Journal of Public Health Medicine
268±274
A prospective health impact assessment of the
Merseyside Integrated Transport Strategy
(MerITS)
Nigel Fleeman and Alex Scott-Samuel
Abstract
Background Prospective health impact assessment is a new
approach to predicting potential health impacts of policies,
programmes or projects. It has been widely recognized that
public policies have important impacts on health. In 1997,
the Liverpool Public Health Observatory was commissioned
to carry out a health impact assessment of the Merseyside
Integrated Transport Strategy (MerITS). A secondary aim
was to pilot a method for health impact assessment at the
strategic level.
Methods The methods used drew on previous health impact
assessments of projects, on strategic environmental assess-
ment, and on policy research. They included policy analysis,
semi-structured interviews with key informants and literature
searches.
Results Four priority impact areas of MerITS were identi®ed:
establishing road hierarchies, economic viability, air quality,
and public transport. Potential health impacts in each of
these areas were estimated, and recommendations were
made to minimize the effects of negative impacts and to
enhance positive ones.
Conclusion This health impact assessment prospectively
identi®ed the key health impacts of a strategy on a de®ned
population and made recommendations to maximize poten-
tial positive and minimize potential negative health impacts.
The methods employed are generally applicable to pros-
pective health impact assessments of public policies and
strategies.
Keywords: health impact assessment, public policy,
transport policy
Introduction
Prospective health impact assessment (HIA) is a recently
developed approach to estimating the health impact of public
policy.1,2 HIA has been de®ned as `the estimation of the effects
of a speci®ed action on the health of a de®ned population'.3
The UK Government has stated its intention to apply health
impact assessments to `major new Government policies'
nationally, and is encouraging health authorities, local autho-
rities and other local agencies to undertake local health impact
assessments,4 in recognition of the evidence that population
health is the outcome of a range of social, economic and
Vol. 22, No. 3, pp.
Printed in Great Britain
environmental factors. In 1998, Liverpool Health Authority
commissioned the Liverpool Public Health Observatory to
undertake a prospective health impact assessment of the
Merseyside Integrated Transport Strategy (MerITS). The pri-
mary aim of this HIA was to predict the likely health impacts
arising from the implementation of MerITS.
The Merseyside region is in the northwest of England. It has a
population of approximately 1.4 million people, mostly living in
conurbations ± of which the largest is the city of Liverpool
(population 0.47 million). MerITS is the regional investment
strategy for achieving an integrated transport system in
Merseyside. It has been developed by a partnership of the
region's ®ve local authorities and the regional passenger trans-
port authority and executive (Merseytravel). The strategy is
subject to continuing review and forms the framework for an
annual package bid for government funding. Its implementa-
tion is based on an approach which focuses on the main
centres in, and gateways to Merseyside, together with the key
corridors of movement between them.
Following the UK Government's White Paper on trans-
port,5 this arrangement will be replaced by a Local Transport
Plan, also based on the MerITS strategy. The health impact
assessment was carried out on the 1997 MerITS package bid,6
which consisted of four broad policies, and a series of policy
actions ¯owing from them (Table 1).
The ®rst prospective health impact assessment carried out
in the United Kingdom was undertaken on the proposed second
runway at Manchester Airport in the early 1990s.7 Prior to
Liverpool Public Health Observatory's programme of work
(which began in 1997),8±11 the only published prospective
health impact assessment in the developed world was in
Melbourne, Australia.12 This adopted a narrow de®nition of
health based solely on physical environmental in¯uences. All
Liverpool Public Health Observatory, Department of Public Health, University
of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB, UK.
Nigel Fleeman, Research Associate
Alex Scott-Samuel, Director
Address correspondence to Dr Scott-Samuel.
E-mail: alexss@liverpool.ac.uk
q Faculty of Public Health Medicine 2000
 HEALTH IMPACT ASSESSME NT OF ME RSEYSIDE INTEGRATE D TRANSPORT STRATEGY 269

