Development of a Health Impact Assessment Implementation Model: Enhancing Intersectoral Approaches in Tackling Health Inequalities- A Mixed Methods Study Protocol

Study design

This research study will use multiple implementation science frameworks (Damschroder et al., 2022; Finch et al., 2018) within an action research approach (Bradbury, 2022) to co-produce in an iterative way a contextualised Health Impact Assessment implementation model with key partners. HIA implementation is optimised when relevant stakeholders contribute evidence and insight (den Broeder et al., 2017). HIA implementation with meaningful community engagement is integral to its sustainability as a public health response for tackling health inequalities, as has been evidenced in previous research (Green et al., 2021a). Using a community-centered and co-design approach, the first Community Engagement Toolkit for HIA in Ireland will be co-created with key partners. This Toolkit will be a practical resource to be used in carrying out participatory HIAs in Ireland, complementing the use of any HIA guidance. In using the HIA approach, the research study is founded on improving health equity for population groups who will be affected by the implementation of the policy under study, which in the case of HIA-IM, includes local urban policy and national climate action policy. The equity lens allows us to consider the health impacts of policies under study. The rationale, approach and timing of this research study is designed to inform the roll-out of the HIA implementation programme led by the Institute of Public Health, synergising with key national population health priorities and policy implementation going forward. Quantitative and qualitative methods will be employed underpinned by co-design and co-production approaches. A scoping review of factors influencing HIA implementation will be carried out in order to create research evidence that informs contextualised responses to create intersectoral policy for population health.

Action research has been shown to improve the contextualised nature of implementation procedures within organisational structures, compared to other research methods (Bush et al., 2017). However, little research has been conducted on the use of action research methods with implementation research, specifically in assessing implementation processes and outcomes of policies and policy-informing processes, such as HIA. Action research is applied in order to improve specific practices through critical reflection (ibid). It is founded on participation and collaboration of individuals who work through an action research cycle which includes planning, acting, outcome, and reflection, to provide feedback (collected data) in order to introduce improvements to a specific practice. It presents a learning opportunity for data collection of participants’ reflections and learnings (McNiff, 2013). Action research is an approach that co-creates research with people, places praxis and reflection as primacy, and is underpinned by social constructivism (Bradbury, 2022). Hence, within this project, the research team adopts a critical sociological lens to allow space for reflections of social and power relationships with any nuanced implementation dynamics arising throughout the research, specifically in the conduct of the HIAs (Ahmed, 2012; Nettleton & Bunton, 1995). The research team, who will participate in the two HIA Working Groups, will consciously embody a reflexive research role within the study in order to capture key reflections with participant observations, aligned in the spirit of meaningful action research (Archibong et al., 2016). Planned time and space for research analysis during data collection will take the form of two research analysis retreats for each HIA. This data will be triangulated with other research data produced within the study to create a holistic picture of HIA in Ireland, informing the resulting implementation model.

Work stream 1: Action research-led design and implementation of two HIAs using revised national HIA guidance. HIA 1 on the Cork City Development Plan (2022–2028) and HIA 2 and on the Irish Government Climate Action Plan (2024)

Two HIAs are planned within this research project, one on the Cork City Development Plan (2022–2028), one on the national Climate Action Plan (2024). Although containing the words ‘plan’ in their titles, both are policies, one operating at the local level, one in the national policy arena. The following outlines detail of the two policies, including their purpose, remit, geographic scope and population groups.

Cork City Development Plan (2022–2028)

The Cork City Development Plan (2022–2028) has a remit in creating a strategic spatial land-use policy for the city of Cork. The remit of the Plan is to guide development in the city across nine strategic objectives, including Compact Liveable Growth, Delivering Homes and Communities, Transport and Mobility, Climate and Environment, Green and Blue infrastructure, Open Space and Diversity, Economy and Employment, Heritage, Arts and Culture, Environmental Infrastructure, and Placemaking and Managing Development (CCC, 2022). The geographic scope of the Plan is within the boundary of Cork city. The population of Cork city residents, comprising of 210,000 people (ibid).

Climate Action Plan (2024)

The national Climate Action Plan (2024) is the third annual update to Ireland’s Climate Action Plan (GoI, 2024). The remit of the annual Plans is to provide a roadmap for taking decisive action to halve Ireland’s emissions by 2030 and reach net zero by no later than 2050. This commitment is included in the Climate Action and Low Carbon Development (Amendment) Act 2021. The Climate Action Plan (2024) builds on the previous iteration, published in 2023. It updates measures and actions that are required to deliver the carbon budgets and sectoral emissions ceilings. The geographic scope of the Plan is within the boundary of the Republic of Ireland. The population of Ireland comprises of 5,149,139 people, based on the latest census figures (CSO, 2023).

Task 1.1. Design and conduct a HIA on the Cork City Development Plan, 2022–2028 (HIA 1) and subsequently on the Government Climate Action Plan 2024 (HIA 2), using recently revised national HIA guidance

The HIA Steering Groups, which will be established before each HIA commences, will steer the direction and scope of each HIA and carry out the work. Minutes from the Steering Group meetings, which will record matters arising and decisions made at each stage of the seven HIA stages, will be used as research data.

