A Foundation for Building Health into Housing Policy

By David Fukuzawa, Rebecca Morley, and Donald Schwarz

Many of the nation’s most pressing public health problems, such as asthma, depression, diabetes, and obesity, are influenced by where people live, work, and play. Leading authorities, including the Office of the Surgeon General, the U.S. Department of Housing and Urban Development, the World Health Organization, and the Robert Wood Johnson Foundation, have highlighted the relationship between housing and health. Decisions that affect housing quality, affordability, and location, as well as neighborhood characteristics, can shape those places to be supportive of health and help reduce—or even prevent—disease.

In the middle of the 20th century, governments separated the previously integrated functions of housing and health agencies. This separation continues today and contributes to housing and public health professionals working in silos—with the former often not involved in the design and implementation of public health programs, and the latter frequently not included in decisions related to housing and community development. Health impact assessments (HIAs), however, can bridge this gap and bring these sectors together when important decisions are being made.

HIAs identify the potential health consequences of a policy, program, or project proposal and how those consequences are distributed across the population, especially among seniors, communities of color, children, and low-income families. HIAs also bring community voices into the decision-making process, empowering people to take greater control over the decisions that affect them. Having such a voice can lead to policies that promote health and increase access to resources such as parks, high-quality schools, and safer neighborhoods.

With funding support from the Kresge Foundation and the Robert Wood Johnson Foundation, the Health Impact Project partnered with the National Center for Healthy Housing and the National Housing Conference and in March 2016 published A Systematic Review of Housing Health Impact Assessments and Guidance for Future Practice, a roadmap for using HIAs to integrate health into decisions about housing. Briefs targeted to public health and housing professionals summarize the guidance.

The review found that housing professionals are becoming increasingly familiar with HIAs. Between 2012 and 2014, 17 HIAs were completed or underway in the United States. Between 2002 and 2004, only one had been done. Housing HIAs cover a wide range of topics, including:

  • Affordability;
  • Zoning and planning decisions;
  • Energy assistance;
  • Inspections;
  • Building features; and
  • Individual housing programs and policies (such as rental vouchers).


Why Are HIAs Useful in Housing Decisions?

First, HIAs can change the narrative by helping policy makers understand the health consequences of their decisions in the housing sector. In an evaluation of HIAs conducted by the Group Health Research Institute’s Center for Community Health and Evaluation, researchers found that in 16 of 23 HIAs studied, decision makers and other stakeholders credited the HIA with broadening their perceptions of health and helping them connect the dots between health and other factors. As one state legislator put it, “This research [on rental subsidies and health] presented to us a very serious problem that we were aware of, but it brought light to it and it helped create action.” In this case, the HIA ultimately contributed to a decision to increase the funding level for the rent subsidies program it examined.

Second, HIAs are a tool for evidence-based policy change. When officials in Curry County, Oregon, recognized that families living in older manufactured homes were suffering more frequently from falls and respiratory conditions such as asthma, they launched an HIA to inform a proposed pilot project called the Housing Stock Upgrade Initiative to provide lower-cost loans or other funds to make repairing or replacing manufactured homes more affordable for county residents. The HIA resulted in 3,000 people becoming eligible for financial assistance to replace their substandard manufactured homes.

Third, HIAs promote community engagement. Housing development is frequently fraught with conflict between developers and the community, and HIAs can offer a practical and systematic way to address these conflicts by ensuring that community concerns are uncovered and addressed before the property is developed. According to Cleveland City Council member Joe Cimperman (D): “HIA helps me win. It does all the work on the front end; nobody is angry, because all the concerns have been addressed.”

Fourth, HIAs get results. When the Denver Housing Authority created its master plan for the redevelopment of a distressed 270-unit public housing complex called South Lincoln Homes, it conducted an HIA. The assessment identified the baseline health conditions of the residents—38 percent were living in poverty; 38 percent had less than a high school education; 55 percent were obese or overweight; 40 percent smoked; and 40 percent were in fair or poor overall health. There also were higher rates of crime and violent crime than in Denver overall. With these data in hand, and with extensive involvement from the community, the HIA led to a wide variety of health-promoting features in the final master plan, including the following:

  • Improved lighting to address crime and safety concerns;
  • A child care facility;
  • Building design that promotes stairway use;
  • Noise barriers and acoustic design to reduce traffic noise;
  • Community gardens;
  • Farmers market and walking paths;
  • Separated bike lanes; and
  • Traffic calming to increase physical activity.


Getting Started with HIAs

HIAs can be fairly quick, using a “rapid” or “desktop” model, or take a longer, more comprehensive approach. Rapid HIAs can be completed in weeks or months, while full-scale HIAs often take from several months to a year or more to complete. An important development in the field of HIAs is the emergence of HIA-inspired strategies—such as checklists, guidelines, and simplified frameworks. These alternatives can be used to ensure that health benefits are optimized during housing decision making when an HIA is not possible or appropriate, or when sufficient evidence and support already exist to embed health directly into policies or projects.

For example, the Health Impact Project partnered in May 2015 with Enterprise Green Communities and the U.S. Green Building Council to streamline the comprehensive and systematic consideration of health in the Enterprise Green Communities Criteria and the Leadership in Energy and Environmental Design (LEED) certification programs. Drawing upon the principles of HIAs and of integrative design, the new standards outline ways that architects, designers, and developers can consider the connections between their work and public health.

Because the housing and health sectors are increasingly aware of their mutual goals, they seek concrete and pragmatic ways to collaborate. HIAs offer one tool to accomplish this. Housing and health professionals interested in exploring the use of HIAs and other approaches for integrating health into their work can contact the Health Impact Project for more information. An additional resource is the Society of Practitioners of Health Impact Assessment, which has a wide array of HIA tools and resources available on its website.

With more housing professionals engaging in HIAs, we believe it is only a matter of time until incorporating the consideration of health into housing decisions is standard practice.


David Fukuzawa is managing director of health and human services at the Kresge Foundation; Rebecca Morley directs the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts; and Donald Schwarz is vice president of programs at the Robert Wood Johnson Foundation.