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Published in final edited form as: J Hous Built Environ. 2021 Jan 9;36(3):1277–1297. doi: 10.1007/s10901-020-09795-9

Use of health impact assessments in the housing sector to promote health in the United States, 2002–2016

Emily Bever 1, Kimberly T Arnold 2, Ruth Lindberg 1, Andrew L Dannenberg 3, Rebecca Morley 4, Jill Breysse 5, Keshia M Pollack Porter 6
PMCID: PMC8555747  NIHMSID: NIHMS1669978  PMID: 34720777

1. INTRODUCTION

The links between housing and health are well documented (Taylor 2018; Krieger & Higgins 2002; Breysse et al. 2004; World Health Organization [WHO] 2006; Jacobs Wilson Dixon Smith & Evens 2009). The primary pathways through which housing affects health include its quality, affordability, location, and influence on community and social cohesion. For example, poor quality housing can cause stress, respiratory disease, neurological disorders, chronic disease, psychological and behavioral issues, and death (Krieger & Higgins 2002; Sandel Sharfstein & Shaw 1999). The absence of affordable housing can force families to make trade-offs between expenses for rent, heating and cooling, food, and health care. High housing costs are associated with hunger, inadequate childhood nutrition, and poor childhood growth (Nord & Kantor 2006; National Energy Assistance Directors Association 2014; Palmieri and Greenhalgh 2002; Snyder and Baker 2010; She and Livermore 2007; Burgard Seefeldt & Zelner 2012). Lack of affordable, quality housing can lead to homelessness and overcrowding and also relegates residents to poorer quality housing and neighborhoods with higher crime and fewer amenities. The location of housing impacts opportunities to live a healthy life by affecting the availability of quality schools, jobs, parks, public transportation, healthy food options, and health care (Joint Center for Housing Studies 2014; Hu & Wang 2017; Pendall et al. 2014; Robert Wood Johnson Foundation 2008).

Yet many housing decisions are made without consideration for health and equity—where everyone has a fair and just opportunity to be as healthy as possible. For example, public housing may be sited in locations with limited community amenities or near environmental hazards. Insufficient public funding for providing housing for low-income individuals and families influences health care utilization and costs. Housing design, renovation, and construction may pay inadequate attention to health concerns such as radon, lead-based paint, effective ventilation, moisture management, and the ease of ongoing maintenance for occupants. The lack of consideration of health and equity in housing policy, programming, and practice yields missed opportunities to improve resident health and can exacerbate health inequities during the process.

Health impact assessment (HIA) is a tool for ensuring that decision-makers systematically consider health effects of their proposed actions (Health Impact Project 2014). HIA brings together scientific data, health expertise, and stakeholder engagement to identify the potential—and often overlooked—health effects of proposed policies, plans, programs, and projects. Through HIA, community members, business interests, and other stakeholders engage in a process to analyze data, generate findings, and make recommendations to promote health benefits and mitigate adverse impacts of a proposed decision (Bhatia et al. 2014). Each HIA follows an established set of six steps, and overall HIA practice in the U.S. is guided by minimum elements and practice standards (Bhatia et al. 2014). HIAs can use a rapid assessment model or a more comprehensive approach, depending on the time and resources available. Equity is one of the core values of HIA. As such, HIAs examine the systemic, avoidable, and unjust differences between socio-demographic groups in environmental, social, and economic factors salient to health and well-being.

Housing HIAs are not routine but have become more common. In 2002, the San Francisco Department of Public Health conducted the first known housing assessment in the U.S. on flooring policies for the city’s affordable housing units (San Francisco Department of Public Health 2002). Since then, more than 50 housing HIAs have been conducted on a wide range of proposals and decisions.

The objectives of the research were to: (1) describe key characteristics of housing HIAs conducted in the United States, including the types of decisions examined, types of organizations leading the assessments, and location; (2) examine common methods and approaches used in housing HIAs; and (3) document the effects of housing HIAs on policymaking, where data are available, and provide three illustrative examples of how HIAs can influence housing decisions. Previous evaluations of HIA have created logic models and frameworks to guide in-depth review and analysis of HIA effectiveness (Bourcier Charbonneau Cahill & Dannenberg 2015; Wismar Blau Ernst & Figueras 2007). This paper represents a descriptive scan of housing HIAs and is not intended to provide generalizable findings. This paper is part of a series of reports exploring the use of HIAs in specific areas including transportation, education, criminal justice, food and agriculture, energy and natural resources, and substance use (Dannenberg et al. 2014; Gase et al. 2017; Hom Dannenberg Farquhar & Thornhill 2017; Cowling Lindberg Dannenberg Neff & Pollack 2017; Nkyekyer & Dannenberg 2018; Packer Belvedere Dannenberg & Barnes 2020).

