Partnership for Preventionand the

UCLA School of Public Health

June 23, 2003

Health Impact Assessment Project

What is health impact assessment?

“a multidisciplinary process within which a range of evidence about the health effects of a proposal is considered in a structured framework, ….based on a broad model of health which proposes that economic, political, social, psychological, and environmental factors determine population health.”

Potential contributions of HIA

Bring potential health impacts to the attention of policy-makers, particularly when they are not already recognized or are otherwise unexpected;

Provide a focus for inter-sectoral action on health promotion;

Highlight differential effects on population sub-groups.

Disciplinary foundations of HIA

Epidemiology, etc.

Health Impact

Assessment

Applied Environmental

Impact Assessment

Evidence-based

interventions

Community Dialogue

e.g. “Healthy Cities”

Risk Analysis, Epidemiology,

etc.

HIA is already being used

Great Britain Sweden Canada Germany Australia New Zealand World Bank E.U.

HIA efforts outside the U.S.

Extensive work for nearly a decade;

Increasing interest;

Usually focused on local projects;

Often linked to EIA or focused on facilitating community participation.

Work is needed to develop the potential of HIA for:

Policy analysis;

Synthesizing and communicating best available evidence;

Extending HIA beyond the confines of EIA;

Adapting HIA to the unique policy-making environment of the U.S.

Our Project

Project goal and objectives

Assess the feasibility, usefulness, and limitations of HIAs for policy decision-making.

• Identify lessons from environmental impact statements that are applicable to HIAs;

• Develop an approach for health impact statements, completing three illustrative HIAs.

Project personnel

Jonathan E. Fielding, Principal Investigator (UCLA)

Gerald Kominski, Co-Principal Investigator (UCLA)

Hal Morgenstern, Co-Principal Investigator (UCLA)

Ashley Coffield, Project Officer(Partnership for Prevention)

Brian Cole, Program Manager (UCLA)

Riti Shimkhada, Research Assistant (UCLA)

Advisory Committee

Jo Ivey Boufford, M.D.New York University Medical School

Edward Brandt, M.D., Ph.D.Univ. of Oklahoma Health Sciences Ctr

Lester Breslow, M.D., M.P.H.UCLA School of Public Health

Peter Briss, M.D.Ctrs for Disease Control and Prevention

Dr. Naihua Duan, Ph.D.UCLA School of Medicine

Marthe Gold, MDCUNY Medical School

George Kaplan, Ph.D.University of Michigan

Joseph Newhouse, Ph.D.Harvard Medical School

Raymond Neutra, Ph.D.California Dept. of Health Services

Gilbert S. Omenn, M.D., Ph.DUniversity of Michigan Health System

William L. Roper, M.D., M.P.H., DeanUniversity of North Carolina at Chapel Hill

S. Leonard Syme, Ph.D.UC Berkeley School of Public Health

Accomplishments

Assessment of the state-of-the-art Environmental impact assessment HIA efforts outside the U.S.

Development of methodologies Screening algorithms Toolkit

Template for HIA summaries

Sample HIAs

Learning from EIA:History of EIA in the U.S.

National Environmental Policy Act (NEPA) passed in 1969;

Served as template for similar legislation in many states and other nations;

Thousands of environmental impact assessments now conducted each year.

Learning from EIA:Lessons for HIA practice

EIA has provided avenue for public participation, but…

Long,complex documents;

Process is time-consuming and expensive;

Often litigious process;

Tends to focus on projects, not policies;

Tends to stop short of considering health outcomes.

Development of methods for HIA

Screening – When to do HIAIn general, HIA is most useful

For policy-decisions outside health sector;

When information on potentially significant health effects is not already considered.

1. Proposed policylikely to have significant

health impacts?

3. Decision-makers & stakeholders

likely to valueinformation from the

HIA?

2. Impactinfo. already familiar to

decision-makers &stakeholders?

4. Sufficientdata available tosupport the HIA

5.Sufficientresources for timely

completion ofHIA?

7.Full HIAcan be completed

before key decisionsare made?

6. Time/costof full HIA considered

worthwhile?

No HIA

Full HIA

Mini-Rapid HIA

Yes orUncertain

Yes or sufficientfor mini-HIA

8. Responsesto 1, 3-7 are

all "Yes"

9. Full HIAwarranted?

Yes

Yes orUncertain

Yes orUncertain

Yes orUncertain

Yes orUncertain

No

No

YesNo

No

Yes

No

No

No

No

No

Development of methods for HIA Screening algorithm

Development of methods for HIA Analyzing potential

impacts Logic frameworks (see next slide);

Assessing research evidence;

Preliminary, rapid HIA;

Qualitative outcomes;

Estimates of morbidity and mortality;

Cost-effectiveness when feasible.

Living WageOrdinance

Increased income

HealthInsurance forLW Workers

Health Care

Housing

Childcare

Education(workers'children)

HealthBehaviors

Stress

SocialSupport

Mental HealthOutcomes

Physical HealthOutcomes

Policy Proximal Impacts Intermediate Outcomes Health Outcomes

?

?

Development of methods for HIA Sample logic framework: Living Wage

Sample HIA (local)City of Los Angeles Living

Wage Employees working on city contracts must be

paid at least $7.99/hour provided health insurance, or an additional $1.25/hour

Covers approximately 10,000 workers.

Health insurance coverage more cost-effective in reducing excess mortality than an equivalent amount in the form of wages.

Any changes to the ordinance should consider increasing health insurance coverage.

Applicability: many living wage ordinances throughout the US.

Sample HIA (state)After-school program funding

California ballot Proposition 49 to set aside $550 million per year for after-school programs in grades K - 8.

Potentially significant health outcomes through effects on education, crime, substance abuse, etc.

Counterintuitive result: unlikely to yield any significant health benefits. Chiefly due to:

small magnitude of effects on key mediators; Inadequate targeting, recruitment and retention of high-risk

youth.

Presentation to policy-makers

Summary format developed based on extensive experience of Partnership and Project Team with national, state and local policy-makers;

Two pages of objective information for ease of use by policy-makers;

Neutral language;

Also introduces policy makers to HIA concept and benefits.

FeasibilityProspects for HIA in the U.S.

Very promising based on demonstrated feasibility;

Need US approach due to limited applicability of other countries’ approaches to U.S. policy-making;

Challenges remain.

FeasibilityKey challenges

1. Uncertainties (data, models, policy);

2. Timeliness;

3. Sectoral boundaries;

4. Relevance to legislators.

FeasibilityOpportunities to advance HIA

1. Screening Methods to efficiently sort through bills/ initiatives

to cull those for which HIA most suitable

2. Standardizing and streamlining impact estimation where appropriate

Common pathways

3. Consultation with policy-makers Identification of policy initiatives most likely to

benefit from HIA Bringing HIA results back into the policy-making

arena

Summary

HIA feasibility demonstrated;

Prototype HIAs have generated significant policy-relevant findings;

Next steps – moving from research to practice.