A realist impact evaluation of a tool to strengthen equity in local government policy-making.

BACKGROUND: Local governments have a critical role to play in addressing health inequities. Health equity impact assessments are recommended to help governments apply an equity lens to the development and implementation of policies and programs. Despite evidence of equity-positive benefits of such tools, adoption remains limited, prompting calls for evaluations to assess their impact and identify factors that will promote uptake across various contexts. METHODS: We conducted a mixed method study to evaluate the impact of an equity impact assessment (EIA) tool and process on policies and organisational capacity in a local government in Victoria, Australia, and identify factors that influenced this impact. We analysed 33 documents related to 18 EIAs, and conducted surveys (n = 40) and in-depth interviews (n = 17) with staff involved in EIAs. RESULTS: Almost all (17 of 18) EIAs resulted in equity-positive changes to policies and programs, most frequently addressing individual-level factors, such as making community communications and consultations more accessible to under-represented or under-served groups. Structural-level recommendations from one EIA, such as increasing diversity in decision-making panels, were found to impact both the current policy and a broad range of future, related projects and services. Improvements in equity-centric organisational culture and capacity (including staff awareness, skills and confidence) and increased engagement with under-represented communities were also reported. Factors perceived to influence the impact of EIA's related to organisational commitment and capacity to prioritise equity, process-level factors related to the type and timing of EIAs, and extent of implementation support. CONCLUSION: Our study supports wider uptake of health equity impact assessments in local government policies and programs. Legislation, leadership and resources from upper-tiers of government can help increase the adoption of equity tools to reduce disparities in population health.

[Assessment of the impact on mortality of air pollution by particles in the city of Valencia during the period 2015-2017]. / Evaluación del impacto en mortalidad de la contaminación del aire por partículas en la ciudad de València en el periodo 2015-2017.

OBJECTIVE: Air pollution is a global public health issue, with particulate matter (PM) being the pollutant with the greatest impact on health. The main objective of this article was to estimate the impact of mortality attributable to particulate pollution in the city of Valencia during the period 2015-2017. METHODS: The Health Impact Assessment (HIA) methodology from the Aphekom project was used. Scenarios of a 5 µg/m3 reduction in the annual mean concentration of PM10 and PM2.5 were employed, along with the assumption of meeting the World Health Organization (WHO) recommendations in effect during the study period, to estimate both short- and long-term impacts. RESULTS: The estimated average concentrations for 2015-2017 were 18.4 µg/m3 for PM10 and 12.3 µg/m3 for PM2.5. The short-term HIA, assuming a reduction of 5 µg/m3 in the averages, resulted in a total of 65.4 premature deaths that could be postponed during that period (21.8 annually), corresponding to a rate of 2.8 deaths per 100,000 inhabitants. In the long term, if PM2.5 concentrations had been reduced by 5 µg/m3, 124 premature deaths could have been postponed annually. CONCLUSIONS: The annual average concentrations of these pollutants meet the limits set by European regulations. However, compared to WHO recommendations, PM2.5 levels are higher by 2.3 µg/m3. An air quality scenario in line with WHO recommendations would have resulted in a reduction of 122 premature deaths annually.

OBJETIVO: La contaminación del aire es un problema de Salud Pública de importancia global, siendo las partículas en suspensión (PM) el contaminante con mayor impacto en la salud. El objetivo principal de este artículo fue estimar el impacto en mortalidad atribuible a la contaminación por partículas en la ciudad de València en el periodo 2015-2017. METODOS: Se utilizó la metodología para la Evaluación del Impacto en Salud (EIS) del proyecto Aphekom. Se realizó un estudio descriptivo y para la correlación se emplearon los escenarios de reducción de la media anual de 5 µg/m3 en la concentración de PM10 y de PM2,5 y el supuesto de cumplir las recomendaciones de la Organización Mundial de la Salud (OMS) vigentes en el periodo a estudio para estimar el impacto a corto y largo plazo. RESULTADOS: Las concentraciones estimadas del promedio 2015-2017 para PM10 y PM2,5 fueron de 18,4 µg/m3 y 12,3 µg/m3, respectivamente. La EIS a corto plazo, en el supuesto de reducir en 5 µg/m3 las medias, tuvo como resultado un total de 65,4 muertes prematuras que se podrían posponer en ese periodo (21,8 anuales), correspondiendo con una tasa de 2,8 defunciones por cada 100.000 habitantes. A largo plazo, si se hubiesen reducido las concentraciones de PM2,5 en 5 µg/m3, se hubieran podido posponer 124 muertes prematuras anuales. CONCLUSIONES: Las concentraciones medias anuales de estos contaminantes se ajustan a los límites marcados por la normativa europea. Sin embargo, respecto a las recomendaciones de la OMS, los niveles de PM2,5 son superiores en 2,3 µg/m3. Un escenario de calidad del aire conforme a las recomendaciones de la OMS se hubiera traducido en una reducción de 122 defunciones prematuras anuales.