2. METHODS

To identify housing-related HIAs conducted in the United States between 2002 and 2016, we systematically reviewed a comprehensive HIA database maintained by the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts (Health Impact Project 2018). We abstracted information from publicly available HIA reports and outcome statements available through this database to create a list of housing-related HIAs to examine the tool’s effects on decisions they sought to inform. The resulting list was cross-referenced with Google and PubMed searches, looking for additional housing-related HIAs not in the Health Impact Project database. Of the 165 potentially housing-related HIAs we found, we excluded 111 that did not directly consider housing in their analyses of decisions concerning other sectors (e.g., highway construction and other transportation issues, land use planning). The final sample included 54 HIAs (Table 1) that fit into two categories: housing-specific HIAs (N=18) addressing specific policies or design features of homes, and community development HIAs (N=36) that addressed broader built environment decisions, such as the construction of new homes as part of community redevelopment. One researcher created the final sample and a second researcher repeated the exclusion and categorization processes for a random subset of HIAs to ensure accuracy. For each of these 54 HIAs, we abstracted data from publicly available materials to determine the focus of the decisions, record data sources and analytic methods, and identify HIA outcomes.

Table 1:

Summary of HIAs Reviewed and Relevant Health Determinants

HIA Title (Year Completed) Lead Agency/Organization (Typea) Decision HIA sought to inform Health determinant categories examinedb
Community Development HIAs (36 of the 54 HIAs identified through the review):
Aerotropolis Atlanta (2012) Center for Quality Growth and Regional Development, Georgia Institute of Technology College of Architecture (Academic Institution) Redevelopment plans for the site of a former Ford Assembly Plant A,L
Atlanta Beltlinef (2007) Center for Quality Growth and Regional Development, Georgia Institute of Technology College of Architecture (Academic Institution) Redevelopment plans to convert a 22-mile span of freight railway into transit and trail loop, with parks, residential and commercial development Q,A,L
City of Ramsey Comprehensive Plan (2008) City of Ramsey, MN (Government Agency) Application of a “threshold analysis” to assess a variety of planning-related areas in Ramsey, MN; also made recommendations to address general accessibility, access to healthy foods, protection of surface waters and the promotion and support of physical activity Q,L
Clark County Highway 99 Sub-Area Plan (2008) Clark County Public Health (Government Agency) Twenty-year land use planning for a healthy community that is economically viable, sustainable, active, and socially cohesive in Washington state A,L,S
Coffelt-Lamoreaux Public Housing Redevelopment (2013) Catalyze Research and Consulting, LLC (Other) Redevelopment of 296-unit complex in Phoenix, AZ Q,L,S
Columbus North East Area Planc (2007) Columbus Public Health (Government Agency) Six key recommendations from area plan in Columbus, OH and how they may affect health through changes to physical activity, air pollution, mental health L
Concord Naval Weapons Station Reuse Project (2009) Human Impact Partners (Nonprofit) Redevelopment of a 5,028-acre former weapons storage site in California, including residential and commercial development, community facilities, parks, roadways, and public transit service Q,A,L
Divine Mercyc (2011) Minnesota Department of Health (Government Agency) Pilot of the Minnesota Environmental Assessment Worksheet, using the Divine Mercy mixed-use development in Faribault, MN A
Eastern Neighborhoods Community Health Impact Assessmentd (2007) San Francisco Department of Public Health (Government Agency) Area planning for redevelopment of several San Francisco neighborhoods Q,A,L,S
Executive Park Subarea Pland (2007) San Francisco Department of Public Health (Government Agency) Land use planning for 2,800-unit residential development on 71 acres in southeastern San Francisco Q,A,L,S
Farmers Fieldc (2012) Human Impact Partners (Nonprofit) Proposed 72,000-seat football stadium in downtown Los Angeles Q,A,S
Georgia Qualified Allocation Plan for Low-Income Housing Tax Credits (2015) Georgia Health Policy Center (Academic Institution) Georgia Qualified Allocation Plan for low-income housing tax credits assessing how criteria for allocating credits could impact health through housing for vulnerable populations and community development decisions Q,A,L,S
