American Journal of Public Health (Vol. 96, pg. 262)  [Printer-friendly version]
February 1, 2006


By Andrew L. Dannenberg and others**


Health impact assessment (HIA) methods are used to evaluate the impact
on health of policies and projects in community design, transportation
planning, and other areas outside traditional public health concerns.
At an October 2004 workshop, domestic and international experts
explored issues associated with advancing the use of HIA methods by
local health departments, planning commissions, and other
decisionmakers in the United States.

Workshop participants recommended conducting pilot tests of existing
HIA tools, developing a database of health impacts of common projects
and policies, developing resources for HIA use, building workforce
capacity to conduct HIAs, and evaluating HIAs. HIA methods can
influence decisionmakers to adjust policies and projects to maximize
benefits and minimize harm to the public's health. (Am J Public
Health. 2006;96:262-270. doi:10.2105/AJPH.2005.069880)

IN RECENT YEARS, AWARENESS that community design, land use,
transportation systems, and other environmental and social factors
affect the health of the public has increased.[1-4] But few health
officials or urban planners have training or experience in each
other's fields.

A health impact assessment (HIA) is commonly defined as "a combination
of procedures, methods, and tools by which a policy, program, or
project may be judged in terms of its potential effects on the health
of a population, and the distribution of those effects within the
population."[5] An HIA can be used to improve communication between
local health departments and community decisionmakers, en- abling the
latter to consider improved designs to favor health promotion or
minimize adverse effects on health. For example, an HIA of a proposed
airport in England focused on noise, air pollution, traffic
congestion, and local employment and led to health-promoting changes
in the developer's plans.[6]

The development of HIAs in recent years has grown in part out of
assessments of the environmental and social impacts of large
projects.[7] Environmental impact assessments (EIAs) focus on air and
water quality and other environmental consequences of proposals with
little attention to health impacts.[8] HIAs and EIAs both promote
public accountability for the con-sequences of decisions that affect
communities; they differ in the scope of impacts analyzed and the
implementation process.[8]

Interest in HIA at the Centers for Disease Control and Prevention
(CDC) developed out of discussions at a 2002 workshop that led to a
research agenda on issues to advance the field of public health in
relation to community design.[9] Numerous HIAs have been conducted in
Europe and elsewhere[10,11] but few have been done in the United

In October 2004, the Robert Wood Johnson Foundation and CDC hosted
discussions about HIA with invited experts at a 2-day workshop in
Princeton, NJ. The workshop objectives were to explore key research
questions regarding HIA methods and to advance the development of HIA
instruments for use by community decisionmakers in the United States.
Five workshop participants from the United Kingdom, Canada, and the
World Health Organization had extensive expertise with HIA. US
participants came from local health departments; transportation,
environmental health, and urban planning groups; academia; the Robert
Wood Johnson Foundation; and the CDC.

Before the workshop, a planning committee developed a set of
research questions regarding HIA methods. The workshop invitees helped
revise these questions and then provided brief answers to the 12
questions that were used to initiate the discussions at the workshop.
Although not representing a consensus of all persons involved, this
article includes ideas from workshop participants and other interested
individuals listed in the acknowledgments.

Key findings and recommendations for further research from the
workshop are summarized in the box.


Steps to conduct an HIA include screening to identify projects or
policies for which an HIA would be useful; scoping to identify which
health impacts should be assessed and which populations are affected;
assessing the magnitude, direction, and certainty of health impacts;
reporting of results to decisionmakers; and evaluating the impact of
the HIA on the decisionmaking process.[13,14] Many existing HIA
methods and instruments[10,11,15] ready for pilot testing in the
United States. Some HIA approaches focus on biomedical health outcomes
(e.g., cardiores- piratory disease),[16-18] some define health
holistically to include social, economic, and environmental
conditions,[19,20] and others focus specifically on the equity impacts
of policies and projects.[21,22] HIA instruments range from simple
checklists[23] to complex collaborative processes.[24]


Box: Summary of Key Findings and Research Needs to Advance the
Field of Health Impact Assessment (HIA) in the United States

Key Findings

Finding No. 1: Existing Hia Tools And Methods

* Some biomedical in scope, some more social/holistic; range from
checklists to multistep processes

* Numerous HIA tools and methods exist; no single tool is best

* Some local health departments in United States now ready to do HIA
pilot tests

Research Needs For Finding No. 1

* Review existing HIA tools and methods

* Conduct HIA pilot tests in United States

* Perform more systematic reviews of evidence used in HIAs in
nonhealth sectors (e.g., housing, transportation)

Finding No. 2: Context For Hia Use: Projects And Policies

* Projects are part of continuum within policies

* HlAs of place-based projects may have better defined target
populations and activities, more readily involve stakeholders, and
have shorter time frame

* HIAs of policies may have broader scope of potential impacts, take
more time, affect more people, involve more stakeholders, and be more
complex Resource needs and limitations of HIAs

Research Needs For Finding No. 2

* Develop social marketing strategy for improved visibility of public
health in nonhealth sectors

* Identify HIA methods best suited for evaluating specific types of
projects and policies

Finding No. 3: Resource Needs And Limitations Of Hias

* Need trained staff, time, and other resources to do HIAs

* Demand for HIA affected by political context and severity of health
outcomes of project or policy

* Need political support and champions to build support for HIAs

Research Needs For Finding No. 3

* Improve communication tools to inform decisionmakers about HIAs

* Develop guidelines for selecting appropriate HIA tool based on
context and resources available

* Develop tool to estimate resource needs to conduct HIAs in US health

Finding No. 4: Hia Measures And Hia Resource Database

* Existing tools (e.g., geographic information systems) may be useful
for conducting HIAs

