The American Public Health Association,
Related APHA Policy Statement
APHA Policy Statement 7325(PP) – Environmental Quality – Environmental Health: Preventative, Planning, and Regulatory Trends and Methodology
APHA Policy Statement 7411 – Supporting the National Environmental Policy Act of 1969
APHA Policy Statement 7629(PP) – Environmental Health Planning
APHA Policy Statement 7633(PP) – Policy Statement of Prevention
APHA Policy Statement 200011 – The Precautionary Principle and Children’s Health
APHA Policy Statement 2004-06 – Affirming the Necessity of a Secure, Sustainable, and Health-Protective Energy Policy
APHA Policy Statement 2004-11 – Threats to Public Health Science
APHA Policy Statement 2004-12 – Support for Community-Based Participatory Research in Public Health
APHA Policy Statement 20066 – Conduct Research to Build and Evidence-Base of Effective Community Health Assessment Practice
APHA Policy Statement 20062 – Reducing Racial/ Ethnic and Soioeconomic Disparities in Preterm and Low Birthweight Births
APHA Policy Statement 20099 – Improving Health Through Transportation and Land-Use Policies
Health impact assessment (HIA) is a systematic process to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA also provides recommendations on monitoring and managing these effects. The strength of HIA rests upon 5 principles: democracy, equity, ethical use of evidence, sustainable development, and a comprehensive view of health. By facilitating the consideration of health in short- and long-term decision making, it contributes to the Health in All Policy. Although HIA is recommended in several existing APHA policies, none specifically promote the broad use of HIA or the development of capacity to use HIA. This policy statement supports institutionalizing HIA at the federal, state, and local levels; building capacity for HIA; and increasing HIA research and evaluation.
Today’s public health problems result not from a single causative agent, but rather from a number of interdependent determinants that are often embedded in complex public policy issues. Disciplines and sectors traditionally outside the domain of public health, such as transportation, education, industrial development, and agriculture, are generally unaccountable to health outcomes and have many competing priorities. To address the broader determinants of health that contribute to poor health and vast health disparities, public health leaders must find ways to incorporate concern for and accountability to health outcomes into a wide range of decision making and public policies. Furthermore, a spending mismatch in public health jeopardizes long-term health gains as “our nation’s investment portfolio with regard to health is weighted far towards short-term returns.”6,7 To date, public health has leveraged only a fraction of external resources that affect health, but it can do so by demonstrating that those investments can create value in the form of long-term community health and well-being.8
The Health in All Policy (HiAP) is an approach that encourages the consideration of health in all decision making, especially public policy. In July 2011, the Institute of Medicine recommended that federal, state, and local decision makers adopt HiAP.9 At the federal level, the interagency National Prevention, Health Promotion, and Public Health Council was created with HiAP in mind; the council’s 2011 National Prevention Strategy is a roadmap to better health that draws in health determinants affected by diverse sectors of government. The institutionalization of HIA will serve HiAP. In some cases, health considerations can be included in a decision without a formal HIA process; this is mostly likely when the health impacts are familiar and the decision-making process is transparent. However, achieving HiAP will require much broader changes in decision-making processes.10 HIA systematically introduces a community-based, holistic understanding of health into decision-making processes for both public- and private-sector activities. It establishes health and well-being as a priority, recognizing that it is the ultimate outcome of economic, social, and political conditions. Widespread HIA could raise public awareness of the broad scope of factors affecting health, emphasize the links between our nation’s health and its economic and social strength, and help policymakers elevate health considerations to the same plane as other outcomes of concern.
The role of HIA in achieving HiAP is being realized in San Francisco, where 21 HIAs have been completed over the past decade. The process has helped “increase public awareness of the determinants of health, routine monitoring of these determinants, cooperation among institutions, health-protective laws and regulations, and organizational networks for health advocacy and accountability.”11 Once health impacts have been considered in a decision, they can be institutionalized in the processes and standards for similar decisions. The Healthy Development Measurement Tool provides one example of this approach.12
Need for the HIA process: The strength of the HIA framework lies in its core principles and its potential to affect policy development. HIA requires that teams of individuals from various disciplines pool their talents with members of the community to develop and implement strategies for change; thus, the process offers the opportunity to overcome disciplinary and sectoral silos, address root causes of health disparities, and bring more resources to primary prevention for public health. HIA proceeds through 6 steps (see below). Practice guidelines and standards have helped to refine the practice so that the process itself also adds value to decision making.13 The HIA steps are as follows.
