The applications of HIA are broad and the methods used to analyze impacts are variable, but the basic steps described for completing an HIA are consistent. These steps can be accomplished fairly quickly (a “rapid” or “desktop” HIA can be completed in a period of weeks), or they can involve a more comprehensive process that includes public meetings, extensive stakeholder consultation and/or collection of new data.
1. Screening: Determines whether the HIA is likely to succeed and add value. Questions include: What specific proposed project, program or policy decision will the HIA address? For example, if the HIA will address a proposal for a coal-fired power plant, what specific decision-making process (such as an air-quality permit or environmental impact statement) will the HIA inform? How important to health is the decision? Will the HIA provide new and important information or insight on previously unrecognized health issues? Is it feasible in terms of available resources (e.g., data, time, money, stakeholder interest and political will)?
2. Scoping: Creates objectives for the HIA, and an outline for the steps of the HIA process by asking: What health effects should the HIA address? What concerns have stakeholders expressed about the pending decision? Who will be affected by the policy or project, and how?
3. Assessment: Involves two steps, describing the baseline health of people and groups affected by the decision, and then predicting the potential health effects. The baseline health analysis attempts to explain not only the important causes of illness, but also the conditions that influence health and could be affected by the decision in question—such as the local economy, air quality, availability of parks and recreation facilities, or access to healthy food choices.
The assessment stage can involve literature review, qualitative analysis and/or quantitative modeling. It identifies not only the important health risks and benefits, but also their distribution among vulnerable subgroups within the population (such as children, the elderly, people with chronic illnesses, racial and ethnic groups, or those with low incomes). The HIA should be conducted in an impartial, scientific way that identifies both the risks and the benefits associated with a decision. Assessment of health-related economic costs and benefits has not been common in HIA but decision makers sometimes request this information; when possible, such analysis may help them weigh the relative importance of identified health issues against other considerations.
4. Recommendations: The HIA should point the way to decisions that protect and promote health. The actions required to integrate an HIA’s analysis and recommendations into a decision-making process will vary. In some cases, simply providing a thorough analysis that outlines the potential risks, benefits and costs of alternatives may help policy makers to make informed choices that support health. In many cases, however, an HIA’s ability to influence outcomes will require additional efforts, including the development of specific recommendations based on the analysis, as well as a health management plan that specifies who will implement each recommendation and how outcomes will be monitored going forward. These products should provide practical, specific actions that can be taken in order to promote health and avoid, minimize or mitigate adverse consequences.
5. Reporting: The findings are disseminated to decision makers, affected communities and other stakeholders with a request for feedback. This stage may result in a revised report that addresses public responses to the draft.
The success of an HIA depends on effective dissemination. Simply providing recommendations is often not enough to ensure their adoption or implementation. The HIA should be conducted with an eye toward the policy levers, legal or regulatory avenues, communications and non-lobbying advocacy tactics, or other methods that will ensure effective dissemination of the findings and facilitate adoption of the recommendations. For example, in some cases when public agencies conduct an HIA, it may be possible to implement its recommendations under existing laws, policies or regulations or through the creation of new policies or regulations. In other cases, media outreach and efforts to engage, educate and build consensus among all stakeholders may be essential to ensuring that HIA insights inform key policy decisions.
6. Monitoring and Evaluation: There are three types of evaluation in HIA: 1) process evaluation gauges the HIA’s quality according to established standards and the original plan for the HIA; 2) impact evaluation assesses the HIA’s impact on decision-making and its success according to the objectives established during scoping; and 3) outcome evaluation assesses changes in health status and health determinants as the decision is implemented. Monitoring tracks indicators that can be used to inform process, impact and outcome evaluations.