چگونه ارزیابی های زیست محیطی استراتژیک در اسکاتلند با مد نظر قرار دادن سلامت انسان ، به خوبی انجام می شود ؟

Objectives Strategic environmental assessment (SEA) is a systematic approach to identifying, describing, evaluating and reporting on the environmental – and health – effects of policies, plans and strategies. SEAs have potential to improve population health because they assess ‘upstream’ health determinants and recommend measures to improve these. The authors studied the range of health issues considered in SEAs in Scotland, and the evidence used in their assessment. Study design Documentary review of 62 consecutive SEA reports. Methods Environmental reports were categorized by sector, and the health-related environmental problems, SEA objectives/criteria, differential impacts, evidence, recommended mitigation and monitoring were identified for each report. Results Environmental reports identified many health-related issues, and set a wide range of health-related objectives/criteria, but these were inconsistent for SEAs assessing similar plans. Few identified differential impacts or mental health impacts. Mitigation focused on mitigating adverse impacts rather than enhancing positive impacts. It was unclear what health evidence was used to inform the judgements made in scoring the plans against SEA objectives. Conclusions Many SEAs in Scotland adopt a wide perspective on health, but most fail to identify differential impacts. Health involvement in scoping of health issues and better use of health evidence may enhance their quality.

Strategic environmental assessments (SEAs) are described as ‘a key component of sustainable development’.1 SEA is a systematic approach to identifying, describing, evaluating and reporting on the environmental effects of policies, plans and strategies (PPS). SEAs assess high-level PPS, whereas environmental impact assessments (EIAs) assess projects. The purpose of SEAs is ‘to ensure that information on the significant environmental effects of the relevant policies, plans and strategies is gathered and made available to decision-makers’. Decision makers must produce a statement showing how the SEA has influenced the plan. SEAs should ‘extend opportunities for participation in public policy decision-making and increase transparency’.1 The European SEA Directive2 identifies the environmental issues to be considered in SEAs, one of which is human health (Box 1). Public health professionals have welcomed this, recognizing that policies and plans in all sectors may impact on health. Integrating consideration of health into SEA can form part of a multisectoral approach to protecting and improving people’s health, and increase the transparency of decision-making.3 SEAs can consider health impacts relating to social as well as biophysical determinants.4 Incorporating the full range of health impacts could avoid the need for separate health impact assessments (HIAs), and therefore reduce duplication of assessment.4 Notably, SEAs are a statutory requirement whereas HIAs are not. The Directive identifies 11 sectors that are required to undertake SEA. Scottish legislation requires all public bodies to perform SEA, but Scottish guidance advocates including a narrower range of health issues. It states ‘the definition of health in the context of SEA should… be considered in the context of the other issues outlined in Schedule 3(6) of the Act, thereby focussing on environmentally-related health issues such as significant health effects arising from the quality of air, water or soil’.1 This is reinforced by the identification of the Scottish Environmental Protection Agency (SEPA) as the health consultation authority for SEA. SEPA’s remit covers air, water and soil quality, but not social determinants of health.

