Assessing health and wellbeing
- Management ,
The new EIA Directive requires an assessment of impacts of projects on human health. Howard Waples provides some guidance
For the first time the effects of a project on population and human health are to feature in environmental impact assessments. The change is being ushered in by Art 3 of the new EIA Directive (2014/52/EU). This will expand on the principles of the previous directive (2011/92/EU), which required only the consideration of ‘human beings’, and the UK’s EIA Regulations 2011, which referred to ‘population’.
The revised demands may be challenging to some, confusing to others – who may think that human health impacts are already considered in EIA – and concerning to those who fear it will remove the essence of what health impact assessment (HIA) is designed for and does most effectively.
High-profile issues, such as the debate over airport expansion in the South East, have placed the effects of major projects on human health among the priorities for stakeholders and the public, and the established mechanisms for assessment of health have come under increased scrutiny. Meanwhile, another piece of legislation, the Health and Social Care Act 2012, is changing the framework for the provision of public health and the organisations involved. Crucially, it introduces a duty on a local authority to ‘take such steps as it considers appropriate for improving the health of the people in its area’.
More than physical health
The European arm of the World Health Organization (WHO) defines health as a state of complete physical, mental and social wellbeing, not merely the absence of disease or infirmity.
Public health, therefore, encompasses general wellbeing as well as the absence of illness. Some effects on health and wellbeing are direct and obvious, others are indirect, and some may be synergistic, with different types of impact acting in concert.
In recent years, the expertise and supporting knowledge behind assessing health and wellbeing impacts have grown rapidly, and there is a wealth of literature, guidance and training available on HIA. It is important that someone wishing to practise HIA is familiar with this information.
A review of some of the literature shows that human health and wellbeing can be influenced by almost everything to a degree. These factors are known as ‘determinants of health’, and it is possible to fit these into four broad groups – individual, lifestyle, environmental and socio-economic factors (see panel, p31). Typically, the EIA process has considered only human effects on the environment, such as air quality and noise, and socio-economic factors, and has made specific connections between impacts and health and wellbeing according to topic. However, health and wellbeing impacts should be considered as a combination of a wider range of health determinants.
Effective steps to integration
Understanding how the environment around us influences health and wellbeing is the key part of how EIA practitioners will need to adapt when 2014/52/EU is transposed into UK legislation – no later than 16 May 2017, though this may depend on negotiations on the UK leaving the EU (pp16–20). HIA has been developed specifically to assess human health and wellbeing rather than the environment in general, so it is reasonable to use this as a basis of best practice.
The stages of HIA largely reflect the stages of EIA:
- Screening – There will still be Sch 1 and 2 developments under the revised EIA directive. Also, Sch 2 will still be subject to development size thresholds and consideration of selection criteria identified in Sch 3. However, more emphasis will need to be put on densely populated areas since they have a greater potential to influence the health of more people.
Regardless of this, the focus of EIA in health terms will be to identify and mitigate likely significant effects. This raises the question of what is significant in human health terms. This has the potential to become a controversial and poorly considered practice without some clear official guidance being issued. Another factor could be that the ‘fear’ of a project could result in anxiety and depression (both mental health issues) when the assessment of the health impacts focuses only on those that actually result from the project itself. In this case, it would seem reasonable that fear in itself should not reasonably trigger an EIA on health grounds (since an EIA would then be required for everything), although it is recommended that early engagement and reassurance of local people would mitigate this.
- Scoping – To understand how a project is likely to affect the health of a population, it is essential to know broadly whose health may be affected, and whether there are likely to be any significant effects. Scoping of this topic would also require a description of the methodology to be used – such as desk-based or engagement driven quantitative or qualitative reporting.
It is important to understand what is reasonable, in terms of proportionality of assessment, and what is achievable in terms of mitigating adverse effects and enhancing beneficial ones. It is also important to understand that sometimes a project can have both a positive and negative impact on different determinants of health. A new bypass may reduce the impact of congestion, driver stress, noise and air quality and community segregation in one location, but could increase it elsewhere and negatively affect landscape and ecology, both of which are important for mental health. However, it is hard to gauge accurately how different health determinants interact. Also, health and wellbeing effects can manifest themselves over different timescales (acute or chronic) and in different ways to different people.
The EIA scoping report should therefore set out what a project’s health and wellbeing effects are likely to be, who they are likely or unlikely to affect, and at what spatial or temporal scale. It should describe the methods proposed to obtain the community profile, the stakeholder engagement proposed, and whether the applicant has any particular aspirations to avoid affecting health and wellbeing. The determining authority for the EIA should ensure that public health authorities, such as Public Health England, are consulted at the scoping stage.
- Establishing a baseline – This will identify the receptor groups in the study area and determine their sensitivity. As a general rule, determining health impacts should not focus on individuals. This is because, first, the ‘individual factors’ determining health are not something a project normally affects; second, every individual is different and will have a different susceptibility or sensitivity to health determinants; and third, the amount of data that would need to be collected to give meaningful results would be prohibitive.
