Tag Archives: HIA

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.

The Long Road Home: Decreasing Barriers to Public Housing for People with Criminal Records

For individuals with a criminal history, finding affordable and stable housing becomes extremely difficult in a place like the Bay Area, with high cost and limited supply. People with a criminal history can legally be excluded from housing. In a survey from the 2015 Ella Baker Center for Human Rights and Forward Together report, “Who Pays? The True Cost of Incarceration on Families,” 79% of people who had been incarcerated were either ineligible or denied public housing as a result of criminal history. More than half of those released from jail or prison have unstable or nonexistent housing.

Safe and affordable housing is a fundamental basis for success in all areas of life, and without stable housing, an individual’s health, employment and education opportunities, family reunification and social networks are compromised. In Alameda County, California, nearly 20,000 people are at risk of residential instability because of having a recent criminal history.

Having housing improves health directly and indirectly, decreases recidivism, improves the chance of becoming employed and having more income, and helps with family reunification. These factors, known in public health as the social determinants of health, create opportunities to succeed and are known to be important for health and wellbeing. For example:

  • Moving often affects recidivism. The odds of recidivism increase by at least 70% for every time someone who is formerly incarcerated changes their residence.
  • Six randomized control trials analyzed supported employment in public housing against other approaches to help residents find jobs, and found 58% of public housing program participants obtained employment compared to 21% in the control group.
  • More than 70% of those leaving prison indicated that family is an important factor in keeping them out of prison, and up to 82% of people leaving prison or jail expect to live with or get help from their families.
  • Having stable housing upon leaving jail or prison decreases a person’s chance of having their probation revoked.

It’s clear from the research; the lack of stable and affordable housing forces families to frequently move and live in unhealthy and crowded environments, increases stress and depression, and can lead to homelessness. Homelessness brings higher rates of infectious diseases; substance use and mental health disorders; exposure to violence; overexposure to cold and rain; and suicide. Studies show that 25% to 50% of people who are homeless have histories of involvement with the criminal justice system.

Public housing admissions screening policies play an important role in creating the conditions for successful reentry of people who were incarcerated. HIP recently released a report called, “The Long Road Home: Decreasing Barriers to Public Housing for People with Criminal Records” done in partnership with Ella Baker Center for Human Rights (EBC). I worked closely with EBC staff starting in September 2015 to complete this Health Impact Assessment (HIA), as part of my Health & Equity Fellowship with HIP. We studied the Oakland Housing Authority (OHA) as a case study to understand the impacts of screening policies on health.

To fully understand OHA’s admission and screening policies, HIP met with two staff from their office. We learned that OHA denials due to a criminal history in the first round of screening have decreased significantly from 12% to 0.8% between 2010 and 2012. Of those who were screened out by OHA due to a criminal history, 75% request an informal hearing, and 64% of those have the decision reversed, allowing them to continue on in the application process. This is a powerful statement for the presentation of mitigating circumstances; at OHA, when people are allowed to tell their story and present supporting documentation, it often results in a reversal. We know that historical policies have created racial inequities in housing and health outcomes. However, data on race and ethnicity is not being recorded or reported, making it impossible in OHA’s case to analyze inequities in screening practices.

While more people with criminal histories are able to move forward in the screening process when OHA allows them to present mitigating evidence, there are additional changes OHA and other public housing authorities can make to improve housing stability for individuals with criminal history:

  • Allow mitigating circumstances to be presented in the initial application for public housing
  • Ensure proper implementation of policies that allow individuals with criminal history to join their family in public housing, and eliminate any practices of evicting existing residents from public housing for allowing a family member returning from prison or jail or denying admission if there is no valid reason for doing so
  • Collect, track, and publicly report the race and ethnicity of applicants and those screened out due to their criminal history to examine the potential impact of screening policies on people of color with a criminal history

Read more of the findings & recommendations in the full report.

