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Due to the centrality of equity to the HIA and the challenges associated with organizing vulnerablecommunities, special attention must be paid throughout the process to those representing vulnerablepopulations, including low-income people, communities of color, people with disabilities, children, andseniors. Many HIAs include organizations with strong ties to the community and increased capacity toengage community members on key objectives and participate with broader constituencies. Throughcommunity-based organizations, residents can:provide valuable inputbuild individual and organizational capacityprovide community outreach resourcesserve as sources of quantitative and qualitative datahelp ground truth findingscontribute political connections important to an HIA‘s successcontribute financial and in-kind resourceshelp create ―buy-in‖ for how results are usedIn turn, an HIA helps organizations develop institutional capacity to consider health in future policy andproject efforts.Because representatives from anorganization will likely be loyal to theorganization‘s core mission andagenda, it is important to exercisecaution in determining eachorganization‘s representation andaccountability to the vulnerablepopulations for which it speaks. Thisis also another reason to ensureparticipation by a diverse range ofstakeholders.Why Is StakeholderParticipation Critical?Stakeholder participation andleadership is an integral part of theHIA process. Such participationsupports empowerment andcapacity-building, particularly amongvulnerable populations, whichinclude low-income people andcommunities of color; this in turnmaximizes health outcomes. Publichealth research shows that citizenswho are more civically engaged andthose who feel a sense of controlover the decisions that impact theirlives experience better healthCase Study: Los Angeles ACORN, a local community-basedorganization, spearheaded an HIA of a housing development in SouthLos Angeles in a low-income community. The HIA looked at the healthimpacts of affordable housing and access to vital healthy goods andservices such as healthy food, public transit, education, parks andrecreation facilities, and neighborhood walkability. There wasintensive community involvement via a 300-person survey andcommunity reporting of HIA findings to city council members. LADepartment of Public Health, the Redevelopment Authority, and thenonprofit developer also participated in the HIA. The HIA andstakeholder participation led to the developer agreeing to lower thecost of the housing units to match what was considered “affordable”in the lower-income sub-area of South Los Angeles. See Section D, partIV for more details on this example.Best Practices for Stakeholder Participation in Health Impact Assessments – March 2012Stakeholder Participation Working Group of the 2010 HIA in the Americas Workshop4

2outcomes. Successful stakeholder participation can lead to a more informed, empowered andcontinuously engaged base.Indeed, stakeholder participation aims to exemplify each core value of an HIA as defined by the World3Health Organization. The way in which stakeholder engagement supports each value is outlined in Table 1.Table 1. How Stakeholder Participation Supports the Core Values of HIAHIA Core ValueWHO Definition*How Stakeholder ParticipationContributes to the Core Values of HIADemocracyEmphasize people‘s rights to participate ina transparent process for the formulation,implementation and evaluation of policiesthat affect their lives, both directly andthrough the elected political decisionmakersEnsures stakeholders—particularly thosewho are disenfranchised from the politicalprocess—are a part of decision-makingprocesses that impact their lives; providesan opportunity for stakeholders to voicetheir concerns and solutions; and buildsstakeholder capacity to become involvedin future decision-making.EquityEmphasize that an HIA is not onlyinterested in the aggregate impact of theassessed policy on the health of apopulation but also on the distribution ofthe impact within the population, in terms ofgender, age, ethnic background andsocioeconomic statusAllows people who might be impacted tohave their needs represented in thedecision-making process, contributes toreduced health inequities and promotesequitable decision-making.SustainableDevelopmentEmphasize that both short-term and longterm, direct and indirect impacts must betaken into considerationStakeholders can present issues thatreflect the needs of both the current andfuture community (services, traffic, etc.).Ethical Use ofEvidenceEmphasize that the use of quantitative andqualitative evidence needs to be rigorousand based on different scientific disciplinesand methodologies to get a comprehensiveassessment of the expected impactsInformation collected from stakeholdersshould be valued as evidence. Groundtruthing scientific data with variousstakeholders helps validate professionalinformation.* From European Centre for Health Policy. Health Impact Assessment: Main Concepts and Suggested Approach. 1999.World Health Organization Regional Office for Europe.The Benefits of Engaged and Active StakeholdersIn the HIA process, engaged and active stakeholders can:Increase the accuracy and value of the HIA by providing multiple perspectives. Workingwith stakeholders brings varying perspectives to the HIA and is integral to identifying the healthimpacts that are of greatest importance to the population identified in the HIA. Through theparticipation process, the knowledge, experience and values of diverse stakeholders can becomepart of the evidence base.Incorporate information not readily available with other forms of evidence. Stakeholderscan share anecdotal information, histories and stories that provide a more well-roundedunderstanding of existing community conditions and potential health impacts. Stakeholders canalso help refine research questions, support context-specific analysis of research findings, andhelp develop more feasible recommendations.Best Practices for Stakeholder Participation in Health Impact Assessments – March 2012Stakeholder Participation Working Group of the 2010 HIA in the Americas Workshop5

