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To influence the planning of the 2014 Commonwealth Games such that the positive impacts are maximized and the negative impacts are mitigated.
Participatory health impact assessment (HIA).
A participatory HIA was performed using standard World Health Organization methods. A scoping event was held to involve decision makers in the process and to identify the key areas for consideration. A large community engagement exercise and a systematic review were conducted as part of the evidence-gathering phase. The results of the HIA were reported to the key decision makers involved in the Glasgow City Council legacy strategy.
The likely net health impact of hosting the Commonwealth Games was uncertain. It was suggested that the main mechanisms through which impacts were likely to be felt were: the economy; civic pride; engagement in decision making; the provision of new infrastructure; and participation in cultural events. A series of recommendations was produced in order to maximize positive health benefits and mitigate negative impacts.
HIA is a useful tool for engaging communities and decision makers in the public health agenda. HIAs of major multi-sport events are limited by a lack of quality evidence and the inability to predict impacts reliably.
On 9 November 2007, it was announced that the city of Glasgow was to host the 2014 Commonwealth Games. The bid put together by Glasgow City Council and the Scottish Government highlighted a range of benefits that playing host would bring to the local population.1 This included a range of ‘legacy’ benefits encompassing the familiar determinants of health (employment, housing etc.) as well as explicit health and wellbeing outcomes:
“This investment will…contribute to the key objectives of improving the health of our population particularly around physical activity and the prevention of obesity. These in turn will contribute also to overall levels of confidence, wellbeing and mental health…”1
Following the announcement that Glasgow had won its bid, a process of designing legacy plans commenced for the City Council and Scottish Government. These were to be the detailed mechanisms through which the benefits outlined in the bid document were to be realized.2 This was similar to the process adopted for the 2012 Olympics in London.3 A group of public health professionals and policy makers advocated for a health impact assessment (HIA) to be undertaken as an explicit attempt to influence those plans, such that the potential health benefits of playing host might be maximized and any negative impacts mitigated. This was proposed to fit into the time scale for the drafting of the legacy documents (with a particular focus on the Glasgow City Council legacy plan).4
The hosting of major sports events can be controversial, particularly where there are perceived to be harmful or unwanted outcomes.5–9 In Glasgow, the most deprived and unhealthy city in the UK,10,11 there is a particular need for policy and interventions to improve health. The Commonwealth Games is seen by policy makers to be part of this effort, and it is for public health professionals to advise on how a positive health legacy can be best realized. Hosting major events is not a remedy for all of Glasgow’s health and social ills, particularly since the city has a long history of such activity (including the 1988 Garden Festival, 1990 City of Culture and 1999 City of Architecture and Design)5,12 without a step change in its fortunes.10 However, Glasgow City Council and the Scottish Government consider that the Games have the potential to have a significant impact, and significant resources have been committed to hosting the event.1
HIA is an important tool to encourage evidence-informed policy making in favour of health.13 It is limited by the quality and breadth of the evidence base upon which to make recommendations and a lack of studies evaluating the effectiveness of HIA in predicting outcomes.14,15 This HIA is the start of a process to predict the impact of hosting the Games on health and the determinants of health; to influence the planning of the Games and the associated legacy programmes; and to evaluate the actual impact of the event (thereby facilitating a comparison between predicted and actual outcomes).
The standard World Health Organization framework for conducting HIAs was followed.16 The first opportunity to perform an HIA arose following the decision to award the Games to Glasgow, and so the purpose of the HIA was not to guide decision makers on whether or not a bid should be entered, but instead to influence the resulting legacy plans based on the information given in the bid document.1 A multi-agency group was formed to discuss the possibility as a proxy for the HIA screening stage, and a recommendation to undertake a participatory HIA was approved by the City Council as a means to inform its Games legacy plan. The geographical boundary of the HIA was agreed to be the City of Glasgow.
A scoping event was held in August 2008 in Celtic Park (the venue for the Games opening ceremony) involving 120 stakeholders. These included elected councillors, council officials and representatives of various other organizations (e.g. housing associations, NHS Greater Glasgow and Clyde, Culture and Sport Glasgow, the Scottish Government, academics and community representatives). The participants at this event were encouraged during a series of interactive workshops to consider all the potential health impacts of the Games, the size of the impact, the groups most likely to be affected, and the potential for influencing decisions pertaining to the impact. This was in order to prioritize potential impacts for further assessment. The scoping event, and the discussions pertaining to it, also facilitated a process of engaging with decision makers such that the findings of the assessment could be produced in a timely and relevant manner.17
The key areas of impact identified at the scoping event were used to develop questions for public consultation. Evidence was gathered from the community utilizing an extensive community engagement exercise (described in Box 1), and from other events using a systematic review18 and discussion with the evaluators from the 2002 Commonwealth Games in Manchester. This evidence was reflected back to the community as a further element of the community engagement exercise; a process which formed the stakeholder involvement phase of the HIA. This also provided an opportunity for community involvement in the appraisal of the evidence and in the formulation of the recommendations.
