Public health practitioners understand that our health is determined by social, economic, and environmental conditions and by underlying patterns of racial, gender, and economic injustice. They’re not alone. There is a burgeoning movement across the United States to take action on the social determinants of health. Yet when policymakers make decisions about housing, transportation, criminal justice, labor, and many other domains, they rarely consider the extensive evidence that connects the dots between their actions and our health.
This special supplement examines the organizations and programs that are addressing social inequalities in housing, transportation, work, and other parts of society that create disparate health outcomes.
How can we get more policymakers to bring the social determinants of health into the policymaking process? Promoting health impact assessments (HIAs) may be the answer. An HIA is a structured research and public engagement practice used to identify the likely health and equity impacts of proposed public policies and to provide recommendations to reduce identified impacts. HIAs have been used effectively to influence social, economic, and environmental policy and to advance equity in local, state, and federal decision-making. In fact, they have led to concrete health and equity-promoting changes, such as improvements in building design, land use, and transportation plans; increased funding for affordable housing and alternatives to incarceration; adoption of paid sick days and other labor policies; and changes in school funding and integration.
But HIAs should not be viewed only as tools to change policy. They can also advance equity in and of themselves. In our experience, the HIAs that have been most successful at changing policy include significant community engagement and deep partnership between public health practitioners and community organizers. Although the final report that results from an HIA is important for achieving policy change, the process by which the HIA is conducted is equally important, because it can empower participating communities to have more control over the decisions that affect their lives. The process itself helps build the leadership, voice, and influence of marginalized communities.
On the basis of our experience conducting HIAs and providing training and technical assistance to practitioners across the country, we propose four measurable objectives for public health practitioners and grantmakers to embrace if they envision using HIA as a tool to advance equity. These objectives can also be employed more broadly in public health research projects; that’s why we frame them expansively:
- The research and research products must focus explicitly on equity and be conducted to advance equity. There are several ways to achieve this focus. To begin, the research topic should ideally be identified by—or at a minimum, be relevant to—communities facing inequities. In addition, the goals of the research project as well as the research questions and methods should explicitly address equity. The knowledge of those facing inequities should be integrated into the research as evidence, and those conducting the analysis should make sure to examine the distribution of effects among various populations. And communities facing inequities should have a role in communicating findings and recommendations.
- The research process should build the capacity of the communities facing health inequities for engaging in future research. The process should also build the ability of those communities to engage in decision making related to the social determinants of health. To accomplish this goal, communities facing inequities should lead or be meaningfully involved in every step of the process, from choosing research questions to collecting data and reporting findings. The process should also explicitly include leadership development training for community participants.
- The process should result in a shift in power that benefits the communities facing inequities. At the end of an HIA, the communities that face inequities should have increased influence over decisions, policies, partnerships, institutions, and systems that affect their lives. In addition, the government agencies and other institutions involved should be more transparent, inclusive, responsive, and collaborative.
- The research should contribute to changes that improve the social determinants of health and reduce health inequities. It should result in a decreased difference in the social, economic, and environmental determinants of health between communities facing inequities and other communities. It should positively influence physical, mental, and social health within communities and decrease inequities. Although this may be the most obvious objective, it may be the most difficult to measure because it is often a long time between when a policy is implemented and when we can see health improvements.
When public health practitioners and funders adopt these four objectives, HIAs will realize their potential as tools that meaningfully improve health and advance equity. By engaging community members in conducting research and by squarely focusing on equity, we will be much more effective at getting policymakers to understand the connection between their decisions and the people whose lives and health are most affected.