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Volume 1, Issue 1October 2016

SOCIAL LEARNING THROUGH STAKEHOLDER 
ENGAGEMENT: NEW PATHWAYS FROM PARTICIPATION 

TO HEALTH EQUITY IN U.S. WEST COAST HIAS
Nicole Iroz-Elardo, PhD; Moriah McSharry McGrath, PhD, MPH, MSUP

While some contend that extensive public engagement 
activities are necessary to meet Health Impact Assessment 
(HIA) practice standards, other work suggests that an HIA 
of  any type hasthe potential to inform decision-making in 
ways that embody HIA’s value of  democracy (Cole & Field-
ing, 2007; Harris-Roxas et al., 2012; Negev, 2012).   These 
divergent perspectives on how to realize democracy through 
public participation represents an area of  evolving debate 
in the ongoing development of  HIA practice in the US.  
Looking to the relatively diverse HIA practice on the west 
coast of  the US, we explore the interplay between engage-
ment strategies and HIA values in completed HIAs.  We 
locate each HIA on Harris-Roxas’s (2011) typology of  HIAs 
– mandated, decision-support, advocacy, and community-led 
– and assess the type(s) and extent of  participation activities 
conducted.  This sample incorporates a variety of  both HIA 
types, target policy/program decisions in different sectors, 
and HIAs conducted by seasoned and novice practitioners.  

This analysis reveals gains in health equity resulting from 
all types of  HIAs and engagement strategies.  We argue that 
in addition to the empowerment of  affected groups that 
occur through direct participation, social learning (Bandura, 
1977) is a mechanism for advancing health equity through 
the moral development of  the participating stakeholders.  
Additionally, we found that HIAs which employed direct 
participation and benefited from vibrant leadership by com-
munity organizations did not necessarily realize HIA’s health 
equity goals.  Just as analytical strategies vary given differ-
ent purposes, engagement strategies vary depending on the 
goals of  an HIA.  We argue that overly rigid definitions of  

participation elide the contributions made by HIAs that take 
a different form than the archetypal community-led HIA.  
This elision is problematic given the institutional infrastruc-
ture that can be built through more technocratic decision-
support HIAs and the relative dearth of  truly community-
led HIAs.  We propose eschewing a singular “optimal” 
participation paradigm as a way to both acknowledge the 
potential of  all types of  HIA to contribute to health-sup-
porting policy and to maintain the idealistic frame for HIA 
to advance health equity. 

Introduction
Given the flexibility of  the HIA technique and the rapid 
growth in its application in the US (see Figure 1), the prac-
tice community is in a dynamic phase of  establishing stan-
dards and norms.  A significant area of  concern for many 
HIA practitioners is the importance of  stakeholder partici-
pation for fostering health equity, defined as “attainment 
of  the highest level of  health for all people” in the federal 
government’s Healthy People 2020 benchmarking program 
(Office of  Disease Prevention and Health Promotion, n.d.).  
Public health practitioners adopting HIA in an effort to in-
fluence policy and programs in the US have cited the values 
of  the Gothenburg Consensus (European Centre for Health 
Policy, 1999) – democracy, equity, sustainable development, 
ethical use of  evidence, and a comprehensive approach to 
health – as guiding principles.  Yet there has been little criti-
cal evaluation of  whether HIAs routinely support democ-
racy, which is defined in the Gothenburg document as “the 
right of  people to participate in a transparent process for the 



10

1  While NEPA’s implementation varies across federal agencies, public input generally comes in the form of  comments submitted to and then rebutted by 
the federal agency (or their consultants).  
2 Glucker et al. (2013) discuss the challenges of  defining participation within EIA while Mahoney et al (2007) suggest the lack of  rigor and clarity in defin-
ing “community participation” is a significant barrier to understanding its appropriate role in HIA.

formulation, implementation, and evaluation of  policies that 
affect their life, both directly and through the elected politi-
cal decision makers.”   

Figure 1. Since the completion of  the first US HIA by the San 
Francisco Department of  Public Health in 1999, the use of  HIA 
has rapidly increased.  

Sources: Bourcier, Charbonneau, Cahill, & Dannenberg (2015); Health 
Impact Project (2016); Rhodus, Fulk, Autrey, O’Shea, & Roth (2013).

The practical challenges of  engaging stakeholders (the 
time and resources necessary to build trust and capacity) 
coexist with aspirational notions of  social change through 
direct participation; yet the choice of  engagement strategies 
in a given HIA are often driven by expediency (Heller, Male-
kafzali, Todman, & Wier, 2013) and resource limitations.  In 
reality, many HIAs use engagement strategies that follow a 
stakeholder engagement paradigm – inviting diverse interests 
to deliberate together – rather than direct participation that 
“centers the margins” by foregrounding the experience and 
leadership of  directly affected and historically marginalized 
groups.  So while the value of  democracy explicitly adopted 
by HIA practitioners has generally been interpreted to mean 
facilitating engagement in decision-making through direct 
participation of  affected parties (Baker et al., 2012; Kemm, 
2005), the US experience to date does not provide clear evi-
dence this relationship is operational (Iroz-Elardo, 2014a).   

We aim to enrich the conversation about democracy and 
equity by exploring participation (i.e., how HIA practitioners 
operationalize democracy) and health equity impacts of  
HIAs in the context of  the relatively diverse practice on the 
west coast of  the US. Our analysis shows the dominance of  
a stakeholder engagement paradigm for participation despite 
a wide range of  engagement strategies (i.e., ways of  partici-
pating).  Further, we demonstrate that HIAs which entail 
little direct participation are still able to foster social learning 
(Bandura, 1977) – the generation of  new knowledge through 
intergroup interaction - that directly contribute to advanc-
ing health equity through moral development and improved 
policy decisions. Consequently, we argue that the emphasis 

on direct participation may be unnecessary to, and may even 
in some cases detract from, realizing other HIA values such 
as equity.  Applying these perspectives to HIA practice, we 
suggest that practitioners expand our conception of  path-
ways to equity and more clearly articulate our visions for 
advancing health equity, given the diversity of  participation 
paradigms and engagement strategies employed in the field.