In summary, the following processes will be implemented using HIA stagiest methodology as outlined in the IPH HIA guidance (Pyper et al., 2021) (orange stream in Figure 1):

Figure 1. Proposed research framework, drawing on the action research cycle employed by Archibong et al. (2017).

Task 1.2. Apply an action research cycle concurrent to carrying out HIA 1 and HIA 2 (Research objective 2)

As illustrated in Figure 1 (blue stream) a five-stage action research cycle comprising Investigate, Plan, Act, Outcome and Reflect will be applied to the seven HIA stages (Figure 1-orange stream) of HIA 1 and HIA 2. Such continual application of an action research cycle while Task 1.1 is delivered will ensure data from HIA processes are captured. This is a novel approach to researching HIA in practice, and will capture data, which is specific to the Irish process of HIA, thus informing the HIA implementation model.

Data on the implementation of both HIAs will be collected at each of the five action research cycle stages:

A co-production workshop for data analysis is planned with key stakeholders including the project’s public involvement consultation group and the Institute of Public Health Ireland will take place. In line with action research ethos, this workshop will ensure key stakeholders will engage in the co-design of data analysis, ensuring that the people envisaged to work with HIA and use the resources of HIA-IM after project completion, will be involved in the research process. Incorporating the outcomes from this co-production of analysis, data will be further refined using the reflexive thematic analytical framework (Braun & Clarke, 2022). Reliability checks will be used in the application of this project’s qualitative research methods (Heikkinen et al., 2012), including the inter-coder reliability measures to ensure the highest possible levels of consistency, validity and transparency in the data analyses.

Work stream 2: Identification of factors that influence the process of HIA implementation, drawing from the Normalisation Process Theory (NPT) and the Consolidated Framework for Implementation Research (CFIR) (research objective 3) (Figure 1, green stream)

HIA-IM will use multiple implementation science frameworks, drawing from the Normalisation Process Theory (NPT) (Finch et al., 2018) and the Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., 2022). Relevant theoretical constructs from both frameworks will be used in order to analyse the process of doing or carrying out a HIA (NPT) and the determining factors affecting HIA implementation (CFIR). NPT comprises of four constructs; Coherence- what is the work?, Cognitive Participation- who does the work?, Collective Action- how does the work get done?, Reflexive Monitoring- how is the work understood? NPT in particular seeks to examine the implementation processes of complex interventions such as HIA, understood as deliberately institutionally sanctioned interventions that are formally defined; planned; and intended to lead to a changed outcome (Finch et al., 2018). NPT works to assess the implementation processes of those directly engaged in the intervention (HIA) as well as individuals not directly engaged but knowledgeable of the process (ibid). CFIR comprises of five domains; intervention/ innovation characteristics, inner and outer setting, the individuals involved, process of implementation. In our research examining the implementation or doing of HIA in practice, the inner and outer settings domains of CFIR will be particularly illustrative in generating data on the wider institutional and policy contexts within which participants are working, enabling us to explore the relevant institutional and policy drivers and levers. CFIR was not developed to only focus on the institutional and policy context within which an intervention or approach such as HIA operates, however, the Outer Setting domain does include policy relevant attributes such as Policies and Laws, Local Conditions, and Local Attitudes that are relevant to the practice of HIA.

HIA 1 and HIA 2 steering group members from Task 1.1 will form Group A for work stream 2. Each HIA Steering Group structure will include 12 participants. Group B will comprise of individuals within key organisations involved in the HIAs with capacity to use and embed the practice HIA within existing structures (Group B). A snowballing technique will be used to identify and recruit Group B participants, estimated between 5 and 10 individuals per HIA (10 to 20 individuals in total).

An explanatory mixed-methods approach in data collection and analysis will be employed to capture implementation processes. Quantitative data will inform qualitative data collection and analysis, integrated sequentially with qualitative data (Figure 1- green stream). The standardised validated NoMAD (Finch et al., 2018) questionnaire, with additional questions from CFIR domains, will be administered to Groups A and B. The NoMAD questionnaire assesses implementation processes from the perspective of professionals involved in the work of implementing complex interventions such as HIA.

Once the HIA stage of Scoping is completed, both groups A and B will be asked to complete the questionnaire online. They will be asked again after the HIA analysis stage, and following completion of the HIA. In total the groups will complete the questionnaire three times during the process of the HIA. Normalisation Process Theory (NPT), from which the NoMAD questionnaire is derived, addresses and highlights factors in the HIA process needed for successful implementation and integration of HIA into routine work (normalisation). Therefore, we administer the NoMAD questionnaire more than once during the HIA process, at the work-intensive points (Scoping, Analysis and Reporting), in order to capture the evolution, if any, of participant’s perceptions of factors needed to enhance HIA implementation.

Once the HIA process is completed, respondents from groups A and B will be invited to participate in semi-structured interviews. A purposive sample will be chosen, using selection criteria (organizational affiliation, decision-making authority, gender and intersectionalities balance), from those who volunteer for interviews. The interview schedules will incorporate the NPT and CFIR constructs as well as findings from the rounds of NoMAD questionnaire administration. This will allow the research team to elicit perceptions and experience on factors affecting the implementation of HIA from the perspective of individuals in Groups A and B.

