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

Housing affects health, yet health is seldom considered in housing decisions. Health impact assessment (HIA) is a tool that can improve housing-related policies, plans, programs, and projects by bringing together scientific data, health expertise, and stakeholder engagement to identify the potential health effects of proposed decisions. We systematically identified and reviewed HIAs of housing decisions in the United States, yielding 54 HIAs between 2002 and 2016. Two examined federal proposals; the others explored decisions in 20 states. A variety of organizations led the HIAs, including non-profits, public health departments, and academic institutions. The primary decision-makers each HIA sought to inform were housing, planning, and/or elected officials. Eighteen HIAs focused on housing policies, codes, design elements, and utilities in residential structures. The remaining 36 HIAs included housing as one element of broader community development and transportation planning decisions. HIA recommendations changed decisions in some cases, and the assessment process helped strengthen connections between public health and housing decision-makers. To illustrate key characteristics of housing HIAs, we purposefully selected three HIAs and described the decisions they informed in detail: off-campus student housing in Flagstaff, Arizona; a rental housing inspections program in Portland, Oregon; and revitalization plans for a major thoroughfare in a suburb of St. Louis, Missouri. With a few exceptions, federal, state, and local agencies in the U.S. are not required to consider the health impacts of housing decisions, such as where housing is sited, how it is designed and constructed, and policies for ensuring that it is affordable and safe. HIA has emerged as a tool for advocates, health and housing practitioners, and policymakers to fill this gap. However, few studies have examined whether HIAs do in fact change housing decisions, shift the way that decision-makers think, or ultimately shift determinants of health (e.g., housing affordability and quality). This review demonstrates that HIAs can facilitate the consideration of health during housing decision-making. Housing HIAs can also help decision-makers address commonly overlooked effects, such as changes to social cohesion, and improve civic participation by engaging communities in the decisionmaking process.