5

Structures and Policies for Promoting Health Impact Assessment

The nation’s highest priorities for health, as articulated in the Healthy People 2020 initiative, include increasing quality and longevity of a life and eliminating health disparities between sexes, classes, races, and ethnic groups (DHHS 2010). Poor health severely undermines a person’s quality of life and places substantial economic burdens on individuals and on society at large. Chapter 2 documents the direct and indirect associations between current health problems and social, economic, and environmental conditions in the United States. It also illustrates how decisions about policies, programs, projects, and plans—especially those emanating from non-health sectors—contribute to conditions that influence the public’s health. Thus, improving public health substantially will require focused efforts to recognize and address the health implications of decisions made at all levels and in all sectors of government—that is, to incorporate health into policy-making, planning, and decision-making.

Health impact assessment (HIA), an emerging practice in the United States, is one approach for promoting health and disease-prevention objectives. As described in Chapter 3, HIA aspires to assist policy-makers, decision-makers, and the public in identifying health considerations and factoring them into proposed policies, plans, programs, and projects that otherwise would not have recognized or addressed important health risks or opportunities. It aims to protect and promote public health and to reduce health disparities by informing decision-making, and it offers substantial potential benefits to improve public health. In contrast with its more extensive use internationally, HIA appears to be underused in the United States. The committee identified several barriers to the development and use of HIA in the United States:

•   The context within which HIA is practiced poses a challenge. There are few legal mandates for the use of HIA in the United States; as described in Chapter 4, the decision-making contexts within which HIA must occur are di-



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5 Structures and Policies for Promoting Health Impact Assessment The nation’s highest priorities for health, as articulated in the Healthy People 2020 initiative, include increasing quality and longevity of a life and eliminating health disparities between sexes, classes, races, and ethnic groups (DHHS 2010). Poor health severely undermines a person’s quality of life and places substantial economic burdens on individuals and on society at large. Chapter 2 documents the direct and indirect associations between current health problems and social, economic, and environmental conditions in the United States. It also illustrates how decisions about policies, programs, projects, and plans—especially those emanating from nonhealth sectors—contribute to condi- tions that influence the public’s health. Thus, improving public health substan- tially will require focused efforts to recognize and address the health implica- tions of decisions made at all levels and in all sectors of government—that is, to incorporate health into policy-making, planning, and decision-making. Health impact assessment (HIA), an emerging practice in the United States, is one approach for promoting health and disease-prevention objectives. As described in Chapter 3, HIA aspires to assist policy-makers, decision- makers, and the public in identifying health considerations and factoring them into proposed policies, plans, programs, and projects that otherwise would not have recognized or addressed important health risks or opportunities. It aims to protect and promote public health and to reduce health disparities by informing decision-making, and it offers substantial potential benefits to improve public health. In contrast with its more extensive use internationally, HIA appears to be underused in the United States. The committee identified several barriers to the development and use of HIA in the United States:  The context within which HIA is practiced poses a challenge. There are few legal mandates for the use of HIA in the United States; as described in Chapter 4, the decision-making contexts within which HIA must occur are di- 119

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120 Improving Health in the U.S.: The Role of Health Impact Assessment verse; and the minimal attention to health in public policy-making has not been identified as a pressing issue on local, state, or national policy agendas.  Societal awareness of the many determinants of health is limited. The general public and people in a variety of nonhealth (and health) sectors often have little understanding of the influence of all the social, cultural, political, economic, and environmental determinants on health and therefore have little awareness about the utility of HIA. As a result, there is little public demand for the use of HIA in the United States.  Another key challenge is related to the professional practice of HIA it- self. Little education and training in HIA are available in the United States. The current practice of HIA is inconsistent and nonstandardized. The quality of ana- lytic methods used by HIA practitioners varies widely and there is not enough synthesized evidence on health determinants that can be used by HIA practitio- ners. In addition, the effectiveness of HIA and its effects on public-health out- comes have not been evaluated sufficiently.  Finally, there are few resources to support the practice of HIA. In response to those barriers, the committee identified four core issues that must be addressed to foster the judicious, deliberative, and rigorous use of HIA in the United States:  Structure and policies to support HIA.  Promotion of education, training, and societal awareness of HIA.  Increase in research and scholarship in HIA.  Development of resources to support HIA. STRUCTURE AND POLICIES TO SUPPORT HEALTH IMPACT ASSESSMENT The continuing adoption and effectiveness of HIA in the United States are predicated on the creation of an institutional framework that facilitates its use in public decision-making at all levels of government (see Appendix A for interna- tional examples of the use of HIA at various levels of government). Although there are a number of ways for such a framework to emerge, two potential ways to support HIA are greater and sustained interagency collaboration among gov- ernment agencies at local, state, and federal levels and better implementation of existing policies with the creation or strengthening of enabling legislation at local, state, and federal levels. Interagency Collaboration It is difficult or impossible to conduct an HIA of policies, programs, and projects of nonhealth public sectors—such as economic policies, job-training programs, and infrastructure projects—without substantial interagency collabo-