Background
Concern for health equity is a distinguishing characteristic 
of  HIA (Harris-Roxas & Harris, 2011) and the connection 
between democracy and equity comes from the notion, as 
articulated by the World Health Organization (n.d.), that 
“to be effective and sustainable, interventions that aim to 
redress inequities must typically go beyond remedying a 
particular health inequality and also help empower the group 
in question.”  Current Adopted Minimum Elements for HIA 
(Bhatia et al., 2014) also establish that HIAs should involve 
and engage “stakeholders affected by the proposal, particu-
larly vulnerable populations.”  This operationalizes the value 
of  democracy and shows how HIA anticipates a higher level 
of  participation than generally occurs under the environ-
mental impact assessment (EIA) procedures conducted 
under the U.S. federal National Environmental Protection 
Act (NEPA).1    

Many leading US HIA practitioners (e.g., Heller et al., 
2013) interpret the equity value as a call to use the HIA 
process to empower historically disadvantaged populations 
through the decision-making process, as mapped in Figure 2.  
This interpretation suggests that HIAs should privilege par-
ticipatory strategies that shift power to citizens most likely to 
be affected by the target decision, lifting up voices that have 
not been heard in previous decades of  decision-making.

Figure 2: Presumed pathway from participation to health equity

Participation, which is generally understood as the 
mechanics or expression of  democracy, is universally seen 
as desirable but can be difficult to define (Glucker, Dries-
sen, Kolhoff, & Runhaar, 2013; Mahoney, Potter, & Marsh, 
2007).2 Engagement strategies is a term for the techniques used 
by a facilitator (in this case, the HIA practitioner) to solicit 
information from participants.   Some engagement strategies 
provide more power and control over the analytical process 
than others; thus the engagement strategies shape the type 
of  participation – or democracy – that occurs within an 
HIA.  Accordingly, we use the term participation to signify 

Social learning Iroz-Elardo; McGrath



11

general involvement in an HIA and participatory to describe 
the use of  engagement strategies that provide more direct 
roles for and control by affected community members, such 
as collecting data and making decisions.  

We distinguish two paradigms for participation: direct 
participation and stakeholder engagement.  Where pos-
sible, these terms are qualified with descriptors that signify 
who is participating.  For example, we distinguish between a 
directly affected community (understood as a smaller subset of  
people, often members of  socially marginalized groups, who 
stand to bear the likely negative impacts of  a decision) and 
stakeholders more generally, which would include the directly 
affected community alongside other parties with a vested 
interest in the outcome (e.g., businesses, landowners, neigh-
boring communities) (Kahane, Loptson, Herriman, & Har-
dy, 2013).  Depending on the type of  engagement strategies 
used, participation can be bureaucratic (e.g., commenting on 
administrative documents) or participatory (e.g., conducting 
the assessment and interpreting the results).  These distinc-
tions are illustrated by the schematic in Figure 3.

Figure 3: Conceptual framework

Relationships among participation, democracy, and 
equity
At least four rationales for citizen participation are found 
within scholarly literature.  First, philosophers argue that citi-
zen participation is intrinsically valuable because it develops 
human capacity (à la Aristotle) and forces individuals to be 
socially responsible for the collective well-being (per Rous-
seau and Mill) (Day, 1997).  Another argument is that citizen 
participation in public decisions develops a more responsive 
government because citizen needs are more likely to be 
articulated well and early; urban planning theorists suggest 
that such participation is more likely to accurately identify 
the public interest and minimize implementation delays 
(Day, 1997).   Others view participation as a means for those 
without power to exercise strength and change the social 
order (Arnstein, 1969/2005).  Specific to impact assessment, 
Glucker and colleagues (2013) suggest that the various ratio-
nales classify participation as normatively desirable, substantive 
in terms of  gathering information, or instrumental in reducing 
conflict or generating legitimacy.  

The prevailing consensus in contemporary urban plan-
ning theory (Forester, 1999; Healey, 1996/2003; Innes & 
Booher, 2010) points toward collaborative, deliberative par-
ticipation processes – i.e., stakeholder engagement – as the 
way to pursue these rationales.  This consensus has arisen as 
a result of  the “communicative turn” in planning, which is 

based on the idea that participation should incorporate 
direct identification of  interests “under conditions of  ratio-
nal deliberation and choice (Connolly) . . . [and] relative per-
sonal autonomy (Lukes)” – a decidedly more social approach 
to participation (Taylor, 1998, p. 68).   Yet in HIA practice, 
democracy has generally been understood to suggest direct 
participation, reflecting the normative value within public 
health that views community engagement, organizing, and 
empowerment as essential in promoting individual and com-
munity health (Kemm, 2013).  

In the context of  HIA, equity is generally understood to 
mean reducing health inequities, or disparate and avoidable 
health burdens among social groups. In the US, these group-
ings are often based on racialized categories and socioeco-
nomic status. Mechanisms for reducing health inequities 
include preventing the implementation of  policies that will 
produce disparate burdens (Minkler, Wallerstein, & Wilson, 
2008) as well as broader deliberation over “social construc-
tionist or structuralist” understandings of  health inequity 
through the HIA process (Harris-Roxas et al., 2012). 

