Health Impact Assessment: A Tool to Help Policy Makers Understand Health Beyond Health Care Brian L. Cole and Jonathan E. Fielding Department of Health Services, School of Public Health, University of California, Los Angeles, California, 90095-1772; email: [email protected], jfi[email protected]Annu. Rev. Public Health 2007. 28:393–412 The Annual Review of Public Health is online at http://publhealth.annualreviews.org This article’s doi: 10.1146/annurev.publhealth.28.083006.131942 Copyright c 2007 by Annual Reviews. All rights reserved 0163-7525/07/0421-0393$20.00 First published online as a Review in Advance on December 15, 2006 Key Words public policy, policy making, decision making, determinants of health, risk assessment Abstract Health impact assessment (HIA)—a combination of methods to ex- amine formally the potential health effects of a proposed policy, program, or project—has received considerable interest over the past decade internationally as a practical mechanism for collabo- rating with other sectors to address the environmental determinants of health and to achieve more effectively the goals of population health promotion. Demand for HIA in the United States seems to be growing. This review outlines the common principles and method- ologies of HIA and compares different approaches to HIA. Lessons learned from the related field of environmental impact assessment and from experience with HIA in other countries are examined. Pos- sible avenues for advancing both the field and the broader goals of population health promotion are outlined. 393 Annu. Rev. Public. Health. 2007.28:393-412. Downloaded from arjournals.annualreviews.org by UNIVERSITY OF IOWA on 02/16/08. For personal use only.
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Health Impact Assessment:A Tool to Help PolicyMakers Understand HealthBeyond Health CareBrian L. Cole and Jonathan E. FieldingDepartment of Health Services, School of Public Health, University of California,Los Angeles, California, 90095-1772; email: [email protected], [email protected]
Annu. Rev. Public Health 2007. 28:393–412
The Annual Review of Public Health is online athttp://publhealth.annualreviews.org
This article’s doi:10.1146/annurev.publhealth.28.083006.131942
First published online as a Review in Advance onDecember 15, 2006
Key Words
public policy, policy making, decision making, determinants ofhealth, risk assessment
AbstractHealth impact assessment (HIA)—a combination of methods to ex-amine formally the potential health effects of a proposed policy,program, or project—has received considerable interest over thepast decade internationally as a practical mechanism for collabo-rating with other sectors to address the environmental determinantsof health and to achieve more effectively the goals of populationhealth promotion. Demand for HIA in the United States seems to begrowing. This review outlines the common principles and method-ologies of HIA and compares different approaches to HIA. Lessonslearned from the related field of environmental impact assessmentand from experience with HIA in other countries are examined. Pos-sible avenues for advancing both the field and the broader goals ofpopulation health promotion are outlined.
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Health impactassessment (HIA):a combination ofmethods to examineformally thepotential healtheffects of a proposedpolicy, program, orproject
HIA AS A NEW TOOL FOR ANOLD WAY OF DOING PUBLICHEALTH
From the time of Hippocrates public healthpractitioners have looked to the environmentto identify the causes of ill health and forpotential opportunities to advance well be-ing. The seminal “Report on a General Planfor the Promotion of Public and PersonalHealth” to the Massachusetts legislature, au-thored by Lemuel Shattuck (69) in the midnineteenth century, and the writings of RudolfVirchow (72, p. 72) in that same century sug-gest a continuing recognition of the centralityof social and physical environmental effectson health. Snow’s apocryphal removal of wellpump handles to stem an outbreak of cholera,Gorgas’ efforts to control yellow fever andmalaria during the building of the PanamaCanal, the dramatic improvements in motorvehicle safety in the United States as a resultof improved vehicle standards and roadwayinfrastructure, and reductions in tobacco useover the past several decades demonstrate thepotential of an environmental approach forimproving public health. Although a more in-dividualistic approach, emphasizing biomed-ical and behavioral paradigms, has frequentlydominated the field since the mid-twentiethcentury (72), concern about the environmen-tal determinants of disease remains a vitalprincipal of public health (45).
Over the past quarter century the WorldHealth Organization has set forth a numberof major declarations and initiatives callingfor a return to an environmental approachto improving population health, including theAlma Ata Declaration (82), the Ottawa Char-ter on Health Promotion (82a), the JakartaDeclaration on Health Promotion (83), theBangkok Charter for Health Promotion (86),and the Healthy Cities movement (5). Similardeclarations have been made at the nationallevel, including most significantly the LalondeReport (39) in Canada and the Acheson Re-port (2) in the United Kingdom. Because theability to modify many of the environmental
determinants of disease lies outside the tra-ditional province of public health agencies,intersectoral cooperation in creating healthypublic policy (46) has been a common themethroughout these declarations and initiatives.Questions remain, however, about how to putthese principles into practice (68).
Health impact assessment (HIA), which isa combination of methods to examine for-mally the potential health effects of a pro-posed policy, program, or project, has receivedconsiderable interest over the past decade asa practical mechanism for collaborating withother sectors to address the environmentaldeterminants of health and achieve more ef-fectively the goals of population health pro-motion (52, 84). Support for HIA grew mostrapidly in Canada (5), Europe (7, 65), Australia(87), and New Zealand (89), perhaps not sur-prisingly because other initiatives rooted inan environmental approach to public healthpromotion, such as Healthy Cities (5) and“healthy public policy” (46), also garneredconsiderable interest in these countries, incontrast with the United States, where a nar-rower, more individualistic approach to healthpromotion has been more prevalent.
Although interest in HIA in the UnitedStates has been relatively slow to develop,it is now growing. Formal HIAs have beenconducted by a number of groups across theUnited States (see Table 1), examining thepotential health impacts of a range of projectsand policies, ranging from local land-use plansand wage ordinances to state funding for after-school policies and federal agriculture subsi-dies. In the past year proposals to mandateHIAs have been put forth in Washington State(79) and the U.S. Congress (75). As demandgrows and HIA becomes more common, is-sues must be addressed regarding dissemina-tion of technical capacity, standardization ofprotocols, and institutional arrangements forfunding, coordination, and implementation.