Table 1 Summary of MerITS's policies and policy actions6

Policy Policy actions

Policy 1: To support economic development and
urban regeneration opportunities
Policy 2: To increase the relative attractiveness of
public transport, cycling and walking
Policy 3: To secure the ef®cient use of the existing
road network
Policy 4: To improve road safety and environmental
quality for all, and to improve access for people
with disabilities
1.1 Local road improvements and traf®c management
1.2 Better links to regional and national networks
1.3 Provide good public transport facilities in all areas of major employment
1.4 Parking policies to promote economic viability
1.5 Promoting use of commercial freight by rail
2.1 Infrastructural improvements to all aspects of public transport ± e.g. bus and
rail stations, bus shelters
2.2 Improved access to public transport vehicles
2.3 High-technology ticketing and passenger information systems
2.4 Complement public transport improvements with demand management
measures, particularly at peak periods
2.5 Bus priorities on major bus routes
2.6 New rapid transit route into Liverpool by high quality, accessible, fast,
frequent, environmentally-friendly and modern form of transport
2.7 Safer cycle routes and training and awareness programmes for cyclists
3.1 Establishing road hierarchies
3.2 Traf®c management and minor road improvement
3.3 Traf®c calming in residential and shopping areas
3.4 Priority for modes of transport which are ef®cient in their demand for road
space
4.1 Removal of through-traf®c from environmentally sensitive roads by speed
regulation, traf®c calming and other traf®c management measures (such as
pedestrianization)
4.2 Minor road works to improve safety, amenity and personal security
4.3 Restraint of traf®c growth (particularly in peak periods) by demand
management, improving public transport and promoting greater use of cycling
4.4 Use of lower emission fuels in buses and encouragement of better vehicle
design (including access)
4.5 All new transport infrastructure to be made fully accessible, and progressively
improve access to existing infrastructure
4.6 Promotion of safer routes between home and school

of these earlier HIAs have in common a focus on projects
rather than on policies. Thus, a secondary aim of this HIA
was to pilot a method that could be applied to policies and
strategies.
Methods
Liverpool Public Health Observatory's approach to health
impact assessment2,3 identi®es potential health impacts using
a socio-environmental model of health, derived from the work
of Lalonde13 and LabonteÂ,14 who acknowledged a broad range
of health determinants (Table 2). A potential health impact
is a predicted change in the frequency of a health determinant
or outcome in the study population.
Given the absence of prior experience of HIAs of strate-
gies, the principles of the approach used built on those of
project assessments8±11 and of strategic environmental assess-
ment,15 and on policy analysis.16,17 The method aimed to
identify potential positive and negative health impacts of
MerITS on its de®ned population, the probability and
quanti®ability of these impacts and who (in social and
demographic terms) would be affected. Like earlier project
HIAs, the assessment also aimed to be participatory in nature, to
re¯ect the range of stakeholder perspectives.
Important health impact assessment procedures include
the establishment of a steering group of commissioners,
assessors, project/policy proponents and other stakeholders ±
including, wherever possible, representatives of affected com-
munities. The steering group de®nes the terms of reference
of the HIA and provides advice and support as it develops.
In this case, the steering group was able to provide detailed
information about the strategy and its policies, suggest rele-
vant contacts and arrange meetings.
The method employed took the four policy elements of
MerITS listed in Table 1 and applied to these the six categories
of health in¯uences listed in Table 2. The resulting 4 ´ 6 matrix
formed the framework for data collection, through a series of
semi-structured interviews with key informant groups invol-
ved with or affected by MerITS. Potential impacts identi-
®ed during interviews were recorded and areas of agreement,
270 JOURNAL OF PUBLIC HEALTH MEDICINE