Hartford Neighborhood Revitalization and Sustainability Plan (2014) Community Solutions (Nonprofit) Revitalization and sustainability plan guiding existing land use, utilities, housing conditions, open space, and access to transportation and healthy foods in Northeast, a neighborhood in Hartford, Connecticut. Q,L,S
HOPE VI to HOPE SF: San Francisco Public Housing Redevelopmentd (2009) University of California Berkeley Health Impact Group (Academic Institution) Past HOPE VI redevelopment at two sites, Bernal Dwellings and North Beach Place, to inform new HOPE SF redevelopment plans for distressed public housing sites, with affordable housing and ownership opportunities Q,A,L,S
Humboldt County General Pland (2008) County of Humboldt Department of Health and Human Services: Public Health Branch (Government Agency) County planning in California with three growth alternatives to accommodate future population: denser development in urban areas, some growth to exurban areas, or unrestricted growth throughout county A,L
Jack London Senior Housing (2007) Human Impact Partners (Nonprofit) Proposed development, with low-income senior housing and 14,000 sq. feet of retail space in Oakland, CA A,L,S
Kings Ridge Apartmentsc (2012) Florida State University (Academic Institution) Use planning for a community center in a low-income apartment complex in Jacksonville, FL L,S
Long Beach Downtown Plan (2011) Human Impact Partners (Nonprofit) Plan for mixed-use development, including residential, commercial, and cultural development in downtown Long Beach, CA Q,A
Long Beach Housing Element (2013) Legal Aid Foundation of Los Angeles (Nonprofit) Assessment of the housing elements, including housing affordability, quality, and location in the Long Beach, CA city general plan Q,A,L
MacArthur BART (2007) University of California Berkeley Health Impact Group (Academic Institution) Mixed-use development on transit station parking lot in Oakland, CA Q,A,L,S
Massachusetts Community Investment Tax Credit Grant Program (2014) Health Resources in Action (Nonprofit) Regulations from the Massachusetts Department of Housing and Community Development that will guide the release of funding for community development corporations under the Community Investment Tax Credit Grant Program. A,L,S
Merced County General Plan (2009) Human Impact Partners (Nonprofit) County planning in California with two growth alternatives: focusing development in existing urban areas and allowing the creation of new towns in the county. L,S
Mid-Michigan Fair and Affordable Housing Plan (2015) Ingham County Health Department (Government Agency) Development of a five-year regional housing plan in central Michigan Q,A,L,S
North Birmingham Community Framework Plan (2014) School of City and Regional Planning at the Georgia Institute of Technology (Academic Institution) Healthy development in North Birmingham, Alabama, through implementation of the Community Framework Plan. L,S
Oak to Ninth Avenue (2006) University of California Berkeley Health Impact Group (Academic Institution) Mixed use development, including residential and commercial development, public open space, marinas, and wetlands restoration on 64 acres in Oakland, CA Q,A,L
Omaha Neighborhood Redevelopment Plan (2015) Douglas County Health Department (Government Agency) Redevelopment including rehabilitation of 33 existing properties and new construction in the Deer Park neighborhood of Omaha, NE Q,A,L,S
Page Avenue Revitalization (2010) Washington University in St. Louis Institute for Public Health (Academic Institution) Residential development, including senior housing, with commercial development and an urban park in Pagedale, MO Q,A,S
Pittsburg Railroad Avenue Transit-Oriented Development (2008) Human Impact Partners (Nonprofit) Transit-oriented development near proposed BART transit station in Pittsburg, CA Q,A,L
PlanOKC (2014) Oklahoma City Planning Department (Government Agency) Comprehensive plan guiding future land use; transportation; environmental and natural resources; preservation, appearance, and culture; parks and recreation; economic development; and public services in Oklahoma City, OK A,L,S
Replacing Public Housing Units Destroyed by Hurricane Iked (2014) Center to Eliminate Health Disparities University of Texas Medical Branch (Academic Institution) Siting and upgrading of public housing to replace units in Galveston, TX that were destroyed by Hurricane Ike in 2008 A,L
San Pablo Avenue Corridord (2009) Human Impact Partners (Nonprofit) Development plans for three potential affordable housing opportunity sites in Richmond and El Cerrito, California. A,L,S
South Lincoln Homesd (2009) EnviroHealth Consulting (Other) Redevelopment plan for 270 public housing units in Denver, CO A,L,S
St. Paul Light Rail (2012) PolicyLink (Nonprofit) Construction of an 11-mile light rail transit line, running through diverse, low-income communities in the Twin Cities area of Minnesota Q,A