A receptor group is a collection of individuals sharing similar characteristics, with a similar sensitivity to health and wellbeing. Sensitivity can be stated in general terms, comparative to other receptor groups – see panel below for examples. In HIA, a large part of understanding the baseline is to establish the community profile. This not only presents the health and wellbeing data from communities affected, but it can build on the availability of social infrastructure – the socio-economic health determinants, such as hospitals, schools and accessible open space. It may also be advisable to cross-reference to other EIA topics to understand congestion and air quality because these contribute to the health determinants.
- Assessment, mitigation and enhancements – The assessment itself must be proportionate to the degree of health impact expected. In principle, there are three main types of HIA, which can also be applied to health and wellbeing in EIA:
- desktop – a shorter duration assessment against a set of health indicator questions undertaken purely using desk-based research;
- rapid – a medium duration assessment, relying on a degree of stakeholder or public engagement, that may include a stronger evidence base and set of recommendations to identify opportunities for mitigation or enhancement; and
- comprehensive (when a project has likely significant health and wellbeing effects) – a longer duration assessment, relying more heavily on stakeholder or public engagement, and using quantitative and more complex data.
To assist in the assessment, there are tools to assess health and wellbeing impacts, such as the Healthy Urban Development Unit (HUDU) checklist (bit.ly/29U8Zf5) and its rapid health impact assessment tool (bit.ly/2aarS3e). The assessment itself can be supported by qualitative discussions with local people, quantitative analysis – such as epidemiological studies and modelling of collisions or airborne particulate matter – and use of the health economic assessment tool (HEAT – bit.ly/1zAYIOh).
The assessment is likely to require input from various documents to provide an evidence base for the assessment. These include: the design and access statement (or equivalent design documentation); statement of community involvement; planning statement or statement of case; transport assessment; construction logistics plan; other technical chapters of the environmental statement; s 106 heads of terms; code of construction practice; and the environmental management plan.
As with other EIA topics, the assessment should be based on a reasonable set of assumptions – for example, standard construction mitigation will be used, and the design will accord with accessibility legislation. The assessment will be subject to the EIA Regulations so it is important to determine whether a health and wellbeing impact is significant. Although guidance on this would be valuable, the assessor will need to rely on expert judgement and discussions with other professionals to determine significance. Broadly, assessing significance of health and wellbeing effects can follow a similar principle to other environmental topics, whereby significance is a factor of both the sensitivity of a receptor group and the magnitude of change (see panel, below). This can be shown in a matrix (below).
- Monitoring – The revised EIA Regulations are expected to include a requirement to monitor impacts identified by the assessment throughout construction and operation. This could entail establishing a monitoring framework based on the same set of health indicators used in the community profile. Over time, the change in the direct and indirect impact of different types of schemes will become clearer, as will information sharing on the effectiveness of mitigation.
However, census findings and data related to public health will give only the overall range of health determinants. This approach would not allow for the isolation of how the project alone affected health and wellbeing. In addition, it may not consider that populations and communities can be transient, and that health data may be misleading. For example, an urban regeneration project may bring in new residents and a new social infrastructure and lead to apparently positive health impacts.
The assessment process outlined allows mitigation or enhancements to be targeted at particular groups of people or the wider population. In common with other EIA topics, it is essential that project applicants commit to mitigation and enhancement measures, and it is helpful for the mechanism for implementation to be described. This aspect will differ from traditional HIA, which allows the practitioner to state recommendations with no guarantee that they are implemented. Other measures for monitoring impacts could be to conduct further stakeholder engagement once operational – particularly involving individuals or organisations that were involved at the project planning stage.
Monitoring health and wellbeing will greatly benefit from sharing outcomes from projects to determine the observed impacts and effectiveness of mitigation. This will ensure that projects can fulfil the opportunities they have to reduce health inequalities and to improve the health and wellbeing of wider communities.
The IEMA impact assessment network has established a health assessment group, which is working on how best to integrate health considerations into future EIAs. Joanna Bagley, who chairs the body and is senior associate director of EIA at consultancy Waterman Group, says the aim is to improve understanding of the HIA and EIA processes among practitioners.
Factors determining health
Age, sex and hereditary issues, pregnancy and disease.
Drinking, exercise, diet, smoking and drug use.
Agriculture and food production, water and sanitation, and housing quality.
Education, deprivation, crime/fear of crime, employment/unemployment/job security, work environment, social networks and social capital, amenity, entertainment, culture, faith, and healthcare and social infrastructure.
Health and wellbeing receptor group
Sensitivity to changes in health determinants (relative)
Children and pregnant women (local residents)
Working age people (local residents)
Elderly people (local residents)
Disabled people (local residents)
Locally employed people (all ages)
Transient people (people travelling through an area)
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