All About Health Impact Assessments

Health Planning and Policy Tarrant County Public Health

Presentation Objectives

At the end of this presentation participants will be informed regarding:

• Definition of a Health Impact Assessment (HIA)• Steps required to complete an HIA• Working examples about the HIA process

Definition

Health Impact Assessment:A systematic process that uses an array of datasources and analytic methods and considersinput from stakeholders to determine the potentialeffects of a proposed policy, plan, program orproject on the health of a population and thedistribution of those effects within the population.

Why Conduct a Health Impact Assessment?

HIAs:• Raise the profile of health and health issues, and

make it more likely that they’ll be considered in all circumstances

• Champion a participatory approach that values, includes, and empowers the community

• Bring the community together • Promote healthy behaviors and practices• Promote equity and ensure health disparities are

considered• Improve decision-making

Types of HIAs

Type TimeHealth Impact Review

Use Methods Example

Desktop 2-6 wks.

Broad Over-view with significant details

Time andresourcesare limited

Collect and analyze accessible data

Sacramento, Ca., a Desktop HIA assessed the Safe Routes to School Program

Rapid HIA6-12 wks.

Detailed overview with some input

Time andresourcesare limited

Collect, analyze existing data with limited expert input; literature review

Decatur, GA., Georgia Tech.: Rapid HIA for transportation plan; literature review & workshop

Intermediate12 wks.

to 6 mos.

Thorough assessment of data and pathways

Requires significant time and resources

Analyze existing data, gather qualitative data from stakeholder

Alameda County, CA. Took 1.5 months - Focused on greening the landscape

Comprehensive6 mos.

to 1 yr.

Assessment of all potential health impacts

Requires significant time and resources

Stakeholder participation; data collection using various methods and sources

In 2011-14 The San Antonio Metropolitan Health District and Urban Strategies conducted HIA of the housing plan.

How do you select the HIA type?

• Status (stage) and complexity of the proposal

• Resources (funding, data, personnel, time)

• Purpose of the HIA and its goals

• Potential scale and severity of health impacts

• Quality of the health evidence base

• Access and availability of quality data

• Support for HIAs at local and/or state level

HIA Processes/Steps

Typical HIA Process

ScreeningScoping

AssessmentRecommendations

ReportingEvaluation and Monitoring

Screening:Establishing Need for the Value of HIA

Timing

Sufficiency of information

Decision’s potential impacts on health

Feasibility, timeliness, value

Openness of the decision making process

Users and uses for HIA

Who are the decision makers?Who are potential HIA partners?Who are the other stakeholders?

Screening:Know Your Partners/Audience

Project Developers Health Department

Planning Department Universities (UNTHSC, UTA,TCC)

Transportation Homeowners/Business Owners

Other Government Departments

Community GroupsNeighborhood Association

Mayor/ City Council JPS Network

Screening Scenario: Bridging the Gap

Stakeholders, including affected communities in transit corridors, have been invited to provide input into the project.

City L has decided to replace a local bridge, including bridge widening to add an additional lane in either direction.

Officials must decide whether the new lanes will:

• Accommodate motor vehicles only• Be a designated bus – only lane• Or be separated bike-only lane.

They will choose only one lane type.

Screening: Check list…..

Screening QuestionsResponses, Supporting

Facts or Rationale

• Does the HIA have potential of adding value to the decision-making process? In what ways?

• What are the most important health concerns?

• Who are the stakeholders and decision-makers?

• Do they have an interest? Do they have the capacity to participate?

• Would stakeholders use the HIA to inform the decision making process?

• What are some challenges (and by what stakeholders) might you anticipate?

Screening: Check list…Bridging the Gap

Other Considerations Responses, Supporting Facts, Rationale

• Is decision making process open to HIA recommendations for changes to design, mitigations and alternatives?

• Are there decision alternatives that are more or less advantageous to public health?

• Have public concerns about the impacts of the decision been documented?

• Do research methods exist to analyze health impacts of concern?

• Is it feasible to analyze health impacts of decision in decision making time frame?

• What are some barriers to timely completion?

• What additional information do you need to decide overall value of this HIA?

Should the HIA be done???

Yes!

