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The influence of health impact assessment on redevelopment plans and decision-makers from cross-sector collaboration and HIA quality

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The influence of health impact assessment on redevelopment plans and decision-makers from cross-sector collaboration and HIA quality
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Roof, Karen Elizabeth ( author )
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Denver, CO
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University of Colorado Denver
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English
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Health risk assessment ( lcsh )
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theses ( marcgt )
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In the US, health impact assessment (HIA) is an emerging field that holds promise for more deliberate, health-informed decision-making. The World Health Organization defines an HIA as a process or tool by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within a population. This study examines whether two HIAs influenced their respective redevelopment master plans and the individuals involved in making the planning decisions. These influences include the extent to which the HIA recommendations were adopted into the redevelopment plans, the presence of health-supportive language in those plans, and any increase in decision-makers' health awareness and knowledge. This study examines the impact of two independent variables on decision-makers and on the plans themselves: the quality of the HIA, and level of cross-sector collaboration during the HIA process. This study used an analytical framework derived from theoretical concepts and best practices in the literature on the socio-ecological model of health, urban sustainable planning, cross-sector collaboration, and impact assessment. Each of the cases were investigated through document review, quantitative content analysis, and purposive, semi-structured interviews of key decision-makers. Outcomes of the study suggest that the independent variables did impact the effectiveness of the HIAs. The HIA that was the highest quality and had the highest level of cross-sector collaboration (the South Lincoln Housing HIA) demonstrated a considerable influence on the master plan and decision-makers; the lower-quality HIA with weak cross-sector collaboration (the NE Downtown Denver Neighborhood HIA) exhibited only mild influence on the plan and decision-makers. Additionally, the study identified variables that further support findings in the literature along with salient variables that potentially enable more effective HIAs as well as new methods to evaluate HIAs that can contribute to the HIA discourse and inform its practice.
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Thesis (Ph.D.)--University of Colorado Denver. Design and planning
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Includes bibliographic references.
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College of Architecture and Planning
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by Karen Elizabeth Roof.

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THE INFLUENCE OF HEALTH IMPACT ASSESSMENT ON REDEVELOPMENT PLANS AND DECISION MAKERS FROM CROSS SECTOR COLLABORATION AND HIA QUALITY by KAREN ELIZABETH ROOF B.S., Radford University, 1988 M.S., University of Denver, 1995 A thesis submitted to t he Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Design and Planning Program 2014

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ii 2014 KAREN ELIZABETH ROOF ALL RIGHTS RESERVED

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iii Thi s thesis for the Doctor of Philosophy degree by Karen Elizabeth Roof has been approved for the Design and Planning Program by Brian H F. Muller Chair Jennifer St effel Johnson Advisor Debbi Main Greg ory Tung November 21 2014

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iv Roof, Karen El izabeth (Ph.D., Design and Planning) The Influence of Health Impact Assessment on Redevelopment Plans and Decision Makers from Cross Sector Collaboration and HIA Quality Thesis directed by Associate Chair, Jennifer Steffel Johnson ABSTRACT In the US, health impact assessment (HIA) is an emerging field that holds promise for more deliberate, health informed decision making. The World Health Organization defines a n HIA as a process or tool by which a policy, program or project may be judged as to its pot ential effects on the health of a population, and the distribution of those effects within a population. This study examines whether two HIAs influenced their respective redevelopment master plans and the individuals involved in making the planning decisio ns These influences include the extent to which the HIA recommendations were adopted into the redevelopment plans, the presence of health supportive language in those plans, and any increase in decision health awareness and knowledge. This study e xamines the impact of two independent variables on decision makers and on the plans themselves: the quality of the HIA, and level of cross sector collaboration during the HIA process. This study used an analytical framework derived from theoretical concep ts and best practices in the literature on the socio ecological model of health, urban sustainab le planning, cross sector collaboration, and impact assessment. Each of the cases were investigated through document review, quantitative content analysis, and purposive, semi structured interviews of key decision makers. Outcomes of the study suggest that the independent variables did impact the effectiveness of the HIAs. The HIA that was the highest quality and had the highest level of cross sector collaborati on (the South Lincoln Housing HIA) demonstrated a considerable influence on the

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v master plan and decision makers; the lower quality HIA with weak cross sector collaboration (the NE Downtown Denver Neighborhood HIA) exhibited only mild influence on the plan and decision makers. Additionally, t he study identified variables that further support findings in the literature along with salient variables that potentially enable more effective HIAs as well as new methods to evaluate HIAs that can contribute to the HI A discourse and inform its practice. T he form and content of this abstract are approved. I recommend its publication. Approved: Jennifer Steffel Johnson

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vi ACKNOWLEDGEMENT S I would like to express my sincerest gratitude to my very supportive committee J enn ifer Steffel Johnson, Brian Muller, Debbi Main and Greg ory Tung. They make up an illustrious committee exemplifying leadership, professionalism and scholarship in every way. Also, Andy Dannenberg for many reviews and other communications sharing his HIA expertise. I am very grateful for their guidance, their wisdom and most importantly their patience and time. Thank you all. To my parents Jack and Beverly Roof who I am eternally grateful for your unfailing love, encouragement, and drive to achieve and be more. Dad for all your reviews and last minute calculation questions throughout this program. Mom for keeping me laughing To my siblings Shelley and Connie, who have also shared in this journey thank you for being my biggest cheerleaders. To my partne r Andy t hank you for being my staunch supporter and for all your wonderful poems of encouragement I love you all dearly. Susie who I started this PhD with and who became a dear friend for life, thanks especially for getting me through the crazy times. T o m y dear longtime friend Mark for your consummate upbeat attitude I am eternally grateful to you both. Finally, to my incredible friends. I could not have made it without your laughter, prayers and support. I would like to thank four graduate research assistants for their work on the research: Chad Reischl (2011 2014) (Urban and Regional Planning ) Beth Wyatt (Public Health) (2011), Pam Sawyer (2012) (Urban and Regional Planning), Karen Bauer (2013 14) (Urban and Regional Planning) from the University o f Colorado Denver. I would also like to thank my editor Tracey McCormick for very useful edits and suggestions that helped with flow and clarity

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vii TABLE OF CONTENTS CHAPTER I. INTRODUCTION ................................ ................................ ................................ .................... 1 Chapter Outline ................................ ................................ ................................ .......................... 1 Overview of HIA ................................ ................................ ................................ ....................... 1 HIA Trends in the U.S. ................................ ................................ ................................ .............. 3 HIA Benefits and Challenges and Purpose Statement ................................ ................................ 3 Research Aims ................................ ................................ ................................ ........................... 4 Resea rch Questions ................................ ................................ ................................ .................... 7 II. HIA BACKGROUND AND THEORETICAL FRAMEWORK ................................ ............ 10 Chapter Outline ................................ ................................ ................................ ........................ 10 Definitions and Background for Understanding HIA ................................ ............................... 10 HIA and Health ................................ ................................ ................................ .................... 11 Influence versus Effectiveness ................................ ................................ ............................. 12 Roots of Impact Assessment ................................ ................................ ................................ 12 Health in All Policies Approach and Role in Supporting HIA ................................ ............. 16 Policy versus Decision Making and its Connection to HIA ................................ ................. 18 Theoretical Frameworks ................................ ................................ ................................ ........... 20 Historical Context o f Planning and Health ................................ ................................ ........... 21 Public Health Historical Context and Theoretical Contribution ................................ ........... 22 Urban Planning Historical Context and Theory Contribution ................................ .............. 26 III. HEALTH IMPACT ASSESSMENT CRITICAL REVIEW ................................ .................. 31 Chapter Outline ................................ ................................ ................................ ........................ 31

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viii Introduction ................................ ................................ ................................ .............................. 31 Proposed Benefits and Value of HIA ................................ ................................ ....................... 33 Emphasis of HIA ................................ ................................ ................................ .................. 33 Core Attributes ................................ ................................ ................................ ..................... 34 Influencing Decision Making ................................ ................................ ............................... 35 Critical HIA Issues and Challenges ................................ ................................ .......................... 38 Definitions ................................ ................................ ................................ ........................... 38 Organizational Issues, Common Features, and Contextual Differences of HIA ................... 40 Proximal Health Impacts ................................ ................................ ................................ ...... 44 Evidence Based Data ................................ ................................ ................................ ........... 44 Methodology/Methods ................................ ................................ ................................ ......... 46 Intersector Collaboration/Education ................................ ................................ ..................... 48 Community/Stakeholder Engagement ................................ ................................ .................. 50 Equity/Disadvantaged Communities/Groups ................................ ................................ ....... 52 HIA Quality ................................ ................................ ................................ ......................... 53 Integrating HIA into Environmental Impact Assessment ................................ ..................... 54 Institutionalization of HIAs ................................ ................................ ................................ .. 55 Lack of Research ................................ ................................ ................................ .................. 57 Concluding Remarks ................................ ................................ ................................ ................ 59 IV. A REVIEW OF CROSS SECTOR COLLABORATION ................................ ..................... 61 Chapter Outline ................................ ................................ ................................ ........................ 61 Introduction ................................ ................................ ................................ .............................. 61 Definitions of Collaboration ................................ ................................ ................................ ..... 63 Historical Context of Collaboration ................................ ................................ ......................... 66

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ix Impediments and Challenges to Cross Sector Collaboration ................................ .................... 68 Benefits, Importance, Value of Cross Sector Collaboration ................................ ..................... 73 Influe nces on Collaboration ................................ ................................ ................................ ..... 73 History of Collaboration ................................ ................................ ................................ ...... 75 Partner Relationship Characteristics ................................ ................................ ..................... 75 Structure, Processes, and Governance Characteristics ................................ .......................... 77 Communication Characteristics ................................ ................................ ........................... 81 Leadership Characteristics ................................ ................................ ................................ ... 82 Resources ................................ ................................ ................................ ............................. 84 Accountability, Reflection, and Evaluation ................................ ................................ .......... 85 Outcomes of Successful Collaboration ................................ ................................ .................... 86 Future Research ................................ ................................ ................................ ....................... 88 Relevance ................................ ................................ ................................ ................................ 89 Conclusion ................................ ................................ ................................ ............................... 90 V. METHODS ................................ ................................ ................................ ............................ 92 Chapter Outline ................................ ................................ ................................ ........................ 92 Case Study Research Methodology ................................ ................................ .......................... 92 Case Study Research Design ................................ ................................ ................................ .... 93 Advantages and Limitations of the Case Study Research Ap proach ................................ .... 95 Case Selection in the Present Study ................................ ................................ ..................... 98 Clarifying the Lead Researcher and Health Assessor Roles in the Research ........................ 99 Defining the Study Population ................................ ................................ ........................... 100 Case Study Sampling ................................ ................................ ................................ ......... 101 Research Framework: Hypotheses and Questions ................................ ................................ .. 102

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x Hypotheses ................................ ................................ ................................ ......................... 102 Research Questions ................................ ................................ ................................ ............ 103 Case Study Methods and Data Collection ................................ ................................ .............. 105 Methods Overview ................................ ................................ ................................ ............. 106 Ensuring Case Study Rigor ................................ ................................ ................................ 107 Determination of the Quality of the HIA ................................ ................................ ............ 109 Exploratory, Semi Structured, In Depth Interviews ................................ ........................... 110 Content Analysis ................................ ................................ ................................ .................... 116 HIA Recommendation Adoption Review ................................ ................................ ............... 120 Case Study Analysis ................................ ................................ ................................ ............... 120 Process Tracing and Congruence ................................ ................................ ....................... 121 Content Analysis of Health Supportive Language ................................ ............................. 129 Intervie w Data ................................ ................................ ................................ .................... 129 Document Review: HIA Quality and HIA Recommendation Adoption ............................. 131 Cross Case Analysis ................................ ................................ ................................ .......... 132 VI. SOUTH LINCOLN HOUSING REDEVELOPMENT CASE ................................ ............ 134 Chapter Outline ................................ ................................ ................................ ...................... 134 Introduction ................................ ................................ ................................ ............................ 134 Background of South Lincoln HIA Case ................................ ................................ ................ 135 Overview of Data Collection and Stakeholder Engagement ................................ ................... 137 Case Study Methodology ................................ ................................ ................................ ....... 138 Section 1. HIA Influence on the Master Plan and Decision Makers ................................ ...... 140 Ho using Master Plan and Outcomes ................................ ................................ ...................... 141 Comparison of Health Supportive Language ................................ ................................ ..... 141

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xi Adoption of HIA Recommendations ................................ ................................ .................. 146 Limitations ................................ ................................ ................................ ......................... 157 Section 2. Influence of HIA Quality on Master Plan and Decision Makers ........................... 158 Determining Quality of HIA ................................ ................................ .............................. 158 Limitations ................................ ................................ ................................ ......................... 169 Section 3. Cross Sector Collaboration ................................ ................................ ................... 170 Determining Cross Sector Collaboration ................................ ................................ ........... 170 Limitations ................................ ................................ ................................ ......................... 179 Key Findings from Research th at Support HIA Influence ................................ ...................... 180 Results Within Cases: Conceptual Framework ................................ ................................ ...... 182 High Influence/Effectiveness Checklist ................................ ................................ ................. 183 Independent Variables ................................ ................................ ................................ ........ 183 Dependent Variables ................................ ................................ ................................ .......... 184 Concluding Remarks ................................ ................................ ................................ .............. 185 VII. NORTHEAST DOWNTOWN DENVER NEIGHBORHOOD CASE .............................. 187 Chapter Outline ................................ ................................ ................................ ...................... 187 Introduction ................................ ................................ ................................ ............................ 187 Background of Northeast Downtown Denver Neighborhoods Plan HIA Case ....................... 188 Overview of Data Collection ................................ ................................ ................................ .. 189 Case Study Methodology ................................ ................................ ................................ ....... 191 Section 1. HIA Influence on Master Plan and Decision Makers ................................ ............ 193 Neighborhood Master Plan and Outcomes ................................ ................................ ............. 194 Comparison of Health Supportive Language ................................ ................................ ..... 194

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xii Adoption of HIA Recommendations ................................ ................................ .................. 199 Limitations ................................ ................................ ................................ ......................... 209 Section 2. Influence of HIA Quality on Master Plan and Decision Makers ........................... 210 Determining HIA Quality ................................ ................................ ................................ ... 210 Limitations ................................ ................................ ................................ ......................... 221 Section 3. Cross Sector Collabor ation ................................ ................................ ................... 221 Limitations ................................ ................................ ................................ ......................... 230 Key Findings from Research that Support HIA Influence ................................ ...................... 231 Results Within Cases: Conceptual Framework ................................ ................................ ...... 233 Low Influence/Effectiveness Checklist ................................ ................................ .................. 234 Independent Variabl es ................................ ................................ ................................ ........ 234 Dependent Variables ................................ ................................ ................................ .......... 236 Concluding Remarks ................................ ................................ ................................ .............. 238 VIII. RES ULTS AND DISCUSSION ................................ ................................ ....................... 239 Chapter Outline ................................ ................................ ................................ ...................... 239 Results ................................ ................................ ................................ ................................ ... 239 Research Question One ................................ ................................ ................................ .......... 241 South Lincoln ................................ ................................ ................................ ..................... 241 NE Downtown ................................ ................................ ................................ ................... 242 Overview ................................ ................................ ................................ ................................ 242 Research Question Two ................................ ................................ ................................ ......... 244 Cross Sector Collaboration and Quality of HIA ................................ ................................ 246 Cross Sector Collaboration ................................ ................................ ................................ 247

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xiii HIA Quality ................................ ................................ ................................ ....................... 250 Discussion ................................ ................................ ................................ .............................. 252 Rival Explanation for Outcomes ................................ ................................ ............................ 258 Factors Less Consistent with the Literature ................................ ................................ ........... 259 Short Term Outcomes/Lessons ................................ ................................ .............................. 260 Limitations ................................ ................................ ................................ ............................. 262 Conclusion Significance of Study and Future Research ................................ ........................ 263 BIBLIOGRAPHY ................................ ................................ ................................ ...................... 268 APPENDIX A. INTERVIEW GUIDE ................................ ................................ ................................ .......... 285 B. RECOMMENDATIONS FOR SOUTH LINCOLN REDEVELOPMENT ......................... 299 C. HIA STANDARDS FOR SOUTH LINCOLN ................................ ................................ ..... 308 D. RECOMMENDATIONS FOR NE DOWNTOWN REDEVELOPMENT .......................... 312 E. HIA STANDARDS FOR NE DOWNTOWN ................................ ................................ ...... 318 F. HEALTH SUPPORTIVE LANGUAGE FOR CENTRAL PARK BOULEVARD .............. 323

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xiv LIST OF TABLES TABLE 1. Description of Research Case Studies ................................ ................................ .................... 101 2. Main Components of Research with Measures, Data Collection, and Analysis ..................... 106 3. Case Study Design Tactics to Enhance Quality of Research and How Addressed in Research ................................ ................................ ................................ ................................ ................... 108 4. Data Collection of Interviews ................................ ................................ ................................ 116 5. HIA Effectiveness/Influence Typology Analysis ................................ ................................ ... 128 6. Content Analysis of Housing Master Plans ................................ ................................ ............ 142 7. Socioeconomic Status Related Content Analysis of Housing Master Plans ........................... 144 8. HIA Recommendation Adoption Levels ................................ ................................ ................ 149 9. HIA Adoption Specific to Sections in the HIA Document ................................ ..................... 150 10. Questionnaire Responses for This Study Section ................................ ................................ .. 151 11. Codes an d Standards and Propositions for Analysis of Interviews ................................ ....... 163 12. Scores of Standards ................................ ................................ ................................ .............. 164 13. Responses and Scores from Interview Questions ................................ ................................ 166 14. Cross Sector Collaboration Responses from Questionnaire ................................ ................. 173 15. Questions about Specific Aspects of Interdisci plinary Collaboration ................................ ... 173 16. HIA Influence/Effectiveness Typology Analysis Summary, South Lincoln Case ................ 185 17. Content Analysis of Neighborhood Master Plans ................................ ................................ 195 18. Socioeconomic Status Related Content Analysis of Neighborhood Plans ........................... 197 19. HIA Recommenda tion Adoption Levels ................................ ................................ .............. 201 20. HIA Adoption Rates Specific to Sections in the HIA Document ................................ ......... 202 21. Questionnaire Responses for thi s Study Section (n=4 respondents) ................................ ..... 204 22. Codes and Standards and Propositions for Analysis of Interviews ................................ ....... 215

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xv 23. Scores of Stan dards ................................ ................................ ................................ .............. 2 15 24. Responses and Scores from Interview Questions Pertaining to HIA Quality ....................... 217 25. Cross sector collaboration respons es from questionnaire ................................ ..................... 224 26. Questions about specific aspects of interdisciplinary collaboration (n=4 respondents) ........ 225 27. HIA Influence/Effectiveness Typology Analysis Summary, NE Downtown Case .............. 237 28. HIA Influence/Effectiveness Typology Analysis Summary, Both Cases ............................. 240 29. ................................ ............ 244 30. Other key results of differences across cases ................................ ................................ ....... 253

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xvi LIST OF FIGURES FIGURE Figure 1. Research Conceptual Model ................................ ................................ ........................... 7 Figure 2. Diagram of Characteristics that Positively Influence Collabo ration for Greater Success ................................ ................................ ................................ ................................ ..................... 86 Figure 3. Research Conceptual Model ................................ ................................ ....................... 104 Figure 4. Original Conceptual Model with Arrows Identifyin g Greatest Influences .................. 247

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1 CHAPTER I INTRODUCTION Chapter Outline The purpose of this chapter is to provide an overview of health impact assessment (HIA) its benefits and challenges and trends in the U S. The chapter also d escribes the case study research that includes the research aims, the hypothesis and research questions and also displays the conceptual model that guides this case study research. We ought to plan the ideal of our city with an eye to four considerations. The first, as being the most indispensable, is health. Aristotle, Politics (ca.350 B.C.) Overview of HIA In the US, HIA is a rising field that holds promise for more deliberate and h ealth informed decision making mprove population health and well being through improved decision and policy making and to explicitly address social and economic inequalities (Parry & Scully 2003; Wismar et al. 2007 ; Davenport et al., 2006; Scott Samuel, 1998; Birley, 2003, NAS, 2011) The World Health Organization (WHO) created the most widely used definition of HIA: i t is a combination of procedures, methods, and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and t he distribution of those effects within the population (WHO, 1999). For the purposes of this research the following more descriptive definition is preferred: HIA is a systematic process used to make evidence based judgments on the health impacts of public and private decisions and to identify and recommend strategies, design changes, and mitigation measures with the purpose of protecting and promoting public health (North American HIA

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2 Practice Standards Working Group, 20 10 ). Aristotle stated it well in the quote above when planning an ideal city health should be the priority. Often lacking in redevelopment plans, HIA recommendations can support specifics on green infrastructure, policy and practice decisions that support inclusion of pedestrian and bicycle f acilities, access to health care, a decrease in the density of fast food establishments and greenhouse gases, and support for children walking and biking to school on safer streets (Collins & Koplan 2009). Moreover, improvements in health interventions c an have limited impact if policymakers in other sectors fail to take into account the health impacts of their work (Metcalfe & Higgins, 2009 ; Bekker, 2007 ), especially with respect to the health of the most vulnerable groups in society (Metcalfe & Higgins, 2009; Forsyth et al., 2010). Inequalities challenge society and decision makers, as the gap between rich and poor accentuate the striking disparities in health status (Whitehead, 2006). For this reason, HIA is critical to addressing and eliminating healt h inequities because it focuses on tackling social determinants of health such as education attainment, housing, and social networks. Unfortunately, in the U.S. or abroad, many HIAs do not address health inequities in a meaningful way (Parry & Scully, 2003 ). HIA has been conducted since the 1990s in the United Kingdom, New Zealand, Ireland, and Australia (University of Pittsburg, 2009). More recently, mounting interest and concern for healthy public policy has led the World Bank to require HIAs as part of i ts large development efforts (Collins & Koplan 2009). The WHO recommends that public policy be health promoting. Statements have been also made in the European Union (EU) treaty that its policies should not have adverse health impacts (Mcintyre & Petticre w 1999). Clearly, HIA has garnered international support, but HIA is still a developing field in the US that according to Wismar, lead author of, The Effectiveness of Health helping public decision makers (Wismar et al., 2007:12). The extent to

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3 which HIA is effective in informing decision making in the U.S. is yet to be determined despite its growing use. HIA Trends in the U.S. Dannenberg et al. (2008) examined 27 HIAs completed between 1999 and 2007, and by March 2012 there was a noticeable trend to complete HIAs with 152 either completed or in progress and approximately 300 in August 2014 (health impact project, 2012, 2014). The HIAs cut across policies, programs, and plans tha t included after school programs, a living wage majority, about 66% of the HIAs, reflect applications in the transportation, housing, or urban planning sectors (NAS, 2011). Even with the upward trend in the use of HIA, the U.S. still lags far behind the United Kingdom, Ireland, Australia, and many other countries in the use and research of HIAs (Dannenberg et al., 2008; Slotterback et al., 2011). Thailand and Lithuania are two of the few countries with a legislative mandate for HIA (Metcalfe & Higgins 2009). Most HIAs in the U.S. have been voluntary, and by all indications it will generally remain that way (NAS, 2011; Metcalfe & Higgins 2009). HIA Benefits and Challenges and Purpose Statement Some researchers claim that HIAs inform policy and planning decisions that minimize negative health impacts and support positive impacts. One cost benefit analysis study conducted by the Department of Health in England, fo und that the benefits derived from the 15 HIAs studied outweighed the cost of undertaking them (Wismar et al., 2007; Metcalfe & Higgins, 2009). Other stated benefits of HIA are that it enhances cross sector collaboration ( Parry & Scully, 2003; Lock,

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4 2000; Wismar et al., 2007) and enhances health promotion (Elliott & Francis, 2005; NAS, 2011). The many benefits and challenges of HIA are described more in Chapter 3. Others more skeptical such as Parry & Stevens (2001) argue that HIA is too subjective and insu comparatively little knowledge about planning problems or current heal al., 2010). Current discourse in the HIA literature highlights two particular concerns: the scientific quality of HIA methods and techniques (Parry & Stevens, 2001; Veerman et al. 2005; Lock, 2000) and the effectiveness of HIA in changing policies and plans (Mannheimer et al., 2007; Wismar e t al., 2007; Bekker, 2007). The purpose of this research study is to focus on informing the later, to improve the understanding of the influences and effectiveness of HIA in improving plans to be more health informed. Many researchers, including Lock (2000), believe processes in public health. Although this may be overstating the significance of a yet unevaluated (p. 1397). As Elliott and Francis (2005) and others point out, the links between HIA and the decision making processes are not clear. The influence of HIAs on the decision or policy making process is largely unknown because of a lack of evaluation (Harris Roxas & Harris, 2012). Therefore, research is needed since little academic research has been conducted in the US to identify and better understand and optimize the influences to and effectiveness of HIA on urban master planning decisi ons and decision makers. Research Aims It is the aim of this thesis to examine how effective HIAs are at influencing redevelopment master plans and decision makers. More specifically, whether HIAs conducted of

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5 two redevelopment master plans in Denver, Col orado influenced the outcomes of the plans and changed health awareness and knowledge of the project team and other decision makers. At one recommendations were adop ted and implemented. Although checking off recommendations against a final master plan can indicate some of its impacts, this only tells part of the story of its ability to influence planning processes and plans (Harris Roxas et al. 2014). Therefore, the study has three measures of influence that are key indicators for operationalizing the influence and effectiveness of an HIA in master plans: 1) Adoption of HIA recommendations into the master plans; 2) Health supportive language used in the master plans; and 3) Health awareness and knowledge of decision makers. Stated a different way, did the completion of the HIAs result in the adoption of healthier and safer options in the urban master plans and more health supportive language (both are referred to as ma ster plan outcomes), and did it increase the decision health awareness and knowledge? This research study focuses on two independent variables: quality of the HIA and cross sector collaboration as illustrated in Figure 1 to determine whether and h ow these variables influence HIA effective ness in changing the health related master plan outcomes and health awareness and knowledge of the decision makers. In an effort to determine the quality of an HIA, American HIA Practice Standards Working Group in 2010. Broadly, the Standards are designed to advance HIA quality and provide guidance and consistency. For the second variable, cross sector collaboration, t he literature supports that a blending of the responsibilities, tools, and perspectives of multiple sectors can result in better outcomes (Kochtitzky et al., 2006; Bryson et al., 2006; Kline, 1990). The literature states that enhanced leadership, resources, partner relationships, history of relationships with team members, structures and processes, and good communication translates into more successful outcomes that are part of examining cross sector

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6 collaboration in this study. Many teams and partnerships ha ve found it hard and have difficulty realizing the full potential of cross sector collaboration (Petts et al., 2008; Weiss et al., 2002; Greenwald, 2008). These variables were examined primarily by using the case study method which is best for analyzing h ow HIAs influence decision making in a local community context. Case studies can assist in understanding complex issues or problems and strengthen what is already known (Yin, 2003). The methods include a content analysis of each of the redevelopment plans, document reviews, and semi structured interviews with a purposive sample of project team members and other key decision makers. Semi structured interviews allow for consistent coverage of the identified areas of interest along with allowing for new and em erging themes (Haigh et al., 2013) The decision making context for the two cases reflects the purposive nature of the case selection, both cases are at the local level and in the same jurisdiction (similar governance, politics, regulations, and policies) and have the same health assessor. Differences are that the decision making agency lead for one is the Housing Authority and for the other, the Planning Department although both agencies participated in both cases. Additionally, the hired planning firm for each case is different. The cases contrast along the independent variables. Different levels of influence and effectiveness were identified and tiered in a typology and analyzed as a final step in the case study to assist with determining to what extent t he independent variables influence d the adoption of the HIA recommendations health supportive language and health awareness and knowledge. This exploratory, retrospective case study design uses a mix of quantitative and qualitative methods. Additionally, t he socio ecological model of health is the theoretical framework used that supports and informs this HIA research.

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7 Figure 1. Research Conceptual Model Research Questions This stud y was designed to test hypothese s and strengthen what wa s already known yet was also exploratory in nature with an inductive and deductive approach. The central research questions are below along with the related sub questions and hypothesis. These research questions served as a framework throughout this study to ultimately determine if the independent variables promote informed and health focused decision makers and redevelopment plans. Pr ior to this study, these variables and associ ations had not be en directly researched in the U S. Overall Hypothesis: It is anticipated that if the level of collaboration among the diverse project team members with varied expertise including health and other decision makers is high and the quality of t he HIA is high, then the degree to which the HIA recommendations and health supportive language are adopted into the master plan should also be high, along with increased health awareness and knowledge of the decision makers. And the opposite should also b e true if the independent variables are low. QUALITY OF HIA CROSS SECTOR COLLABORATION MASTER PLAN & DECISION MAKER OUTCOMES Health Supportive Language Health Awareness and Knowledge Adoption of Recommendations

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8 Below are the two central research questions along with sub questions. The central questions and sub questions are mainly answered in Chapter 8: Results and Discussion. The sub questions in qu estion 1 are within each case (C hapters 6 & 7). Question 1: How do health impact assessments influence decision making in redevelopment master plans, specifically the amount of HIA recommendations adopted, health supportive language used and change in decision h awareness and knowledge? Sub questions: a. How much health supportive language is in master plans when an HIA is completed compared to similar master plans without an HIA completed? b. i. H ow many of the recommendations from the HIA were partially or fully adopted in the master plan? ii. Which of the health sections/chapters in the HIAs had the most recommendations adopted such as Crime and Safety, or Healthy Food Access or Environmental Health ? iii. How many of the HIA recommendations were adopted that focused on changes to policies, the physical changes to the built environment or programs? c. How much does health awareness and knowledge of the project team and other decision makers change when a HIA was completed? Question 2: How do variables such as cross sector collaboration and the quality of the HIA influence whether the HIA is more or less effective in influencing decision knowledge and health related master plan ou tcomes such as the adoption of HIA recommendations and health supportive language ? Sub level questions:

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9 a. How does the level of cross sector collaboration of the project team and other decision makers influence the quality of the HIA document? b. How does the level of cross sector collaboration of the project team influence the dependent variables such as health awareness and knowledge when a n HIA has been completed? c. How does the quality of the HIA influence the dependent variables such as health awareness and knowledge of the decision makers? i. What quality Standards score does the South Lincoln HIA achieve? ii. Were the goals and objectives of the HIA met? As stated, the use of HIA has be en steadily increasing in the U S yet little research and few evaluati ons have been completed and published. Research such as this study is important to potentially understand and identify the extent to which HIA is effective in influencing decision making and decision makers specific to the level of cross sector collaborati on and quality of the HIA. In this study, the goal is to be able to support and verify related HIA and cross sector collaboration propositions and identify new variables a nd methods that enable more effective HIAs to potentially contribute to the discour se and literature.

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10 CHAPTER II HIA BACKGROUND AND THEORETICAL FRAMEWORK Chapter Outline The purpose of this chapter is to provide background and important concepts for clarification about definitions and concepts that are foundational to this HIA study suc h as impact assessment, health in all policies (HiAP), and decision and policy making. There is also an explanation of the historical context of the planning and health disciplines and the more collaborative periods and how and why the two disciplines hav e evolved and in some ways, chapter is the evolution of the theory and models in public health and specifically the socio ecological model that is connected to broad sociological systems theory. This chapter describes the literature on how sustainable, urban planning and design of the social, and built environments affect physical and mental health and how this interconnection supports the use of HIA. Definitions and Background for Understanding HIA There are many definitions and important concepts that are in need of clarification to best understand HIA conceptually that are explained in this chapter and in Chapter 3. For example, policy making and decision mak ing were both used interchangeably and extensively in the HIA literature so definitions and clarifications are provided and distinctions made in relation to the meaning of each of the phrases and to this research study.

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11 HIA and Health Assessment of the im pact of a policy, project, or program intervention on public health needs substantive and reliable data based on a clear and consistent definition of health, HIA and other definitions. The WHO (1948) defines health broadly (Forsyth et al., 2010; Kemm et al definition of health is most commonly used in HIAs and includes issues such as crime, injury, heat, and physical activity and optimal well being. HIA has multiple defi nitions shown below, albeit similarly defined. The most widely used definition of HIA was d eveloped by the World Health Organization European Center for Health Policy (ECHP) and presented in the Gothenburg Consensus paper on HIA, es, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the po represent a lack of ag reement on what HIA is and can accomplish. The quality and effectiveness of HIA could be compromised without a clear vision about how to define HIA. For example, HIA is described as a method, process, tool, procedure, approach, and structured framework. I n order for HIA to be a valid tool, a shared definition of health is needed (Lock, 2000; Forsyth et al., 2010) and terminology needs to be standardized (Parry & Kemm, 200 5 ). A methodology which enables the identification, prediction and health risks (Kemm, 2000; 431 ). Samuel, 1998 ; 704 ). Association., 199 9) (Parry & Stevens, 2001).

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12 is a practice to make visible the interests of public health in decision (North American HIA Practice Standards Working Group, 20 10 ). (Lock, 2000 ; 1395 ). : 2 ). K rieger et al., 2003). Influence versu s E ffectiveness used extensively in the study. I nfluence is defined as the capacity to have an effect on an action or in this ca se the dependent variables (master plan outcomes and the decision awareness and knowledge). E ffectiveness is defined as the degree to which something is successful in producing a desired result (Webster dictionary). Determining the HIAs infl uence is the initial step and whether independent factors had an effect is used throughout the study. A slight difference, in analysis, is to what degree effectiveness is determined using interviewee ratings and comments, and scores and from using the HIA quality standards and the propositions. Roots of Impact Assessment Framework and Purpose o f Impact Assessment Understanding impact assessment (IA) offers a backdrop or framework of how HIA operates, its conceptual roots and its theoretical premise of enge ndering change in the values that

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13 inform decision makers and policy formation and implementation (Cashmore et al., 2010). The universal goal of impact assessment is to bring about a more ecologically, socio culturally and economically sustainable and equit environmental impact assessment (EIA) or other types of impact assessments come from established IA principles. IA focuses on informing decision and policy making and is viewed as a framework for analyzing possible positive and negative impacts of a policy, project or program (Quigley et al., 2006). IA instruments have proliferated in terms of the number of assessments undertaken and the variety of contexts in which they are used. IA potentially d raws causal inferences from knowledge or data that could lie outside the scope of the discipline that generated them. IA also combines propositions from different disciplines, of different degrees of confidence and verification, which can be challenging. O ther challenges are that impact assessments, and certainly HIAs can be obstructive to new planning developments and can slow down progress. Integral to the success and acceptance of impact assessment, both as a decision and policy making approach and as a methodology, depends on it not becoming too cumbersome. The tool is useless for decision and policy makers if it does not offer timely and well informed decision options. The increase in the number of IAs completed potentially demonstrates a need for gre ater accountability and evidence that these instruments can be effective (Cashmore et al., 2010). but instead assembling, summarizing, interpreting, and possibly reconcilin g pieces of existing knowledg e, and communicating them so that they are relevant and helpful for the deliberations of a decision (Parson 1995 :463 ). Another definition of IA is a framework of investigation and the estimation of intended and unintended eff ects of decisions that can be measured. Although, many issues or indicators cannot readily be measured, if at all. However, the aim of an IA is not to provide a type of guarantee; its central purpose is to evaluate the possible consequences of decisions i n order to better inform decision makers of their options (Quigley et al., 2006; Parson,

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14 correctly make it predominantly a predictive rather than an empirical res Stevens, 2001:1178). (Cashmore et al., 2010:6). Harold Laswell (1936), political scientist at Yale University, suggested politics constitutes the strug gle over who gets what when and how, versus policy, which is what is formulated and implemented (Cashmore et al., 2010). Simi larly stated, Mannheimer et al. (200 7 gove (p. 527) Political analysis is learning about the beliefs, values, and aspirations of stakeholders to inform policy decis ions. Understanding the differences between political analysis, politics, and policy is important since these are so closely tied to IA. IA can be understood as executing political analysis to inform an action. Adoption and use of IA instruments in theory However, IA instruments as neutral and rational tools remains deeply ingrained in the social sciences providing substantial evidence to the contrary over the course of several decade Cashmore et al 2010 :19 based frameworks are no less value ridden than any other social interpreta 2010:19). Similarly, public health itself, and HIA are not value Scott Samuel 1998:704). For example, attempts by experts to defin perpetuate a particular way of thinking (Cashmore et al., 2010).

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15 Power R elations with I mpact A ssessment Many would not consider HIAs as an exercise of power relationships and negotiation either i n design or use. As mentioned above, IA instruments are typically portrayed as neutral tools rather than as components of a decision and policy process which can create their own specific effects. Impact assessment tools draw boundaries around how societ al issues are framed, analyzed and debated, including what forms of knowledge are considered pertinent to policy or decision making. Although generally seen as neutral, even methodological decisions in IA namely, what methods, scales, and variables to emp loy, can be interpreted as acts of power, for they involve the push of a particular set of interests upon decisions (Cashmore et al., 2010) and can increase pressure on the process to produce specific results (Forsyth et al., 2010). Who decides to conduct fund, design, and undertake an HIA may well also shape its outcomes (Forsyth et al., 2010; Krieger et al. 2003). Even the push by the Center s for Disease Control and Prevention (CDC), Robert Wood Johnson foundation and the PEW Charitable Trusts to suppo rt HIA with considerable funding and/or staff time can also be considered an attempt to direct policy and decision making in a particular direction. Additionally, practitioners working on the design and use of IA instruments and scholarly contribution hav e a powerful and privileged position (Cashmore et al., 2010) that can significantly influence success, direction, what is emphasized, and outcomes. This impacts how the HIA movement evolves possibly questioning the credibility with so much guiding and supp ort from the top down. IA instruments may also constrain opportunities for those stakeholders with limited power to exert an influence on decision and policy making. IA instruments may support the power based within already influential groups. Lastly, con sensus by stakeholders is ironic because it inevitably involves the exclusion of actors and/or ideas, which involves the exercise of power. Within HIA, the processes that occur within each step/phase can often be political in

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16 nature (Cashmore et al., 2010) Scoping, for instance, determines the health issues to address or not address. Impact Assessment Terms Used Impact assessment, neutrality, political questions, and power issues prompt questions about HIA usefulness, effectiveness, and relevance to societ y. Davenport et al. (2006) believes that HIA is different from other IAs because it is more than just assembling existing data or a final outcome report. Instead, HIA aims to affect change within the decision and policy making process and better informs de cision makers of the trade offs inherent in various recommendations. From these statements, is it not clear whether this is a matter of other IA not living up to the stated benefits, principles or expected outcomes or whether practitioners and academia are trying to make HIA different from other IAs. Are the other IAs only trying to inform and not make change? Is the level of expectation for HIA too high and different when considering the foundation and principles of IA or was the intended purpose and outco mes of be rev isited later in C hapters 3. Health Impact Assessment Critical Review and Chapter 7. Results and Discussion. This is a rather thorough description of impact assessment because of its importance of being the foundation of HIA and provides insight into concepts of power relations, goal of IAs and the theoretical premise and highlights issues related to this type of tool. Health in All Policies Approac h and Role in S upporting HIA In recent decades, there has been a growing recognition of broader health promotion and protection policies, strategies and implementation; this represents a shift from the traditional

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17 vertical and hierarchal approach to a more horizontal and flattened and innovative policy approach. The latter, used mostly in the European Union, Australia, and others, is often referred science which aims at influencing health determinants so as to improve, maintain and protect et al. 2007:526). It is also promoted as a strategy to help strengthen the link d actions planned the two are considered similar in concept. However, HPP is considered a precursor to HiAP. HPP was initially developed by the World Health Or health on the agenda of policy 2009:296). For all three (HIA, HiAP, HPP) a similar broad definition of health is used that encapsulates a state of complete mental and physical health and social well being rather than just the absence of disease (Harris et al., 2012; WHO, 1948). HiAP, considered a model of an innovative, systems change approach is a paradigm shift for both governmental and non governmental organizations: a platform that enables health and well being to be shared values across other sectors. One example is obesity, of which both the probl em and the solution are systemic. Obesity is a disease with a complex system of health determinants that span numerous sectors from transportation to education. HiAP focuses on the co benefits and win win horizontal strategies and uses health as a linking factor for decision makers to combat chronic diseases, whether considering local or national policies in transportation, food, education, or the environment (Kickbusch & Buckett, 2010). HIA has been described as the primary vehicle for fulfilling and opera tionalizing HiAP and a good fit within the broader HiAP umbrella that can support HIA to be more effective. Considering that the HiAP approach can be extremely cumbersome because it emphasizes examining all policies and

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18 proposals reinforces why screening ( initial HIA step) is so important to determine whether to conduct an HIA. Also HIA does not solely focus on policies, but also includes broader decision making such as urban planning proposals. HiAP/HPP and HIA are expected to enable, initiate or guide ch ange in decision and policy making but they could also obstruct (Bekker, 2007). Public health officials could be seen as attempting to impose their own system goals and objectives and outcomes on other sectors (health imperialism). Health imperialism is th e concept that all policy areas are subordinate to public health (Kemm, 2001). Sometimes these different system goals, whether related to health, economics, or sustainability can support or be in conflict with one another (Wismar et al. 2007). But HiAP/ HPP and HIA are not about forcing or imposing a health agenda onto other sectors such as planning or transportation, but more about initiating a discussion and a cross sector, multi agency strategy and response to address endemic problems such as air pollu tion or obesity. Health imperialism should be avoided because it is considered potentially risky to force health into an already complex policy environment with other impact assessments and struggles that include power and politics, and can harm interdisci plinary efforts (Harris et al., 2012; Krieger et al. 2003; Forsyth et al. 2010). NAS (2011) recognizes that adoption and implementation of projects or policies will require some necessary balance of health with many other considerations that are importa nt to any given decision. Policy v ersus Decision Making and its Connection t o HIA HIA can influence both decision and policy making by encouraging healthy behaviors and living. However, in some of the HIA literature there is confusion about public policy versus decision making when describing HIA and its purpose. A basic definition of decision making is

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19 course of action from alternative scenarios. Decision making involves the selection of a course of action from possible alternatives for the purpose of solving a given problem Decision making does not necessarily include policy making, but policy making does include decision making. Steps described by Dr. Pam Brown of Singleton Hospital in Swansea, Wales, and also similarly stated by Peter Drucker, Practice of Management (1955) break decision making down into seven steps: 1) Identify problem/outline goal and outcome; 2) Gather data/analyze problem; 3) Devel op alternatives; 4) Identify pros and cons of each alternative; 5) Make the decision; 6) Convert decision into action; and 7) Reflect or follow up on the decision. These steps are similar to policy making but without formal adoption or resolution that guid es the decision. Decision making can have a course of action but does not emphasize actual implementation, monitoring, and evaluation that is associated with policy making (Metcalfe & Higgins, 2009). Although some of the description above is also similar to defining policy making (e.g. converting decision into action) -causing confusion. The policy process, as described by Thomas Birkland (1997), is problem definition, agenda setting, policy adoption, and implementation. Public policy is a form of decision making and is a combination of basic decisions, commitments, and actions made by those who hold authority or affect government decisions. Policy making is described as a process of weighing and balancing public values and influencing the life of citizens A policy is typically described as a principle or rule to guide decisions and achieve rational outcomes. Adopted policy generally takes the form of a law or regulation, governing principle, plan, or course of action pertinent to an issue or problem (Birk land, 2005) and guidelines and budget (NAS, 2011). Policy making can be an adversarial process, characterized by the clash of competing and conflicting interests and viewpoints rather than an impartial, disinterested, or objective search for correct soluti ons for policy issues. The larger and more diverse the constituency, the more difficult policy making can

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20 be. Sometimes the emergence of a problem through implementation and evaluation of a policy can take over 30 years (Sabatier, 2007). Public policy, inc luding decision making, is more a process with stages that are not necessarily linear. Since the policy pathway is typically seen as uneven incremental steps or even skipping stages, there is often less clarity where HIA should be best undertaken in the pr ocess. Oftentimes HIA risks coming in too late into the policy and decision making process (NAS, 2011). Historically, HIA has occurred outside the decision and policy making process and once a proposal has already been drafted, which considerably limits i ts effectiveness (Davenport et al., 2006). Often economic growth and productivity, not public health, is recognized as a driving force for public policy development and implementation, which again can limit HIA effectiveness. Public policy occurs at many i nstitutional levels of government, whether national, state or local with the local level being considered the easiest to influence (Harris et al., 2012). Being able to influence more at the local level is important since the majority of the HIAs occur at t he local level in the U.S, which then can support HIA effectiveness. Although impact assessment and HIA specifically are steeped in policy making and policy processes, this research study focuses on decision making and adoption of the decisions but does n ot include implementation. Theoretical Frameworks Due to the relatively nascent use of HIA in the U.S. and although more established abroad, the theories that currently establish its foundation and application in the field are largely broad. HIA generally uses conceptual framework s of science whether ecology, social epidemiology, or the social sciences to make predictions. A number of theoretical models and frameworks are employed in public health to examine the determinants that influence health

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21 outcom es (Forsyth et al., 2010; Birley, 2003). Which theoretical framework or model used matters because it can be used to decide the approach of the HIA and whether it is effective or not. Some believe that HIAs have been conducted without clear elaboration of the theoretical framework(s) guiding its implementation. It is rare for the researcher to specify whether or which policy or theoretical framework is guiding his or her research (Krieger et al., 2003). Some of the theoretical frameworks that were documente d and drawn from in the HIA literature were the biomedical model, knowledge utilization, psychosocial model, socio ecological model, and impact assessment. More concrete, evidence based, sociological theory is needed to enhance HIAs' existing ability to de termine the complex relationships between the built environment and health and the resulting impacts HIAs can affect. This lack of theory is especially challenging when attempting to reconcile different fields such as public health and urban planning and t he theory and models that connect them and guides the research ( Krieger et al., 2003) This study is written from a theoretical perspective of using a broad definition of public health, and the socio ecological model that is connected to broad sociological systems theory. Conceptually, t his study also draws on the growing literature on how sustainable, urban planning and design of the social, and built environments affect physical and mental health and how this interconnection supports the use of HIA. Histor ical Context of Planning a nd Health related to the built environment are not new, and similarly evolving goals are renewing these efforts of more healthy and sus tainable communities today From the early 1800s to the 1930s, land collaborative efforts between public health and urban planning professionals began in response to

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22 especially poor sanitation and overcrowding within growing cities, particularly near industrial areas that prompted the need for creating systems for water, sewage treatment, and fire safety (Garb, 2003). Health officials and planners of that day also e nsured that highly noxious and unsanitary industries such as steel production or meat processing did not end up in predominantly pestilential to the morals, the heal disease, noise, air pollution and crime (Frumkin, 2004:30). The period from the late 1800s to the 1930s was a time when planning and health disciplines overlapped and worked toward the improvement o f healthier and safer cities. This time period is one of the strongest identified collaborative historical eras among urban planning and public health, and now, within the 21st century (Garb, 2003; Corbin, 2004) with many missed opportunities and opposing goals in the intervening years. There is a need to re invigorate the historic link between urban planning and public health, to be able to conduct informed science to better guide effective decision and policy making today ( Krieger et al., 2003). This mor e recent attempt to rejoin the two disciplines in sustainability and smart growth efforts is at the crux of HIA and the disciplines working together effectively and is useful in framing the theoretical premise for this research study. Public Heal th Histor ical Context and Theoretical Contribution The WHO broadly defines health as a state of complete physical, mental and social well being and not merely the absence of disease or infirmity (WHO, 1948). Also stated by Stokols (1992), public health is not only about the physical health but is a multi faceted phenomenon that incorporates emotional well health care systems and medicine, but as McKeown (1974) pointed out, reduction in death from

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23 infectious diseases in the latter half of the nineteenth and first half of the twentieth century was more about increased prosperity, better nutrition, better housing, and improved sanitation than the advancements in medicine and treatments (Jackson, 20 07; Milio, 1981). Milio and others acknowledged that the built environment and policy interventions that address broader economic, quality of life, and social determinants of health such as housing, transportation, urban planning and education will have more of an impact on population health than the medical model approach of treatment only (Milio, 1981; Collins & Koplan 2009). The biomedical (medical) model has been around for centuries and dominated in the twentieth century. The medical model developed in line with the Western logical positivist thinking that health equates with the absence of illness. The medical model is a discrete pathological process ( Wade & Halligan, 2004) and emphasizes treatment of disease rather than prevention and the promotion of health (Milio, 1981). This model also dismisses the soci al determinants that contribute to good or bad health and is defended by few practitioners and academics today (Mannheimer et al, 200 7 ; Krieger, 2001). In response to the focus on the treatment of dis ease, Wade and Halligan (2004) suggested the adoption of the psychosocial (also referred to as biopsychosocial) model of health that can (p 1401). Initially HIA seemed to fit into and be grounded within the psychosocial model of health that includes both psychological and sociocultural factor s that focus on the individual and vulnerability to disease to both physical and psychological stress ( Wade & Halligan 2004). For much of the last half century, the majority of U.S. public health interventions have been predicated on an individualist model of health. The premise of this theory and model is focused on the thoughts, emotions, and behaviors of the individua l who has the responsibility to choose healthy choices and better cope with their stress (Krieger, 2001). However, the psychosocial model was developed by a psychiatrist and although broad and includes the determinants of

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24 health still focuses extensively on the individual level, rather than on broad based population health. HIA draws on the broad social determinants of health such as education and income where developments, plans, policies, and programs can significantly influence these determinants. HIA also draws more on sociological theoretical underpinnings such as collective efficacy (mutual trust among neighbors combined with a willingness to act on behalf of the common good) and social capital (expected collective or economic benefits derived from t he cooperation between individuals and groups and the social networks). The emphasis with HIA has been mainly using the broad sociological theory rather than individual psychological theory. What is proposed for this study is the social ecological model ( SEM), developed by sociologists. SEM is a better theoretical framework for the study of HIA as it better supports and SEM is a framework to examine the multiple effects and interrelatedness of social elements in an environment and a combination of individual and population based lifestyle factors as well as of health, disease and well multiple levels and contexts to establish the big picture in broader community networks, and presents a more complex, systems approach to health and illness. Essentially this approach and SEM proposes social and ecological interactions that are seen as affecting one another and together impacting health. In the context of system theory, it focuses on the arrangement of and relations between the parts that connect these p arts into a whole. Change in one component in the systems affects the condition of another component changing an entire community (Wigglesworth, 2012). Systems theory and SEM fit well in explaining HIAs purpose and overarching goal. For example, a redeve lopment project is one change with multiple ripple effects in a community system. HIAs attempt to comprehensively identify the negative and positive

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25 impacts and mitigate the negative impacts that reverberate from the project. Research that focuses on any o ne level underestimates the effects of other contexts and networks (Stokols, 1992). Systems thinking, which is the process of understanding how things influence one another within a whole, is central to the socio ecological model The development of social ecological levels macro exo meso and micro describe influences as intercultural, community, organizational, interpersonal or individual (Bronfenbrenner, 2005). Traditionally, many research ers have considered only two perspectives, either micro (individual behavior) or macro (media or cultural perspective and model in the 1970s of the person, the environment, and the continuous interaction between individuals and the environment. He realized it was not only the environment d irectly affecting the person, but that there were layers in between, which all had resulting impacts on the next level (Bandur a, 1983). Bronfenbrenner (2005), Stokols (1992) and others continued to evolve the theoretical ideas and framework, offering persp ectives for understanding the interplay of social, economic, ecological and ideological forces that shape the development of human beings, their health, and well being. SEM is most useful at informing HIA and the multiple pathways through which the built e nvironment may potentially affect comprehensive health integration. The pathways could at the macro level (historical conditions), meso level (transportation systems, land use) or micro level (housing conditions, crime) into a community redevelopment which looks at how individuals and populations work and play in healthier community environments (Bronfenbrenner, 2005; Krieger et al, 2003). It is also noteworthy that the environmental precautionary principle is a tool for HIA work and specifically for decis ion harm to human health or the environment, precautionary measures should be taken even if some

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26 If this principle were adopted more often, many unsafe practices and policies might not be implemented or used in the first place. Urban Planning Historical Context and Theory Contribution The historical context informs and shapes the design, form, and the ory that has evolved in sustainable planning efforts today and in the future. Early nineteenth century planners believed that reforming the physical environment could revolutionize the society by directing the community onto the paths of social harmony (Fi shman, 1992). Some planners championed health as a key issue within the planning profession, and were expressly interested in housing issues, and the harsh industrial conditions and pollution However, for some planners it meant moving out to the pristine countryside instead of improving the unhealthy cities. Some scholars of planning theory maintain that the philosophical roots of suburbia grew from the concept of Ebenezer The Garden City was a reaction against the overcrowdi ng, voluntary self governing community of comprehensive design, low population density, local industry support, and set in the countryside just outside the crowded city, surrounded by a green belt. The idea of the Garden City was influential in the development of other new towns but sustainable development principles. A prominent planner and well recognized today, Lloyd Wright developed the idea of Broadacre City and shared it in 1932 where families could have This is similarly known as suburbia which does not support the smart growth principles of today. Le Corbusier, also influential, with his idea of the Radiant City, introduced compact, high rise

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27 apartments in 1935 (Hall, 2002; Fishman, 1992 ). This influenced higher density althoug h the high rises would be set far apart by large areas of open space. Each activity would be separated into distinct zones for working, living, and leisure and was to be done on a grand scale (Hall, 2002), with functional and spatial segregation. In cont rast to the earlier more social planners, the City Beautiful movement was ushered in around 1909 with an emphasis on the aesthetics of grandness with boulevards and memorials but with little improvement for the urban poor (Corburn, 2004). The movement coi ncided with the emergence of the planning profession with more rational comprehensive physical designs, more statistical data, and logical positivists who diagnosed urban problems. And later, urban renewal ood intentions to replace dilapidated neighborhoods but whole neighborhoods were destroyed, fractured, gentrified, and rebuilt with higher end developments. However, change evolved as planners became inspired by post modernism and an emphasis on desirable outcomes and the move away from logical positivism toward a substantive concern and openness for ethics, inclusiveness, discourse and public policy (Fainstein, 2000). In the 1950s, Jane Jacobs led a movement back to the cities, promoting diverse and multi use neighborhoods. For Jacobs, the ideal neighborhood focused on common prosperity. She emphasized the need for eyes on the street to protect those on the sidewalks, streets, and parks. She stressed the need for short blocks for better connectivity, and ho w a compact city provides nature decreased as the number of people who moved out increased Urban sprawl became the term for masses of families moving out to the pristine countryside and the repercussions response to urban sprawl.

