"Understanding Health Impact Assessment: A Tool for Addressing Health Disparities,"by Saneta DeVuono-powell & Jonathan Heller July/August 2011 issue of Poverty & Race
Health is a big topic of concern these days. Despite outspending all other developed nations on health care, our nation ranks 26th in life expectancy. In recent years, we have witnessed growing obesity, diabetes and asthma rates, in addition to numerous other health problems. Not surprisingly, these health problems have a disparate impact on vulnerable communities, with people of color and those in poverty bearing a disproportionate health burden. For example, infant mortality rates for African Americans are more than twice the national average, and the life expectancy gap between poor African-American men and affluent white women is more than 14 years. For advocates who work with these communities, health disparities are not new. What is new is the emerging consensus that health outcomes will not improve unless we address social and environmental factors traditionally understood as unrelated to health. Improving access to health care and trying to change behaviors are not enough; we must address the decisions and policies that are not traditionally thought of as associated with health.
For the past few decades, public health agencies focused on trying to improve health by addressing individual behavior related to poor health outcomes. At the same time, social and economic inequalities continued to increase and we witnessed growing and persistent health disparities. Today, the life expectancy gap between the most and least affluent is increasing, and the areas with the greatest social and economic inequalities have the worst life expectancy and mortality rates. Studies repeatedly show that even when you control for individual variables, external factors like where people live, the quality of their housing and education, income attainment and stress levels correlate with depression, chronic disease, mortality and health risk behaviors. Given this knowledge, health advocates have begun to realize that they cannot improve health conditions without addressing these factors, which are known in public health circles as the social determinants of health. Health Impact Assessment (HIA) is a tool that can help highlight these links and mitigate health disparities because HIA addresses these determinants of health. Although HIA has been practiced outside of the United States for many years, its use here is just beginning to gain traction. In 2007, a study found just 27 HIAs had been conducted in the U.S. In the subsequent four years, an additional 92 HIAs have begun or been completed.
A Health Impact Assessment is defined as “a combination of procedures, methods and tools that systematically judges the potential, and sometimes unintended, effects of a proposed project, plan or policy on the health of a population and the distribution of those effects within the population.” HIA aims to increase the consideration of health in decision-making arenas that typically do not consider health. HIA also identifies appropriate actions to manage those effects. There are two desired outcomes of an HIA. One is to influence plans policies and projects in a way that improves health and diminishes health disparities. The other is to engage community members and other stakeholders so they understand what is impacting community health and how to advocate for improving health using a transparent and evidence-based process.
A typical HIA includes six steps:
1. Screening—Determines the need, value and feasibility of an HIA;
2. Scoping—Determines which health impacts to evaluate, the methods for analysis, and the workplan for completing the assessment;
3. Assessment—Provides: a) a profile of existing health conditions; b) evaluation of potential health impacts;
4. Recommendations—Provides strategies to manage identified adverse health impacts or enhance positive health impacts;
5. Reporting—Includes development of the HIA report and communication of findings and recommendations; and
6. Monitoring—Tracks impacts on decision-making processes and the decision, as well as impacts of the decision on health determinants.
Within this general framework, approaches to HIA vary as HIAs are tailored to work with the specific needs, timeline and resources of each particular project. This article briefly describes two HIAs as examples of how and when an HIA can be conducted and then discusses strategies for using HIA to address health disparities.
Case 1: Long Beach Downtown Development PlanIn 2010, the City of Long Beach in Southern California proposed plans for extensive new development in their downtown area. The Long Beach Downtown Plan proposed including 5,000 new residential units, 1.5 million square feet of office, civic and cultural spaces, 384,000 square feet of new retail space, and 5,200 new jobs. The plan, however, did not mention affordable housing or job creation for the current residents of the area. This oversight was particularly troublesome given the demographics of Downtown Long Beach, an area that is currently populated by an ethnically diverse and predominantly low-income population whose current employment and housing needs are not being met (the list for Section 8 housing is currently closed and has a ten-year wait).
Concern about the potentially adverse impacts this plan would have for local residents led local organizations to decide to conduct a rapid Health Impact Assessment. The HIA, conducted by East Yard Communities for Environmental Justice, Californians for Justice and Human Impact Partners (HIP—an Oakland-based nonprofit) in early 2011, focused on measuring what impacts the proposed plan would have on housing and employment and how these changes would affect the health of residents. Because the advocates wanted to be able to use the HIA to respond the Draft Environmental Impact Report (EIR), there was a short timeline. This necessarily limited the scope of the HIA, but it was still a useful tool for concerned community advocates and local organizations. Fortunately, there was a proposed Community Benefits Agreement, which allowed the HIA to focus its recommendations as well as point to a specific and feasible alternative course of action. Over a three-month period, staff worked together to gather data on: (1) existing health, housing and employment conditions in Downtown Long Beach; (2) the potential impacts of the proposed plan; and (3) the potential impacts of proposed community benefits.
