3

Elements of a Health Impact Assessment

Chapter 2 established the rationale for examining the potential effects of decisions on health and health disparities and highlighted health impact assessment (HIA) as a potential tool for assessing the health implications of various decisions. This chapter describes the types, structure, and content of HIAs and summarizes the HIA process, methodologic approaches, and variations in practice. It is informed by a review of U.S. and international HIA literature and guidelines (see Appendixes A and E) and by the experience of committee members and others who provided input during the committee process. On the basis of its review, the committee synthesized the information from guidance, practice, and literature to propose criteria that define an HIA and draw several conclusions regarding HIA practice. As discussed in this chapter, HIAs have been used for a wide variety of applications and at all levels of government (local, state, tribal, and federal) and have been conducted with varied resources over different schedules. The committee does not intend that the definition and criteria proposed in this chapter be considered rigid requirements but rather that they reflect an ideal of practice, deviation from which may occur but should be based on clear and well-articulated needs and rationale.

Before discussing the various elements of HIA, it is important to understand the context in which HIA is undertaken in the United States. As described in Appendix A, there are few laws in the United States that specifically require HIA, although many—such as the National Environmental Policy Act (NEPA)—require a consideration of health that can be accomplished through HIA. Most HIAs in the United States are therefore undertaken outside the formal decision-making process by organizations (such as nonprofit community-based groups), universities, or health departments that do not have decision-making authority over the proposals being addressed. Although less common to date, HIAs are also sometimes conducted by a decision-making agency, such as a metropolitan planning organization or a federal agency complying with NEPA. The decision to initiate an HIA is often made ad hoc when public-health advocates recognize that the proposal may have important health implications that



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3 Elements of a Health Impact Assessment Chapter 2 established the rationale for examining the potential effects of decisions on health and health disparities and highlighted health impact assess- ment (HIA) as a potential tool for assessing the health implications of various decisions. This chapter describes the types, structure, and content of HIAs and summarizes the HIA process, methodologic approaches, and variations in prac- tice. It is informed by a review of U.S. and international HIA literature and guidelines (see Appendixes A and E) and by the experience of committee mem- bers and others who provided input during the committee process. On the basis of its review, the committee synthesized the information from guidance, prac- tice, and literature to propose criteria that define an HIA and draw several con- clusions regarding HIA practice. As discussed in this chapter, HIAs have been used for a wide variety of applications and at all levels of government (local, state, tribal, and federal) and have been conducted with varied resources over different schedules. The committee does not intend that the definition and crite- ria proposed in this chapter be considered rigid requirements but rather that they reflect an ideal of practice, deviation from which may occur but should be based on clear and well-articulated needs and rationale. Before discussing the various elements of HIA, it is important to under- stand the context in which HIA is undertaken in the United States. As described in Appendix A, there are few laws in the United States that specifically require HIA, although many—such as the National Environmental Policy Act (NEPA)—require a consideration of health that can be accomplished through HIA. Most HIAs in the United States are therefore undertaken outside the for- mal decision-making process by organizations (such as nonprofit community- based groups), universities, or health departments that do not have decision- making authority over the proposals being addressed. Although less common to date, HIAs are also sometimes conducted by a decision-making agency, such as a metropolitan planning organization or a federal agency complying with NEPA. The decision to initiate an HIA is often made ad hoc when public-health advo- cates recognize that the proposal may have important health implications that 43