* Consensus on high value of HIA database and need for substantial
resources to build and maintain it

* Existing HIA Web sites from England (http://www.publichealth. and UCLA (
edu/hs/health-impact) are good starts

Research Needs For Finding No. 4

* Improve quantification of effects of changes in social determinants
of health, such as specific health impacts of changes in housing,
income, transportation, or access to recreation

* Build and maintain database that includes inventory of HIA tools,
guide to choice of HIA tools, systematic reviews of health impacts for
range of policies and projects, links to completed HIAs, lists of HIA
experts, and user-friendly search capacity

* Consolidate existing HIA glossaries to reach common terminology

Finding No. 5: International Hia Experience

* HIA tools and methods from Europe and elsewhere should be adaptable
for US use

* European Strategic Environmental Assessment framework incorporates
assessment of health impacts

* Private sector plays more of role in project development in United
States than in Europe Voluntary vs regulatory HIA process

Research Needs For Finding No. 5

* Examine how HIA achieved current levels of support and legitimacy in
Europe and elsewhere to try to achieve similar levels in United States

Finding No. 6: Voluntary Vs. Regulatory Hia Process

* HIAs as regulatory process may ensure legitimacy and build

* Existing EIA laws may now allow but not require HIA; Canada and
other countries have integrated EIA and HIA processes successfully

* Barriers to adding HIA to existing regulatory EIA processes include
adequacy of HIA predictions in litigious EIA environment, political
and legal challenges to changing EIA practices, and need for resources

Research Needs For Finding No. 6

* Perform voluntary HIA pilot tests in United States to establish
credibility and usefulness of HIAs before considering regulatory

* Develop links of health impacts to overall planning processes

Finding No. 7: Hia Community Involvement And Environmental Justice

* Community involvement promotes environmental justice and social
equity, helps identify locally relevant issues, aids community
empowerment, and improves transparency of decisionmaking

* Community involvement requires time and resources and may delay
completion of HIA

* Local health disparities data may not be available

Research Needs For Finding No. 7

* Develop guidelines and identify best practices to facilitate
community involvement

* Train HIA practitioners in skills for community involvement
such as cultural sensitivity and accountable listening

Finding No. 8: Timing And Governance Of Hia Process

* HIA best done as early as practical in decision process during
window of opportunity for usefulness

* Participants in HIA process and interactions with decisionmakers
vary by organization and topic

* Planners can use HIA to educate public health officials about
constraints in planning

Research Needs For Finding No. 8

* Develop model timelines for HIA process

* Develop model agreement for governance of HIA conduct

* Explore potential for various groups to take lead on
conducting HlAs, such as health officers, academics, and

Finding No. 9: Training Public Health Professionals In Hia

* HIA courses are well established in Europe

* Public health officials now have many of the necessary skills but
need some additional training to conduct HIAs ** Public health
officials presenting HIA results need to be credible and knowledgeable
to influence decisionmakers

Research Needs For Finding No. 9

* Adapt existing and develop new HIA training resources for
use in United States (e.g., guides, courses, Web sites,
case studies, core curriculum, distance learning)

* Train multidisciplinary teams in HIA skills

* Educate community stakeholders about HIA process to
increase HIA usefulness

Finding No. 10: Training Planners And Decisionmakers In Hia

* Need to target decisionmakers who can use HIA results

* Need to consider methods to incorporate health into formal
decisionmaking processes so that health officials will be at table

Research Needs For Finding No. 10

* Develop briefings, seminars, short courses, and case
studies about HIA for planners and decisionmakers

* Create media attention to HIA process

* Develop incentives for HIA use, such as involving
decisionmakers in HIA process, promoting HIA as part of
improved policymaking, and motivating communities to ask
for HIA process

Finding No. 11: Evaluation Of Hias

* Major forms are process evaluation of HIA steps done, impact
evaluation of effect of HIA on project or policy, and outcome
evaluation of actual health impacts compared with those predicted

* Useful to evaluate stakeholder involvement

* Some HIA evaluations have been completed, but comparisons of HIAs
are difficult because of variability in reporting

Research Needs For Finding No. 11

* Conduct further HIA evaluations

* Develop practical criteria for process, impact, and outcome
evaluations of HIAs

* Develop staff capacity to conduct evaluations of HIAs

Finding No. 12: Communicating Findings Of Hias

* Potential audiences include planners, politicians, project
developers, health agencies, media, community stakeholders, and

* Nontechnical report, needed for political decisionmakers, community
stakeholders, and lay audiences, should include background, health
impact findings, and recommendations

* Report for technically trained audience should include executive
summary, scoping, literature review, assumptions, major health impact
findings, sensitivity analyses, levels of uncertainty, discrepant
views, and recommendations

Research Needs For Finding No. 12

* Develop guidelines for HIA reporting formats to facilitate
later comparisons and evaluation

* Create model HIA reports that can be used to educate
decisionmakers about HIAs

Note. EIA=environmental impact assessment. Data are from Health Impact
Assessment Workshop, Princeton, NJ, October 12-13, 2004, sponsored by
Robert Wood Johnson Foundation and Centers for Disease Control and


For a given project or policy, the choice of method depends on
purposes of the HIA and available time and resources. A review of
available HIA instruments is currently under way (Mindell J, MBBS,
PhD, FFPH, e-mail communication, September 6, 2005). Guidelines for
selecting the best HIA method for various types of projects and
policies and systematic reviews of the evidence used in existing HIAs
are needed. A few local health departments (e.g., San Francisco[25,26]
and Los Angeles[27] now conduct HIAs; others have discussed with CDC
staff a willingness to conduct HIAs when resources become available.
HIA pilot tests could provide information on the usefulness of HIA
methods in US settings, the availability of needed health impact data,
and the acceptability of the process to local decisionmakers.


