HEALTH IMPACT ASSESSMENT

Occup Environ Med: first published as 10.1136/oem.2004.014969 on 18 November 2005. Downloaded from http://oem.bmj.com/ on April 14, 2020 by guest. Protected by copyright.
M Joffe, J Mindell

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Occup Environ Med 2005; 62:907–912. doi: 10.1136/oem.2004.014969

A
person’s health status is largely determined by factors outside the control of the healthcare
sector. While some of these are fixed, such as inheritance, many are environmental in the
broadest sense of the term. These operate through such socioeconomic sectors as
employment, education, housing and transport, which structure the health risks and
opportunities of individuals. Typically the structuring is unequal—sometimes referred to as
clustering of disadvantage—so that those who are less well placed socioeconomically also have
worse health outcomes, contributing to socioeconomic inequalities in health.
The health impacts of these sectors can be influenced by interventions, whether or not these are
primarily motivated by health considerations. For example, a policy or other intervention to
improve educational status can raise the socioeconomic standard, thereby improving health. Such
interventions have the potential to increase or decrease inequalities.

c AIMS AND BASIC CONCEPTS OF HEALTH IMPACT ASSESSMENT

Health impact assessment (HIA) is concerned with the health of populations.1 It generally
attempts to predict the future health consequences—both positive and negative impacts—of an
intervention such as a policy,2 programme, or project3 (hereafter collectively referred to as a
‘‘proposal’’).1 4 5 There are several definitions of HIA in the literature; for example, ‘‘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 effects within the
population’’.6 The overall aim when conducting an HIA is to influence decision making to
minimise the harm and maximise the health benefit of proposals.7 This might happen in three
ways: (1) by raising the general awareness among decision makers that their actions affect
health; (2) by informing decision makers of the likely specific impacts of particular decisions; and
(3) by helping those potentially affected by decisions to participate in proposal formulation and to
contribute to decision making.5 A second important aim is similar, but focused towards reducing
health inequalities.
HIAs may be retrospective, concurrent, or prospective. Most HIAs are prospective and aim to
predict the health consequences of a proposal before it has been implemented. Some HIA
practitioners also describe two other types of HIA. A concurrent HIA involves monitoring an
intervention during implementation, and is useful when health impacts are expected but their
nature and severity are uncertain, so that the work can be influenced as it progresses. A
retrospective HIA takes place after the proposal has occurred. It differs from evaluation as it
considers all health outcomes, not only those intended. A role is to provide evidence for future
similar interventions. However, it can also be used to address health impacts that have occurred
as a result of proposal implementation in order to mitigate any that are negative and enhance any
that are positive.
An HIA can take place at any level, from local or regional to national or supranational.
Proposals subject to HIA could originate and be developed within the private, public, or voluntary
sector, but at the moment most HIAs are led by the public sector (health or local government).
See end of article for authors’ The concept of health used in HIA is broader than merely the absence of disease, infirmity, or
affiliations injury.8 Ideally, it encompasses all aspects of physical, mental, and social health, including self-
_________________________
reported wellbeing, and considering positive health as well as the absence of illness. As a
Correspondence to: consequence, the determinants of health considered in HIA include not only occupational/
Dr M Joffe, Department of
Epidemiology & Public Health,
environmental exposures and aspects of ‘‘lifestyle’’ such as smoking, but also the factors that
Imperial College London, might affect their presence—the ‘‘determinants of determinants’’.9 For example, an HIA of a
St Mary’s Campus, Norfolk scheme to improve the road infrastructure for cyclists might consider its effects on physical
Place, London W2 1PF, UK;
[email protected] activity, on risk of injury, and on the benefits of being able to gain access to, say, workplace,
_________________________ shops, and family members. Proposals relate not to particular individuals but to a locality or other