This growing interest in HIA in the UnitedStates is driven by a combination of factorsincluding the following:
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Table 1 Health impact assessment in the United States: completed and in-progress HIAs (as of September 9, 2006)1,2
Title or topic
Location of theproposed policy or
project Organization(s) involved DateKey impacts and
pathwaysLos Angeles City LivingWage Ordinance (16)
Los Angeles,California
UCLA school of public health 2003(published2005)
IncomeHealth insurance
After School Programs—Proposition 49 (74)
State of California UCLA school of public health 2003 EducationCrime
2002 Federal Farm Bill (74) United States UCLA school of public health 2004 Subsidies/nutritionBiofuels/air pollution
Sacramento Safe Routes toSchool (74)
Sacramento,California
UCLA school of public healthand CDC, Project Move
2005 Physical activityInjuryAir pollutant exposureSocial capital
Buford Highway/NE Plaza(74)
Atlanta, Georgia UCLA school of public healthand CDC, Project Move
Affordable Housing andChild Health—rentalvoucher program (13)
State ofMassachusetts
Child Health ImpactAssessment Working Group
2005 Housing
Puyallup City Planning (71) Tacoma/PierceCounty,Washington
Tacoma-Pierce County ofPublic Health and Puyallup
In progress Physical activityInjuryCrimeEconomic development
Housing Redevelopment(15)
North Minneapolis,Minnesota
Minneapolis department ofhealth and family support
In progress Housing, builtenvironment
(Continued )
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Table 1 (Continued )
Title or topic
Location of theproposed policy or
project Organization(s) involved DateKey impacts and
pathwaysLand Use and Health Mid-Michigan area Ingham county health
department, Michigandepartment of community healthand Michigan State University
In progress Built environment
Coal-Fired North FloridaPower Project (29)
North FloridaCounties
Healthy Development Inc. 2005 Airborne pollutantsEmployment
School siting Austin, Texas School of Architecture, UTAustin
In progress Physical activityInjuryAir/water pollution
1HIAs identified through search of Internet, NLM PubMed, HIA listserv reports, and follow-up of requests for technical assistance to conduct HIAsreceived by UCLA HIA group and colleagues at the Centers for Disease Control and Prevention, National Association of City and County HealthOfficers and the American Planning Association.2Abbreviations: CDC: Centers for Disease Control and Prevention; UC: University of California; UCLA: University of California, Los Angeles;UT: University of Texas.
1. the increasing importance of health andits underlying determinants as topics ofpublic concern;
2. growing recognition of the influences ofother sectors on public health coupledwith a clearer recognition of the limitsof traditional public health practice forpromoting population health;
3. interest in bringing to bear the results ofsystematic reviews of research evidence,such as the Community Guide for Pre-ventive Community Services (http://www.thecommunityguide.org), onpolicy decisions; and
4. the realization by groups in other sec-tors, such as housing developers and en-vironmental housing groups, that find-ings from HIA can be used to supporttheir proposals.
WHAT IS HIA?
Among the numerous definitions of HIA,a particularly useful one is provided by re-searchers at the Northern and Yorkshire Pub-lic Health Observatory in Great Britain:
A multidisciplinary process within which arange of evidence about the health effects
of a proposal is considered in a structuredframework . . . based on a broad model ofhealth which proposes that economic, po-litical, social, psychological, and environ-mental factors determine population health(55).
This definition incorporates five generallyaccepted key characteristics of HIA:
1. a focus on specific policy or project pro-posals,
2. a comprehensive consideration of po-tential health impacts,
3. a broad, population-based perspectivethat incorporates multiple determinantsand dimensions of health,
4. a multidisciplinary systems-based ana-lytical approach, and
5. a process that is highly structured butmaintains flexibility.
The general tenet underlying HIA isthat by bringing consideration of health is-sues into decision-making in other sectorswhose actions affect population health, HIAcan provide a practical means for facilitat-ing intersectoral action for health promo-tion (84). Its greatest value lies in its abil-ity to identify and communicate potentially
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significant health impacts that are under-recognized or unexpected, addressing, for ex-ample, the potential health effects of policiessuch as agricultural subsidies, wage laws, ed-ucation programs, and urban redevelopmentprojects.
HIA has taken on a wide variety of formsdepending on the sociopolitical environmentof the different countries where it is con-ducted, the characteristics of the particularpolicy questions to which it is applied, thedisciplinary backgrounds of practitioners, andthe expectations of stakeholders who use itsresults.
From its very start HIA has evolved alongtwo distinct, sometimes intersecting paths(35). Some of the earliest systematic efforts todevelop HIA came from Canada (63) whereHIA has been integrated into existing pro-cedures for environmental impact assessment(EIA) (1). This more narrow approach to HIA(34) is typically, but not always, based on abiomedical model of health. It tends to beproject focused. Reflecting the paradigmaticand methodological parallels of EIA, it is wellsuited for integration with existing EIA pro-tocols. In contrast, the “broad approach” toHIA (34) draws from models that consider thesocial and behavioral, as well as physical, de-terminants of health. Correspondingly, it isthe approach used by HIAs examining pro-posed policies, which typically impact healththrough a range of pathways. These narrowand broad approaches to HIA overlap but arenot synonymous with the terms project HIAand policy HIA. For instance, Sweden’s ap-proach to HIA, which is conducted by localgovernment policy-makers, focuses largely onprojects but considers a broad range of socialand economic factors contributing to health(7, 24).
