Assessing impacts on people's relationships to place and community in health impact assessment: an anthropological approach

Abstract

This paper explores a way in which health impact assessment (HIA) practitioners can improve their evaluation of the effects of infrastructure developments on people's intangible connections and emotional attachments to places and communities, and their health impacts. This assessment poses conceptual and methodological challenges. It is argued that social anthropology and the social sciences offer HIA a conceptual vocabulary and a methodology for exploring these relationships. These relationships are defined then positioned in HIA as an outcome of the health determinant, social capital. The paper offers a critique of their treatment in an HIA case study from the United Kingdom. Its shortcomings are used to propose a predominantly qualitative, anthropological methodology. The overall approach offers benefits. Practitioners gain clarification, new tools, a more holistic HIA, and links between these relationships, well-being, and sustainability and resilience. Developers are shown how to sensitise their approach, potentially enhancing community support.

Keywords::

• health impact assessment (HIA)
• social anthropology
• place and community attachment
• social capital
• infrastructure
• UK

Introduction

Infrastructure and natural resource developments, housing and mixed-use projects change the way in which people relate to their physical, social and economic environment. We all relate individually to the places where, and to the people with whom, we live, play, grow and work. These relationships are developed in the psychosocial sphere through prolonged or regular exposure to (1) the characteristics of a geographic place and (2) the locally defined characteristics that constitute/signify membership of the community. Table 1 uses the literature to define these relationships, their constituent aspects and how they are formed.

Table 1 Orientations and attachments to place and community.

Orientations
Place orientation	A generalised ‘personal orientation to place’ (Hummons 1992, p. 262) that rests on ‘awareness of one's location in the environment’ and psychological familiarity (cf. La Grow 2010).
Sense of place	An individual's personal connection to and sensory experience of a built or biophysical place as understood through the meanings given to its characteristics. These include built landmarks/locations, biophysical landmarks/features, spots of emotional significance (Vanclay 2008, p. 3) and the social/community environment (Williams & Kitchen 2012, p. 258). SOP encompasses personal positive, neutral or negative regard for the place, developed psychologically through prolonged or repeated exposure to it (cf. Hummon 1992, p. 262; Trentelman 2009, p. 201; Williams & Kitchen 2012, p. 258).
Sense of community	An individual's personal feeling of being recognised and included in a community based on their experience of membership (cf. Hyde & Chavis 2007, p. 179), and factors identified by that individual that give them a sense of community membership. These can include the way of life, norms and social order, interactions and relationships among members, long-term residence, and participating in events (cf. Forrest & Kearns 2001 on cohesive communities; Dempsy et al. 2009 on sustainable communities; Baldwin 2012 on UK ethnographies of communities).
Attachments
Sense of belonging	An individual's ‘naturalised emotional attachment’ (Yuval-Davis 2006, pp. 197, 199) to a group of people, organisation, biophysical or socio-cultural environment, formed psychologically through social interaction with and within groups, organisations and environments (cf. Hagerty et al. 1992, p. 173). People are more likely to become conscious of to whom, what and where they belong when their belonging is questioned or threatened (cf. Yuval-Davis 2006, pp. 197, 199).
Place attachment	‘The environmental settings to which people are emotionally and culturally attached’ (Low & Altman 1992, p. 5) to varying degrees (Williams & Vaske 2003, p. 832) in a positive sense. Attachments to places are developed through interaction with or experience of them regularly and over time, or through story-telling about and memory of them (Trentelman 2009, p. 200).
Community attachment	A measure of an individual's emotional attachment to their community, and an indicator of their ‘rootedness’ within it (Trentelman 2009, p. 201), arising from interactions and connections with fellow community members (Kasarda & Janowitz 1974, p. 328). It generally contributes to positive individual well-being through the benefits of social connection, social support and information provision by extensive networks (Lee & Blanchard 2012, p. 25).

Social scientists and psychologists describe these relationships using specific concepts in terms of orientation towards place or community: ‘place orientation’, ‘sense of place’ (SOP) and ‘sense of community’; and attachment to them: ‘sense of belonging’, ‘place attachment’ and ‘community attachment’. I call these relationships ‘psychosocial orientation and attachment factors’ (POAFs) for short and present summary descriptions derived from a comprehensive literature review.