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Occup Environ Med: first published as 10.1136/oem.2004.014969 on 18 November 2005. Downloaded from http://oem.bmj.com/ on April 14, 2020 by guest. Protected by copyright.
population-level entity, so a framework is necessary that can STAGES OF HIA
integrate the individual focus with supra-individual The HIA process comprises six main stages: screening; scoping;
‘‘upstream’’ factors.10 appraisal (also called risk assessment); formulation of recom-
As HIA aims to influence the development and implemen- mendations and preparation of the report; submission of the
tation of proposals, it needs to be designed in a way that will report and recommendations to decision-makers; and monitor-
be meaningful to decision makers, as well as to others who ing and evaluation.14 15
908 are likely to be affected by the proposal. In particular, it is The first stage is screening. Its main purpose is to filter out
important to remember that the task of decision makers is to proposals that do not require HIA because the proposal has a
weigh a large number of considerations, of which health may minimal impact on health or inequalities, or because there
be only one. Considerations other than health include, for is little likelihood of being able to influence decisions.
example, economic priorities, equity, discrimination, equal Screening should be a systematic process using a set of
opportunities issues, community safety, etc. More generally, criteria, which are often listed in a ‘‘screening tool’’, against
in planning an HIA it is crucial to ensure that it is structured which proposals are assessed. Screening permits targeting of
in a way that has the potential to influence the decision scarce resources towards proposals that will benefit from
making process.5 It also needs to be conducted with democracy further assessment. For proposals that are selected, the
and the ethical (that is, impartial and robust) use of evidence as screening results provide a useful basis for the rest of the
central principles, as well as using equity and sustainable HIA. ‘‘Desk-top appraisal’’ is similar in process to screening
development to judge the impacts of the proposal; these four but without the function of selection.16 The Netherlands has
criteria are the ‘‘core values’’ of HIA.5 6 These values are considerable experience of screening of national policies for
particularly important when decision makers need to trade health impacts.17
off benefits and disbenefits, or when the former accrue to one The second stage of HIA is scoping. This sets the boundaries
subgroup and the latter to another. for the HIA (that is, the HIA’s Terms of Reference). Scoping
defines:
c Which elements or aspects of the proposal are to be
Depth of appraisal
The term ‘‘health impact assessment’’ is used for many assessed
different depths of appraisal, whose complexity varies, and c What aspects of the proposal are non-negotiable

using a wide range of resources. ‘‘Desk-top’’ appraisal is c The aims and objectives of the HIA

generally undertaken by an organisation’s own officers to c Timescale

gain a picture of potential health impacts to inform proposal c A common understanding of ‘‘health’’, determinants of

development. Rapid appraisal, also called ‘‘mini’’ HIA,11 health, and inequalities
generally uses existing information and evidence that is c Potential health impacts of concern

already available or easily accessible, but usually also involves c The geographical area covered
a half-day stakeholder appraisal workshop or other limited c The populations/communities affected by proposal imple-
community or stakeholder participation. Although termed mentation, and any vulnerable, marginalised, or disad-
‘‘rapid’’, preparing for the workshop and writing the vantaged groups
subsequent report are labour intensive over a short time c What will be included in the community profile of the
period, and the cost is not necessarily low when one takes population/community (see below)
participants’ time into account.12 c Stakeholders for the HIA and the nature of their
Comprehensive (or ‘‘maxi’’11) HIA involves the collection of involvement
new data. This may include a comprehensive literature c Decision-making forum(s) to influence
review, greater participation of local residents such as c Background information for the HIA, including the
through a survey, and/or a primary study of health effects evidence base, HIAs of similar proposals that have been
of the same proposal elsewhere. For a concurrent HIA, the done, and specific local conditions affecting proposal
impacts of the proposal are studied as it is implemented. It is implementation
resource intensive, requiring a significant time commitment c Methods to be used for the appraisal/risk assessment
from a number of people over a prolonged time.13 c Management arrangements, work programme, resources
The depth of HIA undertaken depends on: (human, financial, and material) available and those
c The timescale of the proposal required
c The resources available for the HIA c Arrangements for monitoring and evaluation of the HIA
c The potential importance of the proposal or of the health and its outcomes.
effects. Appraisal or risk assessment, the third stage, is where the
An HIA cannot be started until a proposal is firm enough to potential or actual impacts on health of a proposal are
appraise, but recommendations from an HIA cannot affect identified. It includes a community profile describing the
decisions already taken before the report is written. demographics and health status of the affected popula-
Resources include not only funding, but also time, staff, tion(s), and identification of existing inequalities and of
expertise, and community development. For example, if a excluded or vulnerable groups who may be at increased risk
good quality, up-to-date systematic review is available of all either inherently or as a result of the proposal. This stage
the relevant scientific evidence on a subject, a ‘‘rapid’’ or defines the length of the process (for example, ‘‘rapid’’,
‘‘mini’’ HIA may be easily undertaken. In a more compre- ‘‘comprehensive’’). Many different methods can be used, for
hensive appraisal, the existence of such a review allows a example, modelling and stakeholder workshops. The choice
greater proportion of resources to be directed towards other of method(s) is determined partly by the model of HIA being
components of the HIA process, such as community used, but is also constrained by factors such as timescale and
participation. resources available.

