Health Impact Assessment 101: A Guide to Understanding and Conducting HIAs
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This document provides an overview of health impact assessments (HIAs). It defines HIAs as systematic processes that use data and stakeholder input to determine how policies may affect population health. The document outlines the goals of HIAs in promoting health, equity and evidence-based decision making. It also describes the typical phases of conducting an HIA including screening, scoping, assessment, recommendations and evaluation. Resources for learning more about HIAs are provided.
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Health Impact Assessment 101: A Guide to Understanding and Conducting HIAs
- 1. Health Impact Assessment 101 April 2014 Sandra Whitehead Florida Department of Health Healthiest Weight Florida
- 2. Goals • Define HIA and associated terms • Discuss the values underlying the process • Learn why an HIA should be conducted and when it is appropriate • HIA and its relationship to Health in All Policies • Define the phases of an HIA • Discuss further learning opportunities and resources available
- 3. What is HIA? The National Research Council defines HIA as “a systematic process that uses an array of data sources and analytic methods, and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects” National Research Council, Improving Health in the United States, 2011
- 4. HIA Terms and Definitions • Systematic process: o Definition of a problem for analysis o Observation of current baseline conditions o Predicting possible health effects and outcomes o Assessing the likelihood, severity and distribution of impacts o Design solutions that minimize negative and promote positive health outcomes
- 5. HIA Terms and Definitions • Data sources and analytic methods: o Health data sources o Social, built and economic environmental data o Software that models changing conditions o GIS o Key informants
- 6. HIA Terms and Definitions: Potential Health Effects
- 7. HIA Terms and Definitions • Distribution of health effects: representation of whom, where and when the negative or positive health impacts will be seen
- 8. Value of HIA • Democracy • Equity • Increases awareness of health issues • Holistic approach to health • Scientific and robust practice
- 9. Why Conduct an HIA? • HIA is an important tool for advancing health and equity • HIAs help inform decision makers and other stakeholders about the likely health impacts associated with a proposed public decision • They provide information that serves as the basis of recommendations for ensuring that the decision improves health outcomes, especially for the most vulnerable • Identifies strategies for protecting and promoting public health “Promoting Equity Through the Practice of Health Impact Assessment,” Heller, et al., 2013
- 10. When is it Appropriate to Conduct an HIA As early as is practical in the decision making process When health is not being considered as a factor When conducting on- going work with decision makers and stakeholders As part of a larger process
- 11. Health in All Policies and HIA HIA is a tool that can be used to assess a single proposed decision and its potential impact on health HiAP is an approach that uses multiple strategies to systematize and integrate the governmental decision-making process across agencies so that health is considered Collins, J. & Koplan, J. (2009). Health Impact Assessment: A Step Toward Health in All Policies. JAMA. 2009;302(3):315-317
- 12. Six Phases There are typically six steps in conducting an HIA Screening – Determine whether an HIA is needed and the value added Scoping – Identify which health effects to consider and set the HIA parameters Assessment – Collect qualitative and quantitative information to create a profile of existing health conditions, and identify, evaluate, and prioritize the potential health impacts of the decision Recommendations – Identify alternatives to the decision and/or strategies for promoting the positive health impacts and/or mitigating the adverse health impacts Reporting – Write a final report and communicate the results of the HIA to decision-makers and other stakeholders for implementation/action Monitoring and Evaluation – Evaluate the processes involved in the HIA and the impacts of the decision on health (North American HIA Practice Standards Working Group 2010; Bhatia 2011; National Research Council 2011; Human Impact Partners 2011, 2012)
- 13. Phases of HIA
- 14. Screening The purpose of screening is to “assess the value, feasibility and utility of the HIA in the decision making process,” (Bhatia, 2011) Clearly define the decision to be informed and who is making the decision Is health being considered already? Is it feasible to complete an HIA? Will an HIA be politically viable? What are the health issues involved?