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44 Improving Health in the U.S.: The Role of Health Impact Assessment would not otherwise be recognized or addressed. There are often not clear lines of authority between the team conducting the HIA and the decision-maker. The health effects that are included, the data sources and methods that are used, and the recommendations that are made are therefore determined by the HIA practi- tioners rather than according to a legal or regulatory standard (Wernham 2011). Thus, the assessment phase is separated from the management phase, as recom- mended elsewhere (NRC 1983). The fact, however, that the team conducting the HIA is aware of the decision context allows the assessment to be decision- relevant. CATEGORIES OF HEALTH IMPACT ASSESSMENT Scholars point to a remarkable consistency in the basic elements that are generally included in descriptions of HIA (Mindell et al. 2008). In practice, however, there is some inconsistency in how HIAs are conducted—for example, how stakeholders are engaged and how data are collected and analyzed—and in the structure and content of the final work products of an HIA. The diversity of practice owes partly to the fact that HIAs are undertaken for a wide array of pol- icy-making that spans many sectors, levels of government, types of proposal (policies, plans, programs, and projects), and degrees of complexity. The vari- ability in the practice has evolved in the absence of widely accepted practice standards or formal regulatory or procedural requirements for HIA outside NEPA and related state laws (see Appendix A). However, it appears to be in- creasingly accepted that HIA is carried out to inform the decision rather than to evaluate the impacts after the decision is made, and there is general agreement on the procedural steps of HIA (Harris-Roxas and Harris 2011). HIA practice is often defined in terms of several categories. According to effort, complexity, and duration, HIAs are often described as rapid, intermedi- ate, or comprehensive. Rapid HIAs may be completed in a short time (weeks to months), are often focused on smaller and less complex proposals, and generally involve primarily literature review and descriptive or qualitative analysis. The phrase desktop HIA has also been used to refer to a rapid HIA that entails little or no public engagement. Another variation, rapid-appraisal HIA, has been de- scribed and in some texts includes explicit public engagement through an initial half-day workshop for stakeholders (Parry and Stevens 2001; Mindell et al. 2003; ICMM 2010). Intermediate HIAs require more time and resources and involve more complex pathways, more stakeholder engagement, and a more detailed analysis but include little collection of new data. Comprehensive HIAs are most commonly differentiated from rapid and intermediate HIAs by the scope of potential impacts and the need for collection of new primary data. They can take longer than a year to complete. HIAs are also differentiated according to whether they are integrated into an environmental impact assessment or done independently. Another categoriza- tion is based on the breadth of the HIA and distinguishes HIAs that have a tight

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45 Elements of a Health Impact Assessment focus—such as ones that use a narrow definition of health and emphasize quan- tification—from HIAs that have a broader, holistic focus shaped by the social determinants of health (Kemm 2001). Others have proposed categorizing HIAs as participatory (emphasizing shared governance, public participation, and a focus on socioeconomic and environmental determinants), quantitative or ana- lytic (concentrating on the methods and rigor of the analysis), or procedural (drawing on elements of the other two approaches but emphasizing the proce- dural steps required and often undertaken within a specified administrative or regulatory context) (Cole and Fielding 2007). In practice, the categories are rarely used consistently, and a single HIA often encompasses a blend of various approaches to stakeholder engagement and participation, analytic methods, and interactions with the formal decision- making process. For example, desktop HIAs may consider indirect stakeholder input through review of public comments submitted outside the HIA process, comprehensive HIAs may have relatively little stakeholder engagement, and rapid-appraisal HIAs of smaller-scale proposals may involve collection of some new data to inform the analysis. The various categories of HIAs, although useful for describing distinct themes in the field, do not necessarily represent consis- tently distinct strains of practice. Instead, it appears that the specific methods and approaches used in a single HIA often evolve within the basic framework described above and develop as a pragmatic response to context. Influences on practice include the timeline, resources and skills available to the HIA team, the factors being considered and the data available for analysis, and the legal and regulatory context of the decision-making process. That description is consistent with the earlier characterizations of HIA as a combination of procedures, meth- ods, and tools (WHO 1999; Quigley et al. 2006). The committee notes that the diversity of approaches and decision con- texts imposes challenges for determining the resources required for conducting an HIA. For example, although rapid HIAs are small-scale, low-cost investiga- tions, comprehensive HIAs that require new primary data collection can take longer than a year to complete and require substantially more resources. Infor- mation on costs of HIAs would be valuable in determining whether an HIA can be undertaken with the resources available and could inform the screening proc- ess as described below. However, the committee notes that no published studies in the United States have attempted to quantify the costs of undertaking an HIA across a variety of settings. Such information would be useful for informing future implementation. DEFINITION OF HEALTH IMPACT ASSESSMENT The committee proposes on the basis of its review the following adapta- tion of the current working definition of the International Association of Impact Assessment (Quigley et al. 2006) as a technical definition of HIA:

