Health Impact Assessments: A Policy Tool for Health Reform through Prevention and Planning

SarahBlennerBy Sarah Blenner, JD, MPH

Tamar is a sophomore in high school and plays on the school’s water polo team.  Her team practices in the swimming pool after classes are over for the day.  Following practice, when Tamar takes public transportation home, she has to transfer at two different bus stops before making it home.  Formerly, the trip lasted 45 minutes, but with recent reductions in bus service, the trip now lasts an hour and a half, leaving Tamar less time to complete her homework.  Tamar now has to wait longer on street corners at night, where she is increasingly exposed to a variety of negative elements such as extreme weather, cigarette smoke, gang violence, potential sexual assault, and the use of drugs by the people around her.  Longer exposure to these risks may increase her chance of engaging in behaviors that will negatively affect her health.  Had the policy implementing the bus cuts been subject to a formalized planning process that evaluated future impacts on the health and safety of those who use the public transit system, recommendations may have been implemented including maintaining frequent bus routes in critical neighborhoods or when students who participate in after-school activities are leaving school.

There are many factors that contribute to our health, such as individual behavior, societal influences, genetic predisposition, health care, and the physical environment.  In order to improve our health or the health of our communities, we must address these factors.  For one, environmental exposure can occur both through direct and indirect exposure.  Direct exposure occurs when an individual comes into contact with toxins, e.g. chemicals found in paint, the air, or even baby bottles.  Health can also be affected by indirect environmental factors, such as housing, urban development, land use, and transportation.  Tamar, the high school student who took the bus home from school, will be negatively affected by indirect environmental exposures.

The health of Americans is in need of improvement. According to the Center for Disease Control and Prevention (CDC), 34% of adults are considered obese, and another 34% overweight; 10% of adults in the U.S. have either diagnosed or undiagnosed diabetes; and 7.5% of adults in the U.S. have been diagnosed with asthma.  Former Interim President for Partnership for Prevention Corrine Hudson once said “[r]eal health reform must start with prevention.  Without a much stronger emphasis on prevention than now exists, we have little hope of controlling costs without sacrificing health.”  Health Impact Assessments do just this. Health Impact Assessments have been defined by both the World Health Organization (WHO) and the CDC as “a combination of procedures, methods, and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.

Health Impact Assessments evaluate a proposed policy, program, or project, using both qualitative and quantitative methods that cross multiple disciplines.  The assessments further make recommendations on how to either avoid unintended negative health outcomes or encourage positive health outcomes.  Health Impact Assessments are also oriented towards equity and social justice.  Health Impact Assessments can be conducted on a broad range of projects, including, expansions of an airport, paid sick days, after school programs, gentrification of neighborhoods, and the construction of bridges and highways.

Health Impact Assessments employ a six step process: (1) assessing which  policies are likely to have an impact on health, (2) analyzing potential impacts, (3) assessing risks and benefits, (4) developing recommendations, (5) reporting results, and (6) evaluating the decision.  Screening identifies projects or policies for which a Health Impact Assessment would be useful.  Scoping identifies which health impacts should be assessed and what populations could be affected.  Assessing risks and benefits considers the magnitude, direction and certainty of health impacts.  Developing recommendations provide decision makers with alternative actions that could prevent unintended negative health outcomes and promote positive health outcomes.  Reporting occurs when the results of the Health Impact Assessment are presented to the relevant decision makers.  Finally, the monitoring process determines the effect of the Health Impact Assessment on the decision.

As an illustration, consider a Health Impact Assessment conducted on the revitalization of an area in Minneapolis, Minnesota.  What once was a thriving urban area, had deteriorated over the years and became a center for “poverty, unemployment, crime, and drug use.”  The area is known as Lowry Avenue Corridor and consists of a five mile road that has an impact on 18,000 neighborhood residents.  What actions could the city take to help revitalize what once was an outstanding community asset?  As part of the gentrification efforts, Hennepin County staff completed a Health Impact Assessment to determine the best way to plan for a 16 block portion of the road, promote positive health outcomes in the community, and avoid unintentional negative outcomes.  The methodology used for the Health Impact Assessment in the Lowry Avenue Corridor case included “literature review; secondary data analysis of planning documents, census data, and injury data.”  Through the scoping phase of the process, the County staff working on the project identified “social capital, employment opportunities, pedestrian safety, and physical activity,” as important determinants that would be impacted by the policy decisions concerning the revitalization of the area.  The Health Impact Assessment recommended additional lighting, maps, and increased number of signs.  By making recommendations, the Health Impact Assessment was expected to improve access to transportation, walkability, physical activity, mobility for individuals with disabilities, and social supports.  In the end, the Health Impact Assessment helped secure funding to complete the project.

Health Impact Assessments are closely related, and in some cases intertwined with already existing legislation, programs, and policies, including but not limited to: health reform, the National Environmental Policy Act (NEPA), green building initiatives, and the Leadership in Energy and Environmental Design — Neighborhood Development Program (LEED — ND), which is a certification program designed to identify “environmentally responsible, sustainable development[s].”  With respect to health reform, the Patient Protection and Affordable Care Act adds additional mandates that charitable hospitals must comply with in order to maintain their tax status under the Internal Revenue Code.  Among these mandates, is the requirement that charitable hospitals conduct a community health needs assessment of the surrounding community at least once every three years.  The assessment required seems potentially comparable to the process and purpose of Health Impact Assessments.

Additionally, Health Impact Assessments are similar to Environmental Impact Statements, which in some circumstances are mandated by NEPA, NEPA’s implementing regulations, and parallel state and local laws.  Among the multiple objectives of NEPA, the legislative intent was to create a national policy that will “encourage productive and enjoyable harmony between man and his environment” and “stimulate the health and welfare of man.”  According to the CDC, some Environmental Impact Statements have incorporated Health Impact Assessments into the analysis, but Health Impact Assessments are not mandatory under federal law.  Likely, the impacts of qualifying major projects on human health are not adequately considered in these analyses.

Many countries through Europe and across the globe, such as the UK and Thailand, are implementing or considering the implementation of policies requiring Health Impact Assessments in certain scenarios.  But do Health Impact Assessments have a place in the web of American statutes, regulations, and policies?  Every day, legislators, policy makers, and community leaders are making choices which will have an impact on many people and also on their health.  Health Impact Assessments furnish these decision makers with the tools and information needed to make informed decisions.  In a study that evaluated the use of Health Impact Assessments in the U.S. the authors concluded that the “[Health Impact Assessment] is a promising approach to identify the impacts of proposed policy and infrastructure changes, utilizing quantitative and nonquantitative analyses, in a way that allows health outcomes to be appropriately factored into complex decisions.”  Given the current health status of the American population and the extent of the potential positive impacts on health outcome such as prevention of obesity, asthma, and diabetes, policies should be implemented that encourage, and even in certain circumstances require, Health Impact Assessments.