1. Compatible Frameworks?
Health Impact Assessment and the Policy Sciences
Katrina Smith Korfmacher, PhD
Associate Professor of Environmental Medicine
Director, Community Outreach and Engagement Core
Environmental Health Sciences Center
University of Rochester

2. PRESENTATION GOALS:
How is this framework compatible with a policy sciences perspective on problem solving?
What can/has the policy sciences contribute to this framework?
What potential does this framework have for expanding the practice of the PSF (explicitly or not)

3. Overview Health in All Policies (HiAP)
Health Impact Assessment (HIA) and Policy Sciences Frameworks
Rochester’s Local Waterfront Revitalization Program (LWRP)
Healthy Waterways Project
HIA and PS, revisited

4. Factors Responsible for Population Health
Health status is determined by: genetics (5%), health care (10%), behavior (30%), Social Conditions (55%)
- WHO Commission on the Social Determinants of Health (2008)

5. Health In All Policies (HiAP)
Many public decisions affect
health - not only health policies!
BUT….few non-health decisions
even consider health outcomes
How can we promote health through non- health policies?
“Health in All Policies” (HiAP)
Health Impact Assessment (HIA): one way to support HiAP

6. Health Impact Assessment (HIA)
DEFINITION: “A combination of procedures, methods and tools that systematically judges the potential, and sometimes unintended, effects of a policy, plan, program or project on the health of a population and the distribution of those effects within the population. HIA identifies appropriate actions to manage those effects.”
-International Association for Impact Assessment, 2006

7. History of HIAs Europe, Canada, New Zealand US: California, Alaska….
Human Impact Partners (
PEW/RWJ Foundation (

8. HIA and Determinants of Health
Affect health determinants like:
How does the proposed
project, plan, policy
Housing
Air quality
Noise
Safety
Social networks
Nutrition
Parks and natural space
Private goods and services
Public services
Transportation
Livelihood
Water quality
Education
Inequities
and lead to health outcomes

9. Incorporating Health into Decision-Making
The world would look different if we considered health impacts of decisions on…
Development
Farm Policy
Incarceration
Immigration
Ports
Education

10. HIA Examples from other states
Alaska - North Slope Oil Development: HIA led to compromise lease plan; reduced impacts on hunting and fishing and avoided litigation
Illinois - Smart Metering in Chicago: showed health risks from automatic electricity disconnects; now require site visit prior to shutoff and monitor impacts on low income people
CA -Senior Housing in Oakland: predicted respiratory problems from air pollution; developer incorporated central air filtration and moved air intake away from high traffic area.
According to one recent estimate, caring for a single patient with very poorly-controlled asthma can cost as much as $8,880 per year — roughly half the price of conducting this HIA.3

11. An ANALYSIS that… A PROCESS that… But what IS HIA???
Clarifies health effects of a proposed project, plan or policy
Includes quantitative and/or qualitative information
Highlights health disparities; makes health impacts explicit
Considers multiple health outcomes
Provides recommendations
Shapes public decisions & discourse
A PROCESS that…
Engages & empowers community
Builds consensus
Builds relationships & collaborations

12. Steps of a HIA Screening Determines the need and value of a HIA
Scoping
Determines which health impacts to evaluate, methods for analysis, and a workplan
Assessment & Recommendations
Provides:
1) a profile of existing health conditions 2) evaluation of potential health impacts/alternatives 3) strategies to manage identified adverse health impacts
Reporting
Includes:
1) development of the HIA report
2) communication of findings & recommendations
Monitoring
Tracks:
1) Process: impacts on decision-making processes and the decision
2) Outcomes: impacts of the decision on health determinants

13. HIA and the Policy Sciences: Problem Orientation
Screening
Clarifying goals
Scoping
Assessment & Recommendations
Describing trends
Analyzing conditions
Projecting developments
Inventing, evaluating, and selecting alternatives
Reporting
[Social process]
Monitoring
HIAs are only conducted when likely to affect pending decision

