Volume 1, Issue 1October 2016

AdvocAcy in HiA: increAsing our effectiveness And relevAnce As
PrActitioners to Address HeAltH, equity, And democrAcy

Abstract:
The role of advocacy in Health Impact Assessment (HIA) is debated among practitioners. Concerns revolve around whether
engaging in advocacy undermines objectivity and credibility. While there is agreement that dissemination of findings and
recommendations is necessary, there is a spectrum of activities that can be undertaken in an HIA, one end of which might be
considered advocacy.

In this Perspective from the Field, We posit that in conducting an HIA, practitioners are choosing to advocate for a set of
causes that may include improved health, decreased inequity, and increased democracy. We come to the table with these values
and the intent to advocate for them. For any HIA to be relevant and effective at advancing these causes in decision-making
contexts, practitioners must use the best available evidence and a range of strategies to communicate evidence to policy audi-
ences, including deliberate tactics with community organizations, decision makers, and others that can aid in addressing power
imbalances. Though we believe that HIA practice cannot reach its full potential without embracing advocacy, practitioners
must make decisions given their context, including local power dynamics as to how far into the advocacy spectrum they ven-
ture in any given HIA.

This paper is geared towards HIA practitioners and others who want to understand the opportunity advocacy provides.
We begin by describing the underlying values of HIA that inspire this perspective, including those in the 1999 Gothenburg
Consensus Paper on HIA (Quigley et al., 2006). After briefly describing concerns HIA practitioners may have with advocacy,
particularly that it undermines the objectivity and credibility of the HIA process, we then discuss common advocacy activities
practitioners might undertake, and ways to address risks these activities may pose. These opportunities to undertake advocacy
include partnering with diverse stakeholders, developing advisory committees, gauging the power and policy context, and
thinking broadly about the best tactics to effectively communicate findings. We conclude with a case study describing how
advocacy was used in the Treatment Instead of Prison HIA in Wisconsin to advance health, equity, and democracy.

PERSPECTIVES FROM THE FIELD

Lili Farhang, MPH; Jonathan C. Heller, PhD

Box 1. Examples of Advocacy Activities within HIA
What is perceived as advocacy varies based on the institutional context
of practitioners. Most commonly, however, advocacy is perceived as how
stakeholders are engaged in the process and in HIA communications
and dissemination. Below we describe activities that may be considered to
be advocacy within HIA.
Stakeholder Participation

Including stakeholders, such as those who have a pre-exist-
ing position on a proposal, in the HIA process
Prioritizing the HIA goals and research questions based on
the interests of stakeholders
Using assessment methods (e.g., Community-based Partici-
patory Research) that are directed by only some stakehold-
ers
Prioritizing recommendations based on the interests of
stakeholders
Giving stakeholders decision-making authority over the
process
Inclusion of impacted populations and communities facing
inequities – who are perceived as having a predetermined
position – in the HIA process
Fostering coalition and consensus building within HIA

Communications and Dissemination
Public release of findings and recommendations
Proactive outreach to highlight and translate findings and
recommendations to decision makers, media, and/or stake-
holders
Responsiveness to informational and educational requests
from decision makers, media, and/or stakeholders
Publicly highlighting and translating evidence via interviews,
letter writing, public testimony, and other activities
Working with stakeholders to build their capacity to use
HIA findings and recommendations in decision making
venues
Direct lobbying of decision makers to encourage support
or opposition of a specific action
Grassroots lobbying of the public to encourage support or
opposition of a specific action

Introduction
The 2014 Minimum Elements and Practice Standards for Health
Impact Assessment open by describing the goal of HIA:
“Health Impact Assessment (HIA) is a practice that aims
to protect and promote health and to reduce inequities in
health during a decision-making process” (Bhatia et al.,
2014, p. 1). As practitioners
seeking to accomplish this goal,
we recognize that use of sound
science is necessary. We also
recognize that it is not sufficient;
in our perspective, advocacy is
also necessary.