The Crossings at 29th and San Pedro Street (2009) Human Impact Partners (Nonprofit) Development on 11.6 acres of a former industrial area, with more than 450 units of affordable housing, retail development, and community spaces in South Los Angeles. Q,A
Waters’ Edge (2015) Safe and Healthy Communities (Other) Residential development targeted at adults 55 age and older in Fort Collins, Colorado Q,A,L,S
Yellowstone County/City of Billings Growth Policy (2008) RiverStone Health (Other) Long range planning that will guide land use, economics, aesthetics, natural resources, open space and recreation, transportation, public services and cultural and historic resources in Montana Q,A
Housing-Specific HIAs (18 of the 54 HIAs identified in the review):
Advanced Metering Infrastructure (2012) National Center for Medical Legal Partnership at Boston Medical Center (Nonprofit) Proposed “smart metering” technology deployment plans in Chicago, IL Q,A,S
Benton Accessory Dwelling Unitsd (2010) Benton County Health Department (Government Agency) Five policy options related to accessory dwelling units in Benton County, OR Q,A,L
Eugene-Springfield Consolidated Plan and the Impact of Housing on Children’s Health (2014) Lane County Public Health (Government Agency) Affordable housing policy in the 2010 consolidated plan for the cities of Eugene and Springfield, OR focusing on impacts to children’s health Q,A,L,S
Flooring in Public Housing (2002) San Francisco Department of Public Health (Government Agency) Carpeting policy in public housing developments in San Francisco, CA Q,S
Housing and Urban Development Designated Housing Rulee (2015) Health Impact Project (Nonprofit) Update by the U.S. Department of Housing and Urban Development of its designated housing rule, which allows local housing authorities to allocate certain public housing properties, or a portion of them, for occupancy by senior families, disabled families, or a mixed population of senior and disabled families. Q,A,L,S
Just Cause for Evictionc (2016) Department of Urban Studies and Planning at the Massachusetts Institute of Technology (Academic Institution) Ordinance which would require landlords to have a “just cause,” which includes any violation of the lease terms, before evicting tenants in Boston, MA Q,A,S
Madison Heights (2014) Arizona Department of Health Services (Government Agency) Redevelopment of Madison Heights, a public housing unit near Phoenix, AZ Q,L,S
Massachusetts Low Income Home Energy Assistance Program (2006) Boston University Child HIA Working Group (Nonprofit) Low-Income Home Energy Assistance Program and high energy costs Q,A
Massachusetts Rental Voucher Programc (2005) Boston University Child HIA Working Group (Nonprofit) State-funded housing assistance and homelessness prevention program Q,A
North Carolina Senate Bill 731 (2012) Davidson Design for Life (Government Agency) Amendments to zoning laws to exempt low-density single-family residences from certain building design elements Q
Ohio Housing Inspections (2014) Ohio Housing Finance Agency (Government Agency) Interagency coordination and streamline the current system for inspections of affordable housing units Q
Portland City Council’s Rental Housing Inspections Program (2012) Oregon Public Health Institute (Nonprofit) Rental Housing Inspections Program at a level sufficient to continue, and potentially expand, the enhanced inspections pilot Q,S
Rental Assistance Demonstration Project (2012) Human Impact Partners (Nonprofit) Federal rental assistance demonstration project to reorganize public housing funding and management structures Q,A,L,S
Shelter-in-Place Policy (2015) San Francisco Department of Public Health (Government Agency) San Francisco’s capacity to support shelter-in-place policies after disasters and highlighting areas that need further attention to better protect residents. Q,L
Single Room Occupancy Hotels in San Francisco (2016) San Francisco Department of Public Health (Government Agency) Three policies related to single-room occupancy hotels, which serve as the biggest source of inexpensive housing for San Francisco’s most vulnerable populations, such as seniors, adults with disabilities, and children. Q,L,S
Trinity Plaza Housing Redevelopment (2005) San Francisco Department of Public Health (Government Agency) Proposal to demolish a building with 377 rent-controlled units and replace with 1,400 market-rate condominiums in San Francisco, CA Q,A,S
Universal Design in Single-Family Housing (2013) Davidson Design for Life (Government Agency) Incorporating universal design and other accessibility features within single-family homes in Davidson, NC Q,A
Zoning and Student Housing in La Plaza Vieja (2014) La Plaza Vieja Community Association (Nonprofit) Local rezoning proposal intended to accommodate new student housing in Flagstaff, AZ A,L,S
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a

