Background: Health impact assessment (HIA) has scarcely been developed in Spain, in comparison with other European countries. Moreover, little is known about the effectiveness of HIA, taking into account direct impacts—changes on the decision-making process—as well as indirect impacts or those related to the process outcomes. From this broad perspective of HIA usefulness, the purpose was to assess the effectiveness of five HIAs carried out in Spain at the local level, and the role played by context and process factors on these impacts. Methods: We carried out a qualitative study based on 14 interviews to HIAs participants from different sectors. A documentary review and nonparticipant observation techniques were implemented for an in depth understanding. Results: The direct effectiveness of the HIAs was partial, but they had indirect effectiveness in all cases. The institutional and socio-political context, however, was not favorable to effectiveness. The elements of the process were largely determined by the context, although their influence, mediated by the role of proactive individuals, favored the effectiveness of the HIAs. Conclusions: When assessing HIA effectiveness, it is important to take into account a broad perspective on the nature of impacts and those factors influencing direct and indirect effectiveness. In Spain, the institutional and sociopolitical context was less favorable to HIA effectiveness than process-related factors. In order to implement the Health in All Policies strategy, will be necessary to improve context-related factors, such as institutional facilitators for HIA and democratic quality.
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