Health Impact Assessment: A Missed Opportunity for MCH Professionals in Their Quest to Address the Social Determinants of Health

Introduction Public health professionals, especially ones concerned with maternal and child health (MCH), need to engage in cross-sector collaborations to address social determinants of health. Health Impact Assessment (HIA) systematically brings public health perspectives into non-health decision-making contexts that influence social determinants. Alignment of MCH and HIA practice has not previously been documented. Methods An exploratory review of HIAs conducted in the United States considered several dimensions of MCH-HIA alignment and produced data to test the hypothesis that HIAs involving MCH stakeholders are more likely to address MCH populations and relevant measures. The review examined three key variables for each HIA: inclusion of MCH-focused stakeholders, level of focus on MCH populations, and presence of MCH-relevant content. Results Of the 424 HIAs included in the database of US HIAs, 350 were included in this review. Twenty-four percent (84) included MCH-focused stakeholders, and 42% (148) focused on MCH populations. Ninety percent (317) included metrics or content relevant to at least one Title V National Performance Measure (NPM). HIAs that clearly included MCH stakeholders had seven times the odds of including both a focus on MCH populations and at least one NPM-relevant topic compared to HIAs that did not clearly include MCH stakeholders (OR 6.98; 95% CI 3.99, 12.20). Discussion Despite low engagement of MCH stakeholders in HIAs, many still consider MCH populations and measures. Intentional engagement of MCH workforce in HIAs could ensure greater alignment with existing MCH priorities (such as addressing the social determinants of health and equity) in a given jurisdiction.


Significance Statement
What is already known on this subject? Cross-sector collaboration has become increasingly important for public health practice. HIA is an effective tool for building collaborative relationships across sectors. The MCH workforce is in need of actionable frameworks for cross-sector collaboration to impact social determinants of health and equity.
What this study adds? HIA practice in the US has not seen extensive involvement of the MCH workforce, but it has regularly incorporated MCH-relevant content. By filling this gap and becoming more involved in HIA, MCH professionals have an opportunity to build cross-sector capacity and ensure relevance of MCH content.

Introduction
Researchers, practitioners, and policy-makers need to address social determinants of health to meaningfully reduce population-level disparities and improve maternal and child health (MCH). Social determinants of health are conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks (U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion, 2018). Addressing disparities requires a commitment to health equity, which means striving for the highest possible standard of health for all people and giving special attention to needs of individuals at greatest risk based on social conditions (Braveman, 2014). The Maternal and Child Health Bureau of the Health Resources and Services Administration has emphasized a need for integrating perspectives of social determinants and equity into MCH practice (Fine et al., 2010). Meeting this need requires collaboration between public health and other sectors like education, housing, and transportation (DeSalvo et al., 2016;Koh et al., 2011;Mattessich & Rausch, 2014).
Research on training needs of the public health workforce, and the MCH workforce specifically, emphasizes policy engagement and collaboration with sectors outside traditional public health silos as areas for improvement (Bogaert et al., 2019;DeSalvo et al., 2017;Raskind et al., 2019;Sellers et al., 2015). As a result, the National MCH Workforce Development Center advances strategies to help Title V leaders and MCH practitioners build collaborative policy engagement capacity, using systems integration perspectives that emphasizes social determinants of health and equity (Clarke & Cilenti, 2018;Margolis et al., 2017). One of these strategies is implementing a Health in All Policies (HiAP) approach.
HiAP considers how to systematically integrate public health perspectives on social determinants and equity into decision-making across non-health sectors (Ståhl et al., 2006;Wernham & Teutsch, 2015). One of the more common HiAP approaches is health impact assessment (HIA) (Gase et al., 2013;Rudolph et al., 2013). The National Research Council defines HIA as: A systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects (2011).
