|
Health Impact Assessment |
|
Fundamental Aspects of Health Impact Assessment
HIA is a relatively new approach in the United States where it is frequently a voluntary process—only a few jurisdictions have mandated or institutionalized HIA or an equivalent. In other parts of the world, where HIA is more widely employed, countries have institutionalized HIA in the law-making process. Still, HIA has proven to be a valuable resource in the U.S. and many resources, toolkits, and guidelines can assist state and local governments, public health practitioners, and stakeholders in implementing this approach. As described by the CDC, the steps that occur in the HIA process are listed below.
Steps in the HIA Process
- Screening - Identifying plans, projects, or policies for which an HIA would be useful.
- Scoping - Identifying which health effects to consider.
- Assessing risks and benefits - Identifying which people may be affected and how they may be affected.
- Developing recommendations - Suggesting changes to proposals to promote positive health effects or to minimize adverse health effects.
- Reporting - Presenting the results to decision-makers.
- Monitoring and evaluating - Determining the effect of the HIA on the decision (CDC, 2014).
Pew Charitable Trusts and the Robert Wood Johnson Foundation offer funding, training, and resources to encourage and support practitioners in using HIA through their partnership called the Health Impact Project. This joint project is leading the charge to promote HIA in the U.S. More information can be found here. These national leaders highlight several intrinsic characteristics of HIA, accessible below.
CHARACTERISTICS of HIA
- Looks at health from a broad perspective that considers social, economic, and environmental influences;
- Brings community members, business interests, and other stakeholders together, which can help build consensus;
- Acknowledges the trade-offs of choices under consideration and offers decision makers comprehensive information and practical recommendations to maximize health gains and minimize adverse effects;
- Puts health concerns in the context of other important factors when making a decision;
- Considers whether certain impacts may affect vulnerable groups of people in different ways;
- Increases transparency in the decision-making process; and
- Supports community engagement and democratic decision-making (PEW Charitable Trusts, 2014).
HIA examines the health impacts of policies that may not be directly related to health, but are foundational in prescribing the health of a community. Therefore, HIA draws upon the collective knowledge of multiple sectors and disciplines, including urban planning, construction, transportation, agriculture, community development, environmental protection, etc.Additionally, HIA requires the involvement of community members and draws on their lived experience and desire for change. Together, the information generated by community members, stakeholders, and experts leads to a well conducted HIA that will be used to inform decision makers about the health impacts of a particular policy and identify ways to maximize positive health effects, while minimizing negative ones.
HIA and Health Equity
Often policies may seem to benefit the overall population, but may actually hinder the well- being of vulnerable and marginalized sub-populations. For example, establishing fast-food chains may stimulate the economy and constructing a highway may ease traffic congestion, which both seemingly enhance public good. However, fast-food chains offer cheap meals (that are high in calories, fat, and sodium), which often deters healthy eating among poor individuals. Highways are often constructed near impoverished areas, exposing residents to air pollutants. Therefore, with respect to health equity, HIA can be an effective tool in analyzing the health impacts of policies on marginalized groups and uncovering options to distribute positive effects in ways that level the playing field.
Due to its intrinsic qualities—namely, data analysis, community engagement, and advocacy for population health—HIA promotes equity. By ensuring equity in policies regarding living conditions, policy-makers promote health equity because these structural aspects of society influence the health of communities and individuals. To stress the importance of this concept, experts developed a guide titled, Promoting Equity through the Practice of Health Impact Assessment (2013), an excerpt of which is reproduced in in the figure below. The guide, which includes strategies for ensuring a health equity lens in HIA, can be accessed here
Due to its intrinsic qualities—namely, data analysis, community engagement, and advocacy for population health—HIA promotes equity. By ensuring equity in policies regarding living conditions, policy-makers promote health equity because these structural aspects of society influence the health of communities and individuals. To stress the importance of this concept, experts developed a guide titled, Promoting Equity through the Practice of Health Impact Assessment (2013), an excerpt of which is reproduced in in the figure below. The guide, which includes strategies for ensuring a health equity lens in HIA, can be accessed here
Figure - Principles for Promoting Health Equity in HIA Practice
A. Ensure community leadership, ownership, oversight, and participation early and throughout an HIA from communities of color, low-income communities, and other vulnerable groups. These populations will likely be most impacted by policies under consideration and have valuable expertise and insights that can inform decision making. It is critical to develop partnerships with, and engage, community representatives.
