The essential elements of health impact assessment and healthy public policy: a qualitative study of practitioner perspectives

Health Equity Impact Assessment (HEIA) reporting tool: developing a checklist for policymakers

INTRODUCTION

Health Equity Impact Assessment (HEIA) is a decision support tool that shows users how a new program, policy, or innovation affects health equity in different population groups. Various HEIA reporting and dissemination tools are available, nevertheless, a practical standard tool to present the results of HEIA in an appropriate period to policymakers is lacking. This work reports the development of a tool (a checklist) for HEIA reporting at the decision-making level, aiming to promote the application of HEIA evidence for improving health equity.

METHODS

This is a mixed-method study that was carried out over four stages in 2022-2023: 1) identifying HEIA models, checklists, and reporting instruments; 2) development of the initial HEIA reporting checklist; 3) checklist validation; and 4) piloting the checklist. We also analyzed the Face, CVR, and CVI validity of the tool.

RESULTS

We developed the initial checklist through analysis of 53 included studies and the opinions of experts. The final checklist comprised five sections: policy introduction (eight subsections), managing the HEIA of policy (seven subsections), scope of the affected population (three subsections), HEIA results (seven subsections), and recommendations (three subsections).

CONCLUSION

Needs assessment, monitoring during implementation, health impact assessment, and other tools such as monitoring outcome reports, appraisals, and checklists are all methods for assessing health equity impact. Other equity-focused indicators, such as the equity lens and equity appraisal, may have slightly different goals than the HEIA. Similarly, the formats for presenting and publishing HEIA reports might vary, depending on the target population and the importance of the report.

Mental Health and Mental Wellbeing Impact Assessment Frameworks-A Systematic Review

Mental health is largely shaped by the daily environments in which people live their lives, with positive components of mental health emphasising the importance of feeling good and functioning effectively. Promoting mental health relies on broad-based actions over multiple sectors, which can be difficult to measure. Different types of Impact Assessment (IA) frameworks allow for a structured approach to evaluating policy actions on different levels. A systematic review was performed exploring existing IA frameworks relating to mental health and mental wellbeing and how they have been used. A total of 145 records were identified from the databases, from which 9 articles were included in the review, with a further 6 studies included via reference list and citation chaining. Five different mental-health-related IA frameworks were found to be implemented in a variety of settings, mostly in relation to evaluating community actions. A Narrative Synthesis summarised key themes from the 15 included articles. Findings highlight the need for participatory approaches in IA, which have the dual purpose of informing the IA evaluation and advocating for the need to include mental health in policy development. However, it is important to ensure that IA frameworks are user-friendly, designed to be used by laypeople in a variety of sectors and that IA frameworks are operational in terms of time and monetary resources.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

Evaluation of a professional development experience designed to equip school support staff with skills to facilitate youth mental health promotion

Background: Public policy across the world is increasingly focusing on the role of mental health promotion in whole of health strategies. There is a growing evidence-base that mental health promotion, delivered by trained facilitators, is effective in promoting self-awareness and self-care to prevent the damaging effects of ongoing stress in one's life and to promote early detection of any possible emerging mental health problems. Within Australia, however, few clinicians or school staff are confident or trained in mental health promotion.Aims: This paper reports the results of a two-day training designed for facilitators of a mental health program for secondary-school students. The goal was to develop facilitators' knowledge and understanding of best practice in youth mental health promotion and to increase their confidence in delivering the program.Design: A mixed methods evaluation assessed the impact that a solution-focused training program had on participating facilitators.Methods: A questionnaire was created and included eight quantitative items and one open ended, qualitative question. Twenty-seven nurses and guidance officers from central Queensland were recruited via convenience sampling and data were analysed using descriptive statistics and thematic analysis.Results: The evaluation revealed that participants' perception of their ability to facilitate a youth mental health program significantly improved after completing the training. Qualitative data indicated that participants found the professional development experience to be valuable, provide useful and transferable skills, and believed it to be necessary for mental health promotion work.Conclusion: By providing detailed description of the program's content and processes, other mental health professionals may be inspired to further develop effective learning experiences.

