A recent letter in the Lancet claims that: Shying away from advocacy is comparable to medical negligence. Yet, as Simon Chapman has noted, advocacy has been a fundamentally neglected topic in public health. Chapman suggests that this is partly because many in the public health community perceive a tension, even an incompatibility, between advocacy and ‘the reductionist epistemology that underscores most public health enterprise’.  Consequently, whilst professionals seem comfortable with the idea that research ought to be policy-orientated (and policy evidence-based), it is less obvious that there is a consensus about the role public health professionals should play within ‘advocacy’

For some areas of public health, such as tobacco control, there are multiple large campaigning organisations (e.g. the various national-versions of Action on Smoking and Health, multiple cancer, heart and lung charities and umbrella groups such as the SmokeFree Partnership in Brussels).  These kinds of relatively large, health-focused NGOs tend to be professionally run, evidence orientated and politically savvy. In this context, and given the strong evidence-base demonstrating the health harms of smoking, public health advocacy may feel relatively unproblematic.  However for  more cross-cutting, complex health issues such as health inequalities, there are very few active campaigning organisations, and advocacy is therefore a more contested issue.  In this context, this short blog draws on a review of existing literature, interviews and focus groups to: (1) set out some ideas about what public health advocacy might involvefor professionals; (2) outline (for those who do want to engage in more public health advocacy) the factors that individuals involved in advocacy suggest lead to successful campaigns; and (3) consider who should be involved in this kind of work

1 : What does ‘public health advocacy’ involve?

There are few clear definitions of ‘public health advocacy’ within published studies but here we list activities that we identified as being linked to public health advocacy in both existing literature and our interview and focus group data (which involved various kinds of public health professionals):

  • Developing the evidence-base for key public health issues (i.e. undertaking new research with a view to improving the evidence relating to particular health concerns).
  • Promoting available evidence and ideas about key public health issues to: (i) policy audiences; (ii) the media; and (iii) local communities and the wider public
  • Working to influence policy debates and decisions that are likely to impact on public health (whether at national level e.g. by participating in policy committees and consultations,  or local level e.g. working to introduce speed restrictions in neighbourhoods where road traffic accident fatalities are high).
  • Working to draw attention to, and counter, the influence of actors (such as some corporate actors) who are influencing policies/society in ways that are damaging to public health.
  • Reframing issues to the benefit of public health (e.g. if policy actors or the media seem more interested in economic, than health-related, costs, work to present health-related information in an economic frame).
  • Being strategic and opportunist in efforts to influence public and policy debates (e.g. rapidly responding to external events and news stories that relate to key public health concerns).
  • Working to build coalitions of cross-sector actors with an interest in promoting particular public health issues / solutions.
  • Working with disadvantaged/vulnerable individuals and communities to ensure that their voices and concerns are heard by people involved in decisions impacting on their lives.

For many public health professionals, at least some of the above activities will form familiar parts of their day to day work, and in this sense, most public health professionals are already involved in public health advocacy.  Potential tensions between one’s capacity as a public health professional and public health advocacy may, however, be more apparent around activities which focus on ‘framing’, ‘lobbying’, ‘being strategic and opportunist’ and working with political or campaigning organisations, the media and even local communities.  In all these cases, public health professionals may encounter a tension between the limits of the available evidence, the scope of their official role (within a particular institution) and the opportunity to ‘make a difference’.  This tension is heightened by the existence of an ‘inverse evidence law’ , which means the least is known about the effects of interventions most likely to influence whole populations.  It is also likely to be particularly overt where innovative policy proposals are being proposed (e.g. minimum unit pricing for alcohol or standardised packaging for cigarettes); by their very nature, the evidence-base for the effectiveness and impacts of innovative policy proposals is limited.

2 : What are the ingredients of successful public health advocacy?

