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Public Health : Easier Decision Making

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Health Impact Assessment Program
Health impact assessment (HIA) is defined as a combination of tools, methods and procedures that are used for the evaluation of the potential effects of health of a project, program or policy. Using the techniques of participatory, quantitative and qualitative, the program aims to produce the recommendations that help the stakeholders and the decision makers to make the choices about the improvements and alternatives for the prevention of injury and diseases and promote active health (Winkler et al. 2013). The topic of the health impact assignment program for this assignment will be a population-based prevention program of childhood obesity. The program will be named as Healthy Kids (HK) program and will be carried out in New South Wales (NSW) and will be delivered to the non-aboriginal and aboriginal children of Australia. Childhood obesity is a growing health concern globally and in Australia, one out of four children is found to be either obese or overweight. This has been my topic of interest as obesity in children reduces their psychological well-being and can bring about physical deterioration that includes cardiovascular diseases, breathlessness and sleep apnea. Therefore, it is essential to focus on this growing concern and therefore, this health impact assessment program will analyze the problem and recommend on its prevention.
Childhood obesity is the condition where excessive body fat gets accumulated at an early age. Healthy lifestyle can be of great benefits to the children regarding their wellbeing and heath and prevent them from acquiring childhood obesity (Karnik and Kanekar 2015). In the past 30 years, childhood obesity has increased by two folds and the percentages of children who are aged 6-11 years have increased from 7% to 18% from 1980 to 2014 (Campbell et al. 2013). Childhood obesity is a result of caloric imbalance where little amount of calories are expended against the greater amount of calories consumed. This is affected by the environmental, behavioral and genetic factors. Childhood obesity can have immediate and long-term health effects. The immediate effects include pre-diabetes condition with elevated blood glucose levels and the long-term health effects appear when they grow up into obese adults. In Australia, the rates of childhood obesity are higher among the indigenous and aboriginal children compared to the non-indigenous Australians. This brings about a negative impact on their health and therefore, this widens the gap in life expectancy between the two types of children. In the year 2012 – 2013, 30% of the children of the Aboriginal and Torres Strait Islanders who were aged between 2 to 14 years were found to be obese with regards to their respective BMI. The rates of obesity among the aboriginal girls and boys were found to be 32% and 29% respectively (Hendrie, Coveney and Cox 2012). The government of NSW developed a program named ‘Prevention of Obesity in Children and Young People: NSW government action plan’ and it was found that the prevention policy is still in its infancy and is facing remarkable challenges in delivering the complex changes that are essential in achieving the positive outcomes (Dooyema et al. 2013). However, the policy has built sufficient support and commitment to creating the momentum for strategic policies in future. The current health policy of NSW directs new policies and strategies that have an impact on the health within the communities of the aboriginals and can be subjected to a health impact statement of the aboriginals. The statement is used for ensuring that the health needs of the communities of the aboriginals are integrated and considered during the development of the policies and programs through the encouragement of negotiation and consultation with the Aboriginal people (Kim et al. 2016). Since the HK program addressed these vital issues through the intensive community and HIA consultation project, an agreement was developed with the health branch of the aboriginals so that a health impact statement of the aboriginals was not required. The indicators of good health were found to be lower in the communities of the aboriginals in NSW when compared to their non-aboriginal counterparts. The HK program aimed to address this disparity and therefore, developed several strategies for closing this gap and helping the aboriginal children to stay active and eat well in alignment with the non-aboriginal children. It was commented by the Prime Minister Mr. Tony Abbott in 2014 that the effort to close the gaps was very much disappointing and sufficient direction is required to bring about the positive outcomes (Browne-Yung et al. 2013). According to a study conducted by Lacy et al. (2012), the monitoring of childhood obesity is poorly carried out in Australia. It is a fundamental component of the prevention of obesity and provides essential population health data for tracking the trends over time and identifies the areas that are at the greater obesity risk. The authors have recommended that the authority should collect the weight and height measurements by using the opt-out consent for monitoring the childhood obesity rates in Australia.

