ࡱ>  ҧbjbjVV <<`"5---8e4|- 8  + + + A"\#1$LR6T6T6T6T6T6T6$%:<Zx6M}$"""}$}$x6+ + 7%(%(%(}$+ + 5L%(}$R6%(%(v3h4+ @q_-}%3470 83!=&!= 4!=4@}$}$%(}$}$}$}$}$x6x6%(}$}$}$ 8}$}$}$}$!=}$}$}$}$}$}$}$}$}$ : INFLUENCING DECISION-MAKING IN HEALTH AND WELLBEING: REFLECTIONS FROM HEALTH IMPACT ASSESSMENTS IN AUCKLAND 2007-2010 A. Field1, K. Arcus1, M. Tunks2. 1 Synergia Ltd, Auckland, New Zealand 2 Auckland District Health Board, Auckland, New Zealand Presented at the Australasian Evaluation Society International Conference, Sydney, Australia, 29August 2 September 2011 Abstract This paper reflects on the outcomes and influence achieved in four health impact assessments (HIA) conducted in the Auckland region between 2007 and 2010. Each HIA followed established HIA processes of screening, scoping, appraisal, reporting and evaluation. In three HIAs, a parallel process of whnau ora consultation was undertaken in partnership with a Mori health organisation. All four HIAs incorporated collaborative development of recommendations through the stakeholder engagement process, alongside a structured process of identifying impacts. Changes in approaches across the course of the four HIAs occurred in terms of the role of the external consultant/researcher; in earlier HIAs the consultant took lead responsibility, but by the fourth HIA, as agency capability developed, the external consultants took on more of an advisory and review role. This reflection on HIA practice offers a view that HIA influence requires early engagement with stakeholders in lead agencies; a strong grounding in the research evidence; a clear base of broad community and stakeholder engagement to give voice to the health and wellbeing aspirations; active involvement of stakeholders in the development of recommendations and forward directions; and an active advocate inside the lead agencies for the HIA process and recommendations. Introduction Health impact assessment (HIA) is a collaborative approach to identifying potential health and wellbeing impacts of policies and planning (World Health Organization 1999). HIAs typically explore more than simply the human health impacts, but also the broader determinants of health, reflecting a core public health approach of focusing on the wider environments that promote or deter health and wellbeing. A range of government agencies have issued guidance on conducting HIAs (Commonwealth Department of Health and Ageing 2001, Health Development Agency 2002, Public Health Advisory Committee 2004, World Health Organization 1999). Alongside this, a burgeoning academic literature is reflecting on the approaches, effectiveness and potential improvements to the HIA field (see for example Birley 2011, Harris-Roxas & Harris 2011, Kemm et al 2004, Veerman et al 2007, Wismar et al 2007). HIAs bring together evidence in the form of the published academic literature on potential health impacts, local data and statistics as well as the lived experiences and aspirations of the communities that are the focus of the HIA. Achieving influence in decision-making to enhance population health and wellbeing is a core aim of HIA processes. A comprehensive review of HIAs in Europe identified four general categories of effectiveness of HIAs: Direct effectiveness, where the HIA has contributed to a modification in the pending decisions; General effectiveness, where the HIA findings were taken into account but did not modify decisions; Opportunistic effectiveness, where the HIA may appear to have influenced decisions, but was initiated with a view to supporting a preferred policy option; and No effectiveness (Wismar et al 2007). This presentation explores the impacts achieved in four HIAs in New Zealand over 2007-2010, which focused on the urban environment, transport and health; and the drivers of influence or effectiveness in each case. The HIAs that are the focus of this discussion were the following: A housing development in Papakura, South Auckland, conducted over 2007 and 2008 (Field & Shepheard 2008) A regional transport strategy in Auckland, conducted in 2008-09 (Field et al 2009). A long-term spatial structure plan in Manukau City Centre, a South Auckland urban hub, conducted in 2008-09 (Field et al 2009) A draft spatial structure plan in Wiri, a suburb with high levels of deprivation, conducted in 2011 (Manukau City Council 2010). Methods used in the HIAs Each HIA broadly followed an established process of screening (agreeing