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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 disen-
franchised 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 under-
stand the links between health and the natural and built en-
vironments, and to use HIA as a tool to improve cross-dis-
ciplinary 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 inter-
dependence 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, pro-
ductive and aesthetically and culturally pleasing surround-
ings” (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-transit-
project.html) and the HIA of  oil and gas leasing in the Na-
tional Petroleum Reserve in Alaska’s North Slope Borough 
(Wernham, 2007).    

In 1986, the World Health Organization’s (WHO) Ot-
tawa Charter for Health Promotion was a major step toward the 
development of  HIA. The charter recognized that achiev-
ing 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 Cen-
tury specifically called for the use of  “equity-focused health 
impact assessments as an integral part of  policy develop-
ment” (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 Harris-
Roxas 2012
1969 National Environmental Policy Act passes that included among its purposes to “promote efforts … [to] stimu-

late 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 ordi-

nance, 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  Pub-
lic 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 pro-
spectively 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 deci-
sion-makers have little receptiveness to recommendations 
are of  less value, although they may still facilitate community 
engagement.

Community engagement has long been a central com-
ponent 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 con-
stituencies 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 dis-
placed 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 Alas-
ka, 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 Preven-
tion (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 (Dan-
nenberg, 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 Rob-
ert 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 suc-
cesses 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 peer-
reviewed articles (Figure 2) with U.S. authors have been pub-
lished 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  stake-
holder consultation in HIAs (Tamburrini, 2011), and model-
ing 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 Na-
tional 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  Califor-
nia, Berkeley (Schuchter, 2015).  Based on interviews of  a 
sample of  trainees, Schuchter reported that many trainees 
had met their training objectives, established new collabora-
tions at the trainings, and disseminated what they learned.   

In about 2008, the American Planning Association and 
the National Association of  County and City Health Of-
ficials 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 subse-
quently taken jobs that involve the use of  HIA skills (Pol-
lack, 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 75-

A 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/research-
and-analysis/presentations-and-webinars).  These conferenc-
es 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 rec-
ommendations, 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; Dannen-
berg, 2016).

Funding
No consistent source of  funding has been routinely avail-
able 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-impact-
project) [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 Com-
munity 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 Insti-
tutes.  Some HIAs have been conducted by health depart-
ments 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, of-
ten 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, educa-
tion, 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 encour-
age 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 transporta-
tion and health policy statement (CDC, 2011).

State legislators have proposed or adopted a number of  
bills that include certain elements of  an HIA.  The Na-
tional 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 Massachu-
setts 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 empower-
ment, 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 environ-
ment.   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

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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 

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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.