Increase the efficacy of the HIA to impact the policy decision by fostering active supportfor the HIA recommendations. Participation in the HIA process can provide stakeholders anopportunity to shape the analysis and provide meaningful input. Stakeholders can account forcommunity concerns and visions, political realities, and reach diverse audiences for input andsupport. Since the recommendations stemming from the HIA analysis may also have the mostimpact on communities and other stakeholders, it is imperative they help shape them.When stakeholder participation is successful, community and advocacy groups can use the HIA results toadvocate for the recommendations of the HIA and reach decision makers to influence key opportunities.This increases the likelihood of implementation. For example, community groups can develop campaignsand organize constituencies to advocate for the recommendations of the HIA. Stakeholder support oropposition can be an important factor in determining the success or failure of a policy, project, orprogram.In order to inform an HIA, expandgood practice, and increase thefeasibility of an effectiveimplementation of finalrecommendations, it is important toengage diverse perspectives. At thebare minimum, HIA practitioners areadvised to involve a wide variety ofstakeholders in the HIA at eachstage; if carried out to its maximumpotential, stakeholder participationcan result in a more successful HIA,increased democratic processes andempowered communities.Case Study: Launched in fall 2004, the Eastern NeighborhoodsCommunity Health Impact Assessment (ENCHIA) was an 18-monthlong process to assess the health impacts of the proposed re-zoningand community planning process in Eastern Neighborhoods.Facilitated and staffed by the San Francisco Department of PublicHealth, ENCHIA was guided by a multi-stakeholder CommunityCouncil of over 20 diverse organizations representing a multitude ofinterests including economic and neighborhood development,environmental justice, homelessness, open space, property-owners,and small businesses. ENCHIA resulted in the insertion of healthprotective language in the Community Area Plans, health analysisduring the formal Environmental Impact Review, new city legislationrequiring air quality and noise mitigations for sensitive usedevelopment, and the creation of the Healthy DevelopmentMeasurement Tool. See Section D, part I for more information.The benefits of broad involvementand leadership extend beyond therecommendations of the HIA.Current practice standards, guidanceand peer-reviewed literature for HIA,other forms of impact assessments,and public planning recognize thatmeaningful and effective stakeholderparticipation supports effectivedecision-making. Stakeholderparticipation does not only inform theHIA, it also benefits the communityand decision makers.Best Practices for Stakeholder Participation in Health Impact Assessments – March 2012Stakeholder Participation Working Group of the 2010 HIA in the Americas Workshop6

Levels of Stakeholder ParticipationThe quality of stakeholder participation can vary widely. Sherry R.Arnstein‘s Ladder of Citizen Participation (Figure 1), a framework often4utilized in studies of equity and civic engagement, was published in 1969.It remains a valid framework to describe the spectrum of engagement—from input to empowerment—and to prescribe participation goals andmethods. Although not explicitly used in an HIA, it is presented as apotential tool to help conceptualize and gauge stakeholders‘ desired levelsof participation in HIA practice.Arnstein‘s ladder also helps evaluate the goal of community empowermentin HIA; results should be evaluated by how changes were achieved and atwhich level engagement took place on the Ladder of Citizen Participation.Evaluating empowerment calls for collecting data on stakeholders‘experience with the HIA process and their sense of personal power,accountability, connectedness, vision, etc. This is just one exampleFigure 1. Arnstein's Ladder of Citizenof how participation goals can shape how practitioners plan,Participationimplement, and evaluate participation and overall success of the HIA.Table 2. Ladder of Citizen Participation Applied to HIA PracticeRungArnstein’s Description2Applied to HIA PracticeCitizen Control & Vulnerable populations most impacted obtain HIA stakeholders, including vulnerableDelegated Power majority decision-making power.populations, decide on the HIA scope andrecommendations, have final approval of HIAreport, and decide on the communicationsstrategy.PartnershipVulnerable populations can negotiate andengage in trade-offs with power holders.Stakeholders impact the direction of HIA (scope)and reporting, but decisions are made equallywith project team.PlacationAllows vulnerable populations to advise, butpower holders have right to decide.Stakeholders offer input that may shape the HIA,but the project team make all decisions.Informing &ConsultationCitizens can offer input and be heard, with no Stakeholders offer input but it does notnecessarily shape the HIA.assurance their views will be taken intoaccount.Manipulation &TherapyPower holders ―educate‖ or ―cure‖ citizens— Telling stakeholders what is happening withoutparticipation is not encouraged.soliciting input. Saying stakeholder voices matterbut not acting on input. Not giving out all relevantinformation or giving different information todifferent stakeholders.The rungs of Arnstein‘s ladder also fit nicely into a framework for understanding best practices forstakeholder participation in HIA (Table 2). As noted, there are varied ways to effectively engage thebroader community groups and stakeholders at different levels but at minimum, HIA practitioners shouldseek to achieve participation at the Informing and Consultation rungs or higher.2Authors took liberty to change Arnstein‘s use of the term ―have not‖ and replace it with ―vulnerable population.‖Best Practices for Stakeholder Participation in Health Impact Assessments – March 2012Stakeholder Participation Working Group of the 2010 HIA in the Americas Workshop7