organization type is based on categories in HIA database maintained by the Health Impact Project https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2015/hia-map?sortBy=relevance&sortOrder=asc&page=1

b

health determinant categories examined: Q-quality; A-affordability; L-location; S-social, economic, and political factors

c

denotes a rapid or desktop HIA

d

included analysis using the San Francisco Indicator Project (formerly the Healthy Development Measurement Tool and Sustainable Communities Index)

e

Two authors of this review contributed as authors for this HIA

f

One author of this review contributed as a subject matter expert for this HIA

The 54 HIAs examined in this study included two federal-level decisions and 52 at the state or local-levels: 19 in California; four in Massachusetts; three each in Arizona, Georgia, Minnesota and Oregon; two each in Colorado, North Carolina and Ohio; and one each in 11 other states. Various organizations led the HIAs, including non-profits, public health departments, and academic institutions (Table 1). The primary decision-makers each HIA sought to inform were housing and/or planning officials or elected officials. Overall, the use of HIAs in U.S. housing decisions has increased. Five were conducted between 2002 and 2006, 21 were performed between 2007 and 2011, and 28 occurred between 2012 and 2016.

The 18 housing-specific HIAs focused on policies, codes, design elements or energy use in residential structures. For example, six HIAs (33%) evaluated proposals concerning housing structures such as accessory dwelling units or flooring in public housing; two examined rental assistance or voucher programs; two addressed housing inspection programs; and two explored decisions about utilities and energy assistance.

Of the 36 community development HIAs, 47% evaluated proposed redevelopment plans: 11 addressed new mixed-use development, and six addressed residential land use plans. The other 19 community development HIAs examined city and county planning and construction projects that would affect housing.

We purposefully selected three HIAs as descriptive examples to illustrate the tool’s effects on various decision types and health determinants (housing affordability, housing quality, housing location, and social, economic, and political factors). These examples illustrate how the HIA process can be applied to housing decisions, including how practitioners can engage stakeholders, what methods they employ, and the mechanisms through which the HIA findings and recommendations can inform decision-making. We selected three HIAs that represented a range of locations and topics and for which sufficient information was available to describe how the HIAs influenced decision-makers and mobilized stakeholders to take action to promote health. These HIAs serve as illustrative examples of the diverse contexts and health issues to which HIA can be applied; as such, they are not intended to represent all 54 HIAs in the sample but rather highlight the potential benefits of applying HIA in diverse circumstances. Additionally, the HIAs we examined primarily focus on low-income housing decisions because advancing equity is a central goal for HIA. Bringing health considerations into decisions about the siting, design, renovation, construction, and maintenance of low-income housing has the potential to improve the quality, affordability, location and social context of this housing, and thereby improve health and equity. As such, our findings may not be relevant to housing decisions that do not have clear equity implications (e.g., construction of market rate housing or student dormitory quality).

3. RESULTS

3.1. HIA Data Collection and Analysis

The HIAs varied in the methods they used to capture baseline conditions and predict potential impacts of proposed actions. Forty-four HIAs (81%) followed the established six-step HIA process recommended as a minimum standard (Bhatia et al. 2014): screening, scoping, assessment, recommendations, reporting, and monitoring/evaluation. Eight HIAs (15%) primarily relied on the San Francisco Indicator Project (formerly the Healthy Development Measurement Tool and Sustainable Communities Index), an HIA-inspired set of methods, data sources, and resources designed to embed health indicators into city planning and policy decisions (San Francisco Department of Public Health 2014).

Most housing-related HIAs relied on literature reviews, existing datasets (e.g., the Census Bureau’s American Housing Survey and the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System), stakeholder interviews, and focus groups. Several HIAs, including the Atlanta BeltLine HIA (Ross & West 2007; Ross et al. 2012), HOPE VI to HOPE SF HIA (University of California Berkeley Health Impact Group 2009) and the Pittsburg Railroad Avenue Specific Plan HIA (Human Impact Partners 2008), collected data through surveys or field observations of health indicators, such as traffic and pedestrian features.

3.2. Types of Housing-Related Health Determinants Studied

The 54 HIAs examined health determinants from four categories: housing quality; housing affordability; housing location; and social, economic, and political factors (Figure 1). Fifty-one (94%) considered health determinants in multiple categories.

Figure 1.

Figure 1

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Types of Housing-Related Health Determinants Examined in Housing Health Impact Assessments in the United States, 2002-2016

3.2.1. Housing Quality.

The potential impact of housing quality and design on resident health was considered in 39 of the 54 HIAs (22 community development and 17 housing-specific). Eleven of these included housing quality as a potential outcome of another determinant category, such as affordability or social, economic, and political factors. Two HIAs, the Massachusetts Low Income Home Energy Assistance Program (Child Health Impact Working Group 2007) and the Omaha Neighborhood Redevelopment Plan (Douglas County Health Department 2016), focused on children’s exposure to lead in homes. The remaining nine evaluated multiple physical, chemical, and biological health risks from housing, such as injuries from falls and allergen-related respiratory illnesses.

