By Thomas K. Bias, PhD, Christiaan G. Abildso, PhD, Emily Vasile, MPAff, Jessica Coffman, MA
Over the past decade, great strides have been made to move the discussion of health promotion into the public policy realm. Despite some success, public health researchers have struggled at times to connect with policymakers. This manuscript describes how researchers conducting a Health Impact Assessment were able to work with city officials in West Virginia resulting in evidence-based policy changes and provides information on how to successfully bridge the policymaker and researcher divide. We find that policymakers respond well to local feedback, even when limited in generalizability and sample size. This feedback, however, is important in the policymaking process and, when combined with existing evidence based best-practices for health improvement, can lead to implementation of policies that enhance the health of communities.
Over the past decade, great strides have been taken by public health researchers to move discussion of health promotion into the public policy realm. This work is a natural output of public health theory, most notably discussion of the social-ecological model of health1 and the Health Impact Pyramid.2
These frameworks emphasize that interventions, which address underlying environmental and social determinants of health, have the greatest potential public health benefit.
Several examples of public health policy interventions have demonstrated the relationship between public policy and health including the well-known examples of tobacco3, widespread immunizations,3 and water fluoridation.4 Despite these successes, public health researchers and practitioners have struggled at times to connect with policymakers. Brownson et. al.5 describe this disconnect in great detail and give many recommendations about how to improve the use of research in policymaking, notably through stakeholder involvement and improving communication.5
Health Impact Assessments (HIAs) are a tool used to facilitate policymaker engagement and examine the health effects of potential policy choices in non-health sectors. This interactive process results in direct recommendations to policymakers on which policy decisions are likely to have the most positive or negative impact on health. In the past decade, there has been a wider call for the use of HIA across the policy spectrum in the United States and has been used in fields as diverse as agriculture, education, city planning, and energy6. The HIA process and its potential benefits for physical activity (PA) and built environment (BE) policymaking are well documented6.
Using the recommendations of Brownson and colleagues as a starting point5, this article describes an HIA which took place in Fairmont, West Virginia in 2014. Working directly with policymakers and stakeholders, an in-depth analysis of a proposed comprehensive Bicycle and Pedestrian Connectivity Plan (“Connectivity Plan”) resulted in HIA recommendations that would most impact PA. During this process, researchers learned important lessons about the importance of scientific data to policymakers which can be shared with public health in a broad way to enhance the impact of evidence-based practices on public policy design and implementation. Significant evidenced-based policy changes have begun to take shape since the public release of the HIA report.
The city of Fairmont has approximately 18,700 residents. Fairmont was awarded a grant from the West Virginia Development Office, in collaboration with the West Virginia Bureau for Public Health and the Claude Worthington Benedum Foundation, to create a comprehensive bicycle and pedestrian connectivity plan (“Connectivity Plan”) as part of their “Growing Healthy Communities” grant mechanism. A separate grant, from the Association of State and Territorial Health Officials (ASTHO) funded a rapid HIA to be conducted in parallel. The HIA investigated specific connectivity-related areas related to policy decisions including sidewalks, trail connections, perceptions of crime, etc.
As per best HIA practices7 and the Brownson et. al article5 policymakers were involved in the HIA process alongside local champions to ensure adequate connection to the project. Weekly community meetings convened by Main Street Fairmont (MSF), were held to discuss the Connectivity Plan and gain insight into related issues. MSF was the primary grant recipient of the Growing Healthy Communities grant, in collaboration with the City Planner’s Office. Monthly meetings occurred with the City Planner’s Office to inform policymakers of HIA progress.
The research team followed the HIA process of screening, scoping, assessment, recommendations, reporting, and monitoring/evaluation7. At the screening phase, researchers completed a comprehensive review of evidence-based practices to help policymakers understand the literature around specific proposals (such as the potential health impact of building new sidewalks, community policing, etc.). This review helped demonstrate evidence driven policy solutions that could be implemented. It was also important to capture input from the citizens of Fairmont for the scoping and assessment phases. Feedback from key stakeholders through a very brief online survey in the scoping process helped identify priorities. The research team then designed a more in-depth survey to capture community input online and by mail about potential impacts of Connectivity Plan projects. The survey was designed with a scientific sampling plan for each neighborhood in the city, expecting each to have unique barriers and facilitators to pedestrian and bicyclist connectivity. City officials were involved at each stage of the HIA process as well. They helped design and structure the questionnaire to capture information most useful for policy planning purposes. These policymakers also participated in community meetings where neighborhood connectivity and health impact were discussed.
