Category Archives: Health impact assessments
A session on health in all policies at the American Public Health Association (APHA) meeting in Boston gave prominent attention to a newly released publication on the topic: An Introduction to Health in All Policies: A Guide for State and Local Governments. The guide was issued collaboratively by APHA, the California Endowment, the California Department of Health and the Public Health Institute.
It was released last month and is geared, according to its authors, “toward state and local government leaders who want to use intersectoral collaboration to promote healthy environments.”
The guide includes a history of health in all policies, case studies, a glossary, messaging, resources and a list of critical thinking questions. It draws heavily on the experiences of the California Health in All Policies Task Force, which was created in 2010 by an executive order of the governor and grew out of a common interest among several California agencies in climate change, health and childhood obesity. The task force brings together non-government stakeholders and local government representatives in its “health-in-all-policies” work through workshops, meetings and opportunities for public comment and testimony.
The Guide emphasizes that there is no one “right” way to implement a health-in-all-policies approach, but puts forward five key elements:
- Promote health, equity and sustainability
- Support for Intersectoral collaboration
- Benefit multiple partners
- Engage stakeholders
- Create structural or procedural change
- Health Impact Assessments (HIA) are one of the key tools addressed in the new Guide. See a regularly updated map on HIAs in the United States created by the Health Impact Project, a collaboration of the Pew Charitable Trusts and the Robert Wood Johnson Foundation.
- HIA was front and center at the American Public Health Association meeting, with more than thirty presentations this week. Read a summary of the HIAs discussed at the meeting, prepared by the Health Impact Project.
>>NewPublicHealth was on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Find the complete coverage here.
At the recent 2nd Annual National Heath Impact Assessment Meeting held in Washington, D.C.,Paul Anderson, MD, MPH, manager of the HIA Program at the Alaska Department of Health, spoke about his state’s HIA efforts and successes. NewPublicHealth caught up with Anderson following the meeting to ask about lessons learned that can benefit other public health officials considering and conducting health impact assessments.
NewPublicHealth: Tell us about the HIA program in Alaska and how the health department has made HIA a routine part of decision making.
Paul Anderson: HIA in Alaska started with a couple of health impact assessments done in conjunction with natural resource development permitting and environmental impact statements (EISs) in the north of the state. These studies generated increased interest in the human health concerns that arise during project permitting. The Department of Natural Resources (DNR) contacted the Alaska Division of Public Health, asking us if we could get involved with this new idea—called health impact assessment—as it related to natural resource development permitting.
After some deliberation, we realized the importance of being involved with this work, and so we developed an HIA working group. That working group met for about three years and developed an HIA Toolkit, which is our guidance document for performing HIA in Alaska. Out of that working group came a realization that Alaska needed an institutionalized HIA program in order to lead this process forward effectively. So the group eventually decided to create an HIA Program in the Division of Public Health under the Section of Epidemiology.
NPH: Have you worked collaboratively in Alaska on HIAs?
Anderson: When our program was new, we wanted to conduct field work because we needed additional health information regarding a specific region of rural Alaska. This field work involved utilizing surveys, which can be very tiring for rural communities because they are surveyed frequently. There are several agencies in Alaska that already do surveys as a routine part of their work, and one of those is the Alaska Department of Fish and Game. They go house-to-house and community-to-community and use a very well-designed survey tool to learn about subsistence foods. They worked with us to integrate some important questions about food consumption onto their survey form. This turned out to be an effective cooperative relationship that benefitted both agencies and reduced the strain on rural communities.
A key session at the Second National Health Impact Assessment Annual Meeting held recently in Washington, D.C., was a panel discussion on several evaluations of the value and benefits of health impact assessments (HIAs). Andrew Dannenberg, MD, MPH, an affiliate professor at the University Of Washington School of Public Health, was a consultant on a recent evaluation of HIAs funded by the Robert Wood Johnson Foundation and a member of the evaluation panel at the HIA meeting. NewPublicHealth spoke with Professor Dannenberg about some recent findings.
NewPublicHealth: What have the recent evaluations of HIA as a tool told us about the value conducting health impact assessments?
Andrew Dannenberg: Essentially, HIA works. The tool does seem to promote health, and does have influence in some cases but not others. HIAs can influence the health component of [policy] decisions.
There are also indirect HIA benefits: by getting public health professionals talking with decision makers in other sectors—such as transportation and housing—HIAs create partnerships and collaborations for longer-term value. So a transportation department building a highway may then always realize that there are health implications of what gets constructed.