Figure 1: Childhood Obesity in Australia
Source: Hayes et al. 92016)
The process of screening determines whether the HIA is required or appropriate. Screening assures that resources, effort and time are appropriately targeted. The screening process is carried out to determine whether or not a policy or program have significant impacts on health for warranting the completion of a program of HIA. The process of screening establishes whether or not a particular project, program or policy has a profound impact on health. It determines how policy affects the health of the populations of the vulnerable sections and the scale and direction of the health impacts and measures whether they are speculative, serious or negligible (Harris-Roxas et al. 2012). The screening process identifies whether the effects are long term or short term and indirect or direct and inquires whether there is a requirement for more detailed assessment. The screening process ensures if HIA is the best possible method for effectively addressing the equity and health issues. Although HK program was aimed at conducting on both the aboriginal and non-aboriginal children, it focused on the aboriginal children more as they are the ones who require the attention more than the non-aboriginal children to tackle childhood obesity (Badland et al. 2014). Therefore, the deliberate focus of the program was to the Aboriginal children and the step of screening included focusing on the potential impacts on the health of the aboriginals. The screening process for the HK program was carried out by forming a screening team that consisted of three staff members from an institute of health equity training, evaluation and research and one employee of the department of health of the local health body. An additional panel of experts of nine members was recruited for undertaking the assessment steps of the HIA. All of them were experienced in the process of conducting HIA. The members of the expert panel had expertise in policy analysis, chronic disease prevention, health promotion, early intervention and health equity. The panel identified that the existing processes of HIA requires modifying and reviewing to suit the program needs. An appropriate model of health was selected that included the community health with the environmental and social connection of the individual health. The ‘National Obesity Task Force’ model was selected and combining its framework with the literature provided by the institute of health, a tool was developed for facilitating the screening (Bacelar-Nicolau, Miguel and Saporta 2015). The tool was designed as survey questionnaires that consisted of closed-ended question which can be answered with yes or no. The outcome of the screening process was assessed by analyzing the responses of the screening tool and it was found that HK program could produce negative or positive impacts on the health of the children. From the process, it was identified that the program should be carried out with the further steps of the HIA and the tools have to be modified for suiting the context of Australian   Aboriginal children. A lengthy discussion was not possible with the children as time did not permit but the importance of the discussion was highlighted and employment of Aboriginal stakeholders was encouraged.
Table 1: Survey Questionnaires of the Tool

Is the potential for the impacts of positive health affecting the health determinants of the aboriginal children who are aged 0 to 14 years?
Do the potential effects have serious negative impacts on health?
Do the negative impacts have the ability to increase the existing inequalities in health between the non-indigenous and indigenous people?
Is the proposed HIA program impacting the cultural, mental, spiritual and emotional health and well-being?

The scope of the HIA was designed for the identification of the type of HIA to be undertaken and when and how it has to be implemented. The scoping process included the designing and planning of the HIA by setting out its various parameters. A thorough step of scoping saves considerable resources, work and time in the rest of the steps and therefore, is regarded as the key step (McCallum, Ollson and Stefanovic 2016). In the broader context of the HK program, an extensive process of consultation with the targeted communities of the aboriginals was conducted at the same time along with the HIA. This project of consultation was framed for allowing the aboriginal communities to have their views and inputs in the implementation and further modification of the HK program and express their opinions on the existing strategies of the program (Delany et al. 2014). With this stakeholder-community participation in the designing of the program, a separate process for community consultation was not carried out. A standard community profiling exercise was undertaken as the indicators of the socio-economic status of the aboriginal communities have a holistic view of the entire community (Haigh et al. 2015). It was found that the literature and evidence on the effectiveness of the interventions of physical activity and nutrition for the aboriginal children were limited. Therefore, the working party members of HK agreed to comment on the impacts of the program including their collective experience in the process of delivering the programs to the Aboriginal children. The working party members were aboriginal people and possess experience of working in the community and government agencies and their personal experiences on the knowledge and experiences of the Aboriginal communities. The working party consisted of four cluster coordinators of the Aboriginal health of NSW, the CEO of the medical service of the aboriginals, the coordinator of the health programs of the Aboriginal medical service and the program manager of the Aboriginal health of NSW. It also included the aboriginal educational consultants and advisor with the project coordinator and officer of indigenous health. The members of the working party also included the staff members of the HK and the aboriginal development officer of NSW. The HIA of HK was carried out as a workshop of two days that was facilitated jointly by the representative of the aboriginal health of NSW and the staff members of HK. During the workshop, the settings and streams of the program were detailed and summarized by the staff of the working party as part of the introduction. This was followed by the discussion of the various stream strategies. From the group discussion, primary data was collected for the potential effectiveness of the program and its strategy to benefit the aboriginal children by equally reaching them in the program setting. The discussion tried to identify the mission of the stream and its potential and known health impacts. It was discussed whether the aboriginal children would face any sort of disadvantage by the initiative with unanticipated and inequitable impacts. The final area was the key recommendations for the implementation. Analysis of the collected data framed the recommendations of the program for amending the existing strategies for making them more suitable and new strategies were developed by identifying gaps in the existing strategies (Hirono et al. 2016). The estimated budget of the project was AUS$ 500,000 and the source of funding was the NSW health boards and the stakeholders. The estimated duration of the project was four years.