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28 Sustainability aims for a balance in the development of the environment, the econom y generations to meet their own needs (Brundtland, 2002). The rationale for sustainability is to reduce infrastructure costs, travel time, and fuels (economic), to climate protection, reduce energy and use of resources (environmental), and to strive for social equity with respect to socioeconomic status and hea lth disparities. Sustainable development consists of an urban planning and transportation strategy that concentrates growth in the center of a city to avoid urban sprawl ; it also promotes compact, transit oriented walkable bicycle friendly land use, including mixed use development with a range of housing choices. In planning, sustainable development include s features such as compactness, contiguousness, connectedness, and diversity of housing and urban form. Many of these same characteristi cs were incorporated back in the nineteenth century communities and are similar to the efforts of smart growth and new urbanism communities today (Wheeler, 2003). Different approaches to planning theory such as New Urbanism reflect an enduring tension be tween a focus on the planning process and an emphasis on desirable outcomes (Fainstein, 2000). The New Urbanism and just city approaches are a mix of a physical picture stein, 2000:2). New Urbanism evolved in response to market driven development that destroyed the spatial support for communities (Fainstein, 2000). New Urbanism and Smart Growth both emphasize community and common good as solutions to a society in crisis, exhibited by the decay of cities that are in the process of rebounding, environmental deterioration, loss of farmland and wilderness, homogeneity, and lack of social capital. As with Ebenezer Howard, the leaders and supporters of these movements today are inspired by a desire to solve social ills, but now with more sustainable efforts and outcomes. This more recent movement supports many sustainable

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29 principles but can lack racial, ethnic, and economic diversity, social equity, higher density, and connectivi ty with other neighborhoods. P lanning is challenged to create mixed use communities with balanced transportation plagued by out of date zoning. Incorporating mixed uses into developments and districts with conventional subdivisions is difficult to achieve The fundamental zoning tenet of separating land uses served its initial purpose of separating people from hazardous industrial areas, but today it has also become yet another hindrance to planners attempting to provide mixed use planning, balanced transp ortation, and schools near home and work. Much of the zoning is archaic and supports single use land uses. Some innovative policies and zoning that support healthier lifestyles are in direct conflict with current zoning restrictions and policies that produ ce sprawl and automobile dependent communities (Ewing, 2007). In cities and neighborhoods, difficulties arise when trying to address multiple sustainability issues that cannot possibly be planned, implemented, and evaluated to the degree necessary for su ccess on all fronts. Local governments are increasingly challenged with greater stresses and impacts on population health, urban infrastructure, inequities, energy demand and water supplies; additionally, there continues to be a lack of planning and polici es on these issues (Rosenthal, 2007). Potentially, working with health professionals conducting HIAs can assist planners in these sustainability and equity efforts from a health perspective. Planners are challenged with many decisions; often these values c an conflict with one another as well as among different stakeholders. Challenging further is the potential public health component to add to the tug among planners and the other stakeholders. This is a pull between the many challenges of balancing these su stainable principles that indirectly and directly include public health, equity, and livability of people. Understanding that most health improvements are outside the health care system is meaningful as it demonstrates why the public health field broade ned its emphasis to other sectors

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30 and to wider social system nodes such as accessibility and safety, similar to the 19 th century. health and how much the built environment and policy decisions can impact public health can be a barrier to the success of HIA. However, HIA has grown increasingly over the past decade, especially in its practical use. Now that the field has been established, questions remain as to wh ether it is useful in informing decision makers and can influence planning processes. This issue is at the center of this doctoral research.

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31 CHAPTER III HEALTH IMPACT ASSESSMENT CRITICAL REVIEW Chapter Outline This chapter offers an overview of the ben efits and challenges of health impact assessment (HIA). A critique is offered about the key issues and debate about HIA as a process and approach to informing decision making in mainly non health sectors. Some of the issues discussed in this chapter are th e steps within HIA process, organizational issues and contextual differences of HIA, proximal health impacts, evidence based data, methodology, community engagement, equity/disadvantaged communities and populations, HIA quality, integration of HIA in envir onmental impact assessments, and lack of research. Introduction Research and the practice of assessing public health impacts within urban planning and transportation processes and other sectors are gaining traction within the United States (Dannenberg et al., 2008; Metcalfe & Higgins, 2009; Forsyth et al., 2010). Policy and other decisions have a health cost or benefit that can substantially affect trends in population health and should be considered in non health sector related decision making processes ( NAS, 2011). Public health can play a pivotal role in decision making by considering impacts to physical and mental health, safety, social well being, equity, and environmental sustainability of places. Yet, an understanding of how to systematically incorpo rate and promote public health practice and research within other sectors to influence decision and policy making processes is limited and challenging.

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32 A comprehensive, socio ecological health approach to collaboratively and more systematically address p ublic health issues by decision makers is necessary to achieve mass advances in the health field. Research has shown that factors outside of health care such as social and economic factors, and the physical environment can cause approximately 80% of the im pacts on population health (University of Wisconsin, 2012). Similarly McGinnis et al. (2002) stated that only 10 15 percent of preventable mortality in the United States could be avoided by better availability or quality of medical care From energy and ed ucation to agriculture policy that influences the food served, access to public transit, and environmental decisions that put residents at risk for disease, each choice brings us closer to, or moves us further from, national, state and local health goals. Therefore, policy, program, and project implications in various sectors should be potentially analyzed for their health footprint (Aspen Institute 2013 ). Specifically, this chapter explore s a tool that is growing in interest and use called Health Impact Assessment (HIA) and its effectiveness in incorporating health considerations in non health sector decision making with the ultimate goal to improve population based health outcomes. HIA is increasingly being considered in the United States (U.S.) and the stated value and benefits are substantial (Parry & Stevens, 2001). The World Health Organization (WHO) defines HIA as a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the heal th of a population, and the distribution of those effects within the population. More specifically, HIA is a structured process that brings more explicit focus to and coalesces issues of equity and vulnerable populations, determinants of health, cross sec tor collaboration, community engagement, health promotion, evidence, and recommendations for improving decision and policy making, and implementation. Researchers and practitioners alike insist that HIA can ensure a more deliberate focus on the societal determinants of health (Harris Roxas & Harris, 2012) such as education and access to services and jobs, but its pitfalls warrant critical attention. The perception is that the estimation of

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33 t methods and is of sufficient v alidity to enhance the decision and policy making process (Parry & Stevens, 2001 :1178 ). However, many believe that currently HIA is too subjective, exposed to political drivers, and insufficiently rigorous with too much unc ertainty to make robust assumptions and predictions on the magnitude or direction of the health impacts (Parry & Stevens, 2001; Forsyth et al., 2010; NAS, 2011). Lock stated in 2000 that HIA is hailed as one of the most important new processes in public h ealth (p. 139 7 ) the practice, research and evaluation of HIA evolved to the point where HIA can reliably inform better decision making to benefit public health? The literature indicates that certain aspects and attributes of HIA have been realized and improved, and some have not. This chapter critically reviews these factors. The beginning of the chapter describes and published attributes and propositions of HIA; however, the majority of the chapter is a critique of HIA based on the literature. Outside of Forsyth et al. (2010) and the National Academy of Sciences report (2011), little has be en published in the U.S. that consolidates the challenges and the met and unmet expectations of HIA. Proposed Benefits and Value of HIA Emphasis of HIA being through improved decisi on and policy making and to explicitly address social and economic inequalities (Parry & Scully 2003; Wismar et al. 2007, Davenport et al., 2006; Scott Samuel, 1998; Birley, 2003, NAS, 2011). Broadly, proponents of HIA have two main reasons for their int erest. Some HIAs aim to improve public decision making emphasizing evidence based quantitative data using

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34 a more narrow definition of health, while others strive to more deeply engage the public in discussions on health promotion and by using more qualitat ive data (Kemm et al., 2004; Bekker, 2007; NAS, 2011). Both aims are important but lead to different methods and potential outcomes (Forsyth et al., 2010). Interestingly, most HIAs are a mix of the evidence based, quantitative approach versus community en gaged, qualitative approach but generally emphasize one over the other (Cole et al. 2005; Kemm 2001). These approaches can be seen as being at odds with potential ly different outcomes and focus, and about which is more effective at informing decision ma kings. Whether there is a balance or compromise for these differences is a point of contention in the literature. Is an HIA considered better or more effective if one approach is emphasized or completed over the other? Core Attributes Although there is no consensus about the above contention in the literature and in practice, the literature indicates that many other essential characteristics and desired outcomes of HIA exist. Besides improving and supporting transparent decision making, population health a nd addressing inequalities, other attributes include the following: 1) I ncorporates evidence based health data when possible (Lock, 2000; Birley, 2003); 2 ) Enhances health promotion and knowledge (Elliott & Francis, 2005; NAS, 2011); 3 ) Enhances interse ctoral collaboration (Parry & Scully, 2003; Lock, 2000; Wismar et al., 2007; Slotterback et al., 201 1 ; Metcalfe & Higgins 2009; Mannheimer et al. 2007; Bekker et al. 2004 ); 4) Enhances community participation involving those people affected (Lock, 2000 ; Wismar et al., 2007; Cole et al., 2005, Parry & Stevens, 2001); and 5 ) Bridges the research policy practice gap (Metcalfe & Higgins 2009).

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35 Many of the above characteristics are reflected in a study of guidelines and guidance documents and show relat ive consistency across the guidelines that were evaluated by Hebert et al. (2012); the study identified that 98 percent of the international and national guidelines recommend community engagement; 95 percent include the promotion of equity and social justi ce; 88 percent assert the importance of health determinants; and 88 percent include mention of the need for a steering committee. Interestingly, the Gothenburg Consensus Paper (1999), which is considered the guiding HIA document, proposes four values of HI A that include democracy, equity, ethical use of evidence, and sustainable development (WHO, 1999) which is also included in the International omprehensive approach to health ( Quigley et al. 2006). From the literature, the first three of democracy, equity, and ethical use of evidence are documented as critical to the success of HIA and improvements in public health. The first three are addressed but far less so for sustainable development, which is a principle of IA but not (p. 320). Although Gothenburg states that sustai nability is a core value of HIA, it may be presumed that more sustainable practices can lead to better health, although this is not explicitly stated in the literature. Influencing Decision M aking Are HIAs influencing decision making to improve health out comes ? I f so, in what ways and to what extent? As Elliott and Francis (2005) and others point out, the links between HIA and the decision making process are not clear. The influence of HIAs on the decision or policy making process is largely unknown becaus e of a lack of evaluation (Harris Roxas & Harris,

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36 2012). However, some factors have emerged in the research that support HIA in influenc ing decision making. Indirectly, decision makers can be influenced by the HIA process which, in itself, can raise awaren ess of and lead to im provements in health Conducting an HIA does not always result in a change in the decision(s) the HIA i s trying to influence initially; h owever, that unexpected change could reveal to be another direct or indirect benefit of the HIA pr ocess Therefore, it is essential that the benefits and changes, however minute or indirect, are taken into account when considering the effectiveness of HIA (Metcalfe & Higgins 2009). Specific propositions that have emerged from the literature supporti ng and enabling HIA s influence on decisions and outcomes (Harris Roxas & Harris, 2012) are broken out into subheadings below. Some of the findings have been replicated, many come from Davenport et al. (2006) and are supported by multiple researchers and othe rs have not, as referenced below. Each of the propositions need to be further analyzed and the research replicated. 1) Decision making processes Decision makers are involved in the design and conduct of the HIA (Metcalfe & Higgins, 2009; Davenport et al, 200 6; NAS, 2011) People outside the decision making process provide input (Davenport et al., 2006) Timing of the assessment fits within the decision making process (NAS, 2011; Davenport et al., 2006) 2) Methodology/Methods/Evidence Use a consistent and appropri ate methodological approach (Davenport et al., 2006) Inclusion of empirical evidence (Davenport et al., 2006) Quantification of impacts where possible (NAS, 2011; Davenport et al., 2006) HIA being conducted by an expert assessor (Davenport et al., 2006) 3) Education Health promotion and education for decision and policy makers (NAS, 201 1 )

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37 Educate practitioners on the policy process (Davenport et al., 2006) Tailored presentations of findings (Davenport et al., 2006) 4) Organizational commitment Manpower, inf rastructure, policy, and statutory framework support (Metcalfe & Higgins, 2009; NAS, 201 1 ; Davenport et al., 2006) Shaping of recommendations to reflect organizational concerns (Davenport et al., 2006) 5) Intersectoral support Cross sector collaboration is supported and enhanced (Forsyth et al., 2010; Slotterback et al., 201 1 ; Metcalfe & Higgins, 2009; Mannheimer et al., 2007) Understanding priorities and perspectives of partner organizations (Elliott & Francis, 2005) 6) Controversial/political Subject of the HIA not being a controversial issue (Davenport et al., 2006) Realistic recommendations that concur with political drivers (Davenport et al., 2006) Strong political commitment (Mannheimer et al., 2007) If the factors above are correct, they produce a parad ox for completing HIA in that its success may demand compromise around core values such as independence and impartiality. To maximize the likelihood of an HIA being considered by decision makers requires them to be involved with the process yet a balance m ust be struck with maintaining the credibility of the HIA (Davenport et al., 2006).

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38 Critical HIA Issues and Challenges Since HIA is still a fairly new tool in the U S, debate continues concerning its effectiveness and practical and philosophical use. Kemm ( 2001) describes a n effective HIA as one in which the findings are considered by the decision makers in the decision and policy making process. effectiveness: the scientific qual ity of the HIA in relation to validity and reliability of the methods and techniques used to predict health consequences (Parry & Stevens, 2001; Forsyth et al., 2010; Veerman et al. 2005; Lock, 2000; Bekker et al. 2004); and The effectiveness of HIA in c hanging policies, projects and plans ( Bekker, 2007; Mannheimer et al., 2007; Wismar et al., 2007). There is a rising demand for HIA evaluation to determine its effectiveness in decision making particularly as decision and policy makers question the added value that HIA brings (Bekker et al. 2004). The two concerns are further broken down and critiqued below into the prominent HIA issues and challenges identified in the literature that range from definitions, proximal health impacts, evidence based data, m ethods, equity/disadvantaged communities, community engagement, integrating HIA into EIA, institutionalization of HIA and lack of research. Definitions Most of the HIA definitions that are important to clarify a re in Chapter 2 along with a description of decision and policy making which is further described. Two similar HIA observations have emerged with respect to policy, projects and programs. First, there is a strong emphasis in the HIA literature on influencing policy making and less on decision makin g.

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39 Interestingly, most of the literature uses the WHO definition of HIA potentially influencing project, programs and policies, yet many articles focus almost entirely on the policy making attribute of HIA as if the goal of the HIA were policy making. For example, Harris et al. (2012) proposal to inform policy makers; provides a structured step process to enable stakeholder discussion of policy problems, solutions and their potential impact; makes recommendations to influence policy development and implementation is flexible in relation to the incr emental nature of public policy (p. 4). Although it could be inferred, t here is no mention of influencing decision mak ing. Another exam ple is with Cashmore et al. (2010 ) who state that the main goal of HIA is policy integration. This goal is certainly within the context of Health in All Policies/Healthy Public Policy (HiAP/HPP) described below and HIA but is not complete. Lastly, making process in public polic y (p. 1123). within the literature which could translate to a lack of und erstanding of what HIA is trying to influence. One possible explanation of this difference in the discourse is that those authors mentioned above who prioritize policy making in HIA are generally outside the United States where policy can be used in more general terms, and used somewhat interchangeably with decision making than in the U.S. For example, with Forsyth et al. (2010), the focus is on decision making rather than policy making compared to academic articles from researchers from other countries su ch as Cashmore et al. 2010 who are from the United Kingdom (UK), Sweden and Denmark; Harris et al. (2012) from Australia, and Parry and Kemm also from the UK.

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40 Organizational Issues Common Features and Contextual Differences o f HIA Most of the HIA activi ty in the U.S. happens at the local level and has similarities both conceptually and methodological ly (Davenport et al., 2006). Despite individual contextual differences, most HIAs use both qualitative and quantitative evidence and operate within a particu lar timescale and range in scope from a mini to a comprehensive HIA. A mini HIA (also referred to as desktop version, similar timeframe to rapid version, short document, little to no community engagement), R apid version (approximately < 3 months, uses a vailable data), intermediate (approximately 3 8 months, uses available and some primary data), and C omprehensive (full) (in depth, > 8 months, collects significant new primary data, significant community engagement) (Hall, 200 2 ; NAS, 2011) although there a re no clear cut definitions of these (Davenport et al., 2006). HIA has a structure to follow but also allows for flexibility; it does have a process that includes five or six phases or steps (recommendations and reporting are split out) that aid in consi stency of the process, outcomes, documents, and comparison. 1) Screening determines whether an HIA is warranted, possible health hazards and issues that exist and their implications using a screening criteria. Screening includes considering the size of the pr oject and whether there are vulnerable populations, timeliness of HIA, and level of political support, and a number of other criteria (NAS 2011). 2) Scoping determines which health concerns, health hazards and health opportunities should be further assessed. It also identifies the health impacts based on the available sources of information, data gaps, and profiles the areas and communities affected ( Scott Samuel 1998; NAS, 2011) and establishes a steering/stakeholder group (Birley, 2003; NAS, 2011).

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41 3) Assessm ent determines each health hazard and health determinants in more d etail and identifies a profile and baseline of health status of the people most affected, with particular focus on vulnerable populations and disadvantaged. This step tries to determine the magnitude and direction of the health predictions. This step involves collecting data or using available data; e.g., conducting surveys or focus groups of those people most affected. An explicit statement of data sources, methods, assumptions, and uncerta inty is essential (NAS, 2011). 4) Recommendations and reporting to the decision makers is the important crux of the HIA adopted by a decision maker (p. 8). R ecommendations should be action based ( Scott Samuel 1998) and written as clearly and concisely as possible in the report. This level of detail can also better assist with the evaluation process later. 5) Evaluating and monitoring the process and outcomes to identify whether the HIA brought about change and improvements in health status. E valuation s or monitoring, however are rarely completed. Of those evaluations completed, there is a marked difference in the attention given to the prediction of health impa cts and far less on whether the predictions resulted in modification of the policy, program or project and even less on whether they were actually accurate (Parry & Stevens, 2001; Kemm, 2006; Cole et al. 2005). While the five steps for conducting HIA s a re consistently documented, who conducts them, how they are conducted, and most importantly, how they are interpreted, are details that remain unclear. As a result, it is possible for HIAs to draw conclusions that may not be consistent with what happens wi thin a particular community (Dannenberg et al., 2006). As the use of HIA grows in the United States, a concern is that the screening step can be cumbersome, overwhelming and unrealistic if applied to all potential decisions. For example, in the Netherland s, all proposals are scanned for whether there is a need for an HIA before going to

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42 Parliament. This means approximately 400 projects were submitted for evaluation each day. As a way to narrow the screening process, some practitioners and researchers belie ve that it is necessary t o focus on the big, expensive projects that have more obvious and immediate effects on health (Parry & Stevens, 2001). However, smaller communities and projects that could have similar or worse health impacts on affected population s should not be ignored. Without clear mandates, better screening criteria, and procedural rules for HIA, the selective approach to conducting an HIA may preclude HIA where it would have value. Although screening is considered an essential step in the HIA process, there is little published research or evaluation findings on the implementation of the screening step and little information on those cases where HIA was considered and not conducted based on screening (NAS, 201 1 ). Screening does become extremely important as HiAP and HIA become more common in the U.S. Suggestions have been made for the selecting and ranking of projects on the basis of the likelihood of addressing the Healthy People 2020 objectives or the potential improvements to reducing health i nequalities. While the above steps suggest a chronological order, HIA and decision and policy making are not usually an orderly, linear process. In reality, a short term rapid decision turnaround is necessary at times for an HIA, and health and planning o fficials must accept that it may be impossible to follow a model step by step approach although it can result in a lack of credibility. As far as timescale and range in scope, Parry and Stevens (2001) adds a mini version and suggests the regular use of a m ini rapid HIA process instead of the standard (intermediate) option. A mini rapid HIA use s existing information and measure few variables with little quantification for a much smaller exercise than the standard HIA (Parry & Scully 2003). Local organizatio ns might save time and money and have a more realistic expectation by adopting the mini rapid HIA approach. This approach may not include a robust assessment of future health impacts but might embrace a mechanism to get agencies involved in cross sector co llaboration, bring awareness to equity and health issues, create a tool to undertake community engagement, and develop a

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43 process and framework for evaluation. Parry and Stevens (2001) believe that the standard (intermediate) HIA should be abandoned. Parry and others believe that a full, in depth HIA should be undertaken only in a rigorous and effective way and that there must be evaluation after adoption and/or implementation of the project. As more data become available and with improved evaluation, method s, and evidence based data, as well as better trained health assessors, then more intermediate level HIA can be considered. Another complicating factor in the effective use of HIA is that most local health agencies and professionals usually take the lead in HIA work (Forsyth et al., 2010), and agencies have only a few staff members to conduct reviews of development plans with limited access to peer reviewed journals or epidemiologists for evidence based data and other resources and support. Harris et al. ( 2012) also highlighted that an important contingent factor is the organizational capacity of public health ; and environmental and social scientists and planners by themselves cannot substitute for public health specialists (Birley, 2003). These organizatio nal issues can limit The time and effort needed to undertake systematic reviews and measurement, and to synthesize more evidence relevant to complete an HIA can be extensive (Harris et al., 2012; Forsyth et al., 2010), can be expe nsive (Parry & Stevens, 2001; Krieger et al., 2003; Forsyth et al., 2010), and needs to be cost effective to be successful (Birley, 2003). Part of the problem is that time is needed to complete all the steps, gather feedback, then report the results of an HIA in an appealing, specific, and relevant manner before the final decisions are made. Along with these challenges it is also hard when considering nebulous concepts like addressing intersector collaboration (Forsyth et al., 2010).

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44 Proximal Health Impact s Effective conduct of HIA requires careful consideration of the probable time lag between when a given policy or project may be adopted or implemented and how it translates into health outcomes (Krieger et al. 2003). As with health studies, HIAs have a l ong latency of health effects, difficulty of controlling for confounders, and a changing composition of the affected population over a long time period. Complexities of conceptualizing and measuring health determinants and outcomes at multiple levels in re lation to multiple pathways can be highly challenging, if even possible. Measurement of change also requires adequate baseline data and continual monitoring of the health profile of the population(s) at risk over a sufficient time period in order to assess the actual impacts on population health, particularly among vulnerable subgroups (Krieger et al. 2003). All of these proximal health impacts make health outcomes very challenging to study although they are extremely important and necessary in the assessm ent of HIA outcome effectiveness (Wismar et al. 200 7 ; Kemm & Parry, 2004). Evidence Based Data I t is generally acknowledged that there can be serious gaps in the data required to carry out a rigorous HIA. The lack of rigorous and complete data is a seriou s limitation of HIAs. Predictions of the health impacts of any intervention depend on a synthesis of all available evidence of the likely effects on the affected population ( Joffe & M indell 2002; Parry & Stevens, 2001; Lock, 2000). A challenge for practit ioners is the quality and availability of evidence on which to base the predictions (NAS, 201 1 ) particularly at the local level. The quality of the evidence based data currently available for HIAs may limit the soundness and completeness of the conclusions and recommendations. identification and incorporation of relevant evidence, its appraisal for methodological soundness

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45 and relevance, and its incorporation with qualitative evidence is likely to be difficult, b ut crucial to the validity of health impact assessments (p. 6). Joffe and Mindell (2002) states that HIA work has concentrated more on process and less on the rigor of the evidence based data. Second, an explicit description of the search strategies and q uality assessment criteria used to identify the evidence cited in published HIAs is often absent. This could suggest that many HIAs have not been informed by a systematic review of the evidence. Such potential incomplete and flawed reviews that are not bas ed on evidence based result in biased and inaccurate health effect predictions (Parry & Stevens, 2001; Lock, 2000). Conversely, HIA might be an impediment to action if there is too much of an emphasis on only using evidence based data or policy that could end up precluding important community health input and data (Parry & Stevens, 2001). Although data from the community can be less rigorous, it is very beneficial to the success of the HIA. Additionally, HIA should not exclude less quantifiable determinants ; e.g., how much outdoor greenery improves mental health. Quantitative analysis can be replaced and/or qualitative evidence is preferable to unsound quantificat & Mindell 2002 :136 ). Lastly, it is essential to be proactive in specifying what types of data are needed, and then evaluate the adequacy and quality of what data are available rather than to adopt the more out literature (Joffe & Mindell 2002 :133 ). Also, it is important to be explicit about assumptions and uncertainties and to identify missing or incomplete information. Managing uncertainty of the evidence is an important component to securing a valid HIA and can include planning how the analysis will address uncertainties and establishing procedures to characterize or reduce key uncertainties (NAS, 201 1 ). There is still considerable uncertainty about how or when HIAs should be employed and what t hey should say in the end ( Forsyth et al. 2010 ). Where information is available there can still be no consensus. At the policy level, the precautionary principle many be appropriate. In the longer term, well

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46 targeted research is necessary to generate the necessary data (Joffe & Mindell 2002). Thankfully, as more systematic HIAs are completed more evidence based data will be available for many researchers, disciplines, and the community to use (NAS, 2011). Methodology/Methods Good methodology results in methods appropriate to what is being studied. Robust methods can ensure that results are more accurate and unbiased. It is challenging to prescribe one ideal method for appraising the broad range of health relevant decisions and public policy, so methods a re likely to be required using both a qualitative and quantitative approach for HIA ( Scott Samuel whatever will have the most weight in influencing the decision making proc (p. 1397). Many studies and evaluations are not in the form of the preferred, randomized controlled trials but could include quasi experimental designs, cohort studies, case studies, and qualitative ing field. Predictably, the methods for synthesizing robust evidence from the above sources are complex and still developing (Lock, 2000). Parry and Stevens (2001) state that techniques and existing quantitative epidemiological techniques such as cluster r andomization (groups, such as whole communities are randomized instead of individuals) should be also considered and potentially incorporated as methods for HIA. Community based participatory action research was briefly described by Krieger et al. (2003) a s a useful methodology and approach for future HIA research. Cost benefit analysis was also highlighted in the NAS (2011) report as a useful tool and has been used in one study that determined that the benefits outweigh the cost of conducting an HIA (A t kin son & Cooke, 2005).

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47 Relying exclusively on quantitative estimation can present drawbacks such as high information requirements with commonly sparse data available and variability in practitioner capacity. Additionally, quantification can be much more res ource intensive and may require more time than is allowed to influence a decision. Quantitative estimates can also create an unwarranted impression of objectivity and precision, even if assumptions and measures used in the analysis were based on subjective choices (NAS, 2011). Given the limitations and lack of agreement of some of the methods proposed for and adopted by HIA (Lock, 2000), there is the potential to come to incorrect impact estimates in terms of magnitude and direction (Cashmore et al., 201 0; Parry & Scully, 2003; Lock, 2000). Although intuitively appealing and simple concept :1181 ), there is a gap between the objectives of HIA (making predictions about future health impacts in order to change decision and p olicy actions) and the methods currently adopted by practitioners (Parry & Stevens, 2001; Lock, 2000). There are many methodological problems to overcome such as how to measure and predict health impacts and balancing to be done between resource costs and the depth of analysis (Lock, 2000). There is also a trade off to consider between importance and measurement. Some unimportant factors are easier and/or can be measured while some important factors are not. Without good protocols for measurement, the quest ion remains as to how such issues should be included in an HIA if at all (Forsyth et al., 2010). When attempting to develop generalizable work, it is best to prioritize certain policy or project areas that are more tractable until the methodology is better developed. More suitable assessment areas to pursue include transport, housing, and nutrition because of more reliable data (Joffe & Mindell 2002). Measures of mortality, morbidity, and use of health services, although routinely available, are usually insensitive to short term and small effects. Other measurement challenges include that many spatial units such as at the state or county wide level may be too large to be relevant at the

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48 community level. Or the frequency of collection may be too infreque nt, such as census data being collected every 10 years, to permit analysis of relatively small changes. Additionally, factors that the community may identify as important determinants of health, such as discarded syringes or graffiti, are generally difficu lt to quantify (Parry & Stevens, 2001). Although inductive activities occur, HIA is usually a deductive activity using general theory to make statements about specific situations. Results may be extrapolated to similar communities in other situations, bu t g eneralizability is neither a strength nor the main focus of HIA. This lack of generalizability can slow the ability to spread HIA effectiveness across to other communities and gain the ability to better understand the applicability and effectiveness of uses (Cole et al., 2005). Intersector Collaboration/Education A cross sector collaborative approach also referred to by Mannheimer et al. (2007) as intersectoral action for health is needed to support the development of HIA and is also another benefit of conducting HIAs. Depending on the policy, program or project being evaluated, this type of approach should include professionals from public health, building and landscape architecture, urban and transportation planning, energy, real estate, social servic es and other sectors. It is also important to ensure that steering committee members or other types of stakeholder groups include staff from multiple agencies, community organizers, and community residents. As literature supports, a blending of the respons ibilities, tools, and perspectives of multiple sectors and the community can result in better outcomes than when any discipline or sector does it alone (Kochtitzky et al., 2006). Unfortunately, as Bekker et al. (2004) state, the value of HIA is to support cross sector decision making, yet much of the literature on cross sector collaboration is less than encouraging as far as its success. Many partnerships (also

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49 referred to as collaboratives) are not successful and that up to half of them do not survive the first year because of many challenges and barriers (Lasker et al., 2001). Currently there are siloed government structures with different ways of developing and implementing decisions and policies that create an environment less conducive to cross sector c ollaboration. Collaboration depends on a number of factors to ensure its success. There are characteristics that can support cross sector collaboration success such as enhanced leadership, communication, resources, and processes (Bryson et al., 2006). If an HIA is conducted without interdisciplinary expertise, this can produce only a partial assessment of the potential health impacts and potential unknowns for decision makers (Krieger et al. 200 3 ). Participation of multiple public agencies such as planni ng and transportation professionals not only will contribute expertise but may ensure that the process addresses questions pertinent to the decision at hand and potentially increases the likelihood that the recommendations are adopted (NAS, 2011). For ac ademics and practitioners to improve education and awareness about health and cross sector collaboration, there is a need for more courses to be taught whether as a workshop or at the college level on the connection between public health, land use and desi gn, and on HIA that supports interdisciplinary learning. Educators need to incorporate joint programs for students between schools of public health, planning and other departments or offer a similar concentration or certificate. Model curriculums have been developed (Botchwey et al., 2009). Additionally, practitioners in all disciplines already deal with overwhelming workloads and collaboration is time intensive, and accounting for health is an additional burden that is difficult for planners and others to prioritize among the many other issues they need to address (Forsyth et al., 2010). Lastly, health promotion and educat ion of decision makers and those involved in the HIA is important to HIA success; c onversely, a lack of health awareness by other sect ors is a barrier to success. More education and training is needed to promote health, and the policy process specifically for those conducting HIAs (Davenport et al., 2006).

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50 Community/Stakeholder Engagement Harris et al. (2012) describe the community as th e point where the effects of the policy and other decisions are felt. HIA was singled out as enabling communities to have a democratic voice within policy processes, but practitioners and decision makers need a clear understanding of the realistic expectat ions of what HIA can and cannot deliver. Engaging with the community is a critical tenet of HIA and its effectiveness, but doing so can be very challenging (NAS, 2011; Dannenberg et al., 2011), particularly among vulnerable and disenfranchised populations (Forsyth et al., 2010; Dannenberg et al., 2011). Historically, community involvement in community level projects and developments generally has been poorly executed. There are challenges such as effectively reaching and getting meaningful community input, and getting agency support to seriously consider the communities input. Whether practitioners enable stakeholders to participate in HIA and to what degree varies widely (NAS, 2011; Mindell et al., 2004). Specifically, research and education is needed to fo ster more meaningful and effective engagement with consistent opportunities for input and the ability for community members to influence outcomes in the context of HIAs. New tested engagement tools, methods, activities, and techniques, are needed to suit d ifferent communities at different HIA phases, especially scoping, assessment, and recommendations (Dannenberg et al., 2011). Improvements through research and to the practice can inform and support more authentic, meaningful, sustainable, and equitable com munity engagement that better supports democratic HIAs. For example, how to best choose various techniques and mechanisms and increase the rates for community engagement (Forsyth et al., 2010) in different communities at the different phases is challenging but necessary. The multiple engagement techniques employed depend upon the purpose, timeframe, resources, and goals (Dannenberg et al., 2011), but more research is needed on the specifics of how to be more effective at engaging all portions of the populat ions. Community engagement can be contentious,

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51 time consuming and resource intensive, but when done well it can reinforce and support HIA processes and outcomes. There is the simple but critical matter of conducting the community engagement in a manner tha t is balanced, transparent and reliable. Additionally, social scientists have provided a wealth of experience in the techniques of sampling, interviewing (individual and group level), and analyzing qualitative data. However, HIAs tend not to report missing to Were the interviews or focus groups recorded and their findings transcribed? Accordin g to Dannenberg et al. (20 11 ), people conducting HIAs need many skills such a s cultural sensitivity, accountable listening, and respect for a community driven p rocess and should ensure that community participants understand the objectives o f the process and their roles. An HIA that does not utilize community participation because n o current standard exists to require it may draw inappropriate conclusions and potentially make poor decisions In contrast, another potential problem with community engagement is the inherent challenge of relying mostly on the opinions of community stake holders, which can be in conflict with the evidence based data. This difference is a growing point of tension between HIAs centered on evidence based quantitative data and a community centered process mainly focused on qualitative data, relative to the eff ectiveness of the HIA. It is important to provide opportunities for the education and exchange of information so that residents more fully understand the issues and can participate meaningfully in the process. Additionally, when HIA includes community invo lvement, it becomes an intervention in its own right. The mere acknowledgment that a HIA is needed may change the community's perception of the risk of the intervention in an unpredictable manner. Thus the very process of undertaking an HIA may have an imp act (positive or negative) on community health (Cashmore et al., 2010). The HIA may not have been influential in changing a policy in a given situation but will have had some impact in its own right possibly with something less tangible such as raising hea lth awareness (Davenport et al., 2006).

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52 Equity/Disadvantaged Communities/Groups Equity is another core value of HIA because project program and policy decisions can impact disproportionately and the burden of disease and its economic costs and consequen ces rest more heavily on those already disadvantaged ( Scott Samuel 1998; Metcafe & Higgins, 2009). The determinants of inequalities lie in many different sectors. Most, if not all, published HIAs have not considered the effects of public policies on healt h inequalities in a robust, reliable or meaningful manner (Parry & Scully, 2003). More broadly, there are issues of how to reach more vulnerable, disadvantaged groups. How can equity issues best be addressed through the use of HIA? Additionally, how can HI A practitioners participate, address and adequately report equity and bring more attention to these issues (Forsyth et al., 2010). Different models of HIA exist and most encompass the consideration of health inequalities (Hebert et al., 2012) but lack c onsistency in approaches (Parry & Scully, 2003). The health assessor(s) must consider whether the policy intervention will change the distribution of any of the determinants across a range of population sub groups. As mentioned, there is a paucity of speci fic evidence to predict health impacts from changes in many of the determinants of health, particularly among the sub groups within a community. The evaluation becomes difficult, if not impossible, when target groups are not defined. Explicit consideration of the effects of an intervention stratified by sex, age, ethnicity and socio economic status relative to the whole population is necessary. The criteria for the inclusion and exclusion of other relevant sub groups must be determined by clearly stated and transparent criteria. One particular asset that is less tangible is if HIAs are able to keep the issue of equity at the forefront of decision (Parry & Scully 2003) throughout the process. An international study was conducted by Povall et al. (2013) to clarify if existing HIA methods are adequate for the task of global health equity assessments. There was a review of the

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53 international literature, and in depth interviews were conducted with health equity and HIA experts. The study determined that equity is not addressed adequately for a variety of reasons, including inadequate guidance, absence of definitions, poor data and evidence, perceived lack of methods and tools, and practitioner unwillingness or inability to address values like fairne ss and methodology (Povall et al., 2013:1). HIA Quality There is an urgent need to improve the quality of HIA (Forsyth et al., 2010) since a poor quality assessmen t is unlikely to be influential (Birley, 2003) or yield accurate predictions There is inconsistency in the structure and content of the final work products of an HIA. In the U.S., little evaluation has been conducted about the quality of the various compl eted HIAs. Completing more systematic evaluations during the process and after completing the HIAs will help improve quality. There are many limitations associated with the assessment of the quality of the HIA and a number of researchers argue for the est ablishing standards that include requiring evidence and certain rates of participation (Bekker, 2007; Forsyth et al., 2010; Mindell et al., 2004). The North American HIA Minimum Elements and Practice Standards (2009, 2010) were developed in and for the Uni ted States by the North American HIA Practice Standards Working Group. Broadly, the Standards are designed to advance HIA quality and provide guidance and consistency. The North American Standards are the most likely option, although there is not enough a cceptance or agreement for their use (NAS, 2011). With regular revisions these Standards can be more useful in the future. One challenge is that strict adherence to the Standards can yield an HIA cumbersome and lengthy, while the community and other stakeh olders need a document that is

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54 short, concise, and understandable. Additionally, the Standards are challenging to measure HIA objectively because the components of the Standards could be interpreted differently by various users and evaluators, potentially resulting in alternative outcomes. Also, as minimum standards, some seem unrealistic: For example, the 2010 version describes the need for an HIA management plan to be established or having money available early in the process for subsequent evaluation. Im that the Standards are more precise to improve objectivity, along with complementary guidance Only one guide for HIA practice was located that was produced in the U.S. called, Health Impact Assessment: A Guide for Practice (Bhatia, 2011). Integrating HIA into Environmental Impact Assessment Impact assessment is a concept that first gained prominence in the environmental field. Environmental Impact Assessment (EIA ) is a mainstream and statutory function in many nations and multinational institutions. EIA is a regulatory process that focuses on environmental outcomes such as air and water quality (Forsyth et al., 2010). The National Environmental Policy Act (NEPA) requires an EIA for federally funded projects such as roadways and buildings, plans for federal lands, and federal programs and policies (Forsyth et al., 2010). Although many practitioners and academics believe there is an explicit focus on health require d (NAS, 2011) others believe it is indirectly addressed in the NEPA statute (Forsyth et al., 2010). Not surprisingly, a comprehensive and systematic approach to human health impacts in EIA practice has not evolved and does not adequately consider health imp acts of projects and policies (Bhatia & Wenham 2008; Collins & Koplan 2009). In the United States, the evolution of the HIA followed long after the 1969 legislation of the EIA. However, California and Alaska have demonstrated that a wide range of health effects can be

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55 successfully integrated into an EIA process (Collins & Koplan, 2009). HIA can be supported through integration into other impact assessments, but it also runs the risk of being subsumed and weakened Although integration does represent a mor e permanent position for HIA in the decision making process, it also potentially dilutes HIAs to a reduced exercise that may not consider the vital areas of health (Metcalfe & Higgins 2009; Birley, 2003). Additionally, the EIA is regulatory and its proces s is very lengthy and costly so not necessarily the most suitable placement for HIA particularly since there is only interest in HIA being voluntary (NAS, 2011; Metcalfe & Higgins 2009). A broad approach of integrating the many different types of assessm ents is a way to avoid a large number of single issue, piecemeal assessments that can have a wide degree of overlap. Ultimately, a single assessment that presents a unified compilation of the different potential impacts and recommendations would be helpful Additionally, if HIAs were to be integrated into existing EIA processes, there is a concern that some of the health measures used in HIA would not be able to withstand the potential scrutiny and legal challenges that can often follow environmental review s (Forsyth et al., 2010; Lock, 2000; Dannenberg et al., 2006). Still the NAS (2011) report concludes that improving the integration of health into EIA practice under NEPA would advance the goal of improving public health. Institutionalization of HIAs Insti tutionalization is an important component of the consistent use and acceptability of HIA worldwide. According to Elliott and Francis ( 2005 ) institutionalizing HIA would mean embedding it as a routine part of decision making. Many countries have institution alized HIA to different degrees, such as Canada (Quebec), Netherlands, Australia, Finland, Lithuania, Thailand and the US. The degree of institutionalization varies widely within and across countries.

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56 Throughout Europe, HIA is a key component for measuring policy impacts on health determinants and fulfilling European Union treaty obligations. There has been an increase in the calls for HIA use by groups such as the World Health Organization, the International Finance Corporation and the United Kingdom Natio nal Health Service (Lee et al., 2013). For the institutionalization of HIA to be possible it is recognized that there is a need for cross sector collaboration, increasing international and national movements towards the use of HIA, support from the health sector, and advancement of HIA at the local level. To date, key factors that have enabled the institutionalization of HIA have been legislation such as the inclusion of HIA within public health acts; political will; involvement by the research community a nd creation of research centers; awareness of the inadequacy of Environmental Impact Assessment (EIA) or other assessments in considering health; capacity and resources; and availability of international committal documents (Lee et al., 2013). Some of the challenges to institutionalization and systematic implementation of HIA include narrow definitions of health, lack of awareness of relevance to other sectors, and insufficient funding and tools. Therefore, some of the recommendations for the institutional ization of HIA include: embed HIA in national systems, clarify the definition and operationalization of HIA, strengthen and build capacity for HIA practice, improve cooperation between sectors, and develop guidelines and methodological criteria (Lee et al. 2013) such as the US Practice Standards for HIA; in fact, a stated purpose for the development of these standards Standards Working Group, 2010:1). In the US, t here have been positive steps towards institutionalization. Some cities such as Boston and Baltimore have incorporated Health in All Policies (HiAP) as a framework that includes conducting HIAs; in Denver, political drivers have asked for public health con siderations to be included in the request for proposals for planning

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57 projects. Many of the challenges to institutionalization in the U.S. that still need to be resolved require more research, as well as education about the value and significance of HIAs. L ack of Research The need for more research has been established repeatedly throughout this literature review. Evaluation should first include a review of the draft version of the HIA by the stakeholders and agencies involved and should consider whether th e evidence was collected and used appropriately. An HIA should be also judged whether it met its goals and overall purpose. Lastly, HIAs need to be monitored and evaluated as far as what outcomes were adopted or implemented and changes to health outcomes ( NAS, 2011). Much of the research on HIAs has been conducted outside of the U.S., including the Netherlands (Putters, 2005; Bekker, 2007), Wales (Elliott and Francis, 2005), Slovenia (Lock, 200 0 ), Slovakia (Manheimer, 2007), United Kingdom (Davenport et al. 2006; Birley, 2003; Parry & Kemm, 2005; Scott Samuel 1998), Australia (Harris Roxas & Harris, 2012), across Europe (Wismar et al. 2007) in New Zealand research has b een conducted in a U.S. context. Currently, there are four known, large and mainly qualitative evaluation studies that are ongoing, three in the U.S and one in Australia and New Zealand. Results from these studies will be forthcoming in late 2014. Little research has been conducted and published in the U.S. but examples of published articles in the U.S. are listed below. Even internationally, up to 201 4, only five formal evaluations of the impacts of HIA on decision making and implementation were completed (Harris Roxas & Harris, 2012, 2014). One evaluation briefly described earlier was conducted by Dannenberg et al. (2008) who examined 27 publicly accessible HIAs completed between 1999 and 2007. Hebert et al. (2012) provides a comparison of HIA guidelines and

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58 guidance from around the world. Rajiv Bhatia has four published articles with different peers on HIA: Lessons from San Francisco: Health impact assessments have advanced political conditions for improving population health (2011), Quantitative estimati on in Health Impact Assessment: Opportunities and Challenges (2011), Integrating Human Health into Environmental Impact Assessment (2008), and Health Impact Assessment in San Francisco: Incorporating the Social Determinants of Health into Environmental Pla nning (2007). Cole et al. (2005) wrote, A comprehensive review of the state of the art of HIA methodologies Cole and Fielding (2007) published, Health impact assessment: A tool to help policy makers understand health beyond health care. Forsyth et al. (2 010) wrote, Health Impact Assessment (HIA) for Planners: What Tools Are Useful? Interestingly, the available HIA research has not concluded with negative statements about the process, outcomes, or lack of effectiveness. The studies conducted by many resea rchers such as Metcalfe and Higgins (2009), Davenport et al. (2006); Mannheimer et al. (2007), Mathias and Harris Roxas, (2009), and Wismar et al. (2007) demonstrate that HIAs can have positive results. For example, sometimes the HIA recommendations are ig nored, but some are adopted to different degrees into projects, programs or policies. Yet it is still hard to clearly state whether similar recommendations would have already been adopted without the HIA. The NAS authors concur that in order to target HIA application more efficiently and effectively, there needs to be a better understanding of whether HIA is better suited to address certain characteristics such as equity, particular sectors, or specific health outcomes. NAS authors also state that restricti ng the spectrum of HIA practice to particular de cisions is unwarranted because there is no evidence that HIA is more important, appropriate, or effective in a ny particular decision context. Restricting or concentrating HIA practice is unwarranted but only because very little evaluation has been completed to demonstrate the contrary. This notion of restricting or not restricting HIA use is also challenging because to improve the quality and effectiveness for long term use and success, we

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59 must better understa nd where HIA strengths and weaknesses are and use HIAs when and where they can be the most effective. For example, it could be determined that HIA works more effectively with plans and projects and far less on policies. Understanding these differences is n eeded in order to then determine the appropriate changes for long term HIA effectiveness. Concluding Remarks Even with the identified challenges there is a reason why the use of HIA continues to in what ways from the process, adoption and implementation of HIA remains largely unknown but the evidence is encouraging. This reassurance is due to the growth in its use and the direct and indirect positive results in relation to influencing decision an d policy making even if in limited ways. HIA success is more likely when it is properly funded, designed and executed, follows more rigorous public health and other sectors research literature, and decision makers are prompted to ask more sophisticated que stions about the content, process, and outcomes of their plans and policies. The paradox for gaining success and completing HIAs is that its success may demand compromise around core values such as impartiality with decision makers. What is also clear is t hat a balance must be struck between the depth of analysis, resource costs, and predicting healthy impacts. Numerous limitations and challenges that have been identified in this paper also stem from historical issues or the unknowns about methods, new tool s, intersectoral decision making, and new application of a progressive approach such as HIA Also, it is not clear how reliable or generalizable HIAs are due to the complex, interconnected, and locally place based nature of HIAs that cannot be easily trans ferred or replicated elsewhere. These issues and challenges are not unique to HIA but is a broader struggle in many fields, and less about HIA demonstrating to be ineffective.

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60 HIAs will require considerable effort and careful attention to process and iden tified pitfalls while keeping expectations in check. There will always be uncertainty and assumptions with all types of HIAs that must be made explicit to ensure credibility and an acceptable level of expectation about what HIA can and cannot do. It will a lso require reckoning with the inevitable political nature, limited evidence, organizational issues, lack of clear theoretical frameworks, power and neutrality issues, methodology and methods doubts, impact assessment, and other uncertainties inherent with in HIA. These uncertainties prompt questions about HIA credibility, usefulness and effectiveness. With improvements to the scientific quality of HIA, and ultimately as HIAs become more effective at influencing policies, programs and projects, more equitab le and health focused decision making and outcomes will prevail. Other improvements are through establishing a peer and stakeholder review process, enhancements to and consistent use of the Guide for Practice, and the Standards, and sustainable funding wil l support more acceptability and credibility of the HIA process and its outcomes. As determined repeatedly throughout this paper, more research in terms of process, impacts and outcomes is needed. Research that is articulated and intentionally shared with practitioners is one of the most important focus areas necessary for potential success. The goal is that HIA identifies the health impacts and supportive data, is scientifically feasible, has inclusive community engagement, focuses on equity, and the poli tical will allows the analysis and recommendations to have a real influence on the outcome. This type of success will minimally require engaged and continuous dialogue, debate and evaluation, among and between researchers, practitioners, affected populatio ns, decision and policy makers, about the utility, limitations, expectations, and practice of HIA.