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121 Structures and Policies for Promoting Health Impact Assessment ration among sectors and all levels of government. For example, if an HIA of a proposed road expansion is led by a public-health agency, the HIA team will need to work with the departments of public works, planning, and engineering to understand the proposed project fully. Conversely, if the HIA is led by a non- health agency, the HIA team will need input from a public-health agency on relevant health data. In short, the practice of HIA depends on and benefits from cross-agency collaboration. Such collaboration is also essential because of the resource-constrained environment within which public-policy-makers and public officials work. Although the nature and extent of collaboration will depend on the level of government and the particular decision context, the collaborative arrange- ments—which may be manifested in joint task forces, councils, cabinets, new departments, shared staff appointments, or some other suitable mechanism—are most effective when they represent the widest possible group of professional interests, such as departments of public health, planning, law, and economic development. There are a number of potential ways to promote interagency collabora- tion. The committee notes several examples below.  Federal agencies, such as the Council for Environmental Quality (CEQ) and the U.S. Centers for Disease Control and Prevention (CDC), could establish collaborative relationships—for example, through an interagency working group or a task force—that would be explicitly charged with developing guidance for integrating health concerns into the implementation of the National Environ- mental Policy Act (NEPA). Existing regulations that provide a foundation for such guidance are discussed in Appendix F.  Individual executive-branch agencies could evaluate whether HIA is an appropriate mechanism for incorporating health considerations into their plans and proposals and for meeting standards conferred by their enabling legislation and regulations concerning public health and well-being.  The Affordable Health Care for America Act of 2009 set out objectives for the member agencies of the National Prevention, Health Promotion, and Public Health Council (2010). The council could consider how HIA might be used to achieve those objectives, and it could also recommend use of HIA in the National Prevention and Health Promotion Strategy.  Tribal health departments could become involved in NEPA-related de- cisions made by federal agencies when it appears that decisions would be impor- tant for tribal health or well-being. There are several opportunities for tribal par- ticipation in the NEPA process. First, tribal members and government representatives can submit formal comments. Second, tribal governments may request direct “government-to-government” consultation with lead federal offi- cials at any time during the NEPA process. Third, tribal governments may ask to become “cooperating agencies” in the preparation of NEPA-related documents;

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122 Improving Health in the U.S.: The Role of Health Impact Assessment this role allows them to review, comment on, and contribute new information to the analysis as it is being developed.  Tribes could consider forming multiagency working groups to locate appropriate opportunities to incorporate health into planning, policy, and pro- grammatic decision-making.  As in efforts at the federal level, state health departments and depart- ments of the environment could establish interagency working groups charged with integrating health concerns into decision-making processes at the state level.  State agencies—such as departments of the environment, agriculture, education, and transportation—could invite their health departments to partici- pate in coordinated planning and permitting activities for large projects and for infrastructure or transportation improvement programs. This approach is proving successful in at least one state (Wernham 2009; Health Impact Project 2010).  Local public-health agencies—county and city health departments— could partner with other government agencies, such as agencies of urban plan- ning and economic development, in promoting health. HIA could be used as a tool to engage the agencies. This practice has shown considerable promise in several jurisdictions (Bhatia and Wernham 2008; Corburn 2009).  Local public-health agencies could become more multidisciplinary by deepening expertise in nonhealth sectors and could assist in building capacity in other agencies. For example, public-health agencies might train planners and other officials in the use of HIA.  Given the sparse resources of local government agencies, innovative revenue-generation options will need to be explored to support many of the above activities. For example, health departments that are involved in formal planning or permitting decisions could be funded by such mechanisms as per- mitting fees. Supportive Public Policies and Legislation HIA can be advanced by fully implementing existing policies and legisla- tion that support the use of HIA or through support of the creation of new ena- bling legislation. The key policies that support the use of HIA in the United States are NEPA and state environmental policy acts (SEPAs) (see Appendix A for further discussion). Although the federal NEPA process and equivalent proc- esses at the state level are important tools for advancing HIA, it is possible and probably prudent for the public sector to enact additional policies and legislation outside the context of NEPA and SEPAs to facilitate the use of HIA. Making prescriptive recommendations on the nature of the new policies and legislation is beyond the scope of this report, particularly given the wide variation in policy contexts across the country. Instead, several avenues through which HIA may be advanced are outlined below; some of which focus on reinvigorating and