THE VALUE OF HIA
HIA could add value to public decision-making in several ways. First, it can providea means for “bringing the public’s health to
the table” by adding health information toconsiderations of specific proposals in othersectors. For example, is it likely that a newhighway will increase asthma rates for thoseliving near its route? Will it affect walking orbiking routes to school and within neighbor-hoods? What could be the health impact ofthe increased noise? It can highlight counter-intuitive and differential impacts, such as howa specific approach for funding after-schoolprograms (e.g., California’s Proposition 49)could actually be detrimental to the healthof low income residents (74) or how a planto relocate a school from a town center toan outlying area to allow expansion of facili-ties for physical education and school athleticsmight actually decrease physical activity levelsamong the most sedentary children and low-income families with the least access to placesfor physical activity. Second, HIA provides anexplicit method of assessing possible positiveand negative health effects with a transparentaudit trail for others who may want to ques-tion the methods or results or redo the analysiswith different assumptions. Third, if carefullyperformed, it provides a reasonable projectionof health effects over time that can be impor-tant in public justification of decisions by pub-licly accountable elected decision-makers. Itcan, for example, quantify the health benefitsto future generations by improving walkabil-ity of neighborhoods or reducing the injuryaccident rate from requiring motorcyclists towear helmets.
Besides contributing information that canbear on a specific decision, the HIA pro-cess can have more general, strategic effects.First, it can increase decision-makers’, plan-ners’, and other stakeholders’ general aware-ness about health issues and the health effectsof actions outside the health sector (20, 34,68), much as EIA in general has succeeded inincreasing awareness of environmental issuesacross sectors (18, 80). Second, HIA can alsohelp build working relationships and alliancesfor health promotion among stakeholders andacross sectors (20, 34).
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EIA: environmentalimpact assessment
NEPA: NationalEnvironmentalProtection Act
CEQ: Council onEnvironmentalQuality
SHOULD HIA BE EMBEDDED INEXISTING EFFORTS FOR EIA?
Some of the early interest in HIA in theUnited States focused on links between HIAand existing efforts in the field of environmen-tal impact assessment (EIA). Our study of thestate-of-the-art in EIA, which included con-sultation with a number of experts in that field,led us to conclude that at this point in time,while HIA can learn from EIA, efforts to ad-vance HIA in the U.S. would yield the greatestdividend if focused on developing HIAs inde-pendent of existing EIA efforts (17, 19). Thisconclusion largely derives from how environ-mental impact assessment has evolved in theU.S.
The National Environmental ProtectionAct (NEPA) of 1969 mandated that federalagencies consider the environmental effectsof their actions using explicit methods (53).NEPA requires the preparation of an envi-ronmental impact statement, which summa-rizes the findings of an environmental reviewto help inform agency decisions and makethe process more transparent by making thestatement a public document. Whereas theEnvironmental Protection Agency (EPA) inconjunction with the White House’s Coun-cil on Environmental Quality (CEQ) estab-lishes general guidelines for EIA, differentlead agencies are chosen to coordinate eachEIA, depending on which agency has the mostdirect responsibility over the project beingexamined.
Many volumes have been written aboutthe shortcomings of EIA as it is currentlypracticed in the United States. The meth-ods, which have been either mandated byindividual agencies or accepted as appropri-ate by convention for a particular proposedproject, are laborious. Environmental impactstatements often take years to complete, rang-ing in cost from hundreds of thousands tomillions of dollars (76). Completed docu-ments are often thousands of pages in length.The EPA estimates that only 37% of fed-eral environmental impact statements stay
within the guidelines of 150 maximum pages(77).
Furthermore, NEPA-mandated EIAspresently consider human health impactstangentially at best, even though the statedpurpose of the act is to protect the “humanenvironment” and “stimulate the health andwelfare of man” (53). The categories ofimpacts considered in EIAs in the UnitedStates are determined largely by other federalstatutes, such as the Clean Air Act, whichrequire that a particular environmental im-pact be considered in EIAs, and conventionalpractice, along with some guidance fromstate and federal committees, such as thefederal CEQ. California is one of the fewstates to require a consideration of humanhealth impacts, but this is typically limited toa consideration of cancers linked to exposuresto chemical pollutants subject to EIA (17).Because of concern about potential legalchallenges, and the fact that it is the projectproponent whose employees or consultantsprepare an EIA, it is a highly prescribedprocess not particularly open to investigatingareas of impacts that are not explicitlymandated, such as human health (17).
Another important caution about embed-ding HIA primarily as part of an existing EIAprocesses is that EIA rarely considers impactsoutside place-based projects (17). The CEQitself has acknowledged that “NEPA is virtu-ally ignored in formulating specific policiesand often is skirted in developing programs”(18). The place-based focus of EIA persistsdespite NEPA and CEQ guidelines that callfor the assessment of environmental impactsof most “major federal actions,” includingprojects, programs, and policies (54). Thus,key nonplace-based policies, such as mini-mum wage laws, agricultural subsidies, andeducation policies, which are likely to havesubstantial effects on human health, would notbe addressed by HIA incorporated into EIA ascurrently required and conducted.
In addition to specific problems related tothe legal and methodological frameworks thatsupport existing EIA practice, most of which
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could be potentially ameliorated in the rightpolitical circumstances, a more fundamentalproblem may exist linking the variety of EIAextant in the United States with a robust, com-prehensive approach to HIA. Because of thewide range of determinants of health and thevariety of policies and sectors that affect thesedeterminants, HIA needs to be open-ended,broadly focused, and highly flexible. MeshingHIA with a narrowly prescribed approach toEIA that is inherently conservative and deeplyconcerned about legal defensibility will leadto conflicts. Given that EIA has been in placein the United States for more than 35 yearsand that millions of dollars are invested ev-ery year in EIA, it is far more likely that HIAslinked to EIA will conform to the limits of EIArather than HIA truly expanding the scopeof EIA. The two are necessarily incompat-ible, however. Indeed, researchers have ar-gued that HIA should be linked to EIA tohelp institutionalize HIA (89). Perhaps someHIAs can be linked to EIA when appropri-ate. In nations with other political and le-gal systems it may be easier and more feasi-ble to link HIA with EIA. In fact, integratedHIA/EIA is the dominant approach to HIAbeing pursued in Australia and New Zealand(89).