Advocacy is defined by
Merriam-Webster as “the act or
process of supporting a cause or
proposal” (Retrieved 2015, from
http://www.merriam-webster.
com/dictionary/advocacy) and a
variety of activities within HIA
can be judged as advocacy [see
Box 1]. Advocacy may be seen
as the involvement of stake-
holders with a pre-determined
position in the HIA and giving
them control over aspects of
the HIA. Communications and
dissemination activities are also
often characterized as advocacy,
most often when the HIA is
used to influence the outcomes
of a decision, for example
through direct or grassroots lob-
bying [see Box 2].

The appropriateness of these
activities is debated among
practitioners (Advocacy in HIA
Working Group, 2013). Layered
on the debate are questions
about the relationship between
advocacy and research objectiv-
ity, bias, and neutrality. We posit
that in order for most HIAs
to be relevant and effective at
protecting and promoting health
and reducing inequities – as well
as advancing democracy, another
core value of HIA – in the context of a decision-making
process, it is necessary for HIA practitioners to engage in
advocacy to influence how decisions are made. Many HIAs
that we and others have conducted have failed to affect deci-
sion making as a result of our limited engagement with the
decision-making process.

We believe this is because those who benefit from current
inequities and limitations on democracy are powerful forces

and, in the face of these forces, data by itself does not lead
to change. This is evident in a wide range of policy debates,
from gun control to climate change, and from healthy food
access to access to paid sick days. As Congressman Henry
Waxman says, “When you look back on key legislative fights
over public health issues, you will see that the expertise

and advocacy of public health
professionals provide a critically
important counter pressure to
the lobbying clout of special
interests. The grassroots efforts
by the public health community
help educate legislators and play
a pivotal role in our legislative
efforts to improve the health of
the people of the United States”
(American Public Health As-
sociation, 2005, p. 5).

Practitioners, therefore, must
often use the best available evi-
dence and a range of strategies
to communicate the evidence to
various policy audiences, includ-
ing deliberate tactics with com-
munity organizations, decision
makers, and other stakeholders
that can aid in addressing power
imbalances. There are barriers
and risks to conducting advoca-
cy, but there are also opportuni-
ties throughout the HIA process
to overcome and allay those.

This paper is geared towards
HIA practitioners and public
health professionals who want
to understand the opportunity
advocacy provides to advance a
more effective and relevant HIA
practice. We begin by describing
the larger context of HIA prac-
tice that drives this perspective,
barriers to engaging in advocacy,
and opportunities and best
practices to conduct advocacy
in the context of HIA. We end
with a case study describing how
advocacy was used in an HIA in

Wisconsin to advance health, equity, and democracy.

Foundations of our Perspective
Health Impact Assessment is shaped by a set of founda-
tional values and concepts, and that inspire our perspec-
tive that advocacy is essential to the field’s success. The
1999 Gothenburg Consensus Paper on HIA and the 2006
International Association for Impact Assessment Special

Advocacy in HIA Farhang; Heller,

Box 2. Advocacy and lobbying.
Direct lobbying: attempts to influence a legislative body through com-
munication with a member or employee of a legislative body, or with
a government official who participates in formulating legislation. The
communications must refer to and reflect a view on the legislation (In-
ternal Revenue Service, 2015).

Grassroots lobbying: attempts to influence legislation by attempting to
affect the opinion of the public with respect to the legislation and
encouraging the audience to take action with respect to the legislation.
The communications must refer to and reflect a view on the legislation
(Internal Revenue Service, 2015).

According to the American Public Health Association:

“How is lobbying different from advocacy?” Advocacy is participating in
the democratic process by taking action in support of a particu-
lar issue or cause. Advocacy activities like participating in a town
meeting or demonstration, conducting a public forum or press ac-
tivity, or developing an issue brief for your local policy-makers on
a particular public health issue do not constitute lobbying as long
as you are not urging a policymaker to take a position or action on
specific legislation (American Public Health Association, 20015)

Publication on HIA (Quigley et al., 2006) define values that
guide the practice: democracy, equity, sustainable develop-
ment, ethical use of evidence, and comprehensive approach
to health. The Gothenburg paper contextualizes these values
by stating that: “All policy processes are carried out in the
framework of values, goals, and objectives that may be more
or less explicit in a given society and at a given time. It is
essential that such values are taken into account, otherwise
HIA runs the danger of being an artificial process, divorced
from the reality of the policy environment in which it is be-
ing implemented” (p. 4) As practitioners, these explicit and
motivational values – and the worldview they represent –
inspire us to be part of the field.