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123 Structures and Policies for Promoting Health Impact Assessment strengthening the spirit of NEPA. The examples are by no means exhaustive; they constitute only a sample of general approaches that could be used to further the practice of HIA.  Explicit guidance that demonstrates how health considerations can be incorporated into NEPA could be developed jointly by agencies best suited to the task of integrating health into the NEPA process and provided to federal agencies. For example, CEQ in partnership with CDC and other appropriate public-health and NEPA experts could develop and issue guidance to federal agencies on explicitly incorporating health considerations into NEPA. The guid- ance could also encourage lead federal agencies to solicit appropriate participa- tion of local, state, tribal, or federal health officials as cooperating agencies in the NEPA process.  Without clear health goals, objectives, metrics or indicators, or targets, it is difficult for federal agencies to gauge and monitor the extent to which health and HIA are incorporated into policies. One possibility is for federal agencies to develop such metrics and targets as part of their 5- and 10-year plans. The metrics could be adopted from the Healthy People 2020 initiative, which provides science-based 10-year objectives for measuring improvements in health (DHHS 2010). Such an approach is consistent with the framework of Healthy People 2020, which argues for a “health in all policies” approach.  To overcome institutional barriers, it is important to identify means to facilitate the explicit inclusion of health concerns in domestic policy-making at all levels of government. One strategy for doing so could be the establishment of a committee, council, or task force nested within existing policy-making bodies at the federal level (such as the Domestic Policy Council) with analogues at the state and local levels. To be successful, such an entity would need to have clear points of coordination at all levels of government, identifiable liaisons, and a clearly defined charge.  The Government Accountability Office could review, synthesize, evaluate, and publically disseminate information on HIAs of federal government policies, projects, and programs.  The U.S. Environmental Protection Agency could consider ways of ex- panding their reviews of environmental impact statements to include assessment of health consequences for low-income populations, racial minorities, and native tribes (42 U.S.C. Section 7609 (1970)).  Each policy sector—such as energy, housing, and transportation— could consider including explicit objectives and performance measures in plan- ning, funding, and policy-development activities that are aimed at protecting human health. For example, the transportation sector could include planning and design objectives that would result in reduction of human exposure to air pollu- tion and prevention of injuries to pedestrians, bicyclists, and other users of roads. The housing sector could include objectives and measures for reducing segregation, crowding, and injury hazards.

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124 Improving Health in the U.S.: The Role of Health Impact Assessment  Tribal governments could consider enacting a tribal environmental pol- icy act and include standards for the use of HIA when appropriate (Tulalip Tribes 2000). At the local government level, HIA may be useful as a tool for reviewing the effects of plans and projects on the health of a community. Several examples are noted below.  HIA may be used to gauge the effect of comprehensive plans on the health of a community, especially in cases in which health is not explicitly an element of a local comprehensive plan.  One purpose of zoning is to protect public health and well-being. HIA is proving to be a useful tool for assessing the effects of proposed new or revised zoning codes on public health.  School districts could use HIAs to gauge the effects of various disci- pline policies, exercise curricula, school-meal programs, or school-siting deci- sions on children’s health. Health and wellness committees in school districts can play a key role in initiating a conversation around HIAs. PROMOTION OF EDUCATION AND TRAINING IN AND SOCIETAL AWARENESS OF HEALTH IMPACT ASSESSMENT A few institutions of higher learning in the United States offer formal edu- cation in HIA; for example, the University of Wisconsin-Madison and the Uni- versity of California, Berkeley offer courses that feature HIA. Other courses are taught by practitioners in the field. For example, the San Francisco Department of Public Health has taught an annual 4-day course for practitioners for the last few years, and several other organizations—such as Human Impact Partners, Design for Health, CDC, and the University of California, Los Angeles—have offered training (usually for 1-3 days) and technical assistance. Few professionals in the United States, however, are trained in the practice of HIA. Current HIA practice in the United States is based largely on experien- tial learning, that is, “learning by doing.” The present committee views high- quality education and training as critical for the advancement of HIA in the United States. The committee notes that advancement must occur in basic edu- cation, continuing education, and formation of professional associations. Basic Education in Health Impact Assessment HIA is concerned with bringing health concerns into a decision-making process that would otherwise fail to incorporate health. Therefore, HIA practi- tioners will always work in interdisciplinary settings and with interdisciplinary groups, and the education of future HIA professionals in academic settings must embody a variety of relevant disciplines—health-related (such as public health

