Institutionalizing health impact assessment in London as a public health tool for increasing synergy between policies in other areas

Objectives: To describe the background to the inclusion of health impact assessment (HIA) in the development process for the London mayoral strategies, the HIA processes developed, how these evolved, and the role of HIA in identifying synergies between and conflicting priorities of different strategies.Study design: Case series.Methods: Early HIAs had just a few weeks for the whole HIA process. A rapid appraisal approach was developed. Stages included: scoping, reviewing published evidence, a stakeholder workshop, drafting a report, review of the report by the London Health Commission, and submission of the final report to the Mayor. The process evolved as more assessments were conducted. More recently, an integrated impact assessment (IIA) method has been developed that fuses the key aspects of this HIA method with sustainability assessment, strategic environmental assessment and equalities assessment.Results: Whilst some of the early strategy drafts encompassed some elements of health, health was not a priority. Conducting HIAs was important both to ensure that the strategies reflected health concerns and to raise awareness about health and its determinants within the Greater London Authority (GLA). HIA recommendations were useful for identifying synergies and conflicts between strategies. HIA can be successfully integrated into other impact assessment processes.Conclusions: The HIAs ensured that health became more integral to the strategies and increased understanding of determinants of health and how the GLA impacts on health and health inequalities. Inclusion of HIA within IIA ensures that health and health inequalities impacts are considered robustly within statutory impact assessments. (C) 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved

Community severance and health: what do we actually know?

Community severance occurs where road traffic (speed or volume) inhibits access to goods, services, or people. Appleyard and Lintell's seminal study of residents of three urban streets in San Francisco found an inverse relationship between traffic and social contacts. The extent of social networks predicts unhealthy behaviors, poor health, and mortality; high rather than low social integration is associated with reduced mortality, with an effect size of similar magnitude to stopping smoking. Although community severance diminishes social contacts, the implications of community severance for morbidity and mortality have not been empirically established. Based on a systematic literature search, we discuss what is actually known about community severance. There is empirical evidence that traffic speed and volume reduces physical activity, social contacts, children's play, and access to goods and services. However, no studies have investigated mental or physical health outcomes in relation to community severance. While not designed specifically to do so, recent developments in road design may also ameliorate community severance

Income-based inequalities in self-reported moderate-to-vigorous physical activity among adolescents in England and the USA: a cross-sectional study

Objective: Quantify income-based inequalities in self-reported moderate-to-vigorous physical activity (MVPA) in England and the USA by sex. Design: Population-based cross-sectional study. Participants: 4019 adolescents aged 11–15 years in England (Health Survey for England 2008, 2012, 2015) and 4312 aged 12–17 years in the US (National Health and Nutrition Examination Survey 2007–2016). / Main outcome measures: Three aspects of MVPA: (1) doing any, (2) average min/day (MVPA: including those who did none) and (3) average min/day conditional on participation (MVPA active). Using hurdle models, inequalities were quantified using the absolute difference in marginal means (average marginal effects). / Results: In England, adolescents in high-income households were more likely than those in low-income households to have done any formal sports/exercise in the last 7 days (boys: 11%; 95% CI 4% to 17%; girls: 13%; 95% CI 6% to 20%); girls in high-income households did more than their low-income counterparts (MVPA: 6 min/day, 95% CI 2 to 9). Girls in low-income households spent more time in informal activities than girls in high-income households (MVPA: 21 min/day; 95% CI 10 to 33), while boys in low-income versus high-income households spent longer in active travel (MVPA: 21 min/week; 95% CI 8 to 34). In the USA, in a typical week, recreational activity was greater among high-income versus low-income households (boys: 15 min/day; 95% CI 6 to 24; girls: 19 min/day; 95% CI 12 to 27). In contrast, adolescents in low-income versus high-income households were more likely to travel actively (boys: 11%; 95% CI 3% to 19%; girls: 10%; 95% CI 3% to 17%) and do more. / Conclusions: Policy actions and interventions are required to increase MVPA across all income groups in England and the USA. Differences in formal sports/exercise (England) and recreational (USA) activities suggest that additional efforts are required to reduce inequalities

Inequalities in participation and time spent in moderate-to-vigorous physical activity: a pooled analysis of the cross-sectional health surveys for England 2008, 2012, and 2016

BACKGROUND Evidence is unclear on whether inequalities in average levels of moderate-to-vigorous physical activity (MVPA) reflect differences in participation, differences in the amount of time spent active, or both. Using self-reported data from 24,882 adults (Health Survey for England 2008, 2012, 2016), we examined gender-specific inequalities in these separate aspects for total and domain-specific MVPA. METHODS Hurdle models accommodate continuous data with excess zeros and positive skewness. Such models were used to assess differences between income groups in three aspects: (1) the probability of doing any MVPA, (2) the average hours/week spent in MVPA, and (3) the average hours/week spent in MVPA conditional on participation (MVPA-active). Inequalities were summarised on the absolute scale using average marginal effects (AMEs) after confounder adjustment. RESULTS Inequalities were robust to adjustment in each aspect for total MVPA and for sports/exercise. Differences between adults in high-income versus low-income households in sports/exercise MVPA were 2.2 h/week among men (95% confidence interval (CI): 1.6, 2.8) and 1.7 h/week among women (95% CI: 1.3, 2.1); differences in sports/exercise MVPA-active were 1.3 h/week (95% CI: 0.4, 2.1) and 1.0 h/week (95% CI: 0.5, 1.6) for men and women, respectively. Heterogeneity in associations was evident for the other domains. For example, adults in high-income versus low-income households were more likely to do any walking (men: 13.0% (95% CI: 10.3, 15.8%); women: 10.2% (95% CI: 7.6, 12.8%)). Among all adults (including those who did no walking), the average hours/week spent walking showed no difference by income. Among those who did any walking, adults in high-income versus low-income households walked on average 1 h/week less (men: − 0.9 h/week (95% CI: − 1.7, − 0.2); women: − 1.0 h/week (95% CI: − 1.7, − 0.2)). CONCLUSIONS Participation and the amount of time that adults spend in MVPA typically favours those in high-income households. Monitoring inequalities in MVPA requires assessing different aspects of the distribution within each domain. Reducing inequalities in sports/exercise requires policy actions and interventions to move adults in low-income households from inactivity to activity, and to enable those already active to do more. Measures to promote walking should focus efforts on reducing the sizeable income gap in the propensity to do any walking