Although nearly all of the campaigners and advocates we interviewed suggested the factors required to develop a successful public health advocacy campaign varied by topic and context, the following factors were consistently highlighted as crucial:

  1. A strong evidence-base to underpin the extent of the problem, which highlights health (and other social) costs in quantitative and qualitative ways and economic costs.
  2. Clear, defined, evidence-informed objectives/solutions which are linked to the problem (as decision-makers’ attention and resources are always limited, this objective needs to be clear – too many different objectives can be distracting, whilst policymakers may be unclear whether they can achieve broad goals).
  3. Evidence of the success of similar changes (e.g. where evidence demonstrates that changes relating to a similar issue in the same context have worked or that the same kind of change has worked successfully in a different context).
  4. Identifying main target audiences (e.g. x, y) and then translating, tailoring and/or framing messages in ways which the target audience can easily understand and/or which are emotionally persuasive.
  5. Developing coalitions of credible actors from a wide range of sectors to support both the need to take action and the specific ‘solutions’ being promoted (as different audiences are likely to find different individuals and organisations more or less credible, it’s important to have coalitions that are as broad as possible, without becoming fractured).
  6. Working to limit opposition to proposed changes by getting affected parties on board from an early stage (e.g. those who would need to implement or monitor particular changes) and countering messages from opposing interests (e.g. tobacco and alcohol interests).
  7. Working to sustain and grow interest in the campaign over time (e.g. by developing/promoting new evidence).
  8. Working to gather sufficient resources to support a particular advocacy campaign.
3 : Who should be involved in public health advocacy and why?

The activities outlined above necessarily involve a wide range of people with a variety of skills and resources. Reflecting this, our data highlight the importance of each of the following kinds of public health professional in advocacy efforts:

  • Civil servants with research and/or policy expertise on a particular issue;
  • Individuals working in NGOs / other campaigning organisations with an interest in a particular public health issue;
  • Journalists and other members of the media with an interest in health, inequalities/justice or social policy;
  • Members of local communities or the wider public who see themselves as being affected by public health problems;
  • Politicians who either have a particular interest in a public health issue or who represent a community/area experiencing a particular public health problem;
  • Private sector interests where these overlap with public health interests (though participation of this sector was also contested);
  • Public health practitioners (both medically and non-medically qualified) with expertise relating to particular public health issues (this includes organisations like BACAPH, as well as other groups representing public health professionals such as the British Medical Association, the Faculty of Public Health and some of the Royal Colleges);
  • Relevant local decision-makers and individuals working in other sectors with an interest in the issue/solution (this may be teachers, police, housing officials, etc);
  • Researchers (academic, public sector and others) undertaking relevant work (this includes quantitative and qualitative research, from a wide range of disciplines).

Public health advocacy is not, then, the responsibility of any one sector.  Rather, it is necessarily about bringing a wide range of sectors and expertise together (see below) to focus, first, on promoting the need to address particular public health concerns and second, to develop and promote evidence-informed solutions to these policy problems.

So far, with a few exceptions (such as tobacco control), evidence suggests that public health advocacy efforts have been rather more successful in this first stage of advocacy than they have in the second.  Indeed, of the various sectors listed above, it is perhaps least obvious where responsibility for developing viable, evidence-informed solutions to public health concerns might lie.  In our interviews, civil servants, politicians and staff at NGOs all suggested that public health researchers ought to do more to develop research-informed ‘solutions’ to the problems they were studying; whilst researchers consistently suggested that responsibility for using research evidence to develop viable solutions was beyond their remit.  This, then, may be one of the biggest stumbling blocks for public health advocacy.

Kat Smith is a Reader in the Global Public Health Unit at the University of Edinburgh. Her main research interests centre on the relationships between ideas, evidence, policy and politics, especially in debates concerning public health and inequalities. She is currently undertaking an ESRC funded project exploring: (i) policy actors’ experiences of ‘research impact’ agendas; (ii) academics as advocates; (iii) the role of ‘evidence tools’ and non-state actors (including the third sector and organisations representing health professionals) in public health knowledge transfer.

Ellen Stewart is Chief Scientist Office Postdoctoral Fellow in the Centre for Population Health Sciences at the University of Edinburgh. Her research explores how actors respond to and balance demands for public engagement and evidence-based policy in the field of health. She is currently working on a study of public responses to hospital closure proposals in the Scottish NHS.

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