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Occup Environ Med: first published as 10.1136/oem.2004.014969 on 18 November 2005. Downloaded from http://oem.bmj.com/ on April 14, 2020 by guest. Protected by copyright.
The fourth and fifth stages of the HIA process involve the EVIDENCE
preparation of the report and recommendations and then submis- Evidence used in HIA includes published literature, local
sion of the report and recommendations to decision-makers. It is data, and stakeholder experience. Community and other
essential that this occurs within the decision-makers’ time- stakeholders’ participation can be encouraged through focus
frame, meeting deadlines for any consultation period or groups, workshops, or surveys, and/or through direct
scheduled meetings. Involvement of decision-makers in the involvement on the steering group. The last also aids
HIA process through membership of the steering group and/ understanding if published evidence conflicts with stake- 909
or participation in appropriate methods used during apprai- holder experience. Recommendations in the HIA report
sal, for example, interviews, or stakeholder workshops should be evidence based, with the source of evidence
increases the likelihood of the findings of the HIA being explicit.
considered relevant to the decision-making process, a
prerequisite to acceptance of recommendations. In some Literature searching and involving technical experts
HIAs, the submission of the report is accompanied by a Both quantitative and qualitative evidence are important in
presentation at the decision-making forum. However, even HIA. The quality of the research and the ability of a particular
when decision-makers are committed to an assessment of research design to answer a given question are more important
potential health impacts, the results of an HIA are only one of than the ‘‘hierarchy of evidence’’ used in clinical practice.26
many sets of factors that will influence their decision(s). Synthesising the evidence for HIA has a number of
Although the primary audience for the report and recom- difficulties: usually the evidence on the effects of interven-
mendations is the decision-makers about a particular proposal, tions and on the reversibility of impacts is sparse; the
evidence base is diverse, utilising studies from different
it is also important to communicate the main contents of the
disciplines and a wide range of designs; a range of individuals
report and recommendations to all stakeholders, especially
from different backgrounds and with varying priorities,
those who have participated in the process.
concerns, and prior beliefs is involved; decision-makers need
The output of the HIA needs to be appropriate for the target
recommendations even if the quality of the evidence is
audiences in its content, language, and format (for example,
inadequate; and timescales are typically tight.26 Much useful
web, printed newsletter, poster), and presentation of the
information is available only as ‘‘grey’’ literature—reports not
communication should be designed according to the needs of
published in scientific journals. This presents problems of
stakeholders and their preferred way of accessing informa-
identifying that such reports exist, obtaining copies, and
tion. Access to the full report and recommendations should
assessing the rigour of the work.
always be provided to stakeholders if dissemination has been
‘‘Off-the-shelf’’ reviews conducted proactively by technical
mainly in summary form.
experts on topics frequently the subject of HIA (for example,