Systematic Literature Review of Health Impact Assessments in Low and Middle-Income Countries

Health Impact Assessments (HIAs) motivate effective measures for safeguarding public health. There is consensus that HIAs in low and middle-income countries (LMICs) are lacking, but no study systematically focuses on those that have been successfully conducted across all regions of the world, nor do they highlight factors that may enable or hinder their implementation. Our objectives are to (1) systematically review, geographically map, and characterize HIA activity in LMICs; and (2) apply a process evaluation method to identify factors which are important to improve HIA implementation in LMICs. A systematic review of peer-reviewed HIAs in 156 LMICs was performed in Scopus, Medline, Web of Science, Sociological abstracts, and LILACs (Latin American and Caribbean Health Sciences) databases. The search used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and covered HIAs across all type of interventions, topics, and health outcomes. HIAs were included if they reported a clear intervention and health outcome to be assessed. No time restriction was applied, and grey literature was not included. The eligible studies were subjected to six process evaluation criteria. The search yielded 3178 hits and 57 studies were retained. HIAs were conducted in 26 out of 156 countries. There was an unequal distribution of HIAs across regions and within LMICs countries. The leading topics of HIA in LMICs were air pollution, development projects, and urban transport planning. Most of the HIAs reported quantitative approaches (72%), focused on air pollution (46%), appraised policies (60%), and were conducted at the city level (36%). The process evaluation showed important variations in the way HIAs have been conducted and low uniformity in the reporting of six criteria. No study reported the time, money, and staff used to perform HIAs. Only 12% of HIAs were based on participatory approaches; 92% of HIAs considered multiple outcomes; and 61% of HIAs provided recommendations and fostered cross-national collaboration. The limited transparency in process, weak participation, and inconsistent delivery of recommendations were potential limitations to HIA implementation in low and middle-income countries. Scaling and improving HIA implementation in low and middle-income countries in the upcoming years will depend on expanding geographically by increasing HIA governance, adapting models and tools in quantitative methods, and adopting better reporting practices.

Intersectoral collaboration to implement school-based health programmes: Australian perspectives

Understanding the processes and the factors influencing intersectoral collaboration is vital for the ongoing success of programmes that rely on effective partnerships between sectors, such as the school-based immunization programme, the school dental health programme and health promotion interventions delivered in school settings. We studied school-based health programmes delivered by partnerships between health, education and the local government sectors. We used purposive sampling to identify 19 people working in school-based health programmes and interviewed them about the barriers and enablers of successful collaboration. Data were analysed thematically. We found that collaboration between complex systems was a skilled endeavour which relied on a strong foundation of communication and interpersonal professional relationships. Understanding the core business, operational context and intersectoral point-of-view of collaborative partners was important both for establishing good intersectoral programmes and sustaining them as contexts and personnel changed. Aligning divergent sectoral agendas early in the collaborative process was essential for ensuring that all partners could meet their core business needs while also delivering the programme outcomes.

Bridging the silos in HIV and Hepatitis C prevention: a cross-provincial qualitative study

Objectives

The Our Youth Our Response (OYOR) study explored the scope and accessibility of existing youth-oriented human immunodeficiency virus (HIV) and Hepatitis C (HCV) prevention in Atlantic Canada.

Methods

A cross-provincial, qualitative population health and gender-based analytic approach was used in this study. Four hundred and twenty-five documents were part of the initial scoping review, while 47 in-depth interviews across youth-relevant sectors were undertaken to explore the perceptions related to current approaches to youth-oriented HIV/HCV prevention policies and programs. The study also conducted focus group discussions with 21 key informants aimed at identifying strategies to address the challenges identified from the interview data.

Results

Five overarching themes emerged from our triangulated data in relation to the present state of youth-related HIV/HCV prevention. These included: inter-organizational and intersectoral collaboration; youth engagement; access to testing; harm reduction; and education.