Health impact assessment of port-sourced air pollution in Barcelona.

INTRODUCTION: Air pollution is a major health risk factor. Ports might be an understudied source of air pollution. METHODS: We conducted a spatial health impact assessment (HIA) of port-sourced air pollution for Barcelona for 2017 at the neighbourhood level. Total NO2 and PM10 and port-sourced NO2, PM10 and PM2.5 concentrations were available through the ADMS-Urban model. Population data, mortality and morbidity data, and risk estimates were obtained. We followed standard HIA methodologies and calculated relative risks and impact fractions for 1.35 million adults living in 73 neighbourhoods. RESULTS: The city-wide mean total NO2 and PM10 concentrations were 37.88 µg/m3 (range: 19.61-52.17 µg/m3) and 21.68 µg/m3 (range: 17.33-26.69 µg/m3), respectively, of which 7% (range: 2-36%) and 1% (range: 0-7%) were port-sourced, respectively. The mean port-sourced PM2.5 concentration was 0.19 µg/m3 (range: 0.06-1.38 µg/m3). We estimated that 1,123 (PI: 0-3,060) and 1,230 (95% CI: 0-2,566) premature deaths were attributable to total NO2 and PM10, respectively, of which 8.1% (91; PI: 0-264) and 1.1% (13; 95% CI 0-29) were attributable to port-sourced NO2 and PM10, respectively. 20 (95% CI: 15-26) premature deaths were attributable to port-sourced PM2.5. Additionally, a considerable morbidity burden and losses in life expectancy were attributable to port-sourced air pollution. Neighbourhoods closest to the port in the south-east were most adversely affected, gradually decreasing towards the north-west. CONCLUSIONS: The port is an understudied air pollution source in Barcelona with strong health impacts. Cities need local insight into health risk factors, their sources, attributable burdens and distributions for defining targeted policies.

[On the June 25, 2024 Judgment of the Court of Justice of the European Union regarding Ilva Taranto (Southern Italy)]. / Sulla sentenza della Corte di Giustizia dell'Unione europea del 25 giugno 2024 in merito all'Ilva di Taranto.

The June 25, 2024 Judgment of the Court of Justice of the European Union is based on the Industrial Emissions (Integrated Pollution Prevention and Control) Directive 2010/75/EU and confirms its applicability to the Taranto steel plant, reiterating that the concept of pollution includes damage to the environment and human health; the health impact assessment of polluting industrial activities, such as the Ilva steelworks in Southern Italy, must constitute an internal act in the procedures for granting and reviewing the operating permission; all pollutants attributable to the plant that are scientifically recognized as harmful to health must be considered in the assessment procedures. In the case of serious and significant danger to the integrity of the environment and human health, the operation of the installation must be suspended. The Judgment highlights important elements on the level of principle and application, which are extraordinarily useful for environment and health personnel, for open-minded and aware local, regional, and national administrators, and above all for the citizens and communities most exposed to pollutants recognized as harmful to health. Preventive environmental health impact assessments gain renewed strength as tools for evaluative and authorized decision-making on production activities, in a sense of full integration between environment and health. The right to environmental and health protection and prevention is an integral part of the defence of human rights, especially in sacrifice zones such as Taranto and many other sites to be reclaimed, considered by the UN as "places where residents suffer devastating physical and mental health consequences and human rights violations".

Optimizing BenMAP health impact assessment with meteorological factor driven machine learning models.