How Payday Loan Reforms can Improve Health for the Most Vulnerable Minnesotans

“Every two weeks I was just paying interest. And I think I got frustrated with it because knowing that the interest you’re paying really isn’t even close to what you took, and by the time you know it, you paid more than what you took from them. . . It eats you up, really, and it’s very stressful to deal with that, not knowing where you’re going to live next, or how you’re going to come up with your rent, yeah, it doesn’t really help much.” — Mercy, borrower

Human Impact Partners and ISAIAH are excited to release the report, Drowning in Debt: A Health Impact Assessment of How Payday Loan Reforms Improve the Health of Minnesota’s Most Vulnerable. After examining literature and data from many sources, the study found that the payday lending debt trap harms the health and wellbeing of Minnesota’s payday borrowers, their families, and their communities. And there is no available evidence that access to payday loans has beneficial impacts on borrower health. Ultimately, eliminating the payday lending industry in the state – or else implementing significant reforms – provides the best opportunity to ensure that health risks to borrowers, their families, and communities are minimized.

Here are the facts: Payday loans are marketed as short-term, quick, and easy loans, but the industry thrives on repeat borrowing—90% of their revenue comes from borrowers who cannot pay off their loans when due. Furthermore, between 1999 and 2014, the wealth drain from payday loan fees and interest amounted to more than $110 million from communities in Minnesota—and more than $13 million in 2012 alone.

The evidence also points to that the payday loan business model targets vulnerable populations. Storefronts are more likely to locate in communities with higher proportions of low-income residents, people with lower levels of education, immigrants, renters, and particularly, African Americans. The industry perpetuates the inequities these communities experience. For example, African Americans in Minnesota lag in homeownership, an indicator of wealth, with only 21% owning homes compared to 75% of whites who own homes. African Americans also have a higher poverty rate than whites in Minnesota, 38% versus 11%, respectively.

Along with this wealth drain, targeting of vulnerable communities, and worsening of economic inequities, payday loans were found to directly affect the health of borrowers and their families. Borrowers experience high levels of stress from worrying about being in debt and repaying loans. Chronic stress, particularly financial stress, has profoundly negative effects on health, including cancer, heart disease, stroke, diabetes, hypertension, ulcers, and compromised immune function.

Most counties with a payday loan store rank in the bottom half of the state for health outcomes, and payday loans exacerbate existing health inequities between white Minnesotans and people of color who also have higher rates of infant mortality, obesity, diabetes, heart disease, and premature mortality.

Minnesota is the worst state in the country in terms of the wealth gap between whites and people of color, and payday lending is only one factor that contributes to that reality. These outcomes are the result of long-standing social and economic policies that converged to drain wealth from low-income communities and communities of color, and have resulted in an economy where chronic underemployment, stagnant wages, race and gender discrimination, and other experiences are the norm for many lower wage workers. All of this comes at the expense of health and wellbeing of communities throughout Minnesota and the nation.

In our research, we talked with Gynnie Robnett of the Americans for Financial Reform, who refutes lender claims, and said:

“[Lenders] say, ‘We are providing a service to people who need money. Without these loans where would people go?’ We respond – if someone is drowning you don’t throw them a deflated life raft. People are struggling in this country; they are not making enough money. The loans are marketed as a quick fix, one-time thing and they are not used this way. The loans are used for everyday expenses and they trap people in long-term debt. Instead of relieving a crisis you are creating a new crisis.”

Our report supports the findings of many researchers that regulations are needed to prevent the payday loan industry from taking advantage of the most vulnerable Minnesotans. Stronger regulations on payday loans would help protect more than 50,000 Minnesotans and their families from these impacts.

However, the absolute greatest benefit to health and equity would be the elimination of the payday lending industry altogether. The opportunity has arrived for lawmakers to curb predatory lending practices and help improve the health of Minnesota’s most vulnerable communities.

Follow the conversation on Twitter at #DrowningInDebtMN.

We Thought it was Good, but not THIS Good: Community Participation in HIA

When we started this evaluation of how the field of HIA is doing at encouraging community participation in HIA, we have to admit, we had low expectations. But the results are in, and they are much more encouraging then we thought they might be.