Conclusions

Our findings will assist in informing the next generation for HIV/HCV prevention aimed at youth. Specifically, the results indicate that future prevention initiatives should support the use of intersectoral collaboration, gender-based approaches, and HIV/HCV testing innovation to help de-stigmatize prevention efforts.

Framing health for land-use planning legislation: A qualitative descriptive content analysis

PURPOSE AND SETTING

Framing health as a relevant policy issue for other sectors is not well understood. A recent review of the New South Wales (Australia) land-use planning system resulted in the drafting of legislation with an internationally unprecedented focus on human health. We apply a political science approach to investigate the question 'how and to what extent were health and wider issues framed in submissions to the review?'

METHODS

We investigated a range of stakeholder submissions including health focussed agencies (n = 31), purposively identified key stakeholders with influence on the review (n = 24), and a random sample of other agencies and individuals (n = 47). Using qualitative descriptive analysis we inductively coded for the term 'health' and sub-categories. We deductively coded for 'wider concerns' using a locally endorsed 'Healthy Urban Development Checklist'. Additional inductive analysis uncovered further 'wider concerns'.

FINDINGS

Health was explicitly identified as a relevant issue for planning policy only in submissions by health-focussed agencies. This framing concerned the new planning system promoting and protecting health as well as connecting health to wider planning concerns including economic issues, transport, public open space and, to a slightly lesser extent, environmental sustainability. Key stakeholder and other agency submissions focussed on these and other wider planning concerns but did not mention health in detail. Health agency submissions did not emphasise infrastructure, density or housing as explicitly as others.

CONCLUSIONS

Framing health as a relevant policy issue has the potential to influence legislative change governing the business of other sectors. Without submissions from health agencies arguing the importance of having health as an objective in the proposed legislation it is unlikely health considerations would have gained prominence in the draft bill. The findings have implications for health agency engagement with legislative change processes and beyond in land use planning.

'Including health in systems responsible for urban planning': a realist policy analysis research programme

INTRODUCTION

Realist methods are increasingly being used to investigate complex public health problems. Despite the extensive evidence base clarifying the built environment as a determinant of health, there is limited knowledge about how and why land-use planning systems take on health concerns. Further, the body of research related to the wider determinants of health suffers from not using political science knowledge to understand how to influence health policy development and systems. This 4-year funded programme of research investigates how the land-use planning system in New South Wales, Australia, incorporates health and health equity at multiple levels.

METHODS AND ANALYSIS

The programme uses multiple qualitative methods to develop up to 15 case studies of different activities of the New South Wales land-use planning system. Comparison cases from other jurisdictions will be included where possible and useful. Data collection includes publicly available documentation and purposively sampled stakeholder interviews and focus groups of up to 100 participants across the cases. The units of analysis in each case are institutional structures (rules and mandates constraining and enabling actors), actors (the stakeholders, organisations and networks involved, including health-focused agencies), and ideas (policy content, information, and framing). Data analysis will focus on and develop propositions concerning the mechanisms and conditions within and across each case leading to inclusion or non-inclusion of health. Data will be refined using additional political science and sociological theory. Qualitative comparative analysis will compare cases to develop policy-relevant propositions about the necessary and sufficient conditions needed to include health issues.

ETHICS AND DISSEMINATION

Ethics has been approved by Sydney University Human Research Ethics Committee (2014/802 and 2015/178). Given the nature of this research we will incorporate stakeholders, often as collaborators, throughout. We outline our research translation strategies following best practice approaches.

Proposing a framework for Health Impact Assessment in Iran

Background

Health impact assessments (HIA) of policies and projects are conducted differently in different contexts although there has been less HIA research to date in non-western countries. Global HIA research has however suggested that the technical conduct of HIAs is tied to broader conditions and influences to do with decision making and policy development.

This study was conducted to develop a conceptual framework for progressing HIA in Iran including all factors influencing HIA planning and practice.

Methods

A comprehensive review of the international HIA literature identified core characteristics and principles. Then key informant interviews (n = 14) identified Iranian perspectives about factors influencing HIAs practice. These two stages resulted in a conceptual framework for HIA planning and practice including influencing factors and HIA content that was confirmed by our participants using e-Delphi technique.

