Holly Avey

Holly Avey
Program Director

Holly Avey joined Human Impact Partners in February 2013. Prior to joining HIP, Holly worked at the Georgia Health Policy Center at Georgia State University on a variety of HIA and Health in All Policies projects, including serving as an HIA practitioner, trainer, and technical assistance provider. Holly has a PhD from the University of Georgia and a Master's in Public Health from the University of Michigan, both in the health behavior specialty area. She also holds a bachelor's degree in Creative Writing from the University of Arizona. Her work in the public health field ranges from community, university, and hospital settings, and covers a wide variety of topics. Her research interests include structural sources of chronic stress (such as policies that influence resource access and distribution) and their differential impacts on vulnerable populations. She is interested in innovative research methodologies such as participant photography (PhotoVoice), mixed methodology, and addressing equity issues through policy and community engagement initiatives. Holly currently serves on the steering committee of the Society of Practitioners of Health Impact Assessment (SOPHIA).

Research and the Arts: Combining Efforts for Policy Change

Several months ago I attended an entertainment event called The Body Political. The show was described by the organizers in the following way:

The Body Political is a subversive artistic space created to explore personal stories about our bodies told through performance art. This show is a conversation. A conversation about our assumptions of what the body is and isn’t capable of and why. A conversation about the ways our bodies are controlled, denied, and marginalized through social and political institutions. A conversation about how social control of the body is used to assert authority and maintain existing systems of power.

Yet beyond a dialogue, this show is a space of resistance. We honor and listen to the diverse voices of our community, hearing stories of acceptance and self-love. It is within these stories, and the courage of their storytellers, that we resist, we disrupt, and we reclaim. This is place for us. Our Bodies, Our Rules, Our Stories.

I was incredibly moved as an audience member at this show. The performances explored topics such as:

  • Black Lives Matter,
  • assumptions about lack of safety ascribed to dark-skinned black men,
  • intersectionality pressures for African American women to please others,
  • body image and emotional implications of breast cancer, and
  • light-hearted approaches to challenging gender conformity.

The performers addressed very important topics in a way that went straight to the emotional experience. It resonated with me so much that I can still recall details from many of those performances, several months later.

What does this have to do with our work at HIP? This event addressed many of the same underlying topics that we address in our work, and yet our two worlds of the arts and research are not intersecting. The arts event was billed as socially and politically-informed entertainment, but provided no additional context on research or specific political calls to action, and the research world that HIP works in provides no artistic exploration of our topics of interest, to enhance connection on an emotional level. The audiences might not have much overlap. But it might be a good idea if they did.

There are a few research methods that incorporate the arts, and vice versa. PhotoVoice and VideoVoice engage community members in using photography and videography as research tools to represent their own lived experiences to policymakers. The Dance Your PhD competition sponsored by Science Magazine uses dance as an artistic medium to explain PhD research topics. But these methods are not commonly used by researchers, community advocates, or artists.

As I’ve mentioned in a previous blog, research shows that policymakers are often swayed by a compelling narrative that offers an emotional hook and intuitive appeal. This can provide the context for further data they might use to justify a new or different policy. In February 2016, this connection was made clear by President Obama when he spoke on the Ellen DeGeneres Show. Ellen thanked President Obama for the policy changes that have happened during his presidency to support the LGBT community. President Obama responded that the changes were only possible after her work in television had helped to change the hearts and minds of Americans.

The importance of this should not be underestimated. We all have different ways of making sense of the world we live in. Presenting experiences in a way that speaks directly to the human experience, as the arts are intended to do, can help people bypass previously formed judgments in a way that research data never will. But research data and ongoing advocacy efforts are often needed to achieve policy change in a way that the arts are unlikely to be able to sustain and achieve by themselves. We are truly more powerful together.

To learn more about the inspiration for this post, visit The Body Political (link includes images with some nudity).

