october 2017 volume 2 letter from the editor i in the second issue of the chronicles of health impact assessment we have four articles on hia projects and research and one book review. the society of practitioners of health impact assessment continue to be active partners with the chia board in providing ongoing sharing of information to continue to move forward the work in the field. the chia editorial board would also welcome articles about tools to better measure impact and broader research and interventions on promoting health in all policies. we continue to need more volunteers to be peer reviewers. being a peer reviewer is a time sensitive process as we have a goal to have the comments and suggestions back to the authors within a month of consenting to be a reviewer. as a peer reviewer, you are providing valuable feedback on how to make the article more useful and easier to comprehend. we have included the application to be a peer reviewer at the end of this issue. thank you, cynthia stone drph, rn chronicles of health impact assessment editor-in-chief october 2017 volume 2 letter from the society of practitioners of health impact assessment during times of political uncertainty, it is easy to let the political environment dictate our work. more pressing issues may take precedence over scholarly curiosity, cross-sector collaboration, or genuine community engagement. it is during these precise times, however, that it is more important than ever to maintain integrity and continue the mission of our work. democracy, equity, sustainability, ethical use of evidence, and a comprehensive approach to health are the core values behind all hia practice. it is important that we maintain these values and continue to use hia to improve the health and wellbeing of the communities in which we live and work. as the field grows and advances, hia practitioners will continue to experience uncertain political climates. despite current challenges, practitioners in the field have produced prodigious outcomes. it is the dedication of these practitioners, and the positive outcomes for the communities in which they work that gives life and purpose to what we do. it is for these reasons that the chronicles of health impact assessment continues to be a key resource and outlet for the field. the articles contained in this issue are excellent examples of the continual development of the practice of hia. we hope that this work inspires you to continue to approach your own work with creativity, novelty, and resilience. sincerely, katie hirono, president of sophia ii june 2018 volume 2 c h i a chronicles of health impact assessment improving community health through health impact assessments letter from the society of practitioners of health impact assessment the articles contained in this issue highlight diverse aspects of hia practice, including how hias can be used to demonstrate the interconnected nature of social, environmental, and economic effects from decisions; the role of legislators in exploring policies to support the use of hia; and how the field can equip students to do community-engaged hia practice. a key principle underlying the work highlighted in these articles is equity. it is well documented that health inequities are the result of social, economic and environmental disadvantages. therefore, advancing equity involves identifying and improving those conditions that create avoidable, unfair, and unjust differences in health. hia has been promoted as a tool to address health equity by selecting policies, programs or projects that affect the health of the most vulnerable or disadvantaged populations; engaging community members in decisions that affect their health and well-being; increasing the transparency of evidence generation and the decision-making process; and by creating recommendations that improve health equity and reduce disparities. hia practitioners work to integrate equity into the hia process by ensuring broad community participation in the hia’s planning, organizing and implementation; promoting representation of the communities most affected by the decision; making decisions through a collaborative processes; and respecting the beliefs, culture, perspectives, and histories of disadvantaged communities. in addition to these great practices, the field has more to learn about how it can advance health equity through hia work across the globe. the chronicles of health impact assessment provides a critical vehicle for documenting and sharing best practices. we hope the ideas and recommendations provided through this issue inspire your continuing efforts to advance health equity through your work. sincerely, susan sutherland vice president of development, society of practitioners of health impact assessment (sophia) ii i volume 1, issue 1october 2016 letter from the editor welcome to the inaugural issue of the chronicles of health impact assessment (chia)! it has been quite a journey to launch this journal, but we are happy to present the first edition. the motivation behind the creation of chia was the difficulty experienced when seeking publishing sources for health impact assessment studies. we continually received feedback that our articles were interesting, however the journals “did not publish these types of articles”. the idea to create an avenue for dissemination of health impact literature was born when we learned the indiana university library had the capability to publish online open access journals. in this issue you will find an update on the society of practitioners of health impact assessment (sophia), the history of the work on health impact assessment in the united states, and the support that has been provided and will be necessary to continue to expand the field. you will also find an article about the advocacy needed to further address health equity and democracy. at the 2015 national hia meeting we met to ask what types of questions the chia journal could help answer. it was suggested we discuss successful monitoring and evaluation efforts and highlight more predictive outcomes modeling. people wanted to have access to evidenced based criteria for community engagement and lessons learned. finally, they wanted articles about practical tips from the field, case studies and more methodology focused articles. please consider this first issue as a call for articles addressing these and similar issues. we hope as we move forward to publish two issues a year and eventually include issues with a specific focus, such as hias that address: transportation, land use, or food access and procurement concerns. please begin to submit your articles to chia@iu.edu. in, conclusion i want to thank the society of practitioners of health impact assessment (sophia) board and human impact partners (hip) for agreeing to work on the journal. i also want to thank the iu richard m. fairbanks school of public health dean, dr. paul halverson, my chair dr. nir menachemi, and the faculty and staff for their support and encouragement. i also want to thank the other members of the editorial board who assisted in so many ways in the launching this first issue, especially lyndy kouns. best wishes, cynthia stone drph, rn chronicles of health impact assessment editor-in-chief 49 call for chronicles of health impact assessment (chia) peer reviewers we appreciate your interest in supporting the chia journal as a peer reviewer. in this role, you will be asked to read submitted articles. if you do not have time you can decline the invitation to review and will be placed back in the rotation for future opportunities. if you do have time, your review will address the following: you will submit a written critique that will help determine if the article will be published. you will be asked if you have any conflicts of interest in reviewing an article. all your comments will be anonymous to the authors. you will be given prompts to respond to, such as: what are the article strengths or weaknesses, is this information that is new to the field or building on already known material? all comments should be viewed as constructive criticism for the authors. you will have the choice to accept, recommend acceptance with revisions, or not accept the article. if you are interested, the following information will assist us in matching peer reviewers to specific authors. name email address affiliation phone number area of hia expertise (check all that apply): agriculture criminal justice health equity housing built environment economics hia evaluation labor policy climate change education hia methodology natural resources community development energy hia theory redevelopment transportation other:__________________________________________________ how are you qualified (papers written, journal reviewed for, etc.)? 1050 wishard blvd., indianapolis, in 46202 317-274-2000 chia@iu.edu november 2018 volume 3 issue 2 why should i be a peer reviewer? cynthia stone, drph, rn; amber comer, jd, phd 46 why is peer review important? “peer review does the same thing for science that the inspected by #7 sticker does for your t-shirt: provides assurance that someone who knows what they are doing has double checked it” (berkeley, n.d.) how does a peer review work? an article is submitted and reviewed by the editorial staff. then it is sent to two or more reviewers who work in the same area, and they are considered “peers”. the reviewers give feedback and make recommendations to the editor whether to include the article or not. the peer reviewers also provide comments to the author to improve the article. authors use the suggestions to revise their article and resubmit. this process means that only published articles that meet high scientific standards, that build on previous research, and are based on good evidence are published. when you read articles you want to check that they are published after a peer review process. you also want to submit your work for publication to journals that use the peer review process. in the past few years many why should i be a peer reviewer? many sophia members have been invited to be peer reviewers for chia and other journals and we appreciate everyone that has agreed to work with us in this role. for those that have not been a peer reviewer you might ask, why should i do this? what is peer review? peer review is defined as a “process that is integral to scholarly research. it is a process of subjecting research methods and findings to the scrutiny of others who are experts in the same field. the process is considered essential, but has also been criticized as “slow, ineffective, and misunderstood.” (california state university, n.d.) what is the purpose of peer review? the peer review process is designed to prevent dissemination of irrelevant findings, unwarranted claims, unacceptable interpretations, and personal views. it relies on colleagues that review one another’s work and make an informed decision about whether it is legitimate, and adds to the large dialogue or findings in the field. (the california state university, n.d.) why should i be a peer reviewer? stone; comer 47 more online journals are bypassing the peer review process. if the journal tells you it will be published two weeks after your submission it is probably not peer reviewed. why is it important to secure more peer reviewers? we want to publish articles in chia that have been through the peer review process. we want to be efficient in getting articles out to the public. if we don’t have enough peer reviewers, it slows down our ability to be timely. how can i be a peer reviewer? complete the application to be a peer reviewer found in this issue of chia. when you receive a request to be a peer reviewer please be prompt in your reply. if you do not have time within the provided framework please decline the request. if you agree to be a reviewer please set aside time to carefully complete your review and return your recommendations. your work as a peer reviewer is a critical step in the chia publishing process. thank you for your consideration to become a peer reviewer. why should i be a peer reviewer? stone; comer 48 references berkeley underscience. ( n.d. ) scrutinizing science. available from https://undsci.berkeley, edu/article/_0_-/ howscienceowkrs_16 the california state university. (n.d.) definition of peer review http://teachingcommons.cidi.edu corresponding author cynthia stone, drph, rn department of health policy and management, richard m. fairbanks school of public health indiana university-purdue university indianapolis 1050 wishard blvd. indianapolis, in 46202 317.278.0761 cylstone@iu.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 3 issue 1 (2018) doi: 10.18060/22710 © 2018 author(s): stone, c.; comer, a. this work is licensed under a creative commons attribution 4.0 international license june 2018 volume 2 c h i a chronicles of health impact assessment improving community health through health impact assessments letter from the editor i in the second issue of the chronicles of health impact assessment we have four articles on hia projects and research and one book review. the society of practitioners of health impact assessment continue to be active partners with the chia board in providing ongoing sharing of information to continue to move forward the work in the field. the chia editorial board would also welcome articles about tools to better measure impact and broader research and interventions on promoting health in all policies. we continue to need more volunteers to be peer reviewers. being a peer reviewer is a time sensitive process as we have a goal to have the comments and suggestions back to the authors within a month of consenting to be a reviewer. as a peer reviewer, you are providing valuable feedback on how to make the article more useful and easier to comprehend. we have included the application to be a peer reviewer at the end of this issue. thank you, cynthia stone drph, rn chronicles of health impact assessment editor-in-chief october 2017 volume 2 book review: resources kit for hia practitioners: hia for industrial projects e. westwood and m. orenstein context of resource guide: the need for the resources guide was identified by having 19 million us workers employed on industrial projects and the work generating 20% of the us gross output in 2014. only 19 hias with a focus on industrial projects have been published by 2016, indicating an area for potential expansion of hia work. summary of content: the resource guide begins by defining the terms of industrial projects and industrial facilities. for the guidebook an industrial project must have a contained facility in a physical location, experiences or will experience a life cycle of building, operation and decommissioning; and product generation. a project information checklist is discusses in the third section that provides the hia practitioner with information they may want to gather during the various phases of the industrial project. this includes a complete project description, labor force information, traffic and transportation, noise, environmental interactions, community interaction and engagement of municipal services and reviewing other technical studies. in section four, links to industrial project activities and nine potential effects on human health are presented. this includes land acquisition, air emissions, water quantity and quality, traffic and transportation, noise, workers and employment, taxes and royalties, community investment and accidents and malfunctions. the text does note that additional factors may link health to a specific industrial project, such as waste management or project security. section five in the guide provides background information the guidebook was published in october 2016 by habitat health impact consulting corp with support from the health impact project a collaboration with the robert wood johnson foundation and the pew charitable trusts. the report is available from: https://statc1.squarespace.com/static/56c532fe4b079eaf38b7ed0/t/581100b15016e1a017835a ff/1477509340274/resource+kit+hia+industrial+projects.pdf on human health risk assessment (hhra) which identifies human exposure to chemical substances and how this concept compliments the purpose of hias. hhra specifically looks at risk from three factors which are from a hazard, a receptor and a pathway perspectives. section six reviews the environmental impact assessment practice in the united states since the passage of the national environmental policy act in 1969 and its relationship to hias. the last section provides a framework for organizing the health effects. the section diagrams the health links tied to the project components, determinants of health and health outcomes. the appendices list additional resources for industrial hias and provides information on previous industries focused hias. analysis and evaluation of the resource guide: the project information checklist and potential health factors noted in section three were especially useful. questions to consider for the nine key health impacts are also well defined in section four. conclusion: the resource kit for hia practitioners: hia for industrial projects from habitat impact consulting is a very useful tool for hia practitioners that are new to working in this sector. the resource guidebook has specific checklists and suggested content to use, as well as links to additional resources and previous industries focused hias. i would recommend it for new and experienced hia practitioners. reviewed by: cynthia stone, drph, rn, chia editor-in-chief 62 ii volume 1, issue 1october 2016 letter from the society of practitioners of health impact assessment welcome to the first issue of chia! sophia is thrilled to partner with indiana university (iu) to produce this important resource for the health impact assessment (hia) field. chia was created in response to an important need identified by hia practitioners to have a platform to both share their work in a new way and learn. as the hia field continues to grow and reinvent itself, chia will serve as a compendium of evidence-based approaches to conducting hias. the publication of chia provides an excellent opportunity for sophia to further our mission of providing leadership and promoting excellence in the field of hia. iu has been working hard for almost two years to produce this resource, and sophia has been supporting iu by recruiting our members to serve as editorial board members and reviewers. like many hia field endeavors, the result is a product that reflects the current state of the field, and provides yet another opportunity for the hia community to come together into the future. we encourage all sophia members to take advantage of this incredible opportunity and contribute to the hia community of practice. tatiana lin, sophia president nancy goff, sophia director june 2018 volume 3 issue 1 health equity guide review cynthia stone, drph, rn; danielle boberschmidt 46 under build organizational capacity 2. strategic practice change of internal practices and processes to align internal processes to advance equity. 3. prioritize upstream policy change to improve the social determinants of health. 4. build awareness of the connection between the social determinants and health with different audiences, including health department staff, healthcare institutions, government agencies, elected officials and community stakeholders. 5. allocate resources to advance equity for health equity staff positions and to track and align resources. under work across government to advance health equity 6. build government alliances with other government agencies to advance equity through training. 7. develop a shared analysis with other agencies about government’s role in creating health equity. 8. broaden the administrative and regulatory scope of public health and other agency practices to advance health equity. under foster community partnerships to advance human impact partners (hip) has led the development of a partnership that produced the health equity guide (hipp-a 2017). the guide includes five key organizing concepts that include the following: • mobilize data, research, and evaluation • building internal infrastructure to advance health equity • work across government to advance health equity • foster community partnerships to advance health equity • champion transformative change to advance health equity under the five main concepts there are 15 strategic practices and key actions that local health departments can use to advance health equity within their organizations and with their community partners (hip, 2017). the fifteen strategies include: under mobilize data research, and evaluation: 1. mobilize data, research, and evaluation to make the case for, assess, and inform interventions for health equity. health equity guide review stone; boberschmidt 47 health equity 9. share power with communities by building strategic community relationships, sharing power and decision making, and sparking meaningful participation. 10. build community alliances with community partners to protect against risk and build community power. 11. engage in movements such as social justice campaigns and movements to advance equity by providing data and conducting research, as well as advocating in support of community partners’ interests. under champion transformative change to advance health equity 12. confront the root causes of power imbalances and the racial and other forms of oppression used to maintain those imbalances. 13. develop leadership and support innovation and reward strategic risk taking to advance equity. 14. change the conversation about what creates health equity within public health, across government, and in communities. 15. build a health equity movement by joining with others in public health to build a health equity movement to advance justice and equity (human impact partners-a, 2017). the health equity guide cautions that the guide is not advocating to be a step by step guide, but for organizations to use the provided suggestions to model their own organizational path to improving health equity. the “ways to get started guide” provides additional details. for example, in the actions to build internal infrastructure to advance health equity the suggestions include: creating a team; developing a plan; documenting inequities; leveraging existing staffing; leverage existing funding; using equity tools, surveying your staff, organizing a training and changing your forms (healthequityguide, 2017 ). one resource recommended to use for this step is the bay area regional health inequities initiative (barhii) organizational selfassessment toolkit (2010). the healthequityguide.org website provides information on the strategic practices, and provides over 25 case studies from local health departments (hipp-b, 2017). the website also has over 150 interactive resources you can search by key concepts (hipp-c). the website also provides a link to recordings from a four part webinar series that reviewed the strategic practices and presented related case study examples. the partners on the webinar series included the government alliance on race and equity, the national collaborative for health equity, and the national association of county and city health officers’ health equity and social justice committee (hip, 2017) the healthequityguide is a useful tool for health impact assessment (hia) practitioners so they can implement and advocate with local health department partners. health equity is a key value of hias and the human impact partners project states that “used collectively, these strategic practices can help local health departments systematically address power imbalances, racism, and other forms of oppression which are at the root of health inequities” (healthequityguide.org: a human impact partners project-a, 2017, p.# 4). health equity guide review stone; boberschmidt 48 references bay area regional health inequities initiative. (2010). organizational self-assessment toolkit. available from: http:// barhii.org/download/toolkit/self_assessment_toolkit.pdf human impact partners. (2017). advancing health equity in local health departments: 4-part webinar series. available from: https://humanimpact.org/hipprojects/hegwebinars2017/ human impact partners project-a. (2017). strategic practices and actions to advance health equity in local health departments. healthequityguide.org. available from: https://healthequityguide.org/ human impact partners project-b. (2017). health equity guide case studies. available from: https://healthequityguide. org/case-studies/ human impact partners project-c (2017). health equity guide resources. available from: https://healthequityguide.org/ resources/ corresponding author cynthia stone, drph, rn department of health policy and management, richard m. fairbanks school of public health indiana university-purdue university indianapolis 1050 wishard blvd. indianapolis, in 46202 317.278.0761 cylstone@iu.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 3 issue 1 (2018) doi: 10.18060/21777 © 2018 author(s): stone, c.; boberschmidt, d. this work is licensed under a creative commons attribution 4.0 international license call for chronicles of health impact assessment (chia) peer reviewers we appreciate your interest in supporting the chia journal as a peer reviewer. in this role, you will be asked to read submitted articles. if you do not have time you can decline the invitation to review and will be placed back in the rotation for future opportunities. if you do have time, your review will address the following: you will submit a written critique that will help determine if the article will be published. you will be asked if you have any conflicts of interest in reviewing an article. all your comments will be anonymous to the authors. you will be given prompts to respond to, such as: what are the article strengths or weaknesses, is this information that is new to the field or building on already known material? all comments should be viewed as constructive criticism for the authors. you will have the choice to accept, recommend acceptance with revisions, or not accept the article. if you are interested, the following information will assist us in matching peer reviewers to specific authors. name email address affiliation phone number area of hia expertise (check all that apply): agriculture criminal justice health equity housing built environment economics hia evaluation labor policy climate change education hia methodology natural resources community development energy hia theory redevelopment transportation other:__________________________________________________ how are you qualified (papers written, journal reviewed for, etc.)? 1050 wishard blvd., indianapolis, in 46202 317-274-2000 chia@iu.edu october 2019 volume 4 issue 1 c h i a chronicles of health impact assessment improving community health through health impact assessments letter from the guest editor i since the time that i began to use health impact assessments in my work as an urban planner almost a decade ago, the use of hias and hiap has continued to broaden throughout the u.s. applying the tools to plans, projects, and policies has led to lots of real-world stories of success as well as lessons learned. i believe that as hia and hiap practitioners, sharing our valuable stories of ‘how did you actually do that?’, ‘what worked and what didn’t?’ and ‘what did you learn from it?’ get to the heart of this practice: how to improve health and equity through intentional consideration of the impacts of policies, legislation, and built environment projects on people’s health, wellness, and access to opportunity. i asked several of my many distinguished hia colleagues from around the country to share their real-world stories of their use of hia and hiap to lead to more equitable development outcomes in the built environment. erik calloway at changelab solutions sets the stage with a reflective examination of hiap experiences and lessons from minneapolis, mn, seattle, wa, and richmond, ca. in fort collins, co, kelly haworth and liz young at larimer county public health share their story of creating a new partnership and sharing data with engineers to inform sidewalk construction projects. finally, in denver, co, my colleague maggie kauffman and i share the evolution of our hia 1.0 program to a more integrated hia 2.0 to expand and quantify health and equity. i hope you find these stories informative, inspirational, perhaps entertaining, and encouraging in your practice of hia and hiap. happy reading! gretchen armijo, aicp, leed ap november 2018 volume 2 issue 2 c h i a chronicles of health impact assessment improving community health through health impact assessments letter from the society of practitioners of health impact assessment growth in the field has shown us that there is certainly a place for hias in shaping the built environment and providing input to land use and zoning decisions. however, there is a still a need to better understand the information needs of practitioners across sectors. this issue provides two diverse reads: an hia that examined increasing active transportation through community connectivity; and the unmet information needs and challenges that practitioners face in accessing and using data. many risk factors for chronic diseases can be traced to how communities have been built, including their connectivity patterns, transportation and active living options, access to goods and services, and site plans. in this issue, study authors explore how continuing modifications to the built environment provide opportunities, over time, to institute policies and practices that support the provision of more activity-conducive environments, thereby improving the community’s physical and mental health. a key consideration in the future of hias is how to more readily share, across sectors, information needed for hia research, as well as information contained in hias already produced. in another article, study authors explore the information needs of practitioners, recognizing it as essential to maximizing the use of existing and future hias. the chronicles of health impact assessment provides a valuable resource for highlighting successes and challenges in the field, and sharing novel and innovative methods to advance health and equity. we hope the ideas and recommendations provided through this issue continue to inspire both well-established, as well as fresh approaches to hia practice. prasanthi persad and kerry wyss society of practitioners of health impact assessment ii october 2019 volume 4 issue 1 c h i a chronicles of health impact assessment improving community health through health impact assessments letter from the editor i in the fall 2019 chia issue, we have a special series of articles submitted and invited by our guest editor, gretchen armijo. gretchen has been working at the city of denver as the built environment administrator and has conducted several hia’s as part of her work. gretchen has provided some very interesting articles that she will introduce in her own letter. i very much appreciate all her contributions to making this a meaningful journal issue. thank you also to conner tiffany, an iu graduate service learning assistant, for his help with this issue. if you would like to be a guest editor in the future, please submit your name and the topic you would like to write about and recruit at least two additional articles to me at cylstone@iu.edu. i hope you have a great fall. sincerely, cynthia stone drph, rn chronicles of health impact assessment editor-in-chief november 2018 volume 3 issue 2 susan sutherland, r.s., mph abstract: background: one of the goals of the health impact assessment (hia), was to assess potential health implications in providing opportunities for active transportation to the simon/tanger outlet mall in berkshire township, delaware county, ohio by community connectivity. methods: this case study was conducted by using the health impact assessment model and incorporated community input through survey methodologies, assessment protocols, best practices, and peer-reviewed literature. results: many of the risk factors for chronic diseases can be traced on how communities have been built. several pathways have been identified in the research linking built environments with travel patterns, physical activity levels, body mass index, and associated health outcomes. residential density, land use mix, and neighborhood connectivity have all been consistently associated with multiple outcomes related to good health. by making neighborhoods more walkable, we not only can create converging health benefits, but environmental benefits and more equal access to jobs and opportunities. emerging research on the presence of sidewalks, cycling infrastructure, street design, and building placement and site design have been linked to various health and health-related travel behavior outcomes (frank 2008). discussion: continuing modifications to the built environment provide opportunities, over time, to institute policies and practices that support the provision of more activity-conducive environments, which improve the community’s health. 1 the simon/tanger outlet mall health impact assessment: resulting in active transportation through community connectivity simon/tanger outlet mall health impact assessment sutherland 2 introduction the purpose of the health impact assessment (hia) was to assess the potential health impacts to community health of the development of the simon/tanger outlet mall in berkshire township, delaware county, ohio. convened and facilitated by delaware general health district, and the berkshire township residents’ advisory group, the hia process was supported by the hia steering committee representing 17 organizations whose expertise assisted in providing input on best practices for community planning and design, economic and neighborhood development, open space, green space, active transportation including bicycle, and walking path infrastructure. the simon property group and tanger outlets will develop a 350,000-square-foot outlet center with 90 retail businesses on approximately 50 acres in berkshire township, delaware county, ohio. plans also include additional future commercial and office uses on the remaining land. the analysis of this hia included the impact that the simon/tanger outlet mall project could have on the potential of creating opportunities for connectivity of the surrounding neighborhoods, schools, walking/ biking trails and to existing or planned parks, restaurants, office buildings and other planned development. methods undertaking a hia followed the step-by-step model process as detailed below (see table 1). table 1. the hia step process and methodology hia step methodology screening the health commissioner and the author attended a berkshire township residents’ advisory group meeting, and discussed how an hia might help decision-makers further evaluate and prioritize the residents’ concerns about the simon/tanger outlet mall project and its potential impact on community health and make recommendations to mitigate or minimize negative health impacts. the hia project team determined that an hia would provide an opportunity to examine the potential health impacts of the proposed premium outlet mall development and alternatives to help further refine and improve infrastructures and to help the township possibly prioritize funding for projects that provide health as well as environmental and economic benefits. scoping the scoping phase of this hia was used to gain an understanding of what issues were most important to the community concerning the development of the premium outlet mall. the scoping process was finalized during a meeting where 25 stakeholders and 7 berkshire township residents met with the director of development for the simon/tanger outlet mall. the purpose of the meeting was to give the community an opportunity to voice their concerns and to make recommendations to improve the infrastructure that supports active transportation, decreases traffic congestion, and other improvements to the built environment. the scope of this hia was determined by the entire group based on the discussions held at the meeting. simon/tanger outlet mall health impact assessment sutherland 3 assessment the assessment process was to understand the impact of the development of simon/ tanger outlet mall on community health. data was collected that included the amount of minutes per day of physical activity engaged by adults in delaware county, and adult and child chronic disease rates in delaware county. this information was obtained from the delaware county adult risk behavior factor surveillance survey and the youth risk behavior factor surveillance survey. many literature sources on the built environment and physical activity were reviewed. all sources supported the fact that the built environment impacts community health. in addition, the assessment included a pedestrian and bike infrastructure index scoring. the assessment portion also included prediction models that described the economic benefits of health outcomes by increasing walkability and bikeability through a study conducted by boarnet, greenwald and mcmillan in 2008. recommendations the trans associates engineering consultants, inc. recent traffic impact study prepared for simon property group and tanger factory outlet centers, inc., based conclusions and recommendations to improve roadway design and allow for increased safety for motorists, bicyclists, and pedestrians. the recommendations would also increase opportunities for physical activity that will prevent or reduce chronic diseases should the residents choose active transportation options. reporting the findings and recommendations of this hia were presented and discussed with the community stakeholders, simon properties’ developer, the district advisory council of delaware county, and the berkshire township residents advisory group. an article about the hia appeared in the delaware gazette and the urban studies journal. monitoring/ evaluation the following evaluations were completed: • a survey of the stakeholders was conducted to determine how useful the hia information was in their decision-making. • the number of future land-related projects that consider the hias in their decisionmaking process was collected. • a evaluation of the number of recommendations considered and how it influenced physical activity, the baseline community health status, and community connectivity. monitoring was intended to track the impacts of the hia on the decision-making process and decision, the implementation of the decision, and impacts of the decision on health determinants. simon/tanger outlet mall health impact assessment sutherland 4 results with the potential creation of a park, trails, green space and providing connectivity surrounding the outlet mall, the number of days residents could engage in physical activity could increase. increasing connectivity for pedestrians and bicyclists makes walking and bicycling more attractive choices, enabling people to increase their trips by these active modes. this should increase the health benefits associated with greater levels of physical activity and reduce the costs and negative impacts associated with motor vehicle travel. it is also expected that there is improved mental health indicators with improved access to other regional destinations and associated activities. health impact assessments make evidence-based recommendations to promote positive health outcomes and minimize negative consequences. one of the scopes of this hia is community connectivity. since the scope is very broad, these recommendations not only included the area being developed for the simon/tanger outlet mall, but also included anticipated future development within the surrounding area, and recommendations are multi-jurisdictional. the recommendations, strategies, and evidence are divided into these categories: • policy adoption • promotion of active transportation • increased connectivity • enhanced walkability/bikeability policy adoption to achieve walkable communities, pedestrian considerations and provisions and policies should be fully integrated into ongoing planning activities (comprehensive planning, zoning regulations, site plan ordinances and review, street design standards). the planning process should increase sustainable mobility. safe and convenient bicycling and walking will be the cornerstone of this mobility. effective pedestrianoriented land-use and transportation systems planning will have a significant impact on pedestrian travel, it is recommended that the revised comprehensive plan include options for residents to walk or bike to many of their destinations (connectivity); and, provisions for children to walk or bike to their schools and to nearby parks. the plan should encourage the adoption of street design standards that give priority to safe, easy access for pedestrians in residential and commercial areas, as well as in areas near schools, parks, dining, shopping, and other public places. such things as vehicle speed, number of lanes, overall roadway width, location and width of sidewalks, and intersection crosswalks should be designed for safety to encourage walking. additional plan and policy recommendations include: 1). a bike-transit integration study; 2). improved countywide bike-friendly policies along with marketing and engineering efforts; 3). adoption of a complete streets policy. promote active transportation 1.accommodate all roadway users with comprehensive street design measures such as “complete streets,” including sidewalks, bicycle lanes, and share-the-road signs that provide safe and convenient travel for all users of the roadway. all new roads entering the outlet mall should have sidewalks installed on both sides of the road and wide enough to accommodate people walking in groups or pushing strollers and individuals with disabilities. a ‘furnishing zone” should be added to each sidewalk to provide a buffer between pedestrian and street traffic, which would include pedestrian scale street lighting. 2. provide streetscape amenities such as benches, landscaping, lighting, and public art. amenities are placed to not block or narrow sidewalks simon/tanger outlet mall health impact assessment sutherland 5 particularly for the visually impaired, older adults, people pushing strollers, and individuals with disabilities. 3. encourage wayfinding with signs, maps, and landscape. cues to direct pedestrians and bicyclists to the most direct routes to the outlet mall. 4. provide bicycle parking at workplaces and transit stops. designate bicycle-specific crossings and signals to organize the movement of pedestrian, cyclists, and motorists at the busy intersection into the entry of the mall. offer a buffer between bicyclists and cars to increase safety. 5. ensure that site design, parking, and fences do not preclude safe and comfortable pedestrian connections to future development. 6. support physical activity among people with disabilities and special needs such as elderly and handicapped by making all new roads and paths universally accessible. 7. provide safe and convenient bicycle and pedestrian connections such as a trial or easement to dedicated green space and potential public parks and recreation areas. increase connectivity connectivity of walking and bicycle infrastructure is associated with both increased walking and increased transportation walking (berrigan, pickle, & dill, 2010). connectivity refers to, in this context, as the number of blocks and intersections, as well as the presence of walking/biking infrastructure linking different destinations, mostly because they assist in providing more direct routes for accessing locations. increasing the connectivity of the street network is an important component of this hia. 1. connect existing neighborhoods and greenways by installing sidewalks, bike lanes, and provide connection paths to existing trails. the ohio to erie trail has been partially completed in galena and will eventually connect to sunbury. this is a great opportunity to connect this new development with eastern delaware county. 2. new development and redevelopment should provide pedestrian and bicycle connectivity through walkways, bike lanes, and multi-use paths between individual development sites to provide alternative means of transportation in this area to major destinations such as transit stops, schools, parks, food, and other shopping centers. 3. recommend policies that maximizing the density of neighborhoods requiring new developments be mixed-use and high density with good connectivity by incorporating active transportation infrastructure in neighborhoods. these kinds of changes to the built environment will make the areas more conducive to active transportation, which will have positive health benefits through increased physical activity, decreased air pollution, and reduced car collision fatalities for drivers, pedestrians, and bicyclists. 4. ensure that new parks are easily accessible by foot, bike, or public transit from neighborhoods that are currently underserved by parks. create greenways/pedestrian and bicycle friendly routes and increase transit service, especially on weekends and holidays, from underserved neighborhoods to the site. 5. a needs assessment of existing neighborhoods in berkshire township should be conducted prior to updating the berkshire township comprehensive plan to determine park needs, walkability issues, and other connectivity needs of the residents. enhance walkability/bikeability the placement and proximity of destinations is one of the most important factors in determining how much people walk for transportation. the presence and convenience of utilitarian destinations has been associated with walking for transportation, especially simon/tanger outlet mall health impact assessment sutherland 6 destinations such as grocery stores, restaurants, post offices, and banks. a national survey of more than 12,000 adults found that the most common purpose of walking trips (38%) was for personal errands, such as going to the grocery store. another important factor is the density of housing, which can increase the number of people who can live within a short distance (generally ¼ to ½ mile) of commercial, retail, school, work, or transit-stop destinations. higher density at the parcel level has been associated with odds of walking frequently for transportation. 1. follow development and redevelopment practices that support walking, biking and transit use. 2. consider changing minimum parking requirements. consider alternative parking provision strategies. 3. allow zoning/re-zoning that facilitates mixed-use development. 4. incentivize mixed-use development in berkshire township. 5. provide interconnected streets, pedestrian sidewalks and other pedestrian facilities to increase walking. 6. linkage to a variety of land use/regional connectivity. provide pedestrian and cyclists infrastructure to access shopping, transit, schools, parks, offices and other communities in this region of the county. 7. coordinate between jurisdictions. close coordination with adjacent jurisdictions to meet future pedestrian and cyclists’ connectivity infrastructure. 8. accessible and appropriately located transit. provide transit facility close to commercial area to encourage transit usage, and include shelter, benches, and bike racks. 9. pedestrian-supportive land-use patterns. use a grid street layout with short blocks in commercial area to enhance pedestrian mobility. discussion neighborhood design can also significantly impact physical activity and health, especially through features such as land use mix, walkability, bicycling infrastructure, parks, and open space. the most consistent characteristics positively associated with physical activity were population density, land use mix, and distance to nonresidential destinations. conversely, a study on the association between time spent in cars, physical activity and obesity found that each additional hour spent in a car per day was associated with a 6% increase in the likelihood of obesity. street design facilitates or hinders walking and cycling. other environmental features influencing mode of transport choice include the availability of cycle and pedestrian lanes, preferably separated from other road users and other measures to calm motorized traffic (lee & moudon, 2006). land use practices that isolate employment locations, shopping and services and housing locations can encourage car use, particularly where public transport options are not available or attractive alternatives (heath et al., 2006). where urban development is unplanned or uncontrolled and spreads out into areas adjoining the edge of a city – commonly known as urban sprawl – car dependency is likely to be increased (heath et al., 2006). evidence suggests that people living in sprawling communities drive three to four times more than those who live in efficient, wellplanned areas. compared to those living in compact areas, people living in sprawling areas walk less for exercise, have higher weight levels and are more likely to have high blood pressure (dannenberg et al., 2003). walking or biking for utilitarian trips is an opportunity to incorporate routine physical activity into daily living. there are multiple environmental barriers that both children and adults face to achieving recommended simon/tanger outlet mall health impact assessment sutherland 7 levels of physical activity including: limited discretionary time, barriers to accessing parks and recreational areas, reductions in school physical education programs, and sidewalks, streets, or outdoor spaces that are not or are not perceived as safe to use. encouraging and facilitating active transportation – walking or cycling as a form of travel for utilitarian trips – is a key strategy for increasing daily physical activity. built environmental factors that are associated with active transportation via walking and cycling include increased resident and employment density, greater diversity of land use mix (e.g., residential land use near retail land uses), shorter distances destinations, and street design factors (e.g., grid street networks, the presence of sidewalks) (sustainable communities index, 2018). evidence that physical activity has multiple health benefits is unequivocal. a comprehensive literature review documents the particularly strong evidence for a causal relationship between activity level and enhanced cardiorespiratory and muscular fitness, cardiovascular and metabolic health biomarkers, bone health, body mass and composition in children and youth. in adults and older adults, strong evidence demonstrates that, compared to less active counterparts, more active men and women have lower rates of all-cause mortality, coronary heart disease, high blood pressure, stroke, type 2 diabetes, metabolic syndrome, colon cancer, breast cancer, and depression. for older adults, strong evidence indicates that being physically active is associated with higher levels of functional health, a lower risk of falling, and better cognitive function. a study conducted in atlanta, georgia encourages walking and was associated with a 12% reduction in the likelihood of obesity (city of new york, 2014). this research reported reasonably consistent findings specifically for the health benefits of walking – showing a consistently lower risk of all-cause mortality for those who walk two or more hours per week. a 2011 report issued by an international group of experts using data from copenhagen documents similar all-cause mortality benefits from regular cycling for commuting controlling for socio-demographic and leisure time physical activity (world health organization, 2011) in 1996, commissioned as a response to the rising levels of obesity in the u.s., the u.s. department of health and human services surgeon general’s report on physical activity and obesity was the first to bring to the forefront the positive health outcomes of physical activity. based on this and a number of other comprehensive reviews of the literature, engaging in physical activity affects a variety of health outcomes including: all causes of mortality; cardiovascular disease; diabetes mellitus; cancer (colon and breast); hypertension; bone and joint diseases (osteoporosis and osteoarthritis); mental health (department of health and human services, 1996). the u.s. surgeon general issued a report confirming what is generally known: americans aren’t getting enough exercise (u.s. department of health and human services, 1996). the american heart association has listed physical inactivity as the fourth major risk factor associated with chronic disease (haskell et al., 2007). of great concern to public health officials in all parts of the united states, the trend of physical inactivity is getting worse: a 2009 summary by the robert wood johnson active living research program revealed that fewer than 50% of children and adolescents and fewer than 10% of adults in the u.s. achieve public health recommendations of 30 to 60 minutes per day of moderateto vigorous-intensity physical activity on 5 or more days of the week (designing for active living, 2017). physical activity is associated with all-cause mortality in an inverse dose-response fashion; increasing levels of physical activity being associated with decreasing levels of mortality. in addition, studies have found that physical activity has reduced caused-specific mortality, simon/tanger outlet mall health impact assessment sutherland 8 including deaths from cardiovascular disease. in addition, physical activity is associated with lowered risk of colon cancer and breast cancer in women (american society of clinical oncology, 2016). reviews of physical activity interventions suggest that people may be more willing and able to adopt moderate physical activities. once such activities are set in motion they are more inclined to maintain them over time, as compared with other types of vigorous physical activity (hia guide, 2014). physical activities that are incorporated into daily life or have an inherent meaning, or lifestyle activities, rather than structured exercise regimens, are good strategies for increasing physical activity. even relatively small changes in physical activity can translate into potentially large changes in weight trends at the population level (university of california, los angeles health impact assessment – clearinghouse learning & information center, n.d.). according to the centers for disease control and prevention, a total of 30 minutes of moderate to vigorous physical activity, which can be achieved via brisk walking or cycling on most days of the week, reduces the risk of cardiovascular diseases, diabetes and hypertension, and helps to control blood lipids and body weight. these benefits are conferred even if the activities are done in short tento fifteenminute episodes. thus, cdc’s physical activity recommendations for adults call for at least 30 minutes of moderate to vigorous activity per day for health benefits. an article in the springer journal describes the link between physical activity and health outcomes. an economic study, it revealed that urban design could be significantly associated with some forms of physical activity and with some health outcomes. after controlling for demographic and behavioral covariates, the county sprawl index had small but significant associations with minutes walked. those living in sprawling counties were likely to walk less, weigh more, and have greater presence of hypertension than those living in compact counties. although the magnitude of the effects observed in this study was small, they do provide added support for the hypothesis that urban design affects health and health-related behaviors (frank et al., 2005). another report from the peer-reviewed literature, linking objectively measured physical activity with objectively urban form, claims that there are now sufficient studies documenting associations between the built environment and physical activity and to consider land-use decisions as a critical public health issue (humboldt, 2008). the built environment may be contributing to the obesity epidemic, because obesity is more prevalent in areas where land use makes it difficult to walk to destinations and where there are relatively few recreational resources (frank et al., 2005). sufficient evidence was found in the literature that street-scale design and the land use policies to support physical activity in small-scale geographic areas are effective in increasing physical activity such as bicycle and pedestrian infrastructure (heath et al., 2006). in conclusion, according to the centers for disease control and prevention, environments that support walking, biking and transit trips as an alternative to driving have multiple potential positive health impacts. quality, safe pedestrian and bicycle environments support a decreased risk of motor vehicle collisions and an increase in physical activity and social cohesion with benefits including the prevention of obesity, diabetes, and heart disease as well as stress reduction and mental health improvements that promote individual and community health. environments that encourage walking and biking while discouraging driving can simon/tanger outlet mall health impact assessment sutherland 9 further reduce traffic-related noise and air pollution – associated with cardiovascular and respiratory diseases, premature death, and lung function changes, especially in children and people with lung diseases such as asthma (centers for disease control and prevention, n.d.). simon/tanger outlet mall health impact assessment sutherland 10 references american society of clinical oncology. (2016). physical activity and cancer risk. retrieved from http://www. cancer.net/navigating-cancer-care/prevention-and-healthy-living/physical-activity/physical-activity-andcancer-risk berrigan, d., pickle, l.w., & dill, j. (2010). associations between street connectivity and active transportation. international journal of health geographics, 9(1), 20. centers for disease control and prevention. (n.d.) cdc transportation recommendations. retrieved from https://www.cdc.gov/transportation/recommendation.htm city of new york. (2014). promoting physical activity and health in design active design g. retrieved from https://www.pewtrusts.org/-/media/assets/external-sites/health-impact-project/the-premium-outletmall-hia.pdf?la=en&hash=12eef32aac03a8ed72a00e32b961e212614d18d3 dannenberg, a. l., jackson, r. j., frumkin, h., schieber, r. a., pratt, m., kochtitzky, c., & tilson, h. h. (2003). the impact of community design and land-use choices on public health: a scientific research agenda. american journal of public health, 93(9), 1500-1508. designing for active living. (2017). designing our future: sustainable landscapes. available from: https://www.asla.org/sustainablelandscapes/vid_activeliving.html ewing, r., & cerero, r. (2001). travel and the built environment: a synthesis. transportation research record: journal of the transportation research board, 1780(1), 87-114. frank, l. (2008). the built environment and health: a review. city of calgary. alberta. frank, l., schmid, t., sallis, j., chapman, j., & saelens, b. (2005). linking objectively measured physical activity with objectively measured urban form: findings from smartraq. american journal of preventive medicine, 28(2), 117-125. haskell, w. l., lee, i. m., pate, r. r., powell, k. e., blair, s. n., franklin, b. a., …bauman, a. (2007). physical activity and public health: updated recommendation for adults from the american college of sports medicine and the american heart association. medicine and science in sports and exercise, 39(8), 14231434. heath, g. w., brownson, r. c., kruger, j., miles, r., powell, k. e., ramsey, l. t., & task force on community preventive services. (2006). the effectiveness of urban design and land use and transport policies and practices to increase physical activity: a systematic review. journal of physical activity and health, 3(1), 55-76. humboldt county public health branch humboldt partnership for active living human impact partners. (2008). humboldt county general plan update health impact assessment. available from: https://www. pewtrusts.org/~/media/assets/2008/03/humboldtcountygeneralplanupdate.pdf simon/tanger outlet mall health impact assessment sutherland 11 corresponding author susan sutherland, r.s., mph delaware general health district 1 w. winter street delaware, oh. 46015 ssutherland@delawarehealth.org chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 3 issue 2 (2018) doi: 10.18060/22709 © 2018 author(s): sutherland, s. this work is licensed under a creative commons attribution 4.0 international license sustainable communities index. (2018). for a more sustainable future. available from: https://www. sustainable.org/index.php u.s. department of health and human services. (1996). physical activity and health: a report of the surgeon general. retrieved from https://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf university of california, los angeles health impact assessment clearinghouse learning & information center. (n.d.). physical activity. retrieved from http://www.hiaguide.org/sectors-and-causal-pathways/pathways/ physical-activity november 2018 volume 3 issue 2 karen w. lowrie, phd; leigh ann von hagen, aicp/pp 1 hia training for professionals: how a university-based center can help to build awareness and capacity perspectives from the field hia training for professionals lowrie; von hagen 2 introduction when a group of faculty and research staff from various subfields of planning at the edward j. bloustein school of planning and public policy at rutgers university in new jersey got together in 2012 around their common interest in fostering healthy communities, they realized there were gaps in connections and information-sharing between planners, public health professionals and policy-makers to understand health outcomes in non-health policy and project decisions. from initial discussions and research, the planning healthy communities initiative (phci) was born. phci is a multidisciplinary team at the rutgers bloustein school with expertise in active transportation and infrastructure, green buildings, environmental analysis, advancing health equity, and supporting communitybased efforts. one of the pillars of the phci is capacitybuilding. quick research revealed that by 2012, only one health impact assessment (hia) had been performed in new jersey and that no other institution in the state was conducting or actively promoting hia. therefore organizations and governments had little awareness of them or capacity to perform them. phci stepped in to fill this gap in a number of ways, but perhaps the most in-depth and most direct was the creation of a new one-day hia training course that would be the first ever in new jersey. hia class specifics one of the phci goals is to educate as many decisionmakers and administrators in new jersey as possible about the purpose and goals of hia and health in all policies (hiap). in spring of 2015, the first training course was offered. the course is one of many in varied fields listed with the rutgers office of continuing professional education (cpe). offering the class through cpe has many advantages including their lead role in advertising, classroom facility and catering setup, fee collection and online and onsite registration. cpe staff also assist with securing ceu’s (see table below) from various professional associations, and issue participation certificates. with rutgers cpe staff handling much of the class logistics, the facilitators from phci are responsible for instructing on the content, leading group exercises and discussions, and preparing powerpoint slides and participant packets. phci also advertises the class through its website and that of the bloustein school, and through e-mail blasts to other associations in the planning, development and public health fields. some selected ceu’s offered to hia training participants: rutgers university 0.5 ceus nj site remediation professional licensing board (njsrpb) 4.5 regulatory credits certified health education specialists (ches) 4 category 1 ce credits rutgers planning and zoning certificate 3 technical credits american planners association (apa) 5 ceus nj continuing legal education (cle) 3.4 cles nj health officers and registered environmental health specialists (rehs) 5 nj public health continuing education contact hours (ces) nj professional engineers 5 continuing professional competency (cpc) credits hia training for professionals lowrie; von hagen 3 the one-day class runs from mid-morning through mid-afternoon, with breakfast and lunch provided. the instructional material covers the six steps of hia through a mix of lecture and group exercises with report-outs. exercises on screening, scoping, assessment and recommendations are conducted in groups of 4-8 participants. the class ends with discussion of the application of hia in job settings, and brainstorming about resources needed to help participants to implement it in their workplaces. the facilitators draw on real-life examples from hias that phci has conducted in new jersey over the past five years. participant evaluations as of fall of 2018, about 150 people have attended the six sessions that have been conducted. participants attend mostly from local and regional governments, non-profits and private consultants from the fields of planning, public and environmental health, community development and engineering. recently, hospital employees have attended because hospitals are getting more involved with policy and with community health initiatives. many attend the training sessions for the credits, and some also for points awarded by sustainable jersey, a program that rewards nj municipalities for taking actions to become more sustainable and improve quality of life. others noted that they took the class because it sounded “interesting” and they wanted to learn more about this new screening tool to help with decision-making. the class is open to anyone, and several attendees have also come from outside new jersey. in post-class evaluation, a vast majority rated the class as “excellent” or “very good” on program objectives, content, usefulness and stimulating interest in the topic. the most popular elements of the class are the group exercises and discussions, the breakdown of the six steps, and networking that occurred in the room as people from across different sectors and different parts of the state meet each other and work together. participants were asked for the most valuable parts of the class and to describe what they learned. answers demonstrate the value of the class in raising awareness and building some capacity for hia in new jersey. selected comments by hia class participants on the learning value and benefits of the class: • i learned how to incorporate an hia into a project. • i learned the importance of identifying and engaging subgroups to include in the process. • i learned performing a health pathway. • i really appreciated the sourced information in the presentation. • overall, course was an excellent introduction to the topic of hia. • excellent program, i hope to implement hia with township committee, planning board and green team. • the information was very practical; the team work at tables was great. • i learned that almost every decision has an impact on the health of the community and individuals. • i am better equipped to promote role of health when working with counties and municipalities. • hia is really new to me-so i learned a lot of relevant vocabulary, concepts and case study applications. • it broadened my perspective on health impacts. • class should be mandated for municipal government. extensions and follow-up suggested by attendees include the creation of a sharing distribution to continue collaboration and discussion among program attendees, and the offering of additional training that focuses more on the role of regulation and government and/or that goes into more detail on hia or hia 2.0 applications. hia training for professionals lowrie; von hagen 4 key takeaways for the phci facilitators, the hia training class has been a fun, worthwhile, and interesting experience. we feel that it is an ideal role for a university because we can offer training at a less expensive price, utilize/ leverage in-house expertise and resources, and we are perceived as a “neutral” organization and site without any political or financial motive or connection with advocacy. after almost four years, we have developed a set of take-away messages – some in the form of general observations and some in the form of wishes for the future of the program: • the language of health is different from the language of other professional fields…thinking through a health lens is sometimes a difficult exercise for those in non-health fields. teaching about health pathways and logic models therefore can create “lightbulb moments” in attendees from non-health sectors. • many class participants see the value of hia, but wonder how to get it done. the most common concern usually centers on questions about resources and capacities to conduct hia and justifying the time to do it given the lack of mandates. • many attendees lack the confidence that they will be able to sift through data sources and to analyze, understand and trust data without expert help. • connecting people across disciplines around health impacts can forge new relationships around common goals. people meeting other people from different sectors and different types of organizations, and hearing each other’s perspectives is one of the great benefits of the training. we hope to respond to the recommendations of attendees for a “part 2” class offering. we have also re-packaged the content prepared for the six-hour class into shorter 1, 2 and 3-hour versions to take “on the road” to various other organizations, with similar positive reactions from audiences. we at phci are happy to further discuss our experiences and share our insights with others considering developing similar programs. please contact karen lowrie (klowrie@rutgers.edu) or leigh ann von hagen (lavh@rutgers.edu), and visit our website at phci. rutgers.edu. promotional flyer for hia training course hia training for professionals lowrie; von hagen 5 corresponding author karen lowrie, phd edward j. bloustein school of planning and public policy rutgers university 33 livingston ave. newbrunswick, nj 08901 klowrie@rutgers.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 3 issue 2 (2018) doi: 10.18060/22755 © 2018 author(s): lowrie, k.; von hagen, l. this work is licensed under a creative commons attribution 4.0 international license october 2019 volume 4 issue 1 c h i a chronicles of health impact assessment improving community health through health impact assessments letter from the society of practitioners of health impact assessment as health impact assessment (hia) takes root as an established practice both in the u.s. and globally, the focus has shifted from how to do an hia, to how to integrate it into broader health in all policies (hiap) efforts. this is reflected in discussions at recent gatherings, including the 2019 society of practitioners of health impact assessment (sophia) practitioner workshop, and advancing health and health equity: lessons from around the globe convening. the sophia practitioner workshop, held in st paul minnesota in april 2019, brought together nearly 54 new and experienced hia practitioners for two days of valuable presentations and discussions on the state of the field. presentations offered current applications of hia including techniques for broader integration of health into decisionmaking that support hia, such as ecosystem services, equity analysis tools, and results-based accountability. the plenary panel featured examples of hia practice from the states of georgia and minnesota, and the country of wales which demonstrated how individual hias can be leveraged to create more sustained, integrated work. there were also several sessions focused on health in all policies including: a discussion on hia as a translational research tool which can be used as a strategy for achieving integration of health at higher levels of decision-making; evaluation strategies for hiap; and the sophia hiap working group. you can read the full workshop report at: https://bit.ly/2zegmnh advancing health and health equity: lessons from around the globe convening hosted 35 experts in hia and hiap for a one-day meeting in barcelona, spain in july 2019. experts provided examples of work they are leading to promote the integration of health into decision-making in australia, usa, wales, spain, chile, the philippines and switzerland. many of these examples included cross-sectoral and integrated strategies that are part of or support health in all policies, including: development of health notes in the usa; hiap strategies in south australia; development of statutory frameworks for hia in wales; adoption of hiap strategies as part of public health governance in spain; and use of global governance on air pollution and health as an entry point for health in all policies efforts. a video recording of the proceedings will be available on the sophia website (www.hiasociety.org). having attended both these events i have come away with a renewed appreciation for the importance of viewing hia as an important tool in the larger toolbox of hiap strategies, and of the need to view hiap as a governance mechanism for achieving health and equity. the articles contained in this edition offer examples of work that continue to advance both the practice of hia an hiap. i invite you to reflect on them, as i have, with a view towards understanding how both hia and hiap can be used strategically to advance efforts towards achieving health and equity. sincerely, katie hirono president, society of practitioners of health impact assessment ii https://bit.ly/2zegmnh http://www.hiasociety.org october 2020 volume 5 issue 1 letter from the editor i this issue of chronicles of health impact assessment is centered on the theme of “bridging,” with numerous examples of entities working together to assess and improve community health. this issue also offers many opportunities for potential replication of successful programs and lessons learned from around the country. included in this issue is a book review of “bridging silos,” a book that describes best practices through the examination of three case studies. although community health needs may vary across the country, successful strategies employed in one community may also be implemented effectively elsewhere. an interesting national study of policies and risks associated with motorized scooters reveals that there are significant risks for riders and pedestrians, and knowledge of policies is generally lacking. there are clear public health implications for e-scooters in our country. another article details a study of policy monitoring, with a focus on communication with local health departments and identification of potential health impact assessment opportunities. an informative article describes an hia learning collaborative, designed to improve the ability of community partners to effectively implement hias, an idea which may be replicated in other communities. finally, this issue includes an article featuring a description of how local, state, and federal entities can work together to improve the built environment and improve community health. we continue to need more volunteers to be peer reviewers. being a peer reviewer is a time sensitive process as we have a goal to have the comments and suggestions back to the authors within a month of consenting to be a reviewer. as a peer reviewer, you are providing valuable feedback on how to make the article more useful and easier to comprehend. we have included the application to be a peer reviewer at the end of this issue. additionally, if you would like to be a guest editor in the future, please submit your name and the topic you would like to write about and recruit at least two additional articles to me at cylstone@iu.edu. we hope you have a great fall. cynthia stone, chia editor carol mills, community engagement associate for chia november 2018 volume 3 issue 2 health impact assessment: an information needs analysis of hia practitioners across sectors wes quattrone, ma; melissa callahan, msph; stephen brown, ms; tatiana lin, ma; jamie pina, phd, msph abstract: background: information contained in health impact assessments (hias) provides valuable guidance for professionals in many fields and industries, also known as sectors. however, a growing body of evidence suggests that hia practitioners across sectors have unmet information needs and face challenges accessing health related data, including findings available in hias. methods: the research team conducted a series of focus groups to explore the information needs of practitioners across sectors and to identify challenges they face accessing this information. participants were stratified by geographic location, sector affiliation, and hia expertise. results: findings suggest that practitioners from all sectors can benefit from the integration of health-related information, and the information contained in hias, into their work. reported information needs include baseline data, geocoded socio-demographic information, granular local data, peer reviewed literature on the impacts of social determinants and other factors with health outcomes, and technical assistance and best practices. participants indicated that they obtain information from their professional network, universities sponsoring research, and online resources. information challenges include lack of data that match the size and the scope of the target area of interest, proprietary or pay-for-access sources, varying terminology for the same concepts across sectors, inadequate resources and hia expertise for searching, and limited information on the impact of findings of completed hias. discussion: identifying and understanding the information needs of practitioners is essential to maximizing the use of existing and future hias. an interactive and comprehensive web-based repository system for hias may provide value and assist practitioners in meeting these needs. 1 health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 2 introduction health impact assessment (hia) is a process that determines the potential health effects of a proposed plan, project, or policy before it is created or executed. hia brings public health impacts and considerations to the forefront of the decision-making process in fields that typically fall outside traditional public health arenas. it emphasizes strategies to enhance health benefits while reducing negative effects, and it weighs the strengths and weaknesses of different options (centers for disease control and prevention [cdc], 2018; pew charitable trusts, 2018a). the health impact project, a collaboration of the robert wood johnson foundation and the pew charitable trusts, contracted with rti international to conduct a qualitative study of new and current hia practitioners to explore their information needs, how they seek out that information, and challenges they face with accessing the information included in hias. study participants included a range of professionals, from those who had limited exposure to hias, to those who routinely conducted hias. these professionals used hias for various reasons, such as to locate research and data, complete projects, inform policies, and influence decision makers. this article outlines the findings from the study and describes the information needs and challenges identified by focus group participants. the article also describes the information that hia practitioners require to meaningfully incorporate population health and health equity considerations into their work. the research team assessed how often practitioners use hias to influence policy, programs, practice, planning, and decision-making. participants provided recommendations for maximizing access to information included in hias, including summaries of findings in peer-reviewed literature, outcome and impact assessments, and more comprehensive web solutions. background since the first hia was conducted in the united states in 1999 (bhatia & katz, 2001), the adoption of hias has steadily increased. in 2008, 27 hias were completed (dannenberg et al., 2008), and more than 400 hias are completed or in progress today (pew charitable trusts, 2018b). the health impact project contributed to the growth of hias and has supported the field by funding hia demonstration projects, trainings, and evaluations, and by “serving as a convener for the field” (morley, lindberg, rogerson, bever, & pollack, 2016). hias have gained popularity as a means for public health professionals to demonstrate to colleagues in sectors that traditionally do not focus on health, the impact of decisions made in other sectors on population and community health (dannenberg, 2016a). they also help professionals in positions and sectors outside of the health arena make informed decisions that affect public health (morley et al., 2016) and advocate for health-related policy changes such as active transformation promotion (waheed et al., 2018), emission reduction (likhvar et al., 2015), and green space infrastructure (fischer et al., 2018). in non-health sectors, professionals must consider several factors when planning their work, such as available resources, stakeholder support, access to relevant data, and others (bourcier, charbonneau, cahill, & dannenberg, 2015). hias have been shown to assist decision makers in quantifying the impact of population and community health issues, which they can then communicate to other stakeholders (national research council, 2011). despite these advances in the field of hias, there is evidence that practitioners still face challenges in acquiring and using information necessary for completing assessments. practitioners routinely face challenges when seeking relevant data with which to quantify health impacts. in particular, they have difficulty locating specific data at the local level for health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 3 their community (bourcier et al., 2015; dannenberg, 2016b; hubbell, fann, & levy, 2009), accessing existing data sets (chart-asa & gibson, 2015), and finding current evidence to use in predicting health outcomes (national research council, 2011). with these considerations in mind, stakeholders may have a need for more readily accessible sector-specific information on hias, including tools, lessons learned, and evidence of translation into policy (morley et al., 2016). methods research approach between june and november 2016, the research team conducted a series of focus groups to explore the information needs of hia practitioners across sectors1 and identify challenges they face accessing this information, with the following research questions: 1. what information do hia practitioners need to ensure that their work adequately considers health? 2. what challenges do hia practitioners face when attempting to acquire and use this information? the study included practitioners representing all sectors, with a specific focus on built environment, transportation, disaster/emergency preparedness, and planning. the research team chose these sectors because they each had a history of conducting hias to inform their decision making (pew charitable trusts, 2018b), and they can all benefit from the incorporation of health considerations. in this context, the authors define health in the broadest sense, including not just physical and mental health outcomes, but also environmental, political, social, community, and commercial factors. prior work shows that a narrow definition of health or factors that influence health can limit the scope, application, and value of the assessment (human impact partners, 2011; national research council, 2011). the research team designed the focus groups to understand when and how hia practitioners’ incorporate health into their decision-making processes, their familiarity with hias, the tools and websites they use to accomplish these tasks, and the limitations of these tools and websites. when appropriate, the research team prompted participants to describe the features and functionality of an ideal website that could theoretically be designed to meet their needs. for practitioners with a greater level of experience, we inquired into their background in using hias to inform stakeholders or to prompt policy makers to incorporate health into their decisionmaking processes. each focus group was facilitated by a moderator, who followed a semi-structured interview script. a notetaker/co-moderator also attended each session. the research team conducted two focus groups in person, while holding four sessions using thinktank, a virtual platform. thinktank is designed to increase collaboration among geographically dispersed meeting attendees, engage and stimulate participants, and aggregate group feedback in real time. during the focus groups, participants verbally responded to questions from the moderator, while simultaneously typing their feedback into the thinktank platform. this approach ensured that all participants could respond to each question in the time allotted. it also allowed participants to respond to questions and comments from other attendees, thereby creating a more indepth conversation around each question. see figure 1 for a screenshot of an example thinktank session. this screenshot contains mock data and is only included to illustrate the functionality of thinktank. 1for a full list of sectors, please visit http://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2015/hia-map. health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 4 figure 1. screenshot of an example thinktank session outreach and recruitment focus group participants were identified through various communication methods, including newsletter announcements to members or grantees of the organizations such as the society of practitioners of health impact assessment (sophia), the national network of public health institutes (nnphi), human impact partners, the association of state and territorial health officials (astho), and the health impact project. the research team members also asked their professional network of hia colleagues to suggest experts representing sectors of interest. the team sought to include hia practitioners from all sectors and with all levels of experience. participant stratification to ensure that a group with a broad background was assembled, the research team classified participants by geographic location, sector affiliation, and level of expertise with hias. classifying information was selfreported by participants and confirmed by the research team when possible. for geographic location, the research team sought professionals based out of every region of the united states. regions were assigned based on the u.s. census bureau’s definition (u.s. census bureau, n.d.). recruitment efforts did lead to the inclusion of a few international representatives, who participated as scheduling would allow. participants were primarily affiliated with sectors that incorporated health into their work and had a history of conducting hias to inform their decision making. however, to include as many opinions and perspectives as possible, the research team recruited practitioners from all sectors. participants were asked to choose their affiliation from one of the sectors listed on the health impact project’s map of hias in the united states (pew charitable trusts, 2018b); however, some provided responses that did not health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 5 correspond to these categories, such as “planning” or “disaster/emergency preparedness and response.” in addition, some participants initially reported multiple sector affiliations. in these instances, the research team asked participants to identify the sector where they most recently conducted work pertaining to hias. final sector affiliation was categorized by responses received from participants, with the research team clarifying as needed. the research team attempted to recruit participants of all levels of hia expertise but was constrained by scheduling availability, the low response rate of people with limited levels of hia expertise, and prioritizing recruitment based on sector affiliation. previous hia expertise was divided into three categories: figure 2. geographic representation of focus group attendees, by sector • high: those who had conducted at least one hia • medium: those who had not worked on an hia but considered health in other sectors • low: those who had not yet worked on an hia or considered health in other sectors focus groups the research team held six focus groups, with 10 to 15 participants attending each group. sixty total individuals participated. participants had varying occupations, professional affiliations, and familiarity with hias. every effort was made to evenly recruit participants across the different u.s. regions. figure 2 provides a full breakdown of participants by region. health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 6 participants mainly comprised people from the planning, disaster/emergency preparedness and response, built environment, and transportation sectors. however, people from other sectors, such as housing, public health, and community development, also attended. see figure 3 for a breakdown of participant sector affiliation. most participants classified themselves as having a “medium” (28 individuals) or “high” (24 individuals) level of hia expertise. only six of the focus group participants considered themselves as having a “low” level of experience, and two people did not provide any information on their experience level. results each group expressed diverse information needs, and each indicated different challenges and barriers they face when accessing information. findings suggest figure 3. sector representation of focus group attendees that hia practitioners from all sectors can benefit by integrating into their work health-related information and the information contained in hias. information needs focus group participants described their prior experience incorporating health considerations into their work and noted their information needs. key information needs are as follows. type of information needed focus group participants expressed a need for several different types of information when incorporating health into their programs, policies, projects, and plans. many sought baseline data related to a broad range of determinants of health. these data are often used to assess and demonstrate the effect of a completed intervention or to track changes in indicator status over time, which may establish the need to initiate an health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 7 intervention. participants also expressed a need for more granular local population data, including census tract and block-level information. some mentioned the importance of geocoded socio-demographic information to test for associations with variables of interest. participants also sought access to reputable peer-reviewed sources that provide evidence-based information about the impact of social determinants and other factors with health outcomes. last, specific information on technical assistance and best practices was frequently of interest to focus group participants. sources of information when focus group participants were asked how they accessed the information they needed to incorporate health into their work, a few themes emerged. many of the focus group participants rely on their professional network of colleagues for suggestions or help when information is needed. participants also sought information from universities, which are often working on research projects, have data, and are interested in collaborating with people in the field. participants also noted online resources as one way they access information to incorporate health into their work. although they did not come to a consensus on which specific online sources were most often used, some participants noted that publicly available sites, such as the u.s. census bureau’s data page or the cdc behavioral risk factor surveillance system, are useful. other participants felt that the current tools available to search for and within existing hias were not sufficient to meet their information needs. they indicated that a public online resource containing the following information from or about hias would be useful: • target population • determinants of health addressed • community type • keywords • methods • data sources • evaluation of outcomes conversely, participants sometimes accessed privately available or proprietary information. in these situations, access to these resources is usually restricted to those who requested data, posing barriers to others who might have an interest in that same information. challenges to acquisition and use of information focus group participants indicated several challenges that they encounter when trying to obtain useful information for incorporating health into their work, including using and accessing hias. key challenges are as follows. lack of data at desired level of granularity as focus group participants seek to incorporate health impacts into hia and their work, they often cannot find data that match the size and scope of their target area of interest. for larger communities, data are usually available by zip code or census tract; however, they might not be aggregated by school districts, neighborhoods, or subdivisions. participants indicated that applying data from another comparable area was an ineffective solution, because hia practitioners from that area often faced the same challenges when attempting to acquire data. as a result, seeking information from comparable areas seldom led to any meaningful data acquisition. last, participants mentioned that when they could find data to assess a health impact, the data quality was often a concern. this was because data collection methods were often not adequately described, or analytical approaches had too many limitations. inaccessible information participants noted that, although scientific journals and literature reviews can be especially useful for incorporating health into decision making, many are not available without a paid subscription, which not all organizations can afford. even if cost is not a problem, some information sources are proprietary. health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 8 institutions that own data, such as certain federal and state agencies, provider associations, third-party payers, private businesses, and so on, may be unwilling to share their data with external parties. further, these institutions may keep their data records private, meaning that hia practitioners might never be fully aware of all possible information sources. variations in technology many participants noted that the terminology used in the data sources they find can be difficult to comprehend and to translate to their colleagues. in particular, they indicated that health data can be a challenge to fully understand and to explain to colleagues in other sectors. also, focus group participants encountered difficulties when the same term was used in multiple sectors but had different meanings. limited resources and hia expertise a common issue among participants was having limited resources, such as staff availability or organizational funding, to devote to seeking out hia-related information. the hia process implicitly requires a level of expertise and a time frame that organizations do not always have, so the thought of searching for this information may deter some groups from even conducting an hia. focus group participants also felt that they did not always have enough time to collect data that are most relevant to stakeholders, which can lead to lack of buy-in from key leaders and decision makers. likewise, if they could obtain the desired data, they often could not fully understand the data or effectively translate their impact to another sector. limited information regarding hia evaluation and impacts although outcome evaluations have been conducted at a national level to broadly assess the impact of hias on decision making (bourcier et al., 2015), focus group participants also sought information on the evaluation of individual hias. participants confirmed that results and recommendations from completed hias were useful, but they also wanted to know whether and how these findings were used. for example, has a particular hia been used to sway a stakeholder or inform a policy? information showing the impact of previous hias could help hia champions in an organization make the case to their leadership for conducting subsequent hias. participants also felt that hia recommendations that have produced positive impacts in comparable communities or other sectors could be leveraged by those currently conducting an hia. this impact information could also demonstrate the role of hias in shaping determinants of health and associated health outcomes. feedback indicated that there currently is no location where practitioners can go to find outcomes related to specific hias and that such an online resource would be useful. limitations this study had several limitations. first, insights were gathered through a small convenience sample using focus groups. participation across sectors was uneven and included few participants with limited hia expertise. as a result, it is likely that not all sectors have not been adequately represented in this process, and the findings of this study may not reflect the views of entire sectors. future research can further investigate challenges identified in this study by engaging hia practitioners from a wide range of sectors and a variety of experience levels. furthermore, future studies should also focus on potential users of hias, including decision makers, policy makers, stakeholders, and others. getting a clearer understanding of healthrelated information needs of these groups can inform the structure and design of hias. in addition, the authors categorized focus group participants by their sector. however, the authors could not always conclusively identify the sector of every focus group participant. some participants were unsure about their primary sector or felt that their work spanned multiple sectors. similar analysis in the future should establish firmer definitions of each sector, especially if identifying sector-specific findings. health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 9 finally, the list of challenges included in this article is not meant to be exhaustive or complete, but merely to contain the challenges identified by the focus group participants. focus group questions were open ended, and participants noted a variety of information needs, but did not discuss their experiences performing primary data collection (i.e., surveys and interviews with potentially affected populations). success or barriers with gathering this type of data could be further investigated in future studies. additional information about potential challenges experienced by hia practitioners while conducting hias can be found in the hia handbook for practitioners (lin, houchen, hartsig, & smith, 2017). discussion the study was an assessment of the information needs of new and current hia practitioners. through focus group discussions, the authors sought to learn how these practitioners obtain relevant information, and how information included in hias can be more accessible to people across sectors. identifying and understanding these needs is essential to maximizing the use of existing and future hias. furthermore, improving access to this information can enable stakeholders to more effectively incorporate health considerations in their decisions. feedback from the focus groups identified the information needs of hia practitioners and challenges accessing this information from a variety of sources, including hias themselves. challenges include limited data about the effectiveness of findings and recommendations included in hias, lack of access to some data sets used in hias because of their proprietary nature, and others. focus group participants expressed difficulty accessing information included in hias because of the limited search capabilities of the existing hia data sources. addressing these challenges will require a multi-pronged approach including hia trainings and open access policies at universities. another potential strategy for overcoming these challenges would be the development of a web-based repository system for the more than 400 hias that have been completed as of october 2018. such a repository could provide resources to help future hia contributors develop their content and avoid common challenges, while enabling experienced hia practitioners to determine unmet needs and assess the impact of prior work. access to this information could help address some of the issues associated with a lack of free access to scientific journals. a web-based repository could also help hia practitioners understand sector-specific terminology and expedite searching for health-related information. prior research supports this recommendation. a study by dannenberg (2016a) argued that the community would benefit from pilot tests of existing methods and tools, with the findings of the impacts of projects and policies uploaded to a database for others to learn from. in addition, those conducting or using hias are inherently tasked with justifying the time and funds spent on the hia and expressing their health impact findings in the form of monetary value. this monetary value helps stakeholders (decision makers, hia practitioners, and policy makers) to understand the potential health impacts in the proper context for a given sector (national research council, 2011). consolidating this information in an easily accessible and comprehensive format online could help inform and educate stakeholders. furthermore, a repository would be an excellent location to house various resources and educational materials. as the committee on health impact assessment noted, “a key barrier to the use of hia is the availability of resources for communities 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” (national research council, 2011). as more sectors recognize the need to address social health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 10 determinants more systemically or consider health impacts in decision making, this tool would play an increasingly important role in connecting hia practitioners to the information of interest. we hope that this study will serve as a catalyst for developing this resource. health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 11 references bhatia, r., & katz, m. (2001). estimation of health benefits from a local living wage ordinance. american journal of public health, 91(9), 1398–1402. retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc1446793/ bourcier, e., charbonneau, d., cahill, c., & dannenberg, a. l. (2015). an evaluation of health impact assessments in the united states, 2011 2014. preventing chronic disease, 12, 140376. https://dx.doi. org/10.5888/pcd12.140376 centers for disease control and prevention (cdc). (2018). health impact assessment [web page]. retrieved june 15, 2018, from https://www.cdc.gov/healthyplaces/hia.htm chart-asa, c., & gibson, j. m. (2015). health impact assessment of traffic-related air pollution at the urban project scale: influence of variability and uncertainty. science of the total environment, 506–507, 409–421. https://dx.doi.org/10.1016/j.scitotenv.2014.11.020 dannenberg, a. l. 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(2017). optimizing your health impact assessment (hia) experience: hia handbook for practitioners. topeka, ks: kansas health institute. retrieved from https://www.khi.org/ assets/uploads/news/14753/hiahandbook_final_web.pdf morley, r. m., lindberg, r., rogerson, b. m., bever, e., & pollack, k. m. (2016). seven years in the field of health impact assessment: taking stock and future directions. chronicles of health impact assessment, 1(1), 22–31. https://dx.doi.org/10.18060/21352 national research council. (2011). improving health in the united states: the role of health impact assessment. washington, dc: national academies press. retrieved from https://www.ncbi.nlm.nih.gov/ books/nbk83546/ pew charitable trusts. (2018a). health impact project [web page]. retrieved june 15, 2018, from http://www. pewtrusts.org/en/projects/health-impact-project health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 12 pew charitable trusts. (2018b). health impact project: health impact assessments in the united states [data visualization]. retrieved from http://www.pewtrusts.org/en/multimedia/data-visualizations/2015/hia-map u.s. census bureau. (n.d.). census regions and divisions of the united states [map]. retrieved july 10, 2018, from https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf waheed, f., ferguson, g. m., ollson, c. a., maclellan, j. i., mccallum, l. c., & cole, d. c. (2018). health impact assessment of transportation projects, plans and policies: a scoping review. environmental impact assessment review, 71, 17–25. https://dx.doi.org/10.1016/j.eiar.2017.12.002 health impact assessment: an information needs analysis of hia practitioners across sectors quattrone; callaham; brown; lin; pina 13 corresponding author wes quattrone, ma research health information technology scientist digital health policy and standards program at rti international 6110 executive blvd, suite 902 rockville, md 20852-3907 quattrone@rti.org chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 3 issue 2 (2018) doi: 10.18060/22536 © 2018 author(s): quattrone, w.; callaham, m.; brown, s.; lin, t.; pina, j. this work is licensed under a creative commons attribution 4.0 international license acknowledgements this article draws on work that was completed under contract with the health impact project, collaboration of the robert wood johnson foundation and the pew charitable trusts. the views expressed are those of the authors and do not necessarily reflect the views of the health impact project, the pew charitable trusts, or the robert wood johnson foundation. the authors would like to acknowledge nnphi, sophia, astho, human impact partners, and the health impact project for announcing our study in their newsletters and encouraging their members to participate. this greatly aided in our recruitment efforts. 1 volume 1, issue 1october 2016 a brief history of health impact assessment in the united states andrew l. dannenberg, md, mph background in recent decades, several factors have contributed to the increasing use of health impact assessment (hia) in the united states. initially in california and subsequently in other states, communities that have been traditionally disenfranchised began seeing hia as an opportunity to address the issues impacting their lives and to increase their ability to participate in decision-making processes about those issues. second, public health professionals began to better understand the links between health and the natural and built environments, and to use hia as a tool to improve cross-disciplinary communication. third, public health professionals recognized that hia could be valuable to address economic and social issues, such as educational and wage policies, in addition to built environment issues, such as land use and transportation. some of the major milestones in the growth of the use of hia in the united states are listed in figure 1. the national environmental policy act in 1969 (nepa, 1969) required evaluation of the environmental effects of any “major federal action significantly affecting the quality of the human environment.” in recognizing of the interdependence of environmental quality and human health, nepa was designed “to promote efforts which will prevent or eliminate damage to the environment and biosphere and stimulate the health and welfare of man” (nepa, 1969 §4321) and to “assure for all americans safe, healthful, productive and aesthetically and culturally pleasing surroundings” (nepa ,1969 §4331; bhatia, 2008). while nepa could be used to examine health impacts of projects and policies routinely, in practice, health has received relatively little attention in most environmental impact assessments (eias). for example, eias commonly estimate the change in air quality (an environmental impact) resulting from a proposed project or policy, but do not estimate the associated change in respiratory disease rates (a health impact) that could be expected from that change in air quality. the inclusion of health in the eia process has been encouraged by the national research council report on hia (nrc, 2011) and discussed in several reviews (cole, 2004; bhatia, 2008).examples in which health issues have been incorporated into the eia process include the lake oswego to portland transit project hia in oregon (http:// www.pewtrusts.org/hip/portland-to-lake-oswego-transitproject.html) and the hia of oil and gas leasing in the national petroleum reserve in alaska’s north slope borough (wernham, 2007). in 1986, the world health organization’s (who) ottawa charter for health promotion was a major step toward the development of hia. the charter recognized that achieving health requires working across multiple sectors to fulfill basic human needs including: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity (http://www.who.int/healthpromotion/ conferences/previous/ottawa/en/). in 1997, the who jakarta declaration on leading health promotion into the 21st century specifically called for the use of “equity-focused health impact assessments as an integral part of policy development” (http://www.who.int/healthpromotion/conferences/ previous/jakarta/declaration/en/index2.html). substantial work on hia in the 1990s, primarily in europe, led to the publication of the who gothenburg consensus paper that delineated the core principles of hia practice including democracy, equity, sustainable development, and ethical use of evidence (who, 1999). 2 figure 1. selected milestones in the development of health impact assessment in the us. adapted from ross 2014 and harrisroxas 2012 1969 national environmental policy act passes that included among its purposes to “promote efforts … [to] stimulate the health and welfare of man” 1986 world health organization’s ottawa charter for health promotion recognizes that achieving health requires working across multiple sectors 1997 who jakarta declaration calls for the use of “equity-focused health impact assessments as an integral part of policy development” 1999 who releases the gothenburg consensus paper on hia 2001 san francisco department of public health publishes a paper on the health benefits of a living wage ordinance, the first hia in the us (bhatia 2001) 2004 first book on hia published, primarily with european contributors (kemm 2004) 2006 cdc documents steps to advance hia in the us, based on 2004 cdc/rwjf workshop (dannenberg 2006) 2006 university of california berkeley teaches first graduate school course on hia in the us 2008 cdc documents first 27 hias conducted in the us (dannenberg 2008) 2008 north american hia practice standards working group releases version 1 of practice standards for hias 2008 washington state requires an hia for state route 520 bridge replacement, the first hia required in the us 2008 first hia of the americas workshop held in oakland, ca 2009 massachusetts healthy transportation compact requires hias for transportation projects 2011 national research council publishes improving health in the united states: the role of health impact assessment to guide future of hia in the us (nrc 2011) 2011 society of practitioners of health impact assessment (sophia) established 2012 first national hia conference held in washington, dc, sponsored by rwjf 2014 first textbook on hia in the us published (ross 2014) 2014 first sector-specific review of hias in the us published (dannenberg 2014) 2015 evaluation of the impact of hias in the us published (bourcier 2015) 2016 over 380 hias completed or in progress in the us 2016 first issue of chronicles of health impact assessment published early hia work in the us early work on hia in the us was led by the san francisco department of public health, the ucla school of public health, and partnership for prevention (http://www. prevent.org; cole, 2008). in 1999, the first hia conducted in the us described the health impacts of a living wage ordinance in san francisco; however, it was not called an hia at that time (bhatia, 2001). in 2004, cole discussed the potential for expanded use of hia in the us and identified a number of reports on health impacts of various issues outside of the health sector, such as gambling and building codes. however, many of these reports did not focus prospectively on a specific policy or project and should not be considered hias (cole, 2004). the fact that one can assess the health impacts of any topic (such as air pollution or sea level rise), yet not be doing a health impact assessment, leads to confusion of terminology that persists now. most hias are conducted prospectively on a proposed policy or project in which decision-makers are willing to consider recommendations to promote health or mitigate adverse health impacts. hias that are not timely or in which decision-makers have little receptiveness to recommendations are of less value, although they may still facilitate community engagement. community engagement has long been a central component of hia work (wright, 2005; tamburrini, 2011; cche, 2015). much of the early work in the san francisco bay area focused on efforts with local community partners to address health equity issues. initial work to shape hia practice to be relevant to communities included sessions in which public health and community partners worked to identify the scope of hypothetical hias. after trust between public health professionals and community constituencies was established, these local partners began to call on public health to use hia to help with their project and policy struggles. in one early success, an hia by the san francisco department of public health contributed to the building of affordable replacement housing for low income a brief history dannenberg 3 residents in trinity plaza apartments who were being displaced by the development of market rate condominiums (bhatia, 2007). the creation of the non-profit organization human impact partners (http://www.humanimpact.org/) in 2006 in oakland added to the field’s capacity to conduct hias. similar progress in the mid-2000’s was made in alaska, where work on the health impacts of resource extraction on native alaskan communities led to substantial expansion in the use of hia by the alaska state health department (wernham, 2007; anderson, 2013). in 2002, the centers for disease control and prevention (cdc) hosted a multi-disciplinary workshop in atlanta to develop a research agenda to advance the field of the relation between health and the built environment (dannenberg, 2003). the resulting research agenda listed health impact assessment as one of the recommended approaches worthy of further research. as a result, in 2004, the robert wood johnson foundation (rwjf) and cdc hosted a second multi-disciplinary workshop, including hia experts from europe and canada, to explore approaches to further develop the use of hia in the us (dannenberg, 2006). this workshop suggested next steps including conducting pilot hias, creating a database of completed hias, building capacity to train hia practitioners, evaluating the impacts of hias, and identifying more resources to expand the field. the results of this workshop, as well as the early hia successes in california and alaska, contributed to the expanded involvement of both rwjf and cdc in hia activities in subsequent years. as described below, progress has been made in each of the workshop’s recommended next steps. academic research in addition to the conduct of numerous hias, the field of hia has grown in the united states and internationally over the past 15 years as an area of academic research. two books (nrc, 2011; ross, 2014) and approximately 85 peerreviewed articles (figure 2) with u.s. authors have been published since 2001. some articles focused on hia methods, such as challenges in conducting hias (krieger, 2003), use of quantitative methods in hia (bhatia, 2011), use of stakeholder consultation in hias (tamburrini, 2011), and modeling of traffic noise exposures (seto, 2007). other articles have focused on the effectiveness of hias (bourcier, 2015), teaching hia courses in universities (pollack 2015), and a review of hia guidelines (hebert, 2012). papers focused on the use of hia in specific sectors include: transportation (dannenberg, 2014), housing (morley, in preparation), and education (gase, in preparation). a few articles focused on the conduct and results of a single hia, such as local speed limits in massachusetts (james, 2014), zoning revisions in baltimore (johnson thornton, 2013), and the atlanta beltline transit and redevelopment project (ross, 2012). now containing over 380 hias, the hia database created by the health impact project has been a valuable resource for identifying relevant hias for research and practice (the pew charitable trusts, 2016). figure 2. number of articles with us authors related to health impact assessment, 2001-2015 0 2 4 6 8 10 12 14 16 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 source: http://www.cdc.gov/healthyplaces/docs/hiaarticles_ usauthors_29february2016.pdf teaching and training as the demand for conducting hias has grown over the past decade, there has been a parallel increase in the demand for training professionals to conduct hias. for several years, hia workshops were organized by the cdc, the national association of county and city health officials, and the american planning association with local public health and planning officials in the same classroom to increase their cross-disciplinary collaboration. from 2006 to 2012, over 2200 people in 29 states were trained in at least 75 in-person short courses on hia by four organizations: cdc, the san francisco department of public health, the non-profit human impact partners, and the university of california, berkeley (schuchter, 2015). based on interviews of a sample of trainees, schuchter reported that many trainees had met their training objectives, established new collaborations at the trainings, and disseminated what they learned. in about 2008, the american planning association and the national association of county and city health officials developed a free six-hour on-line training course on hia that has since attracted several thousand users (http:// advance.captus.com/planning/hia2/home.aspx). at least five universities teach graduate level courses focused on hia; a number of students in these courses have subsequently taken jobs that involve the use of hia skills (pollack, 2015). national capacity to conduct hias has been strengthened by the founding of the society of practitioners of health impact assessment (sophia) (http://hiasociety. org/) in 2011 and the development of a network of hia professionals who provide technical assistance to new hia practitioners with support from the health impact project and others. national and international conferences the growth of hia conferences over the past decade has helped advance the field by facilitating interactions among hia practitioners. six national hia workshops have been held in oakland, california, beginning in 2008 (http:// hiasociety.org/?page_id=833). these workshops include 75a brief history dannenberg 4 100 experienced hia practitioners and focus on advancing hia practices. three national hia conferences have been held in washington, dc, beginning in 2012 (http://www. pewtrusts.org/en/projects/health-impact-project/researchand-analysis/presentations-and-webinars). these conferences each attracted 400-500 participants ranging from novices to experienced hia practitioners, and have been primarily sponsored by the robert wood johnson foundation. in addition, hia practitioners from the us have participated in some of the thirteen international hia conferences during 1998-2013, held primarily in europe except for the 2012 conference in quebec (http://www.apho.org.uk/resource/ browse.aspx?rid=93284). hia guidelines and standards early work on developing guidelines and standards for hia was associated with creating structured reports for hia projects conducted by the hia class taught at uc berkeley that began in 2006. this work was furthered by activities associated with the hia workshops in oakland and led to the most recent version entitled minimum elements and practice standards for health impact assessment (bhatia, 2014). while this document recommends standards for hia conduct, the actual practice of hia in the us varies widely on issues such as engaging stakeholders, formulating actionable recommendations, and providing an implementation plan for follow-up. evaluation the need to evaluate the impact of hias on subsequent decisions and health outcomes was evident from early in the growth of the field (dannenberg, 2006). several process evaluations have examined whether specific hias followed recommended methods (schuchter, 2014; us epa, 2013). the largest impact evaluation conducted in the us included detail case studies of 23 hias and concluded that “hias are a useful tool to promote public health because they can influence decisions in non-health-related sectors, strengthen cross-sector collaborations, and raise awareness of health issues among decision makers” (bourcier, 2015). findings from this study were similar to those from hia evaluations conducted in europe (davenport, 2006; wismar, 2007) and in australia (haigh, 2013). several studies have specifically documented facilitators and barriers to successful hias (davenport, 2006; bourcier, 2015: haigh, 2015; dannenberg, 2016). funding no consistent source of funding has been routinely available to conduct hias in the us. many hias have been conducted with support from the health impact project (a collaboration of rwjf and the pew charitable trusts, http://www.pewtrusts.org/en/projects/health-impactproject) [see related hia article from health impact project in this issue of chia]. a number of hias have been supported by the california endowment, blue cross and blue shield of minnesota foundation, kansas health institute, rwjf’s active living research program, and other foundations. other hias have been funded by the cdc’s healthy community design initiative, either directly or through partners such as the national association of county and city health officials and the national network of public health institutes. some hias have been conducted by health departments within the scope of their existing resources or by students enrolled in graduate school hia courses (pollack, 2015). institutionalization the national research council report on hia stated “hia is a particularly promising approach for integrating health implications into decision-making” (national research council, 2011). in recent years, there has been increasing interest in multisectoral approaches to health promotion, often called health in all policies (hiap). an executive order by the governor of california in 2010 set up a task force to advance the use of hiap in the state (http://sgc.ca.gov/s_ hiap.php). hia is a tool that can be used to further the hiap approach (collins, 2009; gase, 2013). the national prevention council (which includes 17 primarily non-health agencies) in its national prevention strategy states that “opportunities for prevention increase when those working in housing, transportation, education, and other sectors incorporate health and wellness into their decision making” (p. 2) and that hia “can be used to help decision makers evaluate project or policy choices to increase positive health outcomes and minimize adverse health outcomes and health inequities” (national prevention council, 2011, p. 15). other national reports that encourage the use of hia include the white house task force on childhood obesity (white house task force, 2010), the department of health and human services healthy people 2020 report (us dhhs, 2012), and the cdc’s transportation and health policy statement (cdc, 2011). state legislators have proposed or adopted a number of bills that include certain elements of an hia. the national conference of state legislatures (farquhar, 2014) reported that 55 bills in 17 states supportive of hia or its components were introduced during 2009-2014, but few passed into law. among successful hia-related bills, a bill in washington state mandated an hia as part of funding for the state route 520 bridge replacement in seattle (seattle king county public health, 2008), and the massachusetts healthy transportation compact mandated hias in transportation-related projects (massachusetts department of transportation, 2009). in alaska, the use of hia has been institutionalized with funding support from the state’s natural resources permitting process (http://dhss.alaska. gov/dph/epi/hia/pages/default.aspx; anderson, 2013). in washington state, “health impact reviews” are conducted on proposed legislation by the state board of health when requested by the governor or a state legislator (http://sboh. wa.gov/ourwork/healthimpactreviews). a brief history dannenberg 5 conclusion the use of hia has grown substantially over the past 15 years since it was first introduced in the us. familiarity with hia has greatly increased both among public health professionals and decision-makers in other sectors and among many community groups. hia is proving valuable as a tool to facilitate community engagement and empowerment, even in cases where changes in a decision explicitly due to that hia may be difficult to document. hias have been useful in sectors well beyond the built environment, including topics such as incarceration, gambling, living wages, after school programs, and climate change policies. little is known about the impact of policies that encourage or require the use of hias; further research on this topic would be valuable. challenges to the further expansion of hia use include the need for reliable funding sources and the potential for pushback in an anti-regulatory environment. in the long term, as the awareness of health impacts increases in other sectors, it may be possible to achieve healthy outcomes without needing to conduct a formal hia on every proposed individual project and policy. should it occur, such an accomplishment would be due in large part to the success of the hundreds of hias that have been and are being done now. a brief history dannenberg 6 references anderson, p. j., yoder, s., fogels, e., krieger, g., & mclaughlin, j. 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(2016). health impact project. health impact assessments in the united states database. http:// www.pewtrusts.org/en/multimedia/data-visualizations/2015/hia-map a brief history dannenberg 8 acknowledgements we thank rajiv bhatia and jonathan heller for their helpful comments on a draft of this paper. corresponding author andrew l. dannenberg, md, mph affiliate professor school of public health and college of built environments university of washington, seattle adannen@uw.edu u.s. department of human services. (2008). healthy people 2020. http://www.healthypeople.gov/2020/about/advisory/ reports u.s. environmental protection agency. (2013). a review of health impact assessments in the u.s.: current state-of-science, best practices, and areas for improvement. https://cfpub.epa.gov/si/si_public_record_report.cfm?direntryid=266763 wernham, a. (2007). inupiat health and proposed alaskan oil development: results of the first integrated health impact assessment/environmental impact statement of proposed oil development on alaska’s north slope. ecohealth, 4(4):500513. http://dx.doi.org/10.1007/s10393-007-0143-z white house task force on childhood obesity. (2010). report to the president. solving the problem of childhood obesity within a generation. may. http://www.letsmove.gov/white-house-task-force-childhood-obesity-report-president wismar, m., blau, j., ernst, k., & figueras, j. (2007). the effectiveness of health impact assessment: scope and limitations of supporting decision-making in europe. european observatory on health systems and policies. brussels. http://www.euro. who.int/__data/assets/pdf_file/0003/98283/e90794.pdf world health organization regional office for europe. (1999). health impact assessment: main concepts and suggested approach. gothenburg consensus paper. brussels. http://www.apho.org.uk/resource/item.aspx?rid=44163 wright, j., parry, j., & mathers, j. (2005). participation in health impact assessment: objectives, methods and core values. bulletin of the world health organization, 83:58-63. http://www.scielosp.org/pdf/bwho/v83n1/v83n1a14.pdf a brief history dannenberg chia staff editor-in-chief cynthia stone, richard m. fairbanks school of public health indiana university-purdue university indianapolis journal manager lyndy kouns, richard m. fairbanks school of public health indiana university-purdue university indianapolis chronicles of health impact assessment vol. 1, no. 1 (2016) doi: 10.18060/21348 © 2016 author(s): dannenberg, a.l. this work is licensed under a creative commons attribution 4.0 international license. 