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61 CHAPTER IV A REVIEW OF CROSS SECTOR COLL A BORATION Chapter Outline This chapter answers important questions about cross sector collaboration, what it is, its impedime nts and intrinsic value, its determinants of success, and future research needs. This chapter includes the definitions of collaboration, and describes the historical context and the challenges of cross sector collaboration as well as benefits, importance, and potential value it can add to society Lastly, the influences and successful factors to cross sector collaboration are described: history of collaboration; p rocesses and s tructures; communication characteristics; l eadership characteristics; resources; and evaluation. Introduction Cross sector collaboration is increasingly assumed to be an essential strategy for al., 2006; Powell & Sable 2001; G reenwald, 2008), particularly since top down and single sector strategies have failed (Lasker et al., 2001; Bryson et al., 2006). In the past 25 years, collaborative activities have become more prominent and extensive across sectors in many nations (Selsky & Parker, 2005) with collaboration considered a growing organizational imperative (Austin, 2000). Some believe that cross sector collaboration ought to be about the production of public value (Moore, 1995; Donahue, 2004), which cannot be created by single sectors alone (Klein, 1990; Bryson et al., 2006). It is difficult to imagine successfully addressing global and domestic problems, such as the influenza pandemic or food poisoning outbreaks, homelessness, urban

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62 sustainability, emergency response, or AIDS, without some level of cross sector understanding, agreement, and collaboration (Robertson et al. 2003; Bryson et al., 2006). 86), and there is understandably wide appeal in this cross sector concept. Interdisciplinary activities are rooted in the ideas of unification and synthesis (Klein, 1990; Mariano, 1989), integration (Mariano, 1989; Weiss et al., 2002), interdependence (Wei ss et al., 2002), epistemological pluralism (Miller et al., 2008), and convergence (Klein, 1990). Educators, researchers, and practitioners have turned to interdisciplinary work in order to accomplish a range of objectives that include the following: answe r complex questions in practice or academia; explore disciplinary, academic, and professional relationships; solve problems that are beyond the scope of any one discipline; and achieve unity of knowledge that can come from bridging gaps between disciplines (Mariano, 1989; Klein, 1990; Petts et al., 2008). Although in research and practice there is confusion with the wide variability in the definition, epistemology, and discourse of collaboration, the lack of research and models (Klein, 1990; Bronstein, 200 3 ), and many partnerships have found it hard and have difficulty realizing the full potential of collaboration (Petts et al., 2008; Weiss et al., 2002; Greenwald, 2008). Cross sector collaboration is also referred to as i nterdisciplinary and intersector, a s the concepts are similarly used in the literature and in this paper. Broadly, cross sector collaboration can mean teams or partnerships from government, businesses, nonprofit organizations, academia, communities, and/or the public as a whole. For purpose s of this literature review, the focus of collaboration is within government, business, nonprofit sectors, and professional and academic disciplines but does not generally include community. A separate literature review is needed for collaborating with the public. In this literature review, I articulate some building blocks for a theoretical framework of collaboration and successful characteristics and factors that support more successful collaboration

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63 efforts. This literature review is organized into sever al key sections to provide insight into cross sector collaboration: definitions; historic context; work teams; impediments and challenges; benefits, importance and value; effects and outcomes; and a framework integrating what influences collaboration posit ively; and future research needs. Although the literature is relatively consistent and many rigorous studies exist, the quality of the collaboration studies are inconsistent (Butterfoss et al., 1993). Whether described as partnerships, coalitions, teams, o r other types of collaboratives, this literature review is an attempt to systematically review this seemingly essential and worthwhile yet generally disappointing endeavor. This literature review draws mainly from organizational theory and how potentially organizations (defined broadly) progress to be more integrated. Organizational theory suggests that different organizational efforts and strategies are important at different points in the life span of organizations (Butterfoss et al., 1993) Organizationa l theory also informs us that under normal conditions organizations maintain boundaries to protect their own turf and operations. Boundaries within organizations, typically limit collaboration (Greenwald, 2008); boundary maintenance is described in detail in a later section. Initially, it was the hope to apply innovation theory and identify strategies for different stages of the progression of a collaboration and what strategies are needed at different points in the development of the collaborative. However the literature related to collaboration provides little guidance in distinguishing what factors facilitate improved functioning at certain points in its progression. Definitions of Collaboration Broadly, collaboration allows for more information to be s hared on a particular topic, providing different perspectives and deeper understanding of the situation, and more integration of ideas that allows for a more accurate assessment (Mills, 1996). Cross sector collaboration is

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64 the linking or sharing of informa tion, resources, activities, and capabilities by two or more sectors interacting together; and to achieve an outcome with a common goal with different perspectives that could not be reached by individual sectors al one (Bryson et al., 2006; Weiss 1997; Bro nstein, 2003; Bruner, 1991; Parker Oliver et al., 2005; Greenwald, 2008). Another useful skills from across disciplines to answer a complex problem and to bui 2009:105). Compared to cross sector collaboration, interdisciplinary is more ubiquitously used, and is defined more in a research context. Success is often determined by progress toward achieving the goals of the collaboration al ong with the mission and objectives (Wandersman et al. 199 7 ), effective team functioning, and achieving benefits for the individual members involved in the collaboration (Amabile et al., 2001). The three forms of collaboration that are mentioned most ofte n in the literature are multidisciplinary, interdisciplinary (cross sector, intersectoral), and transdisciplinary (Collin, 2009; Ray, 1998; Petts et al., 2008). Collaboration can occur between individuals of the same profession (mono disciplinary) or from different professions (multidisciplinary), who mainly work in isolation from each other (Collin, 2009; Ray, 1998) and maintain clear boundaries and identities (Petts et al., 2008). However, when individuals from different professions work together in an in tegrated manner (Ray, 1998) for the benefit of a client or a common goal, interdisciplinary or cross sector collaboration, can be achieved (Collin, 2009). The interdisciplinary level of collaboration is the approach that many desire, but it is hard to achi eve. Professionals spend far more of their time engaged in multidisciplinary functions than in true interdisciplinary functions (Ray, 1998), which requires a greater degree of integration (Miller et al., 2008). Transdisciplinary is a more intensive form of interdisciplinary, where roles in research are further blurred, go beyond the joined disciplines for newer perspectives (Tappeiner, 2007), which is even harder to achieve. Other words that have similar contemporary definitions within different sectors rel ated

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65 to cross sector collaboration are included in this literature review such as partnerships, collaboratives, inter organizational, teams, and coalitions (Weiss et al., 2002; Butterfoss et al., 1993; Parker Oliver et al. 2005). But there is a distinguis hing difference with other types of groups, such as networks or consortia (Butterfoss et al., 1993), which are not generally referenced in this paper. The level of confusion with definitions is real (Collin, 2009) and has three explanations: uncertainty ab out the meaning of the above terms, widespread unfamiliarity of collaboration scholarship, and lack of a unified body of discourse. Given the level of support and interest by funders, agencies, and organizations, it is surprising that little published rese arch has been completed, with little evidence that it works, with the research used by a relatively small group of people (Lasker et al., 2001; Klein, 1990). Interdisciplinary collaboration has been described as wide ranging from not having any real or lim ited demonstrable success (Weiss et al., 2002 ; Greenwald, 2008) to a new stage in the evolution of science (Klein, 1990). When defining collaboration, there is a need for understanding teams because of the inherent connection between collaboration and team s. There have been many types of collaboratives used in research and practice that range in complexity and definition (Hackman, 1987). However, a team i s typically defined as a group of two or more individuals wor king together for a common goal (Kane, 1980 ). Kane (1980) states that coordinated teamwork is characterized by distinct professional roles, designated team leadership, nonconsensual decision making and little emphasis on a group process (Rogerson & Strean 2006). Integrative teamwork, is characteri each other (Kane, 1980; Bronstein, 2003). Differences in team complexity and definitions might cause some inconsistency in what constitutes an effective team. Team effec tiveness has been defined as having continuous, ongoing monitoring and evaluations, a shared purpose, an understanding of resources, and efficient processes (Rogerson & Strean 2006). Interestingly,

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66 effective integrative teamwork is similarly defined as wh at has been identified as supporting successful cross sector collaboration that is discussed later. Petrick and Quinn, in Management Ethics (1997) provide a useful description of teamwork in which they distinguish among pseudo teams, potential teams, real teams, and high performance teams, which similarly coincide with distinguishing levels of collaboration. They committed to a common purpose, goals, and working appro ach for which they hold themselves (p. 229). Their definition of a high performance team is that it meets all the same requirements of a real team and those members are also genuinely committed to one another ccess (Ray, 1998). That level of commitment has similarities to transdisciplinary collaboration. It seems that cross sector falls somewhere in between a real team and a high performance team. Historical Context of Collaboration Although Georges Gusdorf (19 need for interdisciplinarity has been reflected in epistemological writings ever since the origins of Western science (p. 19) it is most 1990 :1 1 ). Most of the literature describes interdisciplinary collaboration as a phenomenon that can be rooted back with ideas from Plato, Aristotle, Kant, Hegel and other historical figures. Overspecialization within disciplines and fragmentation arose quite ear ly as an issue and was highlighted in their writings (Klein, 1990). Consequently, contemporary professional practitioners are still becoming increasingly specialized (Collin, 2009), however, Klein (1990) states that societal problems do not present themsel ves in disciplinary b oxes. Mariano (1989) quoted Koc kelmans (1979) who argued that inte rdisciplinarity is not really progress but instead a

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67 symptom of a pathological situation in which professionals have become too specialized for more than two hundred yea has led to the dangerous fragmentation of our entire epistemological domain (p. 286). Kockelman went as far as saying that b ecause of specialization, even human personality has been also affected by this lack of integration and interdependence A bal ance is needed between specialization and integration (Collin, 2009). On a more positive note, in contemporary times, the health care field is shown to be one of the early sectors engaged in collaborative efforts, followed by other disciplines, focused on the idea of interdisciplinary collaboration in the hope of improving services, population health and many other societal problems (Bryson et al., 2006; Bronstein, 200 3 ; Ray, 1998). Collaborative practice among professionals can be identified with Richard C abot, a well known physician in the early 1900s working for Massachusetts General Hospital, who proposed the idea of teamwork, suggesting that the social worker, doctor and educators work together on patient issues (Parker Oliver et al., 2005). The public health role and tradition evolved to support an open desire to work with other disciplines such as planners, sanitarians, and emergency responders Starting in the early 19 th ation and fire safety issues demonstrated the need for collaboration as a means to reduce tuberculosis, dependent on grant money from private and mainly public secto r sources and therefore eager to build ties with any sectors capable of expanding its economic and political base (Greenwald, of how and why the necessary shi ft occurred and continues to occur. Collaborative efforts are also in response to the very complex chronic health conditions and interventions that are rooted in the cultural, political and economic fabric (p. 315) that needs an effective collaborative approach (Butterfoss et al. 1993).

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68 For decades, research literature has reported collaborative efforts in many different fields of study such as education (Kaufman & Brooks, 1996; McKenzie, 1999; Mills, 1996), public health and health care (Lasker, et al., 2001; Abramson & Mizrahi, 1996; Mariano, 1989; Bronstein, 2003; Gardner, 1989; Robertson et al., 2003; Varda et al., 2008), social work (Bronstein, 2003), urban sustainability, planning, and geography (Petts et al., 2008; Evans & Marvin, 2 006; Innes & Booher, 1999), pharmacology (Ray, 1998), hospice care (Parker Oliver et al. 2005), business management (Amabile et al., 2001; Ring & Van De Ven, 1994), and public administration (Bryson et al., 2006; Simo & Bies, 2007). Interdisciplinary coll aboration seems to be firmly established in many disciplines (Collin, 2009). Many researchers contend that with challenging issues with multi organization of government and the public private di models are needed to exceed the divide. (Bekker, 2007 :12 ). Diverse participants whose heterogeneous traits, abilities, and attitudes can bring complementary strengths to the collaborative and may also have the gre atest potential for improving societal issues (Lasker et al., 2001). Imped iments and Challenges to Cross S ector Collaboration Many assume that collaboration is a panacea to solving complex problems, and it can be tremendously advantageous (Weiss et al., 20 02). But there are still challe nges and reasons to be cautious about the effectiveness and increasing r hetoric of interdisciplinarity (Evans, 2006). Many partnerships struggle to make the most of the collaborative process and accomplish their goals. Many p artnerships encounter huge obstacles and building effective partnerships is time consuming, resource intensive, and difficult (Weiss et al., 2002).

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69 Collaborative research, team teaching, new broader divisions of intellectual work, a blurring and mixing of disciplines: These all encompass ing interdisciplinary concepts defy definition yet evoke (Klein, 1990 :11 ). Still, uncertainty has persisted with little consensus on theory, methodology, or pedagogy (Klein, 1990 :12 ) leading to confusion in research, practice, discourse and curricula (Palmer et al., 2006; Miller et al., 2008). Successful collaborations are very difficult because it requires good working relationships, processes, and structures that are considerably di fferent from the way most people and organizations have been working (Lasker et al., 2001). There are commonly reported barriers and challenges identified in the collaboration literature. Vangen and Huxham (2005) as does Bryson et al. (2006) identify pow er imbalances and unequal benefits as barriers among collaborating partners that can lead to a source of mistrust and threatens effective collaboration. Other barriers are the varying levels of personal commitment among the members (Ray, 1998), usage of di ssimilar jargon and methodologies (Robertson et al., 2003), specializati on and fragmentation (Klein, 199 0; Mariano, 1989; Collin, 2009), role confusion and turf issues (Abramson et al., 1996), excessive time commitment (Lasker et al., 2001; McKenzie, 1999; Weiss et al., 2002), use of intensive resources (Lasker et al., 2001; Weiss et al., 2002), lack of administrative support (Weiss et al., 2002; Ray, 1998; Brown, 1995), fears of intrusion and the loss of control by members (McKenzie, 1999), differences in expectations regarding goals and objectives (Ray, 1998), prevalence of competition, organizational boundary issues, and internal team conflict (Greenwald, 2008; Gardner, 2005), expected benefits not outweighing the costs of engagement (Butterfoss et al., 1 993), professionalism of members which can include when roles are inappropriately blurred or allegiances for the team are too strong (Parker Oliver et al. 2005; Bronstein, 2003), and untrained members in interdisciplinary teamwork (Ray, 1998).

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70 From the le ngthy description of barriers above it is not surprising that many collaboratives are not successful and that up to half of them do not survive the first year, or are unsuccessful in the development of plans or the implementation of interventions. However, particularly those that are mandated to are only se emingly collaborative on paper Foundations and government agencies in the U.S. have invested hundreds of millions of dollars to promote collaboration particularly around health issues. Because of these i nitiatives, thousands of alliances, coalitions, and other health partnerships have been formed in hopes of meeting more health objectives and improving outcomes. Funding agencies have increasingly begun to require collaboration as a condition of funding su pport (Lasker et al., 2001). Although funders such as government and foundations have insisted on backing collaboration, not much research has been completed, and with little evidence that it works though intuitively many people assume this type of effort is effective (Lasker et al., 2001; Bryson et al., 2006). To better understand the challenges and to achieve meaningful collaboration, organizations or individuals residing in separate sectors must overcome challenges related to organizational boundary main tenance. Boundary maintenance is particularly instructive for understanding the ability of organizations to relate and collaborate with one another. Organizational theory informs us that under normal conditions organizations maintain boundaries to protect their own turf and operations. Boundaries within organizations, typically limit collaboration, but there are times that organizations accommodate the needs of the organization to participate in some collaborative effort. Although, even normal boundary main tenance inhibits the formation of the interdisciplinary collaboration. Examination of contemporary organizational theory helps explain the reluctance of many organizations to engage in interdisciplinary collaboration. The n atural tendency is toward boundar :3 ).

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71 In the present context, cross sector partnerships are meant to transcend divisions between the public, private, and non profit sectors. Within these sectors stable cooperati on among organizations can be the norm when historically they may have ignored or competed against one other. Interdisciplinary pa rtnerships go beyond the strategic alliances, and joint ventures familiar in the business world (Rogerson & Strean 2006). The cross sector collaboration is intended to include a commitment of resources, sharing of decision making, and commitment to goals and objectives beyond those that benefit any individual participant (Greenwald, 2008). Abramson (1996) argues that the literat ure is more likely to emphasize the negative aspects of collaboration rather than the positive. This emphasis is because at the core of interdisciplinarity is integrated and cooperative actions of sharing of work, resources, and ideas, and the necessary co mpromises that ironically can be evaluated negatively by others. For example, in research the advantages of interdisciplinarity are rarely properly acknowledged and publications resulting from this type of work are surprisingly less likely to be accepted t han those deriving from a single discipline (Petts et al., 2008; Tappeiner et al. 2007); this is even with the encouraging and compelling appeal of this interdisciplinary research concept. Additionally, in contracts the advantages of interdisciplinary res earch are rarely properly acknowledged (Tappeiner et al. 2007). There are, however, a few interdisciplinary institutions such as Rockefeller University in i nterdisciplinary research (Robertson et al., 2003). Despite high expectations expressed by funders and sponsors, the phenomenon of organizational boundary maintenance still limited the effectiveness, even in these scenarios. All things being equal, organiz ations and agencies and research teams may be expected to protect their boundaries. It is the nature of formal organizations to restrict access to sensitive information, personnel, and resources to guard organizational boundaries. Evaluation data from a nu mber of interventions suggests that cross

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72 sector collaboration does not produce the seamless web envisaged by advocates. Rather, revision (Greenwald, 2008 : 13 ). Collaboration may be necessary and desirable, but the research evidence indicates that it can be too challenging (Bryson et al., 2006; Lasker et al., 2001) especially wh en considering organizational boundary maintenance (Greenwald, 2008). At one end of the spectrum are organizations that hardly relate to each other when it comes to dealing with a public problem. On the other side organizations that have merged in a n ew entity to handle problems through merged authority and capabilities ( Bryson et al., 2006 :44). In the midrange are organizations and undertake coordinated initiatives, or develop shared power arrangements in order to pool (p. 44) to address a problem or challenge ( Bryson et al., 2006 ) This midrange level is where most organizations and agency level collaboratives are working or trying to work within. In the United States, advocates of collaboration acro ss sectors are often responding to a collaboratives do not solve all of the problems they tackle, indeed some are solved badly. Some solutions have created the p roblems they were meant to solve. Cro ss sector collaboration can be partly to blame such that changes anywhere can reverberate in unexpected and unknown ways issues that we previously though t about in fairly narrow terms, such as health care, are now being redefined as issues of economic competitiveness, education policy, tax and expenditure policy, and immigration (p. 44 45). How to respond collaboratively and effectively to problems that are so interconnected and all encompassing is a major challenge (Bryson & Crosby, 2005).

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73 Benefits, Importance, Value of Cross Sector Collaboration Although there are many impediments and challenges, there are many good reasons to adopt an interdisci plinary model of collaboration. Some of these benefits include heightened and enriched respect for professionals in other disciplines and pooling expertise (Abrams on, 1996), and better access to material and human resources (Abramson & Mizrahi 1996; Butterfoss et al. 1993), added new knowledge and understanding of complex issues (Evans, 2006; Miller et al., 2008), increased information sharing and networking (But terfoss et al. 1993; Abramson & Mizrahi, 1996), development of a mindset for working cooperatively with shared values and attitudes (Ray, 199 8 ), enhancing the range of options considered and skills that apply in problem solving (Abramson & Mizrahi, 1996 ; Bruner, 1991), increased productivity by reducing competition for working on the same issues and clientele (McKenzie, 1999), and enjoy a much wider network for accessing policymakers than any individual organization. At its best, cross sector collaboration has the greatest potential for success in areas ranging from the operation of a regional transportation system to water management on publicly owned land (Greenwald, 2008). Influences on Collaboration One of the most important components for understandin g cross sector collaboration is knowing what supports and promotes it positively or hinders its success. Bryson et al. (2006) focus on the initiation, design, and implementation for more successful collaboration, also referred to as the collaborative deter minants by Lasker et al. (2001). A number of studies were conflated that identified successful components of interdisciplinary collaboration and were used to develop seven key factors. Broadly, there is agreement on the factors but a lack of studies with t he specifics about how to formalize or implement the factors that inhibit a comprehensive

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74 strategy on how to improve collaboration. Still, the presence of each of these factors suppo rts interdisciplinary efforts, whereas their absence presents barriers to it happening (Bronstein, 2003) Below is a framework for cross sector collaboration that incorporates and blends the research particularly from Bryson et al. (2006) and Weiss et al. (2002) and many others listed below starting with and adapting from Bronst framework originally was composed of four core successful interdisciplinary factors that has been expanded upon There is a great deal of cross over among the categories; all are described separately, but are interconnected. After the initial listing of the seven key factors that support more successful collaboration they are described in more detail further below. 1) History of Collaboration (Mattessich & Monsey, 1992; Amabile et al. 2001; Bryson et al. 20 09; Ray, 1998); 2) Partner Relationships Characteristics (Amabile et al. 2001; Butterfoss et al. 1993; Mariano, 1989; Bryson et al., 2009; Lasker et al., 2001; Mattessich & Monsey, 1992; Bronstein, 2003; Petts et al., 2008); 3) P rocesses, Structures, a nd Governance (Donahue, 2004; Parker Oliver et al. 2005; Bryson et al., 2009; Butterfoss et al. 1993; Lasker et al., 2001; Greenwald, 2008); 4) Communication Characteristics (Abramson & Mizrahi 1996; Butterfoss et al., 1993; Bryson et al., 2009; Weiss e t al., 2002; Lasker et al., 2001; Mattessich, & Monsey, 1992); 5) Leadership Characteristics (Bronstein, 2003; Bryson et al., 2009; Weiss et al., 2002; Butterfoss et al., 1993; Lasker et al., 2001; Petts et al., 2008); 6) Resources (Weiss et al., 2002; G reenwald, 2008; Lasker et al., 2001; Mattessich & Monsey, 1992); and 7 ) Accountability, Reassessment, and Evaluation (Bronstein, 2003; Butterfoss & Cohen, 1989; Wandersman et al. 199 7 ; Bryson & Crosby 2005).

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75 His tory of Collaboration Mattessich & Monsey (1992) refer to earlier experiences in interdisciplinary settings with colleagues as the history of collaboration. Past positive experiences with partnerships have been shown to be linked with current levels of successful collaboration (Mattessich & Monsey 1992; Bronstein, 200 3 ). Also, preconditions such as the degree to which single efforts to solve a public problem failed then becomes an incentive to collaborate (Bryson et al., 2006). The role of prior relationships or existing networks is important bec ause it is often through these networks that partners judge the trustworthiness of other partners and the legitimacy of key stakeholders. The more partners have interacted in positive ways in the past, will enable team coordination and exchanges (Ring & Va n de Ven, 1994). More specifically, cross sector collaborations are more likely to succeed when existing partnerships are in place at the time of their initial formation (Bryson et al., 2006). Inversely, history can be negative as argued by Ray (1998), suc h as different philosophies of practice and professional training, and prior negative collaborative experience with lack of coordination and trust. (Lasker et al. 2001). If prior relationships do not exist, then collaboratives are likely to emerge more inc rementally and begin with small, informal deals that do not require as much trust (Ring & Van de Ven, 1994). Partner Relationship Characteristics Lasker et al. (2001) state that relationships among partners, which include, building trust, mutual respect, managing conflict and power differentials, and having flexibility and some role blurring influence high levels of collaboration. Bronstein (2003) states that partner relationship characteristics are most similar to interdependence, in which professionals a re dependent on each other to accomplish goals and tasks. Cross sector collaborations are more likely to succeed when there is a process to build trust and the capacity to manage conflict (Gardner, 2005), and it builds

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76 on distinctive competencies of the co llaborators (Lasker et al., 2001) which are described in more detail below. Building T rust and M utual R es pect Trusting and respectful relationships are often depicted as the essence of collaboration (Petts et al., 2008; Bryson et al., 2006) because they f acilitate the work and hold the collaboration together (Mattessich & Monsey, 1992). Trust can influence interpersonal behavior, confidence in organizational capabilities and expected performance, and lead to a common bond and sense of goodwill (Chen & Grad dy, 2005). Amabile et al. (2001) believe that trust is most important along with the presence of mutual respect specifically regarding attitudes and motivation within the ns and input is an important characteristic of effective partner relationships. Many researchers realize that collaboratives begin with varying degrees of trust but emphasize that trust building is an ongoing requirement for successful collaboration (Huxha m & Vangen, 2005; Ring & Van de Ven, 1994). Collaboration partners build trust by sharing information and knowledge, and demonstrating competency, good intentions, and follow through; conversely, failure to follow through can undermine trust. It is also im portant to emphasize the importance of achieving small win s together (Bryson et al., 2006 ). Managing C onflict There can be positive and negative tensions and conflict among partnerships that can determine collaborative success (Amabile et al., 2001; Maria no, 1989). Conflict is common and inherent in partnerships (Butterfoss & Cohen, 1989; Gardner, 2005). One of the greatest challenges of collaboration is how diversity, which is essential, can lead to tension and conflict

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77 (Gardner, 2005). Diversity of secto rs can put great demands on the leadership, coordination, and management skills of a collaborative (Lasker et al., 2001). Conflict emerges from the conflicting aims and expectations that partners bring from differing views about strategies and tactics and likely to succeed when partners use resources and tactics to equalize power and manage conflict effecti al., 2006 :48 ). Partner Flexibility and Role Blurring This extends :300 ). Behavior that characterizes t he 2003 :301 ) As a component of collaboration, flexibility of roles demands less hierarchical relationships. To have the kind of integrative teams that Kane (1980) wrote about, some deliberate role blurring and flexibility are required (Bronstein, 2003). The roles that are taken are not only related to the expertise of the professional but also related to the needs of the organization or agency as a whole. Role blurr ing is identified as both supportive of success and as an impediment. For example, it is considered required by Bronstein 2003, but excessive role blurring can create confusion among partners (Bronstein, 2003; Kane, 1980). Structure, Processes, and Governa nce Characteristics Researchers have emphasized several aspects of process, structure and governance within collaborations whether to guide partnership coordination and development, closely tied to leadership, and influence outcomes (Bryson et al., 2006; Lasker et al., 2001).

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78 Structure Bronstein (2003 ) refer s to collaboration as integration, which is a critical component identifiable durable collaborative structure (p. 300 ). Bryson et al. (2006) emphasize that stru cture is a highly developed concept in organizational theory and typically includes elements such as, goals and missio n specialization of tasks and division of labor, and rules (Greenwald, 2008), and standard operating procedures. Reform involving collabo ration extends beyond the individual collaborators and their direct services to clients, but as new partnership structures (Lasker et al., 2001). Structural factors were also identified in research by Weiss et al. (2002) that suggested that improved colla boration may be related to more effective administration and management defined as coordinating communication between partners or those outside the partnership whether meetings and projects, managing and disbursing of funds, applying and managing grants, p erforming secretarial duties, maintaining databases, and evaluating the progress and impact of the partnership. Bronstein (2003) also refers to structural characteristics as relevant and can include ensuring a manageable caseload, an agency or organization culture that supports interdisciplinary collabo ration, administrative support, and the time and space (Petts et al., 2008) for collaboration to occur. Processes Bryson et al. (2006) emphasized processes that include forging initial agreements, building le gitimacy, and planning. A key process in collaboration is negotiating formal and informal agreements about the purpose of the collaboration after some initial agreement on defining a problem. After agreeing on the purpose of the collaboration, partners may consider elements of the processes, such as roles, responsibilities, and decision making author ity

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79 (Butterfoss et al., 1993). A process is needed that makes good use of different perspectives, resources, and skills in the collaborative (Lasker et al., 200 1). Mattessich & Monsey (1992) found that successful collaborators had clearly understood their roles about what they needed to accomplish and what was offered by others. An important component described in the research by Weiss (198 7 ) is planning efficien cy which is assigning roles properly and efficiently making kind resources. Lasker et al. (2001) also emphasized the importance of efficiency of partnership time as an important determinant of higher level collaborat ion. Forging an initial agreement is an important aspect of processes Donahue (2004) argues formal agreements have the advantage of supporting accountability. Initial agreements might include designation of formal leadership or commitment or resources. The form and content of a ryson et al., 2006). Developing a mission, goals and objectives and planning approaches are important processes for success. Bryson et al. (2006) state that an important key to success is having detailed articulation of a mission, goals, and objectives, ro les and responsibilities, and phases or steps that includ e implementation (Mattessich et al., 2001). Butterfoss et al. (1993) stated that tainment of its common mission and goals and objecti ves. Bronstein (2003) states that collaboratives need to take ownership of the goals, as well as sharing in the entire process of reaching goals, including the design, definition, development, and achievement of the goals and objectives. To engage in colle ctive ownership of goals, each professional needs to take responsibility for his or her part in success and failure and support constructive disagreement and deliberation among colleagues (Bronstein, 2003).

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80 Two different approaches to planning in collabora tive settings are evident in the literature. Cross sector collaborations are more likely to succeed when they combine deliberate and emergent planning; deliberate planning is emphasized more in mandated collaborations, and emergent planning is emphasized m ore in non mandated collaborations. The first approach emphasizes deliberate, formal planning as a precursor to success. The second ap proach is less deliberate and has understanding of mission, goals, roles, and action steps is more likely to emer ge over time as conversations involving groups, and organizations grow to encompass a broader network of involved or affected parti es (Bryson et al., 2006 :48 ). Governance This is key to partnerships functioning well (Butterfoss et al., 1993; Lasker et al ., 2001) and the collaborative being successful (Lasker et al., 2001; Bryson et al., 2006). Governance is described in the literature in this section as similar to leadership processes. For example, (Bryson et al 2006) define governance as a set of coord inating activities that must occur in order for :2 ). Governance seems to be an unnatural characteristic of collaboration becaus e if we assume that collaboratives are horizontal systems, then a hierarchical concept such as governance is problematic (Bryson et al., 2006; Provan & Kenis, 200 8 ). Additionally, governance generally refers to government and can be a part of decision maki ng and/or leadership processes. Even with the conflict above, governance is described as essential. Lasker et al. (2001) state that governance profoundly influences collaboration effectiveness. Through necessary procedures, governance determines who is in volved in the partnership decision making and how partnerships make shared decisions and do their work, governance influences the extent to which

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81 governing struc tures in which shared decision making occurs through regular meeting of members or through informal frequent interactions (Bryson et al, 2006). Shared decision making is one of the dimensions of collaborative practice (Gardner, 2005 :7 ). The form alization of these procedures sustains the way a partnership works beyond the level or tenure of any particular leader or staff person (Lasker et al., 2001). Communication Characteristics Supportive, open, unhindered internal communications that include r egular meetings among stakeholders are desirable and essential for enhancing effective collaboratives (Bryson et al., 2006; Bronstein, 2003; Mattessich, & Monsey, 1992; Butterfoss et al., 1993). Frequent electronic communications and face to face meetings and new forums are important to enhance opportunities for dialogue and information exchange. The level of communication is vital for building cross level, cross sector understandings and commitments (Bryson et al., 2009; Robertson et al., 2003). Abramson ( 1996) argues that communication appears to be very (p. 270). Mariano (1989 ) also found that successful efforts relied on highly effective communication that span s professional boundari es. Communication and other interactions that include formal and informal time spent together (Mattessich, & Monsey, 1992), oral and written communication among ary for successful collaboration (Bronstein, 2003). Butterfoss et al. (1993) state that durable coalitions often have frequent meetings, a well developed system of internal communication to keep members informed. This finding also parallels with Kagan et a l. (1995) and their study of service integration initiatives in four states, which determined that successful collaborations

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82 among service providers for children and families were characterized by clear avenues of communication among key stakeholder (Brons tein, 2003). Leadership Characteristics Leadership characteristics have more robust studies compared to other characteristics that support the importance of leadership in successful collaborations. Collaborations provide multiple roles for formal and infor mal leadership (Agranoff & McGuire 200 4 ; Bryson & Crosby, 2005). Butterfoss et al. (1993) describes needed qualities for supportive leadership as: attentive to the individual members concerns; competent at garnering resources, problem solving, and conflict resolution; and proven at administrative and communication skills. Formal leadership positions might include co chairs of a steering committee, coordinator of a collaborative, or project director. Critical to the success of a collaborative is a project co ordinator who can connect all the parts of the collaboration and control boundary maintenance issues. To be most effective, these term commitment to the collaboration, integrity, and relational and p Simo & Bies, 2007:137 ). Strong central leadership was also emphasized by Petts et al., (2008) in context to urban environments and by (Butterfoss et al., 1993) as an important ingredient in the formation, implementation and maintenance of coalition activities. Two key leadership roles are sponsors and champions (Bryson & Crosby, 2005). Sponsors are individuals who have considerable prestige, authority, and access to resources they can use on behalf of the collaboration, even if they are not closely involved in the day to day collaborative work. Champions are people who focus intently on keeping the collaboration performing and use process and communication skills to facilitate the collaboration with accomplishing its goals (Petts et al., 2008; Bryson et al., 2009; Weiss et al., 2002). Cross sector

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83 collaborations are more likely to succeed when they have committed sponsors and effective champions who provide formal and informal leadership. Sponsors and champions at all levels should continu ally seek the support of and maintain relationships with key political leaders so that elected official support is available when needed (Bryson et al., 2009). As described below in Weiss et al. (2002), leadership is associated most with successful collabo ration compared to other factors they tested which they refer to as partnership synergy. Synergy is defined as the power to combine the perspectives, resources, and skills of a group of hinking and actions that Lasker et al ., 200 1:184 ). Six dimensions of partnership functioning were studied: leadership, administration and management, partnership efficiency, nonfinancial resources, partner involvement challenges and community related challenges. Quantitative data were collected from 815 informants in 63 partnerships. The authors used the term partnership to encompass all the types of collaboration (e.g., coalitions) (Weiss et al., 2002). Respondents were asked t o rate the total effectiveness of the formal and informal leadership in the partnership in the following areas: taking responsibility for the partnership; inspiring and motivating partners; empowering partners; working to develop a common language within t he partnership; fostering respect, trust, inclusiveness, and openness in the partnership; creating an environment where differences of opinion can be voiced; resolving conflict among partners; combining the perspectives, resources, and skills of partners; and helping the partnership look at things differently and be creative (Weiss et al., 2002). Data indicated that partnership synergy was most closely related to leadership effectiveness and partners hip synergy finding is consistent with other research that has documented the importance of leadership across all phases of partnership development (Weiss et al., 2002; Lasker et al., 2001).

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84 As demonstrated in the Weiss et al. (2002) study, achieving high levels of synergy is associated with leadership that effectively facilitates productive interactions among partners by challenging assumptions that limit thinking and (p. 693). Partnerships need leaders who perform boundary spanning functions to counteract boundary maintenance (Weiss et al., 2002). Lastly, Weiss et al. (2002) demonstrated that a common language is an important collaboration reveal that projects involving several contrasting disciplines are limited without the devel (p. 4). Working to develop a common language is necessary so the zone of ideas can occur (Robertson et al., 2003). Resources Lasker et al. (2001) strongly emphasized that resourc es such as sufficient funding (Mattessich, & Monsey, 1992) are an important influence to more effective collaboration and in kind resources (Ray, 1998). Resources also include space, equipment, skills and expertise, and endorsements. Some of the types of s kills needed to enhance the resources to support the partnership include outreach, leadership, communications, and evaluation. Connections to political decision makers and target populations and those champions and endorsers can bring more legitimacy and c redibility and ability to obtain sustainable resources (Bryson & Crosby, 2005).

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85 Accountability, Reflection, and Evaluation their working relationship and processes, incorporating a feedback loop, setting up a system to track progress, and evaluate process, impacts and outcomes to strengthen their relationships and effectiveness (Bronstein, 2003). Accountability Cross sector collaborations are more likely to be succ essful when there is an accountability system in place: that tracks inputs, processes, and outcomes; gathers, interprets, and uses data; and manages the results (Bryson et al., 2006). Two challenges with accountability can be that with a diverse partnershi p, members typically compete in defining the results and outcomes so big and small wins or failures can be less certain Also, this is particularly challenging issue for collaboratives because it is often not clear whom the collaborative is accountable to ( Bronstein, 200 3 ). Reflection and Evaluation Reflecting on the working relationships and incorporating a communication feedback loop is important to strengthen the collaborative. F ailure to achieve desired outcomes can erode supp ort for the collaborative, but many successes can cause supporters to forget the need to ( Bryson & Crosby 2005 :16 ). If big wins are less possible, the collaborative should focus on accomplishing small wins that are publicized among the partnership. Last ly, after the partnership has been fully implem ented, l eaders should evaluate whether the partnership should continue or be ter minated ( Bryson & Crosby, 2005). Thorough evaluation is also one method that is frequently cited for improving outcome effectiven ess ( Wandersman et al. 199 7 ). Considerably more information related to evaluation outcomes of collaborations is further below.

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86 Figure 2 Diagram of C haracteristics that P ositively Influence C ollaboration for G reater S uccess Outcomes of Successful Collab oration After successful design and implementation of the characteristics in Figure 2 this could lead to more successful outcomes for collaboratives. The outcomes to gauge the effectiveness of partnerships identified by Lasker et al. (2001) and Butterfos s et al. (1996) are the following. 1) Satisfaction of stakeholders 2) Quality of partnership plans 3) Sustainability of the partnership 4) Changes in community programs, policies, and practices 5) Improvements in the utilization, responsiveness and costs of services 6) Impr ovements in population health indicators 7) Enhanced creativity 8) More comprehensive thinking, holistic view 9) Produce more grounded, local response to an issue History of Collaboration Resources Leadership Characteristics Partner Relationship Characteristics Processes, Structure, and Governance Characteristics Communication Characteristics Cross sector Collaboration Success Accountability, Reflection, and Evaluation

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87 More succinctly stated by Amabile et al. (2001) and others is that among teams there are three indicat ors of successful collaborative outcomes that include achieving the goals of the collaboration along with the miss ion and objectives (Wandersman et al. 199 7 ), effective team functioning; and benefits achieved for the individual members of the collaboratio n. Greenwald (2008) raised an important question, about what accomplishments should be realistically expected from cross sector collaboration efforts Innes and Booher (1999) explain collaborative planning efforts that can assist with answering the above q uestion. These efforts have short, medium and long term effects and outcomes that they refer to as first, second, and third order effects. Short term effects (first order) are immediately discernible as a direct result of the collaboration process (Butter foss & Cohen, 1989). These short term effects and accomplishments could include the creation of social, intellectual, and political capital; high quality agreements; clear leadership structure, and innovative strategies. Second order effects are likely to occur when collaboration is well under way, or else they may occur outside the formal boundaries of the effort. Examples of second order effects are new partnerships, reciprocal trust and respect, coordination and joint action, implementation of agreement s, and changes in practice and in perceptions. The long term, or third order effects and accomplishments often extend from medium term effects and may not be evident until much later. These might include reduced conflicts among partners, changes of servic es and shared access to resources, and new norms. Gray (2000) offers achieving the goals and outcomes, creating shared meaning, and equalizing the power distribution. Determining successful and detailed evaluation outcomes and what influences them is impo rtant particularly to gain a better understanding of what is possible to achieve, what is considered effective or not effective collaboration, and offers options for growth and improvement (Bronstein, 2003).

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88 Future Research Numerous examples, spanning ove r 200 years, support the notion that a commonly understood language and set of methods are key to overcoming the ontological and :3 ). Parker Oliver et al. (2005) state that s uccessful interdisciplinary teams are generally not understood and need to be explored, articulated, researched on many levels, and translated into action. Lasker et al. technical assistance and training along these lines, including additional conceptualizati on and new methodological tools (p. 197). Another consideration from Varda et al. (2008) is the lack of s benefit presents an opportunity for (p. E5). Robertson et al. (2003) argue that understanding the methods and ensuring more transparency could be the single most valuable step forward in interdisciplinary researc h. They also state that without further studies of methods, It can be challenging to study collaboration and assess validity, reliability or trustworthiness without transp arency of the methods (Robertson et al., 2003 :5 ). The desire and need to further interdisciplinary research is great among and for researchers and practitioners alike whether determining the costs, more transparent methods, a common language, or more evalu ation. However, an important aspect is not discussed as a need to be researched in the literature managing organizational boundaries and identify strategies for boundary spanning. It seems that until there is a better understanding by academics and prac titioners about ways to overcome organizational boundary maintenance issues, real and sustained progress for more successful cross sector collaboration will be slow to evolve. For example, there are significant limitations in the ability of individual enti ties to share resources and merge functions

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89 because of boundaries. Sponsors, funders and evaluators of large collaboration studies or grants are often unrealistically ambitious about the expectations of collaboratives (Greenwald, 2008). Greenwald offers on e solution when the collaborative is in its infancy, which is to consider hiring an individual or organization to manage leadership and administrative functions and who come s from outside the collaborative to help reduce the competitiveness and boundary ma intenance within the organizations. According to Robertson et al. ( 2003 ) the most evidence based characteristics that support collaboration are leadership, process, and communication; partnership efficiency was also identified in a r igorous study by Lask er & Weiss ( 2003 ) L astly partnership relationships for enhancing mutual trust and managing conflict was repeatedly described by multiple researchers as successful to collaboration. Leadership rises to the top as essential for success and is extensively integrated and impacts the other characteristics (less so for history of collaboration). It is the hope that more systematic research within each of the characteristics and the development of model practices will be important for progress in better underst anding the determinants of success. Relevance Based on the literature, and as a means for determin ing cross sector collaboration ( one of the independent variables in this dissertation research) this literature review informs and guides the case study rese arch in many ways. An interview guide was developed that reflects the factors identified in the literature as supporting mor e successful collaboration. This information is vital to learn more about the influences of decision making on master plans (housing and neighborhood) that an Health Impact Assessment (HIAs) was completed and more specifically the level of cross sector collaboration within the selected cases. The questions address successful collaborative

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90 factors such as leadership, communication, proc esses, resources, history of collaboration, and structures. The interviews are important to gaining an understanding of the influences, perspectives, and opinions of the decision makers and team members from the HIAs and master planning processes. The hyp otheses for this research, based on the literature related to cross sector collaboration, is that more successful cross sector collaboration will lead to a high quality HIA and that both ( cross sector collaboration and high quality HIA) will lead to higher levels of adoption of the HIA recommendations into the master plans, more health supportive language (that is compared to similar type master plans without an HIA), and more awareness/knowledge (from the project team and other decision makers). Conclusion Many professions are working on serious societal issues, such as contending with rising poverty, aging, and decreasing resources, which compels the need for a more efficient collaborative practice informed by research. The challenge of initiating, plannin g, and implementing effective cross sector collaboration is daunting. As the literature indicates cross sector collaboration is difficult to create and more difficult to sustain because processes and relationships must be in place, silos torn down, and te ams must effectively work together t o succeed. Different forms of leadership, whether inspiring and motivating partners or fostering trust were highlighted as important for success along with other factors, such as good communication and processes to incre ase effective cross sector collaboration and outcomes. Mariano (1989) argued that interdisciplinarity is not necessarily progress but instead a symptom of a pathological situation in which professionals have become too specialized and fragmented. With a h istorical context and the complexity of modern society, the knowledge boom

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91 and concomitant escalation of specialization and fragmentation, cross sector collaboration will take an ever increasing importance in the years ahead. The unintended institutionaliz ation of fragmentation and specialization of sectors and academia continues with an opposing pull for more effective collaboration. This dichotomy will be the continuous struggle and psychological conflict to bare and overcome to better meet the needs of s ociety. For cooperation and integration to become a well accepted policy among partnerships, there needs to be a more full and detailed understanding of cross sector collaboration and what promotes or hinders it. For example, better understanding the ways to limit organizational boundary maintenance can be an essential part of the solution. Education programs and training courses for professionals and students to learn the concomitant new skills will be required of educators, practitioners, and researchers Then faculty will better participate, research and teach practitioners practice and institutions support more research and practice in cross sector collaboration. This level of collaboration requires common values, a common vision and goals, and an u nderstanding of teamwork with the ultimate goal of adding public value. With the continuing strong appeal, a gradual increase in research and informed practice, and the potential opportunities for interdisciplinary funding suggests a cautious optimism for more sustained success.

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92 CHAP TER V METHODS Chapter Outline The purpose of this chapter is to present the research methodology to address research questions and hypothesis An overview of the main tenets of the case study research design is provided with an accompanying rationale for each method including the advantages and limitations of case study research approach, and ensuring case study rigor. The description of the research framework and approach draws from the literature and models of good practice in social science research, as well as the research questions and hypotheses, methods for data collection and analysis. Case Study Research Methodology Over the past 25 years a number of scholars have contributed to the realm of qualitative and exploratory research and have developed the context for case study research designs (Yin, 2003; George & Bennett, 2005). Case studies can assist in understanding complex issues or problems and strengthen what is al ready known. Yin stated (2003 irical inquiry that investigates a contemporary phenomenon within its real (p. 13). The and the ability to contribute to the development and test The case method is not a new style of data gathering and analytic technique. For many years, physicians, lawyers, social scientists, business schools an d education departments have used case studies as a measure to examine phenomena and relationships in great detail (Berg,

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93 systematic and rigorous research methods f ocusing on the case study approach. Since 1975, numerous works have contributed to the narrative of social science research methodologies and strategies. Most notably, George (1979), Ragin (1992), Stake (1995), George and McKeown (1985), Yin (1994; 2003), Gomm (2004), George and Bennett (2005) and Bennett and Elman (2006) each contributed to the growing school of case study methodological and epistemological thought. Although the case study approach has a number of limitations, such as selection biases, val idity, and theoretical generalizations (George & Bennett, 2005), the approach is widely used in social science research (Yin, 2003; Eckstein, 2000). Case Study Research Design questions. The case study approach tries to illuminate a decision or set of decisions: why they were made, how they were adopted or implemented, and with what result (Schramm, 1971, cited in Yin, 2003). Yin (2003) also states that this design sh ould be considered when the behavior of those involved in the study cannot be manipulated and boundaries are not clear between phenomenon and context. The case study design is also appropriate for investigation into novel areas that have been less explored (Yin, 2003), such as Health Impact Assessment (HIA) research. Case studies come in single case or multiple case forms, depending on the research context and question and hypotheses of each study (Yin, 2003). There is a growing consensus that the strongest means of drawing inferences from case studies is the use of a combination of within case analysis and cross case comparisons within a single research study. The conclusions of single case studies are much stronger if they can be compared to other studies (George & Bennett, 2005).

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94 The present research study investigated the influences of the contextual environment upon the phenomenon of HIA, and housing, planning, and transportation decisions and processes at the local government level. To re state, the ove impact assessments influence decision making in redevelopment master plans and the related decision makers HIA process and impac ts, the case study approach is clearly suitable for this research. The use of case studies is also most suitable because it aligns with and fits the need to capture rich insights into the experiences and views of decision makers and in depth examination of the context (Yin, 2003). In this study, since HIA is a novel approach with sparse research which to compare, a multiple case approach was chosen to elicit patterns within and across two contrasting cases. In all, there are three types of case study desig ns as outlined by Yin (2003): 1) descriptive, 2) exploratory, and 3) explanatory. Descriptive case studies relate to an historical subject matter, aiming to give an account of a particular issue but not necessarily to provide an explanation. Conversely, ex ploratory case studies are conducted to ascertain the relevance of working hypotheses and causal variables in research (Yin, 2003). The most commonly used case study design type is the explanatory category and this can be complemented by the two other type (Yin, 2003; 6). Explanatory design studies are amenable to the use of the process tracing technique (Bennett & Elman, 2006), and the use of pattern matching (Miles & Huberman, 1994; Berg, 2004) to help when there are several pieces of information from the same case that may be related to a theoretical proposition (George & B ennett, 2005). Propositions come from the literature, professional experiences, and theories that are based on empirical data and are very helpful, if available, in any case study (Baxter & Jack, 2008). This doctoral research mainly use s

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95 explanatory case s tudy design, complemented by exploratory components, to establish the contextual environment of a set of decisions within a contemporary environment (Yin, 2003). Advantages and Limitations of the Case Study Research Approach It is important to take into account strengths and weaknesses associated with the case study research approach. Consideration must be made of these issues when designing the overall research plan and conducting the data collection and analysis. George and Bennett (2005) outlined impor tant advantages and limitations of the case study strategy that are described below. Strengths Case study methods have several advantages, including the following. 1) Construct validity: A case study approach allows for high levels of construct/conceptual mean different things in different situations and contexts. It is important that the variables best represent the theoretical concepts the researcher is trying to measure Case studies have the ability for conceptual refinements with a higher level of validity over a smaller number (n) of cases versus statistical studies (George & Bennett, 2005). Such in depth research may lead to discovery of equifinality, meaning that th e phenomena being examined exhibits several explanations for the same outcomes (George & Bennett, 2005). 2) Fostering new hypotheses: Hypothesis and theory generation is a strong advantage of case study research. Theory development is needed particularly with HIA because of its newness and to further test and evaluate theories that are currently available. Often throughout the data collection phase, the researcher may establish that the independent variables initially conceptualized in the literature revi ew are insufficient, not grounded in

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96 reality, or require greater dimensional attention. Case studies are powerful in the heuristic identification of new variables and hypotheses through the study of deviant cases and archival research and interviews. Obtai ning answers other than what was hypothesized offers potential new variables or previously overlooked identifying variables to be considered for new theory and testing (Yin, 2003). 3) Exploring causal mechanisms: Case study design allows the investigation of causal mechanisms both in single case analysis and across cases. Causal mechanisms are (George & Bennett, 2005). Causal mechanisms are the bases for inference and explanation, but causal effects (i.e., expected change in the dependent variable given a unit change in an independent variable) are only possible when there is a well controlled before after case comparison, which is less common. The potential growth of intervening variables for each case is enabled with this awareness of causality. A large number of intervening variables can be inductively observed for unexpected outcomes or to help identify conditions present in a case that activate the causal mechanisms. Case studies allow for the exploration of causal pathways of variables and conditions and can produce findings based upon contingent factors (George & Bennett, 2 005). 4) Understanding complex causal relationships: Finally, case studies have the ability to accommodate complex causal relations such as equifinality, enabling the researcher to assess complex causal relations. To allow for equifinality and complex in teraction effects, case studies can produce both narrower and middle range theories and broader general theories.