The methods for conducting HIAs are similar for place-based projects
(e.g., new residential de- velopments), public policies (e.g.,
subsidized mortgages), and planning processes (e.g., transit system
expansions). HIAs may include both policy and project components, such
as zoning revisions needed to allow smart growth communities to be
built. Although policies may have substantial impacts on public
health, imprecise policy wording or inconsistent implementation (e.g.,
frequent use of variances) can make it difficult to define and
quantify changes in associated health outcomes. Projects typically
affect geographic regions and populations for which it is easier to
define potential health outcomes, identify stakeholders, and collect
baseline data. Health-related data may not be available for a small
geographic region affected by a project or may represent a population
different from the specific population affected by the project. The
available evidence for a health impact (e.g., predicted trail use) may
relate to a population ethnically different from the one impacted by a
project. Results of HIAs of projects may need to be disseminated to
smaller but more intensely interested groups of stakeholders concerned
about their neighborhoods than results of HIAs of policies do.


Resource needs for HIAs vary by scope, depth of analysis, time
available, and processes employed. For example, city council questions
about a proposed policy may require a quick answer, using readily
available evidence and expert opinion but with little stakeholder
input or detailed data analysis. In contrast, an HIA conducted in
parallel with a city planning process could include more impacts and
more extensive literature review, data analysis, and stakeholder
participation. An HIA on 1 specific policy or project may require
fewer resources than a request to compare options to achieve a
specific policy goal (e.g., reduced obesity, increased community
walkability), particularly if the issue is controversial. HIA resource
needs are also influenced by the processes chosen. A mandatory HIA
with defined minimum scope of impacts, rules for evidence, and
procedures for community participation can require more resources than
a voluntary HIA. Decisions to collect original data or hold
stakeholder meetings have resource implications. HIA time and cost are
also determined by analysts' experience and the availability of prior
similar HIAs.[28] Whether health department staff, consultants,
academics, or others are best situated to conduct HIAs depends on

All HIAs have limitations. The quality of evidence connecting policies
and projects to changes in environmental and social conditions may be
strong or weak. Similarly, the causal link between such conditions and
health outcomes may or may not be supported by strong scientific
evidence. Some causal links are relatively clear (e.g., traffic
congestion, air pollution, and respiratory disease), whereas others
are difficult to document (e.g., airport noise, disturbed sleep, and
physical illness).[29] For a place-based HIA, the outcome may balance
the best available science, competing societal objectives, and local
political considerations. Overall, HIA value is determined by
timeliness, completeness, and decisionmaker interest.


Measures to assess health impacts may be derived from knowledge of
determinants of health (e.g., income or housing quality), from
existing methods used in the natural and social sciences, or from
measures identified through a community participatory process.[25,30]
Geographic information systems and health surveillance systems are
useful for many HIAs. Gaps in the evidence both between proposals and
determinants of health and between determinants and health outcomes
may limit the precision of many assessments. For example, the relation
between income and health is well documented, but the impact on health
of interventions designed to increase income is difficult to

HIA practitioners would benefit from the creation of a single easily
accessible source of information about HIAs. Such a searchable
database should contain an inventory of HIA tools, guidelines for
choosing HIA tools, systematic reviews of health impacts for a range
of policies and projects, links to completed HIAs on numerous topics,
and lists of HIA experts. For example, it should contain reviews of
quantitative evidence (exposure-effect estimates) of health impacts
for specific projects when such exists[31] and of qualitative evidence
when quantitative data are lacking. Many such reviews need to be
developed.[32] The maintenance of such a database requires ongoing
resources. The English HIA Gateway Web site[10] is an excellent start
for developing a more extensive database.


Numerous HIAs have been conducted in Europe, Canada, and elsewhere in
recent years, both linked to EIAs or as inde- pendent processes.[33]
Europe is a leader in adopting HIAs to encourage sustainable
decisionmaking, both within and between its borders. The European
strategic environmental assessment framework includes evaluation of
health impacts of policies, plans, and programs across different
sectors;[34-36] in Canada some HIAs are done within a strategic
environmental assessment process under a cabinet directive. Australia,
New Zealand, Thailand, and Canada have integrated HIA into project-
specific EIA legislation.[16,37-39]

On the basis of HIA experience elsewhere, barriers to HIA use in the
United States include the lack of domestic experience and the need for
tools, documentation, training, and resources. HIA practitioners need
better health information systems, knowledge of health impacts, and
access to previous HIAs as models. Decisionmakers need clear
information on the kinds of health impacts expected and measures to
alleviate these impacts. Practical HIA guides developed in Europe and
elsewhere could be adapted for use in the United States.[11,20,40,41]


Whether HIA should be integrated into existing regulatory EIA
practices or should be conducted on a separate voluntary or regulatory
basis is an important issue. In the United States, the National
Environmental Policy Act allows the assessment of health impacts
within the EIA process in the context of physical environmental
changes.[8,42,43] Some state laws (e.g., California[44]) require the
analysis of adverse impacts on humans resulting from such physical
environmental changes. In practice, such assessments are usually
limited to physical and chemical hazards (e.g., pollution of water may
lead to gastrointestinal illness) and exclude sociobehavioral factors
not mediated by toxicological mechanisms (e.g., construction of
walking trails may lead to increased physical activity) [43,45,46]

As a model for HIA, EIA includes rules for process transparency,
quality of evidence, public participation, and accountability and may
require examination of strategies to mitigate environmental impacts.
Conducting an HIA through an existing regulatory process may help
build constituency and ensure legitimacy.

