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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 com-
parable 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 experi-
ence 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 poli-
cies 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 (Na-
tional 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 rec-
ommendations 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 demo-
cratic 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 techni-
cal 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 individu-
als, 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 col-
laborating 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-govern-
mental 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 pre-
sented 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) moni-
toring 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 Decision-
Making
Despite increased interest in public health among profes-
sionals 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 over-
looked health consequences of  policies, plans, pro-
grams, 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 be-
tween 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 consid-
ered legislation that incorporated most elements of  a 
formal HIA. One example of  state HIA legislation is 
what is commonly known as the Healthy Transporta-
tion Compact. Enacted by the Massachusetts Legisla-
ture 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, Colo-
rado 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 Or-
egon 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 estab-
lished the Health Impact Evaluation Center to develop 
the capacity and systems to routinely conduct HIAs. 
As part of  their efforts, this center is creating screen-
ing 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 sec-
tors do business by streamlining the HIA steps or through a 

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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 Com-
munity 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 allocat-
ing 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 well-
being. 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 stakehold-
ers to assess, identify, implement, and monitor achiev-
able 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 world-
wide across all sectors of  the building industry, includ-
ing affordable housing, commercial real estate, schools, 
homes, and neighborhoods.

•	 In the transportation sector, as part of  its 2035 re-
gional transportation plan, the Nashville Area Metro-
politan 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 per-
cent 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 pro-
moting projects (Nashville Area Metropolitan Planning 
Organization, n.d.).  

•	 In the planning sector, Meridian Township, Michigan, 
adopted a checklist-based tool that allows new pro-
posed 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  health-
supportive modifications. 

Institutions such as banks, hospitals, and foundations 
have the ability to impact health equity through their lend-
ing, 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 hospi-
tals 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 simi-
lar to a fiscal note, and provides a brief, objective, nonpar-
tisan 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 po-
tential health effects and corresponding mitigation strategies 
to move directly into implementation. The field could ben-
efit from a central repository of  sector- and decision-specific 
information and tools that could facilitate the translation of  
past HIAs into policy, and make HIA practice more acces-
sible 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 recommenda-
tions 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 acces-
sibility, 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, Char-
bonneau, 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 dissemi-
nate 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). Of-
ten, grants end shortly after release of  the HIA report, leav-
ing 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 monitor-
ing and evaluation plan, and our grant selection criteria 
prioritize proposals with strong plans and partnerships to 
support ongoing engagement with the policies that will fol-
low 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 recommenda-
tions into policy. 

One important consideration in moving HIA recom-
mendations 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 precon-
ceived policy outcome. The risk, therefore, is that decision-
makers 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. Orga-
nizations 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 success-
ful 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 con-
clusion—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 recommenda-
tions 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 commu-
nity 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 practi-
tioners conduct HIAs, engage stakeholders, and disseminate 
products. Process evaluations are common, with practitio-
ners determining whether the HIA was carried out accord-
ing 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 con-
tinues to expand, we have seen how monitoring the imple-
mentation 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 find-
ings 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 deci-
sions, 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 recog-
nition 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 prevent-
able 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 Opportu-
nity Commission; federal immigration reform; federal paid 
sick leave policy; cleanup plans for a Superfund site; and nu-
merous 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  Hous-
ing and Urban Development (HUD) and partners from the 
Oregon Public Health Institute and Metropolitan Area Plan-
ning 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 poli-
cy debates, provide new data to inform federal policy, and 
develop collaborative relationships among agency staff, 
stakeholders, and advocates (Pollack, Heller, Givens, & Lind-
berg 2013). HIAs have the potential to strengthen and sup-
plement 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 con-
ducted 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 immi-
gration 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 com-
municating 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 stake-
holder 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-mak-
ing, 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 differ-
ences 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, initial-
ly 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 prac-
titioners 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 empower-
ment 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 informa-

tion 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 community-
based organizations. One possibility is that mounting a 
successful proposal for HIA funding is beyond the capac-
ity of  smaller community organizations. Larger organiza-
tions 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 self-
efficacy 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 popula-
tions 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 initia-
tives to target social determinants of  health). Grantees will 
also receive coaching and training on stakeholder engage-
ment, 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 ef-
forts, 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  stakehold-
ers 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 environ-

ments 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



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Seven years in the field Morley; Lindberg; Rogerson; Bever; Pollack



30

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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.