There are two important aspects of these relationships for health impact assessment (HIA) and development: a person's knowledge of these characteristics, and their emotions about the place or community. These characteristics and the emotions that accompany them shape people's outlooks on, and behaviour in, a place or community. Two possibilities are of broad relevance: (1) the defining characteristics of place or community membership create a secure knowledge of that place or community; (2) people's emotions about a place or community influence the way in which they regard it. Our knowledge of and emotions about a place and its people influence our understanding of behaviour that is acceptable and desirable within a community or culture. For example, knowledge of an attractive place that stimulates positive feelings can encourage people to walk in the public realm. Similarly, positive feelings about a friendly and inclusive community may promote empowering civic behaviours. These everyday behaviours and activities may appear trivial from a macro-level policy perspective, but they are the social fabric of people's lives and afford reassuring familiarity.

An infrastructure or natural resource development can change the characteristics of place or community, influencing how people feel about it and behave there. For example, constructing a road may require buildings to be demolished, or changes to a landscape, to which people have ‘place attachment’. This can affect people's perceptions of it. Feelings will differ within communities, but some people may express unhappiness about the change. People might move, out of choice or necessity. This can diminish relationships of trust, and hence ‘sense of community’ or ‘community attachment’ among those who stayed. In each of these cases, the counter-factual might be true: some people relish change or stand to benefit from change. These effects will be felt differently within each community. Prospective or actual negative changes can impact on people's emotions about a place and their behaviour there, hence their well-being. The social and health effects of the proposals can be immediate for people who fear change. The health effects may precede any change in the biophysical environment: adverse effects are more noticeable and can include anxiety, frustration and anger about the proposed changes (see discussion in Stewart et al. 2010).

Jenkins (1999) and Baldwin (2012) show how, in the context of the UK, POAFs endure over time. Perceptions of place and community members form long-lasting reference points for personal identities. When the characteristics defining them are changed, the psychosocial and behavioural impacts can last beyond the impact assessment period and project cycle. HIA tries to identify how changes caused by projects affect people. HIA aims to understand how ‘development induces unintended changes to health determinants and resulting changes in health outcomes’ (Quigley et al. 2006). An understanding of POAFs and any psychosocial and behavioural impacts may be useful to HIA. These relationships are addressed in HIA through the health determinant, social capital (SC).

SC is a key way in which POAFs are addressed in HIA. SC is a complex and contested, multidimensional sociological concept and health determinant. It has various components. Putnam (1993) understands it as an asset of communities, mentioning three core components: networks, norms and trust that generate positive outcomes for members. Sense of belonging to a community is another aspect/outcome. Other researchers have considered other POAFs as aspects/outcomes of SC: e.g. ‘sense of belonging and place attachment’ (Schaefer-McDaniel 2004).

Grootaert and van Bastelaer (2001) recognise a division of SC's components into two forms: structural and cognitive. The structural form pertains to networks and the social structure of communities. The cognitive form comprises norms, trust and other cognitive variables. In infrastructure development, the structural component can be connected to the social infrastructure of communities – their facilities, amenities, and services, and even biophysical places (e.g. green spaces), which can help create community networks. Social networks can result from trust between people, or building trust can be an outcome of networks in a place. People develop relationships to place and community (POAFs) as an outcome of both forms of SC. HIAs must assess project impacts on both forms because: ‘Social capital exerts its influence on development as a result of the interactions between two distinct types of social capital: structural and cognitive’ (see examples in Grootaert & van Bastelaer 2001, p. 5). As well as benefits for health, there are benefits for developers.