- 15. Sample Screening Potential Effects on Health Determinants Nexus between Health Determinant and Health Outcomes Likelihood of Impact (unlikely, possible, likely) Likely Magnitude of Impact (low, medium, high) Biophysical Environment Crowded conditions can increase the hazard for infections, respiratory disease, fires and poor mental health. Unaffordable rents or mortgages result in trade- offs between material needs such as housing, food, and medical care. Housing Conditions Fire, building safety Security Sanitation Indoor air quality (including radon) Asbestos Lead Crowding Affordability and access Housing segregation
- 16. Scoping Define the HIA team, stakeholders and timeframes for the process Define the limits of the HIA: Geographic Demographic Health outcomes What type of HIA will you perform?
- 17. Stakeholder Roles Primary Stakeholders (those directly affected , not just in terms of health, include any populations disproportionately affected) On working group To be consulted Gather data from Secondary Stakeholders Key Informants (individuals with knowledge, experience, or information
- 18. Kinds of HIAs Desk Based Rapid Intermediate Comprehensive No more than 3 impacts No more than 3 impacts, assessed in detail 3 to 10 impacts assessed in detail All potential impacts assessed in detail Provides a broad overview of potential health impacts Provides a detailed overview of potential health impacts Provides a thorough assessment of potential health impacts and more detail on predicted impacts Provides a comprehensive assessment of potential health impacts Is an “off the shelf” exercise based on collecting and analyzing existing, easily accessible data Involves collecting and analyzing existing data with limited input from experts and key stakeholders Involves collecting and analyzing existing and primary data as well as new qualitative data from stakeholders Involves collecting and analyzing data from multiple sources (qualitative and quantitative) 2-6 weeks for one person full time 6 to 12 weeks for one person full time 12 weeks to 6 months one person full time 6 to 12 months for one person full time
- 19. Pathways Diagram
- 20. Assessment • Determine the baseline health status, conditions “on the ground” related to health and vulnerabilities in the population or area • Assess the likelihood, magnitude and direction of health impacts using available data, qualitative and quantitative analysis • Identify strategies that eliminate, contain or mitigate negative impacts and enhance positive impacts
- 22. Reporting • Communicate the results and recommendations of the HIA to decision makers and the general public • Clearly relate the process, stakeholder participation and limitations of the HIA
- 23. Evaluation and Monitoring Evaluation •Process evaluation: assesses the effectiveness, transparency and rigor of the HIA process itself Monitoring Outcome evaluation: assesses changes in health status and health determinants as the decision is implemented
- 24. Resources • Health Impact Project: www.healthimpactproject.org • Human Impact Partners: www.humanimpact.org • UCLA Health Impact Assessment Clearinghouse: www.hiaguide.org • Public Health England HIA Gateway: http://www.apho.org.uk/default.aspx?QN=P_HIA • World Health Organization: www.who.int.hia/en
- 25. Resources Improving Health in the United States: The Role of Health Impact Assessment (National Research Council 2011) A Health Impact Assessment Toolkit: A Handbook to Conducting HIA, 3rd edition (Human Impact Partners 2011) Health Impact Assessment: A Guide for Practice (Bhatia 2011)
- 26. Summary • HIA is a systematic process to predict and address the potential health impacts of a single policy, program or project • HIA includes a broad range of stakeholders in the process to create shared values focusing on improving and protecting public health • HIA is evidence-based and uses established analytic tools to demonstrate and communicate the risks associated with the decision under consideration
- 27. Future Educational Opportunities Healthiest Weight Florida and the Florida Public Health Institute will be sponsoring three in-person trainings around the state for those interested in the “how to” of HIA. The classes will be limited in size available on a first-come, first-served basis to those who have completed HIA 101.
- 28. Regional Trainings Orlando: May 12-13 East Central Florida Regional Planning Council in Altamonte Springs Tallahassee: May 14-15 Florida Department of Revenue Sarasota: May 21-22 FDOH in Sarasota (Ringling Blvd)
Editor's Notes
- Welcome to Health Impact Assessment 101. I’m Sandra Whitehead, Director of Healthy Community Design with the Healthiest Weight Florida Team. As part of our on-going efforts to build capacity within the department and with our community partners to inform decisions affecting access to physical activity and healthy food, we here at HWF are offering a series of classes on Health Impact Assessment. It is our hope that after this introductory class, you will attend one of our regional trainings in May to learn more about the hands-on conduct of HIA.
