Health Impact Assessments are used to evaluate the potential health effects of a project or policy before it is built or implemented, in order to increase positive health outcomes and minimize adverse health outcomes. HIA is a particularly valuable tool in advancing health reform work and at the same time, health reform provides a key opportunity to advance HIA and primary prevention. In his testimony to the Institute of Medicine's National Research Council Committee on Health Impact Assessment, Larry Cohen outlines the links between prevention and health reform; how prevention and HIAs intersect; and how a Collaboration Multiplier be used to complement an HIA to improve intersectoral primary prevention.
Testimony to the National Research Council Committee on Health Impact Assessment
July 28, 2010
Background and Introduction
Thank you for the invitation to testify on a very important approach to advancing community health. I am Executive Director of Prevention Institute, a national non-profit center designed to serve as a focal point for primary prevention practice and health equity. Today I will discuss the role that Health Impact Assessments (HIA) can play in the national health reform initiative. HIA is a particularly valuable tool in advancing health reform work and at the same time, health reform provides a key opportunity to advance HIA and primary prevention. I will share the links between prevention and health reform; address the intersections of prevention and HIA; and describe an important tool that can serve as a critical complement to HIA in improving intersectoral primary prevention.
I. HIA is a Valuable Tool for Advancing Community Prevention and Equity
Prevention Institute focuses on community primary prevention—what we can do in the first place to prevent illness, injury, and violence. We define health broadly and comprehensively to include the promotion of equity; physical, mental, and social well-being; and the prevention of illness, injury, and violence. Our primary prevention approach—calling for comprehensive community level changes—aligns perfectly with HIA which seeks to document the potential health impacts of a project or policy before it is carried out. HIA's dual emphasis on community participation and community outcomes makes this tool a significant contributor in advancing primary prevention and equity.
HIA must elevate equity—both by highlighting existing inequities in policies and programs in specific communities and by focusing on and demonstrating the importance of investing in communities with greatest need. While equity seems to be an underlying value of HIA, it would be beneficial to explicitly designate equity as a fundamental principle and goal in HIA guidance and in every HIA conducted. For example, HIA could serve to enhance equitable community planning policies by documenting the conditions that contribute to health disparities. In Oakland, where Prevention Institute is based, Dr. Anthony Iton and his team at the Alameda County Public Health Department found that an African American child living in Oakland's low income flatlands will die, on average, fifteen years before a Caucasian child living in the affluent Oakland Hills. These inequitable conditions are not inevitable but rather the outcome of specific policy and planning decisions. In instances such as these, HIA can be used to tease out the elements that magnify these inequities and to identify strategies to reduce them.
A key element of prevention is that it incorporates a broad understanding of health by focusing on factors that help determine health—including transportation, planning, business, and safety—that at first blush seem far from health (which is far too often conflated with health care). The inclusion of injury and violence under safety is important, as many health practitioners focus solely on illness and death. HIA, too, should explicitly include violence and injury in its definition of health, as these are critical and often overlooked community health issues. One of the greatest strengths of HIA is that it addresses mainly non-medical issues and demonstrates their implicit health effects, creating opportunities to generate broad, cross-sectoral understanding of health impacts. When sectors outside of health not only understand that their decisions have important heath outcomes—positive or negative—but also that they can make adjustments to directly promote health, they are more likely to consider health impacts in their decision making. Thus, HIA not only demonstrates impact, but in so doing, improves the health impact of decisions.
HIA is also based on the notion of Health in All Policies, which Prevention Institute prefers to frame as Health, Safety, and Equity in All Policies. As we have seen in the past with anti-tobacco policy and auto safety, individual behavior and community health can be greatly impacted by changing social and political norms. We at Prevention Institute feel that the health field needs to move in the direction of using HIA broadly to institutionalize health as a component of all policies.
Finally, Prevention Institute's approach to research and evidence is not only informed by the peer-reviewed literature base but also emphasizes the direct wisdom of communities and community based practitioners. Our extensive experience shows that the scientific research base for many cutting edge and cross cutting community health areas is inadequate and lags behind community wisdom. Also, prevention has historically been far less studied than medical interventions and comprehensive community strategies are far less studied than individually oriented strategies. Therefore, while it is implicit in the approach, HIA should more strongly incorporate and value the wisdom of community practitioners. Unless it is explicitly stated as a component of the five stages of the HIA process, however, the translation of wisdom into practice may not be well carried out.
II. Collaboration Multiplier and HIA: Complimentary Tools to Coordinate Intersectoral Efforts
Prevention Institute has extensive experience capturing the wisdom of communities and practitioners across sectors to foster collaborative processes that promote health and equity. We have translated this experience into a suite of strategy tools that serve as natural compliments to the HIA process. By actively promoting the notion of engaging practitioners from a variety of sectors, HIA can engage a broader network of individuals and organizations to understand the problems at hand and seek solutions. In order to mitigate negative health impacts and promote community well-being the solutions must be creative, cross-sectoral, and responsive to community concerns. This can only be achieved after thorough analysis of the approaches, needs, and knowledge base of every sector involved.