the value of conducting an HIA on the area of focus); scoping (identifying the key areas of interest and planning the engagement process); appraisal and reporting (exploring potential impacts and recommendations for mitigation strategies); and evaluation (reflecting on the process of the HIA and the impacts achieved). All HIAs were grounded in a review of the research evidence relating to transport, urban form and health, including a focus on evidence on effective interventions in these areas. As well as reviewing the literature, population profiles were undertaken of the geographic areas of focus, including exploring the issues for high needs population groups. Two of the HIAs (Papakura and the Regional Transport Strategy) were funded through the regional public health service, and in the transport strategys case, with additional funds from the regional council. The remaining two HIAs were funded through the Ministry of Healths Learning by Doing fund. In three of these HIAs, a parallel process of whnau ora HIA (Ministry of Health 2007) was undertaken, focusing particularly on the health of Mori families. Each HIA brought together wide-ranging stakeholder engagement from multiple sectors and communities including public health, social services, community organisations and representatives, police, education, local government and transport planners. In whnau ora engagement, a range of Mori health and social services organisations were consulted through engagement workshops, and the directions emerging from these workshops were reviewed through the lens of a Mori health promotion framework, Te Pae Mahutonga (Durie 1999). The HIAs explored such issues as active transport, liveability and vitality, safety and housing. Consultation with Mori identified themes of cultural connectedness, kaitiakitanga (guardianship) of the environment, healthy lifestyles and participation in society. All four HIAs gave explicit consideration to the impacts and interests of high needs populations, such as Mori and Pacific people, children, older people and people with disabilities. HIAs typically focus on identifying the potential range of impacts; in New Zealand and Australia, there is established guidance on HIAs that supports a systematic identification of potential health and wellbeing impacts (Commonwealth Department of Health and Ageing 2001, Harris et al 2007, Public Health Advisory Committee 2004, Public Health Advisory Committee 2007). However, whilst the guidance gives recognition to identifying mitigation strategies, the overriding emphasis is on identifying scope and scale of impacts, and with little guidance given on how recommendations can be established among community or organisational stakeholders. There appears to be an implicit assumption that the process of identifying impacts will of itself lead to recommendations. In contrast, these HIAs all had a common focus on collaboratively developing recommendations through the stakeholder engagement process, alongside a structured process of identifying impacts. The emphasis was on identifying not only consequences (impacts), but also causes and levers for change. This was undertaken in workshops through use of such questions as those listed in the example below (in this case, looking at the Papakura housing development and its potential impacts on walkability as a theme within the HIA). The approach was intended to foster focused discussion in a way that identified positive and negative health impacts; issues for vulnerable population groups; policy and planning levers; and key actions required. What are the health impacts if the development promotes walkability? Who benefits? What are the health impacts if the development fails to promote walkability? Who suffers? What needs to be in place to ensure that there are good levels of walkability? How do you ensure they are put in place? Differing approaches to the consultant/researcher role were applied in these HIAs. Three were in the traditional mode of consultant leadership across project design, stakeholder consultation, and report development. One HIA (Wiri) involved more agency leadership in the project, including community engagement and report development, with the consultants involved more in ongoing advice, facilitation at engagement workshops, and peer review of documents emerging from the consultation. Outcomes of these HIAs The outcomes achieved by the HIAs can be broadly categorised