Monitoring and evaluation is the sixth stage of HIA.18 There
regeneration27 and transport21) can enable local expertise to
are different aspects, including (1) evaluation of the process
concentrate on local concerns and community participa-
of HIA (process evaluation), (2) monitoring the acceptance
tion.9 20 Readily available evidence reviews, available via the
and implementation of recommendations (impact evalua- internet,28 can expedite robust local HIA.29 Use of existing
tion), and (3) monitoring and evaluation of indicators and expert reviews can also facilitate separation of the technical
health outcomes after the proposal has been implemented work of HIA from the political processes of policy develop-
(outcome evaluation). In the EHIA and New Zealand models, ment and decision-making.9
consent is given to allow the project to go ahead, and
monitoring is performed to ensure compliance with the The role of quantification
conditions attached to that consent,19 but most guidance When choosing outcomes to examine in an HIA it should be
refers to monitoring of health determinants, outcomes, or remembered that what is important may not be measurable,20
indicators. and that which is measured routinely or can be measured
Process evaluation of HIA is important as a source of may be unimportant.20 For example, community severance is
learning, as part of the drive towards quality improvement, a recognised adverse effect of traffic, limiting access to goods,
and as a mechanism of quality assurance. Even where impact services, and social networks, and impeding independent
evaluation shows acceptance of recommendations and mobility,21 but there is no simple or routine measure of such
amendments to a proposal, mechanisms for monitoring the severance, so no quantified assessment of severance can be
implementation of recommendations are important: it is made at baseline nor quantified estimates made of the effects
imprudent to assume that because a recommendation has of proposals. Quantified assessments are necessary for
been accepted it will be implemented. For example, lack of economic appraisal or for other explicit trade-offs: some
resources, or a change in political direction may further alter decision-makers may give more weight to those outcomes
decisions. that can be measured (such as traffic levels or estimates of
Outcome evaluation is fraught with difficulties. If an HIA deaths caused by injuries) than to a qualitative statement
persuades decision-makers to make substantial modifications (‘‘access to healthcare will be impeded’’).
to a proposal or to select a particular option—or not to The reduction in risk attributable to a fall in a given
implement a proposal at all—the anticipated impacts of the exposure consequent on a proposal—that is, the achievable
initial proposal cannot be monitored to examine the accuracy reduction may be small, even if the burden of disease22
of the predictions. Many predicted health effects cannot be (attributable risk) from the same exposure is high.9 Where
monitored using only routine data. Even when data are cause and effect are well established, a proxy measure can be
available, random fluctuations could mask achievable used instead of the eventual health outcomes; for example,
changes in health outcomes, because only a small proportion monitoring air pollution rather than admissions for or
of any relevant health outcomes can usually be attributed to a mortality from cardiorespiratory diseases. The health impacts
change resulting from a project, programme, or policy. can then be modelled.13