32 volume 1, issue 1october 2016 advocacy in hia: increasing our effectiveness and relevance as practitioners to address health, equity, and democracy abstract: the role of advocacy in health impact assessment (hia) is debated among practitioners. concerns revolve around whether engaging in advocacy undermines objectivity and credibility. while there is agreement that dissemination of findings and recommendations is necessary, there is a spectrum of activities that can be undertaken in an hia, one end of which might be considered advocacy. in this perspective from the field, we posit that in conducting an hia, practitioners are choosing to advocate for a set of causes that may include improved health, decreased inequity, and increased democracy. we come to the table with these values and the intent to advocate for them. for any hia to be relevant and effective at advancing these causes in decision-making contexts, practitioners must use the best available evidence and a range of strategies to communicate evidence to policy audiences, including deliberate tactics with community organizations, decision makers, and others that can aid in addressing power imbalances. though we believe that hia practice cannot reach its full potential without embracing advocacy, practitioners must make decisions given their context, including local power dynamics as to how far into the advocacy spectrum they venture in any given hia. this paper is geared towards hia practitioners and others who want to understand the opportunity advocacy provides. we begin by describing the underlying values of hia that inspire this perspective, including those in the 1999 gothenburg consensus paper on hia (quigley et al., 2006). after briefly describing concerns hia practitioners may have with advocacy, particularly that it undermines the objectivity and credibility of the hia process, we then discuss common advocacy activities practitioners might undertake, and ways to address risks these activities may pose. these opportunities to undertake advocacy include partnering with diverse stakeholders, developing advisory committees, gauging the power and policy context, and thinking broadly about the best tactics to effectively communicate findings. we conclude with a case study describing how advocacy was used in the treatment instead of prison hia in wisconsin to advance health, equity, and democracy. perspectives from the field lili farhang, mph; jonathan c. heller, phd 33 box 1. examples of advocacy activities within hia what is perceived as advocacy varies based on the institutional context of practitioners. most commonly, however, advocacy is perceived as how stakeholders are engaged in the process and in hia communications and dissemination. below we describe activities that may be considered to be advocacy within hia. stakeholder participation including stakeholders, such as those who have a pre-existing position on a proposal, in the hia process prioritizing the hia goals and research questions based on the interests of stakeholders using assessment methods (e.g., community-based participatory research) that are directed by only some stakeholders prioritizing recommendations based on the interests of stakeholders giving stakeholders decision-making authority over the process inclusion of impacted populations and communities facing inequities – who are perceived as having a predetermined position – in the hia process fostering coalition and consensus building within hia communications and dissemination public release of findings and recommendations proactive outreach to highlight and translate findings and recommendations to decision makers, media, and/or stakeholders responsiveness to informational and educational requests from decision makers, media, and/or stakeholders publicly highlighting and translating evidence via interviews, letter writing, public testimony, and other activities working with stakeholders to build their capacity to use hia findings and recommendations in decision making venues direct lobbying of decision makers to encourage support or opposition of a specific action grassroots lobbying of the public to encourage support or opposition of a specific action introduction the 2014 minimum elements and practice standards for health impact assessment open by describing the goal of hia: “health impact assessment (hia) is a practice that aims to protect and promote health and to reduce inequities in health during a decision-making process” (bhatia et al., 2014, p. 1). as practitioners seeking to accomplish this goal, we recognize that use of sound science is necessary. we also recognize that it is not sufficient; in our perspective, advocacy is also necessary. advocacy is defined by merriam-webster as “the act or process of supporting a cause or proposal” (retrieved 2015, from http://www.merriam-webster. com/dictionary/advocacy) and a variety of activities within hia can be judged as advocacy [see box 1]. advocacy may be seen as the involvement of stakeholders with a pre-determined position in the hia and giving them control over aspects of the hia. communications and dissemination activities are also often characterized as advocacy, most often when the hia is used to influence the outcomes of a decision, for example through direct or grassroots lobbying [see box 2]. the appropriateness of these activities is debated among practitioners (advocacy in hia working group, 2013). layered on the debate are questions about the relationship between advocacy and research objectivity, bias, and neutrality. we posit that in order for most hias to be relevant and effective at protecting and promoting health and reducing inequities – as well as advancing democracy, another core value of hia – in the context of a decision-making process, it is necessary for hia practitioners to engage in advocacy to influence how decisions are made. many hias that we and others have conducted have failed to affect decision making as a result of our limited engagement with the decision-making process. we believe this is because those who benefit from current inequities and limitations on democracy are powerful forces and, in the face of these forces, data by itself does not lead to change. this is evident in a wide range of policy debates, from gun control to climate change, and from healthy food access to access to paid sick days. as congressman henry waxman says, “when you look back on key legislative fights over public health issues, you will see that the expertise and advocacy of public health professionals provide a critically important counter pressure to the lobbying clout of special interests. the grassroots efforts by the public health community help educate legislators and play a pivotal role in our legislative efforts to improve the health of the people of the united states” (american public health association, 2005, p. 5). practitioners, therefore, must often use the best available evidence and a range of strategies to communicate the evidence to various policy audiences, including deliberate tactics with community organizations, decision makers, and other stakeholders that can aid in addressing power imbalances. there are barriers and risks to conducting advocacy, but there are also opportunities throughout the hia process to overcome and allay those. this paper is geared towards hia practitioners and public health professionals who want to understand the opportunity advocacy provides to advance a more effective and relevant hia practice. we begin by describing the larger context of hia practice that drives this perspective, barriers to engaging in advocacy, and opportunities and best practices to conduct advocacy in the context of hia. we end with a case study describing how advocacy was used in an hia in wisconsin to advance health, equity, and democracy. foundations of our perspective health impact assessment is shaped by a set of foundational values and concepts, and that inspire our perspective that advocacy is essential to the field’s success. the 1999 gothenburg consensus paper on hia and the 2006 international association for impact assessment special advocacy in hia farhang; heller, 34 box 2. advocacy and lobbying. direct lobbying: attempts to influence a legislative body through communication with a member or employee of a legislative body, or with a government official who participates in formulating legislation. the communications must refer to and reflect a view on the legislation (internal revenue service, 2015). grassroots lobbying: attempts to influence legislation by attempting to affect the opinion of the public with respect to the legislation and encouraging the audience to take action with respect to the legislation. the communications must refer to and reflect a view on the legislation (internal revenue service, 2015). according to the american public health association: “how is lobbying different from advocacy?” advocacy is participating in the democratic process by taking action in support of a particular issue or cause. advocacy activities like participating in a town meeting or demonstration, conducting a public forum or press activity, or developing an issue brief for your local policy-makers on a particular public health issue do not constitute lobbying as long as you are not urging a policymaker to take a position or action on specific legislation (american public health association, 20015) publication on hia (quigley et al., 2006) define values that guide the practice: democracy, equity, sustainable development, ethical use of evidence, and comprehensive approach to health. the gothenburg paper contextualizes these values by stating that: “all policy processes are carried out in the framework of values, goals, and objectives that may be more or less explicit in a given society and at a given time. it is essential that such values are taken into account, otherwise hia runs the danger of being an artificial process, divorced from the reality of the policy environment in which it is being implemented” (p. 4) as practitioners, these explicit and motivational values – and the worldview they represent – inspire us to be part of the field. the world health organization’s commission on social determinants of health final report (world health organization, 2008) provides guidance as to what equity and democracy mean in wider public health practice: “any serious effort to reduce health inequities will involve political empowerment – changing the distribution of power within society and global regions, especially in favour of disenfranchised groups and nations…….health equity depends vitally on the empowerment of individuals and groups to represent their needs and interests strongly and effectively and, in so doing, to challenge and change the unfair and steeply graded distribution of social resources (the conditions for health) to which all men and women, as citizens, have equal claims and rights” (p. 18). in other words, both the process of empowerment within the democratic process and the power accumulated by groups currently without power are considered central to the pursuit of health equity. in accepting a set of values to motivate our practice, practitioners acknowledge that we inherently reflect a set of cultural norms and worldviews in our work; foremost among these worldviews is that research should inform policy making. as stated by michael nelson, professor of environmental ethics and philosophy at michigan state university, “advocating for the use of science and for revealing the discoveries of science, as well as for specific policy positions are forms of advocacy. simply because the former is uncontroversial does not mean it is not a form of advocacy, it most certainly is. so in some ways the question is not, is advocacy acceptable, but which kinds of advocacy are acceptable and, most importantly, how ought we to go about advocacy….” (nelson, n.d.). indeed, a recent pew study that found, “a large majority of the public (76%) and nearly all scientists (97%) say that it is appropriate for scientists to become actively involved in political debates on controversial issues such as stem cell research and nuclear power.” (pew research center for the people & the press, 2009, p. 34). in choosing to conduct an hia, practitioners are either consciously or unconsciously choosing to advocate for a set of causes including improved health, decreased inequity, increased democracy, and empowerment. these values – or causes – are not neutral. they reflect a world with a set of policy outcomes and decision-making processes that are different from our current policy climate. the transition to this better world will not occur naturally, even if the evidence points towards it. powerful social forces, including dominant interests, entrenched ideas, and disenfranchisement – that converge to maintain the status quo – need to be overcome. advocacy is a necessary, though not sufficient, tool that can motivate policy makers to overcome these forces and advance health, equity, and democracy. concerns with and barriers to engaging in advocacy some within the hia field have expressed unease with a wider perspective of advocacy, particularly that a practitioner engaging in advocacy undermines the objectivity and credibility of the hia process, findings, and recommendations and may also reflect the biases of researchers (advocacy in hia working group, 2013). concerns can be summarized as follows: engaging in advocacy makes the practitioner seem biased and engaging with others who advocate makes the practitioner biased by extension; scoping and assessing topics based on the priorities and concerns of historically impacted communities may lead to particular findings and recommendations that deviate from the dominant worldview; taking a position is not appropriate when practitioners may not know or understand the universe of competing priorities or unintended consequences related to a decision; and having our role as neutral public health practitioners evolve from informing to advocating to lobbying is potentially problematic. our perspective is that these concerns are based on perceived risks that can be addressed in the hia process. while advocacy in hia farhang; heller, 35 we recognize that these concerns are authentic and real (e.g., both laws and funding sources may limit one’s ability to engage in lobbying), one can carry out a sound hia and advocate for an hia’s findings and recommendations with actions intended to maintain the integrity of the practice. advocacy reflects a spectrum of activity (see box 1), the range of which reflects the institution in which a practitioner is situated. public health professionals, in particular, face numerous barriers to conducting advocacy, including riskaverse agency leadership, political resistance from elected officials, lack of relationships and understanding of other policy domains, and a lack of capacity and resources. public health is also disconnected from movements to advance equity and democracy, and unclear about how to contribute to these movements. addressing these constraints is beyond the scope of this paper or the responsibility of any individual hia practitioner; however, efforts exist to overcome them (national association of county and city health official, 2014; farhang, heller, levey, & satinsky, 2015). opportunities to conduct advocacy in the context of hia there are a number of best practices we can undertake as practitioners to minimize potential sources of bias and to legitimize our advocacy activities. primary among these is to be transparent about every aspect of the hia process, including funding sources, partners and their roles, research approach, and decision-making processes. information about these should be included in the hia report and all other communications about the findings and recommendations. below, we delve more deeply into opportunities to conduct advocacy in the context of hia, the potential causes of concern, and best practices to conduct an effective and relevant hia that leads to improved health, equity, and democracy. partner with a diverse set of stakeholders, including those most likely to be impacted by the decision, to conduct the hia some stakeholders, including community organizations, are often perceived to be advocates – and therefore biased – because they might be seen as having a position, use various tactics to get the attention of decision makers, and engage with populations that will be impacted by the decision. other stakeholders’ motivations, in contrast, are not scrutinized in the same way, either because their perspective aligns with the dominant worldview or because we do not even recognize that they are exerting control over the public agenda (gaventa & cornwall, 2001). often, there are different degrees of power among these various stakeholders. for some hia practitioners, redressing this imbalance of power – i.e., empowerment as discussed by the who’s commission on social determinants of health – in a particular decision-making context may be a goal for the hia, a goal that should be transparently stated. partnership with disenfranchised groups, for example through a community organization, in the hia process may be considered a way to advance empowerment, democracy, and equity. establishing a stakeholder oversight/advisory committee composed of people with variety of experience, including vulnerable populations most likely to be impacted by the decision at hand, to guide the hia is good practice. by including people with varied experience, the hia can represent different perspectives and be used to build consensus and relationships, which helps address past disenfranchisement. establishing such a diverse committee can also address advocacy concerns around partnership with a community organization, as other members may be seen as contributing balance and scientific rigor. the hia should be transparent about the membership of the committee and the committee’s role in the hia process. work jointly with an advisory committee to select and assess research topics as with any research, hias require topic prioritization given budget and time constraints. one might believe that public health professionals, who have training and familiarity with the peer-reviewed literature, are in the best position to prioritize research topics. focusing on topics with which stakeholders – especially members of impacted communities – are most concerned may be considered a form of advocacy, as it prioritizes some topics for research over others and de-prioritizes public health expertise. however, focusing on topics of importance to stakeholders ensures that an hia is adding value by responding to unanswered questions. furthermore, while public health professionals bring their expertise to the hia process, other stakeholders also have legitimate and valuable expertise; community members, for example, can inform the process with their lived experiences. last, topics not well studied in the peer-review literature are still valid if they are of concern to stakeholders. the research priorities of many stakeholders make an hia more robust. again, transparency is important; the hia should clearly state which topics were prioritized and deprioritized and why. in the assessment phase, it is crucial that practitioners do not let their own or stakeholder’s pre-conceived notions influence their findings on any of the selected research topics. guided by the value of ethical use of evidence and the practice standards, (bhatia et al., 2014), practitioners must consider evidence that both support and refutes particular impacts, acknowledge insufficient evidence when that is the case, and communicate that predictions are not definitive but based on best available evidence. review by stakeholders and by professionals not affiliated with the hia can be useful for identifying potential sources of bias and conclusions that are not supported by the evidence. these potential pitfalls and best practices are important in any hia, not just those in which stakeholders such as community members advocacy in hia farhang; heller, 36 are heavily involved. gauge the power and policy context in determining the best strategy for taking a position coming to a decision at the conclusion of the assessment phase, after examining and weighing the evidence, about the benefits and harms of a proposal, and generating a set of recommendations, means we are not neutral. hia recommendations are meant to maximize the benefits and minimize the harms. during the reporting phase, some might consider taking a position on the proposal to be a form of advocacy, believing that an “objective researcher” would let the evidence speak for itself. however, if the research was carefully conducted and leads to clear conclusions about positive or negative impacts on health and equity, and if the hia practitioner’s goal is to improve health and reduce inequities, it is important that the practitioner communicate clearly about the evidence and its conclusions. evidence cannot speak for itself. this can lead to practitioners taking a position on all or part of a proposal, or being perceived as doing so. while some practitioners may be able to take a position and conduct advocacy based on that position and find that this helps achieve healthand equity-promoting change, others (e.g., those working in government agencies) may be constrained from doing so by their institutions or by lobbying regulations (e.g., they may not be able to communicate their views directly to decision makers). in some cases, other stakeholders who were part of the hia process may take positions and lead advocacy efforts. these are all acceptable practices. importantly, practitioners should consider that they may not understand the full context of the competing priorities and choices faced by decision makers. for example, recommending in an hia that a project not move forward in a particular community might just mean the project moves forward in another community not studied in the hia. given this, practitioners must be attuned to uncertainty in our research, be aware that advocating for hia recommendations or taking a position could have unintended consequences, and consider how best to account for this in developing recommendations (e.g., by discussing potential recommendations with decision makers when appropriate). furthermore, if there is insufficient evidence to reach clear conclusions, the hia should state so and communications about the findings should not overreach in those areas. communicating the lack of clear findings can also be informative for decision makers and may, for example through recommendations, point to policy options with more certain impacts. finally, after doing several hias on similar proposals over time, whether the topic is food accessibility or criminal justice, an hia practitioner is likely to develop a knowledge base around a set of topics, and may be able to come to a conclusion and/or take a position on a proposal before completing the hia. researching the local context with respect to a proposal and understanding the differences with previous contexts and proposals is important for minimizing bias and before taking a position. think broadly about the best tactics to effectively communicate findings translation and communication of findings and recommendations in the decision-making process – and to audiences to whom decision makers listen – may be considered advocacy by some. most practitioners make active efforts to inform decisions, which include, for example, sharing the hia report and summary materials extensively, letter writing, hosting public meetings, and disseminating products to the media. some might define these information-sharing activities as advocacy. at a minimum, practitioners have a duty to produce a publicly accessibly report and distribute it to decision makers and other stakeholders. practitioners should also be willing to interpret and assist stakeholders to accurately use findings and recommendations. speaking to decision makers, the media, and other stakeholders fulfills this objective. beyond that, the range of activities in which a practitioner can engage will be construed by their institution and may be considered advocacy. there is no reason classifying such activities as advocacy should delegitimize them. some practitioners are concerned that testifying publicly or speaking with decision makers is lobbying and are concerned with overstepping legal limits. lobbying has specific legal definitions (see box 1) which vary by jurisdiction and which practitioners must understand. lobbying restrictions must be followed. conflating all advocacy with lobbying is counter-productive. there is validity in asking whether it is in the best interest of improving health, and advancing equity and democracy, if an hia practitioner takes a position on the proposal and plays a lead role communicating that position. in some contexts, the hia practitioner may be seen as a “professional expert” and their voice can carry a significant weight. in other contexts, they may be seen as an interfering outsider and their leadership may be counter-productive. ultimately, understanding context is integral to making the most of advocacy efforts and advancing opportunities – ones that have minimal negative consequences – to achieve hia goals and align with practice values. case study: treatment instead of prison hia to elucidate what advocacy to promote health and reduce inequities looks like in the context of a specific hia, we describe here the treatment instead of prison hia (gilhuly, farhang, tsui, puccetti, & liners, 2012). in 2012, human impact partners partnered with wisdom (a statewide congregation-based organizing network based in wisconsin), state agencies, academics, and other experts to conduct an hia to assess the health effects of increasing funding in the advocacy in hia farhang; heller, 37 state budget for wisconsin’s treatment and diversion programs from $1 million a year to $75 million a year. wisconsin, like other states, was incarcerating growing numbers of non-violent drug and alcohol offenders and had stark racial disparities in sentencing. wisdom was campaigning to cut wisconsin’s prison population by expanding access to treatment programs and the hia was conducted to understand the impacts these alternatives would have on incarceration. the hia and other efforts led to a quadrupling of state funding in wisconsin for treatment alternatives to prison. in each phase of the hia, hip worked to ensure the process was responsive to our values of equity, democracy, and empowerment. from the start of the project, we carried out the process to maximize the advocacy for policy change based on our findings and recommendations: project management: hip and wisdom convened an advisory committee comprised of academics, researchers, and public agency staff to guide the hia, evaluate the science to make sure the interpretation of information was accurate, and help develop recommendations grounded in the legislative and administrative reality of the state. members of the advisory committee became natural spokespeople and advocates for the hia’s recommendations. screening: with wisdom, we chose to conduct an hia on a topic for which there were already constituencies engaged; it was a topic that was relevant and meaningful to people. this interest in the topic created a demand for the research and an audience interested in receiving and using the results. these audiences hoped the research would support their campaign, but were taking a risk that it might not. they were also open to changing their policy requests based on the hia findings. scoping: the topics on which the hia focused were based on questions about determinants of health that the advisory committee, wisdom, and its community constituents – including those formerly incarcerated and their families – thought would have the largest impact on health and on the debate. answering research questions prioritized by these partners increased the likelihood that stakeholders would use the research in the decision-making process and decision makers would therefore pay attention to the findings. assessment: the research process drew on multiple sources of information, including the experience and expertise of formerly incarcerated people, their families, service providers, law enforcement, and judges. for hip and the advisory committee, including the voices of these stakeholders was important from an empowerment perspective and because published studies may not have examined some of the prioritized research questions thoroughly. the evidence from the literature used reflected the consensus of researchers across multiple disciplines who participated in the hia process about the potential impacts of the proposal. these researchers participated in meetings to review the evidence and reviewed the draft report. recommendations: the recommendations identified were responsive to the impact predictions and – because of the advisory committee’s local knowledge – reflected the administrative and legislative reality of the state. because stakeholders involved sought the best outcomes for their communities, they were committed to identifying feasible and actionable recommendations for which they could advocate. reporting: findings and recommendations were summarized into easily digestible materials for decision makers to consider and stakeholders, including community members, to use in the decision-making process. while hip participated in press briefings and media interviews to explain the hia process and findings, our perspective was that community members would be the most effective spokespeople to communicate to decision makers and advocacy on their own behalf advanced the goal of empowerment. through this model, where local voices spoke to the findings and recommendations, there was significant press coverage of the hia. hip was transparent with all stakeholders throughout the hia process and in the final products about who funded the hia, who was involved, and how the topics and research categories were selected. through the research, we found overwhelming evidence that expanding alternatives to incarceration would reduce the prison population, reduce crime, lower recidivism, and strengthen families by keeping up to 1,600 parents a year out of prison each year. because studies showed that the cost of treatment was about one-fourth of the cost of incarcerating people, we found that the state would also save up to two dollars for every dollar spent on alternative treatment programs. based on an internal evaluation that included interviews with key partners, the hia was a success on multiple levels. it had a tremendous impact on the conversation around treatment over incarceration in wisconsin. every major media outlet in the state covered its release, with over 30 news stories about it. in addition to the quadrupling of funding, legislators from both parties have pledged continued support for future funding increases. wisdom continues to use the research in meetings with legislators, strengthen relationships with the public health community, organize their communities, and keep the issue in the media spotlight. decision makers and the state budget were directly affected by the hia findings and recommendations; there was a shift in the narrative around what affects health; new collaborations were formed; community members felt empowered by the experience of participating in the process; and the hia continues to contribute to the dialogue around incarceration in the state. success resulted from the hia process and the advocacy it supported. because the project sought to answer a set of socially meaningful and relevant questions, wisdom’s organized constituencies – including citizens, clergy, prosecutors, judges, and service providers – were motivated advocacy in hia farhang; heller, 38 to integrate the findings and recommendations into their campaign. the approach also helped legitimize the research for decision makers, who, while caring about the underlying evidence, also cared to see a broad network of community, academic, and other stakeholders bought into the research. had we not conducted the hia to advocate for our causes of health, equity and democracy, the hia may not have had as significant an impact. the model of the treatment instead of prison hia is reflected in many of our other projects and has resulted in similar successes. in our farmers field hia (lucky, satinsky, & nasser, 2012) and our university of southern california hia, (lucky & heller, 2012) community organizations participating in the hia used research findings to leverage housing, job, and health mitigations via legally binding community benefit agreements. our jack london gateway hia (heller, 2007) led to changes in the design of a local development to address identified health impacts. based on these successes, others, including government agencies (pew charitable trusts health impact project, 2014), are also beginning to conduct more advocacy in their hias as well. in all of these examples, various forms of advocacy – relevance of the topics of focus to local community stakeholders, empowerment of those groups through the hia, and the direct and organized use of findings and recommendations in the decision-making process – led to successful hia outcomes that may not otherwise have been realized. conclusion working within a policy context, and driven by a set of foundational values, we must be thoughtful about how we, as practitioners, can be most effective at accomplishing the wider goal of hia – to protect and promote health and to reduce inequities in health. while we cannot expect that the answers will be the same in all situations and that all practitioners will engage in the same activities, the success of the wisconsin treatment instead of prison hia and other hias provide an example of how advocacy can be woven throughout the hia process in such a way as to increase its relevance, use, and ultimately its efficacy in the policymaking domain. the model of hia described here, that combines sound science with advocacy for health, equity, and democracy, can lead to public health becoming a model of accountable and effective government. while hia practitioners rely on empirical data, we know that data alone is not enough to influence the policy process. context, ideas, and power matter. the process and product of hia can empower vulnerable populations most likely to be impacted by decision making and start to reform the structures and institutions that currently result in inequity. but data alone will not do this. data need advocates. advocacy in hia farhang; heller, 39 acknowledgements we wish to thank marjory givens for her thoughtful review and feedback on this paper. references advocacy in hia working group. 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(2012). healthier lives, stronger families, safer communities: how increasing funding for alternatives to prison will save lives and money in wisconsin. oakland, ca: human impact partners. heller, j. (2007). jack london gateway rapid health impact assessment: a case study. oakland, ca: human impact partners. internal revenue service. (2015). “direct” and “grass roots” lobbying defined. retrieved from: https://www.irs.gov/charities-&-non-profits/direct--and--grass-roots--lobbying-defined lucky, j., & heller, j. (2012). a rapid health impact assessment of the city of los angeles’ proposed university of southern california specific plan. oakland, ca: human impact partners. lucky, j., satinsky, s., & nasser, e. (2012). findings and recommendations of the rapid health impact assessment of the proposed farmers field development. oakland, ca: human impact partners. national association of county and city health officials. (2014). expanding the boundaries: health equity and public health practice. washington, d.c. nelson, m. (n.d.). do scientists have a special responsibility to engage in political advocacy? retrieved from: http://bigthink.com/age-of-engagement/do-scientists-have-a-special-responsibility-to-engage-in-political-advocacy pew charitable trusts health impact project. (2014). fitchburg–nine springs health impact assessment. retrieved from: http://www.pewtrusts.org/en/multimedia/data-visualizations/2015/hia-map/state/wisconsin/fitchburgnine-springshealth-impact-assessment pew research center for the people & the press. (2009). public praises science; scientists fault public, media. washington dc. retrieved from: http://www.people-press.org/2009/07/09/section-4-scientists-politics-and-religion/ quigley, r., den broeder, l., furu, p., bond, a., cave, b., & bos, r. (2006). health impact assessment: international best practice principles. (special publication series no. 5.). fargo, usa: international association for impact assessment. world health organization. (2008). closing the gap in a generation: health equity through action on the social determinants of health. final report of the commission on social determinants of health. geneva: world health organization. corresponding author lily farhang, mph human impact partners 304 12th st, suite 2b oakland, ca 94607 lili@humanimpact.org advocacy in hia farhang; heller, chia staff editor-in-chief cynthia stone, richard m. fairbanks school of public health indiana university-purdue university indianapolis journal manager lyndy kouns, richard m. fairbanks school of public health indiana university-purdue university indianapolis chronicles of health impact assessment vol. 1, no. 1 (2016) doi: 10.18060/21350 © 2016 author(s): farhang, l.; heller, j.c. this work is licensed under a creative commons attribution 4.0 international license. october 2020 volume 5 issue 1 c h i a chronicles of health impact assessment improving community health through health impact assessments letter from the society of practitioners of health impact assessment dear readers, welcome to the fall edition of the chronicles of health impact assessment. whilst the papers in this issue weren’t written with the pandemic we are globally facing in mind, maybe the themes they present is even more paramount in this current climate: using data-driven approaches to understanding public health issues; engagement with community stakeholder network; learning how to implement a new (to the user) framework or lens with which to view emergent issues; and of course, leveraging new partnerships in the face of limited resources to realize demonstrable improvement in health outcomes. for many, life in this modern pandemic has cast a spotlight on this thought: how do we find a balance of the opportunities, challenges, and lasting impacts that inevitably come from decisions made on a community scale? considering this as it relates to hia, a core opportunity is the collaboration it can bring to the table, involving different stakeholders, both internal and external, developing importantly robust and transparent engagement with the communities that will be affected by a policy or program. yet, there is a cost in time, and resources. skills, time and capacity are prime needs to drive both an individual hia and the organizational thinking to consider the value of health impacts no matter what type of policy or program. the overall opportunity and cost need to ultimately provide value to the audience – that what was invested was returned at a desirable rate, such that the investment is made again and again. in that we see institutionalization of the lens through which health receives at least equal billing to financial, political, and other decision-making frames. the papers in this edition highlight great examples of how hia can be used and linking the wider social determinants of health to having a unified approach across organizations which will in the end impact, preferably positively, on their people and communities. using hia is also a good step to developing a culture of health in all policies – an element maybe never envisaged when hia was started to be used, all those decades ago. i sophia letter grinnell and bonner ii the papers also emphasize, the importance of the effect of inequality to those vulnerable communities and the impacts of inequity, whether that is because of transport, access to food or education or green space and housing. they also underline the importance of working with public health as new and innovative practices evolve. as we have all faced unprecedented challenges and change in recent months, these papers maybe offer current practices within the world of hia and public health that shouldn’t be ignored – hia can help bridge new ways of thinking and working together to support those who are most vulnerable. the chronicles of health impact assessment continues to provide examples of classic themes with real-world application; a launchpad for budding practitioners as they continue to digest the evolving science. we hope the ideas here draw forth fresh energy and excitement as you continue to advance health equity in your own work. please continue to stay safe. audrey bonner and sophie grinnell secretary for sophia and director of sophia 22 volume 1, issue 1october 2016 seven years in the field of health impact assessment: taking stock and future directions rebecca morley, mspp; ruth lindberg, mph, mup; bethany rogerson, mssp; emily bever; keshia m. pollack, phd, mph abstract: the u.s. spends more per person on medical care than any other country, yet we have worse health indicators than many comparable wealthy nations. research increasingly shows that social, economic, and environmental factors determine our health; however, there is still an emphasis on curing illnesses rather than addressing these underlying causes of disease. the health impact project is a collaboration of the robert wood johnson foundation and the pew charitable trusts, established in 2009 to promote and support the use of health impact assessment (hia). as of january 2016, there were 386 hias either completed or in progress in the us in a variety of sectors—up from 62 hias in 2009. although built environment hias still make up the largest sector of practice, other topics are emerging including education, criminal justice, and labor and employment. as the field matures, we are presented with new opportunities and challenges. in this article we offer lessons learned from our experience over the last seven years, and a view into the future of hia. specifically, we discuss the challenges and promises of making health a routine consideration in decision-making, translating hia recommendations into policy, monitoring and evaluating the impact and outcomes associated with hias, promoting health considerations in federal decisions, and using hias as a tool for promoting health equity. background an ever-growing body of research shows that the policies shaping our social, economic, and built environments have a significant impact on americans’ health. research has demonstrated how factors such as the affordability and quality of housing, concentrated neighborhood poverty, transportation-related pollutants, and access to employment, education, and affordable, healthy foods affect health (national research council, 2011). despite this, most money dedicated to improving health in the us is spent on medical care (institute of medicine, 2014). to improve population health outcomes and health equity, data and pragmatic recommendations for protecting and promoting health need to be factored into the public policy process. hias have emerged as a widely used tool for promoting the inclusion of health considerations into public policy. hias offer an opportunity for a more robust and democratic policymaking process, strengthening relationships among stakeholder groups and giving community members a stronger voice in decisions that affect them (bourcier, charbonneau, cahill, & dannenberg, 2015). the health impact project—a collaboration of the robert wood johnson foundation and the pew charitable trusts—was established in 2009 as a national initiative to promote and support the field of hia as a way to integrate health considerations into decision-making outside the health sector. our initial goals were to: (1) coordinate and promote efforts to increase the use of hias; (2) support up to 15 hia demonstration projects at the state, local, and tribal levels; (3) develop and manage a training and technical assistance network; (4) complete hias of two federal policies that affect health; and (5) conduct and disseminate 23 a comprehensive review of laws and regulations to identify opportunities to use hias to influence decisions. over seven years, we have attracted and invested more than $22 million in growing the field of practice, including funding over 100 assessments, conducting four federal-level hias, supporting training for more than 1,300 individuals, and serving as a convener for the field. the hia field has grown tremendously. as of january 2016, in the us, there were 386 hias either completed or in progress in 41 states, at the federal level, in the district of columbia, and in puerto rico—up from 62 hias in 2009. over half of the hias conducted to date have been on local decisions (54%), while about 18% have focused on state level decisions. the remaining hias are split among the federal, regional, and county levels. the types of organizations leading or collaborating on hias are diverse. of the hias reported on our online map, government agencies have conducted nearly half (49%), with the remaining conducted by non-governmental organizations (25%), academic institutions (22%), and other organization types (4%) (health impact project, n.d.-b). about 70% of the hias conducted to date have been applied to decisions in the built environment (37%), transportation (19%), and natural resources (11%). hias have also been applied to decisions in other sectors, such as housing, agriculture, climate change, criminal justice, and economic policy (health impact project, n.d.-b). as the field of hia expands and matures, we are presented with new opportunities and challenges. this paper describes our perspectives on the state of the field, current challenges, and future opportunities in five distinct areas: (1) making health a routine consideration in decision-making; (2) translating hia recommendations into policy; (3) monitoring and evaluating the impact and outcomes associated with hias; (4) promoting health considerations in federal decisions; and (5) using hia to promote health equity. making health a routine consideration in decisionmaking despite increased interest in public health among professionals in sectors such as planning, housing, and community development, the integration of these considerations into decision-making is not standard practice. hia practitioners are exploring a range of approaches to embed health into decision-making processes and common practices of various sectors. one strategy is to build on existing legal authorities or to create new ones that facilitate the incorporation of health in decision-making or the use of hia and related approaches. for example: • the legal support for hias is already in place through policies such as the national environmental policy act (nepa) and similar laws at the state level. these existing authorities have been previously described at length (health impact project and arizona state university, 2012). • state policymakers are increasingly exploring how hias can help identify the potential and often overlooked health consequences of policies, plans, programs, and projects across a range of sectors. the national conference of state legislatures (ncsl) conducted a review of state legislation and statutes identifying and addressing hias and found that between 2009 and may 2014, 17 states considered 56 bills that would create a mandate for some consideration of health effects when making decisions (national conference of state legislatures, 2014). many of the analyses proposed in these bills would not fit the strict definition of an hia, but eight states have considered legislation that incorporated most elements of a formal hia. one example of state hia legislation is what is commonly known as the healthy transportation compact. enacted by the massachusetts legislature in 2009, the compact establishes the use of hias to determine the health effects of state transportation projects (an act modernizing the transportation systems of the commonwealth, 2009; massachusetts department of transportation, n.d.). another strategy for making hia routine practice is to develop organizational infrastructure, institutional support, leadership, and process changes. this approach includes adding hia responsibilities to job descriptions, developing and formalizing partnerships within and across agencies, and identifying sustainable sources of funding. in 2012, the health impact project expanded its funding opportunities to provide grants for this purpose. for example, between 2013 and 2016: • the tri-county health department in denver, colorado included “health in all policies” in their strategic plan as a way to better connect the built environment and public health sectors. tri-county’s board of health approved a budget for a new position to make progress toward this goal through the department’s land use and built environment program. • oregon health authority collaborated with the oregon department of transportation to develop a tool that models how specific transportation policy and funding decisions would relate to changes in physical activity. • the los angeles department of public health established the health impact evaluation center to develop the capacity and systems to routinely conduct hias. as part of their efforts, this center is creating screening tools and protocols to guide the agency’s decisions on when to conduct rapid hias, as well as materials to facilitate completion of the screening and scoping steps. a third strategy is to build health into the way other sectors do business by streamlining the hia steps or through a seven years in the field morley; lindberg; rogerson; bever; pollack 24 “checklist” approach. for example: • in the built environment and housing sectors, the health impact project partnered with the u.s. green building council (usgbc) and enterprise community partners to embed health information into the leadership in energy and environmental design (leed) certification system and the enterprise green communities criteria, respectively. these updated green building standards define a process by which architects, designers, and developers can consider the connections between the design, construction, and operation of buildings and public health. the green communities criteria, first launched in 2004, is the leading green building standard for affordable housing in the u.s. and has been adopted by 23 states and eight major cities. in these locations, competitive funding streams critical to affordable housing development, such as states’ qualified allocation plans for allocating low income housing tax credits and municipal affordable housing finance products, list certification to the criteria either as a requirement or a preferential condition of funding. as of february 2016, over 500 affordable housing buildings containing approximately 29,000 units have received the certification, with over 50,000 more units on the path to certification. the 2015 version of the criteria requires that developers identify potential resident health factors and design their projects to address resident health and wellbeing. an optional criterion calls for the developer, at the pre-design phase of development and continuing throughout the project life cycle, to collaborate with public health professionals and community stakeholders to assess, identify, implement, and monitor achievable actions to enhance health-promoting features of the project and minimize features that could present risks to health (enterprise green communities, 2015). approximately 250 projects are expected to implement the required health criterion by june 2016. a similar credit is being piloted by usgbc as part of its leed system, an international green building certification program. between the system’s inception in 2000 and 2015, usgbc certified more than 26,600 real estate projects and more than 70,000 residential units worldwide across all sectors of the building industry, including affordable housing, commercial real estate, schools, homes, and neighborhoods. • in the transportation sector, as part of its 2035 regional transportation plan, the nashville area metropolitan planning organization (mpo) in tennessee adopted new health scoring criteria for selecting and funding transportation projects, dedicating 60 of the 100 points to health promoting projects. seventy percent of the selected roadway projects included active transportation elements, compared with roughly two percent in the prior plan. as part of its 2040 plan, the mpo now dedicates 80 of 100 points to health promoting projects (nashville area metropolitan planning organization, n.d.). • in the planning sector, meridian township, michigan, adopted a checklist-based tool that allows new proposed development projects to be evaluated according to health criteria that include access to safe places to exercise and healthy foods, design that facilitates social interaction, and standards for air and water quality (charter township of meridian, n.d.). planners work with each developer based on the findings of the evaluation to incorporate design elements that will improve health. in the 10 years since implementation, this simple approach has resulted in dozens of healthsupportive modifications. institutions such as banks, hospitals, and foundations have the ability to impact health equity through their lending, land acquisition and development, and investments, respectively. we are exploring policy and financial levers that can facilitate widespread use of hia and related approaches. for example, the patient protection and affordable care act [§ 9007, 26 u.s.c. 501(c) (2010)] requires non-profit hospitals to conduct community health needs assessments and create community health improvement plans. in addition, building on prior state legislative efforts, the health impact project is testing a “health note” to integrate potential health considerations into legislative analysis. a health note is similar to a fiscal note, and provides a brief, objective, nonpartisan summary of the potential positive and negative health impacts of a proposed bill. the health note draws upon the principles of hia, but is streamlined for use on a large number of legislative proposals within a short timeframe. as the field of hia has matured, it is possible that for some decisions we have enough information about the potential health effects and corresponding mitigation strategies to move directly into implementation. the field could benefit from a central repository of sectorand decision-specific information and tools that could facilitate the translation of past hias into policy, and make hia practice more accessible to professionals in a range of sectors outside of health. for example, the health impact project has supported the national center for healthy housing and the national housing conference to develop guidance for incorporating health into housing decisions. similar efforts are underway to facilitate hia practice in other sectors, including planning and disaster recovery. translating hia recommendations into policy there remains a need for targeted hias that inform specific decision points, and focus on translating hia recommendations into policy. one time hias targeting specific decisions can bring new evidence and stakeholder involvement into a decision that has the potential for substantial impact on health or health equity. the policy impacts of past hias are numerous. for seven years in the field morley; lindberg; rogerson; bever; pollack 25 example, an hia on the design of a modern streetcar in tempe, arizona was used by the tempe citizen advisory committee to inform the final streetcar system design. based on the hia recommendations, the city of tempe established a weekly farmers’ market to improve access to healthy food, as well as other goods and services. similarly, as a result of an hia on a community transportation plan in decatur, georgia, the city implemented a comprehensive set of infrastructure improvements to enhance the accessibility, safety, and connectivity of sidewalks, intersections, and streets for users of all ages and abilities. an hia in connecticut contributed to a new law that calls for the identification of state funds to remediate hazardous housing conditions and centralization of this funding within a single agency. in an evaluation of 23 hias, the recommendations in 11 of the hias could be directly linked to the way decisions were developed or implemented, 11 of the hias changed the decision-making process, and 14 influenced changes beyond the decision under consideration (bourcier, charbonneau, cahill, & dannenberg, 2015). however, the same evaluation found that maintaining the hia’s influence after the report’s release is an often overlooked or missing step. hia teams in 10 of the 23 cases did not adequately disseminate the recommendations or follow up on implementation, and only one hia established a detailed monitoring plan to track the implementation of the hia recommendations (bourcier, charbonneau, cahill, & dannenberg, 2014). often, grants end shortly after release of the hia report, leaving little time to implement the report recommendations. further, the funding timeframe does not allow grantees to capture the impact of hias on policy changes. health impact project grantees must include a monitoring and evaluation plan, and our grant selection criteria prioritize proposals with strong plans and partnerships to support ongoing engagement with the policies that will follow after the hia. despite these requirements and selection criteria, it is possible that longer grant periods or funding for implementation and monitoring could go a long way toward increasing the impact of hias. in addition, with a modest infusion of additional resources, many of our prior grantees and their partners are poised to translate hia recommendations into policy. one important consideration in moving hia recommendations into policy is the role of advocacy in hia. some practitioners have expressed concerns that using hia as a tool for advocacy could conflict with the hia value of “ethical use of evidence” since the advocacy viewpoint could mean the group conducting the hia has a preconceived policy outcome. the risk, therefore, is that decisionmakers will become skeptical about the objectivity of the tool, thereby diminishing its future value. when screening, organizations should reference the practice standards to decide whether an hia is the most appropriate approach, if the goal is to support a specific advocacy objective. organizations may ultimately choose not to use hia if bringing diverse perspectives, and often opposing viewpoints, to present a balanced document is contrary to their overarching advocacy strategy. one approach that has proved successful is for organizations with established positions on a topic or issue to collaborate with a third-party. the third-party is responsible for conducting an independent and objective assessment, and the advocate can use the results of the hia as part of a broader advocacy campaign. for hias led by advocacy organizations, the key is to ensure that a neutral party could read the report and come to his or her own conclusion—in other words, that the assessment is based on the best available evidence regarding potential health impacts, and presents the facts fairly and fully. in the future, we will explore opportunities to support implementation of recommendations identified through hias. we also hope to identify ways that hia practice and advocacy can be mutually supportive. for example, hias can generate objective data that advocacy organizations can use in their campaigns. likewise, advocacy organizations know the priorities of the communities they serve and can help hia practitioners select topics of importance to them. we also will help document and scale the strategies that are most likely to lead to the adoption of hia recommendations in decisions, building on lessons from prior evaluations and input from the field. monitoring and evaluating the impact and outcomes associated with hias evaluations of hias in the us have documented their direct effects on decisions in non-health sectors as well as indirect effects, such as building consensus and relationships among decision-makers and their constituents, increased awareness of health among stakeholders, and giving community members a stronger voice in decisions that affect them (bhatia, rajiv, & corburn, 2011; bourcier, charbonneau, cahill, & dannenberg, 2015). health impact project grantees are required to develop monitoring and evaluation plans, and evaluate the hia process and early impacts within the grant period. lessons learned from these hias are helping to inform how practitioners conduct hias, engage stakeholders, and disseminate products. process evaluations are common, with practitioners determining whether the hia was carried out according to the plan of action and applicable practice standards. a number of impact evaluations have examined the effect of hias on the decision-making process and the degree to which recommendations were adopted and implemented (dannenberg, 2016). a recent study evaluated community participation in hias, including its impact on the success of an hia (center for community health and evaluation and human impact partners, 2015). outcome evaluations, which measure changes in health status or indicators resulting from implementation of the proposal, are rare because of methodological challenges such as confounding, effect modification, and meeting the epidemiologic standards for assessing causality. seven years in the field morley; lindberg; rogerson; bever; pollack 26 appropriate methods and analytic techniques capable of assessing whether an hia accurately predicted long-term health impacts need to be developed (taylor, gowman, & quigley, 2003). despite these challenges, as the field continues to expand, we have seen how monitoring the implementation of hia recommendations and evaluating the process, impact, or outcomes resulting from the hia are being embraced as critical steps of the hia process and not merely as an afterthought. we are supporting additional well-designed evaluations to assess the impact of hias and the factors contributing to their success. for example, we are launching an independent, national evaluation that will examine the impact of hias on determinants of health and health equity and the conditions under which hias lead to impact on decisions. the findings from this work will be used to fill gaps in knowledge for hia practitioners, policymakers, and funders and to inform our future investments. promoting health considerations in federal decisions in 2009, there were five completed hias on federal agency decisions, including three focused on the natural resources and energy sectors, one on agriculture and food policy, and one on labor and employment policy (health impact project, n.d.-b). as of february 2016, there were 21 hias completed or in progress in the us on federal agency decisions, an increase of 320% (health impact project, n.d.-b). in 2010, the affordable care act authorized the creation of the national prevention council to catalyze cross-sector collaboration across federal government agencies, in recognition that agencies responsible for our housing, education, transportation, and built environments can play a critical role in improving the public’s health (u.s. department of health and human services, n.d.-a, n.d.-b). in 2011, the council released the national prevention strategy, which prioritizes prevention, emphasizes evidence-based recommendations, and highlights hia as an approach to use in reducing the burden of the leading causes of major illnesses and preventable death (national prevention council, 2011). although half of the hias completed or in progress to date on federal agency decisions have focused on natural resources or energy decisions, the topic areas in recent years include: policies on immigration; agriculture, food, and drug; housing; labor and employment; and transportation (health impact project, n.d.-b). for example, hias have been used to inform: the u.s. department of agriculture’s (usda) nutrition standards for snack foods and beverages sold in schools; policies of the u.s. equal employment opportunity commission; federal immigration reform; federal paid sick leave policy; cleanup plans for a superfund site; and numerous oil, gas, and mining permitting and project decisions (health impact project, n.d.-b). federal agencies are also conducting or requesting hias. for example, regional offices of the u.s. environmental protection agency (epa) have used hia to: (1) compare options for renovation and improvement at an elementary school in massachusetts; (2) examine the impacts of a green infrastructure project on low-income, minority communities in atlanta; and (3) examine expansion plans at the ports of los angeles and long beach. the epa has also integrated hia into a federal environmental impact statement for a proposed expansion of the red dog mine in alaska (health impact project, n.d.-b). in addition, the health impact project collaborated with the u.s. department of housing and urban development (hud) and partners from the oregon public health institute and metropolitan area planning council to conduct an hia to inform an update of its designated housing rule and demonstrate how hia might be used as a tool to advance the national prevention council’s goals (health impact project, 2015). hias can bring a new lens of health to contentious policy debates, provide new data to inform federal policy, and develop collaborative relationships among agency staff, stakeholders, and advocates (pollack, heller, givens, & lindberg 2013). hias have the potential to strengthen and supplement federal decision-making processes, such as through the use of hia data in regulatory impact assessments and environmental impact assessments (as discussed previously). for example, the usda highlighted the importance of the hia on nutrition standards for snack foods and beverages sold in schools to their regulatory impact assessment, citing the hia as “a recent, comprehensive, and groundbreaking assessment.” the usda also incorporated nearly all of the hia recommendations in their interim-final rule (health impact project, n.d.-a; u.s. department of agriculture, 2013). furthermore, federal-level hias help policymakers engage with those affected by the policy decisions at a local level to fully understand the experience and possible effects of proposed policies (health impact project, 2014). federal agencies face technical, economic, and political constraints in their decision-making and the hia process needs to adapt and respond accordingly. in the designated housing rule hia, for example, the goal was to provide hud with data and information to inform the development of an updated rule. as a result, the assessment was conducted before the rule-making process began, necessitating the hia team, in consultation with stakeholders, to develop and examine two scenarios of actions hud could pursue in its rulemaking (keppard et al., 2014). in the federal immigration reform hia, the hia team recognized the need for unique communication methods in the reporting phase, and used a national press call, legislative briefings, and videos, as well as developed a toolkit for advocates interested in communicating the findings and recommendations of the hia to policymakers (pollack, heller, givens, & lindberg 2013). federal decisions have far-reaching impact and the field has an important opportunity to impact public health by increasing the use of hia and related approaches in federal decision-making. the relationships that we have established with federal agency staff will enable us to identify areas where a health lens can add value to federal decisions and yield benefits to health and health equity. we are adapting seven years in the field morley; lindberg; rogerson; bever; pollack 27 existing rapid hia models for federal use. as part of the process, we will identify data sources, methods, and stakeholder input processes for integrating health considerations into federal policy in ways that the agencies can replicate and scale to fit the scope, resources, and timeline of a given decision. for example, in our recent work to inform hud’s update of its designated housing rule, we used existing structures that hud could leverage in future decision-making, such as public housing resident advisory boards, to elicit stakeholder perspectives. using hia to promote health equity equity in health implies that everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that none should be disadvantaged from achieving this potential if it can be avoided (world health organization, 1986). health inequities are systematic differences in health status or the distribution of health resources between different subpopulations, resulting from social conditions. when groups face serious social, economic, and environmental disadvantages, health inequities are the result (american public health association, 2015). hias address the root causes of health inequities by assessing the social determinants of health. equity is a core value that underpins hia practice, initially described in the world health organization’s gothenburg consensus paper on hia (bhatia et al., 2014; world health organization european centre for health policy, 1999). the hia practice standards, first published in 2009 and most recently updated in 2014, require systematic consideration of the impacts of a proposed decision on health equity and development of recommendations to address equity impacts (bhatia et al., 2014). although equity is a core value of hia, the field would benefit from a more consistent and systematic approach to incorporating it into hia practice. many hia practitioners and public health professionals need training and capacity building on how to address and incorporate equity in hia. the society of practitioners of health impact assessment (sophia) published equity metrics for health impact assessment practice as a reflective tool to evaluate the degree to which an hia successfully incorporated equity and to help practitioners consider equity during the planning of their hias (sophia equity working group, n.d.). one of the ways that hia can promote equity is through its inclusive process and ability to build power within the community impacted by the decision. community empowerment involves individuals acting collectively to gain greater influence and control over the determinants of health and the quality of life in their communities (wallerstein, 2006; world health organization, 1998). hias can shift power to communities by bringing their voices to decisions, helping them take action, increasing community member contact with decision-makers, and helping strengthen the skills of community members to influence future decisions (group health and human impact partners, 2014). data collected by community groups, qualitative information from focus groups and interviews, as well as video and photo data projects, have all contributed meaningfully to our understanding of public health problems and solutions. participatory research approaches can involve community members as full partners in research on decisions affecting them. currently, most hias have some level of community involvement; however, few practitioners devote significant resources to community participation in the process (center for community health and evaluation and human impact partners, 2015). in the us, most hias are led by agencies or academic institutions; far fewer have been led by community-based organizations. there are several plausible reasons for the relatively low number of hias performed by communitybased organizations. one possibility is that mounting a successful proposal for hia funding is beyond the capacity of smaller community organizations. larger organizations and institutions typically have grant writers and other infrastructure, such as access to hia training, which can facilitate their success in highly competitive grant programs. most practitioners would agree that greater involvement by community-based organizations in hia practice will lead to greater impact for hias, including the comprehensiveness of the assessment, the likelihood that the recommendations will be adopted and sustained, and the contributions to selfefficacy and social cohesion for participating organizations and participants. we are examining our own funding mechanisms to ensure that community-based organizations and others focused on equity have the capacity and opportunity to conduct hias and related approaches. we are seeking to increase the use of hia and related approaches in places and among populations that are experiencing widening health inequities, such as in southern and appalachian states. in february 2016, the health impact project announced grants to address factors outside of health care that influence population health and health equity in seven states: alabama, arkansas, kentucky, louisiana, mississippi, tennessee, and west virginia (health impact project, 2016). grant recipients will use the first phase of funding to develop a community-driven plan of action, identifying the most pressing health equity issues and the upstream contributors to those issues. following the planning phase, grantees will have the option of completing an hia or using an alternative approach (e.g., health scoring criteria and other checklist-based tools, cross-sector initiatives to target social determinants of health). grantees will also receive coaching and training on stakeholder engagement, hia, health in all policies, and leadership skills. finally, we are working with partners to provide training and technical assistance to increase the consideration of equity in hia practice. we will continue to explore new approaches to promote health equity through our work, evaluate our efforts, and build on lessons learned to inform investments. seven years in the field morley; lindberg; rogerson; bever; pollack 28 conclusions hias and related approaches can effectively bring health information and perspectives from a broad set of stakeholders to decision-making. when we successfully and routinely factor health into the public policy process, we can create a future in which our social, economic, and built environments enable all individuals in the us the opportunity to lead healthy lives. there are thousands of decisions made every day that affect health. now is the time to consider health data and community voice in weighing tradeoffs, and use each decision as an opportunity to address the challenge of widening health inequities. seven years in the field morley; lindberg; rogerson; bever; pollack 29 seven years in the field morley; lindberg; rogerson; bever; pollack 30 references american public health association. 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(1999). health impact assessment: main concepts and suggested approach (gothenburg consensus paper). brussels. acknowledgements work on this article was supported by a grant to the health impact project from the robert wood johnson foundation. the authors thank amber lenhart for her assistance with references. corresponding author rebecca morley health impact project the pew charitable trusts 901 e street nw, 10th floor washington, dc 20004 rmorley@pewtrusts.org seven years in the field morley; lindberg; rogerson; bever; pollack chia staff editor-in-chief cynthia stone, richard m. fairbanks school of public health indiana university-purdue university indianapolis journal manager lyndy kouns, richard m. fairbanks school of public health indiana university-purdue university indianapolis chronicles of health impact assessment vol. 1, no. 1 (2016) doi: 10.18060/21352 © 2016 author(s): morley, r; lindberg, r; rogerson, b; bever, e.; pollack, k.m. this work is licensed under a creative commons attribution 4.0 international license. november 2018 volume 3 issue 2 c h i a chronicles of health impact assessment improving community health through health impact assessments letter from the editor i we want to thank linda realmuto and susan sutherland for working with us as guest editors on this issue. it is a challenge to recruit people working in the hia field to write about their hia work on top of their other commitments. practitioners don’t have the same incentives to publish that drives our academic partners, but we appreciate everyone’s efforts. another continuing challenge is to recruit peer reviewers. dr. amber comer and i included an article in this issue about the need for peer reviewers and how important they are to the publishing process. we continue to work to recruit peer reviewers that can offer comments to critique and strengthen the articles that are submitted. we had another undergraduate service learning assistant josephine johnson working with chia this summer. i want to thank josie for her contributions on this issue and the iupui center for service learning for their financial support of the position. sincerely, cynthia stone drph, rn chronicles of health impact assessment editor-in-chief call for chronicles of health impact assessment (chia) peer reviewers we appreciate your interest in supporting the chia journal as a peer reviewer. in this role, you will be asked to read submitted articles. if you do not have time you can decline the invitation to review and will be placed back in the rotation for future opportunities. if you do have time, your review will address the following: you will submit a written critique that will help determine if the article will be published. you will be asked if you have any conflicts of interest in reviewing an article. all your comments will be anonymous to the authors. you will be given prompts to respond to, such as: what are the article strengths or weaknesses, is this information that is new to the field or building on already known material? all comments should be viewed as constructive criticism for the authors. you will have the choice to accept, recommend acceptance with revisions, or not accept the article. if you are interested, the following information will assist us in matching peer reviewers to specific authors. name email address affiliation phone number area of hia expertise (check all that apply): agriculture criminal justice health equity housing built environment economics hia evaluation labor policy climate change education hia methodology natural resources community development energy hia theory redevelopment transportation other:__________________________________________________ how are you qualified (papers written, journal reviewed for, etc.)? 1050 wishard blvd., indianapolis, in 46202 317-274-3126 chia@iu.edu october 2017 volume 2 the challenges and opportunities of peer review in health impact assessment katherine hirono, mph; kristin raab, mph, mla; arthur wendel, md, mph; tim choi, mph; tina yuen, mph, mcp, cph; joseph schuchter, drph; florence fulk, phd abstract: background: while hia guidelines and practice standards are used throughout the field, peer review is a potentially untapped resource for hia practitioners in the us and potentially internationally. peer review is thought to strengthen hia practice, although very few guidance documents exist, and there has been little research to date on the efficacy of peer review for improving hias. methods: to explore the possible value of peer review in hia, an expert panel was convened at the 2013 hia of the americas workshop, and an online survey was used to query hia practitioners regarding their experience with and motivation for hia peer review. results: most survey respondents (n=20 out of 26) indicated that peer review in hia was helpful, and 15 respondents thought a formal peer review process would improve hia practice. respondents wanted peer review to be timely and the reviewer to approach the review as a mentor rather than a gatekeeper. conclusion: this paper offers the initial development of a peer review typology based on feedback from the online survey and workshop participants. better understanding of the potential challenges and opportunities for using peer review in hia may help to improve hia practice. i introduction in the past 30 years, health impact assessment (hia) has developed into a tool used in many sectors all over the world (vohra, 2007). countries such as australia, england, thailand, and the netherlands have integrated hias into formal decision-making processes. in the united states (us), although initiation of hia practice occurred later than in other parts of the world, practice has grown 10-fold in the past decade from 27 completed hias in 2007 (dannenberg; dannenberg et al., 2008) to 407 completed or in progress hias in 2016 (the health impact project, 2016). the diverse and growing practices in hia in the us have called attenchallenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 2 tion to the need to improve overall hia application (national research council, 2011). one potential area to advance hia practice in the us (and potentially internationally) is through better consideration of the use of peer review. peer review is the evaluation of a process or product by experts in the field to maintain or enhance the quality of the process or product in that field (smith, 2006). peer review plays a critical role within the scientific community to improve the quality and applicability of research and evidence (abelson, 1990). while peer review often occurs after submission of research manuscripts for publication or for proposals for funding, other types of formal and informal peer review processes are used at different stages of research (solomon, 2007). these other types include collegial review of products before they are submitted and reviews of outlines to ensure that a proposed product is well-designed. some institutions may require that reports and other documents undergo internal review prior to being shared externally. though peer review is considered necessary for maintaining scientific standards and quality control, it is subject to its own set of challenges such as bias, complexity, and a lack of understanding of its overall effectiveness (goldbeck-wood, 1999). peer review has been conducted in environmental impact assessment (eia), and though it is not required, it is a recommended practice (office of management and budget, 2004). in eia, peer review tends to focus on the technical quality of assessment standards, methods and results in order to ensure attainment of appropriate levels of scientific rigor (beanlands et al., 1983). in some eia processes, peer review is conducted by the contracted agency by specialists not involved in the work. the report authors respond to the reviewers’ comments and make necessary changes to the scientific report. in some cases, the peer reviewers’ comments and the authors response may become part of the public record (klamathrestoration.gov). given that the focus of peer review in eia is to ensure scientific integrity, it is recommended that peer review be conducted at the inception and design stages, though given the practical complexities of environmental assessment, it is not clear to what extent this is actually completed (beanlands et al., 1983; chaker et al., 2006). it is also argued that as an applied science, eia should conform to the same rules and standards that govern scientific research and therefore eia reports should be subject to peer review (cashmore, 2004). incorporating peer review in hias may be one strategy that can help to improve the quality and usefulness of hias. some guidance exists, particularly for peer review at the end stage of the hia (fredsgaard et al., 2009; vohra, 2005), however there has been little research to date on to what extent, and in what manner, peer review can be used to improve hias. given that hias must be conducted within policymaking cycles (harris et al., 2014), it is unclear how peer review processes can account for timing restrictions and negotiating of interests from multiple stakeholders within diverse hia projects. based on a practitioners workshop and subsequent survey, this paper explores the challenges and opportunities presented by using peer review to support hias. we examine the current use of peer review by hia practitioners primarily in the us, the perceived value of peer review to the hia process, and provide a typology of peer review practice in hia. methods the development of an hia peer review typology was initiated by a working group convened at the 2013 hia of the americas workshop (changed to the hia practitioner workshop), a meeting for hia practitioners to discuss the state of the field and plan steps for future improvements. workshop participants (n=11) self-selected to attend the working group entitled “peer review of hia.” all participants had previously been involved in one or more hia and had some level of experience with peer review in the hia process. the workshop was facilitated by two of the challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 3 paper authors (kr and tc) and incorporated an open format to discuss the potential role of peer review in hia practice in the us. most of the paper authors attended the workshop. during the conference, the working group discussed the potential range of peer review which might be applied to hia. additionally, participants described the positive and negative factors of applying peer review across a range of hia typologies. participants also looked at the hia process (see figure 1) and identified at which steps peer review could be beneficial. following the meeting, the authors designed and distributed an online survey to investigate the experiences of practitioners with peer review of hia projects (see box 1). the survey consisted of eight questions designed to gauge the motivations of hia practitioners to engage in peer review, the perceived value of peer review, and the broad and multiple practices of peer review within hia. the authors did not strictly define peer review in the survey so that a full range of experiences with peer review, both formal and informal, could be captured. the 1. screening determine whether an hia is needed and likely to be useful. 2. scoping develop a plan for the hia, including identification of potential health risks and benefits. 3. assessment describe the baseline health of affected communities and assess the potential impacts of the decision. 4. recommendations develop practical solutions that can be implemented within the political, economic or technical limitations of the project or policy being assessed. 5. reporting disseminate the findings to decision makers, affected communities and other stakeholders. 6. monitoring and evaluation monitor the changes in health risk factors and evaluate the efficacy of the measures that are implemented and the hia process as a whole. box 1. survey questions 1. what type of agency do you work for? a. federal/state/local government b. consulting organization (for-profit) c. community/non-profit organization d. educational institution 2. list some of the hias where you were involved with peer review. 3. based on your general experiences of using peer review in hia, indicate how much you agree with the following statements: “overall, peer review was helpful for improving the quality of the hias” a. strongly agree b. agree c. not sure d. disagree e. strongly disagree figure 1: the steps of hia challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 4 survey was conducted between may and august 2013, and was advertised to the hia practitioner community through state and national organizations’ networks mainly in the us, including hia listservs and blogs. solicitation for the survey was conducted using convenience sampling and is not necessarily representative of the diverse range of hia practitioners. authors used basic descriptive statistics and a qualitative coding scheme to analyze open-ended responses. results sample a total of 26 hia practitioners responded to the survey. respondents represented a variety of organizations although the majority were affiliated with governmental agencies (n=12) (see table 1). the majority of respondents were from the us. respondents’ experience of peer review the roles of respondents in the peer review process varied but generally fell into three categories: • hia project lead – oversees the project and drafting of the hia report and may have received a peer review on their hia; • technical reviewer – has expertise in a given field and reviews part of the assessment; and 4. based on your general experiences of using peer review in hia, indicate how much you agree with the following statements: “i think hias could benefit from a more formal or standardized peer review process” a. strongly agree b. agree c. not sure d. disagree e. strongly disagree 5. what has been your role in the peer review process? 6. briefly describe your experience overall with the hia peer review process: having an hia reviewed (skip, if not applicable.) 7. briefly describe your experience overall with the hia peer review process: reviewing an hia (skip, if not applicable) 8. if peer review added value to the hias, please specify how. organizational affiliation number of respondents (n=26) community/non-profit organization 5 for-profit consulting organization 3 educational institution 6 federal, state, or local government 12 table 1: survey respondent characteristics challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 5 • general editor – provides non-technical revisions to the report. several respondents stated that they performed multiple roles and respondents listed “other” roles, including moderator (conducts peer review process), in the peer review process (see table 2). respondents described several different types of peer review: 1. technical review by “qualified statisticians and scientists” for “technical accuracy;” 2. process review by “hia experts” to “ensure all steps of hia were addressed;” 3. general review for “identification of oversights, corrections,” “general edits,” and “flow and readability” and; 4. political review for “what in the document seemed biased,” to avoid “hot buttons,” and “unnecessarily alienating the local audience.” some of these types of review may be interpreted more as a type of technical assistance, rather than traditional peer review, however the authors have included all types of peer review in order to reflect the respondent’s perception of the meaning of peer review in hia. role in peer review process number of respondentsa (n=29) hia poject lead 16 general editor: identifies and recommends technical corrections in parts of hia 11 technical reviewer: identifies and recommends technical corrections in part of hia 9 moderator: conducts peer review process 3 other 5 no response 1 table 2: respondents’ role in hia peer review arespondents could report more than one role table 3: number of respondents (and %) who agreed or disagreed with statements. (n=26) questions strongly disagree disagree not sure agree strongly agree peer review was helpful for improving the quality of the hias 1 (4%) 0 (0%) 5 (19%) 11 (42%) 9 (35%) hias could benefit from a more formal or standardized peer review process 4 (15%) 2 (8%) 5 (19%) 10 (38%) 5 (19%) challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 6 perceived value and challenges of peer review although the overwhelming majority (n=20) agreed or strongly agreed that peer review was helpful for improving the quality of the hia, fewer respondents agreed (n=15) that hias would benefit from a more formal or standardized peer review process, and six participants disagreed that a standardized peer review process would benefit hias (see table 3). generally, respondents described peer review as beneficial or positive. respondents commented that peer review identified needed corrections or missing information. respondents stated that it also validated “hia leaders’ concerns” and provided further opportunity for answering questions. in addition, participants felt that peer review helped to identify additional data sources, legal citations, and publications to consider or include, and to clarify language and framing of the report. respondents identified peer review as helping to refine logic models and pathway diagrams, and providing useful feedback on recommendations. they highlighted that having the hia reviewed by statisticians, scientists, and other qualified reviewers was crucial to ensuring the technical accuracy of the hia, the alignment with methodological best practices, and the relevance of recommendations. respondents also reported that peer review helped to produce a more credible product, to increase confidence of hia staff in their findings, and to present the information clearly and effectively. respondents also reported that peer review aided incorporation of perspectives of different stakeholders within the hia process. they stated that diverse viewpoints of people with dissimilar skill sets add value by providing input and perspectives on issues not apparent to those leading the hia project. respondents suggested that diversity also adds credibility to the analyses, findings, and recommendations, making the hia stronger overall. respondents stated that the timing of peer review was important. one respondent commented that retrospective reviews of finished hias do little good; the key to an effective review is to engage the reviewer in the hia process early enough to address issues and make changes. another respondent stated that incorporating peer review in the early stages of hia helped to avert complications that would have been more problematic later in the process. respondents identified several challenges to peer review. some found that time limitations impeded addressing and incorporating feedback. one respondent mentioned that peer review could add value, but could also increase the time and resources needed to complete an hia and present a different set of barriers and constraints for the project. another respondent stated that hias are often conducted under tight deadlines by already busy staff, and although reviewers add credibility by identifying realities about the hia being conducted, hia staff may not be able to adequately react to constructive comments. respondents suggested that peer reviewers need to be matched to the work based on their own specific talents, skills, or time constraints. one respondent noted that the benefit of the review is highly dependent on the reviewer. inadequate communication between the reviewer and those leading the hia was also mentioned as a barrier. one respondent found peer review to be useful but indicated that the lack of communication between the reviewers and the hia team can lead to misunderstandings. peer reviewers of journal article submissions are usually seen as gatekeepers, this respondent stated, but hia peer review needs to be less anonymous to ensure that feedback is useful. the respondent suggested that reviewers act more as mentors. to address some of the challenges of conducting peer review of hias, respondents described the need to clarify the purpose of the peer review, the type of review (e.g., general or technical), the level of review, and the timeframe for comments. respondents suggested providing parameters or instructions to reviewers, such as specific questions, concerns, or content challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 7 areas for the reviewers to consider. they noted that providing such details seemed to help manage the work of the peer reviewers, the expectations of the hia project team, and the goals of the peer review within the constraints of the overall hia project. discussion table 4: comparison of peer review factors for traditional journal articles and hia factors traditional, peer review journal protocols hia peer review (lots of variation) primary role of peer review gatekeeper of quality conversational, open peer review lead journal editor hia coordinator peer reviewers field experts selected by editor general hia experts, technical field and community experts anonymity singleor double-blinded; allows review with less identity bias open but varies time of review at completion of final draft varies: process (step-specific review), general review time and cost varies: typically no cost to applicant, only publication expense if accepted varies: depending on availability of funds and reviewers transparency for feedback reviewer identity withheld varies: the public may have open access to comments and review, and agency affiliation opportunities for information exchange limited (communication usually routed through editorial board) varies: may be desirable in most cases practitioners often viewed the peer review they received as helpful but were less supportive of a standardized process. additionally, they described an application of peer review to hia that would be different than the application to a journal article (see table 4). for example, the review process should be sensitive to the timeliness of the hia, the reviewer might act more as a mentor rather than a gatekeeper, and different types of review could be applied, such as a technical review or a general review. based on the open-ended questions querying practitioners about their perceived motivation, value and use of peer review in hia, we found that peer review can address many aspects of an hia: • process (e.g., did the hia follow the steps of hia, did the hia involve significant stakeholder input throughout the process). • analyses (e.g., were quantitative and qualitative analyses performed according to best scientific practices in their respective fields, are the analyses transparent and replicable). • recommendations (e.g., are the recommendations based on the analyses, are the recommendations politically feasible). • reports (e.g., was the final report comprehensive, was the final product written in a format understandable to and useable by the appropriate audiences to inform the decision-making process). challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 8 our findings highlight several key considerations for integrating peer review into hia practice. first, almost all the respondents to the survey reported that peer review, when performed early in the process, when timely and cognizant of resource constraints, and when targeted to the particular step and needs of the hia, is a helpful practice to improve the quality and applicability of an hia. when feasible, peer review should begin as early as possible in the hia process and be incorporated in all steps. second, our findings indicate that peer review in hias should be fit-for-purpose. because the hia process is complex and can involve different disciplines and expertise that are subject to improvement by review, peer review should be conducted in a way that is flexible and appropriate to the needs of the individual hia. in order to represent the different types of peer review being used in hia practice, and when they are best applied, we propose a typology of hia peer review (see figure 2). the typology includes process, technical, general, and political peer review. each of the types of peer review provide different information to improve the hia, can be applied at different stages in the hia process, and may require a different reviewer depending on their individual skill set. process review involves ensuring that the hia performs all steps in a manner consistent with published hia guidelines and best practices. process review could also help to ensure the inclusion of equity considerations in each step of an hia. a process reviewer could draw on their experience as an hia practitioner and be well versed in the many practice guides and standards available. technical review ensures that the qualitative and quantitative data analyses were performed according to best practices and applicable scientific standards, and that the level of evidence and uncertainty for the predictions was stated clearly. the qualifications of the technical reviewer will vary according to the decision and health issues being assessed in the hia. general review includes general editing of documents and can include review related to best methods of communicating results to appropriate audiences. a figure 2: typology of hia peer review challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 9 general reviewer has editing skills, communication knowledge, and familiarity with the hia process. political review helps to understand and negotiate the political space in which the hia occurs. this is especially important for politically sensitive hias, often the norm rather than the exception. politics can influence whether the hia is undertaken, which health table 5: types of review suggested at each hia step. type of review hia step process review technical review general review political review 1. screening x x x 2. scoping x x x x 3. assessment x x x 4. recommendations x x x x 5. reporting x x x 6. monitoring/evaluation x x issues are addressed (e.g., scoping and pathways), the recommendations, and the reporting of the hia. a political reviewer has a firm understanding of the politics and context surrounding the hia and provides insight and advice to the hia practitioner to ensure that the hia recommendations are salient to the decision makers. the four types of review can be applied at various stages of the hia process (table 5). a peer review typology should consider the hia steps as well as the different typologies of practice (harris-roxas et al., 2011). the type of review should be expanded or minimized according to time and resources in accordance with the type of hia (rapid, comprehensive, etc.). for example, minimally-resourced and time-constrained hias might only have the capacity for one reviewer, who may perform several types of review at different stages of the hia. to facilitate and expand peer review opportunities, a pool of potential hia reviewers could be drawn from identified authors of hia reports or from existing hia communities of practice, such as the society of practitioners of health impact assessment (sophia, n.d.) . in summary, several key considerations are important for conducting peer review in hia. • timing and coordination: conducting peer review early within the appropriate stage of an hia helps suggested changes and recommendations to be meaningfully addressed. reviewing an hia after it is completed may do little to improve the hia itself. the hia coordinator or project lead may also need to build in time to possibly respond to or address peer reviewers' recommendations. • reviewer fit: the value of the review is highly dependent on the reviewer. peer reviewers should be matched with the right type of review needed based on their specific skills and availability. for example, if a technical review is needed, the peer reviewer would be well versed or have had experience in conducting the methodology used in the analysis. • peer review scope: clarifying the purpose and scope of the peer review is essential. providing parameters or instructions for reviewers – such as specific questions to consider, areas of the hia in need of attention, time constraints of the challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 10 project, and type of review (i.e., general, technical, process, or political) – will help to increase the usefulness of the peer review and ensure that the issues of greatest concern are most likely to be responded to and addressed within the given time frame of the project. • communication: hia peer review benefits from an open dialogue between the hia lead or project team and the peer reviewers. good communication will decrease the likelihood that peer review recommendations will be misunderstood, will increase the usefulness of the comments, and will increase the potential for the peer review to improve the hia by clarifying any points of concern or suggestions. limitations our study and findings are subject to several limitations. initial input from practitioners was obtained only from participants at the hia of the americas workshop, and survey information from only a subset of (mostly us) hia practitioners. given that most respondents were from the us, the results cannot be taken to reflect the views of practitioners in other international settings. however, while our survey was relatively small, we believe it illustrates a range of useful perspectives on an evolving hia practice. respondents were solicited from a pool of experienced practitioners, and the working group and authors of this article also have a diverse range of hia experience. still, due to the nature of the convenience sampling, and the small number of respondents, we may have excluded other experiences and perspectives on hia peer review. additionally, the survey was only sent out to hia practitioners, and not more broadly to those conducting other forms of impact assessment. while the focus on hia practitioners helped to elucidate hia-specific issues and opportunities for peer review, other insight related to peer review within other impact assessment may have been missed. moreover, the term “peer review” could be interpreted by respondents differently; different potential interpretations were apparent from discussions at the initial working group meeting and survey responses. future research might better define peer review and address similar questions in a more representative sample. nonetheless, we believe our findings highlight several opportunities for improving the practice of hia through peer review. conclusion peer review in the context of hia can be both an endstage quality control measure and an iterative quality improvement process used throughout multiple steps of the hia. hia provides timely and valid evidence amid myriad scientific and political uncertainties. peer review of hia may be an opportunity to support the legitimacy, acceptance and utility of the research findings, thereby increasing the value of hia in decision-making. however, further incorporation of peer review in hia will need to consider the potential pitfalls and criticisms of peer review practice (i.e. bias), the types of practitioners that can conduct peer review (who precisely is considered a “peer”) and how this practice can be applicable in international settings. challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 11 references abelson, p. 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(2007). international perspective on health impact assessment in urban settings. new south wales public health bulletin, 18(10), 152-154. challenges and opportunities of peer review hirono; raab; wendel; choi; yuen; schuchter; fulk 12 corresponding author katherine hirono, mph centre for health equity training, research and evaluation unsw sydney a member of the ingham institute locked bag 7103 liverpool bc, ndw, 1871 australia k.hirono@unsw.edu.au disclaimers: the findings and conclusions in this article are those of the authors and do not necessarily represent the views of the centers for disease control and prevention or the us environmental protection agency. chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 2 (2017) doi: 10.18060/21492 © 2017 author(s): hirono, k.; raab, k.; wendel, a.; choi, t.; yuen, t.; schuchter, j.; fulk, f. this work is licensed under a creative commons attribution 4.0 international license june 2018 volume 3 issue 1 expanding the indianapolis cultural trail: a health impact assessment lisa yazel-smith, ms, mches, ccrp; andrew merkley; robin danek, mph; cynthia l. stone, drph, msn abstract: background: health impact assessments (hia) are used to measure the effect of policies and/or projects that influence the health of populations. as a way to increase hia practitioners, university courses in hia can benefit both students and community organizations by presenting real-world opportunities for students to conduct hia while partnering with community organizations or policy makers. methods: as a course assessment, students in a graduate-level public health course conducted a rapid six step hia of three potential expansion routes of the indiana cultural trail (ict). the six steps were 1) screening, 2) scoping, 3) assessment, 4) recommendations, 5) reporting, and 6) monitoring and evaluation. to complete the hia, students examined local health data, conducted walkability assessments, and conducted seven key stakeholder interviews. results: the analysis results show that the riley hospital drive/gateway bridge (route 3) was the best potential route for expansion due to traffic safety considerations and the impact on residential parking in the adjacent ransom place neighborhood. in general, the key informants were in favor of the expansion, with the two most cited reasons being additional space for exercise and recreation and the potential economic impact and connection to local businesses in the area. conclusion: through the course assessment, students determined the expansion across the proposed gateway bridge would combat parking issues associated with expanding the trail through ransom place as well as be the safest way for pedestrians and vehicle traffic to approach large intersections. the ict trail expansion could lead to improved health outcomes by offering additional space for exercise, recreation, and active transportation. 33 expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 34 introduction many populations in the united states face health disparities attributable to factors such as the environment, social inequality, socioeconomic status, and neighborhood attributes. for instance, lack of access to public services and healthy food options, as well as limited public transportation, can contribute to poor health outcomes (ross, 2014). it is increasingly evident that the health of individuals and communities is largely shaped by the settings in which they live and work (meyer, 2014; robinette, 2017). in order to identify ways to alleviate and overcome health disparities in communities across the united states, communities need resources that will allow identification of the upstream root problems causing the disparities. one tool developed to guide this decision-making process is the health impact assessment (hia) (pollack, 2014). the national research council’s committee on health impact assessment states, “hia is an approach to assessing the risk factors, disease, and equity issues that create poor health outcomes” (committee on health impact assessment, 2011). fundamentally, hia is a mechanism that organizations and legislative bodies can employ to examine current and future policy proposals, programs, and projects to ensure that they will produce the intended health benefits. it should be noted that hias are used more to study projects and proposals that were not intended to have a public health benefit, but that nonetheless impact health (ross, 2014). as hias have become more common in the united states, university programs have developed courses that teach students about the reasoning and methodology behind hias. oftentimes, students have the opportunity to apply the course content to analyze real-world programs in order to identify their potential health impacts. frequently graduate programs are contacted by organizations to conduct hias for one of their projects or proposals before the organization begins work (pollack, 2014). students learning about hias can provide a cost-effective service to community organizations that are interested in learning more about the impact of a problem. however, there are limitations associated with students conducting hia. this paper demonstrates one example of a graduatelevel course utilizing a real-world problem to learn about hia, while offering results to a community partner. project description the indianapolis cultural trail (ict) consists of eight miles of urban bicycle and pedestrian trails in downtown indianapolis, indiana (marion county). the trail connects neighborhoods and cultural districts within the downtown area to the larger greenway system of the greater indianapolis area (indianapolis cultural trail, inc., 2017). though the intent of the trail was to be a transit connector and act as a promoter for economic growth, previous assessments of the cultural trail show that exercise and recreation is a main reason why people use the trail (indiana university public policy institute, 2015). in order to continue serving residents and visitors of indianapolis, ict leaders plan to extend the trail northwest of downtown indianapolis connecting it to ransom place, a residential neighborhood, and 16 tech, a developing industrial park. during initial expansion planning, ict wanted to examine three potential expansion routes that would connect ransom place and 16 tech (figure 1) (table 1). all three proposed routes are within the same zip code. expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 35 figure 1. 1. from the end of the trail at indiana avenue and st. clair street: utilize neighborhood streets in the ransom place residential neighborhood to connect with 10th street and cross the indiana avenue bridge in the direction of 16 tech. 2. from the end of the trail at indiana avenue and st. clair street: follow indiana avenue west to 10th street and cross the indiana avenue bridge in the direction of 16 tech. 3. from the intersection of indiana avenue and 10th street: follow 10th street west to riley hospital drive, cross 10th street and head north into the developing river-front in the direction of 16 tech (future gateway bridge). table 1: three potential expansion routes expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 36 the three route options are in close proximity to each other and all involve the ransom place neighborhood, which is directly adjacent to the indiana university purdue university indianapolis campus, a large medical center, and several area businesses. the area is compact with a great deal of traffic, including emergency vehicles, which exit and enter the neighborhood streets and nearby interstate system. pedestrian and bicycle traffic is common in the area with students, staff, and employees commuting to work or class. to examine the route options, ict approached the richard m. fairbanks school of public health graduatelevel health impact assessment course to conduct a rapid health impact assessment of three potential routes. ict sought to identify the safest, most usable, and least restrictive path for their extension route choice. the hia focused on the following questions: 1. what is the current health status of the resident population in the neighborhood? 2. do neighborhood residents, employees, and visitors believe there is a better route among the three proposed routes? 3. would an extension of the trail be utilized by the residents, employees, and visitors to the area? 4. is one of the three options a better route when considering the health and safety impact of the residents, employees, and visitors of the area? methods during the first week of the course, the ict staff presented an overview of the ict, the potential expansion routes, and the information they were interested in learning with the project. at that time, the class began examining the options for conducting a comprehensive hia, including a standard hia, which requires a substantial time commitment and primary data collection, and a rapid hia, which uses alreadyexisting and available data and resources (mindell, 2003). due to the short turnaround time (approximately five weeks to conduct and complete the hia) and nature of the project, the class decided that the rapid hia would be appropriate to assess the suitability of the three proposed routes. students divided into three groups, with each group examining one proposed route option. students followed a six-step rapid hia process of screening, scoping, assessment, recommendations & reporting, and monitoring and evaluation (ross, 2014) (table 2). in order to answer the key questions and complete the hia, data were collected by three methods: 1) secondary data provided by the local health department and the cdc that detailed the basic demographic, chronic diseases, cause of death, and cause of hospitalization of the zip code, 2) students in the course conducted a walkability assessment of each potential route, and 3) conducting brief, iterative key stakeholder interviews that were guided by a standardized question list but not bound by those questions (table 3). expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 37 table 2: health impact assessment steps screening minimal screening was needed for this project as it was part of an assigned course. the ict staff made an informative presentation to the class that outlined the need for the hia. students began to identify data sources and other resources to assist with the screening process. scoping with the limited time available to perform an hia, students chose to focus on two issues affecting the health of residents and potential trail users, namely physical activity and safety. these were chosen due to the nature of the ict being a center for physical activity. additionally, safety is a concern for the area due to a large amount of traffic and pedestrians. 1. indianapolis continually ranks low in physical activity health-related outcomes on the american fitness index. therefore, increasing access to physical activity options may lead to improve chronic disease health indicators of the affected population. 2. vehicle and pedestrian safety is a concern for many of those living in the area and should be considered when attracting bike and pedestrian traffic to an area. assessment the assessment had three components: 1. the current health status of the area was assessed using existing quantitative data from the local health department and cdc. cause of death and hospitalization data were pulled for the zip code. this secondary data was prepared by an epidemiologist at the local public health department. 2. each student group conducted a walkability survey to help evaluate the existing walkways of the area. these assessments were done in order for students to understand the walkability of the existing walkways and a first-hand look at the potential routes. this helped students to better understand the routes. 3. non-formal, face-to-face interviews were conducted with seven key stakeholders in order to gather information, thoughts, and feelings about the ict expansion from those who may be greatly impacted by the expansion. the interviews were conducted with a sample of residents, students, and employees of the area. the interviews were brief, lasting approximately 15 minutes each, and major ideas were documented in notes by the student(s). students were prepared with a list of interview questions, however they interviews were iterative, allowing for the stakeholder to detail the important aspects of the ict trail expansion in his or her own words. recommendations & reporting the hia team developed an initial set of four main recommendations and four secondary recommendations for ict. a final report was submitted to ict. monitoring & evaluation due to time constraints of the course, only recommendations for monitoring and evaluation could be made to ict. expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 38 table 3: question guide for key informant interview questions stakeholder interview questions summary of stakeholder responses 1. do you currently use the sidewalks along indiana avenue between st. claire street and the bridge that crosses over fall creek into 16 tech? for each section of the trail, most respondents stated that they were familiar with the sidewalks of the proposed routes. 2. if yes, how frequently do you use the sidewalks? the responses for frequency of use differed, but most use was due to small commutes several times a week. 3. if yes, in what capacity do you use sidewalks? for pleasure? for transit to work? for exercise? respondents currently use the sidewalks in the area during their work day to get to and from different locations, such as eating establishments. 4. do you use the indianapolis cultural trail? respondents stated that they had used the cultural trail. 5. if yes, how frequently do you use the trail? the responses for frequency varied from a few times a week to a few times a year depending on proximity to the existing trail. 6. if yes, in what capacity do you use the trail? for pleasure? for transit to work? for exercise? respondents typically only used the existing portions of the trail on special occasions for pleasure, especially if the respondents did not live in the vicinity. 7. how do you feel about extending the indianapolis cultural trail along the proposed route (students explained route options)? respondents were positive about the proposed expansion and saw it as a means to increase foot traffic to area businesses as well as for feasibility in healthy transportation. those living along route 1 only opposed the routes extension through the ransom place neighborhood. many respondents felt that extending the trail along route 3 would help to divert pedestrian traffic away from vehicular traffic at the intersection of indiana ave. and 10th st. riley hospital drive was most the most popular choice. 8. would you use the trail more if more sections were added? respondents unanimously expressed their interest in more frequent use if the trail were extended. 9. if yes, for pleasure? for transit? for exercise? respondents would mostly use of the trail for pleasure and transit. 10. what do you see as the advantages to extending the indianapolis cultural trail along route specified earlier? most respondents commented on the increased economic advantages that the trail would provide, such as the potential for more restaurants, shops, and jobs. expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 39 11. what do you see as disadvantages to extending the indianapolis cultural trail along the routes? respondents commented on the potential cost the trail could incur for the build and other costs for related structural changes, such as road repairs for connected streets. results resident demographics and characteristics the three potential routes fall within the 46202 zip code in indianapolis, inside marion county (table 4). variable n (%) total population 16335 median age (years) 30.4 sex female 7397 (45) male 8938 (55) race/ethnicity white 9043 (55) black 5802 (36) other/don’t know/refused 1490 (9) hispanic/latino 605 (4) median household income (dollars) $32,186 table 4: demographics of the population in the 46202 zip code (2010) note: (marion county public health department, 2017) expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 40 public health data show that residents living in the 46202 zip code fare better than the rest of the county with regard to hospitalizations and deaths from heart disease and stroke. however, there is a higher rate of death from diabetes reported (26 per 100,000 vs 20 per 100,000) (marion county public health department, 2017). in 2017, the overall prevalence of diagnosed diabetes for marion county, which houses the indiana cultural trail expansion, was 10.2%, which is higher than the 9.2% prevalence rate of diabetes for indiana (center for disease control, 2017). likewise, deaths due to hypertension were 239.6 per 100,000 people, which is significantly higher than the national average for 219.8 deaths per 100,000 (cdc, 2017). additional local data shows that life expectancy of those residents in the geographic area is 69.4 years, which is 14 years lower than those living 28 miles north of the area (weathers, 2015). walkability assessment each group conducted a walkability survey (health by design, 2009) that consisted of five sections to assess quality of walkways, intersections and crosswalks, safety, and accessible amenities in the area. the main findings from the walkability surveys were: 1) portions of existing sidewalks were not in good repair due to cracks, uneven pavement, and disconnection to other pathways, 2) all three route options included existing major intersections that are challenging for pedestrians to use due to fast moving traffic from multiple directions, and 3) the proposed routes will all lead pedestrians to local amenities, such as residential areas, restaurants, and hospitals. the main finding resulting from the walkability assessments was the examination of the large intersections that feed vehicle and pedestrian traffic through the area. key stakeholder interviews seven face-to-face key stakeholder interviews were conducted including two employees of local businesses who drive, walk, and work in the area; the president of the local ransom place neighborhood association who represents ransom place residents; a state senator who represents the local area; a local church leader located in the neighborhood; a patient who utilizes a local hospital and drives, parks, and walks in the hospital area; and a college student who lives in the neighborhood and attends the adjacent university. stakeholders were chosen because they live, work, and/or are a community member of the local area that could be affected by the expansion. additionally, they were chosen because of their quick accessibility, which was required due to the limited project timing. interviews were brief, lasting approximately 15 minutes each. a summary of the main findings of the key stakeholder interviews were as follows (see table 3 for summary of interview responses): 1. all but one of the seven key stakeholders stated they were in favor of the ict expansion project. the one who opposed the ict expansion suggested that gentrification would be possible and that already existing parking issues in the area would be heightened. 2. after an overview of the three potential routes during the interview, those in favor of the ict expansion all agreed that the riley hospital drive expansion route (future gateway bridge) would be the best route as long as it was safe to use. 3. the economic benefits of connecting the area with 16 tech could be beneficial to residents, employees, and businesses by driving more pedestrian traffic to local businesses. 4. the new expansion would allow for additional walking/biking paths that can be used for transportation, exercise, and recreation. recommendations after conducting the hia steps, four key recommendations were proposed and four secondary recommendations proposed (detailed in discussion section) to the ict. 1. after discussing the current options with the expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 41 engaged stakeholders, students determined that expanding the trail to use west 10th street and the proposed gateway bridge (option 3) would provide the easiest connection and safest route for trail users. likewise, the new proposed path would link other existing pedestrian and bicycle trails from the west, south, and north of the general area. this would avoid disrupting the ransom place neighborhood and any potential parking issue in the area that a new trail might cause. 2. in order to monitor the expansion and use of the trail, ict trail should conduct pedestrian and bicycle counts to track types of use, times of high and low usage, and whether or not the extension of the trail sees increased pedestrian use after the linkage with 16 tech. additionally, ict should track trends in property development both along the indiana avenue corridor and in 16 tech for use in future trail development. increased employment opportunities, healthier eating establishments, grocery store, and other resource development should be documented should those entities be implemented. 3. indianapolis cultural trail inc, should work in tandem with the marion county public health department to identify and compare healthrelated data and automobile collision data within the 46202 zip code and immediate geographic area during and after the trail expansion. the indianapolis transit authority should be consulted for data pertaining to changes in mass transit use along the corridor as well as changes in frequency and timeliness of mass transit options. 4. finally, future hia or evaluation courses should conduct an evaluation of the trail expansion during a future semester in order to monitor changes in health and the economy along the path as they look at implementing new long-term hias for other trail expansions. discussion conditions that promote health in places where we live, work, and play can have an important impact on the health status of americans. hias can assist decision makers with determining the best options that allow for the promotion of health of those impacted by the planned policy or project. hias help to connect scientific data, public input, and health expertise to guide decisions (pew charitable trusts, 2017). this rapid hia was conducted in order to 1) provide students taking the graduate-level hia course experience with conducting a real-world assessment, and 2) produce recommendations for the ict. the key stakeholder interviews allowed for in-person one-on-one conversations to happen with those most-likely impacted by the proposed trail expansion. although the majority of those interviewed were in favor of the expansion, stakeholders stated that the trail could negatively impact the ransom place residential neighborhood. one interview participant suggested that the development may lead to gentrification. with the potential to increase economic activity in this area of the city, it is critical to emphasize the importance of policies to promote mixed income housing to discourage immediate gentrification (read, 2017). other parts of the city with a current trailway saw vast gentrification, and the housing prices rose quickly leaving many low income residents without the ability to afford their homes. because income and housing can be significant drivers of overall public health, researchers recommend that planners work with city officials to draft policies protecting current residents. to help overcome concerns of disconnectedness that the ict expansion may have on local residents, one stakeholder suggested that the newly expanded trail include local artwork or historical markers by saying, “it would be great; i would want to walk it if it’s close to work; i would like having that area developed to look useable and pretty—it would make me happy to use it. it would benefit my quality of life; it is safe and pleasant to use.” in order to educate local residents expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 42 about the historical significance of the area, planners should include local art, specifically art relative to the african american community who first settled the area and continue to inhabit it. in order to inform trail users of the area, additional signage should be added along the trail to indicate the historic neighborhood of ransom place and informational signs would be useful in maintaining the deep history of the area. the ict plays an important role in exercise and recreation for users. marketing and promotion of the cultural trail expansion should be used to promote use in order to increase physical activity. in cities similar to indianapolis, having a well developed network of biking and walking trails increases walkability and bikeability, thereby increasing physical activity for all residents (brownson, 2000). recent studies have found that walkability is a highly significant predictor of physical activity independent of individual behavior and even socioeconomic status (sallis, 2009). many studies have shown the importance of infrastructure in increasing walking and cycling mode shares. cross-sectional studies consistently show a positive correlation between bike facilities and cycling (pucher, 2010). dill (2003) found each additional bikeway mile per square mile is associated with a roughly one percent increase in bicycle mode share. safety was also a main concern for the ict and the key stakeholders who live and/or work in the area. as each of the three potential routes include large intersections and city streets that carry a large volume of fast moving traffic, it is important for the expansion planners to consider safety as a main priority. safety education is an important aspect of both public safety and encouraging physical activity in potential trail users. safety training programs improve pedestrian skills such as timing and choosing safe crossings (killoran, 2006). marketing programs have been successful in promoting individual behavior change. such programs can increase the use of alternative modes by 10-25 percent (victoria transportation policy institute, 2010). these evidencebased recommendations are potentially useful in indianapolis and are easily applicable to the expansion of the cultural trail. this project had several limitations. first, because the course was a six-week intensive course, there was a limited amount of time in which students could conduct this rapid hia. although the course was six weeks, students had approximately five weeks to design, implement, and report the findings of the hia. if time would have allowed for a full hia, more in-depth primary data could have been collected that might show a more direct health impact of the expansion. second, as students implemented the hia plan, students determined there were gaps in the data collection plan, such as the interview guide did not match the need for the stakeholder interviews and limited data for the specific area of interest. in order to accommodate for these items, students made adjustments as they went along with the guidance of the course instructor. the health impact-related outcomes could not be thoroughly examined in the allotted time frame and with the existing student resources. the recommendations were a product of the planned data collection, but there were unforeseen gaps in the planning and data collection processes which led to less rigorous findings as could have been expected in a full hia. this was due to the lack of student experience conducting hia. third, characterization impact assessment was not made for each of the factors affecting the three routes. impact characterization is an important step to allow for an overview of the full project. this step should be completed if time allows in any future hia of the ict. finally, the potential ict expansion routes were already identified prior to the hia taking place. there could be additional routes that may have a different impact on the area. implications for practice this project allowed graduate students to have handson experience conducting a rapid hia in the real world with potential impact on the project. the outcomes of the hia were meaningful, and contribute to the ict expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 43 organization’s planning process for future expansion of the route. likewise, this hia demonstrates the importance of engaging communities most affected by proposed projects, as they provide valuable insight to unintended consequences of community based projects. the hia project serves as an example for other academic courses that focus on hia. students can use this as a reference or case study for future studies. acknowledgements the authors would like to acknowledge the students in the course who participated in the data collection process: staci kaczmarek, lauren lancaster, ali shahsavar, hadyatoullaye sow, and anthony tarver expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 44 references brownson, r.c., housemann, r.a., brown, d.r., jackson-thompson, j., king, a.c., malone, b.r., & sallis, j.f. (2000). promoting physical activity in rural communities: walking trail access, use, and effects. american journal of preventative medicine, 18(3), 235-241. centers for disease control and prevention. (2017). division of heart disease and stroke prevention. accessed at: https://nccd.cdc.gov/dhdspatlas/reports.aspx?geography type=couty&state=in&themesubclassid=17&filterids=9,2,3,4,7&filteroptions=1,1,1,1,1#report dill, j. & carr, t. (2003). bicycle commuting and facilities in major u.s. cities: if you build them, commuters will use themanother look. abstract presented at the meeting of the transportation research board, washington, d.c. health by design. (2009). how walkable is your neighborhood? retrieved from http://healthbydesignonline.org/ documents/walkabilitysurvey_hbd.pdf indiana university public policy institute. (2015). assessment of the impact of the indianapolis cultural trail: a legacy of gene and marilyn glick. retrieved from http://indyculturaltrail.org.s3.amazonaws.com/wp-content/ uploads/2015/07/15-c02-culturaltrail-assessment.pdf indianapolis cultural trail, inc.(2017). about. retrieved from http://www.indyculturaltrail.org/about/ killoran, a., doyle, n., waller, s., wohlgemuth, c., & crombie, h. (2006). transport interventions promoting safe cycling and walking: evidence briefing. national institute for health and clinical excellence. united kingdom. meyer, o.l., castro-schilo, l., & aguilar-gaxiola, s. (2014). determinants of mental health and self-rated health: a model of socioeconomic status, neighborhood safety, and physical activity. american journal of public health, 104(9), 17341741. mindell, j., ison, e., joffe, m. (2003). a glossary for health impact assessment. journal of epidemiology & community health, 57(9), 647-651 pew charitable trusts. (2017). health impact project. retrieved from http://www.pewtrusts.org/en/projects/healthimpact-project pollack, k. m., dannenberg, a.l., botchwey, n.d., stone, c.l., & seto, e. (2014). the usa. impact assessment and project appraisal, 33(1), 80-85. pucher, j., buehler, r., bassett, d.r., & dannenberg, a.l. (2010). walking and cycling to health: a comparative analysis of city, state, and international data. american journal of public health, 100(10), 1986-1992. read, d., & sanderford, d. (2017). examining five common criticisms of mixed-income housing development found in the real estate, public policy, and urban planning literatures. journal of real estate literature, 25(1), 31-48 robinette, j.w., charles, s.t., & gruenewald, t.l., (2017). neighborhood cohesion, neighborhood disorder, and cardiometabolic risk. social science & medicine, 198, 70-76. ross, c., orenstein, m., & botchwey, n. (2014). health impact assessment in the united states. new york, ny: springer. sallis, j.f., saelens, b.e., frank, l.d., conway, t.l., slymen, d.j., cain, k.l., chapman, j.e., & kerr, j. (2009). neighborhood built environment and income: examining multiple health outcomes. social science & medicine, 8(7), 1285-1293. weathers, t.d., leech, t.g.j., staten, l.k., adams, e.a., colbert, j.t., & comer, k.f. (2015). worlds apart: gaps in life expectancy in the indianapolis metro area. retrieved from http://www.savi.org/savi/documents/worlds_apart_ gaps_in_life_expectancy.pdf victorian transport policy institute. (2016). safer than you think! revising the transit safety narrative. retrieved from http://www.vtpi.org/safer.pdf figure legend figure 1: map of three proposed expansion routes expanding the indianapolis cultural trail: a health impact assessment yazel-smith; merkley; danek; stone 45 corresponding author lisa yazel-smith, ms, mches, ccrp law & policy analyst pediatric and adolescent comparative effectiveness research indiana university school of medicine 410 w. 10th street, ste. 2000a indianapolis, in 46202 phone: (317) 278-9615 smithlg@iupui.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 3 issue 1 (2018) doi: 10.18060/22312 © 2018 author(s): yazel-smith, l.; merkley, a.; danek, r.; stone, c. this work is licensed under a creative commons attribution 4.0 international license acknowledgements the authors would like to acknowledge the students in the course who participated in the data collection process: staci kaczmarek, lauren lancaster, ali shahsavar, hadyatoullaye sow, and anthony tarver october 2017 volume 2 a community grounded hia: the benefits of conducting a hia during the airds bradbury estate redevelopment karla jaques; fiona haigh; michael thorn abstract: background: this paper identifies and discusses the benefits of taking a ‘community grounded’ approach to health impact assessment (hia) in the context of a place based urban renewal setting and reflect on whether this is a useful approach for people and organisations wishing to undertake hia’s in similar settings. the hia was on the redevelopment of the suburban town centre and focussed on the creation of a new multipurpose centre, improvements to a manmade pond and the relocation of sporting fields found in the area. the hia team aimed to explore what the planned redevelopment of the local town centre area would mean for the local community and its potential health impacts upon residents. methods: the hia followed the standard hia steps. the hia team took a community grounded approach where particular focus was engaging community members in the hia process. this included community members being involved in the hia working group, reference group and providing evidence for the hia. results: the hia report contained a series of recommendations for the redevelopment of the airds bradbury estate, found in the outskirts of south-western sydney, the estate prior to redevelopment being a predominantly public housing estate and via redevelopment will include a mixture of privately and publicly-owned housing. these recommendations were presented to the community reference group and were adopted by various stakeholders. conclusion: the community grounded approach influenced both how the hia was carried out, the decisions that were made within the hia and ultimately the findings and recommendations. the hia of this latest stage of the airds-bradbury estate redevelopment was a useful project to encourage further collaboration, dialogue and planning between redevelopment agencies, local government, and residents of the airds bradbury social housing estate. i a community grounded hia jaques; haigh; thorn 2 introduction health impact assessment (hia) can be applied to many different types of proposals and is adaptable to the context in which it is undertaken. this paper identifies and discusses the benefits of taking a ‘community grounded’ approach to hia in the context of a place-based urban renewal setting, and reflects on whether this is a useful approach for people and organisations wishing to undertake hia’s in similar settings. this hia was conducted to inform plans to redevelop the town centre of the airds-bradbury social housing estate* and, through the engagement of residents, to ensure that these plans reflected the needs of the community. this was achieved through the examination of greenspace and infrastructure within the town centre, and how these might be improved or reconfigured to improve the wellbeing and neighbourhood livelihood of residents. to attain this, the project engaged community members of the estate, academics, and service providers in a ‘learning-by-doing’ process. this process was useful in initiating all participants to this process in a manner that was practical and accessible to all members of the hia project team. the effect of undertaking this process was this community grounded approach to hia. community grounded in this context means that the hia is based on the: values, behaviours, norms, and worldviews of the populations they are intended to serve, and therefore are most closely connected to the lived experiences and core cultural constructs of the targeted populations and communities (okamoto, kulis, marsiglia, holleran steiker, & dustman, 2014, p. 104). * throughout this report the term ‘estate’ is used to refer to public/social housing, that is; dwellings that are publically owned and managed by housing nsw within nsw government’s department of family and community services (facs). the proposal the airds bradbury suburban area is approximately 50km south-west of sydney cbd. airds bradbury is one of the most socioeconomically disadvantaged of new south wales (australian bureau of statistics, 2011) consisting of 1,540 dwellings which the majority are publically owned and managed (94%). the suburb has a large aboriginal and torres strait islander community making up 15% of the total airds population. the airds bradbury renewal project is a large public housing estate renewal plan with the objective to redevelop the area as a mixed tenure neighbourhood of 30% social housing and 70% private housing. this involves redeveloping some areas of the estate and constructing new private and social housing and also making new road connections and new community facilities. this includes demolition of some existing housing and re-location of residents. previously established redevelopment plans of the airds bradbury renewal project were used for this hia, as they included crucial community infrastructure that residents of airds bradbury had previously identified as key to a successful renewal and redevelopment of the area. the hia focused on stage 3 of the project concept plan which covers the redevelopment of the suburban town centre which contains the retail centre, local tavern and a multipurpose facility. this stage also includes development of new playing fields, a multipurpose community centre, redevelopment of an existing pond located off the town centre, a new road connection, a reserve and new housing lots. the hia team aimed to explore what the planned redevelopment of the local town centre area would mean for the local community and its potential health impacts upon residents. the hia focused on three local sites that the redevelopment plans had identified as crucial to the well-being of local airds bradbury residents, and the municipal upkeep of the area, once the redevelopment was completed. these sites were the creation of a new multipurpose centre, improvea community grounded hia jaques; haigh; thorn 3 ments to a manmade pond and the relocation of sporting fields found in the area. methods undertaking a hia followed a step-by-step process as detailed below (see table 1) table 1 hia steps 1. screening residents of the airds bradbury social housing estate, and staff working locally for the new south wales (nsw) land and housing corporation, met with trainers from centre for primary healthcare and equity (chetre) to discuss the possibility of conducting a hia on the airds bradbury (ab) renewal project. this was as a result of calls for expressions of interest for the hia training. these parties formed the project team for carrying out the hia. as previously highlighted, this was to be conducted as part of a learning-by-doing hia training conducted by chetre. during day one of the training a screening tools was used by the project team to develop the rationale for the hia. 2. scoping the hia team hosted a scoping workshop, which included members of the airds bradbury community reference group (crg), local school administrators and local high school students. various impacts of the planned redevelopment of the town centre were considered and it was agreed that the hia would focus on the three main sites within the town centre (i.e. the multipurpose centre, upgrades to the pond and relocation of sporting fields). initial health impact pathways were developed and validated by a member of the local aboriginal community. 3. identification members of the hia team conducted a literature review focusing on the health impacts of each of the focus areas. additionally, previous research that had been conducted in the airds bradbury community were identified and examined for relevance to the hia. 4. assessment an assessment meeting was held with local stakeholders, made up of community members, service providers, police, council members, members of the local high school (including administrators and students), nsw land and housing corporation staff and the developers of the redevelopment site (urban growth). the hia presented the findings of the literature review and previous research, stakeholders validated these findings and developed draft recommendations. the findings were also shared with and validated by a member of the local aboriginal community. a community grounded hia jaques; haigh; thorn 4 5. decision making and recommendations the hia team developed an initial set of recommendations based on the assessment workshop and input from the local aboriginal men’s group. these were then shared with and prioritised by local stakeholders and a member of the local aboriginal community, who corroborated these with members of the local aboriginal men’s group. as the hia was undertaken it also was a standing agenda item at monthly crg monthly meetings meeting between may 2016 through to november 2016 with draft recommendations developed at the crg and reported back to the crg for comment. the hia project team developed a series of report drafts informed through various forms of research – census data, the interviewing of local community groups, and consultations with members of the crg. this was incorporated into the final recommendations of the eventual hia report, the report formally submitted to the crg, the developers urban growth, nsw land and housing corporation’s development director and campbelltown city council in december 2016. 