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46 Improving Health in the U.S.: The Role of Health Impact Assessment HIA is 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 the effects within the population. HIA provides recommendations on monitoring and managing those effects. That definition reflects the committee’s finding that the involvement of stakeholders—although the approaches used vary from little or no involvement to robust engagement and participation at every step—has consistently been described as a core element of HIA practice and should be considered essential to it. Although rapid or desktop HIAs may not involve stakeholders or consider their input, this often (although not uniformly) reflects a pragmatic response to limitations, such as the timeframe for the decision or resources available to the HIA team, rather than an optimal practice. The definition also notes that recom- mendations should incorporate monitoring, which is essential for effective con- tinuing management as a decision is implemented. WHO CONDUCTS HEALTH IMPACT ASSESSMENTS? HIAs can be conducted by a variety of agencies, organizations, or indi- viduals. A decision-making body—such as a department of planning or trans- portation—can conduct an HIA to inform its own decision. It is also common for local, state, or tribal health departments to undertake an HIA to inform an- other agency’s decision-making. University researchers have conducted HIAs, and community-based organizations have conducted HIAs with technical assis- tance from public-health experts to inform officials who are deliberating on a legislative or administrative proposal. HIAs are also done by private consultants who are hired by a project proponent or decision-maker or by private-industry stakeholders. Because the assessment of health effects depends on an in-depth under- standing of changes that may affect health—such as changes in traffic flow, roadway design, air quality, or community revenue sources—HIAs are inher- ently multidisciplinary; public-health experts may lead the effort but must draw on resources and expertise from other disciplines. Thus, HIA teams may include not only health experts but professionals in other related disciplines, such as air or water quality or traffic modeling. As discussed in greater depth in the section on scoping, it is common to convene advisory or steering committees, which can include both technical and policy experts and representatives from stakeholder groups that have an interest in the decision outcome. The training and credentials of HIA practitioners are variable, and there is no universally accepted standard for a level of training necessary to lead an HIA. In the United States, HIAs have commonly been undertaken by people who have an MPH or equivalent degree and have attended a brief (2- to 5-day) training

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47 Elements of a Health Impact Assessment session. In this report, HIA practitioner refers to the person (or people) involved in conducting an HIA. PROCESS FOR HEALTH IMPACT ASSESSMENT The tasks or elements that are described as part of an HIA are fairly con- sistent in the peer-reviewed literature and guides reviewed by the committee. The grouping of the elements in discrete stages or steps of an HIA is less consis- tent; some guides list as few as five steps, and others describe as many as nine (Quigley et al. 2006; Bhatia 2010; ICMM 2010). The committee selected a six- step framework as a clear way to organize and describe the critical elements of an HIA. The steps can be described as follows: (1) Screening determines whether a proposal is likely to have health ef- fects and whether the HIA will provide information useful to the stakeholders and decision-makers. (2) Scoping establishes the scope of health effects that will be included in the HIA, the populations affected, the HIA team, sources of data, methods to be used, and alternatives to be considered. (3) Assessment involves a two-step process that first describes the baseline health status of the affected population and then assesses potential impacts. (4) Recommendations suggest design alternatives that could be imple- mented to improve health or actions that could be taken to manage the health effects, if any, that are identified. (5) Reporting documents and presents the findings and recommendations to stakeholders and decision-makers. (6) Monitoring and evaluation are variably grouped and described. Moni- toring can include monitoring of the adoption and implementation of HIA rec- ommendations or monitoring of changes in health or health determinants. Evaluation can address the process, impact, or outcomes of an HIA. The following sections provide an overview of the process of conducting an HIA. For each step, the committee describes the basic purpose, objectives, and practice elements; summarizes the main outputs; and presents conclusions regarding pertinent issues raised. Major issues and challenges for HIA develop- ment and practice are considered in Chapter 4. The reader will notice that some of the committee’s descriptions and characterizations overlap with those of other guides; the similarities highlight the consistencies in the field. Screening Screening establishes the need for and value of conducting an HIA. Be- cause HIAs can address decisions that range from small, localized programs or projects to national policies, screening ensures that HIA is used judiciously and