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97 Limitations 1) Case selection bias is one of the most pertinent limitations of case study designs and requires significant attention by the re searcher (Bennett & Elman, 2006; George & Bennett, 2005). The danger is that the cases are self selected and possibly selected without consideration of linkages to the theory or methodology rationale. However, selection of cases with some preliminary knowl edge of their key elements allows much stronger research designs. There are methodological safeguards against researcher induced bias in case studies such as careful congruence testing and process tracing (George & Bennett, 2005). Case study bias in relati on to my research is addressed in the next section. 2) A limitation of case studies is that the researcher can make only tentative or weak affects the outcome in a case (George & Bennett, 2005). Case studies are stronger at assessing arguments about casual necessity or sufficiency, especially cases that estimate causal effects. Each researcher who employs the case study research design must be aware and make allowances f or the degree of certainty over variables and the scope of explanatory power, especially in the instance of equifinality. 3) Another limitation for this methodology is that it is hard to generalize from a small sample size of a few case studies to other s imilar situations or communities. The generalizability of case studies can be increased by the strategic selection of cases (Flyvbjerg, 2006). George and Bennett (2005) stated that case studies do not claim to make generalizations across instances and popu lations, except in contingent ways. Generalization should focus on the findings and their connection to theory versus just

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98 generalizing to other case studies (Yin, 2003). This research design contains an implicit trade off between the degree of data richne ss and representativeness. 4) Case studies have been criticized for the potential lack of independence across cases and consequently the risk of reaching false conclusions. There exists a relationship and osmosis effect of cross learning in the case study environment. On the one hand, as with large N research, the researcher can fail to identify a lack of independence among the case analysis methods such as process t racing that inductively examines the relationship between cases, can result in greater learning and understanding of the phenomena being studied (George & Bennett, 2005). Case Selection in the Present Study Case selection bias is one of the most challengi ng aspects of case study research design. Information oriented selection is used to maximize the utility of information within a few cases. Cases are selected on the basis of expectations about their information content (Flyvbjerg, 2006). The researcher se lected the cases for this HIA research based on their capacity to generate insights suitable to identify influences in decision making of redevelopment master plans. Diverse cases were selected that seem to have low and high characteristics of the independ ent variables of cross sector collaboration and HIA quality. The case study selection c riteria included the following. 1) Interdisciplinary team: representation from at least planning and health professions also engaged in completion of the HIA and master pla n 2) Same jurisdiction: all cases are within the City and County of Denver to ensure the cases have similar governance, politics, regulations, and policies

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99 3) Measurable outcomes: clear and specific HIA recommendations that can be measured for their degree o f incorporation into the master plan 4) HIA completed and finalized 5) Contrasting cross sector collaboration: One of the cases is seemingly high in cross sector collaboration and one appears to be low. Contrasting cases for this research are the South Linco ln Housing Master Plan (high) and Northeast Downtown Neighborhood Plan (low). 6) Demographics: the context for both cases is a high percentage communities of color with low socioeconomic status 7) Health assessor is the same across the two cases. More specifi c to the decision making context for the two cases that reflects the purposive nature of the case selection, both cases are at the local level and in the same jurisdiction (similar governance, politics, regulations, and policies) and is the same health ass essor. Differences are that the decision making agency lead for one is the Housing Authority and for the other, the Planning Department. Additionally, the hired planning firm for each case is different. Clarifying the Lead Researcher and Health Assessor R o le s in the R esearch As part of improving the integrity and trustworthiness of the qualitative and quantitative research in this study, it is necessary to disclose the dual role of the lead researcher. The author alth impact assessment in each of the cases, and experiences and role of the lead researcher is important for being clear about potential bias, reducing it and still potentially enriching the study. The lead researcher must be aware of how their own positions and interests are imposed at different stages of the research process (Finlay, 2002). In this study, research assistants were

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100 employed throughout the diff erent research phases to help the lead researcher obtain a more neutral position during the study, to ensure the research was not skewed in a particular direction and to improve reliability. During the data collection stage, all interviews were conducted by a research assistant. The lead researcher purposely did not conduct interviews so that there could be full disclosure by the interviewees to an independent interviewer. The lead researcher wanted interviewees to be totally free to be honest and perhaps critical of the heath assessor and HIA if they so chose. However, this approach had both positive and negative implications for the study. The positive side is that bias was reduced in the data and results; yet, there were potentially missed opportunities for the lead researcher/health assessor to ask very pertinent follow up questions that would have been possible due to her intricate knowledge of the cases. During the data analysis stage, all documents were reviewed and scored by two research assistants a long with the lead researcher to improve accuracy and reduce potential bias. Defining the Study Population For this research, the study population refers to the project team members and other key decision makers, mainly those who completed the master plan and/or HIA. These members are generally from the fields of planning, building and landscape architecture, urban and transportation planning, energy, real estate, community engagement, and social services. This group does not include community residents Additionally, sectors are emphasized such as planners, health officials, and transportation engineers since those working on the master plan teams are made up of the different sectors that are being studied, versus governance, such as planning and public w orks departments. More specifically, those interviewed include the following: lead planners (consultants and/or lead governmental agency); health assessor (s);

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101 project managers (consultants and/or lead government agency); or elected official (s) who were i nvolved in the master plan/HIA process. Each case has approximately four to five interviewees. Table 4 describes the details of the interviews. Case Study Sampling The multiple case or collective case study approach was designed to address the aims and research questions across the two selected cases. The cases selected are focused on local housing and neighborhoods and where transportation is an important component. Table 1: Description of Research Case Studies describes the HIA cases that were selected (EnviroHealth Consulting, 2009; 2010). Each of the case studies were investigated through document review, content analysis, and interviews of key participants (that include both open and close ended questions) This triangulation of methods can improve r eliability and validity of case studies (Yin, 2003). Table 1 : Description of Research Case Studies Title of HIA Redevelopment Plan Date of HIA Completion Health Impact Assessment South Lincoln Homes, Denver, Colorado Housing Pu blic housing over 50 years old and community wide revitalization was needed. With the adjacent light rail stop, the South Lincoln neighborhood is now developing into a transit oriented community. September 2009 Health Impact Assessment Northeast Downtown Neighborhoods, Denver, Colorado Neighborhood HIA focused on relationships across all or portions of 10 neighborhoods instead of an individual neighborhood that does include light rail. October 2010 The evaluation of outcomes from conducting the redevel opment plans is useful in identifying whether the HIA influenced master plan outcomes such as whether the HIA recommendations were adopted or not into the planning documents. Another measurable outcome is whether there is a difference in the amount of heal th supportive language in a planning

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102 document when an HIA has been conducted versus not. Lastly, whether a change in health awareness and knowledge occurred and public health discussed more by the decision makers as a result of the HIA. Research Framework : Hypotheses and Questions Hypotheses It is anticipated that if the level of collaboration among project team members with varied expertise and other decision makers, e.g. elected officials, is high and the quality of the HIA is high, then the degree to w hich the HIA recommendations and health supportive language are adopted into the master plan should also be high along with higher health awareness and knowledge And the opposite is also true if the independent variables are low. 1) HIA influences the amount of health supportive language in redevelopment master plans. 2) Majority of the HIA recommendations are adopted in redevelopment master plans. 3) Health awareness and knowledge of the decision makers improves when an HIA is conducted. 4) The level of HIA quality c ontributes to the level of health supportive language, and adoption of HIA recommendations, and health awareness and knowledge. 5) The level of cross sector collaboration contributes to the quality of the HIA, level of health supportive language, adoption of HIA recommendations and health awareness and knowledge.

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103 Research Questions necessary for case study research in order to facilitate analytical explanatory research. A few quest 2 illustrates conceptually the research components and their relationship. Question 1 How do health impact assessments influence decision making in redevelopment maste r plans, specifically the amount of HIA recommendations adopted, health supportive language used and change in decision a) How much health supportive language is in master plans when an HIA is completed compared to sim ilar master plans without an HIA completed? b) c) How much does the health awareness and knowledge of the project team and other decision makers change because of the HIA? Other important sub level questions include the following: How many of the recommendations from the HIA were partially or fully adopted in the master plan? Which of the health sections/chapters in the HIAs had the most recommendations adopted such as Crime and Safety, o r Healthy Food Access or Environmental Health? How many of the HIA recommendations were adopted that focused on changes to policies, the physical changes to the built environment or programs?

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104 Question 2 How do variables such as cross sector collaboration and the quality of the HIA influence whether the HIA is more or less effective in influencing decision knowledge and health related master plan outcomes such as the adoption of HIA recommendations and health supportive language ? a) How does the level of cross sector collaboration of the project team and other decision makers influence the quality of the HIA document? b) How does the level of cross sector collaboration of the project team influence the dependent variables such as heal th awareness and knowledge when a HIA been completed? c) How does the quality of the HIA influence the dependent variables such as health awareness and knowledge of the decision makers? i. What quality Standards score does the South Lincoln HIA achieve? ii. Were the goals and objectives of the HIA met? Figure 3. Research Conceptual Model QUALITY OF HIA CROSS SECTOR COLLABORATION MASTER PLAN & DECISION MAKER OUTCOMES Health Supportive Language Health Awareness and Knowledge Adoption of HIA Recommen dations

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105 Case Study Methods and Data Collection This retrospective, multiple case study design and analysis used both quantitative and qualitative methods. The rang e of data sources and methods employed ensure the rigor of the case study methodology, and enable the researcher to answer all of the research questions. Table 2 & 3 specifies the ways the research design ensures that the study meets the requirements for r igor and robustness. The study was conducted using quantitative content analysis and document review of two redevelopment plans and HIAs, and semi structured interviews with a purposive sample of project team members and other key decision makers involved in the redevelopment plans and the HIAs. The researcher used an analytic framework that consisted of interview data combined with document data from HIAs and master plans coded to identify manifest and latent themes. NVivo and word searches using Microsof t were used for the content analyses; comparisons were made with other, similar redevelopment master plans that were produced without an HIA being conducted by identifying the frequency of the use of health supportive language across the documents. Additio nally, HIAs were analyzed for their quality using the 2010 Practice Standards for Health Impact Assessment and were scored and incorporated into an Excel spreadsheet. Lastly, different aspects of the HIA recommendations for the cases were examined and trac ked whether they were adopted into the master plan using an Excel spreadsheet. Data from the different methods were triangulated to develop an understanding of context, process and influence of the HIA. To reduce bias and increase the reliability of the fi ndings, one or two research assistants along with the lead researcher conducted the different components of the research.

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106 Methods Overview Table 2 has the main components of the research that are examined in this study, including both dependent variables (master plan and HIA outcomes) and independent variables (level of cross sector collaboration and quality of HIA). The key measures and methods for collecting and analyzing data to assess both the dependent and independent variables are listed below. Each data collection method and means for data analysis employed in this study is described in the following sections. Table 2 : Main Components of Research with Measures, Data Collection, and Analysis HIA and Master Plan Outcomes Data Source Measures Analysis Health Supportive Language Content Analysis (quantitative): deductive and inductive. Number of health supportive words in context (healthy eating, active living and socio economic factors) in the master plan; comparing the c ase studies to similar type master plans completed without an HIA. Content Analysis: W ord search es in Word / NVivo Adoption of Recommendations Document review: HIA and master plan for the two cases. Purposive, semi structured interviews of key deci sion makers. Whether HIA recommendations exist or not in the master plan document for each of the cases. Ratings from interviews, 1 5, yes or no, and open ended questions of the perceptions and attitudes of project team members and other decision make rs. Document review: Identified number of HIA recommendations adopted in master plan, compared across each of the case studies, documented in Excel. Purposive interviews: within case analysis, descriptive/explanatory approach and multi case analys is

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107 Table 2 cont.; Health Awareness/ Knowledge Purposive, semi structured interviews. Ratings from interviews, 1 5, yes or no, and open ended questions about health awareness and knowledge. Purposive interviews: within case analysis, descriptive/expla natory approach within case analysis and multi case analysis. Independent Variables Cross Sector Collaboration Purposive, semi structured interviews of key decision makers. W hether the factors identified as supportive of successful collaboration (le adership, communication, history of collaboration, partner relationships) are present and to what degree, using a low medium high scale and open ended questions. Purposive interviews: within case analysis, descriptive/explanatory approach and multi cross case analysis HIA Quality Determination of the level to which the HIA meets the Standards. Purposive, semi structured interviews of key decision makers. HIA Practice Standards Ratings from interviews, 1 5, yes or no, and open ended questions. Low (1), medium (2), high (3), or zero rating for Standards, documented in EXCEL for each of the two cases. Purposive, semi structured interviews of key decision makers Ensuring Case Study Rigor Similar to many other methodologies, cases must be logical ly examined to ensure the rigor and robustness of the study. Table 3 describes tactics to improve the study and how these

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108 issues were addressed in the research. Construct validity, which establishes correct operational measures for the concepts being studi ed and inferences being made, can be problematic in case study research. Researchers can fail to develop a sufficiently operational set of measures. Internal validity establishes a causal relationship, whereby certain conditions are shown to lead to other conditions as distinguished from spurious relations. External validity establishes the domain to be replicated with the same results. Lastly, replication log ic supports the use of multiple cases in a study by replicating the predicted results to develop a theoretical duplication of the results. The evidence from multiple cases is often considered more compelling, and the overall study is regarded as being more robust (Yin, 2008). Table 3 : Case Study Design Tactics to Enhance Quality of Research and How Addressed in R esearch Requirements for Research Quality Case Study Strategies How Addressed in Research Construct Validity Process trac ing Use multiple sources of evidence if possible Triangulation of data collected for more evidence Process tracing focus on construct refinement Internal Validity Pattern matching/ process tracing Explanation building Address rival explanations Use logi c model Sent interviewees their responses back to ensure accurate capture of their responses Use of propositions were used to determine influences Pattern matching/process tracing applied External Validity Use replication logic in multiple case studies Mu ltiple cases were used that predicts contrasting results but for predictable reasons. Reliability Employ research assistants 1 (IR) and consensus with results. IR is tested and assessed. (Adapted from Yin, 20 08)

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109 Determination of the Quality of the HIA At the outset of the review the researcher decided to rate the quality of the HIA based on each of the 63 HIA Practice Standards using a simple scale of low, medium and high, indicating how well the HIA fulfill ed the Standards. In some cases it was necessary to break a long, complex standard into its component parts to be scored. The researcher created an Excel spreadsheet that listed and briefly defined each standard so that the degree to which each was met cou ld be appropriately scored. The 63 standards are broken into nine general standards and specific standards for each of the HIA steps/phases: Screening has three standards; Scoping has 17 standards; Assessment has 13 standards; Recommendations has four stan dards; Reporting has eight standards; and Monitoring has nine standards. An example explains how the researcher used these standards to score the two HIAs in this study. The third section of the Standards concerns the Scoping phase of the HIA process. Th Issues and Public Concerns. Within each element is listed the components that should be included, such as: 3.1.3 Demographic, Geographic, and Temporal Boundaries. Fo r each HIA studied to reduce bias and increase the reliability of the findings, the researcher and RAs rated the degree to which each of the components was present as low, medium, or high. See Appendi ces C and E for the spreadsheet s listing the Standards f or both cases and the related scoring. was for those instances where for pr oject specific reasons a certain standard simply did not apply. For example, no screening formally occurred as part of the South Lincoln HIA. It was determined that due to the high proportion of vulnerable populations including low income households and pe ople of color in the neighborhood, the decision to conduct the South Lincoln HIA had been

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110 before the health assessor was hired. Additionally, a few Standards, mo stly within the the 2010 version of the Standards dictated that an HIA monitoring management plan should be established early in the HIA process. However, a mana gement plan is very seldom completed in an HIA process; while intuitively a plan would seem to be useful, there is no evidence that a management plan improves th e quality or success of an HIA. A systematic review enabled the researcher to identify the HIAs weaknesses, to judge whether their overall quality was low, medium or high, and provided a basis for understanding the usefulness of the Standards in HIA practice. The data collection was documented in an Excel spreadsheet for each of the H IAs. Exploratory, Semi Structured, In Depth Interviews In depth interviews of key project team members and other decision makers generated data about the HIA process and the influence of the HIAs within two different redevelopment master plans. An inter view guide (shown in Appendix A) was developed and piloted by the lead researcher. Development of I nterview Q uestions The interview questions utilized both quantitative measure ments using a Likert scale (1=strongly disagree to 5=strongly agree), yes or no questions, as well as open ended questions. The questionnaire was based on extensive research of existing literature and was divided into sections: introductory questions, influences on and from interdisciplinary collaboration, quality of the HIAs, inf luences of the HIAs specifically health awareness and knowledge, the adoption of

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111 the recommendation into master plans, and wrap up. Questions were developed after completing a literature review of both cross sector collaboration and HIA, the North American HIA Practice Standards, validated survey instruments from Danielle Varda at the University of Colorado Denver who developed a tool ( www.partnertool.net ) that allows public health departments to measu re and monitor their collaborative activity over time, Mathias and Harris Roxas (2009) as well as questions that arose during the review of the South Lincoln HIA. The interview guide was informed and reviewed by those involved with the research; a numbe r of drafts were completed to ensure that the questions, response scales, and the order of the questions were optimal. T he guide was then piloted, which resulted in additional revisions. The interview guide was submitted to the Colorado Multiple Institutio nal Review Board (IRB) at the University of Colorado at Denver for review (protocol number 12 0412) in March, 2012 and was determined not to constitute human subjects research as defined by current policy and regulation. The questionnaire could therefore p roceed, exempt from further IRB oversight. The interview guide, at a minimum, provides data for descriptive cataloguing and a baseline of the status and knowledge, experiences, and perspective on how effective the two HIAs were. These interviews were desi gned to explore relationships and connections and assess the research questions in this study. The interviews also investigated relationships among intervenin g variables such as changes in process during and as a result of completing the HIA, benefits, policy, successes, attributes of and influences from an HIA being completed, and health assessor involvement. Additionally, data from the interviews was used to ascertain what are considered quality HIAs and why, ensure the HIA and cross sector collaboration propositions developed and conceptual framework were on target and reflected the latest thinking. The interview questions in each of the four main research c ategories (independent and dependent variables) are below. There are no specific questions about health supportive language

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112 because the questionnaire was lengthy and the lead researcher was able to get clear answers by conducting a content analysis. Healt h Awareness/Knowledge 1) Was any type of health education/training provided during the HIA process/master plan? 2) Did your level of health awareness increase or not because of the HIA process or health assessor? 3) Can you briefly talk about why you answered this way? 4) Did your level of health knowledge increase or not because of the HIA process/health assessor? 5) If it did increase, what ways did it increase? 6) Did your level of health awareness/health knowledge increase because: a. Health issues raised by community b. He alth Assessor/health expertise being part of the team/process c. Planners or other government staff were concerned about health d. Other design team member being knowledgeable of health e. Elected official concerned about health 7) Do you think more or fewer health is sues were discussed during the master planning process because of the HIA, compared to other planning projects you have worked on without an HIA? 8) Do you believe the HIA contributed to your work? Adoption of Recommendations 1) Did the HIA document influence d ecision making during the master plan process? 2) Did the HIA process influence the master plan? 3) Was health prioritized within the master plan?

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113 4) Broadly, what were the main reasons for not including some of the HIA recommendations into the master plan? 5) How imp ortant is the level of conciseness of the HIA recommendations in terms of whether or not they are incorporated into the master plan or not? 6) What else was needed or could be changed or improved to incorporate more recommendations into the master plan? 7) More broadly, how was the master plan or process changed as a result of having an HIA conducted? Cross Sector Collaboration 1) How would you rate the importance of an interdisciplinary collaborative approach? 2) How effective would you rate the interdisciplinary coll aboration during the South Lincoln HIA/master plan redevelopment process? 3) How would you rate the level of interdisciplinary collaboration of the design team for the South Lincoln master plan? 4) Do you think that all the disciplines jointly achieved an outcom e which could not be achieved by one discipline separately? 5) Had you worked with design team members or the stakeholder group prior to the south Lincoln master plan? If yes, how many did you work with in the past? If yes, positive experience or not? 6) How wou ld you rate the extent to which there was a common, understandable language used among the disciplines on the design team and stakeholder group? 7) To what extent were the following potential outcomes of interdisciplinary collaboration achieved at South Linco ln master plan/HIA? (rating 1 5) a. Improved master plan b. More health awareness among team members

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114 c. You have increased health awareness d. Improved resource sharing e. Improved knowledge sharing across disciplines f. Improved communication (i.e. frequency, modes) g. Improv ed trust and respect for other team members 8) The following lists aspects of interdisciplinary collaboration. How do you feel these aspects contributed to the master planning process if any? (rating 1 5) a. Bringing together diverse stakeholders b. Meeting regular ly c. Exchanging info/knowledge d. Sharing resources e. Strong leadership f. More informed decision making g. Processes, inputs, and outcomes tracked for accountability h. Having a shared mission and goals 9) Can you describe the leadership throughout the master plan/HIA proce ss? HIA Quality 1) Were decision makers [project team and others] interested in the HIA? 2) Were decision makers [project team and others] involved in the HIA? 3) Was your organization/agency notified of the HIA goals early in the master plan/HIA process? 4) Was your organization/agency notified of the HIA process/steps early in the master plan/HIA process? 5) Did your agency/firm/organization have an opportunity to critique or provide comments during the HIA process or the document?

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115 6) Did you feel that the HIA was conducte d in a timely manner? 7) Do you feel the information from the HIA was delivered in a timely manner? 8) How could the HIA have been improved? 9) Did the HIA use evidence based data that supported the recommendations? 10) Was there a comprehensive review of the health is sues in the HIA? Interview P rocedures for Data C ollection. 1) Initial list of potential interviewees for each case began by identifying the project team and other decision makers from the list of people acknowledged in the master plans. 2) All interviewees were initially contacted by email; if no response, follow up reminder emails were sent out and the person was called if still no response. 3) All interviewees were sent the guide in advance of the scheduled interview to be familiar with what questions were to be asked 4) A few interviewees stated they were not able to be interviewed because they were not involved enough in the HIA and sometimes provided another name to potentially interview. 5) Interviews were conducted via telephone or in person by a research assista nt. The interview duration was approximately 45 minutes to an hour. Interviews were carried out with four or five stakeholders from each of the cases (n=9). Interview dates and participants for each of the cases is presented in Table 4. Interviews were rec orded. 6) Interview responses were transcribed, generally within a week or sometimes two (see Table 4). 7) Interviewee responses were sent back to the interviewees to ensure their statements were captured correctly; a few respondents made minor changes.

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116 8) Names o f other potential people to interview were referred by those interviewed. 9) Those who were referred and were part of the project team or were a decision maker were contacted for an interview, but generally there was a short interview list because of the crit eria established. Table 4 : Data Collection of Interviews Cases Date of Interviews Interviews Transcribed Interview Transcriptions Returned and Finalized Decision makers/ Interviewees (For anonymity, most titles are vague) South Li ncoln April/May 2012 (2) April/May 2013 (3) May 2012 *Feb/March 2014 Health assessor consultant; Housing authority, planning consultants (2), elected official NE Downtown November/December 2013 (4) January 2014 *Feb/March 2014 Urban planner, health assess or consultant, planning consultant, community engagement professional *It was decided in January 2014 to return responses to interviewees for comments Content Analysis Content analysis is a research technique used to determine whether certain words or con cepts are within texts or sets of texts (Busch et al., 2012) and for the objective description of the content within written documents (Berke & Godschalk, 2009). This tool quantifies and analyzes the presence, meanings and relationships of words and concep ts, then makes inferences about the messages within the texts, such as the writer (s), audience, culture, and timing. Texts can be defined broadly as books, book chapters, essays, interviews, discussions, newspapers, historical documents, speeches, convers ations, or any occurrence of communicative language. To conduct a content analysis on any such text, the text is coded, or broken down into manageable categories on a variety of levels word, phrase, sentence, or theme and then analyzed. The

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117 specific conten analysis can be thought of as establishing the existence and frequency of concepts most often Content analysis o ffers several advantages (Busch et al., 2012). Specifically, content analysis: looks directly at communication via texts or transcripts and is able to get at the central aspect of the social interaction; can allow for both quantitative and qualitative oper ations; can provide valuable historical/cultural insights over time; is an unobtrusive means of analyzing interactions; and provides insight into complex models of human thought and language use. Content analysis also has several disadvantages, both theore tical and procedural (Busch et al., 2012). In particular, content analysis: can be time consuming; is often devoid of theoretical base, or attempts too liberally to draw meaningful inferences about the relationships and impacts implied in a study; is inher ently reductive, particularly when dealing with complex texts; tends too often to simply consist of word counts; and often disregards the context that produced the text, as well as the state of things after the text is produced. Content analysis procedures for assessing health supportive language are as follows: In the present research, content analysis was conducted on the selected redevelopment plans using NVivo software and word search in Microsoft Word. The content analysis was used to identify the diff erences and similarities in the amount of health supportive language contained in the redevelopment plans. Content analysis yielded quantitative data, as well as contextual

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118 understanding of the data and the ability to compare across different texts within the selected redevelopment plan documents. One means of determining the level of influence the HIA had on the redevelopment master plans was to identify the extent to which health supportive language was incorporated into the plans, as compared with simil ar plans where an HIA was not conducted. Thus, in addition to conducting a content analysis on each of the master plans studied South Lincoln, Northeast Downtown, the lead researcher also analyzed the content of similar type plans (i.e., housing and neighb orhood) that did not have an HIA completed. To identify plans for comparison, the researcher and research assistants conducted an online search and a search on the health impact project website map of completed and in progress HIAs in the U.S. ( http://www.healthimpactproject.org ). Plans that had only diagrams, sketches and very little text were not used in the comparison. The other three housing master plans to be compared with South Lincoln included Yesle r Terrace in Seattle, WA; Braddock East in Alexandria, VA; and Old Colony in Boston, MA. Finding comparable plans to the Northeast Downtown neighborhood plan required a different process from the other types of plans, because neighborhood plans are much more common although this one included about 10 neighborhoods which is unusually high for one plan. Additional criteria were developed to narrow the search: plans were considered that covered large neighborhoods or multiple neighborhoods that were part of or adjacent to a downtown area, contained a mix of uses including industrial, contained a high number of minority residents, had been experiencing decline for the past several decades, plans were created around 2008, and possibly written under similar econ omic situations and planning paradigms. Lastly, the criteria included plans that were written in a similar manner to the NEDNP (i.e., were of a similar length, had substantial text and included an in depth analysis and recommendations). After employing

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119 th plans were selected. Another comparison was also used of station area plans and is in the C hapter 8. Results and Discussion (comparison completed by the researcher for a presentation in 2/2014). Ten station area plans were identified including Central Park Boulevard, CO where an HIA was completed in 2012; the list was ultimately narrowed to four that met all the criteria: Florin Road in Sacramento, CA; 130 th Ave SE in Bellevue, WA; and Alameda in Denver, CO. To conduct the analysis, word search in Microsoft Word was mainly used to determine the number of times that health related words were used in each of the plans. The search included words such as health, bike, walk physical activity, safety, and pedestrian These words were deductively derived from the literature consolidated by the RAs and lead researcher. Words were also inductively developed and added, such as pedestrian friendly Words were also occasionally re document, the included words were scrutinized to ensure proper context. Word counts were entered into a word table with overall word counts for that category pl us specific breakdown of the similar meaning word e.g. (biking versus bicycling). To maximize the reliability of the data, the study implemented intercoder reliability procedures among the researcher and a research assistant (Berke & Godschalk, 2009). Spe cifically, a research assistant randomly selected and tested 10 health supportive words (20% of the three main redevelopment plans.

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120 HIA Recommendation Adopti on Review The document review process assessed the extent to were adopted into the final master plans. This process required carefully reviewing each of the recommendations in each HIA and determining whether the recommendat ions were fully adopted into the master plan, partially incorporated or not adopted at all. The determining factors of how provided. The recommendations were also bro ken down into whether they were related to programs, the built environment, or policies. This information was tabulated in an Excel spreadsheet. Case Study Analysis There are mainly two types of case study analysis. The first is controlled comparison whic h seeks to ensure all variables in the cases are constant except for one, thus furthering scientific explanation of the theories. This analysis is particularly challenging because it is extremely difficult to find two cases that resemble one another in eve ry respect except one. The second technique of process tracing and congruence testing allows a researcher not to replicate the reasoning of such explanation, but to increase confidence in a theory (George & Bennett, 2005). In the present study, data from the different sources listed above were used to inform process tracing and congruence methods. To measure the level of influence of the independent and dependent variables within and across the cases, this analysis breaks out the variables into two levels: potential influences from the HIA on the master plan and on decision makers. This section describes the within case analysis approach of process tracing and congruence with each of the research components. Cross case analysis is also described as a means to effectively analyze the data simultaneously across each of the cases.

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121 Process Tracing and Congruence Process tracing is an integral technique for a case study strategy that requires theoretical narratives and within and across case analysis. This tech nique is an indispensable research method for theory testing and theory development, and it is foundational to the within case qualitative research tradition (Collier, 2011; George & Bennett, 2005). Process tracing in social science is a method for studyin g causal mechanisms linking causes with outcomes (Brady & Collier, 2004). Process tracing enables the relationship between the variables to be examined and the congruence method establishes how congruent (or not) a theory is with the findings of the cases. Process tracing enables the researcher to make potentially strong inferences about how a cause (or set of causes) contributes to producing an outcome. Process tracing generates numerous observations within a case, and the observations must be linked in pa rticular ways to constitute an explanation of the case (George & Bennett, 2005). Process tracing systematically examines evidence in light of research questions and hypotheses posed by the researcher and gives close attention to sequences of independent, d ependent and intervening variables (Collier, 2011). There are three main types of process tracing, including detailed narrative (historical), analytic explanation (theoretical), and a more general explanatory type of process tracing. Analytic explanation converts an historical narrative into a causal explanation couched in explicit theoretical forms. If documenting all steps in a hypothesized process are not possible then the constructs are used in a general explanation rather than a detailed tracing of a causal process. Process tracing can also assess the ways and extent to which possible outcomes of a case were restricted by the choices made at decision points along the way. For example, a proposition states that the timing of completing an HIA is importa nt to its success; using process tracing, this assertion can be examined, which can add to the further development of theory and possibly testing of the theory if it is developed enough to make predictions. It is important to not only

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122 examine the hypothesi s of interest but alternative hypothesis and eliminate alternative causal processes that might lead to the same outcome (George & Bennett, 2005). Process tracing begins with a good narrative or with a timeline that lists the sequence of events, followed by an exploration of the causal ideas embedded in the narrative and events, consideration of the kinds of evidence that confirm or disconfirm these ideas, and testing of the evidence using propositions (Collier, 2011). There are two key limitations to proces s tracing. One is that for process tracing to provide a strong basis for causal inference, an uninterrupted causal path linking the accepted causes to the observed effects must be established at the level of analysis appropriate to the theory being tested. Process tracing can only reach provisional conclusions when data are unavailable or theories are indeterminate. A second limitation is that there may be more than one hypothesized causal mechanism consistent with any given set of process tracing evidence. However, even if it is not possible to exclude all but one explanation for a case, it may be possible to exclude at least some explanations and thereby to draw inferences that are useful for theory building or policymaking. The congruence method can combi ne with process tracing to assess whether the congruence between independent and dependent variables is causal or spurious. The congruence method can also enrich and refine theories (George & Bennett, 2005). Data from the different methods listed above we re used for the process tracing and congruence method. This was completed by identifying causal links to further develop current theory. Also relationships and observations across the independent and dependent variables were identified to explain and furth er develop the theory by using propositions and Standards to support or not the evidence and more broadly how the variables influence the master plans and decision makers. Each of the proposition and Standards serves to focus the data collection, assist wi th determining the direction and scope of the influences and form the foundation for the typologies that through a methodical review of the evidence can inform the process tracing and

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123 congruency for analysis. Also detailed analysis using the documents and interviews can address the counterfactual, e.g. consider what might have happened without HIA intervention or did change occur anyway because of other factors. The researcher developed the H IA Effectiveness/Influence typology to assist with the within case and across case as part of the process tracing and congruence analysis. Two d ifferent typology levels were provided for the effectiveness analysis portion of the two case studies, with a contrasting low and high level of influence with each level defined in detail. The goal of establishing these typologies was to further demonstrate: 1) whether and what differences there low or high levels of influence on their mas ter plans; and 3) whether the research outcomes follow the propositions and what was hypothesized. The typology analysis more methodically assists to establish the level of agreement and understanding on whether the master plan was influenced by the HIA an d in what specific ways. For purposes of this research a checklist for high and low level influence was developed and is organized b y variables and made up of propositions developed from the literature, HIA Practice Standards, and other newly identified m easures from this research that inform this typology about influences from the HIA. The typology helped establish the level of agreement and understanding on the contextual conditions of the cases and theoretical support about whether the master plan and d ecision makers were influenced by the HIA and in what ways. The list below includes some of the propositions with references used to develop the typology. Timing of the assessment fits within the decision making process (NAS, 2011; Davenport et al., 2006) Decision makers are involved in the design and conduct of the HIA (Metcalfe & Higgins, 2009; Davenport et al., 2006; NAS, 2011) HIA is conducted by an expert assessor (Davenport et al., 2006)

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124 Other sectors have health awareness ( Davenport et al. 2006) Cross sector collaboration is supported (Forsyth et al. 2010; Slotterback et al., 2011 ; Metcalfe & Higgins, 2009; Mannheimer et al., 2007) HIA is non controversial ( Davenport et al., 20 06) Recommendations are realistic ( Davenport et al., 2006) Cross sect or collaboration is determined through factors that supports more success such as leadership, communication, partnership relationship, resources, prior team history, and having structure/processes in place. The checklists (high and low) shown below ha ve k ey findings and measure s to be checked as being met or not to sho w levels of influence and overall effectiveness of the HIA on the master plan and decision makers. T o further clarify, each measure is labeled to better understand its context whether it orig inates from a standard, proposition or a measure newly identified. The measures newly identified are shown with a (N), propositions (P), and Standards (S). Low effectiveness/influence for each variable might include: Independent Variables HIA Quality: Completion of HIA too close to completion of master plan (S & P) Recommendations not supported with evidence based data (S & P) Scored between 1.8 and 2.1 against the Standards (S) (low level determined score to half way into medium level) Health assessor not experienced (P) n HIA goals and process not explained early in planning process (S) Little review or critique of HIA by decision makers (S & P)

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125 Decision makers not involved in de sign and conduct of HIA (P) Little quantification of impacts, (where possible) (S & P) Little local/neighborhoo d level data, (where possible) (N) People outside the decision making process did not provide input (S & P) Lacked a consistent and appropria te m ethodological approach (P) Cross Sector Collaboration: Little cross sector collaboration among project team members (P) No formal stakeholder group (S) Low level project team communication (P) rative work (P) Little history with project team; negative past experiences (P) HIA assessor is isolated from decision makers in master planning process (P) Provided no or little input from Stakeholder group (P & S) Poor leadership from decision makers (P ) Little poli tical support for HIA (P) Little participation/input from other disciplines during HIA and planning process (P) Little engagement in HIA from decision makers (P) Little/not enough resources to conduct HIA (P) Understanding little about perspe ctives of partner organizations and team members (P) Dependent Variables Recommendation Adoption: Few (< 50%) HIA recommendations adopted into planning document (N) Few decision modifications of master plan (P) Unrealistic recommendations (P)

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126 Recommendatio ns are not specific to the neighborhood (where possible) (N) HIA is controversial (P) Little to some evidence based data to support recommendations, where possible (P & S) None or few clear and concise recommen dations (N) Little shaping of recommendations to reflect organizational concerns (P) Health Awareness and Knowledge: Few presentations or means to share data/findings (e.g., < 2 community meetings) Little awareness of health gained by other project team members (P) Little tai lored presentation of findings (P) Little or no increase in knowledge of HIA an d/or health by decision makers (P) Little to no education provided about HIA and health (P) Health Supportive Language: Master plan doe s not have significantly more health supportive related words than other, similar plans (N) High influence/effectiveness for each variable might include: Independent Variables HIA Quality: Completion of HIA in reasonable time that fits within the decisio n making process (P) Scored between 2.1 and 2.4 against Standards (S) (split between 1.8 and 2.4) HIA met all 15 required general practice standards (S) An HIA assessor engaged in master planning process (N) Health assessor is expert/ experienced in conduct ing HIA (P)

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1 27 HIA goals and process explained early in planning process (S) Opportunities for review of HIA by decision makers (S & P) Decision makers involved in design and conduct of HIA (P) Quantification of impacts, where possible (S & P) People outside the decision making process provide input (S & P) Use of a consistent and appropriate methodological approach (S & P) Collaboration : High level cross sector collaboration among decision makers (P) Organized and provided and received input from Stakeholder group (P&S) Strong leadership (P) Political support for HIA (P) Collaboration considered to be important among team members (N) Participation/input from other disciplines during HIA process (P) Strong engagement in HIA from decision makers (P) High level of communication (P) Processes in place for project team collabora tion (P) History with project team with positive past experience (P) Resources to conduct HIA (P) Understanding priorities and perspect ives of partner organizations (P ) Dependent Variables HIA Recommendation Adoption : Majority, >50% of HIA recommendations incorporated into planning document (N) Evidence based data inc luded in HIA, where possible (P &S) Clear and concise recommendations (N)

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128 Shaping of recommendations to reflect organizational concerns (P) Realistic recommendations (P) HIA is non controversial (P) Health Awareness and Knowledge: Presentations or other means to share data/findings (e.g. >2 community meetings) Educate practitioner s about the policy process Increased awareness of health by team members and other decision makers (P) Tai lored presentation of findings (P) Greater knowledge of health by decision makers (P) Training provided about HIA and health (P) Education provided about HIA and health (P) Health Supportive Language: Master plan has significantly more health related words than other, similar plans (N) Table 5 is the HIA Effectiveness/Influence Typology Analysis that presents outcomes from the checklist analysis above. The outcome information for this table is describ ed separately in each case chapter and outcomes for both cases are shared in Results Chapter 8. Table 5 : HIA Effectiveness/Influence Typology Analysis Cases Rate/level of Collaboration Quality of HIA Level of Adoption Health suppor tive language Health awareness/ knowledge Outcome (by case) South Lincoln High High High High High

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129 Table 5 cont.; NE Down town Low Low Low Low Low Content Analysis of Health Supportive Language NVivo and word searches in Microsoft word w ere used to perform a content analysis to tabulate the frequency and word order of health supportive language, compared to other phrases and concepts. The initial list of health supportive words included 29 items, and inductively 33 were added for a total of 4 6 Addit ionally, words related to socioeconomic status (SES) such as occupation education and income were added much later. The content analysis of the new words inductively added and the SES words was performed using Microsoft Word. The analysis determined whet her the health supportive words were absent or present and how many times the word was used in a health supportive context. Interview Data Techniques for data analysis that were used for the interview data such as pattern coding was a way of grouping large r summaries of data into smaller number of sets, themes, or constructs. Pattern matching compared an empirically based pattern with a predicted one (or several) and linking data to propositions (Miles & Huberman, 1994), such as those described above in the typology checklist. Miles & Huberman ( 1994 ) emphasize that during analysis it is important to return to the propositions (if any) for more focused analysis and confidence in the finding, and to determine the number of propositions and rival propositions t hat were addressed, accepted, or rejected.

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130 A thematic and pattern analysis that involved coding was conducted with the combined transcripts of the interviewees for each case to identify not only themes that emerged from the interview but causes/explanation s, and relationships among disciplines, as well as to test the propositions and theoretical constructs. Identified patterns and themes were used to code and subcode the transcripts, so details on particular themes could be characterized, compared and contr asted across respondents and cases. This process began with using the headings within the questionnaire for deductive codes based on the literature and descriptive codes and followed by using patterns and themes that emerged from the data to generate induc tive codes. Broadly, the interviews assisted with understanding cross sector collaborative efforts, influences on and changes to decision making within the master plans, health awareness and knowledge or decision makers, and the quality and effectiveness o f the HIA documents and processes. segments of data that depict what each segment is about. (p. 111). Charmaz also states that coding distills data, sorts them, and pr ovides an opportunity for making comparisons with other segments of data. One type of coding is descriptive codes, which entail little interpretation. Pattern coding were also used in this study and are more inferential and explanatory as pattern matching consolidates material into more meaningful data (Miles & Huberman, 1994). For this research, pattern matching or pattern coding began prior to data analysis with a provisional start list that was derived from the conceptual framework, research questions an d propositions. For example, initial broad pattern codes were Patt for pattern, TH for theme, CL for causal link that were adapted from Miles and Huberman (1994). The coding analysis process began with a compilation of the responses for each question from each interviewee from each of the cases. The questions that required respondents to give numeral ratings and responses were put into an Excel 2012 spreadsheet. The qualitative transcript data w ere put into a Word document for each case for coding. Descrip tive, themes and pattern

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131 coding labels were placed in the margin next to each question and transcripts. NVivo software was not used because there was not enough text; there are four to five respondents per case. These coding labels were then entered by cat egory into a table. The deductive codes were applied to the initial few interview transcripts, and examined closely for fit and power. Quite a few codes were revised, but the broad conceptual coding framework was determined to be helpful for fit. Next, a m ore grounded or inductive coding process began with the general conditions, relationships among decision makers/project team, and emerging constructs. Operational definitions were developed for some of the codes to ensure clarity and so that codes could be applied consistently across different researchers, particularly with the broader codes. The inductive coding was applied for more context sensitive analysis and identified regularly occurring phrases. For both deductive and inductive coding techniques the goal was to match the observations to the propositions. Coding tables were ideal for data entry and analysis and were chosen rather than using statistical techniques, which were inapplicable because the study populations was not large enough (Seawright & Gerring, 2008). The limited number of subjects being interviewed would not yield enough power to make any type of statistical assessments with confidence, therefore, the use of statistical software was purposefully excluded. In addition, the purpose of th e study was to not only answer the research questions but possibly test propositions and develop theory, which fits best for case study, qualitative analysis. Document Review: HIA Quality and HIA Recommendation Adoption To indicate the quality of the two HIAs, adherence to each of the standards was assigned a point value: 0 for not present, 1 for low, 2 for medium, and 3 for high. (This scoring process is similar to that undertaken with other types of Standards such as LEED ND.) The scores were

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132 averaged in order to assess the overall quality of the HIA. Standards marked N/A were not given a score and were excluded from the average. In order to determine the overall quality rating for the HIA, numerical scores were defined for each of the HIA. If the average score fell in the 80 th average score fell below the 80 th percentile but above the 60 th percentile (scores between 2.34 and th percentile (<1.8) would in an Excel spreadsheet for each of the HIAs. For the HIA recommendation adoption analysis, the rese archer determined exactly how many and what the total percentage of HIA recommendations were adopted, along with how many were fully or partially adopted, and which of those adopted recommendations were considered related to a program, the built environmen t, or a policy for each of the cases. Cross Case Analysis There has been a substantial growth in studies of complex settings using multi case designs, often with multiple methods. Each case is understood in its own terms, yet a comparative examination acro reasonable question is, do these findings make sense beyond this specific case? At a deeper level, the aim of cross thoroughly complete the analysis of each case bef ore proceeding to cross case analysis, and the

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133 across variables, proposition s and standards that includes to summarize outcomes of analysis.

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134 CHAPTER VI SOUTH LINCOLN HOUSING REDEVELOPMENT CASE Chapter Outline This case study examines whether the Health Impact Assessment (HIA) conducted of the South Lincoln Housing Redevelop ment in Denver, Colorado influenced decision making within the redevelopment plan. Did the completion of the HIA result in the adoption of healthier and safer options in the South Lincoln/La Alma Housing Master Plan (South Lincoln Plan)? The first section of this case study introduces the context of this case and includes a condensed description of the methodology used, including the research questions used to frame the data collection and analysis. Next, the methods, data collection, analysis, and limitati ons of the three main research study areas are presented, followed by results and a broader discussion and concluding remarks. Introduction This study focuses on three main study areas: the outcomes of the HIA and its influences on the decisions makers an d the master plan, the quality of the HIA, and cross sector collaboration. The influences examined include the extent to which the HIA recommendations and health supportive language were adopted into the South Lincoln Plan (master plan outcomes), as well a s change in health awareness and knowledge of project team members and other key decision makers. The study centers on two independent variables: quality of the HIA and cross sector ty assessment is unlikely practice standards in hopes of improving the quality of HIAs. Little evaluation has been

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135 conducted about the quality of HIAs, and the focus of this dissertation research was whether greater quality is reflected in more or less positive master plan outcomes and change in health awareness and knowledge. The second variable, cross sector collaboration, has been identified as an important b enefit of conducting HIAs, but there is less research documenting whether successful cross sector collaboration improves master plan outcomes and/ or improves health awareness and knowledge. The case study was designed to test hypotheses that more success ful collaboration results in 1) higher quality HIAs, 2) more successful master plan outcomes, and 3) increased health awareness and knowledge among decision makers. In short, it is hypothesized that the HIA influences the master planning process and decisi on makers in positive ways. More specifically, it is anticipated that if the level of collaboration among project team members with varied expertise and other decision makers (e.g. elected officials) is high and the quality of the HIA is high, then the deg ree to which the HIA recommendations and health supportive language are awareness and knowledge. The opposite should also be true. If the independent variables are low, then the dependent variables are also low. Prior to this study, these variables and associations had not been directly researched abroad or in the U.S. Although challenging, this study attempted to link planning decision making outcomes with comp letion of an HIA. The linkage can be hard to distinguish because there are many indirect impacts and equally important intangible benefits that may be gained from the HIA and the planning process. Background of South Lincoln HIA Case In 2009, Mithun, an a rchitectural and planning firm selected to be the master planner for the South Lincoln Housing Redevelopment in Denver, sub contracted with EnviroHealth

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136 Consulting to conduct an HIA on the housing redevelopment and surrounding neighborhood. Denver is the most populous city in Colorado with a population of 600,158 (U.S. Census Bureau, 2010). In the South Lincoln neighborhood, residents are predominantly Latino, approximately 38% of residents live in poverty, and approximately half of the children are poor (Piton Foundation, 2009). Located adjacent to an existing light rail station, the South Lincoln Housing oal to promote transit oriented development (the creation of compact, walkable communities centered around access to train systems) The purpose of the HIA was to assess current conditions; identify health issues and risks through evidence based and commun ity data; and provide specific policy, program and built environment recommendations for the South Lincoln neighborhood before completion of the master plan. The Denver Housing Authority (DHA) oversaw, funded, managed, and was the lead decision maker for green, healthy, desirable, and safe neighborhood. At the time the HIA was conducted, the So uth Lincoln into a mixed income, mixed use development with added public housing and new market rate units that together would triple the population of the neighborhood 1 Gentrification was not a significant issue with this redevelopment because current pu blic housing residents in the development would continue to have public housing when the construction is completed, and during the redevelopment residents were provided with temporary housing close to the neighborhood. 1 http://www.denverhousing.org/development/SouthLincoln/Documents/D.%20Master%20Plan SoLi FinalReport JAN%202010%20 %20PART1.pdf

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137 Overview of Data Collection and Stak eholder Engagement The HIA was conducted using the Healthy Development Measurement Tool (HDMT) developed by the San Francisco Department of Public Health (2006). The HDMT is a comprehensive metric checklist with indicators used to consider the health needs of residents potentially impacted in urban development plans and projects. In addition to the HDMT, the HIA used evidence based research, interviews and focus groups with community members and organizations, feedback from an elected official who represent ed the neighborhood, the steering/stakeholder committee members, and walkability and food audits tools that focus on the walking environment and healthy food options. The steering committee was made up of 26 stakeholders who met once a month before the com munity meetings. The steering committee members included decision makers from city council, multiple agencies and community organizations; nine of the 26 members were community residents who regularly participated in the meetings. Participatory strategies and activities were specifically employed in order to build relationships among the residents and those serving them as well as to gather community input and share information about the redevelopment. Lastly, the HIA drew data from two available surveys al ong with agency data from the Denver Police, Environmental Health, Community Planning and Development, DHA, Public Works, and other agencies. The collected data, other available documents, and information exchanged with project team members were analyzed a nd summarized into 61 HIA recommendations. The South Lincoln HIA was used to inform the master plan and was completed before decisions were finalized. Specifically, as the HIA was being completed, EnviroHealth Consulting sent drafts to Mithun and presente d monthly updates to the project team, steering/stakeholder committee, and the larger community. After the start of the HIA and master planning process in April 2009, an initial draft HIA was completed in June to provide a summary of collected data

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138 and hel p identify issues. In September, EnviroHealth Consulting sent a complete draft to Mithun for comments, with the final version completed in November 2009. The HIA was released in early 2010 with the master plan. This timing gave the planners within the City Mithun, and other decision makers the opportunity to learn about, review, and provide input into the HIA as it unfolded. Case Study Methodology This exploratory, retrospective case study design used a mix of quantitative and qualitative methods, each br iefly mentioned here and explained more fully within each of the research sections. These methods included a quantitative content analysis of the South Lincoln Plan, document reviews, and semi structured interviews with a purposive sample of project team m embers and other key decision makers. The central research questions are the following: How do health impact assessments influence decision making in redevelopment master plans, specifically the amount of HIA recommendations adopted, health supportive la nguage used and change in health awareness and knowledge of the decision makers? How do variables such as cross sector collaboration and the quality of the HIA influence whether the HIA is more or less effective in influencing decision aware ness and knowledge and health related master plan outcomes such as the adoption of HIA recommendations and health supportive language ? Decision makers could be from public or private planning organizations, public health, housing and other professionals, and elected officials involved in the master plan and the HIA. Five key decision makers responded to the questionnaire that cut across the different research components. The questionnaire addressed the research questions related to HIA influences on the ma ster plan and decision makers, HIA quality, and

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139 cross sector collaboration. The interview questions included both quantitative measurements using a Likert scale (e.g., 1=strongly disagree to 5=strongly agree), yes or no questions and qualitative data from open ended questions. The interviews were conducted to measure the perceptions of those on the project team and other decision captured in the research using other methods. A co py of the interview guide is in Appendix A. The analytic framework consists of interview data combined with document data from HIA and master plan coded to identify manifest and latent themes. Word searches in Microsoft Word were mainly used for the conten t analyses. Comparisons were made with other housing master plans that did not have an HIA completed e.g., identifying the frequency of the use of health supportive language across the documents. Lastly, the South Lincoln HIA was analyzed for its quality u sing the 2010 Practice Standards for Health Impact Assessment and scores were incorporated into an Excel spreadsheet. As part of improving the integrity and trustworthiness of the qualitative and quantitative research in this study, it is necessary to dis close the dual role of the lead researcher. The author experiences and role of the lead researcher is important for being clear about potential bias, reducing it and still potentially enriching the study. In this study, research assistants were employed throughout the different research phases to help the lead researcher obtain a more neutral position during the study, to help ensure that the research was not skewed in a particular direction and to improve reliability. For data collection and analysis, all interviews were conducted by a research assistant and two research assistants along with the lead researcher reviewed all documents and conducted the scoring to improve accuracy and reduce potential bias.