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125 Structures and Policies for Promoting Health Impact Assessment and medicine) and other (such as public policy, urban planning, public admini- stration, and economics). The teaching must engage faculty and students in the various disciplines. Accordingly, schools of public health and medicine, public policy, urban planning, public administration, and economics should develop curricula that enable studies to learn core HIA skills. The curriculum must ad- here to the highest standards of academic rigor as demanded by the core disci- plines in which HIA is taught. Material, financial, human, and institutional resources are necessary from inside and outside academe to facilitate inclusion of HIA in academic programs. Potential agencies outside the academic setting that might support educational programs in HIA are those whose mission is to promote health (such as the Na- tional Institute of Environmental Health Sciences) and education in general (such as the U.S. Department of Education). Continuing Education of Professionals, Policy-Makers, and Society In addition to introducing HIA into academic programs, the committee views continuing education of HIA professionals, policy-makers, and society in general as important for improving the quality of HIA practice in the country. It is especially important to emphasize broad societal education in the many de- terminants of health so that individuals and communities can make informed decisions about their health and well-being and can participate fully in the HIA process. One possibility for promoting continuing education of professionals is flexible and modular training programs in a variety of agencies—public, non- profit, and private—and in different levels of government. For example, the CDC Healthy Community Design Initiative has supported state health depart- ments in training and mentoring local health departments in HIA; the initiative has made it possible for several jurisdictions to complete HIAs (CDC 2011). Such training should be expanded to reach a wider array of individuals and groups. Furthermore, because HIA practice has to overcome barriers related to the lack of interagency collaborative structures, it is important to engage and train senior-level local, state, and federal agency officials and decision-makers. Leaders of the federal civilian workforce, such as the federal Senior Executive Service (OPM 2011), could benefit from continued education in HIA because it would raise health awareness in their own work. Emergence of Professional Associations and Groups Like any growing field, the field of HIA could benefit from a professional association or society. The society could facilitate continued professional devel- opment of HIA practitioners and develop, monitor, and facilitate standards of professional education and practice in HIA. It could also establish and oversee publication of peer-reviewed research and scholarship in and about HIA through

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126 Improving Health in the U.S.: The Role of Health Impact Assessment a professional journal. Since 2008, a network of practitioners in North America has been working to advance the practice of HIA in the United States. The first collective product of the network was a set of minimum elements and voluntary practice standards for the field (Bhatia et al. 2010). The network has continued to meet periodically and is taking steps to build awareness, mentor new practi- tioners, and support integration of HIA and EIA. It is expected to formalize its relationships and activities in a professional organization in the near future. INCREASE IN RESEARCH AND SCHOLARSHIP IN HEALTH IMPACT ASSESSMENT Scholarship for Developing Methods and Evidence for Health Impact Assessment The methods and evidence used in HIA practice vary widely and are inconsistent in quality. Research to improve the analytic methods available to HIA practitioners is important, and research evidence that ties distal upstream factors to health outcomes that could be used in the HIA process is essential. Suggested research topics on the role of distal or upstream factors1 in health that could strengthen the evidence base available to HIA practitioners include the following:  How health is affected by specific federal policy decisions and actions related to agricultural policy, education, energy development, environmental protection, housing, immigration, infrastructure, military defense, national parks, natural resources, taxation, and transportation.  How health is affected by state fiscal policy (such as property tax law), agriculture, education, welfare-to-work, and land-use and growth-management policies.2  How health is affected by planning processes (such as comprehensive planning, growth-management planning, and land-use planning), regulatory mechanisms (such as subdivision regulations and zoning and building bylaws), fiscal tools (such as local tax regulations and incentives), infrastructure projects, and school district policies. Beyond the primary research suggested above, HIA practice would also be enhanced by developing approaches to apply decision-theory concepts in the con- text of the complex quantitative and qualitative information used in HIA. Evaluat- ing multiple alternative policies in the face of tradeoffs and uncertainty is the 1 These factors include the role of the natural and built environments and social, eco- nomic, and political environments in fostering or hindering public health. 2 Not all states in the country enact statewide land-use and growth-management poli- cies. In states where such policies exist, consideration of HIA is relevant.

