Category Archives: Health Impact Assessment
Health Impact Assessment Looks at Potential Impact of USDA Nutrition Standards on Student Health, School Budgets
Updating nutrition standards for snacks and beverages sold in school so that they meet the most recent Dietary Guidelines for Americans could help students maintain a healthy weight and support school food service revenue, according to a first-of-its-kind health impact assessment (HIA) released today by the Kids’ Safe & Healthful Foods Project and the Health Impact Project. This is the first HIA completed to inform a new federal rule. The Kids’ Safe & Healthful Foods Project and Health Impact Project are both collaborations of The Pew Charitable Trusts and the Robert Wood Johnson Foundation.
NewPublicHealth spoke with Jessica Donze Black, RD, MPH, project director of the Kids' Safe & Healthful Foods Project, about the HIA findings.
>>Read more on the implications of the HIA for the field in an interview with Aaron Wernham, director of the Health Impact Project.
The snacks and drinks sold in school vending machines, stores and à la carte lines are sometimes called “competitive foods” because they compete with school meals for students’ spending. The U.S. Department of Agriculture (USDA) last issued nutrition standards for competitive foods in 1979, but they mostly covered foods sold in cafeterias at meal times. Since then, says Black, the nutrition environment has changed dramatically, and now there is food sold all over the school throughout the school day. In December of 2010, Congress directed USDA to update those standards, and the proposal is due soon.
The HIA was designed to assess the health impact of the updated nutrition standards, as well as their impact on school and district budgets. According to Black, the HIA found that changing the school environment to make healthier foods more available would change students’ eating patterns, increasing their consumption of fruits, vegetables and low-fat dairy. That change, says Black, could ultimately to lead to less chronic disease.
A first-of-its-kind health impact assessment (HIA) released today by the Kids’ Safe & Healthful Foods Project and the Health Impact Project looked at updating nutrition standards for snacks and beverages sold in school from a perspective of both student health and school budgets. This is the first HIA completed to inform a new federal rule.
NewPublicHealth spoke with Aaron Wernham, MD, MPH, director of the Health Impact Project, about what this HIA represents for the field.
>>Read more on the HIA findings in a Q&A with Jessica Donze Black, project director of the Kids’ Safe & Healthful Foods Project.
NewPublicHealth: Isthis is the first time an HIA has been done on a federal rule?
Aaron Wernham: This is a somewhat new topic for HIA. There have been a number of HIAs of federal agency decisions. So, for example, developing permits for mines and oil and gas activities, but this is the first time that we’re aware of that an HIA has addressed a federal rule-making process.
NPH: Why was HIA the right tool to use in this circumstance?
Aaron Wernham: We advocate for doing an HIA on a decision where it absolutely adds value. There are some decisions for which the health implications may be obvious and are already being addressed, and other decisions where there really aren’t such important health implications. In this case we felt as if some of the health implications were known, or at least suspected as far as the potential nutritional benefits, but there were a lot of questions, such as just what are those benefits and how strong is the evidence for them? So I think that was one reason why we thought the HIA would be very valuable was really to put all of that evidence together into a clear picture to help USDA think through the nutritional benefits for children in setting these standards.
The second question, which really sealed the deal, was the realization that setting nutritional standards is great, but what about the practical challenges that schools may face implementing them? So, HIA was the right tool for this job because it really is a good way to bring the perspectives of the different stakeholders into the picture as well as the best available evidence. The HIA serves to make sure that you’re considering not just what might appear best for health on the face of it, but really a deeper look at the tradeoffs and how to make sure that that ultimate decision is a win/win.
NPH: What implications does this HIA have for the practice of HIAs as a tool to enforce important policy?
Aaron Wernham: I hope and believe that the information in this HIA is going to be useful to USDA as they make their decisions on this rule. But I also think that it’s a pilot to help us understand how do you do HIA well to inform a high level federal regulatory decision? What are the data needs? How do you put together a solid team to do the analysis? What sorts of information are most useful? How do you make sure that all of the stakeholders are collaborating effectively through the process? So I think we’ve learned a lot about that through the process of doing this HIA, and I think that will strengthen the field going forward into doing more HIA work at this level. As the first HIA on federal rule making, we wanted to make sure that it was adequately resourced and done very rigorously.