6. monitoring and evaluation as of writing it is anticipated that an evaluation plan will be developed by the hia project team. the implementations of the hia recommendations, as articulated within the final report, are being monitored by the crg. the hia is a standing agenda item for ongoing crg meetings. it is anticipated that this hia could act as a case study in which a ’grounded hia’ approach worked well with the local community, and the case study can outline how this was achieved and what contributed to its success. results the potential impacts of the planned redevelopment of the town centre were identified through a creation of a pathway diagram. this considered the potential impacts that the redevelopment would have on airds bradbury residents. the impacts were identified using existing evidence and data collected in a workshop with crg members. this involved accessing data collected during prior consultations, a rapid literature review, data collected by the airds community renewal team, city of campbelltown council and department of sports and recreation, and anecdotal evidence from the airds bradbury community reference group (crg) members. data included previously collected information from a telephone survey and various community consultations. given the context specific background of the hia team, members had direct experience with the community and had a sound understanding of the current needs of the community. prior hia projects, both internationally and locally based, were also researched by the project team to validate the approach taken. it is noted, however, the limited critical nature of this research, in that this research was undertaken ultimately to identify similar kinds of urban redevelopment. the success of these redevelopment projects remained largely unexplored. a community grounded hia jaques; haigh; thorn 5 while the research demonstrates what is involved in changing the urban landscape the introduction of green spaces, outdoor recreation facilities, and fixed areas for exercise – what is lacking in the commentary of the redevelopment projects is how effective these changes were toward improving living standards in the neighbourhood. while the changes obviously improved the landscapes from an aesthetic standpoint, missing were substantial measurements or metrics demonstrating an improvement of the overall health within the neighbourhoods that these changes took place. what the research did provide value toward, however, was providing solid examples on how landscape design can be directed in the process toward improving the quality of life within urban landscapes. this informed the process that the hia took in assessing what residents considered to be effective urban landscape design.. the hia report contained a series of recommendations for the redevelopment of the airds bradbury estate. these recommendations were presented to the crg and were adopted by various crg stakeholders. while these recommendations are not binding and do not have authority over the key estate redeveloper urban growth, all members of the crg consider the report as capturing the views and wants offered by residents in relation to the redevelopment. as a consequence, the hia report is seen as a substantial document by the crg. as a member of the crg, urban growth considers the community feedback the report offers to be of relevance, as the report forms part of the local consultation requirements required to be legally met when undertaking redevelopment on the airds bradbury estate. before the hia report was completed, urban growth requested any early findings of the hia report to inform their planning, suggesting that urban growth considered the hia as a major source for local feedback regarding the redevelopment. as of writing the crg will have a future role in reviewing the stage 3 concept plan of the airds bradbury redevelopment, through a tabling of the draft activity results upgrades and relocation of the playing fields potential for positive impact on the community as evidence from the literature and the community demonstrates that improvements in the built environment and access to recreational opportunities have the potential to lead to improved physical activity, social cohesion and mental wellbeing. upgrades to pond and surrounding area evidence from the literature and community suggest that this had the potential to positively impact the community. improvements to the built environment have the potential to lead to ownership and improve positive community integration, decrease stigma and improve mental wellbeing. creation of new multipurpose centre evidence from th eliterature and community found that this activity has the potential to impact the community both positively and negatively. positive impacts included an increase in availability of local childcare services and employment. negative impacts included the shifting of the current effective model of practice would lead to a decrease in established community ownership and connection. a reduction in community space would lead to a decrease in utilisation, causing a reduction in community activity, involvement, physical activity and connectedness. table 2: summary of key findings a community grounded hia jaques; haigh; thorn 6 activity recommendations upgrades and relocation of the playing fields • prioritise local sport needs • develop promotion strategy for local use • develop strategy for low cost participation for locals • ensure fields and amenities are safe (lighting, surveillance) • ensuring historical name and significance is displayed • establish adjacent spaces applicable for different age groups and ability levels • acknowledge the sensitivity of the placement of fields near significant aboriginal land. upgrades to the pond and surrounding area • establish ongoing maintenance plan (waste disposal, vegetation, water quality and safety) • physical design to include information about local flora and fauna and local aboriginal history and significance and have facilities including shade, lighting, drinking water and rest stations. • design to encourage participation e.g. walkability, age and ability appropriate. upgrades for multipurpose centre • physical design meets minimum requirements for community use as deemed appropriate by local community • continue to have staffed reception area • adequate amenities including kitchen and toilets • minimum opening hours 5 days a week. participation • employ community development office to encourage and support health and wellbeing and social participation throughout period of change in the estate • continue to support existing relationships between current community centre and local residents • ensure all three design components (playing fields, pond and multipurpose centre) are easily accessible and integrated. • in longer term, consider alternative modes of operation which reflect needs of the changing community, use of iap2 spectrum of public participation recommended. • where possible, naming of existing or newly established infrastructure should be made in consultation with local community including the local aboriginal community. cultural participation • ensure appropriate ongoing engagement with local aboriginal community to recognise the significance of local aboriginal community. • consider introduction of a cultural learning/sharing space within town centre • consider regular organisation of cultural events that reflect local community • consider the use of public art that reflects local cultural diversity table 3: summary of key findings a community grounded hia jaques; haigh; thorn 7 plan by urban growth to the crg, and the crg then seeking to assess this plan against the recommendations contained within the hia. the hia remains as a standing agenda item at crg meetings. redevelopment under stage 3 is expected to commence in the latter half of 2017 after local council consents to urban growth’s future development application. this suggests the hia will continue to exist as an ongoing referencing tool for stage 3 of the airds bradbury redevelopment. that is, the crg making sure the outcomes of the hia are included and fulfilled where necessary during the formation of the draft plan by urban growth, and then later via the development application by urban growth to local government. table 2 displays a summary of the key findings and table 3 gives a brief summary of the key recommendations arising from the hia. discussion hias of social housing regeneration projects are relatively common (harris, haigh, thornell, molloy, & sainsbury, 2014; kearney, 2004; mccormick, 2007). regenration project have significant health impacts on the communities living in in these areas. however, communities often have limited involvement in hia processes. for example kearney (kearney, 2004) in an evaluation of community participation in a regenerartion hia found that “the results suggest that there may be a large gap between professional rhetoric and the reality of community participation, and that barriers to community participation in hia may be substantial and institutionalised” community participation is often considered as a central practice for effective hias (den broeder, uiters, ten have, wagemakers, & schuit, 2017; mahoney, potter, & marsh, 2007). the presence of local residential involvement and contribution in hias has been shown to have a positive impact on the success of projects from development through to implementation (chadderton, elliott, hacking, shepherd, & williams, 2012; chilaka, 2015; den broeder et al., 2017; elliott & williams, 2008; haigh et al., 2015; wright, parry, & mathers, 2005). however, community participation is often hard to establish, and also for it to be best managed within the timeframes and expectations of policy making, which can make a truly collaborative hia process a challenge to attain (chadderton et al., 2012; parry & wright, 2003). this hia provides a case study of taking a community grounded approach in the context of an urban redevelopment project taking place in a locationally disadvantaged community. in the early planning stages of the hia a decision was made to ground the hia in the experiences and knowledge of the local community. the hia was conducted in collaboration with a variety of local stakeholders, particularly those associated with the airds bradbury community reference group (crg). the crg consists of the nsw land and housing corporation (lahc), campbelltown city council, urban growth, family and community services (facs) housing services, local schools, residents, and local churches. in addition, a representative from tharawal aboriginal community provided input into the hia scoping and assessment steps. the hia team consisted of representatives of nsw land and housing corporation, (responsible for the management of the nsw government’s social housing portfolio), residents from the airds and bradbury suburbs, the centre for health equity, training research and evaluation (an academic research unit that is also a unit of the local health district) in collaboration with south west sydney local health district population health unit. although engaging community members in hias is standard good practice, evaluations of hias have found variation in levels of community engagement and community perspectives are often missing or limited to providing evidence in the identification stage (haigh et al., 2015; schuchter, bhatia, corburn, & seto, 2014).this similar to the consideration of equity in hia, where equity is a core value and expected a community grounded hia jaques; haigh; thorn 8 to be considered all hias however in reality is often missed or superficially considered (povall, haigh, abrahams, & scott-samuel, 2013). similar to the equity focussed hia approach developed in australia (simpson, mahoney, harris, aldrich, & stewart-williams, 2005) we felt that it would be useful to adopt an hia approach that was explicitly grounded in the community. in the community grounded approach, community members had ownership and power in the hia process. in practical terms the hia team explicitly considered at each step of the hia how community perspectives were incorporated into the hia. this had two main implications for how decisions were made during the hia: • the views of community members were prioritised when deciding on the areas of focus; and • the views and experience of community members was given a high priority in the assessment stage of the hia. this grounded approach also influenced the process of the hia: • community members were part of the hia working group and therefore had power to influence the hia processes and decision making throughout the hia. • throughout the process opportunities were sought to engage community members. table 4 demonstrates how the community grounded approach influenced each step of the hia process. despite having community members in the hia working group, engaging the community actively in the hia was still challenging. a key issue in the screening and scoping stage of the hia was how the broader airds bradbury community would be engaged in the hia. at the time that the hia project group was screening a key driver for deciding to carry out the hia was the interest from community members in both an hia being carried out and also being directly involved in the hia scoping the views of community members were prioritised when deciding on the areas of focus. community members were part of the hia working group and therefore had power to influence the hia processes and decision making throughout the hia. identification as well as data from the community being included in the identification stage community members were also involved in deciding what data should be collected and were involved in collecting data from other community members (e.g. local school) assessment community members were involved in carrying out the assessment step. the views and experience of community members was given a high priority when identifying and describing priority impacts. recommendations and decision making community members as part of the working group identified an initial set of recommendations that were then validated and elaborated on by a wider community reference group. evaluation and monitoring it is expected that community representatives will be involved in the ongoing monitoring of the recommendations. table 4: implications of community grounded approach for each step of the hia a community grounded hia jaques; haigh; thorn 9 formed, the estate redevelopment that the hia would cover (stage 3) was only in draft phase by redevelopment agencies, and had yet to be approved by local government and still to be tendered by the key developer urban growth. further, as this estate redevelopment stage was only in a draft phase, this also effectively rendered the hia itself a hypothetical exercise at the time of the hia’s undertaking. however, there was substantial good faith within the crg that redevelopment of the town centre area would eventually be made part of the overall redevelopment program for the airds bradbury estate. the crg (which included community representatives) decided to limit consultation so as not to raise suggestions and confusion within the broader community that redevelopment of these key town centre areas had officially commenced. the hia process played a part in a collaborative exercise in identifying and addressing the needs of residents, government agencies, community organisations, and urban growth as the key agency responsible for estate redevelopment. through intensive dialogue with residents, the presence of a steering committee consisting of a variety of stakeholders attached to the airds-bradbury estate, and a redevelopment agency with commitment to participating within community groups such as the airds bradbury crg, the hia has proved to be a useful reference tool for each of these stakeholders. ug involvement in the hia was a way to further demonstrate their commitment to community and potentially enhancing trust with all stakeholders to the estate. as a document informing the decision making of the crg during this current stage of redevelopment on the airds-bradbury estate, the hia itself demonstrated the existence of locational disadvantage within the context of urban renewal. this was demonstrated through the hia highlighting the importance of neighbourhood life to public housing residents, especially those residents that continue to live on the estate, or will return to the estate after stages of redevelopment are completed. also of consideration was the influx of private residents to the estate through the social mix of privately and publicly-owned housing stock established within the redevelopment. this created a challenge for the hia project team, in which the team needed to identify how overall health of public housing residents would be managed within this social mix component. this required the hia project team to identify to what extent the redevelopment stage would identify local need, and from this propose a series of recommendations addressing the specific needs of public housing residents in the face of the pending redevelopment. in the interest of ongoing community vitality within the airds-bradbury estate before and after redevelopment, planning for this redevelopment site would particularly need to consider the maintenance, and even improvement, of the community infrastructure found within this location. this was demonstrated in the hia report through recommending the construction of outdoor exercising apparatus, creation of footpaths and walking tracks, the creation of a multipurpose centre allowing local infrastructure and facilities. therefore an ongoing addressing of needs of both old and new residents, and the restoration of playing fields to reinvigorate organised sport within the suburb. maintaining community vitality through redesigning the local landscape is within the scope of urban growth to manage. there were a range of contextual factors that influenced the success of taking a community grounded approach. the crg ensured the autonomy of the hia project team and due to the sensitivity of the hia project to the local community, the crg maintained confidentiality of the project group during the formation and drafting of the hia report. this provided a space for open discussions with key community stakeholders that would have been otherwise difficult given the sensitivity of the project. this did however place the a community grounded hia jaques; haigh; thorn 10 crg in a position where it needed to be sensitive with how it would mention the activity of the hia project group to residents, as the redevelopment of the part of the airds bradbury estate that the hia would cover was yet to be made official by urban growth. in this hia, taking a community grounded approach was facilitated by the existence of collaborative bodies already attached to a redevelopment project. in the instance of the airds-bradbury estate, this was reflected through the existence of the crg, a steering committee existing within the estate for several years and had a firm presence on the estate prior to estate redevelopment commencing. further to this was the implementation of the hia being based upon draft plans of the redevelopment stage, rather than final plans, thus limiting the scope of the project team. this restricted the amount of engagement that the project team could have with the local community. as they were draft plans, the project team also needed to take into consideration that the plans may be subject to change, and so the team had concerns about the hia raising false expectations for residents, and causing possible concern for activities that may or may not go ahead. this was especially important when the team was required to make comment on the stage of the airds-bradbury redevelopment that the hia was implemented toward, this stage being a substantial one as it incorporates the central area of airds-bradbury, where there will continue to be an ongoing traffic of cars and people before and after redevelopment is completed. this is also a redevelopment stage where much of the central community infrastructure in airds-bradbury is located, which includes a substantial man-made water feature, a multipurpose centre currently owned by the nsw facs, and commercial establishments such as a hotel pub and local shopping centre. it is an important stage of estate redevelopment in terms of maintaining community harmony and identity, and so information relating to the draft plans needed to be handled sensitively by the project team when communicating to estate residents. while urban redevelopment of social housing estates in nsw are no longer a new advent, the challenge toward addressing how redevelopment impacts current and future estate residents, and the incoming cohort of private residents, remains. as a community project, the creation of a hia is especially beneficial towards identifying areas of locational disadvantage within urban renewal projects, and to document the views and needs of a community already having substantial engagement with the agencies responsible for urban renewal. the methodology applied by the hia when creating this final report may have value for future hias within estates undergoing urban redevelopment. this hia has undertaken a ‘community grounded hia’, a report relying upon extensive consultation and documentation of residents, especially long-term residents, and respecting the pre-existing crg as a central body for all stakeholders connected to the airds bradbury estate. the formation of a hia project group was essentially a collaborative effort between government agencies and residents, with the group also able to maintain regular contact with the crg. members of the project group also demonstrated a commitment to documenting the views of residents while remaining linked to the crg. the value that the hia placed upon the stakeholders attached to the airds bradbury estate, and respect towards the collaborative local community bodies also in existence at the time of the hia, primarily served to inform this ‘community grounded’ approach. rather than prescribe or attempt to introduce alternative models toward improving community vitality in lieu of estate redevelopment, the hia instead resolved to identify and respect previously established stakeholders of the airds-bradbury estate. further, the hia actively recognised the strengths and commitment that these stakeholders offered to the collaborative effort. a community grounded hia jaques; haigh; thorn 11 this ‘grounded hia’ model can be applied within other contexts, and other social housing redevelopment programs in nsw, australia and internationally. it serves as a methodology ensuring a documentation of not only how pending redevelopment can affect long term residents of an estate, but also suggesting recommendations for redevelopment that is informed through identifying the views, opinions and efforts of residents and other relevant stakeholders attached to the redevelopment. conclusion the redevelopment of airds bradbury will impact current and future residents of these suburbs. moreover, with specific reference to the areas of focus of this hia, research has shown that a focused introduction of upgrades to existing greenspace has the potential to positively impact local communities. these types of facilities have the potential to considerably influence community members’ participation in sporting and recreational activities and in turn overall physical activity levels (council, 2010; health, 2009; sport, 2016). in this sense, while the hia has formed recommendations on this current redevelopment stage of the airds-bradbury estate, there will still be reliance upon the crg to adhere to these recommendations, and ultimately urban growth to respect these recommendations as ones that have been previously sourced from estate residents. to this end it is unknown how effective these recommendations are until redevelopment on the estate is actually completed. the hia of this latest stage of the airds-bradbury estate redevelopment was a useful project to encourage further collaboration, dialogue and planning between redevelopment agencies, local government, and residents of the airds bradbury social housing estate. however, there remains uncertainty over whether the lessons of this project can be automatically applied to similar redevelopment programs on other estates in australia. while the hia was a useful tool in this instance toward consolidating previously-existing collaboration between residents and redevelopment agencies during estate urban renewal, the local context within other redevelopment programs would need to be identified and then integrated toward the overall ‘grounded approach’. this collaboration extended to the writing of this paper which was a joint effort by all members of the hia working group. a community grounded hia jaques; haigh; thorn 12 references australian bureau of statistics. census: data and analysis [internet].canberra: australian bureau of statistics; 2011 cited 2016 aug 10]. available from: http://www.abs.gov.au/websitedbs/censushome.nsf/home/data?opendocument&navpos=200. chadderton, c., elliott, e., hacking, n., shepherd, m., & williams, g. (2012). health impact assessment in the uk planning system: the possibilities and limits of community engagement. health promotion international, 28(4), 533-543. doi:10.1093/heapro/das031 chilaka, m. a. (2015). drawing from the well of community participation: an evaluation of the utility of local knowledge in the health impact assessment process. community development, 46(2), 100-110. doi:10.1080/15575330.2015.1014 060 council, m. c. (2010). wiri spatial structure plan: health impact assessment report. retrieved from http://www.health. govt.nz/our-work/health-impact-assessment/completed-nz-health-impact-assessments/wiri-spatial-structure-plan-hia: den broeder, l., uiters, e., ten have, w., wagemakers, a., & schuit, a. j. (2017). community participation in health impact assessment. a scoping review of the literature. environmental impact assessment review, 66, 33-42. doi:https:// doi.org/10.1016/j.eiar.2017.06.004 elliott, e., & williams, g. (2008). developing public sociology through health impact assessment. sociology of health and illness, 30(7), 1101-1116. doi:shil1103 [pii];10.1111/j.1467-9566.2008.01103.x [doi] haigh, f., harris, e., harris-roxas, b., baum, f., dannenberg, a., harris, m., . . . spickett, j. (2015). what makes health impact assessments successful? factors contributing to effectiveness in australia and new zealand. bmc public health, 15(1), 1-12. doi:10.1186/s12889-015-2319-8 health, n. (2009). healthy urban development checklist. retrieved from nsw: http://www.health.nsw.gov.au/urbanhealth/publications/healthy-urban-dev-check.pdf mahoney, m. e., potter, j. l. l., & marsh, r. s. (2007). community participation in hia: discords in teleology and terminology. critical public health, 17(3), 229-241. okamoto, s. k., kulis, s., marsiglia, f. f., holleran steiker, l. k., & dustman, p. (2014). a continuum of approaches toward developing culturally focused prevention interventions: from adaptation to grounding. the journal of primary prevention, 35(2), 103-112. doi:10.1007/s10935-013-0334-z parry, j., & wright, j. (2003). community participation in health impact assessments: intuitively appealing but practically difficult. bulletin of the world health organization, 81, 388-388. sport, c. f. (2016). sports facility planning and use. retrieved from: https://www.clearinghouseforsport.gov.au/knowledge_base/organised_sport/sports_administration_and_management/sports_facility_planning_and_use wright, j., parry, j., & mathers, j. (2005). participation in health impact assessment: objectives, methods and core values. bulletin of the world health organization, 83(1), 58-63. a community grounded hia jaques; haigh; thorn 13 corresponding author karla jaques centre for health equity research, training and evaluation part of the unsw centre for primary health care & equity, a unit of population health south western sydney and sydney local health districts, nsw health a member of the ingham institute chia staff: editor-in-chief cynthia stone, drph, rn, professor richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 2 (2017) doi: 10.18060/21560 © 2017 author(s): jaques, k.; haigh, f.; thorn, m. this work is licensed under a creative commons attribution 4.0 international license acknowledgements we would like to acknowledge the hia working group deborah follers, author, jen rignold, author and tuyen duong. we would also like to acknowledge the various individuals and organisations that contributed to this health impact assessment. in particular, this project would not have been possible without the support of the centre for health equity training, research and evaluation and south western sydney local health district. 49 call for chronicles of health impact assessment (chia) peer reviewers we appreciate your interest in supporting the chia journal as a peer reviewer. in this role, you will be asked to read submitted articles. if you do not have time you can decline the invitation to review and will be placed back in the rotation for future opportunities. if you do have time, your review will address the following: you will submit a written critique that will help determine if the article will be published. you will be asked if you have any conflicts of interest in reviewing an article. all your comments will be anonymous to the authors. you will be given prompts to respond to, such as: what are the article strengths or weaknesses, is this information that is new to the field or building on already known material? all comments should be viewed as constructive criticism for the authors. you will have the choice to accept, recommend acceptance with revisions, or not accept the article. if you are interested, the following information will assist us in matching peer reviewers to specific authors. name email address affiliation phone number area of hia expertise (check all that apply): agriculture criminal justice health equity housing built environment economics hia evaluation labor policy climate change education hia methodology natural resources community development energy hia theory redevelopment transportation other:__________________________________________________ how are you qualified (papers written, journal reviewed for, etc.)? 1050 wishard blvd., indianapolis, in 46202 317-274-2000 chia@iu.edu december 2021 volume 6 issue 1 1 sandra whitehead, mpa, phd; emily bever, bs inta; ruth lindberg, ba ch, mph, mup; james e. dills, bs, mup, mph updating the minimum elements and practice standards for hia to reflect evolution in the field of practice: opportunity for input abstract: the minimum elements and practice standards for health impact assessment (meps) is undergoing its first update in six years. this document was first created to standardize health impact assessments (hia) through specific guidance and benchmarks and describe best practices for how an hia should be conducted. a group of leading hia practitioners created the meps in 2009. since then, it has been updated twice to reflect the evolution of hia as a practice and the expanded use of hia as a tool to implement health in all policies. this commentary describes current efforts to revise the meps in the context of continued learnings in the field. updating the minimum elements and practice standards for hia whitehead; bever; lindberg; dills 2 introduction hia is one important strategy to advance health in all policies (hiap), defined by the world health organization as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity” (world health organization, 2014). the society of practitioners of health impact assessment (sophia) is an international association of individuals and organizations that develops high-quality resources to help hia practitioners build capacity, supports member networking and peer mentoring opportunities, and communicates timely information on resources, training, and technical assistance opportunities. data from sophia’s routine membership survey suggests that its guidance documents and publications, including the meps, are among the most used and valued resources. the meps outline the minimum criteria that an hia should address, as well as best practices for conducting an hia. this commentary describes current sophia efforts to revise the meps for the first time in six years. evolution of hia practice and the need for revised standards hia was first used in the u.s. in 1999. practitioners adapted european models of practice, including the use of hias within environmental assessment frameworks, and, by 2009, there was a wide variety of documents labeled hias in the u.s. however, these assessments followed different methodologies and provided a range of evidence levels and research quality. a working group of experienced hia practitioners identified the need for practice standards during the september 2008 north american conference on health impact assessment and published a formal document in 2009 (north american hia practice standards working group, 2009). in 2010, the working group updated the practice standards and added minimum elements (north american hia practice standards working group, 2010). the goals were to offer high-level guidance for distinguishing hia from other assessment methods and provide benchmarks for standardizing north american hia practice. at this early point, the working group determined it was advantageous to establish common hia characteristics and activities to guide practice. the working group completed the most recent meps update in 2014 (bhatia et al., 2014); since then, the hia field has experienced several changes. according to the cross-sector toolkit for health1 maintained by the health impact project, when u.s. hia practice was still emerging in the early 2000s, over 70% of hias focused on decisions related to the built environment, including transportation, land use planning, and housing. this was due in part to funders prioritizing these topics and to the rapidly expanding evidence base connecting built environment interventions to health outcomes (jackson, dannenberg, & frumkin, 2013). since 2014, hias have been applied to decisions in a wider range of topics 1 the health impact project’s cross-sector toolkit for health (www.pewtrusts.org/healthimpactproject/toolkit) catalogs u.s. hias for which there is a publicly available product. it relies on self-reported information from practitioners. while it is updated quarterly, the toolkit may not include every hia conducted in the u.s. to suggest new resources, please complete this form and submit it to healthimpactproject@pewtrusts.org. frequently asked questions and more information about the toolkit are also available. the health impact project is a collaboration of the robert wood johnson foundation and the pew charitable trusts. http://www.pewtrusts.org/healthimpactproject/toolkit https://www.pewtrusts.org/-/media/assets/2019/04/toolkit-content-submission-form.pdf mailto:healthimpactproject%40pewtrusts.org?subject= https://www.pewtrusts.org/en/research-and-analysis/articles/2019/04/03/frequently-asked-questions-about-the-cross-sector-toolkit-for-health https://www.pewtrusts.org/en/research-and-analysis/articles/2019/04/03/frequently-asked-questions-about-the-cross-sector-toolkit-for-health updating the minimum elements and practice standards for hia whitehead; bever; lindberg; dills 3 such as climate change/extreme weather events, criminal justice, education, employment, and economic development. from 2010-2014, an average of almost 48 hias were conducted each year in the u.s. several national-level organizations, such as the u.s. centers for disease control and prevention and the health impact project, funded multiyear, comprehensive hias2 during this time. as the total number of hias grew, the number using rapid hia methods (human impact partners, 2020) also increased. for example, from 1999-2009, practitioners completed 7 rapid hias in the u.s., compared with 42 from 2010-2020. since 2014, overall hia grant funding has decreased, along with the number of hias conducted yearly. in addition, current public health and decision-making contexts have led practitioners to adapt hia principles and standards into new approaches like public health 3.0 and health in all policies using tools such as health impact reviews (harris county public health; washington state board of health) and health notes (health impact project, 2019) to inform proposed legislative and budgetary decisions. rapid hias and similar approaches provide a streamlined process to inform decisions on a short time frame with less time and staffing investments. the resulting products are often one-page summaries, brief reports, fact sheets, or video clips that are accessible to decision makers and stakeholders at various levels. the original working group wrote the meps with a focus on comprehensive hias and at a time when the primary dissemination product for most assessments was a lengthy report. this meps update acknowledges the evolution of the practice to include rapid and adapted methods and streamlined products, while maintaining applicability to intermediate and comprehensive hias and longer reports that document the full process and findings from the assessments. the update further acknowledges that even comprehensive hias can result in condensed communication tools such as those listed above. lead hia organizations have also changed over time. largely due to the funding structure, almost 40% of hias conducted before 2014 were led by state or local health departments (health impact project, 2018). in recent years, a wider variety of organization types are leading hias. since 2014, about 35% of lead hia organizations have been nonprofits, compared to about 30% state or local health departments (health impact project, 2018). as more community-based organizations and resident groups perform hias, practitioners and their partners are more commonly using findings from these assessments to advocate for policy changes that advance health and equity. as the hia field increasingly recognizes the value and opportunity of these assessments to support advocacy efforts, the meps play a critical role in ensuring that all hias use the best available evidence, examine a range of potential health impacts, and present all relevant findings, not just those that support a specific policy position. hias continue to be undertaken for a variety of reasons beyond advocacy, including mandated projects and decision-support scenarios, and practitioners should ensure their hia approach is appropriate and responsive to their specific hia context and stakeholders. hia has always embraced equity as one of several core values (world health organization, 2014). sophia has a history of creating tools 2 hias can be completed quickly, using a “rapid” or “desktop” model over a few weeks or months, or take longer, using either an “intermediate” approach using available data or a “comprehensive” approach involving primary data collection, both of which take several months to more than a year to complete. updating the minimum elements and practice standards for hia whitehead; bever; lindberg; dills 4 and resources to advance equity through hia practice and has a standing equity committee. this committee developed the equity metrics for hia practice, a tool that enables practitioners to plan for and evaluate the inclusion of equity considerations and actions in an hia. in recent years, hia practice has evolved and is now commonly used as a tool to support an overall hiap approach. using a hiap framework encourages the routine inclusion of health and equity in decision making, bringing equity considerations to the forefront. over time, the meps authors have been revising the document to reflect this increasing need to address equity, and the current update working group continues this effort. process for updating the minimum elements and practice standards sophia solicited interest to participate in the meps update workgroup at its practitioner workshop in april 2019. volunteers participated in biweekly meetings from fall 2019 through spring 2020. the workgroup consists of four members representing a total of 40 years of hia experience. workgroup members bring experience from the non-profit, federal, state and academic sectors. core proposed changes to the minimum elements and practice standards in response to the evolution of and trends in the hia field described above, the update workgroup wanted this version of the meps to describe stakeholder engagement as a more significant part of the practice standards in order to emphasize equity and build on emerging evidence of the value of community engagement in hia practice. research suggests that hias can increase civic agency in communities by strengthening community members’ skills to influence future decisions beyond the hia, enhancing relationships between community residents and decision-makers and elevating the voices of community members in the decision-making process (center for community health and evaluation & human impact partners, 2016). research also suggests that stakeholder engagement is one of the factors that contributes to the success of hias (dannenberg, 2016). to make the meps more useful to a range of organization types and new practitioners, this version refers to more hia resources from sophia and other groups, and revisions to the standards increase feasibility for diverse practitioners. while the overall update is still in progress, the recommended core changes include: emphasizing the iterative nature of the hia process. in the 2014 meps, hia was framed as a stepwise process. recognizing the iterative nature of hia, the update workgroup renamed the steps of hia to phases and added prompts for practitioners to re-examine previous decisions. this language gives explicit permission for practitioners to return to prior phases and make updates to reflect new information and stakeholder insights. highlighting the importance of stakeholder and community engagement in hia practice. in each phase’s practice standard, the update workgroup provided examples of typical stakeholder and community member roles. for the assessment phase, the workgroup added language to emphasize lived experience as critical data that should be a part of both existing conditions and the predictive assessment. in the recommendation phase, the revised practice standards explicitly call for collaboration between the hia practitioner and stakeholder groups, including decision makers and community members. since hia recommendations are only effective if they updating the minimum elements and practice standards for hia whitehead; bever; lindberg; dills 5 are adopted and implemented, working with decision makers and potential implementers helps address recommendation feasibility. and community members can help ensure that hia recommendations are responsive to needs and appropriately address community concerns. defining key outputs for each hia phase. as overall hia practice has moved toward rapid methods to be more responsive to shifting decision-making timelines, the workgroup adapted each phase’s definition and practice standard application accordingly. for example, in the reporting phase the revised standards describe that, at a minimum, all hias should document the purpose, findings, and recommendations from the assessment, but the revisions are also explicit that the length and level of detail can vary based on the scale of the hia. the workgroup also strengthened the definition of each phase by adding expected outputs. developing standards for tracking hia effectiveness that are feasible for a range of practitioners. the most significant proposed changes thus far are in the monitoring phase. to recognize the time and financial constraints of hia practice, the workgroup created more realistic standards for this phase. as the practice has shifted to more rapid methods, and a greater diversity of organizations are conducting hias, the revised standards suggest that every hia should complete a process evaluation, but recognize that impact and outcome evaluations may not be feasible for all practitioners due to available time, funding, expertise, or other factors. international applicability the meps were originally developed and updated based on emerging u.s. hia practice, though hia has a longer global history. in parallel to this meps update, sophia is making organizational changes to expand its international focus. the revisions in this update are still based on u.s. hia practice but the update workgroup recognizes the meps may also have implications for international hias. the update workgroup will leverage sophia’s international expertise to identify both intersections and potential conflicts for international practice within the meps. one of the steps in this process included a presentation at the 2021 international association of impact assessment annual meeting. this presentation was an opportunity to have conversations with the international field about global hia standards, as well as the major issues and evolutions in hia that all practitioners experience. next steps for the meps update the sophia leadership team and steering committee, general membership, and the original authors of the meps will have the opportunity to comment on the core proposed changes before public release. sophia anticipates publishing the revised meps document in 2021, to coincide with the organization’s 10-year anniversary. to contribute your hia expertise to this update, please contact the corresponding author, sandra whitehead.  updating the minimum elements and practice standards for hia whitehead; bever; lindberg; dills 6 references bhatia, r., farhang, l., heller, j., lee, m., orenstein, m., richardson, m., & wernham, a. 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(2010). minimum elements and practice standards for health impact assessment, version 2. retrieved 4 may 2021 from https://www.pewtrusts.org/-/media/assets/ external-sites/health-impact-project/hiaworkinggroup_hiapracticestandards_2009.pdf washington state board of health. (2020). health impact reviews. retrieved 8 july 2020 from https:// sboh.wa.gov/healthimpactreviews#:~:text=health%20impact%20reviews-,health%20impact%20 reviews,to%20inform%20legislative%20decision%2dmaking. world health organization. (2014). health in all policies: helsinki statement. framework for country action. retrieved 9 july 2020 from https://www.who.int/publications/i/item/9789241506908. https://hiasociety.org/resources/documents/hia-practice-standards-september-2014.pdf https://humanimpact.org/wp-content/uploads/2018/10/full-report_community-participation-in-hia-evaluation.pdf https://humanimpact.org/wp-content/uploads/2018/10/full-report_community-participation-in-hia-evaluation.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4951082/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4951082/ https://publichealth.harriscountytx.gov/resources/built-environment-toolkit/health-impact-review https://publichealth.harriscountytx.gov/resources/built-environment-toolkit/health-impact-review https://www.pewtrusts.org/en/research-and-analysis/articles/2019/06/19/health-impact-project-health-notes https://www.pewtrusts.org/en/research-and-analysis/articles/2019/06/19/health-impact-project-health-notes http://www.pewtrusts.org/healthimpactproject/toolkit https://humanimpact.org/hipprojects/liberating-our-health-ending-the-harms-of-pretrial-incarceration-and-money-bail/?strategy=research https://humanimpact.org/hipprojects/liberating-our-health-ending-the-harms-of-pretrial-incarceration-and-money-bail/?strategy=research https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3780695/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3780695/ https://www.ncchpp.ca/docs/hia-eis_practicestandards_en.pdf https://www.ncchpp.ca/docs/hia-eis_practicestandards_en.pdf https://www.pewtrusts.org/-/media/assets/external-sites/health-impact-project/hiaworkinggroup_hiapracticestandards_2009.pdf https://www.pewtrusts.org/-/media/assets/external-sites/health-impact-project/hiaworkinggroup_hiapracticestandards_2009.pdf https://sboh.wa.gov/healthimpactreviews#:~:text=health%20impact%20reviews-,health%20impact%20reviews,to%20inform%20legislative%20decision%2dmaking. https://sboh.wa.gov/healthimpactreviews#:~:text=health%20impact%20reviews-,health%20impact%20reviews,to%20inform%20legislative%20decision%2dmaking. https://sboh.wa.gov/healthimpactreviews#:~:text=health%20impact%20reviews-,health%20impact%20reviews,to%20inform%20legislative%20decision%2dmaking. https://www.who.int/publications/i/item/9789241506908. updating the minimum elements and practice standards for hia whitehead; bever; lindberg; dills 7 corresponding author sandra whitehead george washington university 950 n. glebe road arlington, virginia 22203 swhitehead@gwu.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, bs, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 6 issue 1 (2021) doi: 10.18060/25082 © 2021 author(s): whitehead, s.; bever, e.; lindberg, r.; dills, j. this work is licensed under a creative commons attribution 4.0 international license june 2018 volume 3 issue 1 tracking state-level health impact assessment legislation from 2012-2016 joshua waimberg, jd; lindsay k. cloud, jd; andrew t. campbell, jd; ruth lindberg, mph, mup; keshia pollack porter, phd, mph abstract: background: scientifically constructed, open source legal datasets that capture key features of state legislative activity can be used for evaluation, and to identify trends in law across jurisdictions and over time. methods: using policy surveillance methods, a team of legal researchers collected and analyzed state-level health impact assessment (hia) legislation across 50 u.s. states and washington, d.c. between january 1, 2012 and december 31, 2016. one dataset captures the characteristics of all hia bills that were introduced but not enacted during the period of the study. the second dataset captures the characteristics of all hia laws, including statutes and regulations that were enacted or amended during the period of the study. results: between january 1, 2012 and december 31, 2016, 40 hia bills were introduced but not enacted, and three hia laws were enacted or amended. notable trends include: greater legislative activity was observed in the northeastern united states as compared to the rest of the country; a majority of hia legislation was proposed by democratic members of state government; hia mandates were promulgated through state agency rulemaking process more frequently than the legislative process; and most of the proposed legislation provided no explicit source of funding to implement hias within the legislative text. conclusion: evaluation research is necessary to understand the factors that drive the success and failure of hia legislation, and its impact when applied to decision-making, health determinants and outcomes, and health equity. 1 tracking state-level health impact assessment legislation from 2012-2016 waimberg; cloud; campbell; lindberg; porter 2 introduction state policymakers recognize that decisions made in housing, criminal justice, and education also affect public health and state health care spending — spending that amounts to hundreds of billions of dollars each year across the united states (marmot, m. & allen, j., 2014; the pew charitable trusts and john d. and catherine t. macarthur foundation, 2016). as legislators aim to reduce costs and improve population health, some are exploring how health impact assessments (hias), which assess the potential public health effects of a proposed decision, could be used to better inform state-level decision-making. one straightforward way that legislators can promote hias is to require or encourage the practice through legislation. the impact of hia legislation on government practice, policy making, and social outcomes has not been evaluated. in order to gain a deeper understanding of hia legislation, and to support evaluation of its implementation and effects, this research captures and analyzes trends in requiring, encouraging, or incentivizing the use of an hia, including legislation requiring the use of hia as a tool and hias addressing state-level policy, between january 1, 2012 and december 31, 2016. to examine the full legal landscape of hia legislation, the bills research included collecting bills that were introduced and failed, and those that were introduced but still under consideration on december 31, 2016. the laws research included collecting legislation that was enacted or amended during the period of the study. bills were identified independently from laws because identification and analysis of failed or stalled efforts to implement hia legislation, in conjunction with the analysis of the successful laws, allows for a comprehensive understanding of state-level hia policy activity, or lack thereof. this article summarizes hia legislative activity, notes key patterns and trends, and highlights the need for additional research to evaluate the impact of laws on population health. background 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 those effects within the population (quigley, et al., 2006). hias provide recommendations on monitoring and managing those effects (quigley, et al., 2006). the formal elements of an hia include screening of the need for and value of conducting an hia, scoping and creation of objectives, assessment of the baseline health status of affected populations, inclusion of recommendations, reporting on the findings, and the monitoring and evaluation of its results. (national research council, 2011). hias provide pragmatic, evidence-informed recommendations about how to modify the proposed action to reduce risks and promote benefits, as well as provide recommendations on monitoring health effects after implementation (national research council, 2011). hias also examine whether and to what extent decisions could reduce health disparities and improve health equity. a total of 419 hias have been conducted in the united states as of june 2017 (the pew charitable trusts, 2015). they have aimed to inform decision-making at the federal, state, and local levels in a range of sectors, including agriculture, criminal justice, labor and employment, education, transportation, and housing (the pew charitable trusts, 2015). approximately 18% of these 419 hias (n=76) focused on state-level policy decisions (the pew charitable trusts, 2015). these hias examined state legislation, such as paid sick leave and food tax policies; state programs or regulations and their implementation, such as housing inspection and tax credit grant programs; and projects by statelevel decision-makers, such as highway design and redevelopment (the pew charitable trusts, 2015). tracking state-level health impact assessment legislation from 2012-2016 waimberg; cloud; campbell; lindberg; porter 3 prior research by the national conference of state legislatures (ncsl) identified 56 bills that were introduced in 17 states between january 2009 and may 2014 that would require some consideration of health effects in decision-making (national conference of state legislatures, 2014). most of these bills, however, did not meet the formal definition of an hia (health impact project, 2015; national conference of state legislatures, 2014). ncsl’s analysis found eight states that considered legislation that required or encouraged assessments that met most, but not all, requirements of a formal hia. policymakers in three of these eight states ¬— massachusetts, vermont, and washington — enacted legislation that ranged in scope from requiring an hia for a specific bridge replacement project, to establishing the use of hias to determine the health effects of state transportation projects. in 2016, through a grant from the health impact project — a collaboration of the robert wood johnson foundation and the pew charitable trusts — the policy surveillance program of the center for public health law research at temple university developed two longitudinal datasets in order to create a comprehensive and systematic study of recent hia legislative activity. this study, which builds on the research conducted by ncsl from 2009-2014 (national conference of state legislatures, 2014), illuminates the variation that exists in successful, unsuccessful, and pending hia legislation across the 50 u.s. states and washington, d.c., from 2012 to 2016 as it pertains to hia requirements, techniques, and various sectors and industries. methods the research team used the methods outlined in anderson et al., (2013) as a foundation to develop a policy surveillance mapping study on hia legislation. policy surveillance, one form of scientific legal mapping, is the ongoing, systematic collection, analysis, and dissemination of policies across jurisdictions, and over time (burris, 2014). the hia study focused on statelevel hia legislation from january 1, 2012 to december 31, 2016 across the united states. the research team created two distinct datasets. one dataset, hia bills, captures characteristics of all hia bills that were introduced but not enacted during the time period of the study. the second dataset, hia laws, captures the characteristics of all hia laws that were enacted or amended during the period of the study. for the purposes of the study, both statutes and regulations were included as laws. the research team consisted of two legal researchers and one legal supervisor from the policy surveillance program of the center for public health law research at temple university who collaborated with two subject matter experts from the health impact project. the researchers included policies that explicitly use the term “health impact assessment(s)” within the legal text, and/or include the six formal elements of an hia. policies that did not meet the inclusion criteria were excluded, including legislation requiring only health risk assessments, community health assessments, or proposals where vague references to assessing public health impacts were discussed. the researchers identified and recorded citations of relevant bills and laws (including statutes and regulations) from westlaw, a legal research database. the researchers developed search strings and conducted keyword searches for each dataset: “te(health /5 (assessment or impact or review))”; “health and impact and assessment”; and “health and impact and review.” when these searches yielded a relevant bill or law, the researchers examined the table of contents to determine if any of the surrounding statutes or regulations were also relevant. the researchers supplemented keyword searches by consulting secondary sources. for quality control, the team conducted redundant research, in which each researcher independently identified and recorded relevant citations for each jurisdiction. the supervisor then compared the research to identify and resolve tracking state-level health impact assessment legislation from 2012-2016 waimberg; cloud; campbell; lindberg; porter 4 all divergences (or differences in research results) between the original and redundant research. once the citation list was finalized, the researchers collected the legal text from each state legislature’s website. this research process was repeated in batches of ten states at a time until all relevant bills and laws were collected. hia bills that were separately proposed in each chamber of the state legislature were individually collected. however, if there were multiple versions of the same bill, the researchers collected the most recent version of the bill that included the hia requirement. the team developed a list of constructs, or important features of the policies, based on the policies collected for the first ten states. coding questions were drafted from the list of constructs in order to observe the policies’ characteristics. hia experts reviewed and refined the coding questions to ensure that the key elements of the policies were captured within the coding scheme. once the questions were finalized, the team entered them into monqclesm, a codingsoftware platform. each jurisdiction was independently coded by two legal researchers. the supervisor compared the results and the team resolved discrepancies through discussion and consultation with hia experts. the team developed a research protocol to record the divergence rates and outline the coding scheme, definitions, and scoping parameters, including inclusion and exclusion criteria. each dataset contains downloadable text of the policies, an interactive map and table, summary report, research protocol, codebook, and empirical legal data (policy surveillance program, 2017a; policy surveillance program, 2017b). results between january 1, 2012 and december 31, 2016, 40 bills were introduced but not passed in the 51 jurisdictions (50 states and the district of columbia) surveyed across the united states. these 40 hia bills were introduced in 11 jurisdictions (fig. 1; policy surveillance program, 2017a). of the 40 bills, seven were introduced in 2012, ten in 2013, four in 2014, 14 in 2015, and five in 2016. during this period, one law was enacted in california in 2015, one regulation was tracking state-level health impact assessment legislation from 2012-2016 waimberg; cloud; campbell; lindberg; porter 5 readopted in new jersey in 2014, and one regulation was amended in new hampshire in 2016 (fig. 1; policy surveillance program, 2017b). the collected bills and laws varied in focus and scope. some legislation proposed that an hia be conducted for a specific project, such as 2016 md h.b. 363, which required that an hia be conducted by a specific date on the deployment of smart meters across maryland. some proposed legislation would have mandated the use of an hia for specific activities conducted within the state. for example, 2015 ny s.b. 902 proposed that an hia be conducted for all horizontal gas drilling and high-volume hydraulic fracturing activities in new york, while 2015 mn h.f. 3261 proposed that an hia be conducted for projects involving clear-cutting in minnesota. other legislation had a broader focus, such as 2014 nm s.b. 48, which proposed that an hia be conducted whenever a construction or development project in new mexico would require an environmental assessment pursuant to state or federal law. the study shows how state legislatures’ approaches compare to each other, and thereby lays the groundwork for studies evaluating the implementation of state-mandated hias and the potential impact of such legislation on public health. the following subsections describe the key trends and features of hia legislation from 2012-2016 captured by the study. hia required some legislation mandates an hia in order to assess a program or activity’s public health impacts, while others only encourage their use (health impact project, 2015). of the 40 hia bills analyzed, 37 (92.5%) required that an hia be conducted, as opposed to simply encouraging the use of an hia. all three (100%) of the enacted hia laws required, as opposed to encouraged, that an hia be conducted. political affiliation political affiliation of the sponsor may correlate with hia legislative activity (wismar, et al, 2007). democratic members of state legislatures introduced more hia legislation than representatives from other political parties. democrats introduced 30 (75%) of the 40 hia bills, while four (10%) bills were introduced by republicans, and one (2.5%) was introduced by an independent legislator. three (7.5%) bills were sponsored by a combination of republican and democratic legislators. hia provisions were included in two budget bills (5%) with no named sponsor. a democratic state senator initially introduced california’s enacted law. new jersey’s administrative regulation was readopted under a republican governor, and new hampshire’s regulation was amended under a democratic governor. geographic location although non-legislative hias have been conducted in nearly all states (the pew charitable trusts, 2015), legislative activity to mandate or encourage hias was concentrated in specific geographic regions in the study’s period. twenty-four (60%) bills were introduced in the northeastern united states, with the majority originating in new york and massachusetts. states in the midwest followed with seven (17.5%) bills and the southern states introduced five (12.5%) bills. states in the west proposed three (7.5%) bills, while only one (2.5%) bill came from the southwest. two (66.7%) of the three states that enacted an hia law are located in the northeastern united states, in new jersey and new hampshire. the third hia law was passed in the west, in california. sectors specified the research team classified hia legislation based on the various sectors and industries that are generally targeted in hia legislation in order to determine tracking state-level health impact assessment legislation from 2012-2016 waimberg; cloud; campbell; lindberg; porter 6 whether hias are more commonly used to address decisions within specific sectors (national conference of state legislatures, 2014). the sectors were selected based on the north american industry classification system (u.s. census bureau, 2017). the 40 hia bills required their proposed hias to apply in seven distinct sectors. environment – not including agriculture or oil and gas – was included most frequently, with 17 (42.5%) bills focused on issues in that sector, such as air and water, waste facilities, or forestry. oil and gas was the focus in 10 (25%) of the hia bills, the transportation sector accounted for six (15%) of the 40 bills, and the remaining bills were targeting other sectors including two in health care ( 5%), two in construction ( 5%), two in education ( 5%), and one in agriculture (2.5%). three (7.5%) bills did not apply to a specific sector. each of the three enacted hia laws targeted specific sectors. california’s law requires hias in the health care sector; new jersey’s regulation applies to the environmental sector; and new hampshire’s regulation applies to oil and gas. organizations required to conduct hia hia legislation generally specifies the organization that is required to conduct the required or encouraged hia (national conference of state legislatures, 2014). in this study, twenty (50%) of the hia bills tasked their state’s department of health to conduct the hia. a public health program within a local university was explicitly mentioned in eight (20%) of the bills. local governments were required to conduct the mandated hia in five (12.5%) bills. three (7.5%) of the bills required a private, non-government contractor to conduct the hia. the remaining organizations included private entities (2 bills, 5%), a specific committee or task force (2 bills, 5%), the department of transportation (2 bills, 5%) and the department of environment (1 bill, 2.5%). california’s hia law requires that the california health benefit review program, a program established by the university of california (local university public health program), conduct the hia. new jersey’s regulation requires the hia be conducted by a private entity seeking permit approval, while new hampshire’s regulation requires that an independent health and safety expert, (private, non-government contractor) conduct the hia. methods used in conducting the hia the hia process can be accomplished using a variety of methods, including risk assessments, population analysis, and expert opinion (national research council, 2011). twenty (50%) of the collected hia bills required that the entity managing the hia conduct their own original research, data collection, and analysis. other methods that are required within the hia bills include risk assessments in 10 (25%) bills, population analysis in nine (22.5%), literature review in nine (22.5%), and stakeholder engagement in eight (20%). expert opinion was required in six (15%) bills, while secondary data analysis was only specified in two (5%) bills. notably, 14 (35%) bills did not require any specific methods be followed while implementing the hias. california’s hia law requires original research and data collection, expert opinion, and policy analysis. new jersey’s hia law requires original research and data collection, risk assessment, and secondary data analysis, and new hampshire requires just risk assessment and expert opinion. funding mechanism the provision of funding is an important practical consideration in hia legislation (national conference of state legislatures, 2014). of the hia bills, 10 (25%) included a funding mechanism within the language of the bill, while 28 (70%) of the bills did not mandate any funding for the required hias within the legislative text. two of the bills (5%) did not require governmental funding, but did mandate that a private entity that is required to conduct an hia fund such an hia on its own. tracking state-level health impact assessment legislation from 2012-2016 waimberg; cloud; campbell; lindberg; porter 7 of the three states that passed or amended hia laws, only california creates a funding mechanism for hias, requiring that the health care benefits fund in the state treasury fund the assessments. the regulations in new jersey and new hampshire do not create an explicit funding source within the legal text. discussion only three hia laws were enacted or amended at the state-level across the country between january 1, 2012 and december 31, 2016. the failure to pass or amend hia legislation was a common thread throughout the united states regardless of the variation among the legislation’s applicable sector, the hia methods required by the legislation, the geographic location of the state, or the legislation’s inclusion of an hia funding mechanism. although hias do not require legislative authorization, policy support, including hia legislation, has been identified as an enabling factor for hia use (dannenberg, 2016). most bills introduced in state legislatures fail to pass, and this study was not designed to identify the reasons the proposed bills did not become law. it is possible that some or all of these bills failed simply because lawmakers were opposed, or were unfamiliar with hias and their potential utility. other political and contextual factors, such as funding constraints, or controversy over the sector or subject area that would be the focus of the hia (such as fracking), may also be responsible (national research council, 2011). further research on hia policymaking may illuminate how hia proponents can use policy advocacy, policymaker education, or translational research to improve the adoption rate in the future. it would also be valuable to examine if and how the success and failure rates of state hia legislation compare with other types of legislation, which may generate knowledge that can help with policy formulation and adoption. research gaps remain in understanding how hia laws are implemented, the impact of those laws on decisionmaking in various sectors, and ultimately how hia laws affect health determinants and health outcomes. future research could track the implementation of the three successful hia laws from this time period, as well as others that may arise in future state legislative sessions, to understand the facilitators and barriers of these laws and to monitor their impacts. monitoring these laws’ effects on health determinants and outcomes, a formal step of hias that includes process, impact, and outcome evaluation, could also help advance hia practice, since the monitoring step of the hia process is often omitted in practice. (dannenberg, 2016). studying the implementation of these laws could also help to identify and establish the critical components that any hia bill should contain in the future. it is likely that hia laws need to provide sufficient clarity in terms of how the hia will be carried out and provide enough guidance and support, such as funding or staffing mechanisms, for the hia process to be successful. the findings presented in this paper also highlight the disproportionate distribution of hia bills and laws in terms of geography, sector, and political affiliation of the primary sponsor. approximately two-thirds (66%) of the hia bills and laws in the datasets were introduced in the northeastern united states, and most of the bills sought to use hias to inform decisions related to environmental issues, oil and gas, and transportation. future research should explore these trends in more depth and seek to understand why policymakers may be more likely to pursue hia bills and laws in specific sectors or topic areas. the findings also demonstrate that democrats introduced 75% of the hia bills. again, future research may benefit from exploring these differences by political ideology. as of june 2017, hias have been conducted in 42 of 50 states and the district of columbia (regardless of legal mandate), and have informed decisions across a range tracking state-level health impact assessment legislation from 2012-2016 waimberg; cloud; campbell; lindberg; porter 8 of sectors including transportation, natural resources and energy, housing, criminal justice, education, and labor and employment (the pew charitable trusts, 2015). these hias are being conducted across the country, but recent legislative activity has only occurred in 11 states within the period of this study. clearly, hia practice is expanding in the absence of legislation, with 419 hias being conducted as of june 2017 (the pew charitable trusts, 2015). the lack of state-level hia legislation in recent years raises the question of whether state-level hia laws are necessary, and whether they should be promoted to support hia activity over more voluntary practices. future research may test the hypothesis that hia growth and practice differs by whether or not a state has hia legislation, and to examine differences among the impacts of hias conducted because of legislation compared to those undertaken without legislation. this information can help practitioners identify whether hia legislation as policy support is a critical enabler for hia use, and may provide empirical data to support policy diffusion from one state to another (nicholson-crotty, 2015). if research finds that legislation is unnecessary, identifying which non-legislative approaches best support state-level hia activity will be crucial in order to meet the goal of positively affecting population health and health equity. limitations the research team designed the study to exclude bills and laws requiring forms of public health analysis that did not meet the narrow definition, or include the specific criteria, of a formal hia, such as the exclusion of health risk assessments and community health needs assessments. also excluded were bills and laws that included vague provisions ordering the examination of the potential impact of a specific issue or project on health, but did not provide details to suggest that an hia would be the mechanism. moreover, the study’s state-level mapping does not capture hia provisions enacted at the federal or local levels. this focus on formal, state-legislated hias may underestimate the true volume of hia legislative activity. additionally, this project observed the policies as written in the bills, statutes, and regulations, and thus it does not provide insight on how well an hia was carried out in practice. further, if a law was passed prior to january 1, 2012 and was still effective during the period of the study it was excluded as out of scope. lastly, while we captured introduced bills that were not enacted, we did not capture proposed rules and regulations that had failed or were still pending, as only successfully amended or promulgated hia regulations were included in the scope of the study. conclusion legislative action can encourage the use of hias across the united states to examine the public health implications of decisions in a range of sectors. the findings presented in this study highlight the need for additional research to understand the factors that may drive success or failure of hia bills, such as political will and resources, in addition to the question of whether state-level hia legislation is the best approach to drive hia implementation. further research is needed to understand how hia legislation is being implemented and the impacts of hia legislation on decision-making, health determinants and outcomes, and health equity. tracking state-level health impact assessment legislation from 2012-2016 waimberg; 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(2017). north american industry classification system, united states. retrieved from https://www. census.gov/eos/www/naics/2017naics/2017_naics_manual.pdf. wismar m., blau j., ernst k., figueras j (eds.). (2007). the effectiveness of health impact assessment: scope and limitations of supporting decision-making in europe. brussels, belgium: european observatory on health systems and policies. retrieved from http://www.euro.who.int/__data/assets/pdf_file/0003/98283/e90794.pdf. tracking state-level health impact assessment legislation from 2012-2016 waimberg; cloud; campbell; lindberg; porter 10 corresponding author joshua waimberg, jd law & policy analyst policy surveillance program at temple university’s center for public health law research 1819 n. broad street, barrack hall, suite 300 philadelphia, pennsylvania 19122 jwaimberg@temple.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 3 issue 1 (2018) doi: 10.18060/22249 © 2018 author(s): waimberg, j.; cloud, l.; campbell, a.; lindberg, r.; pollack porter, k. this work is licensed under a creative commons attribution 4.0 international license october 2017 volume 2 health impact assessments in hospital community benefit: a multiple case study of the use of hias at children’s hospital colorado gregory tung, phd, mph; venice williams, mph abstract: objective: to explore the use of health impact assessments (hias) within nonprofit hospital community benefit activities. methods: we conducted case studies of three hias that were done in collaboration with children’s hospital colorado as part of the hospital’s community benefit portfolio. we used data from key informant interviews and documents to construct individual explanatory case studies and we then conducted cross-case analysis to compare and contrast across cases. results: hospital staff stated that hias provided children’s hospital colorado with a transparent and systematic process for generating evidence-based recommendations with community and stakeholder feedback within the hospital’s community benefit activities. hias were used to generate recommendations to inform community benefit planning activities and to generate public policy recommendations to enhance child health. the case studies highlighted several issues that need to be addressed in order to further explore and advance the use of hias within hospital community benefit activities including: use of hias on explicit health issues, hospital capacity for hias, potentially broadening the scope of hia recommendations, and the use of hias to generate recommendations from broad priority areas. conclusion: hias have the potential to meet the need for established, evidence-based, and stakeholder responsive tools and processes to be used within nonprofit hospital community benefit activities. in meeting this need, the non-profit hospital community benefit area can potentially serve as a major institutional home for the practice of hias. there is a need for additional research and practice innovation to further explore and refine the use of hias within nonprofit hospital community benefit activities. i the use of hias at children’s hospital colorado tucg; williams 2 introduction the use of health impact assessments (hias) in the united states (us) has grown rapidly over the last decade (dannenberg, 2016). hias have been used in a broad range of sectors including built environment, transportation, housing, energy etc. (dannenberg, 2016). there is now growing evidence and consensus that hias are an important tool to introduce health optimizing recommendations in a variety of program and policy settings (national research council, 2011). the funding and creation of incentives and infrastructure or institutionalization of hias is now a major factor in the more widespread use of hias in the us (morley, lindberg, rogerson, bever, & pollack, 2016). while a number of organizations such as the national research council have highlighted hias as a valuable tool for “integrating health implications into decision-making” and as a tool that fits within the broader health in all policies (hiap) movement, there has been limited institutionalization of hias in the us (national research council, 2011). there are, however, some examples of the hia process being institutionalized on a small scale including legislation in washington state that required an hia to be conducted on a bridge replacement in seattle (seattle and king county public health, 2017). two other interesting examples of hia institutionalization are the massachusetts healthy transportation compact and the funding of hias in alaska through the state’s natural resources permitting process (anderson, yoder, fogels, krieger, & mclaughlin, 2013; massachusetts department of transportation, 2016). both of these examples represent important advancements in the institutionalization of hias in the us. additional avenues to institutionalize hias are needed in order to further advance the practice and realize the potential population health benefits of hias. the use of hias within nonprofit hospital community benefit activities holds promise for the more widespread institutionalization of hias in the us (tung & williams, 2017). nonprofit hospital community benefit activities are those that are required by the internal revenue service (irs) of nonprofit hospitals to justify their nonprofit status (rosenbaum & margulies, 2011). nonprofit hospital community benefit activities have traditionally focused on the provision of charity care but a number of changes associated with the patient protection and affordable care act (aca) have pushed nonprofit hospitals to focus more on population and public health (rosenbaum & margulies, 2011; young, chou, alexander, lee, & raver, 2013). in 2012, nonprofit hospitals in the us reported spending more than $60 billion on community benefit (leider et al., 2016). the redirection of even a small portion of this spending toward more population and public health oriented activities could have a significant impact on the public’s health (corrigan, fisher, & heiser, 2015). this shift in focus from charity care towards population health represents a tremendous opportunity for the integration of hospitals and public health systems, but what community benefit spending levels should be and what specific activities hospitals should engage in have yet to be established (leider et al., 2016). this has created a need for additional tools and processes to guide nonprofit hospital investments and activities to enhance public health (abbott, 2011). this need for tools and process to guide hospital community benefit activities can potentially be served in part by hias in at least two ways. first, there is now a requirement for nonprofit hospitals to conduct community health needs assessments (chnas) and develop corresponding implementation plans (health affairs, 2016). implementation plans are intended to guide and outline specific community benefit activities to address identified community health needs. hias can provide a transparent and systematic process and be used by nonprofit hospitals to generate recommendations to inform implementation plans. the hia process is consistent with the irs requirements that implementation plans (1) address priority areas identified in the chna, (2) be evidence informed, and (3) incorporate community and stakeholder feedback. the use of hias at children’s hospital colorado tucg; williams 3 second, hias can provide a mechanism for hospitals to directly engage in policy and make recommendations to enhance population and public health. an hia used in this way would serve the role of an activity that directly benefits population health as opposed to a tool to guide community benefit planning and investment. hias used to generate policy recommendations can specifically address an identified community health need(s) and provide estimates of the anticipated population health impacts. to further explore the potential for the use of hias within hospital community benefit activities, we conducted a pilot consisting of three hias in collaboration with children’s hospital colorado. these three hias were embedded within various aspects of children’s hospital colorado’s community benefit activities and hospital staff were involved in various rules for all of the hias conducted. this pilot effort was supported with funding from the health impact project, a collaboration of the robert wood johnson foundation and the pew charitable trusts. the three hias conducted were: (1) the colorado marijuana and child abuse and neglect hia, (2) the colorado springs pilot hia, and (3) the colorado child and adolescent behavioral health hia. to explore the experience of using these hias within the context of nonprofit hospital community benefit activities, we conducted case studies informed primarily by key informant interviews of individuals who participated in various aspects of the hias and our own experience as hia practitioners/researchers. methods from december 2016 to march 2017, we conducted case studies with both explanatory and exploratory components for each of the three hias that were conducted as part of this pilot (yin, 2009). the focus of our case studies was to identify and explain the impacts from each hia and explore the utility of each hia within the hospital community benefits context. after all of the pilot hias were complete, we conducted a total of 17 key informant interviews with various stakeholders (e.g. hia team members, hospital staff, community stakeholders, etc.) who participated in the hias. these interviews were guided by a themebased interview guide. six key information interviews were conducted to inform the colorado marijuana and child abuse and neglect hia case study, seven key information interviews were conducted to inform the colorado springs pilot hia, and four key informant interviews were conducted to inform the colorado child and adolescent behavioral health hia. all interviews were audio recorded and memos were then written to synthesize information and abstract key themes from each interview by the interviewer. when appropriate and available, documents such as legislative records were used as an additional data source for the cases. we used a data triangulation and explanation building approach to synthesize the data from the interview memos and documents (yin, 2009). this involved using multiple data sources (e.g. multiple interviewer perspectives) to explain and explore the phenomenon of interest and iteratively developing an explanation of key events and their linkages for each case (yin, 2009). as an additional validation step, interview participants were given an opportunity to review the case studies and any statements attributed to them. the institutional review board at the university of colorado reviewed and approved our research protocol. results here we report our results organized by case. each case begins with a brief overview of the hia, followed by impacts, if any, from the recommendations. we then present perspectives of community stakeholders shared on the hia process, followed by perspectives shared by children’s hospital colorado staff on the utility of the specific hia within the community benefit context. the use of hias at children’s hospital colorado tucg; williams 4 colorado marijuana and child abuse and neglect health impact assessment this hia was led by the colorado school of public health and conducted in collaboration with children’s hospital colorado and the kempe center for the prevention and treatment of child abuse and neglect. the motivation for this hia was to improve child and family health by generating recommendations on state policies surrounding how marijuana use should be handled in child welfare decision-making. more specifically, this hia was scoped to generate recommendations for mandatory reporting and child welfare screening decisions when marijuana is involved and improve consistency in practice across the state of colorado, while reducing the number of families unnecessarily interfacing with the child welfare system. impacts the hia recommendations informed the development of house bill (hb) 16-1385, which updated and modernized the definition of child abuse or neglect in the colorado children’s code as it relates to substances. during the 2016 legislative session this bill passed through the colorado house of representatives, but did not pass through the colorado senate before the close of that year’s legislative session. although hb 16-1385 did not pass in 2016, there is interest among stakeholders involved with the hia to continue work in future legislative sessions. in addition, one of the key stakeholders involved with the hia, the executive director of illuminate colorado – a strategic partnership of the established nonprofits: colorado alliance for drug endangered children, prevent child abuse colorado, colorado chapter of the national organization on fetal alcohol spectrum disorder, and more recently sexual abuse forever ending – noted the potential for the hia recommendations to inform future training and education for mandatory reporters as well as child welfare caseworkers. she develops and assists in the delivery of child welfare curriculum for the state of colorado and expressed interest in using the hia recommendations to develop new materials on marijuana/substance abuse training. another key stakeholder, the state child welfare associate director stated that the state is embarking on modernizing the trails database system, a statewide automated case management system that includes child welfare, child care, and youth corrections data, to better track substance use; which aligns with one of the hia’s data recommendations. this change will help with aggregating data around when and where substance use occurs within the child welfare context, inform counties on how to target their services and supports, and to develop prevention strategies in the future. despite the ongoing policy efforts, stakeholders that we interviewed said that practice among mandatory reporters and child welfare screeners in the state had not changed since the hia recommendations were finalized. stakeholder perspectives interview participants for this hia included two executive directors of institutional partners, two county-level human services division administrators, a state-level child welfare associate director, and the contracted meeting facilitator for the hia. all participants had no previous hia experience. there was consensus among the interviewees that the main objective of the hia was achieved, which was to develop evidence-informed recommendations to assist mandatory reporters and child welfare screeners in their decision-making when marijuana is involved. relationship building among diverse stakeholders was expressed as one of the most effective elements of the hia. interview participants also stated that the stakeholder engagement process in the hia was effective: formal stakeholder meetings created a forum for different perspectives to be incorporated in interpretthe use of hias at children’s hospital colorado tucg; williams 5 ing the implications for the current state of science on the hia recommendations. the perspectives included spanned the spectrum from child abuse pediatricians to marijuana patient advocates and child welfare workers at both the state and local levels. while interviewees agreed that the hia produced valuable recommendations, some stated that the delineation between developing the hia recommendations and drafting policy language was unclear. this hia developed two tiers of recommendations: the first tier focused on recommendations for actual practice and the second tier focused on updating legislation to be consistent with the practice recommendations. many interviewees stated that they were uncertain as to where the hia formally ended and policy and advocacy efforts began. furthermore, some participants felt that the policy efforts that came out of the hia were beyond the original scope; such that a couple participants stated that they were initially unaware that the hia recommendations would lead to proposed legislation. interviewees also stated that the hia team could have improved on the dissemination of the hia findings and recommendations. the final hia report was shared with all stakeholders who participated in the process, but not formally shared with or presented to colorado department of human services, other county child welfare departments, or mandatory reporters such as those in hospital systems. one county child welfare administrator added that there has been little discussion on the issue of marijuana once the hia was completed, which she found disappointing, given the amount of time and energy she had dedicated to the work. children’s hospital colorado perspectives leadership and staff at children’s hospital of colorado stated that while they did view this hia positively and as being consistent with the organization’s overall community benefit objective of improving child health, they ultimately viewed it as motivated more by opportunity and need than being clearly aligned with the hospital’s formal community benefit obligations. they noted that this hia was not embedded within the hospital’s formal community benefit activities in that it was not used to inform implementation plans and was not directly aligned with community health priorities identified in the hospital’s formal chnas. despite this, hospital representatives noted that hias could be used opportunistically like this in order to make policy recommendations to benefit public health and that hias used in this way fit within the larger umbrella of community benefit activities. colorado springs pilot health impact assessment this hia was conducted to generate recommendations to inform children’s hospital colorado’s formal community benefit implementation plan in colorado springs, co. this effort was led by the colorado school of public health and conducted in collaboration with children’s hospital colorado’s child health advocacy institute. this hia was scoped to address health priority areas identified in chco’s chna in el paso county. more specifically, it focused on mental health and physical activity in school-aged children. this hia generated recommendations for children’s hospital colorado to invest in and advance schoolbased health centers as part of the hospital’s future community benefit activities. impacts the hia recommendations informed the development of children’s hospital colorado’s 2016 community health action plan for el paso county (children’s hospital colorado, 2016). the report specifically highlights the school setting as a primary place for programming to address the top six health priorities for the region, particularly that “chco will spearhead the creation of school resource centers that will provide: integrated primary care services, including mental and oral health; community support services; the use of hias at children’s hospital colorado tucg; williams 6 professional development and technical assistance for school personnel; and will inform targeted policy initiatives” (children’s hospital colorado, 2016). stakeholder perspectives interview participants for this hia included three representatives from children’s hospital colorado, two school-based health center employees, a public health planner from the local health department, and the externally-contracted meeting facilitator. none of the interviewees had previous experience with hias. all interview participants stated that the hia’s major objective was to determine chco’s role to address identified health priorities in the colorado springs region. non-hospital interview participants stated that the hospital’s desire to collaborate with the community was evident. participants shared that the hia process also allowed for community voice and feedback to determine where the hospital’s community benefit investment should go. regarding the development of new partnerships, many participants felt that the hia gave the hospital good exposure to the colorado springs’ experience and the region’s uniqueness. the hia’s stakeholder engagement process helped to build stronger relationships between the hospital and local community as well as between local stakeholders. interviewees stated that stakeholder meetings were productive with the right individuals represented; that the conversations facilitated a sharing of experiences, ideas, and resources between groups; that good questions were asked; and appreciation among stakeholders to be able to share their perspectives and have an open dialogue about the health priorities in their community. several stakeholders stated that that they now wanted to become more involved in the health of the community and partake in more face to face interactions with other organizations that focused on the shared goal of improving child health. ultimately, all participants shared that the hia created a better understanding of the community in colorado springs and brought together a stakeholder group to discuss what role the hospital could play in the community. despite these successes, there were several challenges shared by participants. first, many stakeholders and even one of the hospital staff members who was a formal member of the hia team were not aware of the impact of the hia recommendations. they were not aware of how and if the recommendations were being adopted by the hospital and incorporated into its implementation plan. several stakeholders stated that they received a draft report of the hia, but did not realize that the process had been completed. in fact, many participants felt that the hia process ended abruptly with no formal closure; a couple felt that there could have been a final group meeting to “wrap up loose ends” as there was lag time between the last meeting and the distribution of the draft report. another challenge expressed by some participants related to the scope of the hia. the scope of the hia was refined and focused on school-based health centers based in large part on the perspectives and preferences of the hospital. a couple of participants expressed that although this narrowing of scope resulted in good recommendations that could be supported by the hospital, they would have appreciated a broader assessment of the priority areas and determination of scope with greater stakeholder input. children’s hospital colorado perspectives hospital representatives, some of whom directly engaged as part of the hia team, expressed enthusiasm for this hia and stated that using the hia process to inform implementation planning provided an established and transparent process to make evidence-based recommendations with stakeholder and community input. they noted that many hospitals struggled to use information gathered from the community health needs assessment process to develop implementation plans and activities. hospital representatives the use of hias at children’s hospital colorado tucg; williams 7 stated that the hia process validated the community health needs assessment findings and brought things into alignment with local stakeholders to inform the broader implementation plan. hospital representatives noted that the hia allowed the hospital to build new community partnerships and relationships including with those who were not directly involved in the hia process. hospital staff also stated that the implementation of hia recommendations has been difficult and not yet fully developed due to the lack of staff, a physical structure, experience, and hospital resources for execution. some hospital representatives expressed concern that working with community stakeholders through the hia process might create expectations that would be difficult for the hospital to meet. one hospital staff member felt that incorporating hospital employees responsible for developing the implementation plan in the hia process from the beginning would be beneficial and that setting clear expectations and communication channels early on in the process would be helpful for future hias used in this manner. children’s hospital colorado’s community benefit team also noted that the recommendations that came out of the hia process were very detailed and specific and not necessarily calibrated well with the irs community benefit implementation plan requirements. there were initial discussions that recommendations from the hia might serve as the required implementation plan for the hospital in its entirety. as the hia process progressed, hospital staff stated that the implementation plan needed to be broader in that it needed to address all of the identified community health priorities and outline more general strategies that would then need to be further refined when specific community benefit investments and activities would be decided on. as a result, recommendations from the hia were broadened and made less specific when they were incorporated into the hospital’s implementation plan. colorado child and adolescent behavioral health hia this hia was policy focused and motivated by children’s hospital colorado’s implementation plan which stated that the hospital would utilize policy levers to address child and adolescent behavioral health – an identified community health priority area. this effort was initiated as a collaboration between the colorado school of public health, children’s hospital colorado’s child health advocacy institute, the university of colorado’s farley health policy center, and the keystone policy center. this hia was intended to generate recommendations to the state of colorado on how to implement an anticipated competitive grants program that would be made possible through a proposed tobacco tax ballot initiative. the objective of this proposed competitive grants program was to enhance child and adolescent behavioral health services in the state of colorado. impacts this hia was not completed as the tobacco tax ballot initiative intended to fund the proposed grants program did not pass during the november 2016 elections. at the time the hia was in the assessment phase and after consultation with the hia and the stakeholder team, a collective decision was made to terminate the hia as the decision point was longer present. stakeholder perspectives interview participants for this hia included a government affairs specialist and the executive director for advocacy at children’s hospital colorado, a policy director at the farley health policy center, and a senior policy analyst from the keystone policy center. all but one had previous hia experience. in addition, all interview participants were in agreement that the hia’s major objective was to develop recommendations for a grants program targeted at enhancing child and behavioral health services in colorado that was to the use of hias at children’s hospital colorado tucg; williams 8 be funded by the proposed tobacco tax ballot initiative. this hia was conceptualized as flowing directly from the hospital’s implementation plan which highlighted among other approaches, that child and adolescent behavioral health would be addressed through available policy approaches. as such, the initial scope of the hia was very broad and was not initially specific to the tobacco tax funded grants program that became the eventual focus of the hia. the initial broad scope was described both positively and negatively by many participants. the government affairs specialist felt that as collaboration between the different entities was still being built, the hia seemed to move slowly initially. the farley policy director agreed with this perspective and felt the scope of the hia could have been refined earlier in the process. ultimately, through an iterative screening and scoping process, the hia team assessed various potential policy approaches and eventually decided to focus the hia on the tobacco tax initiative. the rationale was that it was likely the initiative would pass and that there was a real opportunity for evidence-based recommendations to be adopted in how the resulting program would be administered. in addition, the campaign director for the tobacco tax initiative was also an hia team member. the broader hia team viewed this involvement as increasing the likelihood that hia recommendations would be adopted. despite this perception and consensus to focus on the tobacco tax initiative, all interview participants shared that the hia was inherently challenging, given that the outcome of the ballot initiative – that would fund and create the grants program – was uncertain. interview participants stated that having an hia team member who was well integrated into the tobacco tax campaign was essential to the process. it was also noted that this team member had the relationships with the key players statewide given her professional background and involvement in the tobacco tax initiative. this resulted in a stakeholder engagement process that members of the hia team viewed as including most, if not all, of the politically influential organizations that are active in child and adolescent behavioral health in colorado. these groups included: the state health department, major state foundations, and representatives from the governor’s office. however, the campaign director and hia team member stated that there was initial skepticism among stakeholders around the authenticity of the hia process and that some foundations wanted to complete this process separately and on their own. overall, the political landscape along with relationships among stakeholders involved in the tobacco tax initiative and administering agencies were expressed as challenging for her to balance. all interview participants stated that if the tobacco tax initiative had passed, the recommendations from the hia would have had an excellent chance of being adopted. furthermore, all participants agreed that the right stakeholders were at the table and engaged in the hia process. the ultimate failure of the tobacco tax initiative during the november 2016 election effectively made the hia irrelevant. after prolonged discussions, the hia team eventually made a decision to terminate the process. children’s hospital colorado perspectives leadership and staff at children’s hospital colorado, who were directly involved as part of the hia team, stated that they had high expectations for this hia. they saw this opportunity as a proof of concept for the use of hias, as a tool that the hospital could use in the future to make recommendations and inform policy as part of the organization’s community benefit portfolio. they also stated that this hia was a test for the hospital to take a more proactive role in policy engagement, as opposed to a more reactive stance that the hospital has adopted in the past. they also stated that they viewed this hia as being very well aligned with the hospital’s chna priority areas and implementation the use of hias at children’s hospital colorado tucg; williams 9 plan strategies. the defeat of the tobacco tax initiative was described by hospital representatives as unfortunate, but they echoed the opinions of other stakeholders and stated that in their opinion the recommendations that would have come out of the hia process would have had a good chance of being adopted if the initiative had passed. hospital representatives also stated that this hia in particular gave them a greater appreciation for what was involved in conducting an hia and the potential for the process in the future. the hospital’s government affairs specialist stated that while he still viewed hias as a useful tool to make policy recommendations, he also now better understood how time and resource-intensive the process is. he noted that for much of the policy work that the hospital engages in an hia is more than is necessary. he went on to state that an hia would be most useful to make policy recommendations when there was (1) a need for more rigorous assessment of scientific evidence and data and/or (2) the need for a very systematic and structured stakeholder engagement process to build consensus among diverse participants. discussion this pilot, the three hias that were conducted in collaboration with children’s hospital colorado as part of the organization’s community benefit activities, has highlighted the potential, limitations, and opportunities for improvement in the ongoing use of hias within nonprofit hospital community benefit. there is a clear need for processes and tools to generate evidence-based recommendations to guide hospital community benefit activities in various ways. the focus of this work was to explore the use of hias within hospital community benefit. in many ways the lessons learned from previous hia practice and evaluations were consistent and apply to our experience such as the importance of authentic stakeholder engagement and the challenges of timing and working on legislation (dannenberg, 2016). in other ways, the community benefit context created unique challenges and considerations. our experience reinforces the potential for hias to be used as a tool within hospital community benefit in at least two ways, (1) embedded within nonprofit hospitals’ formal community benefit assessment and planning activities and (2) to generate evidence-based policy and program recommendations to address identified community health priority areas. our experience also highlights several issues that need to be addressed in order to further advance the use of hia within hospital community benefit activities including: use of hia on explicit health issues, hospital capacity for hia, potentially broadening the scope of hia recommendations, and the use of hia to generate recommendations from broad priority areas. nonprofit hospital community benefit activities have an explicit health focus and the hia field has historically conceptualized the use of the tool as most beneficial when used on topics and sectors where there is typically not an explicit health focus (the pew charitable trusts, 2016). the rationale for this is that in these areas, there are important health implications that are not typically factored into decision making and hias can provide an avenue to include important health considerations that would not otherwise be included. this is true, but hias can still provide significant benefits to important decisions in health explicit areas. all of the hias that we engaged in for this pilot were on health focused topics. the systematic hia process provided structure that resulted in recommendations developed based on more methodical and rational incorporation of scientific evidence and stakeholder perspectives than if an hia was not conducted. in addition, use of hias on health explicit topics could help to more systematically incorporate certain criteria that go beyond the total health impacts such as equity of anticipated impacts. our pilot also highlights the need for capacity buildthe use of hias at children’s hospital colorado tucg; williams 10 ing to conduct hias if there is additional growth in the use and institutionalization of hias within hospital community benefit. this could take the form of training and capacity building among hospital staff involved with community benefit. the technical needs of hospitals could also be served by outside consultants or via collaborations with health departments or other institutions with hia knowledge and expertise. given the potential for hospital community benefits to serve as a mechanism for enhancing hospital and public health collaboration, the potential use of hias collaboratively between hospitals and health departments could serve the technical needs of hospitals and help build collaborations in population heath efforts between hospitals and health departments (abbott, 2011). in our pilot, we found that the detailed and specific recommendations that were generated by the hia process was not always well calibrated with the needs of community benefit planning activities such as irs required implementation plans. in our experience, children’s hospital colorado took the recommendations from the hias we conducted in colorado springs, co and broadened them to be incorporated into the hospital’s formal implementation plan in the region. despite this, children’s hospital colorado expressed enthusiasm for the hia process and expressed that there was clear value in using hias in this way. specific and actionable recommendations are considered best practice in hia and are a great strength of the process but there might be utility in adapting the hia process to generate broader recommendations for use by hospitals in their community benefit planning activities. this is an area where future research and practice innovation is needed. all of the hias used in this pilot generated recommendations from broad priority areas and were not based on an already existing program or policy proposal. traditionally, hias have been used to generate health maximizing recommendations when an existing proposal has already been put forward (the pew charitable trusts, 2016). existing practice already has precedents for the use of hia when there is not an existing proposal in place, but based on our pilot efforts, hias used in this manner hold the most promise for use by nonprofit hospitals as part of their community benefit activities given the need to address broad community health priorities. this does raise questions about adherence to best practices and whether or not these types of changes would make the process different enough to no longer qualify as an hia. limitations this pilot and the corresponding case studies included only three hias conducted in collaboration with one hospital. the stakeholders we interviewed were only a subset of all stakeholders involved in each hia and there could have been different perspectives that we did not capture. what we learned from this pilot and the implications are related to context and may not be generalizable to other nonprofit hospitals with different settings and circumstances. conclusion hias or hia-like processes can potentially help meet the need for established, evidence-based, and stakeholder responsive tools and processes to be used within nonprofit hospital community benefit activities. in meeting this need, the nonprofit hospital community benefit area could potentially serve as a major institutional home for the practice of hia. there is a need for additional research and practice innovation to further explore and refine the use of hia and/or hia like processes within nonprofit hospital community benefit activities. the use of hias at children’s hospital colorado tucg; 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(2011). community benefits and health reform: creating new links for public health and not-for-profit hospitals. j public health manag pract, 17(6), 524-529. doi: 10.1097/phh.0b013e31822da124 anderson, p. j., yoder, s., fogels, e., krieger, g., & mclaughlin, j. (2013). the state of alaska’s early experience with institutionalization of health impact assessment. international journal of circumpolar health, 72, 499-503. doi: artn 2210110.3402/ijch.v72i0.22101 children’s hospital colorado. (2016). community health action plan el paso county. corrigan, j., fisher, e., & heiser, s. (2015). hospital community benefit programs increasing benefits to communities. jama-journal of the american medical association, 313(12), 1211-1212. doi: 10.1001/jama.2015.0609 dannenberg, a l. (2016). a brief history of health impact assessment in the united states. chronicles of health impact assessment, 1(1). dannenberg, a.l. (2016). peer reviewed: effectiveness of health impact assessments: a synthesis of data from five impact evaluation reports. preventing chronic disease, 13. health affairs. (2016). nonprofit hospitals’ community benefit requirements. health policy briefs. retrieved december 13, 2016, from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=153 leider, j. p., tung, g. j., lindrooth, r. c., johnson, e. k., hardy, r., & castrucci, b. c. (2016). establishing a baseline: community benefit spending by not-for-profit hospitals prior to implementation of the affordable care act. j public health manag pract. doi: 10.1097/phh.0000000000000493 massachusetts department of transportation. (2016). a systematic review of health impact assessments on housing decisions and guidance for future practice morley, r., lindberg, r., rogerson, b., bever, e., & pollack, k.m. (2016). seven years in the field of health impact assessment: taking stock and future directions. chronicles of health impact assessment, 1(1). national research council. (2011). improving health in the united states: the role of health impact assessment: national academies press. rosenbaum, s., & margulies, r. (2011). tax-exempt hospitals and the patient protection and affordable care act: implications for public health policy and practice. public health rep, 126(2), 283-286. seattle and king county public health. (2017). health impact assessment (hia). retrieved may 5, 2017, from http:// www.kingcounty.gov/depts/health/environmental-health/healthy-communities/health-impact-assessment.aspx the pew charitable trusts. (2016). health impact project. retrieved october 4, 2016, from http://www.pewtrusts.org/en/ projects/health-impact-project tung, g.j., & williams, v.n. (2017). the potential role for health impact assessments in nonprofit hospital community benefit activities. j public health manag pract, in press. yin, robert k. (2009). case study research: design and methods (vol. 5). los angeles: sage publications. young, g. j., chou, c. h., alexander, j., lee, s. y., & raver, e. (2013). provision of community benefits by tax-exempt u.s. hospitals. n engl j med, 368(16), 1519-1527. doi: 10.1056/nejmsa1210239 the use of hias at children’s hospital colorado tucg; williams 12 corresponding author gregory tung, phd, mph assistant professor department of health systems, management policy program for injury prevention, education and research (piper) colorado school of public health 13001 e. 17th place, ms b119 aurora, co 80045 gregory.tung@ucdenver.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 2 (2017) doi: 10.18060/21517 © 2017 author(s): tung, g.; williams, v.; this work is licensed under a creative commons attribution 4.0 international license december 2021 volume 6 issue 1 perspectives from the field: a health approach to municipal decision-making: the gold star in health lauren skowronski, ba, msw; karen lowrie, phd; leigh ann von hagen, aicp, pp 1 could and should do to contribute to a sustainable future. launched in 2009, sustainable jersey (sj) is a network and movement of municipalities, schools and school districts working collectively to bring about a sustainable new jersey, and acting with state agencies, non-profit organizations, foundations, academia and industry. the program culminates in a prestigious certification award to municipalities and schools that have documented meeting a set of rigorous standards. sustainable jersey provides tools, training and financial incentives to support communities as they pursue sustainability programs. collaborative effort to improve new jersey’s health recognizing that municipalities needed direction on health issues, in 2019, sustainable jersey organized a cross-sector task force of more than 80 stakeholders and experts in public health, health care, social service, prevention, mental health, housing and planning. in july 2021, after a two-year effort of collaborative research, strategy development and program implementation, the health task force developed the gold star standard in health1 that includes standards introduction as the covid pandemic has put a renewed focus on public health infrastructure, people have a renewed appreciation for the important role that the government plays in building and supporting good health outcomes. much of what determines a person’s health and wellness is based on the environmental and social conditions where they live and work. the pandemic revealed striking disparities in health outcomes that are clearly linked to these uneven conditions. (perry et al, 2021; lopez et al, 2021) local governments have a great deal to do with creating and sustaining the conditions that support health and health equity. municipalities exercise important roles in public education, land-use planning and zoning, transportation planning, environmental management, housing, infrastructure investments, recreational programming, provision of open and green spaces, police and public safety, and economic development (northridge and freeman, 2011; who, 2010). in the state of new jersey, sustainable jersey researches best practices for what local governments 1https://www.sustainablejersey.com/actions/gold-star-standards/health-gold/ https://www.sustainablejersey.com/actions/gold-star-standards/health-gold/ perspectives from the field skowronski; lowrie; von hagen 2 and levels of performance that municipalities can implement to build a culture of health and advance health equity. the health gold task force includes members from the camden county department of health and human services, edward j. bloustein school of planning and public policy, the housing and community development network of new jersey, new jersey association of county and city health officials, new jersey chapter of the american academy of pediatrics, new jersey department of environmental protection, new jersey department of health, new jersey health care quality institute, new jersey local boards of health association, new jersey partnership for healthy kids, new jersey prevention network, new jersey public health association and more. individual working groups focused on tackling priority issues such as access to healthy food, land use, housing, and municipal governance. each working group brought dozens of additional content experts to the table in order to develop new standards, update existing sustainable jersey “actions”, and identify available resources to help local governments implement these initiatives in communities across the state. maplewood township health officer candice davenport served on the health gold task force. she explained, “a healthy environment creates a healthy person and vice versa. if we are engaged and present in our relationship with our environment and surroundings, then we will be moved and take action on its behalf. this is the basis of the sustainable jersey gold star in health. it’s a first step to help municipalities implement large scale efforts to impact health behavior and make systemic changes.” she added, “towns that are working towards sustainable jersey goals are really ensuring that their communities are resilient and healthier for future generations.” health gold star standard in order to be eligible to apply for the gold star standard in health, a municipality must be approved and have received points for designated “actions,” or standards. to assist municipalities, each action contains a description outlining why the action is important, who should lead and be involved, projected costs and timeline, what to do and how to do it, documentation to submit, successful models, and a list of resources that can assist in completing the action. sustainable jersey staff and content expert volunteers are on hand to assist towns in the implementation process. the foundational local health assessment and action plan action is a required first step where a municipality will assess and prioritize addressing the health needs and contributing conditions existing within the community. a robust dive into existing demographic and local health data, and a community engagement process are key to this assessment process. using a health lens, a newly established stakeholder committee will review existing conditions that may be contributing to poor health outcomes, for example, lack of access to healthy food, potential exposure to harmful lead contamination, unsafe conditions in parks and recreation areas, lack of opportunities for movement across town by bicycle or on foot, etc. where available, such data will be compared at neighborhood levels in order to assess where strategies to remedy such needs and conditions should be prioritized. health in all policies a key component understanding how municipal policy and programming decisions affect the health of those who live, work, and play within the community is essential for future planning and goal-setting. building a culture of health by incorporating this health lens into municipal operations is a critical goal of the gold star standard in health. perspectives from the field skowronski; lowrie; von hagen 3 to this end, a new action, integrating health into municipal decision-making2 will be required of all towns applying for the gold star in health. to complete the action, municipal staff must complete an hiap training and use a health impact checklist to assess municipal operations and procedures. formalizing this approach through adoption of an hiap resolution or establishing a hiap task force is encouraged. the hiap course required for the action is available through the bloustein school of planning and public policy at rutgers, the state university of new jersey, through its collaborative called the planning healthy communities initiative. the bloustein course is offered as a 6-hr class, with the following learning objectives: • define hiap and recognize why and when to use the hiap approach. • understand the broader context of health influences, social determinants of health and health equity. • learn how to identify and use data to measure progress in health objectives. • gain familiarity with health lens analysis, health impact assessment (hia), and other emerging tools that can provide evidence-based recommendations aimed at enhancing positive health impacts and minimizing negative ones. • explore opportunities to incorporate health in all policies into government decision-making processes. • understand how to effectively engage stakeholders in collaborative and inter-sectoral efforts to promote health. • review the resources available to local government and residents who wish to include health consideration in community planning. the class agenda features four parts and includes a mix of presentations and group exercises. topics include definitions of hiap and health equity, finding and using data and mapping tools, strategies for implementing hiap through process and policy changes and collaborative tools, and fostering leadership in building a healthy community. participants engage in discussion around key questions and also perform a break-out group around social determinants of health and using a health lens to examine a real or hypothetical project or program. participants told course evaluators that they learned how to use data and mapping tools to support decision-making, and programming, how to identify partners and champions in the community, and the importance of understanding health as a “shared value.” one noted that the class spurred a motivation to pass a local hiap resolution, and several relayed their commitment to looking at projects through a deeper health lens. a local health department director commented that the class helped her to gain “a better perspective of how [health departments] can work together to promote the importance of health initiatives and the inclusion of health issues/ matters in our local policy discussions and decisions.” together, the gold star in health and bloustein hiap course will provide local governments with the understanding and support to ensure health is considered in the development of programs and policies moving forward in order to ensure healthy and more equitable communities. for more information on the gold star in health, visit bit.ly/goldstarhealth. for more information on bloustein’s hiap course, please see phci.rutgers.edu, or contact authors. 2https://www.sustainablejersey.com/actions/#open/action/595 https://www.sustainablejersey.com/actions/#open/action/595 perspectives from the field skowronski; lowrie; von hagen 4 references: lopez l, hart lh, katz mh. racial and ethnic health disparities related to covid-19. jama. 2021;325(8):719– 720. doi:10.1001/jama.2020.26443 northridge, m.e., freeman, l. urban planning and health equity. j urban health 88, 582–597 (2011). https:// doi.org/10.1007/s11524-011-9558-5 perry, brea l., brian aronson, bernice a. pescosolido (2021). pandemic precarity: covid-19 is exposing and exacerbating inequalities in the american heartland. proceedings of the national academy of sciences feb 2021, 118 (8) e2020685118; doi: 10.1073/pnas.2020685118. world health organization (who. unmasking and overcoming health inequities in urban settings. world health organization, 2010. corresponding author karen lowrie, phd rutgers university 33 livingston ave. new brunswick, nj 08901 848-932-2937 eac@ejb.rutgers.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 6 issue 1 (2021) doi: 10.18060/25989 © 2021 author(s): skowronski, l.; lowrie, k.; von hagen, l. this work is licensed under a creative commons attribution 4.0 international license https://doi.org/10.1007/s11524-011-9558-5 https://doi.org/10.1007/s11524-011-9558-5 november 2022 volume 7 issue 1 letter from the editor i sophia has started an academic interest group to support sophia members who are teaching hia or hiap courses, or are participating as guest lectures in other courses. a few of the member of the academic interest group have shared their experiences in this edition of chia. we also have an article submitted from a student of a recent hia course that presents their findings. tatiana lin has created a hia health tool and shared that with two universities in kansas. keisha pollack porter shares how she recruited and managed a very large online hia course at johns hopkins university. lindsey realmuto discusses her first hia course experience at the university of illinois-chicago. if you would be interested in joining the sophia academic interest group please contact me at cylstone@iu.edu thank you, cynthia stone drph, rn professor, indiana university richard m. fairbanks school of public health editor, chronicles of health impact assessment journal december 2021 volume 6 issue 1 letter from the editor i welcome to the fall 2021 issue of the chronicles of health impact assessment. it seems longer than a year since we last published an issue. this time dealing with the covid pandemic has been demanding on so many fronts. we have a shorter issue than usual, probably due to all the conflicting demands. in this issue, we celebrate and reflect on sophia’s first ten years with an article titled “ten years of sophia.” sophia’s current and past leadership, founding members and others reflect on the history of hia and sophia as well as the organization’s most notable accomplishments and challenges. they share thoughts on priorities during the next ten years and the value that sophia membership brings to practitioners and those who are interested in learning more about hia. this issue also includes updated work on the minimum standards of practice for health impact assessments from the sophia work group. they also provided an excellent webinar to launch their report. we also include notes from the field about the recent work by our colleagues at rutgers university in new jersey. thank you and keep up your excellent effort to improve the health of your communities. cynthia stone, drph, rn editor of chronicles of health impact assessment gina powers, ba, mph student indiana university richard m. fairbanks school of public health october 2020 volume 5 issue 1 1 katrina smith korfmacher, phd book review: bridging silos: collaborating for environmental health and justice in urban communities introduction environmental health practitioners dedicated to creating healthy places are often looking for replicable policies, processes, and programs to bring to their communities. this can include model policy language or an implementation toolkit to easily be able to execute systems-level change. however, as this book outlines, there is rarely a one size fits all. this book outlines three case studies, including 1.) a community coalition-based lead poisoning prevention effort in rochester, new york; 2.) a wide range of efforts to create an equitable and healthy built environment in duluth, minnesota; and 3.) comprehensive environmental justice efforts near the port freight corridors in los angeles and long beach, california. from these cases, the book extracts concepts, processes, and lessons learned that all communities can utilize. the author (korfmacher) mentions that this book was sparked by a late night conversation after a national institute of environmental health science core centers meeting, where she and three other scholars at the forefront of urban environmental health, reflected on their local collaborative systems-level work in communities across the country. the group realized that their diverse work had several common elements and key lessons learned that any community could apply to their own issues. out of that conversation, came this book, which breaks down how and why local environmental health collaborations can successfully impact systems change. title: bridging silos: collaborating for environmental health and justice in urban communities publishing: 2019 copyright massachusetts institute of technology, westchester publishing services u.s. isbn: 978-0-262-53756-8 reviewed by: alison redenz, murp, aicp book review: bridging silos redenz 2 bridging silos as a guide for health impact practitioners and beyond the title “bridging silos,” gets to core content of this book, as a wide variety of academics, government professionals, advocates, and others understand that often the barrier to successful collaboration is established management silos. this book will probably be most valuable to an interdisciplinary professional who is trying to move the needle on a new idea in their community, and wanting to utilize best practices from other communities. often a professional from one discipline or an advocate will recognize an issue, but then realize the complexity of accomplishing any change within that issue due to silos, complex regulatory barriers, or lack of communication between disciplines. this book outlines step-bystep how these three communities were able to form successful community-based partnerships, and how progress can be measured many different ways. health impact assessment practitioners will find this book useful for: best practices in engaging coalitions of community members, public health professionals, planners, researchers, and other key stakeholders to provide critical ideas and data, expand the definition of public health, and find key intervention points to mitigate any health disparities that are shown as part of the health impact assessment. health impact assessments (hias) were used in two of the three cases studies to impact decision making. coalition building for critical ideas and data in duluth, three health impact assessments were used to assess the health impacts in the non-health decisions of potential neighborhood redevelopment. these three health impact assessments “allowed local stakeholders to develop greater familiarity with hia, use health data to analyze how built environment decisions affect health disparities, and gather community input on improving health equity” (korfmacher, 2019, p. 144). as korfmacher mentions, each of the three hias performed in duluth built “collaboration, capacity, and systems to improve health equity in duluth’s built environment” (2019, p. 144). the core successes from the health impact assessments were the exchange of ideas between city and county health officials, and the community’s exposure to the idea of health impact assessment. the hias were scoped to influence plans for the city, not direct decision-making, but they set the city up for success by creating plans with health impact at the core. expanding the definition of public health impacts through hia in los angeles the impact project was an academiccommunity partnership aimed at increase the consideration of health in decisions related to transportation around the ports of los angeles and long beach. the partnership interacted extensively with the planning process to redevelop a major highway to the ports, the i-710. as part of this process, the impact project pushed for the environmental review process to include both a health risk assessment (hra) and a health impact assessment (hia). the hia assessed a broader range of health impacts than the hra including the “effects of air quality, jobs, noise, access to neighborhood resources, and mobility issues such as safety, travel time, physical activity, and stress involved in commuting for work (human impact partners 2013)” (korfmacher, 2019, p. 212). according to one of the key partners from east yard communities for environmental justice, “the hia made people who were making recommendations to caltrans realize that public health is much broader…building a freeway is not just about happens on that freeway, it is about what happens in the community” book review: bridging silos redenz 3 (korfmacher, 2019, p. 213). this is a replicable example of how hia can show the multiple pathways of health impacts of projects. even if the final decision is not impacted by the hia, the process was successful in broadening the definition of health impacts to include the social determinants of health. finding key intervention points: “hialike” analysis in rochester, ny although the final case study in bridging silos did not include a formal health impact assessment, its process mirrored hia’s use of public health data and community engagement to inform targeted intervention points and create action steps. the coalition to prevent lead poisoning in rochester, new york was able to provide diverse health impact data and knowledge to inform the key intervention: a new local lead law. from health care providers summarizing medical literature, to health department staff providing elevated blood lead data, to lead professionals contributing knowledge from lead risk assessments, a wide variety of data-informed the coalition’s initial step of communicating the problem to the community. these analyses helped the coalition justify their recommendations from a cost-saving and health benefits perspective. providing the cost of “not preventing the lead poisoning,” parallels the hia process as it helps to show the health benefits of the lead law. by leveraging the types of resources and data in traditional health impact assessments, the coalition in rochester was able to show intervention points, and the costs of not implementing them. evaluating the impact of the initiatives korfmacher outlines the different types of impacts of the three case studies’ initiatives, as including outputs (products), social outcomes (capacity and relationships), and impacts of policies, systems, and environments (pse). korfmacher focuses on “upstream,” “systemslevel” work which we know has the most long lasting effort in creating change in communities. all three of the initiatives’ outputs were aimed at creating the conditions for change in systems in environmental health, whether that was conducting an assessment, or providing a training workshop on a topic. social outcomes were another type of output of the initiatives, as when a coalition came together and built social capacity, trust, or relationships. both types of outputs are the building blocks of policy, systems, and environmental changes and provide their own worth for creating awareness and creating the human capital to deliver the improvements. all three cases revealed ways in which the coalitions changed processes by which decisions were made. other direct impacts of policy, systems, and environmental changes are more concrete such as the change in rochester’s lead law, and the changes in processes by county health and human services departments. summary bridging silos provides an excellent outline of the policy, systems, and environmental change impacts and nuanced ways of measuring success for three distinct environmental health efforts across the united states. health impact assessment professionals will find ways to enhance their own work through the diverse range of case studies described. this book provides a great framework for a wide range of professionals looking to understand modern environmental health issues, how three communities addressed them, and how to learn from and apply their success to create healthier places in their own communities. call for chronicles of health impact assessment (chia) peer reviewers we appreciate your interest in supporting the chia journal as a peer reviewer. in this role, you will be asked to read submitted articles. if you do not have time you can decline the invitation to review and will be placed back in the rotation for future opportunities. if you do have time, your review will address the following: you will submit a written critique that will help determine if the article will be published. you will be asked if you have any conflicts of interest in reviewing an article. all your comments will be anonymous to the authors. you will be given prompts to respond to, such as: what are the article strengths or weaknesses, is this information that is new to the field or building on already known material? all comments should be viewed as constructive criticism for the authors. you will have the choice to accept, recommend acceptance with revisions, or not accept the article. if you are interested, the following information will assist us in matching peer reviewers to specific authors. name email address affiliation phone number area of hia expertise (check all that apply): agriculture criminal justice health equity housing built environment economics hia evaluation labor policy climate change education hia methodology natural resources community development energy hia theory redevelopment transportation other:__________________________________________________ how are you qualified (papers written, journal reviewed for, etc.)