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48 Improving Health in the U.S.: The Role of Health Impact Assessment when it is most likely to be valuable. Given the volume and breadth of decisions at the local, state, tribal, and federal levels that can potentially affect health in some way, one of the challenges for HIA practice is to determine which propos- als to screen. In the absence of mandates or formal procedures, topics for screen- ing are often chosen on the basis of the interests of a group wishing to use HIA as opposed to a structured, strategic selection process.1 More structured approaches have also been used. In some cases, collabora- tion between a health department and other agencies has resulted in the identifi- cation of appropriate proposals for screening. In other cases, all proposals in selected agencies or sectors have been screened by local governments (SFCC 1998; Lester et al. 1999; Roscam Abbing 2004). For example, the San Francisco Department of Public Health routinely screens major projects and plans to en- sure adequate analysis and mitigation of environmental health impacts. In Alaska, all large natural-resources development proposals are now screened for the need for HIA in a new program begun by the state health department. Screening involves making an initial rapid judgment of whether an HIA is likely to be feasible and valuable. The central considerations include whether the proposal in question might cause important changes in health, whether health is already a major focus of the decision-making process, whether the legal frame- work provides an opportunity for health to be factored into the decision, and whether data, staff, resources, and time are adequate to complete a successful HIA in time to provide useful input into the decision-making process (that is, can information be provided within the timeline for the decision). Another con- sideration is whether the proposal is likely to place a disproportionate burden of risk on vulnerable populations in the affected community; screening proposals on this basis helps to ensure that the HIA addresses the risk factors that underlie observed disparities in the rates of illness among various populations. A variety of screening tools and algorithms are commonly used (Cole et al. 2005; PHAC 2005; Harris et al. 2007; Bhatia 2010). Some use pertinent screening questions, such as the ones noted, and apply a sequential yes-no query to each (Cole et al. 2005). Some provide a checklist of factors to consider and often focus on health determinants that might be affected by the proposal. Some decisions to conduct HIA may depend on a specific statutory requirement or mandated procedure. For example, in the context of NEPA, the lead federal agency must consider “the degree to which the proposed action affects public health or safety” to determine whether a proposal is likely to have “significant” effects and therefore require an environmental impact statement (40 CFR 1 Under NEPA, a federal agency must determine whether a federal environmental de- cision is likely to have significant effects, and if so, the level of analysis required (40 C.F.R. Section 1508.27). Because the degree to which the proposed action affects public health or safety is one factor considered, this process could be considered the equivalent of the screening step of an HIA. In practice, however, explicit consideration of health has been rare (Steinemann 2000; Cole et al. 2004; Bhatia and Wernham 2008).

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49 Elements of a Health Impact Assessment 1508.27). Ultimately, regardless of the specific tool used, the decision to con- duct HIA in most cases relies on the practitioner’s or decision-maker’s judgment regarding the likelihood of impacts, the time and resources available, and the likelihood that the information produced by the HIA will be a valuable aid to decision-making. Because any actions taken on the basis of HIA recommendations need to be implemented within a specific legal and policy context, screening needs to establish a clear description of the decision-making process and context. It should also identify the points at which there is an opportunity for information from the HIA to influence decisions. Mapping out the timeline for the decision- making process can be helpful, and for large and complex programs and pro- jects, identifying the agencies involved and their jurisdictions is important. Such programs and projects involve many agencies and entities that have authority over some aspect of planning and implementation. For example, the planning of the Atlanta Beltline, as described later in this chapter, involved the regional planning commission, local legislative bodies, state and federal environmental regulators, and private developers. It is also useful to assess the political context of the proposal to be assessed and consider, for example, the major political drivers of the proposal, the arguments made by political supporters and those opposed to the proposal, and any economic or technical constraints that limit the alternatives that can be considered. Public concerns are a common trigger for a decision to screen, and the de- gree of concern or controversy about a proposal may be one of the factors weighed in the decision to undertake an HIA. For example, the Massachusetts Department of Public Health responded to citizen concerns regarding a proposed power plant by considering whether HIA would be an appropriate way to ad- dress them (McAuliffe 2009). The committee notes that public involvement is important in screening; information provided by stakeholders may provide in- sight into the potential effects of a proposal under consideration that contribute to the final determination of whether an HIA is warranted and likely to be useful. Screening is often not well documented, and it is often not clear from an HIA report what factors were considered in making the decision to do an HIA. Moreover, because there is generally no written record of HIAs that stop at screening, still less is known about the reasons that have led to decisions not to proceed with HIA. Box 3-1 provides an example of how screening on a proposal for a residential housing program was conducted. It includes the information that was taken into account and the final output of the screening process, which was a decision on whether to commission and proceed with an HIA. Outputs of Screening Screening should result in a simple statement that includes the following:

