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Health Impact Assessment: U.S. Experience


Health Impact Assessment: U.S. Experience Andrew L. Dannenberg, MD, MPH National Center for Environmental Health Centers for Disease Control and Prevention – PowerPoint PPT presentation

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Title: Health Impact Assessment: U.S. Experience

Health Impact Assessment U.S. Experience
  • Andrew L. Dannenberg, MD, MPH
  • National Center for Environmental Health
  • Centers for Disease Control and Prevention
  • Health Impact Assessment Workshop
  • Design for Health, University of Minnesota
  • Minneapolis, January 30, 2007

Community Design and Health
  • Obesity, physical activity, CVD
  • Water quantity and quality
  • Air pollution and asthma
  • Climate change contribution
  • ? Car crashes
  • ? Pedestrian injuries
  • Mental health impact
  • ? Social capital

Related to land use Related to automobile
dependency Related to social processes
Walkable Community Designs Connectivity and
Physical Activity
Suburban Development
Traditional Neighborhood
Drawing by Duany Plater Zyberk, in ITE Journal
(No Transcript)
Durham, NC
A Vision of Health Impact Assessment
  • Community planners and zoning boards will request
    information on potential health consequences of
    projects and policies as part of their
    decision-making process
  • Local health officers will have a tool to
    facilitate their involvement in community
    planning and land use decisions that impact health

Definition of Health Impact Assessment
  • Collection of procedures and tools by which
    projects, policies, and programs can be evaluated
    based on their potential effects on the health of
    a population and the distribution of those
    effects within the population

Value of Health Impact Assessment
  • Focuses attention of decision-makers, who
    typically do not have a health background, on the
    health consequences of projects and policies that
    they are considering
  • Ideally an HIA will lead to a better informed

Transportation Planning and Land Use Choices
Source Atlanta Journal-Constitution, March 10,
(No Transcript)
Unwalkable park entrance
Steps in Conducting an HIA
  • Screening
  • Identify projects or policies for which HIA would
    be useful
  • Scoping
  • Identify which health impacts should be included
  • Risk assessment
  • Identify how many and which people may be
  • Assess how they may be affected
  • Reporting of results to decision-makers
  • Create report suitable in length and depth for
  • Evaluation of impact of HIA on decision process

Health Impact Assessment Workshop RWJF and CDC,
Princeton, October 2004
  • Purpose To move HIA forward in the United
  • Participants HIA experts from UK, Canada, and
    WHO, and US participants from local health
    departments, academia, transportation,
    environmental health, urban planning, CDC, and
    the Robert Wood Johnson Foundation (RWJF)
  • Findings Priority needs are to conduct pilot
    tests, develop staff capacity, develop database
    of HIA resources, build political support for HIA
    use, and conduct evaluations
  • Summary Dannenberg AL, et al. American Journal
    of Public Health. 96262-270, February 2006

Examples of Health Impact Assessments Conducted
in the United States
HIA on Housing Rental Voucher Program Child
Health Impact Working Group, Boston
  • Examined impact of changes to Massachusetts
    housing rental assistance program for families
    who otherwise would be homeless or live in
    substandard dwellings
  • Qualitative and quantitative assessment
  • Findings Program alterations may lead to
    reduced program eligibility, increased housing
    instability, and adverse effects on childrens
  • Funded by multiple public agencies, two anonymous
    donors, and in-kind donations by working group

HIA of Housing Redevelopment Projects Rajiv
Bhatia, San Francisco Health Department
  • Rapid assessment of health impacts in two housing
    redevelopment projects and one area plan
  • Qualitative review of Environmental Impact
    Report, community engagement, secondary data
  • Findings Effects on housing affordability,
    vehicle commutes, displacement of residents,
    segregation, and public infrastructure
  • HIA analyses led to improvements in project plans
  • Funded conducted by city public health

HIA of Los Angeles City Living Wage
Ordinance Brian Cole, UCLA
  • Quantitative estimate of potential mortality
    reduction from proposed ordinance to raise
    minimum wage for city contract workers or provide
    them with health insurance
  • Findings Employers are more likely to increase
    wages than to offer health insurance, thereby
    losing much of health benefit intended by
  • Funded by Robert Wood Johnson Foundation

HIA of Coal-Fired Power Plant McLeod and
Simmons, Healthy Development, Inc.
  • Examined health impacts of proposed 800 megawatt
    coal-fired power plant in Florida
  • Rapid, quantitative assessment
  • Findings Fine particulate matter pollution
    containing SO2 will decrease life expectancy by 2
    days after 16 years of plant operation
  • Full HIA now funded to recommend social and
    economic interventions to improve local health
  • Conducted by private HIA consultants with county
    health department funding

