A two-year study that looked at how community participation impacted core HIA values like democracy and equity, and how participation affected the success of the HIA.
To date, there has been limited evaluation of the extent to which impacted communities are incorporated into U.S.-based HIA practice. There are three reasons why community participation is important to consider.
- Inherent in the values of HIA are democracy and decreasing health Participation of those most impacted by the policies and programs that affect systemic racism and poverty is key to decreasing health inequities.
- Practitioners report that success of an HIA is dependent in part upon how well impacted community and other stakeholders are engaged in the HIA.
- Resources used to engage community members in HIA differ greatly.
This evaluation offers new data related to community participation in the United States-based practice of Health Impact Assessment (HIA). The findings are intended to inform the work of HIA practitioners, but are relevant to all researchers and organizations intending to authentically engage community members in addressing policy, program, or planning solutions, as well as funders of HIA or similar types of community-based participatory research. This evaluation is the first study of its kind to assess:
- Impact of community participation on HIA values of democracy and health equity, as measured through civic agency (see definition below)
- Impact of community participation on the success of an HIA
- How HIA practitioners differ in implementation of community participation in HIAs
- Barriers and facilitating factors for meaningful community participation
Findings illustrate that there are compelling bene- fits of community participation in HIA, including increased civic agency in communities and increased success of HIA.
For this evaluation the team used two main forms of study: 1) a national survey with participants of completed HIAs and 2) studying four HIAs as they were being conducted. Nearly one-third of the 145 HIAs completed in the U.S. between January 2010 – September 2013 were surveyed, with a total of 93 HIA team and community members participating as survey respondents. Respondents were highly representative of the field with regard to sector, geography, decision-making level, and type of organization leading the HIA. A large proportion (70%) of HIA team member respondents were white, and more than half of community respondents (53%) were people of color. The four recent HIAs that were studied in-depth were analyzed through site visits, document reviews, observations, and interviews to obtain a more nuanced understanding of the concepts studied.
|Health Impact Assessment||HIAs are a voluntary research and public engagement tool used to increase the aware- ness of health and equity in public policy and planning decisions. The HIA process involves six steps: screening, scoping, assessment, recommendations, reporting, and monitoring and evaluation.|
|Community participation levels
(adapted from International Association of Public Participation’s Spectrum of Participation)
|Inform||The community was informed about the HIA process; no other community participation.|
|Consult||The HIA team solicited input from the community through a few opportu- nities with limited participation; input may or may not have been incorpo- rated; community role in the HIA was not defined.|
|Involve||The HIA team offered opportunities for input; got input from the commu- nity; input was included in the HIA; and community role in the HIA was made clear to all stakeholders and decision-makers.|
|Collaborate||All community input and participation outlined above in the “involved” choice, PLUS decision-making authority was shared between HIA team and community.|
|Empower||All community input and participation outlined above in the “involved” choice, PLUS opportunities for feedback were frequent and participatory and the community had final decision-making authority on HIA decisions.|
|Civic agency||A community’s ability to organize and undertake collective action in its own self-in- terest. Civic agency was measured by responses to survey questions about commu- nity members involved in HIAs taking action, increasing contact with decision makers,
strengthening skills to influence future decisions, and if community voices about the HIA topic were heard.
|Success in HIA||In the national survey of community participation in HIA, this question defined success: “How much has this HIA changed the decision-making about the policy or project so far?” with responses on a scale ranging from “Not at all” to “A lot”.|
|Health inequity||Health inequities are systematic, avoidable, unfair, and unjust health outcomes, e.g., decreased life expectancy due to incarceration, to which African Americans are dispro- portionately exposed. “Inequities” contrast with health disparities, or differences in outcomes that are not due to a systematic and avoidable issue; e.g., the elderly have cancer more than younger people. There are racial, economic, gender, sexual identity and other inequitable exposures, which is why it is important to incorporate those most impacted by systemic inequities in decisions that most highly touch their lives and
Our findings provide new insights on the level of community participation in HIAs in the U.S., the impact of community participation on the success of HIAs, and the use of HIA as a means to enhance civic agency.
