Health Impact Assessment Training

1. Health Impact Assessment Training Kristin Raab, MLA, PHA MN Climate & Health Program Director Brenda Hoppe, PhD MN Climate & Health Program Epidemiologist May 20, 2014

2. Outline • What is HIA? • Definitions, background, steps • How has HIA been used to improve health? • Healthy Corridors for All HIA (St. Paul) • HB 2800: Oregon Farm to School and School Garden Policy HIA • Above the Falls HIA (Mpls) • How do I determine if I should do an HIA? • First HIA step: screening

3. What is health? Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Source: World Health OrganizationThis definition has not been amended since 1948

4. Current Health Conditions in the US2000 Avg Life Expectancy and Healthcare Spending US ranked 51stin life expectancy for 2012 https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html http://ucatlas.ucsc.edu/spend.php

5. Health Determinants Health status is determined by: 30% by genetics; only 10% by health care; but 60% by social & environmental conditions, and behavior Source: N Engl J Med 2007;357:1221-8.

6. What do Minnesotans die from? Leading causes of death in Minnesota: 2010 Cause Deaths Rate • Cancer 9,599 166.9 • Heart Disease 7,144 118.7 • Unintentional Injury 2,087 36.4 • Stroke 2,154 35.8 • Chronic Lower Respiratory Disease 2,012 35.1

7. Health Impact Assessment (HIA) • A systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects. • National Research Council, Improving Health in the United States: The Role of Health Impact Assessment, 2011.

8. Values of Health Impact Assessment • HIA aims to advance the values of • democracy • equity • sustainable development • the ethical use of evidence • a comprehensive approach to health • North American HIA Practice Standards Working Group (Bhatia R, Branscomb J, FarhangL, Lee M, Orenstein M, Richardson M). Minimum Elements and Practice Standards for Health Impact Assessment, Version 2. North American HIA Practice Standards Working Group. Oakland, CA: November 2010. Source: http://www.policylink.org/atf/cf/%7B97c6d565-bb43-406d-a6d5-eca3bbf35af0%7D/PROMOTINGEQUITYHIA_FINAL.PDF

9. Why Conduct an HIA? • Identify harms and benefits before decisions are made • Identify evidence-based strategies and recommendations to promote health and prevent disease • Support inclusive and democratic decision-making and increase transparency in the decision-making process • Support community engagement in the decision-making process and foster community empowerment • Advance equity and justice Note: There are many ways to insert health into decision-making. HIA is one way.

10. Types of Decisions Influenced by HIA • Policy Decisions (bills by state legislature, city council decision, local school board on district-wide policy) • Policy Implementation (weigh various implementation options for a policy once it is passed) • Project Specific (siting, permitting, construction, design) • Comprehensive Plans (neighborhood plan, regional growth plans, master planning documents) Provided by Health Impact Project http://www.healthimpactproject.org/

11. What topics have HIAs addressed? Provided by Health Impact Project http://www.healthimpactproject.org/

12. Completed and in progress HIAs Provided by Health Impact Project & CDC http://www.healthimpactproject.org/hia/us

13. HIA at the National Level • Two major national funders • Centers for Disease Control & Prevention (CDC) (directly funds granteesand professional organizations) • Health Impact Project (PEW and RWJF) • SOPHIA (Society of Practitioners of HIA): http://www.hiasociety.org/ • Two conferences: • HIA of the Americas Workshop (Oakland, CA) • National Health Impact Assessment Meeting (WDC) • Local Funder: Blue Cross Blue Shield of MN Foundation

14. History of HIA in MN • HIAs began with Design for Health in 2006 • MDH began providing technical assistance, leading or supporting many HIA-related activities in MN starting in 2009 • Almost all 21 HIAs in MN relate to the built environment: comprehensive plans, land use plans, transportation, except School Integration Strategies, St. Paul Emerald Ash Borer, Safe and Supportive MN Schools Act (not listed). • New HIAs: Winona Co Active Living Plan & Lincoln Park SAP

15. MDH’s Role in Promoting HIA • Leading/performing HIAs: (7) Douglas County Comprehensive Plan; St. Louis Park Comprehensive Plan; Duluth 6th Ave Redesign Plan; Divine Mercy HIA; Gary/New Duluth Small Area Plan HIA; Winona County Active Living Plan HIA; Lincoln Park Small Area Plan HIA • Providing technical assistance: (6)Healthy Corridor for All HIA; Bottineau Transitway HIA; HIA on the Fort DuPont Redevelopment ProjectDE; Second Street Redevelopment Plan GA; Emerald Ash Borer HIA; MN School Location & Design HIA • Providing HIA training:(10+) (250+ people)

16. MDH’s Role in Promoting HIA (II) (http://www.health.state.mn.us/divs/hia/) • Promoting Health in All Policies • EAW & Comprehensive Plans • Tool Development (EAW, comp planning, brownfields, climate change) • Sharing information on HIA:website & listserv (500+) • Promoting HIA through Collaboration