1. Screening: During screening, practitioners (who may include staff from health departments, foundations, private organizations, or others with training in HIA methodology) briefly describe potential connections between the proposed policy, program, plan, or project and the health of affected communities and individuals.1,14 If the proposed undertaking is likely to have significant health impacts—either positive or negative—and an HIA would provide additional information for the decision-making process, proceeding with the HIA process is recommended.
2. Scoping: This step identifies primary health outcomes of interest, affected and vulnerable populations, and stakeholder group concerns. Practitioners also outline the research methodology, including data sources and analysis plans. Scoping determines the nature of community involvement and the depth of the assessment.
3. Assessment: This stage follows through on plans set during scoping and compiles relevant data and information for analysis. Data may be qualitative or quantitative and from a broad range of fields. Analyses should also incorporate stakeholder perspectives. Throughout the process, practitioners must be clear about the limitations of available data and findings.
4. Recommendations: HIA does not prescribe a decision. Rather, it presents actions to maximize health benefits and minimize harm, especially to vulnerable groups, for the decision alternatives. Recommendations specify the parties or stakeholders that should be responsible for implementation.
5. Reporting: The HIA report describes in detail all of the first 4 steps, including the proposed policy, plan, or program; stakeholders and their involvement; data sources and analysis; findings; recommendations; and a plan for monitoring and evaluation. The report must be clear and easily accessible to all stakeholders. For maximum utility, the report format and timeline should align with economic, political, and social considerations and decision points.
6. Monitoring and evaluation: The HIA process, impact of the HIA recommendations, and health outcomes after implementation should be evaluated. This stage is especially important given that HIA is a new and rapidly developing field.
Value of HIA guiding principles: The HIA approach is based on 5 guiding principles: democracy, equity, ethical use of evidence, sustainable development, and a comprehensive view of health. These principles, identified in the World Health Organization’s 1999 Gothenberg consensus paper, underlie the “value added” by HIA.14
Democracy: In general, the public is not authentically engaged in all of the decisions relevant to their health, while decision makers are not fully informed about all potential outcomes.15 Authentic engagement means that “participants are full and equal members of the research or program planning team, have opportunities to make significant contributions to the process, and are involved in decision-making."16 Deliberation—defined as “judicious argument, critical listening, and earnest decision-making”—can yield benefits for both individuals and society, including self-efficacy, community identity, and civic engagement.17 HIA facilitates authentic engagement and provides space for deliberative democracy and decision making.
Equity: The adverse health effects of public policy fall disproportionately on vulnerable groups.18 Ultimately, socioeconomic status, influenced by education, occupation, and income, underlies determinants that account for 80% of premature mortality.19 HIA focuses on the equity impacts of decisions and incorporates equity into the formal decision-making process. During scoping, HIA practitioners identify vulnerable populations and consider impacts the proposed project would have on those groups. This step in HIA is similar to other assessments such as equity impact assessment. Although individual HIAs may choose equity as a specific area of focus, HIA generally incorporates equity as an overarching value and considers it a mediator on the pathway to health outcomes.