- Our goals today are to discuss what an HIA is, define the underlying values and talk about why you would conduct an HIA. We will also briefly describe the process and how it fits into the overall framework of inserting Health into All Policies. At the end, I will talk about some resources for further reading and future training opportunities through the department.
- Basically HIA is a tool that helps planners and policymakers evaluate objectively the potential health effects of a project or policy before it is built or implemented. HIAs are increasingly popular as communities, builders, and politicians weigh the health implications of policies and projects. Whether the policy is to require mandatory physical education classes in a middle school or a project to revitalize a shopping center, there are health implications that are often been ignored. An HIA can take many forms but at its core it is a tool to evaluate objectively a project or policy before it is implemented so that evidence- based findings and recommendations can influence decision-making. HIAs: Encompass a variety of methods and tools. Have been performed extensively in Europe, Canada and other countries. Bring potential health impacts to the attention of policy-makers, particularly when they are not already recognized or are otherwise unexpected. Next, let’s talk about what the italicized terms mean.
- A systematic process involves the definition of a problem, the searching of alternative solutions in general through models, and the selection of the best alternative that will eventually decide the course of action. Translated to an HIA, it involves clearly defining the decision under consideration. This can be the most challenging part of the HIA. Depending on the resources available, you can address a policy as broad as the Farm to School Agriculture bill as the California Department of Public Health did or something as narrow as the redesign process for a segment of a city street as in the Volusia Complete Streets HIA FDOH performed. Once you have narrowed the question, you need to gain an understanding of the current baseline conditions so you can predict changes. You would then use established research methods and models to predict health outcomes and design solutions to mitigate negative outcomes and create or enhance positive health outcomes. Turban, E. and J.R Meredith (1985): Fundamentals of Management Science. Business Publications, Inc.
- Data sources for your baseline conditions would consist the kinds of data sets health professionals use everyday such as the Census data, Florida CHARTS, the Behavioral Risk Factor Surveillance Survey (BRFSS), the County Health Rankings and other epidemiological data. You would also need to assess the social and economic conditions using various data sets like the American Communities Survey, the National Household Travel Survey or the Gallup Healthyways Well-Being Index. To assess the baseline built environment, data can be gathered using geographic information systems that already created or by geo-coding features of concern like bus stops and crosswalks. Analytic methods include established methodologies to predict health outcomes like a literature review, modeling, focus groups or key informant interviews depending on the type and scope of HIA. In order to project possible health impacts, it is also helpful to make a logic model or pathways diagram showing the decision framework.
- Most often, to develop the framework you would first conduct a literature review to find the potential health effects of policy, plan or project. This is a diagram of the potential health effects of implementing a Complete Streets approach to road design. It is important to think through the intermediate outcomes as well as the ultimate health outcomes in order to make appropriate recommendations. As you move through the process, this diagram may change because you will be seeking input from stakeholders and key informants who are most familiar with the local situation.
- The distribution of health effects is usually represented on a map. In this example, it shows the relationship between the location of food access points and the population which does not own a vehicle for transportation in Sarasota County.
- What Values Underpin an HIA? Democracy - the right of people to participate in the formulation of policies that affect their life, both directly and through elected decision-makers. This means that the community plays a major role in HIA process. Equity - the reduction of inequity that results from avoidable and unjust differences in health status between different people. An HIA assesses the distribution of impacts from a proposed policy or project with a particular reference to how the proposed policy or project will affect vulnerable people (in terms of age, gender, ethnic background, and socio-economic status). Increased awareness of health issues—When public health is brought into the discussion through an HIA, it tends to raise awareness of all health-related issues, not just those associated with one project. Scientific and robust practice - emphasizing that transparent, systematic and impartial processes are used, which utilize the best available evidence from different scientific disciplines and methodologies.
- The two most important reasons to conduct an HIA are to improve the decision making process by bringing health considerations to the table where they are not being considered and to identify strategies that would reduce negative health outcomes and enhance positive outcomes.
- When should you do an HIA? As early as practical in decision making process Ideally when decision makers ask for an HIA After sufficient details about the project or policy are defined When conducting ongoing work with decision makers and planners When new or unfamiliar information provided by an HIA has the potential to affect decisions. HIA is of little value when everyone is already familiar with the information provided by the HIA and when decision-makers and stakeholders are not open to reconsidering plans. Think of a project or policy that you believe would have been better executed if there had been an HIA. When should an HIA have been initiated and who should have initiated the process?