17. Collaboration HIA Interagency Workgroup: (12 agencies) MN HIA Coalition: (70+ members) (http://www.health.state.mn.us/divs/hia/coalition.html)

18. HIA Methodology • Six steps • Stakeholder engagement in all steps • Equity considered throughout the steps • Scalable

19. Six Steps of HIA • Screening - to determine if an HIA is useful for a specific project or policy • Scoping - identify which health effects to consider • Assessment - determine which people may be affected and how they may be affected • Recommendations - suggest changes to proposal to promote positive or mitigate adverse health effects • Reporting - present the results to decision-makers • Monitoring and evaluating - determine the affect of the HIA on the decision process

20. Types of HIAs Modified from Harris et al. 2007. Health impact assessment: A practical guide, Centre for Health Equity, Training, Research and Evaluation (CHETRE), Part of the UNSW Research Centre for Primary Health Care and Equity, UNSW: (http://www.hiaconnect.edu.au/hia_a_practical_guide.htm)

21. Evaluation of HIA • Reviewed 23 HIAs completed in the U.S. between 2005 and 2013 • 11 HIAs directly contributed to decision outcomes—the way projects, plans, and policies were developed or implemented • 14 HIAs influenced changes beyond the decision under consideration • 16 HIAs showed key stakeholders the health effects of non-health policies and programs. • 17 HIAs built consensus • HIAs amplified community member voices in the decision-making process Bourcier, E., Charbonneau, D., Cahill, C., & Dannenberg, A. (2014). Do health impact assessments make a difference? A national evaluation of HIAs in the United States. Seattle: Center for Community Health and Evaluation.

22. Case Studies Healthy Corridor For All (MN) http://sapcc.org/node/600

23. Healthy Corridor for All • 1st Comprehensive HIA in MN: funded by Health Impact Project • Rezoning ordinance • Lead by three organizations: • ISAIAH, Take Action MN, PolicyLink • Community driven: • The HIA Steering Committee (20+) was made up of community leaders and residents http://www.policylink.org/atf/cf/{97c6d565-bb43-406d-a6d5-eca3bbf35af0}/HEALTHYCORRIDOR_SUMMARY_FINAL_20120111.PDF

24. Community Concerns • Transit-oriented development can be very beneficial for communities by providing opportunities for people to live, work, and play without having to get into a car, potentially reducing congestion, air pollution, and increasing access to opportunity for transit-dependent households. Yet, as TOD has been constructed in many cities, it has often been associated with displacement of low-income people and communities of color. This HIA helped support equitable development— ensuring that low-income households and communities of color benefit from TOD without being displaced.

25. Scoping First meetings: • Discussed vision for the community • Discuss range of possible issues • Voted • 3 Areas of Assessment: • Healthy Economy • Healthy, Affordable Housing • Safe and Sustainable Transportation

26. Key research questions: how will the proposed zoning… • Healthy Economy • Obj 1: change the amount and quality of jobs that will be available to residents in the corridor neighborhoods? • Obj 2: affect, small, locally and minority-owned businesses by the corridor? • Affordable, Healthy Housing • Obj 3: affect the likelihood of neighborhood gentrification and the involuntary displacement of current residents? • Obj 4: impact the cost of housing in the neighborhood and the availability of affordable housing? • Safe and Sustainable Transportation • Obj 5: coordinate with and affect affordable and accessible public trans? • Obj 6: coordinate with and affect access to safe and connected routs to from and around rail and bus stops?

27. Housing Pathway

28. Assessment: Availability of Affordable Housing • Existing Conditions: • 14% of total housing units in CC are subsidized affordable units (80% of Area Median Income or less). 65% of corridor residents make less than 80% of the AMI • 59% of resident spend more than 30% of their income on housing, compared with 40% St. Paul & 37% Ramsey • 68% of renters pay more than 30% of their income in rent

29. Assessment: Availability of Affordable Housing (II) • Key Impact Assessment Findings: • Market projections suggest nearly 7000 new residential units may be built in station areas by 2030 of which several hundred may be affordable ifprojects use public funding • % of existing subsidized affordable hosing units is likely to decrease, increasing housing burdens and potentially leading to involuntary displacement • Rising rents and home values will likely decrease the amount of affordable housing • If property values near transit stations continue to rise, acquisition of land for affordable housing near transit will be more difficult due to higher land costs

30. Recommendations: 5 Policies • Community Equity Program: Pilot program requiring residential and mixed use projects within ¼ mi of transit stations to make a % of units affordable or facilitate the production of affordable housing • Codify Commitment to Affordable Housing: make explicit statements in the ordinance of the intent to promote diversity and provide a range of affordable housing • Density Bonus Program: expand incentives in the ordinance to offer increased density in the form of floor area and height bonuses and/or modification of parking requirements for affordable housing

31. Recommendations (II): 5 Policies • Relieving Lack of Commercial Parking: adopt regulations that would allow use of undeveloped parcels for temporary parking lots to relieve parking problems during construction • First Source Hiring: all construction contractors notify the St. Paul Human Rights and Equal Economic Opportunity Department of available job openings—a referral system shall identify targeted applications who meet contractor’s qualifications. Contractor would be required to keep a log of referrals and applicants hired to monitor the program for compliance.