Screening: Bridging the Gap

• Break into groups and choose a scenario

• Use screening checklist to determine if HIA would have value

• You are encouraged to make assumptions about facts that you might need, but that are not included, in order to complete this exercise

• Report your findings

Screening Exercise

Typical HIA Process

ScreeningScoping

AssessmentRecommendations

ReportingEvaluation and Monitoring

Scoping:The Strategizing Steps in HIA

What

When

Where

How

Who

Scoping: Planning

Research Plan

• HIA goals

• Decision alternatives that will be evaluated

• Potential health impacts and their pathways

• Demographic, geographic and temporal boundaries

• Vulnerable populations affected

• Data, methods and tools needed

• How the HIA will characterize health effects

Scoping: Planning

Work Plan Who Will Be Involved

• Timeframe and resources • Roles of researchers, experts and stakeholders

• Who will be involved with data collection and analysis

• Plan for stakeholder engagement and public review

• Process for determining significance of impacts

• Plan for external review, findings, dissemination

Scoping:Determining potential health impacts and their pathways

1. Start broad – Most social decisions affect health indirectly through effects on social or environmental conditions

2. Initial scope should consider all factors that collectively influence health:

3. Final scope should focus on impacts with greatest likelihood of occurrence and of greatest public concern

Initial ScopePhysical and mental health outcomes (mortality, disability)

Public services

Behavioral factors Environmental conditions

Neighborhood conditions Economic and political factors

Consider all pathways that link the proposed decision to health. Use pathway diagrams as a way to demonstrate these links:

Scoping:The General Components of a Pathways Diagram

On PolicyPlans orProjects

Impacts on Economic, Environmental, Social, Political

Conditions

Exposuresand Risk

Behaviors

DiseaseInjury

Mortality

There are many potential configurations and pathways

Decision Direct Impacts

Behavioral Impacts

Health Impacts

Indirect Impacts

Scoping: Possible causal pathways between a change in policy (introduction of market-related rents) and health outcomes

Scoping:Which health impacts to evaluate?

The scope should focus on impacts with greatest likelihood of occurrence and of greatest public concern. Include data and methods to reveal inequities in conditions or impacts based on population characteristics, including, but not limited to:

• Age

• Gender

• Income

• Place (disadvantaged locations)

• Ethnicity

Methods requiring least resources

Methods requiring most resources

• Expert opinion• Review of available reports and data• Interviews of focus groups• Systematic literature review• Environment measurement or

modeling• Epidemiologic or spatial analysis• Development or application of

quantitative forecasting methods• Original quantitative data collection

and analysis

Scoping:Determining methods

• Break into groups and choose a scenario

• Work through the steps to complete the scoping step for one of the scenarios you’ve been presented.

• You are encouraged to make assumptions about facts that you might need, but that are not included, in order to complete this exercise

• Report your findings

Scoping Exercise

Discuss:

Establish a policy goal or goals

What populations are going to be impacted by the potential policy? identify: geographic boundaries, vulnerable populations, preliminary data sources and methods

As a group develop pathway diagrams, stakeholder engagement and roles

What are your potential research questions?

Are there identified negative health impacts that could result from your policy?

How will the HIA be communicated and reported

Scoping Exercise

Typical HIA Process

Screening

Scoping

Assessment

Recommendations

Reporting

Evaluation and Monitoring

Developing Community Indicators

Validity

Relevance

Reliability

Measurability

Clarity

Assessment:Criteria for Good Indicators

Assessment: Community IndicatorsIndicator 1: Health Systems

Measures access to and quality of preventative and acute medical care.Factors: physical access to health facilities, transportation, and health insurance status. Note: The timely use of primary care may prevent morbidity and hospitalizations from a number of chronic diseases.Note: Federally Qualified Health Centers, in medically underserved areas, can lower preventable hospitalization rates.

Objectives & Indicators

HS. 1. Assure affordable and high quality public health facilities

HS.1.a. Public health facility transit accessHS.1.b. Hospital bed access

HS.2. Assure access to preventative, outpatient health services

HS.2.a. Early prenatal careHS.2.b. Preventable hospitalizations

The San Francisco Indicator Project

HS.1.a. Public health facility transit access

Assessment Indicator 1: Health Systems

Why Is This An Indicator Of Health and Sustainability?The availability of public transportation to community health facilities is one factor among many that affect access to good quality, affordable, reliable health care.

MethodsTo calculate the Transit Resource Scores, the distance from each residential intersection (intersections within 100 meters of residential lots) to each transit route stop (multiple route stops can be found at one location when multiple transit routes share stop or station) within 1 mile of the intersection was calculated.

Clinics and hospitals with good or very good transit resource scores 2012

Transit Resource Areas

Total Facilities

# in good or very good

% in good or very good

DPH Clinic 22 16 73%Clinic Free 43 36 84%GAC Hospital 13 12 92%Total 78 64 82%

Assessment Indicator 2: Community

The Community indicator includes measures of social inclusion, ethnic and economic integration, and political participation.