Summary of key findings The SEAs reviewed here included a wide range of health issues that were not restricted to impacts directly related to the physical environment. However, there was variation in the issues considered in SEAs of similar plans. There was evidence of health-related mitigation measures in some reports, and that findings of screening and scoping stages of the SEA had influenced the plans. It was not clear what health evidence was used to inform the judgements made in the SEA, particularly in scoring the plans against SEA objectives. The finding that many SEAs set a high-level objective ‘to enhance and maintain health’, without further specification, suggests that assessors had limited understanding of the complex multifactorial nature of the determinants of health. Many plans have a positive impact on some determinants but a negative impact on others. If these impacts are not made explicit in the SEA, it loses the opportunity to enhance the positive and mitigate the negative. There was very limited assessment of differential impacts. Several SEAs mentioned ‘health inequalities’ or ‘deprivation’ in the SEA objectives, but this suffers from the same problem as the high-level ‘enhance health’ objectives, as health inequalities and deprivation are multifactorial. There was very little articulation of how impacts would be distributed among different populations, the sole exception being an SEA that included a health impact screening exercise. As such, SEAs are consistently missing the opportunity to address environmental justice. Current SEA guidance does not require or encourage consideration of how impacts may be borne by different groups of people. This differs from HIA, which stresses the importance of considering health inequalities, by considering not only what impacts there may be, but also their distribution.8 and 9 Comparison with other work Reviews of EIAs consistently find that coverage of health impacts is poor and differential impacts are not considered.10, 11, 12, 13 and 14 Reviews of SEAs are more positive but still find scope for improvement. A review of eight European SEAs reported that a range of health issues were considered; however, there was limited input from health stakeholders and health baseline data were not used in the assessment.15 A Danish study of 100 ERs found that health aspects were considered and included broader issues than those identified in national guidance. However, they were not presented as health impacts, and there was a lack of assessment of differential impacts.16 A 2007 review of appraisal tools that studied guidance on different forms of assessment and appraisal found that HIA was the only form of appraisal that identified differential impacts.17 This mirrors the findings of the current study. Strengths and limitations This was a documentary review and is limited by the information presented in the reports. Further information may have been gained if other SEA reports, for example postadoption statements, had also been reviewed. It is also possible that there was greater involvement of health stakeholders, and greater use of health evidence, in the SEAs than can be gleaned from the documents. However, this does not negate the key finding of variable coverage of health issues in the SEA objectives and criteria. Health determinants include a broad range of issues. A major issue in this study was deciding which of the issues identified in the ERs were health-related, and coding these consistently. Some issues, such as physical activity, are clearly relevant to health. In other cases, the links are less clear, posing difficulties for the assessors as well as this review. Some issues, such as residential and visual amenity, were identified as a human health objective in some reports, but were only related to other SEA issues such as material assets or cultural heritage in other reports. For this review, these were identified as health-related issues. The inter-relationships between environmental issues, especially human health, are complex and were not made clear in the ERs, despite the fact that the guidance notes a requirement to do so. The review identified the issues covered in the SEA objectives/criteria, but the authors did not review each of the plans being assessed in order to judge how appropriate they were in each case. However, even where plans were clearly very similar (e.g. the 17 core paths plans), there were differences in the health-related SEA objectives/criteria. Implications International guidance advocates comprehensive consideration of health within SEAs. For example, the United Nations Economic Commission for Europe protocol on SEA places special emphasis on human health as an ‘integral part of strategic environmental assessment’.18 This study suggests that many of those performing SEA in Scotland are adopting (or trying to adopt) a wide perspective on health, but may need support to ensure the quality and consistency of these assessments. Including health in SEAs may reduce the need for separate HIAs, suggesting it would be worthwhile for public health professionals to engage with them. Greater involvement of public health professionals in SEAs could help to identify appropriate health evidence and encourage greater consistency in the health issues considered. The lack of identification of differential impacts is a particular concern. The only SEA that outlined differential impacts was the SEA that included a health impact screening exercise using a screening checklist, which identifies potential affected populations and health determinants.19 The authors advocate as a priority the use of a similar tool, in a process that includes health stakeholders, in SEA scoping to identify relevant health issues and to ensure that differential impacts are considered. A further support could be the dissemination of health-related evidence reviews and data in a form that is useful for SEA. These could populate the background context sections and inform judgements about appropriate SEA objectives and scoring of plans against these objectives. For some sectors, there are readily available evidence reviews. For some types of plan, there are predetermined planning cycles, which means that all local authorities may be working on, for example, local travel strategies or local housing strategies around the same time. This may be an opportunity to develop timely summaries of evidence on health impacts of these sectors to inform SEAs. In order to evaluate the success of these approaches, further research should study the impact of different ways to enhance the quality of coverage of health within SEAs. SEAs could be an important way to improve population health because of the potential to influence ‘upstream’ determinants of health. More consistent consideration of health determinants and differential impacts is required to achieve this potential.