Recommendations were formulated by the HIA steering group using the evidence gathered as part of the HIA following the appraisal and community engagement. Where possible, account was taken of existing and planned activities in the city.
The full report of the HIA process and recommendations was presented to all the relevant stakeholders (including elected councillors, city council officials and the 2014 Games organizing committee) in time for this to be reflected in the legacy plans and in advance of publication. A summarized version of the HIA report was distributed to the public shortly after the publication of the City’s legacy brochure.19
Only one part of the evaluation phase of the HIA has been completed; an evaluation of the community engagement strategy for the HIA. The evaluations of the impact of the HIA on legacy planning, and of the HIA process, are yet to be completed. The evaluation plans for the overall impact of the Games on health and the determinants of health are emerging but are beyond the scope of the HIA. All the supporting documentation relating to the HIA method is available on the Internet (http://www.gcph.co.uk/content/view/167/143/).
The key areas of potential impact identified from the scoping event were: employment and employability; the impact on Glasgow’s image; regeneration; civic pride; health and wellbeing; infrastructure development; the environment; and a number of cross-cutting themes such as community engagement, tackling inequalities and community cohesion. It was unclear whether the impact on each of these areas was likely to be positive or negative (i.e. the Games were described by participants as both a threat and an opportunity to tackle inequalities). Engagement with senior decision makers within the city was achieved, and the event prepared them to receive the HIA recommendations which they would be expected to implement in due course.
The survey showed that residents believed the Games would have a positive impact on them, their families, their local area and Glasgow as a whole. Those living closest to the planned Games village were less likely to believe that there will be a positive impact on themselves and their families. For Glasgow to benefit as much as possible from the Games, the priorities, according to residents, were to improve the image of Glasgow and to provide access to employment opportunities associated with the Games.
The key areas of potential impacts identified from the workshops included employment and employability, public transport, crime and security, and improved facilities for physical activity. A desire for enhanced community engagement, a reduction in inequalities, social inclusion and community cohesion were also expressed.
There were a total of 1640 electronic responses and 274 paper returns of the questionnaire. The analysis of these responses indicated that boosting civic pride and the cultural programmes attached to the Games were particularly important to respondents. Many thought that promoting a ‘feel good’ factor would be the strongest legacy of the Games. It was perceived that a key legacy would be improved sports facilities in terms of their accessibility and suitability. However, people felt that in order for the Games to have a lasting legacy, the local community would need to be actively engaged throughout the planning and delivery of the Games. Seventy-five percent of those answering the questionnaire expressed a desire to be involved in some capacity.
A systematic review of the impacts of major multi-sport events (1978–2008) on the health and determinants of health was performed. The interim findings were reported to the HIA steering group and were included in the community feedback events. Fifty-four studies were included in the review, but the quality of the evidence was low and there were gaps in the outcomes examined. Five studies reported health outcomes from previous events. These reported that: paediatric and illicit-drug-induced hospital presentations increased; childhood asthma hospital admissions decreased; and suicide rates were unchanged. Economic impacts were unclear because of the use of estimated data beyond the date of the event, but there were studies showing positive and negative impacts on economic growth and employment. The review concluded that the organizers of future events would need to focus on generating health and socio-economic benefits together with a robust evaluation framework if they were to demonstrate any impacts after the event.
The evidence available suggested that the Games were likely to impact on a wide range of the determinants of health. This included relatively ‘hard’ outcomes such as the economy, and ‘soft’ outcomes such as civic pride. The net impact on health was impossible to estimate, but potential impacts on particular determinants of health were identified (Table 1), although it was difficult to predict the likelihood of these impacts (either positive or negative) being realized.
These events provided feedback to local communities and stakeholders on the findings of the evidence gathering and appraisal, and verified that the impacts identified were appropriate.
The summarized recommendations arising from the HIA are shown in Table 1 (full details of the recommendations and the evidence underpinning them are available in the full report).23 The potential impacts of the plans are uncertain and can be seen (and framed) as opportunities or threats. For example, the planning of new sports facilities can be seen as an opportunity for the community to be empowered through being involved in their design, or can be seen as a threat to community empowerment if infrastructure is perceived to be imposed on a community without their involvement or consent. This tension is present in all of the potential impacts of the plans (Table 1). However, a series of clear recommendations was more readily developed for improving the potential impacts of hosting the Games. This drew upon existing strategic plans and the policy context in Glasgow. Thus, even where the overall impact on employment, for example, was uncertain, it was possible to suggest policy modifications that would maximize the positive impact on health and health inequalities.