3.2.2. Housing Affordability.

Housing affordability was addressed in 40 of the 54 housing-related HIAs (74%) (29 community development and 11 housing-specific). The most commonly evaluated affordability-related health determinant (found in 18 assessments) was housing instability, such as difficulty paying rent, overcrowding, moving frequently, or staying with family or friends. Housing instability was discussed as a potential outcome of decreased access to affordable housing and as an inherent part of some decisions. For example, the Farmers Field HIA discussed the health impacts of a stadium development on residents at risk of displacement during and after construction (Human Impact Partners 2012).

3.2.3. Housing Location.

Thirty-seven HIAs (69%) (29 community development and 8 housing-specific) assessed the location of housing relative to health-promoting amenities and services, such as public transportation, parks and recreation, quality schools, steady jobs with adequate compensation, healthy foods, and medical care. For example, the Hartford Neighborhood Revitalization and Sustainability Plan HIA explored how greater access to transportation and healthy foods could positively affect residents’ health and safety (Community Solutions and Michael Singer Studio 2014).

3.2.4. Social, Economic, and Political Factors.

Thirty-two housing-related HIAs (59%) (21 community development and 11 housing-specific) assessed social, economic, and political factors related to housing, including neighborhood segregation, social inclusion and capital, and civic participation. For example, the Yellowstone County Growth Policy HIA examined research demonstrating the positive effects that social networks and community involvement can have on health and recommended that the county’s policy encourage the development of community gathering spaces (RiverStone Health 2008).

3.3. Impacts of HIA on Housing Decisions

To measure an HIA’s effect on decision-making and its success according to the objectives established during the scoping phase of the process, practitioners and their partners can conduct an impact evaluation. These evaluations examine the extent to which the HIA impacted stakeholders and the extent to which the HIA’s recommendations were adopted and implemented (Bhatia et al. 2014). However, impact evaluations are not routine. A review of the documented impacts of the HIAs in the sample indicated that recommendations from at least 19 of the 54 HIAs were incorporated into a final decision or resulted in increased funding for health-promoting actions. For example, the Jack London Gateway Rapid HIA in Oakland, California (Heller Gordon & Bhatia 2007) evaluated a plan to create 55 affordable housing units for low-income seniors. The HIA documented that busy highways around the proposed development posed risks to residents’ health, such as respiratory disease, traffic injury, and noise-related mental health issues. Based on the HIA recommendations, the developer made several modifications to the housing units, including the addition of particulate air filters and sealed bay windows to reduce indoor air pollution and use of an interior courtyard entryway to act as a noise buffer (Rogerson Lindberg Givens & Wernham 2014).

In Texas, an HIA on decisions to replace public housing units destroyed by Hurricane Ike used 23 health-related indicators from public sources to identify optimal neighborhood conditions for the new units (University of Texas Medical Branch, Georgia Health Policy Center & Georgia State University 2014). The Texas General Land Office ultimately required the contractors leading the redevelopment to use the HIA’s recommendations to select housing sites. Additional HIA outcomes are provided in the following examples.

3.4. Three Illustrative Examples of Housing HIAs

3.4.1. HIA of Off-Campus Student Housing in La Plaza Vieja.

In 2014, community organizers and residents worked with a consultant to conduct a rapid HIA of a rezoning proposal that would allow development of off-campus student housing in a historic neighborhood of Flagstaff, Arizona (Zoning and Student Housing in La Plaza Vieja 2014). More than 150 low-income residents lived on the proposed site, the Arrowhead Village mobile home neighborhood. The HIA used a literature search, community meetings with Arrowhead Village residents and members of the La Plaza Vieja Neighborhood Association, and a review of the developer’s proposal to examine how it would affect health through displacement and affordability of basic needs. The HIA demonstrated that re-zoning would lead to the eviction of some residents and a reduction in the number of affordable housing units in the city. It found that the developer’s relocation packages were insufficient for residents whose mobile homes were too old to be moved. Based on these findings, the HIA recommended the rezoning request be denied until the city, the developer, and a trusted non-profit agency that represents the interests and concerns of the community, could agree on a relocation plan that would ensure affected residents received sufficient resources to secure a new home, pay moving expenses, and cover extra costs associated with longer commutes and resulting child care changes. City officials included the HIA findings and recommendations, along with comments from the developer and the public, in the package of materials provided to the planning and zoning commission. After public hearings and debate, the commission voted unanimously against the proposed project. The developer subsequently withdrew the original proposal and submitted a new one for off-campus student housing in a location that would not require zoning changes. The proposal was approved, and construction is underway (Arizona Daily Sun 2018). However, in 2014, a new owner of Arrowhead Village reportedly evicted tenants from the mobile home neighborhood, highlighting how HIAs’ influence may only be short-term in contexts where property ownership or policies change rapidly (Arizona Daily Sun 2018).

