses of mortality and morbidity, and two risk assessments. For most project categories, particularly those with a greater number of projects road and railway infrastructures, power lines and pipelines , the health component is often not present.
EIS for other project categories, with fewer projects but still hazardous for health refinery plants, hazardous waste treatment plants, energy power plants , are provided with a specific chapter for health. Often the context is not adequately described, and both the pollutants and the population are poorly characterized. Exposure quantification, forecast of impacts and food chain contamination are seldom analyzed. A health monitoring plan is never present. The objects of the assessment ranged from national electric networks, to water management and land planning.
The health component is addressed as a goal of sustainability and health is part of a general context exploration. Health assessment does not refer to a standard process in terms of positioning within the assessment procedure either in the scoping or assessment phase. The main shortcomings found in SEA National and Regional , are mainly in line with recent findings [ 34 ]:.
The new high-speed railway between Turin in Italy and Lyon in France is one of the largest national projects foreseen by Italian Government in the next few decades. Due to the absence of a national HIA standard, the methodology was provided to the Company by experienced regional officials. It included a preliminary analysis of the health status of the affected population; b a comprehensive 5-step HIA based on regionally published guidelines [ 35 ].
The envisaged HIA includes both a quantitative and a qualitative assessment of impact; in addition, the different tasks for the involvement of the local Environmental and Health Agencies are explored. Critical aspects of this process can be summarized as follows:. The final project approval was decided by an EIA procedure and HIA was required as enclosed requirement, to monitor impact during and after their occurrence, over a long period of time.
The preventive knowledge of the health status of the population did not inform the HIA screening phase the decision about the feasibility of the Project was made a priori and independently from the evaluation of the health status of the population at baseline. However the absence of a national standard for HIA may influence the achievable results with this specific tool, and the goal of introducing a positive modification to the health impacts of the proposal may be jeopardized. For more than 40 years the ILVA steelworks has contributed significantly to the increased environmental levels of pollutants.
The lack of coverage of health issues within the Integrated Prevention Pollution and Control IPPC permit process entirely based on the negotiation of selected Best Available Techniques for each shop of the plant resulted in the intervention of the Local Prosecutor. A team of expert epidemiologists studied several short-term and long-term effects of the ILVA emissions on the general population.
The cancer and non-cancer risks for inhalation were estimated for the exposed population and showed a decrease compared to the baseline scenario. In order to provide a comparison with a standard HIA procedure a stepwise process can be summarized as follows:. Pre-screening for the definition of a base of evidence needs and the role of the local environmental and health institutions. Screening to provide the systematic analysis of current evidence on the extent of environmental pollution as well as of local health descriptors. The VDS consisted in the independent parallel evaluation of industry-related health outcomes mortality, cancer registry, hospital discharge data and risk assessment based on the EPA residual risk approach [ 37 ].
A monitoring activity is due yearly according to the approved regulations Integrated Environmental Authorization , which include a communication report. For the first time, the combined use of health-based approaches both epidemiological and risk-assessment was used in the context of IPPC. However, a communication plan is lacking, although public audiences were held to inform the local stakeholders. The highly controversial case of ILVA supports the adoption of a transparent scoping phase to define the participation of the relevant parties, the resource available for the comprehensive assessment and prioritization of the health indicators to be monitored over time.
HIA principles stem from, and are guided by, the broad societal values of democracy, sustainability and equity [ 3 ]. HIA definition is based on a broad model of health, which proposes that economic, political, social, psychological, and environmental factors determine population health. In Italy the earliest HIA was based on an a priori biomedical model of illness and disease, and consequently the investigated outcomes were those quantified by mortality and morbidity rates or through risk estimates for selected outcomes.
In particular, a clear definition of the concept of health allows identification of the amount of resources in terms of time and necessary data, quality of health information on the population, skills and expertise necessary for a full assessment of health. Different traditions of environmental and public health developed three different trends in HIA. The third trend, HIA focused on health equity, was proposed to enhance the equitable distribution of effects of proposals particularly policy proposals on the health of populations [ 40 ].
