1. Health Impact Assessment 201
September 23-24, 2014
Sandra Whitehead, PhD
Florida Department of Health
Healthiest Weight Florida

2. First Things First
• Welcoming Remarks
• Housekeeping
• Introductions
• Name
• Organization
• Role
• Something memorable about you
• What do you expect to get from this training?

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. Phases of HIA

5. Road Map to Better Policy

6. Why use Health as a Framework?
• Health is a shared value
• Health is an indicator of
quality of life
• People do not intuitively
connect outcomes to non
health decisions
• Good health is not evenly
distributed throughout the
population

7. Health in All Policies
• Aims to integrate health considerations in
decision making across different sectors that
influence health is a tool that can be used to assess a single proposed
decision and its potential it
• Not intended to put health at the center of all
policies
• CDC defines "policy" as a law, regulation,
procedure, administrative action, incentive, or
voluntary practice of governments and other
institutions that uses multiple strategies to systematize and integrate the

8. Approaches to HiAP
1. Developing and Structuring Cross Sector
Relationships
2. Incorporating Health into Decision Making
Processes
3. Enhancing Workforce Capacity
4. Coordinating Funding and Investments
5. Integrating Research, Evaluation and Data
Systems
6. Synchronizing Communications and Messaging
7. Implementing Accountability Structures

10. 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

11. 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
• To 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

12. Values Underlying HIA
• Democracy
• Equity
• Increases awareness
of health issues
• Holistic approach to
health
• Scientific and robust
practice
• Comprehensive
approach to health

13. Addressing Unintended Consequences
1996 Olympic Games, Atlanta
• 24 hour public transportation
• Addition of CNG buses
• Reduction of auto travel and
congestion
• Public service announcements
encouraging train and bus usage
• Decrease acute childhood asthma
events

14. Evolution of HIA in US
1980’s
WHO encourages Health
Promotion/Healthy Public Policy in
1986 Ottawa Charter
2000’s
World Bank requires HIA on all large
projects
First integrated HIA into a federal EIA
in Alaska
Industry increasingly adopts standards
for HIA as good business
1969
National Environmental Policy Act
1990’s
England, Acheson Report recommends
analysis of impacts on health inequities
WHO publishes the Gothenburg
Consensus Paper on HIA
First HIA in US (SFDPH, Living Wage)
2010’s
North American Practice Standards

16. National Policies Encouraging HIA
White House Task Force on
Childhood Obesity, 2010
“Communities should be
encouraged to consider the
impacts of built envi-
ronment policies and
regulations on human
health [and] .. should
consider integrating Health
Impact Assessments into
local decision-making
processes……”

17. National Policies Encouraging HIA
CDC Recommendations for
Improving Health through
Transportation Policy, 2011
“Health impact assessments and
safety audits may be a useful
tool to identify the impact of a
new policy, program or major
transportation project on
community and individual
health.”

18. National Policies Encouraging HIA
National Research
Council, Committee on
Health Impact
Assessment, 2011
“HIA is a particularly
promising approach for
integrating health
implications into
decision-making….”

19. Use of HIA in Current Practice
• Advocacy
• Some HIAs more academic; others used as
advocacy tool for health
• Timeliness and timing
• Specific policies are moving targets, making
timing and scope of the HIA challenging
• Scope of the policy or project
• A rapid HIA with a smaller scope can sometimes
be sufficient

20. Topics of HIAs
• Land Use
• Transportation
• Housing
• Education
• Energy
• Agriculture
• Economic Equity

21. Problem Domains

22. Completed and In Progress HIAs
United States, 1999–2014 (N = 311)
Completed and In Progress HIAs 1999–2014
(N = 311)

23. HIA in the US
• Growing awareness that health problems are not
exclusively caused by disease
• Health and Urban Planning Practice
• International practice of HIA
• HIA in San Francisco and Alaska required

24. HIA Strengths
• Addresses health and social
inequities
• Brings health to the table
• Builds connections across sectors
• Community engagement
• Long term potential to improve
health
• Institutionalization: increasing
recognition in national reports and
policies
• Various depth and breadth

25. Six Phases
There are typically six phases 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)

26. Screening
The purpose of screening is to “assess the value,
feasibility and utility of the HIA in the decision
making process,” (Bhatia, 2011)

27. 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

28. When Should an HIA Not Be Conducted?
Decision makers have
already decided to support
the proposal
There is not a specific
decision to influence
Data about health impacts
are already being
considered
Example:
A report about food
deserts is released and
the neighborhood
association proposes a
farmers market in the
area.

