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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



33

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,



34

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,



35

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,



36

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,



37

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,



38

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,



39

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.