Expanding Access to Preschool Could Improve Health and Equity in Cincinnati, August, 2016

One of my favorite things about doing HIAs and other projects at Human Impact Partners is the unexpected “Aha!” moments that occur, when we find something in the research that surprises us.

Today, Human Impact Partners and our partners from The AMOS Project are excited to release a report that examines the health and equity impacts of expanded access to preschool for children in Cincinnati. Our study concludes that expanding access to preschool would benefit the health and equity for children, families, and other residents of Cincinnati. That’s actually not an “Aha!” for me. I expected that improved education would have benefits to health and equity. But I didn’t exactly expect all of the connections we found.

To me, it makes sense that if children get a better chance at high-quality education earlier on in life, they will do better in school later on. What I didn’t expect was how far those ripple effects would reach. It makes sense that high-quality preschool education could improve reading and math scores in third grade. But interestingly, those impacts don’t always continue over time. By the fourth grade, children who had access to high-quality preschool don’t always show significantly different reading or math scores from those who didn’t. But, they are less likely to be held back to repeat a grade in school, and they are less likely to require special education services. Essentially, they are able to keep up. And this ability to keep up allows them to remain connected and engaged in the school system, which means that they stay in school. They graduate. And if they graduate, they have better job options with higher wages. Which means they are not as likely to become involved in the criminal justice system.

Higher wages and less crime because of preschool. Those are some far-reaching ripple effects!

Figure 1

And guess what else? I really didn’t expect this one, but it makes sense to me. Family relationships are better. Being a parent of a young child can be stressful. When parents don’t have resources to deal with that stress, a small proportion of the time it can unfortunately manifest in child abuse and neglect. But research suggests that high-quality preschool has some pretty impressive protective factors for this. High-quality preschools not only give parents a break from the stress of parenting, they give children an opportunity to learn social and emotional skills when interacting with other children, and they give parents structured and guided ways to interact with their children. In our study we predicted that nearly three out of ten children in Cincinnati who would have experienced abuse or neglect would not experience it if they were sent to preschool. And improved family relationships last over time as well. Forty-year-old adults who attended preschool as children are still more likely to say their family relationships are better than those who did not. Again – those are some far-reaching ripple effects!

Of course, increased education, improved wages, less crime, less stress, and better social relationships can all lead to improved health. And that’s a wonderful, amazing thing. But it turns out that preschool could also be a key factor in breaking the cycle of generational inequities. Due to multiple forms of structural discrimination, growing up in poverty, in a single-parent household, or with a parent who is incarcerated are all more common experiences for children of color. These experiences increase the odds of negative physical and mental health outcomes and lead to a vicious cycle that continues through multiple generations, further contributing to ongoing inequities. When preschools and the school systems that they feed into have a trauma-informed approach to discipline, focusing on the root causes of the problem behaviors, rather than zero-tolerance suspensions and expulsions, preschools could help break that cycle.

Figure 2

This is especially important for communities like Cincinnati, where many of these risk factors are nearly double the national rate.

Figure 3

Thus, based on our findings, our study recommends the following actions:
1. Expand access to high-quality preschool programs to all children
2. Prioritize to reach those most in need, such as children living in poverty
3. Assure high-quality preschools and teachers through adherence to preschool program and training features that research has proven to be successful
4. Utilize a trauma-informed approach to discipline that incorporates an understanding of the source of the behavior problem, in preschool and beyond, rather than zero tolerance policies such as suspensions and expulsions
5. Assure that high-quality preschools are geographically distributed throughout the city

This Health Impact Assessment was produced in partnership with our Advisory Committee members from Cincinnati Children’s Hospital, StrivePartnership, Interact for Health, Mercy Health, and United Way’s Success by 6.

HIA Research: When is Qualitative Research Warranted?

[As research director at Human Impact Partners, Holly Avey spends a lot of time not just looking at our findings but thinking about how we conduct and use research. This is one in a series of blogs about the role of research in HIA.]

In my research blog published back in 2013, I asked: How far should we go with qualitative research in HIA? Is it just used when we don’t have enough quantitative data to answer our research question, or are there other reasons to consider incorporating qualitative research into your HIA work?