Operating practices in U.S. HIA
Consequently, direct participation and participatory engage-
ment strategies are highly prized in US HIA practice.  For 
example, a recent white paper by prominent innovators in 
the field (Heller et al., 2013) outlines eight principles for 
promoting equity in HIA practice, the first two of  which 
emphasize direct participation and participatory engagement 
strategies (see Table 1).  The operating assumption seems to 
be that adherence to democracy necessitates direct partici-
pation, which leads to empowerment of  members of  the 
most affected community, which in turn leads to equity gains 
when these empowered community members pursue their 
interests in the policy arena (as diagrammed in Figure 2).

Table 1: Strategies for promoting equity in HIA (from Heller et al., 
2013)
A. Ensure community leadership, ownership, oversight, and par-

ticipation early and throughout an HIA
B. Support authentic participation of  vulnerable populations in 

the decision-making process
C. Target the practice of  HIA towards proposals that are identi-

fied by, or relevant to, vulnerable populations
D. Ensure that a central goal of  the HIA is to identify and under-

stand the health implications for populations most vulnerable
E. Ensure the HIA assesses the distribution of  health impacts 

across populations wherever data are available
F. Identify recommendations that yield an equitable distribution 

of  health benefits
G. Ensure that findings and recommendations of  the HIA are 

well communicated to vulnerable populations most likely to be 
impacted

H. Ensure that the actual impacts of  the decision are monitored

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12

However, just as different types of  HIAs are appropriate 
to different decision-making contexts, certain participation 
paradigms and engagement strategies may align with differ-
ent HIA types.  Harris-Roxas and Harris’ (2011) typology of  
HIAs is especially valuable as we interrogate the role of  par-
ticipation in realizing HIA values.  They argue that engage-
ment strategies generally match the purpose of  the HIA, as 
summarized in Table 2.

Table 2: HIA typology and typical participation format
HIA type Purpose Participation
Mandated meet statutory 

requirement
limited - consultants 
may do outreach

Voluntary 
decision-
support

minimize health harms 
and maximize health 
benefits

stakeholder engage-
ment, generally 
with bureaucratic 
engagement strategies

Advocacy promote group values 
to decision-making 
body

direct participation, 
often with bureaucratic 
engagement strategies

Community-
led

increase community 
power through 
participating in an HIA 
that bring health con-
cerns into a decision-
making process

direct participation, 
with participatory 
engagement strategies

A rigid interpretation of  their typology might suggest that 
it is difficult to achieve health equity through less participa-
tory HIAs.  Further, the extent of  deliberation and/or stake-
holder power and control in HIA practice overall are unclear 
(UCLA School of  Public Health, 2014), particularly since 
these aspects of  the process are not always well documented 
in HIA reports.   For example, only a small proportion of  
HIAs – 18.5 percent in a recent study by the U.S. Environ-
mental Protection Agency (Rhodus, Fulk, Autrey, O’Shea, 
& Roth, 2013) – robustly engage stakeholders through an 
advisory committee.  Further, the same study also found that 
only one-quarter of  stakeholder advisory committees “actu-
ally oversaw or guided the HIA process and were engaged as 
decision-makers in equal partnership with the HIA team or 
as the primary decision-makers” (Rhodus et al., 2013).   

One potential explanation for the shortcomings in direct 
participation in US HIAs is that participatory processes are 
difficult to sustain.  Stakeholder engagement has become 
the alternative to direct participation in the urban planning 
world because it ostensibly is efficient at surfacing a variety 
interests with minimal resources invested.  While advisory 
committees may be considered “second-best” to direct 
ownership of  an assessment or decision-making process, 
they are a pragmatic and heavily used engagement strategy.   
Thus, understanding their capacity to further health equity is 
critical for advancing HIA practice. 

Methods/approach
This paper analyzes 12 recent HIAs from the US west 
coast in terms of  HIA purpose, participation paradigm, 
engagement strategies, and health equity outcomes.  We 
use this diverse, geographically bounded subset to elu-
cidate how the participation paradigm of  a given HIA 
affects its contributions to health equity, with the purpose 
of  informing the challenging and resource-intensive fulfill-
ment of  HIA’s democracy value. This analysis extends 
Iroz-Elardo’s (2014b) study of  three3 comprehensive HIAs 
that varied in general nature, specific objectives and goals, 
and scale of  the project. In the present paper, those cases 
are augmented by three comprehensive HIAs completed 
by Oregon Health Authority (OHA) and five rapid HIAs 
conducted in Oregon by county health departments with 
OHA pass-through funding from the Centers for Dis-
ease Control and Prevention. The comprehensive OHA 
HIAs related to climate planning; the first author was the 
technical lead for two (Iroz-Elardo, Hamberg, Main, Early-
Alberts, & Douglas, 2014; Iroz-Elardo, Hamberg, Main, 
Haggerty et al., 2014).  The rapid HIAs addressed a variety 
of  locally identified issues. 

For each case, we identified HIA type, participation 
paradigm, and engagement strategies.  We analyzed how 
democracy and equity were understood by the project 
participants – as represented in project documents and 
our personal knowledge of  the HIA.  We also interviewed 
a former HIA Program Coordinator at Oregon Health 
Authority on two different occasions, asking her to discuss 
the 15 different HIAs (five of  which are mentioned below) 
that were initiated at the county level between 2009-2015.   
For this paper, we paid particular attention to including 
discrepant cases, or situations where the HIA produced 
unexpected results, following the qualitative research tradi-
tion (Maxwell, 2005) that seeks to explicate phenomena 
through exploring perceived outliers. An overview of  the 
study cases is presented in Table 3.