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50 Improving Health in the U.S.: The Role of Health Impact Assessment  A description of the proposed policy, program, plan, or project that will be the focus of the HIA, including the timeline for the decision and intervention points at which HIA information will be used.  A statement of why the proposal was selected for screening.  A preliminary opinion regarding the potential importance of the pro- posal for health.  The expected resource requirements of the HIA and the ability of the HIA team to meet them.  A description of the political and policy context of the decision and an analysis of the opportunities to influence decision-making or otherwise make health-oriented changes. BOX 3-1 Screening: HIA of a Residential Housing Program The Crossings is a proposed housing development in Los Angeles that will provide 450 units in a newly rezoned residential area that needs affordable housing. A local community-based organization worked with a housing developer on the proposal and site plan. They expressed “interest in developing The Crossings in a way that will address local community needs for affordable housing and for other community assets that are safe, healthy, and supportive” (p. Intro-1). In 2009, an HIA was conducted to ensure that health impacts were considered in the design and development of The Crossings and in the broader policies that affected redevelopment in the area. The HIA report describes the screening process but does not provide great detail about it. The HIA notes that the area within which The Crossings is proposed to be built has the following characteristics:  A growing population of families that have children.  Dilapidated housing conditions.  Prevalence of overcrowding.  A lack of access to needed goods and services. The HIA notes that the residential area is inhabited by a vulnerable popula- tion, that the built environment is of low quality, that the development will poten- tially have important health implications for residents in the local and surrounding communities, and that there is a strong commitment shown by the community and the developer to integrate health considerations into the planning process. It was concluded during the screening phase that an HIA would add value to project out- comes. An HIA would identify health assets, health liabilities, and health-promoting mitigations related to the proposed development project. The facts that resources were available and that timelines were appropriate were also relevant to the decision to conduct an HIA. Source: Adapted from Heller et al. 2009.

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51 Elements of a Health Impact Assessment  A screening recommendation—for example, no further action required; no HIA, but health advice and input to be offered in an alternative way; or pro- ceed with HIA. Committee Conclusions Regarding Screening Screening is essential for high-quality HIA. Poorly selected proposals may result in HIAs that add little new information and consume considerable time and resources of the HIA team to complete and of recipients to review. HIA should not be assumed to be the best approach to every health-policy question but should instead be seen as part of a spectrum of public-health and policy- oriented approaches, some of which will be more appropriate than others, de- pending on the specific application. Although the reasons and objectives for HIA are often not articulated at the outset of screening, establishing well-defined objectives will focus the screening process on determining whether HIA is likely to be an effective approach for achieving them. Any approach to determining which proposals will be screened should demonstrate a consistent rationale; should document the rationale in the HIA report; and should take account of public input. Screening should also consider whether a proposal conforms with applicable standards, policies, or laws rele- vant to health inasmuch as there is a wide variety of them that bear directly or indirectly on health. For example, U.S. priorities for improving public health are expressed in the Healthy People 2020 Program of the U.S. Department of Health and Human Services (DHHS 2010). Some laws—such as NEPA, state environ- mental-policy acts, and various local zoning ordinances—may establish protec- tion of health as a requirement or priority. The programs and policies, however, may not provide any guidance on how health should be considered (see, for ex- ample, Pub. L 91-190, 42 U.S.C. 4321-4347 [1970]; EC 2001). Furthermore, some policies may focus on determinants of health—for example, economic development, transportation, or housing—rather than explicitly mentioning health. In each case, it is important to determine how the standards, policies, programs, and laws bear on how health is factored into a proposal. The committee concludes that the following are the most important factors to consider in determining whether to do an HIA:  The potential for substantial adverse or beneficial health effects and the potential to make changes in the proposal that could result in an improved health risk-benefit profile.  The potential for HIA-based information to alter a decision or help a decision-maker discriminate among decision options.  The potential for irreversible or catastrophic effects (including effects of low likelihood).  The potential for health effects to place a disproportionate burden on or substantially benefit vulnerable populations.