Work stream 3- Co-produce a Community Engagement Toolkit in order to optimise community participation in HIA in Ireland (research objective 4)

The aim of this work stream is to capture learning from the HIA Analysis stage (stage 3 of HIA process (Figure 1) using a set of community engagement indicators, building on Frewer et al. (2000) criteria for effective public participation. The HIA Analysis stage includes community consultation, to inform the HIA with community knowledge. The goal is to counter potential community disenfranchisement from transformative policy change from going “over their heads,” as has been highlighted by Haigh et al. (2020: 1).

One of the four values central to HIA is democracy (WHO, 1999). HIA enables a generation and synthesis of quantitative and qualitative evidence, including community knowledge. The Healthy Ireland Framework 2013–2025 with its Strategic Action Plan 2021–2025 both highlight the importance of Empowering People and Communities (DOH, 2021; DOH, 2023) through intersectoral responses including HIA. However, HIA processes often lack meaningful community engagement (den Broeder et al., 2017). As Haigh et al. (2020) conclude from their study of community engagement in HIA, this is identified as a missed opportunity to achieve benefits of community engagement during the assessment of planning processes that occur as part of HIAs. The Institute of Public health HIA guidance does not detail how community engagement could occur. HIA practitioners, scholars and advocates such as Green et al. (2021c) have demonstrated the importance of the community voice in developing sustainable HIA implementation.

A conceptual framework for community engagement will be built from the relevant theoretical and grey literature review, drawing on criteria for effective public participation for HIA (Frewer et al., 2000) and the published literature on the Health Equity Impact Assessment toolkit (Povall et al., 2013).

The review will draw on literature underpinning the rationale for community participation in HIA, identifying tools and practices that have been used to effectively facilitate communities in engaging in the HIA process, as well as carrying out their own HIA's. In addition, toolkits that have been developed to enhance community engagement will be included for review. The findings from the literature review will inform the conceptual framework for data collection for the HIAs. This framework will then be applied when involving communities in both HIAs, forming the conceptual content for data collection using the World Café method during the Analysis stage of the HIAs. Based on the findings from the application of the framework, which involves community participation during the Analysis stages of both HIAs, the Community Engagement Toolkit will be created. The Toolkit will be aimed at people who are doing HIAs and want guidance on community engagement, as well as guidance for community groups on engaging in HIAs. Data for work stream 3 will be drawn from work streams 1 and 2 of community representatives on the HIA Steering Groups, as well as part of the Analysis stage of the HIA.

Work stream 4: Iterative development of a contextualised, contemporary, Irish HIA implementation model by integrating and triangulating qualitative and quantitative data from all work streams (research objective 5)

Identified limitations in the literature will be addressed in HIA-IM including a scoping review of factors affecting HIA implementation, with a view to informing the development of the HIA implementation model. This scoping review will inform the integration of data from all work streams as well as the main output from the research study, the HIA implementation model. Contributions from the Public Involvement in the research study is crucial to the development of the HIA implementation model. This work stream 4 involves four Public Involvement events with the HIA-IM Public Involvement Consultation Group, in the first three years of the project, in order to gather contributions to inform the development of the model. In the fourth and final year of the project, a Public Forum event will be held in order to include further contributions from the public to the model, beyond the Consultation Group. This will ensure the model is both informed by scientific evidence together with contributions from the Public Involvement process.

Upon completion of both HIA 1 and HIA 2, data will be synthesised and analysed in order to iteratively build the contextualised Irish HIA implementation model. The research study will do this through a process that documents the implementation process in the conduct of two HIAs. Work stream 4 will consolidate the findings on impact and effectiveness of HIA 1 and HIA 2 (Task 1.1), themes emerging from Task 1.2, findings from work stream 2, findings from the creation of the Community Engagement Toolkit (work stream 3) and four PPI events (work stream 4) in order to produce the contextualised HIA implementation model.

Integration of data occurs at three stages in HIA-IM. The model will be produced iteratively as findings from HIA 1 will be integrated with findings from HIA 2 creating the report on the application of the action research cycle to HIA implementation. Integration will take place at the interpretation stage of the study, to triangulate findings. Specifically, triangulation will be carried out during the iterative and continual synthesis and integration stages, where a convergence coding matrix will be developed to display findings emerging from all work streams.

A central feature of the research study will be to ensure that research findings and outcomes are interpreted by the research team, staff of the Institute of Public Health Ireland (IPH), and relevant collaborators during research team, Steering Group and Advisory Panel meetings, and meetings with project collaborators. Contributions at PPI events will facilitate contributions to identify key priorities and recommendations, as well as co-production in data analysis, informing the model. The main outcome from work stream 4 will be the continual development of the HIA implementation model, which will be built iteratively and consistently throughout the project. This model will be populated by data findings from all work streams.

The HIA implementation model will include an explanation of the implementation of HIA at local policy level and national policy level, in order to uncover, enhance understanding and offer a guiding tool and process for doing HIAs in Ireland, at the policy, strategic level.