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Assessing impacts on inequalities mean that they have knowledge, experience, or information of
Assessing impact on inequalities in health is integral to most particular relevance to the proposal.
models of HIA. The more common approach considers Assessors are the practitioners who perform the appraisal,
impacts on specific excluded or vulnerable groups. formulate the recommendations, and prepare the report.
However, it is also important to consider a possible gradient They may be experienced in conducting HIA, but frequently
of effects or susceptibility across the whole population (for these tasks are undertaken by health service public health or
910 example, by income, occupational social class, or educational local authority staff who have little practical experience of
level). In most cases, potentially vulnerable groups, defined HIA. A steering and/or management group often oversees the
by age, gender, ethnicity, ethnicity, deprivation, or other process and outputs of an HIA. It should comprise
disadvantage, can be postulated. Such groups are charac- representatives from key stakeholder organisations; ideally
terised (for example, the number of people and their representatives from the affected community should also be
location) during profiling. involved. The HIA report, with its recommendations, is aimed
Whether inequalities represent inequity is a matter of at decision-makers. They may be involved in the process of HIA,
judgement. ‘‘Inequality’’ refers to objective differences, but and in some instances they may be on the steering group. In
inequity conveys unjust differences.23 The former can in large or complex proposals, there may be more than one
principle be measured, whereas the latter is harder to assess. group of decision-makers.
For example, differing educational attainment can be
One of the values underlying HIA is community involve-
monitored objectively, but whether or not it represents
ment as full and active stakeholders (see above). For some
inequity includes elements of judgement and viewpoint.
HIAs, practitioners will link into existing consultations with
Subtle differences in opportunity, such as quality of teaching
the community to avoid ‘‘consultation fatigue’’. Community
and parental support, which could indicate inequity, are
participation can be difficult to attain, particularly when
much harder to determine; if the only difference is due to the
trying to ensure that views or participants are representative
students’ own efforts, opinions may vary as to whether this
(especially from ‘‘hard-to-reach’’ groups), but it is important
represents inequity. Inequalities can also be advocated; for
to obtain the perspectives of at least some of the community
example, providing more resources per capita in areas of
affected.
higher need to reduce inequity.
Some HIAs are undertaken without community involve-
Proposals may impact on equity in four ways:
c No differential effects—for example, the same percentage
ment. For proposal development, this is valid when officers
increase in mortality is anticipated among affluent and are at an early stage, or when public consultation has already
deprived groups, thereby exacerbating existing inequal- occurred and the results are included as components of the
ities in absolute terms. appraisal/risk assessment. HIAs have been led by a commu-
c Differential individual susceptibility, such as the greater nity in some cases. Increasingly, there are examples where
risk from air pollution for people with severe cardio- the public and voluntary sectors have worked in equal
respiratory disease—for quantifiable effects, different partnership with the community on HIA; for example, Belfast
exposure-effect estimates may sometimes be available.24 Healthy Cities Community HIA process.
c Differential aggregate susceptibility because of a larger Formulating recommendations and writing the report need
population of susceptible individuals; for example, cardio- integration of the scientific evidence, local data, and evidence
respiratory diseases are more common in less affluent and from potentially affected communities. Involvement of
less educated groups. community members in the scoping stage is likely to ensure
c Differential exposure—for example, air pollution in that issues of concern to the community are considered as
London is correlated with deprivation, so the predicted part of the technical review and may aid acceptance of
falls due to intervention are greatest in the most deprived technical evidence by the community. Both the published
areas.25 For air pollution, the groups most susceptible to scientific evidence and that from the community should be
exposure have the highest baseline exposure, and falls in summarised in a form that is usable by all stakeholders. The
pollution may therefore cause reductions in health recommendations in the report should be explicitly evidence
inequalities. based. The report should be delivered to decision-makers, and
Estimating effects on inequalities and vulnerable or other stakeholders, in a format and using language con-
excluded groups requires the same processes as for the whole sidered to be most appropriate for that audience.
population, but the effects are described or quantified after
stratifying the population into those subgroups; it uses the
CONCLUSIONS
relevant prevalence of risk factors, effects of exposure, and HIA has the potential to inform decision making directly, and
changes in exposure for each of the subgroups. The effects are also indirectly by increasing decision makers’ understanding
then compared with the effect on the population as a whole of the wider determinants of health. Although few HIAs have
or with other subgroups.
included formal evaluation, those process and impact
evaluations that have been reported have showed a positive
PEOPLE INVOLVED IN HIA
effect on decisions. For example, HIAs resulted in changes to
The stakeholders in an HIA are the people involved in or affected
the content of the London Mayor’s Strategies, and raised
by proposal development and implementation. Stakeholders
officials’ and politicians’ awareness of the links between
come from public, voluntary, and private sectors. They include
decisions in their sector and health.31
affected communities. It is important to identify and include as
many stakeholders as possible to enhance ownership of the
process,30 but participation can be constrained by the timescale
ACKNOWLEDGEMENTS
and other resources available for an HIA. Key informants are This paper has greatly benefited from previous collaborations and
stakeholders whose roles, and/or standing in a community, discussions with Erica Ison.