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52 Improving Health in the U.S.: The Role of Health Impact Assessment  Public concern or controversy regarding health effects of the proposed decision.  The opportunity to bring health information into a decision-making process that may otherwise not include this information.  The potential for the HIA to be completed in the time allotted and with the resources available. Ultimately, the HIA report should provide a rational and consistent expla- nation of how proposals are selected for screening. That explanation is particu- larly important when public funds are to be used for an HIA because the public may want to understand the basis for allocating sparse public resources. Given the breadth of decisions that are likely to warrant consideration, the approach taken will vary on the basis of who is initiating the HIA, the capacity and au- thority of the agency or entity undertaking it, and the objectives for contemplat- ing an HIA. Scoping Scoping establishes the boundaries of the HIA and identifies the health ef- fects to be evaluated, the populations affected, the HIA team, sources of data, methods to be used, and any alternatives to be assessed. Well-executed scoping saves time, work, and resources in the later stages of the HIA (Harris et al. 2007). The choice of what to evaluate will reflect the specific social, political, and policy context of the decision; the needs, interests, and questions of stake- holders and decision-makers; and the health status of the affected population. Potential Health Effects Determining the potential health effects to include in the HIA and propos- ing hypothetical causal pathways are the central tasks of scoping. Scoping con- siders input from many sources, including preliminary literature searches, public input, and professional or expert opinion in fields relevant to the proposal. Be- cause it will often not be practical or possible to address all direct and indirect health effects that appear theoretically possible, it is important to select issues carefully.2 Setting priorities considers pathways that appear most important from a public-health perspective and considers issues that have been raised promi- nently by stakeholders. Questions that are important from a public-health per- spective might include the severity of the health effect, the size and likelihood of the effect, and the potential of the effect to exacerbate health disparities. In prac- tice, some HIAs have focused on a specific health end point, such as obesity, or 2 Identifying high-priority issues has been addressed in numerous contexts outside HIA, including human-health and ecologic risk assessment (see, for example, EPA 1989, 1992; NRC 1996, 2009).

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53 Elements of a Health Impact Assessment health concerns related to a single impact of the proposal, such as the health effects of air pollutants, most likely without using a systematic approach that considered and eliminated other impacts (see, for example, Kuo et al. 2009; Cas- tro et al. 2010). Iteration during scoping and between scoping and assessment often results in additional changes in the final list of issues included in the HIA. During scop- ing, the HIA team may produce an initial list, refine it on the basis of stake- holder input, and then make it final through research and analysis in the assess- ment phase. In other cases, the initial scope is generated by stakeholders and then refined through research and input from advisory or steering committees. Several approaches for scoping are available. One approach uses a logic framework that maps out the causal pathways by which health effects might occur (see Figure 3-1). In general, this approach describes effects directly re- lated to the proposal (such as changes in air emissions) and traces them to health determinants (such as air quality) and finally to health outcomes (such as asthma). The first step in the framework is typically a determinant of health, such as air pollution, traffic, employment, or noise. Logic frameworks can be used as part of stakeholder engagement to develop a shared understanding of how a project will develop and the outcomes that can be expected (Cave and Curtis 2001a,b; Cave et al. 2001). Another method of scoping is to develop a table that facilitates a systematic and rapid appraisal of all the potential ways in which a proposal might affect health (see Table 3-1). In this approach, the as- pects of a proposal that may affect health are listed and considered in major categories of health and illness. Box 3-2 provides an example of scoping for the HIA of a proposed devel- opment in Atlanta. The health issues were identified by determining the popula- tions that would be affected and then considering how they would be affected. A variety of information was used to inform the process Establishing Who Might Be Affected Scoping identifies those likely to be affected by the proposed policy, pro- ject, program, or plan. The process may include identifying communities and geographic regions; demographic, economic, racial, and ethnic groups; and vul- nerable populations, such as children, elderly people, disabled people, low- income people, racial and ethnic minorities, and people who have pre-existing health conditions. The process of describing pre-existing health issues, health disparities, and influences on health may also begin during scoping, although the full characterization of baseline health status generally takes place during as- sessment.