Several impacts were identified from the discussion which was both negative and positive. The positive impact was definite with significant scales for the fact that the HK program was well placed for getting added to the evidence base for the childhood obesity and overweight rates in the communities of the aboriginals. Since the agenda of Aboriginal health is already overcrowded, the HK program has to be made a priority as it included the obesity and overweight management of the Aboriginal children that do not have sufficient data (Jandu et al. 2015). This will raise awareness regarding the health problems that are associated with childhood overweight and obesity and will generate accurate data for reporting the actual situation of the Aboriginal communities in NSW. The negative impact of the HK program was probable and the scale was minimal as the aboriginal people had a lower range of socio-economic status and therefore, it was unclear whether the interventions of the program would place an extra financial burden on the families. Since the aboriginal family models were similar to the extended family, therefore the strategies and objectives of the individual streams have to be different from the nuclear family models for engaging all the family members as carers of the aboriginal children.
Several factors are responsible for limiting the effectiveness of the HK program. The first limitation of the program is the resistance by the government as every government has its primary objectives like environment, agriculture and transport. Health becomes the secondary objective and if it is the health of the Aboriginal children, it will get a setback (Birley 2013). The government of NSW is likely to place the program at the second place for its implementation. The Aboriginal medical services have limited funds and resources that can act as a limitation for the effectiveness of the HIA. Since the government placed health as a secondary priority, grant of funds was also shifted back. As this type HIA is new to the state, therefore skilled professionals are not available for carrying out the work responsibilities and as the aboriginals were also included in the program, they have to be trained appropriately for effective implementation. Sufficient data are unavailable for childhood obesity prevention program in NSW, therefore there is a lack of access to the essential data like community profiling data that is essential for developing strategies (Haigh et al. 2013). Within a short phase of time, the program has to be implemented and all these factors are collectively responsible for limiting the effectiveness of the HK program.
The monitoring of the HK program will be done at every step of its implementation and the evaluation will be done on an annual basis. Assessment of the adoption of the recommendations whether they have resulted in quantifiable outcomes of health will be evaluated along with the accuracy of the predictions of health with the assumptions for the recommendations. It will be evaluated annually whether there has been a change in the lifestyle of the aboriginal children regarding their eating habits and whether there has been a decrease in the occurrence of obesity among the children. The long-term outcomes of health will also be evaluated after the completion of the program.
The findings of the program would be presented in the form of a written report to the department of health of NSW and a copy to the federal government. A power point presentation will also be delivered to the government delegates and stakeholders of the HIA and the report will be discussed to advocate the changes associate with childhood obesity in Australia. The positive impact of the program will be enhanced by implementing various methods of increasing awareness for a healthy lifestyle along with individual counseling of the obese children. The negative impacts can be mitigated by providing financial support to the Aboriginal communities to provide a healthy diet to their children (Pope et al. 2013).
From the unit, I gained elaborate knowledge about the aboriginal community and their social determinants of health that leads to the unhealthy life of their children. These strategies, skills and contacts can help me in improving the equity by which the program was targeted to the non-aboriginal and aboriginal children. The program has been better positioned for meeting the needs of the aboriginal children without increasing the inequalities in their health status. Similar programs can be implemented in future for prevention of adolescent and adult obesity in Australia as it is a current issue that is pertinent to the HIA program.
Bacelar-Nicolau, L., Miguel, J.P. and Saporta, G., 2015. Screening Policies for Health Impact Assessment: cluster analysis for easier decision making.European Journal of Public Health, 25(suppl 3), pp.ckv171-014.
Badland, H., Whitzman, C., Lowe, M., Davern, M., Aye, L., Butterworth, I., Hes, D. and Giles-Corti, B., 2014. Urban liveability: emerging lessons from Australia for exploring the potential for indicators to measure the social determinants of health. Social Science & Medicine, 111, pp.64-73.
Birley, M., 2013. Health impact assessment: Principles and practice. Routledge.