TYPES OF HIA
Approaches to HIA can be categorized in nu-merous ways, such as Kemm’s (34) catego-rization of HIA methodologies as “broad”(holistic, sociological, qualitative) or “tight”(limited, epidemiological, quantitative). Auseful typology considers variants of HIAbased primarily on the different fields fromwhich they draw: epidemiology and risk anal-ysis, evidence-based evaluation and practiceguidelines, community-based health promo-tion, and environmental impact analysis. Al-though a given HIA may draw from all thesefields, HIAs tend to emphasize one or anotherof these fields, clustering into three generalapproaches to HIA: (a) quantitative/analytic,(b) participatory, and procedural.
Each of these three approaches to HIAserves slightly different functions and reflectsdifferent paradigms, corresponding closely toGoulet’s classification of alternative techno-logical, political, and ethical rationalities fordecision-making (26).
In the quantitative/analytic approach toHIA, effect estimates from the research lit-erature and descriptive information on a tar-get population are combined to estimate therange, direction, and magnitude of potentialhealth impacts of a policy or project on a pop-ulation. This approach draws heavily from thefield of risk analysis; however, unlike risk anal-ysis, HIA considers a broad range of potentialhealth impacts, not just a single pathway (36).Among the many impacts examined by anHIA many may not lend themselves to quan-tification, but qualitative assessments usingthis approach will still follow the same logic,which requires a clear specification of an expo-sure, an outcome, and the dose-response re-lation between them for each of the pathwaysexamined (85).
To date quantification in HIA has been rel-atively rare (78). Examples of this approach,which is not necessarily labeled “HIA,” in-clude work in the Netherlands on risks as-sociated with airport siting (3); research inGermany on air pollution policy (23); andanalyses in the United States of the potentialeffects of dietary modification (11), munici-pal “Living Wage” ordinances (9, 16), resi-dential building codes (27), recommendationsto increase fish consumption (60), alternativesfor water treatment (64), and measures to de-crease air pollution (50).
The strengths of this approach are the easewith which potential impacts can be comparedacross policy alternatives and scenarios andapparent objectivity of the approach and its fitwith prevalent paradigms in health, environ-mental, and policy science. It is well suited forevaluating trade-offs between different policyoptions, such as requiring employers to pro-vide health insurance in lieu of a marginal in-crease in wages (16). However, limited dataon the effect estimates of interest and the
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baseline characteristics of the affected pop-ulation may make this approach infeasible. Itis also highly time- and cost-intensive. Time,money, and data limitations often restrictits application to a consideration of single,unmixed, noncumulative exposure, whereasother impacts addressed in an HIA are exam-ined descriptively. Although this type of quan-titative assessment can be more objective thanother approaches, it incorporates numerousvalue- and model-based assumptions that arenot always explicit (4, 12, 38, 61). Among thepotential pitfalls of HIA, Krieger et al. (37)identified erroneous impressions of precisionand confidence in predictions, a problem ex-acerbated by quantification which may givean unwarranted patina of robust science to anHIA. It may also omit or de-emphasize stake-holder participation, which a number of HIApractitioners suggest is a core element of HIA(47, 67).
The participatory approach to HIA drawsheavily from the field of community-basedhealth promotion as outlined in the OttawaCharter on Health Promotion (82a) anddemonstrated in the World Health Organi-zation’s Healthy Cities Initiative (5). MostHIAs have some provision for soliciting stake-holder input, but this is emphasized partic-ularly in this approach to HIA, in whichstakeholder participation is the main input foranalysis and is the primary rationale for con-ducting an HIA. Examples of this approachinclude much of the HIA work in the UnitedKingdom, such as Fleeman & Scott-Samuel’sseminal HIA of the Merseyside TransportStrategy (25) and Winters’ work on assessingthe health impacts of a space exploration cen-ter (81), along with HIA in Sweden conductedthrough community councils (23) and Bhatia’swork with community groups reviewing plan-ning decisions in San Francisco (8).
The strength of this approach is that it pro-vides a mechanism for public participation andthe democratization of government decision-making. Whether this leads to “better” deci-sions or more efficient decision-making maybe of secondary importance because the fo-
cus of this approach tends to be more process-rather than outcome-oriented (47). One of thechief limitations of this approach is that theinformation generated may be given little le-gitimacy in some social contexts, for instancein a litigious legal system that puts a premiumon quantitative “scientific” data. Comparisonsbetween alternatives and with standards arealso difficult because they do not have com-mon metrics. Because it draws on commonknowledge, it may easily neglect unantici-pated or long-term effects. Issues may alsoarise about who represents the “community”(44, 59, 88). As a result, this approach to HIA isprobably better suited for the analysis of localprojects, not for broad policies and programsthat affect larger geopolitical units.
The procedural approach to HIA com-bines elements of the other two approachesto HIA. Like its progenitor, EIA, this ap-proach to HIA puts a premium on efficiencyand is typically driven by procedural concernsto comply with bureaucratic mandates to per-form an impact assessment. This may rangefrom a short impact checklist that must becompleted prior to issuing a building per-mit to a comprehensive analysis of all poten-tial impacts related to the physical and so-cial determinants of health. When the levelof required analysis is more extensive, this ap-proach to HIA may be virtually indistinguish-able from the quantitative/analytic approachto HIA. What sets it apart is the underlyingimperative focusing on compliance and reg-ulation. Differences between these two ap-proaches to HIA are akin to those seen be-tween the Occupational Safety and HealthAdministration (OSHA) and the National In-stitute of Occupational Safety and Health(NIOSH) in assessing workplace chemicalhazards.