While variations exist in practice, conducting HIA typically involves the iterative six-step process illustrated in Table 1 Six steps of health impact assessment and associated outputs (National Research Council, 2011) Step Outputs Screening Describes proposed policy, program, plan, or project, including timeline for decision and political and policy context Presents preliminary opinion on importance of proposal for health and the opportunities for HIA to inform the decision, and states why the proposal was selected for screening Outlines expected resource requirements to conduct HIA Provides recommendation on whether HIA is warranted Scoping Summarizes pathways and health effects to be addressed, and provides rationale for those included and excluded Identifies affected populations and vulnerable groups Describes research questions, data sources, the analytic plan, data gaps, and how gaps will be addressed Identifies alternatives to the proposed action to be assessed Summarizes stakeholder engagement, issues raised by stakeholders, and responses to those issues Assessment Describes the baseline health status of affected populations Analyzes and characterizes beneficial and adverse health effects of the proposal and each alternative Describes data sources and analytic methods used Documents stakeholder engagement and integrates input into analyses Identifies clearly the limitations and uncertainties of the analysis Recommendations Identifies alternatives to proposal or actions that could be taken to avoid, minimize, or mitigate adverse effects and to optimize beneficial ones Proposes a health-management plan to identify stakeholders who could implement recommendations, indicators for monitoring, and systems for verification Reporting Provides clear documentation of the proposal analyzed, the population affected, stakeholder engagement, data sources and analytic methods used, findings, and recommendations Communicates findings and recommendations to decision makers, the public, and other stakeholders in a form that can be integrated with other decision-making factors (technical, social, political, and economic) Monitoring & Evaluation Tracks changes in health indicators or implementation of HIA recommendations Evaluates (a) whether the HIA was conducted according to its plan and applicable standards (process evaluation), (b) whether the HIA influenced the decision-making process (impact evaluation), and (c) when practicable, whether implementation of the proposal changed health indicators (outcome evaluation) Table 1 and components of the eight Minimum Elements listed in Table 2 (Bhatia et al., 2014;Dannenberg, 2016a;National Research Council, 2011). HIA is a practical tool for synthesizing evidence and stakeholder input to foster collaboration and inform decisions made outside the health sector (Cole & Fielding, 2007). Because individual HIAs are primarily oriented toward practice, they are under-documented in peer-reviewed research literature. HIA researchers launched a dedicated journal in 2016 to address this issue and to provide more opportunities for HIA practitioners to publish their results (Stone, 2016). Over the past decade, published research on HIA in the United States has mostly considered effectiveness of the process, while individual case studies remain elusive in traditional research databases (Cole et al., 2019;Dannenberg, 2016b;Sohn et al., 2018). For example, searching the key words "health impact assessment" in PubMed returns a large number of results, but most are not specific to the prospective process defined above.
A PubMed search for "health impact assessment" conducted by the authors in January 2020 returned 1,264 results. When sorted by relevance, the first 100 results included 19 published accounts of specific HIAs, of which five were conducted in the United States. In the MCH context, even fewer research publications regarding HIA are available: as of January 2020, the Maternal and Child Health Journal has published no articles describing "Health Impact Assessment" in their title or abstracts. To the authors' knowledge, the current study is the first of its kind to document potential for alignment between MCH and HIA practice in the United States and to highlight the breadth of opportunities for MCH practitioners to engage in such HiAP initiatives as a strategy to address the social determinants of health.

Research Overview and Key Questions
This study leveraged a repository of HIAs conducted in the United States to answer these questions: (1) to what extent have MCH-focused stakeholders been involved in HIA practice? (2) How often and to what extent do HIAs examine MCH subpopulations? (3) What proportion of HIAs include Title V National Performance Measures (NPMs) or closely related metrics in their analyses? (4) Are HIAs that engage MCH-focused stakeholders more likely to include information on MCH populations and NPM-relevant content? Fig. 1 illustrates the interrelatedness of the four research questions. Collected data also characterize the breadth of non-health policies relevant to MCH outcomes and a range of opportunities for MCH stakeholders to inform them. This study does not include any clinical or patient data.

Data Source and Inclusion Criteria
The Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts, hosts a web-based repository of information about HIAs conducted in the United States (Health Impact Project, 2017). HIA researchers commonly use this repository as a data source (Cole et al., 2019;Cowling et al., 2017;Dannenberg et al., 2019;Gase et al., 2017). Although uploading HIA information to the site is voluntary, this repository has been viewed as a largely complete picture of US practice since its inception in 2010.
As of September 2017, the repository listed 424 HIAs. The entry for each HIA includes hyperlinks and contextual data like project title, lead organization(s), decisionmaking level (local, regional, state, or federal), and target sector (e.g. housing, education, transportation, etc.). HIAs Table 2 Eight minimum elements of health impact assessments (Bhatia et al., 2014) 1. HIA is conducted to assess the potential health consequences of a proposed program, policy, project, or plan under consideration by decisionmakers, and is conducted in advance of the decision in question 2. HIA involves and engages stakeholders affected by the proposal, particularly vulnerable populations 3. HIA systematically considers the full range of potential impacts of the proposal on health determinants, health status, and health equity 4. HIA provides a profile of existing conditions for the populations affected by the proposal, including their health outcomes, health determinants, and vulnerable sub-groups within the population, relevant to the health issues examined in the HIA 5. HIA characterizes the proposal's impacts on health, health determinants, and health equity, while documenting data sources and analytic methods, quality of evidence used, methodological assumptions, and limitations 6. HIA provides recommendations, as needed, on feasible and effective actions to promote the positive health impacts and mitigate the negative health impacts of the decision, identifying, where appropriate, alternatives or modifications to the proposal 7. HIA produces a publicly accessible report that includes, at minimum, documentation of the HIA's purpose, findings, and recommendations, and either documentation of the processes and methods involved, or reference to an external source of documentation for these processes and methods. The report should be shared with decision-makers and other stakeholders 8. HIA proposes indicators, actions, and responsible parties, where indicated, for a plan to monitor the implementation of recommendations, as well as health effects and outcomes of the proposal 1 3 were excluded from the current analysis when project documentation was not available, either because the HIA was in progress or because available hyperlinks were no longer active and reviewers were unable to find publicly available documentation via web search based on HIA title and/or lead organization.