The Atlanta BeltLine
  • Proposed 22-mile urban light rail loop
  • Accompanied by a continuous multi-use trail
  • Connects existing parks and 40 neighborhoods
  • Opens 2500 acres for mixed-use redevelopment
  • To be built on existing abandoned or little used
    rail rights of way

HIA of Atlanta Beltline
  • Examining health impacts of transit component and
    of trails and parks component
  • Conducted during ongoing project planning
  • Quantitative and qualitative estimates of
    physical activity, respiratory disease, injury,
    mental health, social capital, social equity, and
    other health outcomes
  • Conducted by Georgia Tech with technical
    assistance from CDC
  • Funded by Robert Wood Johnson Foundation

Public Health Benefits of BeltLine
  • Opportunity for Recreational Physical Activity
  • BeltLine trails and parks offer an attractive
    setting for walking, bicycling, and other
    recreational physical activity
  • Increased availability of trails is recommended
    by CDC to promote health
  • Existing Silver Comet, Stone Mountain, Chastain
    Park trails are very popular
  • Exercise Easily Incorporated into Daily Commute
  • Walking to and from BeltLine stations could
    readily fulfill the U.S. Surgeon Generals
    recommendation of 30 minutes of physical activity
    each day
  • Obesity Reduction
  • Physical activity helps prevent obesity
  • Obesity and physical inactivity are associated
    with increased risk of overall mortality, heart
    disease, diabetes, hypertension, and some cancers

Public Health Benefits (continued)
  • Cleaner Air
  • BeltLine could reduce use of automobiles whose
    emissions are major contributors to ground level
    ozone in Atlanta
  • Ozone is linked with increased asthma attacks and
    heart disease mortality
  • Atlanta exceeded EPAs air quality standard for
    ozone 51 times in 2002-2003
  • Fewer Traffic Injuries
  • Driving less reduces each individuals risk of
    injury on the highways
  • Nationally, motor vehicle crashes are the leading
    cause of death among persons 1 - 34 years old
  • Brownfield Redevelopment
  • Urban redevelopment of underutilized land can
    reduce sprawl and preserve greenspace
  • Redevelopment promotes health by offering
    economically and socially thriving communities
    that are walkable

Review of 16 Health Impact Assessments Conducted
in the United States, 1999-2006
Location of 16 Completed HIAs in United States,

MA 2

GA 2

FL 2
Other HIAs in progress
HIAs of Projects (N6)
  • Housing redevelopment Trinity Plaza CA
  • Housing redevelopment Rincon Hill CA
  • Urban redevelopment Oak to Ninth CA
  • Corridor redevelopment Buford Hwy GA
  • Transit, parks and trails Beltline GA
  • Power plant Taylor County FL

HIAs of Policies (N10)
  • Local planning Eastern neighborhoods CA
  • School siting Austin TX
  • After-school programs Statewide CA
  • Walk-to-school programs Sacramento CA
  • Living wage ordinance San Francisco CA
  • Living wage ordinance Los Angeles CA
  • Low income rent subsidies Statewide MA
  • Low income home energy subsidies Statewide MA
  • County land use planning Polk County FL
  • Federal farm bill National

Decision-Making Organization for Project or Policy
  • City council planning commission N7
  • State legislature N3
  • Local partnerships N2
  • Nonprofit organization N1
  • US Congress N1
  • School district N1
  • Electric utility company N1

Organization that Conducts HIA
  • Academic group CDC N10
  • Local health department N 5
  • Private consultant N 1

Funder of HIA
  • Robert Wood Johnson Foundation N 6
  • Health department - internal staff N 5
  • Health department - external contract N 1
  • Volunteer multiple sources N 4

Scoping Health Determinants Considered in 16
HIAs in the United States, 1999-2006
  • Physical activity and obesity
  • Housing adequacy and affordability
  • Pedestrian injuries
  • Air quality, asthma, other respiratory diseases
  • Parks and greenspace
  • Income adequacy social equity
  • Diet, nutrition, food safety, food insecurity
  • Adolescent risk behaviors alcohol, drugs, sex
  • Noise
  • Mental health
  • Social capital, community severance
  • Access to jobs, stores, schools, recreation