The Institute's Collaboration Multiplier tool, in particular, enhances the five stages of HIA by fostering meaningful and impactful cross-sectoral collaboration. Collaborations can create a forum for research institutions, grassroots organizations, community members, government agencies, and other participants to cooperate, share information and resources, and minimize reinventing the wheel. Successful collaborations require developing a working knowledge of how other agencies or disciplines think, function, and define success. Mandates, problem definitions, data sources, and stakeholders are likely to be different, especially when working across disciplines. Collaboration Multiplier is both a tool and a process that clarifies and promotes the benefits of cross-sectoral collaboration, suggests what needs to be better understood or studied, and identifies key players that can enhance the process. The tool guides users through a process that helps diverse sectors better understand one another's perspective, identify strengths and gaps in their partnership, and realize the benefits of working together. Collaboration Multiplier is unique in that it identifies the perspectives and shared benefits for other sectors first, so that communication about health impacts can be as engaging, persuasive, and as sensible as possible. HIA can build from the lessons learned in the process of using Collaboration Multiplier and apply them to a single issue or project. In a broad sense, HIA and the Collaboration Multiplier tool are means to institutionalizing a different approach to health across all policies and sectors.
Prevention Institute has recently used Collaboration Multiplier to analyze key opportunities for cross-sectoral collaboration in the Let's Move program for the federal interagency Task Force on Childhood Obesity (see Appendix). The Institute has also used Collaboration Multiplier to reduce traffic related injuries with the Traffic Safety Center at the University of California, Berkeley (see Appendix). In each of these instances, HIA could be used by the collaborative to demonstrate the health impacts of proposed policies and programs, helping to ensure that resources are devoted to promising and best practices.
III. Current Opportunities for HIA in the National Health Reform Initiative
The work of Prevention Institute and partners in the prevention field has been augmented with the historic passage of the Affordable Care Act and an unprecedented federal investment in prevention and wellness. Together, three interrelated components of health reform present key opportunities to not only advance prevention, but also to create broad understanding and utilization of HIA: the National Prevention and Health Promotion Strategy; the Prevention and Public Health Fund, which supports community prevention work; and the National Prevention, Health Promotion and Public Health Council, which consists of twelve agencies at minimum and is led by the Surgeon General. In addition, stimulus funding from the American Recovery and Reinvestment Act established the Communities Putting Prevention to Work (CPPW) initiative, through which 44 communities throughout the United States received grants in 2010.
Our task as public health advocates is to direct these new resources to those strategies that prevent illness, injury, and violence in the first place by focusing on underlying government and community conditions and decisions. In turn, this will reduce the burden on our health care system and promote the health of the American population. What is required in this effort is an understanding of the health impacts of a number of sectors, which HIA can provide. Accordingly, Prevention Institute recommends that CPPW grantee leaders receive training on Health Impact Assessment. Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Health Group, currently funds HIAs in approximately 30 sites, many of which are located near CPPW grantees. Where this is the case, we advise that the people working on the HIAs should reach out to local and state CPPW leaders to create synergy in their work.
One example of a potential partnership is in Hawaii, where a CPPW grant is supporting the enhancement of Hawaiian self-sufficiency. On the local and state levels, Hawaiians are exploring ways to reduce their dependence on imports and gasoline and return to a sustainable, locally-based economy. Building collaboration locally could enhance the process and goals of both initiatives. Given that many people are closely watching CPPW as a model program, this would be another opportunity to elevate HIA on the local, state, and national levels. HIA experts should also reach out to key individuals including the U.S. Surgeon General, who will lead the National Prevention, Health Promotion and Public Health Council, and the Director of Policy for the Centers for Disease Prevention and Control. Naturally, Prevention Institute stands ready to help in this work.
With the passage of the Affordable Care Act we have unprecedented funding to address health in a comprehensive, cross-cutting way that takes into account the broad determinants of health. The approach is rooted in equity and in the needs of communities. In order to do this work well, it must be done sustainably with an emphasis on changing norms and institutionalizing health-promoting principles. We see HIA as playing a critical role in supporting this work and offer the following preliminary recommendations to maximize the added value of HIA in the context of health reform.
- Create a toolkit—including HIA and Collaboration Multiplier—that enhances efforts to work across sectors. The toolkit should help health practitioners demonstrate that health is inextricably linked to the core mission of multiple sectors.
- Balance rigorous data collection with community utility in order to frame HIA as an accessible, pragmatic process rather than a cumbersome requirement.
- Develop and disseminate several modalities of HIA for use in various contexts. Ultimately, the process of a HIA must be adaptable to serve the needs and priorities of the local community and stakeholders.
- Provide training at the community and local government levels, where much of health reform will actually play out.
- Train those who are thought of as leaders and advocates to understand HIA, Health in All Policies, and the importance of multisectoral collaboration. This includes: the National Prevention, Health Promotion and Public Health Council; the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health; and health practitioners and advocates across the nation.