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140 Section 1. HIA Influence on the Master Plan and Decision Makers This section focuses on the dependent variables and strives to answer the first main case study research question: How do HIAs influence decision making in redevelopment master plans, specifically the adoption of HIA recommendations, health supportive language used, and change in decision reness and knowledge? The first part of this section lays out the methods, data collected, and findings focused on health supportive language; the second part has similar information for the adoption of the HIA recommendations into the master plan and last ly, health awareness and knowledge. The specific questions explored in this section include: How much health supportive language is in the master plan relative to other housing master plans without an HIA? ed into the master plan? Of the HIA recommendations that were adopted, how many were adopted that focused on changes to policies, built environment or programs? Of the HIA recommendations that were adopted, were they partially or fully adopted in the maste r plan? Which health categories in the HIA document had the most and fewest recommendations adopted? knowledge increase because of the HIA, and what factors contributed to these outcomes?

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141 Housing Master Plan and Outcomes Comparison of Health Supportive Language Methods Determining the level of influence the HIA had on the South Lincoln Plan began with identifying the extent to which health supportive language was incorporated i nto the plan. A content analysis was conducted on the South Lincoln Plan and three additional housing master plans as a comparison. The other three plans examined were the only ones identified through an online search for housing master plans; those with o nly diagrams, sketches and very little text were not used in the comparison. An HIA was not conducted prior to the development of any of the three comparison plans. The other three housing master plans examined included Yesler Terrace in Seattle, WA; Bradd ock East in Alexandria, VA; and Old Colony in Boston, MA. A word search began the process of identifying the extent to which health supportive language was incorporated into the plans. The search included words such as health, social equity, bike, walk, p hysical activity, safety, and pedestrian friendly (see Table 6 for the complete list for all four housing master plans). These words, phrases or acronyms came inductively while conducting word searches and deductively from the literature consolidated by th e Research Assistants (RAs) and lead researcher. Once found within the document, the words were scrutinized to ensure proper context. To improve the validity and accuracy of the research, an RA selected 10 words, phrases or acronyms randomly (20% of the to tal 56, combining totals from Table 6 and 7) and completed the content analysis. All 10 words were deemed correct by the lead researcher.

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142 Data Collected and Findings Table 6 displays the four housing plans that were compared for their use of health suppor tive language. As background information, Table 6 includes the name of the plan, lead agency for completing the plan, what year the plan was adopted, whether an HIA was conducted or not, and the number of pages of each of the plans. Along the bottom of the table are the total number of words that were reviewed and the total number of health supportive words for each of the plans. Table 6 : Content Analysis of Housing Master Plans Plan Name South Lincoln Yesler Terrace Old Colony B raddock East Lead Agency Denver Housing Authority Seattle Housing Authority Boston Housing Authority Alexandria Dept. of Plan. & Zoning Adopted January 2010 May 2011 Feb 2011 Oct 2008 HIA conducted Yes No No No Pages in plan 28 20 115 88 Categories health, healthy, healthier, healthiest 37 health (21), (y) (14), (ier) (2) 11 health (3), (y) (6), (ier) (1), (iest) (1) 26 health (22), healthy (4) 2 health (2) bicycle, bike, biking, bicycling 23 bicycle (7), bike (15), biking (1), 2 bike (1), bic ycling (1) 9 bicycle (5), bike (3), bicycling (1) 9 bicycle (2), bike (5), biking (2) pedestrian(s), pedestrian friendly 36 pedestrian(s) (34), pedestrian friendly (2) 13 pedestrian(s) (13) 34 pedestrian(s) (34) 49 pedestrian ( s), (46), pedestrian frien dly (3) Health Impact Assessment, HIA 11 Health Impact Assessment (3), HIA (8) 0 0 0

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143 Table 6 cont.; safety, safer, safe, safely 30 safety (15), safe (13), safely (2) 6 safe (6) 15 safety (7), safer (1), safe (7) 19 safety (8), safeguarding (1), safe (10) access to health 1 access to health care 0 0 0 social cohesion, social capital, social interaction, social needs, social network, social activities, social gatherings 22 social capital (9) social cohesion (11), social activities (1), social interact ion (1) 3 social needs (1), social interaction (2) 4 social activities (3), social gatherings (1) 2 social network (2) social equity, health disparities, health equity, equity, disparities, inequalities 12 health equity (1), social equity (1), equity (7), food disparities (1), socioeconomic disparities (1), inequalities (1) 1 social equity (1) 0 0 walk, walking, walkways, walkable 22 walk (11), walking (8), walkways (1), walkable (2) 2 walking (1), walkable (1) 9 walk (3), walking (4), walkable (2) 37 Wa lk (16), walking (11), walkable (10) physical activity, exercise 5 physical activity (2), exercise (3) 0 8 exercise (8) 1 exercise (1) overweight, obese, obesity 2 0 0 0 LEED, Energy Star 12 LEED (10), Energy Star (2) 0 7 LEED (3), Energy Star (4) 2 LE ED (2) market, market, garden, gardening urban market 30 food (4), (1), garden(s) (23), gardening (1), urban market (1) 8 nutritious food (1), grow food (1), gardens (3), gardening (3) 40 food (22), food bank (5), food s tamp(s) (6), garden (1), market (1), market (5) 0 Total (46 words) 243 46 152 121

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144 Table 7 focuses on identifying how many socioeconomic (SES) specific words (e.g., education, occupation, and income) that are part of the broader social determ inants of health that are in the master plans. These health related words and phrases were broken out from the above table to better examine the differences in the plans since a stated attribute of HIA in the literature is to bring awareness to, positively influence, and potentially improve the SES status in communities through enhancements in planning and policy efforts. Table 7 : Socioeconomic Status Related Content Analysis of Housing Master Plans socioeconomic, socioeconomic st atus, SES 1 socioeconomic 0 0 0 income(s), low income 9 income(s) (6), low income (3) 26 income(s) (5), low income (21) 15 income(s) (9), low income (6) 92 income(s) (52), low income (40) job(s), employment, occupation 4 job(s) (3), employment (1) 9 jo b(s) (5), employment (3), occupations (1) 27 job(s) (21), employment (6) 8 job(s) (8) education(al) 6 6 34 7 Total (10 words) 20 41 76 107 Overall, the South Lincoln plan had the most health supportive phrases words with 242 compared with the other thr ee plans with 152, 121, and 46 each. In the South Lincoln Plan, the words walking physical activity and HIA appeared along with many other health related words (see Table 6). The word health appears a total of 21 times. This makes it the 39 th most used wo rd in the document (when removing common articles, prepositions, state of being verbs and words appearing in the title block). The word healthy appeared 14 times, making it the 95 th most common word. When combining the words, health/healthy/healthier appea red 72 times (35 were making it the 19 th most used term in the document. This places health/healthy at the same high

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145 level of use as words such as site residents and transportation which would be expected to be used frequently in a master plan for a large redevelopment. The words health impact assessment and HIA were referenced 11 times in the South Lincoln Plan. This is important since the decision makers of the master plan were not required to use the term HIA or even reference the document at all. It is encouraging how often the HIA was referenced, particularly considering how concisely the master plan was written, with little room for extra or non essential po ints, and it suggests that decision makers considered the HIA worthwhile. The South Lincoln Plan had the most references to health and planning related words in all categories but three (had 243 words or phrases in total, which is 43.2% of the total numb er of words for all the HIAs combined, 562, not included SES specific words). Braddock East counts were highest for walk and pedestrian and Old Colony counts were highest for food and exercise (see Table 6). Based on the four master plans, the data sugges t that the number of pages in the master plan is not as significant a determinant of the amount of health language as is prioritization of health and whether an HIA is conducted. This is meaningful in that although there is a significant difference in the number of pages among the documents, there are far more health supported words and phrases in the plan with an HIA despite the fact it is not the longest plan. Interestingly, when separating out the socioeconomic status (SES) related words such as educat ion, income and occupation (including jobs and employment ), the South Lincoln plan was similar or low in word counts compared to the other plans. There also seems to be an anomaly in the Braddock East master plan in its use of the words income and low inco me The difference between its 92 references and the next closest total of 26 references is 66 ( s ee Table 7). With less or lower SES language used in the South Lincoln master plan, possibly more emphasis was needed by the health assessor in this specific a rea of SES, although more equity/disparity type words were in the South Lincoln plan. The health assessor/HIA was not as impactful in this area unlike seemingly health and planning focused words. The South Lincoln HIA was searched for

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146 SES words for compa rison and has a total of 62, which also seems low, and is not that much more compared to the South Lincoln master plan. Follow up research is needed to focus on the health assessor role in better communicating SES issues, and the HIA process and document r elated to SES to better understand if there could be better results and if so, how? Adoption of HIA Recommendations Methods Assessing the adoption of the South Lincoln HIA recommendations into the final master plan required an in depth review of each of the recommendations presented in the HIA as well as the master plan document. There are only a few published studies that identified changes in the adoption of recommendations due to the conducting of an HIA, and they are in New Zealand and Australia (Mat hias et al., 2009). A search was completed of each recommendation, and it was determined whether the recommendations were fully adopted into the master plan, partially incorporated, or not adopted at all. The recommendations were mostly written as specific actions to take so they were easier to track whether adopted or not. The recommendations were also broken out by how many called for a policy or program versus addressing the built environment directly. Lastly, the recommendations were additionally broken out by the sections/ chapter titles within the HIA document to determine recommendation adoption in terms of chapter topics, such as safety. A ll of the above was documented in an Excel spreadsheet. Additionally, a few questions were included in the quest ionnaire about the adoption of the recommendations, and a within comments. The quantitative responses were added up and divided by the total possible number of points for a score for each question (see Table 10). Two research assistants (RAs) and the lead researcher completed each of the steps.

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147 The following list describes the general reasons and examples of how the lead researcher and RAs determined whether a recommendation was labeled fully adopt ed or partially adopted. 1) Partially adopted: The master plan adopts the main premise of the recommendation but does not comply with the specifics in the recommendation. For example, finding map at the 10th and Osage light rail transit station that clearly shows community assets and amenities there will be an information kiosk at the event plaza and a res ource center in one of the buildings on block A (section of the redevelopment), which is near the light rail station. While the plan has thus complied with the main premise of providing way finding as well as local information, it does not specifically men tion anything at the light rail stop and other details. Therefore this recommendation was only partially adopted. 2) king demand through unbundled parking (charging for parking costs separate from residential/commercial property/rental parking for the buildings on the site that they per sonally construct and manage. However, because not all the properties will be under their jurisdiction (e.g., for sale units and commercial space), the recommendation is only partially adopted. 3) Partially adopted: Recommendation 3b is an example of part of the recommendation and collaborate with Santa Fe artists and nearby students to develop signage markers to mark the routes and denote number of walking steps or mil eage between certain

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148 and 1 mile loops, but fails to say anything about signage; therefore it is only partially adopted. 4) Partially adopted: The recommendation is too detailed to be incorporated into the master plan. some residents and can be a wonderful place for naturally assembling people but must be designed and managed carefully so [there is] no stagnant water for mosquito breeding; filte ring of water for designs where water shoots up and kids can stand over it (spray etails, so this recommendation was only partially adopted. 5) in angle parking provides safety benefits for lower speed roads such as 10th Street promenade and 11th in front of currently city regulations do not allow for this type of parking. 11th Avenue between Osage and Mariposa Streets: back in angled parking adjacent to Dat a Collected and Findings Table 8 displays the number of recommendations and other categorical information such as the determination of degree to which the recommendation was adopted, and whether the recommendations focused on policies, programs or the buil t environment.

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149 Table 8 : HIA Recommendation Adoption Levels Case Study Total # # Adopt ed % Adopted Fully Adopted Partially Adopted Not Adopted Built Environment Programs Policies South Lincoln Plan 61 37 61% 24 (65%) 13 (35%) 24 ( 65%) *36 27 Adopted 9 Not Adopted 75% Adoption *20 9 Adopted 11 Not Adopted 45% Adoption *7 4 Adopted 3 Not Adopted 57% Adoption *Two recommendations had a split of being both related to the built environment and a program, and built environment and a policy for a total of 63 recommendations. The HIA included a total of 61 recommendations, of which 37 were adopted into the master plan for an overall adoption rate of 60.6%. Without a comparison, it is difficult to attribute the adoption rate to the HI A. Of the 37 recommendations adopted, 24 (65%) were fully adopted into the master plan, 13 (35%) were partially adopted into the master plan for a total of 37, and 24 (39.3%) were not adopted at all (see Table 8). Considering the HIA was focused on a redev elopment project, it was not surprising that the built environment had the greatest number of recommendations incorporated (36); second was programs (20), and third was policies (7) shown in Appendix B, Table 2 Also not surprising since this is a redevelo pment plan, is that the majority of the built environment recommendations were either fully or partially adopted (27 out of 36 or 75%), compared to policies (4 out of 7 or 57% adoption) and for programs (9 out of 20 or 45%) as shown in Table 8 The rate of adoption of the built environment recommendations would be assumed to be higher than the other two categories but it is still impressive at 75%; >50% of policy recommendations were adopted, and just under 50% of program recommendations were adopted, which are also striking because policies and programs would be far less likely to be in a redevelopment master plan. The full list of all recommendations is in Appendix B, Table 1. Table 9 displays the adoption levels of the recommendations broken out by the HI health categories/sections; these are in order from most to least adopted within each category.

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150 These categories were developed by the health assessor by grouping the recommendations together. Table 9 : HIA Adoption Specific to Sections in the HIA Document Sections within HIA document # Adopted out of total recommendations in section % Adopted within section Opportunities for all Users 1 of 1 100% Natural Environment 9 of 11 81% Built Environment & Transportation 6 of 8 75% Healthy Eating 3 of 4 75% Social and Mental Wellbeing 7 of 11 64% Safety 8 of 17 47% Access to Amenities 3 of 9 33% The HIA recommendation adoption rates within specific sections of the HIA document are displayed above. The fewest ado pted recommendations were in the Access to Amenities section (33%) (see Table 9), which included recommendations such as expanding a shuttle service and partnering with the local library; this section also listed grant opportunities, which would make progr ammatic changes possible. The Opportunities for All Users was the most adopted category with a 100% although there was only one recommendation and it was focused on the requirements for the American Disabilities Act. Again, since this HIA focused on a rede velopment project, it is not surprising that the second and third most adopted categories were the Natural Environment (81%), and the Built Environment and Transportation (75%). The former included incorporating low impact development techniques and noise barriers, and the latter included more typical planning issues such as improving bike facilities and walking routes. However, it is noteworthy that the Opportunities for Healthy Eating category had a 75% adoption

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151 rate; this included recommendations about p roviding incentives and/or space for a small neighborhood store to expand access to fruits and vegetables. recommendations and the outcomes of interdisciplinary collaboration specific to this study section. The first column displays the questions pertaining to this study section; the second column notes the responses, including the number of each of the responses from interviewees (n=5) followed by a dash ( ) and the selected L ikert scale response (e.g., 3), and what that N/A was an option if the respondent did not feel the question was applicable to them. The third column has the overall score for that question and the percentage in order to better compare across questions. Twenty five is the total number possible for each question because there are a s). For example, the first question below the respondents had a total of 18 points (5+4+9) that is divided by 25 for a percentage of 72% out of 100%. Some questions did not offer an opportunity to comment with a qualitative response. Table 10 : Questionnaire Responses for This Study Sectio n Question Responses Score / Percentage The HIA document influenced decision making during the master plan process? 1 5 strongly agree 1 4 agree 3 3 neither 18/25 72% The HIA process i nfluenced the master plan? 3 5 strongly agree 1 3 neither 1 2 disagree 20/25 80%

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152 Table 10 cont.; How important is the level of conciseness of the HIA recommendations in terms of whether or not they are incorporated into the master plan or not? 3 5 high 1 3 med 1 N/A 18/20 90% Did your level of health awareness increase or not because of the HIA process or health assessor? 1 5 high 2 4 medium high 1 3 some 1 2 medium low 18/25 72% Do you believe the HIA con tributed to your work? 3 5 high 2 4 medium high 23/25 92% Do you believe you contributed to the HIA? 2 5 high 1 4 medium high 1 3 some 1 2 medium low 19/25 76% Did your level of health knowledge increase or not becaus e of the HIA process/health assessor? 3 5 yes 1 0 no 1 not sure 15/20 75% Below is one question with many follow up questions. To what extent were the following potential outcomes of interdisciplinary collaboration achieved at the South Lin coln Plan/HIA? Improved master plan 3 5 completely 2 4 somewhat completely 23/25 92% More health awareness among team members 4 5 completely 1 3 somewhat completely 23/25 92% Improved knowledge sharing across disciplines 2 5 completely 2 4 somewhat completely 1 3 somewhat 21/25 84% Improved trust and respect for other team members 3 5 completely 1 4 somewhat completely 1 3 somewhat 22/25 88% Improved communication 1 5 completely 3 4 somewha t completely 1 3 somewhat 20/25 80% Interviews Findings from the analysis of interviews are organized into three sections: HIA Recommendations, Health/HIA Contributions to/ Influences on the Master Plan, and Health Awareness and Knowledge.

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153 HI A Recommendations The degree to which recommendations from the HIA were incorporated into and influenced the master plan received high marks from the interview respondents (see Table 10). One respondent could not remember if there were any HIA recommendations that were not somehow iding evidence based research that was valuable to the plan. One respondent stated that a possible reason why a recommendation was not evidence based data for many of th e health issues is a challenge because some recommendations and health issues can have significant evidence most cases, they [recommendations] were included. Budget and ability to control decisions (ie. cod When asked what else could be changed or improved to incorporate more based d consider them with other design options and strategies so that they can be weighed to determine if master are going to be placed, and the colors on the wall, and the size of the units, and the ways the

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154 Health/HIA Contributions to/i nfluences up on the Master Plan According to respondents, the HIA did influence decision making within the master plan. Positive statements made were that the strategies in such a way that we could actually I think it provided organization to the conversation around health, and so it put health on the priority list hen asked how the master plan process changed as a result of having an HIA conducted, the respondents had encouraging comments such as ith regard to the process, some things changed by having a n emphasis on health the The HIA document and process were both considered by interview respondents to influence the master plan. In terestingly, the respondents felt that the HIA process influenced more than the HIA document, with one respondent stating that the health assessor was able to present at ficial health issues were discus sed during the planning process because of the HIA compared to other planning projects without an HIA. The respondents felt that health was a priority of the master reas for

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155 critical baseline assessment to determine priorit y issues for the community. This helped us to be Four out of five respondents felt health was of high importance compared to other issues considered in the plan. One respondent recognized, though, that other issues need to be d ealt with very important, but there are definitely other things that have to fall into place for any of this to be When asked whether the HIA contri ess respondents believed that they contributed to the HIA themselves (76%). planning process and how HIA results could inform design, discussed recommended strategi es and their applicability and alignment or conflict with other design goals with the [public health see as well how they themselves contributed to the HIA. The last question in the interview asked if there were any other comments they would like to share. This quote by a decision maker highlights the impact and contribution the HIA made more broadly, particularly about how it changed the framework of how this decision maker works and emphasizes health now within the implementation phase and future redevelopment projects. that economically they feel more safe and have more income to buy healthy foods. How do we bring gardens to provide more fruits and vegetables, which was discovered to be inadequate. But also things like safety or the perceptio n of safety so that people can get out and walk around. That is why I say things like the HIA is so important because it was the backdrop for all of this. But it is how we actually use it and the implementation when

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156 we go vertically with the buildings. Wit hout the HIA we would not have been on this kick of health. Now that we have caught the bug we are going to do it, which is great. In great. We are believers. We are Health Awareness and Knowledge HIAs, in addition to promoting health, well being, and equity, can increase awareness of these issues in urban planning and policy processes in sectors outside of health (Quigley et al. 2006). Similarly in this study, the awareness and knowledge of health issues on the part of the project team and other decision makers changed because of the HIA; this was supported with many positive statements by respondents. During the interview, respondents were asked to rate the extent to which their level of awareness and understanding of health increased as a result of the HIA process. Specifically one respondent mentioned that their awareness of health in the a language to what in my head health increased the success of the H health issues were discussed because of the HIA. However, when asked if their health awareness was increased, 72% felt this way and three out of five felt that their knowledge was increased, and one was not sure. Project team members and other decision makers who participated in the interviews seemed to have a good understanding of HIA: they described quite accurately an HIA as A baseline documentation of various data sources indicating overall an important planning component because it provides data on the health challenges of the area process to understand the health impacts of a particular project, program, or policy on a

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157 performed by a third party and presented to decision All respondents felt that having a health assessor/public health consultant as part of team/process helped to increase their level of health awareness and knowledge. A respondent ultant went beyond the report and presented opportunities, resources, government staff being concerned about health and having health issues raised by the community s health education and training, three respondents felt there was health education and training and that it came in many forms such as during public meetings and presentations, team meetings, stakeholder meetings and presentations, informal conversations a nd meetings with neighborhood organizations. Limitations This one HIA is not necessarily representative of all housing master plan HIAs and should not be generalized as such with other housing related HIAs such as Trinity Plaza Housing Redevelopment, CA (S an Francisco Department of Public Health, 2003). Another limitation is the question of cause and effect between the HIA recommendations and their adoption in the final master plan. For example, did the addition of a bike lane and other traffic calming meas ures occur directly or indirectly because of the South Lincoln HIA or because of recommendations that would have already been made by other disciplines during the planning process? To understand the intentions of the planners and other decision makers, int erviews were conducted with the decision makers to determine direct and indirect impacts of the HIA and to better understand the

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158 motives behind using the HIA recommendations and other HIA influences. Additional research could seek to identify specific oppo rtunistic impacts of the HIA that might address whether the recommendations would have been incorporated into the plan anyway (Wismar et al., 2007) but is not part of this research. Also, the lead researcher was the health assessor for the South Lincoln HI A, which can create obvious biases and preferences or preconceptions about the outcomes, so research assistants were employed to conduct the interviews and duplicate the data collection with the lead researcher. Lastly, the list of phrases and words for th e health supportive language is not an exhaustive list; also similar words or phrases in certain context possibly might not have been included in the counts but would be more likely to be included when the determination was close. Section 2. Influence of H IA Quality on Master Plan and Decision Makers The independent variables, HIA quality and cross sector collaboration, are examined in the next two sections. These two sections help to answer the second central research question which is: Do variables such a s cross sector collaboration and the quality of the HIA influence whether the HIA is more or less successful in influencing the health supportive language, HIA recommendation adoption and health awareness and knowledge? Determining Quality of HIA This sect ion focuses on determining the quality of the HIA and addresses the following questions: What quality Standards score does the South Lincoln HIA achieve? Were the goals and objectives of the HIA met?

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159 Does the quality of the HIA influence decision makers and the master plan outcomes such as the health supportive language and HIA recommendation adoption rate, if so, in what ways? Does the level of quality of HIA along with level of collaboration more greatly influence the master plan outcomes? In an effo Working Group in 2010. Although there are numerous guidance documents (Hebert et al., 2012 ), the Standards are the only practice standards available in the United States and abroad. The ve typical stages of the HIA This study used the Standards as the benchmark for assessment, and the Standards are fundamental to discerning the quality of the South Lincoln HIA and development of the questions in the questionnaire related to the quality of the HIA. The North American HIA Practi ce Standards Working Group developed the Standards. Members of this Working Group are considered steeped in the practice and research of HIA, with the three lead authors being prominent leaders in the HIA field both here in the U.S. and in Canada. They are Rajiv Bhatia, MD, MPH, [now former] Director, Occupational & Environmental Health, San Francisco Department of Public Health; Murray Lee, MD, MPH founder of the Habitat Health Impact Consulting in Calgary, Alberta, Canada, and Lili Farhang, MPH, Associate Director, Human

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160 Impact Partners in Oakland, CA. Still, the Standards are a work in progress with challenges that are described in the limitations section further below. A newer 2014 version was just released in September. Berke and Godshalk (2009), althou systematic evaluation enables us to identify their specific strengths and weaknesses, to judge whether their overall quality is good, and to provide a basis for ensuring that they reach a desirable stan reasoning for the development and use of the Standards in this study. Methods At t he outset of the review, the lead researcher and two research assistants rated the quality of the HIA based on each of the Standards using a simple scale of low, medium and high, which revealed how well the HIA met the Standards. In some cases it was neces sary to break a long, complex standard into its component parts in order to be scored. An Excel spreadsheet was created that listed each standard and has a short explanation of the standard so that each one could be appropriately scored. There are a total of 63 Standards that are broken out with nine general standards and then specific standards for each of the HIA steps. These steps include Screening (three standards), Scoping (17 standards), Assessment (13 standards), Recommendations (four standards), Rep orting (eight standards), and Monitoring (nine standards). The spreadsheet the lead researcher developed with the standards and the related scoring is in Appendix C, Table 3. For example, the spreadsheet lists out each of the Standards associated with the entire scoping phase. This section begins with the title of: 3. Scoping: 3.1: Scope of health issues and public concerns. Underneath 3.1 are standards regarding what is: Scoping 3.1.1 Decision and

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161 alternatives to be studied; Scoping 3.1.2 Health impacts an d pathways; Scoping 3.1.3 Demographic, geographic, and temporal boundaries; and continues up to 3.1.11. for those instances where a certain standard did not apply. For example, no screening formally occurred for this case study (screening is the first step in the HIA process, where it is decided whether an HIA is needed). It was i nformally determined that due to the high proportion of vulnerable populations, including low income and people of color in the neighborhood, the decision to conduct the South Lincoln HIA had been made without feeling a need to conduct an therefore, this standard did not apply. Additionally, a few standards in the 2010 version were in process) were deemed too unrealistic and extremely hard to meet by the lead researcher and two research assistants. For example, the 2010 Standards describe in the monitoring section the need for an HIA management plan to be established early in the HI A process. Management plans are very seldom completed at this point with little evidence based data identified that such a plan improves quality or success of HIAs. So one standard in the monitoring section 7.1: Follow up monitoring plan, track decision ou tcomes, and effect of decisions on health impacts were scored and others in the section were not scored, and a N/A was applied e.g., needed specifics about which individuals and what resources were identified to monitor the outcomes of the HIA. In order t o score the data, each rating was assigned a point value: 0 for no, 1 for low, 2 for medium, and 3 for high. A specific scoring process was selected to provide a more specific determination of to what degree a standard was met and be able to better compare with another case study. This scoring system is similar to that done with LEED ND certification that incorporates a points system of whether a criteria was completed or not. The scores were

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162 averaged in order to assess the overall quality of the HIA. Stand ards that were marked N/A were not given a score and were excluded from the average. In order to determine the overall quality rating for the HIA, numerical scores were defined for each of the qualitative ratings of the HIA components. If the average score fell in the 80 th the average score fell below the 80 th percentile but above the 60 th percentile (scores between 2.34 g. Any scores below the 60 th percentile (<1.8) would e Table 12 for the ratings and scores). Once the scoring methodology was determined, the quality of the South Lincoln HIA wa s assessed. In order to eliminate some of the subjectivity in rating each standard, a research assistant reviewed the HIA independently and came up with a score for each standard. The two research assistants (RA) and lead researcher discussed each standard that was rated differently and why. In many cases there was total agreement, but in other cases a discussion and consensus was necessary. The South Lincoln HIA was assessed thoroughly first and then compared to the other contrasting case in this broader s tudy. The review occurred over six days that included the comparison across the two cases. The analysis was conducted in a close timeframe to ensure that there was consistency in interpreting the standards. Although the majority of standards were met withi n the HIA, some details were not well documented. For example, sometimes information was mentioned only briefly or was shared in detail at stakeholder and community presentations but not documented in the HIA. The RAs questioned the health assessor for the South Lincoln HIA to gain a more complete picture of the standards met. Much later, the project team members and others were interviewed using the full questionnaire about the quality of the HIA.

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163 Additionally, interview questions were asked that pertain to HIA quality in terms of the Standards. A within case analysis was conducted of their responses and comments and the quantitative responses were added up and divided by the total possible number of points for a score for each question. Table 11: The fir st column includes the codes developed deductively and inductively proposition(s) from the literature that are relevant to each of the codes. The complete list of standards are in Appendix C, Table 3. Table 11 : Codes and Standards and Propositions for Analysis of Interviews Code HIA Quality Standard and/or Proposition Understanding Goals and Process of HIA 1.3: Evaluation, explicitly writ ten goals at outset of HIA process. Proposition: Having knowledge and realistic understanding of processes of HIA. Decision maker involvement Stakeholder participation Opportunity to review and provide comments 1.6: Meaningful and inclusive stakeholder participation (officials and residents). 6.6: Distribute HIA and or findings to stakeholders that were involved in the HIA. The HIA reporting process should offer stakeholders and decision makers a meaningful opportunity to critically review evidence, met hods, findings, conclusions, and recommendation. 3.1.10: Plan for external and public review. HIA Quality Timeliness 1.4: HIA should respect the needs and timing of the decision making process it evaluates. Proposition: For better success, timing of the assessment fits within the decision making process.

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164 Table 11 cont.; Comprehensive review of issues and Evidence based data 3.3: Consideration of all potential pathways reasonably linked with decision or direct/indirect. 4.1.2: Evaluation of health im pacts based on best evidence. 4.2.2: Utilize evidence from well designed, peer reviewed systematic reviews. 4.2.3: Consider published evidence that supports and refutes health impacts. Proposition: Inclusion of empirical evidence supports success. There were many positive comments and responses from the interviewees that were related to how the respondents felt about the HIA. If the HIA is determined to be of good quality and credible, this is an enabler for success (Elliott & Francis, 2005), i.e., increa se in health awareness or HIA recommendation adoption. The section below describes the interview comments received by respondents that were broken out into the coded categories from T able 11 Data Collected and Findings Table 12 illustrates the number of s tandards that were rated high, medium, low, no, N/A and the weighted scores (ratings (points) x number of standards within each rating). The greatest each. Table 12 : Scores of Standards Ratings # of standards within each rating Weighted score High (3pts.) 28 84 Medium (2pts.) 8 16 Low (1pt.) 6 6 No (0 pts.) 2 0

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165 Table 12 cont.; N/A (removed) 19 0 Total points 44 106/44 = 2.41 Note: A weighted average score takes different scores, with assigned weights, or percentages. HIA Standards To answer the first research question for this section, the South Lincoln HIA scored a HIA scored high along a wide range of standards. There were specific standards such as identifying the gaps in the data, monitoring, and prioritization of the recommendations that were weak or absent, causing the lower score. Wh ile the score is informative and provides a gauge of the level of quality of the HIA, it is more meaningful when compared with another scored HIA in a contrasting case in this broader study that is in Chapter 7, Northeast Downtown Denver Neighborhood case. The second research question seeks to determine the quality of the HIA based on whether the specific goals of the HIA were met. This question is also specific to standard 1.3: Evaluation, explicitly written goals at outset of HIA process. Broad goals and a purpose statement were written in the HIA. The goals of the HIA were to: Identify potential impacts the redevelopment may have on health and well being of the South Lincoln neighborhood; Suggest ways to improve overall health through evidence based heal th data and to assess potential human health risks; and Provide specific recommendations for the South Lincoln neighborhood through the redevelopment process. By completing a document review, the goals were identified as completed such as identifying poten tial impacts along with evidence based health data and the health risks were documented that support the recommendations for the residents. However, more specific and measureable goals would have provided a better assessment of the quality of whether the g oals were met. Since the last three research questions identified at the beginning of this

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166 section cut across findings in other sections, they will be answered in the Results Within and Across Cases: Conceptual Framework Section toward the end of the docum ent. Table 13 displays the data from the questions that pertain to the quality of the HIA The table first displays the column of questions pertaining to this study section, second column has the responses with the number of responses from interviewees (n= 5 ), a dash ( ) and the selected response (e.g., 3), and what that number represents (e.g. agree). The responses are from the questionnaire with options of picking 1 5, ranging from not effective or strongly disagree (1= low) to very effective or strongly ag ree (5= high) and neither (3 = medium). N/A was an option if were other options. The third column has the overall score and percentage for that question to better compare across questions. Some questions did not offer an opportunity to comment with a qualitative response. Table 13 : Responses and Scores from Interview Questions Question Response Score/Percentage Were decision makers involve d in the HIA? 5 5 yes 25/25 100% Was your organization/agency notified of the HIA goals early in the master plan/HIA process? 4 yes 1 not sure 20/20 100% Was your organization/agency notified of the HIA process/steps early in the ma ster plan/HIA process? 5 5 yes 25/25 100% Did your agency/firm/organization have an opportunity to critique or provide comments during the HIA process or the document? 5 5 yes 25/25 100% Did you feel that the HIA was conducted in a timely manner? 4 yes 1 not sure 20/20 100% The HIA used evidence based data that supported the recommendations? 1 5 strongly agrees 4 4 agree 21/25 84%

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167 Table 13 cont.; Do you think more or fewer health issues were discussed du ring the master planning process because of the HIA, compared to other planning projects you have worked on without an HIA? 3 5 high 2 4 medium high 23/25 92% The findings of the analysis includes Table 13 interview responses that were inc orporated into the coding categories that were developed using the standards and propositions described in Table 11. Interviews Findings from the analysis of interviews are organized into four sections: Understanding Goals and Process of HIA, Decision mak er involvement and stakeholder participation, Timeliness, Comprehensive review of issues and evidence based data. Understanding g oals and p rocess of HIA Respondents felt that they were informed of the goals and had an understanding of the HIA process. Wh en the respondents were asked if they were notified of the HIA goals early in the well described back in the Health Awareness and Knowl edge section also supports this. Interestingly, the hired planning firm was intent on supporting positive health impacts through its master planning process. Health as a priority for the planning firm was clearly stated:

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168 support by those making decisions and completing the master plan. Greater support at the beginning of the planning process can translate into more successful outcomes such as more adoption of the HIA recommendations. Decision Maker Involvement and S takeholder P articipation All five respondents stated that decision makers were involved and interested in the HIA. est. Respondents felt that they were able to critique and provide comments during the HIA process or makers felt they were involved in the HIA and had opportunities to provide input and that the stakeholder group definitely worked collaboratively. Although would have loved more time as the health assessor for more stakeholder input more in depth Timeliness As stated in the literature, the timeliness of the HIA is very important for success. There was a mix of answers related to whether the information from the HIA was shared in a timely manner. Four respondents stated that the HIA was both conducted and delivered in a timely manner and There were challenges in having data available in time to inform the

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169 design. Data collection and reporting took longer than the other existing con ditions and However, respondents seem to feel that it would have conducted prior to the master planning process, it would have been more helpful to have had that the HIA could have been i mproved they stated that it would have helped to have the information up front. Comprehensive Review of Issues and E vidence B ased D ata All five respondents agreed or strongly agreed that there was a comprehensive review of the health issues and that more health issues were discussed and addressed during the master plan jus Limitations There are limitations associated with the assessment of the quality of the HIA, which primarily stem from issues with the 2010 North American HIA Practice Standards themselves. First, the Standards for conducting an HI A can be challenging to objectively measure, and operational definitions are needed. The components of the Standards could be interpreted differently by various users, resulting in an alternative scoring. Second, it is challenging to accurately rate each s tandard from reading the final document only; there is a need at times to rely on outside information to adequately rate a few of the Standards, e.g., were all community

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170 meetings documented in the HIA? Another challenge is that strict adherence to the Prac tice Standards could yield an HIA overly cumbersome and lengthy. While the researcher wants a document that details all aspects of the process, the community and other stakeholders need a document that is reasonable in the number of pages, conciseness, and readability. Finally, although the Standards are designed to advance HIA quality, improvements to the Standards are needed. A revision of the Standards was just released September 3, 2914. Section 3. Cross Sector Collaboration The second independent varia ble, cross sector collaboration, is examined below. This section along with HIA quality helps to answer the second main central research question which is: Do variables such as cross sector collaboration and the quality of the HIA influence whether the HIA is more or less effective in influencing decision health related master plan outcomes such as the adoption of HIA recommendations and health supportive language ? Determining Cross Sector Collaboration This secti on of the case study focuses on identifying the level of cross sector collaboration during the South Lincoln HIA and master planning process. The section also addresses if and how collaboration and specifically public health engagement such as a health pro fessional being involved in the project team and conducting an HIA influenced the quality of the HIA, the master plan outcomes, and health awareness and knowledge. The research questions for this section are below: What level of cross sector collaboration does the South Lincoln project team achieve?

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171 How does the level of cross sector collaboration of the project team and other decision makers influence the amount of HIA recommendation adoption, health supportive language used, and change in he alth awareness and knowledge? Does the level of cross sector collaboration of the project team and other decision makers influence the quality of the HIA document? The literature supports that a blending of the responsibilities, tools, and perspectives of multiple sectors can result in better outcomes than having one sector take on all the responsibilities (Kochtitzky et al., 2006; Bryson et al., 2006; Kline, 1990). A collaborative approach is becoming increasingly a necessary strategy for addressing socie public challenges (Bryson et al., 2006; Petts et al., 2008; Greenwald, 2008). Cross sector collaboration can provide a powerful opportunity to share evidence based data with other agencies and sectors; increase understanding of other agen across sectors; and can allow for more expansive thinking to identify potential unintended health consequences of plans and policies (Quigley et al. 2006). The literature states that enhanced leadership, resources, pa rtner relationships, history of relationships with team members, structures and processes, and good communication translates into more successful outcomes (more in Chapter 4. Cross Sector Collaboration ). Methods As described above, the purposive intervie ws took approximately 45 minutes to one hour to complete and were conducted in the spring of 2012 and 2013. The interview questions utilized both quantitative measurements using a Likert scale with choice of 1 5 ranging from not effective or important (1) to very effective or important (5) and neither (3). The interviews produced both qualitative and quantitative data as questions intentionally encouraged both types of responses.

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172 These questions captured three research categories: cross sector collaboration effect on HIA quality, and the influences of the HIA on the master plan and decision makers. The questionnaire was informed and reviewed by those involved with the research and went through a number of drafts in order to ensure that the questions, resp onse scales, and the order of the questions was optimal. Once complete, the questionnaire was piloted, which resulted in additional minor revisions and then cleared through the Institutional Review Board 2 Data Collected and Findings Table 14 displays the data from the questions that pertain to cross sector collaboration. The table first displays the column of questions pertaining to this study section, second column has the responses with the number of responses from interviewees (n=5), a dash ( ), an d the selected response (e.g., 3), and what that number represents (e.g. agree). The responses are from the questionnaire with options of picking 1 5, ranging from not effective or strongly disagree (1= low) to very effective or strongly agree (5= high) an d neither (3 = medium). N/A is an option if were other options. The third column has the overall score and percentages for that question to better compare across q uestions. Some questions did not offer an opportunity to comment with a quantitative response. 2 The questionnaire was submitted to the Colorado Multiple Institutional Review Board (IRB) at the University of Colorado at Denver for review (protocol number 12 0412) in March, 2012 and was determined not to consti tute human research as defined by current policy and regulation. The questionnaire could therefore proceed, exempt from further IRB oversight.

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173 Table 14 : Cross Sector Collaboration Responses from Questionnaire Question Responses Score/Percentage How would you rate the importan ce of an interdisciplinary collaborative approach? 5 5 very important 25/25 100% How effective would you rate the interdisciplinary collaboration during the South Lincoln HIA/master plan redevelopment process ? 4 5 very effective 1 4 effecti ve 24/25 96% How would you rate the level of interdisciplinary collaboration of the design team for the South Lincoln Master Plan? 3 5 high 2 4 medium high 23/25 92% Do you think that all the disciplines jointly achieved an outcome which could not be achieved by one discipline separately? 3 5 very important 1 4 important 1 3 neither important or not important 22/25 88% Do you believe the stakeholder group for the South Lincoln Master Plan worked collaborati vely? 1 5 very effective 4 4 effective 21/25 84% Table 15: Similar type of questions were asked to help get more detailed answers. Below is one important question with many follow up options to rate and score. The scale was 5 (completely), 4 (somewhat completely), 3 (somewhat), 2 (less than somewhat), 1 (not at all). Respondents could offer comments, which are summarized in Findings, below. Table 15 : Questions about Specific Aspects of Interdisciplinary Collaboration Question Responses Score/Percentage The following lists aspects of interdisciplinary collaboration. How do you feel these aspects contributed to the master planning process if at all?

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174 Table 15 cont.; Bringing together diverse stakeholders 4 5 co mpletely 1 4 somewhat completely 24/25 96% Meeting regularly 4 5 completely 1 4 somewhat completely 24/25 96% Exchanging info/knowledge 3 5 completely 2 4 somewhat completely 23/25 92% Sharing resources 1 5 completely 3 4 somewhat completely 1 3 somewhat 20/25 80% Strong leadership 4 5 completely 1 4 somewhat completely 24/25 96% Informal relationships created 4 5 completely 1 4 somewhat completely 24/25 96% Mor e informed decision making 3 5 completely 2 4 somewhat completely 23/25 92% Processes, inputs, and outcomes tracked for accountability 1 5 completely 4 4 somewhat completely 21/25 84% Having a shared mission and goals 1 5 completely 4 4 somewhat completely 21/25 84%

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175 Interviews Findings from the analysis of interviews are organized into sections that begin with broad answers about IC and the presence of factors supporting cross sector collaboration that in clude more specific sections: Partner Relationships, Leadership, Communication, and Past Relationships with Team Members. Respondents offered high marks when asked about the level of and influences from cross sector collaboration of the project team over t he course of the master planning process and HIA. All respondents agreed that an Interdisciplinary Collaboration (IC) approach is very The IC scored a a collaborative approach was deliberate; the planning firm intended to use th is process as an illustration of inclusiveness of health objectives and IC in order to achieve positive, trusted results. Presence of factors supporting cross sector collaboration As stated in the literature, IC is more successful when specific factors a re pervasive among the team. The six factors include enhanced leadership, communication and partner relationships, resources, history of positive relationships with team members, and structures and processes in place that all translates into more successfu l outcomes. To get a better understanding of whether South Lincoln had high, medium or low collaboration, comments and ratings of these specific successful factors are broken into categories. Below is a description of these successful

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176 factors as described by respondents that relate to the South Lincoln Plan and HIA. Although the focus of this research is the interdisciplinary project team members, the broader stakeholder group collaboration is also important to HIA quality and the broader collaborative envi ronment, so related questions were also asked and shared. Out of the eight choices, the highest rated factors of IC that the respondents felt contributed to the master planning process were meeting regularly (96%), bringing together diverse stakeholders (9 6%), informal relationships created (96%). and strong leadership (96%). Other contributing factors were more informed decision making (92%) and exchanging info/knowledge (92%) with the least rated factor being the sharing of resources (80%). Overall, the s project leadership with creating a collaborative working environment, and another credited the Denver Housing Authority, who was the overall manager of the project. One respondent spoke highly of the community involvement coordinator, who was part of the project team and took meeting notes and then emailed them to everyone for their edits and additions. Others described the process as having respectful trust and shari ng among the team members. Lastly, open collaboration. Cross sector collaboration was rated high overall for the South Lincoln project team; the successful factors are detailed below. Partner r elationships The importance of the team approach and fostering the relationships is best said by one bringing together the diverse stakeholders and meeting regularly really helped the master planning process. It respondent felt that Eighty eight percent of

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177 the respondents felt that there was improved trust and respect for other team members from the Leadership Positive statements were offered by the respondents about the leadership and its contribution to IC, the master plan and the HIA. When asked to des cribe the leadership was good they were dedicated to quality, a team environment was created, and there was good decision makers Promoting and supporting a common language is a component of leadership that was specifically addressed by the respondents. O ne respondent stated that often, generating a commo members there was a good common language. We all had a learning curve with public health to whic h there was a common understandable language as low. It seemed a common language was important and positive among the project team with mixed reviews about how well they thought they did but not without its challenges. One ing we were always striving for. There is so much jargon in our world. In housing there is jargon. In diverse stakeholder group we knew we needed to just boil it all down to a very common level. kind of something hard to overcome with jargon. But we did empower our stakeholder group to

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178 stop us to ask questions or among means. So in terms of language obviously we did translations and interpretation both written and verbal. I think it started at a low common language and definitely increased throughout our Communication One supportive statement that was made about the communication of the project team specifically, good communication was identified as having a mix of conference calls, community meetings, and after meeting gatherings. Also meeting before community and stakeholder meetings were equally rated by three of the responde dership] had a ton of meetings and it was a broad, diverse opportuni ties for sharing of information among the team members. Another responded that documents were put into document share file so everyone on the project team could hav e access to all available documents). As mentioned much earlier, there was a group review of meeting meetings, or stakeholder meetings, community meetings, design meeti ngs, and then people on the design team would edit and add their recollections. This created a thorough documentation of our

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179 Past r elationships with team m embers Two of five of the res pondents stated they had worked with people prior to working on this project. Of the two stated it was a positive and negative experience. One respondent specific to South Lincoln note d, was a small enough neighborhood that most people knew each other, and so there was the In summary, there were a few p ast relationships within the project team members, and communication among the team was described very clearly as having been supportive with many opportunities to interact and share. There was also trust and respect among the team members, and leadership emphasized relationship building. Lastly, strong leadership was identified which also helped to facilitate the other aspects of successful cross sector collaboration. Limitations The interview guide can present limitations because the HIA was completed i n 2010 and the interviews were conducted in 2012 and early 2013. This retrospective timeline can create issues with respondent recall bias, incomplete recollection, and reflexivity. Also, the lead researcher was the health assessor for the South Lincoln HI A, which can create obvious biases and preferences or preconceptions about the outcomes, so research assistants were employed to conduct the interviews and duplicate the data collection with the lead researcher as described in the methods sections. Additio nally, n=5 is a low number of interviewees, but those who were interviewed were key decision makers/creators of the master plan and HIA.

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180 Key Findings from Research that Support HIA Influence Positive and negative key findings were coded during data analy sis whether from content analysis, interviews, or document review. All data were consolidated to assist with better understanding the influences of HIA, answering the research questions, and examining the hypotheses and propositions and determining whether they are congruent with what this study has identified and concluded. Master Plan and Decision Respondents felt that the HIA process (80%) and document (72 %) influenced the master plan. Respondents felt strongly that more health issues were discussed during the master planning process because of the HIA, compared to other planning projects without an HIA (92%). More evidence based data the better; it is important for positively influencing the master plan. HIA provided organization around health as an issue in the master plan and put health as a priority for decision makers. More health supportive language is used in a redevelopment master plan when an HIA is conducted. Greater than 50% of HIA recommen dations were incorporated into the master plan.

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181 said okay every single day how are we Collaboration : he collaboration for a score of 92%. they were dedicated to quality, a team e Factors that support more successful cross sector collaboration such as strong leadership and communication were discussed very positively and considered well done by the project team. Quality HIA: Respondents felt that they were informed of the goals early and all were notif ied of the All five respondents stated that decision makers were involved and interested in the HIA. could have been done before master planning process; HIA [health assessor]

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182 he Practice Standards. All respondents felt they had many opportunities to critique or provide comments during the HIA process or the document Results Within Cases: Conceptual Framework To better assist with answering the research questions, a conceptual framework was developed to more effectively analyze and further demonstrate the level of influence and effectiveness within each case and across the two cases in Chapter 8. Results and Discussion. This framework takes the form of a checklist. A goal of the checklist typology was to thoroughly and methodically evaluate the key findings for the independent and dependent variables, to further demonstrate which cases overall rate as low or high levels for the variables being researched, identify specific measur es met or not within a case, and note specific differences between the cases. The checklist analysis more methodically helps establish the level of agreement and understanding on whether the master plan was influenced by the HIA and in what specific ways. For purposes of this research, it was deemed appropriate to use a conceptual framework made up of propositions developed from the literature, HIA Practice Standards, and other newly identified measures from this research that inform this typology about inf luences from the HIA. On the checklist, a newly identified measure is marked with (N), propositions (P), and specific Standards (S). The measures were broken out into low and high levels to be tested, this analysis further contributes to triangulation and analysis of all the data. For this case, very few measures were checked that were considered low level compared to the high level measures, so only the high level checklist is shown. unmet. Those measures that are not checked could mean that the measure was not completed or

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183 there is no clear answer from the data as to whether it was met or not. Decisions about whether the measure was met or not were based on the results from analysis, and the scores and co mments of the respondents. The checklist typology below shows the key findings and whether that measure was met. This clearly demonstrates that in this case, there was high levels of influence and overall effectiveness of the HIA on the master plan and de cision makers. High Influence/Effectiveness Checklist Independent Variables HIA Quality: Completion of HIA in reasonable time that fits within the decision making process (P) Scored between 2.1 and 2.4 against Standards (S) (split between 1.8 and 2.4) HI A met all 15 required general practice standards (S) An HIA assessor engaged in master planning process (N) Health assessor is expert/experienced in conducting HIA (1 st HIA completed by the assessor) (P) HIA goals and process explained early in planning pr ocess (S) Opportunities for review of HIA by decision makers (S & P) Decision makers involved in design and conduct of HIA (P) Quantification of impacts, where possible (S & P) People outside the decision making process provide input (S & P) Use of a consi stent and appropriate methodological approach (S & P)

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184 Collaboration : High level cross sector collaboration among decision makers (P) Organized and provided and received input from stakeholder group (P&S) Strong leadership (P) Political support for HIA (P) Collaboration considered to be important among team members (N) Participation/input from other disciplines during HIA process (P) Strong engagement in HIA from decision makers (P) High level of communication (P) Processes in place for project team col laboration (answer not clear enough) (P) History with project team with positive past experience (P) Resources to conduct HIA (P) Understanding priorities and perspectives of partner organizations (P) Dependent Variables HIA Recommendation Adoption: Majori ty, >50% of HIA recommendations incorporated into planning document (N) Evidence based data included in HIA, where possible (P &S) Clear and concise recommendations (N) Shaping of recommendations to reflect organizational concerns (P) Realistic recommendat ions (P) HIA is non controversial (P) Health Awareness and Knowledge: Presentations or other means to share data/findings (e.g. >2 community meetings) Educate practitioners about the policy process (not applicable this case) Increased awareness of health by team members and other decision makers (P) Tailored presentation of findings (community and stakeholders) (P)

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185 Increased knowledge of health by decision makers (P) Training provided about HIA and health (P) Education provided about HIA and health (P) Hea lth Supportive Language: Master plan has significantly more health related words than other, similar plans (N) \ Table 16: This typology more clearly illustrates how each of the dependent variables (DV) and independent variables (IV) were rated. If it was close to a low or high, a medium option was added for further clarification. This typology best sums up the answers to the main research questions. Table 16 : HIA Influence/Effectiveness Typology Analysis Summary, South Lincoln Case IV DV Master Plan and HIA Outcomes Cases Rate/level of Collaborat ion Quality of HIA Level of Adoption Health supportive language Health awareness/ knowledge Outcome (by case) South Lincoln Housing plan High High/ Medium High High 61% High (more than other plans; 47% of the total number of words, 564) High/Medi um High Concluding Remarks This case is an example of an HIA that positively influenced a housing redevelopment master plan and the decision makers as shown in Table 16. The research focu sed on the South Lincoln HIA and how it influenced the South Lincoln/La Alma master plan specifically in terms supportive language used in the master plan, and changes in the decision knowledge of health issues. To illustrate its effectiveness, well over half of the HIA recommendations (61%) were adopted into the master plan. There was more health supportive

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186 language in the South Lincoln Plan compa red to other similar housing master plans without an HIA conducted. The HIA document and process, as well as the involvement of a public health professional increased the health awareness and knowledge of the project team and other decision makers. The HIA changed the conversation by emphasizing health throughout the master planning process: having an HIA conducted increased awareness and knowledge about health, provided a comprehensive view of health, and provided a better understanding of the connection b In this case, the HIA not only c hanged how health was prioritized within the planning process but also changed the language used in the master plan, demonstrated by the presence of more health supportive language and more willingness to incorporate the HIA recommendations into the master plan. For the South Lincoln case, both independent variables were rated high by the respondents, which suggests that both contributed to the positive outcomes of the case. South ives that led to more health focused and informed decision hypothesis. The factors and variables that contribute to these outcomes are described and also compared with the contrasting case study (along the independent variables), NE Downtown Denver neighborhoods, in the Results and Discussion Chapter.