? 1050 wishard blvd., indianapolis, in 46202 317-274-3126 chia@iu.edu call for chronicles of health impact assessment (chia) peer reviewers we appreciate your interest in supporting the chia journal as a peer reviewer. in this role, you will be asked to read submitted articles. if you do not have time you can decline the invitation to review and will be placed back in the rotation for future opportunities. if you do have time, your review will address the following: you will submit a written critique that will help determine if the article will be published. you will be asked if you have any conflicts of interest in reviewing an article. all your comments will be anonymous to the authors. you will be given prompts to respond to, such as: what are the article strengths or weaknesses, is this information that is new to the field or building on already known material? all comments should be viewed as constructive criticism for the authors. you will have the choice to accept, recommend acceptance with revisions, or not accept the article. if you are interested, the following information will assist us in matching peer reviewers to specific authors. name email address affiliation phone number area of hia expertise (check all that apply): agriculture criminal justice health equity housing built environment economics hia evaluation labor policy climate change education hia methodology natural resources community development energy hia theory redevelopment transportation other:__________________________________________________ how are you qualified (papers written, journal reviewed for, etc.)? 1050 wishard blvd., indianapolis, in 46202 317-274-3126 chia@iu.edu november 2023 volume 8 issue 1 letter from the society of practitioners of health impact assessment (sophia) i dear readers, as the president of the society of practitioners of health impact assessment or sophia, i am excited to introduce this issue of chia. sophia is dedicated to promoting the practice and the practitioners of hia and health in all policies (hiap). our partnership with chia is one of the ways we provide the connective tissue across the wide array of organizations who lead hia and hiap work. we also host monthly webinars and a virtual practitioner workshop in december every year. the workshop, which takes place december 5 and 6 will feature a presentation on an international research effort to understand hia practice, the introduction of the new hiap screening tool created by the sophia hiap work group and the latest in using health notes as a policy lever. in april of next year, we will also sponsor our in-person practitioner workshop in washington, dc. my keynote address, titled, "cumulative impact assessment is hia 2.0," will explore what is new and different in this emerging practice and the role of practitioners in shaping minimum elements and practice standards for cia. if you want to learn more about cia, we will be hosting a track on the second day of the conference featuring thought leaders like charles lee of the us epa's office of environmental justice and external civil rights. we will also have lightning talks and roundtables on day one and a pre-conference option for an hia 101 class, so please watch the events page on the sophia website. this edition of chia contains two articles that explore health impacts although only one uses the formal hia process. the first article discusses the process and outcomes of a case study from the southern nevada health district and what we can all learn from their work. the second article focuses on the product design process and how it can be influenced to be more health promoting. both articles focus on changes to policy and design that influence health outcomes. i hope you enjoy these articles and can use your takeaways to improve your practice. sandra whitehead president, sophia call for chronicles of health impact assessment (chia) peer reviewers we appreciate your interest in supporting the chia journal as a peer reviewer. in this role, you will be asked to read submitted articles. if you do not have time you can decline the invitation to review and will be placed back in the rotation for future opportunities. if you do have time, your review will address the following: you will submit a written critique that will help determine if the article will be published. you will be asked if you have any conflicts of interest in reviewing an article. all your comments will be anonymous to the authors. you will be given prompts to respond to, such as: what are the article strengths or weaknesses, is this information that is new to the field or building on already known material? all comments should be viewed as constructive criticism for the authors. you will have the choice to accept, recommend acceptance with revisions, or not accept the article. if you are interested, the following information will assist us in matching peer reviewers to specific authors. name email address affiliation phone number area of hia expertise (check all that apply): agriculture criminal justice health equity housing built environment economics hia evaluation labor policy climate change education hia methodology natural resources community development energy hia theory redevelopment transportation other:__________________________________________________ how are you qualified (papers written, journal reviewed for, etc.)? 1050 wishard blvd., indianapolis, in 46202 317-274-3126 chia@iu.edu november 2023 volume 8 issue 1 9 volume 1, issue 1october 2016 social learning through stakeholder engagement: new pathways from participation to health equity in u.s. west coast hias nicole iroz-elardo, phd; moriah mcsharry mcgrath, phd, mph, msup while some contend that extensive public engagement activities are necessary to meet health impact assessment (hia) practice standards, other work suggests that an hia of any type hasthe potential to inform decision-making in ways that embody hia’s value of democracy (cole & fielding, 2007; harris-roxas et al., 2012; negev, 2012). these divergent perspectives on how to realize democracy through public participation represents an area of evolving debate in the ongoing development of hia practice in the us. looking to the relatively diverse hia practice on the west coast of the us, we explore the interplay between engagement strategies and hia values in completed hias. we locate each hia on harris-roxas’s (2011) typology of hias – mandated, decision-support, advocacy, and community-led – and assess the type(s) and extent of participation activities conducted. this sample incorporates a variety of both hia types, target policy/program decisions in different sectors, and hias conducted by seasoned and novice practitioners. this analysis reveals gains in health equity resulting from all types of hias and engagement strategies. we argue that in addition to the empowerment of affected groups that occur through direct participation, social learning (bandura, 1977) is a mechanism for advancing health equity through the moral development of the participating stakeholders. additionally, we found that hias which employed direct participation and benefited from vibrant leadership by community organizations did not necessarily realize hia’s health equity goals. just as analytical strategies vary given different purposes, engagement strategies vary depending on the goals of an hia. we argue that overly rigid definitions of participation elide the contributions made by hias that take a different form than the archetypal community-led hia. this elision is problematic given the institutional infrastructure that can be built through more technocratic decisionsupport hias and the relative dearth of truly communityled hias. we propose eschewing a singular “optimal” participation paradigm as a way to both acknowledge the potential of all types of hia to contribute to health-supporting policy and to maintain the idealistic frame for hia to advance health equity. introduction given the flexibility of the hia technique and the rapid growth in its application in the us (see figure 1), the practice community is in a dynamic phase of establishing standards and norms. a significant area of concern for many hia practitioners is the importance of stakeholder participation for fostering health equity, defined as “attainment of the highest level of health for all people” in the federal government’s healthy people 2020 benchmarking program (office of disease prevention and health promotion, n.d.). public health practitioners adopting hia in an effort to influence policy and programs in the us have cited the values of the gothenburg consensus (european centre for health policy, 1999) – democracy, equity, sustainable development, ethical use of evidence, and a comprehensive approach to health – as guiding principles. yet there has been little critical evaluation of whether hias routinely support democracy, which is defined in the gothenburg document as “the right of people to participate in a transparent process for the 10 1 while nepa’s implementation varies across federal agencies, public input generally comes in the form of comments submitted to and then rebutted by the federal agency (or their consultants). 2 glucker et al. (2013) discuss the challenges of defining participation within eia while mahoney et al (2007) suggest the lack of rigor and clarity in defining “community participation” is a significant barrier to understanding its appropriate role in hia. formulation, implementation, and evaluation of policies that affect their life, both directly and through the elected political decision makers.” figure 1. since the completion of the first us hia by the san francisco department of public health in 1999, the use of hia has rapidly increased. sources: bourcier, charbonneau, cahill, & dannenberg (2015); health impact project (2016); rhodus, fulk, autrey, o’shea, & roth (2013). the practical challenges of engaging stakeholders (the time and resources necessary to build trust and capacity) coexist with aspirational notions of social change through direct participation; yet the choice of engagement strategies in a given hia are often driven by expediency (heller, malekafzali, todman, & wier, 2013) and resource limitations. in reality, many hias use engagement strategies that follow a stakeholder engagement paradigm – inviting diverse interests to deliberate together – rather than direct participation that “centers the margins” by foregrounding the experience and leadership of directly affected and historically marginalized groups. so while the value of democracy explicitly adopted by hia practitioners has generally been interpreted to mean facilitating engagement in decision-making through direct participation of affected parties (baker et al., 2012; kemm, 2005), the us experience to date does not provide clear evidence this relationship is operational (iroz-elardo, 2014a). we aim to enrich the conversation about democracy and equity by exploring participation (i.e., how hia practitioners operationalize democracy) and health equity impacts of hias in the context of the relatively diverse practice on the west coast of the us. our analysis shows the dominance of a stakeholder engagement paradigm for participation despite a wide range of engagement strategies (i.e., ways of participating). further, we demonstrate that hias which entail little direct participation are still able to foster social learning (bandura, 1977) – the generation of new knowledge through intergroup interaction that directly contribute to advancing health equity through moral development and improved policy decisions. consequently, we argue that the emphasis on direct participation may be unnecessary to, and may even in some cases detract from, realizing other hia values such as equity. applying these perspectives to hia practice, we suggest that practitioners expand our conception of pathways to equity and more clearly articulate our visions for advancing health equity, given the diversity of participation paradigms and engagement strategies employed in the field. background concern for health equity is a distinguishing characteristic of hia (harris-roxas & harris, 2011) and the connection between democracy and equity comes from the notion, as articulated by the world health organization (n.d.), that “to be effective and sustainable, interventions that aim to redress inequities must typically go beyond remedying a particular health inequality and also help empower the group in question.” current adopted minimum elements for hia (bhatia et al., 2014) also establish that hias should involve and engage “stakeholders affected by the proposal, particularly vulnerable populations.” this operationalizes the value of democracy and shows how hia anticipates a higher level of participation than generally occurs under the environmental impact assessment (eia) procedures conducted under the u.s. federal national environmental protection act (nepa).1 many leading us hia practitioners (e.g., heller et al., 2013) interpret the equity value as a call to use the hia process to empower historically disadvantaged populations through the decision-making process, as mapped in figure 2. this interpretation suggests that hias should privilege participatory strategies that shift power to citizens most likely to be affected by the target decision, lifting up voices that have not been heard in previous decades of decision-making. figure 2: presumed pathway from participation to health equity participation, which is generally understood as the mechanics or expression of democracy, is universally seen as desirable but can be difficult to define (glucker, driessen, kolhoff, & runhaar, 2013; mahoney, potter, & marsh, 2007).2 engagement strategies is a term for the techniques used by a facilitator (in this case, the hia practitioner) to solicit information from participants. some engagement strategies provide more power and control over the analytical process than others; thus the engagement strategies shape the type of participation – or democracy – that occurs within an hia. accordingly, we use the term participation to signify social learning iroz-elardo; mcgrath 11 general involvement in an hia and participatory to describe the use of engagement strategies that provide more direct roles for and control by affected community members, such as collecting data and making decisions. we distinguish two paradigms for participation: direct participation and stakeholder engagement. where possible, these terms are qualified with descriptors that signify who is participating. for example, we distinguish between a directly affected community (understood as a smaller subset of people, often members of socially marginalized groups, who stand to bear the likely negative impacts of a decision) and stakeholders more generally, which would include the directly affected community alongside other parties with a vested interest in the outcome (e.g., businesses, landowners, neighboring communities) (kahane, loptson, herriman, & hardy, 2013). depending on the type of engagement strategies used, participation can be bureaucratic (e.g., commenting on administrative documents) or participatory (e.g., conducting the assessment and interpreting the results). these distinctions are illustrated by the schematic in figure 3. figure 3: conceptual framework relationships among participation, democracy, and equity at least four rationales for citizen participation are found within scholarly literature. first, philosophers argue that citizen participation is intrinsically valuable because it develops human capacity (à la aristotle) and forces individuals to be socially responsible for the collective well-being (per rousseau and mill) (day, 1997). another argument is that citizen participation in public decisions develops a more responsive government because citizen needs are more likely to be articulated well and early; urban planning theorists suggest that such participation is more likely to accurately identify the public interest and minimize implementation delays (day, 1997). others view participation as a means for those without power to exercise strength and change the social order (arnstein, 1969/2005). specific to impact assessment, glucker and colleagues (2013) suggest that the various rationales classify participation as normatively desirable, substantive in terms of gathering information, or instrumental in reducing conflict or generating legitimacy. the prevailing consensus in contemporary urban planning theory (forester, 1999; healey, 1996/2003; innes & booher, 2010) points toward collaborative, deliberative participation processes – i.e., stakeholder engagement – as the way to pursue these rationales. this consensus has arisen as a result of the “communicative turn” in planning, which is based on the idea that participation should incorporate direct identification of interests “under conditions of rational deliberation and choice (connolly) . . . [and] relative personal autonomy (lukes)” – a decidedly more social approach to participation (taylor, 1998, p. 68). yet in hia practice, democracy has generally been understood to suggest direct participation, reflecting the normative value within public health that views community engagement, organizing, and empowerment as essential in promoting individual and community health (kemm, 2013). in the context of hia, equity is generally understood to mean reducing health inequities, or disparate and avoidable health burdens among social groups. in the us, these groupings are often based on racialized categories and socioeconomic status. mechanisms for reducing health inequities include preventing the implementation of policies that will produce disparate burdens (minkler, wallerstein, & wilson, 2008) as well as broader deliberation over “social constructionist or structuralist” understandings of health inequity through the hia process (harris-roxas et al., 2012). operating practices in u.s. hia consequently, direct participation and participatory engagement strategies are highly prized in us hia practice. for example, a recent white paper by prominent innovators in the field (heller et al., 2013) outlines eight principles for promoting equity in hia practice, the first two of which emphasize direct participation and participatory engagement strategies (see table 1). the operating assumption seems to be that adherence to democracy necessitates direct participation, which leads to empowerment of members of the most affected community, which in turn leads to equity gains when these empowered community members pursue their interests in the policy arena (as diagrammed in figure 2). table 1: strategies for promoting equity in hia (from heller et al., 2013) a. ensure community leadership, ownership, oversight, and participation early and throughout an hia b. support authentic participation of vulnerable populations in the decision-making process c. target the practice of hia towards proposals that are identified by, or relevant to, vulnerable populations d. ensure that a central goal of the hia is to identify and understand the health implications for populations most vulnerable e. ensure the hia assesses the distribution of health impacts across populations wherever data are available f. identify recommendations that yield an equitable distribution of health benefits g. ensure that findings and recommendations of the hia are well communicated to vulnerable populations most likely to be impacted h. ensure that the actual impacts of the decision are monitored social learning iroz-elardo; mcgrath 12 however, just as different types of hias are appropriate to different decision-making contexts, certain participation paradigms and engagement strategies may align with different hia types. harris-roxas and harris’ (2011) typology of hias is especially valuable as we interrogate the role of participation in realizing hia values. they argue that engagement strategies generally match the purpose of the hia, as summarized in table 2. table 2: hia typology and typical participation format hia type purpose participation mandated meet statutory requirement limited consultants may do outreach voluntary decisionsupport minimize health harms and maximize health benefits stakeholder engagement, generally with bureaucratic engagement strategies advocacy promote group values to decision-making body direct participation, often with bureaucratic engagement strategies communityled increase community power through participating in an hia that bring health concerns into a decisionmaking process direct participation, with participatory engagement strategies a rigid interpretation of their typology might suggest that it is difficult to achieve health equity through less participatory hias. further, the extent of deliberation and/or stakeholder power and control in hia practice overall are unclear (ucla school of public health, 2014), particularly since these aspects of the process are not always well documented in hia reports. for example, only a small proportion of hias – 18.5 percent in a recent study by the u.s. environmental protection agency (rhodus, fulk, autrey, o’shea, & roth, 2013) – robustly engage stakeholders through an advisory committee. further, the same study also found that only one-quarter of stakeholder advisory committees “actually oversaw or guided the hia process and were engaged as decision-makers in equal partnership with the hia team or as the primary decision-makers” (rhodus et al., 2013). one potential explanation for the shortcomings in direct participation in us hias is that participatory processes are difficult to sustain. stakeholder engagement has become the alternative to direct participation in the urban planning world because it ostensibly is efficient at surfacing a variety interests with minimal resources invested. while advisory committees may be considered “second-best” to direct ownership of an assessment or decision-making process, they are a pragmatic and heavily used engagement strategy. thus, understanding their capacity to further health equity is critical for advancing hia practice. methods/approach this paper analyzes 12 recent hias from the us west coast in terms of hia purpose, participation paradigm, engagement strategies, and health equity outcomes. we use this diverse, geographically bounded subset to elucidate how the participation paradigm of a given hia affects its contributions to health equity, with the purpose of informing the challenging and resource-intensive fulfillment of hia’s democracy value. this analysis extends iroz-elardo’s (2014b) study of three3 comprehensive hias that varied in general nature, specific objectives and goals, and scale of the project. in the present paper, those cases are augmented by three comprehensive hias completed by oregon health authority (oha) and five rapid hias conducted in oregon by county health departments with oha pass-through funding from the centers for disease control and prevention. the comprehensive oha hias related to climate planning; the first author was the technical lead for two (iroz-elardo, hamberg, main, earlyalberts, & douglas, 2014; iroz-elardo, hamberg, main, haggerty et al., 2014). the rapid hias addressed a variety of locally identified issues. for each case, we identified hia type, participation paradigm, and engagement strategies. we analyzed how democracy and equity were understood by the project participants – as represented in project documents and our personal knowledge of the hia. we also interviewed a former hia program coordinator at oregon health authority on two different occasions, asking her to discuss the 15 different hias (five of which are mentioned below) that were initiated at the county level between 2009-2015. for this paper, we paid particular attention to including discrepant cases, or situations where the hia produced unexpected results, following the qualitative research tradition (maxwell, 2005) that seeks to explicate phenomena through exploring perceived outliers. an overview of the study cases is presented in table 3. this sample represents a wide breadth of participation paradigms and engagement strategies as well as a large proportion of hias completed on the us west coast, where the presence of early adopters and training patterns resulted in a spatially clustered and regionally distinct hia practice. we selected only cases with which we had sufficient information to comment on the analytical processes that are not always captured in hia reports. the sample includes no fully community-led hias, as we are not aware of any such projects taking place during our study period. our interpretation of the data occurs through the lens of our personal experiences in many different roles within the professional community we are discussing. for the past five years or so, both authors have been active participants in the hia community – within portland, oregon, as well as at the regional and national levels. the first author of this paper conducted dissertation research on hia (irozelardo, 2014a, 2014b), teaches graduate-level hia courses, 3 one of the three in-depth hia evaluations looked at a two-part project, presented as two hias in the table accompanying this article. social learning iroz-elardo; mcgrath 13 and is an hia practitioner. the second author developed a graduate-level hia course and worked for five years as an hia analyst at a large urban health department where she collaborated on hias and other “hia-inspired” analyses (clapp & mcgrath, 2012; mcgrath, clapp, maher, oxman, & manhas, 2013; mcgrath & lyons-eubanks, 2011; white & mcgrath, 2012). both have served on steering committees, planning committees, and workgroups for the northwest regional hia network, hia of the americas, and society of practitioners of health impact assessment. these experiences both enrich and bias our interpretation of the information presented in this paper. table 3: overview of cases project lead organization hia type participation paradigm engagement strategies clark county bike/ped plan hias clark county public health (wa) rapid hia: clark county bicycle and pedestrian master plan (haggerty, 2010) decisionsupport none none comprehensive hia: clark county bicycle and pedestrian master plan (haggerty, et al., 2010) decisionsupport stakeholder engagement consulted existing target plan’s advisory group climate hias oregon health authority climate smart communities scenarios (green, et al., 2013) decisionsupport stakeholder engagement several large (37-person) meetings community climate choices (iroz-elardo, hamberg, main, early-alberts, et al., 2014) decisionsupport stakeholder engagement several large meetings augmented by small topic meetings climate smart strategy (irozelardo, hamberg, main, haggerty, et al., 2014) decisionsupport stakeholder engagement several large meetings augmented by small topic meetings county hias – funded by oregon health authority augusta lane bike-pedestrian bridge (washington county public health division, 2014) washington county decisionsupport stakeholder engagement with selected direct participation activities public meetings, partnering with culturally-specific organizations barrett park (mejia, 2011) hood river county decisionsupport stakeholder engagement public meetings, partnering with culturally-specific organizations tumalo community plan (madrigal & wells, 2010) deschutes county decisionsupport stakeholder engagement informal outreach to stakeholders mcloughlin blvd. road safety audit (white & thorstenson, 2014) clackamas county/ oregon public health institute decisionsupport stakeholder engagement informal outreach to stakeholders including joint data collection housing supply upgrade initiative (klinefelter, 2013) curry county decisionsupport stakeholder engagement with selected direct participation activities consulted advisory group created for different purposes, conducted interviews with directly affected community i-710 corridor (human impact partners, 2011) human impact partners mandated stakeholder engagement external technical experts on advisory committee; hia author not in control of advisory committee composition lake merritt bart station area plan (harris, purciel-hill, gilhuly, & babka, 2012) human impact partners advocacy stakeholder engagement with strong leadership by directly affected populations participatory in that cbo controlled most aspects of hia social learning iroz-elardo; mcgrath 14 cases overall, we found that the participatory nature, robust community outreach, and significant community control seen in some early hias (e.g., the eastern neighborhoods community hia in san francisco, as discussed in corburn, 2009) is an exception rather than a rule. as illustrated in the vignettes below, the hias provided limited opportunities for citizens to directly participate in the assessments or target decisions, and in only one hia did community representatives control the scope and content of the hia. engagement strategies varied widely, including: a community-led advisory committee that had control over nearly every decision in the hia (lake merritt); consulting stakeholder groups established as part of the targeted planning decisions rather than creation of their own advisory committee (clark county, curry county); a highly technical stakeholder advisory committee of which the hia facilitator had little control (i-710 corridor); and ad hoc informal outreach (multiple county health department hias). a small number of hias engaged non-english speaking communities directly, using a public meeting format and partnering with other organizations well positioned to engage such communities (washington and hood river counties), and one hia used interviews with residents to collect data (curry county). we present these cases below, in the groupings described above, discussing relationships between participation and health equity. clark county, washington bicycle-pedestrian hias in early 2009 in response to a state mandate, clark county, washington initiated an update of its bicycle and pedestrian master plan governing unincorporated areas (clark county community planning, 2010). planning in this quickly suburbanizing community is challenging due to relatively conservative social ideology combined with large geographic gaps in municipal services. clark county planners were pleased to partner with clark county public health in support of the bike-ped plan in 2010. public health professionals first performed a rapid hia (haggerty, 2010) to provide input on the concept plan; this was followed by a full hia with more detailed analysis of impacts and greater stakeholder input (haggerty, melnick, hyde, & lebowsky, 2010). while this hia did not maintain a separate community or stakeholder engagement strategy, it was able to influence the stakeholder engagement process of the larger plan, primarily through the technical contributions of the hia’s lead author, who used his knowledge of the active transportation literature to advocate for the equity advances. the rapid hia was produced on a short timeline with no input from potentially affected parties. however, the document was shared with clark county planning staff and the plan’s bike-ped advisory committee – the membership of which was split between government bureaucrats and “self-selected and old-school, mainly male, caucasian, older” residents who initially focused on recreational cycling. the rapid hia sparked a social learning (bandura, 1977) process, where the bike-ped advisory committee and county planning staff showed increased awareness of how the general public experienced active transportation and the health equity implications of bike and pedestrian infrastructure. these perspectives were integrated into the comprehensive hia. comparison of the final plan with the preliminary plan shows broader consideration of all road and path users (e.g., utilitarian cyclists and pedestrians, groups more likely to be living in poverty, recent immigrants, children and older adults, and people with disabilities). the final plan prioritized access to health-supporting resources such as healthy food and addressed concerns about dangers to children using active transportation by emphasizing the health benefits. the most tangible evidence of hia effectiveness was the incorporation of 20 public health points in a 100-point scoring criteria used to select locations to add sidewalks. the points system identified areas were walking rates could be increased and where amenities would benefit residents of lower socioeconomic status. oregon health authority climate hias the climate hias conducted by the oregon health authority (oha) were a suite of decision-support hias completed as part of a climate planning process convened by metro – portland, oregon’s metropolitan planning organization. a response to a state legislative mandate, the hias were named the climate smart communities scenarios hia (april 2013), the community climate choices hia (march 2014), and the climate smart strategy hia (september 2014). to account for social co-benefits of climate action planning, the hias used the quantitative integrated transport health impact model (centre for diet and activity research, 2013) to analyze pathways between transportation and health impacts. the model was refined with the input of a 37-person stakeholder advisory committee made up largely of public employees, supplemented with a few academics, a couple of hia practitioners from the local non-profit sector, and several elected officials from the region; notably, there was no direct community representation. an oha hia program staff member convened the committee, on average, twice per hia – generally for scoping and to review the results of the analysis. topic-specific subcommittees met for work sessions on a few occasions, a handful of advisory members served as peer reviewers of hia report drafts, and all committee members evaluated the hia process and the report recommendations via online surveys. the work sessions – which arose when some stakeholders had serious reservations about the analytical strategy – created a venue for social learning. largely attended by a subset of members most interested in the topic at hand, these meetings brought together members from different agencies and sectors. this helped improve understanding of various agencies’ needs and responsibilities as well as different stakeholders’ health equity concerns, fostering intersectoral understanding through interpersonal interaction. these social learning iroz-elardo; mcgrath 15 4 funded by the centers for disease control and prevention’s national center for environmental health community design initiative. 5 oregon solutions (http://orsolutions.org) is a statewide program that offers facilitation services to convene multiparty problem-solving collaboratives addressing complex sustainability issues. conversations and relationships proved transformative for some; for example, an agency staffer reported a transition within her agency in thinking about how health intersects with their regulatory approach to air quality. these fledgling relationships led to the formation of the transportation and health subcommittee of the oregon modeling steering committee, institutionalizing consideration of environmental justice and health equity by the state’s transportation modeling community. oregon health authority hia program-funded hias – “county hias” starting in 2009, the oregon health authority’s public health division provided mini-grants4 to county health departments in an effort to increase local hia capacity; fifteen rapid hias in eleven different counties were completed. because local governments author them and public employees cannot engage in political advocacy, these hias were by necessity decision-support hias. the small dollar value of the grants ($10,000-15,000) also limited the extent of possible engagement strategies. however, oha required that grantees invite stakeholders to scoping training sessions and encouraged ongoing involvement through the assessment and recommendation stage. most grantees chose a stakeholder engagement paradigm and used bureaucratic engagement strategies – literally inviting representatives of government bureaus to comment on their work. for example, the mcloughlin blvd. road safety audit hia (white & thorstenson, 2014) convened representatives of public health, planning, state and local departments of transportation, and a neighborhood organization. they then added a one-day evaluation of social determinants of health metrics to a traditional road safety audit (federal highway administration, n.d.) along the roadway corridor. in curry county, the health department took the approach of clark county, wa (above) and worked closely in parallel with an oregon solutions5 project that was engaging local, state (oregon housing), and federal (hud) stakeholders and decisionmakers. other counties recognized a need for direct participation by citizens who might be affected by the local decisions. for example, deschutes county asked citizens in a public meeting for the tumalo community plan to draw what a healthy, happy community would look like. this information led to an hia that focused on “sense of place” in addition to physical activity and traffic safety in the rural context. counties that directly engaged members of vulnerable populations conducted limited, but effective, outreach by partnering closely with community-based organization, particularly when trying to reach linguistically isolated populations. for example, leaders of hood river county’s barrett park hia subcontracted with a latino-focused organization to host listening sessions associated with their hia. similarly, the center for intercultural organizing helped to engage the geographic community most affected by the proposed augusta lane bridge in washington county. these strategies led to hias that produced health equity benefits by advancing the needs of vulnerable populations. for example, washington county’s targeted public meetings helped the hia authors advocate for the augusta lane bridge, with its the obvious health benefits of connecting a spatially isolated area to health-promoting resources such as an elementary school, two transit lines, and a green space in the face of concerns about interpersonal safety for children walking to school. the curry county hia (klinefelter, 2013), which addressed state funding rules about repair and replacement of manufactured housing, eschewed an advisory committee in favor of small contracts with one topic area expert and one hia expert. the hia author also worked closely with housing inspectors to gain entrance to sub-standard housing units, where she was able to interview residents and observe housing environments. interstate 710 corridor expansion in california, the i-710 corridor hia was initiated with significant support from a coalition of local, community-based, environmental justice organizations. approximately 40 percent of us imports travel this highway, which connects the ports of long beach and los angeles to the greater los angeles region. a proposed expansion would increase the freeway from eight to up to 14 lanes. the coalition successfully lobbied the california department of transportation (caltrans) for an hia to be integrated into the environmental impact assessment (eir) process. though the hia was community-initiated, the scale of the planning process and the politics and funding structure of the eir resulted in the hia being produced with very little input from affected communities. additionally, the hia report was unavailable for many months, and then was only released as a “work-product” separate from the draft environmental impact review (deir) report. this tactic by expansion advocates prevented the hia from obtaining the same legally binding status as eir documents produced under state and federal statute. even though area residents had limited involvement while the hia was being written, the report still reflects residents’ concerns; the scope addressed health concerns beyond typical eir pathways of air pollution and noise. hia findings appear prominently in public comments, suggesting that area residents and advocacy organizations have found the report to be a useful tool to advocate for health equity despite the publication delays. further, the coalition for environmental health and justice used the hia to bolster their legal assertion that the deir social learning iroz-elardo; mcgrath 16 is inadequate. the epa also cited the hia as a factor in their recommendation that caltrans reject the deir/eis. as a result, caltrans has instructed that the plan and deir be reworked to incorporate elements of a community-defined alternative plan. lake merritt bart the lake merritt hia was initiated and controlled by six allied advocacy organizations highly committed to social justice in the oakland chinatown community. the case, an exemplar of advocacy hia practice, illustrates how a robust stakeholder advisory committee with complete control over hia decisions can pursue community interests, even in a planning process where significant competing cultural and economic interests were present. this case also illustrates how social learning can happen with small advisory committees from diverse advocacy backgrounds. the scoping phase of the hia took much longer than expected or budgeted because each organization was accustomed to advocating for social justice in vastly different arenas: housing, health services, policy work, transportation, and environmental justice. the group identified health equity as an expression of social justice, a shared value, and used the social determinants of health as a common language to understand each other’s interests. some stakeholders expressed dismay that the hia did not facilitate more data collection or community organizing yet the final hia makes a clear case for protecting the current community’s concerns, protecting open space, and adopting affordable housing strategies to prevent gentrification. discussion the state of hia practice on the us west coast shows that direct participation does not have a one-to-one relationship with health equity and that stakeholder engagement can lead to health equity gains through social learning. as illustrated in the cases above, we found that different types of hias advanced health equity despite variation in participation paradigms and engagement strategies. our three main findings about the current state of democracy and equity in this practice are: • stakeholder engagement predominates as a participation paradigm, and community-led or -initiated hias are few; direct community participation does not automatically lead to empowerment and equity. • stakeholder engagement and technical decision-making by public health professionals can be successful in advancing health equity. • equity advances can be achieved through social learning that identifies ways to narrow gaps in health-supporting resources among population groups. taken together, these findings suggest an expanded view of pathways between participation and equity in hia. revisiting direct participation despite hia practitioners’ widespread desire to use participatory methods to directly engage and empower citizens in vulnerable communities, it is difficult to find such strategies in broad use in hia practice. hias, particularly those initiated and/or authored by government agencies, generally adopt a stakeholder participation paradigm with some variation in engagement strategies. despite the lack of direct participation and participatory engagement strategies, these decision-supported hias show evidence of gains in health equity. it appears that social learning fostered by multi-party collaboration assists bureaucratic decision-making which supports narrowing health disparities. a major strength of hia is its capacity to assemble and frame a broad array of perspectives on health; yet the mechanics of participation in the hia process are challenged by the very diversity of knowledge, data, interests, and languages held by various stakeholders (glucker et al., 2013). finding common ground between these stakeholders can be generally difficult to impossible (negev, 2012). however, hia stakeholder advisory committees of all sizes are potentially democratizing in a number of ways: identifying new health-related information; providing an additional participation opportunity for community representatives to engage the process; supporting the growth of interdisciplinary relationships; and influencing public decisions (negev, 2012). while many hias encourage social learning, the i-710 corridor hia is a very interesting example where empowerment and even social learning were prevented in the hia process, despite the strenuous advocacy for the hia by seasoned local activists. while community groups whose constituencies would be affected by the port expansion successfully advocated for an hia with the i-710 project committee, that same committee delegated the completion of the hia to another governing body under a completely separate plan. this was done to save resources. however, the shift of oversight resulted in a loss of control and became a barrier to community input. for example, the contrast between the lake merritt and i-710 cases demonstrate the variety of outcomes that may result from hias that strive for direct participation. the lake merritt bart hia clearly shows that community representatives – distinct from members of the general public – can control the hia via an advisory committee, leading to a community-centered report and recommendations. yet the i-710 case – an hia requested by activist citizens and community representatives, but then carried out in large part divorced from those who requested it – suggests that initial community control of the hia process does not neatly equate to empowerment or health equity. the decision-support hias show that stakeholder engagement can support health equity even in the case of limited use of participatory engagement strategies. consistent with greater planning social learning iroz-elardo; mcgrath 17 theory, stakeholder engagement in hia elevates the importance of health in policy decisions as a result of deliberation among stakeholders. less dramatic examples of this phenomenon include the hood river and washington county hias. in hood river county, engaging the latino community was a response to professional knowledge that latinos had the least park access in the region. the engagement helped ground the hia in community concerns. it also offered a population, many undocumented with few official rights to democracy in the us, a way to participate in public decisions. however, engaging the latino community did not result in a power shift; the community did not control the hia analysis. a similar assessment can be made of washington county’s direct engagement of citizens who live near the proposed augusta lane bridge. this suggests direct engagement in the form of one or two public meetings dovetails with a broader stakeholder engagement paradigm in hia by providing additional information to hia authors. however, public meetings are not enough to shift control of the hia, much less the target plan, to the community. bureaucratic decision-making can contribute to health equity finally, hias can foster health equity by expanding the issues considered in the decision. use of a broad, comprehensive definition of determinants of health expanded the interests considered in the clark county bike-ped and mcloughlin road safety cases. hia can be used to more fully understand plans and policies with multiple and often inadvertent disparate impacts. for example, in curry county, oregon, housing policies were preventing low-wealth households from improving their housing due to restrictions placed on financing manufactured housing; the hia advocated for a more healthy approach to managing this important contribution of affordable housing stock in the region. many of the health equity gains from hias can be linked to the role that professional knowledge and discretion of hia practitioners played in pursuing equitable impacts. the six-step process and core values of hia explicitly require analysis of the disproportionately impacted populations and vulnerable populations. this prompts hia practitioners to actively seek information that will elucidate potential disparate even if there is no opportunity to collect new primary data about the affected populations. as professionals, individual actors can articulate health equity concerns through spatial analysis, focus on vulnerable populations, and use the social determinants of health to expand the concerns considered under the target plan. social learning creates pathways to health equity while intersectoral collaboration has long been viewed as a benefit of hia (corburn & bhatia, 2007), our analysis of participation connects this collaboration more directly to health equity by theorizing that social learning provides the pathway for achieving equity. the value of social learning, understood as a process of “cognitive enhancement” and “moral development” (bandura, 1977) has long been recognized by theorists of negotiation and urban planning (forester, 1999; healey, 1996/2003; innes & booher, 2010), and social learning has been a documented outcome of engagement strategies in impact assessment projects (webler, kastenholz, & renn, 1995). the present findings demonstrate that cognitive enhancement – learning about the problem and solutions from both your own and other’s perspectives – occurs across hias with a broad range of participation methods and strategies. under the stakeholder engagement paradigm, interdisciplinary learning occurs as members of cities or regions health and planning departments serve on an advisory committee and realize the complementary skill sets of their departments. in the bike-ped plan hia, public health was able to articulate why urban planners should consider and include access to health-promoting resources within an active transportation plan. as an example from an advocacy hia, cognitive enhancement occurred in the lake merritt hia when the six community-based organization representatives extended the scoping phase to better understand how their individual advocacy positions fit with the hia. in the mcloughlin road safety hia, discussion of social determinants of health allowed public health professionals to explain to transportation engineers why an engineering solution did not fully protect, much less maximize, health. while cognitive enhancement results in better understanding of a problem, moral development is the process of moving toward a more collective approach to problem-solving by setting aside one’s narrow personal (or agency) interests. the oha climate hia illustrate moral development as sister agencies (oregon health authority and the oregon department of environmental quality, or deq) moved from initial antipathy to shared understanding; oha’s choice of transportation-related air pollution indicators shifted how the deq conceptualized the health consequences of airborne particulate matter. conclusion the hia community’s avowal of equity as a guiding value has led to calls for hia to empower historically disadvantaged populations through participation in public decisionmaking. when interpreted narrowly, this conception suggests that the ideal hia is one where disenfranchised citizens initiate and control an hia in order to articulate and advance community health interests, thereby increasing health equity. however, a growing body of evidence shows that hia in the us may not be as participatory or empowering as some practitioners wish it might be. at the same time, the evidence presented here suggests that direct participation may not be the only route to realize the democracy and equity in hia. while some articulations of equity in hia (heller et al., 2013) may view less participatory engagement strategies as undercutting community power, our findings are social learning iroz-elardo; mcgrath 18 consonant with broader literature on public engagement. for example, quick and feldman (2011) distinguish participation, or increasing the input (or information) for the decision, as distinct from inclusion, which increases connections among people and issues. thus engagement strategies can be highly participatory with many citizens providing information but do little to expand the ability of that community to engage each other or the decision. this distinction is important to hia practice because poor or misleading participation and engagement quickly becomes tokenism (arnstein, 1969/2005) and may actually harm the very communities the project hopes to engage (quick & feldman, 2011). in this way, hia practice today seems reminiscent of the era of advocacy planning (davidoff, 1965/2003) equity planning (krumholz & forester, 1990) in us cities through the 1960s and 1970s. just as advocate planners provided technical assistance to groups who had been excluded from the “rational planning” process and had little capacity to shift power relations, hia practitioners can provide technical information about determinants of health. this information can be incorporated into the dominant decisionmaking processes and turned over to affected communities to do their own advocacy, creating multiple pathways to promote health equity, as represented in the schematic in figure 4. figure 4: democracy is realized through new pathways between participation and equity however, scholars of urban planning and social change have struggled to understand the complexity of these relationships between state agencies, citizen empowerment, and equity. both advocacy and equity planning have been criticized as mechanisms for placating the aggrieved and diverting precious energy of communities with limited resources, thereby abetting the status quo (piven, 1970). avoiding this type of cooptation of hia practice require that practitioners articulate participation norms in ways that are more concrete than a blanket preference for direct participation. piven’s critique of participatory planning indeed suggests hia practitioners be open to the idea that generating technical information to be used in advocacy by affected populations could provide benefits which would not occur in the same way through an extensive participatory process. just as analytical strategies within hias vary given different purposes, participation should vary depending on the goals of an hia (baker et al., 2012; harris-roxas & harris, 2011). overly rigid definitions of participation elide the contributions made by hias that take a different form than the archetypal community-led hia. this elision is problematic given the institutional infrastructure that can be built through more technocratic decision-support hias. we suggest that a more complete view of hia practice incorporates both the value of direct participation along with the contributions of less participatory hias to foster health in all policies and health equity. that is, the democratizing elements of hia are less about participatory data gathering or community control of the hia and more about expanding the publics and health pathways considered in public decisions. we have illuminated multiple pathways to pursuing health equity and as a result propose that democracy in hia practice be a pragmatic mix-and-match process of aligning goals, assessment methods, and participation in order to move toward the ultimate goal of health equity. social learning iroz-elardo; 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(2014). augusta lane bicycle and pedestrian bridge health impact assessment. hillsboro, or: washington county health and human services, public health division. social learning iroz-elardo; mcgrath 21 acknowledgements the authors are grateful to andrea hamberg for generously sharing her time to discuss the history of the oregon health authority hia program and to the anonymous reviewers for their critique. corresponding author moriah mcsharry mcgrath, phd, mph, msup school of social sciences pacific university 2043 college way, uc #a165 forest grove, or 97116 moriah@pacificu.edu webler, t., kastenholz, h., & renn, o. (1995). public participation in impact assessment: a social learning perspective. environmental impact assessment review, 15, 443-463. http://dx.doi.org/10.1016/0195-9255(95)00043-e white, s., & mcgrath, m. m. (2012). rental housing and health equity in portland, oregon: a health impact assessment of the city’s rental housing inspections program. portland, or: oregon public health institute. white, s., & thorstenson, k. (2014). se mcloughlin boulevard (or 99e) active transportation road safety audit health impact assessment. portland, or: oregon public health institute. world health organization. (n.d.). health systems: equity retrieved june 14, 2016, from: http://www.who.int/healthsystems/topics/equity/en/ social learning iroz-elardo; mcgrath chia staff editor-in-chief cynthia stone, richard m. fairbanks school of public health indiana university-purdue university indianapolis journal manager lyndy kouns, richard m. fairbanks school of public health indiana university-purdue university indianapolis chronicles of health impact assessment vol. 1, no. 1 (2016) doi: 10.18060/21351 © 2016 author(s): iroz-elardo, n.; mcgrath, m.m. this work is licensed under a creative commons attribution 4.0 international license. october 2020 volume 5 issue 1 electric scooters (e-scooters): assessing the threat to public health and safety amber r. comer phd, jd1,2,4, nate apathy phd3, carly waite1, zoe bestmann jd candidate4, jacob bradshaw jd candidate4, emily burchfield jd candidate4, brittany harmon jd candidate4, rebekah legg jd candidate4, star meyer jd candidate4, patrick o’brien jd candidate4, micha sabec jd candidate4, jami sayeed jd candidate4, alexis weaver jd candidate4, lynn d’cruz pt1, stephanie bartlett pt1, mckenzi marchand1, isabel zepeda1, katelyn endri1, john t. finnell md2,5, shaun grannis md, ms2,5, ross d. silverman jd3,4, peter j. embi md, ms2,5 1 1. indiana university school of health and human sciences 2. regenstrief institute 3. indiana university fairbanks school of public health 4. indiana university mckinney school of law 5. indiana university school of medicine abstract objective: to determine self-reported incidences of health and safety hazards among persons who ride rentable electric scooters (e-scooters), knowledge of e-scooter laws, and attitudes and perceptions of the health and safety of e-scooter usage. methods: a cross-sectional survey of n= 561 e-scooter riders and non-riders was conducted during june of 2019. results: almost half of respondents (44%) report that e-scooters pose a threat to the health and safety of riders. riders and non-riders disagree regarding the hazards that e-scooters pose to pedestrians. among riders, 15% report crashing or falling off an e-scooter. only 2.5% of e-scooter riders self-report that they always wear a helmet while riding. conclusions: e-scooter riders report substantial rates of harmful behavior and injuries. knowledge of e-scooter laws is limited, and e-scooters introduce threats to the health and safety of riders, pedestrians on sidewalks, and automobile drivers. enhanced public health interventions are needed to educate about potential health risks and laws associated with e-scooter use and to ensure health in all policies. additionally, greater consideration should be given to public health, safety, and injury prevention when passing relevant state and local e-scooter laws. electric scooters comer et al. 2 background seemingly overnight, rentable electric motorized scooters (e-scooters) appeared in cities around the country. in addition to creating a new form of transportation, they introduce new public health and safety concerns and the need for new laws and regulations (choron & sakran, 2019). currently, more than 50 cities in the united states allow the use of e-scooters (bird, n.d.a; lime, n.d.). although some cities considered banning e-scooters, those that have approved their use since september of 2017, have passed regulations banning e-scooters from sidewalks, setting parameters for the times that e-scooters may be used, and extending “operating while intoxicated” laws to include e-scooters (hawkins, 2019b; hawkins, 2019c; may & hill, 2018; may, 2019; renki, 2019; sikka et al., 2019). the goals of e-scooter regulations are to protect the health and safety of e-scooter riders as well as non-riders, such as pedestrians and drivers. however, questions arise as to whether these initial regulatory attempts substantively respond to the novel morbidity and mortality risks associated with e-scooter proliferation and use. in portland, oregon, a pilot of rentable e-scooters resulted in 176 e-scooter accidents resulting in emergency department (ed) visits during the six-month trial period (portland bureau of transportation, 2019). additionally, in portland, the bureau of transportation reported a high number of complaints related to e-scooter riding on sidewalks with 3% of all injuries during the pilot program deriving from collisions with pedestrians (portland bureau of transportation, 2019). a study in los angeles, california reported 249 ed visits related to e-scooter use during a one-year period, and salt lake city, utah reported 50 e-scooter-related injuries over a 5-month period in 2018 (badeau et al., 2019; trivedi et al., 2019). individuals renting e-scooters from at least one prominent e-scooter vendor (bird) may self-report accidents through their proprietary mobile application. a safety report issued by bird found that their users’ self-reported accidents via their app at a rate of one injury per 27,000 miles ridden on their e-scooters (bird, 2019). the most comprehensive examination of e-scooter injuries undertaken to date was conducted by the centers for disease control and prevention (cdc) in collaboration with the austin, texas public health department (austin public health, 2019). examining both emergency services (ems) and ed visits over a three-month period in 2018, this study reported a total of 192 injuries resulting in a clinical visit. of those injured, two people were non-riders injured by an e-scooter, and nearly half of those injured sustained a head injury (hawkins, 2019a). similar to the cdc study, a recent study published in the journal of american medical association (jama) found that head injuries were sustained by 40% of those injured in an e-scooter accident (trivedi et al., 2019). in addition to reports of injuries, a survey conducted in san antonio, texas found that respondents had concerns about e-scooter safety (city of san antonio, 2019). although there have been several studies reporting injuries related to e-scooter use, and one white paper produced by the city of san antonio exploring attitudes of citizens toward scooters, there have been no studies published assessing the public’s knowledge, attitudes and perceptions of the health and safety of e-scooter use. in order to ensure health in all policies and pass meaningful policies and regulations which support public health and safety, it is important to identify the public’s perception of e-scooter health and safety risks, as well as their knowledge of existing e-scooter laws. this study is the first to report e-scooter rider selfreported incidents of health and safety hazards associated with e-scooter use, knowledge of e-scooter laws, and the public’s attitudes electric scooters comer et al. 3 and perceptions of health and safety issues associated with e-scooter usage. the results of this study will help inform health in all policies. methods a cross-sectional survey of both e-scooter riders and non-riders was conducted in indianapolis, indiana during june 2019 to determine attitudes and perceptions of the health and safety of scooter usage among both e-scooter riders and non-riders. survey design the survey was designed from a review of the available literature and was reviewed for both content and face validity. feedback was obtained from community members regarding question clarity, word choice, missing items, and overall length. the survey was pretested for content validity with possible survey participants. the survey was designed to measure: 1) self-reported incidences of health and safety hazards associated with e-scooter usage; 2) knowledge of local e-scooter laws; and 3) the attitudes and perceptions of the health and safety issues related to e-scooter usage. the survey prompted participants to selfreport information using the responses of yes, no, or unsure. the indiana university-purdue university indianapolis (iupui) institutional review board approved this survey. survey sample participants located in the downtown area of indianapolis, indiana, who were 18 years of age or older and able to read and write english were included in this study. participants under 18 years of age were excluded because they are prohibited from renting e-scooters due to minimum age requirements. survey administration individuals located in downtown indianapolis, indiana during the week of june 10 – 17th 2019, were asked to participate in this survey. the downtown area with heavy foot traffic was selected for survey distribution because e-scooters are primarily available in this location of the city. potential participants were a convenience sample who were approached by research assistants and asked if they would like to participate in the survey. study participants were not offered an incentive for participation. completed surveys were entered and stored in redcap electronic data capture (harris et al., 2009). statistical analysis descriptive statistical analysis was performed to determine participant self-reported use of scooters, scooter safety, knowledge of laws pertaining to e-scooter use in the city, and attitudes and perceptions of the health and safety of scooter use. chi-squares were performed to determine differences between persons who identified that they have ever ridden an e-scooter (riders) and persons who identified that they have never ridden an e-scooter (non-riders). all analyses were performed using r statistical software and the rstudio development environment (r core team, 2014; rstudio, 2015). results in total, 561 individuals were asked to participate in the survey, 329 of those approached agreed to participate, and 232 declined participation (59% response rate). survey participants represented roughly equal numbers of males (n=163, 49%) and females (n=161, 50%) (table 1). the mean age of survey respondents was 32 years of age (c.i. 13.6). the majority of survey takers were white (n=228, 70%), and 21% (n=68) of survey respondents were current college students. the proportion of scooter riders versus non-riders was equal, with 50% of participants (n=162) self-reporting that they have ridden a scooter (scooter riders). among electric scooters comer et al. 4 scooter riders, 34% (n= 54) reported only using an e-scooter once, 15% (n=23) reported using an e-scooter once per year, 30% (n=49) reported using an e-scooter once per month, 17% (n=27) reported using an e-scooter once all survey takers n=329 n (%) scooter riders n=163 n (%) non-scooter riders n=164 n (%) p-value age, years (mean, sd) 32.1 (13.6) 27.9 (10.5) 36.1 (15.1) < 0.001 gender male 163 (48.9) 91 (55.8) 72 (43.9) female 161 (49.5) 68 (41.7) 91 (55.5) prefer not to answer 5 (1.5) 4 (2.5) 1 (0.6) race 0.313 white 228 (69.5) 99 (63.9) 122 (74.8) black 42 (12.8) 22 (14.2) 20 (12.3) other 48 (14.6) 30 (18.4) 18 (11.0) prefer not to answer 10 (3.0) 7 (4.3) 3 (1.8) college student 68 (20.9) 44 (27.3) 24 (14.7) 0.008 undergraduate* 31 (45.6) 21 (47.7) 10 (41.7) 0.745 graduate* 37 (54.4) 23 (52.3) 14 (58.3) college faculty or staff 32 (9.9) 14 (8.8) 18 (11.1) 0.602 ever used a motorized scooter 163 (49.8) ----frequency of scooter use has only used once --54 (33.5) -- once per year --23 (14.8) -- once per month --49 (30.4) -- once per week --27 (16.8) -- once per day --5 (3.1) -- more than once per day --3 (1.9) --per week, 3% (n=5) reported using an e-scooter once per day, and 2% (n=3) reported using an e-scooter more than once per day. e-scooter riders are younger on average (p<0.001) and more likely to be college students (p=0.008) table 1. demographics *percentages are of iupui student respondents electric scooters comer et al. 5 table 2. self-reported scooter safety than non-riders. among e-scooter riders, 15% (n=24) self-report that they have fallen off or crashed a scooter (table 2). of those participants who had fallen off or crashed a scooter, 46% (n=11) report having sustained an injury from the crash, and 36% (n=4) of those who sustained an injury report having sought medical treatment for the injury. only 2.5% (n=4) of scooter riders selfreport that they sometimes or always wear a helmet while riding a scooter, although 38% (n=62) report that they would wear a helmet if it was provided at no cost, and only 19% (n=31) reporting that they knew helmets could be acquired for free through scooter companies. additionally, while rentable e-scooters are intended for use by individual riders, 30% (n=47) of scooter riders report that they have ridden with another person on the same scooter, and 65% (n=211) of all survey respondents (both scooter riders and non-riders) report having seen multiple people riding on the same scooter. on issues related to public safety, 28% (n=90) of all respondents report seeing an unattended scooter parked on a handicap ramp and 72% (n=235) report seeing a scooter parked in a way that obstructs pedestrians or traffic. almost half of all respondents (43%, n=140) reported having seen someone appearing to be intoxicated riding an e-scooter. n (%) fallen off or crashed motorized scooter* 24 (14.8) sustained injury from motorized scooter crash** 11 (45.8) sought medical treatment for injury (of those injured)** 4 (36.4) always or sometimes wears helmet while riding motorized scooter* 4 (2.5) would wear helmet if provided at no cost* 62 (38.3) knows that helmets are provided for free* 31 (19.3) ridden scooter with someone else* 47 (29.7) seen multiple people riding one scooter+ 211 (64.7) seen scooter parked on handicap ramp+ 90 (27.5) seen scooter parked in a way that obstructs pedestrians or traffic+ 235 (72.1) seen someone riding scooter while intoxicated+ 140 (43.1) *of self-reported scooter users **of self-reported scooter users who also reported a crash or fall +of all respondents electric scooters comer et al. 6 among all survey respondents, 38% (n=121) did not know or were unsure if it was illegal to ride an e-scooter while intoxicated (35% of riders, n=56 and 40% of non-riders, n=65) (table 3). all survey takers n (%) scooter riders n (%) non-scooter riders n (%) p-value illegal to ride scooter while intoxicated 0.404 yes 205 (62.9) 106 (65.4) 97 (59.9) unsure 97 (29.8) 43 (26.5) 54 (33.3) no 24 (7.4) 13 (8.0) 11 (6.8) illegal to ride scooter on the sidewalk < 0.001 yes 153 (47.4) 93 (57.8) 60 (37.5) unsure 108 (33.4) 36 (22.4) 70 (43.8) no 62 (19.2) 32 (19.9) 30 (18.8) illegal to ride scooter in the street 0.003 yes 34 (10.5) 15 (9.3) 19 (11.9) unsure 100 (31.0) 37 (22.8) 61 (38.4) no 189 (58.5) 110 (67.9) 79 (49.7) table 3. motorized scooters and the law less than half of respondents knew that it was illegal under local law to ride an e-scooter on the sidewalk (42% of riders and 63% of nonriders). additionally, 42% of all respondents did not know or were unsure whether it was legal to ride an e-scooter in the street (32% of riders and 51% of non-riders). more than half of respondents either agreed (44%, n=142) or were unsure (14%, n=46) whether motorized scooters pose a threat to the health and safety of the people who ride them (table 4). there was no statistical difference between scooter riders and non-scooter riders (p=.052). more than half (60%, n=194) of all participants report that e-scooters pose a threat to the health and safety of people walking on the sidewalk, with non-scooter riders being statistically more likely to report e-scooters as a threat on sidewalks (p<0.001). forty-six percent (n=150) of all participants report that e-scooters pose a threat to the health and safety of people who are driving in their cars. forty-eight percent (n=158) of participants believe that more people should use scooters to get around the nearby college campus or the city of indianapolis, with scooter riders being statistically more likely to agree with the statement that more people should use scooters (p<0.001). the majority of participants (68%, n=220) do not think that e-scooter use should be banned from the city or electric scooters comer et al. 7 all survey takers n (%) scooter riders n (%) non-scooter riders n (%) p-value motorized scooters pose a threat to the health and safety of the people who ride them yes 142 (43.7) 61 (38.1) 81 (49.7) no 137 (42.2) 78 (48.8) 58 (35.6) unsure 46 (14.2) 21 (13.1) 24 (14.7) motorized scooters pose a threat to the health and safety of people walking on the sidewalk < 0.001 yes 194 (59.7) 75 (46.6) 118 (72.4) no 99 (30.5) 64 (39.8) 35 (21.5) unsure 32 (9.8) 22 (13.7) 10 (6.1) motorized scooters pose a threat to the health and safety of people who are driving in their cars 0.011 yes 150 (46.2) 62 (38.5) 87 (53.4) no 150 (46.2) 88 (54.7) 62 (38.0) unsure 25 (7.7) 11 (6.8) 14 (8.6) motorized scooters make you look hip or cool 0.076 yes 65 (20.0) 40 (24.8) 25 (15.4) no 202 (62.2) 91 (56.5) 109 (67.3) unsure 58 (17.8) 30 (18.6) 28 (17.3) more people should use motorized scooters to get around iupui campus or the city of indianapolis < 0.001 yes 158 (48.3) 102 (63.0) 55 (33.7) no 90 (27.5) 23 (14.2) 67 (41.1) unsure 79 (24.2) 37 (22.8) 41 (25.2) motorized scooters should be banned from the iupui campus or from the city of indianapolis < 0.001 yes 54 (16.6) 17 (10.5) 37 (22.8) no 220 (67.5) 130 (80.2) 88 (54.3) unsure 52 (16.0) 15 (9.3) 37 (22.8) table 4. attitudes and perceptions of the health and safety of motorized scooters electric scooters comer et al. 8 the college campus. discussion our findings illustrate that e-scooters may pose a threat to the health and safety of not only those who ride them, but also to persons who are walking on the sidewalk or driving cars. one reason that e-scooters may pose a danger to those who ride them is that riders are not wearing helmets. only 2.5% of people who ride e-scooters report always or sometimes wearing a helmet. prior studies have found that head injuries are one of the most prevalent injuries for e-scooter riders (trivedi et al., 2019). given the danger of head injury associated with not wearing a helmet and the lack of self-reported helmet use among e-scooter riders, public health interventions are needed to increase helmet usage on e-scooters. one possible public health intervention which is being offered by scooter companies is to provide free helmets to scooter riders (bird, n.d.a). although scooter companies offer free helmets to riders, this intervention may merely work to mitigate risk, as only 38% of e-scooter users report that they would not wear a helmet, even though it is recommended by the scooter company and even if it were provided at no cost. additionally, only 19% of participants knew that free helmets were being offered by the e-scooter manufacturer. due to the risk of injury associated with not wearing a helmet, public health interventions need to be pursued to increase the use of helmets among e-scooter riders. the lack of knowledge of the laws pertaining to e-scooter use is another reason why e-scooters may pose a threat to public health and safety. among e-scooter riders and non-riders alike, almost half of all people do not know that it is illegal to ride an e-scooter while intoxicated, or that it is illegal locally to ride an e-scooter on the sidewalk. evidence shows that riding e-scooters on the sidewalk can result in pedestrian injury (sikka et al., 2019). this is concerning, in part because only 47% of e-scooter riders believe that riding an e-scooter on the sidewalk poses a threat to the health and safety of people walking on the sidewalk, whereas the vast majority of non-riders (72%) believe riding e-scooters on the sidewalk poses a threat to pedestrian health and safety. this gap suggests that e-scooter riders do not appreciate the threat to health and safety that their actions pose to those around them. a lack of knowledge or insight into the dangers of riding e-scooters on the sidewalk may lead to more reckless and improper e-scooter use, in part because they do not believe that their behavior threatens pedestrian health and safety. the results of this study suggest that e-scooter riders may be more inclined to ride on the sidewalk because they believe riding e-scooters in the street is dangerous. one way to combat this issue may be to encourage e-scooter riders and align related e-scooter policies, toward using scooters in bike lanes, rather than ride on the sidewalk or in the street. the e-scooter company bird had recently pledged to pay cities to build bike lanes in order to keep e-scooter riders off of sidewalks (schmitt, 2018). both e-scooter rider and pedestrian safety need to be considered when developing laws, ordinances, and infrastructure within cities that allow e-scooter use. another issue with fidelity of the law which may pose a threat to the health and safety of e-scooter riders is the lack of knowledge that it is illegal to ride a scooter while intoxicated. operating while intoxicated (owi) laws apply to e-scooters, and riding an e-scooter while intoxicated may result in the same penalties as operating other motor vehicles while intoxicated. lack of knowledge of the law may result in people riding e-scooters while intoxicated based on a belief that riding an e-scooter offers a “safer” alternative to electric scooters comer et al. 9 driving while intoxicated. such unawareness is concerning because intoxication while riding e-scooters has been linked to severe injuries in other studies (trivedi et al., 2019). the lack of knowledge of both the legality and danger of operating an e-scooter while intoxicated suggest that public health education interventions should be developed to inform the public of these risks. additionally, steps should be taken to enforce the current e-scooter laws in order to protect the safety and health of the public. this study has several limitations. first, this study was conducted in one city and may not be representative of the attitudes, perceptions and experiences of those in other cities related to e-scooter use. second, participants represented a convenience sample and were asked to selfreport information, such as the number of times they have ridden an e-scooter, which may introduce bias in the responses. third, this study sought to measure the attitudes and perceptions of participants at one point in time. it is possible that the responses given by participants may change over time as indianapolis’ approach to e-scooter regulation evolves. lastly, it is possible that the questions about personal safety and e-scooter use could have influenced answers to the subsequent section on e-scooter laws. although further studies are needed to gain a more in-depth understanding of the health and safety hazards associated with e-scooter use, this study is the first to explore rider and non-rider perceptions of the risks posed by e-scooters. conclusion this study finds e-scooters may pose a threat to the health and safety of the people who ride them, to people on the sidewalk, and people in their cars. when considering health in setting policies, the results of this study indicate three things: 1) that riders are engaging in unsafe behaviors and are being harmed on e-scooters; 2) that despite the risks posed by e-scooters, riders are willing to accept them; and 3) that knowledge of e-scooter laws and safe scooter practices is lacking and needs attention. these findings are concerning from a public health perspective as a significant share of riders engage in risky behaviors when riding e-scooters, such as riding without wearing a helmet, riding with multiple people on one scooter, and riding e-scooters while intoxicated. these risky behaviors have been found to result in severe injury, such as head injuries in other studies. in our study, 15% of scooter riders report falling off or crashing their scooter, with 36% of injury-causing crashes requiring medical attention. these findings are of additional concern because indianapolis has recently approved two more e-scooter vendors, lyft and jump, to bring more rentable e-scooters into the city, although the timelines for e-scooter deployment has not yet been decided. to reduce the risk to public health and safety, we recommend increasing public health interventions to educate e-scooter riders about safe and defensive e-scooter use, potential health and safety risks (to riders and non-riders) associated with e-scooter use, as well as the specifics of local laws and policies. additionally, stakeholders such as city and state law makers need to consider the threat to public health as well as the safety of e-scooter riders, non-riders using local sidewalks, and drivers when passing relevant laws. electric scooters comer et al. 10 references austin public health. 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(2018). scooter company bird offers to pay cities to build bike lanes. streetsblogusa. retrieved from https://usa.streetsblog.org/2018/08/02/scooter-company-bird-offers-to-pay-cities-to-build-bikelanes/. sikka, n., vila, c., stratton, m., ghassemi, m., pourmand, a. (2019). sharing the sidewalk: a case of e-scooter related pedestrian injury. american journal of emergency medicine. doi:10.1016/j.ajem.2019.06.017 trivedi, t.k., liu, c., antonio, a.l.m., wheaton, n., kreger, v., yap, a., schriger, d., elmore, j.g. (2019). injuries associated with standing electric scooter use. jama network open, 2(1), e187381. doi:10.1001/ jamanetworkopen.2018.7381 corresponding author amber comer, phd, jd assistant professor of health sciences indiana university 1050 wishard blvd. rg, 3034 (317) 278-1026 comer@iu.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 5 issue 1 (2020) doi: 10.18060/24194 © 2020 author(s): comer, a.; apathy, n.; waite, c.; bestmann, z.; bradshaw, j.; burchfield, e.; harmon, b.; legg, r.; meyer, s.; o’brien, p.; sabec, m.; sayeed, j.; weaver, a.; d’cruz, l.; bartlett, s.; marchand, m.; zepeda, i.; endris, k.; finnell, j.; grannis, s.; silverman, r.; embi, p. this work is licensed under a creative commons attribution 4.0 international license conflict of interest statement: this project and resulting manuscript was not grant funded nor was it funded in any capacity as it resulted from a class research project conducted at indiana university. none of the authors have any conflicts of interest. financial disclosure: there are no financial disclosures from any authors. https://usa.streetsblog.org/2018/08/02/scooter-company-bird-offers-to-pay-cities-to-build-bike-lanes/ https://usa.streetsblog.org/2018/08/02/scooter-company-bird-offers-to-pay-cities-to-build-bike-lanes/ mailto:comer%40iu.edu?subject= november 2023 volume 8 issue 1 letter from the editor i welcome to the fall 2023 chia issue. this issue has an article about using an hia to improve the built environment to improve activity, decrease bike injuries and decrease obesity in nevada. another article used snapchat and uber’s social media platforms to examine the health impact on lifestyle behaviors and promoting healthy choices. we also included the farewell message with permission from ruth lindberg, the director of the health impact project at pew charitable trust. i would also like to highlight that the robert wood johnson foundation and pew charitable trust hia database has now moved to the institute for people, place and possibility through community commons. access to the database can be found at https://hia.communitycommons.org/. the website can be used for hia and hiap development. it includes health notes, briefs, visualizations and the mapping of health impact assessments. you can browse the hia by vital conditions, priority populations and other factors. we would like to encourage those doing hias and hiap work to please consider submitting an article to share your findings, processes and methods. thank you for all that you do to promote health as a part of community decision making and policy development. sincerely, cynthia stone, drph, rn chronicles of health impact assessment journal editor https://hia.communitycommons.org/ june 2018 volume 3 issue 1 health impact assessment of the construction of hydroelectric dams in brazil diego velloso veronez, md; karina camasmie abe. phd; simone georges el khouri miraglia, phd abstract: background: brazil´s dam-building plans in amazonia imply substantial environmental and social impacts. this study evaluates the relationship between social, environmental, economic aspects, and impacts on the health status of the population of rondônia, brazil, due to the implementation of the jirau and santo antônio hydroelectric dams. methods: a qualitative and retrospective health impact assessment (hia) is used to focus the study objectives. the information is arranged in a structured diagram that enables an outside reviewer to assess the aspects/ impacts relationship derived from the construction of the dams. this comes with outline recommendations for health risk management that can orient national health authorities. we selected a narrative review synthesis as the most appropriate approach for the study. results: the diagram network was built making it possible to analyze the impact changes caused by this enterprise in the health sector. additionally, the model will serve in the implementation of a complete hia approach in an attempt to quantitatively map the impacts and to propose recommendations. conclusion: the diagram pathway has been useful as an important tool for assessing a broader view of direct and indirect impact categories, serving as a basis for further evaluations and studies. this effort is very important for highlighting the priorities in the public policy decision-making process, serving as a basis for the brazilian health system. 11 health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 12 introduction brazil is undergoing a rapid demographic expansion and intensive development process, supported by the implementation of major infrastructure projects in the country to facilitate the development of the national territory (brasil 2013; 2014). to ensure the country’s infrastructure and economic growth in the face of worldwide economic uncertainties, the brazilian government created the growth acceleration program (programa de aceleração do crescimento pac) in its first phase in 2007, which has since promoted the planning and execution of major social, urban, logistical, and energy infrastructure in the country (brasil, 2013). currently, the pac is in its second phase, which started in 2010, in which investments are directed towards the energy sector with the construction of large dams, such as the jirau (9° 15′ s 64° 38′ w) and santo antônio (08° 48′ s 63° 56′ w) dams, both located on the rio madeira in the municipality of porto velho in the state of rondônia (brasil 2013). in the construction of hydropower plants, financial resources are mobilized from the public and private sectors through consortia; furthermore, many inputs, such as labor, machinery, equipment, and the construction materials needed for the work, are required. this mobilization often disfigures the region where the project will be installed, leading to impacts1 with cross-border dimensions (bortoleto, 2001; brasil, 2013; cruz and silva, 2010; fearnside, 2014; rocha, 2014). in large enterprises, the human and ecological impacts must be considered. according to world health organization, health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (who, 1946). to demonstrate the relationships arising from works of large enterprises and the health of the affected population, the need to compile evidence of health impacts and to represent them in an interconnected manner has been identified. an understanding of the impacts of major projects requires socioeconomic and environmental studies, which should be presented according to the relevant legislation (conama no 001/86) to minimize any possible negative impacts in the periods prior to the project, during the construction of the project, and after its completion. thus, it is possible to perform a proper management of the impacts of the project (conama, 1986; cruz and silva, 2010). to minimize the negative impacts and maximize the positive impacts, any project in brazil that will potentially cause an environmental impact must undergo the licensing process, according to conama resolution no. 01/86 and conama resolution no. 237/97. resolution 01/86 defines the concept of an environmental impact assessment, its criteria, its guidelines, and establishes the mandatory environmental impact assessment (eia) and environmental impact report (eir) to exemplify the activities subject to the eia/eir. these reports have less formal language and represent key aspects of the eia, and they are presented at public hearings to all stakeholders (cunha, 2008). however, the eia/eir does not adequately address the possible impacts on the health of the population and the health system (increased demand for medical care) based on the type of project because all constructions of large enterprises result in positive or negative impacts that directly reflect the population’s wellbeing (brasil, 2014). faced with this problem in the conceptual approach of the eia/eir, the world health organization (who) and the national health service of the united kingdom (uknhs) consider that numerous activities of the public and private sectors produce health consequences (who, 2002). due to the fact that the health system can be overloaded by diseases provoked by environmental impacts, in an attempt to improve the health care approach in environmental impact studies, a new method of impact assessment for health has been proposed, the health impact assessment (hia). this methodology, which officially appeared in 1999 in a document called 1 environmental aspects are a result of activities, products, or services that can interact with the environment, causing or possibly causing environmental impacts, whether positive or negative. environmental impacts are any change in the physical, chemical, and biological properties of the environment resulting from human activities(4). health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 13 the gothenburg consensus, is defined by the who as a set of tools and procedures to judge policies, plans, or programs by systematically evaluating the potential effects on public health (who, 1999). the hia is an established method in countries such as canada, the usa, australia, and the member states of the european union. this tool allows one to evaluate a project and its potential health impacts and propose mitigation actions for health promotion (brasil, 2014; winkler et al., 2013). in brazil, the concept was disseminated in 2014 by the ministry of health of brazil with the publication of a national guide aimed at transferring the hia methodology in the country. its application has been encouraged in environmental licensing, aiming at large enterprises that could cause health impacts. the challenge faced by the ministry of health is the integration of the hia and eia/eir (brasil, 2014). considering this scenario, this study aims to identify and organize the direct and indirect health impacts and their determinants due to the environmental alteration caused by the construction of the hydroelectric dams on the madeira river in the state of rondônia, brazil, considering national and international available data and references. we provide a review of various health effects associated with environmental, social, and economic aspects to provide a systematic, integrated, and clear overview of both the aspects and impacts with regard to the scope of the problem detailed in a network schematic diagram. recommendations are proposed for the health authorities to pursue the constructors to seek means to protect the public health associated with the construction’s impacts in the region and to obtain bases for health policy makers. methods a qualitative and retrospective hia was used to focus the study objectives. rapid assessment was performed because of shortages of time and money as well as due to the difficulties of accessing data on projects and their construction. the hia steps conducted in this study were screening, scoping and appraisal (partial). the hia relied on secondary data and expert informants and interviews to obtain essential qualitative data. the information was arranged in a structured diagram that enables an outside reviewer to assess the aspects/ impacts relationship derived from the construction of the dams and to identify gaps that require further study and intervention. the product is a diagram network that enables one to easily visualize the relationships among the aspects and impacts associated with the environmental, social, and economic consequences of the dams’ construction resulting in public health effects. this comes with outline recommendations for health risk management that can orient national health authorities towards indicating the steps required to formulate specific management plans through negotiation with local stakeholders. we selected a narrative review synthesis as the most appropriate approach for the study because studies regarding health impacts derived from hydroelectric dams have been conducted in diverse types of traditional research, with widely different methodologies and often varied but nevertheless related research questions. this heterogeneity makes it difficult to apply a more traditional systematic review approach. the main search engines used to source the literature were pubmed, scientific electronic library online, latin american and caribbean health sciences (lilacs), and google. the search was conducted using the terms “hydroelectric” or “power plants” and “brazil” in combination with the terms “impact” or “effect”, in english, portuguese, or spanish, without time limits. moreover, the date of the last search was august 2016. the references of all of the retrieved original articles and reviews were assessed for additional relevant articles. international guidelines, government sites, grey literature, and expert opinions were also consulted for data and additional references. the articles’ languages considered in this search were english, portuguese, and spanish. the reading of the documents and articles was performed to refine the selection, leaving only those that addressed the issue related to the research objectives. the main articles and retrieved documents were reviewed with the focus on the diagram network impacts of the construction. after collecting the information, a diagram network health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 14 linking the environmental, social, and economic aspects and impacts was built using the cmap software (developed by the florida institute for human & machine cognition). study area the state of rondônia (ro) is located in the northwest of brazil and covers an area of 237,590.543 km2 with 52 municipalities, and it is bordered by the states of amazonas to the north, mato grosso to the east, acre to the west, and the republic of bolivia to the west and south (figure 1) (ibge, 2015). fig 1 location of the state rondônia in brazil. source: prepared by the authors with the arcgis online software both hydropower plants are located in the state of rondônia on the madeira river, in the municipality of porto velho. the first is the santo antônio hydroelectric dam, which has a reservoir with a flooded area of 421.5 km2 at its maximum level and an installed capacity of 3,568 mw, located at a distance of 8 to 10 km from the urban area of the municipality of porto velho (ibge 2015; santo antonio energia, 2016). the second hydroelectric dam is the jirau dam, which has a reservoir with a flooded area at its maximum level of 361.6 km2 and an installed capacity of 3,750 mw. this plant is on the madeira river 120 km from the urban area of porto velho. the work of the santo antônio plant began in the second half of 2008, whereas the construction of the jirau plant began in mid-2009. both began partial power generation from 2012 (ibge, 2015; esb, 2016). results baseline assessment the state of rondônia, whose capital is porto velho, is located in the north of brazil, bordering bolivia. this state represents 2.8% of the country, with an area of 237,765 km2, and contains approximately 0.8% of the brazilian population, with 1,562,409 inhabitants in 2010 (hacon and others 2014). porto velho is a municipality that has an area of 34,090 km2 and a population of 428,527 inhabitants (cruz 2010). the state of rondônia has a predominantly young population and has also recently seen an increase in its population over the past 60 years. between years 2000 to 2010, rondônia saw an increase in the number of people who self-identified as colored or black, brown, and asian; maintained its indigenous population; and saw a decrease in the share of people who self-declared as white in 2010 compared to the data from 2000. in 2010, the black or brown population in rondônia represented 62.5% of the total population, whereas in brazil, this ratio was 50.7%. a relevant piece of information is a 717% increase in the number of asian people in rondônia between 2000 and 2010, increasing from 0.2% to 1.4% in the population distribution and suggesting an intense migratory movement of this portion of the population. the per capita household income of rondônia increased by slightly more than 31% from 2000 to 2010, going from 78.8% of the national income to 84.3%, supported by an approximately 50% drop in the unemployment rate (from 9.88% in 2000 to 5.31% in 2010). in both census years, the unemployment rate in the state of rondônia has remained below the national rate in brazil, whereas the literary rate has remained very close. the rondônia vehicle fleet grew by 330%, from 0.6% of the brazilian fleet by 0.8%. life expectancy at birth for both men and women and for the total population in rondônia remained below health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 15 the brazilian average and showed a small increase in the period, rising from 69.1 years in 2000 to 72.1 years in 2010 (ibge census c). with regard to the existing health establishments in the state and in the capital of porto velho, there was an increase in the number of health facilities, particularly after 2010. however, the number of establishments has not grown in proportion to population growth, and greater attention is required when taking into consideration access to health services and the conditions of service and assistance. the madeira river, which passes through the state of rondônia, belongs to the madeira river basin, which is the most important basin in the state and extends far beyond its limits within the lands of brazil and the republic of bolivia, occupying an area of 1,244,500 km2. the hydroelectric dams of santo antônio and jirau on the madeira river, both in the municipality of porto velho, have a total installed capacity of 7,318 mw. the two projects cost an estimated r$ 18.4 billion. the madeira river, due to its importance has tributaries in bolivia, peru, acre and rondônia. this river is the main tributary of the amazon (downstream), both in volume of water and sediments (de souza moret and guerra, 2009). several irregularities were verified during the dams’ construction, such as the change of dam axis of the jirau unit without the preparation of specific studies required by the environmental legislation, no study was presented on the impacts in the communities downstream of the plant. moreover, there was no mitigation measures regarding the restructuring of the fish spawning area, compromising local and traditional feeding based on fishing, due to decrease of fishing areas (furnas et al., 2005). in addition, the eia/eir states that there would be no impact on indigenous lands (furnas et al., 2005), which is false, since the kaxarari indigenous communities in the extreme region of katawixi, on the upper candeias river, on the karipuninha river, in alto jaci and jacareuba on the mucuinnão river (who live less than 20km from the hydroelectric construction) were not reported in the eia/eir and consequently does not present any assessment data or monitoring of the effects affected by the construction (moret and guerra, 2009). besides that, during the construction only 1,500 workers would stay as permanent workers. between the first and third year would be around 15,000 contracted workers and, at the peak of the work, there will be the hiring of up to 20 thousand workers for only 3 months (moret and guerra, 2009). unemployment itself is detrimental to health and has an impact on health outcomes, for example, increasing mortality rates, causing physical and mental ill-health, and greater use of health services (mathers and schofield, 1998). this shows the importance of exposing and gathering the health determinants, sometimes even unanticipated during the construction of the plants, in order to make it possible to mitigate negative impacts on future infrastructure works. network of aspects and impacts to begin a systemic analysis of the aspects and impacts caused by the jirau and santo antonio hydroelectric dams in rondônia, this paper notes some of the positive and negative impacts related to all phases of the design and construction, showing the relationship between an aspect and an impact through a macro-systemic view. table 1 shows the main potential aspects and impacts observed during the construction of hydroelectric plants. health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 16 processes that induce impacts resulting actions impacts/aspects reference construction site installation occupation of land and changes in land use, deforestation, slash-andburn, and floods elimination of flora and fauna; microand macro-climate change; proliferation of human infectious parasitic diseases. guerra and carvalho 1995. cunha 2008. sanches and fisch 2005. alves and justo 2011. mobilizing communities (riparian, indigenous, and others) and changes in fishing activity guerra and carvalho 1995. alves and justo 2011. rocha 2014. human exposure to mercury and heavy metals lacerda and malm 2008. almeida et al. 2005. luca, 2012. cross-border impacts marengo 2008. recruitment of labor rapid population growth and urban development unplanned territorial occupation, volatility of real estate values, loss of cultural heritage, restructuring of preexisting economic activities, disorderly population growth, unemployment, slums, social marginalization. cruz and silva 2010. rocha 2014. need for expansion of health, transportation, and education infrastructure cruz and silva 2010. franco and feitosa 2013 increased vehicle fleet and air pollution, increased incidence of cardiorespiratory diseases on urban population, increased stress and greenhouse gases. queiroz and motta-veiga 2012. fearnside, 2005a increased noise and number of traffic accidents on urban population expert analysis table 1. processes that induce impacts and actions and impacts/aspects resulting from the construction of hydroelectric dams in brazil health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 17 increase of population (local and migrant) increased income greater access to the consumption of alcohol, drugs, and prostitution, leading to violence and social exclusion queiroz and motta-veiga 2012. increased tax collection expert analysis population lifestyle change due to the purchase power increase queiroz and motta-veiga 2012. change in eating habits, increase in unhealthy food outlets, increasing obesity queiroz and motta-veiga, 2012 increase in prostitution increase in sexually transmitted diseases expert analysis increase in communities and social conflicts inequalities and social conflicts, increased drug use expert analysis increase in neuropsychiatric disorders expert analysis delay in work completion elevated cost of the work worker turnover, fluctuation in workers’ incomes expert analysis start of plant operation reduced supply of unskilled jobs and increase in skilled labor decrease in income and unemployment; increased social conflicts, health impacts of unemployment expert analysis increase in national electricity supply socioeconomic development, increased affordability of energy expert analysis global impacts population increase increased costs in the health system expert analysis change in the population’s quality of life improved regional and national infrastructure expert analysis territorial development expert analysis in figure 2, one can observe the link between environmental areas (highlighted in green), health areas (red), social areas (white), and economic areas (gray). this figure is divided into quadrants to facilitate viewing and understanding during the explanation. health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 18 fig 2. network of aspects and impacts. health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 19 the first stage in the construction of a hydroelectric dam is the installation of the construction site, which, in our study, started in the second half of 2008 and provided changes in the installed location. these changes can be observed in quadrants 1 and 2 in figure 2. in quadrant 1, it appears that the occupation of the land can lead to a change in land use due to deforestation and slashand-burn practices. this can cause the elimination of the diversity of flora and fauna. due to slash-and-burn practices, an increase in the incidence of respiratory diseases may occur in the population caused by the emissions of the generated pollutants (dominici et al., 2006). by analyzing quadrant 2 in figure 2, the flooding of areas for water storage purposes by the plant as well as other potential regional flooding due to the change in land use (observed in quadrant 1) and the installation of the construction site can be observed. this impact can cause the expropriation of areas by relocating the local riparian population, which is mainly composed of fishermen, indigenous people, and other population groups, to other locations. this way of displacement deprives people of their means of production and shifts them from their traditional ways of life. flooding in the riverbed can significantly change fishing activity and the life of the riparian community, which is often completely dependent on fishing for its subsistence. other likely impacts are the proliferation of infectious parasitic diseases and community exposure to heavy metals. for example, mercury, released by erosion and ingested through water use and fish consumption, can trigger diseases linked to bioaccumulation, including neurotoxicity and loss of motor control and other health problems (passos and mergler, 2008). in quadrant 3 of figure 2, a probable population increase is observed due to the need for labor to start the project, which can generate an exacerbated migration of human resources to the construction site installation. the vast majority of this migrant population consists of direct and indirect workers (contractors) of projects that contribute to unplanned land occupation, with an urban growth beyond that tolerated by the city (moret and guerra, 2009) thus, there may be the expansion of poor communities with inadequate housing conditions due to the housing demand generated by migration. in many cases, these are areas that lack basic sanitation and with social conflicts, including indigenous lands, leading to the social exclusion of the population or the individuals who live in the community. another fact is that this change in the place brings a loss of cultural identity, leading to a decrease in tourism in the region and, consequently, lost revenue. this scenario causes a change in the price of real estate or the appreciation of some areas over others (furnas et al., 2005). another change in the population's life is the increase in income provided by the supply of employment. this increase in income boosts the purchasing power of the local population, allowing access to goods and services that improve the quality of life. however, possible negative aspects consist of a higher consumption of alcohol and drugs, which also leads to increased prostitution and violence, producing direct effects on the population's health and wellbeing, such as psychological diseases, sexually transmitted diseases, fractures, and trauma caused by violence. traumas are also accentuated due to traffic accidents, as noted in quadrant 4. the increase in population attracted to the region affects the morbidity and mortality rates of non-communicable diseases, especially those of external causes, such as accidents and violence (silveira, 2016). this effect can have several reasons, among them comes from the change in behavior in the population because the increased income begins to consume a greater number of goods and services, notably the acquisition of cars and motorcycles, in addition to the expansion of industrial production to meet the need for transportation. health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 20 this increased demand can cause environmental consequences, such as a greater generation of solid waste and atmospheric emissions. atmospheric emissions are the result of the increased vehicle fleet and the increase in industrial production because the burning of fossil fuels releases gases into the atmosphere that are harmful to health. consequently, there may be an increase in the incidence of respiratory diseases in the population, such as pneumonia, bronchitis, emphysema, asthma, cardiovascular ischaemic diseases, and cancer, which are diseases commonly associated with air pollution (kampa and castanas, 2008; abe and miraglia, 2016). in addition to these diseases, it is also possible to trigger stress and obesity due to decreased physical activity, and pollution exposure (madrigano et al., 2010). additionally, in quadrant 4 in figure 2, one can observe the need for infrastructure in the state of rondônia, such as roads, avenues, streets, bus terminals, basic sanitation, and others to bring an improvement in people's quality of life. another impact in the increase in the fleet, according to expert analysis, is the generation of noise for residents who live in the vicinity of roads, increasing the morbidity associated with stress. a transversal fact that typically occurs is the delay in the completion of the work (quadrants 3 and 4 in figure 2), which occurs due to factors such as the lack of raw materials, strikes and absenteeism by employees, financial resources, and environmental conditions. all of these factors increase the cost of the work and may lead to dismissal. by analyzing quadrant 5 of the network of aspects and impacts, one can verify the global results of the operation of the hydroelectric plant, which can be positive or negative. the positive results are the increase in quality of life in the country due to higher energy availability and increased purchasing power. the negative results include an accelerated migration, increased health demand in both the public and private network, and increased demand for education, which served a certain number of people prior to the project installation and must meet an increased demand from people but with the same infrastructure after the installation. discussion the socio-environmental impacts from the installation of hydroelectric power plants have received increasing attention from researchers and the media in both the national and international conjunctures. the problems arising from the implementation of these works, both social and environmental, are broader than imagined. in this sense, this is the first time, through an extensive bibliographical survey, that the direct and indirect health impacts of the population, derived from hydroelectric projects, have been gathered in brazil. these effects were addressed in a systemic and networked way, showing the interconnections between environmental effects and people's health. the diagram network impacts elaboration is an efficient and structured method to begin an hia and facilitates the reading of the various impacts and their correlations, allowing the implementation of mitigation actions (policies and actions) at the source, preventing a collapse in the health system. in this case, the effects were analyzed retrospectively, and the experience gained from these analyses will serve as a substrate for future projects on the same topic (harris, 2007; harris et al. 2007). to build the diagram network impacts (figure 2), from the starting point, there were premises that facilitated the understanding of the correlation of the wide range of existing variables, their causes, and the ultimate effects on public health (bortoleto, 2001; guerra and carvalho, 1995; queiroz and motta-veiga, 2012). the objective of this study was to demonstrate the possible consequences of the hydropower project health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 21 by creating a matrix of interconnected aspects and impacts, called the network of aspects and impacts. the target study population was the riparian, urban and indigenous population. nothing in the literature, in which there is a broad view and the dynamics of changes caused by the implementation of a project of this size, similar to this network, has been found. this view is pioneering and allows both a global and a specific analysis of existing problems or potential damage due to the changes stemming from an intervention. the importance of creating a holistic view is noted by wehnham (2011), who describes the importance of a multi-sectorial vision, including sectors such as transportation, energy, and the environment, aiming to understand the health consequences (wernham 2011). the network of aspects and impacts presents a multisectorial vision. this is noted from the installation of the construction site, which causes initial impacts such as the occupation of land and changes in land use through deforestation and slash-and-burn, thereby eliminating the flora and fauna (lerer and scudder, 1999). studies in australia, which has more than 446 hydroelectric dams, show that dams and weirs affect the fluvial fauna and flora (teodoro, 1995, kingsford, 2000, thoms and walker, 1993) and that the ecological impacts on lowland flooded areas are still poorly understood because habitat loss may have widespread impacts on native fish and waterfowl. associated with road construction and the urbanization of the area, one can observe that there is the loss of native habitats, causing deleterious effects on the population of bees, birds, animals, and riparian populations as well as a significant change in eating habits, with most food being purchased in nearby cities rather than produced locally or collected (schmidt 2011). it results in the loss of access to traditional means of life, including agriculture, fishing, livestock, and plant extraction (cruz and silva, 2010). this leads to microand macro-climate change, which, combined with previous environmental changes, exacerbates the proliferation of infectious parasitic diseases for humans (alves and souza 2011; cunha 2008; guerra and carvalho 1995; sanches and fisch 2005). in addition, silting and sedimentation in the soil due to the construction of the dams have affected the water quality of the region of the enterprise, increasing the eutrophication phenomenon, damaging the fauna and the aquatic flora of the reservoir and, with this, the quality of the water of this region, which may constitute not only an environmental and economic problem but also a public health one (carneiro and rubin, 2007). the increase in vector-borne diseases due to the construction of hydroelectric dams is a recurring problem and was also reported during the construction of the dam in turkwel gorge, a semi-arid region in kenya, which was completed in 1994 (renshaw et al. 1998). since then, concerns about the environmental and health impacts have been reported, and authors have noted the proliferation of the main vector of malaria, plasmodium falciparum, near the reservoir of the hydroelectric plant (pantoja and de andrade, 2012). schistosomiasis was also an endemic disease in kenya, but authors suggest that there may be a high risk of an increase in cases of schistosomiasis due to the population migration to the construction site. this risk has also been identified for leishmaniasis. nomadic herdsmen, fishermen, and farmers have been identified as high-risk groups for these diseases (renshaw et al, 1998). in our study, the threat of the proliferation of vector-borne diseases during the construction of large hydroelectric projects in tropical regions is also a reality and impacts the local riparian population, including the indigenous population of rondônia. during the construction of the rosal dam, in south eastern brazil, authors have revealed the potential in the area for the transmission of malaria, schistosomiasis, and cutaneous leishmaniasis (rezende et al, 2009). among the infectious parasitic diseases, the researchers involved in data collection in the health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 22 hydroelectric dam in kenya also identified a risk of an outbreak of the disease known as "rift valley fever", a viral disease transmitted by mosquitoes, because the construction site of the hydroelectric dam has a combination of people, water, animals, and mosquitoes that facilitate a virus outbreak (renshaw et al, 1998). in brazil, there is also the risk of outbreaks of mosquitoborne diseases, specifically dengue, yellow fever, and malaria, which are endemic in the amazon region, where hydroelectric plants on the madeira river are installed (britto, 2007). the change in land use is also a by-product of floods that occur due to the plant, which has resulted in the mobilization of riparian communities, changing people's way of life (guerra and carvalho, 1995; rocha, 2014). the population flows that are configured from the construction of the hydroelectric plants usually occur through two processes in the amazon: the search for territories of contingents looking for work that come to occupy this area and that of lands’ desocuppation, marked by the expropriation of the population of the areas of influence of the reservoir. this results in a behavior of migratory flows and refluxes, with no sustainable convergence of public policies and investments (cavalcante et al. 2011). in canada, the construction of the la grande hydroelectric complex, known as the james bay project, in quebec spurred rapid population growth and the need for housing and infrastructure, which contributed to the expansion of the construction industry in nearby villages and the growth of public services, driving business activity (senécal and égré 1999). however, as with other projects involving the displacement of people, there are always positive and negative aspects because, despite a marked improvement in the quality of life in the new location, several dozen people refuse to leave the premises and move, especially senior citizens who are forced to move due to the construction of the dam where they live. these people seem to experience a sense of loss, which may result in health problems or depression (senécal and égré 1999). another affected community in the amazon region is the indigenous population, which, in addition to removal, undergoes the process of loss of indigenous culture. during the construction of the lajeado hydroelectric plant in the state of tocantins in northern brazil from 1996 to 2001, there was an indigenous environmental compensation program to mitigate the social and environmental impacts of construction on the 3,000 indigenous people from the xerente tribe, who were located a few kilometres downstream of the dam. although there was a mitigation program, the history of indigenous people with so-called "nonindigenous" people has repeatedly been marked by violence and the struggle for land since the time of missionaries, prospectors, and settlers, causing great concern among the heads of tribes who were led to believe in the government programs which announced the advantage of the hydroelectric for getting progress and they had to accept it. in this sense, it caused a great migration of indigenous peoples (hanna et al. 2016; de paula 2000). this clearly shows the importance of analyzing cultural and social aspects when addressing any project. moreover, it is reported in a recent study, that the indigenous chief knew the undesirable side effects that the proximity of the dam construction would bring to his people, for example, the increase in prostitution, alcoholism, the arrival of new diseases, the invasion of xerente land due to the proximity to the construction site, and urban expansion, bringing associated impacts such as roads and noise (hanna et al. 2016). other impacts can be noted in the urban population due to the rapid progress of the city and the increase in the population over a short period of time. according to rocha (2014) and cruz (2010), rapid population growth causes unplanned land occupation, which results in the volatility of real estate values and the loss of cultural heritage, with the degradation of local history in contrast to development (cruz and silva, 2010; rocha, 2014). health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 23 urban development creates a need for the state and municipalities to expand infrastructure to meet the burden on health, transportation, education, and sanitation systems generated by the population growth (cruz and silva 2010; franco and feitosa 2013). due to the large inflow of workers to the construction site, it is common for the basic sanitation infrastructure to be absent or poor, particularly in developing countries, hindering personal hygiene actions and contributing to outbreaks of diseases that are transmitted by poor sanitation, such as diarrhea and cholera (renshaw et al. 1998). the inflow of workers is one of the factors that is felt the most by the local population and was also found in a study on the hydroelectric plant of lajeado in the state of tocantins in northern brazil. the city of lajeado was full of "people from the outside"; according to anecdotal reports at the time, the city had doubled in population (araújo 2003). next to this plant, the city of porto nacional was also affected by the construction of the dam, starting with the flooding of an old and famous beach and sections of a traditional avenue that had mansions owned by old families in the city. due to submersion by the dam, more than 50 of these mansions had to be demolished. the natural beach was often visited by tourists from various regions of the country and generated a significant income for the city (araújo 2003). the year after the construction of the dam, there was the inauguration of a tourist complex on the banks of the dam, including a new avenue, sports courts, a go-kart racetrack, and an artificial beach, to reduce the impact generated by the loss of tourism and to boost new tourism (araújo 2003). unfortunately, it was reported that, a few months after the opening of the tourist complex, the water from the dam was of poor quality and the beach needed to be interdicted to take appropriate action (araújo 2003); thus, there was a decrease in tourism, which was an important source of income, in the region due to poor infrastructure and sanitation. during the construction of the jirau and santo antônio hydroelectric dams, there was also an std increase among the regional population, which is very worrying due to the proximity of the plants to the urban area of the state capital. prevention and awareness campaigns about stds are an alternative suggested by several authors (renshaw et al. 1998) because these cases overwhelm the local health service and reduce the population's quality of life. the change in the population's lifestyle caused by urbanization and the increase in population is also a reflection of increased income. on one hand, increased income may allow access to better health services, however, on the other hand, it may have permitted greater access to the consumption of alcohol, drugs, and prostitution, leading to violence and social exclusion and resulting in direct health effects among the population (queiroz and mottaveiga 2012). construction workers are a vulnerable community because they often live apart from their sexual partners, but they have a sufficient income to pay for sex workers. in this study, there was an increased rate of stds in areas where construction sites are installed, and this event was also observed in the study by renshaw et al (1998), who identified a gonorrhea outbreak during the construction of the turkwel gorge hydroelectric plant in kenya. the construction of a dam has the effect of submerging both wetlands and dry areas and may include rivers, lakes, and nearby towns. in a study after the construction of the rosal plant in brazil, it was reported that the most significant impact during the construction phase was the increase in temporary residents due to the influx of workers. the increased population involved the risk of introducing infectious agents, in addition to resulting in increased disturbances in the environment, waste production, and wastewater. in the operational phase of the plant, the authors suggest that the greatest impact was the formation of the lake and the departure of residents and workers from the area (rezende 2009). the migration of large numbers of workers into the region, the displacement of local residents, and the change in flora and fauna are the main factors for the loss of local culture and health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 24 identity, which may result in a wide range of social and environmental impacts on communities, such as intragroup conflicts and changes in agricultural practices and diets (hanna et al 2016). according to alves and justo (2011), the change in the water flow rate and riverbed flooding significantly alter fishing activity and the life of the riparian community, who are often completely dependent on this activity (alves and justo 2011). changes in the physical environment trigger a higher exposure to heavy metals, especially mercury. this element has high natural concentrations in the soil, which are absorbed by the population when using the water and fishing resources for their needs (lacerda and malm 2008, almeida et al. 2005). according to the who, the maximum allowed concentration of mercury is 50 parts per million (ppm) in water, and in the amazon region, the riparian population has a concentration of 70 ppm in their urine, creating a health risk of mercury poisoning (luca, 2012). the fear of intoxication can cause changes in the diet, passing to the consumption of industrialized products, related to the indices of diabetes and obesity. this change in eating habits has had an economic and cultural impact, as well as not providing a connection with culture and a connection with the land. in addition, the indigenous population presents less life expectancy and face risks of obesity and chronic diseases (queiroz and motta-veiga, 2012). with urban development, there is also an increase in the vehicle fleet to meet the population's needs. however, this increase contributes to air pollution, with an increase in cardiorespiratory diseases in the population, which are commonly associated with air pollution (abe and miraglia 2016; saldiva et al. 1995; veronez et al. 2012). dwellings near roads or highways may also cause health problems related to air pollution. a recent study in beijing suggests that longterm exposure to air pollution related to vehicle traffic on major roads in beijing is associated with lower lung function, airway acidification, and a higher prevalence of chronic cough (hu et al., 2016). other illnesses are also identified, such as the increase in obesity caused by the change in eating habits due to the increased consumption of processed foods and the reduction of physical activity, which alters the previous nutritional behaviour. another factor that causes correlated diseases is the stress caused by vehicular traffic (ferreira et al., 2013). the changes not only impact the riparian population but also reach the entire population of the city of porto velho in the state of rondônia and in other states in the amazon region; that is, they have cross-boundary impacts (marengo, 2008) for example, in the case of air pollution, the contamination plume can be carried by the wind to other areas beyond the site where it was generated, damaging health with diseases associated with air pollution or causing acid rain that deteriorates property. another negative impact caused by air pollution is the emission of greenhouse gases, which result in the destruction of the earth’s ozone layer, raising the planet’s temperature and contributing to drought in places such as the amazon basin, the melting of the polar ice caps, and even the destruction of the planet’s biodiversity (ehrmann and stinson, 1994; ipcc, 2014). the diagram network impacts elaboration at the national or international level will be of great value to enable preventive or mitigating actions to be taken before a change in public health resulting from an environmental impact. the actors engaged in the environmental licensing process in brazil have the perception that health is simply the absence of disease, and the treatment of health in the eia/ rima is sometimes limited to an inventory of the health services infrastructure in the enterprise’s area of influence (brasil, 2014). in spite of the institutionalization and obligatory nature of the eia-eir to have meant a milestone in the evolution of brazilian health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 25 environmentalism (silveira and neto, 2014), it is a fact that the inclusion of the evaluation of health effects in the environmental licensing process is lacking. there is no regulation of any specific health impact assessment tool for the environmental licensing process in brazil (silveira and neto, 2014).negligence with the health effects of the population occurs relatively frequently, since the only legalized mechanisms of health participation in the environmental licensing process is the assessment of malarious potential in malaria endemic regions (mainly the amazon region) (barbosa et al., 2012, conama, 2001, katsuragawaet al., 2009, silveiraet al., 2012, svs/ms, 2006). for other health determinants, there are no specific legislation or directives articulated with brazilian environmental licensing, as opposed to evaluations in developed countries that consider various social and health aspects in large enterprises. stinson (1994) expresses concern over the potential impacts of environmental degradation on human health, indicating the need to increase environmental awareness and unify various parts and sectors of society that analyze environmental risks differently and therefore observe differences regarding the effects on human health (ehrmann and stinson 1994). thus, it is considered that the applicability of this model will be a key point for brazilian public health, which lacks information or studies that show the influence of actions, projects, or programs in the area of health. this model will serve as a basis for the unified health system (sistema único de saúde sus) in its actions and improve the decision-making process of the managers of regional health systems. motta-veiga (2012) states that the effects of the implementation of hydroelectric plants in brazil have been the focus of many discussions due to the size of their impacts. the large scale of the jirau and santo antônio hydroelectric projects provokes the displacement of workers from other localities. however, because this intensive use of labor is temporary, it does not provide permanent employability, that is, as soon as the work get concluded, there will be a vertiginous growth of unemployment and definitive interference in the local social, environmental and economic dynamics (de souza moret and guerra, 2009). however, the approaches found in the literature show an isolated view, such as only environmental or social impacts, without appropriately including the health issue. therefore, we can appreciate and understand the importance of creating the network of aspects and impacts to analyze the interaction of sectors and stakeholders (queiroz and motta-veiga 2012). the proposed model supports the creation of mitigation actions and even remediation actions in health so that an increase in morbidity and mortality resulting from the development of the state of rondônia can be avoided. this promotes the movement of a state’s economy with positive impacts regarding sustainable development and negative impacts with regard to health, which has been estimated to date. the impacts of the installation of the hydroelectric dam can be positive with regard to local and national development in terms of energy availability and a consequent change in the quality of life of this population. however, the development can introduce increased costs in the health system (primary, secondary, and tertiary, included social and mental costs). thus, one can observe the impact on health, which, despite being a sector that is highly affected, is often overlooked in projects of large enterprises. the construction of the hydroelectric dams on the madeira river will add new social and economic plots in the rondônia territory. the implementation of transport and electric energy infrastructures in the brazilian amazon has been marked by major impacts due to the environment and have assigned new functions and forms of organization in the territory. in this way, hydroelectric plants constitute a structural element, generating new arrangements, revealing the political character and the power use in the territory, considering that its construction is to meet a demand external to the amazon region (cavalcanteet al., 2011). health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 26 the balancing of ecological needs with demands of industries and urban centers can be helped with certain technical expertise, but it is largely a contest between powerful political forces and the mute but fundamental needs for sustaining life on our planet (jobin, 1999). it is necessary to consider the health opportunities, managing and mitigating the social conflicts. the cost of a dam is usually stated in terms of the money spent to build the infrastructure and carry out necessary preparatory tasks such as viability studies and resettlement. however, the opportunity cost of sacrificing the land use that would have occupied the site had it not been used for a reservoir should also be part of the decision when a dam-building project is initiated (fearnside, 2005). this study demonstrates the importance of a qualitative diagram that serves as a basis for more efficient quantitative analysis to assist the start of conducting a prospective and quantitative hia. the evidence generated from studies such as this can support the analysis of likely impacts and can predict and mitigate future impacts. the diagram begins to articulate some of the non-environmental outcomes and impacts of dam-building that are important to consider. the brazilian government needs to develop and adopt a credible institutional framework (fearnside, 2006). we are aware of the limitations of our methodological approach in terms of the coverage of impacts and a complete analysis of each different situation and location. the lack of national high quality studies to cover a detailed range of determinants of health on affected population lead us to offer an extensive bibliographic search to summarize the hydroelectric dams impacts and to highlight its relevance. nevertheless, we are confident that we provide an adequate basis for enlarging the overview aspects/ impacts influencing a case study that can be replicated in other situations. we adopt this methodological approach to the evaluation of an environmental policy and its associated health effects and we are finding interesting and significant results. moreover, this tool is promising with regard to both retrospective and prospective hia studies. recommendations some recommendations derived from this qualitative hia retrospective study should be addressed to stakeholders and decision-makers.. we summarize them as follows: 1. dams have to be weighed against alternative energy projects in terms of environmental, social and health costs, sustainability and climate effects; 2. perform a prospective and quantitative hia study to predict and minimize the health impacts; 3. obtain evidence from previous studies to serve as the basis for the probable impacts analysis; 4. develop a monitoring program to be performed along with the construction, enabling interventions with focus on minimizing health impacts; 5. consult stakeholders frequently, searching for changes in habits and in the health status that appear before the increase in demand for the health service; 6. create a communication system with health authorities, the construction company and policy makers to emphasize all of the occurrences of alterations in the project and construction process. conclusion the diagram network impacts elaboration has been useful as an important tool for assessing a broader view of direct and indirect impacts categories, serving as a basis for further evaluations and studies. international data are limited to adapt in a national scenario, however, bring together national and international data and evidences can possibility cover a range of effects, collaborating for the network construction of evidences and country´s environmental licensing system. brazil´s dam-building plans in amazonia imply substantial environmental and social impacts and pose a challenge to the country´s environmental licensing system (fearnside, 2006). we recommend a strategic health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 27 planning in health impacts to avoid externalities, to prevent and reduce costs in the health system, and to obtain continuous improvement with investments lower than that planned. therefore, one can conclude that the implementation of hydroelectric dams has significant regional effects in social, environmental, and economic aspects and especially in the health sector. we suggest a more comprehensive analysis in all of these sectors in order to improve the national knowledge and the adoption of hia model to mitigate the negative impacts and maximize the positive aspects on the environment and the population. ethical approval: this article does not contain any studies with human participants performed by any of the authors. health impact assessment of the construction of hydroelectric dams in brazil 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(2013) untapped potential of health impact assessment. bulletin of the world health organization 91(4):298-305. health impact assessment of the construction of hydroelectric dams in brazil veronez; abe; miraglia 32 corresponding author simone georges el khouri miraglia, phd department: institute of environmental sciences, chemical and pharmaceutical, economics, laboratory, environmental health and pollution, universidade federal de são paulo unifesp, são paulo brazil rua são nicolau 210 4° andar, cep 09913-030 diadema sp phone: (+055) 11 3385-4137 #3592 miraglia@terra.com.br chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 3 issue 1 (2018) doi: 10.18060/21777 © 2018 author(s): veronez, d.; abe, kc; miraglia, s. g. e. k. this work is licensed under a creative commons attribution 4.0 international license november 2023 volume 8 issue 1 nearly 14 years ago, pew and the robert wood johnson foundation (rwjf) launched the health impact project. together, we committed to boosting health equity by promoting health-focused decision-making in transportation, housing, social and economic policy, education, and other sectors. over time, we broadened our work to support a range of health in all policies (hiap) approaches, including cross-sector collaborations and rapid-response approaches such as legislative health notes, and to deepen our emphasis on equity. through collaboration, we’ve accomplished our key goals: 1. build capacity among community and government organizations to use health impact assessment (hia) and hiap approaches to effect policy change. 