This study aims to address accuracy challenges in assessing air pollution health impacts using Environmental Benefits Mapping and Analysis Program (BenMap), caused by limited meteorological factor data and missing pollutant data. By employing data increment strategies and multiple machine learning models, this research explores the effects of data volume, time steps, and meteorological factors on model prediction performance using several years of data from Tianjin City as an example. The findings indicate that increasing training data volume enhances the performance of Random Forest Regressor (RF) and Decision Tree Regressor (DT) models, especially for predicting CO, NO2, and PM2.5. The optimal prediction time step varies by pollutant, with the DT model achieving the highest R2 value (0.99) for CO and O3. Combining multiple meteorological factors, such as atmospheric pressure, relative humidity, and dew point temperature, significantly improves model accuracy. When using three meteorological factors, the model achieves an R2 of 0.99 for predicting CO, NO2, PM10, PM2.5, and SO2. Health impact assessments using BenMap demonstrated that the predicted all-cause mortality and specific disease mortalities were highly consistent with actual values, confirming the model's accuracy in assessing health impacts from air pollution. For instance, the predicted and actual all-cause mortality for PM2.5 were both 3120; for cardiovascular disease, both were 1560; and for respiratory disease, both were 780. To validate its generalizability, this method was applied to Chengdu, China, using several years of data for training and prediction of PM2.5, CO, NO2, O3, PM10, and SO2, incorporating atmospheric pressure, relative humidity, and dew point temperature. The model maintained excellent performance, confirming its broad applicability. Overall, we conclude that the machine learning and BenMap-based methods show high accuracy and reliability in predicting air pollutant concentrations and health impacts, providing a valuable reference for air pollution assessment.

Ecological and human health impact assessments based on long-term monitoring of soil PAHs near a coal-fired power plant.

The combustion of coal in power plants releases significant amounts of polycyclic aromatic hydrocarbons (PAHs), which are highly toxic and carcinogenic. This study assesses the ecological and human health impacts of PAHs contamination from a coal-fired power plant over 8 years. The monitoring site selection considered the distance from the power plant and the prevailing wind direction in the investigated area. The results reveal that, during the monitoring period, PAH levels increased on average by 43%, 61%, and 37% in the zone of the prevailing wind direction, in the area proximate to the power plant, and the zone distant from it, respectively. The site, which has a radius of 4.5 km in the prevailing wind direction, exhibited the highest ecological and human health impacts. Additionally, a strong correlation was observed between environmental and human health impacts, depending on the distance from the power plant, particularly in areas with the prevailing wind direction. These insights contribute to a comprehensive understanding of the intricate dynamics linking power plant emissions, PAHs contamination, and their far-reaching consequences on the environment and human health.

The Use of Health Equity Impact Assessments to Modify Evidence Based Strategies within Local Health Departments in North Carolina.

BACKGROUND: Health equity impact assessments (HEIAs) inform the reduction of health inequities by evaluating programs or policies that affect target populations. Local health departments (LHD) receiving funding through the Improving Community Outcomes for Maternal and Child Health (ICO4MCH) Program conducted HEIAs for evidence-based strategies (EBSs). This paper describes the impact of HEIAs on the implementation of EBSs and highlights lessons learned during implementation of HEIA modifications. METHODS: We conducted a content analysis using data from the HEIA Modification Tracker and focus groups to identify themes and lessons learned. RESULTS: Fifteen HEIAs were conducted by five LHDs between 2016 and 2020. The most common modifications to EBS implementation were 1) increasing education and training for community members and 2) altering messaging mediums and language to reach intended audiences. DISCUSSION: Health equity impact assessments serve as a systematic and tangible way to center health equity, reflect on past processes, and inform improvements.

Long-term exposure to ambient fine particulate matter (PM2.5) and attributable pulmonary tuberculosis notifications in Ningxia Hui Autonomous Region, China: a health impact assessment.