B. Use the HIA as a process to support authentic participation of vulnerable populations in the decision-making process on which the HIA focuses. This is critical because vulnerable communities are often excluded from decision- making processes that stand to impact them. If needed, the HIA process should help build capacity for disadvantaged communities to fully participate in the decision-making process. C. Target the practice of HIA towards proposals that are identified by, or relevant to, vulnerable populations. Resources and capacity should be focused on issues faced by the most vulnerable segments of any community. D. Ensure that a central goal of the HIA is to identify and understand the health implications for populations most vulnerable or at risk for poor health. HIA goals should reflect a focus on expanding opportunities for good health outcomes in vulnerable populations. E. Ensure the HIA assesses the distribution of health impacts across populations wherever data are available. Populations may be defined by geography, race/ethnicity, income, gender, age, immigration status, and other measures. Vulnerable groups should be involved in defining these populations and in developing measures of vulnerability. Where data are unavailable, surveys, focus groups, community oral histories and experiences and other methods can be used to understand the distribution of impacts. |
F. Identify recommendations that yield an equitable distribution of health benefits and maximize the conditions necessary for positive health outcomes among the most vulnerable populations and those who stand to be most adversely impacted by the decision that is being assessed. Identification of the distribution of impacts should be accompanied by recommendations for actions that yield equitable health outcomes.
G. Ensure that findings and recommendations of the HIA are well communicated to vulnerable populations most likely to be impacted by the decision being assessed. Culturally appropriate materials with non-technical language and accessible summaries, distribution of findings via multiple mediums and platforms, and targeted outreach to sub-populations, such as vulnerable youth, are strategies that help ensure effective communication of findings and recommendations. H. After the decision on which the HIA is focused is made, ensure that the actual impacts of the decision are monitored, and that resources and mechanisms are in place to address any adverse impacts that may arise. If implemented with careful attention to these principles for promoting equity, HIAs can help transform how policy and other public decisions are made, who has a voice in those decisions, and how those decisions impact the health of vulnerable communities. Every day, policymakers and other public leaders make decisions that have implications for population health without acknowledgment or careful analysis of the potential impacts on our most vulnerable populations. To ensure these decisions reflect and address community health needs and aspirations, it is critical that vulnerable populations bring their knowledge and expertise to the decision-making process and have an active and affirmative voice in those decisions. |
The HIA process provides opportunities for communities, especially those that endure health inequities, to ensure that decision- making processes reflect their health concerns and aspirations” (Heller, Malekafzali, Todman & Wier, 2013).
Health Impact Assessment - Delaware Focus
HIA is increasingly employed in communities across the nation. Leaders in HIA can take many forms, including community members, non-profit organizations, and government agencies. The diversity of how HIA is implemented reflects the variety of communities that may benefit from its outcome and the different types of policies that it may target.
For example, Delaware Greenways, a non-profit organization aiming to promote health through the use and preservation of green spaces, conducted a HIA regarding land use. In collaboration with the Delaware Coalition for Healthy Eating and Active Living’s (DE HEAL) Environment and Policy Committee and the Governor’s Council on Health Promotion and Disease Prevention, Delaware Greenways applied for and received one of three funding awards from the Association for State and Territorial Health Officials (ASTHO). The $15,000 award supported the formation of an HIA Advisory Committee, data collection and analysis, reporting, and various process tasks.
The HIA, referred to as the Fort DuPont Master Planning and Feasibility Analysis, was intended to discern which scenario of the development of the 450-acre Fort DuPont site promoted health and cost savings. Two development scenarios were analyzed, with a primary focus on how residents of neighboring Delaware City access goods, resources, services, and employment opportunities.
A baseline analysis found that although certain features of the community promoted health, there was an absence of healthy food choices, public transportation options, and access to emergency or trauma care. The proposed development scenarios included the preservation of historic infrastructure while enhancing the built environment to support the growth of the local economy. The HIA uncovered that a key aspect of the development scenarios would be increased connectivity of non-motorized modes of transportation, such as sidewalks, multi-use paths, and other accommodations. This would be more likely to result in positive health outcomes, due to better access to recreational areas and the promotion of physical activity. More information about the effort can be viewed here .
With respect to health equity, the Fort DuPont Master Planning and Feasibility Analysis identified methods for improving access for low-mobility populations, including the elderly, children, and people with disabilities. Additionally, as identified in the baseline analysis, Delaware City experiences educational attainment and income averages that fall below state and county levels. Therefore, by increasing access to services, resources, and goods and by stimulating the local economy, residents may benefit from improved living conditions and economic opportunity. Because of the link between the physical environment and health, the improvements in the built environment proposed by the Fort DuPont development scenarios have the potential to reduce health inequities.
