Lessons From San Francisco: Health Impact Assessments Have Advanced Political Conditions For Improving Population Health

Factors of the policy process influencing Health in All Policies in local government: A scoping review

Objectives

This review aimed to identify factors in the policymaking environment that influence a Health in all Policies approach in local government, how these vary across different municipal contexts, and the extent that theories of the policy process are applied.

Methods

A scoping review was conducted to include sources published in English, between 2001 and 2021 in three databases, and assessed for inclusion by two blind reviewers.

Results

Sixty-four sources were included. Sixteen factors of the policy process were identified, expanding on previously reported literature to include understanding and framing of health, use of evidence, policy priority, and influence of political ideology. Eleven sources applied or referred to theories of the policy process and few reported findings based on different local government contexts.

Conclusion

There are a range of factors influencing a Health in All Policies approach in local government, although a limited understanding of how these differ across contexts. A theory-informed lens contributed to identifying a breadth of factors, although lack of explicit application of theories of the policy process in studies makes it difficult to ascertain meaningful synthesis of the interconnectedness of these factors.

Law and urban governance for health in times of rapid change

Governance is an important factor in urban health, and law is an important element of healthy governance. Law can be an intervention local government wields to influence behavior and shape environments. Law can also be an important target of health promotion efforts: Law and the enforcement and implementation behaviors it fosters can promote unhealthy behaviors and environmental conditions, and can act as a barrier to healthy interventions or practices. Finally, law is a design and construction tool for the organization of governance. Law is the means through which cities are formally established. Their powers and duties, organizational structure, boundaries and decision-making procedures are all set by law. Regardless of the form of government, cities have legal levers they can manipulate for health promotion. Cities can use tax authority to influence the price of unhealthy products, or to encourage consumption of healthy foods. Cities can use their legal powers to address incidental legal effects of policies that they themselves cannot control. Cities may also have the authority to use law to address deeper determinants of health. The overall level of income or wealth inequality in a country reflects factors well-beyond a local government’s control, but city government nonetheless has levers to directly and indirectly reduce economic and social inequality and their effects. A renewed focus on law and urban governance is the key to assuring health and well-being and closing the health equity gap.

Health Impact Assessment of Transportation Projects and Policies: Living Up to Aims of Advancing Population Health and Health Equity?

Health impact assessment (HIA) is a forward-looking, evidence-based tool used to inform stakeholders and policy makers about the potential health effects of proposed projects and policies and to identify options for maximizing potential health benefits and minimizing potential harm. This review examines how health equity, a core principle of health impact assessment (HIA), has been operationalized in HIAs conducted in the United States in one sector, transportation. Two perspectives on promoting health equity appear in the broader public health research literature; one aims at reducing disparities in health determinants and outcomes in affected populations, whereas the other focuses on facilitating community participation and self-determination. Variations in how these perspectives are applied in HIA informed our typology of five ways of addressing health equity in HIA. Transportation HIAs commonly included two of these—selecting vulnerable populations for the focus of the HIA and stakeholder engagement, seen in more than 70% of the 96 HIAs reviewed. Fewer than half of the HIAs assessed current health disparities or changes in their distribution. Only 15% of HIAs addressed equity by focusing on capabilities development or empowerment. Routinely assessing and reporting how an HIA aims to address health equity might better manage expectations and could make HIA practitioners and users more conscious of how an HIA can realistically be used to advance health equity.

Implications of the GC-HARMS Fishermen's Citizen Science Network: Issues Raised, Lessons Learned, and Next Steps for the Network and Citizen Science

This paper is intended to complement our extended documentation and analysis of the activities of the Gulf Coast Health Alliance: Health Risks related to the Macondo Spill project Community Outreach and Dissemination Core entitled, "Building and maintaining a citizen science network with fishermen and fishing communities after the Deepwater Horizon oil disaster using a Community-Based Participatory Research (CBPR) approach." We discuss nuances of CBPR practice, including trust-building, clarification of stakeholder expectations, balancing timelines and agendas, cultural fluency, and the importance of regional history-political-economic context, regulatory practices, and cultural life-ways-in creating social dynamics that overarch and underpin the entire process. We examine the unique role of knowledge-making hybrid structures like the project's Fishermen's citizen science network and compare/contrast this structure with other models of participatory science or deliberation. Finally, we reiterate the importance of environmental health literacy efforts, summarize project outcomes, and offer thoughts on the future roles of collaborative efforts among communities and institutional science in environmental public health.