In Italy, when the HIA is carried out as an independent procedure, a distinction regarding the main focus has been highlighted as to whether the proposal is a policy, plan or project. The assessment of a policy to protect health has been considered more suited to the analysis of the broad determinants of health, and a causal chain can be drafted to identify all possible transversal factors affecting final outcomes.
In this sense, the final recommendations take into account distal risk factors that modify health in an indirect way. An equity issue is explicitly introduced as a factor that can modify the final risk and can be addressed at different points in the causal chain [ 26 ]. When a plan is assessed for potential impact, a social view of health facilitates identifying its effects on culture, knowledge, integration, participation, trust and local perception.
Recommendations from HIA should include the identification of participants to be involved and interventions to address area-specific impact [ 27 ]. In the project assessment of a new plant building [ 25 ], clear identification of the exposed population and the risk for relevant health outcomes were based on community profiling. Moreover, a micro-geographic study on the exposed population supported a scenario analysis oriented towards the selection of an alternative collocation of the plant, minimizing the negative effects. In this case, an equity focus is implicitly considered because the impact on the highly affected population or the vulnerable groups in the study area is scoped.
In the assessment phase, requirements of compliance can be stricter than the regulations demand, when a possible risk is forecast for the environment and the population.
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Nonetheless, currently the health component is disregarded, while focusing on the natural and physical environment. In fact, the approach to health protection is that minimizing the concentrations of pollutant i. However, an analysis of the effects from multiple and aggregate exposures on the health of a given population is not always provided. Currently, this approach drives almost all the procedures carried out within the mandatory assessment of proposals.
In this situation, technical regulations and guidelines have the potential for improving knowledge about impacts. In particular, clarification is needed regarding the theoretical definition of health and describing data needs, available methodologies for quantification of impacts and special threats requiring a more thorough assessment. However, the definition of a minimum standard is challenging in Italy, due to regional heterogeneity of the availability of environmental data.
HIA is typically introduced within the policy and planning cycle after a draft proposal has been developed, but before that proposal is implemented. Openness during the scoping phase will determine the inclusion of different stakeholders and better identification of areas of interest and affected populations [ 41 ]. In Italy, HIA is poorly implemented prospectively. When implemented in a project proposal, the screening phase has provided the definition of the relevance of impact and the lists of stakeholders to be included in the process [ 25 ].
However, the HIA was relevant to introducing changes in the project proposal, minimizing the negative impact. In the definition of a new plan [ 27 ], HIA was undertaken with an open approach, showing its potential to drive the scoping phase. In consideration of the broad range of interests involved, local stakeholders were invited to participate in meeting sessions with the leading HIA group for the definition of boundaries and extension of the assessment.
However, it should be considered that creating collaboration among stakeholders required time and resources. The political context was critical in planning the HIA. The political and administrative component needed a special engagement process, often requiring the adaptation of time scheduled to carry out the process. In conclusion, a planned decision was re-analyzed as the HIA process included the decisional component from the beginning. The realization of the collaboration was fundamental for the accessibility of the area-specific data.
The analysis of a policy, when addressed at the regional level, creates an opportunity for enhancing the effect of reduction of risk factors, acting on a large population affected by the policy [ 26 ]. The definition of the direct connections of the policy with the determinants of health offers different entry points to act on the final health outcome. In particular, non-health-related sectors that indirectly contribute to health and wellbeing can share responsibility in promoting health.
EIA and SEA require the proponent of a project to provide a description of the context, including social, economic and cultural details of the proposal. When a system for recording these data is in place and is managed by the local public administration, a comprehensive assessment of a proposal is feasible in due time. Thus the positioning of the assessment process after a draft proposal is provided can clarify the nature of the potential impact on the health of the exposed population before a project is accepted.
The issue of integration of health assessment is usually used in the discussion of whether it is desirable or necessary to add the HIA tool to those of EIA and SEA [ 43 ]. Independent HIA has been criticized in the past both for overlapping of similar activities and for requiring additional resources. On the other hand, integration of impact assessment tools is common in sectors such as economy, insurance, transport, urban design, and employment [ 44 , 45 ].