Results

91 HIA characteristics were organized into 20 categories. The interviews showed that four core concepts i.e. context, actors, HIA principles and policies and HIA capacities influence HIA practice in Iran. Comprehensive content of HIA considering all health dimensions and health determinants, assessing health inequalities, appropriate HIA type, quantification and participation is formed under influence of the above mentioned four factors. The study also demonstrated need to redefine the HIA principles and make decision about integration of HIA in Environmental Impact Assessment and also about the level of HIA before implementing HIA. The e-Delphi resulted in expert consensus on the variables, concepts, and their relations in proposed framework.

Conclusions

Progressing HIA practice in Iran is perceived locally as subject to similar contextual conditions to those identified in the international literature. Further we have demonstrated the utility of mixed methods to progress HIA implementation in differing country contexts.

Evaluating deliberative dialogues focussed on healthy public policy

BACKGROUND

Deliberative dialogues have recently captured attention in the public health policy arena because they have the potential to address several key factors that influence the use of research evidence in policymaking. We conducted an evaluation of three deliberative dialogues convened in Canada by the National Collaborating Centre for Healthy Public Policy in order to learn more about deliberative dialogues focussed on healthy public policy.

METHODS

The evaluation included a formative assessment of participants' views about and experiences with ten key design features of the dialogues, and a summative assessment of participants' intention to use research evidence of the type that was discussed at the dialogue. We surveyed participants immediately after each dialogue was completed and again six months later. We analyzed the ratings using descriptive statistics and the written comments by conducting a thematic analysis.

RESULTS

A total of 31 individuals participated in the three deliberative dialogues that we evaluated. The response rate was 94% (N = 29; policymakers (n = 9), stakeholders (n = 18), researchers (n = 2)) for the initial survey and 56% (n = 14) for the follow-up. All 10 of the design features that we examined as part of the formative evaluation were rated favourably by all participant groups. The findings of the summative evaluation demonstrated a mean behavioural intention score of 5.8 on a scale from 1 (strongly disagree) to 7 (strongly agree).

CONCLUSION

Our findings reinforce the promise of deliberative dialogues as a strategy for supporting evidence-informed public health policies. Additional work is needed to understand more about which design elements work in which situations and for different issues, and whether intention to use research evidence is a suitable substitute for measuring actual behaviour change.

Creating change in government to address the social determinants of health: how can efforts be improved?

BACKGROUND

The evidence base for the impact of social determinants of health has been strengthened considerably in the last decade. Increasingly, the public health field is using this as a foundation for arguments and actions to change government policies. The Health in All Policies (HiAP) approach, alongside recommendations from the 2010 Marmot Review into health inequalities in the UK (which we refer to as the 'Fairness Agenda'), go beyond advocating for the redesign of individual policies, to shaping the government structures and processes that facilitate the implementation of these policies. In doing so, public health is drawing on recent trends in public policy towards 'joined up government', where greater integration is sought between government departments, agencies and actors outside of government.

METHODS

In this paper we provide a meta-synthesis of the empirical public policy research into joined up government, drawing out characteristics associated with successful joined up initiatives.We use this thematic synthesis as a basis for comparing and contrasting emerging public health interventions concerned with joined-up action across government.

RESULTS

We find that HiAP and the Fairness Agenda exhibit some of the characteristics associated with successful joined up initiatives, however they also utilise 'change instruments' that have been found to be ineffective. Moreover, we find that - like many joined up initiatives - there is room for improvement in the alignment between the goals of the interventions and their design.

CONCLUSION

Drawing on public policy studies, we recommend a number of strategies to increase the efficacy of current interventions. More broadly, we argue that up-stream interventions need to be 'fit-for-purpose', and cannot be easily replicated from one context to the next.