As a field, we also recognize that there’s really a downside to not considering health when we make many decisions—both small or local decisions and larger federal decisions. The National Research Council, in its review of HIA, said that HIA is valuable because it seeks to correct the fundamental problem of failing to consider health at all in decision making, and even with a lack of perfect data it’s still a valuable tool because it’s better to identify potential health risks and benefits than to ignore them. HIA can really be fit for different purposes and different levels of resources.
The American Public Health Association (APHA) will host a free webinar series this summer on transportation and public health, focusing on key issues including active (non-motorized) transportation and how pediatricians can play critical roles in keeping their patients safe during transport and travel. The first webinar will be held on Wednesday June 13 from 2:00 pm to 3:00 pm EST. Register for the webinars here.
NewPublicHealth spoke with Susan Polan, PhD, associate executive director of APHA, about the upcoming series.
NewPublicHealth: What is the focus of the webinars?
Susan Polan: They are designed to bring real-life, on the ground stories and the most current data on public health and transportation to both public health and transportation professionals. Our research around the country has shown that when a community focuses on these issues and creates an approach to transportation that is not based just on individual car, but is based on the big picture, you have more access for formerly under-served communities, and you’re on a step toward building healthier communities overall.
NPH: What’s your goal with the webinars?
Susan Polan: The goal is for participants to understand how to take some of the beginning steps toward necessary changes in transportation for communities. It's also for them to understand what some of the benefits, seen and unseen, might be. We’ll show data, challenges, obstacles and opportunities so that stakeholders who have an interest in making changes in their own communities are better prepared when they start the planning process.
NPH: The second webinar focuses on the role of pediatricians. Why pediatricians?
Susan Polan: Whenever doctors engage in something which is a little bit outside the normal “how are you feeling?” and “what treatment can we offer?” it does have an impact, and that's true for pediatricians probably most of all. And so, engaging those kinds of opinion leaders and opinion shapers in this debate is critical. This is about helping pediatricians engage in education and policy-making for transportation systems, to help make travel for children and teens, whether they’re the passengers or drivers, much safer. Twenty years ago there were a handful of doctors who were engaged in this and were leading the way, and we are hoping to move this towards the norm rather than the exception.
NPH: And the third webinar looks at health impact assessments (HIAs)?
Susan Polan: Yes, the focus of several health impact assessments recently has been on transportation initiatives, whether it be public transit or safe routes to school or a complete streets approach. The webinar leaders will talk about what we seen in the evaluation when these policies have been put forward, and what the HIAs have shown us are the best practices in potential areas of challenge can make a difference on transportation access inequity.
NPH: Is there a registration deadline for the webinars or can participants sign up until the last minute?
Susan Polan: Depending on where we are in terms of registration, participants can sign in until we no longer have room. And if people are not able to participate in the live webinar, they can access the webinars later on; they will be archived on the APHA site.
At the International Making Cities Livable Conference held in Portland, Ore., last month, Lou K. Brewer RN, MPH, director of the Tarrant County Public Health in Fort Worth, Texas, led a session about a toolkit she and a colleague are creating to help communities track health indicators and the progress made on improving them. The toolkit should be available by the fall and is likely to be a very valuable tool for many departments starting to track indicators in their community as both a resource for key measures and an adaptable tool largely ready to use. But Brewer’s experience as part of a Texas team shaping the future of the state around smart growth, community development, land use and transportation is equally valuable as a blueprint for collaboration to bring health to the table as communities across the country look ahead in creating their development plans.
NewPublicHealth: What brought you to the Making Cities Livable conference?
Lou Brewer: The presentation was about a set of indicators that I and a planner in a neighboring region created. We researched existing health indicators and decided to create a useful toolkit for planners and health professionals, using materials that were already available.
NPH: Why is a toolkit necessary?
Lou Brewer: Well, I’ve been part of Vision North Texas classes, run by planners and the Council of Governments to look at what stakeholders—including elected officials, planners, health educators and citizens—want the area to look like in 2030. Our population is supposed to double and that brings with it lots of challenges and opportunities, and so they’ve done an extensive visioning process, including a yearly summit.
