Whilst SEA and SA are widely used and are statutory requirements across a wide range of juridstictions, there is a conspicuous lack of evidence of evaluations in this critical area relating to UK practice, with only three studies identified, and two relating to other forms of integrated appraisal (one an SA and one an EqA). Given the need public authorities to fulfil statutory equalities duties in the UK it is suprising that only one EqIA was identified.
There is little evidence that health issues were incorporated nor that health-related recommendations were incorporated into the adopted plan documents, and there is no information given about implementation. Whilst these case studies are highly applicable to the UK and the current spatial planning system, as only three case studies were identified, it is important to recognise that these examples may not be representative of SA/SEA practice in the UK. Outside the UK, there is strong evidence from all five case studies that health is considered in SEA, but no evidence that the SEA health recommendations had been implemented at post-adoption stage. One might argue, as Fishcher  has done, that, as the SEA directive requires that decision-makers should take the overall results of the assessment into account it is "probable" that health considerations had an impact, but were unable to identify little empirical evidence to support this assumption.
Similar issues in terms of evaluation are found in relation to HIA. Of the eleven UK case studies identified, only one case study reported HIA effectiveness in terms of completion of all stages from health recommendations, to implementation and post adoption evaluation . Many reported that those involved felt the process was useful, indeed successful, in improving the plans, and (in some cases) empowering local communities and environmental interests. Keys to success were seeing the HIA as part of an iterative process throughout plan preparation, and the active involvement of planners with health and other professionals. The evidence from HIA of plans in non UK high income countries suggests that the HIAs generally influenced the plan, although the degree of that influence is varied, even contested, with some analysts suggesting it is more often through raised health awareness of the decision-makers than directly as a result of the assessment.
The case studies strongly suggest that factors such as the timing of appraisal (late HIAs have been reported to have limited impact), and community engagement are critical in the success of appraisal. Full integration of comprehensive health assessment into existing formal and statutory processes increase the likelihood of health being properly considered and incorporated into the plan. However, there is a lack of data on outcomes to support this supposition.
There are limitations in the literature reviewed. Many of the publications are reports from authors who have themselves been directly responsible for undertaking the appraisal, with little independent evaluation or triangulation of reported findings, thus leading to potential bias. We were unable to access the full text of four potentially suitable articles with English abstracts but full text in other languages. Given the complexity and timescale for development, there are practical difficulties in both tracking, and attributing recommendations and changes in plans and subsequent developments to appraisal processes. Whilst the lack of evidence per se does not mean that there is a lack of effectiveness, the dearth of evidence linking appraisals to implementation and subsequent changes in outcomes is challenging. Concerns about the lack of evaluation of the impact of HIA have also been noted in the past by others , and guidance from Breeze and Lock  in 2001 highlighted the need to monitor impacts, record results of HIA, and to consider the need for monitoring of any anticpated impact(s) on people's health, but this seems to have had little impact. This may reflect the current lack of regulatory and financial requirements to carry out such evaluation, a limitation of the current development and planning processes, which are much more orientated to appraisal processes, often conducted by external consultants on a short term contract basis, who have no ongoing input at the implementation stage of the development. There is a clear case now for post hoc analysis of existing appraisals which would provide an opportunity to explore if predicted outcomes, for example on physical activity or mental wellbeing did actually materialise. There is also a case to be made to increase the emphasis on post-development monitoring, and to link appraisals more explicitly to outcomes. Whilst there are of course, significant difficulties in attributing any changes in health outcomes observed by post development monitoring, and in particular in attributing changes to either the appraisal itself, or the resultant changes in the built environment, further work in this area would enhance our understanding of the links between the built environment and health, and could inform further appraisals. Another useful focus for research might be to look at how and why health recommendations are implemented.
The study suggests that there is considerable variation in the degree to which health issues are comprehensively considered, with evidence that mental health and wellbeing issues may be particularly under-reported in SEA and other integrated appraisals. Equity issues, and consideration of the differential distribution of impacts appears to be relatively underdeveloped in all appraisals. This has implications for the training of those involved in undertaking appraisals. It is possible, that particularly during HIA, a fuller more comprehensive range of health issues was considered at the scoping and screening stage, but if no significant impacts were identified that these were not considered further.
Posas summarises the development of HIA in the context of SEA , highlighting that although health was not generally well considered in SEAs in the late 1990s and early 2000's, this began to change with the EU SEA directive (EC42/2001) with a statutory requirement for consideration of significant impacts on health as part of the EU process. This was facilitated in England, by the issuing of a consultation on draft guidance on health in strategic environmental assessment by the Department of Health , which it is anticipated will be re-issued in the near future. With the Protocol on SEA to the United Nations Economic Commission for Europe (UNECE) Espoo Convention coming into force on the 11 July 2010, there is a a legal basis for enhanced attention to human health in the SEA process. This provides a significant opportunity to have a more comprehensive approach to assessing health, and incorporating the use of HIA in informing SA/SEA processes.
However, health appraisal is only one of part of the development plan process; health considerations need to be built in at the very early conception and development of plans (arguably no additional health recommendations would be needed following appraisal of a totally robust plan), and critically, followed through to the development management process. There are clear implications for the training of planners, developers, and those involved in undertaking appraisals.
A particular point of note is the dearth of evidence from low and middle income countries. Outside the EU some countries have adopted SEA practice, or some strategic form of EIA, but there is very variable uptake and use of HIA as highlighted by Erlanger  who in a review of 237 HIA publications found only 6% had a focus on the developing world. Given the rapid scale of development in middle and low income countries and the variable development in planning legislation and environmental assessment, this is of concern.
In conclusion, action is required; firstly, to ensure that a firstly that a comprehensive approach to examining potential health impacts is undertaken, ensuring that relatively neglected areas such as mental health and well being and equity are addressed; secondly that due attention is paid to ensuring that the recommendations arising from consideration of health issues in stand alone or integrated appraisals are embedded into plans; thirdly that attention needs to be given to the current regulatory framework to ensure that evaluation and post-development monitoring is undertaken; and finally that there is more work undertaken to ensure that recommendations translate into the development process and that outcomes are as anticipated.