- Health in All Policies is an approach, like HIA, to incorporate health considerations into non-health sector decisions. HiAP is more of a global approach and would involve a long-term strategy to study and communicate the health implications in a more global manner. It isn’t focused on one policy, plan or project. HiAP is a framework that can be used as a strategy to shift paradigms of thinking about health in a holistic manner.
- The number of phases involved in HIA will vary in the literature. However, these are the six that come up most often and are generally accepted practice per the CDC and the Minimum Standards of HIA Practice (Bhatia, 2011).
- The questions we ask in screening allow us to make an informed decision as to whether an HIA is feasible and will be cost effective. Screening is the phase in which you would precisely define your decision and assess the political and practical viability of conducting an HIA.
- This is a sample of a screening chart that might be used in an HIA assessing the health impacts of allowing high density housing.
- In scoping, you create your scope, objectives and approach. This is your roadmap to the process: it tells you who will be responsible for each task, what the deliverables are and when they are due. You may have to narrow your scope by geography (study area); demography (affected groups) or number of health outcomes you can study. Your limits will depend upon the resources available to you in terms of personnel, time and valid data sources. You will also need to choose the type of HIA you perform.
- Determining who the stakeholders are and what their roles will be in the process is important to forming your scope, objectives and approach.
- The type of HIA depends on the time, personnel and financial resources available to perform the HIA. This slide shows some basic guidelines and is based on the work of Ben Roxas-Harris, et al (2007) in Australia. The chart is meant to be a “rule of thumb,” not definitive. In most cases, an HIA involves a whole team of individuals from different sectors as well as stakeholder involvement so the time frames vary widely. However, the number of impacts and descriptions have proven accurate through the last seven years as practice has grown in the US.
- Scoping is also the phase in which you would create your logic model or pathways diagram to show the intermediate and long-term health outcomes of the proposal. This is a pathways diagram from a study looking at raising fares on public transportation. The right hand side starts with the decision under consideration and moves to intermediate outcomes then the public health outcomes. In the scoping phase, this level of detail is fine, but as you move through the process you would refine the health outcomes and focus on measuring the distribution, likelihood and severity of each on the population affected by the decision.
- Once you have detailed your research questions and predicted the outcomes, you will use your tools to predict the health impacts. This is also the phase where recommendations are developed to enhance positive impacts and try to minimize negative impacts. Once again, you can go back to your logic model or pathways diagram and add the direction, magnitude and likelihood to the model.
- This slide shows the table used to communicate that information for an HIA in Atlanta looking at the effects of a redevelopment project on Buford Highway. Some examples of health indicators that were developed are: number of emergency room visits for respiratory ailments; instances of diabetes; number of accidents (car on pedestrian). Can you think of others?
- The reporting phase is when the team communicates their findings to the stakeholders first, seeking input for changes or impacts not addressed, then to decision makers and the general public. The reporting phase usually involves methods like public presentations, press releases, factsheet distribution and social media campaigns. During this process it is important to not only communicate the recommendations, but also to be certain the process of conducting the HIA is clear and to make sure that the team’s assumptions, data sources and limitations are understood.
- The last two phases, Evaluation and Monitoring are “after the fact.” Evaluation is primarily process evaluation meaning you look at the way you conducted the HIA and test for effectiveness (did you come up with effective strategies); transparency (was the process clear to everyone involved, did you get the right people involved) and rigor (did you use the best evidence and data available upon which to base your recommendations). Monitoring involves looking at your outcomes after the recommendations are implemented. Did you correctly predict outcomes, their distribution and severity? Some of the literature indicates that the HIA team can also evaluate the process using a qualitative process of surveying the decision makers and stakeholders involved asking if the information provided in the HIA made a difference in the decision making process and if the stakeholders felt their input made a difference in the outcome of the decision making process. Depending on the time and effort involved in soliciting this information, it may be a valuable exercise.
- Some resources where you can find further information on HIAs and the practice of HIA in the US and around the world are listed here. If you want to find out about HIA in Florida, you can visit the HIA webpage for the Florida Public Health Institute or the Health Planning Council of East Central Florida.