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20 Mindell J, Hansell A, Morrison D, et al. What do we need for robust and

Occup Environ Med: first published as 10.1136/oem.2004.014969 on 18 November 2005. Downloaded from http://oem.bmj.com/ on April 14, 2020 by guest. Protected by copyright.
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website (www.occenvmed.com/supplemental) http://pubmed.oupjournals.org/cgi/reprint/23/3/173.pdf (accessed 11
August 2005).
21 Watkiss P, Brand C, Hurley F, et al. Informing transport health impact
assessment in London. London: NHS Executive London, 2000. http://
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.................. University Press, 1996.
Authors’ affiliations 23 Kawachi I, Subramanian SV, Almeida-Filho N. A glossary for health
inequalities. J Epidemiol Community Health 2002;56:647–52. http://
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M Joffe, J Mindell, Department of Epidemiology & Public Health, jech.bmjjournals.com/cgi/reprint/56/9/647.pdf (accessed 11 August
Imperial College London, UK 2005).
Competing interests: none declared 24 Goldberg MS, Burnett RT, Bailar JC III, et al. Identification of persons with
cardiorespiratory conditions who are at risk of dying from the acute effects of
ambient air particles. Environ Health Perspect 2001;109(suppl 4):487–94.
http://ehpnet1.niehs.nih.gov/members/2001/suppl-4/487-494goldberg/
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25 King K, Stedman J. Analysis of air pollution and social deprivation. A report
1 Lock K. Health impact assessment. BMJ 2000;320:1395–8. produced for the Department of the Environment, Transport and the Regions,
c A good short introduction to HIA in the peer reviewed literature. The Scottish Executive, The National Assembly for Wales, and Department of
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c A very detailed guide to HIA, including examples of HIAs then in II: Selected evidence base. London: QMUL, 2001. http://
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5 Kemm J, Parry J. What is HIA? Introduction and overview. In: Kemm J, Parry J, 28 Health Development Agency (now part of the National Institute for Health
Palmer S, eds. Health impact assessment. Oxford: Oxford University Press, and Clinical Excellence, NICE). HIA Gateway. http://
2004. www.publichealth.nice.org.uk/page.aspx?o = HIAGateway (accessed 11
c This book is the definitive guide to HIA, with contributions from August 2005).
experienced HIA practitioners and academics from around the world. c Perhaps the most comprehensive collection of HIA related material at
6 WHO European Centre for Health Policy. Health impact assessment. Main present, including toolkits, guidance, and examples of completed HIAs,
concepts and suggested approach. Gothenburg Consensus Paper, December although it can be difficult to search.
1999. Copenhagen: WHO Regional Office for Europe, 1999. http:// 29 McIntyre L, Petticrew M. Methods of health impact assessment: a review.
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August 2005). www.msoc-mrc.gla.ac.uk/Publications/pub/PDFs/Occasional-Papers/
c This WHO consensus paper, the results of an international meeting, is OP-002.pdf (accessed 11 August 2005).
probably the most widely quoted document on HIA. c The best review of HIA methods available in the grey literature,
7 Taylor L, Gowman N, Quigley R. Influencing decisions through health impact although now a little out of date.
assessment. London: Health Development Agency, 2003. http:// 30 Mindell J, Ison E, Joffe M. A glossary for health impact assessment. J Epidemiol
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8 Federation of Swedish County Councils. Focusing on health. Stockholm, 31 Opinion Leader Research. Report on the qualitative evaluation of four health
Sweden: Landstingsförbundet, 1998. impact assessments on draft mayoral strategies for London. London: London
9 Joffe M, Mindell J. A framework for the evidence base to support health Health Commission and London Health Observatory, 2003. http://
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jech.bmjjournals.com/cgi/reprint/56/2/132.pdf (accessed 11 August www.londonshealth.gov.uk/pdf/hiaeval_sum.pdf (summary) (accessed 11
