Lessons Learned from HIAs conducted in the U.S. From 1999 to 2010

Background: The use of Health Impact Assessments (HIAs) in the U.S. is growing rapidly. Coinciding with the high-level of interest in HIAs is an ongoing discussion within the U.S. HIA practice community regarding the effective use of HIAs. Little evidence exists regarding the impacts of HIAs.   

Methods: A multiple case study of the HIAs completed in the U.S. from 1999 through July 2010 to collect process and impact evaluation measures. Data were collected from HIA reports, semi-structured interviews with the lead HIA practitioner, and other published documents. Interviews were transcribed, coded, and thematic analyses were conducted across the entire sample using NVIVO 9.

Results:  Of the 76 HIAs that we identified as having been completed in the U.S. from 1999 to July 2010, we successfully contacted 25 HIA practitioners associated with 59 HIAs (78% of the eligible sample) conducted in 15 different U.S. states. HIAs had both indirect impacts (e.g., culture change around health) and direct impacts (e.g., established new interagency collaborations). Having a trustworthy relationship with the decision-maker and a thorough objective assessment of the evidence were associated with having an impactful HIA. Skepticism about the potential health impacts, timing, and lack of meaningful stakeholder engagement were the most common barriers to the HIA recommendations being adopted.

Conclusions: HIAs are an effective decision-support tool with both direct and indirect impacts. HIAs effectively increase awareness of health and/or social determinants of health when the process is inclusive, timely, balanced in the assessment, and transparent.