Perception survey on the relevance of main categories of health determinants for conducting health impact assessment

Highlights

• Habits and life style are considered a key SDH in population's health status.

• How SDH should be addressed in HIA needs further guidance.

• Multidisciplinary conferences may enhance practitioner's capacity.

Abstract

Addressing the characterization of social and economic determinants of health (SDH) properly is a key aspect in conducting a Health Impact Assessment (HIA). This article explores the level of knowledge on HIA environmental and public health professionals have as well as their perception regarding key concepts such as the definition of ‘health’ and the relevance of SDH. With this purpose in mind, a survey was conducted among experts (n = 41) who attended a technical session on HIA within the framework of the most important conference on the Environment on a national level in Spain. A hierarchical cluster analysis was conducted to categorize groups of respondents depending on their working profile and professional expertise and a Friedman test was used to compare mean ranks so as to assess the importance given to SDH according to the target respondents' perception. Strong differences were found in the relevance given to diverse SDH according to their contribution to a good state of health, the block referring to ‘Habits and lifestyle’ being the one perceived as more significant. SDH were ranked in a diverging order from that reported in the scientific evidence regarding the association between SDH and a wide range of health outcomes. Also, some diverging trends were illustrated between groups of respondents according to the relevance given to each block of SDH. However, differences in responses between groups of respondents were not statistically significant. A self-appraisal by respondents also revealed that the practitioner's level of knowledge on HIA ranged between low to medium. Therefore, it is recommended to improve their capacity.

Introduction

The holistic model promoted by the World Health Organization (WHO) defines health as not just the absence of disease but “a state of complete physical, mental and social well-being” (WHO, 1946). In addition, it is widely accepted that the underlying causes of disease do not depend only on isolated risk factors (e.g., individual biological and behaviour characteristics, air pollution, and so on), but also on the interaction between them and other factors such as socioeconomic conditions, the surrounding environment, culture and traditions and political context at both individual and community level (WHO, 2002; Martin-Olmedo and Mekel, 2014). According to this model, certain factors (e.g. gender, social class, age or ethnicity) can modify the degree of exposure and vulnerability related to different risk factors (i.e. waste disposal), generating an unequal distribution of health and disease (Eshetu and Woldesenbet, 2011). In this sense, the framework of the so-called Social Determinants of Health (SDH) points out the need to deal with health inequalities within a population (Solar and Irwin, 2010).

On the other hand, Health Impact Assessment (HIA) has been practiced in Western Europe since the 1980s and its application is now spreading through a larger number of countries around the world (NRC, 2011). However HIA's institutionalization is not following the same progression as other procedures such as environmental impact assessment (EIA) did in the past (Harris-Roxas et al., 2012). HIA is a tool aimed to efficiently assessing the potential effects on community health and its distribution due to interventions linked to non-health sectors (e.g. construction, industry, farming) (Kemm, 2013). This approach is grounded on the broad model of health that seeks to enhance inter-sectorial responsibility for health (Lock, 2000; Krieger et al., 2003), because it has been noted that activities from other sectors play a major role in terms of public health (Harris-Roxas et al., 2012).

In this context, conducting a proper identification of all SDH that might be modified by a project is one of the pillars on which the contents of HIA must be structured. Several approaches for addressing SDH have been conducted, the one proposed by Dahlgren and Whitehead (2007) being the most broadly accepted (Raphael, 2006). Nevertheless, few studies have simultaneously assessed the relative contribution of ‘social’ and ‘economic’ indicators in health outcomes (Booske et al., 2010; Ahnquist et al., 2012), and there is no consensus on the indicators to be used for measuring SDH (Elias et al., 2019). In addition, practitioners need to use weighting techniques and tools to value impacts and to assess alternatives in a comparable way during planning and project decision making (Ahlroth, 2014). Currently, this complexity increases considerably within multidisciplinary contexts where environmental costs are also a matter of concern (Wegner and Pascual, 2011). Despite the vast amount of literature and resources available to assist decision makers regarding multiple stakeholders' perspectives (Lynam et al., 2007), consultants still need guidance to perform good quality quantitative assessments when addressing the characterization of health impacts within procedures such as HIA and EIA (Morrison-Saunders and Bailey, 2009; Kågström, 2016). However, little is known regarding weighting of multiple factors (e.g. SDH) in HIA (ter Burg et al., 2015). Therefore, there is a need for better characterization of SDH while conducting a HIA, and for exploring whether the way they are perceived may depend on the practitioners' background.

In Spain, HIA was incorporated in the legal system in 2011 (Law 33/2011 on Public Health). Nonetheless, it has been institutionalized in only 1 out of 17 autonomous communities (Iglesias-Merchan and Dominguez-Ares, 2020a). Likewise, Law 21/2013 on Environmental Assessment includes the need to analyse human health with the rest of environmental factors, an aspect now reinforced with Directive 2014/52/EU (OJEU, 2014), replacing the term “human being” under the scope of covered environmental factors (Article 3) for “population and human health”, which brings hope for better evaluations on health issues within the EIA procedures. Regarding EIA, it should be noted that there is still a never ending debate at an international level on the integration of HIA into other processes such as EIA and strategic environmental assessment (SEA), which remains on the table without having yet reached any clear conclusions (Steinemann, 2000; Mahboubi et al., 2015; Iglesias-Merchan and Domínguez-Ares, 2020b). In the meantime, Article 5. 3. (a) of Directive 2014/52/EU (OJEU, 2014) states that “the developer shall ensure that the EIA report is prepared by competent experts…”, which means that when addressing health considerations related to a project, those professionals should have a reasonably good knowledge of the SHD model and the methodologies to characterise potential impacts.

The Spanish National Congress on the Environment is considered the most important conference on sustainability and the environment at a national level that brings together more than 1000 private companies and public institutions. In the 2018 edition (November 26th–29th, Madrid), more than 8000 people took part in this event, in more than 120 scheduled activities. This study, conducted in the context of this edition of the Congress, aimed at providing an initial overview of the knowledge and perception that Spanish environmental and public health practitioners had on HIA and their global concept of health, as well as the relevance they assign to different blocks of SDH in their contribution to a good state of health.