14. -HIA is a collaborative process
WHO does HIA?
-HIA is a collaborative process
-HIA may be LED by: health departments, planners, developers, consultants, community members, or interest groups
-HIAs involve:
The public for relationship building, capacity for advocacy, and empowerment
Public health and other agencies for relationship- building, data, information, and resources
Decision-makers/industry to ensure that recommendations are realistic and account for the practical, economic, and technical limitations on the decision at hand

15. HIA and Policy Sciences: standpoint
Goal is to be a source of “objective information”
Normative orientation toward ‘equity’
Identify ‘vulnerable populations’
Assess distribution of health impacts
Aim to reduce health disparities
Recommendations and Reporting are intended to influence decisions (analysis/advocacy)

16. HOW do HIAs Assess? Conduct a literature review
Find out about other communities’ experiences
Gather existing data or conduct new analysis on health, environmental and social indicators
Compare data to existing regulatory criteria, standards, & benchmarks
Utilize community expertise - e.g., focus groups, surveys
Apply specialized data collection tools for observational data, forecasting, and modeling
MAP environmental, social, health data
NOT “new research” (usually)

17. HIA and Policy Sciences: Multiple Methods
Focus on integrating/applying existing information
Most HIAs elicit information from stakeholders
Surveys
Focus Groups
Interviews
Evidence summaries rate the ‘strength of evidence’ from literature, reports, case studies
Recommendations based on weight of all evidence

18. Case Study 1: Paid sick days
A Health Impact Assessment of the California Healthy Families, Healthy Workplaces Act of 2008
Does public health evidence support the hypothesized impacts of a mandatory requirement for paid sick days on health?

19. Paid Sick Days policy: Screening
Nationally, 60 million lack paid sick days
Potential benefits to individual, family and community health
Limited legislative analysis of health
Legislative sponsors enthusiastic about framing bill using health
Methods exist to contribute to analysis
CA legislation and HIA as national model

20. PSD Pathway Scoping
Additional pathways for dependents completed as well

21. Paid Sick Leave: Health Advocates Help Win A Common Sense Policy (September 10, 2014) “Healthy Workplaces, Healthy Families Act”
Imagine waking up sick with the flu. Wouldn’t you want to take a day off from work? What if not working meant going without pay? After July 1, 2015, fewer California workers will have to struggle with this choice. Last week, California Governor Jerry Brown signed AB 1522 making California the second state (after Connecticut) to guarantee most workers some paid sick leave.
In 2008, Human Impact Partners authored a health impact assessment on California’s first attempt to legislate paid sick days. … 
Public health arguments were clearly central to last week’s passage of AB 1522…

22. HIA and Policy Sciences: Social Process
Participants: HIA often involves broader range of participants than official decision process
Perspectives: Solicits different views on decision
Situations: May create new forums for interaction; BUT HIA takes the policy context as given
Base values: HIA process may enhance base values; recommendations may enhance scope values
Strategies
Diplomatic – integrate decision makers
Ideological – public communication of recommendations
Outcomes and Effects: emphasizes evaluation of:
Process (how did it shape decision)
Outcome (how did decision affect health determinants)

23. HIA And Policy Sciences: Health and Base Values
Power: Highlighting health costs gives more power to groups suffering from health disparities
Wealth: HIA connects economic security to better health, promoting interests of low income groups
Enlightenment: Education is linked to better health outcomes; HIAs often support education improvments
Skill: HIA may engage new groups in decision-making, improving their capacity for future participation
Affection: Social connectedness, and community- building are well established health determinants
Well-being: stress and poor mental health are important health outcomes and also affect physical health
Respect and Rectitude: Participation, equity emphasis, and valuing community knowledge promote these
Health evidence bases connect social determinants to health, so HIA may enhance…

