A New Tool for Assessing Equity in Health Impact Assessments

Urban planning decisions, given their effects on the built environment, have a significant influence on public health and equity. Therefore, it's worth considering how effectively planning tools address entrenched racial and ethnic health inequities in public-facing projects.

In "Evaluating Racial/Ethnic Equity in Planning-Related U.S. Health Impact Assessments Involving Parks and Greenspaces," (Journal of the American Planning Association, Vol. 89, No. 4), Lilah Besser and colleagues scrutinize one tool frequently used by government agencies, international organizations, and other stakeholders — health impact assessments (HIAs).

Equity-focused Tool Evaluates HIAs Effectively

With roots in the 1980s and 1990s, HIAs were developed to understand the possible health repercussions of proposed projects and public policy. Since they emerged, around one-third have been focused on planning-related efforts. While they are of varying lengths and review health outcomes to different extents, equity is supposed to be a core principle of HIAs. The objective is to pinpoint positive and negative health impacts for all populations, with a particular emphasis on historically marginalized communities. When carried out in good faith, HIAs can provide actionable recommendations to mitigate harm and maximize project benefits.

Though the impetus for HIAs is laudable, their value has been questioned considering they add more time to the planning process.

To evaluate how successfully HIAs address inequities, Besser and other researchers developed a novel tool called the TREE-HIA. Building on the Society of Practitioners of Health Impact Assessment (SOPHIA) that seeks to uplift communities during the HIA process using an equity lens, TREE-HIA systematically assesses equity considerations when nothing beyond an HIA report is available. In contrast to SOPHIA, it focuses on marginalized racial and ethnic communities rather than general inequity. Further, TREE-HIA is applied to process equity rather than project outcomes.

The TREE-HIA leverages a comprehensive set of metrics to assess whether equity is centered in an HIA report. Figure 1 shows how scorers using the tool consider whether the HIA promotes equity in community engagement, scope, analysis, recommendations, dissemination, and evaluation and assigns points up to a maximum of 27. Scorers applied the TREE-HIA to 50 HIA reports focused on urban issues such as zoning, parks, housing, and transit. All HIAs reviewed for this study were conducted between 2005 and 2020.

Figure 1: The TREE-HIA scoring guide used by the researchers to evaluate HIAs.

HIAs Lack Focus on Racial Equity

Results from the application of the TREE-HIA suggest insufficient attention to equity. Out of 50 HIAs, 42 percent scored below zero, suggesting limited attention to racial and ethnic equity. Newer and more comprehensive HIAs tend to score better.

However, even while the review shows attention to equity is growing over time, it is not generally well integrated within HIA reports and processes. Between 2017 and 2020, the median TREE-HIA score remained around 4.0 out of 27.

Several areas require improvement in the HIA process:

1. Historically marginalized communities must be included as collaborators in each HIA step. Projects need to draw from local knowledge of the area and incorporate their priorities into both evidence and recommendations.
2. To ensure that projects are accessible to the community, the HIA process should also employ culturally appropriate communication methods to fully involve all concerned individuals.
3. While monitoring/evaluation sub-scores assigned by the researchers were predominantly neutral given HIAs' often limited capacity in this area, equity impacts need to be monitored over time. If there are any obstacles to implementing an equitable project, they should also be addressed in the HIA.

HIAs may lack a focus on racial and ethnic equity for several reasons. In the United States, HIAs are rarely mandatory. As a result, they frequently lack resources to thoroughly address equity issues and may face competing priorities that draw more resources.

Project leadership may also neglect to adopt any recommendations meant to bolster equity goals. Since HIAs are largely conducted by academic or civil society groups rather than project decision-makers, buy-in can be limited.

Furthermore, methods employed by HIA practitioners tend to overlook issues affecting communities of color. Whereas HIAs typically demonstrate a strong preference for quantitative data, their social context is usually best explained through qualitative analysis.

Ultimately, HIAs regularly fail to meaningfully address equity because they are non-binding. The majority of HIAs have few incentives and accountability mechanisms baked in to guarantee impacts to historically marginalized communities are properly addressed.

To advance health equity, the researchers conclude that HIAs need to consistently prioritize racial and ethnic equity at every stage. To this end, systemic power imbalances and racist urban planning practices must be confronted. HIAs represent an opportunity to increase decision-making power in historically marginalized communities, but only if they improve outcomes for those most often left out of planning decisions. The TREE-HIA, a tool with proven inter-rater reliability, provides a useful framework for embedding equity considerations in future HIAs and facilitating a more just distribution of public health resources.

Top image: E+ FG Trade