Many of the best examples of the proce-dural approach to HIA are efforts to coupleHIA with existing EIA procedures, such asHIA initiatives in Canada (1) and Australia(22). In their proposal for incorporating work-place health impacts into EIAs, Rosenberget al. (66) suggested a similar approach in the
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United States. This approach gains efficiencyby utilizing and adapting standardized proto-cols and models. For example, a highly techni-cal predictive model of the effects of air pol-lution on health (50) can be used in a rapidassessment of transport policies (51).
Much of what can be said about thestrengths and limitations of EIA (17, 70) ap-plies to the procedural approach to HIA. LikeEIA, the procedural approach to HIA utilizeswhatever mix of methods is most expedientin producing information relevant to a par-ticular regulatory mandate, whether the man-date specifies consideration of a specific im-pact, such as impacts related to air pollution,or the application of a specific technique, suchas modeling traffic-related injuries.
The strength of the procedural approachto HIA is that the assessment can be per-formed in a relatively transparent, repro-ducible manner with methods that are broadlydisseminated and understood. In theory, itcan be relatively quick and efficient, but inpractice, agency rules and regulations spec-ifying content and methods in great detailcould greatly increase resource requirementsfor this type of assessment, as has been thecase with environmental impact statements inthe United States (17).
The hybrid nature of this approach toHIA and its emphasis on bureaucratic expe-diency are at the root of many of its limi-tations: Bureaucratic imperatives may com-promise analytic rigor; numbers may be usedmerely to give a patina of objectivity and ex-pert sophistication (41); public participationmay also be de-emphasized, becoming littlemore than a vetting of decisions already made;and whether these procedural assessments arereally used in the decision-making process isquestionable.
DETERMINING THEFEASIBILITY AND VALUE OF APARTICULAR HIA
Although interest in HIA in the United Stateshas surged in recent years, U.S. examples of
HIAs are still rare (19). The gap between in-terest and practice may be attributed partly toa lack of practitioners trained in HIA. This gapmay also be due in part to a lack of precedentand imperatives for HIA. However, the termis increasingly used by public health lead-ers and planners and in some form is on theagenda of many public health and planningconferences. The UCLA Health Impact As-sessment Group and the National Associationof City and County Health Officers (NAC-CHO), in conjunction with the Centers forDisease Control and Prevention, have beguntraining public health agency staff and theircounterparts in other agencies in the funda-mentals of HIA methodologies. A Congres-sional bill introduced in 2006 (75) includedrequirements for HIA for certain kinds of fed-eral projects and policies. Despite the growingmomentum, HIA is still a tool whose highestvalue applications are still being defined. Itsuse to advance the goals of population healthis not always technically feasible, valuable, oreasily understood, nor is it the best approachto address all policy questions.
The technical feasibility of HIA depends,of course, on how it is defined. Some level ofHIA is always possible, but to conduct a com-prehensive HIA that yields information notreadily known to policy-makers is challeng-ing, especially if the aim is to estimate po-tential impacts quantitatively. Often, hypoth-esized pathways of health impacts are not wellelucidated or supported by data from well-controlled studies. For example, although astrong body of research supports the multi-tude effects of housing on health, insufficientdata exist to specify the magnitude of thoseeffects in most circumstances. The number ofrelevant studies is often small. In conductingan HIA of the health insurance provisions of aliving wage ordinance, we identified only twostudies that estimated the effect of health in-surance status on mortality (16). Sometimesuncertainty goes beyond simple data uncer-tainty. Divergent models with different as-sumptions may exist, each giving differentresults.
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It is not just constructing models of thedownstream effects of policies and finding andassembling relevant information that are dif-ficult. Frequently, even getting baseline infor-mation on the prevalence of particular healthdeterminants and risk factors in the affectedpopulation is challenging owing to small pop-ulation sizes; differing administrative, geo-graphic, and demographic definitions of pop-ulation boundaries; and the lack of survey dataon the specific determinants of interest. Forexample, while data may be available on thehousehold incomes of residents in a certainarea, information about the wages and in-surance status of the population affected bya living wage ordinance—employees of cer-tain types of municipal contractors—is muchharder to obtain.
In another example, for an HIA relatedto physical education in schools, we weresurprised to find that key baseline data onhow much time children spend each weekin physical education classes was not avail-able at the state or school district level. Evenrelevant data may not be conducive to therequired analysis. For example, data may beavailable on the number of days children meeta given threshold of physical activity (e.g., 30min of moderate physical activity) but not onthe total minutes of daily physical activity—information necessary for modeling the ef-fects of interventions that increase physicalactivity.
Whether an HIA is worth performing de-pends on the potential value of the informa-tion it generates. The decision to proceed withan HIA is usually based on the HIA’s poten-tial to contribute new or previously unrecog-nized information that can be used by policy-makers and stakeholders to evaluate, modify,support, or reject a specific project or pol-icy proposal. Although different HIA users,including policy-makers, impacted commu-nity stakeholders, regulators, and others, mayvalue different kinds of information, they allneed information that is understandable, ac-tionable, and based on the strongest avail-able evidence. Lack of evidence, a high de-
gree of uncertainty about whether and howa proposed policy could affect health, or poortiming with respect to the policy-making pro-cess can argue against performing an HIAat a particular time. In the political process,the timing of decisions, both in the executiveand legislative branches, is difficult to predict.Some bills, for example, can be reintroducedevery year or every legislative term, but theymove only when a number of factors difficultto foresee converge to push an issue to a de-cision point. However, in some cases wherethere are prospects for proposals similar toone voted down or postponed, informationfrom an HIA may still be of value. Also, likelyhealth-relevant decisions in other sectors areworth assessing for HIA if they have a goodchance of coming to center stage in the nearfuture.