Measures of community or social cohesion includes the presence and strength of social networks, social relationships, social capital, civic engagement, group membership and political participation. These are positively associated with health, whereas social exclusion, segregation and isolation negatively impact health.

Objectives and Indicators:

C.1. Promote socially cohesive neighbor-hoods, free of crime and violenceC.1.a. Violent crimesC.1.b. Property crimesC.1.c. Residential mobilityC.1.d. Community center accessC.1.e. Alcohol outlet densityC.1.f. Likelihood of leaving San Francisco

C.1.g. Neighborhood block partiesC.1.h. Spiritual and religious centersC.1.i. Perceived safetyC.2. Increase civic, social, and community engagementC.2.a. Voting ratesC.2.b. VolunteerismC.2.c. Public meeting attendance

Assessment Indicator 3: Education

Education measures the distribution, sufficiency, and quality of public education and child care facilities. Evidence shows that:

• Educational outcomes are positively associated with lifetime earnings, positive health behaviors, and prolonged life expectancy

• When schools are located closer to home, more children walk and/or bicycle to school and vehicle pollution emissions fall

• High quality child care positively affects childhood growth, physical development, and physical health, cognitive, behavioral and school outcomes

Objectives & Indicators

ED.1. Assure affordable and high quality child care for all neighborhoodsED.1.a. Child care capacityED.1.b. Child care subsidiesED.1.c. Child care costs

ED.2. Assure accessible and high quality educational facilitiesED.2.a. Elementary School ScoreED.2.b. School choiceED.2.c. School academic performanceED.2.d. School gardensED.2.e. School graduation ratesED.2.f. Public school participation

Assessment Indicator 4: Economy

Measure economic opportunity and equality. A secure livelihood is a fundamental human need and one of the strongest and most consistent predictors of health and disease in public health research. • Unemployment is associated with premature mortality, cardiovascular

disease, hypertension, depression, and suicide. • Sufficient income is needed for basic material needs; food, clothing,

transportation and shelter. Insufficient income is associated with premature death.

• Among the offspring of low wage workers, higher wages are associated with ‐improved educational outcomes and a reduced risk of early childbirth.

1.a. Jobs paying at least self-sufficiency wage1.b. Worker residents1.c. Job density1.d. Job openings and educational requirements2.a. Health insurance coverage2.b. Occupational non-fatal injury rates

2.c. Paid sick days3.a. Income inequality3.b. Employment3.c. Bank or credit union access3.d. Minority and women owned businesses4.a. Green businesses

Typical HIA Process

ScreeningScoping

AssessmentRecommendations

ReportingEvaluation and Monitoring

Quantitative Estimation in HIA

Is there a causal relationship?Does the data allow for quantitative predictions?• Information on exposure• Baseline health status• Information on exposure

responseIs there a demand for

quantitative information?Can all health effects be quantified?

Identify experts to review analyses or provide

assistance along the way

Assessment:Quantitative Estimation in HIA

Assessment: Quantitative Estimation in HIA

Estimating Freeway Air Pollution Impact on Life Expectancy of

Nearby Residents: Overview of Quantitative Approach

1. Evaluate causal evidence for impacts of traffic air pollutants

2. Obtain baseline measures of mortality in population

3. Estimate (model) air pollutant concentrations attributable to freeway traffic

4. Select and apply exposure response function

5. Assess confidence/uncertainties

Does the data allow for quantitative predictions?• Information on exposure• Baseline health status• Information on exposure

response

In San Francisco, the method people use to travel – by car, bus, foot, or bike –

affects the city's environment and residents' health both positively

and negatively.

The transportation system affects physical activity, air pollution and asthma, injury collisions, and even stress and heart disease.

Analyzing the health impacts of proposed changes to transportation can help us make more informed decisions, save lives, and prevent disease.

Case Study: How Could Road Pricing Impact Our Health?

Can all health effects be quantified?

Identify experts to review analyses or provide

assistance along the way

Case Study: How Could Road Pricing Impact Our Health?

The SFDPH’s Program on Health, Equity and Sustainability received funding from the Robert Wood Johnson Foundation's Active Living Research program to conduct a health impact assessment (HIA) of a congestion pricing policy under study in San Francisco, California.

The SF County Transportation Authority (SFCTA) is studying a potential program that would charge $3 during AM/PM rush hours to travel into or out of the congested northeast quadrant of SF.

This scenario road-pricing fee would fund public transit, road maintenance, and bicycle and pedestrian street improvements.