The 2003 HIA on San Francisco’s Trinity Plaza Apartments exemplifies how equity concerns are operationalized in HIA. It brought to light community concerns that demolition would result in the loss of more than 350 rent-controlled units, leading to stress, overcrowding, food insecurity, and decreased social cohesion.20 These concerns resulted in recommendations that persuaded developers to keep the subsidized units in the new development plan. In this instance and others, the participatory process of HIA addressed the power differential between decision makers and underrepresented groups.18 In the international health arena, the World Health Organization has promoted HIA for more than a decade as a means to improve policy decision making, and it could be used even more broadly to understand the impact of global health programs.14
Ethical use of evidence: Analyses of policies, plans, and programs often lack rigor, transparency, and impartiality and do not always make use of the best available evidence. Environmental impact assessment (EIA), for example, although highly rigorous, is often so bulky and technical that it is difficult to understand. Furthermore, EIAs are frequently conducted by private consultants and are not readily available to the public. HIA values both rigor and full and impartial participation, recognizing that community questions about the research, methods, and relevance create a necessary balance between community control and scientific accuracy. Through community approval of research conduct, HIA responds to the call to move beyond “black-box” epidemiology.21 The process reveals potential biases by requiring that all steps of the process be clearly documented. Finally, whereas recommendations stemming from other processes such as risk assessment can be delayed by questions of scientific certainty, HIA relies on the precautionary principle, which specifies that in lieu of scientific certainty, the best available evidence should be used in making decisions.22 The precautionary principle highlights the opportunity costs of waiting for only the most certain information and, conversely, the costs of decision making without any information. HIA is a practical means of operationalizing this principle.23
Comprehensive and sustainable approaches: Policies influencing food security, a living wage, healthy housing, safe and healthy work environments, and education have far-reaching impacts on health. These may be direct, short-tem impacts or more distal influences, for example through job creation and other economic factors. Decision makers in these other sectors, whether elected officials or agency administrators, may not pay significant attention to health outcomes due to a long list of competing priorities and limited accountability.24,25 While public health professionals regard health as their priority, they do not have the authority or resources to affect the entire population’s long-term health. Given this paradox, collaborations with other fields are required. However, such collaborations are traditionally challenging, as evidenced in a survey of 845 local planning agencies in which only 27% of comprehensive plans explicitly addressed public health.26 The HIA process supports an HiAP approach, bringing public health practitioners together with representatives of other sectors in a process of co-learning and mutual interest. These relationships may help overcome the priority-authority paradox and collectively improve the health of the public.27
Proposed Recommendations Statement
Institutionalize HIA to improve policy and program decision making: There is great potential for HIA to add value to routine governmental decision making. At the federal level, capital investments of more than half a trillion dollars annually in the combined sectors of agriculture, transportation, and housing could be leveraged for health improvements if HIA were incorporated into policy and programmatic decisions in these sectors7 Given the history of the National Environmental Protection Act of 1969 (NEPA), the sensitization provided by the national Healthy Places Acts of 2006 and 2007, the familiarity of similar predictive approaches in the US Government Accountability Office, and new interagency partnerships in the Obama administration, there is an opportunity to institutionalize HIA in federal decision making.
Institutionalized HIA is likely to evolve legally from the process of EIA codified by NEPA. The NEPA legislation calls for consideration of public health for large federal investments in housing, highways, and other public works. While NEPA incorporates additional information into the decision-making process, it often has not yielded improved health outcomes.25,28,29 HIA offers a more practical and meaningful assessment than EIA.29–33 Done properly, HIA is more inclusive and practical than EIA. Still, HIA will be most effective when it supplements an EIA or is used in cases in which an EIA is not required.
While the magnitude and scope of investments at the federal level are far greater, institutionalizing HIA at the state level would also increase health considerations in planning. For example, using stakeholders to monitor adherence to HIA recommendations could hold “nonhealth” agencies more closely accountable for health outcomes. Nineteen states have statues that require some type of EIA, either broadly, as in Maryland, or for specific types of projects, such as transportation in Massachusetts. The health portions of these statutes should be strengthened in accordance with HIA processes and values.34 Several local public health agencies, including the San Francisco Department of Health, have achieved a notable level of institutionalization.29–33
Support capacity building to maximize HIA’s potential: With growth, HIA practitioners must avoid being perceived as simply another special interest.35 To do so, they must increase HIA training opportunities for professionals and laypersons in health and other fields. With that goal in mind, a range of expert groups have led nationwide capacity building for HIA. These groups include the Centers for Disease Control and Prevention, Human Impact Partners, the San Francisco Department of Health, and many others. There are also graduate-level courses on HIA at 8 universities, with 4 more under development. Through all of these efforts, more than 1,000 practitioners have been trained to date, and this training is being evaluated. When funding is not available for in-depth training, HIA practitioners and professional organizations can provide technical assistance to interested parties and agencies.