Even when an HIA is technically feasible,the value of the information may be insuffi-cient to justify the expense of an HIA. High-quality HIAs are expensive. Therefore, a pro-cess for assessing which are likely to be mostcost-effective is appropriate. Although HIAcosts are highly variable—depending on thenature of the issue, the scope of the desiredanalysis, and the experience of the analysts—acomprehensive HIA, analyzing several differ-ent pathways, including a defensible quanti-tative estimation of impacts and a report, caneasily cost $100,000 to $200,000.1 Of course,if an HIA is completed in a single day by anassembled panel of experts, as some have sug-gested is possible (58), then costs will be sig-nificantly less, although commensurately suchan HIA might not contribute much signifi-cant, new information to the decision-makingprocess.
In deciding whether to conduct an HIA,analysts need to consult with policy-makersand stakeholders to assess whether the po-tential value of information produced from
1Cost estimates for HIA are based on our experience work-ing on eight different HIAs, not all of which contained allthe elements listed in the estimate for the cost of a com-prehensive HIA.
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an HIA warrants the investment of resources.Sometimes the perceived added value of HIAinformation can be judged by whether policy-makers are prepared to provide or assist inprocuring funding for the HIA.
WHICH IMPACTS SHOULD BEEXAMINED IN AN HIA?
The primary value of an HIA lies in its abil-ity to provide to the policy-making processa thorough, credible assessment of evidencepertaining to potential health impacts of in-terest and highlight information about previ-ously unrecognized impacts. The HIA needsto gather and assemble carefully the best avail-able evidence linking potential health impactswith the policy decision under discussion.Early on in the HIA process, a determina-tion needs to be made as to the scope of theanalysis: which pathways and impacts and therange of policy alternatives to be examined,given available time and resources. As withthe initial decision on whether to proceed withan HIA, this determination needs to considerboth what is feasible and what is likely to addvalue for decision-makers.
In our experience, this scoping process isiterative, involving both standardized check-lists of potentially impacted determinantsof health and consultation with experts andstakeholders to focus the analysis on the mostimportant potential impacts. Also during thescoping phase a logic framework, which mayhave been outlined earlier in screening dis-cussions, is refined to represent graphicallythe specific causal pathways to be examined inthe HIA (see Figure 1). Linking policy, prox-imate policy effects, determinants of health,and eventual health outcomes, logic frame-works for HIA are not comprehensive repre-sentations of all the determinants of health,but rather are change models focusing on thespecific changes and pathways important tounderstanding the health effects of a particu-lar policy (31). Besides helping organize thereview of the research literature and guidingthe analysis (33), logic frameworks are valu-
able for communicating the results of an HIA(16).
HOW SHOULD AN HIA BECONDUCTED?
Once the focus of the HIA is determinedand the pathways to be examined have beenpreliminarily mapped out, the actual impactassessment can begin. At a minimum thisconsists of describing the relevant existinghealth conditions in the affected populationand assessing the research evidence on theputative causal pathways linking the policyor project with eventual health outcomes.Because many potentially significant impactscannot be quantified for an HIA, evidence per-taining to these impacts will be assessed anddescribed qualitatively (32).
Quantitative analysis in HIA can be ei-ther descriptive or predictive. Although manyHIAs include quantitative information, oftenthis information is used only to describe con-ditions and associations rather than to con-struct mathematical models to predict the po-tential effects of proposals. If feasible and ifit adds sufficient value to justify the addedcosts, information on some effects can bequantified and combined in a model to es-timate magnitude and likelihood of poten-tial health impacts. Although information andresource needs for prediction are sometimesprohibitive, a sound, predictive model can il-lustrate the magnitude of different health ef-fects, which is especially important when theposited effects include both health benefitsand harm (17, 49). Regardless of the strengthof the data, assumptions must be explicit; sen-sitivity analyses are needed to show outcomesunder a range of reasonable assumptions.
The process of describing the prevalenceand distribution of health conditions and riskfactors in the affected population in an HIA issometimes referred to as “profiling.” Its aimis to (a) provide a broad picture of healthand sociodemographic conditions prevalentin the affected population, and (b) assess theprevalence or incidence of specific factors that
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Build/improvepedestrian
infrastructure
Trafficcalming
Additionalpublic transit
Exposure to airpollution
Air pollutionemissions
Intentionalinjury
Policy components Proximal impactsHealth-related
outcomes
Neighborhood safety
(actual and perceived)
Patterns ofphysical activity
Motor vehicleuse
Socialcapital
Additionalautomobile
capacity
Access tohealth services
ssertSNoise
Figure 1A typical logic framework for a policy or program that seeks to improve transportation infrastructure.
might be modified by the proposed policy orprogram, along with factors that may mediatekey effects.
For instance, in an HIA that involves ef-fects on children’s physical activity, one wouldwant to assess current physical activity levels,along with factors such as body mass indexlevels, education, income, and ethnicity in thetarget population, which from the research lit-erature are known to mediate the effects ofenvironmental and programmatic changes onchildren’s physical activity levels.
Although profiling may seem straight-forward, compared with trying other as-pects of quantitative impact assessment, it is
often surprisingly challenging. One of thechief problems is that HIAs are often doneon small or specially defined populationsfor which the relevant health, demographic,and other data may not be routinely col-lected. Improving, standardizing, and rou-tinizing methodologies, such as small area es-timation (56, 62) to make easier for analyststhe estimation of the prevalence of variousdeterminants of health for the population sub-groups of interest to HIA, will be vital to ad-vancing and disseminating HIA. Profiling isalso complicated by particular data gaps andways in which data are reported that inhibitincorporation into predictive models. HIA
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practitioners need to encourage evaluatorsand epidemiologists to report effects in termsof relative (or attributable) risk and meanamount of change in outcomes more often,instead of levels of significance and changein percent meeting a particular outcomethreshold.