This sample represents a wide breadth of  participation 
paradigms and engagement strategies as well as a large 
proportion of  HIAs completed on the US west coast, 
where the presence of  early adopters and training patterns 
resulted in a spatially clustered and regionally distinct HIA 
practice.  We selected only cases with which we had suf-
ficient information to comment on the analytical processes 
that are not always captured in HIA reports.  The sample 
includes no fully community-led HIAs, as we are not aware 
of  any such projects taking place during our study period.  
Our interpretation of  the data occurs through the lens of  
our personal experiences in many different roles within the 
professional community we are discussing.  For the past 
five years or so, both authors have been active participants 
in the HIA community – within Portland, Oregon, as well 
as at the regional and national levels.  The first author of  
this paper conducted dissertation research on HIA (Iroz-
Elardo, 2014a, 2014b), teaches graduate-level HIA courses, 

3  One of  the three in-depth HIA evaluations looked at a two-part project, presented as two HIAs in the table accompanying this article.

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13

and is an HIA practitioner.  The second author developed a 
graduate-level HIA course and worked for five years as an 
HIA analyst at a large urban health department where she 
collaborated on HIAs and other “HIA-inspired” analyses 
(Clapp & McGrath, 2012; McGrath, Clapp, Maher, Ox-
man, & Manhas, 2013; McGrath & Lyons-Eubanks, 2011; 

White & McGrath, 2012).  Both have served on steering 
committees, planning committees, and workgroups for the 
Northwest Regional HIA Network, HIA of  the Americas, 
and Society of  Practitioners of  Health Impact Assessment.  
These experiences both enrich and bias our interpretation 
of  the information presented in this paper.

Table 3: Overview of  cases
Project Lead organization HIA type Participation paradigm Engagement strategies 
Clark County Bike/Ped Plan HIAs Clark County Public Health (WA)

Rapid HIA: Clark County Bicycle 
and Pedestrian Master Plan (Hag-
gerty, 2010)

Decision-
support

None None

Comprehensive HIA: Clark 
County Bicycle and Pedestrian 
Master Plan (Haggerty, et al., 
2010)

Decision-
support

Stakeholder engagement Consulted existing target plan’s 
advisory group

Climate HIAs Oregon Health Authority
Climate Smart Communities Sce-
narios (Green, et al., 2013)

Decision-
support

Stakeholder engagement Several large (37-person) meetings

Community Climate Choices 
(Iroz-Elardo, Hamberg, Main, 
Early-Alberts, et al., 2014)

Decision-
support

Stakeholder engagement Several large meetings augmented 
by small topic meetings

Climate Smart Strategy (Iroz-
Elardo, Hamberg, Main, Hag-
gerty, et al., 2014)

Decision-
support

Stakeholder engagement Several large meetings augmented 
by small topic meetings

County HIAs – funded by Oregon Health Authority
Augusta Lane Bike-Pedestrian 
Bridge (Washington County Pub-
lic Health Division, 2014)

Washington County Decision-
support

Stakeholder engagement 
with selected direct partici-
pation activities

Public meetings, partnering with 
culturally-specific organizations

Barrett Park (Mejia, 2011) Hood River County Decision-
support

Stakeholder engagement Public meetings, partnering with 
culturally-specific organizations

Tumalo Community Plan (Madri-
gal & Wells, 2010)

Deschutes County Decision-
support

Stakeholder engagement Informal outreach to stakeholders

McLoughlin Blvd. Road Safety 
Audit (White & Thorstenson, 
2014)

Clackamas County/
Oregon Public 
Health Institute

Decision-
support

Stakeholder engagement Informal outreach to stakeholders 
including joint data collection

Housing Supply Upgrade Initia-
tive (Klinefelter, 2013)

Curry County Decision-
support

Stakeholder engagement 
with selected direct partici-
pation activities

Consulted advisory group created 
for different purposes, conducted 
interviews with directly affected 
community

I-710 Corridor (Human Impact 
Partners, 2011)

Human Impact 
Partners

Mandated Stakeholder engagement External technical experts on ad-
visory committee; HIA author not 
in control of  advisory committee 
composition

Lake Merritt BART Station Area 
Plan (Harris, Purciel-Hill, Gilhuly, 
& Babka, 2012)

Human Impact 
Partners

Advocacy Stakeholder engagement 
with strong leadership by 
directly affected popula-
tions

Participatory in that CBO con-
trolled most aspects of  HIA

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14

Cases
Overall, we found that the participatory nature, robust 
community outreach, and significant community control 
seen in some early HIAs (e.g., the Eastern Neighborhoods 
Community HIA in San Francisco, as discussed in Corburn, 
2009) is an exception rather than a rule.  As illustrated in the 
vignettes below, the HIAs provided limited opportunities for 
citizens to directly participate in the assessments or target 
decisions, and in only one HIA did community representa-
tives control the scope and content of  the HIA.  Engage-
ment strategies varied widely, including: a community-led 
advisory committee that had control over nearly every 
decision in the HIA (Lake Merritt); consulting stakeholder 
groups established as part of  the targeted planning decisions 
rather than creation of  their own advisory committee (Clark 
County, Curry County); a highly technical stakeholder advi-
sory committee of  which the HIA facilitator had little con-
trol (I-710 Corridor); and ad hoc informal outreach (multiple 
county health department HIAs).  A small number of  HIAs 
engaged non-English speaking communities directly, using a 
public meeting format and partnering with other organiza-
tions well positioned to engage such communities (Washing-
ton and Hood River counties), and one HIA used interviews 
with residents to collect data (Curry County).  We present 
these cases below, in the groupings described above, discuss-
ing relationships between participation and health equity.