into the effectiveness domains of opportunistically, generally and directly effective. These are summarised in the table below, along with the focus areas of each HIA and the key outcomes achieved. HIACore areas of focusOutcomes achievedCategorisation of effectivenessPapakura (2007-08)Community cohesion Service access WalkabilityAwareness raising and cross-sectoral dialogue on interface between urban form and health Identification of issues for vulnerable population groups Raising profile of Mori history and interests in area Alliance building between local government and district health board on service planning Direct (initially)/General Auckland Regional Land Transport Strategy (2008-09)Emissions Safety Access and mobility Active transport Whnau ora aspirationsAwareness raising and cross-sectoral dialogue on interface between urban form and health Identification of issues for vulnerable population groups Engagement of elected representatives Engaging Mori stakeholders in identifying issues and directions to enhance whnau ora through the strategyOpportunistic / General Manukau Built Form and Spatial Structure Plan (2008-09)Active transport Access, Liveability and vitality Safety Whnau ora aspirationsAwareness raising and cross-sectoral dialogue on interface between urban form and health Identification of issues for vulnerable population groups Engagement of elected representatives Informing forward work programmes in urban design Engaging Mori stakeholders in identifying issues and directions to enhance whnau ora through the strategy Enhanced appreciation of Mori world views and application to urban development General/DirectWiri Spatial Structure Plan (2010)Access Housing Safety Economic potential Whnau ora aspirationsAwareness raising and cross-sectoral dialogue on interface between urban form and health Identification of issues for vulnerable population groups Engagement of elected representatives Informing and modifying forward work programmes in urban design Engaging Mori stakeholders in identifying issues and directions to enhance whnau ora through the strategy Enhanced appreciation of Mori world views and application to urban developmentDirect The substantive outcomes of each HIA include the following: Broader understanding of dimensions of health and wellbeing, and their linkages with urban and transport planning: All four HIAs were effective in raising awareness and HIA capability in each of the local government organisations of the links between planning and health, and provided a platform for identifying common perspectives and more informed dialogue. For those from health agencies, the engagement also raised awareness of the alignment between modern thinking in urban design, and core public health approaches. Understanding of equity issues: The HIAs were all able to identify key populations groups likely to be most adversely affected by the proposals, and to develop solutions that focused on their needs and concerns. Developing recommendations to take HIA forward: All four HIAs adopted a systems-oriented approach to collaboratively engage stakeholders in actively identifying directions forward, alongside establishing potential impacts. Engagement and support of elected councillors: Three of the HIAs (Wiri, Manukau and Auckland Regional Transport Strategy) were presented directly to councillors and obtained broad endorsement of the approach taken. Informing forward planning: Both of the HIAs that focused on spatial structure plans had a direct influence in terms of informing ongoing work occurring through each plan. One provided a health orientation that informed a subsequent public domain manual. The second fed into a reappraisal of urban design efforts within the Wiri community, to include landscape design that reflects local cultures; mixture of land uses; improvements in safe pedestrian areas; and to consider in more detail the use, location and size of commercial and community facilities, and the orientation of housing to ensure warm, healthy living environments. Articulating Mori cultural and social wellbeing aspirations: All four HIAs gave voice to Mori health and wellbeing concerns, and in some cases, were able to provide a voice into planning that had not been previously provided to the same degree. The alliance between Synergia and Hapai te Hauora Tapui in leading whnau ora HIA in three of these HIAs fostered Mori significant input to the process. In