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127 Structures and Policies for Promoting Health Impact Assessment hallmark of decision science, and methods that can leverage the strengths of deci- sion-science approaches—such as multiattribute utility analysis (Keeney and Raiffa 1976)—in the context of HIA would be valuable (Merkhofer et al. 1997). Scholarship on Health Impact Assessment Practices and Their Effectiveness Evaluation of HIA has occurred to some extent internationally (Harris- Roxas 2009). However, because HIA is relatively new in the United States, there is a paucity of evidence on the effectiveness of HIA practice in this coun- try. Such research is especially necessary inasmuch as HIA may require the in- vestment of substantial public and private resources. Research is needed to document HIA practices and its effectiveness in influencing decision-making processes and promoting public health. Existing tools of evaluation research might be used and adapted to evaluate HIA (Rossi et al. 1999; Trochim 2000). Potential research includes the following:  Development and empirical validation of theories or frameworks to un- derstand and assess the effect of HIA on decision-making and related social processes.  The effect of HIA on improving short-term and long-term health out- comes.  The role of local, tribal, state, and federal governance structures and decision-making processes in integrating public-health concerns into public policy.  Methods to address the challenges and opportunities in using HIA to inform government decision-making at all levels and branches of government. Improvement of HIA practice requires scholarship for and on HIA prac- tice, and such scholarship cannot be generated without financial support. Finan- cial support can come from philanthropic, private, and public entities, such as the National Institutes of Health, CDC, and the Agency for Healthcare Research and Quality. HIA practitioners are most likely to benefit from translational research that synthesizes high-quality scientific evidence for use by practitioners and policy- makers. Such an effort would have to gauge the quality of the latest available research evidence on the role of distal factors on public health and synthesize that information for use by HIA practitioners. The synthesized evidence can be disseminated to practitioners by using a variety of tools, such as journals, on-line repositories, and newsletters. Among those options, an online repository would be a centralized and dynamic tool for bringing the latest synthesized research to HIA practitioners. Such a repository may be made available by a number of entities, including universities, research

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128 Improving Health in the U.S.: The Role of Health Impact Assessment centers, private groups, and government agencies, such as CDC.3 As a publicly available and credible source of information on public health for the nation, CDC is especially well-positioned to establish and maintain such a repository. DEVELOPMENT OF RESOURCES TO SUPPORT HEALTH IMPACT ASSESSMENT A key barrier to the use of HIA is the availability of resources for commu- nities and groups interested in undertaking it. Resources are also essential for continued education and training of professionals in the field, and the lack of resources affects the quality of HIA. Furthermore, resources are needed for monitoring and conducting evaluations. For more resources to become available to support the development of HIA practice, society as a whole has to recognize the importance of considering health in all policies, programs, plans, and projects to improve quality of life and to protect the health of future generations. Yet, many of the connections that HIA makes explicit are neither obvious nor intuitive to the general public or to decision-makers in nonhealth (and health) agencies. A national information campaign is crucial for highlighting the importance of a wide array of decisions to public health, clarifying the role of HIA in the decision-making process, and advancing HIA practice. Such a campaign could be conducted by existing health agencies, such as CDC, or by new organizations, such as a new association for HIA, if such an entity were to emerge. Such information could be disseminated through an online repository, for example, one managed by CDC. Although this chapter is focused largely on barriers to and options for de- veloping structures and policies to support HIA in the public sector, the commit- tee recognizes that private-sector decisions also have health implications. The committee encourages the private sector to incorporate HIA into projects and developments that are likely to have important impacts on health and health de- terminants. Private-sector planning and development initiatives could also con- sider using HIA as a means of informing stakeholders of possible adverse or beneficial effects and allowing them to participate in planning and shaping pro- posed projects, programs, or plans in a way so as to minimize adverse effects and optimize beneficial ones. REFERENCES Bhatia, R., and A. Wernham. 2008. Integrating human health into environmental impact 3 A number of on-line resources for HIA exist; for example, the University of Califor- nia, Los Angeles offers an on-line learning and information center on HIA, and the Health Impact Project offers an interactive, searchable database of completed and in- progress HIAs in the United States. However, providing a synthesis of research evidence does not appear to be the central function of such Web sites.