The credibility of an HIA hinges on thequality and presentation of evidence. How-ever, the evidence base is often quite thinowing to the intersectoral nature of mostHIAs and uncertainty surrounding many ofthe socioeconomic and behavioral pathways ofconcern. In contrast to more traditional sys-tematic reviews, such as those conducted byCochrane and Campbell Collaborations andthe U.S. Task Force for Community Preven-tive Services, HIAs must typically examine ev-idence from a wide range of fields and sources(30, 49), usually not collected with an HIA inmind, and which may be difficult to integratequantitatively. The aim of evidence review foran HIA is also different. Systematic reviewstypically examine the intended effects of care-fully controlled interventions, whereas HIAis usually more concerned with unintendedhealth effects of policies in other sectors (48).If the bar for high-quality evidence is kept ashigh for HIA as it is for systematic reviews,finding adequate evidence for HIAs would bea rarity (37); it would be virtually impossi-ble to find any evidence on which to base anyHIA, yet policy makers would still make deci-sions without the benefit of information thatan HIA could make available. Still, the limita-tions of this evidence must be communicatedto all stakeholders clearly in HIA reports,not just full reports but also policy briefs,which may be the only documents seen bypolicy-makers.
CHALLENGES
Two types of challenges confront prospectsfor more widespread use and acceptanceof HIA here in the United States and inother developed countries: (a) challenges tothe institutionalization of HIA, that is, get-
ting HIA accepted as an integral input intodecision-making; and (b) technical challengesinvolving the methods of HIA design andconduct. However, these challenges are differ-ent for different types of HIAs (i.e., project-based versus policy-based HIA) and for dif-ferent locales with different political and legalsystems.
Achieving the larger population healthpromotion goals of HIA requires some de-gree of institutionalization, which in turnrequires governmental support. But this sup-port can be difficult to obtain and inconsis-tent. Experience from other countries showsthat enthusiasm for HIA can quickly changeto disillusionment if there are unmet (perhapsunrealistic) expectations, difficulties incorpo-rating HIA into decision-making processes, orshortcomings in the credibility, significance,or utility of information that HIA contributesto the decision-making process. Canada, espe-cially the province of British Columbia, whichwas one of the early innovators in HIA, largelyabandoned efforts to institutionalize HIA fol-lowing a change in government in the late1990s (5). Support for HIA of local projectproposals in Sweden (7) and of national policyproposals in the Netherlands (10, 65) has beentempered by recognition of the challenges ofroutinely incorporating HIA into decision-making, although both countries continue tohave in place governmental policies that sup-port using HIA. In the United Kingdom gov-ernment support for project-based HIA alsoseems to be declining (42); however, some lo-cal U.K. governments, such as London (43),have made HIA a cornerstone of health pro-motion policy, promoting the use of bothproject- and policy-based HIA.
In contrast, HIA seems to be well incor-porated in government decision-making andplanning in New Zealand (40) and Quebec,Canada (6). Factors that seem to be associ-ated with the viability of HIA in these juris-dictions include longstanding experience withcoordinated government planning and legis-lation calling for a commitment to health pro-motion across sectors, such as Quebec’s Public
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Health Act (5) and New Zealand’s Local Gov-ernment Act 2002 (40). Indeed, acceptance ofHIA across different sectors seems to havecome less from specific mandates for HIAthan from the attractiveness of the method forhelping agencies fulfill other government re-quirements for promoting equitable, sustain-able, health-promoting policies (40).
Where and how HIA is institutionalizedwill influence its credibility, responsiveness,viability, and visibility. Housing HIA in reg-ulatory agencies or other government agen-cies that are not well insulated from politicalpressure could compromise its neutrality andlong-term viability. Whereas health agenciesmay have the technical expertise to conductHIAs, they may not have the broad mandate toconsider impacts across bureaucratic bound-aries. Agencies that conduct the kind of cross-cutting analysis required in HIA already exist,although analysis of health impacts may bebeyond their current mandates. Most stateshave legislative analysts’ offices (LAOs). Somestates have legislatively sanctioned public pol-icy institutes. At the federal level similar func-tions are served by the Congressional researchservice (CRS) and the general accounting of-fice (GAO). Such agencies could coordinateHIA of policies within their purview. Depend-ing on resources and the complexity of anal-ysis, actual analysis could be done in-houseor by partners in academia. At the local level,where resources are more limited and pol-icy analysis offices are less common, optionsare more limited. Still, HIA would be wellserved by high-level partnerships betweenagencies
Regardless of whether government pri-orities are conducive to the institutionaliza-tion of HIA, inherent difficulties persist ingetting policy-makers to routinely requestand use HIA. Policy agendas are crowdedwith numerous decisions, goals, and interestgroups. Public health is but one of many con-cerns that most policy-makers must weigh.Because HIAs by their nature cross sectoralboundaries, the health concerns raised by an
HIA may be discounted by policy-makers andstakeholders in other sectors who may feelthat health is trying to encroach on their do-main, that it is an attempt to trump their prior-ities with those of public health. Furthermore,the regulated community may perceive HIAas another onerous government-imposed bur-den, much like EIA (17). Sound analysis and afocus on health impacts of compelling publicinterest are necessary to minimize these ob-stacles to implementation.
Strategic issues in institutionalization co-exist with the more practical. An HIA can beconsidered infeasible, impractical, or too ex-pensive relative to the value of informationproduced. The financial and other resourcecosts of conducting a high-quality HIA can besubstantial. Pulling together different strandsof evidence, consulting experts and stakehold-ers in various fields, using data to constructrobust mathematical models, and synthesizingthis information into understandable, crediblereports require expertise, time, and money.
The long-term viability of HIA hinges onfinding efficiencies in the process. Althougheach policy proposal, affected population, andcorresponding HIA is unique, overlappingmethods and common pathways suggest thatmechanisms for systematically sharing ana-lytic approaches and findings can make theHIA process more efficient, making it fea-sible for a wider group of practitioners andlowering the costs of conducting an HIA rela-tive to the potential value of information froman HIA. One such tool that could facilitatedissemination of the technique and showcasepractical examples of its application would bea central repository of HIAs performed in theUnited States and abroad that is easily search-able by issue, method, and results. Such arepository would provide information on spe-cific pathways, analyses, and references thatcould substantially reduce the work and lin-ear time needed to conduct an HIA on issuesalready addressed in related HIAs (31).