We invited ourselves to the table as a public health entity, and we really wanted to be able to also ask the questions of the impact on health of whatever decisions were made. So we developed a health research team with wide representation and one recommendation was for this health indicator set [to measure progress on health impact], and then we decided we probably needed a toolkit as well. I also have a personal interest in all this because I’m a doctoral student in urban planning and policy, and that’s because I really see an incredibly strong connection between the built environment and health.
NPH: Who else was on the team?
Lou Brewer: We had the immediate past State Health Commissioner for Texas and the current Medical Director of Blue Cross Blue Shield. We had the Assistant City Manager of one of our larger municipalities who’s also a planner and the organizer for the Vision North Texas process. We also had two hospital representatives, a CEO and a community planner, someone from the School of Nursing faculty, and from the Texas Health Institute, and, of course, members of our own public health agency.
NPH: What critical steps did you take as you researched the toolkit?
Lou Brewer: We didn’t want to reinvent the wheel if it was already out there, so we really spent a lot of time going through the literature and looking at websites, and we borrowed heavily from the San Francisco Department of Public Health. They’ve done extensive work in health impact assessments and developing indicators. We also looked at materials from the state of Michigan and the National Association of County and City Health Officials and the American Planning Association. The health research team told us to really concentrate on physical activity and access to nutritious foods, and so we reviewed the literature again to pick out indicators that supported those two objectives and so that’s what helped us come up with them.
Indicator examples include: How far do people have to walk to transit, to schools, to grocery stores? We’re looking at vehicle miles traveled. And we’re looking at the ratio of bicycle routes to vehicle routes—lots of different things that all speak to and support physical activity and access to nutritious foods.
NPH: What response did you get when you spoke about the toolkit?
Lou Brewer: I had a lot of people come up to me afterwards wanting to get a copy. It’s in the draft stage, so I told people who asked that I’d send them a copy, but really wanted them to review it and give me feedback. We’ll have a final version to release soon.
NPH: What were some of the lessons learned?
Lou Brewer: We tied our work to the annual summit and that’s a long time to wait to keep people’s attention. We could have expanded the role of the health research team earlier.
And, while we had representation from faculty, which was great, I think I would have also asked for some student involvement and perhaps they would have had some time and interest in helping us develop some of this.
I’m glad we did involve Vision North Texas, and they in turn are some of the decision-makers for the region, so I think we had support early on. I think they were very respectful of the health piece of this, and I think they were also very glad to have another layer on their argument. We were always asked to be part of any funding opportunities and to make our case there, and so that’s been really great, because there is still a group out there that the light bulb hasn’t quite gone off yet for them in terms of why is health at the table.
NPH: What’s next for the toolkit?
Our next step is going to be feedback from this conference. and feedback from a few more people in the region and we’ll either post the toolkit it to our website sometime this summer or wait for the Vision North Texas Fall Summit and introduce it at a workshop. And then we’ll ask people for feedback on usability and modifications at the summit.
Weigh In: Have you been invited, or invited yourself, to key stakeholder conversations that didn’t have health in the title?
This week is the 49th International Making Cities Livable Conference, taking place this year in Portland, Ore., which will explore how cities can be built and re-shaped in a way that increases opportunities for residents to be active, social and healthy. This year's conference focuses on the theme of "Planning Healthy Communities for All," through inclusive design.
Between 350 and 400 delegates will convene in Portland, "consistently ranked as one of the most livable cities in the United States," to collaborate across the spectrum of fields that play a role in creating healthier communities, including elected officials, urban planners and designers, public health officials, architects, transportation planners, land use developers and more.
Some of the public health speakers on the docket include Richard Jackson, MD, MPH, Chair of the Department of Environmental Health Sciences at UCLA, who recently pioneered a documentary series exploring the development of healthy communities; Andrew Dannenberg, MD, MPH, Professor at the School of Public Health at University of Washington, who will present on health impact assessments; and Lou Brewer RN, MPH, director of the Tarrant County Public Health department in Fort Worth, Texas, who will offer a local "how-to" guide on developing healthy planning policy.
If you couldn't make it to Portland this week, check out the Livable Cities blog, which has interesting articles such as:
- Tips for launching a successful bike-share program.