- Most respondents reported that the level of community participation in their HIA fell in the middle of Spectrum of Public Participation range, at the “involve” Community members ranked their HIAs as higher in community participation than HIA practitioners did.
- Of the respondents from the 47 HIAs surveyed, 84% reported that community participation had a positive or very positive impact on the success of their HIA.
Impact of Community Participation on the Success of the HIA
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- Specifically, 73% reported that their HIA contributed to positive changes in the community, 70% reported their HIA influenced decision-making some or a lot, and 65% of respondents reported the decision-maker was receptive to using the HIA findings.
- HIAs are increasing the civic agency of community Over 60% of survey respondents reported that community members are taking action, increasing contact with decision makers, strengthening skills to influence future decisions, and community voices are being heard because of community participation in HIA.
- HIAs that involved higher levels of civic agency had greater odds of impacting decision-making.
These findings send a strong message to the HIA field that investment in higher levels of community participation pays off in higher levels of civic agency, such as improved individual civic skills and increased capacity for collective action. This evaluation also found that higher levels of community participation showed greater odds of an HIA impacting decision-making. HIA involvement spurs those impacted by decisions to increased action and influence – a powerful outcome for democracy and equity. Based on survey results and observations of the four HIAs studied in depth, success in building civic agency may be less tied to one community participation strategy and more tied to the persistence of trying as many strategies as possible.
Many HIAs are engaging community members at moderate levels of participation, illustrating that there is room for improvement in the field of HIA. One-third of the respondents ranked the level of community participation in their HIA on the lower ends of the spectrum – informing community about the process or consulting them without clarifying whether and how feedback would be used. If HIA practitioners stop at “informing”, “consulting”, or even “involving” community members, they may be limiting the benefits that can be achieved from a higher level of community participation in HIA, i.e., “collaboration” and “empowerment”. This evaluation concludes that the field should reach for higher levels of community participation on the Spectrum of Participation.
This evaluation confirms research about facilitators and barriers of community participation and provides perspectives on the effectiveness of current community participation methods used in HIAs in the United States.
• Methods used to identify and outreach to the impacted community.
- Collaborations with local organizations and utilization of networked contacts helped HIA practitioners identify and effectively reach impacted community members.
- Hiring a community engagement specialist was less common but ranked as an effective strategy by those who used it for identifying, reaching, and encouraging participation of community members.
- Community organizations and academic institutions are more likely to try a broader array of community identification strategies than public health departments and planning agencies, and community organizations are more likely to achieve higher levels of participation in HIA for community members, compared to planning agencies, suggesting that organizational approaches to HIA may influence community participation strategies and outcomes.
• Methods used to encourage community participation.
- Key informant interviews and inclusion on steering committees were common and effective participation methods.
- Other effective participation methods for at least some groups were: getting feedback on a draft of the HIA; holding public meetings; engaging community members in data collection, and holding focus groups.
• Common and effective resources that facilitated community participation.
- Established relationships that HIA practitioners or their partners had with community organizations; participation of government agencies; HIA team familiarity with the decision-making process; and expertise in facilitation, communications, and community organizing.
- Less common but effective resources: having space for public meetings, cultural and linguistic competency, and prior experience with community participation in HIA.
• The most common barriers reported by both groups were lack of time and resources.
- HIA team members reported how much time they spent engaging community members and community members reported the time they spent on the HIA.
- The majority of HIA teams spent 30% or less of their time on community participation.
- One-third of community members reported spending 15 hours or less on their HIA, one-third reported spending 16-30 hours, and one-third reported spending 36 or more hours on the HIAs they participated in.
- Seventy percent of community members did not receive compensation for their time on the HIA.