A national evaluation of HIAs conducted by the Environmental Protection Agency states that “stakeholder and community input lend themselves to qualitative analysis”, and beyond that, qualitative analysis is warranted in HIAs in the following circumstances: “lack of available scientific research, unavailability of local data, time limitations, limited resources, etc.” (p. 39). The implication is that qualitative data is warranted as a means of stakeholder input, but from a data perspective, you might only pursue qualitative data if you don’t have and/or can’t get quantitative data.

The authors further state, “most HIAs qualitatively characterized impacts; the use of quantitative analysis was lacking.” (p. 80). This statement implies that qualitative characterization of impacts is not sufficient or appropriate when quantitative data is available and the process allows it to be obtained.

This perspective is not unique to the EPA, or to the field of HIA. As Margarete J. Sandelowski states in her editorial Justifying Qualitative Research, quantitative research is often the default modality for the health sciences and is therefore introduced first. This results in many health researchers being trained to think of the ways qualitative research is different from, less than, or deficient in comparison to quantitative research. For example, qualitative research may be described as “less mathematically precise and as producing findings that are not generalizable” when compared to quantitative research. Alternatively, one never sees a comparison that assumes the qualitative research perspective and describes quantitative research as, “less descriptively precise and attentive to context” and limited to generalizations based on objective (nomothetic) phenomena (p. 193).

Thus it is no surprise that one of the EPA’s evaluation review criteria assumed the quantitative default perspective and was originally labeled “quantification of impact” but later changed to “characterization of impact” after the full-scale review had been completed, as a means of reflecting the fact that impacts can be characterized both qualitatively and quantitatively (p 12). Although the authors were trying to accommodate the multitude of research approaches that can be used in HIA, their quantitative default perspective still resulted in the summary statement that “quantification of impacts was lacking” (p. 80). How often might we similarly challenge health researchers to say “qualitative analysis was lacking”?

There may be two underlying assumptions here. One, that quantitative research is more rigorous and defensible in comparison to qualitative research, and two, that quantitative data is more compelling to decision-makers (note how both use the quantitative default perspective). To the first point, I would reiterate what I mentioned in my last blog, which is that qualitative and quantitative research are designed to answer different research questions. They are often based on different research philosophies (see my first research blog). They can both be executed in a manner that is rigorous or a manner that is sloppy. Rigor and defensibility are not the domains of one over the other, but many health researchers who are trained with the quantitative default perspective may assume a higher level of rigor with their default approach.

To the second point, what kind of data is more compelling to decision-makers? Well, in an interesting article published in the American Journal of Public Health titled Understanding Evidence-Based Public Health, the authors argue that “there is no single, ‘best’ type of evidence .” (p. 1578). … “Studies from the communication field have shown that the combination of [both qualitative and quantitative] evidence appears to have a stronger persuasive impact than either type of evidence alone.” (p. 1577).

The authors go on to state, “Qualitative evidence can make use of the narrative form as a powerful means of influencing policy deliberations, setting priorities, and proposing policy solutions by telling persuasive stories that have an emotional hook and intuitive appeal. This often provides an anchor for statistical evidence…”(p. 1577). They suggest that quantitative evidence be incorporated within a compelling story that is created with the qualitative data to maximize the potential use of the data in the policy process. They also go on to report that “in a survey of 292 US state policymakers, respondents expressed a strong preference for short, easy-to-digest data” (p. 1577). This finding may contradict what many quantitatively-focused HIA researchers may assume, which is that the more thorough and specific the data, the better.

While quantitative research can provide powerful data to inform our predictions with numerical specificity, we do not need to sacrifice research rigor for qualitative research. Qualitative research can inform new theories about connections to health that have not yet been studied. It can provide the localized context and community-specific perspectives that can create a compelling narrative and provide relevance and meaning. Qualitative data collection analysis processes can be powerful experiences for stakeholders, when they are offered in a participatory fashion.