Key Variables
Researchers coded three primary variables for each HIA reviewed. First, they determined the involvement of MCHfocused stakeholders. MCH-focused stakeholders included organizations or individuals that focus on infants, children, youth, adolescents, mothers, pregnant individuals, and/or families. State or Local Health Departments were only included as MCH-focused stakeholders if available documentation clearly noted representation from an MCHserving division, branch, or team (e.g. the Title V Office, Division of Child Health, etc.). Reviewers did not assume inclusion of these perspectives unless stated. This variable was coded 'yes' if documentation revealed an explicit role for an MCH-focused partner in the conduct of the HIA, ranging from roles on the HIA project team or advisory committee to participation in document review or data collection as part of the process. If available documentation mentioned MCH-focused stakeholders but was unclear about the extent of involvement, reviewers coded this variable as 'partial.' The 'partial' designation was also used when the reviewer was unsure about the extent to which a given stakeholder explicitly focused on MCH, for example local educational institutions were regularly placed in this category. The second variable considers attention given to MCH populations within the HIA. MCH populations include infants, children, youth, adolescents, mothers, pregnant individuals, and/or families. Reviewers coded this variable as 'yes' if documentation noted explicit focus on one or more of these MCH populations as part of the HIA scope. This meant that the HIA not only identified an MCH population as a subpopulation of concern, but that the assessment and/or recommendations reflect elevated attention on that group. Reviewers assigned a 'partial' designation if the HIA mentioned MCH populations but did not clearly incorporate them as part of the assessment. This included instances where a report includes statistics on an MCH population but not as a critical element of the analysis (e.g. the childhood Fig. 1 Interrelatedness of four research questions guiding the review of HIAs 1 3 obesity rate was mentioned as part of existing conditions but not in the assessment of potential impacts).
To define the third key variable, inclusion of MCH content, reviewers determined whether each HIA included topics related to one or more of the Title V NPMs. These 15 measures were selected as the basis for defining "MCH content" in this review because national leaders have identified them as foundational to the work of public health MCH professionals, as measurable, as directly modifiable by states' programmatic activities, and as meaningful when changed (Kogan et al., 2015). Specific guidance and search terms were developed for each NPM and are listed in Table 3, along with examples of reviewer notes from specific HIAs. Reviewers only used the 'yes' designation when the exact NPM was noted in the HIA. They used the 'partial' designation when an NPM topic was touched upon in the HIA, but without including the exact NPM. A goal of this review is to inspire MCH professionals toward more upstream cross-sector engagement and collaboration by documenting the breadth of opportunities where their perspectives could have been valuable in existing HIA practice. Because this retrospective accounting of opportunities was generated from content positioned primarily within non-MCH perspectives, the authors were intentionally inclusive in identifying aspects of a given HIA that could be considered MCH-relevant content, and thus, some instances may stretch the bounds of what is considered closely related to specific NPMs.

Review and Extraction Process
Starting with information available in Health Impact Project's repository, researchers followed a protocol created and pilot-tested specifically for this review. First, they used project hyperlinks to obtain publicly available HIA documentation. This documentation was then reviewed to determine designations for the three key variables described above. In addition to a scan of available documentation for each HIA, variable-specific search terms were employed to more efficiently identify relevant content. Reviewers extracted this relevant content and summarized how it supported designations of 'yes', 'partial', or 'no' for each variable. A pilottest of the protocol on 20 randomly selected HIAs included independent review of each by three researchers, who agreed 85% of the time across all variable designations. No HIA in the pilot explicitly included any of the 15 NPMs, which led researchers to adjust the final review protocol for this variable to be more inclusive of related content within the 'partial' designation. Two co-authors then collaboratively reviewed the remaining HIAs and adjudicated disagreements through discussion as needed. When reviewers could not make a clear determination, the research team made a final coding determination based on collective interpretation of the available content in the context of the study objectives. Reviewers applied the protocol to available materials and coded responses into an Excel spreadsheet.

Analysis
Coded data were transferred to SPSS (IBM Corp., 2017), and frequency tables were produced for each research question. Upon initial review of the data, yes/partial/no responses were recoded to facilitate statistical analysis and hypothesis testing. For the MCH stakeholder and MCH population variables, 'no' and 'partial' responses were combined to allow dichotomous comparison to the 'yes' responses. Because so few HIAs were coded as 'yes' for including NPMs, responses for this variable were dichotomized by combining 'yes' and 'partial' designations for comparison with those HIAs designated as 'no.' Researchers also created a variable that indicated the total number of NPMs each HIA addressed, ranging from 0 to 15.