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187 CHAPTER VII NORTHEAST DOWNTOWN DENVER NEIGHBORHOOD CASE Chapter Outline This case study examines whether the Health Impact Assessment (HIA) conducted of th e Northeast Downtown Denver Neighborhoods P lan in Colorado influenced decision making within the redevelopment plan. Did the completion of the HIA result in the adoption of healthier and safer options in the N ortheast Downtown De nver Neighborhoods Plan (NE DNP). The first section of this case study introduces the context of this case and includes a condensed description of the methodology used, including the research questions used to frame the data collection and analysis. Next, the methods, data collected analysis, and limitations of the three main research study areas are presented, followed by results and a broader discussion and concluding remarks. Introduction The study focuses on three main areas: the outcomes of the HIA and its influences on the ne ighborhood plan and decision makers, the quality o f the HIA and cross sector collaboration The influences examined include the extent to which the HIA recommendations and health supportive language were adopted into the NEDNP (master plan outcomes), as w ell as change in health awareness and knowledge of project team members. Additionally, the study identifies other short term, direct, and indirect impacts and observations that occurred as a result of conducti ng the HIA which are shared in C hapter 8 Resu lts and Discussion. T he study centers on two independent variables: quality of the HIA and cross sector :320 ). Statements such as this have led to the establishment of

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188 practice standards in hopes of improving the quality of HIAs. Little evaluation has been conducted about the quality of HIAs, and the focus of this research was whether greater quality is reflect ed in more or less positive master plan outcomes and change in health awareness and knowledge. The second variable, cross sector collaboration, has been identified as an important benefit of conducting HIAs, but there is less understanding of whether successful cross sector collaboration improve s master plan outcomes and health awareness and knowledge. The case study was designed to test hypotheses that more successful collaboration results in 1) higher quality HIAs, 2) more successful master plan outcomes, and 3) increased health awareness and knowledge among decision makers In short, it is hypothesized that the HIA influences the master planning process and decision makers in positive ways. More specifically, it is anticipated that if the level of collaboration among proje ct team members with varied expertise is high and the quality of the HIA is high, then the degree to which the HIA recommendations and health supportive language are adopted into the master plan should also be health awareness and knowledge. The opposite should also be true. If the independent variables are low, then the dependent variable s are also low. Prior to this study, these variables and associations had not been directly researched abroad or in the U.S. Although challenging, this study attempted to link planning decision making outcomes with completion of an HIA. The linkage can be hard to distinguish because there are numerous indirect and equally important intangible benefits that may be gained from the HIA and the planning process. Background of N ortheast Downtown Denver Neighborhoods Plan HIA Case The Northeast Downtown Denver Neighborhoods Plan HIA focuses on health issues and recommendations to help the City and County of Denver prepare an

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189 area plan for multiple neighborhoods. The NEDNP aims to look 20 to 25 years into the future of NE Downtown and focus on relationships across neighborhoods instead of individual neighborhoods, look at areas of change and stability, and identify t ransitions between neighborhoods and land uses. Moreover, with two new transit lines expected to run through the neighborhoods, the East Corridor commuter rail and the Central Corridor light rail extension, the Plan will help the City achieve a community v ision for the new station areas and the greater community. The broad study area has seen an increase in population, particularly in the Ballpark, Upper Larimer, and Curtis Park areas in the past 10 years but with less development. This plan will help decis ion makers devise strategies to promote future development in line with the C The HIA was an eight month process conducted prior to the completion of the neighborhood plan to inform the plan for the NE Downtown ne ighborhoods. Through background research, site visits, and a few interviews with community residents and public officials, the following four categories emerged as the top health related issues within the study area: 1) Social Issues (displacement); 2) Hea lthy Eating and Active Living (walking, biking, and public transportation; parks and recreation; food access and quality ; aging ; children and schools); 3) Environmental Health (air and water quality; noise; leaking underground storage tanks, spills; odors; hazardous waste/storage; and lead based paint); and 4) Safety (personal and traffic). Overview of Data Collection For each health category within the HIA, strengths and opportunities were identified, along with weaknesses and challenges. Based on these id entified issues and the evidence based research, recommendations were developed to improve the health of the NE Downtown citizens. The recommendations are supported with related research, a small social services survey of

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190 providers in the neighborhoods, co mparative data, and citywide data from various C ity departments. There was no formal steering/stakeholder committee identified, but a lead project team member identified some informal groups within different neighborhoods. Few neighborhood level health dat a w ere available. T he HIA drew agency data from the Denver Police, Environmental Health, Community Planning and Development, Denver Housing Authority and Public Works. The collected data, other available documents, and information exchanged with project te am members were systematically consolidated to form the proposed 61 HIA recommendations. R ecommendations stem from the Healthy Development Measurement Tool (HDMT) indicators; other HIAs; walkability audits which are examinations of the walking environment; informal interviews with a few community members and two elected officials who represented the neighborhoods; and other p roject team members, community organizers, and governmental and non governmental support agencies. The NE Downtown HIA was a prospect ive activity that informed the neighborhood plan. The HIA was completed before decisions were finalized in the master plan. T he neighborhood planning process began around April 2010 and t he HIA began in May of 2010 The health assessor conducted two walkin planning department in May, 2010. The health assessor coordinated and met with the social services consultant in June 2010 and reached out to the community engagement consultant. An initial re port of the health issues and data were developed in late June that were used for the presentation to the public in July of 2010. The health assessor met with the two city councilwomen who represented the NE Downtown area in July 2010 to gain better unders tanding of the issues. The health assessor sent a draft in September 2010 to the hired planning firm for comments, who forwarded the HIA to Denver C ommunity P lanning and D evelopment The final draft version was sen t to the hired planning firm in October 20 10. The health assessor received comments from the C ity in November 2010 and met with the lead city staff in late November

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191 about the comments received. The neighborhood plan was delayed by many months due to additional work needed and unexpected challenges The final HIA was sent to the C ity January 2011. The final NEDNP was adopted in May 2011. This timing gave the planners within the C ity and the hired planning firm the opportunity to learn about, review, and provide comments about the HIA to potentially impact the NEDNP. Case Study Methodology This exploratory, retrospective case study design used a mix of quantitative and qualitative methods, each briefly mentioned here and explained more fully within each of the research sections. These methods included a content analysis of the NEDNP, document reviews, and semi structured interviews with a purposive sample of project team members. The central research questions are the following: How do health impact assessments influence decision making in redevelopmen t master plans, specifically the amount of HIA recommendations adopted, health supportive language used and change in decision How do variables such as cross sector collaboration and the quality of the HIA influence whether the HIA is more or less effective in influencing decision health awareness and knowledge, the adoption of HIA recommendations and health supportive language? Decision makers could be from public or private planning organizations public h ealth, housing or other professionals or elected officials involved in the master plan and the HIA. Four key decision makers responded to the questionnaire that cut across the different research components. The questionnaire addressed the research questio ns related to HIA influences on the master plan and decision makers, HIA quality, and cross sector collaboration. The interview

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192 questions utilized quantitative measurements using a Likert scale (e.g., 1=strongly disagree to 5=strongly agree), yes or no que stions and qualitative data from open ended questions. The interviews were conducted to get the perceptions of those on the project team through in the research A copy of the intervi ew guide is in Appendix A. The analytic framework consists of interview data combined with document data from the HIA and master plan coded to identify manifest and latent themes. Word searches in Microsoft Word were mainly used for the content analyses. C omparisons were made with other neighborhood area plans that did not have an HIA completed, e.g. identifying the frequency of the use of health supportive language across the documents. Lastly, the NE Downtown HIA was analyzed for its quality using the 20 10 Practice Standards for Health Impact Assessment and the score s were incorporated into an Excel spreadsheet. As part of improving the integrity and trustworthiness of the qualitative and quantitative research in this study, it is necessary to disclose t he dual role of the lead researcher. The author experiences and ro le of the lead researcher is important for being clear about potential bias, reducing it and still potentially enriching the study. In this study, research assistants were employed throughout the different research phases to help the lead researcher obtain a more neutral position during the study, to help ensure that the research was not skewed in a particular direction and to improve reliability. For data collection and analysis, all interviews were conducted by a research assistant and two research assist ants along with the lead researcher reviewed all documents and conducted the scoring to improve accuracy and reduce potential bias.

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193 Section 1. HIA Influence on Master Plan a nd Decision Makers This section focuses on the dependent variables and strives to answer the first case study research question: How do HIAs influence decision making in redevelopment master plans, specifically the adoption of HIA recommendation, health supportive language used, and change in decision dge? The first part of this section lays out the methods, data collected, and findings focused on health supportive language ; the second part has similar information for the adoption of the HIA recommendations into the master plan and lastly, health awaren ess and knowledge. The specific questions explored in this section include: How much health supportive language is in the NEDNP relative to other neighborhood plans without an HIA? O f the HIA recommendations that were adopted, how many were adopted that focused on changes to policies, built environment or programs? Of the HIA recommendations that were adopted, were they partially or fully adopted in the neighborhood plan? Which healt h categories in the HIA document had the most and fewest recommendations adopted? Did the project teams and other decision change because of the HIA, and what factors contributed to these outcomes?

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194 Neighborhood Mas ter Plan and Outcomes Comparison of Health Supportive Language Methods Determining the level of influence the HIA had on the NEDNP began with identifying the extent to which health supportive language was incorporated into the plan. A content analys i s was conducted of the NEDNP and three additional neighborhood plans as a comparison. Finding comparable plans to the NEDNP required a specific process plans because neighborhood plans are more common than other plans such as a station area plan Additional crit eria were developed to narrow the search: plans were considered that covered multiple neighborhoods that were part of or adjacent to a downtown area, contained a mix of uses including industrial, contained a high number of minority residents, had been expe riencing decline for the past several decades, and were created from 2008 2012 and possibly written under similar economic situations and planning paradigms. Lastly, the criteria included plans that were written in a similar manner to the NEDNP (i.e., were of a similar length, had substantial text and included analysis and recommendations). After employing the criteria initially, Milwaukee, WI; Kansas City, MO; Omaha, NE; and Baltimore, MD city neighborhood plans were selected. Milwaukee was removed after reviewing the plan in greater detail and determining that it was considered one neighborhood area and not multiple neighborhoods. A word search began the process of identify ing the extent to which health supportive language was incorporated into the plan s The search included phrases and words such as healthy, social equity, bike, walk, physical activity, safety, social capital and pedestrian friendly (see Table 1 7 for the complete list for all four neighborhood master plans). These words, phrases or acrony ms came inductively while conducting word searches and deductively from the literature

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195 consolidated by the Research Assistants (RAs) and lead researcher. Once found within the document, the words were also scrutinized to ensure proper context. To improve v alidity and accuracy of the research, an RA selected 10 words, phrases or acronyms randomly (20% of the total 56) and completed the content analysis. All 10 words were deemed correct by the lead researcher. Data Collected and Findings Table 1 7 displays the four neighborhood plans that were compared for their use of health supportive language. To provide some background information, Table 1 7 includes the name of the plan, lead agency for completing the plan, what year the plan was adopted, whether an HIA was conducted or not, and the number of pages of each of the plans. Along the bottom of the table are the total number of words or phrases that were reviewed and the total number of health supportive words found in each of the plans. Table 17 : Content Analysis of Neighborhood Master Plans Plan Name NE Downtown Greater Rosemont and Mondawmin area Near South Side area North Omaha Village Lead Agency Denver Community Planning and Development Baltimore City Planning Dept. Kansas City, MO City Planning and Development Dept. Alliance Building Communities, Nebraska Investment Finance Authority Adopted October 2010 2012 2012 2011 HIA conducted Yes No No No Pages in plan 97 112 57 121 Neighborhoods addressed 10 neighborhoods 17 neighbor hoods 12 neighborhoods multiple Categories

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196 Table 17 cont.; health, healthy, healthier, healthiest, 41 health (13), (y) (28) 22 health (4), (y) (18) 2 health (1), healthiest (1) 24 health (18), healthy (6) bicycle, bike, biking, bicycling 90 bicy cle (30), bike (53), biking (4), bikeway(s) (3) 40 bicycle (11), b ike (29) 22 bicycle (2), bike (20) 4 bike pedestrian (s), pedestrian friendly 147 pedestrian (s) (144), pedestrian friendly (3) 55 pedestrian (s) (48), pedestrian friendly (7) 33 pedestr ian (s) (27), pedestrian friendly (6) 42 pedestrian (40), pedestrian friendly (2) health impact assessment, HIA 4 health impact assessment (1), HIA (3) 0 0 0 safety, safer, safe, safely 30 safety (15), safe (13), safely (2) 32 safety (20), safe (9), saf ely (2), unsafe (1) 25 safety (5), safe (19), unsafe (1) 22 safety (10), safer (1), safe (11) social cohesion, social capital, social interaction, social needs, social network, social activities, social gatherings 3 social gatherings (1), gathering place (2) 2 social interactions (1), community activities (1) 0 7 neighborhood cohesion (1), cohesion (1), social capital (3), social network (1), community gatherings (1) social equity, health disparities, health equity, equity, disparities, inequalities 0 0 0 0 walk, walking, walkways, walkable, walkability, crosswalks 34 walk (2), walking (14), walkways (0), walkable (16); walkability (2) 16 walk (1), walking (2), walkable (3), walkability (5), crosswalk(s) (5) 11 walk (5), walking (1), walkable (5), c rosswalk (s) (4) 24 walk (5), walking (2), walkways (1), walkable (7), walkability (1), crosswalks (5), walk able (3) physical activity, exercise 1 exercise 0 0 3 physical activity overweight, obese, obesity 0 0 0 0

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197 Table 17 cont.; LEED, Energy Star 0 0 0 0 food (s), 12 food (s) (12) 7 food (6), food desert (1) 3 food (s) 3 1 access to food Total (46 words) *215/392 *119 /174 *63 /96 *85 /127 Table 18 focuses on identifying how many socioeconomic status (SES) specific words (e.g. education, occupation, and income) that are part of the broader social determinants of health that are in the neighborhood plans. These health related wor ds and phrases were broken out from the above table to better examine the differences in the plans since a stated attribute of HIA in the literature is to bring awareness to, positively influence, and potentially improve the SES in communities through enha ncements in planning and policy efforts. Table 18 : Socioeconomic Status Related Content Analysis of Neighborhood Plans NE Downtown Greater Rosemont and Mondawmin area Near South Side area North Omaha Village socioeconomic so cioeconomic status, SES 1 0 0 1 income, low income 2 income (s) (1), low income (1) 7 income (s) 7 1 income 5 income (s) (5) job (s) employment, occupation 12 job (s) (2), employment (10) 34 job (s) (19), employment (15) 34 job (s) (22), employment ( 12) 33 job (s) (16), employment (11), occupation (6) education (al), educate 1 25 education (al) (20), educate (5) 15 education 25 education (al) (24), educated (1) Total (10 words) 16 66 50 64

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198 Overall the NEDNP had the most health supportive phrases and words with 215 compared with the other three plans with 119, 63, and 85 each. In the NEDNP, the words walking exercise and HIA appeared along with many other health related words (see Table 17) The word health, healthier, healthy appears most in the NEDNP with a t otal of 41 times compared to 24 22 and two. The words health impact assessment and HIA were referenced four times in the NEDNP. This is important since the decision makers of the master plan were not required to use the term HIA or even ref erence the document at all. Even though there are only four references, it is positive that the HIA was referenced at all, considering how concisely the master plan was written with little room for ex tra or non essential points. The NEDNP had the most ref erences to health and planning related words in all categories but three ( it had 215 health related words or phrases and 44.6% of the total 482 health related words found in all of the plans not includ ing SES specific words). Great er Rosemont and Mondawmin area plan were only slightly higher for safety and North Omaha Village plan had the highest number in the social capital category and physical activity Based on the four master plans, the data suggests that the number of pages in the master plan is not a s significant determinant of the amount of health language as whether an HIA is conducted. an anomaly as it was used 147 times; the next cl osest total was only 55 (see T able 17) The word was used significantly more in the NEDNP than other plans, so the totals for the word counts Interestingly, when separating out the socioeconomic status type words such as education income and occupation ( jobs employment ), the NEDNP was lowest compared to the other plans (see T able 18) T he health assessor was not impactful in th e area of SES, and p ossibly needed to place more emphasis on this aspect of health Th e NE Downtown HIA was searched and found to have a total of 32 references for the SES concepts, which is not much more

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199 compared to what was identified in the NEDNP (total of 16) Follow up research is needed to focus on the health assessor role in increa sed use and better communicat ion of SES issues, as well as HIA process es and document s related to SES, to better understand how results might be improved Adoption of HIA Recommendations Methods Assessing the adoption of the NE Downtown HIA recommendati ons into the final master plan required an in depth review of each of the recommendations presented in the HIA and the master plan document. There are only a few published studies that identified changes in recommendation adoption, and they are in New Zeal and and Australia (Mathias et al., 2009). A search was completed of each recommendation, and it was determined whether the recommendations were fully adopted into the neighborhood plan, partially incorporated, or not adopted at all. The recommendations wer e written as a mix of specific actions to take and some more general items whose adoption can be harder to track. The recommendations were also broken out by how many called for a policy or program versus addressing the built environment directly Lastly, the recommendations were additionally broken out by the sections/chapter titles within the HIA document to determine recommendation adoption in terms of chapter topics, such as safety. A ll the above was documented in an Excel spreadsheet. Additionally, a few questions were included in the questionnaire about the adoption of the recommendations, and a within comments. The quantitative responses were added up and divided by the total possible number of points for a score for each question ( see Table 21 ) Two RA s and the lead researcher completed each of the steps.

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200 The following list describes the general reasons and examples of how the lead researcher and RAs determined whether a recommendation was labeled fully adopted, partially adopted or not adopted. 1) Fully adopted: The master plan adopts both the premise of the recommendation and its specifics. to the South Platte Riv er from Northeast Downtown. Previous planning efforts (38th & Blake station area plan, River North Greenway Plan) focus on the areas directly adjacent to the trail but do not provide sufficient guidance for those neighborhoods within a one to two mile rad ius of the r iver. With improved connections, people in Northeast Downtown can utilize the r In response, t he neighborhood plan states, Evaluate the potential to improve connections in the River North neighborh ood and provide additional access to the South Platte River corridor via: Pedestrian and bicycle bridges or underpasses across the Union Pacific Railroad right of way at 31st Street and 36th Street. Multi modal bridge or underpass including bicycle, pedest rian, and automobile travel across 2) Partially adopted: The master plan adopts the main premise of the recommendation but does not comply with the specifics in the recommendation. For example, in the HIA the recommendation Section II, B.4 reads Curtis Park a community destination. Improve safety in park by installing lighting, sidewalks, a jogging/running trail, In response, t he neighborhood plan statue or other landmark, where Curtis Street terminates at Mestizo Invest in park improvements and programming to encourage residents to use existing and ne w parks for active and passive specify the details of the recommendation for the Mestizo Curtis Park.

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201 3) Not adopted: The HIA recommendation is not reflected in the ma ster plan. An example of this is HIA recommendation Section II, schools to be more visible to both students and drivers. This could possibly be done through colored paving treatments and flashing pedestrian c there are very few references to schools, and none of these include crosswalks. Data Collected and Findings Table 19 displays the number of recommendations and other categorical information such as the determinatio n of degree to which the recommendation was adopted, and whether the recommendation focus ed on policies programs or the built environment. Table 19 : HIA Recommendation Adoption Levels Case Study Total # # Adopted % Adopted Fully Adopted Partially Adopted Not Adopted Built Environ ment Programs Policies NEDNP 61 22 36.0% 12 19.7% 10 16.4% 39 63.9% 45 20 adopted 25 Not adopted 71.4% Adoption 15 3 Adopted 12 Not Adopted 23.8% Adoption 3 1 Adopted 2 Not Adopted .02% Adoption Originally 62 recommendations but two recommendations were determined to be duplicates so one was removed. *Two recommendations had a split of built environment and program and policy for a total of 63 recommendations. There are a total of 61 recommendations, of which 22 were adopted into the master plan for an overall adoption rate of 36.0%. Without a comparison, it is difficult to attribute the adoption rate to the HIA. Over 50% adoption rate was considered above average by the lead re searcher, less than, below average. Of the 22 adopted, 12 (19.7%) were fully adopted into the master plan, and 10 (16.4%) were partially adopted into the master plan, and 39 (63.9%) were not

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202 adopted at all. The recommendations were also broken out by how H IA is defined, such as policies versus programs or the built environment plan shown in Appendix D, Table 5. Considering the HIA was focused on a redevelopment plan, it was not surprising that the built environment had the majority of recommendations (45, or 71.4% of the total), second was programs (15, or 23.8%), and third was policies (3, or 2% of the total) (two recommendations had a split of built environment and program or policy for a total of 63 recommendations). Once again not surprising, the built environment recommendations had the greatest number of adoptions (20 out of 45 or 44% of the total), and programs (3 out of 15 or 20%) and for policies (1 out of 3 or 33%). The built environment adoption would be assumed to be higher but overall the adopti on rates are low, with 44% for the built environment and policies were about a third and programs at 20% adoption but the last two would be far less likely to be in a redevelopment master plan. A full list of all recommendations and the scoring is in Appen dix D, Table 4. Table 20 demonstrates HIA adoption rates specific to sections in the HIA document. This table has adoption levels of the recommendations broken out by the health categories/sections from the HIA document; these are shown in order of how th ey are listed in the HIA document. These categories were developed by the health assessor when grouping similar recommendations together. Table 20 : HIA Adoption Rates Specific to Sections in the HIA Document Sections within HIA do cument # Adopted out of total recommendations in section % Adopted within section Social Issues 0 of 4 0% Healthy Eating and Active Living 17 of 36 47% Environmental Health 1 of 11 9% Safety 4 of 10 40%

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203 The HIA recommendation adoption rate s within specific sections of the HIA document are displayed above. The Healthy Eating and Active Eating chapter had the most adopted recommendations with 47% and included recommendations such as increasing the number of community gardens in the study area ; or adding a full along Welton Street; or enhancing the bus stops to provide shelters and benches. The second most adopted category was Safety at 40%, which included recommendations such as installing security cameras along Welton Street near the light rail line; developing a neighborhood walk and watch group; or implementing traffic calming measures on 20th and other high accident locations. The third fewest adopted recommendations were in the Environmental Health se ction (9%), which included recommendations such as improving signage of truck routes and enforce use of the truck routes or encouraging and creating incentives for a more energy efficient redevelopment. The fewest adopted recommendations were in the Social Issues section (0%), which included implementing programs to educate current residents about their rights as tenants or homeowners and provide counseling about mortgage related issues. Table 21 displays the interview questions related to the influence of HIA recommendations on the master plan and the HIA process on decision and knowledge The first column displays the questions pertaining to this study section; the second column notes the responses, including the number of each of the responses from interviewees followed by a dash ( ) and the selected Likert scale response (e.g., 3), and what that respondents had the options of picking 1 to 5 was an option if the respondent did not feel the question was was another option The third column has the overall score and percentage for each question to better compare across questions. Twenty is the total number possible for each question because there

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204 are a maximum of five points for each of the four respondents (unless someone on the first question below the respondents had a total of 7 points ( (3x2) + ( 1 x1) ) ; when divided by the maximum possible 20 points, we get a total per centage of 35%. Some questions did not offer an opportunity to comment with a qualitative response. Table 21 : Questionnaire Responses for this S tudy S ection (n=4 respondents) Question Responses Score / Percentage The HIA document in fluenced decision making during the neighborhood plan process? 3 2 disagree 1 1 strongly disagree 7/20 35% The HIA process influenced the neighborhood plan? 3 2 disagree 1 1 strongly disagree 7/20 35% How importan t is the level of conciseness of the HIA recommendations in terms of whether or not they are incorporated into the master plan or not? 2 3 medium 1 1 low 1 7/15 47% Health was prioritized within the neighborhood plan? 3 2 disagree 1 1 strongly disagree 7/20 35% Did your level of health awareness increase or not because of the HIA process and/or health assessor? 1 4 medium high 1 3 medium 2 1 low 9/20 45% Did your level of health knowledge increase or not because of the HIA process? 3 5 yes 1 0 no 15/20 75% Do you believe the HIA contributed to your work? 1 4 medium 2 2 some 1 1 low 9/20 45% Do you believe you contributed to the HIA? 2 5 high 1 4 medium high 1 1 low 15/20 75% B elow is one question with many follow up questions. To what extent were the following potential outcomes of interdisciplinary collaboration achieved at NE Downtown neighborhood plan/HIA? I mproved neighborhood plan 1 5 completely 1 4 somewhat completely 2 2 some 13/20 65%

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205 Table 21 cont.; More health awareness among team members 3 3 somewhat 1 1 not at all 10/20 50% You have increased health awarenes s 1 4 somewhat completely 2 3 somewhat 1 1 not at all 11/20 55% Improved knowledge sharing across disciplines 2 2 somewhat not at all 2 1 not at all 6/20 30% Interviews Findings from the analysis of interviews are organized into three sections: HIA r ecommendations h ealth/HIA c ontributions to/ influences on the ma ster p lan, and h ealth a wareness and k nowledge. HIA r ecommendations T he degree to which recommendations from the HIA were incorporated into and influenced the master plan did not receive high marks (36%) f rom the respondents (see Table 19 ). When respondents were asked about the main reasons for not including some of the HIA recommendations into the neighborhood plan one stated that there was a ity of based analysis to back up what it Another Another respondent stated, about what others on team were working on and doing and more health discussions at more public meetings or informal opportunitie When asked what else was needed or could be changed or improved to incorporate more implementation of recommendations so don't be so rigidly prescriptive. Allow fo r flexibility to

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206 address what the core concern is i.e. safe crossing for kids doesn't necessarily mean put in a cross his last statement supports the notion from the literature to meet the planners where they are and in this case, focus the recommendations on the built environment instead of policies and programs when related to a redevelopment. Another respondent stated, Health/HIA c ontributions to/influences upon the m aster p lan Al l four respondents agreed that n either the HIA document (35%) n or the HIA process (35%) influence d decision making within the neighborhood plan. This is not surprising considering that decision makers were not supportive of HIA or a health assessor from th e beginning. When a decision maker was asked how they learn ed about HIA if at all the answer answered a Respondents felt that health issues were important, with a score of 85%, when compared to other issues considered in the neighborhood plan. Yet all respondents felt that health was not prioritized within the neighborhood plan. Comments fro m respondents included personally [important], but the plan does not place this level of importance. Safety, Economic gly, one respondent emphasized there was one section in the neighborhood plan for health, which was a paragraph about public health, but that is more information than for many master plans (with no HIA).

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207 When asked if the respondents felt the HIA facilitat ed new interdisciplinary relationships, that would have not bee n available like from the police department or Denver Urban Gardens. e a small amount of funding and we'll do something called an HIA. As a result, I don't think that it respondent had similar sentiments stating that [the health assess notion of the HIA not being treated as part of the team is a se nt iment repeated many times. was a lack of interest by the [hired planni ng firm], and some interest from the C ity, there was still more discussion about health than usual from the HIA presentation and review of the HIA planning proc ess with the HIA compared to other projects they worked on without an HIA. managers at the [hired planning firm] reviewed and provided comments on the HIA presentation mostly related to formatting and the City provided comments on the presentation and provided Health a wareness and k nowledge HIAs, in addition to promoting health, well being, and equity, can increase awareness of these issues on urban planning and policy processes in other sectors outside of health ( Quigley et al. 2006). In this study, decision health awareness and health knowledge did n o t change much but possibly somewhat based on self rated answers by respondents. One challenge in determining whether there was an increase is v ery conflicting scores on different but

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208 similar questions. For example, r espondents felt there was somewhat more health awareness among team members as an outcome from the interdisciplinary collaboration achieved from the plan and HIA, but when asked if th ere was more health awareness among team members, it only scored a 50%. When asked if they had increased health awareness, it scored a 55% but when asked if their health awareness was increased from the HIA or from the health assessor, only 45% felt this way. T here seemed to be more of a slight increase health issues Three out of four felt that their knowledge was increased, and one was not sure. Also improved knowledge sharing across disciplines was rated extremely low. The HIA had supportive statements by respondents: Two people felt that their knowledge increased because of having a health assessor part of the team/process and one because an elected official was concerned about the issue The scores were also low w hen asked if there was an exchange of information and knowledge in relation to cross sector collaboration. There seemed to be stronger scores when answering as an individual versus the team or sharing across the team and when asked to respond yes or no ver sus scoring on a Likert scale. Although awareness and knowledge knowing there was an HIA and having a health assessor presenting at one meeting made a difference, al When respondents were asked whether there was health education and training, two respondents felt there was health education and training, and those same respondents felt it came from presentations at a public meeting. The other t wo respondents felt there was no education or training. Respondents felt the HIA did not contribute to their work, scoring a 47%, but they felt that they contributed to the HIA more with a score of 65% reflected in comments such as they contributed to th

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209 Overall, the HIA did not influence the plan much. There were some conflicting statements from respondents about what the health assessor contributed a nd how much health was discussed compared to other plans without an HIA. Respondents also felt that health was important but not a priority within the NEDNP. A l esson learned is that decision makers need education specifically on the role, purpose, goal a w hat is an HIA, what it does that was not know how to integrate it [HIA] with the planning process. It was sort of like waiting to see what Limitations T his one HIA is not necessarily representative of all neighborhood pl an HIAs and should not be generalized as such. Another limitation is the question of cause and effect between the HIA recommendations and their adoption in the final master plan. For example, would the adoption of some of the recommendations have already b een included without the NE Downtown HIA and instead decided by other disciplines during the planning process? To better understand the intentions of the planners and other decision makers, interviews were conducted with the decision makers to better deter mine direct and indirect impacts of the HIA and to better understand the motives behind using the HIA recommendations and other HIA influences. Also, additional research could seek to identify specific opportunistic impacts of the HIA that might address wh ether the recommendations would have been incorporated into the plan anyway (Wismar et al. 2007) but is not part of this research. Also, the lead researcher was the health assessor for the NE Downtown HIA, which can create obvious biases and preferences o r

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210 preconceptions about the outcomes, so research assistants were employed to conduct the interviews and duplicate the data collection with the lead researcher. Lastly, the list of phrases and words for the health supportive language is not an exhaustive li st; also similar words or phrases in certain context possibly might not have been included in the counts but would be more likely to be included when the determination was close. Section 2. Influence of HIA Quality on Master Plan and Decision Makers The in dependent variables, HIA quality and cross sector collaboration, are examined in the next two sections. The two sections help to answer the second central research question which is: Do variables such as cross sector collaboration and the quality of the HI A influence whether the HIA is more or less successful in influencing the health supportive language, HIA recommendation adoption and health awareness and knowledge? Determining HIA Quality This section focuses on determining the quality of the HIA and add resses the following questions: What quality Standards score does the NE Downtown HIA achieve? Were the goals and objectives of the HIA met? Does the quality of the HIA influence decision makers and the master plan outcomes, if so, in what ways? Does t he level of quality of HIA along with level of collaboration more greatly influence the master plan outcomes? merican HIA Practice Standards

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211 Working Group in 2010. Although there are numerous guidance documents (Hebert et al., 2012), the Standards are the only practice standards available in the United States and abroad. The ues underlying HIA and key lessons [learned] from much to ibed in the leading guiding This study used the Standards as the benchmark for assessment, and the Standards are fundamental to discerning the quality of the NE Downtown HIA and development of the questions in the questionnaire related to the quality of the HIA. The North American HIA Practice Standards Working Group developed the Standards. Members of this Working Group are considered steeped in the practice and research of HIA, with the three lead authors being prominent leaders in the HIA field both here in the U.S. and in Canada. There are Rajiv Bhatia, MD, MPH, and [now former] Director, Occupational & Environmental Health, San Francisco Department of Public Health; Murra y Lee, MD, MPH founder of the Habitat Health Impact Consulting in Calgary, Alberta, Canada, and Lili Farhang, MPH, Associate Director, Human Impact Partners in Oakland, CA. Still, the Standards are a work in progress with challenges that are described in t he limitations section further below. A newer 2014 version was just released in September. Berke and systematic evaluation enables us to identify their specific strengths and weak nesses, to judge whether their overall quality is good, and to provide a basis for ensuring that they reach a desirable standard (p. 228).

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212 if you saw one (p. 228) ? So how would we know a good HIA if we saw one? This is a challenge and the rationale for the development and use of the Standards in this study. Methods At the outset of the review, the lead researcher and two research assistants rated the quality of the HIA based on each of the Sta ndards using a simple scale of low, medium and high, which revealed how well the HIA met the Standards. In some cases it was necessary to break a long, complex standard into its component parts in order to be scored. An Excel spreadsheet was created that l isted each standard and has a short explanation of the standard so that each one could be appropriately scored. There are a total of 63 Standards that are broken out with nine general standards and then specific standards for each of the HIA steps. These s teps include Screening ( three standards ), Scoping ( 17 standards ), Assessment ( 13 standards ), Recommendations ( four standards ), Reporting ( eight standards ), and Monitoring ( nine standards ) The spreadsheet the lead researcher developed with the standards an d the related scoring is in Appendix E, Table 6 For example, the spreadsheet lists out each of the Standards associated with the entire scoping phase. This section begins with the title of: 3. Scoping: 3.1: Scope of health issues and public concerns. With in 3.1 are standards regarding what is : Scoping 3.1.1 Decision and alternatives to be studied; Scoping 3.1.2 Health impacts and pathways; Scoping 3.1.3 Demographic, geographic, and temporal boundaries; and continues up to 3.1.11. cable) were added to the low, medium, and high ratings. The for those instances where a certain standard did not apply. For example, no screening formally occurre d for this case study (screening is the first step in the HIA process where it is decided whether an HIA is needed). The decision was made before the health assessor was hired,

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213 therefore, this standard did not apply. Additionally, a few standards in the 2 010 version were the process) were deemed too unrealistic and extremely hard to meet by the lead researcher and two research assistants. For example, the 2010 Stand ards describe in the monitoring section the need for an HIA management plan to be established early in the HIA process. Management plans are very seldom completed at this point with little evidence based data identified that such a plan improves quality or success of HIAs. So one standard in the monitoring section 7.1: Follow up monitoring plan, track decision outcomes, and effect of decisions on health impacts were scored and others in the section were not scored, and a N/A was applied e.g., needed specif ics about which individuals and what resources were identified to monitor the outcomes of the HIA. In order to score the data, each rating was assigned a point value : 0 for no, 1 for low, 2 for medium, and 3 for high. A specific scoring process was selecte d to provide a more specific determination of to what degree a standard was met and be able to better compare with another case study. This scoring system is similar to that done with LEED ND certification that incorporates a points system of whether a cri teria was completed or not. The scores were averaged in order to assess the overall quality of the HIA. Standards that were marked N/A were not given a score and were excluded from the average. In order to determine the overall quality rating for the HIA, numerical scores were defined for each of the qualitative ratings of the HIA components. If the average score fell in the 80 th the average score fell below the 8 0 th percentile but above the 60 th percentile (scores between 2.34 th percentile (<1.8) would 23 for score s of the Standards).

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214 Once the scoring methodology was determined, the quality of the NE Downtown HIA was assessed. In order to eliminate some of the subjectivity in rating each standard, a research assistant reviewed the HIA independently and came up with a score for each standard. The research assistant and lead researcher discussed each standard that was rated differently and why. In many cases there was total agreement, but in other cases a discussion and consensus was necessary. The NE Downtown HIA was assessed thoroughly and then compared to the other case in this broader study. The review occurred over six days that included the comparison across the two cases. The analysis was conducted in a close timeframe to ensure that there was consistency in inte rpreting the standards. Although many standards were met within the HIA, some details were not well documented. For e xample sometimes information was mentioned only briefly or was shared in detail at stakeholder and community presentations but not documen ted in the HIA. A research assistant questioned the health assessor for the NE Downtown HIA to gain a more complete picture of the standards met. Much later, the project team members and others were interviewed using the full questionnaire about the qualit y of the HIA. Additionally, interview questions were asked that pertain to HIA quality in terms of the Standards. A within case analysis was conducted of their responses and comments and the quantitative responses were added up and divided by the total po ssible number of points for a score for each question. The below table lists in t he first column the codes derived deductively and inductively The second column lists the HIA quality S tandards and the proposition(s) from the literature that are relevant to each of the codes The complete list of the Standards are in Appendix E, Table 6

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215 Table 22 : Codes and Standards and Propositions for Analysis of Interviews Code HIA Quality Standard and/or Pro position Understanding Goals and Process of HIA 1.3: Evaluation, explicitly written goals at outset of HIA process. Proposition: Having knowledge and realistic understanding of processes of HIA. Decision maker and involvement Stakeholder participation Opportunity to review and provide comments 1.6: Meaningful and inclusive stakeholder participation (officials and residents). 6.6: Distribute HIA and or findings to stakeholders that were involved in the HIA. The HIA reporting process should offer stakeho lders and decision makers a meaningful opportunity to critically review evidence, methods, findings, conclusions, and recommendation. 3.1.10: Plan for external and public review HIA Quality Timeliness 1.4: HIA should respect the needs and timing of the d ecision making process it evaluates. Proposition: For better success, timing of the assessment fits within the decision making process. Comprehensive review of issues and Evidence based data 3.3: Consideration of all potential pathways reasonably linked with decision and/or proposed activity of health whether direct, indirect or cumulative. 4.1.2: Evaluation of health impacts based on best evidence. 4.2.2: Utilize evidence from well designed, peer reviewed systematic reviews. 4.2.3: Consider published ev idence that supports and refutes health impacts. Proposition: Inclusion of empirical evidence supports success. Data Collected and Findings Table 2 3 i llustrates the number of standards that were rated high, medium, low, no, N/A and the weighted scores (ra tings (points) x number of standards within each rating). Table 23 : Scores of Standards Ratings # of standards within each rating Weighted score High (3pts.) 20 60 Medium (2pts.) 9 18 Low (1pt.) 8 8 No (0 pts.) 10 0 N/A (remo ved) 16 0 Total 47 86 = 1.83 Note: A weighted average score takes different scores, with assigned weights, or percentages.

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216 HIA Standards To answer the first research question for this section, the NE Downtown HIA scored a 1.83 for meeting the criteri (see Table 23 ). The HIA scored medium low along a wide range of standards such as identifying th e gaps in the data, monitoring, and prioritization of the recommendations that were weak or absent, causing the lower score. While the score is informative and provides a gauge of the level of quality of the HIA, it is more meaningful when compared with th e other scored HIA in this broader study that is in Chapter 6. South Lincoln Housing Redevelopment case. The second research question seeks to determine the quality of the HIA based on whether the specific goals of the HIA were met. This question is also specific to standard 1.3: Evaluation, explicitly written goals at outset of HIA process. Broad goals and a purpose statement were written in the HIA. The the Northeast Downtown Neig hborhoods and to provide recommendations as the City and County is comfortable and accessible to people of all ages and abilities; Reducing the need for automobi les by creating mixed use communities with a variety of amenities that are either bikeable or walkable; and Developing neighborhoods that encourage people to get physically By comple ting a document review, the purpose/goals were identified as completed. More specific and measureable goals and a purpose statement would have provided a better assessment of whether the goals were met. The last two research questions identified at the be ginning of this section will be answered in Chapter 8. Results and Discussion under question 2. Within Cases: Conceptual Framework Section toward the end of the document.

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217 Table 2 4 displays the data from the questions that pertain to the quality of the HIA The table first displays the column of questions pertaining to this study section, second column has the responses with the number of responses from interviewees (n=4), a dash ( ) and the selected response (e.g., 3), and what that number represents (e.g agree). The responses are from the questionnaire with options of picking 1 5, ranging from not effective or strongly disagree (1= low) to very effective or strongly agree (5= high) and neither (3 = medium). N/A was an option if the respondent did not fee l the question was applicable to them. and not sure were other options. The third column has the overall score and percentage for that question to better compare across questions. Some questions did not offer an opportunity to comment with a qualitative response. Table 24 : Responses and S cores from I nterview Questions P ertaining to HIA Q uality Question Response Score/Percentage Were decision makers interested in the HIA? 4 yes 20/20 100% Were decision maker s involved in the HIA? 2 yes 1 no 1 not sure 10/15 67% Was your organization/agency notified of the HIA goals early in the master plan/HIA process? 1 yes 3 no 5/20 25% Was your organization/agency notified of the HIA process/s teps early in the master plan/HIA process? 1 yes 3 no 5/20 25% Did your agency/firm/organization have an opportunity to critique or provide comments during the HIA process or the document? 3 yes 1 no 15/20 75% How would you ra te the level of interdisciplinary collaboration for the NE Downtown Denver Neighborhood HIA/neighborhood plan process stakeholder group and project team ?* 1 5 high 1 2 medium low 2 1 low 9/20 45% Do you believe the stakeholder group for the NE Downtown Master Plan worked collaboratively?* 1 2 medium low 3 1 low 5/20 25% Did you feel that the HIA was conducted in a timely manner? 1 yes 2 no 1 not sure 5/15 33%

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218 Table 24 cont.; Do you feel the information from the HIA was delivered in a timely manner? 1 yes 2 no 1 not sure 5/15 33% The HIA used evidence based data that supported the recommendations? 4 agree 1 disagree 1 strongly disagree 1 7/15 47% Do you think more or fewer health issues were discussed during the master planning process because of the HIA, compared to other planning projects you have worked on without an HIA? 2 3 medium 1 2 low medium 1 1 low 9/20 45% *Data also discussed in co llaboration section Interviews There were only a few positive responses from the interviewees that were related to how the respondents felt about the HIA. The section below describes the comments received by respondents that were broken out into the coded categories from Table 2 2 Understanding g oals and p rocess of HIA Respondents felt that they (or their organization or agency) were not notified of the HIA and one was not sure ( ). of an opportunity to do so mainly because the team did not meet to When asked if they were notified of the HIA process/steps early in the HIA process two the h ealth assessor] just showed up at the [hired planning talked about HIAs purpose and process and how HIAs were done in past, etc. Not much

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219 decision makers were not informed much about HIA process or goal s and overall lacked understanding of its purpose Further, decision makers did not provide the opportunities for cross learning or specifically learn ing about HIA which was a new component to the team. Decision maker involvement and stakeholder participation All four respondents stated that the decision makers were interested in the HIA. An elected official and the project managers for the City were mentioned as decision makers who were interested. When asked about whether the decision makers were involved in the HIA the ; one answered having a health assessor involved." One respondent stated when asked how they learn ed about a The question on collaboration with both the stakeholder group and project team scored One resp ondent answered the question specific to the HIA involvement in relation to the two groups, the stakeholder and project team. had a [working] group. There was one for Curt is Park, Arapahoe Square had a working of those groups. There was a disconnect between the planning process and the HIA process. In terms of the stakeholder group there was a lack of awareness that it [HIA] was interpret that as being like [project managers] and other staff who were working on the plan, and then our consultants, there it [HIA] was more so, but still probably not what it needed to be, I think, to get a document like what we needed. So [involvement of HIA ] nonexistent for the stakeholders and also low for the project group. There is a little

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220 difference there. One is nonexist ent [involvement of HIA with Stakeholder groups], the Once again there is evidence of a disconnect in the involvement of the project team and stakeholders in the HIA, which leads to the larger iss ue of the disconnect between the planning process and the HIA process. Timeliness As stated in the literature, the timing of the HIA is very important for success; more specifically, the HIA should be completed before the decision(s) are made that it is t rying to inform. Only one respondent stated that the HIA was conducted in a timely manner. Two was not delivered [The HIA] didn't so the other team member s respondent stated, lete HIA well before decisions on master plan. HIA completed four to five months in advance of the decision makers it did not significantly influence the neighborho od plan. Comprehensive review of issues and evidence based data The respondents agreed that there was a comprehensive review of the health issues in the HIA (85%). But there was far less agreement (47%) that the evidence based data supported the recommend ations. availability of evidence based data and local neighborhood level data often does not match what is desired or the expectation level of other team members and stakeholders.

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221 Limitations There are many limitations associated with the assessment of the quality of the HIA, which primarily stem from issues with the 2010 North Am erican HIA Practice Standards themselves. First, t he Standards for conducting an HIA can be challenging to objectively measure, and operational definitions are needed. The components of the Standards could be interpreted differently by various users, resul ting in an alternative scoring. Second, it is challenging to accurately rate each standard from reading the final document only; there is a need at times to rely on outside information to adequately rate a few of the Standards, e.g., were all community mee tings documented in the HIA? Another challenge is that strict adherence to the Practice Standards could yield an HIA overly cumbersome and lengthy. While the health assessor wants a document that details all aspects of the process, the community and other stakeholders need a document that is reasonable in the number of pages, conciseness, and readability. Finally, although the Standards are designed to advance HIA quality, improvements to the Standards are needed. A revision of the Standards was just releas ed September 3, 2014. Section 3. Cross Sector Collaboration The second independent variable, cross sector collaboration, is examined below. This section along with HIA quality help s to answer the second central research question which is: Do variables such as cross sector collaboration and the quality of the HIA influence whether the HIA is more or less effective in influencing the master plan outcomes and health awareness and knowledge? This section of the case study focuses on identifying the level of cro ss sector collaboration during the NE Downtown HIA and master planning process. The section also addresses if and how levels of collaboration and specifically public health engagement such as a

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222 health professional being involved in the project team and con ducting an HIA influenced the quality of the HIA, the master plan outcomes, and health awareness and knowledge. The research questions for this section are below: What level of cross sector collaboration does the NEDNP project team achieve? H ow does the level of cross sector collaboration of the project team influence the amount of HIA recommendation adoption, health supportive language used, and change in health awareness and knowledge? Does the level of cross sector collaboration of the proj ect team and other decision makers influence the quality of the HIA document? The literature supports that a blending of the responsibilities, tools, and perspectives of multiple sectors can result in better outcomes than having one sector take on all the responsibilities (Kochtitzky et al., 2006; Bryson et al., 2006; Kline, 1990). A collaborative public challenges (Bryson et al., 2006; Petts et al., 2008; Greenwal d, 2008). Cross sector collaboration can provide a powerful opportunity to share evidence based data with other across sectors; and can allow for more expansive thinking to identify potential unintended health consequences of plans and policies (Quigley et al. 2006). The literature states that enhanced leadership, resources, partner relationships, history of relationships with team members, structures and proces ses, and good communication translates into more successful outcomes (see more in Chapter 4 ).

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223 Methods As described above, t he purposive interviews took approximately 45 minutes to one hour to complete and were conducted in late 2013. The interview questi ons utilized both quantitative measurements using a Likert scale with choice of 1 5 ranging from not effective or important (1) to very effective or important (5) and neither (3). The interviews produced both qualitative and quantitative data as questions intentionally encouraged both types of responses. These questions captured three research categories: cross sector collaboration, effect on HIA quality, and the influences of the HIA on the master plan and decision makers. The questionnaire was informed and reviewed by those involved with the research and went through a number of drafts in order to ensure that the questions, response scales, and the order of the questions was optimal. Once complete, the questionnaire was piloted, which resulted in additio nal minor revisions and then cleared through the Institutional Review Board 3 Data Collected and Findings Table 25 displays the data from the questions that pertain to cross sector collaboration. The table first displays the column of questions pertaini ng to this study section, second column has the responses with the number of responses from interviewees (n=4) a dash ( ), and the selected response (e.g., 3), and what that number represents (e.g. agree). The responses are from the questionnaire with opt ions of picking 1 5, ranging from not effective or strongly disagree (1= low) to very effective or strongly agree (5= high) and neither (3 = medium). N/A is an option if 3 The questionnaire was submitted to the Colorado Multiple Institutional Review Board (IRB) at the University o f Colorado at Denver for review (protocol number 12 0412) in March, 2012 and was determined not to constitute human research as defined by current policy and regulation. The questionnaire could therefore proceed, exempt from further IRB oversight.

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224 the respondent did not feel the question was applicable to them. were other options. The third column has the overall score and percentages for that question to better compare across questions Some questions did not offer an opportunity to commen t with a quantitative response. Table 25 : Cross sector collaboration responses from questionnaire Question Responses Score/Percentage How would you rate the importance of an interdisciplinary collaborative approach? 4 5 very important 20/20 100% How effective would you rate the interdi sciplinary collaboration during the NE Downtown HIA/master plan redevelopment process ? 4 1 not effective 4/20 20% How would you rate the level of interdisciplinary collaboration of the project team for the NE Downtown Master Plan? 2 5 hig h 1 4 somewhat high 1 1 low 15/20 75% Do you think that all the disciplines jointly achieved an outcome which could not be achieved by one discipline separately? 1 5 high 2 3 medium 1 2 medium low 1 3 /20 65 % To what extent wer e the following potential outcomes of interdisciplinary collaboration achieved at NE Downtown Denver Neighborhood plan/HIA? Improved resource sharing 2 2 somewhat not at all 2 1 not at all 6/20 30% Improved communication (i.e. frequency, m odes) 1 3 somewhat 1 2 somewhat not at all 2 1 not at all 7/20 35% Improved trust and respect for other team members 1 3 somewhat 3 2 somewhat not at all 9/20 45% Follow up questions were asked to help get more detailed ans wers. Table 26 b elow documents the responses to one important question with many follow up options. The scale was 5 (completely), 4 (somewhat completely), 3 (somewhat), 2 (less than somewhat), 1 (not at all). Respondents could offer comments, which are sum marized in the Findings below

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225 Table 26 : Questions about specific aspects of interdisciplinary collaboration (n=4 respondents) Question Responses Score/Percentage The following lists aspects of interdisciplinary collaboration. How do you feel these aspects contributed to the neighborhood planning process if at all? Bringing together diverse stakeholders 2 4 medium 1 2 somewhat not at all 1 1 not at all 11/20 55% Meeting regularly 2 4 somewhat completely 2 1 not at all 10/20 50% Exchanging info/knowledge 1 4 somewhat completely 1 3 somewhat 1 2 somewhat not at all 1 1 not at all 10/20 50% Sharing resources 3 2 somewhat not at all 1 1 not at all 7/20 35 % Strong leadership 1 3 somewhat 1 2 somewhat not at all 2 1 not at all 7/20 35% Informal relationships created 1 4 somewhat completely 3 1 not at all 7/20 35% More informed decision making 2 4 somewhat completely 1 3 somewhat 1 2 somewhat not at all 13/20 65% Processes, inputs, and outcomes tracked for accountability 1 3 somewhat 3 1 not at all 6/20 30% Having a shared mission and goals 1 4 somewhat completely 2 3 somewhat 1 2 somewhat not at all 12/20 60% Interviews Findings from the analysis of interviews are organized into sections that begin with broad answers about IC and the presence of factors supporting cross sector collaboration that include more specific s ections: Partner Relationships, Leadership, Communication, and Past Relationships with Team Members.