The World Health Organization’s Commission on So-
cial Determinants of Health Final Report (World Health
Organization, 2008) provides guidance as to what equity
and democracy mean in
wider public health prac-
tice: “Any serious effort
to reduce health inequi-
ties will involve political
empowerment – changing
the distribution of power
within society and global
regions, especially in favour
of disenfranchised groups
and nations…….Health
equity depends vitally
on the empowerment of
individuals and groups to
represent their needs and
interests strongly and effec-
tively and, in so doing, to
challenge and change the
unfair and steeply graded
distribution of social re-
sources (the conditions for
health) to which all men
and women, as citizens,
have equal claims and rights” (p. 18). In other words, both
the process of empowerment within the democratic process
and the power accumulated by groups currently without
power are considered central to the pursuit of health equity.

In accepting a set of values to motivate our practice,
practitioners acknowledge that we inherently reflect a set
of cultural norms and worldviews in our work; foremost
among these worldviews is that research should inform
policy making. As stated by Michael Nelson, professor of
environmental ethics and philosophy at Michigan State
University, “advocating for the use of science and for reveal-
ing the discoveries of science, as well as for specific policy
positions are forms of advocacy. Simply because the former
is uncontroversial does not mean it is not a form of advo-
cacy, it most certainly is. So in some ways the question is
not, is advocacy acceptable, but which kinds of advocacy are

acceptable and, most importantly, how ought we to go about
advocacy….” (Nelson, n.d.). Indeed, a recent Pew study that
found, “a large majority of the public (76%) and nearly all
scientists (97%) say that it is appropriate for scientists to be-
come actively involved in political debates on controversial
issues such as stem cell research and nuclear power.” (Pew
Research Center for the People & the Press, 2009, p. 34).

In choosing to conduct an HIA, practitioners are either
consciously or unconsciously choosing to advocate for a
set of causes including improved health, decreased inequity,
increased democracy, and empowerment. These values – or
causes – are not neutral. They reflect a world with a set of
policy outcomes and decision-making processes that are dif-
ferent from our current policy climate. The transition to this
better world will not occur naturally, even if the evidence
points towards it. Powerful social forces, including dominant

interests, entrenched ideas,
and disenfranchisement –
that converge to maintain
the status quo – need to
be overcome. Advocacy
is a necessary, though not
sufficient, tool that can
motivate policy makers to
overcome these forces and
advance health, equity, and
democracy.

Concerns with and
barriers to engaging in
advocacy
Some within the HIA field
have expressed unease
with a wider perspective
of advocacy, particularly
that a practitioner engaging
in advocacy undermines
the objectivity and cred-
ibility of the HIA process,

findings, and recommendations and may also reflect the
biases of researchers (Advocacy in HIA Working Group,
2013). Concerns can be summarized as follows: engaging in
advocacy makes the practitioner seem biased and engaging
with others who advocate makes the practitioner biased by
extension; scoping and assessing topics based on the priori-
ties and concerns of historically impacted communities may
lead to particular findings and recommendations that deviate
from the dominant worldview; taking a position is not ap-
propriate when practitioners may not know or understand
the universe of competing priorities or unintended conse-
quences related to a decision; and having our role as neutral
public health practitioners evolve from informing to advo-
cating to lobbying is potentially problematic.

Our perspective is that these concerns are based on per-
ceived risks that can be addressed in the HIA process. While

Advocacy in HIA Farhang; Heller,

we recognize that these concerns are authentic and real
(e.g., both laws and funding sources may limit one’s ability
to engage in lobbying), one can carry out a sound HIA and
advocate for an HIA’s findings and recommendations with
actions intended to maintain the integrity of the practice.