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79 Elements of a Health Impact Assessment ess evaluation can range from a simple self-assessment that is undertaken at the end of an HIA and focuses on a few variables that are relatively simple to de- scribe, track, or measure—such as the methods used, degree of certainty of pre- dictions, and approach to stakeholder engagement—to a more comprehensive case study that seeks to evaluate the HIA process holistically. Observing and documenting the HIA process—such as methods of engaging stakeholders and interacting with decision-makers and approaches to addressing analytic chal- lenges—and interviewing participants and stakeholders are the main methods of process evaluation. Impact Evaluation Impact evaluation attempts to judge whether the HIA influenced the deci- sion-making process, that is, whether and to what degree the recommendations were adopted and implemented and how the HIA influenced the decision- making process. It can also assess whether the HIA had other important effects, such as building new collaborations among agencies, ensuring that stakeholder perspectives were considered, and increasing awareness of previously unrecog- nized health considerations. In some cases, the impact of the HIA on a decision is clear-cut. For example, in the Alaskan oil and gas HIA mentioned in Box 3-3, the HIA team drafted recommendations in collaboration with the decision- maker, the Bureau of Land Management, which formally adopted the recom- mendations as mitigation measures. In other cases, it may not be possible to attribute a particular decision to the influence of an HIA (Wismar et al. 2007). For example, in Oregon, an inde- pendent health-oriented nonprofit organization conducted an HIA of a series of proposals to reduce vehicle miles traveled in a bill intended to reduce green- house-gas emissions (UPH 2009). The enacted legislation is consistent with some of the recommendations of the HIA, but there were no data to evaluate whether those drafting the legislation were influenced by the recommendations; there were no interviews with legislators over the course of the legislative process (Human Impact Partners 2010). Observations that might indicate some influence of the HIA include discussion about HIA by legislators debating a proposal. In that case, a robust evaluation method, such as interviews conducted with decision-makers before and after the HIA, could provide the data needed to gauge the effect on decisions. Impact evaluation can also help to determine an HIA’s effectiveness rela- tive to the objectives set out during screening and scoping. In most cases, influ- encing decisions to protect or promote health is a central objective but by no means the sole outcome of value. As discussed above, additional benefits may include, for example (Wismar et al. 2007; Harris-Roxas and Harris 2011),  Alerting decision-makers to the more general need to focus on health in future decisions.

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80 Improving Health in the U.S.: The Role of Health Impact Assessment  Developing new cross-disciplinary and interagency collaborations.  Identifying data gaps and questions for future research.  Establishing a foundation for appropriate monitoring.  Ensuring that the public has accurate and complete information on ad- verse and beneficial effects.  Developing new forecasting methods.  Improving relationships and collaboration between stakeholders. Outcome Evaluation Whereas HIA aims to predict the effects of a decision before it occurs, outcome evaluation assesses whether the implementation of a decision has ac- tual effects on health or health determinants (Parry and Kemm 2005). Outcome evaluation requires a suitable research design, ideally an appropriate comparison group, and data from the monitoring of health outcomes or of changes in health determinants as described above. The committee notes that outcome evaluation considers the effects of the whole decision, including changes made as a result of HIA recommendations. Thus, it is generally not possible to attribute out- comes specifically to HIA recommendations because they are implemented with the decision. Evaluation of whether a decision has changed specific health outcomes may often be difficult or impossible because of the complex and multifactorial causal pathways involved in many health outcomes, the length of time from im- plementation of a decision to observable changes in health indicators, and the lack of suitable comparison groups (Quigley and Taylor 2004; Parry and Kemm 2005). However, in some cases, the relationships between the implemented de- cision and health determinants may be more direct and measurable. Because of the timeframe of proposal implementation and effects on health, outcome evaluation often requires a long-term research commitment. The committee notes that outcome evaluation of policy experiments is a field independent of HIA, and many large-scale social interventions—such as Head Start and Moving to Opportunity—have been subject to outcome evaluation that has included con- sideration of health or health determinants (Leventhal and Brooks-Gunn 2003; Schweinhart et al. 2005; Frank et al. 2006; Jagannathan et al. 2010). There are, however, no current examples of HIAs in the United States that include outcome evaluation as described here. Outputs of Monitoring and Evaluation Monitoring should provide information that allows one to conduct the evaluations noted above. An evaluation plan should have been developed early in the HIA process to guide selection of the appropriate methods for conducting

