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 itself. Little education and training in HIA are available in the United States. The current practice of HIA is inconsistent and nonstandardized. The quality of analytic methods used by HIA practitioners varies widely and there is not enough synthesized evidence on health determinants that can be used by HIA practitioners. In addition, the effectiveness of HIA and its effects on public-health outcomes 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.
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 international 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 government 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.
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-