Advocacy reflects a spectrum of activity (see Box 1), the
range of which reflects the institution in which a practitio-
ner is situated. Public health professionals, in particular, face
numerous barriers to conducting advocacy, including risk-
averse agency leadership, political resistance from elected
officials, lack of relationships and understanding of other
policy domains, and a lack of capacity and resources. Public
health is also disconnected from movements to advance
equity and democracy, and unclear about how to contribute
to these movements. Addressing these constraints is beyond
the scope of this paper or the responsibility of any individu-
al HIA practitioner; however, efforts exist to overcome them
(National Association of County and City Health Official,
2014; Farhang, Heller, Levey, & Satinsky, 2015).

Opportunities to conduct advocacy in the context of
HIA
There are a number of best practices we can undertake as
practitioners to minimize potential sources of bias and to
legitimize our advocacy activities. Primary among these is
to be transparent about every aspect of the HIA process,
including funding sources, partners and their roles, research
approach, and decision-making processes. Information
about these should be included in the HIA report and all
other communications about the findings and recommenda-
tions.

Below, we delve more deeply into opportunities to con-
duct advocacy in the context of HIA, the potential causes
of concern, and best practices to conduct an effective and
relevant HIA that leads to improved health, equity, and
democracy.

Partner with a diverse set of stakeholders, including those most likely to
be impacted by the decision, to conduct the HIA
Some stakeholders, including community organizations,
are often perceived to be advocates – and therefore bi-
ased – because they might be seen as having a position, use
various tactics to get the attention of decision makers, and
engage with populations that will be impacted by the deci-
sion. Other stakeholders’ motivations, in contrast, are not
scrutinized in the same way, either because their perspective
aligns with the dominant worldview or because we do not
even recognize that they are exerting control over the public
agenda (Gaventa & Cornwall, 2001).

Often, there are different degrees of power among these
various stakeholders. For some HIA practitioners, redress-
ing this imbalance of power – i.e., empowerment as dis-
cussed by the WHO’s Commission on Social Determinants
of Health – in a particular decision-making context may
be a goal for the HIA, a goal that should be transparently

stated. Partnership with disenfranchised groups, for example
through a community organization, in the HIA process may
be considered a way to advance empowerment, democracy,
and equity.

Establishing a stakeholder oversight/advisory committee
composed of people with variety of experience, including
vulnerable populations most likely to be impacted by the de-
cision at hand, to guide the HIA is good practice. By includ-
ing people with varied experience, the HIA can represent
different perspectives and be used to build consensus and
relationships, which helps address past disenfranchisement.
Establishing such a diverse committee can also address
advocacy concerns around partnership with a community
organization, as other members may be seen as contributing
balance and scientific rigor. The HIA should be transparent
about the membership of the committee and the commit-
tee’s role in the HIA process.

Work jointly with an Advisory Committee to select and assess research
topics
As with any research, HIAs require topic prioritization
given budget and time constraints. One might believe that
public health professionals, who have training and familiar-
ity with the peer-reviewed literature, are in the best position
to prioritize research topics. Focusing on topics with which
stakeholders – especially members of impacted communities
– are most concerned may be considered a form of advoca-
cy, as it prioritizes some topics for research over others and
de-prioritizes public health expertise.

However, focusing on topics of importance to
stakeholders ensures that an HIA is adding value by re-
sponding to unanswered questions. Furthermore, while
public health professionals bring their expertise to the HIA
process, other stakeholders also have legitimate and valuable
expertise; community members, for example, can inform
the process with their lived experiences. Last, topics not well
studied in the peer-review literature are still valid if they are
of concern to stakeholders. The research priorities of many
stakeholders make an HIA more robust. Again, transparency
is important; the HIA should clearly state which topics were
prioritized and deprioritized and why.

In the assessment phase, it is crucial that practitioners
do not let their own or stakeholder’s pre-conceived notions
influence their findings on any of the selected research
topics. Guided by the value of ethical use of evidence and
the Practice Standards, (Bhatia et al., 2014), practitioners must
consider evidence that both support and refutes particular
impacts, acknowledge insufficient evidence when that is the
case, and communicate that predictions are not definitive
but based on best available evidence. Review by stakeholders
and by professionals not affiliated with the HIA can be use-
ful for identifying potential sources of bias and conclusions
that are not supported by the evidence. These potential
pitfalls and best practices are important in any HIA, not just
those in which stakeholders such as community members

Advocacy in HIA Farhang; Heller,

are heavily involved.