So, returning to my original question and the title of this blog – when is qualitative research warranted for HIAs? Hmmm. Now isn’t that a question you’d only ask if you were coming from the quantitative default perspective? We should stop dismissing qualitative research as less-than or if-needed. We need both in HIA.

It’s Time for a Feminine Perspective

Last year I wrote a blog about the stress response, explaining how chronically stimulating the fight-or-flight response to stress can have a host of impacts on health.

But there’s another, less well known, response to stress. In the animal world, females are often responsible for caring for the young. When threatened, they may not be strong enough to fight off the aggressor, and fleeing would mean leaving their young vulnerable to attack. So the females will often group together to surround the young, creating power in numbers to overcome the threat. Researchers have labeled this strategy tend-and-befriend.

This concept should be considered when we assess the impacts of policies. Whether you respond with fight-or-flight, or with tend-and-befriend, each option is a response to what your brain perceives as a threat. If you think about it, many policies are created in response to what some groups consider to be threatening situations or conditions.

Consider school discipline. Disruptions in the classroom, fights between students, bullying and other threats of violence are considered threats by many students and teachers. “Zero tolerance” policies that mandate suspension or expulsion of students who engage in these activities might be considered a fight-or-flight response, by fighting back.

On the other hand, restorative justice policies, which focus on repairing the harm caused by misbehavior and getting students to take responsibility for their actions, might be considered a tend-and-befriend response. These policies suggest that the threat of a lack of discipline (and potential violence) should be addressed by tending to those who are perpetrating the violence, as well as those who have experienced it, encouraging them to befriend each other. Research shows that this approach, and other trauma-informed approaches to improving education outcomes, are more effective – both in reducing the threats and also in improving health and education outcomes.

Let’s look at another example. Human Impact Partners recently assessed the potential health impacts of California Proposition 47, which proposed reducing six low-level, non-serious offenses of drug possession and various forms of petty theft from felonies to misdemeanors and redirecting resources to services to treat the mental health and substance abuse problems underlying many of these offenses. Labeling these behaviors as felonies is often seen as “tough on crime” – fighting the threat of criminal activity.

But providing treatment instead of incarceration tends to the needs of those with mental health and substance abuse problems rather than harshly criminalizing them. Again, research shows that providing mental health and substance abuse services is more effective in reducing crime, as well as improving physical and mental health outcomes.

There are many other examples. For instance, it often costs less and is more effective to take care of people by providing paid sick days, protecting against wage theft, and keeping families intact – tending to their needs – than to deny access to resources or enforce harsh immigration policies and then deal with the domino effect of more expensive public resources required afterward.

Tend-and-befriend policies, reflecting a traditionally feminine perspective, can be equally, if not more, effective than the flight-or-fight approach. If we’re truly interested in improving health outcomes, we should look to them more often.

Confessions of a Former Victim-Blamer

I admit it. I used to be a professional victim-blamer. I didn’t realize it at the time and I always meant well. But as a public health educator, I sometimes contributed to people blaming themselves for their own poor health – because I didn’t mention to them how hard it might be to do the things I was telling them to do, or that there might be other things that could be done to improve their chances. This probably left them thinking that if they didn’t succeed, it was their fault.

An overwhelming majority of Americans blame people, and people blame themselves, for being fat because they don’t eat right or get enough exercise. We in the public health community tell them about all the ways obesity will harm their health. Then our society, from the medical establishment to reality TV, perpetuates this message (even though the relationship between weight and health is more complicated than that). In my days as a public health educator, I toed the party line and supported efforts to encourage individuals to change their eating and exercise behaviors to maintain a healthy weight.

When people live in neighborhoods that lack safe sidewalks, bike paths, parks, or public transit they can walk or pedal to, they’re naturally less likely to be physically active. And when people don’t have easy access to affordable healthy food, but are surrounded by corner stores, gas stations, fast-food places, and food industries pushing cheap unhealthy food, guess what? They’re less likely to make healthy choices. While the public health community is now supporting some neighborhood and policy interventions, most of our messages about food and exercise still focus exclusively on the individual without information about the influence of the environment, which probably contributes to a lot of the blaming mentioned above.