INTRODUCTION: Long-term exposure to fine particulate matter (≤2.5 µm (PM2.5)) has been associated with pulmonary tuberculosis (TB) notifications or incidence in recent publications. Studies quantifying the relative contribution of long-term PM2.5 on TB notifications have not been documented. We sought to perform a health impact assessment to estimate the PM2.5- attributable TB notifications during 2007-2017 in Ningxia Hui Autonomous Region (NHAR), China. METHODS: PM2.5 attributable TB notifications were estimated at township level (n=358), stratified by age group and summed across NHAR. PM2.5-associated TB-notifications were estimated for total and anthropogenic PM2.5 mass and expressed as population attributable fractions (PAFs). The main analysis used effect and uncertainty estimates from our previous study in NHAR, defining a counterfactual of the lowest annual PM2.5 (30 µg/m3) level, above which we assumed excess TB notifications. Sensitivity analyses included counterfactuals based on the 5th (31 µg/m3) and 25th percentiles (38 µg/m3), and substituting effect estimates from a recent meta-analysis. We estimated the influence of PM2.5 concentrations, population growth and baseline TB-notification rates on PM2.5 attributable TB notifications. RESULTS: Over 2007-2017, annual PM2.5 had an estimated average PAF of 31.2% (95% CI 22.4% to 38.7%) of TB notifications while the anthropogenic PAF was 12.2% (95% CI 9.2% to 14.5%). With 31 and 38 µg/m3 as counterfactuals, the PAFs were 29.2% (95% CI 20.9% to 36.3%) and 15.4% (95% CI 10.9% to 19.6%), respectively. PAF estimates under other assumptions ranged between 6.5% (95% CI 2.9% to 9.6%) and 13.7% (95% CI 6.2% to 19.9%) for total PM2.5, and 2.6% (95% CI 1.2% to 3.8%) to 5.8% (95% CI 2.7% to 8.2%) for anthropogenic PM2.5. Relative to 2007, overall changes in PM2.5 attributable TB notifications were due to reduced TB-notification rates (-23.8%), followed by decreasing PM2.5 (-6.2%), and population growth (+4.9%). CONCLUSION: We have demonstrated how the potential impact of historical or hypothetical air pollution reduction scenarios on TB notifications can be estimated, using public domain, PM2.5 and population data. The method may be transferrable to other settings where comparable TB-notification data are available.

Better accounting for long-term health effects in economic assessments: an illustration for air pollution in the Canton of Geneva.

OBJECTIVES: We propose a general framework for estimating long-term health and economic effects that takes into account four time-related aspects. We apply it to a reduction in exposure to air pollution in the Canton of Geneva. STUDY DESIGN: Methodological developments on the evaluation of long-term economic and health benefits, with an empirical illustration. METHODS: We propose a unified framework-the comprehensive impact assessment (CIA)-to assess the long-term effects of morbidity and mortality in health and economic terms. This framework takes full account of four time-related issues: cessation lag, policy/technical implementation timeframe, discounting and time horizon. We compare its results with those obtained from standard quantitative health impact assessment (QHIA) in an empirical illustration involving air pollution reduction in the canton of Geneva. RESULTS: We find that by neglecting time issues, the QHIA estimates greater health and economic benefits than the CIA. The overestimation is about 50% under reasonable assumptions and increases ceteris paribus with the magnitude of the cessation lag and the discount factor. It decreases both with the time horizon and with the implementation timeframe. CONCLUSION: A proper evaluation of long-term health and economic effects is an important issue when they are to be used in cost-benefit analyses, particularly for mortality, which often represents the largest fraction. We recommend using the CIA to calculate more accurate values.

A systematic review of whether Health Impact Assessment frameworks support best practice principles.

OBJECTIVES: Health Impact Assessment (HIA) is an evidence-based approach to assess the likely public health impacts of a policy or plan in any sector. Several HIA frameworks are available to guide practitioners doing a HIA. This systematic review sought to determine whether these support practitioners to meet best practice principles defined by the International Association for Impact Assessment. STUDY DESIGN: This was a systematic review. METHODS: Three complementary search strategies were used to identify frameworks in June 2022. We used three databases to find completed HIAs published in the last five years and hand-searched their reference lists for frameworks. We also searched 23 HIA repositories using Google's Advanced function and contacted HIA practitioners via two international mailing lists. We used a bespoke quality appraisal tool to assess frameworks against the principles. RESULTS: The search identified 24 HIA frameworks. None of the frameworks achieved a 'good' rating for all best practice principles. Many identified the principles but did not provide guidance on how to meet them at all HIA steps. The highest number of frameworks were rated 'good' for ethical use of evidence and comprehensive approach to health (n = 15). Eight frameworks were rated as 'good' for participation, and two for equity. The highest number of frameworks rated 'poor' for sustainability (n = 11). CONCLUSIONS: There is marked variation in the degree to which HIA frameworks support the best practice principles. HIA practitioners could select elements from different frameworks for practical guidance to meet all the best practice principles.