Gauge the power and policy context in determining the best strategy for
taking a position
Coming to a decision at the conclusion of the assessment
phase, after examining and weighing the evidence, about the
benefits and harms of a proposal, and generating a set of
recommendations, means we are not neutral. HIA recom-
mendations are meant to maximize the benefits and mini-
mize the harms. During the reporting phase, some might
consider taking a position on the proposal to be a form of
advocacy, believing that an “objective researcher” would let
the evidence speak for itself.

However, if the research was carefully conducted and
leads to clear conclusions about positive or negative impacts
on health and equity, and if the HIA practitioner’s goal is to
improve health and reduce inequities, it is important that the
practitioner communicate clearly about the evidence and its
conclusions. Evidence cannot speak for itself.

This can lead to practitioners taking a position on all or
part of a proposal, or being perceived as doing so. While
some practitioners may be able to take a position and con-
duct advocacy based on that position and find that this helps
achieve health- and equity-promoting change, others (e.g.,
those working in government agencies) may be constrained
from doing so by their institutions or by lobbying
regulations (e.g., they may not be able to communicate their
views directly to decision makers). In some cases, other
stakeholders who were part of the HIA process may take
positions and lead advocacy efforts. These are all acceptable
practices.

Importantly, practitioners should consider that they may
not understand the full context of the competing priorities
and choices faced by decision makers. For example, recom-
mending in an HIA that a project not move forward in a
particular community might just mean the project moves
forward in another community not studied in the HIA.
Given this, practitioners must be attuned to uncertainty
in our research, be aware that advocating for HIA recom-
mendations or taking a position could have unintended
consequences, and consider how best to account for this in
developing recommendations (e.g., by discussing potential
recommendations with decision makers when appropriate).

Furthermore, if there is insufficient evidence to reach
clear conclusions, the HIA should state so and communica-
tions about the findings should not overreach in those areas.
Communicating the lack of clear findings can also be infor-
mative for decision makers and may, for example through
recommendations, point to policy options with more certain
impacts.

Finally, after doing several HIAs on similar proposals
over time, whether the topic is food accessibility or criminal
justice, an HIA practitioner is likely to develop a knowledge
base around a set of topics, and may be able to come to
a conclusion and/or take a position on a proposal before

completing the HIA. Researching the local context with
respect to a proposal and understanding the differences with
previous contexts and proposals is important for minimizing
bias and before taking a position.

Think broadly about the best tactics to effectively communicate findings
Translation and communication of findings and recommen-
dations in the decision-making process – and to audiences to
whom decision makers listen – may be considered advocacy
by some. Most practitioners make active efforts to inform
decisions, which include, for example, sharing the HIA
report and summary materials extensively, letter writing,
hosting public meetings, and disseminating products to the
media. Some might define these information-sharing activi-
ties as advocacy.

At a minimum, practitioners have a duty to produce a
publicly accessibly report and distribute it to decision makers
and other stakeholders. Practitioners should also be willing
to interpret and assist stakeholders to accurately use find-
ings and recommendations. Speaking to decision makers,
the media, and other stakeholders fulfills this objective.
Beyond that, the range of activities in which a practitioner
can engage will be construed by their institution and may be
considered
advocacy. There is no reason classifying such activities as
advocacy should delegitimize them.

Some practitioners are concerned that testifying publicly
or speaking with decision makers is lobbying and are con-
cerned with overstepping legal limits. Lobbying has specific
legal definitions (see Box 1) which vary by jurisdiction and
which practitioners must understand. Lobbying restrictions
must be followed. Conflating all advocacy with lobbying is
counter-productive.

There is validity in asking whether it is in the best interest
of improving health, and advancing equity and democracy,
if an HIA practitioner takes a position on the proposal and
plays a lead role communicating that position. In some con-
texts, the HIA practitioner may be seen as a “professional
expert” and their voice can carry a significant weight. In
other contexts, they may be seen as an interfering outsider
and their leadership may be counter-productive. Ultimately,
understanding context is integral to making the most of ad-
vocacy efforts and advancing opportunities – ones that have
minimal negative consequences – to achieve HIA goals and
align with practice values.