At HIP, we have focused on community participation as a key way to reach international HIA goals of democracy and equity. We strive in our work to authentically and intentionally encourage community members who are impacted by public decisions to be involved in the HIA process. But, to be honest, we didn’t know for sure if community participation would lead to greater democracy and equity, or how strong the connection would be. So we set out to study it.

How do you measure how much a community participated in an HIA? How do you measure how that participation impacted democracy and equity? We started by diving into the literature and looking for resources to help us figure that out. First, we found the International Association of Public Participation’s Spectrum of Participation, and we adapted it to be more specific to HIA.

Table 1_ spectrum comm parti

Then, we had long discussions about what the ultimate outcome of democracy might be, on an individual and collective level, and we decided it was captured best by the concept of civic agency. We defined civic agency as: a community’s ability to organize and undertake collective action in its own self-interest. We measured civic agency by creating survey questions that lined up with the ways civic agency was discussed in the literature. We asked questions about community members taking action, increasing contact with decision makers, strengthening skills to influence future decisions, and if community voices about the HIA topic were heard.

Once we had our questions ready, we sent out our survey to HIA team members and to the community members that participated in their HIAs. We got nearly 100 respondents (63 HIA team members and 30 community members), representing 47 HIAs across the US. We followed this up with an in-depth study of four HIAs that we followed from beginning to end, to better understand the context of our findings and see if there was anything we missed.

Turns out, the field is doing a better job at incorporating community participation in HIAs than we thought. Most respondents reported that the level of community participation in their HIA fell in the middle of the spectrum, at the “involve” level. Perhaps even more encouraging, community members ranked their HIAs as higher in community participation than HIA practitioners did.

Figure 1. Level of Community Participation as reported by HIA team members (N = 59) and community members (N = 28).

Figure 1

Another finding that was stronger than we expected – no one feels like the community participation has a negative impact on the success of their HIA. In fact, a whopping 84% said they thought it had a positive impact.

Figure 2. Impact of Community Participation on the Success of the HIA

Figure 2

In fact, further analysis showed that HIAs that had higher levels of community participation had better odds of successfully impacting the HIA decision point (this is how we defined success). In other words – it’s not just having the community participate that improves the success of an HIA, it’s having the community participate at high levels of participation.

Finally, HIAs are doing a good job at supporting democracy through civic agency. With responses ranging from 63% to 85%, the majority of respondents reported that each measure of civic agency was achieved through the community participation in their HIA. This is great news. While we always suspected this would be the case – it makes intuitive sense that involving people more in the decision-making process that impacts their lives increases democracy – it is very encouraging to see this documented.

Figure 3. Civic agency outcomes (N = 88)

Figure 3

So overall, this study was able to contribute to the field of HIA by helping to define levels of community participation and impact on democracy through civic agency. We were able to show that the field of HIA is already doing a decent job of community participation in HIA, and community participation is contributing to civic agency and to the success of HIAs. Higher levels of participation led to even more successful HIAs.

But there’s still room for improvement. Less than one-third of the respondents indicated that community participation in their HIA was at one of the top two levels on the spectrum – where the most benefit comes. The findings from this study give us even more reason to keep striving for these higher levels of participation. We thought this was true, and now we know it is. Good news, indeed.

Check out our full report for more information on recommendations to enhance community participation in HIAs.

Building Hope with Community: The Right to Affordable Housing in South Central Los Angeles

This week’s blog is a repost from Esperanza Community Housing. The post discusses the right to affordable housing in South Central Los Angeles and preliminary findings from HIP’s HIA on a development in the area

The narrative of South Los Angeles has been one of serial displacement. Community residents, primarily low-income people of color, have systematically been priced out of our homes and neighborhoods to make way for industry and for gentrifying trends. We’ve faced higher rents, skyrocketing property values, and a cost of living that has become unmanageable — even when working multiple jobs. This combination is a result of the city’s poor planning and spot-zoning policies, and the real estate development industry’s unchecked pursuit of profits without consideration of the human cost of housing, health, and security. This has put not only our homes at risk, but also our health, our identities, our livelihoods, and our environment. Read more…

‘New age trade’ could mean rollbacks on public health – what we found from doing an HIA on the proposed TPP in Australia

Today’s guest blog is by Katie Hirono from the Centre for Health Equity Training, Research and Evaluation at UNSW Australia. She is one of the co-authors of an HIA on the Trans Pacific Partnership Agreement (TPP).