How Stakeholders Can Get InvolvedOne of the primary products of the first HIA in the Americas Workshop (2009) was a ―Minimum Elementsand Practice Standards for HIA‖ (HIA Practice Standards) document,3 which was designed by leadingNorth American HIA practitioners to support the development and institutionalization of HIA by identifyingthe values underlying HIA, the essential elements of a HIA, and best practices to conduct a HIA. 5 Asnoted in these standards, "there exists considerable diversity in the practice and products of HIA due to6the variety of decisions assessed, diverse practice settings, and the nascent evolution of the field.‖ Thisset of conditions also applies to stakeholder participation in HIAs. With the diversity of interests, reach,capacities, and cultures among potential stakeholders, no single approach can be prescribed forstakeholder participation. This document advocates maximizing stakeholder participation foreffective and equitable results, and acknowledges that limited resources, capacities and quickpolitical timelines pose limits on stakeholder participation.The HIA Practice Standards also suggests that stakeholder participation in HIAs should include ―aspecific engagement and participation approach that utilizes available participatory or deliberativemethods suitable to the needs of stakeholders and context.‖ Such methods may include, but are notlimited to: creation of community steering or advisory groups, co-partnership with key stakeholders,consensus-based decision-making, interviews, surveys, questionnaires, fishbowls, comment forms,project website, articles, newsletters, workshops, tours, design charrettes, focus groups, and studysessions. The standards broadly encourage practitioners to ―accept and utilize input‖ at a very minimum.In addition, the HIA Practice Standards identifies a seriesof opportunities at each stage of HIA where stakeholderscan shape and influence the process and outcomes.7Table 3 summarizes these opportunities. When maximizedat each stage, stakeholder guidance and input has thepotential to shape the issues that are scoped into the HIA,the values prioritized, and the stakeholders engaged in theprocess. Stakeholders share local knowledge andexpertise on early drafts of HIA documents, frame the dataaround local realities, provide comments and feedback onthe final report, and help identify recommendations.Table 3 summarizes the Practice Standard‘s essential and recommended standards related tostakeholder participation. The right-hand column references where the identified standards can be foundin the Practice Standards document.3Practice Standards were updated after the HIA of the Americas Conference 2010, and will continue to be updatedas practice develops. The Stakeholder Participation in HIA Working Group has included additional practices in Table2 to reflect enhanced engagement.Best Practices for Stakeholder Participation in Health Impact Assessments – March 2012Stakeholder Participation Working Group of the 2010 HIA in the Americas Workshop8

8Table 3: North American HIA Practice Standards Relating to Stakeholder Participation by HIA StageHIA Standards for PractitionersProcess Oversight:Intended to be used throughout all the stages of the HIAEssential Accept and utilize diverse stakeholder input.Recommended Have a specific engagement and participation approach that utilizes available participatory or deliberative methods suitable to the needs ofstakeholders and contextScreening Stage:Deciding whether an HIA is needed, feasible, and relevantEssential Understand stakeholder concerns in order to determine potential health effects. Identify and notify stakeholders of decision to conduct a HIA.Recommended Identify stakeholders to potentially partner with a HIA. Seek diverse stakeholder participation in screening the target policy or HIA plan.Scoping Stage:Deciding which health impacts to evaluate and evaluation methodology Use input from multiple perspectives to inform pathways (between the policy, plan or project and key health outcomes). Use multiple avenuesEssentialto solicit input (from stakeholders, affected communities, decision makers).

Best Practices for Stakeholder Participation in Health Impact Assessments - March 2012 Stakeholder Participation Working Group of the 2010 HIA in the Americas Workshop 3 B. Understanding Stakeholder Participation Who Are Stakeholders? Stakeholders are individuals or organizations who stand to gain or lose from a decision or process. More