Integrating public health and community development to tackle neighborhood distress and promote well-being

Recently there have been calls for public health to reconnect to urban planning in ways that emphasize the impact of place on health and that address fundamental causes of poor health, such as poverty, social inequality, and discrimination. Community developers have realized that poor health limits individuals' and communities' economic potential and have begun to integrate into their work such neighborhood health issues as access to fresh food and open space. In this article we review recent shifts in the community development field and give examples of programs that operate at the intersection of community development, public health, and civic engagement. For example, in Sacramento, California, the Building Healthy Communities program successfully promoted the creation of community gardens and bike paths and the redevelopment of brownfields. A major housing revitalization initiative in San Francisco, California, known as Sunnydale-Velasco, is transforming the city's largest public housing site into a mixed-income community that provides existing residents with new housing, infrastructure, services, and amenities. These examples and others illustrate the need to identify and make use of interdisciplinary approaches to ensure that all places are strong platforms for economic mobility, full democratic participation, and community health.

Predicting urban design effects on physical activity and public health: A case study

With increasing global concerns about obesity and related health effects, tools to predict how urban form affects population physical activity and health are needed. However, such tools have not been well established. This article develops a computer simulation model for forecasting the health effects of urban features that promote walking. The article demonstrates the model using a proposed small-area plan for a neighborhood of 10,400 residents in Raleigh, North Carolina, one of the fastest-growing and most sprawling U.S. cities. The simulation model predicts that the plan would increase average daily time spent walking for transportation by 17 min. As a result, annual deaths from all causes are predicted to decrease by 5.5%. Annual new cases of diabetes, coronary heart disease, stroke, and hypertension are predicted to decline by 1.9%, 2.3%, 1.3%, and 1.6%, respectively. The present value of these health benefits is $21,000 per resident.

New Approaches for Moving Upstream

Growing evidence shows that unequal distribution of wealth and power across race, class, and gender produces the differences in living conditions that are “upstream” drivers of health inequalities. Health educators and other public health professionals, however, still develop interventions that focus mainly on “downstream” behavioral risks. Three factors explain the difficulty in translating this knowledge into practice. First, in their allegiance to the status quo, powerful elites often resist upstream policies and programs that redistribute wealth and power. Second, public health practice is often grounded in dominant biomedical and behavioral paradigms, and health departments also face legal and political limits on expanding their scope of activities. Finally, the evidence for the impact of upstream interventions is limited, in part because methodologies for evaluating upstream interventions are less developed. To illustrate strategies to overcome these obstacles, we profile recent campaigns in the United States to enact living wages, prevent mortgage foreclosures, and reduce exposure to air pollution. We then examine how health educators working in state and local health departments can transform their practice to contribute to campaigns that reallocate the wealth and power that shape the living conditions that determine health and health inequalities. We also consider health educators’ role in producing the evidence that can guide transformative expansion of upstream interventions to reduce health inequalities.

Health impact assessment of traffic-related air pollution at the urban project scale: influence of variability and uncertainty