The availability of affordable, quality housing and adequate employment opportunities have direct health impacts. The Long Beach HIA cited studies showing that the nature and stability of housing and employment impact a variety of health indicators, including mortality rates, infectious disease, depression and substance abuse. Based on the analysis of the existing demographics and conditions in Downtown Long Beach, the HIA found that the diverse residents (Long Beach is the most ethnically diverse city in California) were already facing a shortage of quality affordable housing and adequate employment opportunities and suffering from associated health problems. For example, the HIA found that 46% of renters were spending more than the recommended 30% of their income on rent and 25% were spending more than 50% of their incomes on rent, and that overcrowding was already a problem in Long Beach. Not surprisingly, the rates of asthma, heart disease and other health issues (which can be related back to housing cost and quality and to jobs) in Long Beach are significantly higher than the county average.
The HIA findings indicated that, as proposed, the Downtown Plan was likely to have negative impacts on a variety of health-related indicators, including: overcrowding, population displacement and unemployment. The HIA also found that the adoption of the proposed Community Benefits Agreement would mitigate some of the negative impacts resulting from the proposed Downtown Plan by providing additional very-low-income and moderate-income housing units and increasing employment opportunities. The HIA recommended that the plan adopt these benefits. The HIA in Long Beach was in response to a city development plan, was submitted as a comment on a Draft Environmental Impact Report, and was limited in scope to impacts on housing and jobs. Findings from the rapid HIA were highlighted in local media campaigns focused on the proposed Downtown Plan. The City of Long Beach is expected to respond to comments on the EIR in the coming months.
Case 2: Paid Sick Days PoliciesIn most developed countries, paid sick days are a given. In the U.S., however, there is no federal law mandating paid sick days and about 4 out of every 10 workers do not have paid sick days. Not surprisingly, low-wage workers, mothers and those who work in the food service industry are much less likely to have paid sick days than most white-collar workers. In 2007, San Francisco became the first jurisdiction in the U.S. to mandate paid sick days for employees. Subsequently, various jurisdictions have introduced legislation that would do the same, including California in 2008 and Congress in 2009—neither of which passed. Surprisingly, although access to paid sick days has clear health implications, initially health was not part of the discussion surrounding efforts to mandate paid sick days. The main frame through which decision-makers viewed this legislation was that of economic impact of requiring employers to provide paid sick days.
From 2008-2010, a series of Health Impact Assessments that looked at paid sick day requirements were conducted. In 2008, an HIA of the California Healthy Families, Healthy Workplaces Act (AB 2716, entitling employees to accrue one hour of paid sick time for every 30 hours worked) was completed by Human Impact Partners and the San Francisco Department of Public Health (SFDPH) at the request of the Labor Project for Working Families. The following year, HIP and SFDPH conducted an HIA of the federal Healthy Families Act of 2009. The California and Federal Paid Sick Days HIAs looked at the potential health outcomes for workers, families and communities, including impacts on recovery from illness, use of preventative health care services versus emergency rooms, as well the transmission of infectious disease in restaurants, schools and workplaces. The HIAs found that paid sick days has many positive health outcomes, including: improved food safety in restaurants; reduced transmission of the flu in childcare settings and nursing homes; and reduced emergency room usage. The HIAs showed that legislation that would entitle more workers to paid sick days would be good for everyone’s health—workers themselves, as well as people whose lives are touched by the same workers.
Paid Sick Day HIAs were used by coalitions of proponents of the various paid sick days legislation. Although neither the California nor Federal legislation passed, the HIA helped advocates articulate a public health rationale for the policy, thereby changing the public discourse about the issue from a question of labor rights or employer costs to the issue of improving the health of all people. At the same time, the HIA offered a rationale for public health officials to support paid sick days, a policy they may not have previously engaged. This health framing was picked up in other jurisdictions, and Milwaukee advocates used the California HIA along with Milwaukee-specific data to inform public opinion on a local 2008 paid sick day ballot measure. Legislative advocates publicized health facts through the local media, and the initiative passed with the support of two-thirds of the votes of Milwaukee residents. More recently, Connecticut became the first state to pass paid sick days legislation. In making their argument, advocates in Connecticut focused on the health benefits the bill would provide.
Strategies for Using HIA to Address HealthThere are a wide variety of projects, policies and plans where an HIA can be useful, and the first step of any HIA helps determine whether it is an appropriate tool. Conducting an HIA requires six steps (as outlined above). During the first two steps (screening and scoping), those involved assess the need for an HIA as well as which health measures to evaluate. HIAs start with hypotheses that are informed by scientific review as well as by lived experience of communities and stakeholders, and then research informs whether the hypotheses are true. This process allows those involved to think about the health of a particular community and understand the variety of ways that social factors are implicated in heath.
The HIA on the Downtown Plan in Long Beach and the HIA on paid sick days highlight how advocates can use a health lens. Framing the issue of equity around health can be a very powerful tool. Because HIA addresses social determinants of health, advocates and communities may find that the use of an HIA can create headway around a social issue. Often a health lens makes it more difficult for opponents to argue against addressing the real needs of a community. Using an HIA as a strategy for developing a health lens can be particularly effective because HIA is a research-based tool that provides scientific data in addition to assessing mitigation strategies.