Negotiators from the 12 TPP countries are convening this week in Atlanta for attempted last-stage negotiations, with ministers expected to meet from 30th September. Over the past five years, many public figures have commented on the TPP, including Senator Elizabeth Warren, Nobel Laureate economist Joseph Stiglitz, and reputable organisations like Doctors without Borders and the AFL-CIO. As we near the potential conclusion of negotiations, what can we say will be the impacts of this “21st century trade agreement?”

What is the TPP?

The TPP, or Trans Pacific Partnership Agreement, would be the largest free trade agreement (FTA) in the world. It will include 12 Pacific rim nations – Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, United States, Vietnam – and will potentially encompass 36% of world gross domestic product. Unlike most ‘old school’ FTAs that set rules related to the import and export of goods between countries, the TPP seeks to standardize domestic rules related to everything from copyright infringement to pharmaceutical patents. It has been argued that the TPP is a mechanism for the U.S. to impose domestic standards and agendas onto other countries. Note the exclusion of China from the current agreement. Once the TPP is finalized, any additional countries that want to join will have to agree to the rules already set in place.

Why should we be concerned?

Despite the broad and far-reaching implications of these trade provisions, the TPP is negotiated without public involvement and draft texts are confidential. Even members of Congress have restricted access to reading the text. Witnessing the effects of other trade agreements, many organisations are concerned with the TPP’s potential effects on health and human rights.

To understand the potential impacts, a team of researchers in Australia conducted a health impact assessment (HIA) on the proposed TPP. Using leaked draft texts, we determined what the potential provisions could be, and then mapped them out onto public health policy scenarios that could be implemented in the future. Keep in mind the TPP will only affect future policies, not ones that already exist. We then looked at how changes to those policies could affect health in Australia, particularly looking at who would be affected most.

Working with a technical and advocacy advisory committee, and knowing that there are no formal channels for the HIA to be supplied to decision makers, we decided to disseminate our findings to advocates who could then use them to inform their efforts.

What did we find?

In a nutshell, we found that the TPP has the potential to harm the health of people in Australia in four areas we looked at: access to medicines, changes to tobacco control policies, changes to alcohol control policies, and the regulation of food labelling.

In the area of medicines, we found that the extensions to monopoly periods which the U.S. is pushing for, would be likely to lead to increased out-of-pocket costs for consumers. This often leads to people taking less of their medication (or not at all) and is associated with higher hospitalizations and declining health, particularly for low income people or people with chronic conditions who are less able to accommodate rising costs.

Although tobacco control is far more advanced in Australia than the U.S., we found that additional policies, such as restrictions to tobacco marketing and regulation of e-cigarettes could be hindered by the TPP. This could happen through TPP provisions that protect intellectual property or protect against barriers to trade. Most concerning is the TPP’s investor state dispute settlement (ISDS) mechanism, which allows foreign companies to sue governments when they feel that their investments have been infringed upon by domestic policy. ISDS has been used to attack public health policy in the past. For example, Philip Morris used the ISDS provision of an investment treaty between Hong Kong and Australia to sue the Australian government over its implementation of tobacco plain packaging. While plain packaging is considered a best practice in tobacco control, Philip Morris’ use of the ISDS clause has cost Australia millions in defending the policy. Although it is extremely unlikely that Philip Morris will win, public health regulations can be put at risk through ISDS. In countries that can’t afford high litigation expenses, even the threat of using ISDS can have a chilling effect in which countries choose not to pursue innovative policies for fear of retribution. This is particularly troubling for populations that have high smoking rates, and that are in need of new and innovative anti-smoking policies.