To test the hypothesis that HIAs with MCH stakeholder involvement are more likely to include a focus on MCH populations and NPM-related topics, a single dichotomous dependent variable was created that combined inclusion of MCH populations and NPM-relevant topics. These binary data were used to conduct Chi-Square and Simple Odds Ratios to test the hypothesis. Statistical significance was determined at alpha = 0.05. Figure 2 illustrates how the 424 HIAs contained in the Health Impact Project database were narrowed to an analysis sample of 350 HIAs.

Results
Research Question 1: To what extent have MCHfocused stakeholders been involved in HIA practice?
Slightly less than one quarter (24%) of the 350 HIAs reviewed demonstrated clear inclusion of MCH stakeholders (Fig. 3). The only example of an HIA that clearly indicated inclusion of a Title V agency considered impacts of potential changes to paid sick leave policy in Vermont (Vermont Department of Health, 2015). In that HIA, led by the Vermont Department of Health, representatives from the Division of Maternal and Child Health were listed as stakeholders, along with the Vermont Commission on Women, several school nurses, and a local child care facility. Under the definition of stakeholders described above, the most common stakeholder groups were school or other education system representatives and child or family-focused advocacy Search Terms: breast Guidance to Reviewers: Breastfeeding did not come up in any of the pilot HIAs and is likely to be rare in the larger sample, so be inclusive of any mention of breastfeeding for this review Example from Review Data: "Barriers to breastfeeding among WIC participants have included sore nipples and pain, perceptions of inadequate milk supply, and social support networks' attitudes about breastfeeding. It is possible that these barriers would be heightened for homeless women because of inadequate access to lactation resources, concerns about inadequate milk production, or because of returning to the workforce" (p. 105).-planokc Comprehensive Plan Health Impact Assessment (Oklahoma City)-2014 Search Terms: Developmental, Screening. Note: 'Screening' is likely to generate false positives because it describes a step in the HIA process Guidance to Reviewers: This NPM focuses on developmental screening of youth up through age 5 (71 months) and appears unlikely to be directly addressed in existing HIAs; however, there may be instances where the physical and/or mental development of young children get discussed in an HIA. In these instances, be inclusive so we can return to them for further discussion Example from Review Data: "PCBs and mercury. Human consumption of these fish can lead to chronic health problems, and children are at the greatest risk for developmental effects from such exposure." (p. 52). Development is also discussed in connection with parks/green spaces, particularly for children with ADHD.-SR 520 Health Impact Assessment: A bridge to a healthier community (Seattle)-2008 NPM 7: Injury Hospitalization (Rate of hospitalization for non-fatal injury per 100,000 children ages 0 through 9 and adolescents 10 through 19) Search Terms: injury, injuries, safe Guidance to Reviewers: Injuries will be one of the more common topics included in HIAs, especially ones focused on transportation-related decisions. Include any mention of statistics related to injury (mortality and morbidity; intentional and unintentional) here and note where youth injuries are called out specifically. To be inclusive, also consider when perceptions of injury risk are being discussed. Likely to get very 'close' on this NPM, but only count as 'yes' over 'partial' if all the exact components of the NPM are noted: Rate of hospitalization for non-fatal injury per 100,000 children ages 0 through 9 and adolescents 10 through 19 Example from Review Data: "In addition, among accidental injuries that result in death for Baltimore children ages 1-17, 39% are motor vehicle-related. Nearly two-thirds of these deaths involved a child who was walking or biking" (p. 16).-The Red Line Transit Project Health Impact Assessment (Baltimore)-2008 Search Terms: physical activity, children Guidance to Reviewers: Physical activity (PA) will also be among the most common topics addressed in the HIAs, allowing for us to be a little more conservative on inclusion. When PA statistics are given that would cover children or youth (anyone under age 19), include it as at least a 'partial'. There may be instances where all the data presented are for adult PA, but the discussion includes youth promotion. Capture these instances as a partial with explanation here and/or in the columns considering inclusion of MCH populations. If the HIA is only focused on adult PA and has no mention of the non-adult population, mark it as a 'no'. As with the injury NPM, HIAs are expected to get very 'close' on this NPM, but only denote it as a 'yes' over a 'partial' if all the exact components of the NPM are noted: percent of children ages 6 through 11 and adolescents 12 through 17 who are physically active at least 60 min per day Example from Review Data: "Children who began and maintained physical activity levels into young adulthood had better mental health outcomes than children who were inactive or those who did not maintain physical activity levels" (p. 15).