I critique the case of a UK HIA of a national-level infrastructure project, called ‘Highway 5’ for client confidentiality. It initially failed to recognise POAFs in its assessment of project impacts on SC, which facilitates a discussion on how HIA practitioners can improve the ways they assess impacts on POAFs. I propose they learn from social anthropology – a behavioural social science. I identify connections between HIA and anthropology, and benefits of linking both, highlighting the benefits of considering POAFs for developers. I acknowledge that social impact assessment (SIA) practitioners working on community-level well-being use social science concepts such as ‘sense of place’ (e.g. Vanclay 2009). However, this also is a matter for HIA which is more prevalent in the UK, but does not employ these terms. I thus seek to explore how these concepts might be used within HIA.

Methodology

This paper is informed by my professional experience of UK ethnography and an HIA. As an anthropologist, I was employed to work on the social determinants of health (SDH) aspect of the Highway 5 HIA. I drew upon my doctoral thesis and its literature review of UK ethnographies to advise my client (see Baldwin 2012). This advice informs the Highway 5 case study. The methodologies recommended to the client and in this paper were used in my doctoral study. The paper adds the voice of a community behaviour specialist to the issue of how impacted communities' perceptions are incorporated into an HIA. The study of medical pathways between people's perceptions and health are beyond its scope.

I conducted a purposive review of literature and sources. Work on SC (e.g. Putnam 1993; Grootaert & van Bastelaer 2001; Schaefer-McDaniel 2004) builds a link to POAFs. The ethnographic literature on British communities (see Baldwin 2012) guided the selection of these terms, as did the SC literature. There are others, but the cited terms were considered the most relevant to SC. Sociological and psychological literature was used to define them (see Table 1).

Linking HIA and anthropology

Anthropologists study the social interactions in communities, members' self-perceptions and behaviours. They use participant observation (PO) whereby they participate in a community over years and simultaneously observe what is taking place. PO followed by the application of qualitative data-gathering methods, i.e. focus groups, semi-structured interviews and open-ended questionnaires enables the researcher to construct a theory by which s/he seeks to understand how the community sees, and operates in their world. Data are analysed inductively using theoretical concepts to produce combined holistic descriptions and analyses of community life – ethnographic texts. There is an ethnography of UK communities which describes the cultural importance of POAFs, how they guide local behaviour and fare in response to change (e.g. Cohen 1982; Dawson 1998; Jenkins 1999; Baldwin 2012). Prominent themes are ‘community, continuity and change’ (Macdonald et al. 2005, p. 587). These works show that people develop POAFs at individual and community levels, and that those relevant in a specific place may not be relevant elsewhere.

An example from my doctoral thesis – an ethnography of community life in Swindon, an English town – shows how a POAF impacted on town residents' response to a development. The community-level SOP expressed by residents encompassed disdain for the run-down built environment, and adulation of green spaces and the surrounding landscape (Baldwin 2012). The SOP involved both a distancing from the built environment and attachment to the biophysical one. This resulted in an emotionally charged and successful campaign to prevent developers building housing and a university on Coate Water Country Park (Baldwin 2012). Examining the SOP would have shed light on the community's likely response. It would have shown that regeneration of the existing physical environment would be more socially sustainable, given the importance of green space. POAFs reveal much about a good or bad quality of life. If an SOP is defined by negative characteristics, the place may fail to attract emotional attachments. HIA practitioners and developers can think about ways of enhancing the good characteristics and mitigating the bad ones.

Anthropologists can sensitise HIA practitioners to the concepts describing POAFs, and how to operationalise them in HIAs. Anthropologists' approach, ethnographic sources, and data-gathering methods can be applied in HIA's community profiling exercise. This offers communities and developers several benefits.

In impact mitigation, the provision of social infrastructure to support the structural form of SC alone may be experienced by the community as ‘tokenistic’ compensation and reflective of a disinterest in its long-term well-being. This can result in a failure to win members' trust and gain support for a project. Providing facilities does not on its own improve their quality of life. The quality of local interactions and people's emotions about a place or community is also an important indicator. A community centre may be built, but if there is a lack of communicative relationships between residents, who hence do not feel a ‘sense of community’, they may see no reason to use it. Developers may improve a community's trust by improving and demonstrating their understanding of people's experience of the social community environment, and psychosocial impacts of development, rather than simply providing amenities. This communicates a genuine interest in people's well-being.