Population Affected by Project or Policy in 16
  • Small area within city N 5
  • City or county-wide N 5
  • Statewide N 5
  • National N 1
  • --------------------------
  • Primary impact on
  • Persons with low income N 9
  • Children/adolescents N 3
  • Whole population N 4

Community Involvement in Conduct of 16 U.S. HIAs
  • Community input involved in conduct of 10 of 16
  • Barriers to community involvement in HIAs include
    lack of time or resources, IRB or OMB restrictions

Conduct of 16 HIAs in U.S.
  • Screening
  • Some targeted to goal, others more academic
  • Scoping
  • Generally clearly described
  • Risk assessment
  • Various quantitative and qualitative methods
  • Reporting
  • Most on web, a few published public testimony
  • Evaluation
  • Relatively little conducted

Quantitative and Qualitative Health Indicators in
16 U.S. HIAs
  • Quantitative
  • Physical activity
  • Pedestrian injuries
  • Mortality
  • Impact of particulate matter in air
  • Crime
  • Parks and greenspace
  • Qualitative
  • Academic performance
  • Income adequacy social equity
  • Diet, nutrition, food safety, food insecurity
  • Adolescent risk behaviors alcohol, drugs, sex
  • Noise
  • Mental health
  • Social capital, community severance
  • Access to jobs, stores, schools, recreation
  • Housing adequacy and affordability

Key Results in 16 HIAs in U.S.
  • Most identified improvements needed to mitigate
    adverse health impacts
  • Redevelopment projects that lacked affordable
    housing rental voucher program
  • A few encouraged projects or policies that would
    be health-promoting as designed
  • Walk-to-school program Beltline transit project
  • One concluded that proposed program would fail to
    reach its intended target population
  • After-school programs

Impact of HIA on Subsequent Decisions 16 HIAs
in U.S.
  • Documentable impacts, such as change in
    redevelopment plans to add affordable housing,
    was evident in only a few HIAs
  • Most HIAs raised awareness of health issues for
    some audiences

Challenges in Conducting Health Impact
Assessments Conducted in the United States
HIA Level of Complexity
  • Qualitative describe direction but not
    magnitude of predicted results
  • Easy to predict hard to use in cost/benefit
  • Example Build a sidewalk and people will walk
  • Quantitative describe direction and magnitude
    of predicted results
  • Difficult to obtain data useful for cost/benefit
  • 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

Minutes of Walking To and From Public Transit Per
Data from National Household Travel Survey, 2001,
USDOT N 3312 transit users
Besser LM, Dannenberg AL Amer J Prev Med 29273,
Voluntary vs. Regulatory Approach to Using an HIA
  • 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

Relationship of HIA to Environmental Impact
  • HIA components could logically fit within an EIA
  • HIA incorporated into EIA is necessarily
    regulatory and insures it is conducted
  • Extending an EIA to include an HIA likely to
    encounter resistance from developers who see it
    as an additional barrier

Community Involvement in Conducting an HIA
  • Increases community buy-in to project
  • Helps identify social issues as well as health
  • Commonly used in HIAs in Europe
  • Need balance of community input with scientific
  • May add substantially to time and resources
    needed to conduct HIA

Other Challenges in Conducting HIAs in the U.S.
  • Resources - who pays?
  • Resistance - some decision-makers may not want
    health input
  • Evaluation of impacts of HIA requires time and
  • Quality of science - cause and effect may be
    difficult to prove

Asthma and Air Pollution
  • Natural experiment during 1996 Summer Olympic
    games in Atlanta
  • Peak morning traffic decreased 23 and peak ozone
    levels decreased 28
  • Asthma-related emergency room visits by children
    decreased 42
  • Childrens emergency visits for non-asthma causes
    did not change during same period

Friedman et al. JAMA 2001285897
HIA Capacity Building Activities
  • NACCHO/APA training workshop on HIA held in 2006
    repeat workshop planned in 2007
  • Course on HIA now being taught by Rajiv Bhatia at
    University of California, Berkeley
  • HIA training manual being prepared
  • Seattle group has begun an HIA listserve for the
    United States
  • Several states and one U.S. Senator are beginning
    to mention HIA in proposed legislation

HIA in the United States Next Steps
  • Conduct pilot tests of existing tools for HIA of
    projects and policies
  • Develop staff capacity to conduct HIAs including
    training materials and train-the-trainer
  • Develop incentives and political support for use
    of HIAs
  • Develop a database for measuring health impacts
    of common projects and policies
  • Conduct process, impact and outcome evaluations
    of HIAs

Health Impact Assessments can help guide
community design and land use choices to promote
human health