particular, there was an appreciation of Mori world views and their relevance and value to modern planning processes. Foundation for ongoing dialogue: Each HIA fostered closer links between health interests/advocates, and planners from urban design and transport, some of which have been sustained. Local alliance-building: The Papakura housing development HIA achieved some initial direct influence in terms of a broad partnership across the district health board, district council and developer, with a view to developing joint planning for primary health care services around the planned new housing area, and developing community orientation programmes and resources for new residents in the planned suburb. However, the subsequent delays in construction (substantially due to the 2008 financial crisis and recession) saw this alliance lose momentum. In other areas, the influence of the HIAs were more limited. As noted above, the impact of the Papakura housing HIA was significantly constrained by the economic environment that unfolded later that year, which at the time of writing, continues to delay construction. In another example, the Auckland Regional Land Transport Strategy HIA was praised by the councillors and stakeholders when it was tabled, but the net effect of the HIA on the content of the strategy is unclear, and general or even opportunistic effectiveness is likely. The HIA validated some of the established directions of the strategy (such as active and public transport modes), but some of the more challenging directions of the HIA (such as promoting whole of journey approaches for the transport disadvantaged) were not picked up to the same degree. Achieving Influence: Reflections for practice A common concern among advocates of HIA is how to establish these processes more systematically. However, a more fundamental concern is how to ensure that HIAs are able to constructively achieve influence. From these four examples, the following factors appeared to be important determinants of influence: Organisational commitment, and in particular, the active involvement of an advocate for HIA who was able to gain the buy-in of his or her own organisation, and other organisations to participate. A foundation in the published research and evidence base, to give validity to the recommendations that emerged. Early engagement with key staff members across stakeholder organisations, with people who were directly involved in the drafting and development of plans and strategies, so that the HIA could be woven as a part of the overall project/policy development process. The strength of the engagement process that gave a broad range of sectors, communities and interest groups an avenue for participation in local or regional planning through the HIA, and which was able to be communicated to senior and representative levels in council organisations. Involvement of Mori organisations and communities through whnau ora HIA was seen by many to provide a  value add that other engagement processes lacked. A determination across all four HIAs that the engagement process would be driven as much by developing directions forward as it was in identifying impacts; this gave the HIA participants a tangible future focus from the HIA that helped maintain interest and visibility; and allowed the recommendations from the HIA process to be validated by those participating. A home for the HIA recommendations so that they can be monitored and incorporated into future planning. Of note in the Wiri HIA was the shift in the role of consultant as leader and writer, to active supporter of internal HIA capacity. In this case, we gave support to a capable operator inside an organisation who was in a strong position to mobilise organisational action. This approach we have repeated across HIAs in the Waikato and Canterbury regions (Environment Canterbury et al 2010, Environment Waikato & Population Health Waikato 2010), and the outcomes in each have been highly engaged health and local government lead organisations that have established a stake in the longer-term success of the HIA. A key challenge is organisational change. The last three years have seen significant retrenchment in the public sector in New Zealand nationally; and in the last 12 months, the seven local authorities in the Auckland region have been amalgamated into a single Auckland Council. In some instances, the personal relationships that were developed between