This paper develops and then demonstrates a new approach for quantifying health impacts of traffic-related particulate matter air pollution at the urban project scale that includes variability and uncertainty in the analysis. We focus on primary particulate matter having a diameter less than 2.5 μm (PM2.5). The new approach accounts for variability in vehicle emissions due to temperature, road grade, and traffic behavior variability; seasonal variability in concentration-response coefficients; demographic variability at a fine spatial scale; uncertainty in air quality model accuracy; and uncertainty in concentration-response coefficients. We demonstrate the approach for a case study roadway corridor with a population of 16,000, where a new extension of the University of North Carolina (UNC) at Chapel Hill campus is slated for construction. The results indicate that at this case study site, health impact estimates increased by factors of 4-9, depending on the health impact considered, compared to using a conventional health impact assessment approach that overlooks these variability and uncertainty sources. In addition, we demonstrate how the method can be used to assess health disparities. For example, in the case study corridor, our method demonstrates the existence of statistically significant racial disparities in exposure to traffic-related PM2.5 under present-day traffic conditions: the correlation between percent black and annual attributable deaths in each census block is 0.37 (t(114)=4.2, p<0.0001). Overall, our results show that the proposed new campus will cause only a small incremental increase in health risks (annual risk 6×10(-10); lifetime risk 4×10(-8)), compared to if the campus is not built. Nonetheless, the approach we illustrate could be useful for improving the quality of information to support decision-making for other urban development projects.

Case study: San Francisco's use of neighborhood indicators to encourage healthy urban development

Neighborhood indicators are quantitative measures of neighborhood quality, including measures of attributes such as crime, noise, proximity to parks, transit services, social capital, and student performance. In 2007 the San Francisco Department of Public Health, with broad public input, developed a comprehensive system of neighborhood indicators to inform, influence, and monitor decisions made by the Department of City Planning and other community development institutions. Local public agencies, businesses, and citizens' groups used the indicators to identify disparities in environmental and social conditions, inform and shape neighborhood land use plans, select appropriate sites for development projects, craft new environmental regulations, and justify demands on developers to make financial contributions to community infrastructure. Among other things, the use of indicators contributed to policies to prevent residential displacement, a city ordinance requiring stricter building ventilation standards in areas with high air pollution, and the redeployment of traffic police to high-injury corridors. Data that can be used to create neighborhood indicators are increasingly available, and participation by public health and health care institutions in the indicators' development, dissemination, and application could help improve several conditions that contribute to poor population health.

"Health in All Policies": taking stock of emerging practices to incorporate health in decision making in the United States

OBJECTIVE

Policies affecting the determinants of health lie largely outside the control of the health care and public health sectors. Ensuring health considerations in the formation and implementation of policies, programs, projects, and plans from all sectors, though lofty, is the overall aim of Health in All Policies. The purpose of this article was to identify categories of strategies that illustrate how Health in All Policies had been implemented in the United States.

DESIGN

We used a 3-phased process: (1) review of the published and gray literature; (2) analysis of case examples to identify a draft framework, which included tactics and strategies for implementing Health in All Policies; and (3) vetting the draft framework through individual and group consultation.

RESULTS

We identify 7 interrelated strategies for incorporating health considerations into decisions and systems: (1) developing and structuring cross-sector relationships; (2) incorporating health into decision-making processes; (3) enhancing workforce capacity; (4) coordinating funding and investments; (5) integrating research, evaluation and data systems; (6) synchronizing communications and messaging; and (7) implementing accountability structures. For each strategy, we provide illustrative examples from the United States to help public health leaders identify effective tactics for Health in All Policies implementation.

CONCLUSIONS

Through our review, we offer a starting point for categorizing and describing the emerging practices used to work across sectors and address the determinants of health. By delineating the different types of strategies and tactics to achieve Health in All Policies, we provide public health practitioners with a "menu" of options for incorporating Health in All Policies into their work.

Protecting labor rights: roles for public health

Federal, state, and local labor laws establish minimum standards for working conditions, including wages, work hours, occupational safety, and collective bargaining. The adoption and enforcement of labor laws protect and promote social, economic, and physical determinants of health, while incomplete compliance undermines these laws and contributes to health inequalities. Using existing legal authorities, some public health agencies may be able to contribute to the adoption, monitoring, and enforcement of labor laws. We describe how routine public health functions have been adapted in San Francisco, California, to support compliance with minimum wage and workers' compensation insurance standards. Based on these experiences, we consider the opportunities and obstacles for health agencies to defend and advance labor standards. Increasing coordinated action between health and labor agencies may be a promising approach to reducing health inequities and efficiently enforcing labor standards.