Health Impact Assessment:U.S. Experience

Andrew L. Dannenberg, MD, MPHNational Center for Environmental Health

Centers for Disease Control and Preventionacd7@cdc.gov

Health Impact Assessment WorkshopDesign for Health, University of Minnesota

Minneapolis, January 30, 2007

Community Design and Health

• Obesity, physical activity, CVD• Water quantity and quality

• Air pollution and asthma• Climate change contribution Car crashes Pedestrian injuries

• Mental health impact Social capital

Related to land use

Related to automobile dependency

Related to social

processes

Walkable Community Designs: Connectivity and Physical Activity

Suburban Development

Traditional Neighborhood

Drawing by Duany Plater Zyberk, in ITE Journal 1989;59:17-18

Durham, NC

A Vision of Health Impact Assessment

• Community planners and zoning boards will request information on potential health consequences of projects and policies as part of their decision-making process

• Local health officers will have a tool to facilitate their involvement in community planning and land use decisions that impact health

Definition of Health Impact Assessment

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

Value of Health Impact Assessment

• Focuses attention of decision-makers, who typically do not have a health background, on the health consequences of projects and policies that they are considering

• Ideally an HIA will lead to a better informed decision

Source: Atlanta Journal-Constitution, March 10, 2006

Transportation Planning and Land Use Choices

Unwalkable park entrance

Steps in Conducting an HIA• Screening

– Identify projects or policies for which HIA would be useful

• Scoping– Identify which health impacts should be included

• Risk assessment – Identify how many and which people may be affected

– Assess how they may be affected

• Reporting of results to decision-makers– Create report suitable in length and depth for audience

• Evaluation of impact of HIA on decision process

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

• Purpose: To move HIA forward in the United States

• Participants: HIA experts from UK, Canada, and WHO, and US participants from local health departments, academia, transportation, environmental health, urban planning, CDC, and the Robert Wood Johnson Foundation (RWJF)

• Findings: Priority needs are to conduct pilot tests, develop staff capacity, develop database of HIA resources, build political support for HIA use, and conduct evaluations

• Summary: Dannenberg AL, et al. American Journal of Public Health. 96:262-270, February 2006

Examples of Health Impact Assessments

Conducted in the United States

HIA on Housing Rental Voucher ProgramChild Health Impact Working Group, Boston

• Examined impact of changes to Massachusetts housing rental assistance program for families who otherwise would be homeless or live in substandard dwellings

• Qualitative and quantitative assessment

• Findings: Program alterations may lead to reduced program eligibility, increased housing instability, and adverse effects on children’s health

• Funded by multiple public agencies, two anonymous donors, and in-kind donations by working group members

HIA of Housing Redevelopment ProjectsRajiv Bhatia, San Francisco Health Department

• Rapid assessment of health impacts in two housing redevelopment projects and one area plan

• Qualitative review of Environmental Impact Report, community engagement, secondary data analysis

• Findings: Effects on housing affordability, vehicle commutes, displacement of residents, segregation, and public infrastructure

• HIA analyses led to improvements in project plans

• Funded & conducted by city public health department

HIA of Los Angeles City Living Wage Ordinance

Brian Cole, UCLA

• Quantitative estimate of potential mortality reduction from proposed ordinance to raise minimum wage for city contract workers or provide them with health insurance

• Findings: Employers are more likely to increase wages than to offer health insurance, thereby losing much of health benefit intended by ordinance

• Funded by Robert Wood Johnson Foundation

HIA of Coal-Fired Power Plant McLeod and Simmons, Healthy Development, Inc.