3.4.2. HIA of Portland’s Rental Housing Inspections Program.

In 2012, the nonprofit Oregon Public Health Institute conducted an HIA to inform decisions about the Portland City Council’s budget for the city’s rental housing inspections program. The HIA compared the standard inspection program—driven by complaints from tenants and neighbors—to an enhanced complaint-driven program that had been piloted in two areas of the city in which a certain number and type of violations triggers the inspection of the property owner’s other rental units. The HIA included a literature review, tenant and landlord surveys, and analyses of data on rental housing conditions, inspection records, health behaviors, and hospitalizations. It found that low-income renters often refrain from complaining about housing quality, fearing it will prompt rent increases or evictions. The HIA demonstrated that the enhanced model could improve housing conditions, health, and health equity, because it would lead to inspections in units which have no resident complaints but are likely to have housing quality issues. The model would also increase the number of units inspected and repaired. The HIA helped support the City Council’s decisions to hold level the inspection program’s 2012 budget and increase funding for enhanced inspections in 2014 (S. White, personal communication, Sept. 17, 2017).

3.4.3. HIA of Page Avenue Revitalization Efforts in Pagedale, MO.

In 2009-10, researchers from Washington University worked with community partners in St. Louis County, Missouri to conduct a comprehensive HIA of revitalization plans for Page Avenue, located in a low-income African-American community in the City of Pagedale. The redevelopment proposal included new homes, businesses, and an urban park, as well as street and sidewalk improvements. The HIA examined the plan’s effects on housing quality and affordability and community features, such as access to public transportation, jobs, healthy food, financial institutions, and health care. The research methods included focus groups; household surveys; mapping and assessing conditions of food stores, bus stops, streets, and sidewalks; and interviews with 20 city and county decision-makers.

The HIA found that the redevelopment project would generally have positive effects on the existing community; however, gains in determinants such as employment, pedestrian safety, and community safety would take longer to realize due to lack of detail in the proposed plan, and because the redevelopment would occur over several years. Changes in elected leaders, funding uncertainty, and potential shifts in community priorities led the HIA to recommend periodic reassessment of stakeholder interests and continued public information-sharing by city and county decision-makers.

Decision-makers and local organizations worked together to implement several changes that aligned with the HIA recommendations, including addressing sidewalk and street improvements and beautification in the redevelopment area, which led to a new city initiative to plant fruit orchards and gardens in vacant lots (Hoehner et al. 2010). In partnership with an affordable housing developer, a grocery store, a bank, and a movie theater have opened on Page Avenue in the years since the HIA was completed (Moffitt 2015).

4. DISCUSSION

The findings of this review demonstrate the (1) wide applicability of HIA to a diverse range of housing topics, (2) variety of organization types that can lead an HIA, (3) broad range of methods used to assess health implications of housing-related proposals; and (4) the potential for HIAs to influence health-promoting changes to housing decisions. While this review focused on U.S.-based HIAs, the health implications of housing are likely to be similar in an international context, particularly around housing affordability and quality (WHO 2018). Housing regulations, building codes, and other practices affecting housing that are explored through this sample of HIAs may differ by country.

Our review found housing practitioners can serve as recipients of HIA information or initiate and actively participate in HIAs. For example, the Denver Housing Authority sponsored the South Lincoln Homes HIA (Roof 2009), and the Phoenix office of the Local Initiatives Support Corporation sponsored the Coffelt-Lamoreaux Public Housing Redevelopment HIA (Narayan 2013). The Ohio Housing Finance Agency and The Ohio State University College of Public Health conducted an HIA to inform interagency coordination and streamline the inspection process for affordable housing units in the state (Holtzen Klein Hood & Keller 2014). Prior research shows that decision-makers are more likely to act on HIA recommendations when they are politically, economically, and technically feasible (Dannenberg, 2016). Future research could examine the benefits and challenges of having decision-makers lead HIAs and explore how outcomes of HIAs led by decision-makers compare with those led by community-based organizations, academic institutions, or other organizations that do not hold decision-making power.