Table 2 Key areas in¯uencing health

Categories of in¯uences on health Examples of speci®c in¯uences

1 Biological (®xed) factors 1.1 Genetic

1.2 Sex
1.3 Age
2 Lifestyle 2.1 Diet
2.2 Physical activity (including exercise)
2.3 Recreation
2.4 Means of transport
2.5 Risk-taking behaviour and substance use (includes
cigarettes, alcohol, drugs and sexual behaviour)
3 Social and economic environment 3.1 Employment
3.2 Culture
3.3 Peer pressures
3.4 Social exclusion
3.5 Discrimination
3.6 Community and spiritual participation
4 Physical environment 4.1 Housing conditions
4.2 Working conditions
4.3 Water quality
4.4 Air quality (including smell)
4.5 Noise
4.6 Public safety and security
5 Access to services 5.1 Education
5.2 Health ± primary and secondary services
5.3 Social services
5.4 Housing services
5.5 Transport
5.6 Leisure
5.7 Police
5.8 Voluntary services
6 Public policy 6.1 Local policies/priorities
Economic
Social
Environmental
Health
6.2 National policies/priorities
Economic
Social
Environmental
Health

disagreement and speculation were noted. A literature review Results

was conducted to identify evidence relating to known impacts
of transport on health. Priority impact areas were then
identi®ed, on the basis of at least one of the following criteria
being satis®ed: (1) predicted impacts having clear and impor-
tant health implications; (2) the high frequency with which
key informants identi®ed particular impacts as a priority; (3)
identi®ed impacts being causal precursors of further (more
proximal) impacts; (4) predicted impacts having clear and
important policy implications. Recommendations were then
drafted, in conjunction with the Steering Group, to address
these areas.
Many known impacts of transport on health of relevance to
the MerITS policies were identi®ed in the literature (Table 3).
There is now widespread acknowledgement of transport as
a public health issue.26,27 From these known impacts and the
key informant data, four priority impact areas were identi®ed
using the above criteria: (1) road hierarchies; (2) economic
viability; (3) air quality; (4) public transport (Table 4).
Recommendations to address potential health impacts within
these priority impact areas were formulated with the assistance
of the Steering Group.
 HEALTH IMPACT ASSESSME NT OF ME RSEYSIDE INTEGRATE D TRANSPORT STRATEGY
Table 3 Summary of known health impacts of transport which are of relevance to the MerITS
Impact area
Road traf®c accidents
Air pollution
Noise pollution
Social exclusion
Access to friends and family and shops and services
Dependence on cars
Cycling, walking and the use of public transport
Review of potential health impacts within priority
impact areas
Road hierarchies
Although the health of people in Merseyside will be improved
overall by prioritizing traf®c on certain roads as a result of
implementing road hierarchies, for a minority of people,
living in areas where heavy traf®c on roads is given greater
priority, there will be negative impacts on health. These
include increased social exclusion as a result of greater traf®c
¯ows, reduced access to many shops and services, reduced
access to healthy diets and lifestyles, and increased noise
levels. But there are options available for addressing these
problems, including resurfacing carriageways with lower-
noise surfaces, noise barriers, secondary acoustic glazing,
speed restrictions (to improve air quality and reduce acci-
dents), `polluter traps' and targeted pollution testing to remove
271
Health impacts
Road traf®c accidents can result in a variety of injuries ranging from very minor
to death
Air pollution increases the likelihood of eye, nose and throat irritations, chest
pain, asthma attacks, headaches, drowsiness, nausea, slowed re¯exes,
respiratory disease, chronic bronchitis, anaemia, reduced lung function and
increased risk of cancer, particularly leukaemia and lung cancer.18 Public
transport generally reduces the risk, except when old ¯eets of buses are used
High noise levels can disturb sleeping patterns, increasing stress and depres-
sion19 and impair the performance and educational attainment of children20,21
Social exclusion can result in reduced physical activity. This has many negative
health impacts: coronary heart disease, respiratory disease, stroke, stress,
depression, anxiety and a general lack of well-being; greater risk of
cardiovascular disease, obesity and non-insulin dependent diabetes mellitus.
A lack of social support may also reduce life expectancy and resistance to
infections, although increasing the likelihood of depression, coronary heart
disease, and a recurrence of cancer.22 Particularly vulnerable groups include
children, older adults and people with disabilities
Access to friends and family reduces the risk of social exclusion, stress,
depression and anxiety. Access to shops selling food at affordable prices is