Victim-blaming can also result from the way we talk about sexually transmitted diseases. I cringed when I heard an NPR story reporting that when people are told how bad STDs such as herpes are, they are less likely to want to get tested and find out if they’re infected. I used to be one of those people who did condom demonstrations on plastic bananas and then handed out brochures with scary pictures of what might happen if they didn’t use them.

These messages, like the ones about healthy eating and exercise, were focused exclusively on the actions individuals should take, without any context about how the environment might influence their choices. When we use messages that talk about the bad or scary things that can happen to people in an effort to motivate them to change, the underlying message can easily become if you don’t do these things to protect your health, you deserve it if you get fat or get an STD – leading people to blame themselves, and others to blame them as well.

But again, look at the neighborhood. If you live in a neighborhood where there’s nothing for teens to do after school, a neighborhood where there aren’t enough jobs so people resort to selling drugs, a neighborhood saturated with alcohol advertising, you have a higher chance of contracting an STD. Neighborhood factors can create a vicious cycle. In some urban neighborhoods more than half of the young men have been in prison, most often for selling drugs. Prison gives them a higher exposure to STDs. With so many of them locked away, people in the neighborhood have fewer partners to choose from, so those who have STDs are more likely to share them with others.

There was even some level of victim-blaming when I taught stress management, though perhaps this was more subtle. For nine years, I taught patients in an outpatient clinic of a hospital that primarily served a low-income African American population how to manage stress. I offered them guidance in different forms of meditation and ways to change their thoughts. It was deeply rewarding on one level – I loved hearing things like “My family says I smile more now!” – but I worried that people would not be able to sustain the benefits long-term, and eventually I came to see it as putting a Band-Aid over a bigger, deeper problem.

The fact is that poverty and racism are stressful. Learning how to manage your own stress does nothing to get rid of the root causes, and when you are surrounded by root causes that never go away, you must continually swim upstream to take care of yourself, and may blame yourself if you don’t succeed. Meanwhile, policies that work to reduce the impacts of poverty, such as minimum wage laws and wage theft ordinances, are a different way to tackle stress at the population level.

I’m not saying we should stop talking about the importance of physical activity, healthy food, safer sex, and ways to manage stress. And I’m not saying messages directed at individuals are inherently victim-blaming. But I am saying that when we know neighborhood and policy factors influence individual behaviors and we only tell people about the individual behaviors they should change, it can lead to moralizing about those behaviors and to victim-blaming.

In the systems thinking world, some might call victim-blaming an unintended consequence of individually-focused prevention messages. It’s time to recognize and address this unintended consequence by complementing those messages with information and advocacy for public policies that promote health and well-being. It’s time to stop fanning the flames to blame the victim and work together to change the conditions that lead to poor health.

The Three Mile Island You’ve Never Heard Of

In 1979, a dam broke at a uranium mill near Church Rock, N.M., releasing more than 1,100 tons of mining waste and 100 million gallons of radioactive water. It was the second largest radioactive materials accident in U.S. history, resulting in contamination worse than the nuclear reactor meltdown at Three Mile Island that same year. But unlike Three Mile Island, chances are you’ve never heard of it.

Recently, my HIP colleague Sara Satinsky and I visited the Red Water Pond community, a Navajo community near the site of the spill. We joined a caravan of 14 cars, led by Jordon Johnson of the McKinley Community Place Matters team, to the home of Bertha Nez. We ate dinner under a home made shaded area, sitting on benches and folding chairs, while Bertha, Tony Hood, and Philmer Bluehouse told us their stories.

They showed us pictures of hillsides that used to have trees until one of many clean up processes began to remove contaminated soil and uplifted their roots. Their family members are buried under the trees.