This review is consistent with prior research demonstrating that HIA recommendations can lead to health-related changes in final decisions and can strengthen relationships among decision-makers and stakeholders. Although comprehensive data do not exist to track HIA outcomes, in this sample of 54 housing-related HIAs at least 35% produced recommendations that were incorporated into a final decision or resulted in increased funding for health-promoting actions. The three HIAs we selected as examples illustrated how HIA findings and recommendations can inform housing decisions, demonstrate the power of HIA in making housing decisions more equitable, and make the case for the routine use of HIA to uncover and address the impacts of housing decisions on disenfranchised communities. Practitioners in all three of the examples elevated equity as an issue in decision-making and highlighted the potential effects of the proposals on low-income communities. The three examples also showcase the range of ways that stakeholders can engage in the HIA process, such as through community meetings or by providing their perspectives in surveys and interviews. Two of the three HIAs occurred through partnerships between community-based organizations and public health practitioners. Prior research has documented that community participation and engagement in the HIA process may increase the chances that HIA recommendations will be successfully adopted and civic participation will increase (Center for Community Health and Evaluation and Human Impact Partners 2015). Stakeholder engagement and partnerships formed during the HIA process may be as valuable as the direct impacts on the decision (Dannenberg 2016). An evaluation of five California HIAs found that the process made decision-makers aware of the connections between health and the proposals at hand (Health Impact Project 2016). Relationships and collaborations formed among different sectors during the HIA process can assist future endeavors (Heller et al. 2013).

The review also illustrates some challenges facing the broader HIA field. For example, quantitative modeling and environmental sampling are infrequently used as assessment methods in housing-related HIAs, because they may be outside of the scope, cost prohibitive, or beyond the HIA team’s technical expertise (National Center for Healthy Housing 2016). Only four housing-related HIAs (7%) used these methods: Pittsburg Railroad Avenue Transit-Oriented Development, PlanOKC, Replacing Public Housing Units Destroyed by Hurricane Ike, and San Pablo Avenue Corridor.

While this review focused on HIA, it is important to note that health may be integrated into decisions through mechanisms other than HIA, including formal and informal agreements between agencies, legislative requirements and voluntary approaches. San Francisco’s public health and planning departments conducted some of the earliest HIAs in the U.S. Over time, the departments established regular communication channels about projects and plans and could bring many benefits of HIA to planning and development decisions without conducting one for each proposal. There is growing interest among housing practitioners to consider health in their decision-making, but HIAs may not be appropriate or feasible given time and cost considerations. For some projects and policies, streamlined tools including the San Francisco Indicator Project are available to help bring health into the decision-making process. Other examples of efforts to bring health into housing development without conducting a full HIA include the green building programs of Enterprise Green Communities and the U.S. Green Building Council, which have both adopted health-based planning criteria (Health Impact Project 2015).

4.1. Limitations

The HIA database maintained by the Health Impact Project was the major source used to identify potential housing HIAs. While this database is frequently updated, some housing-related HIAs may be missing. This review is limited to U.S.-based HIAs. Sources such as the now-archived HIA Gateway database contain many U.K. and other non-U.S. housing-related HIAs (Public Health England 2007). Additionally, impacts from any HIA process can take time to realize, especially when the proposed action involves complicated decisions such as housing financing and construction. Finally, since we purposefully selected the illustrative examples that demonstrate the diverse, distinct, and unique contexts and health issues to which HIA can be applied, findings from these examples cannot be generalized across all 54 HIAs in our sample.

4.2. Conclusions

This systematic review of housing-related HIAs demonstrates that the tool can be applied to proposals in a wide range of housing decision-making process types and locations and that HIAs can spur decision-makers to adopt and implement critical health- and equity-promoting actions. Based on this scan, there are opportunities to expand the use of HIAs in housing decisions, particularly by geography and type of housing decision. The majority of housing-related HIAs examined decisions in the western and midwestern part of the U.S., leaving a sizable gap in the southern and northeastern regions.

Few HIAs examined in the scan addressed specific policies or design features of homes, providing an opportunity to improve health through policies, codes, design elements, and energy use in residential structures. Future research should build on this scan and previous in-depth HIA evaluations to explore whether HIAs are more effective for assessing certain types of housing decisions, fill data gaps on whether recommendations from housing HIAs were adopted and implemented over time, and explore factors that may lead to the adoption of HIA recommendations in housing decisions. As cities and rural areas across the U.S. confront pressing housing issues, including stability and displacement, incentives to develop affordable housing, and building and housing codes, expanding the use of HIAs can effectively bring health and equity evidence, stakeholder input, and community voices into the decision-making process.

Footnotes

This is a post-peer-review, pre-copyedit version of an article published in Journal of Housing and the Built Environment. The final authenticated version is available online at: http://dx.doi.org/10.1007/s10901-020-09795-9

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