Support HIA research and evaluation: HIA practitioners must be aware of the critiques of HIA.36 Ecological, life course, and cumulative effects frameworks are continuing to change public health practice, but the field still faces “the plural of anecdote as policy.”37 Hence, public health and environmental agencies are reasserting themselves through performance measurement and accreditation. There is also a small but growing interest in economic framings and forecasts in public health, such as return on investment, as an impetus for expanded community development and sustainable urban communities.38 HIA compliments these processes of measuring performance and returns on investment. Emphasizing monitoring and evaluation as a necessary component of HIA will also help practitioners ensure their practice follows guidelines and meets professional standards.
Opposing Arguments and Evidence
Methodological considerations: A common critique is that HIA is not sufficiently rigorous. This will not be resolved quickly because the complex relationship between environments and health outcomes makes it difficult to obtain quantitative data for both baseline and predicted outcomes. Despite a lack of reliable indicators for environmental effects and causal pathways, the evidence base is growing each year. In other instances, stakeholder input may not be perceived as “scientific evidence” in lieu of robust qualitative and quantitative measures. However, expert opinion and community acceptance are both critical elements of HIA and should be given significant weight.
Measuring HIA’s impacts on decision making or changes in community health is challenging. For some, the lack of peer-reviewed evaluations limits credibility. However, 4 major evaluation projects are under way, including evaluations of 25 HIAs completed in the United States (A. L. Dannenberg, personal communication, December 2011), that will provide practitioners with more robust data.39
Some HIA opponents argue that another risk assessment tool is one too many. However, the National Research Council’s review of commonly used risk assessment methods found them to be either too narrowly focused on negative health effects, deemphasizing group discussion, or not appropriate for assessing specific geographic locations. HIA, by contrast, evaluates root causes of disease, is applicable to a broad array of projects and plans, highlights beneficial health impacts and offers alternatives to help decision makers better weigh their options.1 Those resistant to HIA can learn from urban planners who have more readily customized HIA to meet their professional needs.40
Other barriers to improving HIA methodology include lack of site-specific or neighborhood-level data, synthesizing diverse health data, and balancing health-related recommendations with other decision-making criteria. These challenges are being addressed by practitioners and academic institutions. For example, the San Francisco Department of Public Health partnered with researchers to build local databases and continues to look for ways to help community members access them.
Workforce and resource considerations: In times of diminished resources, directors and managers may not have available staff or funding to conduct HIA. However, creative health departments have leveraged staff time, found cost savings through reorganization, and used permitting fees to support HIA activities. Because HIA relies on community partnerships, it makes more efficient use of the formal public health workforce. Some argue that many public health agencies lack the time and resources necessary to train staff in HIA methods and values.41 For example, it is unclear whether the public health workforce has the requisite community engagement skills to mediate complicated stakeholder relationships.42 However, organizations such as Human Impact Partners offer training and technical assistance regarding this and other issues and are working to strengthen practice networks across the country.
Agencies and departments strapped for resources may also debate as to whether or not HIA should be mandatory or voluntary; however, HIA does not have to be either-or. Health elements can be incorporated into mandated EIA processes, thereby mitigating the need for additional legal statutes. Voluntary HIA could be more appropriate for smaller projects that do not fall under NEPA review.
Political considerations: As HIA often addresses large, publicly funded projects, it functions in an inherently political sphere. The rhetoric and reality of HiAP is contentious for some decision makers who argue that they should not be asked to consider such a broad range of factors for site-specific projects. Nonhealth agencies and partners may be resistant to a new framework that measures success in terms of health, making it appear they have not achieved their objectives.24 As well, managers might presume that additional collaboration means additional costs. To encourage more dialogue about this, public health practitioners should emphasize how HIA promotes transparency, accountability, and long-term cost effectiveness.
There are others who oppose HIA on the principle that governments (and their departments) should not police each other. However, some governments are working to proactively address this power-sharing issue. In 2010, the governor of California issued an executive order establishing a task force in support of interagency collaboration and the incorporation of HiAP.43 Staff from the Alaska Department of Health and Social Services created an interagency workgroup and an HIA program to encourage more formalized consideration of human health in resource extraction procedures. A representative from the Division of Public Health also joined the Departments of Natural Resources, Commerce, Transportation, Law, and others on the state’s large mine permitting team.