- A post about why young people aren't buying cars.
- A guest post from Zurich on how most cities are livable—if you're male, older, wealthy and have a car.
>>Read more on building healthier cities.
Model practices were the focus of a session, “Building Partnerships for Healthy Places,” on the first day of the Weight of the Nation conference. Bringing diverse groups together to improve community health was a common element of each of the presentations.
Chris Danly of Vitruvian Planning in Boise, Idaho, talked about his firm’s recently completed health impact assessment (HIA) on the Haywood County (North Carolina) Community Bicycle Plan—which aimed to determine what projects, policies and programs were needed to foster a bicycle-friendly community, through a collaborative process with diverse partners such as County officials, the Recreation and Parks Department, the Department of Transportation, bicycle clubs and the local general store. The HIA found the plan would have positive health impacts on community health, including making virtually all members of the community aware of bicycling as an option for recreation and transportation, and also for drivers to be more aware of bikers on the road.
Danly also suggested to conference-goers that they work on both short- and long-term goals with partners when it comes to the built environment: “It’s a great long-term vision to have everyone walk or ride, but in the meantime existing conditions needs to be fixed.”
Danly’s other suggestions:
- Identify places where people are active and build on those small areas to get your long-range vision.
- Get excited about small victories such as kids walking two blocks to the pool, instead of driving.
- Near-term improvements can include sidewalks, pedestrian lighting, landscaping, crosswalks, bike racks, public art and lighting for tracks to make them usable in the evenings.
- Partnership opportunities include citizen’s patrols, site sharing, joint use agreements and organized runs.
The connection between health and energy consumption is an area just beginning to be understood, but when some people are forced to choose between paying their energy bill and paying for food or medicine, it becomes critical. The Health Impact Project has just released a new health impact assessment (HIA) of a pilot program run by Illinois' largest electric utility, Commonwealth Edison. The HIA looked at the health effects of implementing "smart metering," which replaces existing mechanical meters with digital meters that record customer usage in 15-minute increments. The new meters are coupled with a new two-way communication system that allow a utility company to remotely connect and disconnect service, as well as get real-time, detailed customer usage. The purpose of this HIA was to evaluate the potential health impacts of smart metering for residential customers in the ComEd service territory in Illinois.
The HIA looked at three key issues:
- Whether smart metering will raise customer rates for electricity service because of the additional infrastructure investment costs;
- Whether new energy pricing programs enabled by smart metering will provide benefits to customers or increase costs to vulnerable customers at a time when they can least afford it; and
- Whether the use of a remote service switch to connect or disconnect service, particularly in the case of disconnection for non-payment, will have adverse impacts on vulnerable populations
NewPublicHealth: Why is energy a health issue?
Megan Sandel: Understanding how energy and health are connected is a burgeoning field. We understand that the cost of energy can sometimes be particularly important because families may have to make tradeoffs, such as trading off between paying for their heat and necessarily eating enough. Or they’re trading off between paying for their heat or their electricity bill and being able to pay for medicine. And while some people may see the potential concern for some users over heating costs, they may not connect those similar problems can occur with cooling costs. People have actually died in heat waves because they were not able to access their energy needs in a timely way. And so, we were interested looking at this energy proposal and being able to add in possible health implications.
NPH: What populations are most vulnerable or affected due to a lack of affordable energy and why is that?
At the recent first-ever National Health Impact Assessment (HIA) meeting, convened by the Health Impact Project and partners, the break-time chatter was just as fascinating as the official sessions. Attendees ranged from a public health graduate student who applied for a scholarship to attend the meeting as part an independent study on HIA, to a veteran of the San Francisco Department of Health who has been conducting health impact assessments for over a decade.
The meeting addressed the burgeoning number of HIAs completed or in progress, but it also addressed issues related to determining the need for an HIA, preparing and engaging stakeholders, and helping HIA practitioners both assess the findings and determine how best to convey them and make recommendations. The wide range of HIAs presented spanned a wide range of disciplines including housing, transportation, built environment, incarceration, community development and more.