We also considered how the TPP could impact future alcohol control measures, particularly restrictions on alcohol availability, bans on alcohol advertising, and pregnancy warning labels. We found similarly that TPP provisions may restrict the ability of the Australian Government to implement new alcohol control policies. Rules in the cross-border services chapter may prohibit governments from limiting the number of licensed alcohol outlets per geographic area. The public health evidence clearly shows that when alcohol is more available, people are more likely to drink, and to have higher rates of violent assault, drunk driving, and pedestrian injury. These impacts are particularly relevant to adolescents who have higher rates of risky drinking.

Lastly, front-of-pack nutrition labelling is not mandatory at this stage in Australia. Rather, it relies on industry compliance with a voluntary scheme. TPP provisions could require greater involvement of the processed food industry in policy decision making, which could influence the effectiveness of food labelling systems. Without adherence to best practices in food labelling, it is likely that there will be no change to the current high rates of overweight and obesity in Australia and their associated health effects, which is particularly relevant to low socioeconomic populations who often have high rates of obesity but lower health literacy rates.

While we focused on the particular impacts that could occur in Australia, it is likely that similar impacts, including those we did not assess, could take place in many of the 11 other countries involved, including the U.S.

What can we do about it?

We developed recommendations that could be applied to the current negotiations to avoid the potential harms we identified. For example:

  • The TPP could include strong and clear public health exceptions which would prevent public health policy from being affected by trade concerns. They could also completely exclude harmful and unnecessary provisions like ISDS.
  • HIA should be conducted after the final text is available to fully understand the potential impacts from the trade provisions.
  • To improve the trade negotiating process in general, there should be greater transparency and public involvement, and formal channels for involvement of public health experts. This could include the release of draft texts and publication of the government’s negotiating position on issues of public interest.

Our advocacy partners used the findings and recommendations to put pressure on the political bodies involved in the negotiations. In some ways, we have seen great success from this – with Minister of Trade Andrew Robb refusing to agree to any monopoly extensions for some medications. Yet he still hasn’t ruled out having the ISDS clause apply to Australia.

Although negotiations have gone through 20 rounds, with many claiming to be “the final round,” it behoves us to consider the Atlanta negotiations as a key opportunity to inform the discussion. The U.S. Congress will need to approve the trade agreement once negotiations are final – so make sure you let your congress person know how you feel about the TPP! You can also throw your support towards many of the existing advocacy campaigns that are taking place in the U.S. Or simply read the findings from the full HIA report to keep yourself informed.

The Health Impact Assessment of the TPP was conducted by:

Katie Hirono and Fiona Haigh, Centre for Health Equity Training, Research and Evaluation, UNSW Australia

Deborah Gleeson, School of Psychology and Public Health, La Trobe University

Patrick Harris and Anne Marie Thow, Menzies Centre for Health Policy, University of Sydney

For more information about the TPP HIA in Australia, contact: Katie Hirono (k.hirono@unsw.edu.au).

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.

The Complexity of Considering Both Mental and Physical Health in an HIA

Earlier this year the World Health Organization (WHO) released The Social Determinants of Mental Health, which outlines the connections between social factors and mental disorders, and describes how taking a lifespan approach to addressing inequality is the best strategy to impact mental health and well-being. The authors have this to say about the connections between a healthy mind and a healthy body:

The social determinants of health shape and profoundly influence both mental and physical health. Furthermore, the relationship between physical and mental health indicates that poor physical health can cause mental disorders, and vice versa. Reducing inequalities in mental health cannot be achieved without reducing inequalities in physical health. Therefore, a social determinants of health approach should consider both mental and physical health implications within all actions to tackle health inequalities.

This is common sense: The relationship between mental and physical health has been described by researchers and validated by people’s real-life experience. But as an HIA practitioner, how do you address both at the same time?

You only have to start to outline a scoping pathway to see the difficulty in considering both mental and physical health impacts of an action at the same time. For example, a decision to increase recreational opportunities could impact both the risk of cardiovascular disease and stress or anxiety levels. The circularity between mental and physical health defies the linear relationship HIA traditionally calls for. If chronic disease and mental disorders are engaged in a dance, with either partner leading at a given time, how can we predict which will impact the other?