The differences between the two above case studies highlights two complementary strategies for using HIA to address health disparities: focus on process, and focus on outcomes. Ideally, an HIA utilizes a robust process of multi-stakeholder participation, and also uses robust data analysis to influence the outcome of the project it is assessing in a manner that produces good health outcomes. However, HIA can have powerful impact even if it ends up being more outcome- than process-driven, or vice versa.
In Long Beach, advocates were concerned about a land use plan and wanted a tool they could use to weigh in on an existing, fast-moving process. Although the HIA process was important, given the short timelines, what mattered most was to have an impact on the proposed plan. HIA was appealing because it could produce an evidence-based report, highlighting potential health consequences, to submit as a comment on the Draft Environmental Impact Report that was being prepared. In this case, this created a time constraint, which limited and therefore deemphasized the HIA process. HIAs provide stakeholders with multiple ways to weigh in at various stages in a decision-making process, almost always with the goal of influencing the final decision. The HIA can be used to legitimize or assuage concerns, and can offer a mechanism to introduce recommendations or alternatives.
Although HIAs are typically set up in a way that allows them to have some impact on outcomes, there are also reasons for conducting an HIA that focuses more on process. Through conducting an HIA, structured opportunities for capacity-building, relationship-building, transparent and democratic process (e.g., stakeholder participation), community organizing, and developing messages are available. Regardless of outcome, an HIA can be useful and impactful because of these opportunities.
Often, the process of engaging multiple stakeholders in HIA actually brings about change in the decision. In addition to quantitative data, HIAs often include community surveys or focus groups, which help lend a voice and credibility to concerns about the issue. In the Paid Sick Days HIAs, the material gathered from focus groups was useful for highlighting the health concerns of workers, giving a personal voice to the issue, and for engaging more people in the policy-making process. The process of gathering these narratives and combining them with more quantitative (e.g., statistical) data creates a story about the people impacted by the proposed plan, project or policy. As this story emerges, powerful messages that can be used for advocacy also emerge, as do powerful spokespeople. Although the HIAs on paid sick days did not lead to the immediate passage of new legislation mandating paid sick days, their impact was felt through the narratives that emerged during the process. The health frame that was established through the data and personal stories has been picked up by other paid sick days advocates and was used in recent legislative victories.
Because HIA is a collaborative process, when effectively executed it can build capacity and relationships. HIA is a tool in which multiple stakeholders have an opportunity to engage, allowing for deepening relationships but also building the capacity of these stakeholders to engage meaningfully. The process of the HIA can be so important that the skills and opportunities for advocacy it provides become primary goals and are as important as outcome-related goals. When a group of community organizations in West Oakland decided to learn about HIA, they decided to conduct a rapid HIA on a proposed neighborhood development. Although they were initially more interested in the HIA process than in any specific outcome, during the HIA they began to work with the developer and as a result the project ended up adopting many of the HIA recommendations to protect future residents from air pollution and pedestrian injury from traffic.
In another HIA conducted in Los Angeles, a community organizing group successfully engaged community members in data collection as well as advocacy. The HIA, conducted on a development project in South Central Los Angeles, involved multiple stakeholders, including the developer, the public health agency and the redevelopment agency from the beginning, which led the stakeholders to agree to changes based on the community findings. Here, the process and outcome were both considered important, and the success of the outcome depended on the success of the process.
Another potential use of HIA is as a litigation tool or as a tool to prevent litigation. For a plaintiff, an HIA can serve to: (1) provide notice of potential harm, and (2) show the feasibility of alternatives. Alternatively, where steps have been taken to address concerns raised in an HIA and recommendations are adopted, the HIA could insulate projects from subsequent litigation by showing that health was seriously considered and that necessary steps were taken to address legitimate concerns. After adopting mitigations to address environmental health concerns for low-income housing raised in an HIA in Pittsburg, California, City agencies then used the HIA to defeat NIMBY efforts to eliminate that housing.
ConclusionRegardless of what type of project, plan or policy decision is being considered, a Health Impact Assessment may be a strategic tool for a variety of reasons. In addition to providing a health lens and health analysis, an HIA can contribute a robust participatory process and a structure for communities and other stakeholders to collaborate and provide input on decisions being made. HIAs may be appropriate on a wide variety of subjects (see box on p. 6 for a partial list of topics HIAs have covered). The value of an HIA can be determined by the magnitude and likelihood of potential health impacts, the distribution of those impacts, an accurate assessment of the likelihood of achieving the process and/or outcome objectives of the HIA, and a realistic evaluation of resources, capacity and stakeholder interest.
Saneta DeVuono-powell is a Research Associate at Human Impact Partners. firstname.lastname@example.org
Jonathan Heller co-founded Human Impact Partners in 2006. jch@human impact.org
Completed Health Impact Assessments:
Information on Income Disparities and Health:
More information on the relationship between HIA and EIA can be found at http://www.humanimpact.org/hia#EIA
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