Anthropological methods cultivate the trust of a community and provide information on this wider social environment. Ethnography, PO and qualitative data reveal the characteristics of place and community that define POAFs. Investigating disturbances to these characteristics and resulting impacts shows when changes to place and community-based factors influence negative psychosocial impacts. The same methods – especially PO – can be used to monitor the course of these changes in the long-term. I apply the benefits of linking HIA with anthropology to a case study of Highway 5 HIA's treatment of SC.

Highway 5 and SC

The initial Highway 5 HIA plan proposed to assess impacts on SC using two indicators of the community infrastructure of inhabited areas pre/post-development: (1) the number of community and cultural venues and (2) the number of places of worship. The cognitive form of SC was not recognised, and hence impacts on POAFs. I alerted the HIA leads to the problem, who became open to addressing POAFs with new indicators, data sources and methods.

The scheme proposed to cut through urban and rural communities over a sizeable geographic area. Anticipated biophysical changes were those caused by potential housing blight, acquisition of commercial and green land, and the presence of the scheme. A change in the perception of the biophysical environment is linked to potential changes to the POAFs connected to ‘place’. Potential changes to the social community environment included changes to the composition of the community – the addition of the construction workforce – and demographic change caused by people forced to stay in or leave an area due to effects on property. These changes could affect the perception of community, and hence changes to POAFs linked to ‘community’, e.g. ‘sense of community’ or ‘community attachment’. Alterations to both place and community-based POAFs can impact on a ‘sense of belonging’ to either.

Face-to-face and telephone consultations, undertaken for a separate environmental impact assessment (EIA) with residents and business owners to address other impact areas, coincidentally revealed high anxiety and emotional anticipation over changes to the landscape, and community environments. Both groups expressed place and community attachments. However, the precise POAFs would need substantiating through investigation. Their responses provided an early indicator of emotional distress that would escalate if/when the project disturbed these attachments, and these changes were not mitigated. The HIA's initial approach was problematic in this regard due to the known links between environmental risks/changes perceived and felt/experienced by the public, and health.

POAFs and health

Stress and anxiety are likely to be immediate health effects arising from any development, proposed or actual. The development itself may never occur but the expectation of change can have adverse health effects (see discussion in Stewart et al. 2010). These may be low-level but can be pervasive.

Qualitative input to HIA methodology

What happened in Highway 5 HIA

In the Highway 5 HIA, the following methodological steps were proposed and some adopted:

• Drawing from UK ethnography, POAFs were anticipated as potentially significant to communities affected by the proposal.

• I proposed a scoping exercise using focus groups or semi-structured interviews with residents to solicit articulations of their POAFs. At minimum, semi-structured interviews with local government ‘community relations officers’ with a local overview were recommended. These data would enable a rapid analysis of locally significant POAFs.

Although the HIA leads were positive about the use of direct contact methods, the proponent forbade community involvement in the HIA scoping exercise. They restricted it to ‘expert’ public health stakeholders, probably in view of public opposition, and an unwillingness to jeopardise the project's future.

Instead, the idea of POAFs was pursued through pre-existing statistical indicators from national data-sets, which were dropped if the sample size was considered too small. The HIA eventually focused on ‘sense of belonging’ to represent the cognitive form of SC.

This prescriptive approach is problematic. Using pre-defined statistics to search for evidence of ‘sense of belonging’ fuels an assumption of how people will relate to place/community. It assumes that they will ‘belong’ or not, without understanding the biophysical or community characteristics that positively instil this ‘belonging’ that may potentially change. ‘Sense of belonging’ is usually preceded by a ‘sense of place’ or ‘sense of community’, and/or ‘place’ or ‘community attachment’, which provokes a ‘sense of belonging’. Temporary visitors may have a simple ‘place orientation’. These different possibilities merit a proper investigation.

Overall problems were: a focus on the structural side of SC, a lack of understanding of the different concepts describing POAFs and the lack of an adequate methodology to assess project impacts on POAFs.