This question is probably more significant for HIA practitioners who feel they have little understanding of mental health and well-being to begin with. After all, there is not much direction on how to measure population mental health outcomes, and mental health data is either lacking or nonexistent. For those reasons the Adler School of Professional Psychology’s Institute on Social Exclusion decided to focus primarily on mental health in our Mental Health Impact Assessment. We wanted to include a more thorough understanding of mental health and well-being, and consider how community mental health processes like collective efficacy impact individual mental health outcomes. It was our goal to expand the HIA field to provide a model showing how mental health is broader than just mental disorders and illness.

While there are a growing number of HIAs with mental health considerations, there haven’t been many examples where the circular relationship with chronic disease has been acknowledged. This is why the Society of Practitioners of HIA (SOPHIA) has a workgroup on incorporating mental health into HIA, which you can find more about here. Through the workgroup we are producing resources to assist practitioners interested in applying a more comprehensive view of health, including both mental and physical health impacts. While considering both mental and physical health impacts in an HIA is complex, it’s also profoundly important. Stay tuned for more resources from our workgroup to help you address mental health as well as physical health in your assessments.

Tiffany L. McDowell, PhD, is the Executive Director for the Institute on Social Exclusion at the Adler School of Professional Psychology in Chicago. She can be reached at tmcdowell[at]adler[dot]edu. 

Transit Policy Gets Moving in Columbia, Missouri with Help from HIA

By Jason Wilcox

“Believe it or not, when I started working on transit, I had hair.”

Mayor Bob McDavid of Columbia, Missouri, joked about the stressful discussions surrounding the city’s public transit system. The conversations kept circling back to whether the financial impact of public transit was positive or negative. City representatives and pro-public transit groups searched for ways to keep the transit system economically feasible, while many opponents wondered why the city continued to subsidize what they saw as a non-essential service.

To take a new approach, in 2013 a Health Impact Assessment was conducted, providing an opportunity to present information through a health lens – not the usual frame for discussing public transit. The Columbia/Boone County Department of Public Health and Human Services focused the HIA on the potential impacts of expanding the public transit system on physical activity, mobility and access to jobs, health care, employment, and social capital.

With the release of the HIA, transit policy started moving. Within three months, Columbia Transit presented a draft of a new, budget-neutral public transit system, COMO Connect. The new system would feature neighborhood routes, as recommended by the HIA, ensuring access to essential services. New routes would run near large employers, health care facilities, and stores that offered healthy food options. After a year of public input, COMO Connect began running the new routes on August 4, 2014.

After completion of the initial HIA, a subsequent assessment was performed to focus on the potential health impacts of a transportation utility fee to help fund COMO Connect. The fee would be tacked on to residents’ utility bills, allowing them to ride the bus without paying a fare. The assessment found that the additional fee could hurt low-income households. Interviews with local residents discovered that many in the community already go without food or medical care due to high utility bills. This potential funding source is still being considered by the City, with a likely vote in 2016.

The completed HIAs have not only strengthened existing partnerships between the health department and community organizations, but have also allowed for the creation of new relationships. The interest in HIAs continues to grow in the community, with various City departments choosing to approach issues from a health perspective. The value of seeking out changes that impact the City’s overall landscape and infrastructure, as well as changes that positively impact citizen health, is becoming clearer.

Jason Wilcox is a Senior Planner with the Columbia/Boone County Dept. of Public Health & Human Services in Columbia, Missouri.


Treatment, Not Prison: Reforming Sentences for Low-Level Crimes Will Boost Health and Safety for All Californians

[Originally posted at The Pump Handle]

Reforming California’s sentences for low-level crimes would alleviate prison and jail overcrowding, make communities safer, strengthen families, and shift resources from imprisoning people to treating them for the addictions and mental health problems at the root of many crimes, according to a study by Human Impact Partners.

Rehabilitating Corrections in California, a Health Impact Assessment of reforms proposed by a state ballot initiative, predicts the changes would reduce crime, recidivism, and racial inequities in sentencing, while saving the state and its counties $600 million to $900 million a year – but only if treatment and rehabilitation programs are fully funded and implemented properly.

Read the full article at The Pump Handle.