As a result of several data collection limitations experienced in the community (related to finite resources), researchers quickly realized that a randomized scientific sample was not going to be achieved. Because the HIA was funded as a small scale project, there were not financial resources to conduct a citywide randomized sample mailing with return postage. Surveys were instead collected via an online tool which was disseminated through city groups, postcards, and sent home via students in local schools (because many questions dealt with parks, school connectivity, and other activities for children). Only 240 surveys were collected city-wide (out of 18,700 residents), ranging from single digit results in one neighborhood to dozens in another. Disheartened, researchers reported the lack of a scientific, generalizable sample to policymakers at the city level.
Much to the researchers’ surprise, city personnel and policymakers were very excited to receive feedback from over 200 citizens. Policymakers described small attendance at general city council meetings, where input on any single issue may be small or nonexistent. They discussed that they rarely having access to public input of that scale, scientific or not. Residents reported both barriers and facilitators to active transportation and the BE. The top three issues reported were the lack of infrastructure, lack of activities downtown that people would want to visit, and concern about crime/safety.
An HIA report was released as an appendix to the Connectivity Report developed by the city and its engineering consultant. This report detailed the potential impact of various proposed connectivity measures grounded in the BE literature. Each project was given a separate health impact “grade”. Additionally, survey results were broken down by city-defined neighborhoods and presented individually to help refine findings to specific areas of the city. Findings from this HIA report were presented to various groups including policymakers and citizens.
Short-Term Policy Outcomes
There have been many important outcomes as a result of the concurrent Connectivity Plan and HIA. The City is using the projects identified in a Five-Year Action Plan as an addendum to the city’s Comprehensive Plan (Comprehensive Plans are required documents which serve as the main outline of city priorities and goals and are required to be updated at least every ten years in West Virginia). Based on community feedback gathered through the HIA process, the research team made specific suggestions to implement a combination of Encouragement, Engineering, and Enforcement activities. To address these, the City has initiated multiple projects.
Encouragement of PA, through events, promotions, and improvements to parks and downtown were endorsed by residents and highlighted in the HIA. To encourage active living, MSF, the City, and community members are working with Try This WV, a statewide campaign to encourage PA. Another initiative to encourage active living is the “Walkable Blocks” project. This project is an initiative based on a portion of the Connectivity Plan and data pulled from the HIA and will introduce painted mural crosswalks, sculpted bike racks, and “Share the Road” signage. MSF will host an early summer festival celebrating community wellness and will highlight the Connectivity Plan, the HIA, and the public art designed to encourage PA by providing a safe, aesthetically pleasing environment.
Key engineering activities recommended in the HIA were to improve sidewalks, intersections, and trails, especially within walking and cycling distances of key attractors. MSF used the HIA to start Friends of the Trail, which is a collaboration between local government, non-profits and citizens to connect the Mon River Trail that terminates just north of the City and the West Fork River Trail that terminates just south of the City. This group is currently using recommendations of the HIA to prioritize next steps and identify opportunities for small visible wins. Further engineering activities to improve sidewalks include a recommendation by the Fairmont Planning Commission to establish a Pedestrian Safety Board, whose will prioritize sidewalk repair and construction projects through a Sidewalk Improvement Plan. This recommendation will be made to Fairmont City Council for budget considerations.
Due to concerns voiced by residents about safety from crime, which were highlighted in the HIA, MSF has engaged the support of local law enforcement. The Fairmont Police Department has agreed to reinstate community policing. Finally, one intangible outcome of the HIA and Connectivity Plan is an increased understanding and focus city-wide on the impact of local-level policies on health. This relationship was not discussed in the past. The HIA served as a tool for relating local level decision-making to potential implications on the health of Fairmont citizens, effectively empowering local level decision makers to make evidenced based policy changes.
At the time of this manuscript, a year had passed since the release of the HIA report in July 2014. During that brief time, policymakers seriously considered the input given by residents of the city related to the BE, PA, and connectivity. Although this input was not a scientific, randomized sample, community concerns were paired with evidence-based practices to identify specific policies and programs in the HIA report. This idea of combining local data with evidence-based practices is in line with the idea of “ground truthing” recommended as a best-practice in HIAs.8 Policymakers have begun to implement changes to address issues identified in the HIA recommendations and the unique political context in their city. The involvement of community members at weekly meetings also created champions within the city that continue to advocate for healthy interventions. The description of this project is important, as it demonstrates a way to bridge the gap between science and policy implementation in a timely and relevant fashion. Using this strategy, proven and scientific interventions can be paired with community engagement and input.
The authors would like to thank Kathy Wyrosdick who is the director of Planning at the City of Fairmont and Kate Greene, Director of Main Street Fairmont for their willingness to keep the authors up to date on policy activities in the city and for their involvement with the Health Impact Assessment process.
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