2. increase awareness among policymakers about the factors that shape health. 3. galvanize philanthropic partners. 4. expand use of hiap approaches across the united states. over the past year, we spoke with many of you about our plans to close out the work of the health impact project. as federal, state, and local initiatives build momentum, it is time for us to pass the torch to the many leaders championing this effort. one common reflection we hear from our grantees is that the relationships forged and strengthened through hia and hiap work are often the greatext outcome. although the health impact project is ending, i feel confident that our large network of committed partners will continue to work together toward meaningful change and a healthier, more equitable future. health impact project 2 please visit the health impact project website. over the years, the project has worked alongside many partners, organizations, and people devoted to this work. while there are too many to list here, you know who you are, and we are grateful for your collaboration and continued commitment to our collective mission. all of us at pew thank you for your support over the project’s tenure. as we transition, take a look through some of the achievements we’re proud to have been a part of and check out a few ways to stay in touch with pew. sincerely, ruth lindberg director, health impact project https://www.pewtrusts.org/en/projects/archived-projects/health-impact-project november 2022 volume 7 issue 1 1 keshia m. pollack porter, phd, mph teaching health impact assessment in an online format teaching health impact assessment in an online format pollack porter 2 background during the 2010-11 academic year at the johns hopkins bloomberg school of public health (bsph), i created and launched a course on health impact assessment (hia) in the department of health policy and management (hpm). since the course sits in hpm, and because i am a “policy person,” i promote hia as a tool to elevate health and equity considerations for proposed policies such as legislation and regulation, at both the governmental (e.g., federal, tribal, state, and local) and nongovernmental (e.g., private/ institutional) levels (pollack porter et al., 2018). students must have completed a graduate level course in health policy or seek permission prior to enrolling. the course is typically taught during an 8-week term, when it meets once each week for three hours. the course is limited to graduate students and has primarily been taken by graduate students in public health. i have never had to recruit students to the course per se. each year, i discuss hias during lectures i give in policy courses and a course on the built environment and health. during these sessions i mention the hia course so people are aware that they can learn more about the topic. in addition, the hia course was added as one of the courses to meet competencies for several degree programs, which helped increase enrollment annually. during the first year when i taught hia, i capped the course at 15 students and because of increased popularity and interest, i increased the cap to 30 students in 2011-12. in the 201415 academic year i increased the cap to 40 and then in 2019-2020, i increased it again to 60, which is where it stayed through the 2021-22 academic year. in addition to teaching the course during a full term for over a decade, the course has been taught three times in a condensed format; the 8-week course was taught over 2-3 days during the bsph fall and summer institutes. this shortened format draws students from the part-time degree programs or other non-degree students. for example, learners from public health agencies, nonprofits, and the world health organization have completed the course in the condensed format. the course includes an option for students in the school’s mph program to obtain 25 practicum hours (towards the minimum of 100 hours they must complete) in support of handson public health training. these credits are obtained by providing additional opportunities for students to collaborate with a communitybased organization or local government partner. for example, one year, we partnered with a state legislator and conducted rapid hias on a proposal bill. students who took the course for practicum hours did additional work with the legislator and supported their efforts on a bill that would require hias. the students helped create materials for the bill hearing to educate the committee on social determinants of health and hias and attended the bill hearing. approximately, 5% of the number of enrolled learners in the hia course opt to use the course towards their 100 hours. while the pandemic forced many of us to move our in person courses online, in 2019 i decided that i would create an online offering of my hia course. the bsph has fully online degree programs, and these students repeatedly asked if i would create an online offering. during the 2019-20 academic year one part-time master’s student even flew to baltimore each week just to take the class because they thought the content was critical for their career aspirations! i finally decided to create an online version once the bloomberg american health initiative wanted to add the course as one of the elective offerings for their fellows (bloomberg american health teaching health impact assessment in an online format pollack porter 3 initiative, n.d.). as such, i applied for funds from the initiative to support some of my time to record the lectures and launch an online offering of hia during the 2020-21 academic year. online format i greatly benefited from the bsph center for teaching and learning (ctl) that supports, “educational excellence in public health, ensuring innovative and engaging learning experiences in the classroom and online” (center for teaching and learning, n.d.). once i initiated creating an online version of my course, i worked with an instructional designer from ctl to create a syllabus that would work well in a fully online course. the course was designed for asynchronous learners, with required “livetalks” for synchronous learning. i was paired with excellent producers who worked with me to ensure the recordings were clear and accessible, and over several months i recorded all the lectures. my approach to developing on online offering of hia was consistent with the skills and competencies some colleagues and i promoted in an article we wrote in 2014 about teaching hia at the graduate level (pollack km et al. 2014). the schedule required students to watch recordings each week that began with an introduction of health in all policies (hiap), review of each step of the hia process, including separate lectures on equity and stakeholder engagement. the students also learned about hias applied for policy decisions and the types of policies that can support institutionalization or routinization of hias. the course was designed to front load the initial weeks with lectures on the steps of the hias process so that learners would have the knowledge to complete the first assignment, which was a critique of a completed hia. the first livetalk of the course involved a discussion of the hias that were critiqued. the second livetalk was a discussion involving a panel of hia practitioners. the final assignment was a brief written reflection that involved learners sharing their thoughts about the value of hias, how to support their growth, and any personal insight from working on a rapid hia, which was required for the course. the course has a hands-on component that involves working on a rapid hia. since the course is in hpm, hias are always applied to proposed governmental or nongovernmental policies. students are placed into groups of 5-6 to work on a rapid hia. a final report is not produced, instead students submit their powerpoint presentations and have to clearly delineate each group member’s contribution to the project. we typically work with a partner involved with the proposal that is the subject of hia. we remain in close contact with the partner throughout the course and they attend the final livetalk to watch the groups present. once the course is complete, with permission from the students, i provide the partners with slides and other resources compiled by the students. during the first year that i taught the course online, we worked on a proposed policy by the washington d.c. city council. a representative from the washington d.c. government served as a resource for the students. for the second year of the online course offering, we partnered with the baltimore city health department on a bill being consider by the state legislature that would impact city residents. these partners were identified by leveraging my existing partnerships. reflections on teaching online in reflecting on creating a fully online hia course, there are three insights that i want to share. first, during the initial year that i taught the course online, i tried to essentially replicate what i had done onsite because the onsite teaching health impact assessment in an online format pollack porter 4 course worked well, and my course had always been highly rated. overall, the evaluations for the online course were good, but i noted that the students hoped for more interactions with me. in reflecting on when the course was in person, the students saw me each week and could speak with me before and after class (i want to note that students are always able to schedule 1-on-1 meetings with me). with most of the sessions being recorded, the learners heard from me each week but did not have live interactions with me. as a result, during the second time that i taught the course online, i added weekly optional office hours via zoom. this created a drop-in space for learners to speak with me about the field, to ask additional questions, and to feel connected. as i continue to offer the course online, i will ensure that there are always regularly scheduled optional office hours. second, the 8-week term continues to be a challenge, especially because it means that learners only have a few weeks to become familiar with the hia process to successfully complete the assignment and then work in groups on a rapid hia. the final presentations occur during the eighth week, which essentially means that students have seven weeks to learn all the material and complete a rapid hia. having additional office hours and several teaching assistants (tas) to serve as resources for the students are a couple of ways that i provided them with support during the 8-week term. despite this, the short time frame to grasp the content is a challenge for students. this comment about tas brings me to my third point – the course size. during the 2021-22 academic year, 182 students took my course (and about 12% opted to obtain practicum hours). while exciting for the field, the course was very large, which created administrative challenges regarding engagement, responsiveness, grading, etc. even though i had four tas, the workload was high for everyone. an additional challenge with the size was that course enrollments were large for all classes at bsph, which meant that tas were in high demand, so i ended up having tas who had not taken hia before. although the tas played a critical role and were able to respond to student inquiries, and with clear instructions and rubric help grade, i had to answer all technical questions. for the upcoming 2022-23 academic year, i decided to add a cap to the class (100 students) to make it more manageable. i am now the chair of my department, which means time is limited; thus, i will not offer additional practicum hours. conclusions i have taught hia for a dozen years. i have adapted the course in recent years, so it remains relevant. for instance, while the core elements of the course have remained the same, i have added more content regarding hiap, including discussing other tools like the washington health impact review (pollack porter km, et al. 2019) and the health note, which i helped create and implement with colleagues at the health impact project (health impact project, 2021). the course has received strong ratings and in terms of the impacts on the learners, the following quote from a former student reflects many that i have received: “i have thoroughly enjoyed the process of learning and thinking of ways that i can apply the hia in the way that i think through my other public health courses, and as a future public health professional.” over the years the partners that i have worked with have noted how valuable it was to receive the powerpoint slides at the end of the term. one partner described the presentation slides and resources as follows, “it truly is a treasure trove of information! please pass along my thanks to your students.” teaching health impact assessment in an online format pollack porter 5 any time that i ask myself if i should take a break from teaching the course, i seem to receive an email from a student sharing how much they are looking forward to taking the course or from a former student sharing how valuable the course was for their current position. i believe that hias are one important tool to help change to advance health equity, and as long as there is progress to be made towards this goal, i will continue to teach the course. teaching health impact assessment in an online format pollack porter 6 references bloomberg american health initiative. the bloomberg fellows program. retrieved 15 august 2022 from https://americanhealth.jhu.edu/fellowship. center for teaching and learning. retrieved 14 august 2022 from https://publichealth.jhu.edu/offices-andservices/center-for-teaching-and-learning. health impact project. (2021) a user’s guide to legislative health notes. retrieved 14 august 2022 from https://www.pewtrusts.org//media/assets/2021/04/apractitionersguidereportfinal.pdf. pollack, k.m., dannenberg, a.l., botchwey, n., stone, c.l., seto, e. (2014). developing a model curriculum for a university course in health impact assessment in the united states. impact assessment and project appraisal. http://dx.doi.org/10.1080/14615517.2014.960213. pollack porter, k.m., rutkow, l., mcginty, e.b. (2018). the importance of policy change foraddressing leading public health problems. public health reports, 133(1s):9(s)-14(s). pollack porter, k.m., lindberg, r., mcinnis-simoncelli, a. (2019) considering health and health disparities during state policy formulation: examining washington state health impact reviews. bmc public health 19:862. https://doi.org/10.1186/s12889-019-7165-7. corresponding author keshia m. pollack porter, phd, mph department of health policy and management johns hopkins bloomberg school of public health baltimore, md 212105 kpollac1@jhu.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, bs, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 7 issue 1 (2022) doi: 10.18060/26471 © 2022 author(s): pollack porter, k. this work is licensed under a creative commons attribution 4.0 international license https://americanhealth.jhu.edu/fellowship https://publichealth.jhu.edu/offices-and-services/center-for-teaching-and-learning https://publichealth.jhu.edu/offices-and-services/center-for-teaching-and-learning https://www.pewtrusts.org//media/assets/2021/04/apractitionersguidereportfinal.pdf http://dx.doi.org/10.1080/14615517.2014.960213 https://doi.org/10.1186/s12889-019-7165-7 november 2022 volume 7 issue 1 1 tatiana lin, m.a.; wyatt beckman, mph, ches; vicki collie-akers, phd, mph guest lectures: increasing student knowledge of health in all policies by using the health impact checklist guest lectures: increasing student knowledge of health in all policies lin; beckman; collie-akers 2 setting for guest lectures the university of kansas medical center (kumc) department of population health is home to the university of kansas mph program, which is the first and longest-standing mph program in kansas. the program has two concentrations: public health practice and epidemiology. in addition, the university of kansas edwards campus (ku-e) has a newly launched, fully online generalist master of public health program. the mph curriculum consists of a series of core classes required for all concentrations and a set of concentrationspecific classes. a core class required for all students, regardless of concentration, is prvm 804: community health assessment, intervention, and advocacy. average class enrollment is 20 students. the course is divided into three sections: understanding and assessing factors which drive health in communities, using theoryor evidence-based approaches for intervention, and advocating for community health improvement. curriculum for guest lectures the guest lecture curriculum was built upon khi’s decades-long experience in hiap efforts and was tailored to a virtual setting due to covid-19 risk mitigation policies (including a campus shut-down in spring 2020 and a policy restricting guest access to campus in fall 2021). since 2010, khi has completed six health impact assessments, developed a workbook, delivered trainings, created the hi-c tool and provided technical assistance to communities across kansas and nationally. introduction evidence-based information, objective analysis and civil dialogue can position policy leaders to become effective champions for healthy communities. given that young people have a significant role to play in transforming communities, the kansas health institute (khi) has a goal of collaborating with academic institutions to build student capacity in recognizing, assessing and communicating the health and equity impacts of policies. to accomplish this goal, khi began collaborating with the department of population health at the university of kansas school of medicine (kumc) in 2020 to provide one guest lecture a year to master of public health (mph) students enrolled in the prvm 804 community health assessment, intervention, and advocacy class. as of october 2022, khi has delivered two guest lectures. the guest lectures introduced students to health in all policies (hiap) concepts and ways to examine potential positive and negative health and equity implications of policies by using the health impact checklist tool, which is also referred to as hi-c. a seven-question qualtrics survey was developed and administered following each lecture to assess student perception of the lecture and its effectiveness. additionally, following the 2021 presentation, students were asked about ways they could implement hiap approaches in their mph studies, with results immediately shared for all to review using poll everywhere. hiap is a collaborative approach that integrates and articulates health and equity considerations into policy making and programming across sectors, and at all levels, to improve the health of all communities and individuals. -association of state and territorial health officials (astho) https://www.khi.org/articles/2020-hi-c-health-impact-checklist/ https://www.khi.org/articles/2020-hi-c-health-impact-checklist/ guest lectures: increasing student knowledge of health in all policies lin; beckman; collie-akers 3 the lectures aimed to achieve the following outcomes: 1. advance student understanding of the hiap framework. 2. increase student ability to identify strategies to implement hiap. 3. increase student understanding of potential health impacts of policies by participating in a structured activity to complete sections of the hi-c. to achieve these outcomes, the class time in each guest lecture was divided into two sections: an introduction to hiap and a small-group activity. each section included a discussion and a question-and-answer session. introduction to hiap introduction to hiap the introduction set the foundation for the small-group activity and covered potential reasons for adopting an hiap approach, as well as the definition and principles of hiap practice. the hiap principles described were those identified in the association of state and territorial health officials (astho) report health in all policies: framework for state health leadership. the introduction also described several strategies for implementing hiap principles, including hiap resolutions and ordinances, hiap meetings, cross-sector partnerships around specific projects, ways to incorporate health and equity considerations into requests for proposals and strategic plans, and conducting content analyses of key documents that establish a vision for the community from an hiap perspective. for each example, the speaker demonstrated which hiap principles were met (figure 1). figure 1. example of hiap strategy and alignment with hiap principles, from lecture slide deck guest lectures: increasing student knowledge of health in all policies lin; beckman; collie-akers 4 following the introduction to hiap section, students participated in a discussion centered on these questions: • reasons for using hiap: what other approaches can be used to describe why health should be part of the decisionmaking process? what questions or push back do you anticipate? • hiap strategies: of the examples discussed during the session, which seem feasible for your county or community to implement? health impact checklist small-group activity the hi-c was developed by khi and designed to inform decisions at many levels (e.g., organization, city, county and state). the hi-c builds on existing tools, such as health notes from the health impact project, the health lens checklist from kent county, michigan, and the health in all policies: health lens analysis tool from tacoma-pierce county health department in washington state. the small-group activity section of the curriculum guided students in identifying potential social, economic and environmental impacts of policies, how those policies could impact health, and which populations may be particularly impacted. students accomplished this by collaboratively completing and discussing key sections of the hi-c. for these classroom exercises, two example policies were pre-identified by the khi instructors. students in one lecture reviewed a county-level nuisance abatement policy while students in the other lecture reviewed a municipal policy preventing suspension of utility service disconnections in response to covid-19. for both policies, khi had previously completed examples of hi-c which supported facilitating the classroom activities. students in the guest lecture were collectively asked to complete questions 1 and 2 from the hi-c tool by naming the policy, decision or proposal being evaluated and describing its main goals or key points. students were then randomly placed in two virtual breakout groups facilitated by khi to discuss and collectively complete question 3 and 5 from the hi-c. for question 3, the students used the table shown in figure 2 on page 5 to identify potential social, economic and environmental conditions that could be impacted if the proposal were implemented. for question 5, students used their knowledge and experience to describe the potential impacts of the proposal on each of the conditions they identified. for example, if they identified “housing quality” as a condition which may be impacted by the nuisance abatement policy, students would then think through how changes to housing quality stemming from the policy may impact health. after 10 minutes, the breakout sessions ended and groups reported to the class on their discussion. students then returned to their breakout groups to complete question 6 of the hi-c which asked them to identify the specific populations which might be impacted by the policy for each identified social, economic or environmental condition (figure 3 on page 5). the breakout groups completed this activity and then reported back to the class after 10 minutes. the session concluded with an overview of the remaining components of the hi-c, examples of other hiap resources, and time for questions and discussion. guest lectures: increasing student knowledge of health in all policies lin; beckman; collie-akers 5 social, economic, and environmental conditions 1,2 economic stability neighborhood & physical environment education � employment � housing quality � early childhood education and development � income � transportation � high school graduation � housing instability/ homelessness � environmental conditions(e.g., water, air, and soil quality) � higher education � food insecurity � access to healthy food � language � poverty � safety � literacy � other: � other: � other: � other: � other: � other: community and social context health and health care note: the number of social, economic, or environmental conditions examined could depend on available resources, stakeholder interest and timeline. after examining three, additional conditions may be examined further. � civic participation � health coverage � discrimination � provider availability � toxic stress � access to health care � social isolation � access to behavioral health services � incarceration � quality of care � other: � other: � other: � other: figure 2. table of social, economic and environmental conditions, from hi-c figure 3. table for identifying health impacts for specific populations, from hi-c social, economic, or environmental condition impacted population impact on health overall impact on health � positive � negative � mixed � none � unclear guest lectures: increasing student knowledge of health in all policies lin; beckman; collie-akers 6 lessons learned to assess student perception of the lecture and its effectiveness, students were asked to complete a short online survey. the survey questions focused on assessing changes in student understanding of hiap, health impact assessments, connections between policies and health, and potential impacts that policies could have on populations. students also rated the lecture in terms of its quality and effectiveness. across both lectures, 15 students completed the survey. overall, the survey results showed that students found the sessions increased their understanding of hiap and that the hi-c group activity contributed to their understanding of how policies may impact health through modifying social determinants of health. in addition, several students suggested focusing more time on a small-group activity, peersharing from each group and working through policy scenarios, while spending less time on lecture material. while solidifying the overall concepts of hiap, the group activity provided a valuable opportunity for the students to make connections between policy changes and health impacts. importantly, the group activity facilitated interaction between students and allowed them to see potential impacts and implications they had not considered. taken together, the introduction to hiap and the course activity supported further utilization of, and engagement with, hiap approaches in other areas of their academic study and future professional work. discussion fostering student understanding and competence related to health in all policies is an important element of mph education. mph programs are designed to prepare students to skillfully fulfill the mission of promoting and protecting the health of the public. the growing focus on public health 3.0 and hiap necessitates inclusion of related content to ensure students are well-prepared to engage in cutting-edge public health practice and research. at kumc, integrating content related to hiap practices and approaches enables this preparation and supports development of skills and competencies directly related to the foundational competencies of the mph program. for a public health institute such as khi, partnering with kumc through these lectures to support public health training and engagement with hiap helps advance the vision of healthier kansans through effective policy. khi continues to support utilization of the hi-c tool through technical assistance. these lectures offer opportunities to refine khi’s teaching and resources for hiap and the hi-c. it was nice to be challenged to think differently and to work through the process with an example. -student guest lectures: increasing student knowledge of health in all policies lin; beckman; collie-akers 7 references association of state and territorial health officials. (2020). health in all policies. http://www.astho.org/ programs/hiap. association of state and territorial health officials. (n.d.). health in all policies: framework for state health leadership. http://www.astho.org/health-in-all-policies-framework.pdf kansas health institute. (2020). hi-c: health impact checklist; hi-c: suspension of disconnections of utility services due to covid-19 (hutchinson, reno county); hi-c: dangerous and unfit structures ordinance – chapman, ks; and hi-c: environmental nuisance abatement – linn county. https://www. khi.org/articles/2020-hi-c-health-impact-checklist/ corresponding author tatiana lin kansas health institute 212 sw eigth ave., suite 300 topeka, ks 66603 tlin@khi.org chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, bs, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 7 issue 1 (2022) doi: 10.18060/26481 © 2022 author(s): lin, t.; beckman, w.; collie-akers, v. this work is licensed under a creative commons attribution 4.0 international license http://www.astho.org/programs/hiap http://www.astho.org/programs/hiap http://www.astho.org/health-in-all-policies-framework.pdf https://www.khi.org/articles/2020-hi-c-health-impact-checklist/ https://www.khi.org/articles/2020-hi-c-health-impact-checklist/ call for chronicles of health impact assessment (chia) peer reviewers we appreciate your interest in supporting the chia journal as a peer reviewer. in this role, you will be asked to read submitted articles. if you do not have time you can decline the invitation to review and will be placed back in the rotation for future opportunities. if you do have time, your review will address the following: you will submit a written critique that will help determine if the article will be published. you will be asked if you have any conflicts of interest in reviewing an article. all your comments will be anonymous to the authors. you will be given prompts to respond to, such as: what are the article strengths or weaknesses, is this information that is new to the field or building on already known material? all comments should be viewed as constructive criticism for the authors. you will have the choice to accept, recommend acceptance with revisions, or not accept the article. if you are interested, the following information will assist us in matching peer reviewers to specific authors. name email address affiliation phone number area of hia expertise (check all that apply): agriculture criminal justice health equity housing built environment economics hia evaluation labor policy climate change education hia methodology natural resources community development energy hia theory redevelopment transportation other:__________________________________________________ how are you qualified (papers written, journal reviewed for, etc.)? 1050 wishard blvd., indianapolis, in 46202 317-274-2000 chia@iu.edu december 2021 volume 6 issue 1 1 gina powers cynthia stone, drph, msn, rn ten years of sophia introduction in 2021, the society of practitioners of health impact assessment (sophia) celebrates its 10-year anniversary. to commemorate this milestone, we surveyed sophia founding members and key leaders in july of 2021, asking them to reflect on the organization’s formation in 2011, to share thoughts on sophia’s key challenges and to highlight important accomplishments. survey respondents also weighed in on the future of sophia and the value of sophia membership. the first section, titled “history of health impact assessment and the formation of sophia,” is based on a combination of survey responses and published materials as sources. the second section titled “sophia’s first 10 years: accomplishments, challenges, the future, and the value of membership” summarizes perspectives shared by survey respondents on sophia’s current and future state and the value of sophia membership. the final section, “summary and conclusions,” summarizes key messages in the first two sections. history of health impact assessment and the formation of sophia history of health impact assessment the development of hia was preceded by the 1969 national environmental policy act (nepa). nepa was one of the first laws ever written to protect the environment (summary of the national environmental policy act, n.d.), establishing a national policy with the following purpose: to declare a national policy which will encourage productive and enjoyable harmony between man and his environment; to promote efforts which will prevent or eliminate damage to the environment and biosphere and stimulate the health and welfare of man; to enrich the understanding of the ecological systems and natural resources important to the nation; and to establish a council on environmental quality (the national environmental policy act of 1969, as amended, 1971). ten years of sophia powers; stone 2 while stimulating the “health and welfare of man” was one of nepa’s stated purposes, most environmental impact assessments have emphasized environmental impacts without directly connecting environmental impacts to health impacts (dannenberg, 2016). ross, orenstein and botchwey (2014) point out that environmental impact assessments (eias) “rarely incorporate broad measures of health, or focus too narrowly on exposure to environmental toxins.” (p. 5). this void led to the development of other methodologies designed to examine the social and health outcomes of proposed policies, projects and programs and the distribution of those social and health outcomes (ross, orenstein and botchwey, 2014). in 1986, the world health organization (who) set the stage for the development of hia with the ottawa charter for health promotion and in 1997, with the jakarta declaration on leading health promotion into the 21st century (dannenberg, 2016). the jakarta declaration lists “equityfocused health impact assessments as an integral party of policy development” as a priority for health promotion in the 21st century. (who, 1997). in 1999, the who outlined hia definition and values in the gothenburg consensus paper. (ross, orenstein, & botchwey, 2014, p. 6). early hias were conducted primarily in europe in the 1990s (dannenberg, 2016). the first hia in the united states was commissioned in 1999 by the san francisco department of health (sfdh) and published in 2001 (bhatia & katz, 2001). in 2002, the centers for disease control and prevention (cdc) hosted a workshop in atlanta to discuss research on health and the built environment. hia was one recommended approach that emerged from this meeting as a promising approach to assessing how the built environment can affect health. in 2004, the robert wood johnson foundation (rwjf) and the cdc hosted a second workshop to discuss providing hia examples and resources, building hia training capacity and expanding the field (dannenberg, 2016). the cdc and rwjf remained involved in the next steps that were identified during the second conference. in the years following the second conference, hia grew as a topic of academic research. a database of academic articles was created by the health impact project, a collaboration between rwjf and the pew charitable trusts (dannenberg, 2016). hia teaching and training was provided by multiple organizations, including the cdc, the san francisco department of public health, human impact partners, and the university of california – berkeley, and the american planning association with the national association of county and city health officials (dannenberg, 2016). hia use expanded in scope to become a tool for analyzing health impact for policies beyond its original use for the built environment. the formation of sophia beginning in approximately 2008, a group of hia practitioners in north america started hia of the americas, an annual meeting to discuss hia practice and to advance the field. the society of practitioners of health impact assessment (sophia) is the product of a working group during the 2010 hia of the americas meeting, and the organization was formed in late 2011 (about sophia, n.d.). according to survey response from founding members and sophia leadership, sophia was formed to advance the practice of hia with the following goals in mind: ten years of sophia powers; stone 3 1. to establish and promote standards of practice for hia practitioners 2. to build capacity by promoting and expanding the field of hia 3. to build a community of practice to share experiences and learn 4. to conduct workshops and conferences 5. to promote community engagement and equity 6. advocate by producing position statements, papers, and resources for addressing emerging challenges and opportunities today, sophia is an international association that provides leadership and promotes excellence in the field of health impact assessment (hia). sophia’s first 10 years: accomplishments, challenges, the future, and the value of membership methodology this section summarizes survey feedback from sophia leaders and founding members regarding sophia accomplishments, challenges, the future, and the value of membership. a survey was distributed in july of 2021 to eleven active sophia members, many of whom have served as president, vice president, board member or founding member for sophia. eight responses to survey questions were returned, seven in writing and one verbally (see survey questions in appendix). of those who responded to the survey, nearly all have been conducting health impact assessments (hias) for 10 or more years. survey respondents’ hia experience included assessments focused on a variety of policies, projects and programs, including housing, land use, economic security, the built environment, transportation, immigration policies, minimum wage policies, criminal justice and more. sophia accomplishments according to survey respondents, sophia has contributed substantially to the field of hia during the first 10 years. key accomplishments that respondents identified are summarized below. practitioner resources high-quality resources that have defined hia standards of practice were frequently mentioned as a key sophia accomplishment during the first ten years. one survey respondent specified that guidelines on stakeholder engagement and equity stand out as key materials that have strengthened and advanced the field. the website and document library and the health in all policies screening tool were also included as important practitioner resources that sophia developed and made available. education and services practitioner workshops (formerly known as hia of the americas) and webinars were cited as top accomplishments. specifically, practitioner workshops were called out as a consistent and wonderful environment for peer learning and sharing. also, the support provided to new practitioners and basic hia education for those looking for more information were listed as important contributions to the field. other notable accomplishments related to education and services include the journal, chronicles of health impact assessment, and the peer exchange program. established professional network one major contribution to the field of hia has been the network of practicing hia professionals that comprise sophia. sophia has kept the field going by providing a forum for continued discussion and collaboration among colleagues. ten years of sophia powers; stone 4 sustainability as an organization / expanding the field finally, sophia’s continued existence through four presidents and leadership transitions is notable and points to the organization’s sustainability. sophia is viewed as a driver behind the more widespread understanding over the past 15-20 years that policy decisions have health impacts. sophia has grown to be an international organization and facilitates connections between members. challenges while sophia has accomplished a great deal as an organization, respondents acknowledge challenges exist. funding a lack of funding has presented significant challenges. in the absence of funders, sophia relies on membership fees to support a part time staff member. the amount of money raised through membership fees limits sophia’s services and activities. resource challenges sophia does not have full time dedicated staff; rather, officers, workgroups and others serve as volunteers. limited individual and group bandwidth makes participating in workgroups or being a workgroup chair challenging. organization leaders must balance their daily work responsibilities with their efforts to move sophia forward. the voluntary nature of sophia leadership or workgroup participation sometimes leads to sophia work being deprioritized in favor of work responsibilities. shifting field and social priorities interest in the field from funders and government agencies appears to be waning. when sophia was established ten years ago, there was significant energy focused on hia work. there appear to be fewer people fully allocated to hia work and as a result, fewer people are active in sophia. the future of sophia – the next 10 years as sophia moves into its second decade, it is important to analyze current state and consider priorities for the next 10 years. survey respondents shared their thoughts on the future of sophia. health in all policies some respondents raised the question of whether sophia should incorporate health in all policies (hiap) as a focus in addition to hia. as stated on the sophia website (health in all policies, n.d., 1st paragraph), “hia is a powerful and effective tool used to achieve the larger goal of hiap.” student training in 2015, sophia leadership made efforts to evaluate which universities offered courses on hia to students. it is important to update this information to understand to what extent student training is continuing, and to evaluate whether gaps exist and how to fill them. information hub the cdc and pew have archived some of the hia information on their websites. sophia should continue to track and share information on upcoming hia-related publications. sophia should also retain information from the pew and cdc sites that has been archived or add this information directly to the sophia site. sohia should advocate for continued presence from these organizations. funding, staffing and membership there is a need to consider how to sustain the association from a funding and staffing ten years of sophia powers; stone 5 perspective, to re-invigorate the membership base and working groups and to increase membership retention and growth. having a ten-dollar membership fee for new members was a great way to celebrate sophia’s 10-year anniversary. value and mission the environment is ever-changing, and it is important to ensure hia is still relevant in today’s world. sophia should expand its mission to be broader than hia, but to continue emphasizing hia as a gateway tool for health in all policies. sophia must examine and define the unique value that sophia provides and convey this value relative to others working in the hiap and health equity spaces. another approach might be for sophia to connect to other emerging practices with similar values and focus on being a network for a broader mission, not just hias. benefits of sophia membership survey respondents were asked what benefits they have received from sophia membership. nearly all emphasized that the relationships built with other practitioners and the learning opportunities stand out as important membership benefits. network of practitioners for most, sophia has provided a forum for practitioners to connect and discuss updates and challenges. being part of a supportive community provides a space to discuss sticky questions. ruth lindberg writes, “i have received many benefits from my involvement with sophia, particularly deep and enduring relationships with other members who have become thought partners in my own hia and health in all policies work. i continually learn from other members, and really value the peer learning and collaborative aspects of the organization.” professional resources and best practices creating, using, and disseminating hia guidance documents and other resources have been a major benefit of sophia membership. the resources that sophia creates and disseminates plays a key role in advancing hia practice and supporting hia development. leadership development sophia membership can provide opportunities to develop and refine leadership skills by participating in workgroups or by serving as an officer in the organization. advice for those considering sophia membership respondents were unanimous in their advice for those considering sophia membership: join. they also provided advice on maximizing the value received by joining workgroups and getting involved. sophia provides an excellent opportunity to get to know wonderful and interesting people who are passionate about health and equity. all survey respondents highly recommended sophia membership as an excellent opportunity to advance personal and professional goals by networking with passionate professionals in the areas of hia and hiap. joining a workgroup, participating in the practitioner workshop and webinar offerings, and using available resources and services can help members maximize value. summary and conclusions the history of hia in the u.s. has roots in the 1969 national environmental policy act. however, assessing the impact of proposed ten years of sophia powers; stone 6 policies, projects and programs on population health needed sharper focus. the who played a leading role in promoting and defining health impact assessments as essential policy development tools between 1986 and 1999. during the 1990s, hia practice grew primarily in europe. the first hia in the united states was commissioned in 1999 and the practice grew in the u.s. in the early 2000s, supported by involvement from the cdc, rwjf and pew charitable trusts. sophia was founded in 2011, the product of a group of hia practitioners in north america who attended the 2010 hia of the americas meeting. sophia leaders and founding members who responded to our july 2021 survey indicate the organization was formed to establish and promote standards of practice, promote the field and build professional capacity, establish a community of practice to share experiences and learn, educate practitioners through workshops and conferences, promote hia ideals such as community engagement and equity and to advocate by producing position statements, papers and resources to address emerging challenges and opportunities. after 10 years of existence, is sophia fulfilling its goals? what value does sophia add to the field? what challenges exist for sophia and the field of hia? and how does the organization address emerging challenges and opportunities in the coming years? in july and august of 2021, sophia’s leaders and founding members weighed in on the organization’s accomplishments, challenges, future direction and the value of membership by way of survey response. the good news? sophia has contributed to the field by developing high-quality practitioner resources. respondents pointed to the website, document library and the health in all policies screening tool as key accomplishments, with one respondent calling the guidelines on stakeholder engagement and equity a “stand out.” sophia has contributed to education and service to practitioners through practitioner workshops, webinars, the chronicles of health impact assessment, and the peer exchange program. finally, the professional network that sophia comprises makes professional expertise, experience and mentorship available to practitioners at all experience levels. sophia’s significant accomplishments and contributions to the field point to a clear focus on the organization’s original goals. yet, challenges exist. a lack of funding limits the scope of services that sophia can provide. sophia is volunteer-led, requiring already busy professionals to balance their work responsibilities with their efforts to move sophia to the next level. perhaps most significantly, interest from government agencies and hia funding appear to be declining. when sophia was initially formed, the field of hia had significant momentum. one survey respondent said, “there was a lot of energy around hia when sophia came to be, but since then fewer and fewer people are fully resourced to do hia work, and thus, their ability to be active in sophia is harder to justify. i see this as a huge missed opportunity since hia is still an effective tool with robust applications it’s just not the ‘shiny thing’ anymore. as sophia leadership considers future priorities, the organization’s mission, strategy, goals and funding plan must be assessed and aligned with a changing environment. some survey respondents suggest broadening sophias mission beyond hia to encompass health in all policies and health equity. another recommends connecting with other emerging practices with similar values and building ten years of sophia powers; stone 7 a network with a broader mission. some respondents suggest that sophia should continue to remain abreast of hia course offerings at universities and to be an important informational resource. above all, survey responders value sophia’s supportive practitioner network, best practices, professional resources, the practitioner workshop, webinars and leadership opportunities as key membership benefits. their advice to those considering sophia membership? join! ten years of sophia powers; stone 8 references about sophia. (n.d.). society of practitioners of health impact assessment. retrieved september 5, 2021 from https://hiasociety.org/about-sophia bhatia, r., & katz, m. (2001). estimation of health benefits from a local living wage ordinance. american journal of public health, 91(9), 1398–1402. https://doi.org/10.2105/ajph.91.9.1398 dannenberg al. a brief history of health impact assessment in the united states. chronicles of health impact assessment. 1(1), 2016. https://journals.iupui.edu/index.php/chia/article/ view/21348 health impact assessment (hia) tools and methods. (n.d.). world health organization. retrieved november 10, 2021, from https://www.who.int/tools/health-impact-assessments health impact assessments. (n.d.). united states environmental protection agency. retrieved september 5, 2021 from https://www.epa.gov/healthresearch/health-impact-assessments health in all policies. (n.d.) society for practitioners of health impact assessment. retrieved september 10, 2021 from https://hiasociety.org/health-in-all-policies2 ross, c., orenstein, m., & botchwey, n. (2014). health impact assessment in the united states. springer. summary of the national environmental policy act. (n.d.). united states environmental protection agency. retrieved september 5, 2021 from https://www.epa.gov/laws-regulations/summary-nationalenvironmental-policy-act the national environmental policy act of 1969, as amended. (1970, january 1). retrieved september 5, 2021 from https://www.energy.gov/nepa/downloads/national-environmental-policy-act-1969 world health organization. (1997, july 21). the jakarta declaration: on leading health promotion into the 21st century. world health organization. https://www.who.int/publications/i/item/who-hpr-hep-4ichpbr-97.4 https://hiasociety.org/about-sophia https://doi.org/10.2105/ajph.91.9.1398 https://journals.iupui.edu/index.php/chia/article/view/21348 https://journals.iupui.edu/index.php/chia/article/view/21348 https://www.who.int/tools/health-impact-assessments https://www.epa.gov/healthresearch/health-impact-assessments https://hiasociety.org/health-in-all-policies2 https://www.epa.gov/laws-regulations/summary-national-environmental-policy-act https://www.epa.gov/laws-regulations/summary-national-environmental-policy-act https://www.energy.gov/nepa/downloads/national-environmental-policy-act-1969 https://www.who.int/publications/i/item/who-hpr-hep-4ichp-br-97.4 https://www.who.int/publications/i/item/who-hpr-hep-4ichp-br-97.4 https://www.energy.gov/nepa/downloads/national-environmental-policy-act-1969 https://www.who.int/publications/i/item/9789241506908. ten years of sophia powers; stone 9 appendix indiana university study information sheet for research ten years of sophia you are being asked to participate in a research study. scientists do research to answer important questions that might help change or improve the way we do things in the future. this document will give you information about the study to help you decide whether you want to participate. please read this form, and ask any questions you have, before agreeing to be in the study. all research is voluntary. you can choose not to take part in this study. if you decide to participate, you can change your mind later and leave the study at any time. you will not be penalized or lose any benefits if you decide not to participate or choose to leave the study later. this research is intended for individual 18 years of age or older. if you are under age 18, do not complete the survey. this research is for residents of the united states. if you are not a u.s. resident, do not complete the survey. the purpose of this study is to gather information on the founding of the society of practitioners of heath impact assessment (sophia) and leadership over ten years. we are asking you if you want to be in this study because you are a past or current leader of sohia. the study is being conducted by cynthia stone and gina williams of iu richard m. fairbanks school of public health. if you agree to be in the study, you will do the following things. complete the survey or be interviewed. before agreeing to participate, please consider the risks and potential benefits of taking part in this study. you may become uncomfortable with the questions. you can decline to answer or stop at any time. the interviews will inform sophia members about the founding. we don’t think you will have any personal benefits from taking part in this study, but we hope to learn things that will help sophia in the future. you will not be paid for participating in this study. there is no cost to participate in the study. ten years of sophia powers; stone 10 we will protect your information and make every effort to keep your personal information confidential, but we cannot guarantee absolute confidentiality. no information which could identify you will be shared in publications about this study. the recording will be stored on encrypted devices and destroyed after the analyses is complete. your personal information may be shared outside the research study if required by law. we also may need to share your research records with other groups for quality assurance or data analysis. these groups include the indiana university institutional review board or its designees, and state or federal agencies who may need to access the research records (as allowed by law). if you have questions about the study or encounter a problem with the research, contact the researcher, cynthia stone at 317 278-0761 or cylstone@iu.edu. for questions about your rights as a research participant, to discuss problems, complaints, or concerns about a research study, or to obtain information or to offer input, please contact the iu human research protection program office at 800-696-2949 or at irb@iu.edu. questionnaire: name______________________________________ current position: _____________________________________ how long have you been conducting health impact assessments? check one 0-2 years 3-5 years 6-9 years 10 or more years ten years of sophia powers; stone 11 your role in sophia and years involved please complete all that apply role starting year of role ending year of role president vice president board member general member founding member how did you get involved with hia work? what topics or questions have you explored with your hias? how did you get involved with sophia? what do you know about the founding of sophia and its initial goals, and how were you involved? what were challenges you faced during your role in sophia? what benefits have you received from your activity with sophia? what advice would you have for those considering membership in sophia? what do you think are the most notable sophia accomplishments in the first 10 years? what do you think are the most important goals for sophia during the next 10 years? what next steps do you think are important? ten years of sophia powers; stone 12 anything else you would like to share? is there anyone else you think we should interview? thank you for your time. corresponding author cynthia stone, drph, msn, rn indiana university purdue university indianapolis 1050 wishard blvd. rg 6146 317-278-0761 cylstone@iu.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, bs, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 6 issue 1 (2021) doi: 10.18060/25658 © 2021 author(s): powers, g.; stone, cl. this work is licensed under a creative commons attribution 4.0 international license october 2017 volume 2 insights into how hias are characterized in the press: findings from a media analysis of widely circulated united states newspapers maxim gakh, jd, mph; courtney coughenour, phd; jennifer pharr, phd; aaliyah goodie, mph candidate; samantha to, mph candidate abstract: background: health impact assessments (hias) are burgeoning tools in the policy arena, where media plays an important role by focusing attention on issues, informing the public, and influencing positions. examining how media portrays hias is critical to understanding hias in the policy context. methods: this study considered how widely circulated, u.s. newspapers represent hias. after searching newspaper databases, we used a qualitative document analysis method consisting of open and axial coding to examine specific phrases of hia depictions. results: in coding over 1,000 unique phrases from the 62 documents generated in our search, we found an uptick in hia-related publications since 2010. coding these documents identified 46 distinct codes across 10 different themes. the two most prominent hia-centered themes focused on hia engagement and the hia setting. while themes of policy and science, health determinants, and explanations of hias were also frequently featured, specific mentions of projected impacts, hia processes, hia values, and health outcomes were less prevalent. conclusion: hia media portrayals warrant further inquiry by researchers and practitioners. focusing on how media portrays hias is consistent with several hia steps. it is also important for a broader strategy to educate stakeholders about hias and to understand hias’ utility. hia practitioners should develop and implement guidelines for media interaction and tracking that encourage practitioners to seek additional media attention and to focus such attention on health impacts and outcomes, hia recommendations, and hia values. building on our work, researchers should examine hia media portrayals beyond the context of this study. 1 insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 2 introduction the use of health impact assessments (hias) in the united states is on the rise. to date, over 400 hias have been completed across the country (pew charitable trust, 2015). according to the national research council (nrc)(2011), an hia is a “systematic process...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” (p. 46). hias rely on a six-step process -consisting of screening, scoping, assessment, recommendations, reporting, and monitoring and evaluation -and utilize assorted data, methods, and stakeholder inputs to draw meaningful conclusions (nrc, 2011). hias are especially useful for bringing health concerns to decisions and issues that originate outside of the health sector, enhancing relationships across sectors, and empowering communities (bourcier, charbonneau, cahill, & dannenberg, 2015; dannenberg, 2016). in particular, hias can be instruments to address the social determinants of health, defined by the world health organization (2017) as “conditions in which people are born, grow, live, work and age [which] are shaped by the distribution of money, power and resources at global, national and local levels [and] are mostly responsible for health inequities the unfair and avoidable differences in health status.” addressing these social determinants is critical to tackling health inequalities across groups (cdc, 2014). however, gottlieb, fielding, and bravemen (2012) argue that, in isolation, hias do not constitute “healthy public policy.” they define “healthy public policy” as “a comprehensive approach to achieving more health-informed decision-making in other sectors, [that] generally requires multiple components,” including hias and also other strategies (p.158). in other words, hias can be an important component of a multifaceted health in all policies approach (rudolph, caplan, ben-moshe & dillon, 2013; gase, pennotti, & smith, 2013). challenging questions about the effectiveness of hias -and how to measure this effectiveness -remain critical for the field to resolve (quigley & taylor, 2004; ali, o’callaghan, middleton, & little, 2009). studies demonstrate that hias can be useful in emphasizing the connections between health outcomes and some of their causes, both for policymakers and communities (bourcier et al., 2015). proponents frequently point to the ability of hias to raise awareness about health and public policy connections across sectors and communities (winkler et. al, 2013; gottlieb et al., 2012; harris-roxas & harris, 2013). since hias appear to impact how health-related issues are perceived, it is important to understand how they are portrayed and discussed in public discourse. media is a powerful outreach tool to enhance health-promoting behaviors (randolf, & viswanath, 2004). in addition -and perhaps more salient to the social determinants of health and hia work -media plays an important role in public health policy. according to dorfman & krasnow (2014), media can blend “communications, science, politics, and advocacy to advance public health goals” (p. 293). golden & moreland-russell (2016) explain that it does so by focusing public attention on issues as well as “raising awareness of a problem, stimulating coverage of issues, generating support for proposed policy solutions, and communicating information regarding the implementation of a policy” (p. 34). shih, wijaya, & brossard (2008) have found that how issues are framed in the media impacts ways in which audiences perceive them and can “activate certain thoughts or feelings in readers’ minds that make them more likely to react in a somewhat predictable manner” (p. 142); media helps readers form heuristics to process complex issues (shih, wijaya, & brossard, 2008). thus, determining how media portrays hias is critical to understanding the relationships between hia and policy. we were unable to locate any studies in the literature that systematically examine hias’ portrayal in u.s. media sources. aiming to reduce this gap, our insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 3 study focused on understanding how hias are portrayed in u.s. print media. methods our study aimed to examine how hias have been portrayed in u.s. media sources. specifically, our study asked: how have hias been covered and characterized in the most widely circulated u.s. newspapers? to answer this question, we used qualitative research methodology to analyze newspaper documents discussing hias. according to bowen (2009), this type of “document analysis is a systematic procedure… [that] requires that data be examined and interpreted in order to elicit meaning, gain understanding, and develop empirical knowledge” (p. 27). its methodology is especially useful to understand context, identify research questions, follow the development of issues, and enrich other research findings (bowen, 2009). this type of analysis involves breaking down the content of selected documents and synthesizing and organizing data (i.e. document excerpts and quotations) into meaningful themes (bowen, 2009). the process consists of skimming documents, followed by examining them thoroughly and then conducting content and thematic analyses to make meaning of the subject matter (bowen, 2009). it is comprised of open coding, axial coding, and selective coding (neuman, 2004). in our analysis, we focused on newspapers to the exclusion of other news sources. research suggests that consumers increasingly rely on television, online, and radio sources for news and that reliance on newspapers is declining (pew research center, 2016). nevertheless, many researchers continue to focus on newspaper texts to analyze how media portrays public health concerns (rooke & amos, 2014; caulfield, clark, mccormack, rachul, & field, 2014). as rooke & amos (2014) explain, newspapers perform an important gatekeeping function; they serve as “a useful proxy for reporting in other media as they often set the agenda for other formats and are easy to access and search” (p. 508). we also limited our analysis to newspapers because, compared to other news sources, the quality of newspaper reporting is high. for example, an analysis of three large newspapers and five local tv news channels in the san francisco bay area assigned overall “a” grades to all three newspapers while the local television channels earned grades ranging from “d+” to “c+.” these grades were based on measures of context, newsworthiness, explanation, civic contribution, local relevance, and enterprise (mcmanus, 2003). using document analysis methodology, our team developed and implemented a research protocol starting in january 2017. first, we selected the specific newspapers to include in our study. we chose the 50 u.s. newspapers with the widest circulation. these newspapers were identified using the world almanac and book of facts 2016, which relied on data from the alliance for audited media (janssen, 2016). the most recent circulation data available to generate this list dated to march 2014. we relied on these 50 newspapers because of the readership reach. we also selected the time-period of 1990 to january 31, 2017 for our analysis. we did this primarily because hias are a fairly new tool in the u.s. (schuchter, bhatia, corburn, & seto, 2014). therefore, related newspaper documents would be unlikely to predate 1990. two members of our team searched for newspaper documents published in each of the 50 most circulated newspapers by using three different databases: proquest newspapers, lexisnexis academic, and access world news. for the selected newspapers and dates, we searched each database using the key term: “health impact assessment.” two members of the team then downloaded and saved all of the documents found, eliminating any duplicate results uncovered through multiple databases or documents printed only online. online-only articles were excluded because of the differences in online presence and archiving across newspapers and also because the circulation and readership for online-only documents was difficult to ascertain. insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 4 we then proceeded to code the documents and identify themes. during open coding, two members of the research team read through all of the resulting documents, twice, to familiarize themselves with their content and the ideas discussed. then, the two team-members re-read each document individually. for each main idea related to our research question, each of the two team-members selected one to three representative words, or codes, keeping detailed notes on the meaning of each code. after the initial codes were created, three members of the team met to resolve differences and compile an agreed-upon, final list of codes and code definitions. using this final list, two members of the research team together re-coded each document over several sessions. sessions consisted of each researcher reading and coding alone and then the two researchers immediately and thoroughly discussing the document codes to resolve any discrepancies in order to agree on all final codes. the team then calculated the number of times each code emerged in the documents. after each document was coded in the open coding phase, the research team completed axial coding by arranging the codes into meaningful themes. in this phase, the team organized the codes generated during open coding into larger, categorical themes that discussed related ideas. once the list of themes was finalized, we tallied the number of times each theme appeared. finally, the team engaged in selective coding to pick out representative quotations that could illustrate the character of each code and theme. we deemed a quotation representative when it exemplified the meaning of that particular code. results the initial search generated 70 documents, eight of which were excluded because they were duplicative or online only. the database searches ultimately produced 62 documents that met inclusion criteria. the 62 documents came from 27 newspapers (see table 1). of these 27 newspapers, six newspapers contained 28 total documents -or 45.2% of all documents found in our search; specifically, two newspapers published six documents each while four newspapers published four documents each. these six newspapers were: the oregonian (n=6), orange county register (n=6), los angeles daily news (n=4), star tribune (n=4), st. paul pioneer press (n=4), and buffalo news (n=4). four additional newspapers contained three documents each (a total of 12 documents, or 19.4% of all identified documents); five contained two documents each (a total of 10 documents or 16.1% of all identified documents); and 12 newspapers printed one document each (a total of 12 documents or 19.4% of all documents). in some of these newspapers, one author produced most or all of the hia-related content. we found no relevant documents in the remaining 23 newspapers. of these 23 newspapers, we were unable to search for complete results for five. three of the five (long island newsday, phoenix republic, and the detroit free press) were not indexed in the databases available to us and two of the five were only partially indexed for our period of interest (pittsburgh tribune-review indexed from 2001-2015 and woodland park herald news indexed from 1998 to 2016). table 1 lists the newspapers that contained documents relevant to our search. newspaper document citations are provided in the appendix. insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 5 table 1. number of documents mentioning “health impact assessment” in the top 50 most circulated newspapers of 2014 published between 1990 and january 31, 2017 rank newspapers results (n) rank newspaper results (n) 1 usa today 3 26 the oregonian 6 2 wall street journal 1 27 san diego union tribune 3 new york times 1 28 cleveland plain dealer 3 4 los angeles times 2 29 san francisco chronicle 5 new york post 1 30 kansas city star 6 san jose mercury news 2 31 pittsburgh tribune-review^ 1 7 new york daily news 32 st. paul pioneer press 4 8 chicago tribune 1 33 detroit free press* 9 long island newsday* 34 milwaukee journal sentinel 1 10 washington post 1 35 sacramento bee 3 11 chicago sun times 36 miami herald 12 dallas morning news 1 37 tampa tribune 13 los angeles daily news 4 38 atlanta journal-constitution 2 14 denver post 3 39 fort worth star telegram 15 houston chronicle 40 st. louis post-dispatch 16 orange county register 6 41 salt lake city tribune 17 philadelphia inquirer 42 baltimore sun 2 18 star tribune 4 43 pittsburgh post-gazette 2 19 st. petersburg times [aka tampa bay times] 44 ft. lauderdale sun-sentinel 20 newark star-ledger 1 45 indianapolis star 21 honolulu star-advertiser 46 little rock democrat gazette [aka arkansas gazette] 22 boston globe 1 47 woodland park herald news^ 23 phoenix republic* 48 buffalo news 4 24 seattle times 1 49 fresno bee 25 las vegas review-journal 1 50 orlando sentinel notes: * = not indexed in the databases used; ^ = partially indexed in the databases used while our search dated back to 1990, the first document we found was published in 1996 and the last document we found was published in 2015 (see figure 1). between the calendar years of 1997 to 2002, we found no documents that met our search criteria. most of the documents (n=57 or 91.9%) appeared in 2010 or after, with 21 documents (or 34.0%) appearing in 2014 alone. of the 62 documents that met inclusion criteria, 37 were news articles (59.7%), 11 were editorials or commentaries (17.7%), 9 were other opinion pieces such as letters to the editor (14.5%), four were news briefs (6.5%), and one was a crossword puzzle (1.6%). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 6 figure 1. frequency of documents mentioning “health impact assessment” within the top 50 mostly widely circulated u.s. newspapers of 2014 with publication dates between 1990 and january 31, 2017 by coding over 1,000 individual phrases from the 62 documents using a final list of 46 codes, grouping the codes into 10 different themes to capture related codes, and selecting quotations to illustrate the essence of each code, we identified several important patterns of how newspaper documents characterized hias. these patterns -in order of theme frequency -are discussed below. code definitions and frequencies as well as illustrative quotations are presented in table 2. in addition, figure 2 illustrates the relative frequency with which each code was observed. table 2. definitions and illustrative quotations for each code, categorized by theme theme code (n) definition quotation general reference to hia or other hia-related work hia steps (4) mentions 6 hia steps “it’s not clear how extensive the dec’s health-specific review has been or will be, or whether it will follow the guidelines and methodology laid out for health impact assessments laid out by leading medical organizations” (campbell, 2012, september 21, p. arc). “getting information out to the public ahead of the official scoping process, perhaps beginning in june, inspired creation of www.coaltrainfacts.org” (dickie, p. a15). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 7 hia-related assessment (40) mention of mental health impact assessment; environmental impact assessment; other assessment related and similar to hia but defined differently “the study coincides with a 20-month, $3 million draft environmental impact study, which is a required part of the government funding process” (mohr, p. a3). “the dec has already released a draft set of regulations and two non-final versions of its environmental impact statement, which has grown to 4,000 pages” (campbell, 2012, september 20, p. arc). hia background (9) mentions or discusses when, why, and by whom hias are used or performed – not specific to the hia that is the main topic of the newspaper piece “ross said that the “health impact assessment” is about improving quality of life, such as finding best practices for sound-proofing homes near an airport” (tobin, p. a11). “a health impact assessment is a relatively new tool in urban planning. it uses existing epidemiological data to project the likely health outcomes of a change to a community’s built environment” (mccurdy, sec. clark community). previous hias (14) mentions or discusses other hias in the us or abroad – mention should be of a specific hia other than the one that is the main topic of the article “doctors elsewhere are starting to call for a health assessment along the entire corridor. the concept is not new. a study was done in 2008 on the highway 520 replacement” (dickie, p. a15). “a similar health impact assessment was completed last year for the bottineau transitway, which is slated to be a 13mile extension of the blue line light-rail …” (mohr, p. a3). general hia definition (6) defines in general (that is, not specific to the hia that is the topic of the newspaper piece) what hias are “what if proposed policies had to include a health impact assessment in addition to the oft-required fiscal impact analysis? including information about a policy’s health impacts could shift the view” (gara, sec. my town). “to measure how planning decisions affect health in city neighborhoods, collier said his department would use a new digital tool called health impact assessment, which employs data to measure the potential effect of policy on public health” (litt, p. 6). miscellaneous other (64) information not related to the hia “cities were sickly places 150 years ago. dysentery, typhoid, measles, influenza and other diseases thrived in overcrowded and unsanitary conditions. it took heroic and creative leadership by city planners, architects and health advocates to create healthier cities” (kaufman, p. m6). “freed, a former board member for environmental advocates of new york, ceased working for the state in march of this year. both he and the department of health declined comment on why he no longer works there” (campbell, 2012, september 21, p. arc). author opinion (67) opinion or conjecture of the author of the editorial or letter – not fact “the mayor has been a stubborn disappointment since taking office, but he hit a high note with his june 5 speech commemorating world environment day” (duin, sec. local news). “when is a proposed moratorium on oil and gas drilling really not a moratorium at all but an excuse to ban such operations for a couple of years?” (loveland is the latest, 2014, p. 15a) hia values social justice (3) discusses or mentions social justice “ben duncan, chairman of the environmental justice task force, said the trains tend to pass through lower-income neighborhoods, whether in eastern oregon, portland or eugene. that’s “an environmental justice issue that cannot be ignored,” he said” (learn, 2012, july 20, sec. local news). “the worst part of this story is that this compressor and pipeline, which are slated to be built in pendleton and wheatfield, will get the toxic gases and threat of malfunctions, while canada gets “clean gas” (stanley, p. 5). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 8 vulnerable population (21) discusses or mentions a vulnerable population “delaying disconnection can cause other problems for vulnerable populations, allowing them to accrue more debt” (wernau, p. 2.1). “metro-area faith leaders say a $1.8 billion plan to widen a portion of interstate 70 in northeast denver should be scuttled because it is a public health threat and will break up low-income families…” (whaley, p. 17a). equity (9) discussion of a population that is at risk of inequity or harm “today, if collier’s views hold sway, equity would mean a greater emphasis on improving public health through parks, bike trails and healthier food options for residents in economically challenged neighborhoods” (litt, p. 6). “and communities have become willing to overcome earlier hesitation over connecting racially and economically diverse areas with bike lanes and other recreational pathways” (litt, p. 1). hia setting geographic setting (24) mentions or discusses the geographic setting for the decision related to the hia “metro-area faith leaders say a $1.8 billion plan to widen a portion of interstate 70 in northeast denver should be scuttled because it is a public health threat and will break up low-income families…” (whaley, p. 17a). “a $100,000 grant will fund a yearlong study of potential health effects resulting from the development of the gateway corridor, the transit link being developed along interstate 94 from the eastern end of woodbury to downtown st. paul” (anderson, p. 2n). hia decision (65) mentions or discusses the proposal, policy, law, program etc. that is the subject of the hia “the eastside greenway [project] … would bring nature and recreation closer, among other benefits” (litt, p. 1) “placer county has proposed developing the power-generation facility on county-owned land off highway 89 between truckee and squaw valley” (litt, p. 1). problem background (86) mentions or discusses the situation that led to the proposal being examined in the hia “today’s cities are plagued with traffic, violence and overcrowding” (kaufman, pg. m2). “when matt pakucko and hibino bought their four-bedroom home in porter ranch eight years ago, they say it was never disclosed it sat on an oil and gas field. the closest well pumps crude 1,200 feet from their house” (bartholomew, p. 3) timeline (25) timeline for the decision related to the hia “the council unanimously agreed last month that owner sam chew must cease new shipments and clear the lot by feb. 1, 1997” (central los angeles, 1996, p. 5). “city manager tom bakaly said … the analysis should be finalized by the end of june” (cooley, p. h). legal mandates (11) mentions or discusses government requirements related to the hia “tuesday is the last day to comment on new proposed fracking regulations in california as mandated by sb 4” (russell, p. 11a). “such measures have historically been a tough sell in wisconsin, where the legislature passed the truth-in-sentencing law in 1999 and last year rescinded a program that released prisoners early for good behavior or health reasons” (russell, p. 11a). decision-makers (42) mention or discussion of those who are making a decision related to the topic of the hia “coal export critics ramped up pressure on gov. john kitzhaber on thursday to delay any oregon projects until a comprehensive “health impact assessment” is completed” (learn, 2012, july 20, sec. local news). “several environmental and medical groups had on martens and gov. andrew cuomo to tap an independent, non-governmental group to assess hydrofracking’s physical effects on humans” (campbell, 2012, september 20, p. arc). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 9 baseline conditions (33) discusses or mentions baseline or existing conditions about the community affected by the hia decision related to health or other factors “despite almost 60 years of nationwide experience proving the safety and tooth-saving benefits of maintaining a consistent level of this naturally occurring element in the water, fewer than 14 percent of new jerseyans receive fluoridated drinking water” (harris, p. 4). “among other issues, mariposa’s assessment found that more than 55 percent of the neighborhood’s predominantly latino residents were overweight, about 75 percent had high blood pressure or were borderline, and nearly 40 percent had a condition that prevented them from working” (gose, p. b8). process for this particular hia hia authors (20) mentions or discusses authors of hia “the health impact assessment that the city commissioned mcdaniel lambert inc. to complete…” (cooley, 2014, june 12, p. 1). “research team member courtney coughenour, an assistant professor in public health courses at unlv…” (ortega, p. b1). hia funding (12) mentions or discusses grant or other funds used to conduct the hia that is discussed in the newspaper piece “georgia tech’s work is being funded in part by more than $300,000 in grants from sources including the ford motor co., the pew charitable trusts and the robert wood johnson foundation” (tobin, p. a11). “a $100,000 grant will fund a yearlong study of potential health effects resulting from the development of the gateway corridor…” (anderson, p. 2n). availability (11) mention or discussion of where completed hia or its related documents are available “residents can read the report online at www.henn epin.us/ bottineauhia. copies are available at hennepin county libraries at brookdale, brooklyn park, golden valley, rockford road and sumner” (bottineau transitway, p. 2aa). “the report documenting the expected health impact of the proposed bottineau light-rail line is now available online and at local libraries” (bottineau transitway, p. 2aa). community event (14) mention of public forum or event related to the hia where community members are present “the prospect of whatcom county hosting the annual export of 54 million tons of power river basin coal helped turn out more than 800 people for a community meeting on what the environmental review of the project should cover” (bottineau transitway, p. 2aa). “the gathering attracted st. paul citizens representing a cross-section of ethnic and religious groups advocating for protection for low income people, small businesses and history in the heart of st. paul” (simons, p. 1b). steering committee (4) discusses or mentions a steering committee created to work on the hia “coyne is helping to lead a steering committee that includes planners and elected officials from shaker heights, cleveland heights, university heights, euclid, south euclid, beachwood, lyndhurst, pepper pike, mayfield, mayfield heights, highland heights, orange, warrensville heights and bratenal” (litt, p. 3). “the committee also included former mayor miesha headen of richmond heights.... christel best, director of economic development, represented the city at the last steering committee meeting” (litt, p. 3). projected impact of decision, program, or policy hia impact of decision (19) discusses or mentions the decision’s expected impact on health or its determinants (e.g. projections) “if vaccine mandates are weakened, we will see pockets of unvaccinated kids putting at risk infants, pregnant women and people whose immunity has waned or never took when first inoculated” (harris, p. 4). “the report found several possible negative health impacts, including a likely increase in mortality locally due to exposure to air pollution, increased traffic injury risks and both mental and physical problems associated with the project’s odors” (cooley, p. k). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 10 recommendations (9) mention or discussion of the hia’s recommendations “because research shows that giving children information about nutrition early in life can have a positive effect on their attitudes later, the team suggested schools provide professional workshops to kindergarten teachers to improve their nutrition education strategies. it also recommended free universal meals for all kindergartners to ensure they receive proper nutrition” (ortega, p. b1). “the health impact assessment recommends that the icc disallow remote disconnection” (wernau, p. 2.1). cost (30) discusses or mentions projected impact of the decision that is the subject of the hia on monetary cost (in dollars) to the government or private parties “the gateway corridor project is expected to cost about $400 million” (mohr, p. a3). “city staff estimate that the first phase of construction for the project… will cost $563,000” (cooley, p. h). economics (15) mentions or discusses projected impact of the decision that is the subject of the hia on the economy and/or economic well-being of the community or groups or individuals in the community “supporters say the project can be done without long-term harm to the environment, providing an economic boost to the regional economy” (myers, p. a8). “the city council on tuesday night asked for additional changes to a cost benefit analysis taking place on the proposed e&b natural resources oil drilling project” (cooley, p. h). engagement stakeholders (100) mentions or discusses involvement and input into the hia or related decision by stakeholders (i.e. persons or organizations invested or interested in the decision being discussed by the hia) “healthy corridor for all, a coalition of st. paul community groups, unions and churches, organized the event to push this message: decisions surrounding the central corridor project should be made in a way that improves life for the low-income and minority residents that populate the neighborhoods along university avenue” (simons, p. 1b). “in february, a group of 19 duluth-area physicians, nurses and medical school faculty sent letters to state and federal regulatory agencies saying the effects of copper mining on human health haven’t been adequately addressed” (myers, p. a8). collaboration (21) mentions or discusses relationship between different sectors (e.g. public health and other sector) “the pennsylvania department of health is charged with ensuring and protecting the health of all state residents. it fulfills this obligation by partnering with communities to monitor existing and emerging health problems and to establish programs that prevent disease and injury” (mcdermott-levy & katkins, p. b1). “ross said the studies are being done by several georgia tech departments, including mechanical engineering, and city and regional planning” (tobin, p. a11). health department (24) mentions or discusses local, state, or federal health department (e.g. cdc, state health department) “the groups want the minnesota department of health to conduct the review, saying none of the human health issues has been vetted in the ongoing environmental impact statement that has focused on how minnesota’s first copper mine might affect air and water quality, wildlife and other natural resources” (myers, p. a8). “officials at the centers for disease control say raw milk consumption is 150 times more likely to cause similar infections than pasteurized milk” (harris, p. 4). expert (10) mentions or discusses opinion of an expert in the field related to the hia, other than the hia authors “ann stahlheber, a county public health dietician who helped collect the data, said that well-used trails and parks could improve safety and public health” (litt, p. 1). “three outside experts assisting new york with a health review of hydraulic fracturing say their work was completed more than a month ago, which the state health department didn’t reveal during lengthy testimony before lawmakers last week or in a public statement” (campbell, 2013, february 8, p. arc). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 11 feedback (154) mentions or discusses testimony or feedback about the hia or related issue from someone in community or a stakeholder “ophthalmologist andy harris, an advisory board member for oregon psr, said coal export out of oregon and washington ports poses ‘a significant risk to public health’” (learn, 2012, july 20, sec. local news). “michael schommer, a health department spokesman, said that “commissioner ehlinger looks forward to discussing the issue with the governor later this week, and to addressing any of his questions about the requests for a health impact assessment” (marcotty, p. b1). policy and science community advocacy (21) discusses how community members affect policy or policymaking process “the records obtained by gannett’s albany bureau show that several organizations have been privately pushing the department of environmental conservation and gov. andrew cuomo’s office to take a broader look at the potential health impacts of hydrofracking” (campbell, 2012, september 21, p. arc). “more than 250 doctors asked gov. cuomo yesterday to order a thorough review of potential health hazards before allowing hydraulic fracturing in upstate’s marcellus shale” (kriss, p.14). science advocacy (2) discusses how scientists affect policy or the policymaking process “unfortunately, health professionals contribute to this confusion by their silence. some who dare to speak out are attacked professionally and personally. some have trouble communicating complex issues in understandable language. many work for public institutions, such as universities and health agencies, with strict rules about ‘lobbying’ and can’t speak directly to legislators without their employer’s consent” (harris, p. 4). “legislators should invite academic researchers to present objective testimony without concerns over lobbying. the state’s significant data resources and newly developed health information networks should inform their deliberations” (harris, p. 4). misinformation (4) mentions or discusses information that is not scientifically accurate or groups espousing such information “opponents of fluoridation, citing concerns about cost, toxins and lack of consent, ignore the fact that 72 percent of the nation’s water is already fluoridated without adverse health effects. every dollar spent on fluoridation saves $38 in dental care” (harris, p. 4). “vaccine deniers painted a somber portrait of children damaged by vaccines, while public health professionals cited detailed research studies showing that vaccinations prevent, rather than cause, serious disease” (harris, p. 4). lack of evidence (7) mentions or discusses lack of consensus on an issue related to the hia topic “los angeles city councilman mitch englander and l.a. county supervisor michael antonovich only repeat what socal gas says: the leak is ‘non-toxic,’ ‘no health concern.’ neither repeats what dozens of residents said about being sick from the gas” (frazer, p. 4). “instead, self-proclaimed experts citing personal anecdotes or cherry-picked factoids fresh off the internet are heard in the same forum and often given the same credence as scientific experts with decades of training and experience dedicated to advancing public health” (harris, p. 4). scientific evidence (27) mentions or discusses credible, scientific evidence related to an issue related to the hia “a separate analysis that used comed’s data from its pilot study said education will be especially important to the area’s most vulnerable populations: the sick, the poor and the elderly, who otherwise won’t receive the benefits they’re paying for” (wernau, p.2.1). “research shows that fewer patients die when their caregivers are vaccinated against the flu, but last year, only 64 percent got the shot” (harris, p. 4). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 12 failure to conduct hia (12) refusal to conduct hia, despite stakeholder or community interest in an hia “new york’s top environmental regulator on thursday dismissed calls for a lengthy outside analysis of natural-gas drilling’s health effects, instead calling on the department of health to tap experts to assist in the state’s review” (campbell, 2012, september 20, p. arc). “since the department has failed to provide a public registry of fracking-related complaints, there is no way to determine whether it is adequately monitoring and investigating fracking’s health effects” (mcdermott-levy & katkins, p. b1). hia pushback (4) resistance by stakeholders or decision-makers to the findings of a completed hia “following the preliminary report’s release in february, e&b’s attorneys sent the city a letter demanding it “retract and disavow” the report, claiming it failed to address existing laws that regulate air, water and soil quality” (cooley, p. e). “e&b asked the city to retract and disavow the report, claiming that the hia failed to address existing laws that regulate air, water and soil quality. the oil company also claimed that statements in the report were either not backed up by science or used untested methods for verification” (cooley, p. k). hia resistance (23) resistance to conducting an hia by stakeholders or decision-makers “the city of hermosa beach has withdrawn the health impact assessment for the proposed oil drilling project at the request of the consulting group that compiled the report” (cooley, p. k). “in february 2011, a cuomo administration official sent a letter to a doctor who had pressured the department of health on hydrofracking, outlining his position that an extensive health assessment would be redundant” (campbell, 2012, september 21, p. arc). health determinants healthy community (21) mentions or discusses attributes of a community that are termed or described as healthy or desirable for health purposes “by redesigning the area where people live, they hope to change how they live, making it so simple to move and eat good foods that people start leading a healthier life” (dworkin, sec. living). “‘we seek a solution that demonstrably improves the health and wellness of residents beyond conditions that exist today -that is, a solution that results in measurably better health conditions for residents, schoolchildren, workers and visitors to these neighborhoods,’ the letter says” (whaley, 17a). access to healthcare (3) mentions or discusses a person’s or community’s access to the healthcare system and/or clinical services (e.g. paying for health insurance, getting to a doctor) “large hospital groups typically make these transactions to keep smaller, financially distressed nonprofit hospitals open so they can continue to serve their communities” (maiman, p. 11a). “do we want to hold a community’s access to critical health care while the litigation process resolves itself?” (maiman, p. 11a). community development (31) mentions or discusses building projects in the community (e.g. related to housing, transportation, and/ or planning) “so activists are working with portland’s bureau of planning and sustainability to map out new sidewalks and other changes that could turn the area around southeast 122nd into a ‘20-minute neighborhood’” (dworkin, sec. living). “‘we are the test bed for the re-creation of urban spaces, neighborhoods and communities,’ said catherine ross, director of the school’s center for quality growth and regional development. ‘my hope is that we develop this reputation -with atlantic station, the beltline and the aerotropolis -as cutting edge examples of recreating communities’” (tobin, p. a11). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 13 environment (24) mentions or discusses the natural environment or attempts to address impacts on the natural environment by government or others “the preliminary finding said air pollution, noise and increased traffic from the project would subject neighboring residents to numerous physical and mental problems” (cooley, p. e). “it is also clear fracking will cause environmental damage, especially to water. it has happened everywhere fracking is allowed and it can’t be stopped” (guy, p. 17a). health behavior (6) mentions or discusses individual behaviors that can have positive or negative impacts on health outcomes (e.g. smoking, substance abuse, sexual practices, healthy eating, exercise) or associated risks “in addition to encouraging convenience stores to offer healthier food, mortell and other officials have been working to encourage county residents to walk and bike” (mccurdy, p. clark community). “‘for example, developments that include sidewalks and nearby places to walk to such as coffee shops and grocery stores can encourage people to exercise -even casually - and can help in the war against obesity,’ he said” (frankston, p. f1). health outcomes injury (3) mentions or discusses injury-related morbidity or mortality (e.g. car crash, fall, gun violence, etc.) or associated risks “the data show that from 2008 to 2012, there were 330 accidents involving bikes on east side roads and streets, and 596 pedestrian accidents” (litt, p. 1). “with more time spent in the car, the probability of a crash becomes greater. a lack of sidewalks also can lead to more pedestrian fatalities” (frankston, p. f1). chronic disease (26) discusses or mentions morbidity or mortality data related to chronic disease “sprawling cities that force people to drive long distances to work, school or shopping reduced the amount of exercise people got by replacing walking with increased driving. problems linked to sprawl include heat stroke, road rage, obesity, asthma and diabetes” (frankston, p. f1). “‘for example, developments that include sidewalks and nearby places to walk to such as coffee shops and grocery stores can encourage people to exercise -even casually - and can help in the war against obesity,’ he said” (frankston, p. f1). insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 14 figure 2. number of times each code appeared in examined documents insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 15 theme 1: engagement the most common theme that appeared in the documents focused on hia-related engagement. this theme includes codes that captured documents’ discussions of collaboration and feedback across sectors, with stakeholders, and with experts. within the engagement theme, which appeared 309 times in the documents, “feedback” was the most frequently used code (n=154). the “feedback” code was used when a phrase focused on a reaction to the hia or related issues from a stakeholder or community member. the second most commonly used code under this theme was “stakeholder” (n=100). the “stakeholder” code was used when an article mentioned involvement in the hia or a related decision by a stakeholder. phrases discussing collaborations between public health and other sectors (e.g. city planning, academia, or engineering) also appeared within this theme. theme 2: hia setting the second most frequently appearing theme (n=286) consisted of codes depicting the environment in which the hia was occurring. the most frequently used code in this theme captured language discussing the “problem background” (n=86), or the situation that led to a proposal examined by the hia. this theme also included discussions of the “hia decision” (n=65) -that is, the proposal, policy, law, or program that was the subject of the hia -and “decision-makers” (n=42), the individuals, groups, and organizations involved in making decisions on a proposal examined by the hia. this theme also included codes that captured the scope of the hia, such as existing conditions (n=33), hia or decision timelines (n=25), hia geographic settings (n=24), and any related mandates (n=11). theme 3: miscellaneous many of the documents contained authors’ opinions (n=67) and other statements (n=64) that were not directly related to the hias or the issues they were examining. we grouped these two codes into a theme that we called “miscellaneous” (n=131). while not focused on the hia, phrases coded under this theme were still prominent. the “author opinion” code in particular was often used in opinion pieces. theme 4: policy and science the fourth most frequently detectable theme represented discussions of various aspects of the policy process and its interaction with scientific evidence (n=100). within this theme, the most frequently used code, “scientific evidence” (n=27) captured phrases that connected scientific evidence to an issue examined by the hia. many documents mentioned ways in which community members affect policy or the policymaking process (n=21). they also contained language that discussed resistance to conducting an hia by stakeholders or decision-makers (n=23), refusals to conduct an hia despite stakeholder or community interest (n=12), or resistance to the findings of a completed hia (n=4). mentions of how scientists affect policy were infrequent (n=2). some documents discussed a lack of scientific consensus on an issue related to an hia topic (n=7) or discussed information that was not scientifically accurate (n=4). theme 5: health determinants the “health determinants” theme appeared in the documents 85 separate times. the most frequently used code under this theme was “community development” (n=31), which captured discussions of built environment projects related to housing, transportation, or planning. codes capturing mentions of the natural environment (n=24) and attributes of healthy communities (n=21) also appeared in the newspaper documents with moderate frequency. in contrast, individual health behaviors (n=6) and access to healthcare (n=3) were mentioned infrequently. theme 6: general reference to hia or other hia-related work many documents made general references to hias or the hia process or discussed other hias previously completed (n=73). within this theme, mentions of hia-related assessment, such as environmental iminsights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 16 pact assessments or mental health impact assessments, were frequent (n=40). the documents also contained phrases intended to explain hias to readers. this included language that defined hias (n=6); explained when, why, and by whom hias are typically performed (n=9); specifically mentioned the 6 hia steps (n=4); and discussed previously completed hias (n=14). theme 7: projected impacts discussions of the projected impacts of the decision, program, policy, or issue at the center of the hia were appeared in the documents 73 times. this included projections of monetary costs (n=30) and broader economic impacts (n=15). it also included projected health impacts (n=19). we coded nine times when specific recommendations were mentioned in the documents. theme 8: process for a particular hia codes centered on the process of a particular hia appeared in the documents with some frequency (n=61). this theme included mentions of an hia’s authors (n=20) and funding sources (n=12). it also included mentions of events or fora held as part of the hia process at which community members were present and input was solicited (n=14), and any steering committees or similar groups created to work on or guide the hia (n=4). mentions of the publication of the hia report or related documents were coded as “availability” and appeared 11 times. theme 9: hia values discussions of hia-related values were relatively infrequent (n=33). this theme manifested primarily through mentions of vulnerable populations (n=21) and equity (n=9). in a few cases, social justice was also specifically referenced or discussed (n=3). theme 10: health outcomes while mentions of health outcomes did appear in the documents, the use of mortality and morbidity data was relatively infrequent (n=29). the majority of these references focused on chronic diseases (n=26), such as asthma and diabetes, and their risk factors. a few phrases referenced injuries (n=3). discussion this study examined how hias are portrayed in widely circulated u.s. newspapers. while previous research has considered hias in the broader policy-making context, we were unable to locate studies that systematically analyzed discussions of hias in u.s. media sources. this is an important line of inquiry because of media’s prominent role in policymaking, particularly in focusing attention. we concentrated our research on representations of hias in major newspapers, searching newspaper databases for documents published in the most widely circulated newspapers in the u.s. between 1990 and january 31, 2017. we found 62 unique documents from 27 newspapers in our search. approximately two-thirds of these documents were news pieces and the remaining one-third were opinion pieces. almost 92% of these documents were published in 2010 or thereafter and 45.2% were published in just six sources. for the pieces found through our search, we used a qualitative document analysis method consisting of open and axial coding to examine more than 1,000 individual phrases. we ultimately identified 46 unique codes across 10 different themes. the two most prominent themes focused on engagement around an hia and the hia setting. while policy and science, health determinants, and explanations of hias were also frequently featured themes, specific mentions of projected impacts, hia processes, hia values, and health outcomes were less prevalent. attention to hias in major u.s. print media sources is on the rise. this is not surprising because the use of hias is steadily increasing nationwide (the pew charitable trusts, 2015). more surprisingly, however, is that while over 400 hias have been completed in the u.s. (the pew charitable trusts, 2015), their coverage in print versions of major u.s. newspapers has been limited. this may be in part because many hias, insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 17 including the ones that were the subjects of the newspaper documents in our analysis, considered local-level decisions about the built or natural environment and most of the newspapers we searched focused primarily on limited geographic areas where hias may not have been taking place. another potential explanation for this limited coverage may be a lack of knowledge of or interest in hias and the issues they analyze by newspapers. a reader relying primarily on printed versions of usa today, the wall street journal, the new york times, the los angeles times, the chicago tribune, the washington post, or other major u.s. newspapers as a main source of news, therefore, will have only very limited exposure to hias from news media. in fact, even in the last seven years, when the vast majority of hia-related documents were printed in the newspapers we searched, readers might be exposed to only one to three stories. in many large newspaper markets, exposure to hia-related newspaper documents may be non-existent. in large market newspaper media sources, it seems, hia discussions are still very much a novelty. our analysis indicates that hia depictions in newspapers center on two major themes: (1) hia-related engagement and (2) setting the scene for the hia. within the engagement theme, which appeared over 300 times in the 62 documents, the two most prevalent types of depictions focused on stakeholder feedback (n=154) and involvement in the hia (n=100). this suggests that newspaper documents are primarily used to demonstrate how stakeholders and community members interact with hia processes and their underlying questions. additional research is needed to better understand why media portrayals focus on engagement and setting the hia scene. one possible explanation that merits study is whether focusing on hia engagement and setting the scene for an hia provides what news outlets would consider newsworthy content when compared to other important facets of an hia, such as its processes, recommendations, and values. newspaper documents are also consistently used to draw attention to the setting and scope of the hia, emphasizing questions leading to the assessment (n=86) and the specific decisions being assessed (n=65). this includes emphasizing decision-makers, timelines, settings, and conditions giving rise to the issues central to the hia as well as presenting hias as tools to understand problems and address uncertainty. relatedly, newspaper and other media sources appear to underscore the connections between policy and science, explain hias, and discuss health determinants. the prominence of these themes across newspaper documents is consistent with previous research that stresses the ability of hias to heighten awareness across communities and sectors (winkler et al., 2013; gottlieb et al., 2012; harris-roxas & harris, 2013). our analysis supports the possibility that media depictions are a mechanism through which hias raise awareness beyond the hia team and its partners and may also present an important way to measure attempts to heighten awareness. a more surprising finding of this study is that the documents examined focused less on projected impacts (including impacts on health, costs, and the broader economy) and hia recommendations; hia processes; health data; and hia values. information on the hia process – including its authors, steering committees, funding, community events, and availability – for example, arose only 61 times across all documents. readers of these newspaper documents therefore may end the pieces without a sense of the hia process or what happens next. perhaps even more surprising, while scholars have found that hias can be useful in emphasizing the connections between health outcomes and some of their causes (bourcier et al., 2015), these connections appeared infrequently in the documents we analyzed. although there were references to costs (n=30) and economic impacts (n=15), we found only 19 phrases specifically mentioning health impacts related to an hia and 29 references to health outcomes data. specific recommendations made in the hia appeared only 9 times across all 62 documents. hia values (i.e. social justice, vulnerable populations, and equity) were mentioned in the documents in aggregate insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 18 only 33 times. these findings are surprising because, in contrast to the portrayal we observed in the newspaper documents, hias are organized around projecting health impacts and recommending health-promoting actions around core values. an implication of this finding is that in contributing to newspaper documents, both hia practitioners and authors of newspaper documents should frame hias in terms of their scope and values and emphasize the health-related projections and recommendations that are central hia outputs. a concerted focus on media depictions during an hia and after its completion is critical for hia practitioners (lin, houchen, hartsig, & smith, 2017). it is especially useful as part of reporting, stakeholder engagement, and monitoring and evaluation. this is because of media’s prominence in the public policy process (golden & moreland-russell, 2016). hia coverage in major newspaper sources is limited, leaving an important mechanism of dissemination and potential impact underutilized, especially in the reporting phase. our finding that only about 14.5% of the documents analyzed were letters to the editor also suggests untapped opportunities to use hia findings in media-based advocacy. a practitioner-led effort to use media more frequently and in ways that emphasize health impacts, recommendations, and hia values – especially in larger markets – may be important for a shared strategy of informing community members about hias and the social determinants and building momentum in the field. employing such a strategy may require that practitioners work with trained communications experts or receive additional training on both how to work with media effectively and how to portray and frame their work around hia processes, projected impacts, recommendations, and values. such a strategy would be consistent with the major strengths of hias: inserting health concerns into non-health sector decisions and empowering communities (bourcier et al., 2015; dannenberg, 2016). hia practitioners should also build on existing practices to track hia media portrayals as part of monitoring and evaluation (lin et al., 2017). in addition to aiding with monitoring issues and tracking impacts of specific hias, media analysis can also assist in understanding the aggregate impact of the hia field, which remains a challenge (quigley & taylor, 2004; ali et al., 2009). uniform practitioner standards to track hia-related media reporting are imperative for the success and utility of individual tracking efforts. while our study presents important findings, it has several limitations. our study focused on large market (i.e. top 50), print newspapers. however, we were unable to comprehensively search five of the 50 newspapers in the databases available to us. the study also excluded all other newspapers. in the process, it excluded any discussions of hias occurring in other markets or in smaller newspapers in the same markets. furthermore, the study excluded other frequently consumed media sources, such as television, radio, and the internet. these exclusions may affect the generalizability of this study beyond the sources we considered. nevertheless, analyzing newspaper documents is important, particularly because of their gatekeeping function and because of the relative quality of their content. in addition, while we analyzed newspaper documents, our study did not take into account whether readers actually read these documents or how they interpreted them. finally, while we used an established method of document analysis, the phrases that triggered certain codes and themes for our team may have triggered other codes or themes for other researchers or led other researchers to select alternative themes and taxonomies. this study and its limitations raise vital questions for future research. media can be important to the policy process and advancing public health (dorfman & krasnow, 2014). future research in this area should aim to understand hia portrayals in the media beyond large markets and beyond print newspapers. one strategy could involve a media analysis for each completed hia. our recommendation to create and use uniform practitioner standards for tracking would greatly assist insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 19 in conducting this type of research. studies should also examine the actual impact of media portrayals of hias on stakeholders and community members. such research can help hia practitioners understand the most effective ways to employ this important tool and contribute to new standards in the field. conclusion a central purpose of hias is to contribute best-available evidence to questions of policy. as such, hias function in a larger policy landscape. a powerful feature of this landscape is the media, which has the ability to inform and shape ideas and actions of communities, stakeholders, and decision-makers both about specific policy questions and the connections between the social determinants and health outcomes. thus, it is critical to understand how hias are represented in media sources. by aiming to examine how widely circulated, u.s. newspapers depict hias, our study begins to build systematic evidence to answer this question. our findings indicate that there is substantial room in both how much hias are discussed in major media sources and how they are discussed. while discussions of hias in newspaper documents are on the rise, many readers are never confronted with hias in major newspaper sources. those who are exposed, more frequently encounter depictions focused less on hia projections, recommendations, and values and more on engagement and the hia setting. this presents tremendous opportunities for hia practitioners to increase efforts to both study these portrayals in greater depth and enhance these portrayals through media interaction. in addition, hia practitioners should establish and utilize uniform media engagement and tracking guidelines to understand and meaningfully compare this aspect of hias. this is significant because the media is a powerful tool for reporting, monitoring and evaluation, and stakeholder engagement. it is also important because of media’s potential to educate stakeholders about the connections between health outcomes and social factors and to help build an hia movement. insights into how hias are characterized in the press gakh; 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(2011). improving health in the united states: the role of health impact assessment. washington, d.c.: national academies press. retrieved from: https://www.nap.edu/catalog/13229/improving-health-in-the-united-states-the-role-of-health. neuman, w.l (2004). basics of social research: qualitative and quantitative approaches. san francisco, ca: pearson education, inc. the pew charitable trusts. (2015, november 4). health impact assessments in the united states. [map illustrating of hias completed in the u.s.]. retrieved from http://www.pewtrusts.org/en/multimedia/data-visualizations/2015/hia-map. pew research center. (2016). the modern news consumer: news attitudes and practices in the digital era. retrieved from: http://www.journalism.org/2016/07/07/pathways-to-news/. quigley, r. j., & taylor, l. c. (2004). evaluating health impact assessment. public health, 118(8), 544-552. doi:10.1016/j.puhe.2003.10.012. randolph, w., & viswanath, k. 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(2008). media coverage of public health epidemics: linking framing and issue attention cycle toward an integrated theory of print news coverage of epidemics. mass communication & society, 11(2), 141-160. winkler, m. s., krieger, g. r., divall, m. j., cissé, g., wielga, m., singer, b. h., . . . utzinger, j. (2013). untapped potential of health impact assessment. world health organization. bulletin of the world health organization, 91(4), 298-305. world health organization. (2017). social determinants of health. retrieved from: http://www.who.int/social_determinants/sdh_definition/en/. insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 22 appendix: newspaper documents analyzed in this study anderson, j. (2014, november 23). news brief grant to fund health study of transit corridor. star tribune: newspaper of the twin cities, p. 02n. bartholomew, d. (2015, august 19). public health residents call for health study of proposed oil wells. los angeles daily news, p. 3. bottineau transitway health report available. (2014, january 8). star tribune: newspaper of the twin cities, p. 02aa. campbell, j. (2012, september 21). dec's fracking announcement months in the making. usa today, p. arc. campbell, j. (2013, february 8). health consultants made fracking recommendations weeks ago. usa today, p. arc. campbell, j. (2012, september 20). health department to assist dec in hydrofracking review. usa today, p. arc. carroll, v. (2012, march 24). new front in frackingwars [editorial]. the denver post, p. 9b. central los angeles; council affirms plan to clean up dump. (1996, march 20). los angeles times, p. 5. cooley, r. (2014, june 12). can hermosa learn from huntington?. the orange county register, p. cover. cooley, r. (2014, june 5). city asks for more details on oil drilling project. the orange county register, p. h. cooley, r. (2014, april 17). city withdraws health report for oil project. the orange county register, p. k. cooley, r. (2014, may 30). hermosa beach asks for more details on oil plan. the orange county register, p. central_b. cooley, r. (2014, july 24). report: oil project has minimal health impact. the orange county register, p. e. cooley, r. (2014, july 16). report: oil project would not cause health problems. the orange county register, p. b. dickie, l. (2012, march 30). huge coal-export terminal needs rigorous environmental review [editorial]. the seattle times, p. a15. doctors, nurses prod cuomo on “fracking.” (2012, october 19). the buffalo news, p. d3. duin, s. (2013, july 2). ending the island's misery. the oregonian, sec. local news. dworkin, a. (2010, february 10). health movement. the oregonian, sec. living. dyrszka, l.m. & gibbs, l.m. (2012, april 10). new yorkers have a right to know the health impacts [editorial]. the buffalo news, p. a8. frankston, j. (2003, november 17). health pros link sprawl with spread suburbs, obesity stir debate. the atlanta journal – constitution, p. f1. frazer, g. (2015, november 20), porter ranch gas leak provides cause to worry [letter to the editor]. los angeles daily news. p. 14. gara, m. (2014, november 24). all measures should reveal health impacts [letter to the editor]. san jose mercury news, sec. my town. gose, j. (2013, march 06). construction that focuses on health of residents. the new york times, p. b.8. guy, j. (2014, october 11). no fracking in western md. [letter to the editor]. the baltimore sun, p. 17a. harris, d. (2012, february 26). base public health policies on real science [editorial]. the newark starledger, p. 004. hill, p. g. (2011, february 07). fathers' group opposed sjc pick for good reasons. boston globe. johnson, a. (2012, november 29). study urges prison alternatives | advocacy group says investing in mental health could save millions. milwaukee journal sentinel, p. 03. kaufman, n. (2004, december 5). city fixes; good design keeps the doctor away [commentary]. los insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 23 angeles times, p. m.2. kriss, e. (2011, october 6). docs' frack attack. the new york post, p. 014. landers, j. (2011, september 9). projects urged to consider health. the dallas morning news, p. d01. learn, s. (2012, july 20). critics seek delay in coal export permits. the oregonian, sec. local news. learn, s. (2012, september 20). stoked about coal, city leaders affirm opposition, call for study. the oregonian, sec. local news. litt, s. (2014, july 27). designing with health in mind a goal of new planning director. the cleveland plain dealer, p. 006. litt, s. (2015, january 25). opinions sought on eastside greenway multiuse paths would connect communities. the cleveland plain dealer, p. 001. litt, s. (2014, september 30). planners seek input on east side greenways: many suburbs have few parks or trails nearby. the cleveland plain dealer, p. 003. loveland is latest front on fracking [editorial]. (2014, june 17). the denver post, p. 15a. maiman, b. (2014, september18). bill grants too much power to ag [editorial]. the sacramento bee, p.11a. marcotty, j. (2015, november 18). dayton weighs health review of copper mine. star tribune: newspaper of the twin cities, p. 0b1. mccurdy, c. (2012, august 25). obesity a county problem. the oregonian, sec. clark community. mcdermott-levy, r. & kaktins, n.m. (2014, july 27). is the pa. health department fracko-phobic? it’s actions don’t instill confidence that it is protecting us [editorial]. pittsburgh post-gazette, p. b-1. mohr, e. (2014, november 11). gateway corridor study to focus on how project will affect health – emphasis to be on land use around bus rapid transit station. st. paul pioneer press, p. a3. myers, j. (2014, october 22). northern minnesota -more medical groups want study of proposed mine. st. paul pioneer press, p. a8. nielsen, s. on the stump: wheat v. coal [editorial]. (2012, july 30). the oregonian, sec. editorial. ortega, m. (2015, july 6). unlv study connects full-day kindergarten to better health, achievement. las vegas review-journal. p. b001. paweewun, o., & murray, l. (2009, december 03). world news: thai court keeps projects frozen on environmental concerns. the wall street journal, p. a18. o'brien, m. r. (2012, november 25). valid science must prevail on hydrofracking decision [editorial]. the buffalo news, p. g4. osborn, b.b. (2012, march 5). biomass project's impact on health to be discussed. the sacramento bee, p. b2. pakucko, m. (2015, december 4). porter ranch gas leak provides cause for worry [letter to the editor]. los angeles daily news, p. 14. pakucko, m. (2015, november 30). porter ranch gas leak provides cause for worry [letter to the editor]. los angeles daily news, p. 14. ruggles, r. the true costs of the csx rail plan [editorial] (2014, september 18). the baltimore sun, p. 19a. russell, c. (2014, january 14). impose moratorium on fracking in state [letter to the editor]. the san jose mercury news, p. 11a. sandel, m. making smart meters truly smart [letter to the editor]. (2010, august 10). the washington post, p. a.16. simons, a. (2011, march 6). light-rail ralliers: 'build it better' central corridor residents' needs must be respected, neighborhood advocates said. star tribune: newspaper of the twin cities, p. 01b. simpson, t. & weintraub, d.m. (2010, november 14). urban, hip and healthy can wellness be a priority in plans for future growth?. the sacramento bee, p. e1. stanley, a.b. (2015, december 13). compressor, pipeline endanger communities [letter to the editor]. insights into how hias are characterized in the press gakh; coughenour; pharr; goodie; to 24 the buffalo news, p. 5. stassen-berger, r. e. (2015, december 8). at the capitol commissioners oppose additional polymet public health impact review dayton agrees after raising the issue. st. paul pioneer press, p. a5. stassen-berger, r. e. (2015, december 6). state agencies nix polymet public health impact review. st. paul pioneer press, sec. politics. thompson, k. (2009, october 25). mon valley citizens deserve an impact assessment [letter to the editor pittsburgh post-gazette, p. b-2. tobin, r. (2010, october 23). city a 'test bed' for urban spaces georgia tech puts grant money toward revitalizing atlanta. the atlanta journal-constitution, p. a11. wernau, j. (2012, april 24). will smart grid save? the chicago tribune, p. 2.1. whaley, m. (2014, november 29). faith groups want i-70 plan curbed. the denver post, p. 17a. zurkowski, m. across [crossword puzzle]. (2014, december 21). pittsburgh tribune-review, sec. crossword. corresponding author maxim gakh, jd, mph assistant professor school of community health sciences university of nevada, las vegas box 453064 4505 s. maryland parkway las vegas, nv 89154 maxim.gakh@unlv.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 2 (2017) doi: 10.18060/21549 © 2017 author(s): gakh, m.; coughenour, c.; pharr, j.; goodie, a.; to, s. this work is licensed under a creative commons attribution 4.0 international license november 2022 volume 7 issue 1 1 haleigh kampman, mph; annika whitlock, bs; heidi hosler, mph health impact assessment: the impacts of increasing tree canopy coverage in marion county, indiana abstract background: urban tree canopies help to address issues of climate change related to all dimensions of health. certain areas of the city of indianapolis are more prone to the negative effects that lack of tree coverage can cause. this assessment explored the short term and potential long-term impacts of the efforts to increase the tree canopy coverage in vulnerable areas of indianapolis. this effort was a collaboration of faculty members from the indiana university richard m. fairbanks school of public health, indianapolis department of public works, keep indianapolis beautiful, and the indianapolis office of sustainability. methods: our team used the standard seven-step health impact assessment (hia) process to make the recommendations provided. using direct observation of the neighborhood, secondary data collection, literature review, and a key stakeholder interview, we examined key dimensions of health including environmental, physical, and personal health outcomes resulting from increased tree canopy coverage within census tract 3505 of marion county, indiana. results: increasing the percentage of tree canopy coverage in census tract 3505 – crown hill has significant positive health impacts with minimal negative outcomes. such impacts may be, but are not subject to, lower temperatures, reduced cases of respiratory and cardiac infections/illnesses, promoting animal life, increasing neighborhood property values and filtering pollutants that result from human production activity. conclusions: further implementation of the thrive indianapolis project has broad positive implications for the community members living in this area. while few negative implications were found, we make recommendations to mitigate these effects while attempting to supplement the current project plan with a focus on the effects to human health. keywords: hia, health impact assessment, census tract 3503, crown hill, indianapolis, marion county, tree canopy, thrive indianapolis, keep indianapolis beautiful (kib) impacts of increasing tree canopy coverage kampman; whitlock; hosler 2 introduction as the climate patterns change across the world, there must be action taken within communities to adapt to these changing temperatures. in indianapolis, extreme weather changes affect certain populations disproportionately and areas of high poverty are especially prone to the negative side effects of poor climate-centered infrastructure planning (vilfranc, 2021). tree canopy coverage in urban areas has many benefits to the health of the individuals who live and work there (indianapolis office of sustainability, 2019). the local nonprofit organization, keep indianapolis beautiful (kib), has been working toward addressing this issue, along with numerous other nature related tasks in the community, for over 40 years (keep indianapolis beautiful [kib], 2022). in 2006 kib began an initiative in partnership with the indianapolis office of sustainability to address the need for more tree canopy coverage in indianapolis (sheridan, 2021). this health impact assessment explores the reasoning behind this program, how the program was implemented, the successes of the program, and how it can be improved to better address the social determinants of health as identified. the primary objective of this assessment is to evaluate the thrive indianapolis program and provide recommendations to maximize the positive outcomes while minimizing the negative consequences of the program. project under assessment an urban tree canopy is defined as the layer of leaves and the amount of coverage or shade that is provided by a tree to the ground below (u.s. department of agriculture, forest service, 2019). cities can assess the amount of coverage provided by a canopy and use this information to track the growth and progress of the canopy. these tree canopy projects are more than just an effort to beautify a community; they also assess and evaluate specific social and environmental health determinants in areas that are lacking resources (u.s. department of agriculture, forest service, 2019). after an assessment and analysis has been conducted on a specified area, stakeholders provide input on the best places to strategically plant trees to address the identified environmental, social, and health risks. in addition to the initial implementation of the tree plantings, continued shortand long-term monitoring of these canopies is vital to the project. the monitoring not only assesses the growth and progress of the canopy, but also the effectiveness of addressing the health impacts and goals initially intended. this hia was conducted by graduate students at the indiana university richard fairbanks school of public health. health impact assessment methodology our hia sought to evaluate census tract 3505 (the crown hill area) within marion county, indiana. the graduate student research team used the standard seven-step health impact assessment (hia) process adapted from ross and colleagues (2014); the steps are outlined below: 1. screening – determine if usefulness of hia for the project 2. scoping – plan the hia 3. assessment – identify immediate and long-term impacts of project 4. recommendations – provide strategies to enhance the positive impacts of the project while minimizing any negative impacts 5. reporting – communicate and disperse findings to stakeholders and community 6. evaluation – understand the implications of the project 7. monitoring – continue to track key metrics over time after project implementation (ross, orenstein, & botchwey, 2014) impacts of increasing tree canopy coverage kampman; whitlock; hosler 3 screening due to time limitations, faculty members at the indiana university fairbanks school of public health conducted this step in the hia process. prior to student engagement, the faculty members identified project opportunities which allowed our team to proceed through the subsequent steps of a rapid hia. further discussion of the screening step included: 1) an evaluation of whether the project will affect a new population; 2) an evaluation of whether the decision makers are open to collaborating; and 3) an hia, if there was a value-add to the decision and if there was sufficient information to conduct additional research (ka hilts, 2022). scoping our team relied on literature reviews, secondary data collection, and a stakeholder interview to assist in the development of a scoping document to guide the execution of this hia. stakeholders were identified by the faculty members in the screening process of the hia and included decision-makers from the indianapolis office of sustainability, department of public works, and keep indianapolis beautiful. in our hour-long interview with the stakeholders, 10 priority areas were identified to expand tree canopy coverage using the key neighborhood identification tool (knit). a knit score is derived using four major factors: • social vulnerability index (svi) data • percent canopy coverage • concentration of litter and illegal dumping complaints • kib program score (adler, kincius, & mcreynolds, 2022) one of the priority areas having a high knit score was selected by the graduate student research team for subsequent evaluation and is the focus of this hia – census tract 3505 in marion county, indiana. this census tract represents a 0.6 square mile area within marion county, indiana having a population of approximately 2,379 (u.s. census bureau, 2022). the team selected census tract 3505 for review due to time limitations. familiarity of the area, proximity, and background knowledge of inequities occurring in this area were additional contributors to the selection of this census tract. after conducting a literature review, we developed a scoping document which outlines the goals of the hia. these goals were extracted from action plans developed by various governing agencies with the intent of implementing the thrive indianapolis program: 1. increasing community resilience through a focus on equity (indianapolis office of sustainability, 2019) 2. 100% renewable energy use by 2028 (who, 2022) 3. achieve net zero greenhouse gas emissions in marion county, indiana by 2050 (indianapolis office of sustainability, 2019) 4. plant 30,000 native trees in marion county, indiana by 2050 (indianapolis office of sustainability, 2019) the above outlined goals are the principal drivers in the selection and subsequent assessment of further expanding tree canopy coverage in census tract 3505. assessment our team relied on stakeholder interviews, literature reviews, secondary data collection and direct observation of the area to develop baseline health, social and environmental metrics, and a community profile. to aid in the prioritization of health-specific outcomes, we created a pathway diagram displaying how increasing tree canopy coverage in census tract impacts of increasing tree canopy coverage kampman; whitlock; hosler 4 3505 would affect the three primary groups of social determinants of health (environment, individual/family, and institutional). the pathways diagram (figure 1) further outlines the proximal, intermediate, and long-term effects that increasing tree canopy coverage might have. our literature review also elicited the development of four research questions that this report further discusses in the results section: 1. what impact will an increase in tree canopy coverage have on premature deaths, hospitalization rates, and mental health outcomes? 2. what are the necessary requirements to reduce any negative outcomes related to increased tree canopy coverage? 3. how will increasing tree canopies affect food insecurity, cost of living, and other equity-related issues? 