A common barrier to the wider use of HIAis lack of technical expertise. There is a strong
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need for training for HIA analysts. Such train-ing needs to be adapted to different levelsand types of analytic needs. Potential users,including governmental decision-makers inboth legislative and executive branches, needto know how health information from anHIA can be interpreted and how it can in-form better decisions. Multidisciplinary ana-lytic teams with the ability to crosswalk be-tween health and nonhealth-sector researchneed to learn the HIA techniques and agreeon common nomenclature to bridge the per-spectives of different disciplines and sectors.Advocacy groups and other appropriate stake-holders also need to be familiarized with HIAand learn how they can contribute to theprocess.
Over time, demand needs to be generatedfrom decision-makers. Funding may accom-pany individual requests, but it is also nec-essary to have some core funding to createand maintain centers of excellence, such asthe intersectoral policy office set up by theDutch Government (65), that can screen ma-jor policy proposals and respond quickly toad hoc requests, while pursuing the broaderset of HIA generic priorities as time permits.The inherent attraction on the part of HIAenthusiasts for promoting HIA by makingit mandatory in some circumstances is bal-anced by the risk that approaches and meth-ods will become rigid. Furthermore, if suchmandates do not set up independent sourcesof funding, results could be influenced by thefunders.
CONCLUSION
HIA could help bring attention to the broaddeterminants of health and suggest ways topromote healthy public policy across sectors.
Although it is a promising tool, its ultimatevalue may be compromised by premature andunrealistic expectations. Despite its limita-tions, U.S. demand for HIA seems to be grow-ing, in part owing to recognition that modi-fiable determinants of health in populationsare rooted primarily in characteristics of thephysical and social environments, thus requir-ing intersectoral analyses of possible health-promoting policies and projects.
The proper uses of HIA as well as its lim-itations must be well communicated to otherpublic health professionals, policy-makers,and ultimately the larger public. It can pro-vide helpful information to policy-makers andstakeholders about potential health impacts,but it cannot by itself create healthy publicpolicy. Indeed, HIA seems to be most success-ful internationally in those places where gov-ernments have made a commitment to pro-moting public health by actions that cross allmajor sectors. Of course, this presents a bitof a “chicken and egg” problem: How canwe advance understanding of intersectoral op-portunities to improve public health withoutanalyses of how changes in other sectors haveaffected health? At the current stage of diffu-sion of this technical tool, a limited numberof high-profile analyses highlighting intersec-toral health linkages could increase demandby policy makers. Wise choice of topics andefficiencies in the conduct of HIAs could alsocontribute to wider demand for them. As HIAbecomes more common and moves are madeto institutionalize HIA learning, the lessonsprovided by EIA and other types of institu-tionalized policy analysis in this country, aswell as lessons from HIA in other countries,can help improve the likelihood that HIA canfulfill its long-term goals of promoting popu-lation health.
ACKNOWLEDGMENTS
The authors acknowledge the Robert Wood Johnson Foundation and the California Endow-ment for their support of the authors’ work on health impact assessment that provided thefoundation for this review.
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First Responders: Mental Health Consequences of Natural andHuman-Made Disasters for Public Health and PublicSafety WorkersDavid M. Benedek, Carol Fullerton, and Robert J. Ursano � � � � � � � � � � � � � � � � � � � � � � � � � � � � 55
Epidemiology and Biostatistics
Network Analysis in Public Health: History, Methods, and ApplicationsDouglas A. Luke and Jenine K. Harris � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 69
Methods for Improving Regression Analysis for Skewed Continuous orCounted ResponsesAbdelmonem A. Afifi, Jenny B. Kotlerman, Susan L. Ettner,
The Epidemiology of Autism Spectrum DisordersCraig J. Newschaffer, Lisa A. Croen, Julie Daniels, Ellen Giarelli,
Judith K. Grether, Susan E. Levy, David S. Mandell, Lisa A. Miller,Jennifer Pinto-Martin, Judy Reaven, Ann M. Reynolds, Catherine E. Rice,Diana Schendel, and Gayle C. Windham � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �235
Beryllium: A Modern Industrial HazardKathleen Kreiss, Gregory A. Day, and Christine R. Schuler � � � � � � � � � � � � � � � � � � � � � � � � � � �259
Adverse Late Effects of Childhood Cancer and Its Treatment onHealth and PerformanceKirsten K. Ness and James G. Gurney � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �279
First Responders: Mental Health Consequences of Natural andHuman-Made Disasters for Public Health and Public Safety WorkersDavid M. Benedek, Carol Fullerton, and Robert J. Ursano � � � � � � � � � � � � � � � � � � � � � � � � � � � � 55
Health Services
Managed Behavioral Health Care Carve-Outs: Past Performance andFuture ProspectsRichard G. Frank and Rachel L. Garfield � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �303
viii Contents
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Rationale and Public Health Implications of Changing CHD RiskFactor DefinitionsRobert M. Kaplan and Michael Ong � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �321
Delivery of Health Services to Migrant and Seasonal FarmworkersThomas A. Arcury and Sara A. Quandt � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �345
Public Health Practice
Lessons from Cost-Effectiveness Research for United States PublicHealth PolicyScott D. Grosse, Steven M. Teutsch, and Anne C. Haddix � � � � � � � � � � � � � � � � � � � � � � � � � � � � �365
Health Impact Assessment: A Tool to Help Policy Makers UnderstandHealth Beyond Health CareBrian L. Cole and Jonathan E. Fielding � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �393
How Can We Increase Translation of Research into Practice? Types ofEvidence NeededRussell E. Glasgow and Karen M. Emmons � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �413
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