For example, Delaware Greenways, a non-profit organization aiming to promote health through the use and preservation of green spaces, conducted a HIA regarding land use. In collaboration with the Delaware Coalition for Healthy Eating and Active Living’s (DE HEAL) Environment and Policy Committee and the Governor’s Council on Health Promotion and Disease Prevention, Delaware Greenways applied for and received one of three funding awards from the Association for State and Territorial Health Officials (ASTHO). The $15,000 award supported the formation of an HIA Advisory Committee, data collection and analysis, reporting, and various process tasks.
The HIA, referred to as the Fort DuPont Master Planning and Feasibility Analysis, was intended to discern which scenario of the development of the 450-acre Fort DuPont site promoted health and cost savings. Two development scenarios were analyzed, with a primary focus on how residents of neighboring Delaware City access goods, resources, services, and employment opportunities.
A baseline analysis found that although certain features of the community promoted health, there was an absence of healthy food choices, public transportation options, and access to emergency or trauma care. The proposed development scenarios included the preservation of historic infrastructure while enhancing the built environment to support the growth of the local economy. The HIA uncovered that a key aspect of the development scenarios would be increased connectivity of non-motorized modes of transportation, such as sidewalks, multi-use paths, and other accommodations. This would be more likely to result in positive health outcomes, due to better access to recreational areas and the promotion of physical activity. More information about the effort can be viewed here .
With respect to health equity, the Fort DuPont Master Planning and Feasibility Analysis identified methods for improving access for low-mobility populations, including the elderly, children, and people with disabilities. Additionally, as identified in the baseline analysis, Delaware City experiences educational attainment and income averages that fall below state and county levels. Therefore, by increasing access to services, resources, and goods and by stimulating the local economy, residents may benefit from improved living conditions and economic opportunity. Because of the link between the physical environment and health, the improvements in the built environment proposed by the Fort DuPont development scenarios have the potential to reduce health inequities.
“Using HIA can ultimately lead to more cost-effective, health- enhancing decisions” (Trabelsi, 2013).
“Using HIA can ultimately lead to more cost-effective, health- enhancing decisions” (Trabelsi, 2013).
Recommendations and Toolkits for HIA
The Fort DuPont Master Planning and Feasibility Analysis marked the first use of HIA in Delaware. Its HIA Advisory Committee developed recommendations for conducting HIAs. The following is a selection of those recommendations:
- Select a project/policy/program identified by a local stakeholder group, community leader, or elected official for assessment to help ensure effective stakeholder participation, local commitment, and open communication.
- Initiate stakeholder engagement before the HIA officially begins and maintains an effective stakeholder engagement strategy throughout.
- To the extent possible, select a subject project/policy/program that has been well defined and about which there are sufficient data available.
- Select for assessment a project or health issues/impacts that have greatest potential for impacting population health.
- Work with subject project representatives to clearly define and agree upon how the subject project efforts and HIA efforts will interact, including reporting and communications strategies.
- Allocate sufficient resources (time, funding, and personnel) since subject projects often have fluctuating timelines; building in a cushion will help ensure a successful HIA. Effective HIAs also require commitment from a broad coalition of professionals.
- Be thorough in scoping phase brainstorming; plan for the scoping phase to be one of the longest phases of the HIA process and expect to adjust.
- Think beyond the strict definition of the HIA and the process for opportunities to bring health into the decision-making process; if the process is not going as planned, identify the opportunities that have arisen unexpectedly that offer possibilities for bringing health into the discussion.
- Select a project for which health, demographic, and other data are generally available, especially if new data collection is not possible. Also, use the most local data available so that the HIA can focus on the subject project population (Trabelsi, 2013).
Additional Resources
As interest in HIA grows, many tools and resources are becoming available nationally. The website of Human Impact Partners provides links to many helpful sources. Similarly, the Community Tool Box presents valuable information about HIA and resources for its implementation. Many toolkits exist to assist state and local governments, public health practitioners, and stakeholders in implementing this approach. Within its website devoted to the concept of Healthy Places, the CDC provides several toolkits for conducting HIA with respect to parks and trails and transportation. (click here for more information). Additionally, the Society for Practitioners of Health Impact Assessment (SOPHIA) developed a series of metrics to ensure a focus on equity in HIAs. A worksheet to support the use of such metrics can be found here.