The impact of hosting the 2014 Commonwealth Games on the health of Glaswegians, and the determinants of their health, is uncertain. There are high public and governmental expectations of playing host, and the Games have generated a great deal of interest and debate about the possible impacts. A range of recommendations have been outlined (the recommendations contained within the full report are more specific, achievable and measurable than those in the summarized version outlined in Table 1) that reflect the available evidence and collective wisdom of the public and participants in the HIA process. Careful evaluation is required to determine whether these impacts are realized and whether the HIA process has influenced the decision-making process. It is likely that the Games will mainly influence health through impacts on the economy, civic pride, engagement in decision making, the provision of new infrastructure, and participation in cultural events. It was challenging to provide accurate estimates of the effects because of a lack of quality evidence from similar interventions.
The HIA community engagement process was evaluated using the National Standards for Community Engagement and the VOiCE (Visioning Outcomes in Community Engagement) tool with support from the Scottish Community Development Centre. The final score was 5 (out of a possible 6) indicating a ‘very good’ performance with major strengths in relation to the National Standards, and also in terms of achieving the stated outcomes of the work. The main strengths were in relation to planning, using a range of methods, working together, sharing information and providing feedback. The main deficits were that some elements of the engagement were rushed, and it was not certain that a representative cross-section of the community was reached. The evaluation found that the community engagement was successful in raising awareness of the delivery plans for the Games, the potential health impacts of the Games, and the National Standards for Community Engagement. Individuals involved in the process developed an increased sense of ‘connectedness’ to the Games, and some also gained skills and experience in community engagement. This has left people with increased capacity to participate in any further community engagement opportunities. The community engagement work undertaken as part of the HIA has had a clear influence on the community engagement and consultation strategy being developed by the Council’s legacy team.
HIA is an established mechanism for public health professionals to inform policy making with the available evidence and expertise. This is particularly important for social interventions not aimed specifically at generating health effects, which are likely to be an important influence on health but may not have sufficient health input into their planning and conduct. There are precedents for conducting HIAs on major multi-sports events,45 and there may be an increasing desire for quality public health input to policy making.46
The impact of major multi-sport events on health and the determinants of health is unknown, and the 2014 Games cannot be expected to solve all of Glasgow’s health challenges.10 However, HIA can be used to engage with the public and policy makers such that the health agenda is made more explicit and high profile. It may be that the Games can act as a catalyst to support existing aims around health, and can help to focus efforts of a wide range of organizations on such challenges. It is clear that the Glasgow public are keen to be involved in planning the Games legacy and that, when given opportunities to be involved, they provide a useful and unique insight.
As with all HIAs, the value of this work is limited by the evidence base upon which it draws, the inability to predict impacts accurately and with certainty, and the extent to which its recommendations are acted upon.14
The survey methods used to gather the opinions of residents have the potential for selection bias. For example, the Glasgow Household Survey sampling method involves selecting addresses in an area, and if there is no response, sampling from nearby dwellings. Similarly, the ‘Have your say’ questionnaire was open to selection bias because of its ‘opt-in’ nature (responses were gathered from Internet users on the Glasgow City Council website and from postal responses to questionnaires distributed in public buildings across the area). This potential for bias was less important in the generation of a list of possible impacts than it was for determining public priorities.
Assistance with the conduct of the HIA was received from: the members of the HIA steering group; the Scottish Health Impact Assessment Network; Andrew Lyon; Councillor Archie Graham; Adam Brown; Clare Johnson; the Scottish Community Development Centre; the Glasgow Community Planning Partnership Engagement Network Coordinators; the Glasgow East Regeneration Agency Community Health Initiative; Glasgow Student Councils; Glasgow City Council 2014 Team; and numerous individuals and community groups who participated.
Gerry McCartney was funded by the Chief Scientist Office at the Scottish Government Health Directorate as part of the Evaluating Social Interventions programme at the MRC Social and Public Health Science Unit (wbs U.1300.00.002.00024.01). Susie Palmer, Jo Winterbottom and Duncan Booker are employed by Glasgow City Council. Russell Jones is employed by Glasgow Centre for Population Health (which is co-funded by Glasgow City Council, the Scottish Government and Glasgow University). Ruth Kendall works as part of the Public Health Resource Unit at NHS Greater Glasgow and Clyde.
Gerry McCartney is a member of the Scottish Socialist Party and was involved in a project to have a velodrome built in the West of Scotland. The other authors have no competing interests to declare.