They talked about people being sick from cancer and respiratory diseases. They told us about the goat that was born with no hair and died within 30 minutes of being born, about the sheep they slaughter for food being yellow inside.

They told us about working in the mine, about a manager who kept yellowcake (concentrated uranium powder) on his desk, about not understanding the risks they were taking. They pointed to a Hogan (a traditional Navajo house) no one could live in because the hearth had been built with contaminated soil.

Tony explained to us that a Hogan is built to honor the four directions. Philmer sang us a song and prayer in Navajo and showed us the area where they will build a new Hogan to offer healing to the people. He showed us how to enter such a place – with the leaders entering first, then the women, then the men, all circling the perimeter in a clockwise direction.

When they told us their stories, they all cried. And as we listened to them, so did we. The people living in this community don’t want to leave the area – the place blessed by their elders, the place where they were born, where their loved ones are buried. They asked us for nothing – no request to sign a petition, make a donation, or organize a protest. They only wanted us to hear them, to be witnesses to their struggles.

So we did. We listened. We witnessed. And we are sharing their story with others.

Human Impact Partners is providing training and technical assistance to the McKinley Community Place Matters Team via the New Mexico Health Equity Partnership to conduct a Health Impact Assessment on a proposed moratorium of uranium mining for the county.

HIA Research: What’s the Right Approach for Your Question?

[As research director at Human Impact Partners, Holly Avey spends a lot of time not just looking at our findings but thinking about how we conduct and use research. This is one in a series of blogs about the role of research in HIA.]

Last week I discussed philosophies of research, and how different people might see the same information as either an appropriate source of data or a source of bias. This week, let’s think about different approaches to answering research questions. While your philosophy influences how you think about research, the questions you ask influence how you collect and analyze your data.

A document from the National Institutes of Health (NIH), explains the difference between quantitative and qualitative approaches to research. When people have strong reactions about the pros and cons of these, I believe it stems from a difference in their underlying philosophy of research.

Quantitative research uses numeric data that can be analyzed statistically to assess relationships among variables and understand cause and effect

Qualitative research uses interviews, observations, and reviews of documents (among other methods) to understand the context and meaning of the situation

So which is right for HIA? Our personal philosophy of research will guide how we think about this initially, but the next question should be what kinds of questions do we want our research to answer?

First, what is the purpose of HIA? In 2001, the Merseyside Guidelines for Health Impact Assessment, were published for HIA practitioners in the UK. They state that the aims of HIA are:

  • “to assess the potential health impacts, both positive and negative, of projects, programmes and policies
  • to improve the quality of public policy decision making through recommendations to enhance predicted positive health impacts and minimise negative ones”

Based on this thinking, your overarching research questions might be:  “What are the relationships between the pending decision and any potential health impacts?” “Is the pending decision likely to cause any health effects?” The quantitative approach is good for assessing relationships among variables and cause-and-effect, so you should use a quantitative approach, right? But what happens when you don’t have the quantitative data to answer those questions? Often there are times when HIAs are focused on neighborhood or local-level decisions, with significant limitations on the available quantitative data. In these cases, a combination of methods may be the best bet.

Let’s look back at that NIH document, which defines this combination of methods in this way:

Mixed methods research “involves the intentional collection of both quantitative and qualitative data and the combination of the strengths of each to answer research questions.” (p. 4-5).

One example of combining quantitative and qualitative data is a story that is often told by Aaron Wernham, of the Health Impact Project. Wernham tells about a small community where a natural resource extraction processing facility was operating. Quantitative air quality data for the area did not show any significant violations of air quality standards after the facility began operating. Asthma rates tracked by the state also didn’t show an increase. But community members consistently reported that they perceived asthma rates to be higher. During the HIA, community members offered testimony at public meetings, which was tracked by the HIA team. During the testimony, one of the community members specified that the asthma rates got worse for people when certain conditions aligned – when the facility flared gas under certain weather conditions, with the wind directed toward the village. Community members also testified that the air quality data would not be likely to detect emissions under these conditions because of the location of the air quality monitor for the area.