-Winona County Active Living Plan HIA (Minnesota)-2015 NPM 9: Bullying (Percent of adolescents, ages 12 through 17, who are bullied or who bully others) Search Terms: bully Guidance to Reviewers: In the pilot, at least one HIA came up for discussion under this NPM. While it did not directly note bullying or measures thereof, the assessment did spend some time discussing possible impacts on student behavior/disruption in school, which could include bullying. To be inclusive, use your judgement as to whether or not any mentions of youth behavior in school or other social settings might include bullying Example from Review Data: "Studies that have examined how social capital is reflected in children's health and educational outcomes suggest the effect is positive on behavior problems" (p. 43). Also-"Another study notes that among victims of child maltreatment, psychological problems are prevalent and often manifest in aggressive behaviors towards both adults and peers," (p. 44).-Transitional Jobs Programs: A Health Impact Assessment (Wisconsin)-2013 NPM 10: Adolescent Well-Visit (Percent of adolescents, ages 12 through 17, with a preventive medical visit in the past year) Search Terms: well-visit, adolescent Guidance to Reviewers: Similar to NPM 1, this NPM is focused on preventive care-in this case for youth. While no instances occurred in the pilot, there may be times when data on aspects of youth prevention are included. Use your judgement, but err on the side of inclusivity since presence of this topic is likely to be a rare instance within the HIAs Example from Review Data: Access to healthcare for children and adolescents-"More broadly, in a comparison study of schools with and without [school-based health centers], [Denver Health's School-Based Health Centers] located within school were more effective at reducing barriers to care and increasing access to and use of health care services for children and adolescents" (p. 21).-Addressing Search Terms: dental, dentist, oral, oral health Guidance to Reviewers: Few HIAs are likely to include oral health, much less for women and children specifically. To be inclusive, note any references to oral health found during your search, as 'partial' with explanation to inform future discussion Example from Review Data: "According to a survey performed by the National Energy Assistance Directors Association (NEADA) in 2005, a significant proportion of LIHEAP participants in the Northeast reported making precisely these kinds of budget trade-offs due to high energy costs:... 28% went without medical or dental care;" (pp. 2-3). Also see "Housing instability and homelessness pose welldocumented threats to child physical health-have 10 times more dental caries than housed children" (p. 8 Eighty-four percent of the 350 HIAs reviewed at least partially considered MCH populations according to publicly available materials. As illustrated in Fig. 4, this 84% was split almost equally between HIAs designated as having a clear focus on MCH subpopulations (148 HIAs) and HIAs that only partially included them (147 HIAs).

Mental Health and Physical Activity in K-12 Children in Colorado Springs: A Health Impact Assessment-2016
Research Question 3: What proportion of HIAs include Title V National Performance Measures (NPMs) or closely related metrics in their analyses?
Eighty-nine percent of the 350 HIAs included information designated as closely related to or relevant for at least one NPM, and less than 2% included specific NPMs. The Search Terms: smoke, smoking, tobacco Guidance to Reviewers: This topic did not come up in the pilot reviews. Include instances that consider smoking and second-hand smoke as 'partial' and explain Example from Review Data: "Parks and recreational facilities should be a smoke-free environment to reduce exposure to secondhand smoke − especially for youth who respire more frequently than adults while being physically active" (p. 10).-"One in five children is exposed to secondhand smoke in cars. Switching from car to bus, where smoking is not allowed, could help decrease children's exposure to secondhand smoke" (p. 23). included two NPMs, and most (61%) included one to three topics (Fig. 5). All 15 NPMs were represented at least once across all HIAs reviewed (Fig. 6). Injury and physical activity were the most common NPM-related topics, included in 61% and 59% of the 350 HIAs reviewed, respectively. None of the 214 HIAs including information about injuries used the specific NPM. However, all of them referenced injuries and hospitalizations in a way determined by reviewers to be relevant for MCH populations or practice. For physical activity, only one of the 205 HIAs coded as relevant for NPM 8 specifically included NPM itself.
Research Question 4: Are HIAs that engage MCHfocused stakeholders more likely to include information on MCH populations and NPM-relevant content?
The MCH stakeholder, MCH population, and NPM inclusion variables described above were used to test the hypothesis that HIAs involving MCH stakeholders are more likely to address both MCH populations and relevant measures. MCH stakeholder inclusion was the independent variable and dichotomized into HIAs with clear inclusion of MCH stakeholders (designated by reviewers as 'yes'; 24% of the sample, 84 HIAs) and ones with no clear inclusion of MCH stakeholders (designated as either 'partial' or 'no'; 76% of the sample, 266 HIAs). The dependent variable was a combination of MCH population focus and inclusion of NPMrelated topics, where an HIA had to satisfy both conditions to be coded as 'yes' (41% of the sample, 143 HIAs).