Clark County, Washington Bicycle-Pedestrian HIAs
In early 2009 in response to a state mandate, Clark County, 
Washington initiated an update of  its Bicycle and Pedestrian 
Master Plan governing unincorporated areas (Clark County 
Community Planning, 2010).  Planning in this quickly subur-
banizing community is challenging due to relatively conser-
vative social ideology combined with large geographic gaps 
in municipal services. Clark County planners were pleased to 
partner with Clark County Public Health in support of  the 
Bike-Ped Plan in 2010.  Public Health professionals first per-
formed a rapid HIA (Haggerty, 2010) to provide input on 
the concept plan; this was followed by a full HIA with more 
detailed analysis of  impacts and greater stakeholder input 
(Haggerty, Melnick, Hyde, & Lebowsky, 2010).  While this 
HIA did not maintain a separate community or stakeholder 
engagement strategy, it was able to influence the stakeholder 
engagement process of  the larger plan, primarily through 
the technical contributions of  the HIA’s lead author, who 
used his knowledge of  the active transportation literature to 
advocate for the equity advances.

The rapid HIA was produced on a short timeline with 
no input from potentially affected parties.  However, the 
document was shared with Clark County planning staff  and 
the plan’s Bike-Ped Advisory Committee – the membership 
of  which was split between government bureaucrats and 
“self-selected and old-school, mainly male, Caucasian, older” 
residents who initially focused on recreational cycling.   The 
rapid HIA sparked a social learning (Bandura, 1977) process, 

where the Bike-Ped Advisory Committee and county plan-
ning staff  showed increased awareness of  how the general 
public experienced active transportation and the health 
equity implications of  bike and pedestrian infrastructure.  
These perspectives were integrated into the comprehensive 
HIA.  Comparison of  the final Plan with the preliminary 
Plan shows broader consideration of  all road and path users 
(e.g., utilitarian cyclists and pedestrians, groups more likely 
to be living in poverty, recent immigrants, children and older 
adults, and people with disabilities).  

The final Plan prioritized access to health-supporting re-
sources such as healthy food and addressed concerns about 
dangers to children using active transportation by empha-
sizing the health benefits.  The most tangible evidence of  
HIA effectiveness was the incorporation of  20 public health 
points in a 100-point scoring criteria used to select locations 
to add sidewalks.  The points system identified areas were 
walking rates could be increased and where amenities would 
benefit residents of  lower socioeconomic status.

Oregon Health Authority Climate HIAs
The climate HIAs conducted by the Oregon Health Author-
ity (OHA) were a suite of  decision-support HIAs completed 
as part of  a climate planning process convened by Metro 
– Portland, Oregon’s metropolitan planning organization.  
A response to a state legislative mandate, the HIAs were 
named the Climate Smart Communities Scenarios HIA 
(April 2013), the Community Climate Choices HIA (March 
2014), and the Climate Smart Strategy HIA (September 
2014).  To account for social co-benefits of  climate action 
planning, the HIAs used the quantitative Integrated Trans-
port Health Impact Model (Centre for Diet and Activity 
Research, 2013) to analyze pathways between transportation 
and health impacts. The model was refined with the input of  
a 37-person stakeholder advisory committee made up largely 
of  public employees, supplemented with a few academics, 
a couple of  HIA practitioners from the local non-profit 
sector, and several elected officials from the region; notably, 
there was no direct community representation.  An OHA 
HIA Program staff  member convened the committee, on 
average, twice per HIA – generally for scoping and to review 
the results of  the analysis.  Topic-specific subcommittees 
met for work sessions on a few occasions, a handful of  
advisory members served as peer reviewers of  HIA report 
drafts, and all committee members evaluated the HIA pro-
cess and the report recommendations via online surveys. 

The work sessions – which arose when some stakeholders 
had serious reservations about the analytical strategy – cre-
ated a venue for social learning.  Largely attended by a sub-
set of  members most interested in the topic at hand, these 
meetings brought together members from different agencies 
and sectors.  This helped improve understanding of  vari-
ous agencies’ needs and responsibilities as well as different 
stakeholders’ health equity concerns, fostering intersectoral 
understanding through interpersonal interaction.  These 

Social learning Iroz-Elardo; McGrath



15

4 Funded by the Centers for Disease Control and Prevention’s National Center for Environmental Health Community Design Initiative.
5 Oregon Solutions (http://orsolutions.org) is a statewide program that offers facilitation services to convene multiparty problem-solving collaboratives 
addressing complex sustainability issues.

conversations and relationships proved transformative for 
some; for example, an agency staffer reported a transition 
within her agency in thinking about how health intersects 
with their regulatory approach to air quality.  These fledgling 
relationships led to the formation of  the Transportation 
and Health Subcommittee of  the Oregon Modeling Steer-
ing Committee, institutionalizing consideration of  environ-
mental justice and health equity by the state’s transportation 
modeling community.

Oregon Health Authority HIA Program-funded HIAs – 
“county HIAs”
Starting in 2009, the Oregon Health Authority’s Public 
Health Division provided mini-grants4 to county health 
departments in an effort to increase local HIA capacity; 
fifteen rapid HIAs in eleven different counties were com-
pleted.  Because local governments author them and public 
employees cannot engage in political advocacy, these HIAs 
were by necessity decision-support HIAs.  The small dollar 
value of  the grants ($10,000-15,000) also limited the extent 
of  possible engagement strategies.  However, OHA required 
that grantees invite stakeholders to scoping training sessions 
and encouraged ongoing involvement through the assess-
ment and recommendation stage.  Most grantees chose a 
stakeholder engagement paradigm and used bureaucratic 
engagement strategies – literally inviting representatives of  
government bureaus to comment on their work.  For ex-
ample, the McLoughlin Blvd. Road Safety Audit HIA (White 
& Thorstenson, 2014) convened representatives of  public 
health, planning, state and local departments of  transporta-
tion, and a neighborhood organization.  They then added a 
one-day evaluation of  social determinants of  health metrics 
to a traditional road safety audit (Federal Highway Adminis-
tration, n.d.) along the roadway corridor.  In Curry County, 
the health department took the approach of  Clark County, 
WA (above) and worked closely in parallel with an Oregon 
Solutions5 project that was engaging local, state (Oregon 
Housing), and federal (HUD) stakeholders and decision-
makers.