4. how will increased tree canopies affect climate change challenges such as heat waves, droughts, and flooding? figure 1: pathways diagram note: arrows under the proximal outcomes section represent the direction (positive/negative) of the predicted outcomes impacts of increasing tree canopy coverage kampman; whitlock; hosler 5 table 1: demographic characteristics and composition of census tract 3505 population results summary we conducted three distinct analyses to develop a community profile and baseline health metrics worthy of further monitoring and evaluation. first, our team developed a community profile by reviewing publicly available data sets from savi, the centers for disease control and prevention (cdc), environmental protection agency (epa), and through direct observation of the neighborhood. these results are outlined in the sections below. quantitative data were compared to marion county, indiana rates to comprehend possible disparities occurring in this area. community profile – quantitative results savi data were used to understand the demographic characteristics of the population in census tract 3505; results are presented in table 1. as a benchmark, we used marion county, indiana to understand how census tract 3505 compares using the same metrics. savi data were also used to understand organizational resources currently available in this area; findings can be viewed in table 2 and figure 2. secondly, our team completed a windshield survey/direct neighborhood observation focusing on the housing characteristics, environmental infrastructure, resources, and neighborhood life to get a sense of this population’s living circumstances. metric census tract 3505 crown hill marion county, indiana population 2,379 951,869 unemployment rate 13% 6% poverty 47 18 per capita income 15,339 30,013 violent crime rate per 1,000 92 6 % african american 78% 28% median age 35 34 poverty (children under 18) 55% 24% poverty (65+ yo) 27% 10% educational attainment bachelor's degree 6% 32% (savi, 2010; u.s. census bureau, 2022) impacts of increasing tree canopy coverage kampman; whitlock; hosler 6 table 2: organization resources available within census tract 3505, crown hill figure 2: organizational resources of census tract 3505 map one member of our research team surveyed census tract 3505 – crown hill on a thursday morning during the summer season; this thursday morning was laden with heavy rain and thunderstorms with a temperature of 69 degrees fahrenheit. photographs were taken to express housing characteristics, available open spaces, community resources, and the neighborhood life in the area. housing characteristics per the u.s census bureau survey completed in 2020, there are a total of 1,235 housing units in this census block (figure 2); 21% of these units are vacant which is nearly double the rate of marion county, indiana (11% vacancy) (u.s. census bureau, 2022). the number of housing units outweigh the number of households (seen in figure 3) in this area – there are 973 households with an average of 2.4 persons per household (u.s. census bureau, 2022). majority of these households are owned by female members which is 1.5 times the rate of marion county, indiana (u.s. census bureau, 2022). it was also observed that numerous houses had boarded-up or broken windows, with a run-down appearance. impacts of increasing tree canopy coverage kampman; whitlock; hosler 7 figure 3: housing unit located in census tract 3505 – crown hill figure 4: representative household & structure in census tract 3505 – crown hill open spaces while this area had open spaces, the appearance aligned with that of some of the housing characteristics. the state of the observed open spaces can be seen in figure 5. there were a handful of empty gravel or concrete-paved lots not in use – some construction debris could be seen laying in these areas. the buildings in proximity to these lots had graffiti in addition to vacant buildings. figure 5: open space example within census tract 3505 – crown hill impacts of increasing tree canopy coverage kampman; whitlock; hosler 8 community resources as discovered in our quantitative overview, it was found that this area has very limited resources; however, within near proximity outside the census tract boundaries, more resources can be found. our team found no fire or police stations in the area although police presence was observed (figure 6). one elementary school was found to be in the area. there are extreme limitations to food in the area – a dollar general, mcdonald’s, a few gas stations, and liquor stores were found in the area suggesting limited potential for obtaining healthy food options. per savi, this census tract has been deemed a food desert (savi, 2018) and could benefit from alternative project options like a community garden or farmer’s market to provide healthy food options. this area has also been deemed a medically underserved area – meaning there are no hospitals or healthcare clinics. due to this fact, we found it essential to prioritize baseline metrics including hospitalization rates due to inhaled air pollutants, rates of disease correlated with inhaled air pollutants including copd, asthma, cardiovascular-related disease, and mental health-related disease. finally, it was found that there are six churches in this census tract that could provide additional resources and feedback. neighborhood life our team observed a largely african american population confirmed by our quantitative results that this area is 78% african american (u.s. census bureau, 2022). although not observed at the time of the windshield survey, a member of our team has previously observed homelessness when driving through the area on sunny days. we suspect that no interaction was occurring from members of the neighborhood due to the rain in the area at the time of observation; previous sightings by a team member of neighborhood interaction had occurred outside of the survey timing. neighborhood infrastructure the observations in this section promote a significantly higher health risk for the members living in this census tract – in particular, members whose houses border major streets. this community is adjacent to a main highway, i-65; this community is also segregated by several major indianapolis streets, including 38th street, illinois street, and capitol street. all these heavy traffic areas increase the citizen’s exposure to particulate matter, and toxic air pollutants. furthermore, it was found that multiple major bus routes move through this area further increasing the chances of airpollutant related hospitalizations and disease prevalence (figure 7). these bus routes serve as a point of transportation for the citizens living in this area; however, the risks of the bus routes may outweigh the benefits and further research would be necessary to determine this. finally, the overall infrastructure was run-down, consistent with the housing characteristics. to better align this area with the goals outlined in the thrive indianapolis plan, funding to improve the built environment to include the displacement of debris-laden vacant lots with a community garden or plant native figure 5: open space example within census tract 3505 – crown hill impacts of increasing tree canopy coverage kampman; whitlock; hosler 9 trees may improve the mental health of this area’s citizens and subsequently reduce the excessive prevalence of violent crimes by providing a more serene, aesthetically pleasing appearance (park, et al., 2011). figure 7: bus routes moving through census tract 3505 – crown hill baseline health status we reviewed various health, behavioral, and environmental metrics to evaluate the inequities occurring in census tract 3505 – crown hill. disease prevalence and health risk behavior data were obtained from the places database – these data are a combination of the behavioral risk factor surveillance system (brfss) and census data (cdc, 2022). the environmental metrics are a combination of data from the environmental protection agency’s (epa) environmental justice screening and mapping tool (epa, 2022) and thrive indianapolis action plan reports. baseline metrics were prioritized by us to express potential disease exacerbations directly correlated with exposure to poor air quality as well as the underlying mechanisms of stress influencing poor mental health status. the selected rates are displayed in table 3 comparing census tract 3505 to marion county, indiana. impacts of increasing tree canopy coverage kampman; whitlock; hosler 10 metric census tract 3505 crown hill marion county, indiana baseline health metrics high blood pressure 52% 35% copd 13% 7% asthma 14% 10% stroke 8% 4% heart disease 10% 6% diabetes 25% 13% depression 21% 20% obesity 48% 34% baseline health behavioral metrics physical inactivity 51% 34% sleep < 7 hours 48% 38% mental health status (“not good” for >=14 days) 23% 16% physical health status ("not good" for >=14 days) 23% 13% environmental respiratory risk due to cumulative air toxics 0.472 0.777 n/a summertime maximum daily temperature 97.1 98 degrees n/a social vulnerability high n/a percent tree cover 5 15% n/a table 3: baseline metrics of census tract 3505 – crown hill compared to marion county, indiana: disease prevalence rates, behavioral risk factor rates, and environmental metrics impacts of increasing tree canopy coverage kampman; whitlock; hosler 11 outcome likelihood magnitude additional considerations & details high blood pressure likely small to moderate literature suggests more green space may lower the odds of hypertension, diabetes and cardiovascular disease (astell-burt & feng, 2019) copd likely small to moderate certain trees are associated with higher levels of allergens (sousa-silva, et al., 2021). allergies have the potential to exacerbate symptoms for those with copd (gayle, et al., 2020). exacerbation of symptoms could be minimized by planting trees approved by those directly affected. asthma likely small to moderate certain trees are associated with higher levels of allergens, it would be essential to seek guidance from community members where trees will be placed to ensure increased asthma-related conditions are mitigated (sousa-silva, et al., 2021) stroke likely small to moderate those living in greener areas had a lower risk of death in those having a prior stroke (kondo, et al., 2020) heart disease likely small to moderate literature suggests more green space may lower the odds of hypertension, diabetes and cardiovascular disease (astell-burt & feng, 2019) diabetes likely small literature suggests more green space may lower the odds of hypertension, diabetes and cardiovascular disease (astell-burt & feng, 2019) depression likely small to moderate higher levels of green space are associated with lower depressive symptoms, anxiety and stress (beyer, et al., 2014) obesity likely small increasing tree canopy coverage shows an increase in physical activity thereby having the potential to reduce rates of obesity (wolf, et al., 2020) physical inactivity likely small increased heat is directly correlated with lower levels of physical activity; increasing tree canopy coverage from 4% to 60% reduced daily maximum temperatures by approximately 3 5.23 degrees celsius (esfehankalateh, et al., 2021) sleep < 7 hours likely small the odds of insufficient sleep were lower among participants having higher tree canopy coverage (astell-burt & feng, 2019) low-level vegetation was not associated with sufficient sleep (astell-burt & feng, 2019) mental health status (not good for >=14 days) likely moderate higher levels of green space are associated with lower depressive symptoms, anxiety and stress (park, et al., 2011) table 4: summary outcomes, likelihood, magnitude, and additional considerations in implementation impacts of increasing tree canopy coverage kampman; whitlock; hosler 12 outcome likelihood magnitude additional considerations & details physical health status ("not good" for >=14 days) likely small direct impacts can be measured through increases in physical activity and associated reductions in cardiovascular disease, diabetes, and other chronic health conditions (wolf, et al., 2020) respiratory risk due to cumulative air toxics likely moderate the planting location of the trees are essential; research suggests that trees planted close to the street may disrupt wind flow and subsequently trap pollutants below the tree canopy line (vos et al., 2013) summertime maximum daily temperature likely moderate tree canopy coverage is associated with fewer ambulance calls for heat-related events (e.g. heat stroke, heat exhaustion) and subsequent heat-related mortality (graham, et al., 2016). crime rates likely small to moderate tree canopy coverage is inversely associated with crime rates (robbery, theft, shootings). trees planted near the street were associated with decreased crime (troy, et al., 2012) table 4: continued explanations: * likelihood: strength of evidence in the literature (likely or unlikely); magnitude: estimated size of the impact (effect on number of disease cases or adverse events) projected impacts we evaluated each of the metrics outlined in table 3 and assessed the likelihood that increasing tree canopy coverage has on influencing the respective metric and the intensity and magnitude of the effect; these effects are outlined in table 4. in summary, increasing tree canopy coverage or additional green spaces in this community have the potential to reduce all reviewed health outcomes if the proper mitigation strategies are executed. mitigation metrics & considerations while the projected impacts of expanding the thrive indianapolis program to include increasing tree canopy coverage are overwhelmingly positive, it is also essential in the hia process that mitigation metrics be developed to reduce any potential negative impacts. our team would suggest tracking or considering the following to ensure mitigation of negative outcomes: 1. planning proper tree planting location; literature suggests that trees planted in near proximity of the street can disrupt air flow thereby trapping air toxins (vos et al., 2013) 2. while increased tree canopy coverage is associated with reduced gun assaults (wolf, et al., 2020), researchers found that small view-obstructing trees are associated with increased crime rates (donovan, 2012) 3. careful consideration must be placed on the tree species planted to ensure community members are not allergic impacts of increasing tree canopy coverage kampman; whitlock; hosler 13 4. while increased urbanization is linked to an increase in the incidence of vectorborne diseases, increasing eco-habits for these species also provides opportunity for increased exposure and hospitalizations (diuk-wasser, et al., 2020) recommendations our team exhibited vigilance to not duplicate current efforts and measures that are being taken in conjunction with the thrive indianapolis program. rather, we found limiting factors in the plans that would help to supplement and accelerate meeting currently devised metrics. recommendation 1: convert empty vacant lots into community gardens or rain gardens direct observation of census tract 3505 – crown hill enables the research team to recommend the conversion of vacant lots to either community gardens, rain gardens, or green spaces. this recommendation directly aligns with three of the current metrics being reported: 1) total tons of materials recycled; 2) square feet of rain garden; and 3) % impervious area (city of indianapolis office of sustainability, 2021). addressing these metrics would have further implications on select public health and safety metrics reported out like the percentage of adults who are overweight or obese (city of indianapolis office of sustainability, 2021). while the 2021 report describes current funding and efforts to enhance violence prevention, the project plan does not report any mental-health related outcomes. our team seeks to supplement the plan by encouraging additional violence-related health metrics to fully understand the effect that the built environment, including green areas, has in reducing indianapolis-based crime. community gardens are a proven way to encourage social connectivity in communities and enhances the sustainability of communities with this opportunity. additionally, green areas have a sustainable impact on the mental well-being of populations near these areas (south, et al., 2018). recommendation 2: develop partnership with indygo the expansion of bus routes in the indianapolis area are contributing to increased diesel exhaust exposing members to poor air quality (epa, 2022). our analysis found that census tract 3505 – crown hill is wedged between multiple high-traffic city streets (38th street, meridian street, capitol street, and illinois street) and is also adjacent to i-65. our recommendation to engage leaders from indygo with the intent to evaluate bus routes to lessen the effects of air pollution from bus exhaust would improve psychological stress as well as asthma/copdrelated hospitalizations. careful consideration must be taken to resolve the increase in air pollution while either maintaining or reducing the level of transportation options available to this community. our team stresses that barriers to transportation would increase vulnerabilities in this population. recommendation 3: mitigation measures the safety and security of members in this community are of utmost importance. while evidence shows an overwhelming number of positive outcomes stemming from increased tree canopy coverage on human health, environmental health, and further downstream effects, mitigation metrics are an essential component to minimize any potential negative outcomes. we further recommend the mitigation measures outlined in a prior section of this report be reported on a regular cadence to governing and funding authorities. reporting results of this analysis will be presented in three separate formats. first, this report will be provided to the stakeholders for review and impacts of increasing tree canopy coverage kampman; whitlock; hosler 14 additional feedback. second, our team will be presenting a summarized version of this report to stakeholders and faculty members. third, we have intent to submit this report to a peerreviewed journal for wider dissemination of findings. monitoring & evaluation project plans for the thrive indianapolis program currently provide robust evidence, analyses, and tracking that allow for continual reporting to governing and funding authorities. these project plans currently track metrics related to the built environment, energy-use, food and urban agriculture, transportation/ land use, and waste/recycling efforts. this hia serves as a supplement to these project plans by providing health-related metrics showing the direct effect on the populations of the target communities. we found several metrics that are formally reported with varying timelines by the project stakeholders: most occurring every year or every three years. however, there were minimal health-based outcome measures developed. our team’s recommendations would be to partner directly with data-collecting organizations such as the indiana state department of health to obtain hospitalization data from mental health conditions, asthma, copd, heat-related, and cardiovascularrelated events. this partnership would aid in regularly monitoring the downstream health impacts of increasing tree canopy coverage in census tract 3505 – crown hill. publishing quantitative results using these data would also be beneficial in securing additional funding to continue sustainability efforts in indianapolis communities. conclusion this health impact assessment was conducted to determine the health-related benefits and consequences of thrive indianapolis, specifically focusing on the impact of increased tree canopy in the crown hill neighborhood of marion county, indiana. crown hill has disproportionately high rates of unemployment, poverty, and violent crime and thus has the most to gain from the benefits of increased tree canopy and/or green space. the assessment was initiated by keep indianapolis beautiful and the indianapolis office of sustainability and conducted by graduate students at the richard m. fairbanks school of public health at indiana universitypurdue university indianapolis. through key interviews, direct observation, secondary data analysis, and review of the existing literature, our team of graduate researchers assessed the impact of the increased tree canopy on morbidity and mortality, social equity, and mitigation against climate change. we also provide recommendations for maximizing the positive and minimizing the negative effects of the program. the major limitation of this assessment was time. because of time constraints we were also unable to engage community members; additional input from these key stakeholders is essential to the success of the program and should be considered prior to planting. in addition to engaging community members in planning and evaluation, we make the following specific recommendations: 1) convert vacant lots into community gardens or rain gardens to reduce the effects of climate change; 2) develop a partnership with indygo to align public services to achieve the city’s climate change goals ; and 3) continuous monitoring of potential threats such as crime and vectorborne disease to ensure that conditions in the crown hill neighborhood are not made worse by the program initiatives. impacts of increasing tree canopy coverage kampman; whitlock; hosler 15 references adler, m., kincius, b., & mcreynolds, m. 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(2022, may 17). h644: health impact assessment screening & scoping. indianapolis, indiana. indianapolis office of sustainability. (2019). thrive indianapolis. indianapolis. keep indianapolis beautiful. (2022, june 16). about keep indianapolis beautiful. retrieved from keep indianapolis beautiful: https://www.kibi.org/about-keep-indianapolis-beautiful ross, c. l., orenstein, m., & botchwey, n. (2014). health impact assessment in the united states. new york: springer. ruiz-tagle, j., & urria, i. (2022). household overcrowding trajectories and mental well-being. social science & medicine. savi. (2010). savi community assessment & planning tool. retrieved from savi: https://assessment.savi. org/assessneeds savi. (2018, november 29). savi. retrieved from estimated 200,000 indy residents live in food deserts: https://www.savi.org/2018/11/29/estimated-200000-indy-residents-live-in-food-deserts/ sheridan, j. 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(2019). urban tree canopy assessment: a community’s path to understanding and managing the urban forest. retrieved from united states department of agriculture: https://www.fs.usda.gov/sites/default/files/fs_media/fs_document/urban%20tree%20 canopy%20paper.pdf u.s. census bureau. (2022, june 18). census reporter. retrieved from american community survey 5-year estimates: https://censusreporter.org/profiles/14000us18097350500-census-tract-3505-marion-in/ vilfranc, c. (2022, june 18). as climate change makes indianapolis hotter, some communities will suffer more than others. retrieved from the indianapolis star: https://www.indystar.com/story/ news/environment/2021/08/27/indianapolis-weather-extreme-heat-caused-climate-change-hitshard/8208625002/ vos, p. e., maiheu, b., vankerkom, j., & janssen, s. (2013). improving local air quality in cities: to tree or not to tree? environmental pollution, 113-122. who. (2022). 2022 health & climate change urban profile indianapolis. who. https://www.kibi.org/about-keep-indianapolis-beautiful https://assessment.savi.org/assessneeds https://assessment.savi.org/assessneeds https://www.savi.org/2018/11/29/estimated-200000-indy-residents-live-in-food-deserts/ https://www.wfyi.org/news/articles/tree-planting-gives-boost-to-citys-urban-canopy https://www.fs.usda.gov/sites/default/files/fs_media/fs_document/urban%20tree%20canopy%20paper.pdf https://www.fs.usda.gov/sites/default/files/fs_media/fs_document/urban%20tree%20canopy%20paper.pdf https://censusreporter.org/profiles/14000us18097350500-census-tract-3505-marion-in/ https://www.indystar.com/story/news/environment/2021/08/27/indianapolis-weather-extreme-heat-caused-climate-change-hits-hard/8208625002/ https://www.indystar.com/story/news/environment/2021/08/27/indianapolis-weather-extreme-heat-caused-climate-change-hits-hard/8208625002/ https://www.indystar.com/story/news/environment/2021/08/27/indianapolis-weather-extreme-heat-caused-climate-change-hits-hard/8208625002/ impacts of increasing tree canopy coverage kampman; whitlock; hosler 17 corresponding author haleigh kampman indiana university purdue university indianapolis 1050 wishard blvd. hkampman@iu.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, bs, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 7 issue 1 (2022) doi: 10.18060/26368 © 2022 author(s): kampman, h.; whitlock, a.; hosler, h. this work is licensed under a creative commons attribution 4.0 international license wolf, k., lam, s., mckeen, j., richardson, g., van den bosch, m., & bardekjian, a. (2020). urban trees and human health: a scoping review. international journal of environmental research and public health, 17(12): 4371. acknowledgements we would like to recognize several key partners who assisted in providing additional education on processes, project background, initiatives, and experiences that allowed our team to compile this report: • faculty members at the indiana university fairbanks school of public health • city of indianapolis stakeholders in the office of sustainability and department of public works • stakeholders of the keep indianapolis beautiful (kib) organization october 2020 volume 5 issue 1 1 cynthia stone, drph, rn; alison redenz, murp, aicp; andrea bochenek, mph; ellie hansotte, mph methods to conduct a health impact assessment learning collaborative abstract background: indiana university richard m. fairbanks school of public health (iu fsph) and the health and hospital corporation of marion county, through the marion county public health department (mcphd), created a health impact assessment (hia) learning collaborative. the purpose of the hia learning collaborative was to strengthen the capacity of both the academic and community partners to carry out hias. entities recognize the value of creating a collaborative team to assure personnel are trained and available to provide time and expertise for plan reviews, formal feedback, data reports, literature summaries, and input in potential health/social impacts related to projects, which can ensure these impacts are considered in development work. in addition, the mcphd and iu fshp intend to increase hia capacity in indiana and remain committed to including health impact data into non-health sector decision making. methods: the group planned to meet monthly over the year with the following learning objectives. a survey was created in survey monkey in order to evaluate the overall hia learning collaborative experience and to assess whether or not the learning objectives were met. the survey consisted of 11 questions: nine were multiple choice and two were open-ended. results: the majority of the objectives were met. conclusion: there is interest in conducting hias in the future and several ideas were generated. methods to conduct a hia learning collaborative stone; redenz; bochenek; hansotte 2 introduction/background indiana university richard m. fairbanks school of public health (iu fsph) and the health and hospital corporation of marion county, through the marion county public health department (mcphd), created a health impact assessment (hia) learning collaborative to be conducted over one year. the collaborative was formed with a small funding opportunity from the indiana university center for translational science, community health engagement program. mcphd wanted to increase staff that were familiar with the steps of a hia and were able to apply the hia process with community based projects. the u.s. department of health and human services recommends hia as one important resource for implementing many of the healthy people 2020 objectives, particularly those that focus on the social determinants of health (healthy people 2020 advisor committee, 2010). the purpose of the hia learning collaborative was to strengthen the capacity of both the academic and community partners to carry out hias. entities recognize the value of creating a collaborative team to assure personnel are trained and available to provide time and expertise for plan reviews, formal feedback, data reports, literature summaries, and input in potential health/social impacts related to projects, which can ensure these impacts are considered in development work. in addition, the mcphd and iu fsph intend to increase hia capacity in indiana and remain committed to including health impact data into non-health sector decision making. additional partner organizations were invited to participate in the hia learning collaborative, including the top 10 coalition, the ymca of greater indianapolis, and the indiana state department of health. a total of eight individuals from the various organizations routinely participated during the yearlong collaborative sessions. the learning collaborative members wanted to discuss the concept of health in all policies. this led to a video conference with a staff person at the national association of city and county health organizations (naccho). naccho has been providing technical assistance to several local health departments about putting health into all policy discussions and evaluating the impact of this change. hias are one tool that can be employed to put health into the policies and programs of non-health sectors, which is the intent of health in all policies (american public health association (apha), 2012). method for conducting hia learning collaborative the group planned to meet monthly over the year with the following learning objectives: 1. describe the purpose, benefits, and challenges of a health impact assessment. 2. develop an in-depth knowledge of the process and analytic methods used in the assessment step. 3. demonstrate the ability to think critically and analyze how the findings related to policy decisions. 4. conduct an hia on a local project/ process/ or policy. a canvas web-based course site was created from the learning management system at indiana university to store materials and allow for sharing of information. access to the course was generated by completing a guest account request. several of the participants had previously used canvas. the textbook health impact assessment in the united states by ross, et al. (2014) was used for the background sessions of the hia process. during the first five months, different steps of the hia process were studied. each session methods to conduct a hia learning collaborative stone; redenz; bochenek; hansotte 3 lasted for 90 minutes and covered the readings and discussion of application using the cases in the book (ross et al. ,2014). the session following the book discussion included a case presentation with each participant reviewing and analyzing a different hia case from the pew charitable trusts website (pew health impact project, 2020). the group also discussed potential hia topics that could be conducted in marion county. the second half of the year was used to meet the objective to conduct a hia on a local project or policy. to accomplish this objective, the learning collaborative worked with the graduate health impact assessment course at iu fsph. the hia learning collaborative generated a problem statement for the city of indianapolismarion county, stating a need for more access to parks and green space. according to the trust for public land, park score index (2019), only 35% of indianapolis residents have access to a park within a 10-minute walk, compared to the national average of 54%. the 10-minute walk campaign, a partnership between the national recreation and park association (nrpa) and the trust for public land, uses the 10-minute walk as a benchmark. the project calls on cities across the u.s. to “make the 100% promise to make sure that everyone in your city has safe, easy access to a quality park within a 10-minute walk of home by 2050” (nrpa, 2019, para 1). two topics were chosen by the hia collaborative that could address the statement of need for more parks and greenspace access within the city-county’s current funding limitations. this includes, 1) opening access or allowing shared use agreements to school grounds and 2) green schoolyards in indianapolis schools to increase greenspace access. two hia learning collaborative members presented an overview on the benefits to communities of having open access to school grounds and the health benefits of green schoolyards for healthy communities and suggested assessment tools that could be used to explore these topics. the students conducted windshield surveys to begin to learn about two neighborhoods that could be used for the hia topics. the students conducted interviews of school personnel using the assessment tools that were recommended. an additional hia that updated a previous hia performed to support building a grocery store in a food desert was conducted by a third group of students, and two other hia learning collaborative members assisted them with demographic data to use as part of the assessment of their area. the final hia learning collaborative meeting included power point presentations by a student representative of each of the hia projects. a good question and answer discussion occurred after each presentation. method of evaluation two members of the collaborative created a survey in survey monkey in order to gather data to evaluate the overall hia learning collaborative experience and to assess whether or not the learning objectives were met. the survey consisted of 11 questions: nine were multiple choice and two were open-ended. the survey link was disseminated to all hia learning collaborative members through email. of the eight members who regularly participated, seven group members completed the survey. once responses from all members were collected, the results were exported into microsoft excel for analysis. frequencies were calculated and graphs were generated using microsoft excel. a copy of the actual survey can be found in appendix a. results of survey the nine multiple choice questions were answered by all seven respondents. the results are displayed in the section below. methods to conduct a hia learning collaborative stone; redenz; bochenek; hansotte 4 table 1: number and percentage of respondents who felt that the hia learning collaborative objectives were met hia learning collaborative objective n percent describe the purpose, benefits, and challenges of a health impact assessment 7 100.00% develop an in-depth knowledge of the process and analytic methods used in the assessment step 6 85.71% demonstrate the ability to think critically and analyze how the findings related to policy decisions 6 85.71% conduct an hia on a local project/ process/ or policy 3 42.86% one hundred percent (7/7) of hia learning collaborative members who completed the survey reported that they believed objective 1, “describe the purpose, benefits, and challenges of a health impact assessment,” was met during the allotted time. nearly 86% (6/7) of hia learning collaborative members who completed the survey reported that the believed objectives 2 and 3, “develop an indepth knowledge of the process and analytic methods used in the assessment step” and ”demonstrate the ability to think critically and analyze how the findings related to policy decisions,” respectively, were met. nearly 43% (3/7) of hia learning collaborative members who completed the survey reported that they believed objective 4, “conduct an hia on a local project/ process/ or policy,” was met. overall, participants responded that using in person sessions with a zoom option was accommodating (pre covid-19 restrictions). the majority reported that using the canvas site for resources and minutes was useful. the majority reported the book was helpful to access the baseline content. an adequate number of meetings were held with 10 total meetings over the calendar year. the majority of participants reported they have adequate personnel to conduct an hia and feel confident to lead an hia in the future. future/ next steps several ideas were generated from the survey for potential hias in marion county. this includes the following: • determining the health impact of the future proposed transit lines • identifying the health impacts of zoning land use changes • examining the health impacts of the proposed i-70-i-65 freeway improvement project there is also interest in continuing the hia learning collaborative by expanding the membership and using the collaborative to provide technical assistance when participant organizations are ready to begin a hia. there is need to seek out additional funding to further expand hia efforts. the group is also interested in better collaboration between the county health department and the city of indianapolis to expand on the health in all policies work that has begun. methods to conduct a hia learning collaborative stone; redenz; bochenek; hansotte 5 references american public health association. (2012). health in all policies. american public health association. health impact assessment: a tool to benefit health in all policies. american public health association. http://www.apha.org/nr/rdonlyres/171af5cd-070b-4f7c-a0cd0ca3a3fb93dc/0/ hiabenefithlth.pdf. healthy people 2020 advisory committee. (2010). healthy people 2020: an opportunity to address societal determinants of health in the u.s. healthy people advisory committee. https://www.healthypeople. gov/sites/default/files/societaldeterminantshealth.pdf ross, c.l., orenstein, m., & botchwey, n. (2014). health impact assessment in the united states. new york: springer publications. pew charitable trusts). (2020). health impact projects health notes. https://www.pewtrusts.org/en/ projects/health-impact-project national recreation and park association. (2019). trust for public land: 10 minute walk campaign: are you 100% in? 10 minute walk.org https://10minutewalk.org/#join-us http://www.apha.org/nr/rdonlyres/171af5cd-070b-4f7c-a0cd0ca3a3fb93dc/0/hiabenefithlth.pdf. http://www.apha.org/nr/rdonlyres/171af5cd-070b-4f7c-a0cd0ca3a3fb93dc/0/hiabenefithlth.pdf. https://www.healthypeople.gov/sites/default/files/societaldeterminantshealth.pdf https://www.healthypeople.gov/sites/default/files/societaldeterminantshealth.pdf https://www.pewtrusts.org/en/projects/health-impact-project https://www.pewtrusts.org/en/projects/health-impact-project https://10minutewalk.org/#join-us methods to conduct a hia learning collaborative stone; redenz; bochenek; hansotte 6 appendix a health impact learning assessment learning collaborative 1. please select which of the following objectives you felt were reached during the learning collaborative (choose all that apply): r describe the purpose, benefits, and challenges of a health impact assessment r develop an in-depth knowledge of the process and analytic methods used in the assessment step r demonstrate the ability to think critically and analyze how the findings related to policy decisions r conduct an hia on a local project/ process/ or policy 2. did you feel that the setup of the learning collaborative (meeting in person or via zoom) was accommodating? r very accommodating r accommodating r neutral r not very accommodating r not accommodating at all 3. how helpful was it to use canvas for sharing articles and powerpoint presentations? r very helpful r helpful r neutral r not very helpful r not at all helpful r n/a, i did not have access to canvas 4. how useful was the book (health impact assessment in the united states) in learning about hias and meeting the learning collaborative objectives (listed in question 1)? r very useful r useful r neutral r not very useful r not useful at all 5. how do you feel about the number of meetings for the hia lc? r too many meetings r adequate number of meetings r not enough meetings methods to conduct a hia learning collaborative stone; redenz; bochenek; hansotte 7 6. do you believe that your organization has the capacity to complete a hia? r yes r no r undecided 7. after participating in the hia learning collaborative, how confident would you feel leading a hia? r very confident r confident r neutral r not very confident r not confident at all 8. after participating in the hia learning collaborative, how confident would you feel being a part of a hia? r very confident r confident r neutral r not very confident r not confident at all 9. do you think health notes would be a useful tool in the future? https://www.pewtrusts.org/en/research-and-analysis/factsheets/2017/11/pilot-program-to-help-states-and-localities-consider-health-inpolicymaking r very confident r confident r neutral r not very confident r not confident at all 10. what do you think is needed to conduct a hia in the future? 11. please list ideas for potential hias in the space below. https://www.pewtrusts.org/en/research-and-analysis/factsheets/2017/11/pilot-program-to-help-states-and-localities-consider-health-inpolicymaking https://www.pewtrusts.org/en/research-and-analysis/factsheets/2017/11/pilot-program-to-help-states-and-localities-consider-health-inpolicymaking methods to conduct a hia learning collaborative stone; redenz; bochenek; hansotte 8 corresponding author cynthia stone, drph, msn, rn department of health policy and management indiana university-purdue university indianapolis 1050 wishard blvd. rg 5128 indianapolis, in 46202 cylstone@iu.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 5 issue 1 (2020) doi: 10.18060/23874 © 2020 author(s): stone, c.; redenz, a.; bochenek, a.; hansotte, e. this work is licensed under a creative commons attribution 4.0 international license mailto:cylstone@iu.edu october 2019 volume 4 issue 1 a case study on incorporating health and equity into urban plans, transportation, and land use policies kelly haworth, mph; elizabeth young winne, mph, murp abstract: in 2017, the built environment program at the larimer county department of health and environment (colorado, usa) collaborated with a partner municipal agency to create a health and equity index to be a component of a revitalized sidewalk prioritization model. the health equity index uses indicators that are linked to the determinants of health to spatially understand factors that contribute to an individual or household’s likelihood of being more vulnerable. the data to create the health equity index is publicly sourced at block group level from the united states census american community survey 5-year estimates and at census tract level from the center for disease control and prevention’s 500 cities dataset. the score is one of three factors used to determine sidewalk improvement priorities in the city. the new model mapped prioritization and created broader geographic distribution than what was previously used. the creation of the health equity index was a valuable partnership that led to multiple outcomes outside of the sidewalk prioritization process. first, its creation has established a foundation for partnership between two sectors across different government agencies. second, the health and equity index has also been used as an assessment tool for the adopted city plan, the guiding comprehensive plan for the municipal agency. through this process, we have learned that elements of health impact assessment can be a powerful tool for understanding the health impacts of a policy or process on community, as well as for building and developing trusted cross-sector relationships. 1 a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 2 introduction the united states (u.s.) spends nearly $3.0 trillion in health care annually, 90% of which is to treat chronic and mental health conditions (oash, 2016; cdc, 2019). however, the exorbitant expenses are not leading to better health outcomes. compared to similar wealthy countries, americans are dying younger and faring worse in measurable health indicators like obesity, diabetes, and injury (oash, 2016; cdc, 2019). in the u.s., obesity affects almost 30% of adults and 20% of children, nearly one-third of all deaths can be attributed to heart disease or stroke, and approximately 30 million people have diabetes (cdc, 2019). as health professionals see the expenses, morbidity, and mortality climb, the viable programmatic solutions to address chronic diseases have become more complicated. according to the office of the assistant secretary for health (oash) at the u.s. department of health and human services, “scholars estimate that behavioral patterns, environmental exposure, and social circumstances account for as much as 60% of premature deaths. these factors shape the context of how people make choices every day and reflect the social and physical environments where these choices are made” (oash, 2016, p. 7). furthermore, the robert wood johnson foundation states, “…positive changes in health behaviors require action on the part of the individual, but also require ‘that the environments in which people live, work and play support healthier choices’ ” (robert wood johnson, 2014, p. 6). this research demonstrates the need for interventions that take a system and environmental approach to addressing chronic diseases. in 2003, the american journal of public health released a special issue on “built environment and health,” which led other professional journals to do the same over the next few years; a sign that design professionals are engaged in the topic, research, and practice of including health into land use (jackson et al., 2013). as a result of the research instigated by this special issue, there has been a growing body of strategies that public health practitioners and urban planning professionals are able to leverage to address built environment in their communities. for example, the community preventive services task force through the cdc has recommended a combined built environment approach to increasing physical activity in the community (cdc, 2019b). this combined approach includes connecting every-day destinations to activity friendly routes to create a strategy that leverages both land use and transportation policies. health in all policies (hiap) is another example of an approach that can be utilized to consider the health ramifications in all policies and all sectors including transportation, land use, agriculture, and housing (robert wood johnson, 2014). health impact assessments (hia) are an example of a tool that can be used to implement an hiap strategy; where hia’s use a standardized process to understand the effects a development, policy, or plan can have on the health of a local community before it is implemented (cdc, 2016). public health practitioners are able to leverage public health 3.0, a national call to action crafted by the department of health and human services which emphasizes designing public health interventions to address the upstream determinants of health, or “... the macro factors that comprise social-structural influences on health and health systems, government policies, and the social, physical, economic and environmental factors that determine health” (bharmal et al., 2015, p. 1). all these examples are evidence that the public health field has a growing body of tools, resources, and models to address chronic diseases through a built environment lens. this article will discuss, from a public health practitioner’s perspective, how a local public health agency has begun to incorporate principles of hia’s to address chronic disease by working closely with a local municipal organization to incorporate health factors into their sidewalk prioritization process. we review the local context, partnership, methods, and results of how a prioritization of sidewalk development shifted after including health as a key factor for decision making. a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 3 context in 2016 the larimer county department of health and environment (lcdhe), a local public health agency, launched a new built environment program (bep) that works to promote physical activity and address health inequities by promoting healthy community goals in urban plans and subsequent policy documents. lcdhe does not have the authority to implement land use and transportation policies, so in order to achieve desired program goals, bep staff must collaborate closely with municipal staff who implement the transportation and land use policies. as a result, bep uses a two pronged approach: working directly with professional partners who implement land use and transportation policies to support them in finding ways to include health into plans and policies, and working with community members, non-profit agencies, and advocacy organizations to develop community-driven projects and support community engagement efforts. implementation of the bep’s two-pronged approach is simple: the bep seeks projects from partners and offers technical assistance to create and increase organizational capacity to incorporate health into plans and policies (see figure 1). although not formalized through a policy mandate or resolution, the bep follows a hiap approach. in practice, this requires a diverse range of partners, representing sectors including non-profit, community-based groups, data analysts, planning, transportation, public works, and engineering. with this strategy described above, a partnership was formed with a municipal engineering department in the city of fort collins and resulted in the creation of the health equity index (hei) which was used as a portion of the municipal agency’s sidewalk prioritization model. the hei described in this paper followed the same process as conducting a hia and was used as a tool to implement our hiap strategy. figure 1: technical assistance graphic a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 4 sidewalk prioritization prior to the inclusion of the hei into the sidewalk prioritization model, the partner municipal agency used a process that was largely based on pedestrian demand, and as a result the downtown and the area around the university were the highest scoring areas to target infrastructure funding and changes (duggan, 2014). to address this, municipal engineering staff worked with bep to develop a new model that would incorporate indicators that would identify health inequities and ultimately redistribute funding to areas of the municipal boundary as referenced in figure 2 (city of fort collins, 2017). below, we will discuss the methods for creation of the hei portion of the overall sidewalk prioritization model. figure 2: updated sidewalk prioritization model a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 5 health equity index the intent of the hei is to identify where vulnerable communities may be concentrated within the municipal boundary so prioritization of sidewalks can be targeted to assist those who may be more likely to need access to higher quality sidewalk infrastructure. the index is part of an overall location model and represents just one factor for final decision making. the hei methods that are listed below provide more details of the assessment phase for an hia. including the hei as part of a prioritization process required following the standard hia process (screening, scoping, assessment/recommendation, reporting, evaluation). a summary of these steps is included in table 1 and is expanded upon below. table 1: summary of hia process screening the screening process was conducted in partnership with the municipal agency. through conversations it was identified that there was an opportunity for a process to include health and equity as criteria for a decision to prioritize future sidewalk development. stakeholders involved in screening were staff from bep and the municipal agency’s engineering department. scoping stakeholders identified relevant community health outcomes that were likely impacted by sidewalks through literature reviews and best practices. equity indicators were included as a consideration of which populations were more likely to be impacted by sidewalk availability. assessment/ recommendation the hei described in the methods section below provides more details of the assessment phase of the hia. recommendations were to include the hei as a portion of the sidewalk model to prioritize future sidewalk development in vulnerable communities. report the municipal agency incorporated the hei into the city plan, the city’s comprehensive plan. evaluation no formal evaluation has yet been conducted. a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 6 methods screening and scoping a brief literature review of sidewalk prioritization models used by cities was conducted. after reviewing and discussing with the municipal agency, the indicators and methods for the hei were adapted from the seattle department of transportation’s pedestrian master plan (seattle department of transportation, 2017). assessment the hei is made up of two scores: a health score and an equity score. the equity score is 70% of the total score and the health score is 30%. the two scores are combined and standardized to a 100-point scale (see figure 3). a score of 100 indicates the most health and equity vulnerabilities and implies a geographic area with greater need for sidewalk quality and availability. figure 3: health equity index graphic a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 7 the equity score the equity score uses block group level 2011-2015 american community survey 5-year estimates for age (under 18 and over 65 years old), households at or below federal poverty level, hispanic/latino, race (non-white), households without a vehicle, and disability status. the population count for each indicator was compiled and standardized by the total population of the block group. block groups were then ranked from highest to lowest by decile and each block group received an equity score between one and ten; ten being the highest possible rank, indicating the most vulnerable. it is important to note, disability status is only reported at census tract-level, so an assumption was made that the population of people with disabilities was evenly spread throughout block groups based on population, and a proportion was created at the block group level. the health score the health score uses 3 indicators: rate of obesity in adults, rate of no leisure time physical activity in adults, and rate of poor mental health for more than 14 days in adults. these indicators were identified by staff creating the hei and the new prioritization model as the most relevant indicators to measure overall health that could be attributed to absence or presence of sidewalk. additionally, this data was used as it was readily available through the cdc’s 500 cities project, which uses the behavioral risk factor surveillance system’s (brfss) data. the percent of each health indicator was combined, and census tracts were sorted according to overall percent and were assigned a score of one through five; five being the highest, indicating poor health. block groups within the same census tract were assigned the same health score. the two scores were combined and standardized on a 100-point scale, which created a final health equity score. the score was visualized geospatially, as referenced in figure 4. a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 8 figure 4: health equity index for the city of fort collins a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 9 recommendation the municipal agency ultimately decided to use a weighted scale to incorporate three different priorities into the sidewalk prioritization process, shown in figure 2. the three different priorities included are: demand (weighted at 35%), health equity index (weighted at 20%), and safety (weighted at 45%). the weighted health score is the final health and equity score that was calculated by bep. discussion the original demand model that was used for sidewalk prioritization concentrated infrastructure investments near the central downtown and the area surrounding colorado state university, a local university, shown in figure 5 (robert mosbey, personal communication, march, 2019). the areas of dark red indicate areas of the city with the highest demand for sidewalk infrastructure. figure 5: gis map of previous city of fort collins pedestrian priority rating figure 6: gis map of updated sidewalk priorities and safety a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 10 after modifying the model to include safety and health, the priority sidewalks became more geographically dispersed throughout the municipal boundary, as shown in figure 6 (city fort collins, 2017). at this point in time, no formal analysis on the comparative models has been done to determine a percentage of change. however, visually, users can note that with the updated model, the downtown is still the major focus area but some of the priority ratings have shifted. for example, there are hotspots in the southern end of the city that are no longer identified as medium-high priority using the updated model. additionally, there are more identified areas in the north and west of the city that heightened their priority ranking by becoming a medium or mediumhigh priority. limitations there are several identified limitations of the hei. first, there are two potential issues with the accessible data utilized for the hei to be acknowledged: first, there are self-report concerns in brfss data that cannot be accounted for; second, hei uses estimated and modelled data from the american community survey 5-year estimates and from the centers for disease control and prevention’s 500 cities data. in knowing that this is estimated and modelled information, we acknowledge there may be a diluted effect when this information is weighted again and again in the hei and in the sidewalk prioritization model. the hei is an attempt to spatially understand factors that contribute to an individual or household’s likelihood of being vulnerable, and therefore, it is just an example of one tool to be considered in a decision-making process. second, disability status is not reported at a block group-level. the american community survey estimates do not report disability status at a block group level only at the census tract-level. this information was estimated by assuming the population of people with a disability are spread evenly throughout the block groups in a census tract. each block group received a proportionate number of people reporting a disability based on the total population size of that block group. third, the 500 cities data only reports on 14 cities in colorado and only 500 cities in the united sates. users outside of those 14 cities (or 500 cities, nationally) may consider talking with the state health department about accessing community level estimates or any other available health data. fourth, the 500 cities data compiles information at the census tract-level; additionally, some of the indicators do not exist at the census tract-level. the information that does not exist was estimated by finding the block groups with the same equity score as the census tract that did not have corresponding health data and an average of the health scores using the block groups with the same equity score is used as an estimated health score. fifth, american community survey estimates and the 500 cities data is updated regularly and therefore, the model becomes outdated annually. ideally, hei would have the ability to pull data and update automatically. last, the indicators were not weighted individually and are weighted as a combined number. therefore, some individuals and households (depending on the indicator) are counted multiple times and the percent of total for a block group may be over 100%. implications and lessons learned although there was a shift in sidewalk distribution due to the inclusion of the hei into the sidewalk prioritization model, we also saw two large unintended outcomes that are worth discussing: 1) the relationship built between two sectors and 2) the inclusion of the hei in the municipal agency’s city plan, the comprehensive urban planning document (city fort collins, 2019). in the paragraphs below we will discuss the implications of these two outcomes. a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 11 an important outcome was the development of a relationship between a local health department and a municipal organization. the creation of the hei was dependent on two different sectors coming together to utilize the skills and expertise of the other which required a thoughtful approach to understanding organization context and skills as well as dedicated staff time to develop the partnership. for example, to better understand the skills and expertise from the bep the municipal engineering staff worked with bep to become knowledgeable on best practices for inclusion of health and equity, the determinants of health, and the relationship between health and the built environment. conversely, bep staff worked with municipal engineering staff to understand the previous sidewalk location model, how sidewalk funding was allocated, the policies associated with sidewalk prioritization, decision making process, and timing of sidewalk development. in these two examples listed above the education and capacity building was delivered during oneon-one conversations. ultimately, taking the time to understand and value each sectors contribution to changing a process was essential in the creation and utilization of the hei. the staff time that was dedicated to this process is important to note as building relationships in order to follow the hia process required significant time and may be unique to the lcdhe bep. bep staff capacity is currently supported through state level competitive grants that allow staff to provide technical assistance to conduct assessments and co-create tools with partner agencies. the second unintended implication was the inclusion of the hei into the municipal agency’s city plan, which is both the comprehensive and transportation plan for the city of fort collins (city of fort collins, 2019). the bep was able to leverage the work already done in partnership with the city engineer and provide the hei to the planning staff at the city of fort collins for consideration of including the hei in the city plan. the hei was then included in the “trends and forces” chapter which outlined existing conditions in the city of fort collins and is central to the health equity “spread” presented in the introductory chapter of the adopted city plan. as the city plan is a foundational urban planning document, it is likely the hei will lead to the inclusion of health into future decisionmaking regarding distribution of capital improvement projects and land use policies that will have an impact on health equity within fort collins. however, as comprehensive plans are 20-30 year guiding documents, this plan has yet to create any tangible benefits for vulnerable communities in the city. conclusion local public health agencies have numerous tools, resources, and models to address upstream determinants of health, especially through a built environment lens. elements of hia can be a powerful tool for not only understanding the health impacts of a policy or process on community, but also for building and developing trusted cross-sector relationships. a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 12 references bharmal, n., derose, k. p., felician, m., & weden, m. m. (2015). understanding the upstream social determinants of health. california: rand, wr-1096-rc, 1-18. retrieved from https://www.rand.org/content/dam/rand/pubs/ working_papers/wr1000/wr1096/rand_wr1096.pdf center for disease control and prevention (cdc). (2016). health impact assessment. retrieved from https://www.cdc. gov/healthyplaces/hia.htm center for disease control and prevention (cdc). (2019). health and economic costs of chronic diseases. retrieved from https://www.cdc.gov/chronicdisease/about/costs/index.htm center for disease control and prevention (b) (cdc). (2019). connecting routes and destinations. retrieved from: https:// www.cdc.gov/physicalactivity/community-strategies/beactive/index.html city of fort collins. (2019). city plan. retrieved from https://ourcity.fcgov.com/560/documents/4764 city of fort collins. 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(2017). pedestrian master plan. retrieved from https://www.seattle.gov/ documents/departments/sdot/about/documentlibrary/seattlepedestrianmasterplan.pdf https://www.rand.org/content/dam/rand/pubs/working_papers/wr1000/wr1096/rand_wr1096.pdf https://www.rand.org/content/dam/rand/pubs/working_papers/wr1000/wr1096/rand_wr1096.pdf https://www.cdc.gov/healthyplaces/hia.htm https://www.cdc.gov/healthyplaces/hia.htm https://www.cdc.gov/chronicdisease/about/costs/index.htm https://www.cdc.gov/physicalactivity/community-strategies/beactive/index.html https://www.cdc.gov/physicalactivity/community-strategies/beactive/index.html https://ourcity.fcgov.com/560/documents/4764 https://www.fcgov.com/engineering/pdf/pedneedsreport.pdf?1475014663 https://www.fcgov.com/engineering/pdf/pedneedsreport.pdf?1475014663 https://ajph.aphapublications.org/doi/abs/10.2105/ajph.2013.301482 https://ajph.aphapublications.org/doi/abs/10.2105/ajph.2013.301482 https://www.healthypeople.gov/sites/default/files/public-health-3.0-white-paper.pdf https://www.healthypeople.gov/sites/default/files/public-health-3.0-white-paper.pdf https://www.rwjf.org/en/library/research/2014/08/the-relative-contribution-of-multiple-determinants-to-health-out.html https://www.rwjf.org/en/library/research/2014/08/the-relative-contribution-of-multiple-determinants-to-health-out.html https://www.seattle.gov/documents/departments/sdot/about/documentlibrary/seattlepedestrianmasterplan.pdf https://www.seattle.gov/documents/departments/sdot/about/documentlibrary/seattlepedestrianmasterplan.pdf a case study on incorportating health and equity into urban plans, transportation, and land use policies haworth; young winne 13 corresponding author kelly haworth, mph larimer county department of health and environment 1525 blue spruce drive fort collins, co 80524 970-498-6774 khaworth@larimer.org chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 4 issue 1 (2019) doi: 10.18060/23354 © 2019 author(s): haworth, k.; young winne, e. this work is licensed under a creative commons attribution 4.0 international license acknowledgements the authors would like to acknowledge annemarie heinrich, mph, murp for her work in creating the original health equity index model, as well as robert mosbey at the city of fort collins for implementation of the sidewalk prioritization model. phonejwaimberg@temple.edu october 2019 volume 4 issue 1 made to order: using gubernatorial executive orders to promote health in all policies maxim gakh, jd, mph abstract: the health in all policies (hiap) approach presents different and often complementary avenues to address the social determinants of health. but at its core, hiap relies on collaborations to make health a governmental priority across sectors. in the united states, hiap efforts can involve multiple levels of government and strategies that may vary in formality. in some states, state-level hiap efforts may be advanced by gubernatorial executive orders (geos). geos are often used to promote health. geos may be powerful in the hiap context because of their potential to manage the different sectors that comprise state government and thereby address the social determinants of health. by synthesizing the relevant literature and providing illustrative examples of hiappromoting geos, this review explores how, why, and whether to use geos for hiap. it demonstrates that geos may advance hiap with or without using a hiap label, along different steps in the policymaking cycle, and by addressing common hiap challenges. champions of hiap should therefore examine the possible utility of geos to promote state-level hiap efforts. 1 made to order: using gubernatorial executive orders to promote health in all policies gakh 2 a hiap strategy aims to promote health through collaboration across sectors health impact assessments (hias) can help address the social determinants of health across sectors that make decisions with health consequences (nrc, 2011). these sectors include the built environment, housing, education, agriculture, and energy (nrc, 2011; rudolph, caplan, ben-moshe, & dillon, 2013; wernham & teutsch, 2015; towe et al., 2016). hias have the ability to engage communities in decisionmaking, educate policymakers, create partnerships, and link data and scientific evidence to real-time decisions (nrc, 2011; dannenberg, 2016; wernham & teutsch, 2015). in fact, hias are one of the few existing, systematic tools available to target decisions that impact these social determinants (nrc, 2011). addressing the social determinants of health can simultaneously impact populations across multiple health outcomes (frieden, 2010). yet hia work also faces challenges (nrc, 2011; dannenberg, 2016; rudolph et al., 2013). an important challenge of using hias to target the social determinants is that most hias analyze a limited number of issues rather than creating consistent and sustainable change in how decisions with indirect health impacts are approached (nrc, 2011; wismar et al., 2006). thus, it is important that hias are part of a larger movement aiming for comprehensive integration of health into all sectors’ decisions (iom, 2011; kemm, 2006; rudolph et al., 2013; wernham & teutsch, 2015). this movement, sometimes called “health in all policies” (hiap), is rooted in the “healthy public policy” concept (gottlieb, fielding, & braveman, 2012; iom, 2011; rudolph et al., 2013; sihto, ollila, & koivusalo, 2006; gase, pennotti, & smith, 2013; wernham & teutsch, 2015). hiap has gained acceptance in the public health field both in the u.s. and globally (rudolph et al., 2013; ollila, 2011; sihto et al., 2006; wimar et al., 2006; wernham & teutsch, 2015) along with the recognition that the social determinants of health are critical in shaping health outcomes (sihto et al., 2006; frieden, 2010; wernham & teutsch, 2015; who, 2008; cdc, 2018; iom, 2011; apha, 2012; hhs, 2019). like hias, at its core, hiap focuses on integrating health concerns into non-health sectors (iom, 2011; rudolph et al., 2013; sihto et al., 2006; gase et al., 2013; wernham & teutsch, 2015; gakh & rutkow, 2017). it involves addressing the health implications of policy decisions in non-health sectors, because “other sectors are often key in terms of health determinants” (ollila, 2011, p.13). but this is easier said than done: “the central issue facing hiap is how to enhance the feasibility of placing health criteria on the agendas of policy-makers who have not previously considered health” (sihto et al., 2006, p.11). operationally, hiap-related efforts can take many forms (sihto et al., 2006; rudolph et al, 2013; ollila, 2011; wernham & teutsch, 2015; gase et al., 2013). they can focus on specific social determinants or health-related issues (sihto, et al., 2006; rudolph et al., 2013; ollila, 2011; wernham & teutsch, 2015). alternatively, hiap efforts can directly focus on decision-making processes and systems change to encourage consideration of health across decisions (sihto et al., 2006; rudolph et al., 2013; ollila, 2011; gase et al., 2013; wernham & teutsch, 2015). cross-sector partnerships are also central to hiap endeavors (sihto et al., 2006; rudolph et al., 2013; ollila, 2011; gase et al., 2013; wernham & teutsch, 2015). in the broadest sense, these partnerships involve collaboration among governmental, forprofit, and non-profit organizations formed around health-related goals and comprised of contextspecific activities and enabled by different structures (johnston & finegood, 2015). hiap efforts are not exclusively government-centric (rudolph et al., 2013; ollila, 2011; wernham & teutsch, 2015). however, governmental hiap efforts usually involve collaboration by government agencies that are organized around sometimes seemingly inconsistent missions (rudolph et al., 2013; sihto et al., 2006). in the hiap context, greer & lillvis define “intersectoral governance” as “the set of political, made to order: using gubernatorial executive orders to promote health in all policies gakh 3 legal, and organizational structures that enables the coordination of multiple sectors to address causes of ill health, and is therefore the mechanism permitting hiap” (2014, p.13). implementing this type of cross-sector governmental collaboration can encounter barriers, such as variable organizational cultures; limited understandings across organizations; inconsistent definitions of success; and limited resources, tools, and expertise (johnston & finegood, 2015; sihto et al., 2006; rudolph et al., 2013; gase et al., 2013; wernham & teutsch, 2015). hiap implementation can pursue formal strategies, informal strategies, or both (rudolph et al., 2013; gase et al., 2013; wernham & teutsch, 2015). formal hiap endeavors, including implementation that relies on law, can catalyze or set out cross-sector hiap work (rudolph et al., 2013; gakh, 2015; wernham & teutsch, 2015). in fact, as hall & jacobson found in interviews with policy actors, legal mandates can sometimes “encourage buy-in for cross-sector collaboration” (2018, p.6). different formal, lawbased mechanisms are available to issue hiap-related mandates – including legislation, regulation, and memoranda of understanding – and choosing among them can involve balancing structural factors like legal authority and political realities (rudolph et al., 2013; gakh, 2015). gubernatorial executive orders (geos) may be the right mechanisms for state-level hiap efforts, depending on legal structures and de facto realities (rudolph et al., 2013; gakh, 2015). geos allow governors to mandate action from multiple statelevel sectors simultaneously and may present fewer procedural obstacles and require less political capital to adopt than other legal mechanisms that formalize hiap (gakh, 2015). a closer look at geo documents and how they can be crafted to encourage hiap is therefore in order. examining these documents in detail is also an important first step to inform studies on how geos impact hiap implementation. geos are an important public health policy mechanism that is well suited for hiap geos are an essential and sometimes overlooked policy mechanism that can advance public health (gakh, vernick, & rutkow, 2013; gakh, callahan, goodie, & rutkow, 2019). a geo may allow a state governor to set or operationalize formal changes to programs and policies without the need for official legislative support (gakh et al., 2013). state laws vary in what a governor can legitimately direct by executive order (csg, 2010; ferguson & bowling, 2008; gakh et al., 2013). geos may be used for symbolic gestures, such as flying flags on state property (ferguson & bowling, 2008). but they may also undertake various substantive public health goals by targeting public health emergencies, establishing or modifying government agencies or programs, directing public health agencies, prioritizing health issues, and controlling state operations (gakh et al., 2013). geos can promote the cross-sector governmental work that constitutes hiap. the literature contains examples of geos as law-based, state-level mechanisms to promote hiap (pepin, winig, carr, & jacobson, 2017; weisman, helmy, moua, & aoki, 2018; gakh, 2015; polsky, stagg, gakh, & bozlack, 2015; rudolph et al., 2013; gase et al., 2013; wernham & teutsch, 2015). but a closer look at the mechanism itself in the context of hiap is warranted because most public health-related geos tend to include directives salient to hiap. these directives include managing government agencies, establishing new government entities, mandating cross-sector collaboration, or requiring the investigation and development of recommendations to address particular health problems (gakh et al., 2019). this review uses frameworks focused on public health policy and cross-sector collaboration to demonstrate that, like other formal mechanisms, geos (1) can promote hiap with or without using a hiap label; (2) help prioritize, formulate, adopt, implement, and evaluate hiap efforts; and (3) address some common made to order: using gubernatorial executive orders to promote health in all policies gakh 4 barriers to state-level governmental hiap efforts. to illustrate these points, this review relies on geos identified through key terms searches in relevant databases (e.g., westlaw’s netscan executive orders database and the lexis advance databases containing state statutes and legislation and administrative codes and regulations) and from a priori knowledge. geos may promote hiap with or without an articulated commitment to hiap hiap implementation can involve sweeping efforts that focus on modifying decisions that impact the social determinants of health or on more discrete health-related priorities (rudolph et al., 2013). geos can support both types of efforts and can do so with or without labeling the effort as “hiap.” this is important because it demonstrates that geos that support hiap can take many forms. at the broad and explicit end of the range of geo types, for example, in 2015, vermont governor shumlin issued an order to establish a hiap task force (vt. exec. order no-07-15 (oct. 6, 2015)). this order recognizes the role that non-health sectors play in health behaviors and outcomes and therefore that health necessitates a “shared responsibility and an integrated and sustained policy response across government” (vt. exec. order no-07-15 (oct. 6, 2015, p.1)). the vermont hiap task force, chaired by the state health commissioner and with representatives from different state agencies (e.g., agriculture, commerce, transportation, public service, education, human services, natural resources), is responsible for determining how “to more fully integrate health considerations into all state programs and policies, and promote better health outcomes through interagency collaboration and partnership” (vt. exec. order no-07-15 (oct. 6, 2015)). california’s hiap efforts similarly include a 2010 geo, issued by governor schwarzenegger, that also directly establishes an intergovernmental hiap task force rooted in the state’s efforts to manage growth (cal. exec. order no. s-04-10 (feb. 23, 2010)). a recent new york geo requires state government entities to integrate the state’s prevention agenda priorities and world health organizations domains of livability, which focuses on healthy aging, into their plans, “guidance, policies, procedures, and procurements” to promote “health across all policies” (n.y. exec. order no. 190 (nov. 14, 2018, p.1)). however, considering only geos that institute broad hiap initiatives and include hiap labels overlooks hiap-promoting geos that contain substantive directives that can facilitate cross-sector hiap work but are not cast in “health in all policies” language. at its core, hiap is defined as integrating health concerns into other sectors (iom, 2011; rudolph et al., 2013; sihto et al., 2006); hiap implementation strategies are therefore not limited to hiap-oriented government organizations (rudolph et al., 2013; wernham & teutsch, 2015; gase et al., 2013). understanding how hiap-like orders can integrate health into other sectors is critical because it reveals a more subtle use of geos to advance the hiap approach. geos focused on education and children from several states illustrate how geos with no mention of hiap can encourage more nuanced hiap-like practice. for example, on its face, a kansas geo makes no mention of hiap, the social determinants of health, or the connection between education and health (kan. exec. order no. 10-05 (jun. 17, 2010)). however, the order creates a statewide advisory group, with a state health agency representative, focused on early childhood education to examine opportunities for collaboration among state government agencies and to improve existing data systems (kan. exec. order no. 10-05 (jun. 17, 2010)). a connecticut order uses a similar approach; it requires the state office of early childhood to establish an interagency effort around early childhood education that includes the health department (conn. exec. order no. 35 (jun. 24, 2013)). it also requires the state executive branch to “collaborate and cooperate with the office” (conn. exec. order no. 35 (jun. 24, 2013, p.2)). similarly, recognizing that many state government made to order: using gubernatorial executive orders to promote health in all policies gakh 5 agencies “lead programs that are important to the success and well-being” of children, a tennessee geo establishes a children’s cabinet focused on “shared policy, planning, coordination, cooperation, and collaboration” (tenn. exec. order no. 10 (jan. 30, 2012, p.1)). this cabinet includes state-level government entities, including agencies responsible for education, human services, and health, and requires executive agencies to support the cabinet’s efforts (tenn. exec. order no. 10 (jan. 30, 2012)). the kansas, connecticut, and tennessee orders illustrate that, even when geos do not contain hiap language, they can include hiap-like content requiring crosssector collaboration around health and integrating health into government work in areas that are important to the social determinants. geos may prioritize, formulate, adopt, implement, and evaluate intergovernmental hiap work policymaking is a complex and dynamic process with the ability to change health (brownson, chriqui, & stamatakis, 2009; golden & moreland-russell, 2016). multiple models and frameworks are useful to understand policy in the context of health (oliver, 2006). although policy-making is difficult to categorize meaningfully, one way to visualize policymaking is as a five-step cycle comprised of policy prioritization, formulation, adoption, implementation, and evaluation – and back to the start (golden & moreland-russell, 2016). geos can support hiap efforts throughout each step of this policymaking cycle. geos can prioritize integrating health into other sectors through cross-sector collaboration. prioritization involves identifying, selecting, or framing a health-related issue for policy intervention (golden & moreland-russell, 2016). both hiap-based and hiap-like geos can do this. for example, the vermont, new york, and california geos clearly establish health as a cross-cutting issue for state government agencies, elevating the importance the importance of considering health across government decisions and the pursuit of hiap as a goal (vt. exec. order no-0715 (oct. 6, 2015); n.y. exec. order no. 190 (nov. 14, 2018); cal. exec. order no. s-04-10 (feb. 23, 2010)). hiap-like geos can also prioritize health issues and approaches across sectors. for instance, a louisiana geo names an existing commission as an interagency council to establish, review, update, and implement the state’s plan to address homelessness (la. exec. order no. bj 2013-5 (mar. 19, 2013)). similarly, a north dakota order establishes a statewide, crosssector coalition to improve “collaboration and coordination on behavioral health services for service members, veterans, and their families and survivors” (n.d. exec. order no. 15-01 (jan. 8, 2015, p.1)). in these examples, geos emphasize the importance of health issues and frame health-related problems as cross-sector problems. geos can also formulate policy to incorporate health into other sectors. policy formulation involves developing, articulating, and considering policy solutions to health problems (golden & morelandrussell, 2016). vermont’s executive order, for instance, requires the interagency hiap task force to report to the governor “potential opportunities to include health criteria in regulatory, programmatic, and budgetary decisions” and strategies from other jurisdictions to integrate health across government decisions (vt. exec. order no-07-15 (oct. 6, 2015, p.2)). although not explicitly focused on hiap, nevada’s geo establishing a cross-sector food security council in the health department calls for annual reports with recommendations (nev. exec. order no. 2014-03 (feb. 12, 2014)). both geos require cooperation around identifying and articulating crosssector policy solutions focused on health. in addition, geos can be vehicles to adopt hiap or hiap-like policy. adoption involves processes that result in choosing a particular policy (golden & moreland-russell, 2016). the issuance of the vermont, new york, and california hiap geos embodies the adoption of a hiap approach through made to order: using gubernatorial executive orders to promote health in all policies gakh 6 formal policymaking channels (vt. exec. order no07-15 (oct. 6, 2015); n.y. exec. order no. 190 (nov. 14, 2018); cal. exec. order no. s-04-10 (feb. 23, 2010)). similarly, while not explicitly hiap-focused, a massachusetts geo that formally adopts for multiple state executive agencies a policy of “procuring environmentally preferable products and services” to conserve natural resources, limit generation of toxic substances, and reduce negative impacts on health and the environment also operates as formal adoption of state policy integrating health concerns across sectors (mass. exec. order no. 515 (oct. 27, 2009, p.2)). executive orders issued by governors can help implement polices that embed health into non-health sectors through collaboration. the implementation phase involves operationalizing adopted policy through specific strategies, tasks, and responsibilities (golden & moreland-russell, 2016). the california, new york, and vermont hiap geos lay out specific implementation strategies to operationalize hiap. the vermont and california geos both create hiap task forces (vt. exec. order no-07-15 (oct. 6, 2015); cal. exec. order no. s-04-10 (feb. 23, 2010)). in addition, the california order requires the state health department to staff and facilitate the work of the hiap task force (cal. exec. order no. s-04-10 (feb. 23, 2010)), while the vermont order requires its hiap task force to develop tools to help state agencies consider health impacts of policy decisions (vt. exec. order no-07-15 (oct. 6, 2015)). the new york order requires each agency to appoint and deputize a coordinator responsible for hiap implementation (n.y. exec. order no. 190 (nov. 14, 2018)). hiap-like geos can also help implement policies that embed health across sectors. for example, maryland’s governor hogan used a geo to create an executive council committee centered on paid sick leave with representatives from multiple agencies and duties that include collecting data, surveying employees and employers, developing policy recommendations, providing regular updates, and submitting a final report (md. exec. order no. 01.01.2017.08 (may 25, 2017)). while varying in hiap scope and, with or without using hiap labels, the vermont, california, new york, and maryland geos illustrate how geos can be used to operationalize the hiap approach and hiap principles. finally, geos can also be helpful mechanisms to launch evaluation of efforts that bring health into other sectors. evaluation is the last stage of the policy cycle and involves examining the impacts of an implemented policy on its target and on other indicators so necessary adjustments can be made (golden & moreland-russell, 2016). the vermont geo encourages evaluation of hiap efforts by requiring task force members to describe how they are integrating health concerns into their respective decisions (vt. exec. order no-07-15 (oct. 6, 2015)). while not mentioning hiap, a michigan geo that forms a state interagency council on homelessness, with representatives from many government agencies including health, orders the council to craft a plan to end homelessness and then “monitor and oversee the implementation” of the plan through measurable goals, coordinated data and reporting systems, and progress reports (mich. exec. order no. 2015-2, jan. 16, 2015, p.1)). geos can therefore include evaluation components to state-level efforts that bring the health lens into other sectors. geos may address some of the problems of cross-sector collaboration around health geos can also tackle some common challenges faced by cross-sector collaborative efforts to bring health into governmental decision-making. greer & lillvis identify two major barriers to hiap’s intersectoral governance – (1) “coordination” (i.e., how to get the non-health sector to focus on health) and (2) “durability” (i.e., how to maintain hiap efforts across time) – by synthesizing relevant literature from the public health, political science, and public administration fields (2014, p.14). they identify three categories of possible ways to overcome these barriers: (1) “political leadership” (i.e., actualizing commitment from leaders), (2) “bureaucratic change” made to order: using gubernatorial executive orders to promote health in all policies gakh 7 (i.e., modifying existing processes, procedures, and modes of interaction) and (3) “indirect strategies” (i.e., pursuing longer-term changes to policymaking) (greer & lillvis, 2014, p.14-15). related to these solutions, kania and kramer articulate five common conditions of “successful collective impact”: (1) shared agendas, (2) consistent metrics, (3) collaborative work that reinforces each other, (4) constant communication, and (5) an organization that can take on coordination (2011, p.23). they argue that “collective impact” – or “the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem” – provides a way to solve complex problems like health (kania & kramer, 2011). both frameworks provide guidance for hiap efforts. they are also consistent with other discussions in the hiap literature (rudolph et al., 2013; gase et al., 2013, wernham & teutsch, 2015). geos are important tools that can be part of the solution to overcome barriers to hiap. leadership by policymakers and shared agendas can promote hiap (kania & kramer, 2011; greer & lillvis, 2014). geos can foster both. issuing a hiappromoting geo formally establishes hiap as a crosssector priority at the highest level of state executive leadership. by using geos to create hiap task forces, the vermont, new york, and california governors formally signaled to state government agencies from different sectors and to others that they recognize the value of and are committed to hiap (vt. exec. order no-07-15, (oct. 6, 2015); n.y. exec. order no. 190 (nov. 14, 2018); cal. exec. order no. s-04-10 (feb. 23, 2010)). the language of all three orders acknowledges that health policy is made across sectors and the importance of incorporating health into decisionmaking (vt. exec. order no-07-15, (oct. 6, 2015); cal. exec. order no. s-04-10 (feb. 23, 2010); n.y. exec. order no. 190 (nov. 14, 2018)). all three orders establish hiap as a shared priority for state agencies and health as a cross-sector responsibility through formal policy mechanisms issued by the state’s chief executives (vt. exec. order no-07-15, (oct. 6, 2015); cal. exec. order no. s-04-10 (feb. 23, 2010); n.y. exec. order no. 190 (nov. 14, 2018)). the vermont, california, and new york geos also enshrine at least some robustness into their hiap efforts. california requires delivering one report with recommendations to state government (cal. exec. order no. s-04-10 (feb. 23, 2010)); vermont requires an annual report with recommendations to the governor and periodic reporting of progress (vt. exec. order no-07-15, (oct. 6, 2015)). and new york requires establishing responsible parties (n.y. exec. order no. 190 (nov. 14, 2018)). hiap efforts would likely be sustained at least until completion. furthermore, as long as these geos remain in effect, they can serve as a formal commitment to hiap articulated for all state agencies by the state’s chief executives. hiap-like geos, too, can be a vehicle for leadership to support coordination and durability and to set cross-sector agendas on issues with health impacts. a colorado geo, for example, adopts a shared agenda of supporting “zero emissions vehicles” (colo. exec. order no. b-2019-002 (jan. 17, 2019, p.2)). it creates a cross-sector workgroup of state agencies, including health, and encourages agencies to coordinate efforts while requiring workgroup members to modify their rules, programs, and plans to support this healthpromoting goal (colo. exec. order no. b-2019-002 (jan. 17, 2019)). by requiring the implementation of specific policies and clarifying that the geo stands “until modified or rescinded” (colo. exec. order no. b-2019-002 (jan. 17, 2019, p.1)), this geo also supports the robustness of hiap-related work. hiap can involve modifying bureaucratic processes and entities to support coordination and durability, establish coordinating organizations, require reinforcing work, and encourage continuous communication (kania & kramer, 2011; greer & lillvis, 2014). geos can support these types of changes. the california and vermont geos design new state government entities – hiap task forces – as organizations to coordinate hiap and assign the responsibility of leading the hiap efforts to health made to order: using gubernatorial executive orders to promote health in all policies gakh 8 departments (vt. exec. order no-07-15 (oct. 6, 2015); cal. exec. order no. s-04-10 (feb. 23, 2010)). both orders also require agencies to collaborate in ways that augment each other’s work and encourage communication. california’s geo calls upon all agencies that report to the governor to cooperate with the hiap task force (cal. exec. order no. s-04-10 (feb. 23, 2010)). vermont’s order requires agencies constantly to interact through the new task force as they identify health-promoting strategies; integrate health into their “rulemaking, policies, and programs;” and regularly report progress (vt. exec. order no-07-15, oct. 6, 2015, p.2). while new york’s order requires establishing hiap-responsible staff across agencies who also must liaise with a central hiap committee (n.y. exec. order no. 190 (nov. 14, 2018). these changes attempt to modify normal bureaucratic structures and processes to enable hiap. a hiap-like geo from washington focused on carbon pollution (wash. exec. order 14-04 (apr. 29, 2014)) also changes bureaucracy, establishes coordinating entities, requires reinforcing work, and encourages continuous communication. among its mandates are requirements to non-health agencies like the departments of transportation, commerce, ecology, and administration, to take on specific tasks related to clean energy (wash. exec. order 14-04 (apr. 29, 2014)). it contains requirements for mutuallysupportive work, such as including reviewing statutory limits on greenhouse gas emissions, reducing state government contributions to emissions, and stimulating renewable energy (wash. exec. order 14-04 (apr. 29, 2014, p.8)). these tasks contribute to a more comprehensive state policy. this washington order also shifts existing government structures. it creates an “energy, transportation, and climate subcabinet […] to organize, coordinate, and implement state agency work” related to carbon pollution, comprised of senior leaders from various state departments (wash. exec. order 14-04 (apr. 29, 2014)). furthermore, this geo encourages communication through collaboration on recommendations and by including federal, tribal, regional, and local partners in implementation (wash. exec. order 14-04 (apr. 29, 2014)). finally, stressing transparency and inclusiveness as well as creating and using shared data and metrics can support sustaining hiap indirectly (kania & kramer, 2011; greer & lillvis, 2014). here too geos may be a helpful mechanism. for example, the california geo requires its hiap task force to “convene regular public workshops to present its work plan” and also to “solicit input from stakeholders” to inform its hiap report (cal. exec. order no. s-04-10 (feb. 23, 2010, p.2)). the california and vermont geos may also indirectly encourage transparency and inclusiveness through hiap reports and recommendations that are made publicly available. similarly, a pennsylvania hiap-like geo, which focuses on cross-sector management, policy, and problem-solving, attempts to “engage internal and external stakeholders” to improve state government operations through “continuous process improvement methods” and by tracking key data indicators and publishing online the goals and progress of the governor’s administration (pa. exec. order 2018-01 (feb. 1, 2018, p.1)). by improving data systems, integrating stakeholders into government decision-making, and promoting transparency, these geos may indirectly contribute to hiap efforts. order with caution geos serve as a legal mechanism with the potential to support state-level hiap efforts. they can do this by focusing directly on hiap or by championing hiap-like principles. they can help prioritize, formulate, adopt, implement, and evaluate hiap efforts. they can also target some of the common obstacles that hiap crosssector efforts face. however, geos may not always be the most appropriate vehicle to establish formal hiap endeavors, and cautious optimism is in order. the geos presented here demonstrate the potential of geos to promote hiap. but geos are just mechanisms made to order: using gubernatorial executive orders to promote health in all policies gakh 9 – means to ends. like all mechanisms, geos as mechanisms are outcome-neutral. the extent to which they promote or hinder hiap is a function of what they actually say and how they are actually implemented. even though, on their face some geos look like they could support hiap, they miss opportunities; they do not contain language to integrate health into other sectors even when they recognize the role other sectors play in health. florida’s order on transportation in one of the state’s economic hubs serves as an example. while this geo articulates the importance of health and the connections between health, transportation, community development, economic activity, and the environment, and also includes cross-sector collaboration and community engagement directives, the order alludes to health without saying that some of the cross-sector partners must bring a health perspective to the collaboration (fla. exec. order no. 13-319 (nov. 1, 2013)). therefore, the precise language of the geo plays a vital part in the geo’s ability to promote cross-sector collaboration with health in mind. geos also have structural limitations that are consequential in the hiap context. for example, as previously discussed, there is state-by-state variation about what governors can do with geos (csg, 2010; ferguson & bowling, 2008; gakh et al., 2013). in some states there is no express legal authority to issue geos in areas especially relevant to hiap – such as reorganizing the executive branch, creating governmental entities, or targeting administration – though there nevertheless may be implied authority to do so (csg, 2010). similarly, in some states, certain geos may need to undergo legislative review or the same procedural processes as administrative regulations (csg, 2010; ferguson & bowling, 2008). such requirements may lessen the appeal of geos for hiap by negating some of the speed and simplicity that makes geos appealing in the first place. like other policy mechanisms, geo requirements can change over time, lapsing in many ways; they can sunset by their own provisions, expire by operation of law, or be over-ridden through political processes – by the same or a subsequent governor or through legislative action (gakh et al., 2013). recognizing these limitations is important in deciding whether to pursue a hiap-promoting geo. while state governments are critical for hiap implementation in the united states, federal and local governments should not be overlooked. there are many important hiap efforts at the local level, some that also use executive orders. for example, the sustainability effort in washington d.c. includes a mayoral order creating a cross-sector hiap task force to plan for and recommend hiap operationalization (d.c. exec. order no. 2013-209 (nov. 5, 2013)). local-level orders should be examined in further detail. beyond executive orders, municipal, county, and regional government entities are important hiap partners (rudolph et al., 2013; wernham & teutsch, 2015), especially because many of the social determinants of health (e.g. education, housing, transportation) are particularly affected by local policy (dean, williams, & fenton, 2013). relatedly, in evaluating the potential use of a geo for hiap, interactions between federal, state, and local government entities should be considered. as washington state’s partnership council on juvenile justice geo demonstrates, sometimes hiap-like geos may be in direct reaction to federal policy. this order makes clear that the council it establishes is a direct response to federal legislation that “requires each state to establish a state juvenile justice advisory group to receive [federal] funds” (wash. exec. order no. 10-03 (sept. 13, 2010, p.1)). while orders like these can simultaneously respond to federal policy and promote hiap, the extent to which they evidence a genuine commitment to state-level, hiap-promoting policy merits asking. it may be difficult to distinguish policy from politics; the intent of a geo that looks like it promotes hiap may actually be to achieve an alternative goal. this is important because the intent of a hiap-promoting geo may affect the robustness of the resulting hiap effort. made to order: using gubernatorial executive orders to promote health in all policies gakh 10 notably, whether hiap-promoting geos actually result in hiap implementation is an important question. just because a health sector representative is involved in cross-sector collaboration around health does not mean the health perspective will prevail or even receive adequate attention. limited authority, resources, commitment, bureaucratic changes, or know-how that accompany a geo that appears hiap-promoting may result in unsuccessful state citation with date issued online availability order topic additional information on implementation (where available) california ca. exec. order no. s-04-10 (feb. 23, 2010) https://wayback.archive-it. org/5763/20101008184544/http:// gov.ca.gov/executive-order/14537/ health in all policies https://www.cdph. ca.gov/programs/ohe/ pages/hiap.aspx colorado colo. exec. order no. b-2019-002 (jan. 17, 2019) https://www.colorado.gov/ governor/sites/default/files/ inline-files/b_2019-002_supporting_a_transition_to_zero_emissions_vehicles.pdf zero emissions vehicles https://www.colorado. gov/pacific/cdphe/ zero-emission-vehicle-mandate-proposal connecticut conn. exec. order no. 35 (jun. 24, 2013) https://portal.ct.gov/-/media/ office-of-the-governor/executive-orders/others/governor-dannel-p-malloy--executive-order-no-35.pdf office of early childhood https://www.ct.gov/ oec/site/default.asp washington, d.c. d.c. exec. order no. 2013-209 (nov. 5, 2013) https://www.dcregs.dc.gov/ common/noticedetail.aspx?noticeid=n0045216 sustainable dc https://www.sustainabledc.org/ florida fla. exec. order no. 13-319 (nov. 1, 2013) https://www.flgov.com/wp-content/uploads/orders/2013/13-319plan.pdf east central florida corridor task force https://spacecoasttpo. com/plan/east-central-florida-corridor-task-force/ kansas kan. exec. order no. 10-05 (jun. 17, 2010) https://kslib.info/documentcenter/ view/578/eo-10-05?bidid= early childhood advisory council --louisiana la. exec. order no. bj 2013-5 (mar. 19, 2013) https://www.doa.la.gov/pages/osr/ other/2013bjexo.aspx interagency council on homelessness --massachusetts mass. exec. order no. 515 (oct. 27, 2009) https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy environmental purchasing policy https://www.mass. gov/environmentally-preferable-products-epp-procurement-programs hiap efforts or even further undermine public health. even more crucial but difficult to evaluate is whether hiap-promoting geos actually improve the social determinants of health. of course, these evaluation questions are equally important to ask of all public health efforts, including efforts that use other legal mechanisms to formalize policy. despite these cautions, geos should not be overlooked by hiap practitioners and advocates as vehicles to promote cross-sector hiap efforts in 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https://kslib.info/documentcenter/view/578/eo-10-05?bidid= https://kslib.info/documentcenter/view/578/eo-10-05?bidid= https://www.doa.la.gov/pages/osr/other/2013bjexo.aspx https://www.doa.la.gov/pages/osr/other/2013bjexo.aspx https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs made to order: using gubernatorial executive orders to promote health in all policies gakh 11 maryland md. exec. order no. 01.01.2017.08 (may 25, 2017) https://content.govdelivery.com/ attachments/mdgov/2017/05/25/ file_attachments/822423/executiveorder%2b01.01.2017.08.pdf committee on paid sick leave policy https://www.dllr.state. md.us/paidleave/paidleavereport.pdf michigan mich. exec. order no. 2015-2 (jan. 16, 2015) https://www.michigan.gov/ documents/snyder/eo_20152_479496_7.pdf interagency council on homelessness https://www. michigan.gov/whitnorth dakota n.d. exec. order no. 15-01 (jan. 8, 2015) http://www.nd.gov/veterans/ files/resource/2015.1.8%20executive%20order%202015-01.pdf cares coalition https://www.ndcares. nd.gov/ nevada nev. exec. order no. 2014-03 (feb. 12, 2014) http://gov.nv.gov/uploadedfiles/ govnvgov/content/news_and_media/executive_orders/2014_images/eo_2014-03_governorscouncil_foodsafety.pdf governor’s council on food security http://dpbh.nv.gov/ programs/ofs/gcfs_ meetings/ofs_-_governor_s_food_security_council/ new york n.y. exec. order no. 190 (nov. 14, 2018) https://www.governor.ny.gov/ news/no-190-incorporating-health-across-all-policies-state-agency-activities health across all policies https://health.ny.gov/ prevention/prevention_agenda/health_ across_all_policies/ pennsylvania pa. exec. order 201801 (feb. 1, 2018) https://www.oa.pa.gov/policies/ eo/documents/2018-01.pdf governor’s office of performance through excellence https://www.governor.pa.gov/about/ office-performance-excellence/#about tennessee tenn. exec. order no. 10 (jan. 30, 2012) https://publications.tnsosfiles. com/pub/execorders/exec-orders-haslam10.pdf governor’s children’s cabinet --vermont vt. exec. order no07-15 (oct. 6, 2015) https://legislature.vermont. 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(p. 231-252). finland: ministry of social affairs & health. retrieved from http://hiaconnect. edu.au/old/files/health_in_all_policies.pdf made to order: using gubernatorial executive orders to promote health in all policies gakh 15 world health organization (who). (2008). closing the gap in a generation: health equity through action on the social determinants of health, geneva, switzerland: who press. retrieved from http://apps.who.int/iris/ bitstream/10665/69832/1/who_ier_csdh_08.1_eng.pdf. corresponding author maxim gakh, jd, mph school of public health, university of nevada, las vegas box 453063, 4505 s. maryland parkway las vegas, nv 89154-3063 maxim.gakh@unlv.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 4 issue 1 (2019) doi: 10.18060/23268 © 2019 author(s): gakh, m. this work is licensed under a creative commons attribution 4.0 international license acknowledgements the author would like to thank his university for supporting this work and also to thank and acknowledge contributions of researchers and practitioners in the area of health in all policies. the publication fees for this article were supported by the unlv university libraries open article fund november 2022 volume 7 issue 1 1 lindsey realmuto, mph building a receptive audience for hia: a phd student’s journey to create an hia course abstract there are few academic institutions in the united states currently offering courses on health impact assessment (hia). this commentary describes a phd student’s experience in building a receptive audience for an hia course within the urban planning and policy program at the university of illinois at chicago, how they went about developing the course, and details about the course and its implementation. key lessons learned from the experience of developing and implementing the course include: having a real-life hia project for students to work on can be challenging but very rewarding, for both students and partners; utilizing virtual meeting technology to invite guest lecturers from across the world provided an enriching learning experience; and providing clear milestones and setting deadlines for different components of the hia is helpful for students as they work through the different hia steps. while the course was successful by almost all metrics, institutionalizing hia courses within interdisciplinary planning/public health programs remains an ongoing challenge. building a receptive audience for hia realmuto 2 background when i was finishing my master of public health program at george washington university, i thought i was done with school. phd program? no thank you, absolutely not. in my professional life i had always been interested in the intersection of health and urban planning and i thought i could get by with what i had learned in my master program and my professional experiences. the decision to return to school was a direct outcome of my experience conducting a health impact assessment (hia) on the east harlem neighborhood plan in 2015. my experience with this hia left me feeling like i knew about urban planning, but not enough. i wanted to deepen my knowledge. i thus decided to pursue a phd in urban planning and policy. as i started my first year at university of illinois at chicago’s department of urban planning in 2019, i was full of energy to bring my ten years of experience working in public health to bare in this new academic pursuit. my first semester i took a planning healthy cities course with a faculty member who had previously written about incorporating health into planning programs (botchwey et al., 2009) and i told him about my professional experiences, particularly with hia. as a result, he asked me to do a guest lecture on hia for his planning studio class in the spring 2020 semester. the guest lecture was well received and from the students i sensed an interest in learning more. around the same time, i started working on a research project in uic’s school of public health and was excited to hear that the university was starting a joint public health and urban planning graduate degree program (mph/mupp). the timing of my phd at uic seemed perfect for someone interested in bridging the public health and planning fields. i began to ask around, does uic offer (or have they ever offered) an hia class? no. are there other classes that bring the planning and public health students together? besides the planning healthy cities course, an urban food systems course, and curriculum typical of environmental & occupational health programs in the school of public health, there were not a lot of interdisciplinary courses. in talking with the professor who had invited me to speak on hias for the studio class, i was encouraged to develop a draft hia course to present to the department. developing the course building off my experience conducting hia trainings with the san francisco department of public health program on health equity and sustainability as well as training materials available from other organizations, specifically human impact partners, i developed a course syllabus and presented it to department leadership in early spring 2021. feedback on the syllabus was mostly supportive and constructive, but the department’s primary concern was whether there would be enough interest and enrollment in the class to justify having it. since i had already been asked to do a repeat of my guest lecture on hia for the planning studio class in a few weeks, i used that lecture opportunity to do a quick poll among students to gauge interest and report back to department leadership. in that guest lecture poll, nearly 80% of 34 responding students indicated they were interested or very interested in taking an hia class. with this information, i received the green light to teach the class and was put on the schedule for spring 2022. i spent fall 2021 finalizing the syllabus and readings as well as reaching out to guest presenters and potential project partners. as part of this process, i reached out to several colleagues that i knew through society of practitioners of health impact assessment (sophia) about their experiences teaching hia and asked them to share their syllabus. i building a receptive audience for hia realmuto 3 compared my syllabus to theirs to see if i was missing any major topics, issues, or important readings. for potential projects, i reached out to professional connections i had in organizations around chicago, but i also surveyed different planning initiatives going on in the city. were there opportunities to collaborate where an hia makes sense? the projects had to roughly align with the timing of the class, which can be very challenging, but i was able to identify two potential projects for students to work on (more detail on those below). with this component finalized, i was ready to teach the course in the spring. organization and details about the course course details the hia course was a graduate level class offered over a 16-week semester in spring 2022. it was a hybrid virtual/in-person model. the first four weeks were held virtually as the university felt it was safer to hold virtual cases during the peak-omicron covid-19 wave and the rest of the class sessions were held in-person (except on a few occasions due to personal circumstances). i also offered a virtual option in the event students needed to isolate for covidrelated exposure or illness (i.e., students could connect via zoom to the in-person classroom). the class had 10 students, representing five mupp students, four mupp/mph students, and one mph student. i also had one additional mupp student who audited the course. to note, the class was not required for any of the degree programs mentioned. class organization broadly, the course was broken into two segments. the first segment – taught within the first seven weeks – was devoted to teaching the different steps of hia in-depth so that students could feel prepared to begin working on the main assignment for the course – which was a team hia project. the other segment during the second half of the semester covered a number of different topics relevant to the practice of hia, for example, the consideration of equity, community engagement, and institutionalizing health considerations into decision making (see full course syllabus appendix a). for several of the class sessions in the second half of the semester, i invited guest speakers for specific topics, which included equitable transit-oriented development, health in all policies, equity in hia and hias in the international context. in one of the last class sessions, i facilitated a professional panel of four guest speakers whose careers spanned the health and planning worlds. all of the invited speakers were from my professional network or recommended by someone within that network. assignments as part of the course, the students had one individual case study assignment and the larger team hia project. for the case study assignment, each student had to choose an hia from a list (curated by me) to read in-depth and present to the class. the goal of this assignment was for the students to get a sense of different hias that have been done, the breadth of topics covered, and teach the other students what they learned from the hia. for the team hia projects, the students were split into two groups, and each worked with a project partner: the chicago department of planning and development and cabrini green legal aid. for this project, they had a mid-term presentation to discuss their progress, a final presentation, and a final report. the students were able to complete the hia within the timeframe of the class. the students were primarily evaluated on these two assignments, but their final grades were also determined by their level of in-class participation and the results of a peer and project partner evaluation survey distributed at the end of the semester. building a receptive audience for hia realmuto 4 hia projects the two hia projects chosen for the class were both curated by me prior to the start of the semester. while i think it is helpful for students to get experience conducting the hia scoping step and understanding how one might decide to engage in an hia, the timeline of an academic semester is generally not sufficient. it does not provide enough time for students to find a topic area, go through the scoping phase, and come to a decision on whether to conduct the hia. although this was an urban planning focused class, i did aim to find hia projects that went outside the normal transportation/urban planning field in order to facilitate a greater understanding of the wide range of social, environmental, economic, and political determinants of health. with this in mind, i contacted cabrini green legal aid, a legal aid organization based out of chicago that participates in policy advocacy at the state level (cabrini green legal aid, 2022). i approached the cgla policy team about the class with information about hias, their goals, and whether they were working on any policy agenda’s that may benefit from such a project. i luckily found very welcome and interested colleagues who saw value in bringing health data into their advocacy efforts. the second hia project came about more as a function of planning projects going on in chicago. the chicago department of planning and community development was in the process of doing a neighborhood planning study of a 5 mile stretch of western avenue (chicago’s longest north/south street – spanning 25 miles) (chicago department of planning and development, 2022). i heard about the planning study through various channels and reached out to the lead planner to tell them about the class, what hias are, and if they would be interested in working with a group of students on an hia of the planning study. again, i was pleasantly surprised to receive a positive and quick response. after a telephone conversation with the planner shortly thereafter, i had the second project. at the end of the semester, i asked both project partners to fill out a brief survey about the student’s performance and their experiences with the project. i also had a follow-up call with one of the project partners to further discuss the project. outcomes, lessons learned, and recommendations in addition to the evaluation survey sent by the university, i sent a survey to the students at the end of the semester asking specific questions related to the structure of the course, assignments, and my performance as an instructor. feedback and recommendations provided below are largely based on responses from this additional survey. based on informal and formal feedback received from the students, the course went very well and was well received. the student feedback and interest in the course revealed a real desire to have more opportunities to work and study interdisciplinary topics that bridge planning and health. the creation of the mupp/mph degree at uic and the feedback received from students speaks to the desire of graduate students to have this type of interdisciplinary exposure and training. the overall structure and content of the course fit nicely into the weekly seminar class structure and the 16-week semester, although i know the students would have preferred to have some extra time to complete their hia. the inclusion of guest speakers was one of the strongest aspects of the course. it provided students with a broader range and greater depth of understanding about the topics covered in class and introduced them to a wide array of professionals – locally, nationally, and internationally working within the planning/ health realm in some way. although most of building a receptive audience for hia realmuto 5 our classes were held in-person, the ability to use virtual conferencing software within the classroom setting was a major asset in that i could invite speakers from across the country (and even across the world) to speak to the class. in this case, the virtual normalcy engendered by the covid-19 pandemic was a huge benefit as it broadened the pool of individuals i thought to invite and made the class much richer in terms of the variety of perspectives represented. the project partners also seemed very satisfied with the caliber of the projects and work of the students. in evaluating the work of the hias, one of the project partners noted: the team assembled some really useful data and recommendations. this hia will hopefully help support the need for these initiatives in [neighborhood name] … i appreciate the thoughtful work and enthusiastic participation! the two hia projects worked out incredibly well, although the timing wasn’t perfect. a major challenge of working on real life projects within an academic semester timeline is that it’s so difficult to align with the project timeline. it’s important to be upfront about that and communicate appropriate expectations with both the students and the project partners. be honest about what is possible and feasible. in terms of the hia case studies, i aimed to choose a broad range of hia topics, methods, and geographic locations. i believe this helps students engage more fully with a broader range of social determinants of health and better understand different methodological approaches in hia. as part of our case studies, i also included a racial equity impact assessment, and i am so happy that i did. not that i am an expert on racial equity impact assessments but there was a lot of interest from the students on this topic and one even mentioned they would have liked to spend more time on this topic. while equity has always been a fundamental driver of hia work, i believe it is important for current and future hia practitioners to consider racial equity explicitly. i hope to incorporate more on this in future iterations of the course. for their hia project, i wanted to provide students with a decent amount of autonomy, and i tried my best to provide at least 10-15 minutes at the end of each class for the teams to meet and work together (with the expectation that they would also meet outside of class). i also made myself available to answer questions during this time and in designated office hours. based on feedback from the students, there could have been more structured assignments to help them work through the different hia steps throughout the semester (e.g., creating a pathway diagram, completing the literature review, etc.). i found this to be one of the most helpful pieces of feedback on the course. it is clear to me that this needs to be more structured and that providing deadlines on specific components of the hia can be a useful experience for the students. for any novice (or even experienced) hia practitioner, it is useful to have strong guideposts along the way. conclusions as of the time of this writing, i have been invited to teach the hia course again in the spring 2023 semester. and while i am excited that i have succeeded in building a receptive and interested audience for this course, and hopefully the intersection of health and planning more broadly, i feel less optimistic about the sustainability of the course. my assumption is that as soon as i am done with my phd and if i am no longer there, the course will disappear as well. in many ways this feels analogous to the state of hia more generally; without proper resources and policies to make it part of the building a receptive audience for hia realmuto 6 system, their future is unknown. despite these challenges, we keep moving forward, working to build those receptive audiences, inspiring interdisciplinary professionals, and promoting the values of hia in our everyday lives. building a receptive audience for hia realmuto 7 appendix a – course syllabus week 1: introduction to the course; understanding the relationship between public health and planning; social determinants of health required readings: • corburn j. (2004). confronting the challenges in reconnecting urban planning and public health. available at: https://ajph.aphapublications.org/doi/epub/10.2105/ajph.94.4.541 • schilling j, linton ls. the public health roots of zoning: in search of active living's legal genealogy. am j prev med. 2005 feb;28(2 suppl 2):96-104. doi: 10.1016/j. amepre.2004.10.028. pmid: 15694517. • review cdc social determinants of health page: https://www.cdc.gov/socialdeterminants/ index.htm week 2: introduction to hia history and practice; review screening and scoping steps; introduction to hia projects required readings: • dannenberg, al. a brief history of health impact assessment in the united states. http:// journals.iupui.edu/index.php/chia/article/view/21348 • human impact partners. screening worksheet. • sophia. minimum elements and practice standards for health impact assessment. https:// hiasociety.org/resources/documents/hia-practice-standards-september-2014.pdf (pages 1-6 stop at standards for the assessment step) • improving health in the united states: the role of health impact assessment. summary https://www.nap.edu/read/13229/chapter/3 (pages 3-13) • review health impact project hias and other resources to advance health-informed decisions: https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2015/ hia-map?sortby=relevance&sortorder=asc&page=1 week 3: health pathway diagrams; review assessment step (pt. 1) – baseline conditions required readings: • skim executive summary: snap benefits hia • complex causal process diagrams for analyzing the health impacts of policy interventions. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1470508/ • sophia. minimum elements and practice standards for health impact assessment. https:// hiasociety.org/resources/documents/hia-practice-standards-september-2014.pdf (pages 6-8; standards for the assessment step) • who. health impact assessment toolkit for cities. https://www.euro.who.int/__data/assets/ pdf_file/0007/101500/hia_toolkit_1.pdf (pages 13 – 19; 2.2 appraisal: assessment – stop at reporting and dissemination) • community health assessment or healthy community assessment: whose community? whose health? whose assessment? by trevor hancock and meredith minkler from community organizing and community building for health and welfare • review the cdc built environment assessment tool: https://www.cdc.gov/nccdphp/dnpao/ state-local-programs/built-environment-assessment/index.htm https://ajph.aphapublications.org/doi/epub/10.2105/ajph.94.4.541 ttps://www.cdc.gov/socialdeterminants/index.htm ttps://www.cdc.gov/socialdeterminants/index.htm http://journals.iupui.edu/index.php/chia/article/view/21348 http://journals.iupui.edu/index.php/chia/article/view/21348 https://hiasociety.org/resources/documents/hia-practice-standards-september-2014.pdf https://hiasociety.org/resources/documents/hia-practice-standards-september-2014.pdf https://www.nap.edu/read/13229/chapter/3 (pages 3-13) https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2015/hia-map?sortby=relevance&sortorder=asc&page=1 https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2015/hia-map?sortby=relevance&sortorder=asc&page=1 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1470508/ https://hiasociety.org/resources/documents/hia-practice-standards-september-2014.pdf https://hiasociety.org/resources/documents/hia-practice-standards-september-2014.pdf https://www.euro.who.int/__data/assets/pdf_file/0007/101500/hia_toolkit_1.pdf https://www.euro.who.int/__data/assets/pdf_file/0007/101500/hia_toolkit_1.pdf https://www.cdc.gov/nccdphp/dnpao/state-local-programs/built-environment-assessment/index.htm https://www.cdc.gov/nccdphp/dnpao/state-local-programs/built-environment-assessment/index.htm building a receptive audience for hia realmuto 8 hia presentation: snap benefits hia week 4: review assessment step (pt. 2) – literature reviews, collecting primary data required readings: • unc health sciences library: literature review. https://guides.lib.unc.edu/c. php?g=8369&p=2634604 • avey h. (2015). hia research: when is qualitative research warranted? available at: https:// humanimpact.org/hia-research-when-is-qualitative-research-warranted/ • reumers lm, et. al. (2021). quantitative health impact assessment methodology for societal initiatives: a scoping review, environmental impact assessment review, volume 86. available at: https://www.sciencedirect.com/science/article/pii/s0195925520307873 • skim executive summary: family unity, family health hia optional readings: • health impact and social value of interventions, services, and policies: a methodological discussion of health impact assessment and social return on investment methodologies. https://www.frontiersin.org/articles/10.3389/fpubh.2020.00049/full hia presentation: family unity, family health hia week 5: review assessment step (pt. 3) – assessing impacts; developing recommendations, and reporting step required readings: • (skim) epa. the health impact assessment (hia) resource and tool compilation: a comprehensive toolkit for new and experienced hia practitioners in the u.s., available at: https://www.epa.gov/sites/default/files/2017-07/documents/hia_resource_and_tool_ compilation.pdf • sfdph environmental health. transbase: linking transportation systems to our health. https://sfdph.org/dph/hc/hcagen/hcagen2014/may%206/transbase%20dec2013%20 final-2.pdf • sophia. minimum elements and practice standards for health impact assessment. pages 8-9 – standards for reporting • who. health impact assessment toolkit for cities. pages 19-20. 2.2.3 reporting and dissemination. optional: • skim executive summary: sf road pricing • review oecd “modelling work in public health: the oecd’s sphep models.” available at: https://www.oecd.org/health/modelling-work-in-public-health.htm • health equity implications of retail cannabis regulation in la county. http://publichealth. lacounty.gov/chie/reports/cannabis_hia_final_7_15.pdf • urban institute. do no harm guide: applying equity awareness in data visualization https:// www.urban.org/research/publication/do-no-harm-guide-applying-equity-awareness-datavisualization https://guides.lib.unc.edu/c.php?g=8369&p=2634604 https://guides.lib.unc.edu/c.php?g=8369&p=2634604 https://humanimpact.org/hia-research-when-is-qualitative-research-warranted/ https://humanimpact.org/hia-research-when-is-qualitative-research-warranted/ https://www.sciencedirect.com/science/article/pii/s0195925520307873 https://www.epa.gov/sites/default/files/2017-07/documents/hia_resource_and_tool_compilation.pdf https://www.epa.gov/sites/default/files/2017-07/documents/hia_resource_and_tool_compilation.pdf https://sfdph.org/dph/hc/hcagen/hcagen2014/may%206/transbase%20dec2013%20final-2.pdf https://sfdph.org/dph/hc/hcagen/hcagen2014/may%206/transbase%20dec2013%20final-2.pdf https://www.oecd.org/health/modelling-work-in-public-health.htm http://publichealth.lacounty.gov/chie/reports/cannabis_hia_final_7_15.pdf http://publichealth.lacounty.gov/chie/reports/cannabis_hia_final_7_15.pdf https://www.urban.org/research/publication/do-no-harm-guide-applying-equity-awareness-data-visualization https://www.urban.org/research/publication/do-no-harm-guide-applying-equity-awareness-data-visualization https://www.urban.org/research/publication/do-no-harm-guide-applying-equity-awareness-data-visualization building a receptive audience for hia realmuto 9 hia presentation: sf road pricing week 6: hia evaluation & monitoring; hia effectiveness required readings: • sophia. minimum elements and practice standards for health impact assessment. (page 10; evaluation and monitoring) • who. health impact assessment toolkit for cities. (pages 21-22; 2.3 monitoring and evaluation: did the health impact assessment lead to any change?) • american planning association. metrics for planning healthy communities. https://www. planning.org/publications/document/9127204/ • dannenberg, al. effectiveness of health impact assessments: a synthesis of data from five impact evaluation reports. available at: https://www.ncbi.nlm.nih.gov/pubmed/27362932 • do health impact assessments promote healthier decision-making? https://www. pewtrusts.org/en/research-and-analysis/issue-briefs/2019/02/do-health-impactassessments-promote-healthier-decision-making • the effectiveness of health impact assessment in influencing decision-making in australia and new zealand 2005-2009. available at: https://www.ncbi.nlm.nih.gov/pubmed/24341545 • skim executive summary: alternatives to prison hia hia presentation: alternatives to prison hia week 7: community engagement in hia required readings: • community, community development, and the forming of authentic partnerships: some critical reflections by ronald labonte from community organizing and community building for health and welfare • guidance and best practices for stakeholder participation in health impact assessments. https://hiasociety.org/resources/documents/guide-for-stakeholder-participation.pdf • health impact assessment in the uk planning system: the possibilities and limits of community engagement. https://www.ncbi.nlm.nih.gov/pubmed/22801987 • policylink. arts and culture: creates new ways to engage. https://www. communitydevelopment.art/ • farhang l, heller j. (2016) advocacy in hia: increasing our effectiveness and relevance as practitioners to address health, equity, and democracy. http://journals.iupui.edu/index.php/ chia/article/view/21350 • or https://www.pewtrusts.org/-/media/assets/2016/10/tce_brief.pdf optional reading: • skim executive summary: san diego restorative justice hia • iroz-elardo n, mcsharry mcgrath m. (2016). social learning through stakeholder engagement: new pathways from participation to health equity in u.s. west coast hia. http://journals.iupui.edu/index.php/chia/article/view/21351 https://www.planning.org/publications/document/9127204/ https://www.planning.org/publications/document/9127204/ https://www.ncbi.nlm.nih.gov/pubmed/27362932 https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2019/02/do-health-impact-assessments-promote-healthier-decision-making https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2019/02/do-health-impact-assessments-promote-healthier-decision-making https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2019/02/do-health-impact-assessments-promote-healthier-decision-making https://www.ncbi.nlm.nih.gov/pubmed/24341545 https://hiasociety.org/resources/documents/guide-for-stakeholder-participation.pdf https://www.ncbi.nlm.nih.gov/pubmed/22801987 https://www.communitydevelopment.art/ https://www.communitydevelopment.art/ http://journals.iupui.edu/index.php/chia/article/view/21350 http://journals.iupui.edu/index.php/chia/article/view/21350 https://www.pewtrusts.org/-/media/assets/2016/10/tce_brief.pdf http://journals.iupui.edu/index.php/chia/article/view/21351 building a receptive audience for hia realmuto 10 hia presentation: san diego restorative justice hia week 82: student presentations on hia progress no readings or hia presentation week 9: promoting health through zoning reforms opportunities and challenges guest speaker on equitable transit-oriented development required readings: • associations between active living-oriented zoning and no adult leisure-time physical activity in the u.s. https://pubmed.ncbi.nlm.nih.gov/27364934/ • hanlon, j. success by design: hope vi, new urbanism, and the neoliberal transformation of public housing in the united states. environment and planning a. https://journals-sagepubcom.proxy.cc.uic.edu/doi/pdf/10.1068/a41278 • tehrani, so. et. al. the color of health: residential segregation, light rail transit developments, and gentrification in the united states. https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc6801918/ or transit-oriented displacement or community dividends? – chapter 5 • incomplete streets – intro hia presentation: tod and health hia week 10: promotion of equity in hia guest speaker: illinois public health institute required readings: • promoting equity through the practice of health impact assessment: https://www.naccho. org/uploads/downloadable-resources/programs/community-health/hia-promoting-equity. pdf • health impact assessment of transportation projects and policies: living up to aims of advancing population health and health equity? https://pubmed.ncbi.nlm.nih. gov/30601724/ • towards environmental health equity in health impact assessment: innovations and opportunities. https://pubmed.ncbi.nlm.nih.gov/29911285/ • health equity impact assessment workbook (skim): http://www.health.gov.on.ca/en/pro/ programs/heia/docs/workbook.pdf • (skim) racial equity impact assessments: https://www.dcracialequity.org/racial-equityimpact-assessments optional readings: • equity metrics • communicating about equity (sophia resource) • center for neighborhood technology. equity in practice: a guidebook for transit agencies. https://www.cnt.org/transportation-and-community-development • metropolitan planning council: https://www.metroplanning.org/costofsegregation/roadmap. aspx https://pubmed.ncbi.nlm.nih.gov/27364934/ https://journals-sagepub-com.proxy.cc.uic.edu/doi/pdf/10.1068/a41278 https://journals-sagepub-com.proxy.cc.uic.edu/doi/pdf/10.1068/a41278 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6801918/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6801918/ https://www.naccho.org/uploads/downloadable-resources/programs/community-health/hia-promoting-equity.pdf https://www.naccho.org/uploads/downloadable-resources/programs/community-health/hia-promoting-equity.pdf https://www.naccho.org/uploads/downloadable-resources/programs/community-health/hia-promoting-equity.pdf https://pubmed.ncbi.nlm.nih.gov/30601724/ https://pubmed.ncbi.nlm.nih.gov/30601724/ https://pubmed.ncbi.nlm.nih.gov/29911285/ http://www.health.gov.on.ca/en/pro/programs/heia/docs/workbook.pdf http://www.health.gov.on.ca/en/pro/programs/heia/docs/workbook.pdf https://www.dcracialequity.org/racial-equity-impact-assessments https://www.dcracialequity.org/racial-equity-impact-assessments https://www.cnt.org/transportation-and-community-development https://www.metroplanning.org/costofsegregation/roadmap.aspx https://www.metroplanning.org/costofsegregation/roadmap.aspx building a receptive audience for hia realmuto 11 hia presentation: chicago racial equity assessment week 11: spring break – no class week 12: institutionalizing health in decision making guest speaker on health in all policies required readings: • health impact project. hias and other resources to advance health-informed decisions (review different tools) – https://www.pewtrusts.org/en/research-and-analysis/datavisualizations/2015/hia-map?sortby=relevance&sortorder=asc&page=1 • american planning association. integrating health into the comprehensive planning process. available at: https://www.planning.org/publications/document/9148247/ • national conference of state legislatures: http://www.ncsl.org/research/health/healthimpact-assessments.aspx • urban health: an example of a “health in all policies” approach in the context of sdgs implementation. https://pubmed.ncbi.nlm.nih.gov/31856877/ • public health institute. health in all policies: improving health through intersectoral collaboration. available at: https://www.phi.org/thought-leadership/health-in-all-policiesimproving-health-through-intersectoral-collaboration/ optional readings: • health impact project. health notes. https://www.pewtrusts.org/en/research-and-analysis/ articles/2019/06/19/health-impact-project-health-notes • kansas health institute – health impact checklist: https://www.khi.org/policy/article/hi-c hia presentation: kentucky pregnant workers hia week 13: environmental impact assessments and health; climate and health required readings: • bhatia, r & wernham, a. integrating human health into environmental impact assessment: an unrealized opportunity for environmental health and justice. environ health perspect. 2008 aug;116(8):991-1000. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2516559/ • integrated environmental health impact assessment for risk governance purposes; across what do we integrate? available at: https://pubmed.ncbi.nlm.nih.gov/26703709/ • dannenberg, a.l., rogerson, b. & rudolph, l. optimizing the health benefits of climate change policies using health impact assessment. j public health pol 41, 139–154 (2020). https://doi. org/10.1057/s41271-019-00189-y. available at: https://link.springer.com/article/10.1057/ s41271-019-00189-y#citeas • kovats, r. s., menne, b., ahern, m. j., & patz, j. a. (2003). national assessments of health impacts of climate change: a review. climate change and health: risks and responses. geneva, world health organization. https://www.who.int/globalchange/publications/ climatechangechap9.pdf?ua=1 https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2015/hia-map?sortby=relevance&sortorder=asc&page=1 https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2015/hia-map?sortby=relevance&sortorder=asc&page=1 https://www.planning.org/publications/document/9148247/ http://www.ncsl.org/research/health/health-impact-assessments.aspx http://www.ncsl.org/research/health/health-impact-assessments.aspx https://pubmed.ncbi.nlm.nih.gov/31856877/ https://www.phi.org/thought-leadership/health-in-all-policies-improving-health-through-intersectoral-collaboration/ https://www.phi.org/thought-leadership/health-in-all-policies-improving-health-through-intersectoral-collaboration/ https://www.pewtrusts.org/en/research-and-analysis/articles/2019/06/19/health-impact-project-health-notes https://www.pewtrusts.org/en/research-and-analysis/articles/2019/06/19/health-impact-project-health-notes https://www.khi.org/policy/article/hi-c https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2516559/ https://pubmed.ncbi.nlm.nih.gov/26703709/ https://doi.org/10.1057/s41271-019-00189-y https://doi.org/10.1057/s41271-019-00189-y https://link.springer.com/article/10.1057/s41271-019-00189-y#citeas https://link.springer.com/article/10.1057/s41271-019-00189-y#citeas https://www.who.int/globalchange/publications/climatechangechap9.pdf?ua=1 https://www.who.int/globalchange/publications/climatechangechap9.pdf?ua=1 building a receptive audience for hia realmuto 12 hia presentation: climate change in kivalina, alaska hia week 14: bridging the professional gap • guest lecture panel of 3-4 individuals whose professional careers bridge the planning/public health fields hia presentation: the long road home: decreasing barriers to public housing for people with criminal records no other readings for class week 15: hias in the international context required readings: • health impact assessment in latin american countries: current practice and prospects; https://www.sciencedirect.com/science/article/pii/s0195925516302335 • health impact assessment and health equity in sub-saharan africa: a scoping review; https://www.sciencedirect.com/science/article/pii/s0195925519301817 • review: https://www.health.govt.nz/our-work/health-impact-assessment hia presentation: no place like home? exploring the health and well-being impact of covid-19 on housing and housing insecurity: supplementary report (wales) • https://phwwhocc.co.uk/whiasu/hia-reports/ • https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11480-7 week 16: student hia presentations methods of evaluation & grading policies evaluation criteria you will be graded on both your individual contributions to class and a final team project. as part of the final project, i will be asking each member of the hia teams to evaluate each other, the results of which will account for 5 out of the 40 points for the final hia report and presentation. point breakdown for determining final course grade: i will provide more detailed information on how assignments will be evaluated over the course of the semester. class participation – 20 points, 20% mid-semester hia progress presentation – 20 points, 20% hia case presentation – 20 points, 20%= final hia report and presentation – 40 points, 40% total points: 100 https://www.sciencedirect.com/science/article/pii/s0195925516302335 https://www.sciencedirect.com/science/article/pii/s0195925519301817 https://www.health.govt.nz/our-work/health-impact-assessment https://phwwhocc.co.uk/whiasu/hia-reports/ https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11480-7 building a receptive audience for hia realmuto 13 references botchwey, n. d., hobson, s. e., dannenberg, a. l., mumford, k. g., contant, c. k., mcmillan, t. e., et al. (2009). a model curriculum for a course on the built environment and public health: training for an interdisciplinary workforce. american journal of preventive medicine, 36(2 suppl), 63. doi:10.1016/j. amepre.2008.10.003 cabrini green legal aid. homepage. retrieved oct 14, 2022, from https://www.cgla.net chicago department of planning and development. western avenue corridor study. retrieved oct 14, 2022, from https://www.chicago.gov/content/city/en/sites/western-avenue/home.html corresponding author lindsey realmuto, mph, phd (c) university of illinois at chicago department of urban planning and policy 412 s peoria st, chicago, il 60607 lrealm2@uic.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, bs, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 7 issue 1 (2022) doi: 10.18060/26567 © 2022 author(s): realmuto, l. this work is licensed under a creative commons attribution 4.0 international license acknowledgements the authors would like to thank the hia course students and project partners for their constructive and helpful feedback that helped to inform this paper. https://www.cgla.net https://www.chicago.gov/content/city/en/sites/western-avenue/home.html october 2019 volume 4 issue 1 health in all policies in denver, co: moving from plans to equitable development outcomes gretchen armijo, aicp, leed, ap; maggie kauffman, mph abstract: the city of denver’s departments of public health and environment and community planning and development have worked together using health impact assessments (hia) and health in all policies (hiap) frameworks to formalize using a health equity lens for city planning and resource prioritization. previous land use and transportation planners did not consider health or equity impacts on future growth and development. hias and a health-focused approach were initiated with neighborhood planning and expanded into the blueprint denver plan for land use and transportation. the neighborhood equity index was also developed to help city agencies prioritize financial and programmatic resources to be more equitable. lessons learned from the process include the need to develop relationships across organizations, more data and mapping can inform policy decisions and the need for health and equity champions inside and outside of organizations. 1 health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 2 introduction health impact assessment (hia) and health in all policies (hiap) have been used widely in the last decade in the u.s. to bring health research and evidence into civic decision-making. over 400 hias have been conducted in the u.s. over the past 20 years to inform policy making in areas including housing, education, labor and employment, criminal justice, natural resources and energy, climate change, and the built environment. hiap is a collaborative approach to improving a community by incorporating health, sustainability and equity considerations into decision-making across government agencies and policy areas (change lab solutions, 2015). hia and hiap are different in that hia is used to assess a single proposed decision and its potential impact on health; whereas hiap is an approach that uses multiple strategies, including hia, to integrate health into governmental decision-making processes (national association of county and city health officials, 2012). while hia has always included an analysis of health equity – the differences in the distribution of health impacts across groups of people – hiap has more recently included the consideration of not only health equity, but economic, social, environmental, and racial equity, among others (public health institute, 2019). this article will explore the ways in which the city of denver’s departments of public health and environment (ddphe) and community planning and development (cpd) have worked together using hia and hiap frameworks to formalize how a health equity lens is incorporated into city planning and resource prioritization. hia 1.0: evolving use of hias in denver in denver, co, like many other cities, land use and transportation planners typically have not considered the health or equity impacts of future growth and development. planning and zoning were initially used in the 1800s to protect public health through separation of nuisance uses, but since then the focus changed to regulatory protection of public and private property rights. even in plans drafted within the last 10 years in denver, ‘public health’ was defined in plans to include anything from building bike lanes to replacing dead street trees to promoting urban gardens. while these actions ultimately contribute to good health, there was no examination of the health status of residents as a group, the existing environmental conditions in specific communities, and any disparities in health or exposures experienced by certain groups. therefore, the recommendations were not targeted to solving specific health issues that may have been historic and place-based. in 2013, a denver city councilperson organized council support for a budget priority that all new neighborhood plans include a health impact assessment to better understand the impacts that the built environment had on health. she represented the north denver council district, which was home to heavy industry, freight rail, highways, and residents who experienced higher-than-average serious health conditions that they attributed to their polluted environment. globeville elyria swansea hia over the next 2 years, ddphe and cpd partnered to simultaneously conduct the globeville elyria swansea health impact assessment, with the globeville neighborhood plan and elyria swansea neighborhood plan. for the first time, planning for the future growth of these neighborhoods included specific strategies to address the negative health impacts of growth and development. for example, reducing exposure to poor air quality, noise, and odors from industry and highways, rerouting trucks out of residential areas to reduce pollution and crashes, and building a safe crossing over the railroad tracks to the elementary school. https://www.denvergov.org/content/dam/denvergov/portals/746/documents/hia/hia composite report_9-18-14.pdf https://www.denvergov.org/content/dam/denvergov/portals/746/documents/hia/hia composite report_9-18-14.pdf https://www.denvergov.org/content/dam/denvergov/portals/646/documents/planning/plans/globeville_neighborhood_plan.pdf https://www.denvergov.org/content/dam/denvergov/portals/646/documents/planning/plans/elyria_swansea_neighborhood_plan.pdf https://www.denvergov.org/content/dam/denvergov/portals/646/documents/planning/plans/elyria_swansea_neighborhood_plan.pdf health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 3 westwood hia the successful partnership between ddphe and cpd resulted in a second comprehensive hia conducted to inform the next neighborhood plan, the westwood neighborhood plan. the westwood neighborhood was mainly residential and had little environmental pollution, yet residents had no grocery store or recreation center and were surrounded by two high-speed state highways. they also had one of the largest populations of children and youth in the city, who showed early signs of poor health, including obesity. the westwood neighborhood plan included recommendations identified through the hia process that could improve health, such as prioritizing the construction of a new recreation center, slowing speeds on the ‘main street’ of the neighborhood, and adding a range of housing types to accommodate families and ‘aging in place’. hia 2.0: neighborhood planning with health and equity following these two neighborhood-specific hias conducted between 2013-2015, city council, city staff and community members concluded that the hias had been successful in adding health considerations, awareness and strategies to neighborhood planning. the globeville elyria swansea and westwood hias allowed city agencies beyond public health to see the direct connections between planning, public works services, parks and recreation services and health. these two hias provided a basis of understanding for the health impacts of any project a city conducts, and because community input was a critical part of the hia process, the health impacts included in the hia were validated by both quantitative and qualitative data. however, hias are time and resource intensive, and there was no way to conduct a comprehensive hia for every neighborhood in denver. previously, neighborhood planning had occurred on an ad-hoc basis in reaction to specific development pressures. some neighborhoods had never received a formal plan. as denver continued to grow rapidly and involuntary displacement, uneven development, and lack of access to services grew across the city, it was clear that the neighborhood planning process needed a new approach. cpd needed to accelerate neighborhood planning in order to give timely policy guidance to the denver city council about local redevelopment and public investment, while also prioritizing areas of the city that were experiencing the most inequity as a result of uneven growth and investment. this urgent need led to the development of the neighborhood planning initiative (npi), a ten-year endeavor that will update all neighborhood plans across the city. there are 78 neighborhoods in denver, so the city developed a systematic way to prioritize neighborhoods that were most in need of an updated plan and work through the priority list over ten years. neighborhoods were grouped together into small planning areas, which allowed for 100% coverage of the city over about ten years while still keeping planning areas small enough to allow for resident input and neighborhood-specific recommendations. this prioritization process was the foundation of the partnership between cpd and ddphe staff to consider health and equity in neighborhood planning, and the denver neighborhood equity index was developed to help prioritize the plans based on indicators of health and economic opportunity. neighborhood planning initiative and the denver neighborhood equity index after the npi process was created, city agencies worked together to agree on how to prioritize the planning areas. this process took place in three steps. step 1) each neighborhood was ranked in terms of planning need by considering quantitative indicators related to: • livability • investment • policy and regulation • economy • demographics https://www.denvergov.org/content/dam/denvergov/portals/771/documents/ch/westwood hia/westwood hia compressed.pdf https://www.denvergov.org/content/dam/denvergov/portals/646/documents/planning/plans/westwood_neighborhood_plan.pdf https://www.denvergov.org/content/denvergov/en/community-planning-and-development/planning-and-design/neighborhood_planning_initiative.html health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 4 step 2) after considering indicators in each of the areas above to prioritize individual neighborhoods, cpd then defined the neighborhood planning areas based on the following criteria: • shared histories, issues, and aspirations • built environment and natural features • planning need • character, context, and development patterns • major destinations (institutions, amenities, shopping districts) • common infrastructure (major roads, drainage) • geographic size and population • councilmember and public input • avoiding splitting neighborhood boundaries into different planning areas to maintain ability to track data and trends over time figure 1: neighborhood planning need health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 5 step 3) after the planning areas were created, the planning staff prioritized the order in which the city would work on plans for each area using the following criteria: • previous planning: prioritize groupings where most neighborhoods have either outdated plans or no plan. • impact: prioritize groupings where change is already taking place, and/or where new planning will have the most impact. figure 2: neighborhood planning area • funding: prioritize areas that already have funding or grants in place for small area planning. • efficiency: where possible, ensure the efficient use of city resources by combining forces with other concurrent/related planning efforts. • geographic equity: conduct plans in different parts of the city as part of each phase. health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 6 based on priority, the npi was separated into phases. the map below shows the planning areas prioritized for phases i and ii of the npi, of which one plan (far northeast denver) has been completed and formally adopted by the city of denver. development of the neighborhood equity index measuring health equity is complex, especially in the absence of a common definition and set of indicators. the city of denver used the following definition of health equity to guide which indicators were included in the index: health equity means that everyone has a fair and just opportunity to be as healthy as possible, regardless of race, income, age, gender or ability (colorado health institute, 2018). equity embraces a larger set of factors that shape access to opportunity. equity is when everyone, regardless of who they are or where they come from has the opportunity to thrive. this requires eliminating barriers like poverty and repairing injustices in systems such as education, health, criminal justice and transportation (colorado department of public health and environment, 2019). figure 3: neighborhood planning initiative phase i and ii planning areas health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 7 measuring health equity requires inclusion of not only health outcome indicators, but a combination of health, socioeconomic, and other environmental factors to paint a more complete picture of the environment people face in their everyday lives that can promote, or hinder, opportunity and a high quality of life. these factors can include economic and housing stability, educational opportunities, safety, and access to necessary goods and services. with new demand for neighborhood-specific plans and given that denver is a city with strong neighborhood identity, ddphe developed an index in 2017 to help illustrate health equity at the neighborhood level. ddphe quantified health equity-related factors in each neighborhood, which were considered in the livability section of neighborhood ranking in the npi. the neighborhood equity index was developed to help city agencies prioritize financial and programmatic resources to more equitably serve the city and county of denver. it takes into account issues of the built environment in addition to traditional public health data around morbidity, mortality, and social determinants of health. given the inclusion of built environment indicators alongside traditional public health surveillance indicators, the neighborhood equity index is particularly useful for planning and geographic prioritization. the neighborhood equity index is divided into five sub-category areas and consists of seven total indicators: 1. socio economic factors a. poverty – measured by median household income b. education – measured by percent population (25+ years) with a high school diploma or equivalent 2. built environment factors a. access to food – measured by percent of living units within ¼ mile walk to a fullservice grocery store b. access to parks – measured by percent of living units within ¼ mile walk of a quality park 3. access to care a. prenatal care – measured by percent of women that receive prenatal care in the first trimester of pregnancy 4. morbidity a. childhood obesity – measured by percent of children 2-17 years that are considered obese (based on bmi greater than 25) 5. mortality a. average life expectancy while some indicators were available at a neighborhood level geography, others were available at the census tract level and had to be aggregated into neighborhoods. each of the 78 denver neighborhoods were ranked according to each indicator measure, and then grouped into four equal groups. the ranking and grouping process allowed for each indicator to score in the same direction, where a lower group number indicated more inequity, and a higher group number indicated less inequity. once each neighborhood received a group number for each indicator, the group numbers for indicators in the same sub-category were averaged to create the socioeconomic, built environment, access to care, morbidity, and mortality scores (note that sub-categories with only one indicator were not averaged). finally, the sub-index scores were averaged to create an overall equity score for each neighborhood. while many of the indicators in the sub-indices come from secondary sources, the built environment indicators were developed by the city and county of denver to try to illustrate the relationship between the built environment, health, and equity. while it is clear there are many factors contributing to inequities across the city of denver that are not included in the equity index, the index still provides valuable information about what kinds of interventions and programs to prioritize in particular https://www.arcgis.com/apps/mapjournal/index.html?appid=2f30c73e83204e96824a14680a62a18e https://www.arcgis.com/apps/mapjournal/index.html?appid=2f30c73e83204e96824a14680a62a18e health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 8 areas, as well as which city agencies should be engaged in those interventions in order to be most effective. not only does the equity index give a comprehensive picture of inequities across the city, but it also provides an opportunity to begin to understand what might be driving health inequities in particular neighborhoods by allowing users to drill down to sub-index scores. for example, if a neighborhood scores a 1 in the built environment sub-score (even if the overall index score is a 3), it’s an indication that poor access to green space and healthy food may be disproportionately driving health inequity in that neighborhood. further, it helps justify the need for public health, public works, city planning, and parks and recreation to work together to improve access to those resources, whether through changes in mobility opportunities, acquisition of available land for park space, or education about healthy eating and active living. this type of strategic prioritization and partnership has helped the city of denver be more efficient with limited resources, as well as more effective in working with community, using shared messaging and setting common goals. figure 4: denver neighborhood equity index health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 9 the index has also allowed for internal alignment in the way agencies across the city of denver look at and consider equity in their plans and programs. health equity considerations were formally integrated into the way neighborhood planning areas were prioritized for the npi, as well as integrated into blueprint denver, the comprehensive planning framework the each npi plan is nested under. with each step toward formalizing equity considerations into city planning and partnership in denver, ddphe has played a more significant role in informing the way that health equity is incorporated into planning. since the development of the neighborhood equity index and its incorporation into blueprint denver, health equity and equity measurement has been an immediate conversation at the beginning of new city plans and projects. ddphe staff helped author a chapter on quality of life in the far northeast denver neighborhood plan, the first npi plan to be adopted, lifting up the way the built environment and other social determinants of health connect planning recommendations and health outcomes. each subsequent npi plan will include a quality of life chapter with input from ddphe staff. ddphe has partnered with the cpd planning teams to explore existing conditions, prioritize which specific conditions may be driving health inequities, and write recommendations, both infrastructure and policy related, that could help improve health outcomes through built environment change. considering equity in other city plans and projects below are several examples of the way ddphe, cpd, and other city agencies have worked together in formally incorporate health equity into city projects and plans. denveright comprehensive plans the neighborhood equity index served as a catalyst for the city to explore deeper issues of inequity across city investment and development policies. from 2017-2019, denver embarked on a comprehensive update of its citywide plans governing land use, transportation, parks and mobility (known as denverite). through this extensive planning effort, community stakeholders and city staff realized that ‘business as usual’ land use planning had not only not improved conditions for the worstoff communities, but had perhaps contributed to more significant gentrification, involuntary displacement, and greater inequity. after decades of increasing racial diversity, denver saw a reversal of those gains over the past 10 years, with fewer racial minority groups in the city. this analysis led to the formation of a “blueprint denver equity subcommittee” to review the draft plans through an equity lens. the subcommittee hired an equity expert to educate the team and help lead review of the plans. the results led to changes in many of the recommendations to avoid unintended consequences affecting the most at-risk communities and improve access to opportunities for those most locked out. for example, the initial concentration of future economic development along existing ‘centers’ and ‘corridors’ left out some areas already with the lowest access to opportunity. also, the recommendations to create a range of housing types and price points was strengthened to give decisionmakers the levers they needed to add more affordable housing in denver. finally, equity data and analysis were explicitly built in to other city processes such as budgeting and development permitting, or equitable development would not occur. vision zero the neighborhood equity index map was also used to inform denver’s vision zero planning. in considering equity for changes to the built environment, ddphe also developed a high injury road network map to help illustrate where most of the traffic injuries occur. when used as a complement to equity indicators, ddphe was able to highlight ‘communities of https://www.denvergov.org/media/denvergov/cpd/blueprintdenver/blueprint_denver_city_council_draft-print.pdf https://www.denvergov.org/content/denvergov/en/denveright.html https://storymaps.arcgis.com/stories/178f60a595ab449a903aa85c3815cdd9 health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 10 concern’, or areas of denver that scored low on socioeconomic indicators and were in closest proximity to a high injury roadway. safe routes to school the ‘communities of concern’ data layer is also used by denver’s safe routes to school program as a method of deciding where to prioritize infrastructure changes around schools. importantly, the prioritization work occurs in partnership with denver public works, ensuring that the conversation around health and equity related to the built environment spreads throughout city agencies. elevate denver bond program in 2017, denver voters approved a 10-year, $937 million bond fund to pay for over 500 citywide infrastructure projects. the neighborhood equity index, along with other datasets, was used to help decision-makers prioritize projects for bond funding. figure 5: denver communities of concern and the high-injury network https://www.denvergov.org/content/denvergov/en/environmental-health/community-health/safe-routes-to-school.html https://www.denvergov.org/content/denvergov/en/elevate-denver.html https://www.denvergov.org/content/denvergov/en/elevate-denver.html health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 11 where are we now? over the last seven years, from the first hia conducted by the city to inform neighborhood planning to today’s integration of ‘hia 2.0’ into city plans, projects and processes, it is important to consider questions such as: how did we do? has health improved? has equity improved? seven years in: what we know in the globeville and elyria swansea neighborhoods, an hia was used by the community to inform many decision points after the neighborhood-specific plans were adopted. of the 36 recommendations in the hia, about 75% are either completed or in process. many of these are related to built environment improvements such as street redesign and connectivity, additional pedestrian infrastructure, a mix of land uses, and reduction or mitigation of environmental pollution. some recommendations are changes to city processes, such as licensing and permitting for marijuana businesses, while other spurred improvements to community engagement such as increasing spanish language outreach. the hia also helped lead to the settlement of a lawsuit between the state transportation department and the north denver neighborhoods in 2019, with $550,000 allocated for a health study of residents to better understand environmental impacts on health. ideally the study will be able to select some longtime community residents to get a true picture of changes in health and equity. figure 6: cdc recommendation for combined built environment approaches to increase physical activity (cdc, 2019) health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 12 the westwood hia was completed in 2016 and recommended many built environment changes to improve health. as a result of strong community demand for a recreation center, the elevate denver bond program included funding for a new recreation center in the neighborhood, a $37.5 million project that will likely lead to increases in physical activity, employment, green space, community pride and potentially decreases in criminal activity. some pocket parks are being developed as of 2019, and additional funding was procured to complete streetscape improvements on the main street in the neighborhood to slow traffic and increase pedestrian activity. the westwood hia also helped to elevate vision zero program activities in westwood, including addressing speeding and fatalities on the state highways bordering the neighborhood. finally, a number of the hia recommendations were included in the process of drafting blueprint denver, the citywide land use and transportation plan adopted in 2019. both hias and both neighborhood plans supported increased creation of mixed land uses, residential density, parks and recreation, and pedestrian and bicycle infrastructure. according to the guide to community preventive services, combining activity-friendly routes with everyday destinations has been shown to lead to increased physical activity (cdc, 2019) this can help mitigate the higher rates of obesity and diabetes that residents of both planning areas experience. what we don’t know in terms of changes to health outcomes of residents, it is too early to see those changes show up in the data yet because changes to the built environment and changes in population health take time. in addition, a confounding factor was discovered that may make it hard to measure future changes in health. as neighborhoods receive new attention and investment, gentrification and involuntary displacement have taken root. demographic data show that over the last 5 years, the globeville neighborhood became whiter and richer (american community survey, 2017), indicating that the once predominantly hispanic, lower income neighborhood has had an influx of white, middleupper class residents move in, and longtime residents move out. whether that demographic shift is due to increasing cost of living in the city of denver, changes in employment, or other reasons, it is expected that health and socioeconomic data will show ‘improvements’ in factors such as child obesity, diabetes, education attainment, income, and employment. however, those improvements are likely due to the shift in population demographics rather than a true improvement in the health of residents experiencing inequity and poor health outcomes because different people are being measured. a true measure of change would need to consider the same people and indicators that were measured before and after the hia was conducted. this type of approach would require studying populations longitudinally across geographic boundaries. health outcomes in westwood may not have changed after only 3 years. however, the westwood community saw the displacement that occurred in the globeville and elyria swansea neighborhoods after new planning and investment activities, and to their credit, they organized and fought for protections to reduce such displacement. in response to these efforts as well as more organized advocacy from groups throughout denver, new city programs were created to help low-income homeowners pay for rising property taxes, and residents are pushing back on plans to dramatically increase density which they feel will further drive up property values. with such protections in place, measurement of health and equity outcomes in westwood may actually include largely the same group of residents who were there before the changes took place, which would show a much more accurate picture of long-term changes in health and equity. http://the guide to community preventive services health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 13 lessons learned the evolution of hia and hiap in denver has yielded a number of lessons learned for city staff. while the lessons themselves are similar to other hia and hiap case studies, the context of how each of these lessons learned have played out in denver may help give specificity to other municipalities and health departments working to formalize health and equity considerations and cross-sector partnerships. 1. developing relationships across organizations is key to building partnerships and collaboration in denver’s case, ddphe built a new relationship with cpd through two comprehensive hias and neighborhood plans. by the time the citywide plans were initiated, that relationship was already in place, and public health had a seat at the table. it is important to start building relationships early, even on a small project or initiative, so that mutual trust is in place when significant opportunities arise to collaborate. 2. data and mapping are needed to inform policy one of the biggest lessons learned is that data do not have to be complicated to be powerful. the neighborhood equity index is a relatively simple index, made up of only seven indicators. yet, because it was mapped at the neighborhood level, a geographic unit that almost every person in denver can relate to, it has a powerful impact on the way city agencies continue to work together to make planning and implementation more coordinated. further, using datasets that are relatively simple makes explaining their meaning to those who aren’t data savvy more straight forward, meaning that the message lands more effectively with decision makers; that certain populations in the city experience more inequities than others and that city resources should be prioritized to serve those populations and neighborhoods so that we all may advance as a city and have improved quality of life. the neighborhood equity index has provided a relatively simple way for ddphe to begin the conversation around equity at many different tables, often leading to deeper and more complex conversations specific to the project or geography in question. 3. it is important to build capacity of stakeholders to advocate for the consideration of health and equity in planning and decision making public health staff can’t be the only ones advocating for health and equity. it takes engineers, planners, city council staff, housing officers, etc., to all normalize health and equity discussions and expectations in everyday city work. public health can build capacity by offering in-house trainings or workshops to staff so that when a decision point arises, there are already advocates in place throughout the organization. 4. getting health and equity into plans or projects is not enough; they must be built into decision making processes in order to have staying power a budget is an expression of values. how, where and on whom a municipality spends its money shows what it values most. health and equity need to be considered and quantified as part of the budgeting process, just like other factors; if not, other priorities will take precedence. 5. you need health and equity champions both inside and outside the organization one denver city councilperson championed hias as a new tool to highlight health inequities almost a decade ago. her championship health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 14 elevated health and equity as legitimate concerns for decision makers to consider, not just responding to the loudest voices in the community. by the time the citywide and neighborhood plans were initiated, other council people, community members, and other city staff were aware and vocal about including health and equity in the planning process. 6. implementation plans are necessary entities need to be clearly designated as accountable for plan implementation, including city departments or community organizations. plan recommendations should use standard language for easier tracking and implementation. also, standard performance or outcome metrics should be selected across as many plans as possible to standardize progress reporting. 7. finally, timing is everything: “luck is what happens when preparation meets opportunity” the first two hias and the support that was built from those processes laid the groundwork for the acceptance of health and equity in other city plans, projects and processes in denver. be on the lookout for possible intervention points to partner to add health and equity considerations: it might be as small as a plan for a new trail or bikeway, a chance to collaborate on a grant application for infrastructure that also considers health, or as large as a 20-year comprehensive planning effort to guide land use, housing, and transportation into the future. look for those ‘lucky’ windows of opportunity. next steps in denver as ddphe continues to learn from ongoing work and partnerships, there are a number of actions that can be taken to help further the existing efforts to include health and equity considerations in all city plans and projects. 1. add more data and maps to public website for wide accessibility after publishing the neighborhood equity index, it is clear that we need to continue to make health and health equity data more available and accessible. ddphe plans to continue to add ready-to-use maps, raw datasets, story maps, and topic-specific data products to their website going forward so an example of lessons learned in data from city staff in addition to simplifying datasets, it has also been helpful to standardize, as best as possible, what data and conditions are analyzed in every city plan. through the first npi plans, ddphe has begun to develop a standard set of indicators to look at in the very beginning to understand the existing conditions in any given neighborhood. this is not to say we do not consider neighborhood specific issues as well, but the standard set allows us to compare across neighborhoods, making the data more relative. for example, if we know the average rate of emergency department use for youth asthma across the city, and for neighborhoods surrounding a planning area, it gives a much better picture of whether youth asthma should be a factor that a particular plan focuses on. we try to focus on factors that are modifiable through built environment and infrastructure change for the standard set, but also add in indicators around access to medical care and health outcomes. though we don’t expect to see short-term change in health outcomes, understanding which health outcomes are concerns in specific planning areas often helps inform which built environment changes to recommend and implement. health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 15 that the conversation and momentum around addressing health inequities does not slow down. further, it is hoped that these data products will be put into the context of equity and be easily understandable for any audience. 2. continue to embed health and equity into city processes in 2019, ddphe added health and equity criteria to their internal budget prioritization process, requiring that all budget requesters answered a series of questions about unintended consequences and what specific populations their work would impact. the intention is to expand these criteria to the citywide budgeting process starting in 2020. also, with the wider availability of neighborhood-level health and equity data, the intention is to use this to inform processes such as zoning, licensing and permitting, and rules for community input into public hearings. 3. add progress reporting on health and equity metrics to public website regular reporting and transparency about progress in meeting (or not meeting) the metrics will serve to build trust and hold decisionmakers accountable to the public. 4. explore health and equity differences beyond geographic boundaries ddphe has explored geographic areas of denver through the neighborhood planning initiative and other neighborhood-based projects. as ddphe continues to consider displacement and gentrification, it is important to start to understand changes in specific populations that exist beyond geographic boundaries. while neighborhood-specific historical inequities may still be present in the built environment and burden of disease, looking more closely at socioeconomic status and race and ethnicity clearly shows neighborhoods populations are changing. as neighborhoods continue to shift, we must be careful to not leave behind those being displaced, meaning we need to think beyond neighborhood boundaries and start to follow changes in specific populations in order to best prioritize resources and programming. health in all policies in denver, co: moving from plans to equitable development outcomes armijo; kauffman 16 corresponding author gretchen armijo, aicp, leed, ap norris design 1101 bannock street denver, co 80204 gaarmijo@live.com chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 4 issue 1 (2019) doi: 10.18060/23353 © 2019 author(s): armijo, g.; kauffman, m. this work is licensed uner a creative commons attribution 4.0 international license references denver department of public health & environment. 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(2019). an introduction to health in all policies: a guide for state and local governments. retrieved from: //https://www.phi.org/uploads/files/four_pager_health_in_all_policies-a_guide_for_state_and_ local_governments.pdf https://www.denvergov.org/content/denvergov/en/environmental-health/communityhealth/office-of-health-equity/health-equity-data/neighborhood-health-profiles.html https://www.denvergov.org/content/denvergov/en/environmental-health/communityhealth/office-of-health-equity/health-equity-data/neighborhood-health-profiles.html https://www.thecommunityguide.org/findings/physical-activity-creating-orimproving-places-physical-activity https://www.changelabsolutions.org/product/start-finish-health-all-policies https://www.colorado.gov/pacific/cdphe/ohe https://www.coloradohealthinstitute.org/sites/default/files/file_attachments/mdph_he_guidebook_final08142018_0.pdf https://www.coloradohealthinstitute.org/sites/default/files/file_attachments/mdph_he_guidebook_final08142018_0.pdf https://www.naccho.org/programs/community-health/healthy-community-design/health-in-all-policies https://www.naccho.org/programs/community-health/healthy-community-design/health-in-all-policies https://www.phi.org/uploads/files/four_pager_health_in_all_policies-a_guide_for_state_and_local_governments.pdf https://www.phi.org/uploads/files/four_pager_health_in_all_policies-a_guide_for_state_and_local_governments.pdf october 2020 volume 5 issue 1 health impact assessment and city council policy: identifying opportunities to address local social determinants of health & place-health relationships, 10 years later ryan j. petteway, drph, mph; shannon cosgrove, mha 1 abstract background: health impact assessment (hia) can be used to assess any type of policy/program related to social determinants (sdh). however, local public health departments (lhds) have been slow to adopt formal use of hia in efforts to address local sdh, even with growing evidence linking sdh and place-health relationships. ten years ago, we completed a review of baltimore city council policies to advance this conversation within the lhd. our goal here is to revisit this review and, again, outline a process by which lhds can: a) monitor local policies in regard to sdh and b) identify opportunities for potential hia use. methods: we reviewed all policies introduced into baltimore city council in calendar years 2008 and 2009 to identify and assess those with potential health impacts. we then categorized these policies as: a) “explicitly health-related” or b) “related to sdh.” we then tabulated the number and sub-types of these policies that were referred to the lhd legislative director for review/comment, i.e. submission of formal lhd assessment/comment for the legislative record. results: we assessed 597 total policies. in total, 89 policies (15%) were identified as “explicitly health-related,” 34 (38%) of which were referred for lhd review/comment. in addition, 208 policies (35%) were identified as “related to sdh,” 13 (6%) of which were referred for lhd review/comment. overall, 297 (50%) policies were identified as having potential health impacts, 47 (16%) of which received lhd review/comment. conclusion: this policy review effort represents a potentially replicable process to identify hia opportunities, and potential launch point for health-in-all-policies efforts. in baltimore, this review work facilitated dialogue with baltimore city officials and led to the lhd’s first hia grant. keywords: health impact assessment, social determinants of health, health in all policies, local health departments, place and health, policy health impact assessment and city council policy petteway; cosgrove 2 background health impact assessment, social determinants of health, and place the world health organization recognizes that “the social determinants of health are mostly responsible for health inequities” (who, 2016). the distribution of social determinants of health, or sdh, is largely determined by policy decisions, and experts emphasize the importance of understanding that “every aspect of government and the economy has the potential to affect health and health equity” (who, 2008, p.10). as such, leading public health organizations have increasingly turned attention towards addressing factors that shape the social, economic, political, and environmental conditions in which we live, learn, work, play, and age (cdc, 2015; dhhs, 2011; naccho, 2011; prevention institute, 2008; ramirez et al., 2008). in focusing attention on addressing sdh, local health agencies have begun developing public health strategies that engage policies and practices that traditionally have been viewed as “non-health” related, including those concerning transportation, housing, zoning, education, and land use (barhii, 2015; bphc, 2015; schaff et al., 2013; schaff & dorfman, 2019). one analytic tool that has facilitated this work is health impact assessment, or hia (bhatia, 2011; harris-roxas et al., 2012; heller et al., 2014). hia is commonly understood as: use of hia has been increasing in the us (dannenberg et al., 2006; ross et al., 2014), with recent reviews showing that they have been conducted on a wide range of projects and policies (bourcier et al., 2015; dannenberg et al., 2014; dannenberg et al., 2008; nchh, 2016). however, hia is not used regularly at local levels to assess potential health impacts of policy decisions as part of standard practice. rather, it is used mostly on a voluntary basis by only a few city/county agencies, usually in collaboration with non-profits, universities, and the private sector. for example, based on our 2016 review of publicly available data tracking all hias conducted in the us, just 53 city/county health agencies had served as the lead/authoring partner for an hia since 1999, with 90 total hias completed among them. this represents just 2% of the 2,532 city/county agencies defined by the national association of city and county health officials as local health departments, or lhds (naccho, 2013). based on a more recent review of these data (health impact project, 2020), 71 city/county lhds—3% of all lhds— have now served as lead/authoring partner, with 134 total hias completed among them. san francisco department of public health has led the way, serving as a lead partner on at least 19 hias. douglass county health department, ne has been a lead partner on at least 9 hias, and a handful of other lhds have served as a lead on at least three hias, including maricopa county department of public health, (az), los angeles county department of public health, and ingham county health department (mi). with a growing appreciation for how “place” matters for health (acevedo-garcia et al., 2014; diez roux & mair, 2010; kawachi & berkman, 2003; policylink, 2007; rwjf, 2008, 2011), one would expect lhds to actively pursue tools and strategies that hold potential to address “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.” (national research council, 2011, p.5) health impact assessment and city council policy petteway; cosgrove 3 elements of local built, social, economic, and political environments. a core feature of hia is that it can be used to assess any type of policy, program, project, or plan, including zoning, land use, community development, and housing—all elements, for example, that shape distributions and patterns of place-based sdh exposures, experiences, and opportunities (braunstein & lavizzo-mourey, 2011; frank et al., 2006; maantay, 2001; northridge & sclar, 2003; pastor & morello-frosch, 2014; rogerson et al., 2014; wernham, 2011; wilson et al., 2008). thus, by its very nature, hia is a tool designed to address local sdh, improve place, and promote health equity (heller et al., 2014; policylink, 2013). hia, sdh, and place: a baltimore story despite connections between hia, sdh, and place-health relationships, lhds have been slow to adopt the formal use of hias or incorporate the application of its core components and principles in the policy development process. baltimore city health department (bchd) was one such lhd. a 2010 report on health inequities revealed that, like many large cities, baltimore has far to go to achieve health equity (bchd, 2010). moreover, a 2011 report focused on sdh and health at the neighborhood-level revealed significant inequities within the city (bchd, 2011). for example, compared to other communities, predominantly black and highpoverty communities have up to 3 times as many liquor stores, 4 times as many tobacco stores, 35 times as many vacant buildings, 2.5 times as many vacant lots, and 3 times as many fast-food and carry-out restaurants (petteway, 2012). within this sdh context, the report uncovered a 21-year gap in life expectancy between the city’s mostand leasthealthy neighborhoods. another report in 2012 demonstrated a strong connection between historic patterns of racial residential segregation (e.g. from redlining), persistent poverty, and health (joint center, 2012). these reports make it abundantly clear that place (and how it is “made”) matters for health, and that addressing sdh is integral to any strategy to achieve health equity. moreover, inequities in these social and environmental conditions are shaped by local policy and practice decisions, and accordingly could benefit immensely from hia. two baltimore projects that have employed hia include the redline project, related to the proposed development of a new light-rail transit route (ricklin, 2008), and transform baltimore, related to a comprehensive zoning code rewrite (thornton et al., 2013). a third hia related to a proposed community redevelopment plan, the downtown-westside redevelopment implementation plan, was completed in 2014. however, while hia is not entirely foreign to baltimore city, to date there is no standard hia process to evaluate the potential health impacts of local policy decisions. moreover, currently there is no general process established to ensure health is considered from the very beginning of the policy development process, e.g. a health in all policies (hiap) approach (rudolph et al., 2013). the work presented here describes an attempt to move the needle in this regard, and could prove particularly timely given the iterative releases of updated neighborhood health profiles (bchd, 2017), which continue to highlight the importance of examining local policy roots of place-based sdh inequities in baltimore city. building momentum towards hia through local policy reviews: revisiting a baltimore study in this paper, we revisit and present findings from a policy review of city council policy for baltimore city for calendar years 2008 and 2009. we completed this work ten years ago with the following goals in mind: health impact assessment and city council policy petteway; cosgrove 4 1. ascertain the amount, types, and magnitude of policies that may potentially impact the health of baltimoreans, i.e. a low-level “screening” of all policies introduced 2. identify policies that were referred to the baltimore city health department (bchd) for review and those that were not 3. identify gaps in bchd referral patterns, i.e. what kind of policy does bchd not receive that could have potential health impacts? 4. outline replicable processes that lhds can use to monitor sdh policies and explore potential hia opportunities we have previously shared the results of the 2008 review with various lhd officials and practitioners (petteway, 2010). we shared both the 2008 and 2009 reviews within the lhd and with various baltimore city officials as part of our efforts to scale-up and deepen local efforts to address local sdh, and to build interest and capacity for hia and, potentially, hiap. these reviews were foundational in local efforts related to addressing sdh and led to the bchd’s first hia grant in 2011. we revisit this work now as an opportunity to again highlight it’s potential value in outlining a way forward for lhds to make inroads towards hia use and hiap considerations in local practice to address sdh and place-health relationships. given the pace at which public health discourse regarding sdh and health equity has grown over the last decade, we believe this “excavation” of sorts could present as timely and potentially instructive. we briefly describe the review process and present summary review data. we then discuss major findings, limitations, and potential practice impacts and implications for lhds. methods legislation search for the 2008 policy review, the online legislative database for baltimore city council was searched for resolutions and ordinances with legislative file numbers beginning with “08.” in addition to an overall search, separate searches were performed for legislation sponsored by each of the 15 active city council members for both types of legislation, and by legislative status. only legislation introduced between 1/1/2008 and 12/31/2008 was included for the 2008 searches. all searches were performed between 2/25/2009 and 4/15/2009. this same procedure was repeated for 2009 city council policy using “09,” with all searches being performed between 4/1/2011 and 6/24/2011. legislation review and classification summaries for all policies, including both resolutions and ordinances, were evaluated to ascertain basic degree of health-relatedness. entire legislative files were read only if healthrelatedness of summary content was unclear or insufficient to make a determination. polices that were determined to be health/safetyrelated—directly or indirectly, and regardless of magnitude or degree of explicitness—were collated, re-evaluated, and categorized based on if they were: a) explicitly health/safety-related, or b) related to sdh. policies categorized as “explicitly health/safety-related” (ehr) explicitly mentioned health, safety, and/or health-related topics (e.g. asthma, smoking, trans fats), or otherwise pertained to matters commonly recognized as being related to health/safety (e.g. child welfare, firearms, sanitation, animal control) (see table 1). policies involving topics commonly considered sdh, or that influence sdh (directly or indirectly), were categorized as related to sdh. considerations for which policies constituted/ health impact assessment and city council policy petteway; cosgrove 5 affected sdh were rooted in sdh literature and core guiding documents within health equity and hia work (policylink, 2007; ramirez et al., 2008; rwjf, 2008; who, 2008). these included policies that are traditionally outside the scope of “health” policy, e.g. policy regarding homelessness, parks, green buildings, affordable housing, transportation, vacant housing/ lots, living wages, zoning and community development (see table 1). legislation that was reviewed and did not fall into the ehr or sdh categories was excluded in the remaining analysis. the ehr and sdh policies were then sorted based on their current or final legislative status: enacted (for resolutions), adopted (for ordinances), withdrawn, failed, or in committee. these categorized and sorted policies were then compared to a list of policies that were forwarded from city council to bchd for comment and review of potential health concerns. these policies were forwarded at the discretion of each city council subcommittee, i.e. committee members determined whether or not formal assessments/comments would be sought from various agencies for each pending policy, including bchd. policy review results were then tabulated—stratifying by year, type of policy, ehr or sdh, policy status, and bchd review status. findings summary we identified and assessed 179 resolutions and 418 ordinances—597 total policies—across the 2008 and 2009 calendar years (figure 1). again, a total of 89 policies (15%) were identified as “explicitly health-related,” 34 (38%) of which were referred for lhd review. 208 policies (35%) were identified as “related to sdh,” only 13 (6%) of which were referred for lhd review. overall, 297 (50%) policies were identified as having potential health impacts, only 47 (16%) of which were reviewed and commented on for potential health considerations by bchd (figure 2). health impact assessment and city council policy petteway; cosgrove 6 2008 & 2009 resolutions bchd reviewed ordinances bchd reviewed r&d bchd reviewed total 2008 and 2009 181 433 614 total reviewed (on file) 179 418 597 total health/ safety-related 93 (52%) 16 (17%) 204 (49%) 31 (15%) 297 (50%) 47 (16%) explicitly health/ safety 44 (47%) 13 (30%) 45 (22%) 21 (47%) 89 (30%) 34 (38%) related to sdh 49 (53%) 3 (6%) 159 (78%) 10 (6%) 208 (70%) 13 (6%) figure 1: summary of 2008 & 2009 polices referred for health review figure 2: summary of 2008 & 2009 polices referred for health review figure 1: bchd is baltimore city health department. note that a total of 17 policies were not on file in the database and were therefore not included in this review. figure 2: bchd is baltimore city health department. note that a total of 17 policies were not on file in the database and were therefore not included in this review. 2008-2009 resolutions & ordinances total health/safetyrelated explicitly health/safety related to sdh health impact assessment and city council policy petteway; cosgrove 7 table 1: 25 illustrative examples of policies reviewed & categorized for potential health impacts table 1 provides an illustrative overview of the types of policies that were identified as having potential health impacts, distinguishing those that were “explicitly health-related” and those that were “related to sdh.” table 2 highlights some major sdh-related policies that were not reviewed for potential health impacts, thus representing significant missed opportunities to potentially improve place-health relationships in the city. illustrative examples of policies reviewed & categorized for potential health impacts policy category policy type policy topic status1 bchdreviewed explicitly healthrelated (ehr) resolution asthma awareness month acknowledgment adopted no resolution baltimore green week acknowledgment: healthy cities & healthy lives adopted no resolution informational hearing; public wellness and disease prevention program; request for bchd to discuss available practices/resources for baltimore city adopted yes resolution informational hearing; vector control; request for city council briefing on effectiveness of efforts adopted yes resolution investigative hearing; decommissioning, dismantling, and closure of hazardous material sites in committee yes ordinance trans fats; exempting certain bakeries from the provisions governing food containing trans fat enacted yes ordinance repeal ban, sale of contraceptives to minors enacted yes ordinance zoning ; conditional use; nonprofit home and transitional housing facility for the care and custody of homeless persons enacted yes ordinance city streets bike-safe grates; requiring that all city street paving and repaving contracts require that drainage grates be installed in a bike-safe alignment enacted no ordinance flavored tobacco wrappings; sale or distribution; prohibiting the sale or distribution of flavored tobacco wrappings enacted yes ordinance tobacco products; strengthening the prohibition against the sale or transfer of unpackaged cigarettes failed yes 1at time of review health impact assessment and city council policy petteway; cosgrove 8 illustrative examples of policies reviewed & categorized for potential health impacts policy category policy type policy topic status1 bchdreviewed explicitly healthrelated (ehr) ordinance baltimore city sustainability plan; establishing a sustainability plan for the city of baltimore enacted yes ordinance food service facilities suspension or nonrenewal of licenses; authorizing the suspension or non-renewal of a license for a food service facility that has received multiple environmental or civil citations enacted yes related to sdh resolution urging baltimore city public schools ceo to adopt non-violent conflict resolution curriculum (education) adopted no resolution informational hearing; revocation of federally subsidized housing assistance; to keep housing free of “criminals” and those “associated with criminals or persons with criminal intent” (housing; criminal justice) adopted no resolution celebration/acknowledgment of bike to work week (transportation) adopted no resolution task force on noise laws and enforcement (environment) adopted no ordinance plastic bags; imposing a surcharge on certain bags provided by dealers to customers (environment) enacted yes ordinance zoning ; conditional use; nonprofit home and transitional housing facility for the care and custody of homeless persons (housing) enacted yes ordinance urban renewal; greenmount west (community development) enacted no ordinance zoning; condition use; incinerator (community development) enacted no ordinance speed monitoring systems (transportation) enacted no ordinance planned unit development; the state center, transit oriented development business planned unit development (transportation; community development) enacted no ordinance transit and traffic; bike lanes for the purpose of allowing the creation of bike lanes (transportation) enacted no ordinance westport waterfront development district (community development) enacted no health impact assessment and city council policy petteway; cosgrove 9 table 2: 25 missed opportunities to inform policy decisions related to sdh: illustrative examples of place and health-impacting policies not reviewed by bchd 25 illustrative examples of place and health-impacting policies not reviewed by bchd policy type year policy topic status2 resolution 2008 informational hearing; revocation of federally subsidized housing assistance; to keep housing free of “criminals” and those “associate with criminals or persons with criminal intent” (housing; criminal justice) adopted resolution 2008 allowing students to use mta transfers until 8pm on school days (education; transportation) in committee resolution 2008 request for state legislation; increase penalty for all felony gun crimes (criminal justice) adopted resolution 2008 request for development & implementation of gangrelated violence training for baltimore city public school teachers (education; criminal justice) adopted resolution 2009 baltimore city youth development task; establishing a citywide task force to provide substantive direction on how to expand and allocate resources on positive youthcentered activities (education; community development) adopted resolution 2009 requesting the baltimore city police department to implement online reporting systems to disclose the final internal investigation results of officer-related shootings provide a greater level transparency to the citizens of baltimore (criminal justice) adopted resolution 2009 informational hearing; inviting the baltimore police commissioner to report to the city council on the recent mass dismissal of internal misconduct cases (criminal justice) failed resolution 2009 request for budget action; requesting the mayor to restore funding for recreation centers, childcare centers, police athletic league centers, and city pools (recreation; education) adopted resolution 2009 informational hearing; requesting the senior vice president of customer relations and account services for bge to report to the city council on efforts to help low-income customers manage energy costs (energy security) adopted 2at time of review health impact assessment and city council policy petteway; cosgrove 10 policy type year policy topic status2 ordinance 2008 city trees; extending certain laws for the protection of trees along public ways to apply also to trees in parks, squares, and other public places (natural environment; climate) enacted ordinance 2008 planned unit development; the state center, transit oriented development business planned unit development (transportation; community development) enacted ordinance 2008 planned unit development; the state center, transit oriented development business planned unit development (transportation; community development) enacted ordinance 2008 westport waterfront development district (community development) enacted ordinance 2009 urban renewal; harlem park ii (community development enacted ordinance 2009 urban renewal; park heights (community development enacted ordinance 2009 urban renewal; greenmount west (community development enacted ordinance 2009 zoning; conditional use permit; incinerator (zoning; land use) enacted ordinance 2009 speed monitoring systems (transportation) enacted ordinance 2009 urban renewal; belair-erdman (community development enacted ordinance 2009 urban renewal; reistertown plaza transit station (transportation; community development) enacted ordinance 2009 bike-safe grates; requiring that all city street paving and repaving contracts require that drainage grates be installed in a bike-safe alignment (transportation) enacted ordinance 2009 transit and traffic; bike lanes for the purpose of allowing the creation of bike lanes (transportation) enacted ordinance 2009 land bank authority; for the purpose of establishing the land bank authority of baltimore city (community development) withdrawn ordinance 2009 newly constructed dwellings; reauthorizing and extending for a certain period the property tax credit for newly constructed dwellings (community development) enacted ordinance 2009 downtown management district; extending the downtown management district to encompass an area bounded by franklin street to the north, howard street to the east, saratoga street to the south, and eutaw street to the west (community development) enacted health impact assessment and city council policy petteway; cosgrove 11 discussion: implications for policy and practice there are perhaps three major takeaways from the work we summarized here. first, based on our review, bchd reviewed/commented on just 16% of potentially health-impacting policies introduced during 2008 and 2009 calendar years (figure 2). in other words, an overwhelming majority—84%—of baltimore city council policies with the potential to impact health were not reviewed accordingly. moreover, bchd was much more likely to review policies with explicit connections to health—reviewing 38% of ehr policies vs. just 6% of sdh polices (figure 2). this means that dozens of opportunities to address local sdh were missed (see some major examples in table 2). overall, the pattern of bchd reviews during these two years suggests a pronounced “downstream” perspective regarding what constitutes “health” policy, e.g. policies related to tobacco, trans fats, vector control, and contraceptives (table 1). second, bchd reviews of policy were proportionately similar between resolutions (17%) and ordinances (15%) (table 1). resolutions tend to be more symbolic and affirmational gestures towards policy values and priorities, or requests for additional information regarding topics that might eventually become a policy priority. they do not in themselves constitute true policies in the manner traditionally understood within the scope of hia and hiap, as they do not change laws, budgets, or practices in ways that would fundamentally alter the lived contexts of health opportunity. this suggests, perhaps, a need to better prioritize review energies such that more substantial policies, i.e. actual laws, are subjected to more frequent and rigorous review/ comment for health—particularly given the extent to which major sdh-related ordinances were enacted into law without bchd review or comment (table 2). and third, from our review, it was clear that most of the major policies that fundamentally alter place-based contexts of health opportunity and risk were not reviewed, many of which were related to zoning, urban renewal, and community development (table 2). critically, many of these un-reviewed policies directly affected the neighborhoods experiencing the highest burden of health inequities, e.g. park heights, greenmount, harlem park (bchd, 2011, 2017)—communities in which the distribution of health opportunities and risks has been historically shaped by mechanisms of structural racism, like redlining (joint center, 2012). there is quite literally no point in completing future iterations, for example, of the neighborhood health profiles if the policies responsible for (re)producing, maintaining, or exacerbating the inequities revealed in these reports continue to be developed and enacted without application of a critical health lens. this suggest a critical need to develop mechanisms so that such polices (e.g. urban renewal, community development) are routinely reviewed in light of potential health impacts—even in the absence of hia resources. reviews like the one discussed here could be used to contextualize the outcomes data made available by an increasing number of tools/platforms (cdc, 2020; naphsis, 2020; policymap, 2020; rwjf, 2020), and perhaps allow for more robust and locally actionable assessments of place-health relationships, drawing from—and enhancing the geographic resolution of—legal epidemiology approaches in public health (burris et al., 2016; ramanathan et al., 2017). this review also had several limitations worth noting here. first, we relied on a publicly accessible policy database to identify policies in each of the years included in our review. as indicated in figure 1, a total of 17 policies health impact assessment and city council policy petteway; cosgrove 12 were not on file in the database and we were thus unable to include them in our review. this review, while still rather extensive, is incomplete. second, we relied on a generally imprecise process for categorizing policies in regard to their health-relatedness. as noted above, we relied on our knowledge of sdh and the guidance of core documents related to sdh and hia in developing our broad categories of “explicitly-related to health” and “related to sdh.” moreover, we did not complete interrater reliability testing as part of the policy categorization process, primarily because our intention was to simply complete a rough/ cursory examination of what the lhd was reviewing and not reviewing. we were aiming for a quick process that could be applied/adapted in the practical contexts of local practice, wherein many lhds, like bchd, do not have the staff resources or technical capacity to more formally structure and evaluate policy categorizations. we thus approached the two years of policy as a sort of test of concept/ process, with the intention to enhance/refine in future iterations. we do not discount that separate reviewers more than likely would have made different category allocations for some policies, and likely would have included/retained additional policies at the health-relatedness categorization stage (we excluded 300 policies). given that we were indeed hoping from the outset to explore/arrive at a process that other lhds could potentially follow/replicate, formally assessing policy categorization reliability from the beginning would have afforded greater technical guidance for uptake elsewhere. and third, we also acknowledge that our decision to use two discrete categories—ehr and sdh—presumes that each is mutually exclusive, even though, in effect, many policies have direct health connections and indirect impacts via various sdh mechanisms. even so, we believe these categories afforded us sufficient direction to complete what we intended as a cursory/exploratory review and assessment of policies. and we accordingly believe that our general process remains transferrable if not fully replicable with the enhancement of inter-rater reliability testing. it’s important to note here that while this review was partly intended to reveal the potential vitality of hia as a tool to assess local policy, it was mostly a way to demonstrate the need to simply consider the potential health impacts of ‘non-health’ policies, i.e. policies that are/ affect sdh. conducting an infinite number of hias is obviously not a viable goal or solution. accordingly, we approached this review as a means to use the discourse and lens of hia as a vehicle to open discussions regarding long-term, proactive approaches to promote health equity within and through standard policy processes, similar to efforts undertaken elsewhere (den broeder, 2003; gagnon & michaud, 2008; wernham & teutsch, 2015). thus, we considered the broader aims of this work to support progress towards: 1. developing a replicable process through which local policies possessing the ability to significantly impact the health are identified and referred for lhd review 2. expanding the scope of ‘health’ policy to include all policies that shape residents’ built, social, and economic environments and opportunities, including those related to zoning, community development, land use, transportation, education, and housing, i.e. moving lhd review of polices closer to hiap as noted above, lhd engagement and uptake of hias has been remarkably limited, and in the absence of either interest, resources, or capacity to conduct hias, lhds might benefit from more rudimentary—but ultimately, more health impact assessment and city council policy petteway; cosgrove 13 foundational—tools and processes. at the time of our review, the health review process in baltimore was not proactively led by lhd staff. rather, city council committee members made determinations regarding which city agencies should review/comment on each policy (e.g. the education subcommittee sending school/ education-related policies for review by baltimore city public schools leadership). our review makes it clear that such a process is insufficient. moreover, it suggests that real-time tracking/monitoring of policy by lhd staff is a viable and more robust way to ensure a health lens is applied. the work presented here, we believe, highlights the potential value of local policy reviews as a low-cost “screening”-like process for lhds. such reviews can serve as a tool to identify the most significant policies in need of detailed lhd review as they are introduced. in this way, the reviews serve as a sort of gateway tool to identify potential hia opportunities (should resources become available) and as a model process to move towards hiap within local government, with every policy given at least a cursory examination in regard to health equity implications. in an absence of such a review process in baltimore city for 2008 and 2009, several significant polices were approved without any analysis of potential health impacts—failing to even be referred to bchd for a cursory review, comment, or sign-off (table 2). examples range from transportation policy for public school students and energy security for low-income residents, to transit-oriented development projects and protecting city tree canopy, to the aforementioned community development policies. and, given the emotional and psychological health toll that deaths at the hands police #freddiegray #korryngaines have on families and entire communities (bor et al., 2018), it’s worth noting that there was an entire collection of policies related to police (mis)conduct and criminalization that went unreviewed for potential health impacts, including policies that investigated the massdropping of police misconduct cases and called for greater transparency regarding officerinvolved shootings and misconduct (table 2). as previously noted, these sorts of policies would not have been referred automatically to bchd for review. someone would have had to have been proactively monitoring all policies as they were introduced, then flagged them for review. the fact that these policies were not referred to bchd, and the fact that bchd staff either did not see them or feel the need to review/comment on them, speaks rather poignantly to the myopic tendencies of lhds in regard to health equity efforts, often failing to see the nuanced structural factors driving community and population health risks and outcomes. certainly, not all of the 297 policies we identified as having potential health impacts needed a detailed review. indeed, many did not appear to need much more than a simple acknowledgment, e.g. dozens of zoning policies that modified basic elements of property lines or rights of way. on the other hand, there were dozens of policies that could have benefitted from and been potentially strengthened by a more health-conscious review, some of which possessed the ability to alter the landscape of place-based opportunities and risks for years to come. we believe this could have been averted with a basic commitment to more closely monitor policy development activities across all sectors of local government. in this light, this review could serve as a potential model process for lhds to move in that direction—generally, the direction of an hiap orientation and practice among lhd leadership and legislative/policy directors. health impact assessment and city council policy petteway; cosgrove 14 conclusion the review presented here represents a potentially replicable process to monitor policy with potential health impacts and can serve as a starting point to identify hia opportunities, or as a foundational process for hiap. in baltimore, this work facilitated dialogue around hia with key city officials, including focused discussion with various city council members on how to incorporate the principles and core philosophy of hia into city policy development processes. these discussions strengthened rapport between the lhd and city hall and engendered additional support/motivation to formally pursue hia. this work led directly to the first hia grant for the city health department, which improved prospects for integrating hia into standard practice, and led to completion of at least 2 hias between 2011 and 2015. moreover, this work was a key element to development/ framing of two major lhd reports: one highlighting neighborhood sdh for the first time (the 2011 neighborhood health profiles), and the other outlining the city’s strategic plan/vision for health (healthy baltimore 2015)—which was the first official lhd report to mention hiap as policy priority. other lhds might benefit from engaging in similar review processes to facilitate movement towards hia and hiap as part of standard practice to address local sdh, improve place-health relationships, and promote health equity. health impact assessment and city council policy petteway; 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(2008). closing the gap in a generation: health equity through action on the social determinants of health: commission on social determinants of health final report. world health organization, commission on social determinants of health. acknowledgment: this article’s publication was funded by the portland state university open access article processing charge fund, administered by the portland state university library." mailto:petteway%40pdx.edu?subject= https://doi.org/10.1377/hlthaff.2011.0050 https://doi.org/10.1097/phh.0000000000000130 https://doi.org/10.1089/env.2008.0506 http://www.who.int/social_determinants/sdh_definition/en/ http://www.who.int/social_determinants/sdh_definition/en/ september 2023 volume 8 issue 1 brittany e. sigler, drph; keshia m. pollack porter, mph, phd; lindsay thompson, phd, ma; cyrus y. engineer, drph, mhs, mha; sara singer, mba, phd; darrell gaskin, ms, phd a case study analysis of how products might be designed to promote health abstract background: consumer technology products are changing lifestyle behaviors like how we eat, how we sleep, and how we get around, but existing research has not examined whether they are being designed to promote healthy choices. this study assesses the health impact of two products, snapchat and uber, through the lens of their companies’ environmental, social, and governance (esg) goals in the context of the covid-19 pandemic. methods: we use an exploratory multiple case design to present how health might be considered as a growth strategy for consumer technology products. using publicly available material, we analyze the strengths, weaknesses, and opportunities for the products’ design, policy, and implementation to promote health. results: this distinct approach to health impact assessment successfully revealed existing organizational beliefs and practices with health impact. snapchat’s social media platform fosters social interaction but lacks responsible design features, while uber’s mobility platform has safety and privacy measures but lacks focus on physical activities as forms of mobility. conclusions: by using these products, positive health impact is possible: whether through social connection and information access (snapchat), or increased mobility and physical activity (uber). this case study highlights the untapped potential of intentionally designing products to influence health behaviors and promote health, especially through new uses of existing features. leveraging external partnerships and subject matter experts will be crucial for success, but companies that choose to do so and embrace a health-positive mindset will lay a foundation for a replicable business strategy for those too reticent to lead in this nascent field. a case study analysis of how products might be designed to promote health 2 introduction consumer technology use greatly impacts various lifestyle behaviors in the u.s., including eating habits, entertainment choices, transportation options, and social interactions. these behaviors are closely linked to chronic diseases, such as cardiometabolic and mental health conditions, which have been increasing (cdc, 2022). existing research has not fully examined whether consumer products in these categories align with companies’ publicly stated environment, social, and governance (esg) goals – especially those tied to health. presumably companies with reported health-focused goals in their public esg strategy should have healthpromoting features, but no model of product development or design has emerged to guide health-positive business choices (that is, intentional choices to promote positive health impact (koh, singer & edmondson, 2019)) across diverse sectors. this case study investigates the integration of health-positive product features within the context of major disruption. the extraordinary, immediate, cross-sector response to covid-19 provides a unique opportunity to observe product development efforts, during a period which potentially created an enabling environment for innovation (sturmberg, tsasis & hoemeke, 2020). this study aims to characterize what was a rapid effort to operationalize health-positive features for consumers to determine whether any might have value more broadly, as a replicable and sustainable approach to achieving positive health impact through products. study context the covid-19 global pandemic disrupted the typical drivers of organizational strategic decision-making: regulatory pressure, investor demand, consumer patterns. existing product roadmaps and painstakingly crafted annual strategic plans became moot. as the gravity of covid-19 became clear in march 2020, the response was urgent and farreaching. companies had little choice but to respond. for many, the pandemic was the first time that health was seen not only as a material consideration, but also a driver of value-enhancing competitive advantage (hhs, 2021; battilana et al., 2019). examining the response to covid-19 can yield important lessons for future major public health problems that upend the status quo, as covid-19 did. the objective of this case study is to understand how consumer technology products can become more “healthpositive”, by which we mean supportive of health-inducing behavior. this research will explore two distinct ways tech companies can promote health through their products: 1) how products might be designed (or modified) to promote healthier behavior, and 2) how these products in their original state can be applied in service of health. this approach for determining strategic directions for growth resembles the ansoff matrix, which considers how combinations of either new or existing products and/or markets can drive expansion (see figure 1) (campbell, stonehouse & houston, 2002). in this research, we put a particular emphasis on market penetration (creating deeper value with existing products in existing markets) and market development (that is, creating new uses for existing products). sigler; pollack porter; thompson; engineer; singer; gaskin 3 figure 1. the ansoff matrix this research aims to surface examples of processes and/or features that should either be emulated or improved to achieve health-positive product design, by considering these strategies. through the lens of the covid-19 response, this case study asks: 1. how did two companies extend their existing stated beliefs and organizational practice to implement health-positive product development? 2. how did two companies adapt existing products to be health-positive? extrapolating a process through which companies can implement health-positive thinking would ideally encourage wider adoption. methods study design we used an exploratory multiple-case design with purposeful sampling to gather and analyze relevant products and documents. the protocol for this case study follows the methodology outlined by yin (2009) and creswell & creswell (2017). we identified the two cases using a frame derived from preceding research that examined external-facing views on health impact described in a corporate proxy statement, which is a document provided by publicly traded companies to its shareholders, outlining important information regarding corporate governance, executive compensation, and proposals to be voted on at the annual shareholder meeting. the cases were obtained from a list of public technology companies with products influencing lifestyle behaviors that are determinants of chronic disease (e.g., physical activity, eating, sleep, social interaction, time spent outside) (rowen, 2021; sigler, 2022). we only considered products available during data collection in october 2022. two products from different sectors were selected to affirm replication and allow for cross-case synthesis: snapchat (social media), and uber (rideshare) (see table 1). we selected these products as they represent different behaviors (social connection and mobility) and the products are widely used, avoiding a niche analysis. building on established concepts of social proof, network effects, and diffusion of innovation, we hypothesize that the more users a product has, the greater opportunity for influence (roethke, klumpe, adam & benlian, 2020; katona, zubcsek & sarvary, 2011; min, so & jeong, 2021). this hypothesis supports our decision to examine more commonly used products and increases the relatability of the findings. while facebook may be a more obvious choice for the social media sector, we were more interested in how companies demonstrate value to both shareholders and consumers – and this value is being questioned for facebook (slotnik, 2021). a case analysis can say more about standard operations in an environment where the company does not have a poor reputation and is instead more neutral, leading to the decision to analyze snapchat (islam et al., 2021; singh & misra, 2021; schaarschmidt & walsh, 2020). a case study analysis of how products might be designed to promote health 4 data collection we used multiple forms of public documentation and direct-observation as data sources to increase construct validity (i.e., the appropriate conceptualization of the cases under analysis, and the operationalization of the concept of health-positivity). to understand external and internal motivators, we reviewed findings from a literature review, stakeholder interviews, and content analysis of proxy statements from earlier research (sigler, 2022). where relevant data were not available in proxy statements, we reviewed annual reports (10-ks) and separate esg reports. all reports were for the 2021 reporting year. we also employed direct observation via direct testing and use of the products. where available, product analysis was supplemented by building h profiles, which assess the health impact of products on consumers in six steps: product selection, product research, influence analysis, company input, crowd rating, and h-score calculation (a scale based on reviewer scores to determine the overall health influence of a product). different types of products are assessed using different core measures, as appropriate. for more details on the building h index methodology, see building h, 2022 and singer & downs (2023). while only possible for uber, we employed comparable logic to evaluate snapchat. we also cataloged product policies, including privacy policies, community guidelines, and terms of use, to define business and user context. all product data (policies and feature analysis) were collected in october 2022. data analysis the logic model presented in figure 2 guided analysis of collected data sources. during preceding research, we identified motivators through stakeholder interviews and content analysis of public corporate proxy statements. we also used proxy statements and 10-ks to identify business priorities, the defined purpose of relevant products, and esg goals. by surfacing these product goals, we identified relevant health behaviors to investigate in the associated product (e.g., a goal of building community can be tied to social interaction). we used product policies to identify those that may influence user health, either positively or negatively. all sources of documentation provided detailed background and context to inform the product analysis. the first stage of analysis yielded a foundational overview of each product, describing context for the company, their stated business priorities, reported esg figure 2. logic model for case analysis sigler; pollack porter; thompson; engineer; singer; gaskin 5 goals, along with their product’s purpose and primary features. we next built on this foundation and analyzed each product for strengths, weaknesses, and opportunities. this analysis was based on reports for 2021, and the products as experienced in october 2022. we analyzed consumer product policies (privacy policies, community guidelines, and terms of use), their design, and their implementation: design was considered in terms of functionality built, while implementation centers on how this core capability has been used. assuming the role of a user, we analyzed the selected products, which we refer to as our two cases, and their features to discern the presence of, or opportunity for, health-positive features, and user behaviors susceptible to influence accordingly. we triangulated these analyses within and across cases to develop feasible recommendations for healthpositive product development that can be aligned with business goals according to strengths, weaknesses, and opportunities. we focused the analysis on narrowing the set of identifiable opportunities to product changes that maintain alignment with business operations, as it is understood that these would have the highest likelihood of adoption. it is intended that these recommendations be applicable across consumer technology products, not solely those analyzed in this case study. results product overview these results are first presented by identifying the business priorities for each case using publicly available corporate reporting before diving into their policies, and finally assessing the products themselves. we then use this knowledge to present their in-product covid-19 response. snap and uber represent distinct sectors – social media and ridesharing – yet analysis of primary materials from both companies yielded findings in support of health-positive product development (note: snap is the name of the company; snapchat is the name of the product). product and company overviews are found in table 1 (snap) and table 2 (uber). both companies reported esg goals with health implications, which directly tie to their product purpose. snap aims to strengthen community, empower self-expression, and build connection by having fun together. these goals are directly tied to the positive mental health of users, particularly through avoiding loneliness and building positive social interaction (jeste, lee & cacioppo, 2020). a case study analysis of how products might be designed to promote health 6 company context a camera company that focuses on helping people communicate visually through ephemeral short videos and images called snaps. 319m daily active users: 51.8% female, 20.5% 13-17, 39.1% 18-24, 22.6% 25-34, 13.4% 35-49, 3.6% 50+. competitors: meta (facebook, instagram, whatsapp), alphabet (google, youtube), twitter, apple, pinterest, bytedance (tiktok), tencent. pertinent regulation: extra focus on data and consumer protection, privacy, and content regulation as more restrictive outside u.s. business priorities revenue is generated primarily through advertising. ad tools are created based on features most successful in consumer product. product innovation is intended to increase user engagement, which is then monetized through advertising. research and development focus on product development, advertising technology, and large-scale infrastructure. reported esg goals society: • strengthen community (partnerships, giving and volunteering), • responsible design and product use (inclusion, safety, privacy,) º content safety and governance, promotion of beneficial content, protection. and rights of minors, • leverage platform for social impact (mental health, civic engagement). planet: • reduce carbon footprint of product and operations, • conserve natural resources, reduce waste, • building responsible supply chain (worker well-being + materials). people: • strengthen culture through dei, • encourage wellness and healthy, safe environment, • support commitment to integrity. governance: • maintain structure for value + transparency, • do business responsibly and ethically, • integrate robust risk framework. product purpose empower people to express themselves, live in the moment, learn about the world, and have fun together. table 1. product overview (snap) sigler; pollack porter; thompson; engineer; singer; gaskin 7 table 1. product overview (snap) (continued) primary features -camera: app homepage, includes companyand community-created creative and contextually relevant tools (including augmented reality) to personalize snaps. snaps can be saved to, and searched in, memories; and can be taken with spectacles, a wearable glasses device. -communication: ephemeral messages through text, snaps, voice, and video calls; stickers and bitmojis; opportunity to play games and minis together. -snap map: live map of nearby friends, stories, heatmap of recent snaps on “our story”, and local businesses (including places, rich profiles of businesses that overlay experiences which enable direct action on top of snap map, e.g. ordering takeout). -stories: snap content from publishers, creators, and community, with discover based on user subscriptions and interests (including news and entertainment). includes public profiles for permanent creator and advertiser content. -spotlight: share user-generated and trending content with entire snapchat community, display based on user preferences and favorites. source: data extracted from corporate 10-k and proxy statement available on sec.gov for 2021, and esg report from investor relation section of company website. uber focuses on mobility, with an interest in safety and wellbeing for both drivers and riders (though there is broadly greater attention to the environmental impact of the business than these social impact topics across sources reviewed). while physical safety and wellbeing are respectable health goals, there is a significant opportunity to address the relationship between how people move from point a to point b and physical activity. a case study analysis of how products might be designed to promote health 8 company context uber is a technology platform that powers movement from point a to point b by connecting consumers with independent providers of ride services, merchants, and couriers. 19m trips/day: 52% male, 37% 16-24, 28% 25-34, 17% 35-44, 12% 45-54, 6% 55-64. competitors: taxi companies, public transit, lyft, ola, didi, grab, bolt, yandex. taxi. pertinent regulation: different and sometimes conflicting laws based on jurisdiction, including (but not only) privacy, cybersecurity, data protection, consumer protection, labor and employment, and transportation services. business priorities revenue is generated directly through product use of ridesharing services, meal and grocery delivery, financial partnership offerings, and freight carriers. continued research and development focus on the platform’s synergies: a massive network, leading technology (including marketplace, routing, and payments), operational excellence, and product expertise. reported esg goals environmental: • climate change: focus on zero-emission vehicles, micromobility, and public transit, • energy efficiency + renewable energy, • local air quality, water consumptions, waste reduction/recycling. social: • covid-19 response, • dei and culture, • driver and courier well-being, • local impact and urban use, • user privacy and safety. governance: • data privacy and security, • human rights in the supply chain, • political activities, • ethics and compliance, • board composition, executive compensation. product purpose while uber has mobility, delivery, and freight segments, this case focuses on mobility (“ride”). the purpose of the mobility product is to move consumers from where they are to where they need to be, efficiently, safely, and on-demand. table 2. product overview (uber) sigler; pollack porter; thompson; engineer; singer; gaskin 9 table 2. product overview (uber) (continued) primary features -rideshare: call a car for door-to-door service via mobile app. -bikeshare: use the app to book a bike at nearest available bikeshare station. -scooters: use the app to reserve a scooter per above. -car rentals: ability to rent cars through select agencies. -uber one: subscription service provides discounted rides and priority access to top-rated drivers. source: data extracted from corporate 10-k and proxy statement available on sec.gov for 2021, and esg report from investor relation section of company website. y website. both cases demonstrated a multitude of strengths, along with weaknesses and opportunities to take advantage of existing organizational practices to evolve in a more health-positive direction (see table 3 and 4). snapchat at its core, snapchat is a product meant to facilitate social connection, which it makes easy to do immediately upon opening the app. there are multiple ways to connect with other users, through direct messaging or image/video-sharing, or posting more publicly on stories, indicating strong follow-through on the company’s stated purpose of building community. this is likewise supported by snapmap, whereby upon giving consent, users can easily connect with friends offline by digitally following friends. users also have the ability to control their self-expression, especially through their digital avatars (bitmojis), which are available in an especially representative swath of skin tones and hairstyles. the heavy emphasis of these personalized avatars promotes equity by encouraging users to come as they are, without limiting how they can be represented. snap has an implicit emphasis throughout its reporting on supporting the mental health of its users, and on creating a healthy product environment – though there is an opportunity to make the connection between banned activity and the health of users directly. there are ample policies (pointedly crafted in plain language, though not intuitively accessible in-app) governing use of the product, including a privacy policy, terms of use, and community guidelines with persistent mention of a desire to keep users safe, and empower them to take control over their experience. it appears contradictory, then, to observe the lack of content moderation in-app or ability to self-impose restrictions on the content a user chooses to see. without the ability to control content visible through discover (snap’s newsfeed) or spotlight (short-form video content), a user is likely to engage with sensationalist news stories, lewd imagery and videos, and minimal display of credible sources. this increases risk of misinformation and negative self-image and fails to create a healthy sense of community (sheldon, rauschnabel & honeycutt, 2019). spotlight’s endless stream of content amplifies this state by enabling constant engagement and addictive behavior (sun & zhang, 2021; bányai et al., 2017). this reality does not align with snap’s stated goal of responsible design and product use. a case study analysis of how products might be designed to promote health 10 this misalignment appears to be a function of a disconnect in how the organization is structured: the trust and safety team is responsible for development of content moderation tools and implementation, while the public policy and social impact team engages in external partnerships and advocacy efforts. that is, one team determines which content is noncompliant with product policy requiring removal, another develops impact-driven content, but none is asserting how the remaining content should be prioritized, presented, or experienced by users. this also leaves a gray zone of content which is not counter to policy, yet still negatively impacts users. the public policy and social impact team has spearheaded thoughtful partnerships with industry experts and non-governmental organizations to target snapchat’s key user demographic (largely gen z and younger millennials, snap’s primary users) with campaigns especially salient to them, e.g., drug use reduction, mental health education, and bullying awareness and prevention, along with the creation of a digital safety center. these partnerships produce excellent, credible content; however, they do not receive much prominence in-app, nor are credible sources identified, which offers room for improvement. users must happen across the correct search terms, or know they exist, to surface mental health support and drug use awareness campaigns. while snap’s own wellness resources claim that being safe on social media is not merely the absence of danger, but the presence of wellness, features seem to focus on reactive support and reporting rather than proactive prevention and moderation. there are multiple opportunities to build on existing design to extend the product’s positive health impact. the app already allows users to subscribe to creators and select lifestyle interests to personalize advertising content. this ability to control content should extend to content filters of what a user does not want to see, especially for younger users. as established by social cognitive theory, increasing user agency can improve wellbeing by supporting their preferences (bandura, 2001; martin, 2004) – in this case for the parts of the broader product community with which they seek to engage. adding an option native to the app to control length of session would minimize addictive design features by limiting a continuous content stream (such timer features are available native to most mobile devices) (sheldon, rauschnabel & honeycutt, 2019). opportunity to promote offline events and activity through snapmap can also further foster social connection inperson. current policy outlines how data are used, largely governing advertising and content offered. snap can choose to use this data to promote health information pertinent to the user in partnership with local health departments. these data can also be combined with that of “friends” users interact with most to determine group-level interventions. still, the policy should specify which behaviors or personal information do not, or will not, dictate ads. user behavior determines content displayed through discover and spotlight, creating either positive or negative reinforcement loops. more can be done to help this content skew toward a positive user impact. verification and recommendation features can help sigler; pollack porter; thompson; engineer; singer; gaskin 11 health behavior: social interaction and connection variable strengths weaknesses opportunities design • encourages social interaction: strongfollow-through on stated purpose to build community • emphasizes the use of digital avatars (“bitmoji”) to personalize the experience: customization promotes diversity and inclusion • ease of social connection offline through snapmap • lack of ability to filter: concerning given sensational content in discover and lewd content in spotlight • misaligned with stated goal of responsible design and product use; negative influence on self-image • constant stream of spotlight content risks addictive behavior • filters for what users do not want to see, and not just what they do see • ability to control session length • promotion of offline activities for further social connection policy • plain language explanation of access • data used to protect user rights, safety • focus on building a safe product community • community guidelines have heavy focus on mental health of users • failure to acknowledge offline behaviors that results from online product use • bulk of policies related to health and safety in community guidelines, not easily accessible within the user experience (ux) design • no explicit mention of impact of banned content, or misuse broadly, on mental health • information collected can be used to personalize health-related content through partnerships, instead of just ads • adjust algorithm to avoid negative reinforcement loops to help skew toward positive user impact table 3. product health assessment (snap) a case study analysis of how products might be designed to promote health 12 health behavior: social interaction and connection variable strengths weaknesses opportunities implementation • safety by design, collaboration with outside experts • development of “here for you” content, partnership with crisis text line • development of “heads up portal” • snap originals focus on mental content • lack of identification of credible sources in search • no explicit mention of safety by design principles used, no promotion in-app of safety feature or health-related content • focus on absence of danger, not presence of wellness, counter to own guide • validation feature to discern credible content • recommendation feature to surface valuable content partnerships and wellbeing resources more easily. • partner with communities who can benefit from social connection evaluation • impact reported impact in citizen snap report, covering quantity of content removed, percentage of content that violated guidelines, and use of support resources • no mention of impact of covid-19 partnerships or campaigns, use of covid-focused ar experiences and creative tools. • no discussion of reach of covid-19 content. • no discussion of reach or impact of here for you content. • all campaigns launched with health goals should be explicitly evaluated • any health-related goal in impact reports should be tracked at minimum qualitatively. table 3. product health assessment (snap) (continued) amplify credible content, avoid misor disinformation, improving the responsible design elements the company claims to aspire to. uber as a mobility product, uber’s main priority is to move users to where they want to be. this suggests a seemingly obvious opportunity to allow users to choose to walk as part of their journey, but modalities are limited to car, bike, and scooter. while biking and scooting are more active transportation modes, these choices receive reduced prominence in-app. the only option which integrates walking is by choosing to meet one’s driver at a more convenient location for the driving route, centering driver preference. given this functionality, it would not be a stretch to center this capability from the user-side, allowing the user to plan in walking time on either end of a ride. sigler; pollack porter; thompson; engineer; singer; gaskin 13 policy and design are strongly aligned in a focus on safety: there is clear emphasis on how both riders and drivers should be treated, and how they should treat each other, creating equitable expectations and community guidelines. this includes the use of mutual ratings, building an expectation for positive social interactions during rides in order to receive a positive score. use of privacy-by-design practices and community guidelines which center on respect likewise promote a healthy user experience. in-app, the “safety toolkit” provides both riders and drivers with the ability to report incidents, record uncomfortable situations, contact emergency support, and share location, while ridecheck auto-detects rare events like long stops. given users must scroll to view this toolkit feature, periodic reminders of its availability could maximize its utility. similarly for the robust community guidelines, reminders of expected behavior could increase the likelihood of positive social interactions and safety. this repetition is already employed for seatbelt use. core features like the map and ads have the opportunity to be optimized to promote healthy locations or items, and dynamic pricing could integrate health-related variables like opting to walk to shorten rides. ultimately, as a robust logistics platform, uber has the functionality to be used for additional purposes. indeed, the company has initiated a fledgling healthcare business to help coordinate non-emergency medical transportation as its first product line. additional health behavior: mobility variable strengths weaknesses opportunities design • ample safety features: verification, ratings, reporting, ability to share location; safety toolkit with ability to record audio, share trip, and 911 help • ratings system creates dual accountability for health interpersonal behavior • seat belt alerts • no acknowledgment/ promotion of walking as form of mobility • minimal promotion of micromobility (i.e., lightweight transport options like bikes and scooters) over other modes of transportation, despite emphasis in esg report • embed walk options • increase prominence of bike and scooter table 4. product health assessment (uber) a case study analysis of how products might be designed to promote health 14 health behavior: mobility variable strengths weaknesses opportunities policy • data used to enhance safety and security • focus on “privacy-bydesign” • community guidelines center on respect • promote safety • lack of mention of how “privacyby-design” has translated to product development • lack of recognition and accountability of connection between mobility and physical activity • robust community guidelines not central to in-app user experience (ux), opportunity to be more intrinsically embedded to optimize for positive experiences implementation • logistics expertise and mobility platform being used as foundation for uber health product line • impaired driving prevention through “decide to ride” campaign • ride donation and in-app donation as part of humanitarian response efforts • use map to promote healthy locations (grocery stores, parks) • partner with nonprofits focused on communities suffering from social isolation due to limited transportation • integrate health variables into dynamic pricing model (e.g. deter short rides by increasing price, promoting more active transit) • use personalized ads feature for good evaluation • frequency of trips without safety incident evaluated in esg report • reporting of philanthropic initiatives, e.g., rides for pregnant people, job interview access, health appointment access, humanitarian relief • no discussion of impact of covid-19 initiatives (e.g. reach of vaccine education, # of rides to vaccine sites). • same as snap, bearing repeating: • all campaigns launched with health goals should be explicitly evaluated • any health-related goal in impact reports should be tracked, at minimum qualitatively. table 4. product health assessment (uber) (continued) sigler; pollack porter; thompson; engineer; singer; gaskin 15 positive impact can be achieved through emphasizing partnerships with nonprofits focused on communities suffering from social isolation due to otherwise limited access to transportation (some work in this regard has begun through the uber health product line). evaluation to discern whether any of these features or campaigns are successful, additional evaluation is needed for both products. all campaigns launched with health goals should be explicitly evaluated, indicating their influence on baseline metrics as a model for other companies. companies need to share which efforts are successful to contribute to developing a standard. any healthrelated goal in impact reports should be tracked: if quantitative measurement is not possible, at minimum there should be a qualitative assessment. covid-19 response both products leveraged their core functionality in responding to covid-19, as illustrated in table 5. snap developed creative tools and ar experiences which allowed users to share reputable health information with their connections. snap also collaborated with partners to develop original content with credible resources. while content partnerships with a health focus appear to have been temporary, there are still efforts to create shareable health-related information through filters, gifs, and bitmojis. the here for you channel which focused on the pandemic’s effects on youth mental health still exists, but without regular updates on general mental health (its original purpose). uber donated rides and made it possible to receive free transportation to vaccination sites, consistent with ongoing health-related philanthropic ride donation efforts. this initiative has not been sustained for other user-facing initiatives, e.g., had the company chosen to implement a similar strategy for promoting flu shots. additionally, while the company launched a new feature to prompt mask use before entering a vehicle, the ability to offer public health messaging has not been repurposed for other health topics. a case study analysis of how products might be designed to promote health 16 case covid feature continued discontinued snap creative tools to share expertapproved best practices to stay healthy (e.g., gifs, bitmoji designs) still available, not promoted. promotion of anti-bullying content (october 2022). published regular safety updates with public health officials and agencies, including who and cdc no usage for other health updates, e.g., flu season. focus on sharing credible information in discover from trusted sources: efforts to provide access to information about covid-19 and how to stay safe: • news providers (3 dozen partners) produced constant coverage of pandemic on-app • collaborated with syndicated partners to publish and share episodes around covid vaccines targeting young users unclear if other partnerships currently exist with social impact focus through discover feature. vaccine education initiative in-app in partnership with white house discontinued, partnership does not appear to have been sustained around other topics. expanded here for you content focused on the pandemic’s effects on youth mental health and loneliness. discontinued, partnership does not appear to have been sustained around other topics. expanded here for you content focused on the pandemic’s effects on youth mental health and loneliness. still exists, but appears to be updated on a limited basis, if at all. table 5. maintenance of covid-19 product response sigler; pollack porter; thompson; engineer; singer; gaskin 17 table 5. maintenance of covid-19 product response (continued) case covid feature continued discontinued uber requirement of mask to ride, with in-app prompt at outset of each ride. ethos maintained through seat belt alert, but no clear indication that product decision related to mask feature. meal delivery to frontline responders (uber eats) discontinued. transported essential goods in times of crisis (uber freight) continued for other philanthropic or humanitarian efforts. donated 10m free rides to healthcare workers, seniors, and others to get vaccinated (partnership with organizations with ties to communities disproportionately impacted by pandemic) ride delivery for other philanthropic causes. in-app feature to donate to vaccine access fund which provided free rides to vaccination sites and other places to learn about the vaccine from trusted contacts will use remaining funds to address systemic barriers to access to health services beyond vaccines. no other donation campaign related to health. in-app experience integrating vaccines.gov, allowing users to find nearby available appointments (included free rides for both legs of trip to get first 2 vaccinations) feature not used for any other in-app health education campaign, e.g., flu shot. a case study analysis of how products might be designed to promote health 18 discussion this study of two distinct products’ policy, design, and implementation choices revealed that existing organizational beliefs and practices have resulted in decisions with health impact. this suggests that health promoting decision-making can feasibly be integrated into organizations outside the healthcare sector. however, there is minimal intentionality for positive health impact in current product design, as existing design aligns predominantly with business priorities. while some companies may have health-related social impact goals in their esg reports, there is no requirement for these goals to be accounted for in core products based on current regulations (snap comes close to integrating the goal of strengthening community by inherently promoting social connection). while covid-19 has triggered new applications of existing product capabilities, there has not been significant new feature development that has been initiated or sustained as a result of the pandemic. though covid-19 is now endemic, the lessons here are powerful for future pandemics and public health crises. upon analyzing snap and uber for their strengths, weaknesses, and opportunities in terms of health impact, it would be idealistic to expect healthcentric product development without external accountability, creating an opportunity for regulation. through this case study, relationships between product use and product outcomes became better understood. snap is effectively contributing to outcomes of social connection and information access, while uber is contributing to increased mobility. still, each company could do more. snap could contribute to improved health literacy, healthy relationships, and reduction in loneliness, depending on information campaigns implemented. uber could positively influence the physical activity of users through featured modalities (i.e., greater emphasis on biking, scooting, and walking). reporting is how distinct stakeholders communicate: how companies report is how investors evaluate. mandating that corporate reporting include health impact would hold companies accountable to consider how their product development decisions affect the health of their users (pérez, 2015; kickbusch et al., 2018; wilson, 2022; ajayi & mmutle, 2021). such regulation might also introduce a common language for creating a healthy product environment. that is, how companies position themselves in their public-facing materials contributes to how they are perceived and assessed as much as the products themselves (forman & argenti, 2005; van riel & fombrun, 2007). indeed, all conclusions in this case analysis are limited to the perception of publicly available sources. existing products can still be adapted to become health-positive before policy catches up to technology. the opportunities presented in table 3 and 4 are examples of that, but each company would need to assess the business perspective. to do so, a company can first identify the user behaviors it could impact. at minimum, technology companies influence how users engage with others, and how they spend their time. next, a company can identify its products’ levers of influence (e.g., content availability, marketplace prominence, pricing), then assess the risks and benefits to using those levers sigler; pollack porter; thompson; engineer; singer; gaskin 19 to intentionally create positive health impact. once that decision has been made, a clear plan must be outlined for measuring and enforcing health impact through product policy to avoid a moot effort. self-imposing accountability mechanisms, similar to sustainability assessments, could be considered. after building functionality or implementing changes within existing designs, the company can evaluate the health impact achieved. iteration would be assumed: digital products can and should always be continuously refined to improve outcomes, and health outcomes are no different should a company choose to prioritize them. limitations while exploring the health impact of products on their consumers is an exciting new field of research, this also creates limitations. there is minimal publicly available data to consult as a baseline, putting pressure on this research to contribute reliable evidence as a strong foundation on which others can build. while the findings here are consistent with those from separate studies with distinct methodologies from this same research team (sigler, 2022), these conclusions are restricted in their generalizability given the limited samples used. conclusions this case study demonstrates the tremendous untapped potential in the tech sector to intentionally design products that sustainably influence health behaviors and promote health, particularly through new uses of existing features. as with other social impact initiatives, companies will need to leverage external partnerships and subject matter experts to actualize this opportunity. the learnings from this analysis provide a path forward for companie that boldly embrace intentionally designing products to influence health behaviors and promote health. a case study analysis of how products might be designed to promote health 20 references ajayi, o. a., & mmutle, t. 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indiana university, indianapolis chronicles of health impact assessment vol. 8 issue 1 (2023) doi: 10.18060/27348 © 2023 author(s): sigler, b.e.; pollack porter, k.; thompson, l.; engineer, c.; singer, s.; gaskin, d. this work is licensed under a creative commons attribution 4.0 international license mailto:bsigler3%40jhu.edu?subject= october 2020 volume 5 issue 1 promoting health equity through the built environment in duluth, mn: external resources and local evolution toward health in all policies katrina smith korfmacher, phd abstract: communities, professionals, and researchers recognize that environmental factors contribute to the health inequities experienced by vulnerable populations in the u.s. these environmental health injustices persist despite well-developed systems for both public health and environmental protection. the root cause of these issues is often “siloed” decision-making by separate health and environmental institutions. health impact assessment (hia) can be an important tool for bridging these silos to promote health equity at the local level. this raises the question: how can external resources best support local initiatives? this paper examines the interaction between national, state, and non-governmental efforts to promote hia and local actions to promote healthy and equitable built environment in duluth, mn. a wide range of local activities in duluth aimed to alter the long term trends, decision processes, and institutions shaping its built environment. these included integrating health in brownfield redevelopment, local land use plans, food access, and transportation decisions. technical and financial support from external groups played a key role in developing the community’s capacity to promote health equity across public, private, and non-profit organizations. these multiple streams of action culminated in the mayor’s declaration in 2016 that health and fairness would be adopted as key goals of the city’s new comprehensive plan. how did such innovative efforts thrive in a small, post-industrial city with limited resources? duluth’s experiences provide insight into how external governmental, funding, academic, and non-profit entities can more effectively, efficiently, and equitably support the evolution of local initiatives. 1 promoting health equity through the built environment in mn korfmacher 2 introduction in her first state of the city address in march 2016, mayor emily larson referenced the 11 year life expectancy disparity between adjacent zip codes in duluth, and commented that “our right to a good and healthy life should not be determined by our zip code, or our income, education, race, gender or religion…my vision is of a healthy – prosperous – sustainable – fair – and inclusive community” (larson, 2016). this small, post-industrial city may seem an improbable place for such a strong vision for health equity to be expressed by a city leader. this statement built on over ten years of local work promoting the importance of a healthy and equitable built environment. this work evolved through a complex interplay of external resources and local activities that developed capacity in hia. duluth’s efforts to promote health equity involved improving access to transportation, healthy food and opportunities for physical activity. the literature is rich with examples of communities where initial efforts at health impact assessment evolved into broader adoption of health in all policies (collins & kaplan, 2009) (armijo et al., 2019; calloway, 2019; rudolph et al., 2013). this raises the question of whether and how external institutions (funding, training, etc.) can support such local evolution. this paper explores the role of external resources, relationships, and initiatives that helped to grow duluth’s local initiatives over more than ten years. the paper concludes with lessons learned about the potential impact of external support and recommendations for future efforts to support evolution towards health in all policies in other communities. the setting: duluth, minnesota duluth, minnesota is a small city (86,000 residents) on the western tip of lake superior. duluth emerged in the 1800’s as a transportation hub for the midwest’s agricultural and industrial products. later, it became an important industrial center focused around steel and other heavy industries. with the decline of the steel industry and growth of alternate transportation routes, duluth’s economy shrank, resulting in a 30% population loss between 1960 to 1980. as of 1983, duluth had an unemployment rate of 16%, more than double the statewide rate and among the highest in the country (bunnell, 2002). because of this industrial history, the city has a large number of brownfields, sites of known or potential environmental contamination (u.s. environmental protection agency, 2020). two former industrial sites totaling around 800 acres together comprise the largest superfund site in minnesota. the western part of the city is located on a narrow strip of flat land between the lake and a steep escarpment, limiting land available for new development. duluth’s economy has expanded in recent years, with several new businesses locating on former industrial sites. duluth has become a regional center for healthcare and a gateway to outdoor recreation in the region. the city is renowned for its extensive network of bike and hiking trails, contributing to its being named the “best place to live in the u.s.” by outside magazine in 2014 (pearson, 2014). despite the city’s growing prosperity, significant disparities exist in economic and health status, particularly for racial and ethnic minorities. recognizing this, community groups, public health professionals, and city staff have engaged in a wide range of “policy, systems, and environmental” (pse) change efforts to promote health equity (honeycutt et al., 2015). this “healthy duluth” work has included several health impact assessments, brownfields redevelopment, transportation planning, and a comprehensive plan update. taken together, promoting health equity through the built environment in mn korfmacher 3 these efforts aimed to reduce health disparities by focusing on the built environment in lowincome neighborhoods. table 1 traces how external resources fostered and enhanced local health equity initiatives in duluth between 2005 and 2017. although the city has not formally adopted health in all policies, health equity is now infused in many local decision processes. initiation of healthy duluth efforts building on its reputation as an outdoor activity and recreation-focused community, the city of duluth applied for and was granted designation as a governor’s fit city in 2007 (duluth to be named,” 2007). fit city was a voluntary designation established under the minnesota department of health (mdh) in 2005 to encourage and highlight cities’ commitment to supporting healthy living (new ulm, 2006). through fit city, city staff convened a group of community stakeholders to promote physical activity opportunities in duluth. this city-led effort soon spun off into a community organization also called fit city. fit city members attended a cdc conference on “community approaches to obesity prevention” where they learned about other communities’ efforts to pursue health equity through work to change “policies, systems, and environments” (pse). convinced of this approach, fit city members decided to focus on policy work, which transitioned into the healthy duluth area coalition (hdac). hdac aimed to bring together multiple groups that were working to promote health and equity in the community. according to its website, “the healthy duluth area coalition is committed to changing the policies, systems and environments of our city to encourage active living and affect how residents access healthy foods. we bring together the people who can facilitate the greatest change, who advocate for wellness, and who strive for health equity. we are here to help everyone be well by supporting active living and healthy eating, and by working to make the healthy choice the default choice.” hdac’s efforts were organized into five objectives, the most active of which were to promote “a comprehensively healthy local food environment and a “balanced and diverse community transportation system” (healthy duluth area coalition, 2018). hdac has been supported by a variety of local and external funders over time, including grants from foundations and state agencies. for example, the center for prevention at blue cross blue shield minnesota provided several grants to the healthy duluth area coalition, including support for the fair food access campaign’s work in lincoln park in 2014 and funding to establish a health equity collaborative in 2016 (center for prevention at blue cross blue shield of minnesota, 2020). the hdac partners varied over time depending on current funding and projects. hdac leveraged the knowledge and contributions of multiple partners whose work aligned with these initiatives, but whose organizations had limited ability – whether due to staff, financial, legal, or institutional constraints to directly advocate for policy change. in addition to hdac’s activities and convening functions, many individual organizations in duluth engaged in related activities to promote health equity through changes in the built environment. taken together, these activities are referred to here as “healthy duluth” efforts. the st. louis county health department was a key player in many of these efforts. in 2008, the center for prevention at blue cross blue shield of minnesota distributed copies of the video “unnatural causes” to local health departments across the state. “unnatural causes” showcases how the environment significantly impacts disparities in public health (unnatural causes, 2008). health department staff who viewed promoting health equity through the built environment in mn korfmacher 4 this video connected its message with health disparities they observed in duluth. as one health department staff member noted, “i don’t think the impact that unnatural causes had on us can be overstated” (j. gangl, personal communication, march 17, 2016). by sharing this video of systems change efforts in other communities, the center for prevention played a role in mobilizing health department engagement in health equity. the growing focus of the local health department on changing systems to promote health equity was strengthened and sustained by minnesota’s state health improvement program (ship, renamed the state health improvement partnership in 2016). ship was a cornerstone of minnesota’s 2008 health reform law and funded local health departments to conduct community-based activities aimed at reducing risk factors for chronic disease. the program explicitly encouraged health departments to engage in “policy, systems, and environment” (pse) change, and later ship grant guidelines added a health equity focus. with ship support, st. louis county health department staff played a significant role in building coalitions, sustaining local partnerships, and participating in planning efforts. for example, health department staff supported convening the safe and walkable hillside coalition, which contributed to community engagement in the first health impact assessment in duluth (6th avenue hia). health impact assessment in duluth another important external contribution to the healthy duluth work was mdh support for three health impact assessments (hias). as described below, these hias built community partners’ capacity and complemented hdac’s ongoing efforts to promote health equity through shaping decisions about duluth’s built environment. health impact assessment (hia) is a voluntary approach to identifying the potential health impacts of non-health decisions (bhatia, 2011; national research council committee on health impact assessment, 2011; ricklin et al., 2016; rhodus, et al., 2013). hia has been promoted as a way to build consensus, engage affected communities, and develop recommendations that improve health equity. starting around 2008, the minnesota department of health made a significant and sustained commitment to supporting hia as a tool to promote health equity. mdh obtained grants from federal agencies and foundations to help build capacity for hia throughout the state (as of 2018, the program had identified 34 hias conducted in minnesota (minnesota department of health, 2020)). as part of these efforts, duluth received technical support and funding for three hias between 2010 and 2014. these opportunities allowed local stakeholders to learn about hia, use health data to analyze how built environment decisions affect health disparities, and gather community input on ways to improve environmental health equity. although the hias were led by mdh, the experience of working together on these hias built local stakeholders’ capacity and provided data, analyses, and recommendations that informed future work. 6th avenue redesign hia, january-june 2011 the first hia in duluth was supported through a mdh grant from the association of state and territorial health officials (astho) to conduct three hias in the state. the hia examined an ongoing effort to redesign 6th avenue, a busy road that bisects the low-income hillside neighborhood in downtown duluth (st. louis county health and human services, 2011). 6th avenue posed a major challenge to the walkability of the neighborhood. consolidation of two neighborhood schools in 2011 required many children to cross 6th avenue to get to their new school. due to the dangerous traffic promoting health equity through the built environment in mn korfmacher 5 on 6th avenue, many of these children were bussed to school, despite living only a few blocks away. the hia assessed the health impacts of the proposed 6th avenue redesign with respect to accessibility, safety, physical activity, and livability, with a focus on vulnerable populations including children, older and disabled adults, and low-income residents. the hia recommended increasing the number of bus stops, adding a traffic signal, enhancing crosswalks, creating a designated bike lane, and improving snow clearing (minnesota department of health climate & health program, 2014). the hia’s public engagement efforts built local stakeholders’ understanding of how transportation planning affects community health. gary-new duluth small area plan health impact assessment, june 2013 – june 2014 in 2013, duluth conducted a second hia on an ongoing small area planning (sap) process with mdh support through a grant from the health impact project, a partnership of pew charitable trusts and the robert wood johnson foundation (korfmacher, 2019; korfmacher 2020). the gary-new duluth neighborhood, located around 10 miles west of downtown, was a disinvested area that had originally been developed to house workers at the nearby u.s. steel duluth works plant (city of duluth, 2006; minnesota department of health climate & health program, 2014). the neighborhood lost 50% of its population between 1950 and 1980 (bunnell, 2002). the hia team conducted several public meetings, focus groups, and a community survey to solicit feedback from the public. the survey identified “jobs and economic development, crime prevention, and access to goods and services” as top community concerns. the hia identified “children, older adults, lowincome people, people with lower educational attainment, disabled people, and people with pre-existing health conditions” as potentially vulnerable community members, and focused its analysis on how the sap might affect the health of these groups in particular. the hia provided for significant additional community engagement in the sap process. for example, residents suggested incorporating a “community events board” into the design of new neighborhood entrance monuments recommended in the sap (minnesota department of health climate & health program, 2014, p. 51). in addition to increasing community engagement, this hia built diverse professionals’ understanding of hia. the hia’s technical advisory committee (tac) included community groups and representatives from the county health department, arrowhead area agency on aging, the city department of parks and recreation, regional transportation planners, and the local hospital. because several members of the hia tac also served on the sap steering committee, they were able to enhance additional stakeholders’ understanding of how the plan’s recommendations could promote health equity. lincoln park hia, january 2014 – september 2015 whereas the gary-new duluth hia was conducted parallel to the small area planning process, duluth’s third hia (also supported by the mdh health impact project grant) integrated hia fully into the planning process. this reflected a growing appreciation of hia among community leaders. this third hia addressed lincoln park, a low-income neighborhood just to the west of downtown duluth. it is a dense urban neighborhood with some of the highest racial and ethnic diversity in the city (minnesota department of health climate & health program & division, 2015). promoting health equity through the built environment in mn korfmacher 6 the 2011 st. louis county health status report identified lincoln park area as having the lowest life expectancy in the city (gilley, et al. 2011). non-profit and government agencies had been actively pursuing community revitalization of the lincoln park neighborhood for many years. one goal of the sap process was to provide steps the city could take to build on these efforts. in 2011, a study by university of minnesotaduluth and umn extension had documented residents’ food access challenges, including distance to full service grocery stores (10 minutes by car, 30 minutes by bus) and higher prices for food at local convenience stores (pine & bennett, 2011). since 28% of households in the study area did not have a car, the study concluded that 10-15% of residents experienced significant barriers to accessing healthy food. the hia made several recommendations to increase food access for residents. the hia’s housing recommendations focused on the potential to increase social cohesion through more home ownership, reducing housing costs so people had more money to purchase healthy food, and improvements in housing quality with stronger enforcement of housing codes. additional recommendations related to increasing safety, community building, and social cohesion, and creating a positive sense of place. this hia process strengthened connections between local stakeholders around health equity and enhanced their focus on food access. summary: hia in duluth these three hias together had a significant impact on integrating health in public decisions in duluth, including: 1. providing an evidence base and data that could be easily referenced to inform future implementation decisions, grant proposals, and evaluation efforts. 