Health Impact Assessment in New South Wales & Health in All Policies in South Australia: differences, similarities and connections

BACKGROUND

Policy decisions made within all sectors have the potential to influence population health and equity. Recognition of this provides impetus for the health sector to engage with other sectors to facilitate the development of policies that recognise, and aim to improve, population outcomes. This paper compares the approaches implemented to facilitate such engagement in two Australian jurisdictions. These are Health Impact Assessment (HIA) in New South Wales (NSW) and Health in All Policies (HiAP) in South Australia (SA).

METHODS

The comparisons presented in this paper emerged through collaborative activities between stakeholders in both jurisdictions, including critical reflection on HIA and HiAP practice, joint participation in a workshop, and the preparation of a discussion paper written to inform a conference plenary session. The plenary provided an opportunity for the incorporation of additional insights from policy practitioners and academics.

RESULTS

Comparison of the approaches indicates that their overall intent is similar. Differences exist, however, in the underpinning principles, technical processes and tactical strategies applied. These differences appear to stem mainly from the organisational positioning of the work in each state and the extent to which each approach is linked to government systems.

CONCLUSIONS

The alignment of the HiAP approach with the systems of the SA Government increases the likelihood of influence within the policy cycle. However, the political priorities and sensitivities of the SA Government limit the scope of HiAP work. The implementation of the HIA approach from outside government in NSW means greater freedom to collaborate with a range of partners and to assess policy issues in any area, regardless of government priorities. However, the comparative distance of HIA from NSW Government systems may reduce the potential for impact on government policy. The diversity in the technical and tactical strategies that are applied within each approach provides insight into how the approaches have been tailored to suit the particular contexts in which they have been implemented.

Investigating underlying principles to guide health impact assessment

BACKGROUND

Many countries conduct Health Impact Assessment (HIA) of their projects and policies to predict their positive and negative health impacts. In recent years many guides have been developed to inform HIA practice, largely reflecting local developments in HIA. These guides have often been designed for specific contexts and specific need, making the choice between guides difficult. The objective of the current study is to identify underlying principles in order to guide HIA practice in Iran.

METHODS

This study was conducted in three stages: 1) Studies comparing HIA guidelines were reviewed to identify criteria used for comparison seeking emphasized principles. 2) The HIA characteristics extracted from published papers were categorized in order to determine the principles that could guide HIA practice. 3) Finally, these principles were agreed by experts using nominal group technique.

RESULTS

The review of the studies comparing HIA guides demonstrated there are no clear comparison criteria for reviewing HIA guides and no study mentioned HIA principles. Investigating the HIA principles from peer-reviewed papers, we found 14 issues. These were, considering of general features in planning and conducting HIAs such as HIA stream, level, timing and type, considering of the wider socio-political and economic context, considering of economic, technical and legal aspects of HIA and capacities for HIA, rationality and comprehensiveness, using appropriate evidence, elaborating on HIA relation to other forms of Impact Assessment, considering of equity, and encouraging intersectoral and interdisciplinary cooperation, involvement of stakeholders and transparency as underlying principles to guide HIA practice. The results emphasize how critical these technical as well as tactical considerations are in the early scoping step of an HIA which plans the conduct of the HIA in reponse to local contextual issues.

CONCLUSION

Determining the principles of HIA from peer-reviewed papers provides an opportunity for guiding HIA practice comprehensively. It seems to be feasible to develop a universal guide that covers all principles required.

Housing, health and master planning: rules of engagement

OBJECTIVES

Knowledge about health focussed policy collaboration to date has been either tactical or technical. This article focusses on both technical and tactical issues to describe the experience of cross-sectoral collaboration between health and housing stakeholders across the life of a housing master plan, including but not limited to a health impact assessment (HIA).

STUDY DESIGN

A single explanatory case study of collaboration on a master plan to regenerate a deprived housing estate in Western Sydney was developed to explain why and how the collaboration worked or did not work.

METHODS

Data collection included stakeholder interviews, document review, and reflections by the health team. Following a realist approach, data was analysed against established public policy theory dimensions.

RESULTS

Tactically we did not know what we were doing. Despite our technical knowledge and skills with health focussed processes, particularly HIA, we failed to appreciate complexities inherent in master planning. This limited our ability to provide information at the right points. Eventually however the HIA did provide substantive connections between the master plan and health. We use our analysis to develop technical and tactical rules of engagement for future cross-sectoral collaboration.