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226 Respondents offered low marks in their answers to the first research question in this section, regarding the level of and influences from cross sector coll aboration of the project team over the course of the master planning process and HIA. Respondents did agree that an yet it scored only a 20% by gs for the NE Downtown HIA/master planning process. Also, there were low scores when asked about whether the stakeholders worked collaboratively (only 25% agreement) or the project team and stakeholders worked collaboratively (45%). R espondents also rated interdisciplinary relationships. Interestingly, t contrasting comments such as Another respondent felt that there were many stakeholders working collaboratively but no collaboration with the health assessor or others in other disciplines on the team. For example, one resp give that task to [ the health assessor] and let her come back with something. Not a lot of conversation in b Contrastingly, another respondent stated that t Another the h of perspectives about the level of collaboratio n of the project team, which could state something about the cohesiveness of the team, or in this case, lack thereof. Interesting ly the scores and comments for the project team were rated high by a few, which could result if they do not view the health as sessor as part of the project team, but after looking at the comments, it seems the others interviewed did not see the health assessor as part of the project team. Literature states that HIAs are more successful when the entire team is working

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227 collaborativ ely including members such as the health assessor or community engagement consultant or a social services consultant. Presence of factors supporting cross sector collaboration As stated in the literature, IC is more successful when specific factors are pervasive among the entire team. The six factors include enhanced leadership, communication, and partner relationships; resources; history of positive r elationships with team members that all translates into more successful outcomes. To get a better unders tanding of whether NEDNP had high, medium or low collaboration, comments and ratings of these specific successful factors are broken into categories. Below is a description of the factors as described by respondents that relate to the NEDNP and HIA. Althou gh the focus of this research is the project team members, the stakeholder group collaboration is also important to HIA quality and the broader collaborative environment, so related questions were also shared here. Out of the eight choices, the factors of IC that the respondents felt most strongly contributed to the master planning process were more informed decision making (65%); having a shared mission and goals (60%); bringing together diverse stakeholders (55%); exchanging info/knowledge (50%); and meet ing regularly (50%). The least rated factors were strong leadership (35%), informal relationships created (35%), sharing of resources (35%) and processes, inputs and outcomes tracked for accountability (30%). Scoring was very low overall with a 65% of info rming decision making rating being the highest. Cross sector collaboration was rated low overall for the NEDNP project team and specifically the factors listed above that are enablers to success.

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228 Partner r elationships There was only 45% agreement on im proved trust and respect for other team members from the neighborhood plan and HIA. Leadership Negative statements were offered by the respondents about the leadership and its contribution to IC, the master plan and the HIA. Strong leadership was rated poorly with a very Another respondent stated that ore input needed during the process from the health assessor to describe leadership throughout the and [hired planning firm] to get the plan done well. There seemed to be a lack of regular Very challenging to even know who else was working on team or what they were doing, no conference calls or meetings with all of sector collabo ration literature, leadership among the other factors has the most rigorous research that clearly demonstrates its importance in more successful teams that was noticeably lacking among the NE Downtown team. There are a lot of layers to leadership. There i s a lot of involvement and scrutiny of the planning process from various managers of departments. Project managers would be would be like the planning director, the econo mic development directors, parks director, public works director, the top people a lot of interest in the plan. The HIA was b uried and not really discussed.

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229 Looking back, a barrier and mistake was not communicating directly with leadership at the City be cause it seemed [as a subcontractor] that I should communicate with the hired planning firm instead of the City directly, until the end of the process when it became necessary. Educating project team members should have been more of a priority from the sta rt but more specifically those at the City. This can work if health Overall more education on HIA was needed, especially with the managers/lea dership on the team. In the literature ensuring a common language is a component of leadership that was common, understandable and the stakeholder group as 70% which is at least in satisfactory range. Another respondent stated that uncommon language in planning. Could do a better job of making it understandable for to be little focus on this by those managing the Communication There were no supportive statements made or scores offered about the communication of the project team or stakeholders. After asking the respondent why they scored or responded the w ay they did Improved communication was overall rated very poorly when asking about outcomes of interdisc iplinary collaboration in the neighborhood plan and the HIA. Past r elationships with t eam m embers Three out of four of the respondents had worked with team members prior to working on this project, and one shared that it was a positive experience. Some o f the past relationships listed were or

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230 group] was an outlier and so was the publi In summary, there were past relationships within the project team members, and communication among the team was described as lacking and not supportive with only little opportunities to interact and share. Respondents felt that there was also little improvement in the trust and respect achieved among the team members, and relationship building was not emphasized as an attribute of the leadership. Lastly, along with the other factors, strong leadership was rated poorly, and overall the project team failed to effectively facilitate the aspects of successful cross sector collaboration. Based on the literature, this translates into the products: whether the HIA or master plan theoretically are not as good as they could be. Limitations The interview guide can present limitations because the HIA was completed in 2011 and the interviews were conducted in late 2013. This retrospective timeline can create issues with respondent recall bias, incomplete recollection, and reflexivity. Also, the le ad researcher was the health assessor for the NE Downtown HIA, which can create preferences or preconceptions about the outcomes, so research assistants were employed to conduct the interviews and duplicate the data collection with the lead researcher as d escribed in the methods sections. Additionally, n=4 is a low number of interviewees, but those who were interviewed were key decision makers/creators of the neighborhood plan and HIA. Unfortunately, the City councilwoman passed away before she was able to be interviewed for this study.

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231 Key Findings from Research that Support HIA Influence Positive and negative key findings were coded during data analysis whether from content analysis, interviews, or document review A ll data were consolidated to assist wit h better understanding the influences of HIA, answering the research questions, and examining the hypotheses and propositions and determining whether they are congruent with what this study has identified and concluded. Master Plan and Decision Makers O utcomes: Lack of support for the HIA or health assessor. A decision maker stated that they were told by client to do an HIA and hire a health assessor and another res pondent stated that they had to bring the health assessor on to the consulting team. Doing an HIA was prompted by a city councilwoman, not by decision makers on project tea m Health was not a priority within the neighborhood plan but there was one long paragraph devoted to public health in the plan which is still more than most plans without an HIA. Respondents felt that neither the HIA process nor the document influence d the master plan. Respondents felt that health issues were important when compared to other issues considered in the neighborhood plan. Yet all respondents felt that health was not prioritized within the neighborhood plan. Respondents felt that health issues were not discussed significantly more during the planning process because of the HIA compared to other projects, except for an HIA presentation at one public meeting. The HI More evidence based data is important for positively influencing the master plan.

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232 There was l ittle increase in self rated health awareness as a result of the HIA Part elf rated h ealth knowledge was mildly increased although there were conflicting responses with other similar questions. More health supportive language was used in NEDNP compared to other similar plans without an HIA. Less than 40% of HIA reco mmendations were incorporated into the neighborhood plan. Decision makers, especially managers and leadership, needed more explanation of what HIA is all about and how to incorporate into planning process. Collaboration : Interdisciplinary collaboration wa s considered to be very important by all interviewees a lthough it was not perceived to be effective during the NE Downtown HIA/master plan redevelopment process. fairly high, but t here were incon sistencies in the assessment. Factors that support more successful cross sector collaboration such as strong leadership and communication, and trust and respect were lacking in the planning process or poorly executed by the team or managers. It seemed tha t the HIA/health assessor was seen by decision makers as not part of the project team T he stakeholder group and project team A respondent felt they s hould have communicated directly with top leadership much earlier on in stead of the end of the process when it became necessary.

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233 HIA Quality: Respondents felt that they were not notified of the HIA goals early in the planning and HIA process. Only one respondent felt they were notified of the HIA process/steps early in th e HIA process. Three out of four respondents stated that the decision makers were interested in the HIA. When asked about whether the decision makers (project team and other key stakeholders) were involved R espondents agreed that there was a comprehensive review of the health issues in the HIA. T he evidence based data was not seen to support the recommendations. tations were too high about what data/evidence Respondents felt they had opportunities to review and comment on the HIA. Results Within Cases: Conceptual Framework To better assist with answering the research questions, a conceptual framework was developed to more effectively analyze and further demonstrate the level of influence and effectiveness within each case and across the two cases in Chapter 8. Results and Discussion This framework takes the form of a checklist A goal of the checklist typology was to thoroughly and methodically evaluate the key findings for the independent and dependent variables, to further demonstrate which cases overall rate as low or high levels for the variables being

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234 researched, identify specific measures met or not within a case, and note specific differences between the cases. The checklist analysis more methodically helps establish th e level of agreement and understanding on whether the master plan was influenced by the HIA and in what specific ways. For purposes of this research, it was deemed appropriate to use a conceptual framework made up of propositions developed from the literat ure, HIA Practice Standards, and other newly identified measures from this research that inform this typology about influences from the HIA. On the checklist, a newly identified measure is marked with (N), propositions (P), and specific Standards (S). The measures were broken out into low and high levels to be tested ; this analy sis further contributes to triangulation and analysis of all the data. For this case, most measures were considered low level, so only the low level checklist is shown. There is a ch eck that are not checked could mean that the measure was not completed or there was no clear answer from the data as to whether it was met or not, and some migh t have been met better than the statement reflects because this is the low influence checklist. Decisions about whether the measure was met or not were based on the results from analysis, and the scores and comments of the respondents. The checklist typolo gy below shows key findings and whether that measure was met This clearly demonstrates that in this case, there was a low level of influence and overall lack of effectiveness of the HIA on the master plan and decision makers. Low Influence/Effectiveness Checklist Independent Variables

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235 HIA Quality: Completion of HIA too close to completion of master plan (S & P) o Recommendations not supported with evidence based data (S & P) o Scored between 1.8 and 2.1 (low to medium low) against the Standards (S) Health assessor not experienced (P) n monitoring) (S) HIA goals and process not explained early in planning process (S) Little review or critique of HIA by decision makers (S & P) Decision mak ers not involved in design and conduct of HIA (P) Little quantification of impacts, (where possible) (S & P) Little local/neighborhood level data (what local level data available was shared) (N) People outside the decision making process did not provide i nput (S & P) o Lacked a consistent and appropriate methodological approach (followed HIA steps but no survey or focus groups, etc.) (P) Cross Sector Collaboration : Little cross sector collaboration among project team members (P) No formal stakeholder group (S) Low level project team communication (P) Little history with project team; negative past experiences (P) HIA assessor is isolated from decision makers in master planning proc ess (P) Provided no or little input from Stakeholder group (P & S)

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236 Poor leadership from decision makers (P) Little political support for HIA (P) Little participation/input from other disciplines during HIA and planning process (P) Little engagement in HIA from decision makers (P) o Little/not enough resources to conduct HIA (P) Little u nderstanding about perspectives of partner organizations and team members (P) Dependent Variables Recommendation Adoption: Few (< 50%) HIA recommendations adopted into planning document (N) Few decision modifications of master plan (P) Unrealistic recommendations (P) o Recommendations are not specific to the neighborhood (where possible) (N) HIA is controversial /contentious (P) o Little to some evidence based data to support recomme ndations, where possible (P & S) o None or few clear and concise recommendations (N) Little shaping of recommendations to reflect organizational concerns (P) Health Awareness and Knowledge: Few presentations or means to share data/findings (e.g., < 2 communi ty meetings)

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237 Little awareness of health gained by other project team members (P) Little tailor ing of presentation of findings (community and stakeholders) (P) Little or no increase in know ledge of HIA an d/or health by decision makers (P) Little to no education provided about HIA and health (P) Health Supportive Language: Master plan does not have significantly more health supportive related words than other, similar plans (N) Table 27 clear ly illustrates how each of the dependent variables (DV) and independent variables (IV) were rated. If it was close to a low or high, a medium option was added for further clarification. This typology sums up the answers to the central research questions ; f urther description and discussion is available in Chapter 8. Results and Discussion. Table 27 : HIA Influence/Effectiveness Typology Analysis Summary, NE Downtown Case IV DV Master Plan and HIA Outcomes Cases Rate/le vel of Collabora tion Quality of HIA Level of HIA Recommendation Adoption Health supportive language Increase Health awareness/ knowledge Outcome (by case) NE Downtown Neighbor hood HIA/ plan Low Medium low Low 36% < 50% of HIA recommendations incorpor ated into neighborhood plan Higher than other similar plans (44.6% of the total number of words, 482) L ow L ow Medium Low

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238 Concluding Remarks This case is an example of an HIA that only mildly influenced the neighborhood plan document and process and th e decision makers as shown in Table 27 The research focused on the NE Downtown HIA and how it influenced the Northeast Downtown Denver neighborhood plan in terms of the amount of HIA recommendations that were adopted into the neighborhood plan, the healt h supportive language used in the plan, and changes in the decision awareness and knowledge of health issues. To illustrate its lack of influence, far less than 50% of the HIA recommendations were adopted into the neighborhood plan Decision makers felt that the HIA did not have many positive outcomes and only provided a small increase in their health awareness and knowledge. ground being treated as something that was done on the T his case suggests that there could be an association between having poor cross sector collaboration among the project team and completing a l ower quality HIA, and having little or low i nfluence on the neighborhood plan. Both independent variables influenced the master plan outcomes according to the hypothesis that if the independent variables were low than the dependent variable would also be low. Surprisingly, one difference in the hypo thesis is the positive outcome from more health supportive language in the NE Downtown neighborhood plan compared to other similar neighborhood plans without an HIA conducted. The factors and variables that contribute to these outcomes are described and al so compared with the contrasting case study (along the independent variables), South Lincoln Housing Redevelopment, in the following Results and Discussion Chapter.

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239 CHAPTER VIII RESULTS AND DISCUSSION Chapter Outline The purpose of this chapter is to pre sent the theoretical findings of the research along with practical lessons learned and conclusions. By employing a deductive and inductive approach to data analysis, contingent generalizations have been concluded from this case study research. Results incl ude the answers to the research questions, the over arching differences between the two cases, and a discussion about the implications from both cases for decision makers, redevelopment plans and HIAs. Lastly, the contributions to the literature from this research are discussed, the limitations along with lessons learned, future research, and other concluding remarks. Results For each of the cases a conceptual framework in the form of a checklist was employed and is more fully described within the finding s in each case study chapter. The framework effectively organized and demonstrated the level of influence and effectiveness within each case by thoroughly evaluating the key findings for the independent and dependent variables. These findings further demon being researched. The checklist analysis decisively placed South Lincoln into the high level checklist. The NE Downtown case fit, although not as decisively, into the low level chec klist. The determinations for each case from the checklist framework in each c ase study chapter are in Table 28 below, which concisely summarizes the findings to answer the cen tral research questions. Table 28 outcomes mostly agreed with the hypothesis des cribed in this study. Research

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240 marks for the master plan and decision makers, and the NE Downtown HIA was far less health supportive language, which is discussed further below. Table 28 more clearly illustrates how each of the dependent variables (DV) and independent variables (IV) were rated. This typology sums up the answer central research questions, a description and discussion of which is provided in detail further below. Table 28 : HIA Influence/Effectiveness Typology Analysis Summary, Both Cases IV DV Master Plan and HIA Out comes Cases L evel of Collabor ation Quality of HIA Level of HIA Recommend ation Adoption Health Supportive L anguage Increase Health Awareness/ K nowledge Outcome (by case) South Lincoln Housing HIA/plan High High Medium High High 61% Higher than other similar plans (43. 2% of the total number of words ) High/ Medium High NE Down town Neighbor hood HIA/ plan Low Medium low Low 36% Higher than other similar plans (44.6% of the total number of words ) L ow L ow / Medium Low

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241 Research Question One How do health impact assessments influence decision making in redevelopment master plans, specifically the amount of HIA recommendations adopted, health supportive language used and change in decision South Lin coln This case is an example of an HIA positively influencing decision makers and a redevelopment master plan, as shown in Table 28 The research focused on the South Lincoln HIA and how it influenced the South Lincoln/La Alma master plan, specifically in terms of the number of HIA recommendations that were adopted into the master plan, the health supportive language used in the master plan, and changes in the decision of health issues. To illustrate its effectiveness, well o ver half of the HIA recommendations (61%) were adopted into the master plan. There was more health supportive language in the South Lincoln Plan compared to other housing master plans without an HIA conducted. The HIA document and process, as well as the i nvolvement of a public health professional, increased the health awareness and knowledge of the project team and other decision makers. The HIA changed the conversation by emphasizing health throughout the master planning process: provided a comprehensive view of health, and provided a better understanding of the connection d the In this case, HIA not only changed how health was prioritized within the planning process but also changed the language used in the master plan as demonstrated by the presence of more health supportive language and mo re willingness to incorporate the HIA recommendations into the master plan.

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242 NE Downtown This case is an example of an HIA that mildly influenced the Northeast Downtown Denver neighborhood plan document and process and the decision makers as shown in Tabl e 28 Fewer than 40% of the HIA recommendations were adopted into the neighborhood master plan. Decision makers felt that the HIA did not have many positive outcomes related to the neighborhood plan, including only a low increase in decision awareness and knowledge. Respondents also felt that health was important but not a priority within the NE Downtown Plan. HIA] being treated as something that was done on the Surprisingly, there was still more health supportive language in the NE Downtown plan compared to other similar neighborhood master plans without an HIA conducted. This case suggests that there could be an association between having poor cross sect or collaboration among the project team and completing a lower quality HIA, and having little or low influence on the neighborhood plan. Except for the health supportive language, the outcomes follow the initial hypothesis. The factors and variables that c ontribute to these outcomes are described below. Overview To contribute to the HIA literature, this study has identified a potentially new benefit or value of HIA: it can increase the health supportive language within redevelopment master plans, resulting Both South Lincoln and NE Downtown are examples of neighborhood and housing plans whose health supportive language increased compared to simila r plans without an HIA conducted. It was also hypothesized that with increased health awareness and knowledge

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243 there would be greater health supportive language but that was not the case with NE Downtown. Although there was a low increase in health awarene ss and knowledge self rated by the respondents, more research is needed on other possible factors that influenced the higher level of health supportive language in the neighborhood plan. Another example of health supportive language increasing is of a stat ion area plan in Denver that also demonstrated an increase of health supportive language among other station area plans using the exact methodology as South Lincoln and NE Downtown. An HIA was completed of the Station Area Plan compared to similar plans wi thout an HIA (see Appendix F Table 7 ). Similarly to the two cases, Central Park Boulevard Station Area Plan had the most health total within the Central Park Boule 235. There were a total 1,021 words and phrases across all four plans, which means that Central Park has 42.2%, of the total health supportive language compared to the other three plans, and is similar to the percentages of the other two cases as shown in Table 28 Additionally, quantitative content analysis could be considered as a method in future HIA research which has not been identified as a method in other HIA studies. This study suggests through both contrasting HIAs that there can be very demonstrable, positive and direct influences on redevelopment plans and decision makers depending on important variables discussed in Research Question Two below. Table 2 9 compares the two cases more dir ectly in relation to the independent variables: cross sector collaboration and HIA quality.

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244 Research Question Two How do variables such as cross sector collaboration and the quality of the HIA influence whether the HIA is more or less effective in influ encing decision knowledge and the adoption of HIA recommendations and health supportive language ? Table 2 9 succinctly contrasts the cases, using quotes and scores to assist with answering estion. The italicized information on the right are the key points summarized from the information from either columns on the left. Table 29 South Lincoln HIA NE Down town HIA Independent Variables Interdisciplinary collaboration all five interviewees. collaborative process is the only The respondents rated the project team as having high Le were dedicated to quality, a team environment was created, and there was good other teams, this one had an increased level of frequency of Strong leadership and communication, relationsh ip building were discussed very positively and considered well was set up to be i nterdisciplinary. We worked Interdisciplinary collaboration all four interviewees. Yet, l ow scor es for how effective the cross sector collaboration was during the HIA and master planning process. Strong leadership and communication were scored poorly of the planning process and considered not well executed by team or managers. There was a l ack of knowledge about what others on the team were doing during the project. that HIA was even part of the Cross sector collaboration (CC) Extensive variation on the level of collaboration between the two cases. Decision makers understand the importance of CC but being successful is much more challenging to execute, but necessary. Good leadership and communication, relationship buildi ng, informal relationship building, and processes among team members supports a more effective HIA. HIA/Health Assessor needs to be an integral part of the project team for a more collaborative, effective team.

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245 Table 29 cont.; Practice Standards. Respondents felt that they were informed of the goals early and were notified of the HIA process/steps early in the what an HIA was and how we All five respondents stated that decision makers were involved [HIA] was one of the reasons using the Practice Standards. Respondents felt that they were not notified of the HIA goals early in the planning and HIA process. Only one respondent felt they were notified of the HIA process/steps early in the HIA process. Respondents stated that the decision makers were interested in the HIA; but decreased when asked if they were involved in the HIA. Quality HIA There was marked variation in the quality of HIA between the two cases. Goals, purpose and process described early in process are important. Interest and involvement of decision makers support more effective HIAs. Below are the italicized key findings and enablers and challenges to more effective HIAs identified in Table 2 9 specific to the independent variables. Cross Sector Collaboration Extensive variation in the level of collaboration between the two cases. Decision makers understand the importance of CC but being successful is much more challenging to execute, but necessary. Good leadership and communication, relationship building, informal relationship building HIA/Health Assessor needs to be an integral part of the project team for a more collaborative, effective team. Quality HIA There was marked variation in the quality of the HIAs between the two cases. Goals, purpose and process described early in process a re important. Interest and involvement of decision makers support more effective HIAs.

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246 Cross Sector Collaboration and Quality of HIA The independent variables of HIA quality and the level of cross sector collaboration were both contributing factors to this study. The study sought to answer whether cross sector collaboration and HIA quality both influenced the dependent variables or each separately, and if collaboration influenced quality as illustrated in Figure 4 Each independent variable can influence th e effectiveness of an HIA, but the independent variables working together are more likely to produce positive outcomes. For the South Lincoln case, both independent variables were rated high by the respondents, which suggests that both contributed to the p ositive outcomes of the case; for NE Downtown, both independent variables were low, which contributed to poor outcomes in the case as described in this study. This case study suggests that there is an association between levels of cross sector collaboratio n and a quality HIA and whether positive or negative, they influence the decision makers and their respective redevelopment plans. Both variables influence the master plan outcomes according to the hypothesis except for health supportive language, which is explained more below. Because these two variables are newly studied in the context of HIA, more research is needed on both variables and their contribution. Figure 4 displays the original conceptual model with changes to the thickness of the arrows to ind icate the greatest influences yielded by the independent variables. The greatest influence is from both CC and Quality of HIA on the dependent variables. Next level of influence is from only CC on the dependent variables and equally influencing is from CC to Quality of HIA (no distinction between these two can be made from the findings). The least influential is Quality of HIA alone on the dependent variables. The asterisk represents a difference from what was hypothesized.

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247 Figure 4 Origi nal Conceptual Model with Arrows I dentifying Greatest I nfluences As described in the cases (Chapter 6 & 7) and in the Chapter 5. Methods the original hypothesis was that if the level of collaboration among project team members with varied expertise is hi gh and the quality of the HIA is high, then the degree to which the HIA recommendations and health supportive language are adopted into the master plan should also be e results of the study show that the l evels of cross sector collaboration and quality HIA had little identifiable influence on health supportive language. The only factor identified that influenced health supportive language was whether an HIA was conducte d. Based on the literature, the level of collaboration and HIA quality should have been a factor in the level of health supportive language, so future research is needed to determine what other factors contributed to this outcome. Cross Sector Collaboratio n Cross sector collaboration is a main variable of this study, and it impacted the level of effectiveness of the HIAs in influencing the master plans. The South Lincoln case suggests that the level of cross sector collaboration among the project team and o ther decision makers can QUALITY OF HIA CROSS SECTOR COLLABORATION MASTER PLAN & DECISION MAKER OUTCOMES Health Supportive Language Health Awareness and Knowledge Adoption of Recommendations

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248 certainly influence the adoption of the HIA recommendations in the master plans as well as the increase of health awareness and knowledge of the decision makers. According to Butterfoss et al. (1993) good cross sector collaboration increases information sharing; it also adds new knowledge and understanding of complex issues (Evans, 2006; Miller et al., 2008). For South set up to be interdisci working as a highly functioning collaborative has greater influence on the redevelopment master plans than HIA quality, making it the stronger variable. One reason is that there is more rigorous research available on collaboration than on HIA quality. As demonstrated in this case, t he level of cross sector collaboration during the South Lincoln HIA and master planning process rated high in importance and effectiveness by the responde nts. The literature is clear that certain factors support successful cross sector collaboration ( Lasker al., 2003; Bryson et al., 2006 ; Robertson et al., 2003; Bronstein 2003 ) and these factors were also rated high by the respondents in scoring and in t he comments provided, mo stly leadership, communication and good team relationships to more health focused and informed decision makers and master plan. The stu agreed that high level cross sector collaboration would lead to a more effective project team and to a more positively influenced master plan. Contrastingly, the level of cross sector collaboration during the NE Downtown HIA process was rat ed very poorly during the process and effectiveness by the respondents although they were in 100% agreement about the importance of cross sector collaboration in general A lack of willingness to engage in cross sector work was a barrier. As stated by one respondent, Lack of knowledge about what others on the tea m were doing during the project, overall lack of ore input during the process from the health assessor and better leadership This case highlights how

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249 lower levels of collaboration and specifically public health engagement, such as a health assessor being involved in the collaborative, influenced the quality of the HIA, the master plan outcomes and decision makers. Additionally, the factors identified in the literature as supportive of more communication. Many low scores and negative statements were made related to the vari ous factors that usually support and define effective cross sector collaboration. The hypothesis was that low level cross sector collaboration would lead to less influence from the HIA on the master plan and decision makers. Reiterated in the NAS report (2 011), participation by multiple public agencies such as transportation or health can not on ly contribute expertise but also pot ential ly increase or decrease the likelihood that the recommendations are adopted. Again, this study suggests that the level of c ross sector collaboration was a factor in determining how much the HIA influenced the neighborhood plan. Lastly, the differences between these cases in levels of collaboration also became apparent in the consistency of the responses from the interviewees. South Lincoln interviewees were much more consistent in their responses with mostly high marks. While the NE Downtown interviewees gave lower scores in general, the marks were much more disparate with fives and ones as responses for the same questions. The NE Downtown team lacked agreement on and was seemingly less cohesive about how they felt regarding the HIA, the team, expectations and the master plan outcomes. This contrast is another potential indicator of the lack of collaboration among the team membe rs of the NE Downtown case versus South Lincoln. Additionally, this study has somewhat informed the cross sector collaboration literature. First, leadership, communication and other factors did prove to be critical to whether the project team was performin g collaboratively as evidenced through scores and comments from respondents that specifically addressed these factors. However, the fact of whether there were past working relationships among some team members seemed to be of less importance,

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250 especially wh en the remaining team members were not treated as part of the team. As identified in Table 29, the health assessor also needs to be an integral part of the team. When only part of the team is working collaboratively an d not including the entire team then t he variety of disciplines is missing, which is at the core of cross sector collaboration, and is less effective Also identified in Table 2 9 decision makers understood the importance of cross sector collaboration ; however, executing this can be challengin g. Managers/leadership in teams must ensure that the entire team, including the health assessor, are collaboratively working together. The willingness to engage in cross sectoral work, which is at the heart of HIA, should be encouraged from managers/leader ship, such as those creating the master plan and HIAs. Level of resources did not seem to be a distinguishing factor because the level of funding was similar for both cases (low), but it was more effectively used at South Lincoln, a more collaborative team The level of collaboration seemed to be important and helped the team to use resources, particularly time and money, more effectively. For example, if a team member was meeting with an organization in the community or conducting an interview, good commun ication allows for the ability for other team members to participate in what was already organized, saving time and money. HIA Quality The second independent variable studied was HIA quality. The cases suggest, as hypothesized, that the quality of the HIA can influence the dependent variables. The South Lincoln respondents found the high quality HIA document to be useful and understandable with realistic and clearly written recommendations supported with evidence based data; this utility influenced the rat e of adoption of the recommendations and led to more health awareness and knowledge, but further studies are needed to understand to what degree. The NE Downtown HIA was considered medium low as far as its quality, and as hypothesized, had lower rates of a doption

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251 of HIA recommendations into the plan and little to no increase in health awareness and knowledge. As stated before, with a lower quality HIA it was assumed that the health supportive language in the master plan should have either been the same or l ower than the other similar plans, not higher. It seems viable that the quality of the HIA document influenced decision awareness and knowledge, but the impact is limited because the HIA document was not shared until later in the process; st ill, some respondents stated that their increases in health awareness and knowledge occurred during the review of the document. Additionally, some of the HIA Standards, which form the basis of the quality determination, are related to not just the document itself but also parts of the HIA process such as whether there was stakeholder engagement. There can be significantly better understanding of the HIA and health concepts when, for example, the health assessor presents finding to the stakeholders earlier i n the process. It was also hypothesized that a highly collaborative project team would contribute to the development of a high quality HIA. More specifically, cross sector collaboration can influence the quality of the HIA. Based on the South Lincoln case sector collaboration literature, high level collaboration should improve the quality of the HIA. The study used the Standards, HIA p ropositions along with feedback from interviewees to better determine the quality of the HIA, and the South Lincoln HIA met the Standards very well. NE Downtown HIA did not. Literature states that with more opportunities for good communication, strong leadership and sharing by a project team, the product or outcome sh ould be improved (Brys on et al., 2006), as with the quality of the HIA. For NE Downtown, with so few opportunities for good communication and sharing by the team, the health assessor felt the lack of exchange lessened the quality. As stated by Krieger et al. (200 3 ), if an HIA i s conducted without cross sector expertise, this may produce only a partial assessment of the potential health impacts and potential unknowns for decision makers. T he respondents also felt that with South Lincoln,

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252 the exchange among the team improved the q uality of the HIA by having enhanced access to decision makers and more opportunities for better integration and sharing of ideas and information from a mix of disciplines and perspectives. As stated earlier, with high collaboration among team members, few er resources are needed for a better quality HIA. For this study, the level of collaboration seems to have influenced the quality both good and bad for each of the respective HIAs. High level cross sector collaboration is not necessary for a quality HIA to be completed, but it seems viable that it significantly contributes to the likelihood of better quality. Lastly, it was hypothesized that with low level collaboration among the team there would be a low quality HIA, but instead it was medium low. Also ba sed on the interview responses, the quality should have been scored low, but the S tandards provided a methodical means to evaluate the quality. So there seems to be a connection to the level of collaboration and the quality of the HIA, but this study sugge sts that the connection is possibly less important than originally theorized. Although HIA is a newly researched variable, and the Standards are a work in progress, they, along with the interviews, did provide additional means with which to evaluate the HI A quality, which can potentially inform the HIA literature. Also using the Standards as a more formal HIA evaluation tool with scoring could be useful in the HIA practice and future research. Discussion Table 3 0 succinctly contrasts the cases, using quote s and scores to better understand the other contributing factors, lessons learned, and enablers of more effective HIAs. All quotes are from respondents. The italicized information on the right are the key points summarized from the information from either columns on the left. Described further below is an intervening variable, a rival explanation and factors that are less consistent with the literature identified in this study.

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253 Table 30 : Other key results of differences across case s South Lincoln HIA NE Downtown HIA Other Variables Health as a priority was It was one of the reasons Respondents felt strongly that more health issues were discussed durin g the master planning process because of the HIA compared to other planning projects without previously included health in such a way organize the data and put it forward in a One full page of the m aster plan was dedicated to health issues e.g. graphs with demographic and poverty data, and health objectives. Respondents felt that the HIA process (80%) and document (72%) influenced the master plan. boiled it down, and said o kay every single day how are we going to lives who live here. Without the HIA we would not have been on Lack of support for the HIA or health assessor from the beginning. When a decision maker was asked how did t hey learn about the HIA Or s tated [health assessor] on to the was prompted by a city council woman. It seemed that the HIA/health assessor was seen by decision makers as not part of project team because comments such as outlier and so was the public Respondents felt that health was important w hen compared to other issues considered in the plan. Yet all respondents felt that health was not prioritized Although health was not a priority, there was one long paragraph devoted to public health in the plan. it with the planning process. Respond ents felt that the HIA process and document equally did not influence the master plan. There where some stuff from the HIA [in plan] that was incorporated but not much. I think it had a much larger impact on how our plan ning process is evolving to incorporate HIA [in Health as a priority for decision makers; support for and influence from HIA Early intention by decision makers to supports more effective HIAs. HIA/Health Assessor needs to b e an integral part of the project team. HIA should not be done in isolation. Incorporate HIA/health assessor into planning process. HIA process and document can change the language used in a redevelopment plan. Political support can be key to how HIA are prioritized and effecti ve. considered important compared to other issues in a plan is not enough must be prioritized in a plan. Understanding that redevelopment projects are about improving the health of people.

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254 Table 3 0 cont.; in context to the built environment did previously [about health], assessor spoke at every All respondents felt that having a he alth assessor/public health consultant as part of team/process helped to increase their level of health awareness and knowledge. directly with leadership at the City directly until the end of the process when it became nec essary. Educating project team members should have been more of a priority from the start but more specifically Decision makers needed more explanation of what HIA is all an HIA, what it does, tha t was not well known or understood. HIA Education Health assessor needs to communicate/ educate with all decision makers particularly those who are the ultimate decision makers. Understanding HIA goals, pur pose, process and expectations by decision ma kers is important to its effectiveness Considerable increase in the health awareness and knowledge of decision makers can support HIA effectiveness. Having a health assessor as part of team/process helped to increase their level of health awareness an d knowledge. Health assessor should work closely with team in educating about how HIA fits into planning process.

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2 55 Table 30 cont.; More evidence based data the better; it is important for positively influencing the master plan. t new evidence for [HIA] uncovered things I HIA also provided process expectations were too high about what data/evidence is availabl e particularly for some The HIA could have been improved Low agreement that the evidence based data supported the recommendations. Evidence Based Data/ Expectations Evidence based data can positively influence redevelopment plans. Expectations need to be established among decision makers with a clear understanding of what HIA can and cannot deliver. Evidence based data and recommendations support HIA effectiveness. Below are the italicized key findings identified in Table 3 0 which include enablers to more effective HIA, contributing factors and the lessons learned from this study. Health as priority for decision makers; support for and influences from HIA Early intention by dec ision HIA/Health Assessor needs to be an integral part of the project team. HIA should not be done in isolation. Incorporate HIA/health assessor into planning process. HIA process and document can ch ange the language used in a redevelopment plan. Pol itical support prioritized and the effective ness of HIA This confirms the findings of Davenport et al. (2006). plans is not enough, must be prioritized in plan. Understanding that redevelopment projects are about improving the health of people.

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256 HIA Education Health Assessor needs to communicate/educate with all decision makers particularly those who are the ulti mate decision makers on the team Unde rstanding HIA goals, purpose, process and expectations, and the broad health connection by decision makers is important to its effective ness The HIA practice standards also highlight the importance of sharing of expl icit goals early in the HIA process (North American HIA Practice Standards Working Group 2010). Co nsiderable increase in the health awareness and knowledge of decision makers can support HIA effectiveness. Having a health assessor as part of team/process helped to increase decision makers level of health awareness and knowledge. Health assessor should work closely with team in educating about how HIA fits into planning process. A lack of understanding of HIA and lack of health awareness w ere also identifie d as barrier s in research conducted by Davenport et al. ( 2006 ) Evidence based data/Expectations Evidence based data can positively influence redevelopments plans. Exp ectations need to be established among decision makers with a clear understanding of wha t HIA can and cannot deliver. Ray (1998) similarly identified differences in expectations specifically regarding goals and objective s as a barrier to effective interdisciplinary practice Evidence based data and recommendations support HIA effectiveness. Intervening Variable Identified This case study allows for the exploration of potential causal links between the variables and can produce findings based upon the contingent factors (George & Bennett, 2005). The independent variables were identified as co ntributing factors to this study. Additionally, an

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257 intervening variable not articulated in the literature rose to the top from interviewees as key to effectiveness of HIA in influencing the decision makers and redevelopment plan outcomes: whether decision makers had health as an intention of the project from the beginning. makers from the beginning. For example, the hired planning firm decided to search out a public health consultant for the team when it submitted the proposal to win the housing master planning part of the reason why the planning firm was ultimately selected by th e lead agency because stated by a respondent. This intention was significant, and not hypothesized earlier; the decision makers were not only interested in and supportive of health considerations, but there was a incorporated into the master planning process. The literature discusses the importance of having health at the tabl e or need for incorporating health into planning processes or importance of decision makers involvement in the HIA process, but the crucial point made manifest in this study is the intention from the beginning. Examining the contrasting case further stres ses the importance of incorporating health from the beginning. The NE Downtown case is an example of having a lack of desire and intention to include health in the project. There was a l ack of interest for an HIA or having a health assessor on the team fro m the beginning. When a decision maker was asked how they project managers.

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258 Rival Explanation for Outcomes The findings in the South Lincoln case related to higher adoption levels of the HIA recommendations could be explained a as was described by one respondent from NE Downtown when referring to the terminology of and language in the Another respondent stated that with the project teams This rival explanation has been identified by researchers (Harris Roxas et al. 2014) and among practitioners that planners might have included similar recom mendations anyway without the HIA through the normal planning processes. The point is that possibly the HIAs did not necessarily have to be conducted to have more health focused and supportive language and recommendations. While some of the recommendations and language used and positive impacts from the analysis or inclusion through the planning process instead of an HIA, in practice they may have been difficult to ide ntify or anticipate. Some of the concepts, words or phrases or related and fields such as organizational psychology and management, with information and recommendations being discounted as obvious despite not having been considered in described in a recently released article by Harris Roxas et al. (2014: 28). This suggests that the HIAs were influential to different degrees of including health informed language and recommendations into the redevelopment plans instead being or just assumed to be included in the plans.

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259 Factors Less Consistent with the Literature Timing A significant parameter that was identified in the findings that is not consistent with what is found in the literature is th e importance of the timing of when an HIA should be conducted (Davenport et al., 2006; Harris Roxas et al., 2014). Both HIAs studied were completed before the master plans were completed, which is essential. However, the NE Downtown HIA was completed about four months in advance of the completion of the master plan, yet it was less influential than South Lincoln that was finished about two months in advance. It is very important that the HIA is done before the master plan is completed, but it is not clear h ow far in advance is ideal. Also HIA should not be done too early when there are too few plan details available to conduct the HIA. Interviewees for both cases stated earlier start dates for the HIA would have been helpful, and would have provided addition al opportunities for review and sharing. Timing seems to be less of an important factor in this study compared with, for example, cross sector collaboration; this is because the South Lincoln process and document was completed soon before the master plan, but decision makers were already very open about the inclusion of health and involved in the HIA and educated about the HIA findings. When cross sector collaboration is high and there has been significant sharing and overall communication throughout the pr ocess, the timing of the HIA is less important. Health Assessor Expertise Propositions state that HIA expertise supports success (Davenport et al., 2006) but this was not found to be true in this case study. As discussed, South Lincoln was more influenti al in

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260 changing the master plan and decision makers than NE Downtown, yet it was the first HIA completed ever by the health assessor. Since the health assessor was more experienced for the NE rience level was essential. Other factors, including the level of collaboration and the fact that the health assessor was not considered as part of the project team could have a greater influence than previously considered. Short Term Outcomes/Lessons A nu mber of positive outcomes, observations and lessons were identified in this study that are not specific to the dependent variables and independent variables but to HIA more broadly. The first four points are specific to South Lincoln 4 ; others are a mix of points from both cases. Str ong engagement by a City Councilwoman who attended a presentation about the HIA Department of Community Planning and Development (CPD). Now Proposals for redevelopment projects include a request that large redevelopment projects address public health considerations which is a means for institutionalizing HIA in the planning process, although an HIA is not necessarily requir ed, and implementation has been weak. During the early data collection period, the HIA assessor identified a free shuttle that would take community members to the closest hospital. Few residents had been aware of this resource, and since 65% of local resid ents lacked vehicles, the shuttle increased 4 Fi

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261 Other changes were less directly tied to the HIA process. At the same presentation about the HIA at an early steering committee meeting mentioned above, a portion of the discuss ion focused on reducing bike crashes and traffic speeds by adding bike lanes on a wide, main community street. Approximately a month later, funding became available and was reallocated to construct bike lanes along the street; construction was completed ab out a year later in August 2010. Immediately upon completion of the master plan and South Lincoln HIA, Denver Housing Authority paid to have the Health y Development Measurement Tool, now referred to as Sustainable Communities Index, customized to improve applicability to Denver by adding Denver specific indicators to be used in future DHA housing projects. Writing the recommendations clearly and concisely is important, without being too prescriptive. Many of the recommendations were incorporate d fully, yet the text was shortened when put into the master plan. Clear and concise recommendations make it easier for the decision makers to use, adopt, or implement them. Some of the recommendations were not specific enough to give direction. For exampl e, if a park, bike lanes or crosswalks are needed, the recommendation should provide pictures and/or exact locations and reasoning so decision makers are clear. Being specific can also assist with the evaluation process later. Quantitative c ontent analysi s had not been identified as a method in other HIA studies, but its effectiveness in the present study demonstrates that it could be considered as a viable method in future HIA research. More emphasis by the health assessor is needed on socioeconomic facto rs such as

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262 makers on these important health factors that can be significantly impacted by planning decisions. Limitations Limitations are provided in each of the research case chapters and a summary of the limitations are provided here. Either of the cases is not necessarily representative of all housing or neighborhood HIAs or master plans and should not be generalized as such. Also, g eneralizability of this study to othe r communities is challenges considering there are only two cases. There are also limitations associated with the assessment of the quality of the HIAs, which primarily stem from issues with the 2010 North American HIA Practice Standards themselves, e.g., t hey are challenging to objectively measure and could be interpreted differently by va rious users but the newest version in 2014 could improve some of the issues. The questionnaire can present limitations because the HIAs were completed in 2010 and 2011, a nd the interviews were conducted in 2012 and 2013. This retrospective timeline can create issues with respondent recall bias, incomplete recollection, and reflexivity. Also, the lead researcher was the health assessor for both HIAs, which can create obviou s biases, so research assistants were employed to conduct the interviews and duplicate the data collection with the lead researcher as described in the methods chapter and methods sections within each case Additionally, n=4 and n=5 for each case is a low number of interviewees, but those who were interviewed were key decision makers as creators of the master plans or HIAs. Lastly, the list of phrases and words for the health supportive language is not an exhaustive list. Similar words or phrases in certain contexts might not have been included in the counts but would be more likely to be included when the determination was close.

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263 Conclusion Significance of Study and Future Research This study suggests that through both contrasting HIAs there can be demons trable, positive and direct influences on a redevelopment plan and on decision makers, depending on important variables. Contributing and less contributing factors were identified along with intervening variables in this case as were a rival explanation, s hort term outcomes and lessons learned to potentially contribute to the HIA disc ourse, literature and practice A new potential benefit of HIA was also identified: It can increase the health supportive language within master An intervening variable for HIA success that surfaced is the importance of decision and intention for health to be a focus of the master plan from the beginning. Other contributing fa ctors for this case were the independent variables, quality of the HIA, and the level of cross sector collaboration among the project team Other possible contributing factors and variables such as level of resources, availability of local data, expertise of health assessor, or timing were determined to be non issues or far less important factors for success in this study. Additionally, a new method for HIA study, quantitative content analysis could be considered in future HIA research. Likewise, u sing the HIA Practice S tandards with a scoring system as a means to evaluate HIA s could also be consider ed in future HIA research Lastly, this study offers a precedent for other researchers of what should be considered adoption rates of HIA recomme ndations in redeve lopment plans. As mentioned, there are contributing factors and other lessons learned that can lead to more influential HIAs: 1. High level of cross sector collaboration and quality HIAs; 2. Considerable positive support for and involvem ent in the HIAs by decision makers; 3. Intentionality and prioritization of health by decision makers before the master plan begins. Considering these factors, the firm that is hired to produce a master plan or the approach that is

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264 selected by an agency ca n considerably impact the success and influence of the HIA. For example, when planning firms are hired by city planning or housing agencies, considerations should be given to those firms/teams that make human health a priority and consider it an important dimension of planning. Also, hiring a team for the master plan that includes a health assessor and that stresses the importance of cross sector collaboration and makes it part of their regular practice could make a difference on the influence of the HIA. U nfortunately, in an effort to better understand health awareness and knowledge there was a missed opportunity to employ a pre and post test by asking the respondents to define HIA before the HIA process began. This test could have more thoroughly answered how much was learned about HIA and health. Future research should include these pre and post tests on HIAs. The hope is that this study can make a small contribution to the literature on the influences HIAs can have on redevelopment master plans and brin ging more health awareness and knowledge to the process. Additionally, this study can potentially contribute to further building the confidence of practitioners, policy makers and funders about the potential value of HIA as well as supportive factors and v ariables to consider; however, great clarity is required regarding many aspects of HIA to considerably enhance the field. The fact that an important health recommendation was included in a redevelopment plan does not guarantee its final implementation. Con tinued monitoring and evaluation must occur to determine which recommendations not only got adopted but implemented during the detailed design phase and final construction. Future research could also focus on whether the positive outcomes were more opportu nistic in nature and might address if and what percentage of the HIA recommendations would have been incorporated into the plan anyway; this aspect has not been researched much As determined in the South Lincoln case, the HIA process influenced the master plan more than the HIA document In the future, how the document can be more influential should be emphasized (i.e., how to best emphasize the social determinants of health improve readability, focus on

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265 different audiences). The Standards are a step in t he right direction as far as improving, supporting and emphasizing the HIA document, but more evidence based, realistic standards are needed. Also, more research is needed, regarding t he importance of timing of HIAs in the planning process as well as the e xpertise of the health assessor and the impact of cross sector collaboration on their influence This study further accentuates cross sector collaboration as particularly important to the success of HIA Cross sector collaboration is considered a growing organizational imperative (Austin, 2000). Going back t o the gap in the literature and whether HIAs are effective at changing policies, programs, and plans in this research, one case was influential while one case was far less with a major difference bein g the level of cross sector collaboration This suggests that cross sector collaboration is potentially fundamental to HIA effectiveness. M ore research is needed not only about the details of the factors for success but more generally how to enhance the s uccess of collaboratives such as that which occurred at South Lincoln Mainstreaming or the institutionalization of HIA has been slow in the US and is a significant challenge. A fundamental need is to have a systematic process or framework in place to sup port it. Health in All Policies is one such framework that more methodically adopts HIA as a normative course of action that may move US policy in a direction that supports the regular use of HIA s Without such a framework in place to consistently incorpor ate health that include s training for different disciplines to better understand the purpose, process, and benefits of HIA, HIAs will be less influential in changing decision making. In the present research study, the NE Downtown case is an example of why HIAs should not be institutionalized yet in the US without first having the training and a framework in place However, to make a significant impact toward more substantial institutionalization of HIA in the US, many issues still need to be resolved along with more research, resources and education about the value and significance of HIAs.

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266 The level of contrast of the cases is described in Table 2 9 and 3 0 and is most evident with the following quotes. This partial quote highlights the impact and contributio n the HIA directly changed the framework in which this decision maker now works and incorporates health: health. Now that we have caught the bug we are going to do it, which is great. In that way it was such a positive experience for us to potentially emphasizes ho w this decision maker could have a new enthusiasm and emphasize incorporating public health in current and future redevelopment projects. For NE Downtown, an opposing statement was made: fro NE Downtown stated, r planning process is and the HIA did increase the health supportive language in the plan. HIA can play an important role in urban planning and be a catalyst for change in the master planning process through i ncreased use of more health supportive language, increased health awareness and knowledge, and adoption of HIA recommendations that together better support public health, safety, and well being. For the advancement of HIA, a cross sector collaboration appr oach is an important factor, along with a quality HIA to include more sharing of resources, strong and consistent leadership and communication, and sharing of knowledge and expertise to influence decision makers and master plans. HIA had already been ackno wledged as a worthwhile tool to inform decision makers (Wismar et al 2007), and ensuring sustainable and healthy development (Birley, 2003), and this study further supports these conclusion s whether it is a hired planning firm or a planning and health ag ency.

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267 When conducting an HIA, a high level of collaboration, meeting the HIA quality standards and supporting health as a priority e arly in the planning process can support more health informed decision makers and decision making in redevelopment plans. However, one of the most important points to reiterate is understanding that redevelopment projects are about improving the lives including the health of people.

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280 Parson, E. (1995). Integrated assessment and environmental policy making: In pursuit of usefulness. Energy Policy, 23(4/5), 463 475. Petts, J., Owens, S., & Bulkeley, H. (2008). Crossing boundaries: Interdisciplinarity in the context of urban environments. Geoforum, 39(2), 593 601. Piton Foundation (2009). US Census Bureau Data from 2000. Retrieved from http://www.piton.org/index.cfm?fuseaction=CommunityFacts.Search. Search Auraria Lincoln Park. Accessed 21 May 2009. Povall, S., Haigh, F. Abrahams, D., & Scott Samuel, A. (2013). Health equity impact assessment. Health Promotion International, 1 13. Provan, K., & Kenis, P. (2008). Modes of Network Governance: Structure, Management and Effectiveness. Journal of Public Administration Research and Theory 18 (2), 229 252. http://dx.doi.org/ 10.1093/jopart/mum015 Special Educators Using a Collaborative, Transdis ciplinary Approach. Journal of Leisure Studies and Recreation Education 16, 33 48. Putters, K. (2005). HIA, the next step: Defining models and roles, Environmental Impact Assessment Review 25(7 8), 693 701. Quigley, L., Watts Ltd and Department of Public Health Wellington School of Medicine (2006 ). Cross sector Dialogue For Healthier Policies: An overview of the 2006 Health impact Assessment Conference. Retrieved from http://www.msd.govt.nz/documents/about msd and our work/publications resources/journals and magazines/social policy journal/spj29/2 9 pages 184 191.pdf Quigley, R., L. den Broeder, L., Furu, P., Bond, A., Cave, B., & Bos, R. (2006). Health Impact Assessment. International Best Practice Principles. Special Publication Series No. 5. International Association for Impact Assessment.