32. Monitoring/Evaluation • Increased relationships among SC members who never worked together in the past • Increased community capacity to understand land use policy and its impacts on health and equity • Research and data SC leaders can continue to use • City Council: resolution to create affordable housing workgroup • Commissioned a feasibility analyses on a number of affordable housing recommendations • Shifted policy debate to include more community voices and introduced health into the discussion

33. Farm to School and School Garden Policy • Bill 2800 (HB 2800), the Farm to School and School Garden legislation, as introduced in January of 2011: • (1) allocate $19.6 million in state funds, equivalent to 15 cents per lunch and 7 cents per breakfast, to reimburse schools for purchasing Oregon food products, and • (2) provide $3 million in competitive education grants to support food, garden and agriculture activities, up to 150 school teaching gardens each fiscal year. Source: Henderson, T., Rader, M., Sorte, B., Ratcliffe, M. M., Lawrence, A., Lucky, J., and Harris, C. (2011) Health Impact Assessment: Farm to School and School Garden Policy, HB 2800, Upstream Public Health and the Health Impact Project. http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

34. Screening/Scoping: Health Determinants • Employment • Diet & Nutrition • Farm to School & School Garden Education • Environmental Health • Social Capital All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

35. Key Research Questions HB 2800 Farm to School http://www.healthimpactproject.org/resources/document/Upstream-HIA-Oregon-Farm-to-School-policy.pdf

36. Assessment • Literature review • Secondary data analysis (food insecurity, school meal eligibility, school nutrition services, unemployment) • Economic analysis • Interviews, committee feedback, community forums All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

37. Assessment: Employment All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

38. Current Conditions/Assessment • Oregon’s unemployment rate was 10.5% in December 2010, higher than the national average of 9% . • The recession hurt Oregon’s farms: almost 2/3 of farms reported net losses. Small & mid-sized farms especially are struggling to compete. • Unemployed are up to twice as likely to die earlier than others of the same age and sex. • The meal reimbursement program would create jobs and stimulate economic growth. All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

39. Conclusions All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

40. Assessment: Farm to School & School Garden Education All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

41. Current Conditions/Assessment (II) • Current Oregon learning standards do not require children to learn where food comes from or how it is made. • Cafeterias are not connected to classroom curriculum. • 1 in 4 Oregon adolescents are overweight or obese. • 58% of 11th graders eat three or less servings of fruits and vegetables a day. • Research on F2S & SG programs report that children choose more fruits and vegetables - leading to potential increases in consumption. • Studies show that children who spend time in the garden learn better, get physical activity and behave better in the classroom. All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

42. Conclusions (II) All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

43. Recommendations • Amend HB 2800 to specify that schools can only get reimbursed for foods produced/processed in OR • Food, Agriculture and Garden education grants will be preferentially given to school districts serving: • a low-income student population • schools with a racially diverse student population • schools in rural or urban areas with limited food access • Support schools developing multiple-component programs, having at least one element in each of the following categories: Education, Promotion, Procurement and Community Involvement All pictures and text from: http://www.upstreampublichealth.org/sites/default/files/F2SHIA_FINAL.pdf

44. Above the Falls Master Plan • (2000) City of MSP & MPRB adopted redevelopment plan for Upper Mississippi Riverfront • Phase out heavy industry, address land use conflicts • Some projects completed, but not to scale • Stakeholders raised concerns over practicalities, costs • (2012) Above the Falls Policy Review and Implementation Study

45. ATF: Screening • Feasible • Resources (staff, money, info) • Interest • Timely • Fit into timeline for incorporation of Review & Implementation Study • Stakeholders already mobilized • Value • Opportunity to increase awareness of health impacts & disparities • Research unknowns • Highlight common ground & accelerate implementation

46. ATF: Scoping Identify Alternatives • Many land use alternatives to consider so developed criteria for selection • 4 measurable land use decision alternatives that HIA would investigate

47. ATF: Scoping (II) Determine Study Area Determine Goals • Elevate health considerations • Maximize benefits & mitigate risks • Collect input from diverse stakeholders, esp. untapped groups • Serve as catalyst for redevelopment efforts

48. ATF: Scoping (III) Identify pathways • Obesity • Environmental quality (air, noise, water quality) • Mental health • Safety & security • Neighborhood cohesion • Neighborhood livability • Employment

49. ATF: Scoping (IV) Scoping Results • Research questions • What draws/inhibits residents to RF? Links to health? • Which land uses draw the most residents to RF locally & regionally? Links to health? • Which land uses could improve/harm health of residents? • Measurable health indicators • Proposed research methods

50. ATF: Assessment Literature review Baseline Health Profile Analysis of Impacts