Health Impact Assessment: U'S' Experience

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Health Impact AssessmentU.S. Experience

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

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

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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

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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

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Transportation Planning and Land Use Choices
Source Atlanta Journal-Constitution, March 10,
2006
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(No Transcript)
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Unwalkable park entrance
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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

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

• Purpose To move HIA forward in the United
  States
• Participants HIA experts from UK, Canada, and
  WHO, and US participants from local health
  departments, academia, transportation,
  environmental health, urban planning, CDC, and
  the Robert Wood Johnson Foundation (RWJF)
• Findings Priority needs are to conduct pilot
  tests, develop staff capacity, develop database
  of HIA resources, build political support for HIA
  use, and conduct evaluations
• Summary Dannenberg AL, et al. American Journal
  of Public Health. 96262-270, February 2006

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Examples of Health Impact Assessments Conducted
in the United States
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HIA on Housing Rental Voucher ProgramChild
Health Impact Working Group, Boston

• Examined impact of changes to Massachusetts
  housing rental assistance program for families
  who otherwise would be homeless or live in
  substandard dwellings
• Qualitative and quantitative assessment
• Findings Program alterations may lead to
  reduced program eligibility, increased housing
  instability, and adverse effects on childrens
  health
• Funded by multiple public agencies, two anonymous
  donors, and in-kind donations by working group
  members

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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

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HIA of Los Angeles City Living Wage
OrdinanceBrian Cole, UCLA

• Quantitative estimate of potential mortality
  reduction from proposed ordinance to raise
  minimum wage for city contract workers or provide
  them with health insurance
• Findings Employers are more likely to increase
  wages than to offer health insurance, thereby
  losing much of health benefit intended by
  ordinance
• Funded by Robert Wood Johnson Foundation

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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

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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

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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

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Public Health Benefits of BeltLine

• Opportunity for Recreational Physical Activity
• BeltLine trails and parks offer an attractive
  setting for walking, bicycling, and other
  recreational physical activity
• Increased availability of trails is recommended
  by CDC to promote health
• Existing Silver Comet, Stone Mountain, Chastain
  Park trails are very popular
• Exercise Easily Incorporated into Daily Commute
• Walking to and from BeltLine stations could
  readily fulfill the U.S. Surgeon Generals
  recommendation of 30 minutes of physical activity
  each day

• Obesity Reduction
• Physical activity helps prevent obesity
• Obesity and physical inactivity are associated
  with increased risk of overall mortality, heart
  disease, diabetes, hypertension, and some cancers

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Public Health Benefits (continued)

• Cleaner Air
• BeltLine could reduce use of automobiles whose
  emissions are major contributors to ground level
  ozone in Atlanta
• Ozone is linked with increased asthma attacks and
  heart disease mortality
• Atlanta exceeded EPAs air quality standard for
  ozone 51 times in 2002-2003
• Fewer Traffic Injuries
• Driving less reduces each individuals risk of
  injury on the highways
• Nationally, motor vehicle crashes are the leading
  cause of death among persons 1 - 34 years old
• Brownfield Redevelopment
• Urban redevelopment of underutilized land can
  reduce sprawl and preserve greenspace
• Redevelopment promotes health by offering
  economically and socially thriving communities
  that are walkable

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



MA 2


CALIF 9
GA 2

TEXAS 1
FL 2
Other HIAs in progress
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HIAs of Projects (N6)

• Housing redevelopment Trinity Plaza CA
• Housing redevelopment Rincon Hill CA
• Urban redevelopment Oak to Ninth CA
• Corridor redevelopment Buford Hwy GA
• Transit, parks and trails Beltline GA
• Power plant Taylor County FL

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HIAs of Policies (N10)

• Local planning Eastern neighborhoods CA
• School siting Austin TX
• After-school programs Statewide CA
• Walk-to-school programs Sacramento CA
• Living wage ordinance San Francisco CA
• Living wage ordinance Los Angeles CA
• Low income rent subsidies Statewide MA
• Low income home energy subsidies Statewide MA
• County land use planning Polk County FL
• Federal farm bill National

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Decision-Making Organization for Project or Policy

• City council planning commission N7
• State legislature N3
• Local partnerships N2
• Nonprofit organization N1
• US Congress N1
• School district N1
• Electric utility company N1

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Organization that Conducts HIA

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

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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

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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

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

• Small area within city N 5
• City or county-wide N 5
• Statewide N 5
• National N 1
• --------------------------
• Primary impact on
• Persons with low income N 9
• Children/adolescents N 3
• Whole population N 4

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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

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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

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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

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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

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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

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Challenges in Conducting Health Impact
Assessments Conducted in the United States
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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

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

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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

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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

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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

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Asthma and Air Pollution

• Natural experiment during 1996 Summer Olympic
  games in Atlanta
• Peak morning traffic decreased 23 and peak ozone
  levels decreased 28

• Asthma-related emergency room visits by children
  decreased 42
• Childrens emergency visits for non-asthma causes
  did not change during same period

Friedman et al. JAMA 2001285897
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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

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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

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