









































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 Full-
Service 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 worst-
off 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, middle-
upper 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. (2019). American Community Survey Five-year Estimates, DDPHE 
Neighborhood Health Profiles. Retrieved from:  https://www.denvergov.org/content/denvergov/en/environmental-
health/community- health/office-of-health-equity/health-equity-data/neighborhood-health-profiles.html 

Centers for Disease Control and Prevention. (2019. The Guide to Community Preventive Services. Retrieved from: 
https://www.thecommunityguide.org/findings/physical-activity-creating-or- improving-places-physical-activity

Change Lab Solutions. (2015). From Start to Finish: How to Permanently Improve government through Health in All 
Policies. Retrieved from https://www.changelabsolutions.org/product/start-finish-health-all-policies 

Colorado Department of Public Health and Environment, Office of Health Equity. (2019). Health Equity. Retrieved from:  
https://www.colorado.gov/pacific/cdphe/ohe

Colorado Health Institute. (2018). Health Equity: A guidebook for public health practice: Metro Denver Partnership for 
Health. Retrieved from: https://www.coloradohealthinstitute.org/sites/default/files/file_attachments/MDPH_HE_
Guidebook_FINAL08142018_0.pdf 

National Association of County and City Health Officials. (2012). Health in All Policies: Frequently Asked Questions. 
Retrieved from:  https://www.naccho.org/programs/community-health/healthy-community-design/health-in-all-
policies

Public Health Institute. (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/community- health/office-of-health-equity/health-equity-data/neighborhood-health-profiles.html
https://www.denvergov.org/content/denvergov/en/environmental-health/community- health/office-of-health-equity/health-equity-data/neighborhood-health-profiles.html
https://www.thecommunityguide.org/findings/physical-activity-creating-or- improving-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