required for access to a healthy diet. A healthy diet reduces the risk from
coronary heart disease and cancer. Access to emergency and other services
(e.g. leisure) enhances health generally
A high dependence on cars increases the road traf®c risks including accidents
and levels of air and noise pollution, as well as reducing physical activity. There
may also be a loss of independent mobility for those without cars, increasing
the likelihood of social exclusion and reducing both levels of physical activity
and access to friends, family, shops and essential services23
Cycling, walking and the use of public transport increase physical activity and
reduce the risk of social exclusion. However, potential negative impacts to
cyclists and pedestrians exist but are largely a result of con¯ict with other
forms of motorized transport (increase in accidents)24,25 and air pollution
(vehicle emissions). Potential negative impacts in terms of public transport
relate to old buses increasing levels of air pollution. Negative health impacts
have also resulted from bus deregulation and the loss of conductors (see text)
grossly polluting vehicles, and `greener' motoring advice
and training.
Economic viability
There was some concern as to whether the better links to
national networks proposed in MerITS would actually improve
the economic viability of centres in Merseyside, or alterna-
tively, result in services more readily moving elsewhere within,
or beyond, Merseyside. As well as employment implications,
there could be an increased dependence on cars, reduced
independent mobility (especially amongst children and older
adults), reduced access to affordable healthy diets, reduced
access to recreation and leisure, and reduced access to essential
services, simply by services moving and jobs being lost.
Similar problems were feared with regard to MerITS'
proposed parking policies (i.e. fewer available car parking
spaces, with more emphasis on short-stay parking) in terms
272 JOURNAL OF PUBLIC HEALTH MEDICINE
Table 4 Summary of priority impact areas relating to the MerITS policies and policy actions
Priority impact area
Road hierarchies (in particular, the following health impact areas: road
traf®c accidents; air pollution; and social exclusion)
Economic viability
Air quality
Public transport
of the impacts of these on town centres. Although fewer
cars parking should have positive impacts on the physical
environment, there was the fear that it could act as a deterrent to
economic improvement.
Unfortunately, there is a lack of available evidence to
support or refute these fears about economic viability. Inas-
much as the outcomes depend on the quality of services
currently provided in Merseyside they lie outside the control
of MerITS. Nevertheless, if public transport in Merseyside
is improved as a result of MerITS, this can only enhance the
region's services, and thus reduce the likelihood of economic
viability being prejudiced. Thus, by effective synchronization
of policy measures, the probability of negative health impacts
can be reduced.
Air quality
MerITS is likely to have mixed impacts on air quality. For
example, promoting alternative fuels to petrol/diesel and
alternative means of transport to cars should reduce harmful
emissions into the air, but in areas near roads where heavy
goods vehicles are given priority, harmful emissions will
increase. However, the identi®cation of potential negative
impacts and the taking of measures to combat them should
result in positive impacts outweighing negative ones.
Using lower-emission fuels in buses would have very
positive health impacts on air quality. For example, using ultra
low sulphur fuel in tandem with the right catalytic converter
reduces signi®cantly particulate matter, hydrocarbons, and
carbon monoxide emissions.28 Potentially there are negative
impacts on air quality if old bus ¯eets are used, as these are
more polluting. Unfortunately, many old buses are still in use
in Merseyside.
Public transport
Perhaps the major barrier to encouraging a healthier public
transport system is the deregulation of buses. This has pro-
duced an uneven distribution of buses on bus routes (and the
termination of some services). People living on routes deemed
not to be economically viable are more at risk of suffering
negative health impacts from social exclusion, whereas those
on popular bus routes receive a saturation of buses during
peak hours, which is environmentally damaging and slows
Main related MerITS policies/policy actions (see Table 1)
Policy 3
Policy 1 actions, especially 1.2±1.4
All policy actions
Primarily policy 2 actions
journeys as a result of congestion. But as a result of
deregulation, Merseytravel is unable to directly control bus
routes chosen by bus companies. Although it is clearly
impossible for MerITS to reverse deregulation (and, similarly,
the privatization of rail services), the negative impacts of these