29. Screening
• Poorly selected
proposals may
result in HIAs
that add little
new information
and consume
resources
• HIA may not
always be the
best approach
HIA Screening Worksheet

30. How do you choose a topic?
• The decision is under
consideration, but not made
• The decision important to
stakeholders with whom you
have an on-going relationship or
with whom you hope to work in
the future
• The decision may glaring
increase health or economic
disparities or prevent them

31. Things to Keep in Mind
• HIA is an iterative, dynamic process that
considers available data from varying
perspectives
• The process is not always
linear
• Many activities may occur
simultaneously and/or require repeated efforts

32. Screening Questions
What are the goals of the HIA?
What is 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?

33. Common HIA Goals
• Improve decisions to account for health
• Involve diverse stakeholders and community
members
• Build the capacity of stakeholders to use HIA

34. Sample Research Questions
• Housing: Will the plan provide healthier housing
choices?
• Comprehensive Plan: How will the proposed Plan
impact measures of housing and employment?
• Transportation: What are the impacts of the plan
on the ability to be physically active?
• Access to health care: How will those without
access be affected?
• Food: Will providing incentives for a grocery store
improve health?

35. Define the Problem Set
• The decision under
consideration
• The stakeholders
• Geographical
boundaries of the
impacts
• Possible health
impacts
• Pathways
• Time frames

36. Defining the Problem Set
• Who is making the decision?
• Define the goals of the HIA
• How does the policy, plan or project relate to
health?
• What are the problem domains?
• Do you have enough information?
• What are your assumptions?
• Are there special populations involved?

37. Time and Resources
• How much time is needed relative to the decision
time frame?
• Which skill sets are needed for the team?
• Do you have the right mix of people?
• Are decision makers open to hearing about health
impacts?
• To what extent are community
members engaged already?

38. 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 full time 6 to 12 weeks full time 12 weeks to 6 months full
time
6 to 12 months full time

39. Stakeholders Commonly Include:
• The local community/public, particularly vulnerable groups
• Developers
• Planners
• Local/national governments
• Voluntary agencies, nongovernmental organizations
• Health workers at local, national or international levels
• Employers or representatives of other sectors affected
• The decision-makers
• The network of people and organizations who will carry out
the HIA

40. Who are the Stakeholders?
Example:
A city plans to develop
a blighted
neighborhood. The
redevelopment will
include demolishing 3
blocks of dilapidated
retails shops, an aging
supermarket and 200
low income housing
units.

41. Pathway Diagram
• Organize existing
knowledge
• Communicate information
• Guide analysis
• Identify how the policy will
affect health directly and
indirectly
• Assess correlation versus
causality

42. Health Status is Determined By:
• Genetics: up to 30%
• Clinical Care: ~15%
• Health Behaviors:
~20%
• Environmental
Conditions: ~5%
• Social and Economic
Factors ~30%
Booske, et. al. 2010. County Health Rankings Weighting
Methodology

47. Policy or Project Intermediate
Impacts
Health
Outcomes
Education: Safety
training
Street design: ped
facilities, traffic
calming
Enforcement:
crossing guard,
police
Resources:
walking school
buses

48. Policy or Project Intermediate
Impacts
Health
Outcomes
Education: Safety
training
Street design: ped
facilities, traffic
calming
Enforcement:
crossing guard,
police
Resources:
walking school
buses
Walkability
Safety
Car usage

49. Policy or Project Intermediate
Impacts
Health
Outcomes
Education: Safety
training
Street design: ped
facilities, traffic
calming
Enforcement:
crossing guard,
police
Resources:
walking school
buses
Walkability
Safety
Car usage
Injuries
Asthma
Obesity
Mental Health
Outcomes
More physical
activity

50. Screening Output: Problem Set
• Description of the decision under consideration
• Paragraph describing the decision time line
• Preliminary stakeholder list
• Why the proposal was selected:
• Potential health impacts and inequities
• Expected resources needed to conduct the HIA
• Description of the political context and how you
expect to influence the decision-making
process

51. Case Study: Exercise
• Describe the decision under consideration
in your case study: decision makers and
time frames
• List three goals of the HIA
• Fill out your stakeholder worksheet
• Describe the geographic area of interest
• What are the demographics of your
population affected?
• What are the public health effects?