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129 Structures and Policies for Promoting Health Impact Assessment assessment: An unrealized opportunity for environmental health and justice. Envi- ron. Health Perspect. 116(8): 991-1000. Bhatia, R., J. Branscomb, L. Farhang, M. Lee, M. Orenstein, and M. Richardson. 2010. Minimum Elements and Practice Standards for Health Impact Assessment (HIA), Version 2. North American HIA Practice Standards Working Group, Oakland, CA. November 2010 [online]. Available: http://www.sfphes.org/HIA_Tools/HIA_Pract ice_Standards.pdf [accessed May 23, 2011]. CDC (Centers for Disease Control and Prevention). 2011. Healthy Community Design Initiative: Recent Accomplishments. Centers for Disease Control and Prevention [online]. Available: http://www.cdc.gov/healthyplaces/accomplishments.htm [ac- cessed July 25, 2011]. Corburn, J. 2009. Toward the Healthy City: People, Places and the Politics of Urban Planning. Cambridge: The MIT Press. DHHS (U.S. Department of Health and Human Services). 2010. Health People 2020 Framework. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services [online]. Available: http://www.healthypeople.gov/ 2020/consortium/HP2020Framework.pdf [accessed Feb. 2, 2011]. Harris-Roxas, B. 2009. Conceptual Framework for Evaluating the Impact and Effective- ness of Health Impact Assessment. Centre for Health Equity Training, Research and Evaluation (CHETRE), The University of New South Wales, Sydney [online]. Available: http://www.hiaconnect.edu.au/evaluating_hia.htm [accessed May 25, 2011]. Health Impact Project. 2010. Alaska Department of Health and Social Services Seeks to Hire a Medical Epidemiologist for HIA Program. Health Impact Project In the News: January 12, 2010 [online]. Available: http://www.healthimpactproject.org/ news/in/alaska-department-of-health-and-social-services-seeks-to-hire-a-medical-e pidemiologist-for-hia-program [accessed July 25, 2011]. Keeney, R.L. and H. Raiffa. 1976. Decisions with Multiple Objectives: Preferences and Value Tradeoffs. Hoboken, NJ: John Wiley and Sons. Merkhofer, M.W., R. Conway, and R.G. Anderson. 1997. Multiattribute utility analysis as a framework for public participation in siting a hazardous waste management facility. Environ. Manage. 21(6):831-839. National Prevention, Health Promotion and Public Health Council. 2010. Status Report. July 1, 2010 [online]. Available: http://www.hhs.gov/news/reports/nationapreven tion2010report.pdf [accessed Feb. 2, 2011]. OPM (U.S. Office of Personnel Management). 2011. About the Senior Executive Service. U.S. Office of Personnel Management, Washington, DC [online]. Available: http://www.opm.gov/ses/about_ses/index.asp [accessed Feb. 3, 2011]. Rossi, P.H., H. Freeman, and M.W. Lipsey. 1999. Evaluation, Sixth edition. Thousand Oaks, CA: Sage Publications. Trochim, W. 2000. The Research Methods Knowledge Base, 2nd Edition. Cincinnati, OH: Atomic Dog Publishing. Tulalip Tribes. 2000. A Comprehensive Guide for American Indian and Alaska Native Communities. The Tulalip Tribes of Washington Present: Participating in the Na- tional Environmental Policy Act and Developing a Tribal Environmental Policy Act. October 2000 [online]. Available: http://knowledge.fhwa.dot.gov/ReNEPA/ ReNepa.nsf/All+Documents/C3A140A5BC48BC8D852570240073CFA3/$FILE/ TEPA.pdf [accessed July 25, 2011]. Wernham, A. 2009. Building a statewide health impact assessment program: A case study from Alaska. Northwest Public Health 26(1):16-17.