Several obstacles may prevent adding health impacts to existing EIA
procedures in the United States. Laws or regulations that broaden the
required scope of EIAs would face political and legal challenges. Some
HIA predictions (e.g., the associations between sidewalks, walking,
obesity, and heart disease) are insufficiently robust to withstand the
litigious environment of EIA practice. Quantitative modeling of some
HIA outcomes (e.g., mental health) is more difficult than modeling of
EIA outcomes (e.g., air pollution). Changes in practices may have
limited support from regulatory officials who oversee EIAs. Finally,
conducting an HIA within the EIA process would require funding.

Using HIA on a voluntary basis to further develop methods and
demonstrate its value seems most practical in the United States at
this time. Where legal language is permissive, an HIA may be done
voluntarily within an EIA if requested by a decisionmaker or a
community. Guidance on including health in environmental assessments
is available from the World Bank and other sources.[20,47]


HIA processes in many countries incorporate active participation of
interested stakeholders.[48-51] Advantages of such participation
include promoting social equity and environmental justice,[52,53]
identifying locally relevant issues, improving transparency of
decisionmaking, providing information for estimating or mitigating
impacts, and facilitating community empowerment. Local participants
also may help promote HIA recommendations to decisionmakers.

Community participants may be individuals or representatives of
organizations, such as service providers, business or neighbor- hood
associations, or advocacy groups. Meaningful participation in public
agency decisionmaking may be difficult for persons with limited
economic or political resources.[54-56] Persons conducting HIAs need
skills such as cultural sensitivity, accountable listening, and
respect for community experience and should ensure that community
participants understand the objectives of the process and their roles.
Such roles could range from providing input for consideration to
having a vote in the decision. The level of community participation
may be influenced by the importance of the issue, scope of the
assessment, and time and resource availability. Decisionmakers may
need to judge the significance of information provided by community
participants, such as a claim that a new trail would attract crime in
the absence of evidence of crime near other trails.

Some HIA practitioners believe HIAs are incomplete without community
stakeholder input. For an HIA of a policy affecting a large
population, extensive participation is often appropriate, involving an
advisory board that includes stakeholders and is empowered with
oversight, direction of the assessment, and communication of its
findings. Community involvement in HIAs may be integrated into other
community input processes. For an HIA needed promptly to influence a
decision, community involvement may not be feasible.[57] Existing
literature on community involvement in HIAs describes diverse
approaches and their impacts in various settings.[54.58] Best
practices are needed.


The timing of an HIA affects the likelihood of influencing
decisionmakers. An HIA early in the decisionmaking process enables
greater involvement and buy-in of decisionmakers and stakeholders. The
time available influences the depth and breadth of the HIA.[59] In
this article, the term HIA refers to a prospective process. Opinion is
divided on whether concurrent and retrospective assessments of
projects and policies should be considered in HIAs.[60] As with
evaluation processes, nonprospective activities can influence a
decisionmaker to modify a project only after the project has started.

HIA practitioners and decisionmakers should work together throughout
the assessment process. Input from decisionmakers enhances
understanding of the proposal and the scope for change; their
involvement increases their "ownership" of the HIA activity and
likelihood of accepting subsequent recommendations. HIAs can be used
to educate health officials about planning constraints and planners
about the health effects of their decisions.[61,62]

Close involvement with decisionmakers, who may strongly support or
oppose a proposal, could compromise the independence of the HIA. To
help maintain credibility, decisionmakers and health impact assessors
should have a written agreement defining the scope, governance,
products, use, and dissemination of the HIA. Integrity of the HIA
process is enhanced by adherence to the values of transparency,
democracy, equity, sustainability, and the ethical use of evidence
described in the Gothenburg and Merseyside guidelines.[5,24]


Training of Public Health Professionals

Training of public health professionals is needed to build capacity to
conduct HIAs. To influence decisionmakers, HIA professionals should be
credible and knowledgeable. A training curriculum should include
skills to understand the HIA process, identify stakeholders, analyze
policies, identify and quantify health impacts, communicate re- sults,
and understand land use and transportation planning.[63] Although
public health officials already possess many of these skills, the
introduction of HIA requires training and continuing education of
multidisciplinary teams including other public officials, planners,
social scientists, epidemiologists, economists, and environmental
health specialists. Training community stakeholders to provide
informed input is also useful. To build capacity, training
opportunities should be developed, such as school of public health
courses, state-level workshops, and distance learning modules.[64]
Various HIA training materials and case studies are available
online.[10] In-depth training courses have been developed by the
University of Liverpool, the London Health Observatory, and the World
Health Organization.[65-67] Existing European training materials can
be adapted for use in US communities. As demand increases, development
of "train the trainer" courses would be valuable.[68] A certification
process for HIA practitioners should be considered, similar to that
for environmental professionals.[69]

Training of Planners and Decisionmakers

Planners and decisionmakers would be more likely to request and use
HIA processes if trained to understand their value. Existing training
materials, such as the University of Birmingham manual[70] and others
on the HIA Gateway Web site,[10] cover the basics of HIA methods well
and could be revised to incorporate examples from US communities. HIA
seminars, briefings, short courses, case studies, and primers could be
offered by national and state planning, public health, and
environmental organizations.

HIA training for planners and decisionmakers should be
interdisciplinary, problem-based, and not overly technical. Joint
training programs could be established in which health professionals,
planners, decisionmakers, and interested public participants could
learn together. Familiarity with HIA basics would be enhanced if
taught routinely in all schools of planning and of public health.
Further work is needed to develop incentives to conduct HIAs so
planners, decisionmakers, and communities will request health impact
information as part of their decisionmaking processes. For example,
the value of HIA for improving decisionmaking processes needs to be
better documented.