When a prospective HIA was explicitly required by an institutional subject or when it was carried out within a research framework, the integration of information for a comprehensive assessment of impact was possible [ 25 , 27 ]. Different point and linear sources within the study area were analyzed to identify the contribution for the overall population [ 25 ] and individual risk [ 27 ].
The entire process covered a period lasting longer than 1 year.
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In EIA and SEA, what is challenging for the completion of the health assessment by the proponent is the definition of proposal alternatives when the context data are not available. To fulfill the mandate of assessing the impact on human health, a great deal of non-specific data are always provided regarding pollutants, expected effects, etc. Efforts have been made by the Ministry of Environment and ISPRA to gather national resources of environmental data [ 46 ] and to define a checklist of the minimum information required to draft the Environmental Impact Statement EIS [ 47 ].
In some regional contexts, health surveillance and environmental monitoring data have a good level of accessibility and quality. According to the Italian laws on EIA and SEA, and coherently with European Directives, the competent authority will examine the comments received on the draft proposal, after a period established for stakeholder consultation. In HIA methodology the participation and involvement of stakeholders are included in most of the phases, with special attention to screening, scoping and the production of recommendations.
When a participatory scoping phase was performed to examine different proposals, a committee, including local participants, was established with the task of evaluating the relevance of impacts by using a checklist [ 31 ]. Another project developing an HIA of a new local waste plan provided a systematic framework for the engagement of the community through assemblies and thematic working groups [ 27 ].
HIA methodology, as a tool for reinforcing the evaluation of health components of EIA and SEA, could provide the competence to properly place the evaluation in a social context, involving stakeholders and understanding their attitude towards the proposed project or plan. This could have substantial added value for the assessment. The fundamental elements of HIA practice have been analyzed to identify the characteristics of health assessment performed in Italy, in voluntary and mandatory procedures.
Differences are introduced in the focus of the health assessment process, mainly according to the distinction between voluntary and mandatory assessment of impacts. A different level of application i. Adopting a broader involvement of stakeholders always provides more opportunities for data collection enabling area-specific quantification of impacts. While environmental sustainability pursues an integrated holistic approach in the assessment, in practice data availability is a fundamental limiting factor for a contextual and broad assessment of impact.
Finally, a pattern of different implementation of deep and contextualized assessment is expected, depending on local from regional to municipal level availability of data, regarding both the environment and the health datasets. To encourage the use of assessment procedures based on a holistic health concept, more effort must be directed toward the definition of technical legislation and of adequate guidelines [ 49 ].
For this purpose, a synergistic contribution from all those working on the common ground of human health protection with different impact assessment tools is needed. The National Prevention Plan acknowledges the shortcomings in the standards and instruments for the full application of the HIA. The plan calls for the development of tools for health assessments carried out by public health professionals to support the government in decisions related to the procedures for SEA and EIA. Nunzia Linzalone was involved in study conception and design, analysis of cases, drafting of manuscript.
Fabrizio Bianchi supervised the work and the collaborative working, provided critical revision of the manuscript.
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Find articles by Sabrina Rieti. Find articles by Maria Eleonora Soggiu. Find articles by Fabrizio Bianchi. Jeffery Spickett, External Editor. Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Keywords: public health policy, Health Impact Assessment, Environmental Impact Assessment, Strategic Impact Assessment, impact assessment tools, policy decision-making.
Introduction There has been substantial interest worldwide in promoting the inclusion of healthcare within policy in order to achieve Health in All Policies HiAP goals, since its first acknowledgment in Europe in [ 1 ]. Methods, Selection of Cases and Framework for HIA Case Evaluation The experience of impact assessments presented here both case studies done by the authors or reviews of EIA and SEA reports were chosen because they are representative of the issues relating to the activities of health impact assessment and their effective integration with the components of environmental assessment.
Table 1 Questions for analyzing case studies regarding the key aspect of health impact assessment. Is the definition of health outlined within the circulated documents? Where is it described in the process development?