Health Impact Assessment: U.S. Experience

1
Health Impact AssessmentU.S. Experience

• Andrew L. Dannenberg, MD, MPH
• National Center for Environmental Health
• Centers for Disease Control and Prevention
• acd7_at_cdc.gov
• Health Impact Assessment Workshop
• Design for Health, University of Minnesota
• Minneapolis, January 30, 2007

2
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
3
Walkable Community Designs Connectivity and
Physical Activity
Suburban Development
Traditional Neighborhood
Drawing by Duany Plater Zyberk, in ITE Journal
19895917-18
4
(No Transcript)
5
Durham, NC
6
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

7
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

8
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
  decision

9
Transportation Planning and Land Use Choices
Source Atlanta Journal-Constitution, March 10,
2006
10
(No Transcript)
11
Unwalkable park entrance
12
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
  affected
• Assess how they may be affected
• Reporting of results to decision-makers
• Create report suitable in length and depth for
  audience
• Evaluation of impact of HIA on decision process

13
Health Impact Assessment Workshop RWJF and CDC,
Princeton, October 2004

• Purpose To move HIA forward in the United
  States
• 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

14
Examples of Health Impact Assessments Conducted
in the United States
15
HIA on Housing Rental Voucher ProgramChild
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
  health
• Funded by multiple public agencies, two anonymous
  donors, and in-kind donations by working group
  members

16
HIA of Housing Redevelopment ProjectsRajiv
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
  analysis
• 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
  department

17
HIA of Los Angeles City Living Wage
OrdinanceBrian 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
  ordinance
• Funded by Robert Wood Johnson Foundation

18
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

19
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

20
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

21
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

22
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

23
Review of 16 Health Impact Assessments Conducted
in the United States, 1999-2006
24
Location of 16 Completed HIAs in United States,
1999-2006



MA 2


CALIF 9
GA 2

TEXAS 1
FL 2
Other HIAs in progress
25
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

26
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

27
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

28
Organization that Conducts HIA

• Academic group CDC N10
• Local health department N 5
• Private consultant N 1

29
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

30
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

31
Population Affected by Project or Policy in 16
U.S. HIAs

• 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

32
Community Involvement in Conduct of 16 U.S. HIAs

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

33
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

34
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

35
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

36
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

37
Challenges in Conducting Health Impact
Assessments Conducted in the United States
38
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

39
Minutes of Walking To and From Public Transit Per
Day
Data from National Household Travel Survey, 2001,
USDOT N 3312 transit users
Besser LM, Dannenberg AL Amer J Prev Med 29273,
2005
40
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

41
Relationship of HIA to Environmental Impact
Assessment

• HIA components could logically fit within an EIA
  process
• 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

42
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
• Need balance of community input with scientific
  evidence
• May add substantially to time and resources
  needed to conduct HIA

43
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
  resources
• Quality of science - cause and effect may be
  difficult to prove

44
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
45
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

46
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
  workshops
• 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

47
Health Impact Assessments can help guide
community design and land use choices to promote
human health
www.hiagateway.org.uk www.cdc.gov/healthyplaces