Evaluation of HIA effectiveness is important to advance the field,
demonstrate value, document influence on decisions, improve quality,
facilitate training, enhance institutional relationships, raise
awareness of health impacts for decisionmakers, and examine adherence
of processes to underlying values.[5] Three types of HIA evaluation
have been described.[60] Process evaluation examines how the steps of
the HIA process were done. Impact evaluation assesses the effect on
decisions made; documenting the cause and effect of observed changes
can be difficult.[71] Outcome evaluation compares the health outcomes
after implementation with those predicted by the HIA and may be
complicated by differences between the initial proposal and subsequent

Most published HIM are the reports presented to decisionmakers[10] and
lack documentation of subsequent outcomes.[72] Some
process[6,19,73,74] and impact[7] evaluations have been conducted;
most found positive benefits of HIAs.[75,76] Ideally, process
evaluations should be done on all HIM, and impact and outcome
evaluations done where resources permit. A set of standards for the
conduct and evaluation of HIAs would be useful. Despite methodological
problems, outcome evaluations of recent HIM could be conducted now.
Criteria for evaluating HIAs have been developed.[77] Evaluating HIA
as a field requires the synthesis of evalua- tions of individual HIM.
Longterm evaluations should consider the cumulative effects of HIAs on
planning processes. One impact of the EIA process may be its influence
over time in encouraging developers to propose more environmentally
sound projects.[78]


To have an impact, HIA findings must be communicated to decisionmakers
who require concise, synthesized information presented in a compelling
fashion. Other interested audiences include community members,
advocacy organizations, journalists, and public health professionals.
In addition to study results, an HIA report in the United States
should communicate the aims, rationale, and validity of HIA methods in

HIA reports should be based on quantitative and qualitative analyses.
Consensus standards for evidence would support the legitimacy of
HIAs.[32] For political decisionmakers and community stakeholders, a
nontechnical HIA report should include background, methods, health
impact findings, and recommendations. For technically trained
audiences, the report should include an executive summary, the scope
of health impacts considered, a logic framework showing possible links
between the proposal and health impacts,[14,29] a literature review,
analytic methods and assumptions, sensitivity analyses for
quantitative results, discussion of analytic uncertainties, discrepant
views, trade offs, health equity issues, and recommendations for
proposal changes to maximize positive and minimize negative health
impacts. Development of HIA report format guidelines would improve
communication to various audiences and facilitate evaluation of HIA


There is substantial potential to improve public health by bringing
decisionmakers' attention to the health consequences of their actions;
city councilpersons, zoning commissioners, and other decisionmakers
typically have little background in health. HIA is a new tool that
could be valuable to improve communication between these
decisionmakers and their local health departments.

Sufficient experience has accumulated in Europe, Canada, and elsewhere
to demonstrate that HIAs can be a useful tool for advancing public
health objectives. There was a clear consensus among the October 2004
Princeton workshop participants that now is the opportune time to move
forward on the development and use of HIA methods in the United

One high priority is to conduct voluntary pilot tests[26,27,79] of
existing HIA methods to examine their usefulness in US settings and to
educate planners, developers, health agencies, community advocates,
and the media about the value of HIAs. Another priority is to develop
training courses and materials to enable public health officials to
conduct HIAs; such training materials can be adapted from those
developed in Europe and elsewhere. Other priorities include developing
a database for measuring health impacts of common projects and
policies and conducting process, impact, and outcome evaluations of

The potential value of HIA methods was recognized at a 2002 conference
in Boston.[80] Participants at that conference also examined
difficulties in HIA processes such as establishing an adequate
theoretical framework, working with health impacts that are difficult
to quantify, balancing health impacts with other societal outcomes in
decisionmaking processes, and ensuring that HIAs add value rather than
barriers to decisionmaking processes.[80] These concerns should be
addressed when HIA pilot studies are conducted.

After numerous publications in Europe, papers and presentations about
HIA are beginning to appear in the American public health
literature[9,14,26,79,81,82] and at national planning and public
health conferences. The next steps to move the field forward in the
United States have been identified. We believe planners and public
health leaders should begin now to tap into the potential of HIA
processes to improve the health of our communities.

**About the Authors

Andrew L. Dannenberg is with the National Center for Environmental
Health, Centers for Disease Control and Prevention, Atlanta, Ga. Rajiv
Bhatia is with the San Francisco Department of Public Health, San
Francisco, Calif. Brian L. Cole is with the University of California,
Los Angeles School of Public Health. Carlos Dora is with the World
Health Organization Health Impact Assessment Programme, Geneva,
Switzerland. Jonathan E. Fielding is with the University of
California, Los Angeles School of Public Health and the Los Angeles
County Department of Health Services. At the time of the study,
Katherine Kraft was with the Robert Wood Johnson Foundation,
Princeton, NJ. Diane McClymont-Peace is with Health Canada, Ottawa,
Canada. At the time of the study, Jennifer Mindell was with the London
Health Observatory, London, England. Chinwe Onyekere is with the
Robert Wood Johnson Foundation, Princeton. James A. Roberts is an
environmental impact as- sessment consultant, Sacramento, Calif.
Catherine L. Ross is with the Georgia Institute of Technology College
of Architecture, Atlanta, Ga. Candace D. Rutt is with the National
Center for Chronic Disease Prevention and Health Promotion, Centers
for Disease Control and Prevention, Atlanta. Ala Scott-Samuel is with
the Liverpool Public Health Observatory, University of Liverpool,
England. Hugh H. Tilson is with the University of North Carolina
School of Public Health, Chapel Hill, NC.

Requests for reprints should be sent to Andrew L. Dannenberg, National
Center for Environmental Health, CDC, 4770 Buford Highway, Mail Stop
F-30, Atlanta, GA 30341 (e-mail: acd7@cdcgov).