We also came away with a list of factors that influence HIAs to make them successful. The list includes:
- Timeliness is often a factor when doing an HIA (in that the HIA must be completed and recommendations made in time to support or influence the policy decision).
- Involving stakeholders and decision makers gives a better chance that the recommendations will be considered.
- It is important to have community engagement and feedback, or, particularly when it is an HIA being done rapidly, it is critical to have a well-informed health leader at the helm.
- It is critical to screen the topic to be sure it is appropriate for an HIA.
- Dissemination to stakeholders, decision makers and media is very important, using methods, length and language appropriately customized for those audiences.
- HIA recommendations need to be clear and actionable.
- The Australian evaluation found that a key to successful HIAs was getting the right people at the right time to work together.
NPH: Do you have an example of an HIA that showed that using the tool leads to better decision making?
Dannenberg: An HIA conducted in San Francisco several years ago is one of our clearest examples. A developer wanted to tear down some low-income housing to build more expensive apartments that would have displaced the low-income people living at the site. The Department of Health conducted an HIA, which made it clear that it is bad for health to take low income people in an expensive city and throw them out in the street with no housing.
“[Health Impact Assessments have] taught people how to think and speak differently, clearly, objectively,” according to Cleveland Councilman Joe Cimperman. “Suddenly we are saying those words we don’t say often enough in government: Are you comfortable with the environmental and health impacts of this decision?”
NewPublicHealth caught up with Cimperman soon after his plenary address at the second annual National Health Impact Assessment meeting held in Washington, D.C., this week. He is an HIA supporter and enthusiast who is already engaged in health impact assessments for the city of Cleveland.
NewPublicHealth: What was your impression of the HIA meeting?
Joe Cimperman: I was blown away by so many different things—the geographic diversity of the people attending, and the many ideas they presented in questions and in private conversations after I spoke.
NPH: In your opinion, what is the intrinsic value of health impact assessments?
Cimperman: HIA has been a model for how to get things done right. But the tool also allows us to get closer to people and their specific needs by going through the process—which is such an important component—to find out how we help individuals when we make policy-level decisions. If we want to restore our cities, we need to ask what problems we’re solving.
NPH: What’s a strong example of an HIA in your community that was innovative and beneficial?
Cimperman: We have completed an HIA on the health implications of proposed legislation to expand agriculture into urban areas. Cities like ours have enough land that we can think about the different and best ways to use some of it—and urban agriculture is a means of helping people use the land themselves, and use it for something other than home and industrial construction. I think we’ve been able to do so much good by applying an HIA because we’re answering questions right up front. The Urban Agriculture overlay district is a proposed piece of legislation that would introduce intense farm uses in an urbanized environment, including livestock, community gardens and commercial gardens. While the uses are thought to have positive impacts on human health—such as access to fresh fruits and vegetables, community cohesion through the establishment of gardens, potential economic opportunities and a productive reuse of vacant land—unintended adverse impacts to human health include increased animal waste, potential exposure to carcinogens created by insecticides, and increases in noise and odor levels.
NewPublicHealth Q&A: Florence Fulk and Tami Thomas-Burton on the Impact of the Environment on Health
Florence Fulk, MS, BS, a research biologist with the Environmental Protection Agency (EPA) and Tami Thomas-Burton, BS, MPH, of the Office of the Regional Administrator-Environmental Justice at EPA, will be speaking at the National Health Impact Assessment meeting this week on HIAs and environmental policy. NewPublicHealth caught up with Fulk and Thomas-Burton ahead of the conference to ask about EPA’s use of health impact assessments.
NewPublicHealth: What steps has the Environmental Protection Agency (EPA) taken with respect to health impact assessments?
Florence Fulk: Within EPA is the Office of Research and Development, and within that office we have a Sustainable and Healthy Communities Research Program which is providing tools, models and approaches to support HIAs across the country. We’re also demonstrating HIA as an approach to integrate and weigh tradeoff in community decision making.
NPH: Why is the EPA investing in health impact assessments?
Fulk: The primary vision for the Sustainable and Healthy Communities Research Program is to inform and empower communities to look at human health, economic and environmental factors in their decision making, and to do it in a way that fosters community sustainability. And that vision is very closely linked to the values and the function of HIAs. The number of HIAs that are being conducted in the United States and the number of people that are conducting HIAs in the United States has formed this growing community of practice, which can inform our Sustainable and Healthy Communities Research Program by understanding the decisions that communities are facing and how they’re bringing health, economic and environmental information to the process.