Other counties recognized a need for direct participation 
by citizens who might be affected by the local decisions. For 
example, Deschutes County asked citizens in a public meet-
ing for the Tumalo Community Plan to draw what a healthy, 
happy community would look like.  This information led 
to an HIA that focused on “sense of  place” in addition 
to physical activity and traffic safety in the rural context.  
Counties that directly engaged members of  vulnerable 
populations conducted limited, but effective, outreach by 
partnering closely with community-based organization, par-
ticularly when trying to reach linguistically isolated popula-
tions.  For example, leaders of  Hood River County’s Barrett 
Park HIA subcontracted with a Latino-focused organization 

to host listening sessions associated with their HIA.  Similar-
ly, the Center for Intercultural Organizing helped to engage 
the geographic community most affected by the proposed 
Augusta Lane Bridge in Washington County. 

These strategies led to HIAs that produced health equity 
benefits by advancing the needs of  vulnerable populations.  
For example, Washington County’s targeted public meet-
ings helped the HIA authors advocate for the Augusta Lane 
Bridge, with its the obvious health benefits of  connecting a 
spatially isolated area to health-promoting resources such as 
an elementary school, two transit lines, and a green space in 
the face of  concerns about interpersonal safety for children 
walking to school.  

The Curry County HIA (Klinefelter, 2013), which ad-
dressed state funding rules about repair and replacement 
of  manufactured housing, eschewed an advisory committee 
in favor of  small contracts with one topic area expert and 
one HIA expert.  The HIA author also worked closely with 
housing inspectors to gain entrance to sub-standard housing 
units, where she was able to interview residents and observe 
housing environments. 

  
Interstate 710 Corridor expansion
In California, the I-710 Corridor HIA was initiated with sig-
nificant support from a coalition of  local, community-based, 
environmental justice organizations.  Approximately 40 
percent of  US imports travel this highway, which connects 
the ports of  Long Beach and Los Angeles to the greater Los 
Angeles region.  A proposed expansion would increase the 
freeway from eight to up to 14 lanes.  The coalition success-
fully lobbied the California Department of  Transportation 
(Caltrans) for an HIA to be integrated into the environmen-
tal impact assessment (EIR) process.  

Though the HIA was community-initiated, the scale of  
the planning process and the politics and funding structure 
of  the EIR resulted in the HIA being produced with very 
little input from affected communities.  Additionally, the 
HIA report was unavailable for many months, and then was 
only released as a “work-product” separate from the Draft 
Environmental Impact Review (DEIR) report. This tactic 
by expansion advocates prevented the HIA from obtaining 
the same legally binding status as EIR documents produced 
under state and federal statute.  Even though area residents 
had limited involvement while the HIA was being written, 
the report still reflects residents’ concerns; the scope ad-
dressed health concerns beyond typical EIR pathways of  air 
pollution and noise.  HIA findings appear prominently in 
public comments, suggesting that area residents and advo-
cacy organizations have found the report to be a useful tool 
to advocate for health equity despite the publication delays.  
Further, the Coalition for Environmental Health and Justice 
used the HIA to bolster their legal assertion that the DEIR 

Social learning Iroz-Elardo; McGrath



16

is inadequate. The EPA also cited the HIA as a factor in 
their recommendation that Caltrans reject the DEIR/EIS.  
As a result, Caltrans has instructed that the plan and DEIR 
be reworked to incorporate elements of  a community-de-
fined alternative plan.

Lake Merritt BART
The Lake Merritt HIA was initiated and controlled by six 
allied advocacy organizations highly committed to social 
justice in the Oakland Chinatown community. The case, an 
exemplar of  advocacy HIA practice, illustrates how a robust 
stakeholder advisory committee with complete control over 
HIA decisions can pursue community interests, even in a 
planning process where significant competing cultural and 
economic interests were present. This case also illustrates 
how social learning can happen with small advisory commit-
tees from diverse advocacy backgrounds.  

The scoping phase of  the HIA took much longer than 
expected or budgeted because each organization was ac-
customed to advocating for social justice in vastly different 
arenas: housing, health services, policy work, transporta-
tion, and environmental justice.  The group identified health 
equity as an expression of  social justice, a shared value, and 
used the social determinants of  health as a common lan-
guage to understand each other’s interests.  Some stakehold-
ers expressed dismay that the HIA did not facilitate more 
data collection or community organizing yet the final HIA 
makes a clear case for protecting the current community’s 
concerns, protecting open space, and adopting affordable 
housing strategies to prevent gentrification.

Discussion
The state of  HIA practice on the US west coast shows that 
direct participation does not have a one-to-one relationship 
with health equity and that stakeholder engagement can lead 
to health equity gains through social learning.  As illustrated 
in the cases above, we found that different types of  HIAs 
advanced health equity despite variation in participation 
paradigms and engagement strategies.  Our three main find-
ings about the current state of  democracy and equity in this 
practice are: 
•	 Stakeholder engagement predominates as a participa-

tion paradigm, and community-led or -initiated HIAs 
are few; direct community participation does not auto-
matically lead to empowerment and equity.

•	 Stakeholder engagement and technical decision-making 
by public health professionals can be successful in 
advancing health equity.

•	 Equity advances can be achieved through social learn-
ing that identifies ways to narrow gaps in health-sup-
porting resources among population groups.

Taken together, these findings suggest an expanded view 
of  pathways between participation and equity in HIA. 

Revisiting direct participation
Despite HIA practitioners’ widespread desire to use par-
ticipatory methods to directly engage and empower citizens 
in vulnerable communities, it is difficult to find such strate-
gies in broad use in HIA practice.  HIAs, particularly those 
initiated and/or authored by government agencies, gener-
ally adopt a stakeholder participation paradigm with some 
variation in engagement strategies. Despite the lack of  direct 
participation and participatory engagement strategies, these 
decision-supported HIAs show evidence of  gains in health 
equity. It appears that social learning fostered by multi-party 
collaboration assists bureaucratic decision-making which 
supports narrowing health disparities.