This article was accepted August 29, 2005.


A. L. Dannenberg, B.L. Cole, K. Kraft, J. Mindell, C. Rutt, and H.H.
Tilson conceptualized and did the initial plan- ning for the workshop.
All authors par- ticipated in the workshop and contributed to the
writing and revising of the article.


We thank the Robert Wood Johnson Foundation for its financial and
logistical support of the October 2004 Health Impact Assessment

The authors gratefully acknowledge the contributions of the other
participants in the October 2004 workshop including: David Buchner,
National Center for Chronic Disease Prevention and Health Promotion,
CDC, Atlanta, Ga; Allen Dearry, National Institute of Environmental
Health Sciences, Research Triangle Park, NC; James Krieger, Seattle-
King County Health Department, Seattle, Wash; Dennis McDowell, Office
of Strategy and Innovation, CDC, Atlanta; Marya Morris, American
Planning Association, Chicago, Ill; Jill Muirie, NHS Health Scotland,
Glasgow; Valerie Rogers, National Association of County and City
Health Officials, Washington, DC; Pamela Russo, Robert Wood Johnson
Foundation, Princeton, NJ; Michael Savonis, Federal Highway
Administration, US Department of Transportation, Washington, DC.

The authors also thank Margaret Douglas, Howard Frumkin, Roy
Kwiatkowski, William Lyons, Anthony Moulton, Jayne Parry, and Michael
Pratt for their contributions to this article.


1. Frumkin H, Frank L, Jackson R. Urban Sprawl and Public Health:
Designing, Planning, and Building for Healthy Communities. Washington
DC: Island Press; 2004.

2. Frumkin H. Urban sprawl and public health. Public Health Rep. 2002;
117:201-217. [2.3 Mbyte PDF]

3. Jackson RJ. The impact of the built environment on health: an
emerging field. Am J Public Health. 2003;93: 1382-1384.

4. Wilkinson R, Marmot M, eds. Social Determinants of Health: the
Solid Facts. 2nd ed. Copenhagen, Denmark: World Health Organization;
2003. Available at: Accessed
October 19, 2005.

5. Health Impact Assessment: Main Concepts and Suggested Approach.
Brussels, Belgium: European Centre for Health Policy, World Health
Organization Regional Office for Europe; 1999. Gothenburg Consensus
Paper. Available at:
gpaper.pdf. Accessed October 19, 2005.

6. Aziz MIA, Radford J, McCabe J. The Finningley Airport HIA: a case
study. In: Kemm J, Parry J, Palmer S, eds. Health Impact Assessment.
Oxford, England: Oxford University Press; 2004:285-297.

7. Kemm J, Parry J. The development of HIA. In: Kemm J, Parry J,
Palmer S, eds. Health Impact Assessment. Oxford, England: Oxford
University Press; 2004: 15-23.

8. Cole BL, Wilhelm M, Long PV, Fielding JE, Kominski G, Morgenstem H.
Prospects for health impact assessment in the United States: new and
improved environmental impact assessment or something different? J
Health Politics, Policy Law. 2004;29:1153-1186.

9. Dannenberg AL, Jackson RJ, Frumkin H, et W. The impact of community
design and land-use choices on public health: a scientific research
agenda. Am J Public Health. 2003;93:1500-1508.

10. National Institute for Health and Clinical Excellence. Health
Impact Assessment Gateway. Available at: http://www.publichealth.n Accessed October 19, 2005.

11. World Health Organization HIA Web site. Health impact assessment.
Available at: Accessed October 19, 2005.

12. University of California Los Angeles School of Public Health,
Partnership for Prevention. Health Impact Assessment: Information &
Insight for Policy Decisions. Available at:
u/hs/health-impact. Accessed October 19, 2005.

13. World Health Organization HIA Web site. The HIA procedure.
Available at: Accessed
October 19, 2005.

14. Cole BL, Shimkhada R, Fielding JE, Kominski G, Morgenstern H.
Methodologies for realizing the potential of health impact assessment.
Am J Prev Med. 2005;28:382-389.

15. McIntyre L, Petticrew M. Methods of Health Impact Assessment: A
Literature Review. Glasgow, Scotland: Medical Research Council Social
and Public Health Sciences Unit; 1999. Available at: http://www.msoc
Accessed October 19, 2005.

16. New Zealand Ministry of Health. Public Health Advisory Committee.
a Guide to Health Impact Assessment: A Policy Tool for New Zealand.
2nd ed. Wellington, NZ: National Health Committee; 2005. Available at: Accessed
October 19, 2005.

17. Fehr R. Environmental health impact assessment: evaluation of a
ten-step model. Epidemiology. 1999;10: 618-625.

18. Kemm JR. Can health impact assessment fulfill the expectations it
raises? Public Health. 2000;114:431-433.

19. Bowen C. HIA and policy development in London: using HIA as a tool
to integrate health considerations into strategy. In: Kemm J, Parry J,
Palmer S, eds. Health Impact Assessment. Oxford, England: Oxford
University Press; 2004:235-242.

20. Health Canada. Environmental Health Assessment Services. The
Canadian Handbook on Health Impact Assessment. 4 vol. Ottawa, Ont:
Health Canada; 2004. Available at:
mt/pubs/eval/index_e.html. Accessed October 19, 2005.

21. Barnes R, Scott-Samuel A. Health impact assessment and
inequalities. Pan Am J Public Health. 2002;11:449-453.

22. Douglas M, Scott-Samuel A. Addressing health inequalities in
health impact assessment. J Epidemiol Commun Health. 2001;55:450-451.
Available at:
Accessed October 19, 2005.