health and local/regional government have been lost through the substantial organisational restructuring that has occurred. It is notable however, that the city council health advocate who led the Wiri HIA has been appointed to a similar role in Auckland Council, and is now working as a catalyst for health and wellbeing assessment activity across areas of policy and strategy. There is a tension between the potential effectiveness of HIAs on localised projects, versus regionalised or national strategies and policies. It can be argued that a HIA focused on a single urban planning project may have less influence than a HIA that seeks to intervene in the broader strategic and policy frameworks that drive project design and development. However, our experience in these four HIAs is that both project and policy/strategy HIAs were able to elicit constructive engagement across multiple levels of the participating organisations and communities. In the Wiri case, the role of the council officer leading the HIA provided a foundation for further HIA activity, which is currently extending into new policy areas. This may suggest that where a project is seen to have wider ramifications for practice across an organisation, an HIA may be in a stronger position to achieve influence. As researchers and consultants, we are accustomed to being commissioned to undertake discrete assignments, with a common end product of a report that a client may or may not choose to implement. In some respects, HIAs are suited to such a process, with clear phases of development and implementation, and an actionable set of recommendations for consideration by decision makers. Yet, if a HIA is to achieve influence, a distant process of expert facilitator, advisor or writer, may have only limited impacts if the agents of change are not effectively engaged in the process, and do not feel that they own the outcomes of the process. Achieving influence in HIA may therefore significantly depend on the recruitment of capable and enthusiastic people who can advance HIAs internally, supported by HIA capacity building initiatives. The advantage offered by agency-led HIAs is the potential to obtain organisational-wide buy-in to the HIA outcomes; to support a transition from local-level projects to broader upstream policy and strategic processes; and in particular, to weave HIA processes within the development of key policies and strategies. Conclusion The outcomes and learnings from these HIAs echo those of other research published in the field, which gives support to HIAs as catalysts for cross-sectoral dialogue and alliance-building, and influencers of change in policy and planning. A common outcome of HIAs focusing on urban form issues is to provide a forum through which people can ask how 5@kuv< \ u v w x  + : TUu`DCD޳ެvvvhG.mHnHu h'>`hG.hG.hG.B* phI}hG.hG.5B* phI}jhG.0JUhG. h}hG.hWhG.B* H*\phI}hWhG.56B* \phI}hWhG.B* H*phI}hWhG.B* phI}hG.5B* phI}hWhG.5B* phI}.vww x bcEF/0 jo  & F^gdwZ@&gdwZgdwZ fgiknp3jmnoes RT!(!""""##%B&&&' ''''''' (Y(((E)U)*o*h}hG.mHnHuhG.mHnHujhG.0JUhG.hG.5B* phI} hWhG. h(hG.hG. h}hG.Jlmmmnors##C&D&F)G)(,@&gdwZ  & F^gdwZgdwZo*****(,M-N-5/6/M/T0000004363366&76;8;~;t?v??l@B#BBCCCCCDȯȠ||||toggogh0hG.5 hG.5hghG.5hG.h]CJaJhG.hG.CJaJhG.hG.5CJ\aJhG.h]B* CJaJphI}0jhG.hG.0J5B* CJU\aJphI}#hG.hG.5B* CJ\aJphI}hG.hG.5B* phI} hWhG. h}hG.hG. h'hG.&(,{,,$-M-N-5/6/M/N/Q0R0S0T0X0l0~00 <$IfgdG.@&gdwZgdwZ  & F^gdwZ000000:1t1H22_TTTTTTTT <$IfgdG.kd$$Ifl\f5&3 t0OOOOOOl(OOOOOOOOOOOOOOOO44 la5ytG. 2436333$kd$$Ifl\f5&3  t(0OOOOOOl(OOOOOOOOOOOOOOOO44 la5p(ytG. <$IfgdG.333 4844^5566 <$IfgdG. 66&7H7Z7777z88_TTTTTTTT <$IfgdG.kd $$Ifl\f5&3 t0OOOOOOl(OOOOOOOOOOOOOOOO44 la5ytG. 8:99v:;6; <$IfgdG.6;8;~;;;/$$$ <$IfgdG.kd$$Ifl\f5&3  t(0OOOOOOl(OOOOOOOOOOOOOOOO44 la5p(ytG.;;;;X<<<<>f?t? <$IfgdG. t?v?x?z?|?~??BB_ZZZZZNN  & F^gdwZgdwZkd $$Ifl\f5&3 t0OOOOOOl(OOOOOOOOOOOOOOOO44 la5ytG.BCD GKLNNOORRKRLRSSSCTTUWXZD[E[]  & F^gdwZ@&gdwZgdwZ  & F^gdwZDDDDE G G^HKL(LLLNNRKRLR~SSD[E[[\'\R\\\``dPfffRgSgTghhhi$%ȑ̑ƿƛƿhG.hG.aJmHnHuhG.hG.B* phI}U hWhG.hG.mHnHu h!hG. h}hG.hG.hG.5B* phI} hBDhG. htkhG. hG.5hG. hghG.hghG.5 h0hG.1]]``ddSgTghhhhhi%&đƑȑʑ̑I0x^`0gdG.