Congestion Pricing Boundaries for the Northeast Cordon Scenario

Is there a demand for quantitative information?

Case Study: Pathways through which Road Pricing Policies Potentially Effect Health

Is there a causal relationship?

Stakeholder Engagement

ScreeningScoping

AssessmentRecommendations

ReportingEvaluation and Monitoring

Typical HIA Process

Provide valuable input

Build individual/organizational capacityProvide community outreach resourcesProvide quantitative/ qualitative data

Help ground truth findings

Contribute political connections important to an HIA’s successContribute financially and in-kind

Help create buy-in

StakeholdersWhy Engage Community in HIA?

Typical HIA Process

ScreeningScoping

AssessmentRecommendations

Reporting and CommunicationEvaluation and Monitoring

Know Your Audience(s)

Clearly Synthesize and Prioritize Findings• Overall magnitude of health

benefit• Benefit to most vulnerable

populations• Feasibility of solutions• Perceived public concerns

Tailor and Target Your Messages

Work with Stakeholders to Communicate, Translate

Successful analysis and reporting not necessarily result in change…

Reporting and CommunicationsKey Points

Methods of Communication

Briefing PaperComment LetterPeer-Reviewed Journal Article

Fact Sheet

• Document the HIA process and findings in writing• Prioritize findings and recommendations• Provide an opportunity for public review• Identify stakeholders as communicators• Develop messages and communication approaches for

specific audiences• Use opportunities in the decision’s regulatory process

(public hearings, EIA comment)• Engage with decision makers and the media

Reporting and CommunicationsOverview

Typical HIA Process

ScreeningScoping

AssessmentRecommendations

ReportingEvaluation and Monitoring

Evaluations and MonitoringEvaluation

Don’t evaluate too late!Continuously ask the question:

“Is the HIA process on track?”

ScreeningScopingAssessmentRecommendationsReportingEvaluation and Monitoring

Process Evaluation – can provide lessons about why and how the HIA worked

• How was the HIA undertaken – details of time, place, geographic area/population affected, what the proposal sought to achieve, and the methods used?

• Resources used (financial, human, time) and what was the cost?

• Evidence used, and how was it utilized to develop recommendations?

• How were health inequalities assessed?

• How were recommendations formulated and prioritized?

• How were the decision makers involved in the process?

• How were the recommendations delivered to the decision-makers? When?

• What did those involved in the HIA think about the process?

Evaluation

Impact Evaluation – can consider whether, and how well, the HIA worked•How and when were the recommendations accepted and implemented by the decision makers – what factors contributed to this?

•What are the likely reasons why recommendations were rejected?

•Were the aims and objectives of the HIA met?

• What other impacts were associated with the HIA? • improved partnership working • raising the profile of local health needs • putting health on partner agencies’ agendas • organizational development and new ways of working within and

across the organizations involved

Evaluation

The HIA should include a follow-up monitoring plan to track the decision outcomes as well as the effect of the decision on health impacts and/or determinants of concern.

The monitoring plan should include:

1. Goals for short and long-term monitoring

2. Outcomes and indicators for monitoring

3. Lead individuals or organizations to conduct monitoring

4. A mechanism to report to decision-makers and HIA stakeholders

5. Triggers or thresholds that may lead to review and adaptation

6. Identified resources to conduct, complete, and report the

monitoringMinimum Elements and Practice Standards for Health Impact Assessment - November 2014, North American HIA Practice Standards Working Group

Monitoring

• Recommended mitigations should be developed and integrated into an HIA. Clearly outline how each mitigation measure will be implemented.

• Include information on: deadlines, responsibilities, management structure, potential partnerships, engagement activities and monitoring and evaluation related to the implementation of the HIA mitigations.

• HIA management plans should be developed in collaboration with the entity responsible for implementing the plan.

• Management plans are living documents that will need to be revised and improved on an on-going basis.

• Make methods and results from monitoring available to the public.

Monitoring

Common HIA Funding Resources

• The Health Impact Project (Pew Charitable Trusts and the RWJ Foundation)

• Robert Wood Johnson Foundation

• Association of State and Territorial Health Officials (ASTHO)

• The Centers for Disease Control and Prevention

• National Association of County & City Officials (NACCHO)-www.naccho.org

• American Planning Association- www.planning.org

HIA Information Resources

• Human Impact Partners HIA resources www.humanimpact.org/hips-hia-tools-and-resources

• National Research Council Report, “Improving Health in the United States: The Role of Health Impact Assessment” www.nap.edu/catalog.php?record_id=13229

Questions?