Assessing the Impact of Health Impact Assessments in the United States Arthur M. Wendel, MD, MPH National Center for Environmental Health Centers for Disease Control and Prevention

Emergence of Health Impact Assessment (HIA) in the U.S. First known HIA in United States in 1999 Modeled after European HIAs Small number of early U.S. practitioners No formal regulatory requirements

Funder and Practitioner Goals Primary –Increase consideration of health-related consequences in programs, policies, and projects Secondary –Gain experience with conducting HIAs –Grow the field of HIA practitioners –Develop a sustainable field

What Are Best Practices? Voluntary versus regulatory –Environmental law provides foundation for possible regulations Important HIA characteristics Improving screening

Methods Previous work identified 27 completed HIAs in the United States Data sources –Extracted from written reports –Interviews and/or exchanges with practitioners

Data Collection Form Components –Geographical setting –Funding –Sector –Depth of HIA –HIA components completed –Community participation –Decision-makers support of HIA Reports reviewed by 2 persons

Practitioner Queries Verified data from written materials Queried to determine the HIA’s effect

Decisions modified due to HIA YES NO Health issues adequately acknowledged YES Direct effectiveness: Changes made because of HIA General effectiveness: HIA acknowledged but changes not made; health awareness raised NO Opportunistic effectiveness: Health-promoting choice made anyway No effectiveness: HIA ignored Types of HIA Effectiveness Wismar M, et al. Effectiveness of HIA. WHO, 2007

Strong Versus Weak Effectiveness Strong, directly effective –Confident of substantial effect –Able to describe process Strong, generally effective –Practitioner identified ways decision-makers accommodated the HIA process to hear HIA input or how a specific decision-maker championed the HIA recommendations

Results Obtained written materials on 31 HIAs 10 practitioners representing 20 HIAs reported effectiveness

Results Studied HIAs were conducted between Unit of analysis (N=20) –12 project –7 policy –1 program Geographic scale (N=20) –12 subsection of a city –6 metropolitan area or region in a state –2 state-wide

Results HIA depth (N=20) –9 rapid –3 intermediate –8 comprehensive Timing of HIA completion (N=20) –13 prior to decision –3 during decision –4 after decision 2 not intended to be timely

HIA Primary Sector (N=20) Housing N=7 Land Use N=7 Transportation N=3 Energy N=2 Employment N=1

Direct effectiveness: Total: 12 General effectiveness: Total: 7 Opportunistic effectiveness: Total: 1 No effectiveness: Total: 0 HIA Effectiveness Rating

CharacteristicNumber (N=20)Percent Decision-makers support HIA945% Community requested HIA525% Community involved1470% Vulnerable populations addressed 1890% New data collected210% Quantification of any health impact 840% Characteristics of HIAs

Characteristic Direct N=12 General N=7 Opportunistic N=1 Decision-makers support HIA 67%14%0% Community requested HIA25%28%0% Community involved75%57%100% Vulnerable populations addressed 100%86%0% New data collected0%14%100% Quantification of any health impact 33%57%0% Characteristics of HIAs by Effectiveness Type

RapidIntermediateComprehensive Direct615 General313 Opportunistic010 HIA Depth by Effectiveness

Characteristic Strong N=5 Weak N=7 Decision-makers support HIA80%57% Community requested HIA40%14% Community involved100%57% Vulnerable populations addressed 100% New data collected0% Quantification of any health impact 0%57% Strong Versus Weak Direct Effectiveness

Characteristic Strong N=2 Weak N=5 Decision-makers support HIA0%20% Community requested HIA100%0% Community involved100%40% Vulnerable populations addressed 100%80% New data collected50%20% Quantification of any health impact 50%60% Strong Versus Weak General Effectiveness

Summary Community involvement common characteristic of HIAs with strong effect Decision-maker support common among directly effective HIAs No HIAs included a formal evaluation component

Defining Success Multiple routes for success –Directly changing the project or policy –Influencing other projects or policies –Create more demand or supply –Expanding the field of HIA Conducting an HIA elevates health

Limitations Effectiveness based on self-report from practitioners Few U.S. HIA practitioners Written reports varied in scope and content Characteristics based on interpretation by two reviewers Established definitions of HIA characteristics lacking

Next Steps Continue identifying HIAs and interviewing practitioners Interview other involved stakeholders

Disclaimer The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Acknowledgments CDC –Hilary Heishman –Sarah Heaton –Andrew Dannenberg San Francisco Department of Public Health –Rajiv Bhatia Alaska Inter-Tribal Council –Aaron Wernham

Conclusions HIA practitioners encouraged to evaluate Unrestricted growth of HIA likely to benefit health More HIA effectiveness research is needed as field expands