Funding the pandemic response for Indigenous Peoples: an equity-based analysis of COVID-19 using a Health Equity Impact Assessment (HEIA) Indigenous lens tool.

This study examines the allocation of COVID-19 funding for Indigenous Peoples in Canada, Australia, New Zealand, and the United States during the pandemic's first wave. Indigenous communities, already facing health disparities, systemic discrimination, and historical forces of colonisation, found themselves further vulnerable to the virus. Analysing the funding policies of these countries, we employed a Health Equity Impact Assessment (HEIA) tool and an Indigenous Lens Tool supplement to evaluate potential impacts. Our results identify three major funding equity issues: unique health and service needs, socioeconomic disparities, and limited access to community and culturally safe health services. Despite efforts for equitable funding, a lack of meaningful consultation led to shortcomings, as seen in Canada's state of emergency declaration and legal disputes in the United States. New Zealand stood out for integrating Maori perspectives, showcasing the importance of consultation. The study calls for a reconciliation-minded path, aligning with Truth and Reconciliation principles, the UN Declaration on the Rights of Indigenous Peoples, and evolving government support. The paper concludes that co-creating equitable funding policies grounded in Indigenous knowledge requires partnership, meaningful consultation, and organisational cultural humility. Even in emergencies, these measures ensure responsiveness and respect for Indigenous self-determination.

Regional impact assessment of air quality improvement: The air quality lifecourse assessment tool (AQ-LAT) for the West Midlands combined authority (WMCA) area.

Poor air quality is the largest environmental health risk in England. In the West Midlands, UK, ∼2.9 million people are affected by air pollution with an average loss in life expectancy of up to 6 months. The 2021 Environment Act established a legal framework for local authorities in England to develop regional air quality plans, generating a policy need for predictive environmental impact assessment tools. In this context, we developed a novel Air Quality Lifecourse Assessment Tool (AQ-LAT) to estimate electoral ward-level impacts of PM2.5 and NO2 exposure on outcomes of interest to local authorities, namely morbidity (asthma, coronary heart disease (CHD), stroke, lung cancer), mortality, and associated healthcare costs. We apply the Tool to assess the health economic burden of air pollutant exposure and estimate benefits that would be generated by meeting WHO 2021 Global Air Quality Guidelines (AQGs) (annual average concentrations) for NO2 (10 µg/m3) and PM2.5 (5 µg/m3) in the West Midlands Combined Authority Area. All West Midlands residents live in areas which exceed WHO AQGs, with 2070 deaths, 2070 asthma diagnoses, 770 CHD diagnoses, 170 lung cancers and 650 strokes attributable to air pollution exposure annually. Reducing PM2.5 and NO2 concentrations to WHO AQGs would save 10,700 lives reducing regional mortality by 1.8%, gaining 92,000 quality-adjusted life years (QALYs), and preventing 20,500 asthma, 7400 CHD, 1400 lung cancer, and 5700 stroke diagnoses, with economic benefits of £3.2 billion over 20 years. Significantly, we estimate 30% of QALY gains relate to reduced disease burden. The AQ-LAT has major potential to be replicated across local authorities in England and applied to inform regional investment decisions.

The Performance of Environmental and Health Impact Assessment Implementation: A Case Study in Eastern Thailand.

Environmental impact assessment (EIA) performance has remained of interest, and over the past ten years, the evaluation technique has evolved. Thailand implemented an EIA with a health impact assessment (HIA) as an environmental health impact assessment (EHIA), which necessitated investigating and developing these instruments; however, its implementation performance has been questioned. The main goal of this study is to comparatively assess how well EIAs and EHIAs are performed in projects in an area in Thailand. Six projects in various sectors that were implemented in Eastern Thailand were studied. The 162 residents (nine local authorities and 153 villagers) closest to the project completed a survey and evaluated the performance according to three aspects (i.e., substantive, procedural, and transactive), using a rating scale and evaluation checklists. The results were presented as a percentage of the total scores and interpreted according to the five scales. The overall performance reached a satisfactory level, albeit not significantly different between cases; however, it was pointed out that the shortcomings of EHIAs and EIAs, particularly their dependability, lack of public involvement, and the need for more transparency, could be addressed through the establishment of an open access database, which would help to simplify the assessment of all stages of EIAs and EHIAs.