In this case, quantitative data was available but limited to one monitor, which provided a limited perspective on conditions for the area. Qualitative data from initial discussions with community was also limited, as it provided general perceptions without specificity. Additional qualitative data from the testimony provided the specific context that allowed the HIA team to interpret some of the quantitative data from a new perspective, and understand the discrepancies between the two types of data in other cases. The combination of these two approaches allowed the HIA team to explore a new causal pathway for the HIA to investigate potential health impacts. Thus, combining the two approaches provided the opportunity for the HIA researchers to explore a more complete and accurate picture, and identified data gaps that were limiting the ability to address community concerns. Ultimately, this contributed to a recommendation that was adopted by the decision-makers as a formal requirement for more specific air quality modeling and modeling near potentially affected communities.

How far should we go with qualitative research in HIA? Is it just used when we don’t have enough quantitative data to answer our research question, or are there other reasons to consider incorporating qualitative research into your HIA work? That’s the next research blog topic.

Bias in HIA Research – What is Your Research Philosophy?

[As research director at Human Impact Partners, Holly Avey spends a lot of time not just looking at our findings but thinking about how we conduct and use research. This is the first in a series of blogs about the role of research in HIA.]

A persistent discussion in the HIA world is bias: Are findings biased if they are too heavily influenced by the participation of members of the community being studied? Although HIA practitioners in North America have concluded that input from stakeholders is an essential part of the process – guides have been written about how to engage stakeholders – there is still a tension in the field about how to do this and how it might impact the quality of the research. The National Collaborating Centre for Healthy Public Policy has summarized this tension in two fact sheets that discuss the risks and obstacles of citizen participation and the principal reasons to support it for HIA.

A core argument about bias is that if you involve community members in research, you’re just getting their opinions, and opinions aren’t the same as scientific fact (as Celia Harris discussed in her blog about the recent National HIA Meeting). You’re muddying the waters; you’re diluting or contaminating the scientific validity of the process if you include unsubstantiated opinion as part of the data in your final report. Interviews aren’t the same as air quality data.

That’s clearly true – interviews aren’t the same as air quality data. But is one a source of data and the other a source of bias?  Michael Crotty, author of The Foundations of Social Science Research: Meaning and Perspective in the Research Process, says your answer might depend on your philosophy about research as a whole. I’ve summarized his argument to show that the perceived difference between interviews and statistical analysis of data might really be a reflection of how different researchers see the world in very different ways.

Four Basic Elements of Research1

Four elements of research process

Example 1

(often associated with quantitative research)

Example 2

(often associated with qualitative research)

Your research philosophy: what knowledge is and how to get it

Objectivism: things exist in an objective reality. The way they exist does not have anything to do with the way we think about them or experience them. Good research can measure this objective truth.

Constructionism: everything is relative and depends on context. The way things are is just a construct of the way we make sense of them. It’s just our own personal theory. Research needs to capture this context and personal meaning.

Your theoretical perspective: how you explain what things mean through research

Positivism: information is not scientific unless it can be proven right or wrong by observation and experiment.

Critical inquiry: reality is constantly changing. Every action changes the context. We must constantly be critical of our assumptions when we do research.

Methodology: how you design your research

Experimental research: start with a general scientific theory of how things work, then propose an explanation for how something more specific works, then try to prove your idea wrong (if you can’t prove it wrong, we’ll assume it’s right).

Action research: design your research so that the data that is collected and analyzed can be used for problem solving actions. This should be a collaborative process that allows you to understand the context of the information collected and how it can be used.

Methods: the research toolbox of tools you use to ask and answer your questions

Statistical analysis


1 Adapted from Crotty, M. 1998.The Foundations of Social Science Research: Meaning and Perspective in the Research Process. Sage Publications, London.

If you think things exist in an objective reality and the purpose of research is to measure this objective truth, information from interviews might indeed seem biased. But if you believe that everything is relative and depends on the context and the meaning of the events and experiences, interviews might seem like very valuable data.