2005). August 2005).
c Provides a typology for processes that might be considered as HIA or
related to it. Proposes use of a change model when assessing potential
health impacts of policy proposals. QUESTIONS (SEE ANSWERS ON P 835)
10 Krieger N. Epidemiology and the web of causation: has anyone seen the
spider? Soc Sci Med 1994;39:887–903. (1) Health impact assessment:
11 Parry J, Stevens A. Prospective health impact assessment: pitfalls, problems, (a) Aims to maximise health benefits
and possible ways forward. BMJ 2001;323:1177–82. (b) Should not involve decision-makers in the process
12 Ison E. Rapid appraisal tool for health impact assessment. Commissioned by
the Directors of Public Health of Berkshire, Buckinghamshire,
(c) Is most often used on healthcare proposals
Northamptonshire and Oxfordshire. London: Faculty of Public Health (d) Should also include assessment of impacts on
Medicine, 2002. http://www.fph.org.uk/policy_communication/ inequalities
downloads/publications/toolkits/Rapid_appraisal_toolkit/Introduction.pdf
(accessed 11 August 2005).
(e) Is commissioned most often by the private sector
c An even more detailed guide to rapid appraisal, particularly the many (2) In health impact assessment:
steps required to run a successful stakeholder workshop. (a) Unquantifiable health outcomes are ignored
13 Mindell J, Joffe M. Predicted health impacts of urban air quality management. (b) Poor health is more easily measured than good
J Epidemiol Community Health 2004;58:103–13. http://
jech.bmjjournals.com/cgi/reprint/58/2/103.pdf (accessed 11 August health
2005). (c) Achievable risk reduction and attributable risk are
14 Cameron M. A short guide to health impact assessment. London: NHS the same
Executive London, 2000. http://www.londonshealth.gov.uk/pdf/
hiaguide.pdf (accessed 11 August 2005). (d) Consultation with stakeholders is a legal requirement
c An excellent brief guide to HIA, what it aims to achieve, and the steps (e) ‘‘Consultation fatigue’’ is not an issue
involved. (3) Proposals that influence determinants of health:
15 Scott-Samuel A, Birley M, Ardern K. The Merseyside Guidelines for Health
Impact Assessment. Liverpool: Merseyside Health Impact Assessment Steering (a) Seldom affect health
Group, 1998. http://www.phel.gov.uk/hiadocs/ (b) Generally affect health inequalities
172_The_Merseyside_guidelines_for_health_impact_assessment.pdf (c) Generally produce health impacts that can be
(accessed 11 August 2005).
c The best-known guidelines for HIA.
measured
16 Ison E. Rapid appraisal techniques. In: Kemm J, Parry J, Palmer S, eds. Health (d) Are often developed for reasons other than health
impact assessment. Oxford: Oxford University Press, 2004. (e) Are most often developed by the healthcare sector
17 Putters K. Health impact screening. Rijswijk: Ministry of Health, Welfare and
Sport, 1997.
(4) Underlying values of HIA include:
18 Quigley R, Taylor L. Evaluation as a key part of health impact assessment: the (a) Evaluation
English experience. Bull World Health Organ 2003;81:415–19. (b) Democracy
c Summarises the reasons for evaluating HIA and the evidence currently (c) Sustainability
available from evaluations.
19 Public Health Commission. A guide to health impact assessment. Wellington: (d) Ethical use of evidence
Public Health Commission, 1995. (e) Equity

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Occup Environ Med: first published as 10.1136/oem.2004.014969 on 18 November 2005. Downloaded from http://oem.bmj.com/ on April 14, 2020 by guest. Protected by copyright.
(5) Vulnerable populations: (6) ‘‘Stakeholders’’:
(a) Include children, minority ethnic groups, and low (a) Include only those with a direct financial interest in
income households the proposal
(b) Often have different exposure to hazards compared (b) Is a synonym for ‘‘decision-makers’’
with the general population (c) Exclude individuals working within the private
(c) May have different susceptibility to a given exposure sector
than the general population (d) Include members of affected communities
912 (d) Are seldom represented on HIA steering groups (e) Are defined by law
(e) Are statutory consultees in HIA

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