52. Scoping
Refine the objectives of the HIA
Define stakeholders, roles
and times to engage
Define the limits of the HIA:
Geographic
Demographic
Health outcomes

53. 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

54. Refine the Objectives
• Do you need to adjust your objectives based on
discussion or new information?
• Remember, your objectives will be used to
evaluate your process

55. Stakeholder Engagement Plan
• At what point(s) will stakeholders be engaged?
• Outreach methods
• Input mechanisms: focus groups, community
events, surveys, campaigns
• How will feedback be incorporated into the
process?
• How will the incorporation be communicated?
• How do you keep stakeholders’ attention
throughout the process?

57. Measuring Community Engagement
• Community engagement measures
• Number of stakeholders/decision makers attending an
informational session
• Number of those who attended more than one session
• Number of persons who took an action based on
participation
• Number of persons who contributed information to the
process
• Number of persons who felt their participation made a
difference

58. Boundaries
• Based on your problem set, are there logical
geographical boundaries?
• Are the health effects transferrable outside this
geographic boundary?
• Who is the population of interest?
• Are there special populations within the
population of interest who will be affected
differentially?
• Over what period of time will effects occur?

59. Methodology
• What are your objectives?
• What are the health outcomes of interest?
• How will you assess the health impacts, their
severity and likelihood?
• What data do you need?
• Is the data available at the necessary scale?
• Who will carry out the data collection?
• What is the strength of evidence available?

60. EXERCISE: WHAT METHODS
WOULD YOU USE?

61. Predicting the Outcomes
• Using a systems approach to the issue
under consideration, conduct a literature
review of links between the decision and
public health
• What data is available already?
• Are there models that can be used?
• Define your approach to the Problem Set
and how you will validate the predicted
outcomes

62. Finding the Information
• Gray literature
• Peer reviewed literature
• Key informants or stakeholders who provide local
information that may not be available in the public
domain
• Experts in relevant fields who can identify the
health related outcomes

63. Examples of Models, Tools and Data Sets
All-Ages Lead Model (AALM)
The All Ages Lead Model (AALM) guidance will predict lead
concentration in body tissues and organs for a hypothetical
individual, based on a simulated lifetime of lead exposure
Community-Focused Exposure and Risk Screening Tool (C-FERS
C-FERST is a community mapping, information access,
and assessment tool designed to assess risks and assist in
decision making within communities
ATSDR's Toxicological Profiles contain information for more
than 200 chemicals (
http://www.atsdr.cdc.gov/toxprofiles/index.asp)

64. Strength of Evidence
•To ensure transparency,
include a chart showing:
•Description of literature
review process including
key words
•Chart showing strength
of evidence (qualitative
and quantitative)
•Limitations and
assumptions
•Identification of data
gaps

66. Predicting Impacts
• Predicting impacts with certainty is impossible
• Using best available evidence, the HIA team can
have some measure of confidence
• Use qualitative and quantitative analysis—when
possible use existing data

67. Indicator Health Outcome Likelihood Magnitude or
Distribution
Soil tests positive
for PAH
Skin irritation Likely Workers, children,
gardeners
Predicting Health Outcomes

68. Scoping Outputs
• List of stakeholders, their roles
and how each group will be
engaged
• Pathways diagram
• Time line, data sources,
strength of evidence and task
assignments
• Demographic and geographic
boundaries of the HIA

69. Collaborative Scoping Meeting
• Review what you’ve done so far
• Prioritize research questions
• Identify community resources
• Focus on issues not in evidence
• Invite more partners and stakeholders as needed
• Identify at-risk groups
• Discuss outcomes of interest and prioritize those
to be examined in conjunction with stakeholders

70. Assessment
The Assessment phase is
defined as:
“mobiliz(ing) evidence to
characterize baseline
health conditions,
characterize expected
health effects and evaluate
uncertainty,” (Bhatia, 2011)