24. HIA and Environmental Health Problem Solving
Explicitly connects environment and health
Integrating multiple sources of data
Making use of available data
Clarifying equity impacts of decisions
Communicating policy consequences in health terms engages diverse stakeholders
Health care reform: Clarifying health impacts (especially health disparities) = monetization
Informing decisions, not “doing research”

25. Bringing HIA to Rochester
Initiated by County Health Director(2009)
National dialogue - Can HIA help Monroe County?
Guide MCDOPH input to local decision makers?
Childhood lead poisoning efforts were like HIA
Shape health-promoting decisions;
HIA “Learning Group” (2010)
40 participants
Presentations, work groups, project planning
Pew Health Impact Project grant (2012): Healthy Waterways
City of Rochester’s Local Waterfront Revitalization Program
“Healthy Waterways” HIA
Rochester examples: College Town, School Modernization Plans, county transportation plan, project Green, HealthiKids

26. Applying HIA to Rochester’s Local Waterfront Revitalization Program

27. New York State’s Local Waterfront Revitalization Program
Develop long-term plan for waterfront
Guides decisions at all levels of government
Opportunities for public involvement
13 policy statements
Many relate to health
Not required to consider health

28. Rochester’s LWRP 1990 LWRP; drafted update in 1999
Revision underway; expected completion 2014
Waterfront Advisory Committee (WAC)
Involves City, County, Community, NYS DOS
Once approved by NYS Department of State, applies to all activities within waterfront zone
Communications Bureau, City of Rochester

29. Healthy Waterways: How might the LWRP impact health?
What are the biggest health issues in Rochester?
How do these relate to the waterfront?
How could waterfront changes affect health?
Goal:
Make policy and planning recommendations to minimize health risks and maximize benefits in LWRP
Communications Bureau, City of Rochester

30. LWRP “Elements” Assessed
Waterfront trails
Beaches
Residential/commercial development
Water-based recreation
Stormwater management

31. ASSESSMENT METHODS: County health data Community surveys
Stakeholder interviews
Published literature
Case studies
First off, Health Impact Assessments (HIA) aim to…
As part of the HIA of the LWRP, we have been inviting community partners to help us investigate links between the LWRP and ways to promote decisions and policies that improve the built environment and community health.
Why SW Rochester? Since the proposed LWRP boundary follows the Genesee River north from the Erie Canal to Lake Ontario, and includes downtown Rochester. We are interested in the health and wellbeing of the people living in Southwest Rochester—a population that has direct access to the waterfront.
The purpose of the survey was to collect data on the Southwest community’s health and wellbeing, and the impact that proposed plans/features of the Local Waterfront Revitalization Program may have on the health of the community.
What will we do with data? Provide recommendations.
Communications Bureau, City of Rochester

32. TRAIL USER SURVEYS/COUNTS
265 Trail users surveyed
Demographics, trail use frequency
Preferences for trail improvement
COUNTS:
12 sites, 54 hours of observation
Counted 2019 trail users
User numbers vary by location
National model estimates total use at sites from 25,000 to 300,000/year

33. WHO USES THE TRAIL? Demographically similar to County population
EXCEPT: 69% male
44% walkers live less than half a mile from trail (locals)
Incomes of local users close to City average
76% of local users use trail at least weekly
Trail is an important exercise resource, especially for low income neighbors

34. 40% of Rochester’s population lives in a ‘waterfront neighborhood’
Includes 45% of DEC “environmental justice” areas
The mean income in PLEX, a southwest neighborhood , is a third lower than city average
The PLEX low birth weight rate is nearly double that of the County
Mean Years Potential Life Lost (YPLL) in PLEX is twice as high as County average