HIAs that clearly included MCH stakeholders had seven times the odds of including both a focus on MCH populations and at least one NPM-relevant topic compared to HIAs that did not clearly include MCH stakeholders (OR 6.98; 95% CI 3.99, 12.20). This association is statistically significant (Chi-square, p < 0.001). Table 4 displays the distribution across these two variables.
To demonstrate the breadth of non-health policies informed by HIA, Table 5 includes the distribution of HIAs across different target sectors. Table 6 summarizes ten HIAs that illustrate the range of potential opportunities for MCH engagement in this type of cross-sector collaboration. These examples were selected to reflect variation in the three key review variables and in two key contextual factors: target sector and decision-making level (local, regional, state, or federal). They were also chosen to reflect the geographic diversity in HIA practice in the US.

Discussion
Nearly all HIAs reviewed (95%) considered an MCH population in some way or included information relevant to at least one NPM. In contrast, just over a third (36%) contained evidence of MCH stakeholder involvement. The current analysis demonstrates that MCH stakeholder involvement in an HIA is associated with greater odds of that HIA addressing MCH populations and relevant topics, suggesting an opportunity for MCH professionals and HIA practitioners to engage with one another in strategic efforts to inform decisions made outside the traditional public health sector. Aligning these efforts allows both MCH professionals and HIA practitioners to better advance a "Public Health 3.0" approach, wherein public health leaders partner across multiple sectors to address social, environmental, and economic conditions that affect health and health equity (DeSalvo et al., 2017).
MCH professionals have opportunities to advance health equity through cross-sector collaboration by actively pursuing involvement in HIA taking place in their respective jurisdictions and strategically considering it as a means for addressing issues relevant to their stakeholders and communities. Where HIAs are more common, there appears to be opportunity for intentionally integrating MCH perspectives into ongoing cross-sector collaborations addressing health determinants of significance for MCH outcomes. Where HIAs are less common, there may be opportunities for MCH leaders to initiate or strengthen those critical collaborations through the use of this specific tool. As practice continues to coalesce around advancing health equity, both in MCH efforts and through the HIA process, opportunities for collaboration will emerge and can be leveraged to advance population health outcomes for MCH populations. Collaborative cross-sector opportunities are not exclusive to HIA, and future research could expand upon the current review to further explore roles for MCH in other HiAP approaches.
HIA practitioners have opportunities to more actively seek engagement with MCH stakeholders, which could lead to broader applicability of HIA findings and recommendations. Incorporating more intentional MCH perspectives within HIA could be a mechanism to garner broader stakeholder and community engagement, which in turn can raise visibility of strategic approaches to population health and health equity. There could also be practical benefits in terms of access to and interpretation of MCH-relevant data that might otherwise be absent in a given assessment. Incorporating this perspective could strengthen the recommendations that are a primary output of the HIA process.
Although not coded as a key variable for this analysis, reviewers noted general MCH implications of recommendations in roughly two thirds of HIAs. If Title V or other MCH professionals are engaged in developing these recommendations, they can better ensure strategic relevance for MCH stakeholders and alignment with other MCH activities in a given jurisdiction. For example, with Title V involvement, an HIA could move past general discussions of an MCH-related issue to include NPM-specific data and strategies, resulting in direct advancement of relevant existing Title V priorities.
Intra-sector silos within public health may provide one explanation for underrepresentation of MCH stakeholders in HIA practice. When led by public health entities, HIAs are often housed within an environmental health or chronic disease unit; though in recent years, HIAs led by offices focused on evaluation, policy, or equity have become more common (J. Dills, personal communication, April 1, 2020). This assignment of HIA responsibility to  1 3 specific public health content areas might raise barriers to supporting active involvement of MCH professionals from within an agency, among other bureaucratic challenges. Without active attempts to bridge these intra-sector silos and address these challenges, HIA work done by one arm of a public health agency can easily occur in isolation from the other. As MCH leaders become more engaged in upstream policy work, awareness of opportunities to leverage existing cross-sector experience from within their own agencies is an asset. HIAs potentially present this type of opportunity, as do HiAP approaches more broadly (Rudolph et al., 2013). A more thorough examination of variation in resources available to support HIA over time is beyond the scope of this review; however, future research could determine if greater availability of resources to support HIA is associated with greater likelihood of MCH inclusion in those HIAs.
In terms of connecting to sectors outside of public health, Table 5 shows the distribution of HIAs by target sector. HIAs aimed at informing decisions related to agriculture/food systems, education, and labor/employment have included MCH stakeholders more regularly than HIAs targeting other sectors, but all sectors have included MCH stakeholders to some degree. These data are included to demonstrate the breadth of sectors covered by HIAs generally and to note the sectors most common to HIAs that specifically include MCH stakeholders. This review does not consider the temporality of MCH involvement in HIA and the MCH-relevant content contained therein. Some decisions considered by HIAs may be more directly tied to MCH populations and have a readily apparent reason to include MCH practitioners, leading to more MCH-relevant content in those HIAs. For example, decisions made in the education sector are likely to influence children, so an HIA of those decisions may naturally include some level of MCH perspectives from the outset. As a collaborative approach, different perspectives inform HIAs throughout the process, with the screening and scoping stages as the most opportune time for robust MCH involvement that would potentially guide assessment and recommendations toward more MCH-relevant content.