23. National Association of County and City Health Officials.
Connecting Public Health with Land Use Planning and Community Design
checklist. Available at:
LandUseChecklist-03-10-03.pdf. Accessed October 19, 2005.

24. Scott-Samuel A, Birley M, Ardem K. The Merseyside Guidelines for
Health Impact Assessment. 2nd ed. Liverpool, England: International
Health Impact Assessment Consortium; 2001. Available at: http://ww Accessed October 19,

25. San Francisco Department of Public Health. Eastern Neighborhoods
Community Health Impact Assessment. Available at: http://www.sfd Accessed October 19, 2005.

26. Bhatia R, Katz M. Estimation of health benefits from a local
living wage ordinance. Am J Public Health. 2001;91: 1398-1402.

27. Cole BL, Shimkhada R, Morgenstern H, Kominski G, Fielding JE, Wu
S. Projected health impact of the Los Angeles City living wage
ordinance. J Epidemiol Commun Health. 2005;59:645-650. Available at: Accessed
October 19, 2005.

28. London Health Observatory Web site. Health impact assessment cost
calculator. Available at:
Accessed October 19, 2005.

29. Joffe M, Mindell J. Diagrams specifying complex causal processes:
use in analyzing the health impacts of policy interventions. In press.

30. Mittelmark MB. Promoting social responsibility for health: health
impact assessment and healthy public policy at the community level.
Health Promot Int. 2001;16:269-274.

31. Veerman JL, Barendregt JJ, Mackenbach JP. Quantitative health
impact assessment: current practice and future directions. J Epidemiol
Commun Health. 2005;59:361-370. Available at: http://jech.bmjjourna Accessed October 19, 2005.

32. Mindell J, Boaz A, Joffe M, Curtis S, Birley M. Enhancing the
evidence base for health impact assessment J Epidemiol Commun Health.
2004;58:546-551. Available at:
print/58/7/546.pdf. Accessed October 19, 2005.

33. Kemm J, Parry J, Palmer S, eds. Health Impact Assessment:
Concepts, Theory, Techniques, and Applications. Oxford, England:
Oxford University Press; 2004.

34. Dora C. HIA in SEA and its application to policy in Europe. In:
Kemm J, Parry J, Palmer S, eds. Health Impact Assessment. Oxford,
England: Oxford University Press; 2004:403-410.

35. Wright J, Parry J, Scully E. Institutionalizing policy-level
health impact assessment in Europe: is coupling health impact
assessment with strategic environmental assessment the next step
forward? Bull World Health Organ. 2005;83:472-477. Available at: Accessed October
19, 2005.

36. United Nations Economic Commission for Europe. Protocol on
Strategic Environmental Assessment: Implications for the health
sector. Available at:
EABudrpt.pdf. Accessed October 19, 2005.

37. Kwiatkowski RE, Ooi M. Integrated environmental impact assessment:
a Canadian example. Bull World Health Organ. 2003;81:434-438.
Available at:
kowski.pdf. Accessed October 19, 2005.

38. National Framework for Environmental and Health Impact Assessment.
Canberra, Australia: National Health and Medical Research Council;

39. Phoolcharoen W, Sukkunmoed D, Kessomboon P. Development of health
impact assessment in Thailand: recent experiences and challenges. Bull
World Health Organ. 2003;81:465-467. Available at:
t/bulletin/volumes/81/6/en/phoolcharoen.pdf. Accessed October 19,

40. Abrahams D, den Broeder L, Doyle C, et M. EPHIA-European Policy
Health Impact Assessment: A Guide. Liverpool, England: IMPACT,
University of Liverpool; 2004. Available at:
k/document/ephia.pdf. Accessed October 19, 2005.

41. National Institute for Health and Clinical Excellence. Links to
published short guides about health impact assessment. Available at:
http://www. Accessed
October 19, 2005.

42. US Department of Transportation, Federal Highway Administration
Web site. National Environmental Policy Act of 1969. 42 USC paragraphs
4321-4327 (1970). Available at:
t/nepatxt.htm. Accessed October 19, 2005.

43. Steinemann A. Rethinking human health impact assessment. Environ
Impact Assess Rev. 2000;20:627-645.

44. California Environmental Quality Act. California Public Resources
Code. Division 13: Environmental Protection. 21000 et seq. Available
at: Accessed October 19,

45. Arquiaga MC, Canter LW, Nelson DI. Integration of health impact
considerations in environmental impact studies. Impact Assess.

46. Davies K, Sadler B. Environmental Assessment and Human Health:
Perspectives, Approaches, and Future Directions. Ottawa Ont: Health
Canada; 1997. Available at:
al/health-perspective-sante/index_e.html. Accessed October 19,

47. World Bank Environment Department. Health Aspects of Environmental
Assessment. Environmental Assessment Sourcebook Update. Vol. 18, July
1997. Available here:
7.pdf. Accessed October 19, 2005.

48. United Nations Economic Commission for Europe. Aarhus Convention.
Convention on Access to Information, Public Participation in Decision-
Making and Access to Justice in Environmental Matters. Aarhus,
Denmark, 25 June 1998. Available at:
Accessed October 19, 2005.

49. Dietz T What is a good decision? Criteria for environmental
decision making. Hum Ecology Rev. 2003;10(1): 33-39.

50. Fang A, Wright EO. Deepening democracy: innovations in empowered
participatory governance. Politics Soc. 2001;29(1):5-41.

51. Barnes R. HIA and urban regeneration: the Ferrier estate, England.
In: Kemm J, Parry J, Palmer S, eds. Health Impact Assessment. Oxford,
England: Oxford University Press; 2004: 299- 307.

52. US Environmental Protection Agency. Environmental Justice Web
site. Available at:
environmentaljustice. Accessed October 19, 2005.