We found a session on policy HIAs to be especially interesting as a tool to look at the potential for use of HIA to impact health outcomes. Examples included:
School Discipline Policies
Human Impact Partners is nearing completion of an HIA on school discipline policies, including zero tolerance (suspending or expelling students for any infraction) and restorative justice. In Los Angeles, Oakland and Salinas school districts, the HIA analyzed how these policies impact those being disciplined, other students and the broader communities through pathways to health outcomes from drop-out rates and educational attainment, prison, violence, drug abuse, mental health and community cohesion.
Wisconsin Treatment Instead of Prisons
WISDOM, a statewide congregation-based community organization in Wisconsin, has been advocating for state funding for treatment alternatives to prison for almost a decade. In 2006, WISDOM and their allies succeeded in convincing the state to fund treatment alternatives such as drug courts, mental health courts and bail diversion projects in seven counties. WISDOM has been funded by a Robert Wood Johnson Foundation Roadmaps to Health Community Grant to work on a policy that would increase the funding to a statewide level. Human Impact Partners is conducting an HIA to answer the question: How would increasing treatment alternatives to prison impact the health of individuals targeted for incarceration, their families, their communities and the state?
Another theme that emerged throughout the conference was the critical nature of engaging communities and diverse partners throughout every step of the HIA. During a plenary session, Health Impact Project director Aaron Wernham said of the recommendations from one HIA he conducted in Alaska, "A lot of these recommendations fall outside anyone’s regulatory authority. If you’re going to get anything done there needs to be a strong relationship with the community." Wernham said he expects to convene a national meeting again in about a year and a half. And he knows they’ll need a bigger facility next time!
Catch up on the rest of our coverage of the National HIA Meeting:
Last week’s inaugural National Health Impact Assessment (HIA) Meeting held in Washington, discussed the impact of decisions in a broad range of sectors on the health of individuals and communities, and housing sector decisions featured prominently. In a recent interview with NewPublicHealth, Aaron Wernham, MD, MPH, director of the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts, said he was excited to see the growing number of housing HIAs, which he called “very important to health.” Among the housing HIAs presented at the conference were two on low-income rental housing inspections—one on a rental housing inspection program in Portland, Ore. and the other on interagency housing inspection coordination based out of Ohio. NewPublicHealth spoke with lead authors of both HIAs.
>>Follow our coverage from the National HIA Meeting.
Ohio Housing Inspections
Ohio currently has a proposal on the books to streamline the rental housing inspection program on affordable housing units, including improved interagency coordination. An HIA is underway to help inform decisions on the proposal. Right now, separate individual inspections are conducted or required by local housing authorities, the U.S. Department of Housing and Urban Development (HUD), the Internal Revenue Service, and the U.S. Department of Agriculture (USDA) to help identify and repair substandard physical conditions such as water leaks and mold, pests, peeling paint and structural hazards, which can contribute to a wide range of health problems including asthma, injury and burns, and mental illness.
NewPublicHealth spoke with Holly Holtzen, PHD, Strategic Research Coordinator at the Ohio Housing Finance Agency, about the HIA.
NewPublicHealth: What is the goal of the HIA?
A new report finds that some existing laws on the books across the nation offer critical opportunities to improve Americans’ health through the use of health impact assessments.
>>Read more on the new report.
>>Follow our coverage from the National HIA Meeting.
NewPublicHealth spoke with Professor James G. Hodge, Jr., JD, LLM, principal investigator and director of the Western Region of the Network for Public Health Law, about the report.
NewPublicHealth: What’s the background on the report?
James Hodge: This project that we’ve done in conjunction with The Pew Charitable Trusts and the Robert Wood Johnson Foundation has taken a very interesting and important look at the role of law in relation to support for the use and implementation of health impact assessments nationally. This was really uncovered material prior to our research in this arena. We were aware of specific instances where federal, state, tribal or local governments had suggestively made HIAs an important component of particular reviews for public safety or public health through laws, but we had not done any national, systematic study to really assess how extensive that is, particularly in non-health sectors. So, for example, in areas like transportation and environment and waste management, to what extent did law support the use of HIAs? The report has provided some initial answers that really are quite profound in this attempt to illustrate just how extensively law can be supportive of these particular initiatives.
NPH: Based on your review of the laws, is it still a novel concept to consider health impacts in projects in sectors as varied as the environment and transportation?