national policy measures on the health of local populations
require acknowledgement.
Public perceptions of safety on, and waiting times for,
public transport are other issues that need highlighting.
Currently, many women and older adults are reluctant to
travel on buses or trains late at night. This emphasizes the
importance of infrastructural improvements and the importance
of providing more buses on uneconomical routes (often those
serving housing estates). For example, greater penetration of
buses would reduce the distances people may have to walk
alone in the dark, thus reducing both their fear of and actual risk
of crime, improving access to services and reducing the risk of
social exclusion. Although it could be argued that such
measures would slow bus journeys down and actually deter
some people from using buses, other measures ± such as high-
technology ticketing (e.g. pre-paid swipe cards), bus priorities
(e.g. bus lanes and bus-only streets) and demand measurement
schemes (e.g. traf®c calming and parking policies) ± can play a
major role in speeding up journeys.
It has been suggested that the reintroduction of bus con-
ductors could increase passenger satisfaction (and volume)
and make public transport safer. However, the recent develop-
ment of high-technology ticketing measures could be seen as
running counter to this, in addition to its lack of impact on
passengers', or drivers', security.29 Despite this, pilot projects
undertaken by Merseytravel have demonstrated high-technol-
ogy ticketing to be popular with customers.6
In addition to coverage, it is also important that an ade-
quate volume of bus services is provided over holiday
periods, to prevent people such as older adults and single
mothers being socially excluded from family and
friends. Finally, better vehicle design will have many life-
style bene®ts for older adults, disabled people and people
with prams or pushchairs, who currently ®nd public trans-
port dif®cult to use.30 This will improve their access to shops,
services and recreation, and also lead to more physical activ-
ity as they get out and about more. The introduction of
SMART bus services (buses with low ¯at ¯oors on new
 HEALTH IMPACT ASSESSME NT OF ME RSEYSIDE INTEGRATE D TRANSPORT STRATEGY
routes, coupled with high-quality bus shelters with real-time
information) in 1994 has already demonstrated that such
measures increase patronage.6
Recommendations for addressing priority impact areas
Road hierarchies
Targeted mitigation measures are required for communities
adjacent to priority traf®c routes.
Economic viability
To allay fears about economic viability, traf®c demand
management measures, including parking restrictions, could
be phased in to ensure adequate public transport provision was
already in place.
Air quality
Local authorities should continue to monitor air quality and
build datasets for the key traf®c-related pollutants; air quality
data should be linked to available health datasets on a
geographical basis. Buses that use lower-emission fuels
should continue to be promoted.
Public transport
All available powers and means should be used to maintain
non-commercial public transport services and to avoid exces-
sive service saturation on commercial routes.
Steps should be taken to reduce the real and perceived
dangers of using public transport at night; services should be
improved at night and over holiday periods; and considera-
tion should be given to the reintroduction of bus conductors.
Finally, bus patronage should continue to be closely monitored
and accessible buses continue to be promoted.
Discussion and conclusions
Data collection in future health impact assessments of
strategies or policies may be more effective if an initial
brainstorming session is held with all key informants
to identify priority impact areas, using the matrix method
employed here. Once these have been identi®ed, the research
could then look more in depth at impacts from speci®c
policy areas or projects, resulting in more complete ®nd-
ings than was possible in this instance. Nevertheless, the ease
with which the matrix system focused discussion on the
broad categories of health affected by each policy measure,
was particularly useful in identifying recurring themes and
priority impact areas.
As a result of the priority impacts identi®ed and the result-
ing recommendations, an action plan is being developed to
adjust MerITS to address the issues they raise. The health
impact assessment has also helped to ensure that health is
®rmly on the transport agenda in Merseyside.
273
Acknowledgements
We would like to thank all the key informants who took part
in the health impact assessment and also the project Steering
Group members for their assistance throughout. Kate Ardern's
advice was particularly helpful.
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Accepted on 6 March 2000