Browne-Yung, K., Ziersch, A., Baum, F. and Gallaher, G., 2013. Aboriginal Australians’ experience of social capital and its relevance to health and wellbeing in urban settings. Social Science & Medicine, 97, pp.20-28.
Campbell, M., Bryson, H.E., Price, A.M. and Wake, M., 2013. Childhood obesity in secondary care: National prospective audit of Australian pediatric practice. Academic pediatrics, 13(2), pp.168-176.
Delany, T., Harris, P., Williams, C., Harris, E., Baum, F., Lawless, A., Wildgoose, D., Haigh, F., MacDougall, C., Broderick, D. and Kickbusch, I., 2014. Health impact assessment in New South Wales & Health in all policies in south Australia: Differences, similarities and connections. BMC public health, 14(1), p.1.
Dooyema, C.A., Belay, B., Foltz, J.L., Williams, N. and Blanck, H.M., 2013. The childhood obesity research demonstration project: A comprehensive community approach to reduce childhood obesity. Childhood Obesity, 9(5), pp.454-459.
Haigh, F., Baum, F., Dannenberg, A.L., Harris, M.F., Harris-Roxas, B., Keleher, H., Kemp, L., Morgan, R., Chok, H.N., Spickett, J. and Harris, E., 2013. The effectiveness of health impact assessment in influencing decision-making in Australia and New Zealand 2005–2009. BMC public health, 13(1), p.1.
Haigh, F., Harris, E., Harris-Roxas, B., Baum, F., Dannenberg, A.L., Harris, M.F., Keleher, H., Kemp, L., Morgan, R., Chok, H.N. and Spickett, J., 2015. What makes health impact assessments successful? Factors contributing to effectiveness in Australia and New Zealand. BMC public health, 15(1), p.1.
Harris-Roxas, B., Viliani, F., Bond, A., Cave, B., Divall, M., Furu, P., Harris, P., Soeberg, M., Wernham, A. and Winkler, M., 2012. Health impact assessment: the state of the art. Impact Assessment and Project Appraisal,30(1), pp.43-52.
Hayes, A., Chevalier, A., D’Souza, M., Baur, L., Wen, L.M. and Simpson, J., 2016. Early childhood obesity: Association with healthcare expenditure in Australia. Obesity, 24(8), pp.1752-1758.
Hendrie, G.A., Coveney, J. and Cox, D.N., 2012. Defining the complexity of childhood obesity and related behaviours within the family environment using structural equation modelling. Public health nutrition, 15(01), pp.48-57.
Hirono, K., Haigh, F., Gleeson, D., Harris, P., Thow, A.M. and Friel, S., 2016. Is health impact assessment useful in the context of trade negotiations? A case study of the Trans Pacific Partnership Agreement. BMJ open, 6(4), p.e010339.
Jandu, M.B., de Medeiros, B.C., Bourgeault, I. and Tugwell, P., 2015. The inclusion of migrants in health impact assessments: A scoping review.Environmental Impact Assessment Review, 50, pp.16-24.
Karnik, S. and Kanekar, A., 2015. Childhood obesity: a global public health crisis. Int J Prev Med, 2012. 3 (1), pp.1-7.
Kim, S., Macaskill, P., Baur, L.A., Hodson, E.M., Daylight, J., Williams, R., Kearns, R., Vukasin, N., Lyle, D.M. and Craig, J.C., 2016. The differential effect of socio-economic status, birth weight and gender on body mass index in Australian Aboriginal Children. International Journal of Obesity.
Lacy, K., Kremer, P., Silva‐Sanigorski, A., Allender, S., Leslie, E., Jones, L., Fornaro, S. and Swinburn, B., 2012. The appropriateness of opt‐out consent for monitoring childhood obesity in Australia. Pediatric obesity, 7(5), pp.e62-e67.
McCallum, L., Ollson, C. and Stefanovic, I., 2016. Prioritizing health: a systematic approach to scoping determinants in health impact assessment.Frontiers in Public Health, 4, p.170.
Pope, J., Bond, A., Morrison-Saunders, A. and Retief, F., 2013. Advancing the theory and practice of impact assessment: setting the research agenda.Environmental Impact Assessment Review, 41, pp.1-9.
Winkler, M.S., Krieger, G.R., Divall, M.J., Cissé, G., Wielga, M., Singer, B.H., Tanner, M. and Utzinger, J., 2013. Untapped potential of health impact assessment. Bulletin of the World Health Organization, 91(4), pp.298-305.

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