Limitations
Three interrelated limitations should be considered in interpreting these findings. First, approximately one in six HIAs listed in the Health Impact Project database did not have the publicly available documentation needed to be included in this analysis. Further, the database is populated mostly by voluntary self-reports from the HIA field, and thus, an unknown number of HIAs in the U.S. are not included in the data. How information from these HIAs might influence study results is unclear. Second, thoroughness of available HIA documentation varies widely (Rhodus et al., 2013). HIA is both a process and a report. This review only judged aspects of the process based on how well the associated reports (and other available documentation) described them. This limitation leads to an incomplete picture of HIAs that may have had a more robust process than reflected in their final reports and could have led to underestimating MCH stakeholder involvement. Finally, because of the exploratory nature of this review, the research team erred on the side of inclusivity when coding HIA content. Regular discussions of the data as they were being collected and resulting iterations of the review protocol may have introduced increased subjectivity in comparison to a more traditional systematic review of research studies. Future research examining involvement of MCH stakeholders in HIA practice could address some of these limitations by including interviews with leaders of and participants in specific HIAs.

Conclusion
HIA is an established tool that supports prospective engagement by public health stakeholders in non-health decisionmaking contexts. This exploratory review indicates limited involvement of MCH-focused practitioners in HIA practice to date. The results reveal that despite this lack of engagement, a large portion of HIA practice considers populations and measures with clear relevance to MCH. When the MCH workforce is involved, HIAs are significantly more likely to include specific MCH content. Therefore, intentional alignment of MCH and HIA practice, along with capacity building to support use of HIA by MCH stakeholders, would potentially reinforce strategies seeking to inform decisions made in other sectors. As noted earlier, these decisions influence social determinants of health, the inequitable distribution of which underpin many health disparities. HIA is one method through which public health perspectives can be integrated into these influential decisions for population health. Limited involvement of MCH practitioners in HIA points to a missed opportunity to ensure that their particular perspectives on public health are actionably included in these cross-sector collaborations to address social determinants.  (1, 3, 6, 8, 9, 11, 14, & 15). Sample content is included below specific to NPMs 6, 9, and 15 NPM 6-Developmental Screening ('Partial'): Child development is referenced throughout the HIA as a key health outcome, but no specific screening data are mentioned. The summary of findings notes that the proposed food tax would be regressive and potentially "harm family economic security, which could have negative impacts on childhood development and learning capacity," among other issues (p. 12). The report also notes that "taxing food could also have an adverse impact on food security, diet, and nutrition, which would have important and harmful implications for health, particularly… childhood development and learning capacity, malnutrition issues, the incidence of low birth-weight and/or preterm babies, and the need and demand for food assistance" programs (p. 12). The impact characterization table on p. 13 emphasizes that these negative impacts are most likely to burden "children and pregnant mothers in food insecure or low-income residents." NPM 9-Bullying ('Partial'): "Behavioral problems at school" is included as an intermediate impact in the pathway that considers how increased food costs could potentially connect to health outcomes of concern, such as "cognitive, development and educational outcomes" or "diet-and nutrition-related disease (diabetes, hypertension, heart disease, stroke, obesity)"    HIA has content judged to be at least partially related to five (6, 8, 9, 11, & 14). Sample content is included below for NPMs 6, 11, & 14 NPM 6-Developmental Screening ('Partial'): In discussing the role of CDCs in promoting Asset Development, which includes "activities that improve an individual's ability to acquire and maintain assets," the HIA includes passing reference to developmental delays in children and specifically connects housing insecurity to "behavioral problems, developmental delays, and poor mental health among children" (p. 66). By potentially facilitating CDC activities related to Asset Development, the proposed Community Investment Tax Credit (CITC) program could help reduce these issues. No data about screening rates are included or referenced NPM 11-Medical Home ('Partial'): While not specifying access to a medical home for children with or without special health care needs, the HIA does include access to medical care as one of the health outcomes likely to be positively impacted by the CITC program through all pathways examined. For example, local economic development activities facilitated by the program "can contribute to increases in residents' income, which enables individuals and families to afford…medical care" (p. 17). For the purposes of this review, this increase in access is assumed to precipitate improvement in this NPM NPM14-Smoking ('Partial'): The HIA makes a few connections between CDC activities facilitated by the CITC program and reducing unhealthy behaviors, including smoking. In discussing the broad implications of local economic development, the report notes that "the creation and sustainability of small businesses in a community" can minimize neighborhood deprivation that "is associated with increased risk of physical inactivity, unhealthy diet, smoking, and obesity" (p. 63). They also briefly discuss implications of youth empowerment programs that "may impact a wide range of health behaviors and outcomes as well as help to reduce risky and unhealthy behaviors, such as smoking… and promote more positive behaviors in this group" (p. 73 it does reference children as a vulnerable population that could be impacted positively by implementation of the CITC program. The report offers some content at least partially relevant for five NPMs, including developmental screenings, physical activity, bullying, medical home, and smoking; however, none of these topics is thoroughly examined. Generally, "this HIA predicts that the CITC will have an overall positive impact on public health of low-and moderate-income households across the state served by the certified CDCs" (p. 95), and recommendations set a context in which MCH could clearly become a more integral part of the of community development programs, plans, and policies health is referenced in the HIA, but only as part of the general baseline table of "Measures for Health of Children in Nevada," which notes 67.4% "of children with preventive dental visit in the last year," compared to 77.2% nationally (p. 84). This content was considered as partial inclusion of the NPM because it did not specify the age range, nor did the HIA include information about pregnant individuals' dental visits. This topic is not represented anywhere else in the HIA Because they consider FDK, all the recommendations have some level of relevance for MCH, as they deal with improving health of children through various pathways.