• Examined health impacts of proposed 800 megawatt coal-fired power plant in Florida

• Rapid, quantitative assessment

• Findings: Fine particulate matter pollution containing SO2 will decrease life expectancy by 2 days after 16 years of plant operation

• Full HIA now funded to recommend social and economic interventions to improve local health

• Conducted by private HIA consultants with county health department funding

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

HIA of Atlanta Beltline

• Examining health impacts of transit component and of trails and parks component

• Conducted during ongoing project planning

• Quantitative and qualitative estimates of physical activity, respiratory disease, injury, mental health, social capital, social equity, and other health outcomes

• Conducted by Georgia Tech with technical assistance from CDC

• Funded by Robert Wood Johnson Foundation

Public Health Benefits of BeltLine

Obesity Reduction• Physical activity helps prevent obesity

• Obesity and physical inactivity are associated with increased risk of overall mortality, heart disease, diabetes, hypertension, and some cancers

Opportunity for Recreational Physical Activity• BeltLine trails and parks offer an attractive setting for walking, bicycling, and

other recreational physical activity• Increased availability of trails is recommended by CDC to promote health• Existing Silver Comet, Stone Mountain, Chastain Park trails are very popular

Exercise Easily Incorporated into Daily Commute• Walking to and from BeltLine stations could readily fulfill the U.S. Surgeon

General’s recommendation of 30 minutes of physical activity each day

Public Health Benefits (continued)

Cleaner Air • BeltLine could reduce use of automobiles whose emissions are major

contributors to ground level ozone in Atlanta• Ozone is linked with increased asthma attacks and heart disease

mortality• Atlanta exceeded EPA’s air quality standard for ozone 51 times in

2002-2003

Fewer Traffic Injuries• Driving less reduces each individual’s risk of injury on the highways• Nationally, motor vehicle crashes are the leading cause of death

among persons 1 - 34 years old

Brownfield Redevelopment• Urban redevelopment of underutilized land can reduce sprawl and

preserve greenspace• Redevelopment promotes health by offering economically and

socially thriving communities that are walkable

Review of 16 Health Impact Assessments

Conducted in the United States,

1999-2006

CALIF 9

TEXAS 1

GA 2

FL 2

MA 2

•

••

••

Location of 16 Completed HIAsin United States, 1999-2006

•

• Other HIAs in progress

HIAs of Projects (N=6)

1. Housing redevelopment: Trinity Plaza CA

2. Housing redevelopment: Rincon Hill CA

3. Urban redevelopment: Oak to Ninth CA

4. Corridor redevelopment: Buford Hwy GA

5. Transit, parks and trails: Beltline GA

6. Power plant: Taylor County FL

HIAs of Policies (N=10)

1. Local planning: Eastern neighborhoods CA

2. School siting: Austin TX

3. After-school programs: Statewide CA

4. Walk-to-school programs: Sacramento CA

5. Living wage ordinance: San Francisco CA

6. Living wage ordinance: Los Angeles CA

7. Low income rent subsidies: Statewide MA

8. Low income home energy subsidies: Statewide MA

9. County land use planning: Polk County FL

10. Federal farm bill: National

Decision-Making Organization for Project or Policy

City council; planning commission N=7

State legislature N=3

Local partnerships N=2

Nonprofit organization N=1

US Congress N=1

School district N=1

Electric utility company N=1

Organization that Conducts HIA

Academic group; CDC N=10

Local health department N= 5

Private consultant N= 1

Funder of HIA

Robert Wood Johnson Foundation N= 6

Health department - internal staff N= 5

Health department - external contract N= 1

Volunteer; multiple sources N= 4

Scoping: Health Determinants Considered in 16 HIAs in the

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

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

Small area within city N = 5City or county-wide N = 5Statewide N = 5National N = 1

--------------------------Primary impact on: Persons with low income N = 9 Children/adolescents N = 3 Whole population N = 4

Community Involvement in Conduct of 16 U.S. HIAs

Community input involved in conduct of 10 of 16 HIAs

Barriers to community involvement in HIAs include lack of time or resources, IRB or OMB restrictions

Conduct of 16 HIAs in U.S.• Screening

– Some targeted to goal, others more academic

• Scoping– Generally clearly described

• Risk assessment– Various quantitative and qualitative methods

• Reporting– Most on web, a few published; public testimony

• Evaluation– Relatively little conducted

Quantitative and Qualitative Health Indicators in 16 U.S. HIAs

• Quantitative– Physical activity– Pedestrian injuries– Mortality– Impact of particulate matter in air– Crime– Parks and greenspace

• Qualitative– Academic performance– Income adequacy; social equity– Diet, nutrition, food safety, food insecurity– Adolescent risk behaviors – alcohol, drugs, sex– Noise– Mental health– Social capital, community severance– Access to jobs, stores, schools, recreation– Housing adequacy and affordability

Key Results in 16 HIAs in U.S.