2. increasing public engagement, which enhanced community involvement in future efforts. 3. building the capacity of local stakeholders to do hia, strengthening relationships between professionals in diverse organizations, and increasing leaders’ commitment to promoting health equity. however, without external funding, the city could not provide the resources needed to complete additional hias on a regular basis. one more hia was conducted in duluth with support from the u.s. epa on waterfront habitat restoration (williams, et al. 2020)). nonetheless, the experience of doing these hias motivated stakeholders to find other ways to integrate health into ongoing local decisions. the next sections describe additional approaches through which stakeholders in duluth have considered health when making decisions that affect the built environment. integrating public health in brownfields redevelopment in addition to health impact assessments, efforts in many other sectors, agencies, and groups in duluth aimed to promote a healthier, more equitable built environment. the duluth business and economic development department was in an important early contributor to promoting health equity through brownfield redevelopment. state and federal brownfields programs have increasingly emphasized the broad public health improvements that may be gained by constructive reuse of contaminated land (u.s. environmental protection agency, 2018). starting around 2008, city staff noted that the u.s. epa’s requests for brownfields redevelopment proposals prioritized projects that would improve public health outcomes. this guidance from u.s. epa encouraged local officials to identify health-promoting promoting health equity through the built environment in mn korfmacher 7 redevelopment projects. for example, with the business and economic development department’s leadership, the 10.2 acre clyde iron works brownfield site (“clyde park”) was developed into a multi-sport complex with a restaurant and event venue. clyde park anchored the redevelopment of the distressed lincoln park neighborhood as a hub for recreational and sports activities. with a documented 400 blighted and/or brownfield sites in lincoln park alone, the ongoing focus on promoting public health through brownfield redevelopment is expected to have a significant impact on shaping this neighborhood’s future. duluth’s groundbreaking work on linking brownfields with health, in turn, leveraged additional outside resources. for example, staff at the agency for toxic substances and disease registry (atsdr) brownfield/land reuse initiative heard about duluth’s ongoing efforts and in 2010 invited the city to partner with them on a proposal to the great lakes restoration initiative to assess the public health benefits of restoring the st. louis river and lake superior waterfront. although the project was not funded, it resulted in a stakeholder workshop in july 2012 to identify community health indicators for successful restoration. this workshop strengthened the brownfield program staff’s connections with the ongoing healthy duluth efforts. another example of leveraging outside resources came from duluth’s business resource manager heidi timm-bijold’s ongoing relationship with the statewide nonprofit minnesota brownfields. in 2012, minnesota brownfields partnered with duluth to develop and pilot their health indicator tool, which bolstered the city’s ability to identify health benefits of redevelopment projects. the health indicator tool has since been disseminated as a statewide resource for documenting the public health impacts of brownfields redevelopment (minnesota brownfields, 2018). the city of duluth continued to integrate health assessments in numerous brownfield plans and related infrastructure projects, such as expansion of bike paths in low income neighborhoods. for example, in 2014 duluth received a u.s. epa area-wide planning grant for the irving fairmount brownfields revitalization plan that included health department staff on the team and emphasized health equity as a goal for redevelopment. as duluth business resource manager heidi timm-bijold said, “we were not intentional about the health conversation (before), but now …we are very clear about the conversation as it relates to food, safety, connectivity – it is just part of the discussion. so as we move forward… it is becoming normalized to think about health as part of the process” (h. timmbijold, personal communication, march 17, 2016). transportation equity as noted above, duluth’s initial efforts focused around promoting healthy lifestyles by providing trails and other resources for physical activity. over time, the healthy duluth efforts came to reframe their efforts in terms of “transportation equity” – shaping the local transportation system so all duluth residents could access health-supportive resources, including opportunities for active and public transportation. as st. louis county health department educator josh gorham stated, not only is transportation about health – active living it’s about getting to healthy food, healthcare, social activities, and much more… as socio-economic disparities became more of a priority in public health efforts in duluth, we needed to reframe our promoting health equity through the built environment in mn korfmacher 8 approach. we were no longer just talking about active transportation; we were talking about transportation equity” (j. gorham, personal communication, march 18, 2016). although individual groups still relied on outside resources to support staff and specific projects, these efforts were sustained by the integration of transportation equity goals into existing organizations’ agendas and activities. for example, the hdac organized a series of activities to highlight the potential for promoting health equity in the built environment. some of these events were inspired by similar efforts in other cities, and supported by local financial and staff resources. the hdac coordinates an annual “bike/bus/walk” month, including a “bike with the mayor” event (french, 2014). “parklets” have been created by businesses temporarily taking over parking spaces as public seating and recreation spots (french, 2015). these and other events helped engage the public and raise the community’s awareness of healthy duluth’s efforts. in addition to these “pop up” events and projects, healthy duluth stakeholders engaged in ongoing efforts to promote transportation equity. for example, the lincoln park hia identified low-income residents’ challenges accessing healthy and affordable food. in response, the city established a “grocery bus” specially equipped with racks for bags of food with scheduled runs from high need communities to the nearest full service grocery store (lundy, 2016). on an ongoing basis, healthy duluth area coalition members participated in public hearings and commented on street redesign programs, advocating successfully for traffic calming, bike lanes, and improved bus stops. in 2014, duluth initiated a “st. louis river corridor initiative” to expand trails, parks, and neighborhood improvements after the floods of 2012 (city of duluth, 2016). in 2016, mayor larson affirmed her commitment to implementing the plan, prioritizing segments that serve lower income neighborhoods. meanwhile, the metropolitan planning organization’s technical advisory committee appointed a public health representative to ensure that health equity was “at the table” for a wide range of regional transportation decisions. these and other ongoing transportation equity efforts reflected stakeholders’ success in building community understanding and support for improving the built environment into ongoing local decisions in a wide range of sectors. having health equity-oriented stakeholders involved helped counter concerns about costs and negative impacts on private businesses (e.g. loss of public parking, added construction costs). toward health in all policies? these examples show how healthy duluth efforts increased consideration of health equity in a wide range of decisions. these initiatives started with voluntary efforts to encourage healthier lifestyles. after learning about the power of other communities’ efforts to promote systems change, healthy duluth’s efforts began to focus on policies, plans, and programs that shape the built environment. funding and directives from the minnesota department of health through the local health department supported local efforts to promote health equity, as did funding for three hia’s over a period of 4 years. at the same time, with encouragement from the u.s. epa, the city of duluth’s brownfields redevelopment programs increasingly focused on public health outcomes. the robust network of community and government groups fostered by these activities increasingly integrated health equity considerations throughout their work, notably in the area of transportation planning. promoting health equity through the built environment in mn korfmacher 9 despite this highly evolved ecosystem for considering health in a wide range of decisions, these efforts remain decentralized and vulnerable to loss of staff and technical capacity developed through past experience. the city of duluth considered adopting a health in all policies resolution, but it did not decide to do so. stakeholders reported concerns that adopting an hiap resolution might result in a “checklist” mentality, rather than meaningful consideration of systems changes. however, these ideas have clearly been taken up by the city leadership, as evidenced by mayor larson’s declaration that health and fairness would be key goals in duluth’s 2016 comprehensive planning process (larson, 2016) . promoting health equity through the built environment in mn korfmacher 10 date external resource local initiative 2005 minnesota governor pawlenty establishes voluntary “fit city” program duluth recognized as a “governor’s fit city, forms advisory committee 2007 2008 blue cross blue shield’s center for prevention distributes copies of unnatural causes video to local health departments fit city duluth obtains non-profit status as an organization st. louis county health department staff view unnatural causes video fit city members attend cdc conference 2009 cdc hosts “community approaches to obesity prevention” conference fit city duluth forms 10-person team to attend cdc conference st. louis county health dept. initiates of safe and walkable hillside coalition 2010 health duluth area coalition begins meeting 2011 mdh supports first hia in duluth (redesign of 6th avenue) st. louis county health status report issued; credits “unnatural causes” stakeholders participate in hia 2013 mdh supports second hia (gary-new duluth small area plan) stakeholders participate in hia to support small area plan for gary-new duluth 2014 mdh supports third hia (lincoln park small area plan) u.s. epa awards brownfield planning grant for irving fairmount bcbs center for prevention grant to hdac for fair food access work hia integrated into small area plan process for lincoln park city pilots brownfields health indicator tool in lincoln park st. louis river corridor initiative begins hdac engages lincoln park residents in fair food access work 2015 “grocery bus” begins running 2016 bcbs center for prevention grant to hdac for health equity work mayor sets “health and fairness” as goals of city’s comprehensive plan hdac initiates health equity collaborative 2000-2017 u.s. epa emphasizes public health as goal of brownfields redevelopment city receives over $17 million in brownfield grants; leverages over $100 million table 1. external resources and evolution of duluth’s local health equity initiatives* *this table highlights several types of external resources (financial, technical, or human) supporting health equity initiatives in duluth, but is not comprehensive. promoting health equity through the built environment in mn korfmacher 11 what can we learn from duluth about supporting evolution of hiap in other communities? “there has been a momentous but intentional aligning of the stars around this work” (heidi timm-bijold, city of duluth business resource manager, personal communication, 2016) the experience of duluth, mn offers insight into how one small city embraced and implemented the idea of enhancing health equity in the built environment through policy change. by creating informal yet robust networks for collaboration, stakeholders in duluth were able to leverage varied community, local, state, and national resources to promote a healthier, more equitable built environment through a wide range of systems and policy changes. duluth’s experience endorses the idea that local crosssection collaboration around hia can evolve into pervasive and powerful changes in systems to promote health equity. at the same time, the healthy duluth efforts also may be viewed as a case of how national, state, and non-governmental efforts to promote community innovation can make an impact at the local level. duluth’s efforts benefitted from staff support, funding, and technical resources from external private, non-profit, and government groups. indeed, several national programs that supported particular initiatives point to duluth as a successful model of how their ideas, programs, and resources that can be replicated in other communities. looking closely at duluth’s efforts over time shows that the whole story is more complex. there was an ongoing exchange of ideas, initiatives, and opportunities between local stakeholders and external resources. local stakeholders took advantage of state and national programs, expertise, and funding to build a strong network of diverse organizations working to promote health equity through changes in the built environment. stakeholders in duluth attributed the sustained growth of these health equity efforts to the community’s size, progressive nature, and commitment to collaboration. these characteristics allowed them to develop relationships across and collaborate between organizations with minimal formal structures. these relationships also in turn helped them identify, successfully access, and sustain resources from external agencies. these outside resources were particularly helpful during the initial development of duluth’s initiatives. however, continued support – for example, through the mdh state health improvement program, center for prevention funding of health equity projects, and federal agencies’ (particularly u.s. epa and department of transportation) integration of health equity goals in their funding, policies, and programs – has been essential to sustaining these efforts. this version of the story suggests that duluth’s evolution toward health in all policies may not be replicable in other communities that lack the ability to initially access resources, collaborate, and build local capacity. however, it does suggest strategies for regional and national actors to make such local initiatives possible in a broader range of communities: • provide opportunities for locals to learn. duluth stakeholders reported numerous examples of learning from others’ initiatives and ideas about how to promote health equity. even the simple act of distributing the unnatural causes video affected locals’ thinking. the opportunity to convene a team and travel to the building healthy communities conference to learn from national – and particularly other local – leaders was even more promoting health equity through the built environment in mn korfmacher 12 impactful. bringing such opportunities to communities that are not actively seeking hiap assistance may help seed new local initiatives. • make collaboration an expectation. by its nature, hiap requires crosssector collaboration. however, many organizations inadvertently discourage collaboration, because it can take time away from achieving direct institutional or professional goals. building collaboration into job descriptions, performance reviews, and reporting can counteract these barriers. external institutions can encourage this. for example, the state health improvement program’s guidance to local health departments to foster local partnerships had a tremendous impact on the human resources available to health equity efforts in duluth. • build health equity into review criteria for funding. an increasing number of funders, including both foundations and government agencies (e.g. the u.s. epa and u.s. department of transportation) include public health promotion among the criteria for evaluating proposals for non-health projects. these cues were acted upon by duluth’s brownfield redevelopment and transportation agencies, significantly advancing the local focus on health in externally funded plans and projects. providing incentives and guidance on how to address health in a non-health funding opportunities could significantly boost local efforts. • support sustained convening. it is particularly difficult for local groups to sustain funding for convening collaborative efforts. collaboration by definition takes a long time, has uncertain outcomes, and often results in unexpected new directions. as the duluth case reaffirms, sustained convening over many years is necessary to build local capacity, leverage additional funding, bring in new partners, and adapt action agendas over time. modest longterm support for local conveners can have a multiplier effect on local initiatives’ evolution toward hiap. • be patient. collaboration takes a long time, but making impacts on local decision processes takes longer. evidence of policy, environmental, or health outcomes – takes longer still. as well, local systems changes can seldom be attributed to a single effort. duluth’s experience shows how stakeholders can “help the stars align” toward health equity-promoting decisions, but that the process may be indirect, diffuse, and non-continuous. funders should be mindful of this timeline as they set expectations for outcomes, encourage documentation of process changes, and integrate intermediate metrics like increased capacity into evaluations. with increasing recognition that environmental factors contribute to the health inequities experienced by vulnerable populations, moving toward health in all policies at the local level is critical. strategically deployed human, financial, and technical resources from external sources can fertilize local cross-sector collaborations and build local capacity for hiap. duluth’s experience shows that such local initiatives have tremendous potential to bridge the silos between environmental and public health and address the root causes of environmental injustices. promoting health equity through the built 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(2020, january 01). kingsbury bay-grassy point habitat restoration: a health impact assessment [powerpoint slides]. the united states environmental protection agency’s center for computational toxicology and exposure. https://doi.org/10.23645/ epacomptox.11740134.v1 corresponding author katrina smith korfmacher, phd department of environmental medicine university of rochester box ehsc 601 elmwood avenue rochester, ny 14642 katrina_korfmacher@urmc.rochester.edu chia staff: editor-in-chief cynthia stone, drph, rn, professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, ba, richard m. fairbanks school of public health, indiana university-purdue university indianapolis chronicles of health impact assessment vol. 5 issue 1 (2020) doi: 10.18060/24034 © 2020 author(s): korfmacher, k. this work is licensed under a creative commons attribution 4.0 international license acknowledgement: this paper builds on a case study included in (korfmacher, 2019). this work was supported in part by the national institute of environmental health sciences through grant p30 es001247. research protocols were deemed exempt by the university of rochester’s research subjects review board. the author greatly appreciates the information provided by numerous stakeholders involved in the healthy duluth efforts. the content of this manuscript is solely the responsibility of the author and does not necessarily represent the views of the national institutes of health, interviewees, or organizations featured in the case study. http://www.pewtrusts.org/~/media/assets/2011/06/20/6thavenueeastfinalreport.pdf?la=en http://www.pewtrusts.org/~/media/assets/2011/06/20/6thavenueeastfinalreport.pdf?la=en https://www.epa.gov/brownfields/brownfield-overview-and-definition https://www.epa.gov/brownfields/brownfield-overview-and-definition http://www.unnaturalcauses.org/ https://doi.org/10.23645/epacomptox.11740134.v1 https://doi.org/10.23645/epacomptox.11740134.v1 mailto:katrina_korfmacher%40urmc.rochester.edu%20?subject= september 2023 volume 8 issue 1 maxim gakh, jd, mph; courtney coughenour, phd; emily strickler, mph; megan r. mcdonough, ms, rd; priyambda kumra; jennifer r. pharr, phd; timothy bungum, drph; nicole bungum, ms, ches; mindy meacham enhancing health through built environment improvement: a southern nevada health impact assessment case study abstract background: health impact assessment (hia) is a public health tool to evaluate how choices made outside the health sector can affect health. hias are utilized in transportation, housing, planning, and other fields. since the built environment can impact community health outcomes, including physical activity rates, injuries, and overweight and obesity, an interdisciplinary team composed of public health, planning, transportation, and land use professionals conducted an hia in las vegas, nevada. methods: the hia consisted of (1) screening, (2) scoping, (3) assessment, (4) recommendations, (5) reporting, and (6) monitoring and evaluation. it examined proposed physical improvements to a 0.66 mile stretch of a major arterial roadway in the city of las vegas where nearby residents experience many health inequities. collection and analysis of land use and survey data, analysis of secondary data, and literature reviews were completed to predict potential health effects produced by built environment changes. stakeholder feedback informed each hia step. results: the hia generated recommendations to improve physical activity, reduce pedestrian and bicyclist injury rates, and decrease obesity and overweight prevalence, by presenting “good,” “better,” and “best” physical infrastructure improvements. the process and resulting recommendations enhanced collaboration among health and nonhealth sectors. conclusions: data and analysis revealed that the proposed changes could improve walkability and bikeability and reduce pedestrian and bicyclist injury. by encouraging active transportation through bicycling and walking, the plan could, over time, contribute to reduced overweight and obesity. the hia facilitated inter-sector cross collaboration and the integration of health into future decision-making. enhancing health through built environment improvement 2 introduction connections between land use and health are well documented. one prominent area of research is the use of urban planning and infrastructure changes to increase rates of active transportation within neighborhoods. enhancing neighborhood walkability and bikeability can increase rates of physical activity through exercise (physical activity for physical fitness) and active transport (physical activity for transportation) (grasser et al., 2013; prins et al., 2016; sallis et al., 2016). the relationship between regular physical activity and human health is likewise well documented (centers for disease control and prevention [cdc], 2022b). benefits of physical activity include improved cognition and thinking, weight management, reduced chronic disease risk, strengthened muscles and bones, and improved quality of life (cdc, 2020b). unfortunately, only about half of u.s. adults engage in the recommended amounts of aerobic physical activity (cdc, 2020a). and about $117 billion are spent annually on healthcare costs associated with physical inactivity (cdc, 2020b). prioritizing physical activity in a community can have economic, safety, and workforce benefits (cdc, 2022a). walkable communities can enhance safety for all users (cdc, 2020b; reynolds et al., 2009). some of the most common measures of neighborhood walkability include net residential density, street connectivity, land use mix, and the proportion of retail land-area to retailbuilding-floor area (also known as retail floor area ratio) (adams et al., 2015; frank et al., 2010; grasser et al., 2013; sallis et al., 2016; wei et al., 2016). in addition, availability of sidewalks, overall aesthetics, and users’ perceptions of these features, including safety, are also related to walking and rates of physical activity (barnett et al., 2017). similarly, bikeable communities are associated with increased rates of bicycling (winters et al., 2016), and certain types of infrastructure improve safety (reynolds et al., 2009; digioia et al., 2017; pucher & buehler, 2016). it must be acknowledged that active transport may increase crash risk in terms of absolute numbers, as “[t]he more a person travels, the more they are exposed to the potential risk of a traffic-related injury or death” (merlin et al., 2020). bicyclists and pedestrians are vulnerable road users and make up a disproportionate share of crashes (the league of american bicyclists, 2018). there were 6,516 pedestrian fatalities and 938 bicyclist fatalities in the u.s. in 2020 (national center for statistics and analysis [ncsa], 2022). pedestrian fatalities from motor vehicle crashes increased by 46% between 2011 and 2020 while bicyclist fatalities increased by 38% in the same period (national highway traffic safety administration, n.d.). improving pedestrian and bicyclist infrastructure can substantially reduce these fatalities (schneider et al., 2017; united states department of transportation, 2014). although land use and health are linked, integrating health into planning and design decisions remains a challenge (nieuwenhuijsen et al., 2020). health impact assessment (hia) is a tool that can help identify and inform health implications of choices, plans, and projects that traditionally do not consider health (national research council [nrc], 2011; cdc, 2016; the pew charitable trusts, n.d.). regular use of hias could gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 3 lead to more consistent integration of health into decisions made by other sectors and better prioritization of health equity (morley et al., 2016). land use decisions are especially conducive to hias because hias can enhance collaboration between the health and planning sectors, improve land use plans, and catalyze more systematic assessments of health in land use choices (wernham, 2011). an hia on proposed built environment improvements along a 0.66 mile stretch of a major arterial roadway was conducted in the city of las vegas. residents near the stretch exhibited various health disparities. the primary aim of the hia was to advance the integration of health and equity into regional land use decisions through analysis and collaboration. this paper provides an adapted report of the hia and its findings in the context of hia and health in all policies work. methods this hia consisted of all six steps: (1) screening, (2) scoping, (3) assessment, (4) recommendations, (5) reporting, and (6) monitoring and evaluation, along with stakeholder engagement throughout (nrc, 2011; the pew charitable trusts, 2014). a research team (rt) consisting of university of nevada, las vegas school of public health faculty and students partnered with a working group (wg) representing the southern nevada health district (snhd); city of las vegas – department of public works (clv dpw); nevada minority health & equity coalition; the regional transportation commission of southern nevada (rtc); and the nevada institute for children’s research & policy to complete the hia. the hia was supported by a racial and ethnic approaches to community health grant from the cdc, which was awarded to the snhd. in screening meetings, the rt and wg identified land improvement projects that were in the planning stage that could benefit from the use of hia. screening discussions of the rt and wg also generated selection criteria for a proposed project. the project had to (1) be within a las vegas zip code with residents who experience health disparities, (2) be in the appropriate phase of planning so that recommendations could be considered, (3) contain built environment features studied in literature, (4) potentially impact the health determinants and outcomes of interest (5) potentially impact connectivity to schools, parks, and transit, (6) highlight existing processes at clv dpw into which health considerations could be integrated, (7) be executable with available time and resources, and (8) serve as a case study to build a project scoping tool (pst) to bring health concerns into future land use decisions. the rt and wg chose the charleston medical district improvement plan because it met all of these selection criteria. this project was a 0.66 mile stretch of a major east-west arterial road in the medical district within the city of las vegas. this area is home to numerous medical facilities, including a major public hospital, a dental school, medical school facilities, and a mix of commercial, retail, and other land uses. it also has a relatively high prevalence of pedestrian activity. the proposed improvement plan at the time included adding bicycle lanes, enhanced crosswalks, pedestrian activated beacons, signage, trees, and landscaping; narrowing vehicular travel enhancing health through built environment improvement 4 lanes; reducing speed limits; and acquiring rights of way to improve and widen existing sidewalks. the hia examined demographic and health-related data from adjacent census tracts. the residents of these adjacent tracts are at higher risk for negative health outcomes compared to many other parts of southern nevada (healthy southern nevada, 2022). the activities associated with each of the six hia steps are summarized in table 1. gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 5 screening the rt and wg met to determine selection criteria and choose an appropriate project from numerous improvement plans that were in planning stages. scoping the rt and wg selected hia goals and objectives and key health concerns to examine. the hia aimed to reveal the baseline conditions of the area and then determine potential impacts if certain recommendations were implemented. five key focus areas identified were: 1) health equity, 2) walkability, 3) bikeability, 4) pedestrian and bicyclist injury, and 5) overweight and obesity. the rt and wg crafted research questions to guide assessment of direct, intermediate, and downstream health outcomes in these focus areas. see figure 1 for the pathway diagram linking the proposed decisions to health outcomes. assessment the assessment was a three-step process: 1. examine baseline conditions of the census tracts immediately adjacent to the project corridor based on the key focus areas. a. health equity & obesity/overweight: secondary data from the american community survey (acs) and the city health dashboard were used to examine socio-demographic, economic, and health factors, including median household income, adult physical inactivity, obesity, and health insurance status (united states census bureau [uscb], n.d.; city health dashboard, 2019). b. walkability & walking: walkability was assessed through primary data on five segments of the project corridor using the 54-item microscale audit of pedestrian streetscapes (maps), abbreviated version (cain et al., 2017). walking rates were assessed using secondary data from the clv dpw, rtc, and the acs commuting database (uscb, 2017). c. bikeability & bicycling: bikeability was assessed by evaluating bicycle infrastructure using the bicycle level of traffic stress secondary data metric (alta planning and design, 2017) and through primary data using the active neighborhood checklist (active neighborhood checklist, 2011). bicycling rates were assessed using secondary data: the acs commuting database (uscb, 2017) and rtc information on the number of bicycles brought onto buses that traverse the project corridor. d. pedestrian & bicyclist injury: injury rates were determined utilizing secondary motor vehicle crash data from the nevada department of transportation. 2. conduct an intercept survey of pedestrians in the area during varying times of the day over three weeks in june and july 2019. primary data obtained included demographics, reasons users were in the area, primary modes of transportation, perceptions of safety and available infrastructure, and preferences regarding pedestrian and bicycle infrastructure. table 1. summary of health impact assessment steps enhancing health through built environment improvement 6 3. assess project impacts through a series of literature reviews. the rt searched google scholar for relevant systematic reviews and meta-analyses to examine how the proposed built environment features relate to physical activity and downstream health indicators like overweight, obesity, and injury. sample search terms included walkability, pedestrian, sidewalk, bikeability, bicycle, bicycling, bike lane, speed, injury, traffic, health, built environment, obesity, overweight, and bmi. recommendations the rt used findings from the assessment, wg suggestions, and feedback from a stakeholder input session to develop recommendations to improve the project corridor. the stakeholder session was attended by the rt, wg, and representatives from organizations like the county school district, health-focused community organizations, academia, and the state public health department. it included discussion of the hia’s screening, scoping, and assessment; how to encourage bicycling and walking in the area; community members’ involvement in land use decisions; and better connections between the land use and health sectors. final recommendations were organized into “good,” “better,” and “best” categories to maximize health outcomes in each focus area but also enhance flexibility and feasibility for project partners. reporting a final report summarizing the hia and key recommendations was made available to the wg. wg members were asked to share the final report with their partners and networks. the rt also presented the hia’s findings to regional, health-focused community coalitions and to transportation-focused community partners in spring 2019. monitoring & evaluation monitoring: to support continued monitoring of the project area, the rt developed a system of tracking spreadsheets to outline applicable indicators and provide relevant data sources. these spreadsheets were provided to wg partners. they could be used periodically to monitor land use modifications and changes to priority health behaviors and outcomes. as hia partners developed the pst, they also continued to track land use changes and health indicators in the area. evaluation: the rt completed a process evaluation through an anonymous survey of the wg and a facilitated face-to-face discussion between the rt and wg. the survey and discussion evaluated the execution of each step of the hia, the hia’s potential to improve community and cross-sector collaboration, and the opportunities for stakeholders to engage in the hia process. table 1. summary of health impact assessment steps (continued) gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 7 figure 1. charleston medical district pedestrian improvement plan pathway diagram linking proposed decisions to health outcomes results baseline conditions after analyzing available secondary data, the rt found that project area residents were more racially and ethnically diverse than the overall average for the city of las vegas. some adjacent census tracts had lower high school graduation rates, higher rates of unemployment, poverty, and uninsured status, and lower median incomes (uscb, n.d.; city health dashboard, 2019). some census tracts likewise had higher rates of obesity and chronic health conditions like diabetes and high blood pressure compared to city of las vegas and national averages (uscb, n.d.; city health dashboard, 2019). area residents also had higher rates of high-risk health behaviors, including smoking and physical inactivity (city health dashboard, 2019). average life expectancy in all census tracts in the project area was well below that of city and national averages (city health dashboard, 2019). see table 2 for demographic and health-related baseline characteristics for the project area’s adjacent census tracts. enhancing health through built environment improvement 8 table 2. demographic and health-related baseline information for residents in census tracts adjacent to charleston corridor, with comparisons to the city of las vegas and the 500-city average census tract 2.03 value (90% confidence interval) census tract 3.01 value (90% confidence interval) census tract 2.04 value (90% confidence interval) city of las vegas value (90% confidence interval) 500city average social and economic factors median age (years)* 35.3 (30.7-39.9) 37.6 (32.1-43.1) 45.2 (43.6-46.8) 37.4 (37.1-37.7) education (population 25 years and over) high school graduate or higher* 76.1% (70.3-81.9) 73.9% (68.5-79.3) 84.9% (75.4-94.4) 84% (83.5-84.5) bachelor’s degree or higher* 18.4% (11.8-25) 5.4% (2.5-8.3) 36.7% (24.7-48.7) 23.2 (22.6-23.8) race & ethnicity white* 52.2% (40.7-63.7) 32.1% (24.2-40.0) 69.7% (56.4-83.0) 62.7% (62.1-63.3) black or african american* 17.3% (11.1-23.5) 46.4% (39.9-52.9) 3.7% (0.8-6.6) 12.2% (11.8-12.6) american indian, alaskan native* 0.5% (0-1.1) 0.2% (0-0.6) 0.2% (0-0.7) 0.7% (0.6-0.8) asian* 9.3% (4.4-14.2) 2.6% (1.0-4.2) 18.8% (6.6-31.0) 6.7% (6.4-7.0) native hawaiian, other pacific islander* 0.6% (0-1.5) 0.3% (0-0.9) 0.7% (0-2.0) 0.7% (0.6-0.8) some other race* 16.0% (7.0-25.0) 16.0% (9.5-22.5) 3.4% (0-6.8) 12.3% (11.7-12.9) two or more races* 4.2% (1.9-6.5) 2.4% (0.4-4.4) 3.5% (0.5-6.5) 4.8% (4.5-5.1) hispanic* 40.4% (33.4-47.4) 39.9% (33.5-46.3) 23.5% (10.3-36.7) 32.7% (32.2-33.2) economic factors children in poverty 54.5% (37.8-71.3) 47.6% (32.5-62.6) 12.5% (0-32.7) 23.7% 21.4% households with excessive housing cost 53% (42.7-63.2) 43% (34.1-52) 34.1% (19.0-42.9) 37.4% 36.3% gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 9 economic factors median household income* $32,476 (24,069-40,883) $30,000 (23,586-36,414) $66,111 (57,137-75,085) $53,159 (52,282-54,036) unemployment 16.4% (8.9-23.8) 13.4% (6.8-20.0) 3.8% (0.4-7.1) 8.8% 6.9% uninsured 27.8% (20.4-35.3) 31.0% (24.9-37.1) 27.5% (16.0-38.9) 18.1% 12.4% below 100% of the federal poverty level* 40.9% (30.5-51.3) 41.0% (32.5-49.5) 11.2% (0-23.2) 16.2% (15.6-16.8) food insecurity+ 26.7% 27.9% 7.3% no vehicle access+ 23.4% 31.4% 0.0% physical environment average daily concentration of air particulate matter (pm 2.5) 7.7/m3 7.7/m3 7.7/m3 6.9/m3 8.8/m3 walkability index (2019) 37.4 55 39.3 40.6 41.3 limited access to healthy foods 96.7% (96.3-97.2) 36.5% (35.0-37.9) 47.0% (44.6-49.5) 57.2% 65.9% health behaviors current adult smoking 25.8% (23.9-27.7) 29.5% (27.9-31.1) 15.0% (13.0-17.0) 20.5% 17.2% adult physical inactivity 37.3% (35.5-39.1) 42.9% (41.5-44.3) 25.9% (23.8-28.0) 29.9% 26.2% health outcomes adults with high blood pressure 37.8% (37.1-38.5) 45.8% (45.1-46.5) 37.8% (36.7-38.9) 31.8% 29.6% adults with diabetes 15.0% (14.4-15.6) 19.9% (19.2-20.6) 12.2% (11.4-13.0) 11.2% 10.0% average life expectancy at birth in 2015 (years) 71.2 (68.7-73.7) 69.3 (66.8-71.8) 65.1 (59.4-70.8) 77.4 79.1 adult obesity 33.5% (32.7-34.3) 41.0% (40.3-41.7) 24.0% (23.1-24.9) 28.2% 29.7% enhancing health through built environment improvement 10 definitions: • children in poverty – children living in households ≤100% of the federal poverty level • housing cost, excessive – households where ≥30% of household income is spent on housing costs • unemployment – population aged ≥16 years that is unemployed but seeking work • uninsured – current lack of health insurance among people aged 0-64 years • air pollution-particulate matter – average daily concentration of fine particulate matter (pm2.5) per cubic meter • walkability – neighborhood amenities accessible by walking as calculated by walk score® • limited access to healthy foods – population living more than ½ mile from the nearest supermarket, supercenter, or large grocery store • adult physical inactivity – no leisure-time physical activity in past month among adults aged ≥18 years • food insecurity – estimated percentage of population that experienced food insecurity at some point during the year • no vehicle access – estimated percentage of households without a vehicle the five segments assessed for walkability using the maps abbreviated audit (primary data collection) (cain et al., 2017) earned scores between 1932, indicating the area was “somewhat walkable.” the main project area received the highest walkability score of all the segments assessed, likely because it had a high land use mix, including many retail and healthcare destinations. the audit revealed that the area needed improvement in the perception of safety and sidewalk width to accommodate multiple pedestrians and/or mobility device users. data on the rate of walking to work in the census tracts immediately surrounding the project was not available. however, a recent equity analysis indicated that the area just north of the project falls into parts of the las vegas valley experiencing the highest inequity. the area just south falls into parts experiencing the second highest inequity. inequity was measured, in part, based on (1) household percentages with no car for daily use, (2) household income below 200% of the federal poverty level, (3) non-white population, and (4) under 18 and over 64 years population (rtc, 2017). these characteristics are associated with higher rates of walking to work (mckenzie, 2014). pedestrian counts obtained by clv dpw at two intersections within the project area during peak times (7am-8am and 5pm-6pm) on multiple dates between 2002 and 2015 indicated a relatively high presence of pedestrians in this area. this walking data was compared with national and regional walking data. nationally, 2.7% of all work trips are made by walking (uscb, 2017). in las vegas overall, 1.8% of residents report walking to work, which is slightly higher than the entirety of clark county (1.7%) (rtc, 2017). the bikeability assessment conducted by the rt found no physical separations or painted markings for designated bike paths or bike lanes and no signage to alert drivers to share the roadway. according to secondary data, bicycling in the area would be uncomfortable for most, meaning only avid bicyclists, often termed the “strong and fearless,” would voluntarily cycle along this stretch (geller 2009; alta planning and design, 2017). gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 11 bike lanes crossed the segment only once through an intersecting street and the nearest bike routes were over a mile away. bicycling rates for the project-adjacent census tracts were not available. however, because of the project’s proximity to parts of the las vegas valley with high inequity (rtc, 2017), demographic factors indicated that nearby residents would be more likely to bicycle to work than others in the region. rtc secondary data (2017) indicated that between january 2015 and february 2019, about 3,514 bicycles were loaded onto the public bus route running eastwest along charleston boulevard in and beyond the project area. this bicycling data was also considered in light of other secondary national and local biking data. only 0.6% of all work trips are made by bicycle nationally (uscb, 2020) and in las vegas, about 0.5% of residents bicycle to work, which is slightly higher than the 0.4% in clark county (rtc, 2017). nevada department of transportation (ndot) secondary crash data indicated that 3.7% of motor vehicle crashes between 2015 and 2017 along this segment involved a pedestrian (ndot, n.d.), which is well above the national average of 1.1% (campbell et al., 2016). of the 11 pedestrian crashes in the corridor, seven involved vehicles turning right, suggesting increased hazards to pedestrians in the project area (ndot, n.d.). there were three bicycle crashes along this segment between 2015 and 2017 (ndot, n.d.). all three crashes were classified as “injuries” or “injuries reported by the person” and two of them involved a driver turning right at an intersection (ndot, n.d.). community input an intercept survey involved primary data collection and was completed by 81 participants. it was developed by the rt with wg guidance and implemented by rt partners. surveyors approached individuals who were outside and were walking, biking, standing, or otherwise in the project area. people were approached to participate at various points in time (7:30 am – 8 pm) and on multiple days of the week (mondays-fridays) over a three-week period in june and july 2019. individuals who expressed interest in participating received research study information and a survey. surveyors collected completed information. if participants requested help, surveyors assisted by orally reading questions and/or recording answers. this survey was deemed exempt by the university of nevada, las vegas institutional review board. the rt then examined the collected data. the highest proportion of participants resided in surrounding zip codes (89101, 89102, and 89106), which are some of the zip codes experiencing the greatest health inequities in the region (“health equity index,” 2022). most participants self-identified as white (43%), followed by african american (24%), and hispanic or latino (22%). over half reported using automobiles as their primary mode of transportation (53%), followed by public transportation (36%), and walking (8%). about a quarter reported that they walk in the area most days of the week and over 40% reported they walk less than once per month. at the time of the intercept survey, participants were walking to get to work (27%), seek healthcare services (26%), and connect to public transportation (18%). enhancing health through built environment improvement 12 only about 9% of survey participants said they were walking there that day because they lived in the area, which is adjacent to census tracts experiencing health inequities. this may potentially limit the conclusions that can be drawn from the survey about nearby residents. however, proposed project changes would impact all area users, including residents. in addition, other survey participants may also be members of communities experiencing inequities. for example, about 26% of respondents said they were in the area for medical reasons. some of them may have been in the project area to visit the county’s public hospital. this hospital sees 10% uninsured, 18% medicare, 48% medicaid, and 5% government insured patients and provides almost $41 million of uncompensated care annually (american hospital association, 2023). about 74% of participants in the intercept survey believed that cars traveled too fast in the area to feel safe walking or bicycling. only 22% reported that existing bicycling infrastructure was sufficient for safety. participants identified the top three area safety concerns as: (1) vehicle speeds (59%), (2) distracted driving (58%), and (3) potential for crime (48%). when shown detailed pictures of bicycle and sidewalk infrastructure and asked which they would most likely use to walk and bicycle, participants most commonly chose bicycle lanes raised higher than street level and lower than sidewalk level (43%; n=74) and 10-foot-wide sidewalks, with 8 feet dedicated to the sidewalk and 2 feet to a landscape buffer (43%; n=75). table 3 presents detailed survey results. main form of transit used (n=73) automobile 53% public transit 36% walking 8% wheelchair/scooter 1% other 1% how often you walk in the area (n=81) less than once per month 41% 1-3 times per week 21% 1-3 times per month 12% most days of the week 26% reasons for walking in the area day of the survey (n=79) i go to school in this area 10% i live in this area 9% i work in this area 27% i'm connecting to another bus route 18% other: 37% other/medical 26% other/errands 2% other/roaming 3% table 3. pedestrian intercept survey results gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 13 road design options "i feel" cars are too fast for: pedestrians (n=79) bicyclists (n=79) strongly agree 37% 44% agree 37% 29% i don't know 5% 6% disagree 14% 11% strongly disagree 8% 9% i feel safe from traffic while: walking (n=78) bicycling (n=80) strongly agree 13% 3% agree 24% 11% i don't know 9% 43% disagree 33% 20% strongly disagree 21% 24% i feel enough infrastructure exists for safety in: walking (n=80) bicycling (n=78) strongly agree 14% 10% agree 36% 12% i don't know 3% 17% disagree 21% 23% strongly disagree 26% 38% safety concerns (n=81) speed of cars/trucks 59% motorists 58% distracted driving 58% potential for crime 48% too many cars/trucks 35% narrow sidewalks 33% conflicts or collision with cars/trucks 28% not enough lighting 25% not enough other people out walking 20% poles/light posts in the sidewalk 20% overgrown bushes/vegetations 14% i have no safety concerns 6% other “other” written-in concerns: crosswalks too far apart, older adult population usability, not enough shade/trees 11% enhancing health through built environment improvement 14 project impacts available data and literature supported the prediction that walkability and associated walking behaviors would likely increase under the plan, especially for populations experiencing inequities. literature suggests that objectively measured built environment features, such as street connectivity, diversity of land uses, and population and employment density, are consistently associated with walking and neighborhood walkability. in addition, perceptions of the built environment (e.g., perceived sidewalk availability, safety, and aesthetics) correlated more strongly with physical activity than objective measures (barnett et al., 2017). objective measures of walkability include land use mix and street connectivity (khanal & mateo-babiano, 2016), gross population density (grasser et al., 2013), walk score (hall & ram, 2018; walk score, 2019), and design and diversity (ewing & cervero, 2010). the area contained existing features that support walkability (e.g., access to services and destinations, public transit, high land use mix, and jobs/ housing balance). the proposed changes, including improved 10-foot sidewalks, landscaping, crosswalks, and slower posted travel speed limits, could improve perceived walkability. furthermore, because populations experiencing health inequities walk more – particularly as transit – walking among the population residing adjacent to the project area would be even more likely to increase. available data and literature also supported the projection that the plan could enhance bikeability and increase bicycling rates. bikeability and bicycling rates are closely related to: (1) availability of bicycle infrastructure, including separating bicyclists and motorists (pucher & buehler, 2008; pucher et al., 2010), (2) higher density, more connectivity, and greater land use mix (saelens et al., 2003), and (3) enforcement of traffic laws to reinforce policies that favor bicycle travel over motor vehicle travel (pucher et al., 2010). the amount of infrastructure necessary to increase bicycling rates is not fully understood (buehler et al., 2012); however, one model suggests that a onemile increase in bicycle lanes per 100,000 people is linked to about a 0.07% increase in bicycle commuting (nelson & allen, 1997); another suggests that every additional urban mile of bicycle lanes per square mile generates a 1% bicycling increase (dill & carr, 2003). since the original plan focused on separating vehicles and bicyclists, it could enhance the level of comfort for bicyclists. increased bicycle infrastructure and connectivity would likely yield increased bicycle commuting. given the uncertainty about the exact connection between bicycle infrastructure and bicycling rates and the fact that the project would create less than 1 mile of new bicycle lanes, the rt expected changes to bicycling rates under the plan to be small. the rt also concluded that there would be an increased likelihood of bicycling in this area compared to other parts of las vegas and clark county because of the high bicycle counts data, area demographics, and survey participants’ indications of insufficient bicycling infrastructure in the area. over time, adding more infrastructure could increase bicycle commuting rates, particularly as connectivity grows. given that changes in walkability gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 15 and bikeability predicted increases in both walking and bicycling, the rt likewise predicted reductions in the downstream health effects of injury and overweight. several infrastructure changes show promise in the literature for reducing pedestrian and bicyclist injury. interventions such as reduced motor-vehicle speeds (cairn et al., 2014), improved traffic or pedestrian signals, separation of pedestrians from traffic with fencing or refuge islands, and increased roadway lighting (retting et al., 2003) are linked to pedestrian crash reductions. a meta-analysis by bunn and colleagues (2003) found a pooled rate ratio of 0.89 for pedestrian injury with use of traffic-calming measures. literature findings specifically for bicycle injury reduction were less clear. it is possible that increasing the numbers of bicyclists on the road could likewise increase the probability of bicycle versus motor-vehicle crashes; however, there is a nonlinear relationship between number of bicyclists on the road and injury rates (kondo et al., 2018). this is likely due to the “safety in numbers” phenomenon, in which more bicyclists on the road actually seems to offer protection from motorists, perhaps because it makes motorists more aware of bicyclists in general (kondo et al., 2018; prati et al., 2018). bicycle versus motor-vehicle crashes are more likely to occur at intersections or roundabouts, in areas of high vehicle speed, where there is insufficient lighting at night, in the presence of high traffic volumes, in the presence of obstacles (such as road signs), or where there are entrances/exits to the roadway, such as driveways, parking lots, or tunnel entrances (kondo et al., 2018; morrison et al., 2019; prati et al., 2018; reynolds et al., 2009). dedicated bike lanes are a common intervention to reduce bicycle crashes, but evidence that bike lanes alone reduce bicyclist injury is lacking (mulvaney et al., 2015). morrison et al. (2019) suggest that this is because bicycle lanes decrease risk of crashes at different rates depending on the type of bicycle lane and other roadway infrastructure. bicycle lanes appear to be most effective at reducing crashes where vehicle speeds are high, traffic lanes are narrow, and bus or tram routes are present (morrison et al., 2019). the best protection of bicyclists has been found with paved, bike-only tracks with a high degree of separation from the roadway, adequate lighting, and low-angled grades (reynolds et al., 2009). reducing vehicle speed limits and providing dedicated bike paths separated from traffic are ubiquitous recommendations in the literature for reducing risk of bicycle crashes (morrison et al., 2019; prati et al., 2018; reynolds et al., 2009). overall, the rt predicted that planrelated changes would likely reduce pedestrian injuries, but impacts on bicyclist injury were difficult to determine. bicycle crashes could increase under the plan with more bicyclists, but the addition of a bicycle lane and bicycle signage as well as decreased speed limits could also decrease bicycle injuries (and possibly crashes) compared to the existing infrastructure. pedestrian and bicyclist injury projections would likely disproportionately apply to populations experiencing health inequities, including those residing adjacent to the project, because such populations tend to walk and cycle at higher rates, particularly for utilitarian purposes. the rt also concluded that a healthier neighborhood built environment under enhancing health through built environment improvement 16 the recommended plan could contribute to reductions in overweight and obesity. it would likely be in a limited way, however, because overweight and obesity are extremely complex; due to the size of the project and the fact that persons residing near the project area were already overburdened by obesity and overweight, reductions may be harder to realize. research shows a strong link between walkability and obesity, as well as hypertension and type 2 diabetes outcomes; it also strongly supports a relationship between measures of urban sprawl and obesity outcomes (chandrabose et al., 2019). it appears that improved perception of walkability is most important (as opposed to objectively measured walkability) when it comes to improving health outcomes (barnett et al., 2017; chandrabose et al., 2019). despite the fact that walking only to proximate destinations may not be enough to reduce obesity (chandrabose et al., 2019), it could be that even improving residents’ perceptions of walkability in the area could contribute to overall increases in walking and therefore improved health outcomes. the literature connecting bicycling and overweight and obesity outcomes was also promising, but inconclusive. one study conducted in a low-income community found that adults who bicycled were less likely to be overweight or obese than the general population (noyes et al., 2014). others found associations between bicycling to work and reduced obesity risk (brown et al., 2013; wojan & hamrick, 2015). suminski et al. (2014) found that bicyclepromoting policies were associated with more bicycle infrastructure, a higher percentage of adults bicycling to work, and lower rates of overweight and obesity. to summarize, the plan was expected to increase walkability through wider sidewalks, enhanced landscaping, improved crosswalks, and decreased motor vehicle speed limits. such changes would build on the area’s existing features that favor walkability, including high residential and employment density, mixed land use, and public transit access. this, along with plans for enhanced bicycle infrastructure, could increase both walking and bicycling rates. thus, the project could also contribute to reductions in overweight and obesity, while simultaneously reducing risk of injury. recommendations & reporting the rt combined assessment findings, wg suggestions, and feedback from a stakeholder input session to determine the focus of recommendations, namely separation of vehicles in time and space from pedestrians and bicyclists, reduction of speed limits, traffic calming, improved pedestrian and bicyclist infrastructure, enhanced connectivity, improved visibility, and enhanced aesthetics – categories identified in the literature as relevant to bikeability and walkability (retting et al., 2003). recommendations were presented as “good,” “better,” and “best” to provide best-case scenario ideas for healthenhancing improvements, but also allow for flexibility given budgeting or other constraints. for example, to help separate vehicles from pedestrians, it was suggested that it would be “good” to retain the proposal to install and maintain 10-foot sidewalks; “better” to install and maintain 10-foot sidewalks plus add pedestrian islands at a proposed crosswalk and paint driveways to alert drivers to yield; and “best” to gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 17 survey respondents strongly agreed that because of the hia they had a better understanding of the hia tool and were more likely to recognize the link between built environment and health. a majority reported thinking that the hia would benefit the community. all respondents either “strongly agreed” or “agreed” that the hia (1) met its aims and objectives, (2) was beneficial to them and their organizations, and (3) the process valued their input during feedback discussions. most respondents also indicated that they were given adequate opportunity to provide hia comments and that the benefits of the hia outweighed the time associated with wg participation. survey results were mixed about whether hia recommendations would be considered during plan implementation. the rt and wg continued to refer to and discuss the hia and to track changes to land use and health indicators as it worked on the pst to aid with future land use decisions. discussion this hia focused on the charleston medical district improvement plan, which proposed modifications to the built environment. it relied on data on baseline conditions, pedestrian and bicyclist use and injury, built environment audits, an intercept survey, literature reviews, and stakeholder feedback. using this analysis, it was determined that implementation of the plan could help improve walkability and bikeability, reduce crashes involving pedestrians and bicyclists, and increase physical activity through active transport – especially among residents living adjacent to the project area. this hia produced evidence-informed alternatives to modify the plan to further improve health determinants and outcomes of interest. these recommendations were shared with project partners and install and maintain 10-foot sidewalks, add pedestrian islands at a proposed crosswalk, consolidate driveways, and add driveway pavement markings. to help add bicycle infrastructure, a “good” suggestion was to add ample bicycle parking; “better” to add ample bicycle parking near popular destinations and bicycle-specific traffic signals; and “best” to add ample bicycle parking near popular destinations, bicycle-specific traffic signals, and bicycle lockers closer to destinations. to reduce motor vehicle speeds, we suggested it would be “good” to retain the proposal to reduce posted speed limits to 35 miles per hour (mph) and reduce lane width to 11 feet; “better” to reduce it to 30 mph, reduce lanes to 11 feet, and add radar signs; and “best” to reduce it to 20 mph, reduce lanes to 11 feet, add radar signs, and approve future buildings that promote more pedestrian and bicyclist-oriented frontage. further examples of recommendations will be included in a separate manuscript describing a project scoping tool (pst) generated from this analysis (manuscript in progress). these and other detailed recommendations were included in the final hia report and shared with other partners (unlv, 2019). monitoring and evaluation during the in-person process evaluation discussion, wg members expressed that the hia helped them understand the “how” behind connecting health implications to planning decisions. one weakness the group noted during the evaluation discussion was the ability to quantify health impacts more, e.g., a specific type of bike lane reducing crashes by a specific percent. the wg process evaluation survey (n=11) yielded generally positive feedback. enhancing health through built environment improvement 18 stakeholders, and monitoring of plan implementation and health behaviors and outcomes continues. this hia provides a practical example of how to connect land use and public health in the context of a specific project. literature indicates that improving a community’s built environment is likely to encourage physical activity for that area’s population (carlson et al., 2019; cambra & moura, 2020; forsyth & krizek, 2010; stappers et al., 2018; wei et al., 2016). the focus on physical activity and its connection to chronic disease is a major avenue for collaborations between the health and planning sectors (frank et al., 2019). literature also indicates that land use choices impact pedestrian and bicyclist crashes and injuries (cairns et al., 2014; prati et al., 2018). however, hias are often not used in transportation planning, which instead tends to focus on assessing monetary costs and associated project benefits (nieuwenhuijsen et al., 2020). while hias have promise to bridge this gap and enhance the planning process and its outcomes (wernham, 2011; nieuwenhuijsen et al., 2020), land use hias can be highly contextual (nieuwenhuijsen et al., 2020; waheed et al., 2018). this hia used existing data, literature, and feedback to generate actionable recommendations to promote walkability and bikeability, and thereby help address physical activity rates, injury, and obesity. through this process, the hia demonstrated how southern nevada could meld health and land use considerations and also fostered connections for future collaboration in this area. many wg participants indicated that the process helped make practical connections between these sectors. the outcomes of this hia were consistent with their potential, as articulated by wernham (2011): enhanced collaboration and improved plans. the hia outcomes were also consistent with findings that primary hia benefits include building cross-sector relationships and raising awareness of health issues among decision-makers (bourcier et al., 2015; dannenberg et al., 2008; sohn et al., 2018). a remaining challenge for hias is how to integrate health concerns into decisions of other sectors systematically (morly et al., 2016). this hia focused on one short stretch of a roadway in a large urban area. however, one goal of this hia at the outset was to build capacity and interest in integrating health concerns in transportation and land use decisions more broadly. there is growing interest in tools that can help shape how transportation projects are developed and prioritized and some indication that they may promote projects that support active transportation (chirstofa et al., 2020).this hia served as an entry point for continued collaboration among the partners to create a pst for future built environment project decisions to assess existing baseline conditions and built environment infrastructure in a geographic area through a process that necessitates less time and fewer resources than an hia. dannenberg’s and colleagues’(2008) suggestion to incorporate recommendations as a formal step between the assessment and reporting steps is now integral to an hia. the recommendations generated during this hia are central to the pst. this hia suggests that hia-generated recommendations may be used beyond one specific hia to inform subsequent projects and to integrate health gakh; coughenour; strickler; mcdonough; kumra; pharr; bungum; bungum; meacham 19 concerns into land use decisions more systematically. this hia also encountered a challenge experienced in other hias: how to prioritize health equity (morley et al., 2016). health equity was central to the structure of this hia, since it was part of a larger project focused on improving health in geographic areas where residents were experiencing health inequities – areas that included disproportionate numbers of african american and latinx residents. this resulted in a project that considered disparities in the hia assessment, conducted an intercept survey, and fostered close collaboration with stakeholders who engaged with these communities in other contexts. in the typology of integrating health equity into transportation-related hias, this hia focused on populations experiencing disparities, examined disparities, worked with stakeholders and incorporated stakeholder ideas, and aimed to build stakeholder capacity (cole et al., 2019). these efforts enriched the hia process and outcomes. however, with additional resources, deeper community engagement in this hia process may have enhanced the ability to integrate experiences and perspectives from the resident populations directly into the hia process and perhaps also into the pst. finally, this hia process, including conversations of the wg, the process evaluation, and the stakeholder feedback event, revealed broader considerations adjacent to this plan and other built environment projects. improving bikeability and walkability can be a slow and long-term process. this work requires initial investment and sustained efforts, which can make it difficult to catalyze these types of projects given competing interests for local infrastructure funding. sustained collaborations across mutually beneficial projects may effectuate true change. in addition, walkability is especially influenced by land use mix. questions of land use can involve stakeholders beyond governmental transportation and planning departments. this can pose additional challenges. collaborative efforts, such as the pst, which aim to bolster existing processes with practical and contained health-focused-analysis, may help address some of the sustainability and equity concerns articulated in the literature and echoed through this hia. as this hia demonstrates, hias can spark partnerships (chirstofa et al., 2020) and can be indispensable in establishing collaborations, articulating priorities, uncovering data, generating recommendations, and discovering existing decision-making processes that can serve as a foundation for sustained and equity-focused systems change work. moving beyond any one hia is also important to further systematic change and make progress in health in all policies efforts.   enhancing health through built environment improvement 20 references active neighborhood checklist. 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professor, richard m. fairbanks school of public health, indiana university-purdue university indianapolis journal manager angela evertsen, bs, richard m. fairbanks school of public health, indiana university-purdue university indianapolis acknowledgements this project was supported by grant #nu58dp6578, funded by the centers for disease control and prevention and awarded to the southern nevada health district. its contents are solely the responsibility of the authors and do not necessarily represent the official views of the centers for disease control and prevention or the department of health and human services. we also want to acknowledge and thank our project partners, whose contributions to the project are discussed in this piece. chronicles of health impact assessment vol. 8 issue 1 (2023) doi: 10.18060/26864 © 2023 author(s): gakh, m.; coughenour, c.; strickler, e.; mcdonough, m.; priyambda, k.; pharr, j.; bungum, t.; bungum, n.; meacham, m. this work is licensed under a creative commons attribution 4.0 international license mailto:maxim.gakh%40unlv.edu?subject= october 2019 volume 4 issue 1 the long road to the “all” of hiap erik calloway abstract: the objective of health in all policies (hiap) is straightforward: integrating health and equity considerations into policies across all sectors of government will transform systems and environments in ways that support healthier, more equitable outcomes. however, pursuing that objective is complex and achieving those outcomes takes time. this article examines three communities (minneapolis, mn, seattle, wa, and richmond, ca) which have been pursuing hiap long enough to achieve meaningful policy, systems, and environmental change. we identify when and how each community employed five key strategies for effectively adopting and implementing hiap. and we present policies each community has adopted with examples of outcomes these initiatives have achieved. the purpose of this assessment is to set realistic expectations for how long it may take to achieve hiap and to identify themes that could help other communities realize this level of progress more quickly and efficiently. based on our assessment of these communities, we conclude that it is not uncommon for it to take ten years or more to integrate health and equity into a substantial and coordinated set of policies across government agencies and departments. however, we also see that each step taken toward hiap makes subsequent steps easier. and as more policies include health and equity concerns, the entire system does become more effective at improving health and equity outcomes. finally, we show that that integrating health and equity across a range of plans and policies does shape decisions, lead to actual community transformation, and improve community health outcomes. 1 the long road to the “all” of hiap calloway 2 introduction what does it look like when a community has successfully integrated health and equity in all policies (hiap)? and how long does it take to get there? there are countless examples of communities across the country drafting plans, adopting policies, and building projects with the intention of improving community health and equity. there are also many lessons to learn about hiap by examining these communities; some show common ways to use planning or capital improvement projects as a vehicle for opening discussions about the importance of hiap; some show the type of early wins that hiap initiatives can lead to. however, the objective of hiap is much more ambitious than just adopting a policy or building a project which addresses the social determinants of health in one way or another. hiap is a collaborative approach to improving the health of a community by systematically incorporating health, sustainability, social justice and equity considerations into decisionmaking across departments, institutions, agencies and policy areas.¹ decision making processes in local government are complex and involve a wide range of sectors and stakeholders. communities can have hundreds or thousands of plans, policies and regulations on the books. moving any one plan or policy from start to finish can take time. local governments only have the capacity to work on so many plans, policies or projects at a time. given all of this, it should not be surprising that it takes time and effort to fully operationalize hiap and see it result in changes across any community’s decision-making processes, policies, built environment, and health outcomes. a few pioneering communities have been working to apply hiap long enough to have seen their efforts influence decision-making processes and result in a coordinated portfolio of policies across sectors. this article provides a brief overview of three such communities that are further along in their efforts to comprehensively integrate health and equity in all policies. by focusing on these communities, we can identify themes of successful implementation. we can see what it looks like to have health integrated across a range of policies in a coordinated way. because these communities have reported on some level of tracking, evaluation, or action, we can also show how their hiap perspectives have resulted in decisions that have shaped healthy and equitable community transformation in measurable ways. community review in this section, we present three case study communities: minneapolis, mn, seattle, wa, and richmond, ca (see table 1 for case study community profiles). these communities were selected for three primary reasons. first, these communities were among the first in the country to either adopt a resolution or update a comprehensive plan with a stated objective of addressing the social determinants of health across city policies. this results in a selection of communities that have been pursuing hiap for over 10 years. second, each community has made significant progress operationalizing health and equity in all policies as is evidenced by the fact that each community has adopted multiple plans or policies that explicitly address health in coordinated ways across multiple city departments. third, these communities have their plans and policies online, making it possible to easily review (and link to) their content, understand their policy and planning processes, and track the progress they have made to date. these communities’ initiatives go by different names. however, we consider them all examples of hiap because 1) they all state that improved health outcomes are a goal, 2) they all address the social determinants of health and 3) they have all involved the local, county, and/or state health department. each community has done a wide spectrum of work including 1) resolutions, or similar documents committing their community to health or equity in the long road to the “all” of hiap calloway 3 table 1. case study community profiles minneapolis mn seattle wa richmond ca government structure mayor yes yes yes city council election structure by wards at large at large city manager / coordinator yes no yes annual operating budget (billions) total $1.7 $6.02 $.37 population (2010) total 382,578 608,660 103,701 race and hispanic origin (2017) white alone, not hispanic or latino 59.9% 65.3% 17.9% black or african american alone 18.9% 7.1% 20.6% asian alone 6.0% 14.5% 14.8% hispanic or latino 9.8% 6.5% 42.0% two or more races 4.9% 6.6% 4.8% income & poverty (2017) median income $55,720 $79,565 $61,045 persons in poverty 20.7% 12.5% 15.7% life expectancy (2015) range 67.2 89.4 73.2 88.3 73.0 84.5 average 78.6 81.2 78.8 table 1. sources: government structure: http://www.ci.minneapolis.mn.us, https://www.seattle.gov/, http://www.ci.richmond.ca.us/ annual operating budget: 2019 minneapolis budget in brief, seattle open budget website, 2019 richmond budget in brief population, race and hispanic origin, income and poverty: www.census.gov/quickfacts life expectancy: www.cityhealthdashboard.com http://www.ci.minneapolis.mn.us, https://www.seattle.gov/, http://www.ci.richmond.ca.us/ http://www.minneapolismn.gov/www/groups/public/@finance/documents/webcontent/wcmsp-217478.pdf https://openbudget.seattle.gov/#!/year/default http://www.ci.richmond.ca.us/documentcenter/view/47540/fy2018-19-budget-in-brief-web-version http://www.ci.richmond.ca.us/documentcenter/view/47540/fy2018-19-budget-in-brief-web-version http://www.census.gov/quickfacts http://www.cityhealthdashboard.com the long road to the “all” of hiap calloway 4 all policies 2) internal strategic plans, action plans, committees and task forces that operationalize healthy and equitable decision-making within the local government 3) inclusive and representative community engagement that has demonstrably shaped planning or budgeting decisions 4) comprehensive plans or similar long-range, multisector planning documents where health or equity are fundamental guiding principles 5) health and equity data which is used to inform planning processes or track progress 6) health or equity-driven prioritization of capital investments or budgeting. for this review, we identify the genesis of each case study initiative and present how each initiative evolved over time. we highlight some of the key plan and policy milestones in each community. we map the processes they went through as their initiatives spread across government departments and agencies over time. we summarize the resulting plans and policy changes each community has adopted to date. we show how they are tracking success. and we give some examples of how their hiap initiatives have guided decisions or resulted in healthy and equitable investments. we also flag where, at different points in their journeys, each community has employed the following five key strategies for effectively adopting and implementing hiap (changelab solutions, 2015): these key strategies were originally identified by interviewing a dozen communities and reviewing policies used to guide such initiatives. these strategies do not need to occur in a specific order. this is in part because individual planning and policy processes are • [convene & collaborate]: this involves meeting, communicating, and exchanging health-promoting ideas, resources, and programs between departments, agencies, institutions, and partners • [engage & envision]: this involves engage communities in public discussions to define what it means to be a healthy, equitable community by describing what success looks like and specifying the health equity outcomes the community is trying to achieve. • [make a plan]: this involves coming to a shared understanding of the barriers to and opportunities for health in a community and establishing strategies, policies, and actions to remove barriers and leverage opportunities to achieve the community’s vision. • [invest in change]: this involves looking for ways to save, repurpose, combine, and attract new resources to operationalize hiap and fund plan implementation. • [track progress]: this involves gathering and analyzing data to evaluate and report on progress toward planned outcomes. figure 1. five key strategies for communities to adapt and implement hiap (changelab solutions, 2015) the long road to the “all” of hiap calloway 5 not always linear. it is also because hiap initiatives can involve many different planning, policy, and implementation actions that are at different phases and are being worked on across multiple departments simultaneously. as a result, different planning, policy, and implementation actions could be employing different strategies at any given time. however, we do believe that all five strategies must ultimately be employed for a hiap initiative to be successful. this review shows that each community has employed all five of these strategies at multiple points during their initiatives. [note: this review attempted to highlight major milestones of each community’s hiap journey to date. there are likely additional healthy, equitable plans and policies or collaborations with other state, regional, and local agencies that have been completed in these communities but are not included below] minneapolis, minnesota 2008 our review of minneapolis’ journey toward health in all policies begins in may 2008 when racial disparities data related to the city of minneapolis employment and training program led the city council through resolution 2008r-184 to participate in a joint city of minneapolis and hennepin county “racial disparities in employment steering committee” (minneapolis city council, 2008). [convene & collaborate] this resolution and steering committee had a relatively narrow charge (racial disparities in employment) and it did not explicitly focus on health outcomes. however, by focusing on concentrations of poverty and unemployment localized in neighborhoods of color, it established a trajectory which would ultimate intersect with policies addressing the social determinants of health. 2012 by 2012, the city had updated its sustainability indicators and targets to include eliminating racial disparities in employment for minneapolis residents (gordon, n.d.). [track progress] this action was informed in part the minneapolis foundation, which released a report with racial, education, jobs, housing, and other data which “shines a light on the shocking and unacceptable differences in how minneapolis residents are faring on the most essential indicators of a healthy and productive life” (minneapolis department of civil rights, 2011). [track progress] in an attempt to address these challenges, the minneapolis foundation convened a one minneapolis call to action conference to begin a conversation about how to address disparities in the city. [convene & collaborate] [note re: 5 key strategies in minneapolis, although a vision and plan had not yet been established, tracking and evaluating data was an effective way to influence decisionmakers about the importance of the initiative] 2012 the minneapolis foundation report and the racial disparities in employment steering committee’s work had uncovered the role of institutional racism in driving inequity. this understanding led the city to declare through resolution (2012-456) supporting equity in employment in minneapolis and the region that institutional racism is a problem in minneapolis and called on city government to “lead by example” and use a racial equity framework to inform city budget, policy and program decisions” (gordon, n.d.). this racial disparity work was beginning to converge with the health department’s increasing involvement with the city’s placebased policy and planning activities. for example, in 2012, the health department prepared a health impact assessment (hia) for the park and recreation board’s above http://minneapolismn.gov/www/groups/public/@council/documents/proceedings/wcms1q-070143.pdf http://www.minneapolismn.gov/www/groups/public/@cped/documents/webcontent/wcms1p-109092.pdf https://www.minneapolisparks.org/_asset/pxm4rh/atf_masterplan_draft.pdf the long road to the “all” of hiap calloway 6 the falls: master plan for the upper river in minneapolis (department of health and family support, city of minneapolis, 2012). [track progress] and, “in fall 2013, the [city’s] public health advisory committee (phac) engaged in a prioritizing activity to better align its discussions, actions, and efforts with the minneapolis health department and city of minneapolis goals” (health department, city of minneapolis, 2015). [make a plan] that process yielded housing and homelessness as one of six priorities (health department, city of minneapolis, 2015). in the short term, this led to a meeting between the residential finance manager from the city’s community planning & economic development office and the city council’s public health policy & planning sub-committee in order to discuss housing policies, funding, and development (health department, city of minneapolis, 2015). [convene & collaborate] in the longer term, this focus on housing would create multiple points of alignment with policies and actions in the city’s upcoming comprehensive plan update. 2014 as the city’s commitment to racial equity expanded beyond employment, the city began to review its own historic policy context of institutional discrimination. this included studying best practices from other communities about how to address racial equity (city of minneapolis, n.d.b). by april 2014, the ideas and concepts the city had learned up to this point were reflected in a new city vision and set of adopted goals and strategic direction which were drafted with public health department participation as well as broad public comment. [engage & envision] these now included values of both equity (fair and just opportunities and outcomes for all people) and health (the wellbeing of people and our environment) as well as the goal that disparities are eliminated so all minneapolis residents can participate and prosper (city of minneapolis, 2019b). each department was directed to use these goals, strategic directions and values to create individual business plans (city of minneapolis, n.d.d). [make a plan] for example, the community planning and economic development department business plan includes a visions to “address equity in the planning process through effective and meaningful public processes” and “proactive coordination on planning efforts with the city’s public works department and with the park board, school district, police department, health department, and other interested organizations” (community planning & economic development, city of minneapolis, n.d.). [note re: 5 key strategies once minneapolis had convened, collaborated, and reviewed data to define the problem as well as engaged the community to establish a vision, the city made an internal plan for how to operationalize the initiative] 2015 by 2015, conversations such as a one minneapolis discussion about what was working and what wasn’t made it clear that more guidance was needed for departments to incorporate racial equity principles into their operations, programs, services and policies (city of minneapolis, 2015). to provide this guidance, the city established a dedicated division of race and equity within the office of the city coordinator (21 m.m., § 10). [convene & collaborate] 2016 with health and equity now fully committed to, minneapolis began to see changes to their internal policies and protocols that guide government processes across https://www.minneapolisparks.org/_asset/pxm4rh/atf_masterplan_draft.pdf https://www.minneapolisparks.org/_asset/pxm4rh/atf_masterplan_draft.pdf http://www.minneapolismn.gov/www/groups/public/@citycoordinator/documents/webcontent/wcmsp-212813.pdf http://www.minneapolismn.gov/www/groups/public/@citycoordinator/documents/webcontent/wcmsp-212813.pdf http://www.minneapolismn.gov/www/groups/public/@citycoordinator/documents/webcontent/wcmsp-212813.pdf the long road to the “all” of hiap calloway 7 city departments. for example, a critical component of integrating health and equity in all policies is community engagement and in january 2016 the city’s neighborhood & community relations department released a blueprint for equitable engagement. this was “adopted by the city council in may 2016 as a five-year plan to ensure an innovative and equitable engagement system for the city of minneapolis” (gordon, n.d.). [engage & envision] 2016 perhaps most importantly, in april 2016, the city council “directed the department of community planning and economic development (cped) to update the policies of the city’s comprehensive plan in service to the values of growth and vitality, equity and racial justice, health and resilience, livability and connectedness, economic competitiveness, and good government” (city of minneapolis, n.d.a). (emphasis added) [make a plan] the comprehensive plan update began with a significant amount of community engagement through a variety of methods designed to be inclusive and empowering. this included specific attention given to questions about health and an entire phase of engagement dedicated to equity as well as access to housing, jobs, and transportation equity. [note re: 5 key strategies minneapolis used the comprehensive plan update process to make a plan for improving community health through policies across city departments] 2018 the processes followed a typical comprehensive planning timeline, taking a little over two years for the city to engage the community about big ideas [engage & envision], develop a policy framework, and prepare a draft plan [make a plan]. the city council adopted the minneapolis 2040 comprehensive plan in december 2018. health and equity, both major themes that came out of community engagement (city of minneapolis, n.d.c.), are reflected in the 14 goals (minneapolis city council, 2017) that are the foundation for the plan. the final plan includes 28 policies related to the “health” goal and 39 policies related to the “eliminate disparities” goal. furthermore, the implementation chapter includes a range of actions intended to ensure the plan’s health and equity goals were realized. this includes identifying the health department as a key partner agency in many activities such as updating the transportation action plan as well as making changes to the city’s housing ordinance, the proactive housing inspection program, capital improvement program funding process, and rezoning study. the implementation chapter also states the city’s decision to merge its recurring strategic planning process with its race and equity planning for the first time. the initial results of this alignment resulted in a set of goals and policies to operationalize equity which were adopted in 2018. 2019 even through the comprehensive plan has an implementation chapter, the city needed more detailed guidance and action steps to operationalize the health and equity-related actions in that chapter. toward this end, the city is currently in the process of developing a strategic and racial equity action plan (sreap). [make a plan] “the strategic and racial equity action plan builds on the city’s comprehensive plan and will inform the city’s budgets in 2020 and beyond” (city of minneapolis, 2019a). “a small number of policy areas from the comprehensive plan will be selected as priorities for sreap. these will provide guideposts to steer resource allocation across departments and inform http://www.minneapolismn.gov/www/groups/public/@ncr/documents/webcontent/wcmsp-187047.pdf https://minneapolis2040.com https://minneapolis2040.com https://lims.minneapolismn.gov/download/file/1933/racial%20equity%20action%20plan%20enterprise%20operational%20polivies_revised%20dec%205%202018.pdf https://lims.minneapolismn.gov/download/file/1933/racial%20equity%20action%20plan%20enterprise%20operational%20polivies_revised%20dec%205%202018.pdf the long road to the “all” of hiap calloway 8 policymaker decisions” (city of minneapolis, 2019a). the sreap process started with a cross-department retreat [convene & collaborate] where participants rated all 97 comprehensive plan policies to establish priorities. policy priorities as of jan 2019 are public safety, housing, and economic development. the sreap is in its final stages and looks to be on track for adoption at some point in 2019. integrating health and equity throughout the updated comprehensive plan was an important step in minneapolis’ journey. since the comprehensive plan has been adopted, the city has continued to expand health and equity in its policies. two of the short-term priorities the city is pursuing with a health and equity perspective are transportation and housing. the housing priority is aligned with the sreap’s prioritization of housing as well as the health department’s prioritization of housing dating back to 2014. according to the comprehensive plan, the first step was to make “incremental changes [to the city’s unified housing policy] as needed to implement comprehensive plan policies” and “explore new strategies and tools to create and preserve affordable housing throughout the city, such as inclusionary zoning and naturally occurring affordable housing (noah) preservation” (city of minneapolis, 2019c). the city prepared a series of reports in august-november 2018 which concluded that the city’s housing ordinance should be updated. recommendations included tax increment financing policy and a program to support affordable housing requirements relating to the city’s interim inclusionary zoning ordinance. in december 2018, the city adopted an amended and restated unified housing policy (city of minneapolis, 2018). [invest in change] to address the transportation priority, the public works department has started a transportation action plan and related vision zero action plan to be completed in 2020. these plans will be built on the foundation of the comprehensive plan with health-aligned goals including climate, safety, and equity. [make a plan] [note re: 5 key strategies minneapolis’s initiative has included making multiple plans to: operationalize the initiative internally, improve community-wide health through policies across departments, and ensure health and equity goals are translated to implementation] the city has created extensive health and equity policy infrastructure which includes a racial justice resolution, committee, department, strategic plan, staff trainings, departmental business plans, and comprehensive plan. the power of having established this infrastructure can be seen when we turn our focus to the city’s budgeting process. [invest in change] the city convenes a capital and long range improvement committee to evaluate capital requests and develop recommendations for the city’s capital improvement program (city of minneapolis, 2019e). the committee uses alignment with the city’s adopted vision, mission, values, and goals to evaluate proposed projects. in addition, projects must support the city’s comprehensive plan policies. among other criteria, projects score well if they have previously been deemed as a high priority in plans (such as the comprehensive plan), if they achieve equity in service delivery, if they improve environmental health, and if they enhance quality of life in neighborhoods. http://www.minneapolismn.gov/cped/housing/cped_affordable_housing_resolution http://www.minneapolismn.gov/cped/housing/cped_affordable_housing_resolution the long road to the “all” of hiap calloway 9 [note re: 5 key strategies investing in change can include allocating budget differently. the minneapolis capital and long range improvement committee’s project evaluation process shows how changing decision-making processes can lead to increased investment in health and equity.] budgeting process outcomes: highly rated capital improvement projects whose funding has been shaped by this process include: neighborhood parks rehabilitation with a 2020-2024 budget of $24 mill; pedestrian and bike improvements including safe routes to school, protected bikeways, and special bike boulevards with a 2020-2024 budget of $18.6 million (city of minneapolis, 2019e). the city continues its pursuit of health and equity in all policies through its current policy work (city of minneapolis, 2019d). seattle, washington 2005 similar to the city of minneapolis, seattle’s hiap journey began with a focus on race. their race and social justice initiative (rsji) [convene & collaborate] developed from narratives collected during mayor greg nickels’ campaign in 2001 (race and social justice initiative, 2008). over the course of the campaign, it was reaffirmed that certain populations in seattle felt represented, while others did not, and mayor nickels found the one recurring factor was race. beginning in 2005, the rsji was developed to address race and social justice across all city departments in pursuit of racial equity. one of the initiative’s first actions was to require all city departments to implement work plans for how each department would address key indicators of racial and social injustice including: health, education, criminal justice, environment, and the economy (race and social justice initiative, 2008). [make a plan] 2009 from the beginning, the rsji has guided its work through three-year strategic plans. [make a plan] over the first three years, the initiative’s work concentrated on laying groundwork. this started with building an understanding of racial and social injustice across departments. it included establishing a management structure for the initiative by creating an office of civil rights as the lead department as well as “change teams” within every other city department to guide implementation.[convene & collaborate] the city also began transforming its community engagement processes.[engage & envision] executive order 01-07 established a translation and interpretation policy which required all city departments to translate government documents into all languages spoken by a substantial number of seattle residents. the city also developed a new outreach and public engagement policy. this policy requires departments to designate liaisons to coordinate and implement inclusive public engagement. furthermore, the city created a racial equity toolkit for all departments to use to assess policies, initiatives, programs, and budget issues. [invest in change] as a result of this early work, racial disparities considerations began shaping the practices and policies of various departments including human services, housing, and public utilities (race and social justice initiative, 2008). [note re: 5 key strategies investing in change includes changing internal protocols. in seattle, an early investment involved creating toolkits to help staff integrate race and equity considerations into their decisionmaking processes] the 2009-2011 rsji strategic plan focused on reducing disparities within the city as an organization, strengthening community and https://www.seattle.gov/documents/departments/rsji/rsji-2008-overview-executive-summary.pdf https://www.seattle.gov/documents/departments/oira/seattle_executive_order_01-07_0.pdf https://www.seattle.gov/documents/departments/parksandrecreation/business/rfps/attachment5%20_inclusiveoutreachandpublicengagement.pdf https://www.seattle.gov/documents/departments/rsji/racialequitytoolkit_final_august2012.pdf https://www.seattle.gov/documents/departments/rsji/rsji-2008-looking-back-moving-forward-full%20report-final.pdf the long road to the “all” of hiap calloway 10 access to services, and beginning to develop a shared vision and a collaborative action plan to achieve racial equity (race and social justice initiative, 2008). although the city had taken initial steps toward building up the internal infrastructure necessary to plan for and address racial and social justice, they had still not successfully integrated health or equity into many city policies. so, the city council re-affirmed the city’s commitment – through resolution no. 31164, adopted on november 30, 2009 to racial and social equity and re-directed all city departments to assist in eliminating racial and social disparities (simmons, 2019). 2012 following an assessment involving over 40 community meetings and a roundtable with 25 seattle institutions and organizations [engage & envision], the 2012-2014 rsji strategic plan showed positive progress over the previous three years in equitable contracting, expanded and inclusive public engagement, and internal training and education.[track progress] priorities for the next three years included the need to improve coordination and linkages both between city departments and the community, and to make better use of data to measure progress (racial & social justice initiative, city of seattle office for civil rights, n.d.b). the city’s state-mandated deadline for a major review of its comprehensive plan was approaching in 2015. we will see how this provided an excellent opportunity to improve coordination and linkages both between city departments and the community by integrating equity and health into the new comprehensive plan.[make a plan] in 2011, the city began early community engagement to scope the comprehensive plan update. [engage & envision] by march – may 2012, the city had an initial public engagement report. health and equity-related themes identified in this initial public outreach report included: building healthy, complete communities; policies related to the city’s climate action plan; and policies that encourage equitable access to healthy food (city of seattle, department of planning and development, 2012). however, the report also provides an example of the challenge of coordinating health, equity, and social justice concerns across city activities. the report shows that racial and social justice was not included in the initial questionnaire sent to the public. despite this, it did come up as an additional community-suggested item. 2014 after a round of project planning and research, the city initiated the plan update process. the city took the next few years to translate the community’s core values of race and social equity, environmental stewardship, community, quality of life, and economic opportunity and security into a comprehensive plan document. as the city drafted the plan, it used the city’s racial equity toolkit and drew from the values in the rsji and equity & environment initiative (eei). it attempted to integrate health and equity principles across the plan’s various elements through issues such as access to jobs, education, healthy foods, parks, and affordable housing. these concepts are reflected in both the citywide planning sections and individual neighborhood plans. tying it all together is a strategy which concentrates growth, development, and investment in select “urban villages” (note that the urban villages strategy has its origins in washington state’s 1990 growth management act). http://clerk.seattle.gov/search/results?s1=race+and+social+justice&s3=&s2=&s4=&sect4=and&l=200&sect2=theson&sect3=pluron&sect5=resny&sect6=hitoff&d=resf&p=1&u=%2f~public%2fresny.htm&r=2&f=g http://clerk.seattle.gov/search/results?s1=race+and+social+justice&s3=&s2=&s4=&sect4=and&l=200&sect2=theson&sect3=pluron&sect5=resny&sect6=hitoff&d=resf&p=1&u=%2f~public%2fresny.htm&r=2&f=g https://www.seattle.gov/documents/departments/rsji/rsji-three-year-plan_2012-14.pdf https://www.seattle.gov/documents/departments/rsji/rsji-three-year-plan_2012-14.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/comprehensiveplanreportonpubilcengagement.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/comprehensiveplanreportonpubilcengagement.pdf https://www.seattle.gov/environment/equity-and-environment/equity-and-environment-initiative https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/counciladopted2016_citywideplanning.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/counciladopted2016_neighborhoodplanning.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/counciladopted2016_neighborhoodplanning.pdf the long road to the “all” of hiap calloway 11 2015 at this time, the rsji had achieved clear successes since the 2012 strategic plan, such as using the racial equity toolkit to shape the comprehensive plan update process. the 2015-2017 rsji strategic plan also highlighted the challenges and slow pace that policy, systems, and environmental change can move.[track progress] generally, the city was still struggling to see consistent implementation and measurement of the rsji’s equity tools and processes across departments (race and social justice initiative, seattle office for civil rights, n.d.a). [note re: 5 key strategies the way that seattle has tracked progress through threeyear strategic plans has allowed them to systematically build on successes and address gaps or barriers to implementation as their initiative has progressed] however, seattle’s work on the comprehensive plan update seems to have been somewhat of a tipping point for their efforts to integrate racial and social justice and health equity in policies across departments. building the comprehensive plan on fundamental themes of racial and social justice and health required the city to engage in a wide range of analyses and to develop a suite of reports and plans to work in parallel with the comprehensive plan. first, in response to feedback received during community outreach, city council passed resolution 31577 in may 2015 to confirm that the city’s core value of race and social equity is one of the foundations on which the comprehensive plan is built (office of planning and community development, city of seattle, 2016). this resolution also required an additional equity analysis and growth & equity analysis of the draft comprehensive plan. these analyses identify how the comprehensive plan’s growth scenario as presented in the environmental impact statement could positively or negatively impact marginalized populations. the analyses also include potential strategies to mitigate negative outcomes. [note re: 5 key strategies it is not uncommon to encounter sticking points in the process of making a plan. engaging and envisioning, convening and collaborating or, as seattle did, tracking and analyzing data are all strategies that can help get through these sticking points] another action that emerged during the comprehensive planning process, the office of sustainability & environment initiated an equity & environment initiative (eei) in april 2015.[convene & collaborate] many communities negatively impacted by the environment are also underrepresented communities with significant health disparities and poor health outcomes so the city established the eei to connect the city’s race and social justice work with environmental justice. the eei began by establishing an equity & environment agenda (2015-2016) which sets a framework with goals and strategies to achieve environmental justice in seattle.[make a plan] the city’s rsji, work on the comprehensive plan update, and the eei all converged when the city focused on the duwamish river valley. in feb 2015 the city established an interdepartmental duwamish valley action team. [convene & collaborate] the team was led by the office of sustainability & environment (ose) and the office of planning & community development (opcd) and included 16 other city departments, including public health – seattle & king county (phskc) & seattle human services department (hsd). https://www.seattle.gov/documents/departments/rsji/rsji-2015-2017-plan.pdf https://seattle.legistar.com/view.ashx?m=f&id=3859422&guid=256d2f78-e2b3-4e1d-96a8-3214fbc4fd4b https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/2035equityanalysissummary.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/finalgrowthandequityanalysis.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/finalgrowthandequityanalysis.pdf https://www.seattle.gov/environment/equity-and-environment/equity-and-environment-initiative https://www.seattle.gov/documents/departments/environment/environmentalequity/seattleequityagenda.pdf the long road to the “all” of hiap calloway 12 the team was tasked to better align and coordinate efforts to advance environmental justice, address racial and neighborhoodlevel disparities, reduce health inequities, build community capacity, create stronger economic pathways and opportunity, and build trust in government among residents of the duwamish valley area of the city. 2016 after four years of work involving all city departments, consultants, community groups, residents and stakeholders, two rounds of community engagement as well as an additional growth and equity analysis and a health and equity analysis, the city adopted the seattle 2035 comprehensive plan in october 2016 (city of seattle, office of planning and community development, n.d.). the amount of cross-departmental work surrounding the comprehensive plan update resulted in significantly increased alignment between departments and increased integration of health and equity in plans and policies. this work resulted in a suite of reports, plans, and policies to implement, build off, or evaluate the comprehensive plan. for example, the seattle and king county public health department released a health & equity assessment as part of the king county public health and equity in comprehensive planning project.[track progress] the objective of the assessment was to identify and analyze health and equity disparities in the city in response to significant population growth and to ensure all residents can reach their full potential. using the assessment’s findings, the public health department provides policy recommendations to reduce inequities among certain populations that negatively impact health, such as access to health care, limited food choices, and home ownership. these recommendations are connected to specific city and county plans, like the comprehensive plan, and existing programs and initiatives. in addition, similar to minneapolis, the city developed documents to provide more detailed and actionable guidance to implement the comprehensive plan. in april 2016, the city released an equitable development implementation plan with strategies to prioritize public investments, policies, and programs in locations that will reduce disparities while avoiding displacement. that was followed in june 2016 by an equitable development financial investment plan which outlines key initiatives the city is undertaking toward racial equity. [invest in change] [note re: 5 key strategies – it is common for comprehensive plans and other planning documents to be supplemented by implementation plans. implementation plans such as seattle’s equitable development and equitable financial investment plans are good ways to ensure the community invests in the changes that are committed to in other planning and policy documents] equitable development financial investment plan outcomes: the plan provides detailed workplans for equitable development projects that have been prioritized by and are driven by the community. these projects are in neighborhoods with high levels of chronic and recent displacement risk as well as a history of disinvestment and are intended to mitigate further displacement and increase access to opportunity. each project has been allocated at least $40k from the city with some able to leverage up to multiple millions of dollars of outside funding for activities such as feasibility studies and site acquisition to help these projects proceed. https://www.psrc.org/vision-2040-documents https://www.psrc.org/vision-2040-documents http://www.futurewise.org/assets/reports/seattlehea.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/ediimpplan042916final.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/ediimpplan042916final.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/equitabledevelopmentfinancialstrategy.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/equitabledevelopmentfinancialstrategy.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/equitabledevelopmentfinancialstrategy.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/equitabledevelopmentfinancialstrategy.pdf the long road to the “all” of hiap calloway 13 2017 growing out of the eei, the city stablished an environmental justice committee in 2017. [convene & collaborate] this committee provides a space for those most-affected by environmental inequities to have ownership of equity & environment agenda implementation. it also provides another opportunity for connections between city departments as well between government and community-based action. 2018 an early action that the department of transportation has taken towards implementing the comprehensive plan’s goals of health and equity has been to develop a transportation equity program (january 2018). this program is intended to “provides safe, environmentally sustainable, accessible, and affordable transportation” to underrepresented communities, to build healthier communities, and to mitigate racial disparities in the city. through resolution no. 31773 (january 2018) the seattle city council affirmed its commitment to racial equity and social justice through the work of the department’s transportation equity program. after three years of work, the duwamish interdepartmental team released its first duwamish valley action plan in june 2018. this action plan builds on the implementation plan of the eei and works with communities “most affected by inequities and disparities in health, education, opportunity, and access to beautiful green spaces.” the action plan seeks to coordinate with city efforts to reduce health inequities, which is just one of many other objectives aligning with the rsji and eei work. duwamish valley action plan outcomes [invest in change]: during the two years the plan was in development, the city took 50 actions to address community priorities, show responsiveness, and build trust such as through a tree canopy improvement program; $50,000 to convert an underutilized area of an elementary school into a pollinator garden; $23,000 to increase fresh food availability; construction of high priority shoreline street end improvement projects; $10,000 to improve parks amenities, and bus service changes and improvements. the plan also specifies over $26 million of approved funding to take over 130 mid-term actions to pursue 37 opportunities toward a healthy environment, parks and open spaces, community capacity, mobility and transportation, economic opportunity and jobs, affordable housing, and public safety. in order to track progress toward seattle’s long range planning goals, the city completed an urban village indicators report in june 2018.[track progress] this report monitors growth and progress toward the implementation of the comprehensive plan in urban centers and villages. the report is broken into three sections: growth, affordability, and livability. all components of the report further address equitable development to ensure a healthy seattle. health specific indicators include access to transportation and parks, because transit is important to a healthy life and access to parks promotes health and wellbeing. urban village indicators report outcomes [track progress]: because this is the first report, it primarily establishes a baseline and not many conclusions can be drawn yet. however, the report finds that, despite housing and employment growing faster than anticipated during the initial years of the planning period, housing is still a burdensome cost for lowincome households. https://www.seattle.gov/transportation/projects-and-programs/programs/transportation-equity-program https://seattle.legistar.com/view.ashx?m=f&id=5779419&guid=77dae9d9-e60d-4dc9-a267-acd51f4ffee8 https://seattle.legistar.com/view.ashx?m=f&id=5779419&guid=77dae9d9-e60d-4dc9-a267-acd51f4ffee8 http://greenspace.seattle.gov/wp-content/uploads/2018/06/duwamishvalleyactionplan_june2018.pdf http://greenspace.seattle.gov/wp-content/uploads/2018/06/duwamishvalleyactionplan_june2018.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/opcd comprehensive plan urban village indicators monitoring rpt 6 26 2018 w_pg 47 corr.pdf https://www.seattle.gov/documents/departments/opcd/ongoinginitiatives/seattlescomprehensiveplan/opcd comprehensive plan urban village indicators monitoring rpt 6 26 2018 w_pg 47 corr.pdf the long road to the “all” of hiap calloway 14 2019 some of the most recent information about seattle’s progress can be found in the city’s environmental progress report. [track progress] this report tracks the city’s climate and environmental goals developed to support healthy people, communities, and natural environment. progress is tracked in the categories of climate change, buildings and energy, transportation, food access, trees and green space, healthy environment, and environmental justice. specifically, the report presents indicators of the successes of other city agendas in addition to frameworks like the rsji, how all those frameworks align with broader environmental goals, and areas open for improvement. environmental progress report outcomes [track progress]: food: seattle’s fresh bucks program was used four times more in 2018 over 2014 and the percent of participants who are people of color increased 23% between 2017 and 2018 transportation: transit ridership grew by 33% and drive alone rate decreased by 25% between 2010 and 2018; bicycle and pedestrian volumes increased by between 62%-64% from 2011 to 2018 parks: in priority neighborhoods, the city dedicated 3 new parks in 2018 with 14 more in development.[invest in change]. 2019 the 2019-2021 rsji strategic plan focuses on further refining, improving, strengthening, and expanding on the work done over the past 10 years of the initiative (racial & social justice initiative, city of seattle office for civil rights, n.d.). [note re: 5 key strategies tracking progress is about more than gathering and analyzing data. reporting on progress is also important both for accountability and to communicate hiap successes to elected officials and the general public] richmond, california 2005 unlike minneapolis and seattle, richmond’s road to hiap began by building directly off a general plan update (aka a comprehensive plan). with a general plan that dated back to 1994, the richmond city council formally launched a general plan update process in 2005 (city of richmond, n.d.). from the beginning, the city decided it would supplement the general plan update with a community health and wellness element. this would make the city the first jurisdiction in california to incorporate a community health and wellness element (chwe) into its general plan. the city received grant funding from the california endowment for this supplemental effort. the city created a technical advisory committee consisting of all city department heads as well as a technical advisory group with academic, community, and public agency representatives including contra costa health services. [convene & collaborate] 2006 the city began analyzing and understanding the needs and conditions surrounding health equity through a series of community meetings.[engage & envision] this existing health conditions analysis culminated in an issues & opportunities paper on community health and wellness completed in 2007 (city of richmond, n.d.). [note re: 5 key strategies while the 5 key strategies are not always done in a particular order, engaging and envisioning should generally be done early and often when making a plan.] 2008 in order to identify promising frameworks and strategies to organize the chwe, build staff awareness and capacity, draw connections to health with other sections https://www.seattle.gov/environment/environmental-progress https://www.seattle.gov/environment/environmental-progress https://www.freshbuckseattle.org/ https://www.freshbuckseattle.org/ https://www.seattle.gov/documents/departments/rsji/18-21_rsji_strategic_plan_4.6.19_final.pdf the long road to the “all” of hiap calloway 15 of the general plan, and build partnerships to ensure effective plan implementation, the city launched a chwe implementation planning and pilot program team in 2008 (mclean, wilson, and kent, 2011). [convene & collaborate] the team identified four strategies for the chwe to pursue [make a plan] 1) operationalize health and equity in the regular processes, daily practices, and ongoing policies of the city of richmond 2) improve the physical environments in richmond to improve health choices and outcomes and reduce disparities 3) track and monitor changes in community and health conditions 4) engage the community to ensure relevance and impact. 2009 the team also piloted frameworks and strategies from the in process chwe to test approaches and build partnerships. this included working with the west contra costa unified school district and engaging the community on safe routes to school in the city’s the iron triangle and belding woods neighborhoods (city of richmond, 2015), city of richmond, 2013). 2010 similar to seattle, preparing the chwe required richmond to engage in a wide range of analyses and to develop a suite of reports and plans to implement the general plan. much of this work occurred in parallel with the broader general plan update. for example, in december 2010 the city adopted a parks master plan and in november 2011 the city adopted a bicycle master plan and pedestrian plan. these plans involved a health-oriented parks survey conducted by youth, pedestrian and bicycle safety assessments, community engagement, and cross-department coordination. each plan is aligned with and informed by the health and equity goals of the chwe. 2011 the city established an interagency chwe implementation data working group, [convene & collaborate] to determine how to track chhwe implementation. the group included staff from the richmond city manager’s office, contra costa health services, and policylink. the chwe data working group was part of the larger richmond chwe implementation launch team, which included staff from the city of richmond planning and building services, the city of richmond redevelopment agency, contra costa health services public health division, the university of california at berkeley, and mig, inc. in december 2011 the working group completed a health in all policies, health data in all decisions report. the report includes recommendations on indicators and data collection in order to support tracking progress toward the chwe’s goals. [track progress] [note re: 5 key strategies convening and collaborating is not an independent strategy. richmond’s interagency chwe implementation data working group shows how convening and collaborating was an integral part of tracking progress.] 2012 after nine years of work involving all city departments, consultants, community groups, residents and stakeholders, extensive community engagement, and a set of supplemental plans and reports, the city adopted the richmond general plan 2030 including the community health and wellness element in april 2012. the chwe addresses 10 determinants that impact healthy living and how to best support the community to reduce health disparities: the adopted chwe immediately began shaping city policy processes and decisionmaking. for example, in parallel with, but not https://www.ci.richmond.ca.us/documentcenter/view/7196/new-richmond-parks-master-plan-dec-22-2010?bidid= https://www.ci.richmond.ca.us/2739/bicycle-master-plan https://www.ci.richmond.ca.us/2738/pedestrian-plan http://www.ci.richmond.ca.us/documentcenter/view/8663/health-in-all-policies-health-data-in-all-decisi?bidid= http://www.ci.richmond.ca.us/documentcenter/view/8663/health-in-all-policies-health-data-in-all-decisi?bidid= http://www.ci.richmond.ca.us/documentcenter/view/8663/health-in-all-policies-health-data-in-all-decisi?bidid= http://www.ci.richmond.ca.us/2608/general-plan-2030 http://www.ci.richmond.ca.us/2608/general-plan-2030 http://www.ci.richmond.ca.us/documentcenter/view/8579/health-and-wellness-element?bidid= http://www.ci.richmond.ca.us/documentcenter/view/8579/health-and-wellness-element?bidid= the long road to the “all” of hiap calloway 16 directly connected to richmond’s general plan update, the city had been working on richmond livable corridors, a form-based code for several commercial corridors and surrounding areas. from 2012 to 2014, the city worked in coordination with contra costa health services (cchs) to prepare toward a healthier richmond. this report presented health issues and preliminary recommendations for the richmond livable corridors project area followed by a health impact assessment (hia) of the code. the report and hia present recommendations to improve health through topics that will be most directly influenced by the new code. the hia also found the code may create new health inequities, such as affordability and air quality, which will be critical to track moving forward. individual projects such as the richmond livable corridors hia are important. but in order to more systematically operationalize the vision of health established in the chwe, the city began developing processes to implement health in policies beyond the comprehensive plan. in march 2012 the city established the richmond health equity partnership (rhep).[convene & collaborate] the rhep brings together the city, west contra costa unified school district, contra costa health services, and community partners and organizations to advance health equity in the city. the partnership achieves this goal through three strategies, with one strategy being hiap. 2013 the rhep released a health in all policies strategy in 2013.[make a plan] this strategy provides guidance for integrating health and figure 2. community factors addresses by the richmond health and wellness element graphic by mig, inc. http://www.ci.richmond.ca.us/documentcenter/view/27685/rlc_fbc_publicdraft_061813_lowres_rev9-25-2013?bidid= http://www.ci.richmond.ca.us/documentcenter/view/9060/toward-a-healthier-richmond?bidid= http://www.ci.richmond.ca.us/documentcenter/view/30781/rlc---richmond-livable-cooridors-final-7-30-14-2?bidid= http://www.ci.richmond.ca.us/documentcenter/view/30781/rlc---richmond-livable-cooridors-final-7-30-14-2?bidid= http://www.ci.richmond.ca.us/2574/richmond-health-equity-partnership-rhep http://www.ci.richmond.ca.us/2574/richmond-health-equity-partnership-rhep http://www.ci.richmond.ca.us/documentcenter/view/28771/attachment-2---hiap-strategy?bidid= http://www.ci.richmond.ca.us/documentcenter/view/28771/attachment-2---hiap-strategy?bidid= the long road to the “all” of hiap calloway 17 equity in city decisions from budgeting to parks and from engineering to partnerships with community-based organizations (city of richmond, 2014) the rhep has also prepared a health equity report card, which establishes a baseline to measure richmond’s progress towards a more equitable city.[track progress] 2015 to effectively implement and maintain health in all policies, the city passed ordinance no. 27-15 n.s. (adopted december 2015). among other actions, this ordinance establishes an interdepartmental health in all policies team with representatives from every department. [convene & collaborate] it also requires a triannual report on the status of health, health equity, and progress toward hiap in the city of richmond. [note re: 5 key strategies – early in the process of pursuing hiap, convening & collaborating may be more informal or tied to individual projects. establishing an official interdepartmental health in all policies team is a good way to ensure early wins lead to sustainable convening & collaborating over time.] the city’s first hiap report was released in 2015 the report provides an overview of how hiap is making an impact at the level of city government as well as actions the city has taken to implement the hiap strategy.[track progress] hiap report investments [invest in change]: • the city’s focus on health through climate change helped it secure $5.1 mill in california senate bill no.375 funds for affordable senior housing and creek restoration. • the hiap initiative’s focus on violence as a health issue has led to a city budget increase for the office of neighborhood safety. • eight park improvement projects were completed in underserved communities with an additional $6 mill secured for three additional community-driven park projects. • the city approved $3 mill in social impact bonds to rehabilitate vacant properties for future sale to low-income residents, the city brought the community air monitoring system online. hiap report outcomes [invest in change]: • the city exceeded its regional housing needs allocation for the past two cycles. • homicides in 2014 were the lowest in the city in 40 years. [track progress] • finally, based on surveys before and after the hiap ordinance, residents felt city services, such as parks, police, street lighting, affordable and quality housing, and recreation programs, positively impacted health more after the ordinance was adopted. across ten city services, resident ratings increased between 16% and 33%. 2019 capital improvement program outcomes [invest in change]: richmond’s most recent capital improvement program (cip) reflects priorities and projects that are a direct result of the city’s healthy planning and hiap initiatives. for example, the chwe pilot work done in the iron triangle neighborhood in 2009 grew into the yellow brick road: iron triangle walkable neighborhood plan, which was adopted in 2015. as of 2019, the city has allocated $7.3 mill in its capital improvement program for projects that are part of this neighborhood plan. https://cchealth.org/health-data/pdf/richmond-health-equity-report-card-full.pdf http://www.ci.richmond.ca.us/archivecenter/viewfile/item/6999 http://www.ci.richmond.ca.us/archivecenter/viewfile/item/6999 http://www.ci.richmond.ca.us/documentcenter/view/36978/hiap_report_final?bidid= http://www.ci.richmond.ca.us/documentcenter/view/36978/hiap_report_final?bidid= https://leginfo.legislature.ca.gov/faces/billnavclient.xhtml?bill_id=200720080sb375 http://www.fenceline.org/richmond/data.php http://www.fenceline.org/richmond/data.php http://www.ci.richmond.ca.us/documentcenter/view/36978/hiap_report_final?bidid= the long road to the “all” of hiap calloway 18 [note re: 5 key strategies hiap initiatives can make it easier to attract funds to invest in change. the funding richmond received for senior housing and creek restoration is an example of how having a plan and showing coordinated commitment to health and equity can make communities more competitive for various state and federal funding sources.] discussion the communities reviewed reveal the following common themes and lessons about the realities of successfully pursuing hiap: hiap can start anywhere: there are many ways to start down the path toward hiap. for example, you could start small by convening and collaborating with partners to include health as part of the design of a project such as a streetscape improvement. you could include health as part of the community engagement or envisioning for a project such as a comprehensive plan as was the case for the city of richmond’s initiative. you could gather or analyze community data highlighting health and other inequities like minneapolis’s initiative, which grew out of racial disparities data related to the city of minneapolis employment and training program. or you could follow seattle’s approach by passing a resolution committing the community to health and equity in all policies. no matter where you start, it is just the beginning. hiap takes ongoing commitment: achieving health and equity in all policies requires persistence and work long past the initial project. some policy and decision-making processes can take months, or even years to complete from start to finish (the minneapolis 2040 comprehensive plan took two years to draft and adopt). then it takes additional time and effort to operationalize that commitment. over these long timeframes, there will likely be stops and starts. there will be successful and failed pilots. there will be evaluation and refinement. and there will probably be staff and elected official turnover. as a result, it is not uncommon that the community may need to reaffirm its commitment to hiap at some point (four years into its initiative, seattle passed a resolution to re-affirm its commitment to racial and social equity). hiap requires changing internal protocols and processes: in addition to the ongoing process of integrating health across the spectrum of externalfacing policies, communities must also do internal work to operationalize, institutionalize, and systematize health and equity across departments. this includes changes to internal government processes and protocols such as requiring all departments to develop health and equity plans or to submit regular reports about progress made toward identified healthy, equitable outcomes (ten years into its initiative, richmond passed an ordinance which requires a tri-annual report on the status of health, health equity, and progress toward hiap). this also includes establishing necessary internal infrastructure such as designating individuals or establishing departments that will oversee hiap implementation (minneapolis established a dedicated division of race and equity within the office of the city coordinator). even with new protocols and decisionmakers, staff may require training to understand and be sensitive to health and equity issues, especially when the issues involve racial and social justice (from the beginning, seattle’s initiative included training and education for city employees). health and equity disparities analyses are powerful communication tools: analyzing and illustrating the spatial distribution of health and equity disparities within a community is important. this type of analysis can help decisionmakers see which neighborhoods have the greatest needs and understand what those needs are. it can also reassure decisionmakers, stakeholders, and the community at large that healthy policies can address those needs and have positive health and equity outcomes (supplemental equity the long road to the “all” of hiap calloway 19 analyses were integral to the city council’s decision to adopt the seattle 2035 comprehensive plan). inclusive and meaningful community involvement takes time, but it also makes a difference: one reason achieving hiap takes time is that community engagement takes time. large numbers of people must be engaged consistently over time about a wide range of topics. and many of these topics cannot be resolved after a single, short interaction. inclusive and meaningful community involvement is necessary to identify the community’s health needs but especially the needs of structurally disadvantaged neighborhoods and populations (feedback from over 200 participants at the one minneapolis: a call to action conference was an important start to the conversation about how to address disparities in the city). but this engagement can provide more than just data. it can provide stories that are a powerful way to promote hiap initiatives. and it can build a coalition to support adoption of healthy plans and policies (richmond partnered with the west contra costa unified school district to pilot community engagement around the safe routes to school). community engagement can also provide a means of accountability to ensure implementation over time. health and equity in comprehensive plans tend to accelerate the process towards hiap: the process of creating comprehensive plans requires participation from most, if not all community departments. so comprehensive planning is an effective way to engage many departments in health and equity discussions. in addition, comprehensive plans typically guide a wide range of city decisions, investments, and actions across department. so, when health and equity become fundamental guiding principles of major policy documents such as comprehensive plans, health and equity concerns tend to spread to other related plans and policies across departments (comprehensive plans were key milestones for minneapolis, seattle, and richmond’s initiatives). health and equity in internal protocols increases health and equity-driven decisions: health and equity concerns must become fundamental guiding principles in the core documents that guide decision-making in different departments or around specific topics (such as transportation plans, budgets, housing ordinances, etc.). when this occurs, a community’s actions and decisions, and the community transformation that results, will also be guided by health and equity (minneapolis, seattle, and richmond all show evidence of policy decisions, investments, and outcomes guided by health and equity as a result of their initiatives). conclusion communities cannot achieve hiap overnight. convening and collaborating, engaging and envisioning, making a plan, investing in change, and tracking progress are processes that occur incrementally and take both time and effort. however, the communities reviewed in this article illustrate that each step taken toward hiap makes subsequent steps easier. and as more and more policies include health and equity concerns, the entire system does become more effective at improving health and equity outcomes. finally, these communities show that integrating health and equity across a range of plans and policies does shape decisions, lead to actual community transformation, and improve community health outcomes. the long road to the “all” of hiap calloway 20 references changelab solutions. 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