71. Tasks
• Provide a profile of baseline health and
environmental conditions
• Race, gender, income, age and place
• Identify vulnerable populations
• Describe factors responsible for changing
vulnerability and how health is affected
• Evaluate the possible health outcomes
• Describe how the health risks associated with
the proposal and generate Solution Sets

72. Building Baseline Data Sets
• Environmental conditions
• Built environment = man-made systems
• Natural environment = natural systems
• Demographic make up of the affected population
• Race
• Ethnicity
• Age
• Income, Socio-Economic Status
• Proximity to the hazard

73. Where’s the Data?
• Other HIAs on a similar topic
• Census data
• Florida CHARTS
• Behavioral Risk Factors Surveillance Survey
• National Health and Nutrition Survey
• Environmental Public Health Tracking Portal
• Travel Behavior Inventory
• Gray literature and published articles

74. National Collaborative Data Sets
• National Collaborative on Childhood Obesity
Research http://tools.nccor.org/measures
• National Neighborhood Indicators Partnerships
www.neighborhoodindicators.org/data-tech/sources
• Urban Institute Online Visualization Resources
http://datavis.urban.org

75. Medical Services Data
Emergency Department
Hospital Discharge
Population-Based Surveys
Behavioral Risk Factor Surveillance System (BRFSS)
Florida Youth Substance Abuse Survey (FYSAS)
Florida Youth Tobacco Survey (FYTS)
Florida Data

76. • Records for all emergency room visits
• Collected & managed by the Florida Agency for
Healthcare Administration (AHCA)
• Data available 2005–present
• Type of data available: principal diagnosis, other
diagnosis fields, payer, race/ethnicity, age,
gender, procedure codes
Emergency Department Data

77. FDOH Data Sets
Florida Charts (County level)
Bureau of Epidemiology
BRFSS, FYTS, PRAMS/WISH
http://www.floridahealth.gov/%5C/reports-and-data/survey-da
County level reports
Department of Children and Families
FYSAS
http://www.myflfamilies.com/service-programs/substance-abu

79. Behavioral Risk Factor Surveillance System
Ongoing population-based telephone survey, following Centers for
Disease Control and Prevention (CDC) survey protocol
Monitors behavioral risk factors, health conditions, and emerging health
issues
Surveys adults 18 years and older
Conducted annually in Florida since 1986
Data reported by calendar year
County data: 2002, 2007, 2010
2013 data coming soon

80. BRFSS Data
Demographics
Age, sex, race, ethnicity, income, educational level, marital
status
Risk behaviors
Smoking, diet, physical activities, overweight, cancer
screening, access to care
General health and health conditions
Health status, diabetes, high blood pressure, high cholesterol,
oral health, asthma, cardiovascular disease, arthritis
Emerging Issues
Hurricane, preparedness, antibiotic resistance

81. Florida Youth Tobacco Substance Survey
Administered annually since 2000
Monitors prevalence of substance abuse and delinquent
behaviors
 Alcohol, tobacco, and other drug use
 Carrying a weapon, selling drugs
Monitors risk and protective factors for substance abuse
and delinquent behaviors
Family, school, and community perceived availability and involvement
School rewards for pro-social involvement
Overseen by the Florida Department of Children and
Families

82. EHPT

83. Census Data
Data available
Population estimates
Race/ethnicity
Gender
Age
Housing characteristics
Poverty estimates
Provides local data (state, county, census tract, block,
and block group levels)
U.S. Census Bureau: American Fact Finder
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml

84. Qualitative Methods
• Assess evidence pertaining to each of the links in
the pathway diagram leading to health outcomes
• If possible, use evidence from the literature to
determine direction and likelihood

85. Quantitative Methods
• Construct quantitative models and estimate
potential effects
• Perform sensitivity analysis (confidence intervals)
• List assumptions and limitations
Quantitative analysis is not always feasible due
to insufficient time, staff or funding.

