Health Impact Assessment (HIA)

1. Health Impact Assessment (HIA) A combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population (Gothenburg consensus statement, 1999)

2. Health Impact Assessment • Tool to objectively evaluate a project/policy before it is implemented • Provide recommendations to increase positive and minimize negative health outcomes • Encompasses a variety of methods and tools • Qualitative and quantitative • Community input and/or expert opinion • Has been performed extensively in Europe, Canada and other countries • Regulatory and voluntary basis

3. Potential Contributions of HIA • Bring potential health impacts to the attention of policy-makers, particularly when they are not already recognized or are otherwise unexpected • Highlight differential effects on population sub-groups

4. Using HIA for Projects vs. Policies • Projects: Physical developments (highway, rail line, park, trail, housing complex, etc) • Affect smaller population • More detailed plans • Easier to define target population, stakeholders, and perform impact estimation • Policies: Set of rules and regulations that govern activities and budget expenditures (zoning, farm subsidies, living wage law, etc.) • Affect larger population • Greater impact on public health • Health impacts may be harder to quantify

5. HIA Level of Complexity • Qualitative – describe direction but not magnitude of predicted results • Easy to predict; hard to use in cost/benefit models • Example: Build a sidewalk and people will walk more • Quantitative – describe direction and magnitude of predicted results • Difficult to obtain data; useful for cost/benefit models • Hypothetical example: Build a sidewalk and 300 people who live within 200 yards of location will walk an average of 15 extra minutes per day

6. Voluntary vs. Regulatory • Voluntary (a tool used by a health officer to inform a planning commission) • Simpler, less expensive, less litigious • Less likely to be used if not required • More politically acceptable • Regulatory (modeled on a required environmental impact statement) • More complex, more expensive, more litigious • More likely to be used if required • Less politically acceptable

7. Community Involvement in Conducting an HIA • Increases community buy-in to project • Helps identify social issues as well as health issues • Commonly used in HIAs in Europe • May add substantially to time and resources needed to conduct HIA • Combining lay vs. expert knowledge • Difficult to identify all stakeholders

8. Timing of HIA • HIAs best done as early as practical in decision process • Ongoing work with decision makers and planners is best • Ideally decision makers will ask for HIA to be done and may provide comments on draft HIA • HIA needs to wait until sufficient details about project or policy are defined • Close involvement with decision makers could compromise HIA independence

9. Tools & Guidelines • Merseyside Guidelines for HIA – general • European Policy HIA Guide • New Zealand Guide to HIA • Swedish County Council model – inequities focus • British Columbia model – policy focus • West Midlands, Univ of Birmingham – checklist • IMPACT – rapid HIA tool • WHO Healthy Cities website – HIA toolkit • Framework developed for current CDC/UCLA HIAs

10. Relationship of HIA to Environmental Impact Assessment • EIA • Regulatory • Thousands conducted each year • HIA components could logically fit within an EIA

11. Learning from EIA • But EIAs… • Long, complex documents • Process is time-consuming and expensive • Often litigious process • Tends to focus on projects, not policies • Tends to stop short of considering health outcomes

12. HIA efforts outside the U.S. • Extensive work for nearly a decade • Increasing interest • Usually focused on local projects • Often linked to EIA or focused on facilitating community participation

13. HIA in the U.S. • To date only a handful have been completed • Voluntary basis • Very few people currently trained to complete HIAs • However, there is a lot of interest in HIA (APA, NACCHO, CDC, RWJF, FHWA, ARC, CQGRD)

14. Examples of Completed HIAs • London Transportation Strategy • California’s After School Programs • California’s Living Wage Ordinance

15. Steps in Conducting a Health Impact Assessment • Screening • Identify projects or policies for which an HIA would be useful • Scoping • Identify which health impacts should be included • Risk assessment • Identify how many and which people may be affected • Assess how they may be affected • Reporting of results to decision-makers • Create report suitable in length and depth for audience • Evaluationof impact on actual decision process

16. Screening – When to do HIA • In general, HIA is most useful • For policy-decisions outside health sector • When there are likely to be significant health impacts that are not already being considered • The HIA can be completed before key decisions are made and stakeholders are likely to use information • There are sufficient data and resources available

17. Scoping - Health Impacts to Consider in an HIA • Physical activity, obesity, CVD • Air quality, asthma, other respiratory diseases • Water quality, waterborne diseases • Food quality, food borne diseases, nutrition • Motor vehicle, pedestrian and other injuries • Accessibility for persons with disabilities • Noise • Mental health • Social capital • Social equity, environmental justice

18. Risk Assessment • Logic frameworks • Assessing research evidence • Qualitative vs. quantitative outcomes • Calculate estimates of morbidity and mortality • Cost-effectiveness when feasible

19. Reporting of Results • Full report • Provides details of scoping, literature review, analysis, assumptions, findings, sensitivity analysis, level of uncertainty, discrepant views, and recommendations • Helpful to others conducting similar HIAs • Non-technical report • Often litigious process • Short and easy to read • Include background, findings, and recommendations • Created for decision makers, community stakeholders, and lay audiences

20. Evaluation of HIA • Three major forms of evaluation • Process evaluation of HIA process steps done • Impact evaluation of effect of HIA on project or policy • Outcome evaluation of later health impacts from project or policy compared to predicted • Also evaluate level of stakeholder involvement • Some HIA evaluations have been completed; more needed • Develop a list of criteria for HIA evaluation • Variability in HIA reporting makes evaluation difficult

21. Examine Feasibility of HIA is U.S. • Received funding from RWJF to complete two case studies of HIA • Worked with UCLA to complete these case studies • Both case studies are still in progress but preliminary results from one case study will be presented

22. Screening – Initial List of HIAs • General Walkability • Walk to School • Trails (recreation and transportation) • Active Commuting to Work • Worksite Interventions • Mass Transit • Zoning • Location Efficient Mortgage • Buford Highway • Beltine

23. Screening - Selection Criteria • Specific enough to create quantitative estimates • Impact physical activity • High quality data • Not overly complicated • Political interest • Target at risk populations • Foundation for other HIAs • Generalizability

24. Screening - Selecting Case Studies • Walk-to-school HIA • Natomas school district in Sacramento, CA • Little seasonal variation • Poor and ethnically mixed • Lots of political interest and ongoing in many communities • Buford Highway HIA • Highway redevelopment in Atlanta, GA • Part of International Corridor • Most dangerous highway in Atlanta for pedestrians • Many similar locations around the U.S. • Hypothetical redevelopment plan created by Georgia Tech.

25. Case Study: Buford Highway HIA • Hypothetical redevelopment included: • Reduce the number of lanes from 7 to 4 • Build sidewalks and add crosswalks • Add bike lanes • Add center median • Change local parking requirements to allow shared parking and on-street parking • Increase density and land-use • Develop unused greenspace