An example particularly relevant for potential collaboration with MCH stakeholders outside the education system is that "school districts, the Nevada Division of Public and Behavioral Health, and local health departments could consider collaborating to measure height and weight annually and to track data over time by using unique student identification numbers to maintain the confidentiality of personally identifiable information and make the data publicly available for monitoring purposes" (p. 11) High: This HIA included several MCH stakeholders from the education sector and a few from public health. By nature of considering an education topic, child health is clearly an associated focus. The report presents content related to eight NPMs, including risk-appropriate perinatal care, developmental screening, injury, physical activity, medical home, dental visits, smoking, and adequate insurance. However, many of these are only briefly mentioned and do not receive any attention in the assessment or findings.
Recommendations are for expanding and improving FDK in Nevada and offer several opportunities for further MCH engagement around nutrition, education, health, and school-based services    (p. 12), going on to note that "births to study area residents are more likely to result in low-birth weight; premature deliveries; and higher rates of infant mortality," adding that these "residents have a high rate of publicly funded births, but poorer birth outcomes" than others in the county (p. 33). Perhaps most relevant for this NPM, "births among residents of the study area are more likely to be to women with inadequate prenatal care;" however, no data are presented specific to perinatal care and percent of very low birth weight (VLBW) infants born in a hospital with a Level III + Neonatal Intensive Care Unit (NICU) (p. 33) NPM 11-Medical Home ('Partial'): The HIA discusses regular access to health care through the lens of transit accessibility, or lack thereof, for residents of the study corridor (pp. 100-104). The report does not specify medical home explicitly, but this discussion of spatial access was judged to be a relevant precur-  HIA has a specific focus on families, and the HIA project logic model includes "family cohesion" and "child maltreatment" as key intermediate health indicators potentially impacted by the program and associated with health outcomes that include "improved child well-being" and "improved birth outcomes" (p. 2) Though it does not explicitly address any specific NPMs, this HIA has content judged to be at least partially related to six (3, 6, 7, 8, 9, & 14). Sample content is included below for 3, 6, 9, & 14 NPM 3-Risk-Appropriate Perinatal Care ('Partial'): Though the HIA does not include data on perinatal care, it does consider how the jobs program influences contextual factors for maternal risk. For example, "prenatal exposure to alcohol and tobacco results in negative birth outcome[s], including premature deliveries, sudden infant death syndrome, and decreased lung growth. Birth outcomes resulting from prenatal exposure to alcohol includes infants born with significantly lower birth weights, height and head circumference and brain damage such as fetal alcohol syndrome" (p. 40) NPM 6-Developmental Screening ('Partial'): While not considering screening rates, this HIA does touch on topics relevant to child development. In exploring evidence from evaluations of other transitional jobs programs, the report notes that "researchers observed some lasting effects for the participants' children including improvement in school progress, boys' standardized test scores, positive expectations for future school performance, the quality of social relationships, and participation in extracurricular activities" (p. 20) NPM 9-Bullying ('Partial'): The HIA does not address bullying directly, but it examines relationships between the transitional jobs program and behavioral problems in children. Among evidence supporting this connection, the assessment identifies "studies that have examined how social capital is reflected in children's health and educational outcomes," which "suggest the effect is positive on behavior problems" (p. 43). The report also "notes that among victims of child maltreatment, psychological problems are prevalent and often manifest in aggressive behaviors towards both adults and peers" as part of a pathway connecting the jobs program to family cohesion (