86. Distribution of Impacts
• Impacts are distributed throughout a population
over time
• Depending on the method of transmission and the
dose, the time frame may be very short or very
long
• Impacts are often distributed unevenly to
members of the same group or even family
• Some populations are particularly vulnerable to
certain kinds of impacts and that should be taken
into account in the analysis

90. Spatial and Temporal Distribution

91. Qualitative versus Quantitative
• Qualitative describes the direction and certainty
but not the magnitude of predicted results
• Quantitative describes the direction and
magnitude of predicted results

92. Developing Solution Sets
Solution Sets are alternatives to the proposal
that address the risk associated with the
predicted health outcomes:
Generate a list of ways to
Eliminate negative outcomes
Mitigate negative outcomes
Enhance positive outcomes

93. Opportunities for Community Involvement
• Stakeholders guide project team field visits
• Staff conducts interviews and focus
groups with community members and
engaged stakeholders
• Stakeholders interpret and
verify staff research
• Staff and community conduct
participatory research to answer HIA
questions

94. Assessment Outputs
• Statistical summary of predicted health impacts
based on the literature review
• Distribution of impact maps (GIS)
• Time lapsed distribution of impacts (GIS over
time)
• Data sources, strengths, assumptions and
limitations summary
• Solution sets with costs where feasible
(Recommendations)

95. Reporting
Reporting is the phase
where the findings of the
HIA are communicated
to the decision makers
and stakeholders
The team provides
evidence-based
recommendations to
mitigate the negative
health outcomes and
amplify the positive

96. Transparency in Reporting
• Standard practice requires transparency in
reporting the findings and recommendations, but
also the process
• Allows findings and recommendations to be
reviewed and improved
• Informs stakeholders of predicted impacts
• Warns decision makers of possible
consequences, thus providing accountability
• Provides options to avoid, contain, mitigate or
adapt to health impacts

97. Methods of Reporting
• Formal presentations
• Letters to decision
makers
• Public testimony
• Factsheets/newsletter
• Peer reviewed articles
• Social media
• Press conferences

98. Considerations in Reporting
• Framing
• Using cost data
• The “i” message
• Suit the message
format and medium to
the audience
• Make a “one pager”
• Use the executive
summary format
• Communicate about
the process as well as
the outcomes
• Report on stakeholder
involvement
• Note how the process
changed over time
• Be clear about
assumptions and
limitations

99. Exercise
• Craft 2-3 messages about your HIA using a
health frame and an “i” message
• Tell us how you would use the reporting
opportunity to talk about your findings and your
process

100. Evaluation
Process evaluation measures the
effectiveness of the HIA process
• Did you meet your objectives?
• Did you keep to your timeframe and budget?
• Did your process address the underlying values
of HIA?
• What were your stakeholder engagement
ratios?
• What challenges did you face and how did you
overcome them?

101. Evaluation
• Impact evaluation measures whether the
HIA influenced the policy, program or
project decision
• Were recommendations adopted? Percentage
adopted or incorporated into the decision
• Were new collaborations built as evidenced
through agreements or partnerships?
• Did the stakeholders feel their participation
mattered?

102. Evaluation and Monitoring
• Outcome evaluation focuses on the changes in health
determinants identified in the HIA after the decision is
implemented
• Outcome evaluation is planned for in the HIA through a
Monitoring Plan
• Long-term commitment and funding are required to follow
through, but the HIA team can suggest how to monitor
expected outcomes

103. HIA Weaknesses
• Qualitative vs. quantitative
measures
• Voluntary vs. regulatory
• Community engagement level
varies
• HIA standards of practice vary
• Requires time and resources
• Requires timeliness
• Sector bearing costs may not be
sector accruing benefits

104. HIA Opportunities
• Qualitative can be used with quantitative modeling
• Reintegrate into the EIA process
• Introduce HIA to public health, planning and other
professions
• Build capacity in health departments
• Educate public health and
planning students about HIA
• Growth of HIA conferences and
research

105. HIA Challenges
• Not mandatory
• Funding streams
• Need for more evaluation
• Anti-regulatory environment
• Balancing capacity to conduct HIA with the
demand for information
• Availability of data at the proper scale
• Estimating costs of Solution Sets
• Funding for long-term monitoring

106. Wrap Up and Discussion
• Current and future HIA work
• Opportunities in your community
• Funding sources
Thank you for attending!
Please fill out the evaluation forms!

107. Sandra Whitehead, PhD
Director of Healthy Community
Design
Sandra.Whitehead@FLHealth.Gov
850.245.4444 Ext. 2989
www.HealthiestWeightFlorida.com