35. Physical Activity in Southwest Rochester
63% residents reported meeting CDC’s weekly recommended activity level (150 minutes exercise); similar to county mean
71% of whites
58% of blacks
County health data show racial differences in obesity, heart disease, diabetes, etc.
Obesity cost calculator
“If the trail weren’t here, I wouldn’t exercise.”
Due to time and space constraint of surveys, we did not ask participants to specify what kind of physical activity they participated in. So, the physical activity average values may be overestimated esp. because we included allowed walking as a form of physical activity.
The CDC recommends adults to engage in moderate-intensity physical activity for 30 minutes or more on 5 or more days of the week, therefore, at least 150 minutes of moderate-intensity physical activity a week.
59% of participants reported that they engage in the recommended amount of physical activity. 53% Monroe County, 48% in NYS reported in the Monroe County Adult Health Survey. Referring to the 96% of participants who perceive their health to be very good or excellent, this emphasizes the need to disseminate the importance of adequate physical activity for a healthy lifestyle. Blacks (14, 54%) compared to Whites (24, 69%) were less likely to report they engage in the recommended amounts of physical activity. All physical activity responses was based on the past week’s physical activity. Note: we allowed walking as physical activity.
TRAIL is more than a “recreation destination” – opportunity for physical activity and transportation by low income waterfront residents

36. Example: Trail Recommendations
Policies: “Prioritize connecting trail through downtown and to adjacent neighborhoods”
Projects: “Add amenities like better lights, water fountains, benches, fishing areas, or exercise equipment to encourage use”
Programs: “Expand programs to encourage trail use by diverse populations, especially waterfront residents;”
Communication: “Improve signage TO trail from neighborhoods and vice versa.”
Monitoring: “Conduct annual trail user surveys”; “Establish trail management group to coordinate improvements, maintenance, use by neighbors and visitors”

37. SUMMARY: Healthy Waterways and the LWRP
Health considered as a ‘goal’ in LWRP
Community health data included in inventory and analysis
Shifted focus from “destination” to include “waterfront neighbors”
Recommendations integrated into LWRP subpolicies
New partners identified for implementation (future grants, projects, planning, monitoring)
Full report: bit.ly/QorjRS or

38. Providence, RI Riverwalk
In 1994, replaced the world’s widest bridge at 1,147 feet with new streets, cobblestone pathways, Venetian-style bridges, sculptures, fountains, boat landings, and parks including the four acre Waterplace Park with an open air auditorium.
The Riverwalk hosts year round public art and cultural events
Waterfire events regularly attract over 350,000 people.
Hotel room rentals doubled between 1999 and 2000, and in August 2003 they rose over 50%.
Payne, Thomas. Waterfire Providence Organization.
13 June Web.

39. HIA and PSF: Decision Process
Intelligence: HIA assessment
Promotion: HIA reporting
Prescription: HIA recommendations + assessed decision process
Invocation: ??
Application: ??
Appraisal: HIA evaluation
Termination: ??

40. What can PSF Bring to HIA
Standpoint:
Can one be ‘objective,’ ‘collaborative’, decision-relevant recommendations’ and ‘equity promoting’?
Social process:
HIA takes the “decision context” as fixed; other ‘situations’ may matter
Decision process:
HIA engages primarily in intelligence and promotion
Helps explain frequent “recommendations beyond the recommendations.”
Plan better for monitoring/evaluation of impact on decision, implementation, and health outcomes?

41. What can HIA contribute to PSF
HIA is both an analysis and a process – limited, but broader than what would happen without it (partial application?)
Language of health is easy to understand and has broad support; includes equity, participation, and well-being

42. Summary: HIA and PSF
How is this framework compatible with a policy sciences perspective on problem solving?
Goal = multimethod, problem-oriented, equity-promoting ways to improve of policy decisions
What can/has the policy sciences contribute to this framework?
Provide conceptual grounding for practice
Heighten awareness of limits to HIA role in policy process
What potential does this framework have for expanding the practice of the PSF (explicitly or not)
Translation of ‘base values’ into ‘health language’ / data
Cross walk into public health issues
Growing field of ‘practicioners’ with problem orientation