My personal research philosophy – and HIP’s – leans more toward constructionism – the context and personal meaning influence the realities people experience. Does this mean that we don’t see the value in experimental research and quantitative data like air quality monitoring data? Not at all. We agree that this information is important as well. What it does mean is that the research we do will likely be a combination of these types of data, whenever possible. It means we think context is extremely important, that we need to pay close attention to our assumptions, and that our role as practitioners is to use research and the research process to inform decisions in a way that improves health and reduces inequities.

Tune in next week for another blog on research, where I’ll muse about how to come up with the right research questions to match the purpose of your HIA.

The Stress Response: How HIAs Can Help Connect the Dots

Seems like every time you turn around stress is in the news. A recent article in the New York Times discussed how Dutch researchers were able to use hair samples to show a link between a major stress homrmone called cortisol and cardiovascular disease and diabetes.  Another article published in Discover Magazine discusses how traumatically stressful events can even influence the genes of future generations.

But what is stress, exactly, and how does it make you sick? And what does all of this have to do with Health Impact Assessments?

Stress is what happens when you perceive that your demands exceed your resources. If you were taking a stress reduction course the teacher might tell you not to over-commit yourself, to learn how to meditate, or to change your way of perceiving things. But what if you’re stressed out from living in an overcrowded apartment because there aren’t enough affordable housing options? Or you’re a U.S. citizen but one of your parents is undocumented and may be deported? Policy and project decisions can affect the stress levels of large groups of people, including those who have the fewest resources to deal with it. And many of those stressors are chronic, which means they may have the worst influence on health.

The body’s stress response is like a light switch. Every time you perceive a situation as stressful your body reacts by flipping the switch and releasing stress hormones. This stress response is an evolutionary holdover, designed to protect you from physical danger, like a tiger charging toward you. The stress response prepares your body to fight off the tiger or flee. Your blood pressure increases to push the blood to the muscles that will help you fight or run away. Fats and sugars are released into the bloodstream for a quick energy supply. Your blood clots more easily, so if the tiger scratches you you can still survive, and your immune system increases to fight off any infection from that potential wound. Your mind becomes more alert so you can notice all of the details of the situation and make the best move.

The problem is, you’re not supposed to have a tiger charging toward you every day. But if you have ongoing stressors that switch might get flipped on a daily basis. And the switch doesn’t work very well that way. Sometimes it gets stuck in the on position. Your blood pressure might stay high all the time. Your blood might try to clot all the time. You might always have high levels of sugars and fats in your bloodstream. Sometimes the light bulb burns out and you can’t turn it on anymore. The neurochemicals that help your mind stay alert might get depleted and you end up with a foggy memory and depression. Your immune system wears out and you end up more prone to everyday infections. Over time, these conditions could contribute to diabetes, high cholesterol, heart disease, stroke, depression, and anxiety.

So when policy and project decisions expose whole populations of people to chronically stressful circumstances, it can affect their health. This is where HIAs have a unique opportunity to connect the dots. HIAs can help decision-makers understand the impacts of those decisions on health outcomes through the stress response. For example, an HIA conducted by the Adler School Institute on Social Exclusion helped connect the dots between hiring practices and mental health outcomes for a community.

Another HIA conducted by Human Impact Partners helped connect the dots between a proposed football stadium in downtown Los Angeles, the gentrification and displacement that could result for the community nearby, and how those potential implications could influence stress and health.

The field of HIA is just beginning to explore these possibilities in more depth. At the March 2013 HIA of the Americas meeting, a mental health workgroup was established. Members of this group committed to work over the next 18 months to create resource sheets that would help define mental health terms that are often relevant to HIAs, describe some of the typical pathways for policy and project decisions to affect health outcomes, and identify data resources to utilize in HIA work.

Helping people understand how some decisions could create more stress for people, and how that could impact their health, is just what HIA was built for.

For more information about the mental health workgroup, contact info@hiasociety.org.