A major strength of  HIA is its capacity to assemble 
and frame a broad array of  perspectives on health; yet the 
mechanics of  participation in the HIA process are chal-
lenged by the very diversity of  knowledge, data, interests, 
and languages held by various stakeholders (Glucker et al., 
2013).  Finding common ground between these stakehold-
ers can be generally difficult to impossible (Negev, 2012).   
However, HIA stakeholder advisory committees of  all sizes 
are potentially democratizing in a number of  ways: identify-
ing new health-related information; providing an additional 
participation opportunity for community representatives to 
engage the process; supporting the growth of  interdisciplin-
ary relationships; and influencing public decisions (Negev, 
2012). 

While many HIAs encourage social learning, the I-710 
Corridor HIA is a very interesting example where empow-
erment and even social learning were prevented in the HIA 
process, despite the strenuous advocacy for the HIA by 
seasoned local activists.  While community groups whose 
constituencies would be affected by the port expansion 
successfully advocated for an HIA with the I-710 Project 
Committee, that same committee delegated the completion 
of  the HIA to another governing body under a completely 
separate plan.  This was done to save resources. However, 
the shift of  oversight resulted in a loss of  control and be-
came a barrier to community input.

For example, the contrast between the Lake Merritt and 
I-710 cases demonstrate the variety of  outcomes that may 
result from HIAs that strive for direct participation.  The 
Lake Merritt BART HIA clearly shows that community rep-
resentatives – distinct from members of  the general public 
– can control the HIA via an advisory committee, leading 
to a community-centered report and recommendations.  Yet 
the I-710 case – an HIA requested by activist citizens and 
community representatives, but then carried out in large part 
divorced from those who requested it – suggests that initial 
community control of  the HIA process does not neatly 
equate to empowerment or health equity.  The decision-sup-
port HIAs show that stakeholder engagement can support 
health equity even in the case of  limited use of  participa-
tory engagement strategies. Consistent with greater planning 

Social learning Iroz-Elardo; McGrath



17

theory, stakeholder engagement in HIA elevates the impor-
tance of  health in policy decisions as a result of  deliberation 
among stakeholders.  

Less dramatic examples of  this phenomenon include the 
Hood River and Washington County HIAs. In Hood River 
County, engaging the Latino community was a response to 
professional knowledge that Latinos had the least park ac-
cess in the region.  The engagement helped ground the HIA 
in community concerns.  It also offered a population, many 
undocumented with few official rights to democracy in the 
US, a way to participate in public decisions.  However, en-
gaging the Latino community did not result in a power shift; 
the community did not control the HIA analysis.  A similar 
assessment can be made of  Washington County’s direct 
engagement of  citizens who live near the proposed Augusta 
Lane Bridge.  This suggests direct engagement in the form 
of  one or two public meetings dovetails with a broader 
stakeholder engagement paradigm in HIA by providing 
additional information to HIA authors.  However, public 
meetings are not enough to shift control of  the HIA, much 
less the target plan, to the community. 

Bureaucratic decision-making can contribute to health 
equity
Finally, HIAs can foster health equity by expanding the 
issues considered in the decision.  Use of  a broad, com-
prehensive definition of  determinants of  health expanded 
the interests considered in the Clark County Bike-Ped and 
McLoughlin Road Safety cases.  HIA can be used to more 
fully understand plans and policies with multiple and often 
inadvertent disparate impacts. For example, in Curry County, 
Oregon, housing policies were preventing low-wealth 
households from improving their housing due to restrictions 
placed on financing manufactured housing; the HIA advo-
cated for a more healthy approach to managing this impor-
tant contribution of  affordable housing stock in the region.  
Many of  the health equity gains from HIAs can be linked 
to the role that professional knowledge and discretion of  
HIA practitioners played in pursuing equitable impacts.  The 
six-step process and core values of  HIA explicitly require 
analysis of  the disproportionately impacted populations and 
vulnerable populations.  This prompts HIA practitioners to 
actively seek information that will elucidate potential dispa-
rate even if  there is no opportunity to collect new primary 
data about the affected populations.  As professionals, indi-
vidual actors can articulate health equity concerns through 
spatial analysis, focus on vulnerable populations, and use 
the social determinants of  health to expand the concerns 
considered under the target plan. 

Social learning creates pathways to health equity
While intersectoral collaboration has long been viewed as a 
benefit of  HIA (Corburn & Bhatia, 2007), our analysis of  
participation connects this collaboration more directly to 
health equity by theorizing that social learning provides the 
pathway for achieving equity. The value of  social 

learning, understood as a process of  “cognitive enhance-
ment” and “moral development” (Bandura, 1977) has long 
been recognized by theorists of  negotiation and urban plan-
ning (Forester, 1999; Healey, 1996/2003; Innes & Booher, 
2010), and social learning has been a documented outcome 
of  engagement strategies in impact assessment projects (We-
bler, Kastenholz, & Renn, 1995). 

The present findings demonstrate that cognitive enhance-
ment – learning about the problem and solutions from both 
your own and other’s perspectives – occurs across HIAs 
with a broad range of  participation methods and strategies.  
Under the stakeholder engagement paradigm, interdisciplin-
ary learning occurs as members of  cities or regions health 
and planning departments serve on an advisory committee 
and realize the complementary skill sets of  their depart-
ments.  In the Bike-Ped Plan HIA, public health was able to 
articulate why urban planners should consider and include 
access to health-promoting resources within an active 
transportation plan.   As an example from an advocacy HIA, 
cognitive enhancement occurred in the Lake Merritt HIA 
when the six community-based organization representa-
tives extended the scoping phase to better understand how 
their individual advocacy positions fit with the HIA.  In the 
McLoughlin Road Safety HIA, discussion of  social deter-
minants of  health allowed public health professionals to 
explain to transportation engineers why an engineering solu-
tion did not fully protect, much less maximize, health.