Case Study: Treatment Instead of Prison HIA
To elucidate what advocacy to promote health and reduce
inequities looks like in the context of a specific HIA, we
describe here the Treatment Instead of Prison HIA (Gilhuly,
Farhang, Tsui, Puccetti, & Liners, 2012). In 2012, Human
Impact Partners partnered with WISDOM (a statewide
congregation-based organizing network based in Wisconsin),
state agencies, academics, and other experts to conduct an
HIA to assess the health effects of increasing funding in the

Advocacy in HIA Farhang; Heller,

state budget for Wisconsin’s treatment and diversion pro-
grams from $1 million a year to $75 million a year. Wiscon-
sin, like other states, was incarcerating growing numbers of
non-violent drug and alcohol offenders and had stark racial
disparities in sentencing. WISDOM was campaigning to cut
Wisconsin’s prison population by expanding access to treat-
ment programs and the HIA was conducted to understand
the impacts these alternatives would have on incarceration.
The HIA and other efforts led to a quadrupling of state
funding in Wisconsin for treatment alternatives to prison.

In each phase of the HIA, HIP worked to ensure the
process was responsive to our values of equity, democracy,
and empowerment. From the start of the project, we carried
out the process to maximize the advocacy for policy change
based on our findings and recommendations:

Project management: HIP and WISDOM convened an Ad-
visory Committee comprised of academics, researchers, and
public agency staff to guide the HIA, evaluate the science to
make sure the interpretation of information was accurate,
and help develop recommendations grounded in the legis-
lative and administrative reality of the state. Members of
the Advisory Committee became natural spokespeople and
advocates for the HIA’s recommendations.

Screening: With WISDOM, we chose to conduct an HIA
on a topic for which there were already constituencies
engaged; it was a topic that was relevant and meaningful to
people. This interest in the topic created a demand for the
research and an audience interested in receiving and using
the results. These audiences hoped the research would sup-
port their campaign, but were taking a risk that it might not.
They were also open to changing their policy requests based
on the HIA findings.

Scoping: The topics on which the HIA focused were based
on questions about determinants of health that the Advisory
Committee, WISDOM, and its community constituents –
including those formerly incarcerated and their families –
thought would have the largest impact on health and on the
debate. Answering research questions prioritized by these
partners increased the likelihood that stakeholders would
use the research in the decision-making process and decision
makers would therefore pay attention to the findings.

Assessment: The research process drew on multiple sources
of information, including the experience and expertise of
formerly incarcerated people, their families, service provid-
ers, law enforcement, and judges. For HIP and the Advisory
Committee, including the voices of these stakeholders was
important from an empowerment perspective and because
published studies may not have examined some of the pri-
oritized research questions thoroughly.

The evidence from the literature used reflected the
consensus of researchers across multiple disciplines who
participated in the HIA process about the potential impacts
of the proposal. These researchers participated in meetings
to review the evidence and reviewed the draft report.

Recommendations: The recommendations identified were
responsive to the impact predictions and – because of the
Advisory Committee’s local knowledge – reflected the ad-
ministrative and legislative reality of the state. Because stake-
holders involved sought the best outcomes for their com-
munities, they were committed to identifying feasible and
actionable recommendations for which they could advocate.

Reporting: Findings and recommendations were summa-
rized into easily digestible materials for decision makers to
consider and stakeholders, including community members,
to use in the decision-making process. While HIP partici-
pated in press briefings and media interviews to explain the
HIA process and findings, our perspective was that com-
munity members would be the most effective spokespeople
to communicate to decision makers and advocacy on their
own behalf advanced the goal of empowerment. Through
this model, where local voices spoke to the findings and
recommendations, there was significant press coverage of
the HIA. HIP was transparent with all stakeholders through-
out the HIA process and in the final products about who
funded the HIA, who was involved, and how the topics and
research categories were selected.