Established relationships with community organizations emerged as the strongest facilitator of community participation in HIA. HIA practitioners can more quickly and easily reach out to community organizations they already know to identify and recruit community member participation. There is also corresponding trust, role clarity, and the ability to quickly develop shared expectations.
Expertise in facilitation, communications, community organizing, and cultural competency were also facilitators of community participation in HIA. When HIA teams lack skills or expertise in these areas, collaborating with community groups that have these resources could be an effective way to enhance community participation efforts.
Because the most common barriers to community participation in HIAs are time and resources, realistic funding of HIAs to support community participation activities would better support HIA values of increased participatory democracy and equity and overall success of HIAs. Just as HIA team members are compensated for their work on an HIA, community participants should also be compensated for their time and efforts.
Lack of time and resources is a barrier for HIA practitioners in monitoring the outcome of an HIA over time. Therefore, we found it was meaningful that 38% of respondents reported that community members are actively monitoring implementation of the decision that was the topic of their HIA. A lack of monitoring has been recognized in national HIA meetings, in peer-reviewed journal articles, and among providers of training and technical assistance. It is logical that community members would monitor the implementation of decisions – after all, the projects are being built or implemented around them, the policies will directly affect them, and the programs will serve them. Thus, community involvement can strengthen the HIA practice of monitoring.
When asked about any positive outcomes that resulted from community participation in the HIA, respondents indicated that working with the community “helped to legitimize the concerns of the different alternatives of the decision” and “added to the credibility of the (HIA) and transparency about the (decision-making) process”.
Incorporating potentially impacted community members in HIA activities at higher levels on the Spectrum of Public Participation shows promise to increase transparency, accountability, and credibility of HIA findings. The HIA field has done moderately well at engaging impacted community members. HIAs that engage community members at higher levels build civic agency – defined as a community’s ability to organize and undertake collective action in its own self-interest – and report more success – defined as the HIA impacting the decision topic. Thus, this evaluation concludes that engaging community members in HIA at higher levels of the Spectrum of Public Participation holds promise for HIAs to better attain international HIA values of democracy and equity.
The main resource that facilitates implementation of community participation is activating existing rela- tionships that HIA practitioners or their partners have with impacted community groups.
The authors make the following set of recommendations, informed by the findings and authors’ expertise, with the goal of enhancing community participation in HIAs and to maximize the benefits of those activities. For greater detail and examples, see the full evaluation and appendices.
- Develop relationships with community groups before any HIA arises.
- Choose topics for HIAs based on identified community interest versus deciding on HIA topic and then trying to recruit community members.
- Create a community engagement plan for each HIA.
- Establish familiarity with the decision-making process.
- Invest in facilitation skills training.
- Develop communications and communications planning skills.
- Partner with existing community/interest groups and organizers.
- Engage community for data collection efforts.
- Establish community roles for disseminating HIA findings.
- Engage community members as key monitoring actors.
Reduce Barriers to Community Participation
- Do not rely solely on email or the internet for communications.
- Offer meetings at accessible times and locations.
- Provide transportation, translation, childcare, as needed.
- Be mindful of the time commitment for community representatives.
- Create interim products and check-ins to keep community members engaged through shifting timelines for decisions.
Make Participation Meaningful for Community Representatives
- Pay community organizations and members for their expertise and time.
- Invite community members to be on the HIA Steering/Advisory Committee.
- Make sure the community role is clearly defined and communicated.
- Create skills and knowledge development opportunities.
- Solicit and incorporate feedback from the community.
- Engage and utilize community representatives as key data sources.
- Share decision-making authority.
Build the Field
- Include community participation as an outcome in HIA process evaluations.
- Engage community members to serve as key monitoring agents.
Enhance Civic Agency
- Increase community member contact with decision makers.
- Ensure that community members are aware of how decisions are made and opportunities for public input in decisions.
- Ensure that community voices are heard.
- Support community action to influence the decision and its impacts.
- Help community acquire or strengthen skills to influence other decisions.