We also see that by growing a community of practice as a network to disseminate EPA tools, models, data and guidance, the research that we do to support HIAs also gives us a way to raise awareness about sustainable alternatives in community decisions.
One of the most sought-after experts at the second national Health Impact Assessment (HIA) meeting, currently underway in Washington, D.C., is Arthur Wendel, MD, MPH, team lead for the Healthy Community Design Initiative at the U.S. Centers for Disease Control and Prevention (CDC), which is a sponsor of the HIA meeting. Health impact assessments are decision-making tools that help identify the health consequences of policies in other sectors.
NewPublicHealth caught up with Dr. Wendel just after the first plenary session.
NewPublicHealth: How’s the meeting so far?
Arthur Wendel: The first plenary speaker, councilman Joseph Cimperman form Cuyahoga County in Cleveland, was just an outstanding speaker and made such a good impression for the whole conference. When you have a policymaker come in and provide a fresh perspective about how health impact assessments can make a difference, that sets the stage for attendees.
>>Editor’s Note: NewPublicHealth will be speaking with Councilman Cimperman later this week about his championing of HIA work in Cleveland, including a health impact assessment on the city’s budget, the first time the tool has been used that way.
NPH: How long has CDC been involved in health impact assessments?
Arthur Wendel: CDC has been involved with health impact assessments, through the Healthy Community Design Initiative, since 2003. The initiative is part of CDC’s National Center for Environmental Health, and initially we were just kind of trying to figure out the field of health impact assessments, learn a little bit about it from some domestic and international groups that conducted health impact assessments. Some of the initial steps were just trying to provide technical assistance for a few HIAs. That gave us a little bit of flavor for how health impact assessments were done, and from that initial effort we started to compile some research. One of the initial papers that came out of our group was identifying the first 27 HIAs that were conducted in the United States and some of the common characteristics among them.
>>Looking for examples of successful HIAs? Read stories from the field from CDC grantees.
A key panel discussion during the National Health Impact Assessment (HIA) meeting will be on perspectives on health impact assessments with policymakers. Ahead of the meeting, NewPublicHealth spoke with State Representative Denise Provost (D), of Somerville, Mass., who will be one of the panel members.
NewPublicHealth: How does it value governing, communities and population health by factoring health into policies made in other sectors?
Denise Provost: Governance should always take consideration of health. Legislators should actually embrace the first principle of the Hippocratic Oath, which is “first do no harm.” Sometimes by action or inaction we, as a nation, have pursued policies which we’ve discovered are not so good for health. Some are market forces that end up being reinforced by the actions of government. Looking out for the health impact on the population needs to be part of the long-term view of what we do. The particular discipline of looking at health through a health impact assessment is valuable for government because policy makers are often disparaged by scientists for governing by anecdote and that’s a real danger in the absence of quantitative analysis based on peer reviewed studies. The HIAs I’ve seen employ that kind of methodology.
The value of HIAs to communities is that they will in the long term—and even in the short- or middle-term—enjoy better health and fewer negative health effects from government decisions or government failure to reign in market forces that result in conditions that cause bad health as part of their business model.
NPH: Can you give us examples of HIAs in your community that have been innovative and beneficial?
Provost: We’re still in early days with HIAs but one, as contemplated by our 2009 transportation reform bill, has some fairly groundbreaking language in it that requires our secretaries of transportation, health and the environment to convene regularly and look at healthy transportation projects very broadly. They’re also charged with developing tools such as HIAs for use in the evaluation of transportation projects.
Building on the success of the Inaugural Health Impact Assessment (HIA) meeting held in April 2012, leading HIA stakeholders including the Health Impact Project—a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts—and the U.S. Centers for Disease Control and Prevention (CDC) convened the second national HIA meeting today, in Washington D.C.
>> Follow the real-time Twitter conversation about the conference with the hashtag #NatHIA13.
An HIA is a tool that helps evaluate the potential health effects of a plan, project or policy before it is built or implemented. It can provide recommendations to increase positive health outcomes and minimize adverse health outcomes. It can also bring potential public health impacts and considerations to the decision-making process for plans, projects and policies that fall outside the traditional public health arenas, such as transportation and land use.
While HIAs have been conducted for decades, their wider use has become more common in just the last few years. According to the Health Impact Project, more than 200 HIAs have been conducted in the United States on issues as diverse as transportation, economic policy and climate change.
NewPublicHealth has created a short HIA resource list with links to background information on health impact assessments.