A review of the use of health examination data from the Health Survey for England in government policy development and implementation

Background Information is needed at all stages of the policy making process. The Health Survey for England (HSE) is an annual cross-sectional health examination survey of the non-institutionalised general population in England. It was originally set up to inform national policy making and monitoring by the Department of Health. This paper examines how the nurse collected physical and biological measurement data from the HSE have been essential or useful for identification of a health issue amenable to policy intervention; initiation, development or implementation of a strategy; choice and monitoring of targets; or assessment and evaluation of policies. Methods Specific examples of use of HSE data were identified through interviews with senior members of staff at the Department of Health and the Health and Social Care Information Centre. Policy documents mentioned by interviewees were retrieved for review, and reference lists of associated policy documents checked. Systematic searches of Chief Medical Officer Reports, Government ‘Command Papers’, and clinical guidance documents were also undertaken. Results HSE examination data have been used at all stages of the policy making process. Data have been used to identify an issue amenable to policy-intervention (e.g. quantifying prevalence of undiagnosed chronic kidney disease), in strategy development (in models to inform chronic respiratory disease policy), for target setting and monitoring (the 1992 blood pressure target) and in evaluation of health policy (the effect of the smoking ban on second hand smoke exposure). Conclusions A health examination survey is a useful part of a national health information system

Income-based inequalities in hypertension and in undiagnosed hypertension: analysis of Health Survey for England data

Objective: To quantify income-based inequalities in hypertension and in undiagnosed hypertension. Methods: We used nationally representative data from 28 002 adults (aged 16 years and older) living in private households who participated in the cross-sectional Health Survey for England 2011–2016. Using bivariate probit regression modelling, we jointly modelled hypertension and self-reported previous diagnosis of hypertension by a doctor or nurse. We then used the model estimates to quantify inequalities in undiagnosed hypertension. Inequalities, using household income tertiles as an indicator of socioeconomic status, were quantified using average marginal effects (AMEs) after adjustment for confounding variables. Results: Overall, 32% of men and 27% of women had survey-defined hypertension (measured blood pressure ≥140/90 mmHg and/or currently using medicine to treat high blood pressure). Higher proportions (38% of men and 32% of women) either self-reported previous diagnosis or had survey-defined hypertension. Of these, 65% of men and 70% of women had diagnosed hypertension. Among all adults, participants in low-income versus high-income households had a higher probability of being hypertensive [AMEs: men 2.1%; 95% confidence interval (CI): −0.2, 4.4%; women 3.7%; 95% CI: 1.8, 5.5%] and of being diagnosed as hypertensive (AMEs: men 2.0%; 95% CI: 0.4, 3.7%; women 2.5%; 95% CI: 1.1, 3.9%). Among those classed as hypertensive, men in low-income households had a marginally lower probability of being undiagnosed than men in high-income households (AME: −5.2%; 95% CI: −10.5, 0.1%), whereas no difference was found among women. Conclusion: Our findings suggest that income-based inequalities in hypertension coexist with equity in undiagnosed hypertension

Developing a questionnaire to assess community severance, walkability, and wellbeing: results from the Street Mobility Project in London

This working paper describes the development of the survey questionnaire component of the toolkit designed to measure community severance, and assess its potential associations with transport and health. We discuss the cognitive testing and piloting of the questionnaire in two contrasting case study areas in inner London, and present results from the survey data

The effect of mode and context on survey results: analysis of data from the Health Survey for England 2006 and the Boost Survey for London.

BACKGROUND: Health-related data at local level could be provided by supplementing national health surveys with local boosts. Self-completion surveys are less costly than interviews, enabling larger samples to be achieved for a given cost. However, even when the same questions are asked with the same wording, responses to survey questions may vary by mode of data collection. These measurement differences need to be investigated further. METHODS: The Health Survey for England in London ('Core') and a London Boost survey ('Boost') used identical sampling strategies but different modes of data collection. Some data were collected by face-to-face interview in the Core and by self-completion in the Boost; other data were collected by self-completion questionnaire in both, but the context differed. Results were compared by mode of data collection using two approaches. The first examined differences in results that remained after adjusting the samples for differences in response. The second compared results after using propensity score matching to reduce any differences in sample composition. RESULTS: There were no significant differences between the two samples for prevalence of some variables including long-term illness, limiting long-term illness, current rates of smoking, whether participants drank alcohol, and how often they usually drank. However, there were a number of differences, some quite large, between some key measures including: general health, GHQ12 score, portions of fruit and vegetables consumed, levels of physical activity, and, to a lesser extent, smoking consumption, the number of alcohol units reported consumed on the heaviest day of drinking in the last week and perceived social support (among women only). CONCLUSION: Survey mode and context can both affect the responses given. The effect is largest for complex question modules but was also seen for identical self-completion questions. Some data collected by interview and self-completion can be safely combined