Health impact assessment of the surface water pollution in China.

China suffers from severe surface water pollution. Health impact assessment could provide a novel and quantifiable metric for the health burden attributed to surface water pollution. This study establishes a health impact assessment method for surface water pollution based on classic frameworks, integrating the multi-pollutant city water quality index (CWQI), informative epidemiological findings, and benchmark public health information. A relative risk level assignment approach is proposed based on the CWQI, innovatively addressing the challenge in surface water-human exposure risk assessment. A case study assesses the surface water pollution-related health impact in 336 Chinese cities. The results show (1) between 2015 and 2022, total health impact decreased from 3980.42 thousand disability-adjusted life years (DALYs) (95 % Confidence Interval: 3242.67-4339.29) to 3260.10 thousand DALYs (95 % CI: 2475.88-3641.35), measured by total cancer. (2) The annual average health impacts of oesophageal, stomach, colorectal, gallbladder, and pancreatic cancers added up to 2621.20 thousand DALYs (95 % CI: 2095.58-3091.10), revealing the significant health impact of surface water pollution on digestive cancer. (3) In 2022, health impacts in the Beijing-Tianjin-Hebei and surroundings, the Yangtze River Delta, and the middle reaches of the Yangtze River added up to 1893.06 thousand DALYs (95 % CI: 1471.82-2097.88), showing a regional aggregating trend. (4) Surface water pollution control has been the primary driving factor to health impact improvement, contributing -3.49 % to the health impact change from 2015 to 2022. It is the first city-level health impact map for China's surface water pollution. The methods and findings will support the water management policymaking in China and other countries suffering from water pollution.

Determining the Public Health Impact of Climate Change: A National Study Using a Health Impact Assessment Approach in Wales.

Objective: Climate change is recognised as the biggest threat to global health of the 21st century and impacts on health and wellbeing through a range of factors. Due to this, the need to take action in order to protect population health and wellbeing is becoming ever more urgent. Methods: In 2019, Public Health Wales carried out a comprehensive mixed-method Health Impact Assessment (HIA) of climate change. Unlike other risk assessments, it appraised the potential impact of climate change on health and inequalities in Wales through participatory workshops, stakeholder consultations, systematic literature reviews and case studies. Results: The HIA findings indicate potential impacts across the wider determinants of health and wellbeing. For example, air quality, excess heat/cold, flooding, economic productivity, infrastructure, and community resilience. A range of impacts were identified across population groups, settings, and geographical areas. Conclusion: These findings can inform decision-makers to prepare for climate change plans and policies using an evidence-informed approach. The work has demonstrated the value of a HIA approach by mobilising a range of evidence through a transparent process, resulting in transferrable learning for others.

Risk-based public health impact assessment for drinking water contamination emergencies.

Chemical spills in surface waters pose a significant threat to public health and the environment. This study investigates the public health impacts associated with organic chemical spill emergencies and explores timely countermeasures deployable by drinking water facilities. Using a dynamic model of a typical multi-sourced New England drinking water treatment facility and its distribution network, this study assesses the impacts of various countermeasure deployment scenarios, including source switching, enhanced coagulation via poly­aluminum chloride (PACl), addition of powdered activated carbon (PAC), and temporary system shutdown. This study reveals that the deployment of multiple countermeasures yields the most significant reduction in total public health impacts, regardless of the demand and supply availability. With the combination PAC deployed first with other countermeasures proving to be the most effective strategies, followed by the combination of facility shutdowns. By understanding the potential public health impacts and evaluating the effectiveness of countermeasures, authorities can develop proactive plans, secure additional funding, and enhance their capacity to mitigate the consequences of such events. These insights contribute to safeguarding public health and improving the resilience of drinking water systems in the face of the ever-growing threat of chemical spills.