Many private real estate developers perceive the process as an additional regulatory hoop that generates costs, but such claims have not been validated (A. L. Dannenberg, personal communication, December 2011). They have subsequently claimed that HIA impedes economic development, but again this is not substantiated by research. Cost projections for HIA are often best guesses as there are no published data on them. It is important to consider that not every project, policy, and program warrants HIA, and the resources required vary. HIAs can be completed in as little as a few weeks and, when incorporated into existing development review processes, can be a crucial way to identify potential health concerns early on and prevent future litigation and related costs.33
Ethical considerations: In most major development projects, some stakeholders hold polarized positions, and there is difficulty foreseeing all of the short- and long-term outcomes. For example, construction projects might create jobs and boost economic activity, but the final design does not incorporate safe and healthy working conditions, active living elements, or ways to reduce traffic and carbon emissions. HIA helps illuminate such concerns along with the concerns of populations that do not normally have a voice in the decision-making process. In these instances, decision makers unwilling to cede authority to other stakeholders may oppose HIA. However, this is precisely why HIA is a valuable addition to public health tools that promote social justice and human rights.18 Without requirements for HIA, marginalized and underrepresented communities remain at greater risk for the negative impacts of poorly designed policies and development projects, impacts that include pollution, poor housing, and lack of access to jobs and health care. HIA allows these voices to be heard in an official forum where they can be part of the decision making.
The challenges of multi-agency collaborations with convoluted regulatory oversight add complexity. For example, the advisory group for a bridge-building project in Seattle, WA, had representatives from more than 30 stakeholder groups.44 Incorporating all of their views satisfactorily was difficult. Stakeholders who do not understand the HIA process and the importance of objectivity may have unrealistic expectations or feel entitled to their preferred outcome. If HIA is to be a useful and credible means for all stakeholders to feel fairly included, represented, and heard, practitioners must refine and follow existing practice standards for participation.45 The challenge is to have all parties understand the mutual benefits of engaging in an authentic process.
Impact of HIA: Even if the challenges of methodological, workforce, political, and ethical considerations are addressed, other variables may influence the ability of the HIA process to influence decisions. The timing and framing of health impacts and recommendations are crucial to HIA’s effectiveness. Research has begun to demonstrate how HIAs have influenced both the immediate decision being assessed and the organizational and political culture in which it occurred.11
The US Congress should:
1. Incorporate HIA principles and processes in policy, planning, and program decisions that affect the health of communities. This may include but is not limited to formal HIA practice. Examples include past legislation such as the Healthy Places Acts and the Poverty Impact Statement Amendment to the American Energy and Infrastructure Jobs Act.
2. Incorporate HIA principles and processes into bills governing decisions that affect health, health care, and upstream health determinants such as, but not limited to, transportation or education.
3. Continue legislative attempts to bolster NEPA and incorporate stronger consideration of health impacts into EIA and NEPA legislation and regulations.
Both the US Congress and executive branch should:
1. Support public financing for HIA through existing funding streams such as the Prevention and Public Health Fund, including monitoring and evaluation of HIA projects.
2. Support public financing for HIA training and education as a component of existing workforce development funds in the Department of Health and Human Services and other agencies.
3. Support public financing for interagency and multisector collaborations such as the National Prevention, Health Promotion, and Public Health Council that increase awareness of the multiple determinants of health.
State legislatures should:
1. Incorporate HIA mandates into relevant legislation.
2. Fund state and local health departments to establish HIA infrastructure, enabling them to conduct HIA to aid in policy and program decision making or as a component of state-mandated EIA.
3. Designate professional development funds for HIA training and education for public health practice and academic professionals at the state and county levels.
Schools and other institutions that offer education and training related to public health, policy, and planning should:
1. Develop and teach interdisciplinary and transdisciplinary courses in HIA history, methods, and principles to students who will work in domestic and international community development.
2. Encourage the development and implementation of practice standards and guidelines and include them in HIA curricula. Existing resources include the North American Practice Standards and the new Society of Practitioners of HIA (SOPHIA).
3. Pursue research on the HIA process and outcomes.
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