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81 Elements of a Health Impact Assessment evaluations. An evaluation report should be produced at the conclusion of the HIA that includes the following:  An evaluation of the HIA process against the HIA plan and applicable standards and consideration of whether the process used was appropriate given the decision-making context, needs, objectives, and resources available (a proc- ess evaluation).  A description of the HIA’s impact on decision-making (to the extent that salient decisions have occurred by that time) as measured by an accounting of HIA recommendations that were adopted and an evaluation of available evi- dence that suggests whether and how the HIA played a role in decisions or con- tributed to changes in decision-makers’ knowledge, attitudes, or positions.  A discussion of whether the HIA achieved its initial objectives.  Acknowledgement of plans for future outcome evaluation or discussion of limitations that prevent such an evaluation. Committee Conclusions Regarding Monitoring and Evaluation Few HIA evaluation data have been published in the United States and relatively few elsewhere. The committee notes that some guides consider evaluation not as a step of HIA but rather as an independent practice that sup- ports the development of the field (see Appendix E). Although completed HIA reports are readily available, peer-reviewed or gray literature that discusses the impacts of specific HIAs is still rare. Evaluation is important for the quality of individual HIAs and for the success of the HIA field as a whole. It is not reason- able to expect decision-makers to adopt HIA widely in the absence of evidence of its effectiveness and value. Consequently, the committee concludes that the lack of attention to evaluation is a barrier that will need to be overcome if HIA practice is to be advanced in the United States. Evaluation can be thought of in two useful and complementary ways: self- evaluation of the HIA process and impacts and independent external evaluation. Self-evaluation performed by the HIA team—for example, against a set of proc- ess objectives or practice criteria—serves quality-assurance aims and can pro- duce insights that will improve the field. Self-evaluation should be considered a valuable step of the HIA process. It may lack the objectivity and rigor of an ex- ternal evaluation conducted by an experienced evaluator, but it is important be- cause it contributes to a database that informs other efforts in the field and pro- vides basic information about the applications of HIA, the methods and strategies used by HIA practitioners, and the success of and challenges to its use. In contrast, independent evaluation can yield unbiased insights about an HIA from the perspectives of stakeholders and decision-makers, can contribute to a more robust external peer review, and can provide rich information regarding the strengths, weaknesses, and most effective methods and approaches in the field.

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82 Improving Health in the U.S.: The Role of Health Impact Assessment The characteristics and approaches of evaluation should be chosen to fit the time, resources, and data available to the HIA team. Building evaluation into the plans for an HIA early in the process may support and reinforce a more de- liberate and careful approach to designing and implementing the HIA itself. Al- though HIA may not always include or provide resources for independent evaluation, more in-depth, independent evaluation will generate more robust conclusions about HIA’s effectiveness and best practices in the field and should be given high priority. The committee considers self-evaluation and independent evaluation to be essential for moving the field ahead. Outcome evaluation will continue to be challenging, but it can generate useful information in well-selected cases. Monitoring outcomes can in some cases help to test the validity of predictions and inform future analytic methods. Although there are many potential benefits of undertaking an HIA, one common objective is to inform decisions to promote changes that support improvements in health determinants or health outcomes. For that reason, it is important for the field to define the circumstances under which outcome evaluation may be prac- ticable. Outcome evaluation should be undertaken when available resources and data will allow reasonable judgments regarding the association between the im- plementation of decisions and observed changes in health outcomes or health determinants. SUMMARY: WHAT CRITERIA DEFINE A HEALTH IMPACT ASSESSMENT? This chapter has described HIA categories, defined HIA, discussed current HIA practice, noted variations in practice, and provided the committee’s conclu- sions regarding each step of the HIA process. The discussion recognizes that the practice of HIA varies because it is adapted for use in different decision-making contexts. The variability also reflects a lack of clear criteria that define HIA as a distinct field. On the basis of its review of available literature, HIA guides, and practice standards, the committee has synthesized the key criteria that define HIA and that set it apart from related approaches to public-health practice and policy. Not all HIAs will meet all proposed criteria, but the criteria are intended to describe typical practice. Although deviation from the criteria may occur, a valid and clearly articulated rationale for such deviation should be described when the HIA is reported.  Health impact assessment is conducted to inform a decision-making process and is intended to be concluded and communicated in advance of the decision that is being assessed.  It develops the scope of health effects for analysis through systematic consideration of all factors associated with the proposed action that have a po- tential to influence health, and it narrows the scope to effects that are judged most important for health.

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