What should have happened in Highway 5 HIA

The anxiety and negative emotional expressions about potential changes caused by the proposal merited a qualitative investigation of POAFs and any health impacts. Data-gathering on POAFs, using anthropological principles, should be integral to an HIA's community profiling exercise. HIAs demand a more rapid time-frame than ethnography, but the principles of ‘self-revealing’ rather than ‘pre-emptive’ engagement should still be applied. Ethnography and PO can provide an understanding of potentially pertinent community issues. Face-to-face data-collection methods give impacted people the opportunity to open up about locally significant POAFs, and what experiences, environmental and community characteristics constitute them.

Mixing qualitative with quantitative methods

HIA practitioners can use survey data to expand the sample of people asked about POAFs, and cross-check qualitative against quantitative data to uncover discrepancies. The initial qualitative data can guide a search for indicators of POAFs and data from pre-existing data-sets. In the Highway 5 HIA, there was cross-over between some POAFs highlighted as significant in the ethnography of British communities (‘sense of community’ and ‘sense of belonging’) and several national survey indicators. Although there is a recognised shortage of survey data measuring POAFs, there are some exceptions.

The ideal combination of survey data is pre-existing national or local surveys with local-level indicators, and a section of an original HIA questionnaire survey informed by the initial qualitative data. This section can measure the number of people expressing POAFs, investigate trends in their constituting characteristics and people's feelings about possible changes to them. Questions can be asked using proxies for POAFs expressed in everyday language, and a master list of indicators created. The questionnaire can be applied across different local geographies. Those indicators which are irrelevant in a specific area can be dropped from that area's final list. It is likely that enough standard items will remain on the master list to allow for cross-area comparison. It should ideally be delivered in person or by phone if a wide geographical distribution of the human sample prevents this. A 3-month time-frame is possible for achieving samples ranging from around 800 to 1300. Workshops should be used to validate and explore these responses in detail, where scenario-building tools can be applied to elaborate on impacts and discuss mitigation possibilities.

Conclusion

This paper has presented an argument that links POAFs to the negative emotional, behavioural and health impacts of developments that adversely affect them. Social anthropology and the social sciences were introduced to offer a conceptual vocabulary for POAFs, an approach and methodology that can improve an HIA's assessment of impacts on POAFs under the health determinant, SC. To operationalise this proposal, a UK HIA was critiqued, and the methodological steps taken and their short-comings were discussed. An alternative methodology blending qualitative with quantitative strategies was proposed. The case for people who are adversely impacted by changes to their POAFs was made.

In other cases, people will not be affected as described. Some people like change, and businesses often benefit from infrastructure development. Communities are not homogenous, spanning individuals and different groups, and people have many relationships to the physical and social community environments. Moreover, any health effects will be differentially distributed. Vulnerable people may suffer more, such as the less mobile elderly, who are more likely to be rooted in one place. The effects are low-level and personal, which may be a reason why POAFs are less routinely assessed in HIA and IA more broadly.

However, as HIA practice strives to improve, my approach offers further benefits for practitioners internationally. Already stated were: making the topics (e.g. POAFs) and methods of an HIA's community engagement process more convincing to communities, and sensitising a developer's approach, with business benefits. The SDH brings a more holistic consideration of health impacts to HIAs by examining the social causes of health issues. A holistic HIA requires a multidisciplinary team, including an engagement with social science and social scientists, with experience of monitoring long-term changes. This paper shows the fruits of this partnership. The argument made could be developed further through a collaboration between social, psychological and biomedical scientists.

Finally, the link between POAFs and health benefits broader planning and development research and policy, which aspires to create more sustainable and resilient communities. POAFs are an asset to the well-being and social sustainability of communities (Dempsey et al. 2009). POAFs are also a feature of social cohesion (Forrest & Kearns 2001), both of which are factors that build community resilience to unforeseen adversities, and are directly linked to well-being (Zautra et al. 2008). As a trend, HIAs will become more intertwined with the sustainability and resilience agendas, as the conditions that we can control must be made robust in the light of global increases in the ones we cannot.

Acknowledgements

Thanks to Ben Cave for kindly commenting on and editing this paper, Atkins colleagues for supporting the approach, and Andrew Simmons for edits.