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281 Ragin, C.C. (1999). The Distinctiveness of Case oriented Research. Health Services Research 34(5), 1137 1151. Ray, M.D. (1998). Shared borders: achieving the goals of interdisciplinary patient care. American Journal of Health System Pharmacy 55(13), 1369 1374. Ring, P., Van De Ven, A. (1994). Developmen tal Processes of Cooperative Interorganizational R elationships. Academy of Management Review, 19(1), 90 118. Robertson, D., Martin, D., & Singer, P. (2003). Interdisciplinary research: putting the methods under the microscope. BM C Medical Research Methodology Rogerson, L., & Strean, W. (2006). Examining Collaboration on Interdisciplinary Sport Science Teams. University of Alberta. Roof, K. (2013). Health Impact Assessment in Colorado: A Tool used to Inform Deci sion Making. In M. O'Mullane (Ed.), Integrating Health Impact Assessment with the Policy Process: Lessons and experiences from around the world (pp. 187 198). Oxford: Oxford University Press. Rosenthal, J., Sclar, E., Kinney, P., Knowlton, K., Crauderueff, R., & Brandt Rauf, P. (2007) Links between the Built Environment, Climate and Popul ation health: Interdisciplinary Environmental Change Research in New York City. Annals Academy of Medicine 36( 10 ), 834 846. Rousseau, D. M., Sitkin, S. B., Burt, R. S., & Camerer, C. (1998). Not so different after all: A cross discipline view of trust. Academy of Management Review 23, 393 404. Sabatier, P. A. (2007). Theories of the policy process (Ed.) (Vol. 2). Boulder: Westview Press. San Francisco Health Department of Public Health (2006). Sustainable Communities Index Retrieved from http://www.sustainablecommunitiesindex.org Scott Samuel A. (1998). Health impact assessment: theory into practice. Journ al of Epidemiology Community Health, 52, 704 5.

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282 Seawright, J., & Gerring, J. (2008). Case Selection Techniques in Case Study Research. A Menu of Qualitative and Quantitative Options. Political Research Quarterly, 61(2), 294 297. Selsky J., & Parker, B. (20 05). Cross Sector Partnerships to Address Social Issues: Challenges to Theory and Practice. Journal of Management, 31(6), 849 873 Simo, G., & Bies, A. (2007). The Role of Nonprofits in Disaster Response: An Expanded Model of Cross Sector Collaboration. Pu blic Administration Review, Special Edition. 125 142. Slotterback, C., Forsyth, A., Krizek, K., Johnson A., & Pennucci, A. (2011). Testing Three Health Impact Assessment Tools in Planning: A Process Evaluation. Environmental Impact Assessment Review, 31( 2), 144 153. Stake, R.E. (1995), The Art of Case Study Research, London and New York: SAGE publications. Stevenson, A, Banwell, K., & Pink, R. (2005). Greater Christchurch Draft Urban Development Strategy, Canterbury District Health Board, New Zealand Chri stchurch City Council, New Zealand. Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47 ( 1), 6 22. Tappeiner, G., Tappeiner, U., & Walde, J. (2007). Integrating disci plinary research into an interdisciplinary framework: A case study in sustainability research. Environmental Modeling and Assessment. 12, 253 256. http://dx.doi.org/ 10.1007/s10666 006 9067 1. Taylor, L., & Quigley, R. (2002). Health impact assessment: A re view of reviews. Health Development Agency 2 4. Retrieved from www.hda online.org.uk/evidence. Tennant, K., & Newman, C. (2007). Greater Granville Regeneration Strategy, Centre for Population Health, Sydney West Area Health Service corresponding author. N SW Public Health Bulletin 18, 9 10. University of Wisconsin, (2012). Populations Health Institute, County Health and Roadmap, A Healthier Nation, County by County Rankings: Wisconsin.

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283 Vanclay, F. (2 003). International Principles f o r Social Impact Assessme nt. Impact Assessment and Project Appraisal 21(1), 5 12. http://dx.doi.org/10.3152/147154603781766491. Vangen, S., & Huxham, C. (2003). Nurturing collaborative relations: Building trust in interorganizational collaboration. Journal of Applied Behavioral S cience 39(1), 5 31. Varda, D., Chandra, A., Stern, S., & Lurie, N. (2008). Core Dimensions of Connectivity in Public Health Collaboratives. Journal of Public Health Management Practice 14(5), E1 E7. Veerman, J L Machenbach, J. & Barendregt, J. (2007) Validity of predictions in health impact assessment: Theory and Methods. Journal of Epidemiology Community Health 61, 362 366. Wade, D. T., & Halligan, P. W. (2004). Do biomedical models of illness make for good healthcare systems? Journal 329 (7479), 1398 1401. Wandersman, A., Goodman, R. & Butterfoss, F. (1997). Understanding coalitions and how they operate. Community organizing and community building for health New Brunswick, NJ: Rutgers University Press. Weiss, E. S. Anderson R. M., & Lasker, R. D. (2002). Making the Most of C ollaboration: Exploring the Relationship Between Partnership Synergy and Partnership Functioning, Health Education & Behavior 29(6), 683 698. http://dx.doi.org/10.3152/147154603781766491 10.1177/10901980 2237938. Weiss, J. (1987). Pathways to Cooperation among Public Agencies. Journal of Policy Analysis and Management, 7, 94 117. Wheeler, S. (2003) The Evolution of Urban Form in Portland and Toronto: implications for sustainability planning. Local Enviro nment 8 ( 3 ), 317 336. Wigglesworth, R., Rankin, K., & Hammond, B. presentation on 26 October 2012. http://prezi.com/bsekkgzyq2po/developmental systems theory/?utm_source=website&utm_medium=prezi_landing_related_solr&utm_campaign=pr ezi_landing_related_solr

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284 Wismar, M., Blau, J., Ernst, K. & Figueras, J. (2007). The Effectiveness of Health Impact Assessment: Scope and Limitations of Supporting Decision Making in Europe World Health Organization. European Observatory on Health Systems and Policies. Copenhagen: Denmark. World Health Organization (1948). Pre amble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 2,100. World Health Organization. ( 1999 ) Health impact assessment: main concepts and suggested approach Gothenburg Consensus Paper WHO Regional Office for Europe World Health Organization (2002). Regional Office for Europe. Technical briefing: Health impact assessment a tool to include health on the agenda of other sectors. Current experience and emerging issues in the European Region. Copenhagen: WHO Regional Committee for Europe, 52nd session, 16 19 Yin, R. (2003) Case Study Research: Design and Methods Third Edition Thousand Oaks, London, New Delhi : SAGE Publications.

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285 APP ENDIX A INTERVIEW GUIDE The interview guide below was used for both cases. The titles of the plans were changed within the version for the interviewees whether referring to South Lincoln housing redevelopment and/or South Lincoln HIA or NE Downtown Denver neighborhood plan and/or NE Downtown (housing and neighborhood) is used instead. Interview Guide Introduction to Interview: Thank you for participating in the following interview regarding the (housing and neighborhood) Plan and Health Im pact Assessment, also referred to as HIA. This interview will be a vital component of the research efforts to learn more about the influences of HIAs on (housing and neighborhood) plans; more specifically, the influences the (housing and neighborhood) HIA had on the (housing and neighborhood) plan. This interview is important to gaining an understanding of influences, perspectives, and opinions of the decision makers (project team and other key stakeholders) and key participants in the HIA and planning proc ess. Questions: The interview questions are organized by topic areas informed by research about different components of HIA such as interdisciplinary collaboration, and the quality of the HIA 5 Please 5 Questions (approximately six with minor changes) come from Danielle Varda, Assistant Professor at the School of Public Affairs at the University of Colorado Denver online survey on collaborative p artnerships 5 and approximately five questions come from a survey conducted by Mathias et al (2009).

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286 answer each question as thoroughly as possible and f eel free to add additional comments wherever you see fit. No names will be directly associated with the responses. A. Introductory Questions: 1. What is your job title for this project? 2. H o w long have you been in this position (in years)? 3. How did you learn about HIA if at all? 4. In your own words, how would you describe an HIA? 5. What was your role in the (housing and neighborhood) Plan? Definitions: Since HIA, project team, and interdisciplinary collaboration are highlighted so much in this questionnair e, definitions are provided of each. HIA is a process, tool and/or method to assess a policy, program or project as to its potential effects on the health of a population, and the distribution of those effects within the population 6 Generally HIAs are use d in non health sectors. HIA is a process using local health and national evidence based data to assist in decision making 6 European Centre for Health Policy, WHO Regional Office for Europe. Gothe nburg Consensus Paper (1999) http://www.who.int/hia/about/defin/en/

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287 Project team refers to those who worked on completing the master plan and/or HIA that could include those from planning, architectu re, real estate, community engagement, and social services but does not include community members. Interdisciplinary collaboration is the linking or sharing of information, resources, activities, and capabilities by organizations or agencies to achieve jo intly an outcome that could not be achieved by any discipline or sector separately 7 B. Influences to and from Interdisciplinary Collaboration: 6. How would you rate the importance of an interdisciplinary collaborative approach in general? Not Importan t Somewhat Important Neither Important or Not Important Important Very Important 7. How effective would you rate the interdisciplinary collaboration during the NE Downtown Denver HIA/ (housing and neighborhood) plan redevelopment process ? Not Effective So mewhat Effective Neither Effective or Not Effective Effective Very E ffective 8. Do you feel the HIA facilitated new interdisciplinary relationships? 1 2 3 4 5 Not at all Somewhat Completely 7 Bryson, J., Crosby, B., Middleton Stone, M., Saunoi Sandgren, E. (2009) Designing and Managing Cross Sector Collaboration: A Cas e Study in Reducing Traffic Congestion, IBM Center for The Business of Government. p. 78 81.

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288 Can you briefly talk about why you answered this way? 9. Do you believe that there was anyone or discipline(s) on the project team that were missing of those who participated in the (housing and neighborhood) plan /HIA? Yes No Not Sure For Interviewer: Use list to prompt if needed, in other projects th ere might have been representatives from: Community Planning and Development Planning Firm Housing Authority Public Works RTD Health Department Transportation Planning Environmental Health Community Involvement Energy Economic Development Other___ 10. H ow would you rate the level of interdisciplinary collaboration for the (housing and neighborhood) HIA/ (housing and neighborhood) plan process stakeholder group and project team ? 1 2 3 4 5 Low Medium High

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289 Can you briefly talk about why you a nswered this way? 11. How would you rate the level of interdisciplinary collaboration of the project team for the (housing and neighborhood) Plan? 1 2 3 4 5 Low Medium High Can you briefly talk about why you answered this way? Do you ha ve any thoughts about how interdisciplinary collaboration could have been improved for either the stakeholder group or the project team? If higher rating (4 or 5 above) answer below otherwise skip to question 12, what do you feel helped to facilitate the collaborative approach? Conference calls Community meetings After meeting gatherings Meeting before community and stakeholder meetings Emails, what regularity?____________________ Other____________________________________________________ 12. Do you believe the stakeholder group for the (housing and neighborhood) Plan worked collaboratively? 1 2 3 4 5 Not Sure Low Medium High Can you briefly talk about why you answered this way?

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290 13. Had you worked with project team members or the st akeholder group prior to the (housing and neighborhood) plan ? Yes No Not Sure If yes, how many did you work with in the past? If yes, positive experience or not? 14. How would you rate the extent to which there was a common, understa ndable language used among the disciplines on the project team and the stakeholder group? 1 2 3 4 5 Low Medium High Can you briefly talk about why you answered this way? 15. Do you think that all the disciplines jointly achieved an outcome w hich could not be achieved by one discipline separately? 1 2 3 4 5 Low Medium High

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291 16. To what extent were the following potential outcomes of interdiscip linary collaboration achieved at the (housing and neighborhood) plan/HIA? a. Improve d (housing and neighborhood) plan 1 2 3 4 5 Not at all Somewhat Completely b. More health awareness among team members 1 2 3 4 5 0 Not at all Somewhat Completely n/a c. You have increased health awareness 1 2 3 4 5 0 Not at all Som ewhat Completely n/a d. Improved resource sharing 1 2 3 4 5 0 Not at all Somewhat Completely n/a e. Improved knowledge sharing across disciplines 1 2 3 4 5 0 Not at all Somewhat Completely n/a f. Improved communication (i.e. frequency, modes) 1 2 3 4 5 0 Not at all Somewhat Completely n/a

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292 g. Improved trust and respect for other team members 1 2 3 4 5 0 Not at all Somewhat Completely n/a h. None of the above i. Other_______________________________________________ _________ 17. The following list are aspects of interdisciplinary collaboration, how do you feel these aspects contributed to the (housing and neighborhood) planning process if any? a) Bringing together diverse stakeholders 1 2 3 4 5 0 Not at all Somewhat Completely n/a b) Meeting regularly 1 2 3 4 5 0 Not at all Somewhat Completely n/a Exchanging info/knowledge 1 2 3 4 5 0 Not at all Somewhat Completely n/a c) Sharing resources 1 2 3 4 5 0 Not at all Somewhat Completely n/a Strong leadership 1 2 3 4 5 0 Not at all Somewhat Completely n/a

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293 d) Informal relationships created 1 2 3 4 5 0 Not at all Somewhat Completely n/a e) More informed decision making 1 2 3 4 5 0 Not at all Somewhat Completely n/a f) Processes, inputs, and outcomes tracked for accountability 1 2 3 4 5 0 Not at all Somewhat Completely n/a g) Having a shared mission and goals 1 2 3 4 5 0 Not at all Somewhat Completely n/a h) Other_______ _______________________________________________________ Please provide your top one or two most compelling reasons for your answers above? ____________________________________________________________________ 18. Do you feel health issues are as importan t as the other issues considered in the (housing and neighborhood) plan? 1 2 3 4 5 Least Important Somewhat Important High Importance Why or why not?

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294 19. Do you think more or fewer health issues were discussed during the (housing and neighbor hood) planning process because of the HIA, compared to other planning projects you have worked on without an HIA? 1 2 3 4 5 Low Medium High 20. Did your level of health awareness increase or not because of the HIA process and/or health assess or? 1 2 3 4 5 0 Low Medium High n/a Can you briefly talk about why you answered this way? 21. Did your level of health knowledge increase or not because of the HIA process? Yes No Not Sure If it did increase, what ways did it increase? Did your level of health awareness/health knowledge increase because: (Number below statements 1 5 in order of importance with 1 being the least important and 5 being the most important) Health issues raised by community Health Assessor /health expertise being part of the team/process Planners or other government staff were concerned about health Other project team member being knowledgeable of health Elected official concerned about health Other ___________________________________ _______________________ 22 Do you believe you contributed to the HIA? 1 2 3 4 5 Low level of contribution Some level of contribution High level of contribution If yes, in what way(s)? 23. Do you believe the HIA contributed to your work? 1 2 3 4 5 0 Low level of contribution Some level of contribution High level n/a If yes, in what way(s)?

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295 24. Was any type of health education/training provided during the HIA process/ (housing and neighborhood) plan? Yes No Not Sure If yes, what types of education/training did you get? (check all that apply) Public meetings/presentations Team meetings Stakeholder meetings/presentations Informal conversation Meetings with organizations HIA workshop Other___________________________________ __________________ 25. Were decision makers (project team and other key stakeholders) interested in the HIA? Yes No Not Sure Which decision makers ? 26. Were decision makers (project team and other key stakeholders) involved in the HIA? Yes No Not Sure How? Which decision makers ? 27. Can you describe the leadership throughout the plan/HIA process? C. Effect on HIA Quality: 28. Was your organization/agency notified of the HIA goals early in the (housing and neighborhood) plan/HIA process? Yes No Not Sure If yes, how? If no, why?

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296 29. Was your organization/agency notified of the HIA process/steps early in the (housing and neighborhood) plan/HIA process? Yes No Not Sure If yes, how? If no, why? 30. Did your agency/ firm/organization have an opportunity to critique or provide comments during the HIA process or the document? Yes No Not Sure If yes, when? (check all that apply) Stakeholder meeting Community meeting HIA draft document review Team meetings Other____ _____________________________________________________ 31. Did you feel that the HIA was conducted in a timely manner? Yes No Not Sure Why? 32. Do you feel the information from the HIA wa s delivered in a timely manner? Yes No Not Sure Why? 33. How could the HIA have been improved? For the following 5 questions please use the following scale: Please indicate the extent to which you agree or disagree with the following state ments with 1 indicating you

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297 1= Strongly Disagree 2= Disagree 3= Neither Agree or Disagree 4= Agree 5= Strongly Agree 0= 34. There was a comprehensive review of the health issues in the HIA? 0 1 2 3 4 5 DK Strongly Disagree Disagree Neither Agree Strongly Agree 35. The HIA us ed evidence based data that supported the recommendations? 0 1 2 3 4 5 DK Strongly Disagree Disagree Neither Agree Strongly Agree D. Influences on HIA adoption into (housing and neighborhood) plan: 36. Health was prioritized within the (housing and neighborhood) plan? 0 1 2 3 4 5 DK Strongly Disagree Disagree Neither Agree Strongly Agree Can you briefly t alk about why you answered this way? 37. The HIA document influenced decision making during the (housing and neighborhood) plan process? 0 1 2 3 4 5 DK Strongly Disagree Disagree Neither Agree Strongly Agree Can you briefly talk about why you answered this way? 38. The HIA process influenced the (housing and neighborhood) plan? 0 1 2 3 4 5 DK Strongly Disagree Disagree Neither Agree Strongly Agree Can you briefly talk about why you answered this way?

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298 39. Broadly, what were the main reasons for not including some of the HIA recommendations into the (housing and neighborhood) plan? 40. How detailed do yo u think the HIA recommendations should be? Very Somewhat Little None Can you briefly talk about why you answered this way? 41. How important is the level of conciseness of the HIA recommendations in terms of whether or no t they are incorporated into the (housing and neighborhood) plan or not? Low Medium High Can you briefly talk about why you answered this way? 42. What else was needed or could be changed or improved to incorporate more recommendations into the (housing and neighborhood) plan? E. Wrap Up 43. From the (housing and neighborhood) planning process and HIA, do you think interdisciplinary collaboration will be improved for future neighborhood or other planning projects? Yes No Can you b riefly talk about why you answered this way? 44. More broadly, how was the (housing and neighborhood) plan or process changed as a result of having an HIA conducted if at all? 45. Are there any other comments you would you like to add related to the HIA and/or (housing and neighborhood) plan? 46. Is there anyone you might recommend for us to also interview?

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299 APPENDIX B RECOMMENDATIONS FOR SOUTH LINCOLN REDEVELOPMENT Table 1: Recommendations for South Lincoln Redevelopment Partially adopted Fully Adopted Not ado pted BE, policy, program Recommendation Social and Mental Wellbeing 1 BE a) Incorporate attractive and safe streetscape amenities such as benches, game tables, decorative pedestrian level lighting. 1 BE b) Design and display a colorful, way findi ng map at the 10th and Osage LRT station that clearly shows community assets and amenities such as the park, as well as the art district and bus routes. 1 Program c) Childcare: Establish a relationship with a non profit to provide a child care facilit y. If a new or retrofitted child care facility is included in the redevelopment, it should be designed to meet best practice standards for childcare environmental design. http://www.bridgehousing.com/Childcare_S ervices 1 Program c 1) Consider incent ing licensed child care providers by providing below market rate rent, or subsidizing other operating costs such as utilities or security. 1 policy d) Consider that schools should be used and advertised for multiple functions for students and the comm unity; for example, adult classes or community meeting facilities, pre and after school, community recreational facility, and neighborhood park. Greenlee is a landscape learning school but not advertised as an open community school.

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300 Table 1 cont.; 1 BE e) Water fountains can be a wonderful place for naturally assembling people but must be designed and managed carefully so there is no stagnant water for mosquito breeding; filtering of water for designs where water shoots up and kids can stand over i t (spray pads), and design considers water conservation measures. 1 BE f) Provide barbeque pits within South Lincoln and smaller parks. 1 BE g) Consider hiring local artists to create culturally appropriate, functional art and/or architectural op portunities for the display of artwork. Incorporate art into the streetscape that also ties into the Santa Fe Arts District. Consider benches and other public realm elements as an expression of art (e.g. students of Greenlee and/or seniors develop design) 1 BE h) Provide kiosk or community bulletin board to publicize arts and community meetings or events, etc. 1 BE i) To promote physical activity within buildings, use art and lighting to highlight stairs and draw more people to use the stairs (i nstead of elevators). Consider a security camera in stairwells in the senior building and other multi level buildings. 1 program j) Create and support ongoing community organization or associations, i.e. South Lincoln resident council. 1 BE a) In corporate low impact+M10 development stormwater management techniques (e.g., grass swales, rain gardens, wetlands, designing parking lots to naturally drain into perimeter and island landscaping, permeable pavers, etc.) to improve water quality while provi ding an attractive natural amenity.

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301 Table 1 cont.; 1 program b) Increase residential and commercial/school recycling: curbside is free for residents but residents need to call to get bin and recycling pick up. Consider truck access in alleys and s treets (some trouble at Stapleton redevelopment). City has instructors for free who will come out and teach about recycling and sign residents up. 1 BE c) Air quality will be one of the biggest future challenges; seek to reduce automobile use and VMT in the new development. 1 policy c 1) Reduce parking demand through unbundled parking (charging for parking costs separate from residential/commercial property/rental costs), making parking costs transparent and optional. 1 program c 2) Reduce pa rking footprint through shared parking which is included in the design of the site plan to meet the conceptual program). 1 policy/BE Back in angle parking provide safety benefits for lower speed roads such as 10th street promenade and 11th in front of the recreation center but currently city regulations do not allow for this type of parking. 1 BE d) Constructing noise barriers is an important consideration (e.g. wall, berm, buildings, landscaping with trees). A balance is needed about a type of ba rrier to block noise from rail yard and not block the mountain views. Use acoustic/noise reducing materials in buildings facing the railroad. 1 policy d idling freigh t trains that expel smoke. 1 BE e) Replace dead or dying trees and allow for additional (drought and disease resistant) trees that will shade pedestrians and enhance air quality. Denver has initiatives that provide free trees.

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302 Table 1 cont.; 1 BE f) Ensure mitigation measures that reduce greenhouse gas emissions, i.e. vehicle miles traveled. 1 program g) City has free graffiti removal for private and commercial property. They also have instructors who will come to schools, etc. to teach ch ildren/teens about graffiti. Built Environment and Transp: Opportunities for recreation and healthy eating 1 BE Bicycle lanes provide an environment that not only encourages physical activity but is safer. Bike lanes narrow streets to slow traffic such as Mariposa. For those streets not wide enough for separate bike lanes, sharrows can work within existing widths. 1 BE b) Identify walking route(s) (1/2 and 1 mile) and collaborate with Santa Fe Artist a nd nearby students to develop signage markers to mark the routes and denote number of walking steps or mileage between certain destinations (transit to arts district, park to King Soopers). 1 BE c) Improve biking facilities (potentially reduce availab ility of parking if needed), such as bicycle racks and/or secure bike lockers at housing, retail and recreational destinations. 1 program d) Partner with Denver City B Cycle program to explore a bike sharing station at the South Lincoln housing, park or other. 1 BE e) In the proposed design plan having a bus route included at light rail stop is very beneficial along with working with RTD to integrate more bus stops within the South Lincoln community. Routing new or existing fixed route service to provide direct access to the 10th/Osage light rail station via 9th and 11th. Coordinating existing or new private sector shuttles to supplement fixed route service (e.g., shared stops, marketing)

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303 Table 1 cont.; 1 program f) Need to work with Parks & Rec. to provide more activities for people at the north end of the South Lincoln Park and to potentially conduct usage study to gain understanding and baseline data. 1 BE locations such as on Mariposa. 1 B E h) In high pedestrian activity areas, such as 10th ave, use wider sidewalks. Opportunity for Healthy Eating 1 BE a) Improve opportunities for access to more fruits and vegetables at grocery stores (improve lighting, better crossings, etc. for clear and safe routes to the King Soopers grocery store), community gardens, and farmers markets. 1 BE b) Create one large public space for community gardens, specifically, at least 25 plot community garden. Provide amenities for the garden, including a gr eenhouse to extend the growing season, a compost area, and watering facilities. Currently the City has instructors to come teach the community about composting for free. 1 BE/program c) Potentially encourage with incentives or space, etc. to assist ne ighborhood small grocer to expand fruit and vegetable offerings. Participate in Healthy Corner Stores Initiative that promotes efforts to bring healthier foods into corner stores in low income and underserved communities. 1 BE d) Provide information k iosk particularly in front of community garden with instructions of gardening and nutrition. Opportunities for All Users 1 policy a) New or redeveloped construction properties incorporate features consistent with LEED or similar standards, as well as meet or exceed the Americans with Disabilities Act (ADA) standards and standards.

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304 Table 1 cont.; Access to Amenities: Services, Programs, Heath Care Education 1 BE a) Focus on closed La Mariposa clinic as pote ntially being a clinic again or at least use building for other social services. Work with Denver Health, about potentially bringing building into ADA compliance, etc. or selling. Other option is Clinica Tepeyac, David Lack, a clinic for the uninsured in G lobeville and interested in opening a clinic in South Lincoln. 1 program b) Extend Denver Health FREE shuttle past 9am 3pm everyday for nearby south Lincoln residents to be picked up and taken to the hospital (by volunteer driver). This information sh ould be posted at community kiosk, at the onsite office location and printed on community materials. 1 program c) WIC (Women, infant and children) discount healthy food vouchers are able to be used at the three closest grocery stores. WIC information needs to be advertised throughout community about signing up for program (bus stops) and use at local groceries. WIC participants are given vouchers for foods that contain selected nutrients. Typical foods are milk, cereal, eggs, cheese and infant formula. Women need to call (303) 692 2400. 1 program d) Continue to partner with the Byers Library to develop and implement an awareness and education campaign that includes skills such as nutritious shopping and cooking, healthy eating out, importance of tr ees, environment and other determinants that impact health. Include groups such as, Operation Frontline to conduct shopping education and nutrition classes. Cooperative Extension also has great education for low income, diverse populations and is funded th rough the City. 1 program e) Apply for LiveWell Colorado grant to modify and enhance healthy lifestyles to achieve maximum health status and well being.

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305 Table 1 cont.; 1 program f) Partner with Colorado Health Foundation, Healthy Living progra m to better understand and encourage healthy food outlets and discourage unhealthy food (e.g. The Food Trust). 1 program g) Obtain grants for local schools to collect student health data for all age groups, including Head Start, such as body mass inde x. 1 program h) Write grant for Colorado Safe Routes to School funds for either education or infrastructure. Funds can also be used for obtaining Bicycle Colorado who has an education curriculum for schools. They implement and teach school staff and s tudents about being crossing guards, curriculum, etc. 1 program i) Encourage the development of Wellness Committees at local schools and support their actions for health promotion with their students and families, including implementation of policies and programs that support Safe Routes to School, healthy eating, active living, violence prevention, etc. Safety: Personal and Traffic 1 BE a) Allow for future traffic flows with single lane traffic circles. 1 BE b) Separate pedestrians from veh icles by time/space, i.e. improved crosswalks, street closures, street trees. 1 BE c) Institute measures that increase the visibility of pedestrians such as exclusive pedestrian signal phasing, pedestrian refuge islands (and need to improve current is land on mariposa); and increase the intensity of roadway lighting. 1 policy d) Work closely with Public Works to remove policy restrictions on traffic calming measures such as, speed humps, and speed tables.

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306 Table 1 cont.; 1 policy e) Consider truck restrictions along roads which are more used or will be more used by pedestrians and specifically children (for example 10th St. ) 1 BE f) Bike lanes along a wide road such as Mariposa are important to slow vehicle speeds so it can be safe for a ll users whether in a wheel chair, bicycling or taking a jog. 1 BE g) In the draft plan there are a good amount the design of buildings with porches, balconies, and residential space above street level r etail space. 1 program h) Work with the Police Department to enforce current vehicle speeds. Use mobile speed trailers (driver feedback speed signs) for periods in areas where children are likely to cross major roads to go to school and near major ped estrian crossings. 1 BE i) Territorial safety reinforcement such as considering the use of pavement treatments, landscaping, art, signage, screening, and fences to define ownership of property. 1 BE j) Other principles for safety are to consider the placement and design of physical features to maximize visibility. This includes, building orientation, window, entrances and exits, parking lots, walkways, guard gates, and landscape trees and shrubs, fences or walls, signage, and any other physical ob structions. 1 BE k) Need for improved energy efficient lighting of current and future bus stops and space to sit at all bus stops. 1 program l) Use security cameras in higher crime and less safe areas such as the future parking structure. 1 BE couple police to come and go throughout day and have computer, desks, and phone available.

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307 Table 1 cont.; 1 BE n) Increase lighting on streets, parking lots, routes to King Soopers, Denver Health and Gr eenlee and West High and install more lighting in the park. 1 program o) Collaborate with and support community policing programs such as neighborhood watch, walk and watch groups and blight/graffiti elimination programs. 1 BE p) Work with the Ci ty to improve crosswalks and safer routes, bike lanes, etc. for routes to Greenlee and other schools, King Soopers, Santa Fe and Auraria campus. 1 BE q) Use zebra striping and countdown meters at pedestrian crossings located at all future planned reta il nodes (10th), major intersections as on Santa Fe and near schools. Recommendation Summary Partially adopted Fully adopted Not adopted Full/Partial Adopted Total 13 24 24 61 21.3% 39.3% 39.3% 61% 100% Table 2: Built Environment Program and Polic y Totals for South Lincoln Totals Built Environment 45 Program 11 Policy 3

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308 APPENDIX C HIA STANDARDS FOR SOUTH LINCOLN Table 3: HIA Standards for South Lincoln HIA Standards Checklist 1. General Standards High Med Low No N/A 1.1: Minimum stages Sc reening, Scoping, Assessment, Recommendations and Reporting 1 1.2: Monitoring plan to track outcomes 1 1.3: Evaluation, explicitly written goals at outset of process 1 1.4: Timely reporting 1 1.5: Interdisciplinary exp ertise and approach, including community 1 1.6: Meaningful and inclusive stakeholder participation (officials and residents) 1 1.7: Prospective activity 1 1.8: Integrated into other impact assessment process for efficiency 1 1.9: If Integrated in other assessment processes, adhere to standards therein 1 2. Screening High Med Low No N/A 2.1: Consideration of all decision alternatives 1 2.2: Addresses value of HIA in decision making process 1 2.3: Documentation of goals and notification of decision to conduct HIA 1 3. Scoping High Med Low No N/A 3.1: Scope of health issues and public concerns 3.1.1: Decision and alternatives to be studied 1 3.1.2: Health impacts and pathways 1 3.1.3: Research questions for impact analysis 1 3.1.4: Demographic, geographic, and temporal boundaries 1 3.1.5: Evidence sour ces and research methods 1 3.1.6: Identity of vulnerable subgroups 1 3.1.7: Approach for evaluation of the distribution of impacts 1

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309 Table 3 cont.; 3.1.8: Roles for experts and key infor mants 1 3.1.9: Standards or processes to determine significance of health impacts 1 3.1.10: Plan for external and public review 1 3.1.11 Plan for dissemination of findings and recommendation s 1 3.2: Establish person/team responsible for HIA/define roles 1 3.3: Consideration of all potential pathways reasonably linked with decision or direct/indirect 1 3.4: Identification of pathways by experts, local officials, sta keholders and affected community and solicit input from community and decision makers 1 3.5: Focus on impacts with greatest potential signif. magnitude, stakeholder priortites, equity 1 3.6: Evaluate potential inequities in impacts using demographically inclusive scope 1 3.7: Incorporate new information and evidence as it arises 1 4: Assessment High Med Low No N/A 4.1: Minimum components 4.1.1 Documentation of baseline health condit ions including vulnerabilities and inequalities 1 4.1.2 Eval. of health impacts based on best evidence 1 4.1.3 Characterize health impacts, direction, likelihood, distribution within population 1 4.2 : Judgements of health impacts based on best available evidence meaning: 4.2.1: Evidence may include, existing data, professional expertise, empirical research, local knowledge 1 4.2.2: Utilize evidence from well designed, peer reviewed systematic reviews 1 4.2.3: Consider published evidence that supports and refute s health impacts 1 4.2.4: Collect expertise/experiences of affected public as evidence 1 4.2.5: Justification for selection or exclusion of methods/data sources 1

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310 Table 3 cont.; 4.2. 6: Acknowledge when available methods were not utilized and why 1 4.3: Impact analysis should explicitly acknowledge methodological assumptions and strengths and limitations 4.3.1: Identify data gaps that prevent complete assessment 1 4.3.2: Describe uncertainty in predictions 1 4.3.3 Assumptions or inferences made in the context of modeling made explicit 1 4.4: Lack of rigorous evidence should not preclude reasoned predictions of impacts 1 5. Recommendations High Med Low No N/A 5.1: Need specific recommendations with modifications, mitigation measures 1 5.2: Use expert guidance to ens ure recommendations reflect effective practices 1 5.3: Criteria i.e. specificity, technical feasiblity, enforceability, authority of decision makers, may be considered 1 5.4: Recommendations may include monitoring, reassessment, adaptatio ns to manage uncertainty 1 6. Reporting High Med Low No N/A 6.1: Report completed with findings and recommendations 1 6.2: Provide succinct communication of findings that can be understood by all stakeholders 1 6.3: Report screening and scoping processes, sponsor, health assessor team/participants with roles and contribution 1 6.4: Documentation for each health issue should discuss evidence, describe data sources, analytic methods and list corresponding reco mmendations 1 6.5a: Recommendations whether policy, mitigation or decision alternatives should be specific and justified 1 6.5b: Criteria for prioritization of recommendations be explicit, evidence based and inclusive of stakeholder value s 1

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311 Table 3 cont.; 6.6: A draft report should be accessible for public review and comment, revisions included before finalization 1 6.7: Final HIA report should be publicly accessible 1 7. Monitoring Phase High Med Low No N/A 7.1: Follow up monitoring plan, track decision outcomes, and effect of decisions on health impacts 1 7.2: Monitoring plan should include: 7.2.1: Goals for short/long term monitoring 1 7.2.2: Outcomes and in dicators for monitoring 1 7.2.3: Lead individuals or organizations to conduct monitoring 1 7.2.4: Mechanism to report outcomes to decision makers and stakeholders 1 7.2.5: Triggers and thresholds that may lead to revi ew/adaptation in decision implementation 1 7.2.6: Identified resources to conduct, complete, and report monitoring 1 7.3: where possible, Integration of recommended mitigations into a management plan, outlining how each is implemented 1 7.4: When monitoring conducted, methods and results are available to public 1 TOTAL SCORE High Med Low No Sum Net score of all boxes above 28 8 7 1 44 Weighted Score (Net score x criteria weight (yes/high=3; Med=2; Low=1 ; No=0)) 84 16 7 0 107 Average score (Weighted Score/no. of criteria) 2.43 OVERALL RATING: If average score is less than 1.8 then HIA quality is LOW If average score is greater than or equal to 1.8 but less than 2.4, then H IA quality is MEDIUM If average score is greater than or equal to 2.4, then HIA quality is HIGH

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312 APPENDIX D RECOMMENDATIONS FOR NE DOWNTOWN REDEVELOPMENT Table 4: Recommendation s for NE Downtown Re de velopment Partially adopted Fully Adopted Not adopt ed BE, policy, program Recommendation S ection I 1 program A.1: Provide incentives for affordable/mixed income housing coalitions such as the Urban Land Conservancy and the Denver Housing Authority to acquire land in the study area and develop mixed i ncome housing. 1 program A.2: Utilize Neighborhood Stabilization Program funds to acquire foreclosed properties in the study area, as well as vacant or abandoned sites that meet the federal requirements. 1 program A.3: Implement programs to educa te current residents about their rights as tenants or homeowners and provide counseling about mortgage related issues. 1 program A.4: Consider tax abatement programs to defer payments on tax increase until homes are sold Section II 1 BE A.1: Pri oritize pedestrian circulation on all local and collector streets, as well as on streets with bus routes and light rail lines (esp. Welton/Downing, Walnut and Larimer 1 BE A.2: Fill in missing gaps in the sidewalk network identified in previous plann ing efforts 1 BE A.3: Continue to build a safe, connected bicycle route network through the study area with preference for separated bicycle lanes over sharrows where there is adequate right of way

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313 Table 4 cont.; 1 BE A.4: Ensure that the tran sportation needs of underserved populations are taken into account in the NEDNP, including needs of children, seniors, persons with disabilites and low income residents 1 BE A.5: Make improvements to the streetscape that will enhance vibrancy of pedes trian experience and improve safety, including increasing pedestrian lighting on busy routes, creating higher transparency rates (windows) in the zoning code, and installing street trees and other vegetation along the curb. 1 BE A.6: Consider converti ng many of the one way streets into two way streets 1 BE A.7: Install more bike sharing stations at key locations including, Curtis Park and Downing Street at the light rail stations 1 BE A.8: Improve existing bus stops by providing benches, shel ters and other structures to improve the transit experience 1 BE A.9: Use complete streets principals and traffic calming techniques to reduce traffic speeds 1 BE A.10: Concider installing planting buffers rather than attached sidewalks (esp. on Welton and Larimer St). 1 BE B.1: Improve connections to the S. Platte River from Northeast Downtown. 1 BE B.2: Ensure that the proposed new connections across RR tracks and River as envisioned in 38th and Blake SAP and RNGMP improve accessibilty for NE Downtown Residents as well as neighborhoods adjacent to the river. New sidewalks, bike lanes and other multimodal street improvements should extend into NE Downtown from these areas 1 BE B.3: Improve bike access to large parks such as City Pa rk and Commons Park

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314 Table 4 cont.; 1 BE B.4: Focus on making Mestizo Curtis Park a community destination. Improve safety in park by installing lighting, sidewalks, a jogging/running trail, new playground equipment and better landscaping. 1 prog ram B.5: Add programming to Lawson Park and others to reclaim and activate them for community residents 1 BE B.6: Add a playground to Benedict Park 1 BE B.7: Identify surface parking lots in the area that could be transformed into parks or garden s as redevelopment occurs 1 Policy, program C.1: Include NE Downtown in current citywide efforts to improve food access; Concider creating a new program and incentives modeled after the Park Hill Thriving Communities Grant to lure a full service groce ry to the area, support policy recommendations developed from the Denver Healthy Food Access Initiatve for encouraging grocery retail in NE Downtown and concider applying for funding through the newly created Federal Food Financing Initiative 1 BE C.2 : Realign bus routes or provide transportation to ensure access to supermarkets/grocery stores 1 policy C.3: Use zoning regulations to enable healthy food providers 1 policy C.4: Introduce or modify land use regs to promote, expand and protect p otential sites for community gardens, farmers' marktes, and backyard farming 1 BE C.5: Investigate the feasiblity of adding a farmers market along welton street. 1 BE C.6: Increase the number of community gardens in the study area 1 BE C.7: Encourage developers to include and agricultural or garden component in their new projects 1 program C.8: Create programs aimed at education of local residents about gardening and urban agriculture.

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315 Table 4 cont.; 1 program C.9: Work with existing convenience stores to introduce produce to their stores 1 BE D.1: DPS should require all schools to have a sufficient number of bike racks in good condition in a safe area that is easily accessible to students 1 BE D.2: Upgrade crosswalks around schools 1 BE D.3: Consider adding mid block crossings where appropriate (ex: at Gilpin elementary where there is a T intersection 1 program D.4: Utilize Safe Routes to Schools funding in the NE Downtown area 1 program D.5: Develop an education campaign for parents to encourage walking/biking to school and identifying barriers 1 BE E.1: Improve public spaces and bus stops to e nsure that seniors feel safe, especially in high traffic areas like Welton and Downing 1 BE E.2: Ensure that existing and new housing developments address the accesibility needs of seniors 1 BE E.3: Set aside units in new construction for seniors to ensure longtime residents can continue to live in the neighborhood as they age 1 program/BE E.4: Explore provision of subsidies for older adults to live in new developments, consider allowing/developing accessory dwelling units 1 BE E.5: Atte mpt to attract a full service pharmacy to the study area Section III 1 BE A.1: Improve signage of truck routes and enforce use of truck routes within the study area 1 BE A.2: Continue to collect and monitor air quality data to determine changes due to new development and rail construction

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316 Table 4 cont.; 1 BE A.3: Replace dead or dying trees and allow for additional trees to shade pedestrians and homes 1 program A.4: Encourage and create incentives for energy efficient redevelopment 1 BE B.1: Use porous paving for parking lots and driveways; incorporate other low impact (natural) storm water management techniques 1 program B.2: Reduce parking demand through unbundled parking (charging separately from rent) 1 BE C.1: Gain background noise levels and then monitor and enforce and mitigate to maintain safe levels of noise near the construction of the expanding and new commuter and light rails. 1 BE DE.1: Evaluate environmental conditons for areas that are redeveloped and consider engineering controls in the form of subslab ventilation. 1 program DE.2: Evaluate environmental conditons to identify areas of concern followed by use of a material management plan identifying proper disposal options and need for worker prot ection 1 BE DE.3: Asbestos containing building materials are common in the area and should be properly managed prior to demolition or remodeling work 1 BE F.1: Lead based paint: Follow lead safe working practices, remediate lead paint in housing units, educate residents about the issues around lead based paint Section IV 1 BE A.1: Install security cameras along Welton St near the light rail line to actively monitor high activity areas 1 BE A.2: Install more pedestrian scale lighting in areas of high pedestrian activity esp. Welton and Downing Streets

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317 Table 4 cont.; 1 BE A.3: Improve safety of Curtis Park and other parks by adding more lighting and reconstructing/moving current facilites closer to the street for improved visibility 1 BE A.4: Limit shrubbery to no more than three feet height and keep trees trimmed to allow for natural surveillance by residents 1 BE A.5: Increase lighting in alleys, side streets, parking lots and along major corridors 1 BE A.6: Encourag e movement of families into the area (increase density) to increase eyes on the street and stimulate social capital among neighbors 1 program A.7: Develop a neighborhood walk and watch group or expand existing neighborhood watch groups 1 BE B.1: Implement traffic calming measures on 20th St. and other high accident locations took out B.2: Concider transforming one way streets to two way streets. 1 BE B.3: Improve crosswalks at all intersections but especially at ones with awkward, non rectilinear crossings such as at Broadway and the historic Five Points Corner 1 BE B.4: Install bike boxes on bike routes Recommendation Summary Partially adopted Fully adopted Not adopted Full/Partial Adopted Total 10 12 39 22 61 16.4% 19.7% 63. 9% 36.1% 100% Table 5 : Built Environment Program and Policy Totals for NE Downtown Totals Built Environment 45 Program 11 Policy 3

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318 APPENDIX E HIA STANDARDS FOR NE DOWNTOWN Table 6 : HIA Standards for Northeast Downtown HIA Standards Checklist 1. General Standards High Med Low No N/A 1.1: Minimum stages Screening, Scoping, Assessment, Recommendations and Reporting 1 1.2: Monitoring plan to track outcomes 1 1.3: Evaluation, explicitly written goals at outset of pr ocess 1 1.4: Timely reporting 1 1.5: Interdisciplinary expertise and approach, including community 1 1.6: Meaningful and inclusive stakeholder participation (officials and residents) 1 1.7: Prospective activity 1 1.8: Integrated into other impact assessment process for efficiency 1 1.9: If Integrated in other assessment processes, adhere to standards therein 1 2. Screening High Med Low No N/A 2.1: Consideration of all decision alte rnatives 1 2.2: Addresses value of HIA in decision making process 1 2.3: Documentation of goals and notification of decision to conduct HIA 1 3. Scoping High Med Low No N/A 3.1: Scope of health issues and public con cerns

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319 Table 6 cont.; 3.1.1: Decision and alternatives to be studied 1 3.1.2: Health impacts and pathways 1 3.1.3: Research questions for impact analysis 1 3.1.4: D emographic, geographic, and temporal boundaries 1 3.1.5: Evidence sources and research methods 1 3.1.6: Identity of vulnerable subgroups 1 3.1.7: Approach for evaluation of the distribution of impacts 1 3.1.8: Roles for experts and key informants 1 3.1.9: Standards or processes to determine significance of health impacts 1 3.1.10: Plan for external and public review 1 3.1.11 Plan for dissemination of findings and recommendations 1 3.2: Establish person/team responsible for HIA/define roles 1 3.3: Consideration of all potential pathways reasonably linked with decision or direct/indirect 1 3.4: Identification of pathways by experts, local officials, stakeholders and affected community and solicit input from community and decision makers 1 3.5: Focus on impacts with greatest potential signif. magnitude, stakeholder priorities equity 1 3.6: Evaluate potential inequities in impacts using demographically inclusive scope 1 3.7: Incorporate new information and evidence as it arises 1 4: Assessment High Med Low No N/A 4.1: Minimum components 4.1.1 Documentation of baseline health conditions i ncluding vulnerabilities and inequalities 1 4.1.2 Eval. of health impacts based on best evidence 1

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320 Table 6 cont.; 4.1.3 Characterize health impacts, direction, likelihood, distribution within population 1 4.2: Judgments of health impacts based on best available evidence meaning: 4.2.1: Evidence may include, existing data, professional ex pertise, empirical research, local knowledge 1 4.2.2: Utilize evidence from well designed, peer reviewed system atic reviews 1 4.2.3: Consider published evidence that supports and refutes health impacts 1 4.2.4: Collect expertise/experiences of affected public as evidence 1 4.2.5: Justification f or selection or exclusion of methods/data sources 1 4.2.6: Acknowledge when available methods were not utilized and why 1 4.3: Impact analysis should explicitly acknowledge methodological assumptions and strengths and limit ations 4.3.1: Identify data gaps that prevent complete assessment 1 4.3.2: Describe uncertainty in predictions 1 4.3.3 Assumptions or inferences made in the context of modeling made explicit 1 4.4: Lack of rigorous evidence should not preclude reasoned predictions of impacts 1 5. Recommendations High Med Low No N/A 5.1: Need specific recommendations wi th modifications, mitigation measures 1 5.2: Use expert guidance to ensure recommendations reflect effective practices 1 5.3: Criteria i.e. specificity, technical feasiblity, enforceability, authority of decision makers, may be considered 1 5.4: Recommendations may include monitoring, reassessment, adaptations to manage uncertainty 1

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321 Table 6 cont.; 6. Reporting High Med Low No N/A 6.1: Report completed with findings and recommendations 1 6.2: Pro vide succinct communication of findings that can be understood by all stakeholders 1 6.3: Report screening and scoping processes, sponsor, health assessor team/participants with roles and contribution 1 6.4: Documentation for each health issue should discuss evidence, describe data sources, analytic methods and list corresponding recommendations 1 6.5a: Recommendations whether policy, mitigation or decision alternatives should be specific and justified 1 6.5b: Criteria fo r prioritization of recommendations be explicit, evidence based and inclusive of stakeholder values 1 6.6: A draft report should be accessible for public review and comment, revisions included before finalization 1 6.7: Final HIA report s hould be publicly accessible 1 7. Monitoring Phase High Med Low No N/A 7.1: Follow up monitoring plan, track decision outcomes, and effect of decisions on health impacts 1 7.2: Monitoring plan should include: 7 .2.1: Goals for short/long term monitoring 1 7.2.2: Outcomes and indicators for monitoring 1 7.2.3: Lead individuals or organizations to conduct monitoring 1 7.2.4: Mechanism to report outcomes to decision makers and stakeholders 1 7.2.5: Triggers and thresholds that may lead to review/adaptation in decision implementation 1 7.2.6: Identified resources to conduct, complete, and report monitoring 1 7.3: Integration of recommended mitig ations into a management plan, outlining how each is implemented 1

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322 Table 6 cont.; 7.4: When monitoring conducted, methods and results are available to public 1 TOTAL SCORE High Med Low No Sum Net score of all boxes above 20 9 8 10 47 Weighted Score (Net score x criteria weight (yes/high=3; Med=2; Low=1; No=0)) 60 18 8 0 86 Average score (Weighted Score/no. of criteria) 1.83 OVERALL RATING: If average score is less than 1.8 then HIA q uality is LOW If average score is greater than or equal to 1.8 but less than 2.4, then HIA quality is MEDIUM If average score is greater than or equal to 2.4, then HIA quality is HIGH Medium Low

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323 APPENDIX F HEALTH SUPPORTIVE L ANGUAGE FOR CENTRAL PA RK BOULEVARD Table 7 : Findings of Hea lth Supportive language for Central Park Boulevard Station Area Plans Central Park Florin Road 130 th Ave SE Alameda Lead Agency Denver Community Planning and Development Sacramento, CA Bellevue, WA Denver CPD Adopted /Accepted September 2012 February 2009 March 2012 April 2009 HIA conducted Yes No No No Length (pages) 85 105 89 63 Word Categories h ealth, healthy, healthier, healthiest 29 h ealth (10), healthy (18), healthier (1) 1 h ealthcare Check other thre e 0 2 h ealth (2), healthy (0), healthier (0), healthiest (0) b icycle, bike, biking, bicycling 139 b icycle (74), bike (59), biking (1), bicycling (5) 25 b iking (0), bicycle (17), bike (7), bikes (1), bicycling (0) 101 b icycling (85), bike (10), bikeway (2 ), biking (0), bicycling (4) 106 b icycle (70), bike (29), biking (4), bicycling (2), bikeway (1) p edestrian, pedestrians, pedestrian friendly 149 p edestrian (132), pedestr ians (11), p ed ( ) friendly (6) 77 p edestrian (55), pedestrians (13), ped ( ) friend ly (9) 66 p ede strian (52), pedestrians (12), pedestrian friendly (2) 90 p ede strian (73), pedestrians (17), pedestrian friendly (0) h ealth impact assessment, HIA 14 h ealth impact assessment (7), HIA (7) 0 0 0 s afety, safer, safe 27 s afety (13), safer (0), safe (14) 13 s afety (5), safer (0), safe (8) 8 s afety (2), safer (0), safe (6) 15 s afety 7, safer (0), safe (8)

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324 Table 7 cont.; s ocial cohesion, social capital, social interaction, social needs, social network, social activities, social gatherings, soc ial services, social 10 s ocial services (1), social opportunities (1), social systems (3), social sustainability (2), social diversity (1), social objectives (1), socially diverse (1) 0 2 s ocial Services (1), socialization (1) 1 s ocial activity s ocial equ ity, health disparities, health equity, equity, disparities 3 social equity (2), health disparities (0), health equity (0), equity transit equity (1) 0 0 0 w alk, walking, walkways, walkable, crosswalk, walkability 39 w alk (0), walking (10), walkways (0 ), walkable (20), crosswalk (8), walkability (1) 17 w alk (6), walking (7), walkways (1), walkable (2), crosswalk (0), walkability (1) 42 w alk (22), walking (11), walkable (6), walkways (0), crosswalks (2), walkability (1) 20 w alk (1), walking (13), walkwa ys (0), walkable (2), crosswalk(s) (3), walkability (1) physical activity, e xercise 2 physical activity (0), exercise (2) 0 0 0 overweight, obese, o besity 0 0 0 0 LEED, e nergy s tar 4 LEED (4) 1 LEEDs (1) 0 0 f market, garden(s) 1 5 f ood (15), healthy food, sustainable food, fresh food, food options, mobile food vendor; (0), garden (0) 1 s mall food service center 1 f ood (0), market (0), garden(s) (1) 1 f ood (0), rooftop gardens (1), (1), Total 431 135 220 235