Through the research, we found overwhelming evidence
that expanding alternatives to incarceration would reduce
the prison population, reduce crime, lower recidivism, and
strengthen families by keeping up to 1,600 parents a year out
of prison each year. Because studies showed that the cost of
treatment was about one-fourth of the cost of incarcerat-
ing people, we found that the state would also save up to
two dollars for every dollar spent on alternative treatment
programs.

Based on an internal evaluation that included interviews
with key partners, the HIA was a success on multiple levels.
It had a tremendous impact on the conversation around
treatment over incarceration in Wisconsin. Every major me-
dia outlet in the state covered its release, with over 30 news
stories about it. In addition to the quadrupling of fund-
ing, legislators from both parties have pledged continued
support for future funding increases. WISDOM continues
to use the research in meetings with legislators, strengthen
relationships with the public health community, organize
their communities, and keep the issue in the media spotlight.
Decision makers and the state budget were directly affected
by the HIA findings and recommendations; there was a shift
in the narrative around what affects health; new collabora-
tions were formed; community members felt empowered by
the experience of participating in the process; and the HIA
continues to contribute to the dialogue around incarceration
in the state.

Success resulted from the HIA process and the advocacy
it supported. Because the project sought to answer a set
of socially meaningful and relevant questions, WISDOM’s
organized constituencies – including citizens, clergy, pros-
ecutors, judges, and service providers – were motivated

Advocacy in HIA Farhang; Heller,

to integrate the findings and recommendations into their
campaign. The approach also helped legitimize the research
for decision makers, who, while caring about the underlying
evidence, also cared to see a broad network of community,
academic, and other stakeholders bought into the research.
Had we not conducted the HIA to advocate for our causes
of health, equity and democracy, the HIA may not have had
as significant an impact.

The model of the Treatment Instead of Prison HIA is
reflected in many of our other projects and has resulted in
similar successes. In our Farmers Field HIA (Lucky, Satinsky,
& Nasser, 2012) and our University of Southern California HIA,
(Lucky & Heller, 2012) community organizations participat-
ing in the HIA used research findings to leverage housing,
job, and health mitigations via legally binding community
benefit agreements. Our Jack London Gateway HIA (Heller,
2007) led to changes in the design of a local development to
address identified health impacts. Based on these successes,
others, including government agencies (Pew Charitable
Trusts Health Impact Project, 2014), are also beginning to
conduct more advocacy in their HIAs as well. In all of these
examples, various forms of advocacy – relevance of the
topics of focus to local community stakeholders, empow-
erment of those groups through the HIA, and the direct
and organized use of findings and recommendations in the
decision-making process – led to successful HIA outcomes

that may not otherwise have been realized.

Conclusion
Working within a policy context, and driven by a set of
foundational values, we must be thoughtful about how we,
as practitioners, can be most effective at accomplishing the
wider goal of HIA – to protect and promote health and
to reduce inequities in health. While we cannot expect that
the answers will be the same in all situations and that all
practitioners will engage in the same activities, the success
of the Wisconsin Treatment Instead of Prison HIA and other
HIAs provide an example of how advocacy can be woven
throughout the HIA process in such a way as to increase
its relevance, use, and ultimately its efficacy in the policy-
making domain.

The model of HIA described here, that combines sound
science with advocacy for health, equity, and democracy,
can lead to public health becoming a model of accountable
and effective government. While HIA practitioners rely on
empirical data, we know that data alone is not enough to in-
fluence the policy process. Context, ideas, and power matter.

The process and product of HIA can empower vulner-
able populations most likely to be impacted by decision
making and start to reform the structures and institutions
that currently result in inequity. But data alone will not do
this. Data need advocates.

Advocacy in HIA Farhang; Heller,

ACKNOWLEDGEMENTS
We wish to thank Marjory Givens for her thoughtful review and feedback on this paper.

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CORRESPONDING AUTHOR
Lily Farhang, MPH
Human Impact Partners
304 12th St, Suite 2B
Oakland, CA 94607
lili@humanimpact.org

Advocacy in HIA Farhang; Heller,

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: 10.18060/21350
© 2016 Author(s): Farhang, L.; Heller, J.C.
This work is licensed under a Creative Commons Attribution 4.0 International License.