- Health Impact Assessment posts on NewPublicHealth
- HIA Issue Brief from the Robert Wood Johnson Foundation
- HIA in the United States, a map from the Health Impact Project
- An HIA Infographic from the Health Impact Project
- CDC’s Healthy Places collection of HIA information
- CDC Resource on HIAs and Public Policy Development
- The World Health Organization HIA site
Last week the Public Health Accreditation Board (PHAB) awarded five-year national accreditation status to five public health departments, bringing the number of health departments now accredited to 19 since the credential was launched two years ago. Hundreds more health departments are currently preparing to apply for accreditation, which includes a peer-reviewed assessment process to ensure it meets or exceeds a set of public health quality standards and measures. Among the newly accredited is the Chicago Department of Public Health.
"This is an important achievement and recognition that highlights the city of Chicago’s ongoing commitment to health and wellness on the part of all of our residents,” said Chicago Mayor Rahm Emanuel in a statement issued by PHAB. "We are focused on policies that will help all Chicagoans and their families enjoy the highest quality of life, [and w]e will continue to strive to make Chicago one of the healthiest cities in the world."
NewPublicHealth recently spoke with Bechara Choucair, MD, MS, Commissioner of the Chicago Department of Public Health, about the value of accreditation for improving the health of the community—and about how this effort supports Healthy Chicago, the city’s public health agenda.
>>Read more about Healthy Chicago in a previous NewPublicHealth Q&A with Choucair.
NewPublicHealth: You’re one of the first public health departments to be accredited. How did that happen so quickly?
Bechara Choucair: When we released Healthy Chicago in 2011, one of the strategies we identified was to obtain accreditation. We wanted to be the first big city to earn the credential. It took us 18 months and we are excited that we are the first big city to be accredited and the first in Illinois. And one of the added bonuses of accreditation is a sense of pride. It says a lot to our staff, residents and our mayor.
NPH: A community health assessment is required as part of the accreditation application. What did Chicago’s community health assessments entail?
The Supplemental Nutrition Assistance Program (SNAP) is the federal government’s principal program for helping low-income families purchase enough food. More than 47 million Americans currently receive SNAP benefits; approximately half of the beneficiaries are children. As part of the debate over the Farm Bill—legislation that authorizes SNAP and other federal nutrition programs—Congress is considering legislation that would cut SNAP benefits and limit who qualifies for the benefits.
Yesterday, the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts, released a white paper that provides a rigorous, objective and nonpartisan analysis of the potential health impacts of the proposed changes to SNAP.
NewPublicHealth spoke with Aaron Wernham, MD, director of the Health Impact Project, along with lead researcher Marjory Givens, to learn more about the study’s findings.
NewPublicHealth: What is the goal of the health impact assessment on the potential changes to the SNAP program?
Aaron Wernham: Congress is deliberating reauthorizing the U.S. Farm Bill, and one of the parts of that is the Supplemental Nutrition Assistance Program or SNAP, which was formerly known as food stamps. This is one of the federal government’s main programs for ensuring that people who have low incomes are able to get enough to eat. We did this health impact assessment because so far the public health effects of these proposed policy changes have not really been a part of the political debate. We wanted to make sure that the best available public health evidence was brought to bear to help ensure that everyone has complete information—those affected by the change, the general public and decision-makers in Congress.
NPH: What’s the big picture on what SNAP has to do with health in the first place?
Wernham: Not having enough to eat—or being what’s called “food insecure”—is attached to a higher risk of a lot of diseases. So, adults who are food insecure have a higher risk of heart disease, high blood pressure, diabetes and some other problems. Children who are food insecure are more likely to be reported by their parents as being in poor health, are more likely to be hospitalized and also have a higher risk for a number of health related problems from asthma, to depression and anxiety. We actually have a number of studies that have looked at the health benefits of receiving SNAP and found, for example, that adults who had access to SNAP when they were children are less likely to have problems in adulthood, such as obesity, high blood pressure and heart disease.
NPH: What did the health impact assessment find?
Wernham: We looked at ways in which the House and Senate have proposed to change how eligibility for SNAP benefits is determined and how the amount of benefits is determined. Both the House and Senate have proposed changes, and we found that as many as 5.1 million people could actually lose eligibility under changes proposed by the House. Under the changes in the Senate, about 500,000 people might receive lower benefit amounts. With the House changes, as many as 1.4 million children and nearly 900,000 older adults would be among those five million people who could be affected. So, for those people, they would lose upward of an average of 35 percent of their total income and would be at higher risk for the health problems that relate to food insecurity.