53. Bhatia R. Towards equity in land use development using health
impact assessment. NACCHO Exchange. 2005; 4(1):1,4-5. Available at:
Accessed October 19, 2005.

54. Arnstein SR. A ladder of citizen participation. J Am Institute
Planners. 1969;35(4):216-224.

55. Narayan D, Patel R, Schafft K, Rademacher A, Koch-Schulte S.
Voices of the Poor: Can Anyone Hear Us? New York, NY: Oxford
University Press; 2000.

56. Wright J, Parry J, Mathers J. Participation in health impact
assessment: objectives, methods and core values. Bull World Health
Organ. 2005;83:58-63. Available at:
bulletin/volumes/83/1/58.pdf. Accessed October 19, 2005.

57. Parry J, Wright J. Community participation in health impact
assessments: intuitively appealing but practically difficult. Bull
World Health Organ. 2003;81: 388. Available at:
bulletin/volumes/81/6/en/parry.pdf. Accessed October 19, 2005.

58. Abelson J, Forrest PG, Eyles J, Smith P, Martin E, Gauvin FP.
Deliberations about deliberative methods: issues in the design and
evaluation of public participation processes. Soc Sci Med.

59. Parry J, Stevens A. Prospective health impact assessment:
pitfalls, problems, and possible ways forward. BMJ.

60. Mindell J, Ison E, Joffe M. A glossary for health impact
assessment J Epidemiol Commun Health. 2003;57: 647-651. Available at: Accessed
October 19, 2005.

61. Regeneration and Planning Task Group of the Health of Londoners
Project. A Guide to Health and Health Services for Town Planners in
London. London, England: East London and the City Health Authority;
2004. Available at:
Accessed October 19, 2005.

62. Regeneration and Planning Task Group of the Health of Londoners
Project. A Guide to Town Planning for the Health Service in London.
London, England: East London and the City Health Authority; 2004.
Available at: http://
Accessed October 19, 2005.

63. Malizia EE. City and regional planning: a primer for public health
officials. Am J Health Promot. 2005;19(5 suppl): 1-13.

64. University Laval, Faculte de medecine. Health Impact Assessment
online Training module. Available at: http://machaon.fmed.ulaval.c
a/medecine/hia/index.asp?Langue=EN&IdDiscipline=2. Accessed October
19, 2005.

65. University of Liverpool. International Health Impact Assessment
Consortium. Learning. Available at:
ning.html. Accessed October 19, 2005.

66. London Health Observatory. HIA training courses. Available at: Accessed October 19,

67. Intersectoral Decision-Making Skills in Support of Health Impact
Assessment of Development Projects. Geneva, Switzerland: World Health
Organization; 2000. Available at:
ion_health/resources/wsh0009/en. Accessed October
19, 2005.

68. Mindell J, Boltong A. Supporting health impact assessment in
practice. Public Health. 2005;119:246-252.

69. The Academy of Board Certified Environmental Professionals Web
site. Available at: Accessed October 19, 2005.

70. University of Birmingham. Health Impact Assessment Research Unit A
Training Manual for Health Impact Assessment. Birmingham, England:
University of Birmingham. Available at:
lichealth/hiaru/files/training%20manual.pdf. Accessed October 19,

71. Mindell J, Sheridan L, Joffe M, Samson-Barry H, Atkinson S. Health
impact assessment as an agent of policy change: improving the health
impacts of the mayor of London's draft transport strategy. J Epidemiol
Commun Health. 2004;58:169-174. Available at: http://jech.bmjjournal Accessed October 19, 2005.

72. Davenport C, Mathers JM, Parry JM. The use of HIA in incorporating
health considerations in decision making. J Epidemiol Commun Health.

73. Close N. Alconbury Airfield Development health impact assessment
evaluation report. Cambridge, England: Cambridgeshire Health
Authority; 2001. Available at:
s/alconbury_airfield_evaluation_report.pdf. Accessed October 19,

74. Opinion Leader Research. Report on the Qualitative Evaluation of
Four Health Impact Assessments on Draft Mayoral Strategies for London.
London, England: London Health Commission and London Health
Observatory; 2003. Available at:
df/hiaeval.pdf. Accessed October 19, 2005.

75. Quigley RJ, Taylor LC. Evaluation as a key part of health impact
assessment: the English experience. Bull World Health Organ.
2003;81:415-419. Available at:
s/81/6/en/quigley.pdf. Accessed October 19, 2005.

76. Taylor L, Gowman N, Quigley R. Evaluating health impact
assessment. London, England: Health Development Agency; 2003.
Available at:
aluating%20HIA%20pdf.pdf. Accessed October 19, 2005.

77. Parry JM, Kemm J. Criteria for use in the evaluation of health
impact assessments. Public Health. 2005;119: 1122-1129.

78. Karkkainen BC. Toward a smarter NEPA: monitoring and managing
government's environmental performance. Columbia Law Rev.
2002:903-972. Available at:
arkkainen.pdf. Accessed October 19, 2005.

79. Rutt CD, Pratt M, Dannenberg AL, Cole BL. Connecting public health
and planning professionals: health impact assessment Places: Forum
Environmental Design. 2005;17(1):86-87.

80. Krieger N, Northridge M, Gruskin S, et al. Assessing health impact
assessment: multidisciplinary and international perspectives. J
Epidemiol Commun Health. 2003;57:659-662. Available at: http://jec Accessed October 19, 2005.

81. Northridge ME, Sclar E. A joint urban planning and public health
framework: contributions to health impact assessment Am J Public
Health. 2003;93:118-121.

82. Besser LM, Dannenberg AL. Walking to transit: steps to help meet
physical activity recommendations. Am J Prev Med 2005;29:273-280.