@&gdwZgdwZcommunities will come to life, and in so doing, provide a reference point for concerns and aspirations. However, to go beyond providing a starting point for change and to genuinely achieve influence, the experience of these HIAs show that they must not only be methodologically robust, they must also be grounded in organisational commitment; foster internal HIA capability; provide a breadth of stakeholder involvement; and engage people internally within organisations to act as champions of the process and agents for change. Acknowledgements The authors wish to acknowledge the Auckland Regional Public Health Service, Auckland Regional Council, Ministry of Health, Counties Manukau District Health Board and Manukau City Council, who acted as catalysts for the HIAs profiled in this report, either as funders or as lead advocates for their initiation. Our particular thanks are extended to our partners at Hapai te Hauora Tapui Ltd, who brought whnau ora aspirations to life in three of these HIAs. Grateful thanks are also extended to the many people who took part in the HIAs from local government, communities, non-governmental organisations and government agencies. References Birley M. 2011. Health Impact Assessment: Principles and Practice. London: Earthscan. Commonwealth Department of Health and Ageing. 2001. Health Impact Assessment Guidelines. Canberra: Commonwealth Department of Health and Ageing. Durie M. 1999. Te Pae Mahutonga: a model for Mori health promotion. Health Promotion Forum of New Zealand Newsletter December 1999 Environment Canterbury, Canterbury District Health Board, Christchurch City Council. 2010. Health and Wellbeing Impact Assessment: Canterbury Regional Land Transport Strategy, Environment Canterbury, Christchurch Environment Waikato, Population Health Waikato. 2010. Waikato Regional Land Transport Strategy Review (2009/10) Health Impact Assessment Appraisal Report, Environment Waikato, Hamilton Field A, Dale-Gandar L, Tunks M, Arcus K. 2009. Manukau Built Form and Spatial Structure Plan Health Impact Assessment. Auckland: Synergia Ltd Field A, Shepheard M. 2008. McLennan Health Impact Assessment: Appraisal Report, Synergia Ltd, Auckland Harris-Roxas B, Harris E. 2011. Differing Forms, Differing Purposes: A Typology of Health Impact Assessment. Environmental Impact Assessment Review 31: 396-403 Harris P, Harris-Roxas B, Harris E, Kemp L. 2007. Health Impact Assessment: A Practical Guide. Sydney: Centre for Health Equity Training, Research and Evaluation (CHETRE), University of New South Wales. Health Development Agency. 2002. Introducing health impact assessment (HIA): Informing the decision-making process, Health Development Agency, London Kemm J, Parry J, Palmer S, eds. 2004. Health Impact Assessment: Concepts, Theory, Techniques and Applications. Oxford: Oxford Medical Publications. Manukau City Council. 2010. Wiri Spatial Structure Plan Health Impact Assessment, Manukau City Council, Manukau Ministry of Health. 2007. Whanau Ora Health Impact Assessment. Wellington: Ministry of Health. Public Health Advisory Committee. 2004. A Guide to Health Impact Assessment: A Policy Tool for New Zealand. Wellington: National Health Committee. Public Health Advisory Committee. 2007. An Idea Whose Time Has Come: Opportunities for Health Impact Assessments in New Zealand. Wellington: National Health Committee. Veerman JL, Mackenbach JP, Barendregt JJ. 2007. Validity of predictions in health impact assessment. Journal of Epidemiology & Community Health 61: 362-66 Wismar M, Blau J, Ernst K. 2007. Is HIA effective? A synthesis of concepts, methodologies and results In The Effectiveness of Health Impact Assessment: Scope and limitations of supporting decision-making in Europe3} 0Io٘KjU pq(*,dfhlnrtxz~̽hWhwZCJjhwZUhwZ hG.0J-hG.jhG.0JUhG.hG.CJPJhG.hG.CJjhG.hG.0JCJUhG.h|aaJUhG.aJmHnHuhG.hG.aJmHnHuhG.hG.6aJmHnHu.Iے,tܗ|HޙrB֛Xq*dfjlpgdG.gdwZxgdG.0x^`0gdG., ed. M Wismar, J Blau, K Ernst, J Figueras. WHO Regional Office for Europe: Copenhagen World Health Organization. 1999. Health Impact Assessment: Main concepts and suggested approach (Gothenburg Consensus Paper), European Centre for Health Policy, Brussels  The views presented in this paper are those of the authors rather than of the organisations they represent.  Whnau ora is defined in He Korowai Oranga (Mori Health Strategy) as Mori families being supported to achieve their maximum health and wellbeing.  Based on Wismar et al 2007     Page |  PAGE \* MERGEFORMAT 1  prvx|~ħƧȧ̧ΧЧҧxgdG."gdwZ$gdwZ$$a$gdwZgdG. §ħȧʧЧҧhG.h|aaJjhG.UmHnHuhwZh]CJmHnHuhWhwZCJjhWhwZCJU 21h:pwZ. A!"#$% n@CIkL2&:qPNG  IHDRiR sRGB@VIDATx^{WřcȂ Aa𮁘h%1I6oVdlULf+TfF/1QJ@DE0 "0\@0WowΥ>|) <>}9x@|"A@ .   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