Most identified improvements needed to mitigate adverse health impacts Redevelopment projects that lacked affordable

housing; rental voucher program

A few encouraged projects or policies that would be health-promoting as designed Walk-to-school program; Beltline transit project

One concluded that proposed program would fail to reach its intended target population After-school programs

Impact of HIA on Subsequent Decisions: 16 HIAs in U.S.

Documentable impacts, such as change in redevelopment plans to add affordable housing, was evident in only a few HIAs

Most HIAs raised awareness of health issues for some audiences

Challenges in Conducting Health Impact Assessments

Conducted in the United States

HIA Level of Complexity

• Qualitative – describe direction but not magnitude of predicted results – Easy to predict; hard to use in cost/benefit models– Example: Build a sidewalk and people will walk more

• Quantitative – describe direction and magnitude of predicted results– Difficult to obtain data; useful for cost/benefit models– Hypothetical example: Build a sidewalk and 300 people

who live within 200 yards of location will walk an average of 15 extra minutes per day

Minutes of Walking To and From Public Transit Per Day

10

19

31

0

10

20

30

40

Min

ute

s p

er d

ay

Besser LM, Dannenberg ALAmer J Prev Med 29:273, 2005

Data from National Household Travel Survey, 2001, USDOT

N= 3312 transit users

Voluntary vs. Regulatory Approach to Using an HIA

• Voluntary (a tool used by a health officer to inform a planning commission)– Simpler, less expensive, less litigious– Less likely to be used if not required– More politically acceptable

• Regulatory (modeled on a required environmental impact statement)– More complex, more expensive, more litigious– More likely to be used if required– Less politically acceptable

Relationship of HIA to Environmental Impact

Assessment• HIA components could logically fit within

an EIA process

• HIA incorporated into EIA is necessarily regulatory and insures it is conducted

• Extending an EIA to include an HIA likely to encounter resistance from developers who see it as an additional barrier

Community Involvement in Conducting an HIA

• Increases community buy-in to project• Helps identify social issues as well as

health issues• Commonly used in HIAs in Europe• Need balance of community input with

scientific evidence• May add substantially to time and

resources needed to conduct HIA

Other Challenges in Conducting HIAs in the U.S.

• Resources - who pays?

• Resistance - some decision-makers may not want health input

• Evaluation of impacts of HIA requires time and resources

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

Friedman et al. JAMA 2001;285:897

Asthma and Air Pollution

• Asthma-related emergency room visits by children decreased 42%

• Children’s emergency visits for non-asthma causes did not change during same period

• Natural experiment during 1996 Summer Olympic games in Atlanta

• Peak morning traffic decreased 23% and peak ozone levels decreased 28%

HIA Capacity Building Activities• NACCHO/APA training workshop on HIA held in

2006; repeat workshop planned in 2007

• Course on HIA now being taught by Rajiv Bhatia at University of California, Berkeley

• HIA training manual being prepared

• Seattle group has begun an HIA listserve for the United States

• Several states and one U.S. Senator are beginning to mention HIA in proposed legislation

HIA in the United States: Next Steps• Conduct pilot tests of existing tools for HIA of

projects and policies

• Develop staff capacity to conduct HIAs including training materials and train-the-trainer workshops

• Develop incentives and political support for use of HIAs

• Develop a database for measuring health impacts of common projects and policies

• Conduct process, impact and outcome evaluations of HIAs

Health Impact Assessments can help guide community

design and land use choices to promote human health

www.hiagateway.org.ukwww.cdc.gov/healthyplaces