While cognitive enhancement results in better under-
standing of  a problem, moral development is the process of  
moving toward a more collective approach to problem-solv-
ing by setting aside one’s narrow personal (or agency) inter-
ests.   The OHA climate HIA illustrate moral development 
as sister agencies (Oregon Health Authority and the Oregon 
Department of  Environmental Quality, or DEQ) moved 
from initial antipathy to shared understanding; OHA’s choice 
of  transportation-related air pollution indicators shifted 
how the DEQ conceptualized the health consequences of  
airborne particulate matter. 

Conclusion
The HIA community’s avowal of  equity as a guiding value 
has led to calls for HIA to empower historically disadvan-
taged populations through participation in public decision-
making.  When interpreted narrowly, this conception 
suggests that the ideal HIA is one where disenfranchised 
citizens initiate and control an HIA in order to articulate 
and advance community health interests, thereby increasing 
health equity.   However, a growing body of  evidence shows 
that HIA in the US may not be as participatory or empow-
ering as some practitioners wish it might be.  At the same 
time, the evidence presented here suggests that direct par-
ticipation may not be the only route to realize the democracy 
and equity in HIA. 

While some articulations of  equity in HIA (Heller et al., 
2013) may view less participatory engagement strategies 
as undercutting community power, our findings are 

Social learning Iroz-Elardo; McGrath



18

consonant with broader literature on public engagement.   
For example, Quick and Feldman (2011) distinguish participa-
tion, or increasing the input (or information) for the decision, 
as distinct from inclusion, which increases connections among 
people and issues.  Thus engagement strategies can be highly 
participatory with many citizens providing information but 
do little to expand the ability of  that community to engage 
each other or the decision.  This distinction is important 
to HIA practice because poor or misleading participation 
and engagement quickly becomes tokenism (Arnstein, 
1969/2005) and may 
actually harm the very communities the project hopes to 
engage (Quick & Feldman, 2011).  

In this way, HIA practice today seems reminiscent of  
the era of  advocacy planning (Davidoff, 1965/2003) equity 
planning (Krumholz & Forester, 1990) in US cities through 
the 1960s and 1970s.  Just as advocate planners provided 
technical assistance to groups who had been excluded from 
the “rational planning” process and had little capacity to 
shift power relations, HIA practitioners can provide techni-
cal information about determinants of  health.  This infor-
mation can be incorporated into the dominant decision-
making processes and turned over to affected communities 
to do their own advocacy, creating multiple pathways to 
promote health equity, as represented in the schematic in 
Figure 4.  

Figure 4: Democracy is realized through new pathways between 
participation and equity

However, scholars of  urban planning and social change 
have struggled to understand the complexity of  these rela-
tionships between state agencies, citizen empowerment, and 
equity.  Both advocacy and equity planning have been 
criticized as mechanisms for placating the aggrieved and 
diverting precious energy of  communities with limited 
resources, thereby abetting the status quo (Piven, 1970).   
Avoiding this type of  cooptation of  HIA practice require 
that practitioners articulate participation norms in ways that 
are more concrete than a blanket preference for direct par-
ticipation. Piven’s critique of  participatory planning indeed 
suggests HIA practitioners be open to the idea that generat-
ing technical information to be used in advocacy by affected 
populations could provide benefits which would not occur 
in the same way through an extensive participatory process.  

Just as analytical strategies within HIAs vary given differ-
ent purposes, participation should vary depending on the 
goals of  an HIA (Baker et al., 2012; Harris-Roxas & Harris, 
2011).  Overly rigid definitions of  participation elide the 
contributions made by HIAs that take a different form than 
the archetypal community-led HIA.  This elision is prob-
lematic given the institutional infrastructure that can be built 
through more technocratic decision-support HIAs. 

We suggest that a more complete view of  HIA practice 
incorporates both the value of  direct participation along 
with the contributions of  less participatory HIAs to foster 
health in all policies and health equity.  That is, the democ-
ratizing elements of  HIA are less about participatory data 
gathering or community control of  the HIA and more about 
expanding the publics and health pathways considered in 
public decisions.   We have illuminated multiple pathways to 
pursuing health equity and as a result propose that democ-
racy in HIA practice be a pragmatic mix-and-match process 
of  aligning goals, assessment methods, and participation in 
order to move toward the ultimate goal of  health equity. 

Social learning Iroz-Elardo; McGrath



19

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ACKNOWLEDGEMENTS
The authors are grateful to Andrea Hamberg for generously sharing her time to discuss the history of  the Oregon Health 
Authority HIA Program and to the anonymous reviewers for their critique.

CORRESPONDING AUTHOR
Moriah McSharry McGrath, PhD, MPH, MSUP
School of  Social Sciences
Pacific University
2043 College Way, UC #A165
Forest Grove, OR 97116
moriah@pacificu.edu

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CHIA STAFF
Editor-in-Chief
Cynthia Stone, Richard M. Fairbanks School of  Public Health Indiana University-Purdue University Indianapolis

Journal Manager
Lyndy Kouns, Richard M. Fairbanks School of  Public Health Indiana University-Purdue University Indianapolis

Chronicles of  Health Impact Assessment Vol. 1, No. 1 (2016) DOI: 10.18060/21351
© 2016 Author(s): Iroz-Elardo, N.; McGrath, M.M.
  This work is licensed under a Creative Commons Attribution 4.0 International License.


