Using Health Impact Assessment (HIA) to identify the potential health, wellbeing and equity impacts of a proposed national lung cancer screening programme in Wales

Abstract

Lung cancer remains the leading cause of cancer mortality, with prognosis strongly dependent on early detection. Emerging evidence from major trials and pilot programmes in the United Kingdom (UK) demonstrates that low dose computed tomography (LDCT) within a lung cancer screening programme (LCSP) can shift diagnosis toward earlier stages and reduce mortality. However, little is known about the wider health, wellbeing and equity implications of a LCSP. This study reports the first prospective Health Impact Assessment (HIA) of a proposed national LCSP in Wales. A rapid prospective HIA was undertaken by the Wales Health Impact Assessment Support Unit in partnership with the Screening project team at Public Health Wales, UK. Evidence sources included a national clinical review, evaluation findings from a 2023 Lung Health Check pilot, national demographic and epidemiological data for the impacted population groups, and a participatory stakeholder workshop involving primary care, third sector organisations, screening specialists and service user representatives. Thematic analysis was applied to synthesise the collected quantitative and qualitative evidence, guided by established HIA population and determinants checklists. The HIA identified a wide range of population groups likely to be affected by the potential LCSP in Wales. For example, people who smoke and those who may have a history of smoking could be impacted positively, and older adults, people with disabilities or sensory needs, carers, shift workers, rural residents, transient populations, asylum seekers, and those facing language or digital barriers could be impacted negatively. Potential positive impacts included earlier diagnosis, opportunities for smoking cessation, improved access to wider health services, and strengthened community engagement. Potential negative impacts related to stigma, anxiety, accessibility challenges, travel costs, digital exclusion for example by not having access to a smart phone or laptop, data gaps, and risks of widening inequalities if implementation was not carefully designed. Potential determinants affected included mental wellbeing, social cohesion, environmental accessibility, economic burden, and technological considerations such as bias from using artificial intelligence. Recommendations focused on inclusive communication, trauma-informed delivery, flexible appointment models, community-based outreach, safeguarding, and ensuring fully funded, person-centred pathways. This HIA demonstrates the value of applying a participatory, determinants-based approach to a national cancer screening policy. Through the early identification of wider health and equity impacts, the process informed the Welsh Government’s decision-making and shaped the LCSP’s design. The findings offer transferable learning for other nations developing LCSPs and highlight the importance of embedding equity, accessibility and community engagement in screening implementation.