CONCLUSIONS

This case study from the field provides insight for future health focussed policy collaboration. We demonstrate the technical and tactical requirements for future intersectoral policy and planning collaborations, including HIAs, with the housing sector on master planning. The experience also suggested how HIAs can be conducted flexibly alongside policy development rather than at a specific point after a policy is drafted.

The fit between health impact assessment and public policy: practice meets theory

PURPOSE AND SETTING

The last decade has seen increased use of health impact assessment (HIA) to influence public policies developed outside the Health sector. HIA has developed as a structured, linear and technical process to incorporate health, broadly defined, into policy. This is potentially incongruent with complex, non-linear and tactical policy making which does not necessarily consider health. HIA research has however not incorporated existing public policy theory to explain practitioners' experiences with HIA and policy. This research, therefore, used public policy theory to explain HIA practitioners' experiences and investigate 'What is the fit between HIA and public policy?'

METHODS

Empirical findings from nine in-depth interviews with international HIA practitioners were re-analysed against public policy theory. We reviewed the HIA literature for inclusion of public policy theories then compared these for compatibility with our critical realist methodology and the empirical data. The theory 'Policy Cycles and Subsystems' (Howlett et al., 2009) was used to re-analyse the empirical data.

FINDINGS

HIAs for policy are necessarily both tactical and technical. Within policy subsystems using HIA to influence public policy requires tactically positioning health as a relevant public policy issue and, to facilitate this, institutional support for collaboration between Public Health and other sectors. HIA fits best within the often non-linear public policy cycle as a policy formulation instrument. HIA provides, tactically and technically, a space for practical reasoning to navigate facts, values and processes underlying the substantive and procedural dimensions of policy.

CONCLUSIONS

Re-analysing empirical experiential data using existing public policy theory provided valuable explanations for future research, policy and practice concerning why and how HIA fits tactically and technically with the world of public policy development. The use of theory and empiricism opens up important possibilities for future research in the search for better explanations of complex practical problems.

The effectiveness of health impact assessment in influencing decision-making in Australia and New Zealand 2005-2009

BACKGROUND

Health Impact Assessment (HIA) involves assessing how proposals may alter the determinants of health prior to implementation and recommends changes to enhance positive and mitigate negative impacts. HIAs growing use needs to be supported by a strong evidence base, both to validate the value of its application and to make its application more robust. We have carried out the first systematic empirical study of the influence of HIA on decision-making and implementation of proposals in Australia and New Zealand. This paper focuses on identifying whether and how HIAs changed decision-making and implementation and impacts that participants report following involvement in HIAs.

METHODS

We used a two-step process first surveying 55 HIAs followed by 11 in-depth case studies. Data gathering methods included questionnaires with follow-up interview, semi-structured interviews and document collation. We carried out deductive and inductive qualitative content analyses of interview transcripts and documents as well as simple descriptive statistics.

RESULTS

We found that most HIAs are effective in some way. HIAs are often directly effective in changing, influencing, broadening areas considered and in some cases having immediate impact on decisions. Even when HIAs are reported to have no direct effect on a decision they are often still effective in influencing decision-making processes and the stakeholders involved in them. HIA participants identify changes in relationships, improved understanding of the determinants of health and positive working relationships as major and sustainable impacts of their involvement.

CONCLUSIONS

This study clearly demonstrates direct and indirect effectiveness of HIA influencing decision making in Australia and New Zealand. We recommend that public health leaders and policy makers should be confident in promoting the use of HIA and investing in building capacity to undertake high quality HIAs. New findings about the value HIA stakeholders put on indirect impacts such as learning and relationship building suggest HIA has a role both as a technical tool that makes predictions of potential impacts of a policy, program or project and as a mechanism for developing relationships with and influencing other sectors. Accordingly when evaluating the effectiveness of HIAs we need to look beyond the direct impacts on decisions.