Advocacy in public health: roles and challenges

Most public health researchers aspire to have their work published in high impact journals, reasoning that this is a key measure of their work's importance and influence. Publication in these journals accords peer recognition, enhances promotion and can attract media1 and hopefully public and political attention2 to research and its implications for public health. Currently, the epidemiology journal with the highest impact factor is the American Journal of Epidemiology with 3.870. The journal you are now reading scores 1.892. In wider public health, the peak journal is the Annual Review of Public Health with 4.524.3 Sixty-three per cent of the Institute of Scientific Information's indexed journals have impact factors below or equal to one,4 meaning that in these the average paper is cited less than once in the 2 years after publication.5 These depressingly modest numbers that define high impact in our field together with the global circulations of the journals themselves (Int J Epidemiol 2434, Tobacco Control, the international journal I edit, 980); the size of the audience that might hear a paper at a main session of the world's largest public health conference (the American Public Health Association with recent attendances of around 12 000); and library shelf use studies (20% of journals are responsible for 80% of borrowings, with many bound volumes of scholarly journals being never opened in a survey year6) all make salutary contrast with the audience size of even low rating late evening national news programmes or the readerships of provincial newspapers. While epidemiological research should provide the foundation for public health advocacy, only a tiny fraction of often high quality research ever percolates out of academic circles to inform advocacy efforts. In most research environments, it is de rigeur to rehearse a conference presentation that might be heard by 30 people at a specialized session. Yet a radio or television interview heard by millions including key decision makers is often undertaken with a casualness that contrasts with the unparalleled opportunities it presents to promote change. If a public health research report is selected as newsworthy by international news syndicates, its salient features in the eyes of journalists will be broadcast to hundreds of millions, and sometimes billions of people. People repeatedly nominate news media as their leading source of information on health issues, and there are few examples of major legislative or funding reforms in public health that have not been preceded by protracted periods of news coverage involving advocacy by those both promoting and opposing change. I assume epidemiologists aspiring to be influential understand that the goals of epidemiology and public health lie well beyond the pursuit of growing scientific publications that will be read by few and cited by even fewer. They want their research to influence political or institutional policy and practice, or the personal agendas of large numbers of people, and so hope that there can be a continuum or partnership between epidemiological research and advocacy. They will frequently find the journalistic compression of their often voluminous research reports into 200 words or a popularized radio sound bite to be a traumatic experience that tramples on most of the heavily qualified conventions of scientific writing. Yet they will recognize that without such attention to their work, it may never influence any policy or practice. However, few postgraduate courses in public health place anything but passing attention on how to advance or advocate the policy implications of research. Public health advocacy remains barely a sub-discipline within our field. Unlike medical psychology, education, sociology, anthropology, economics, biostatistics or epidemiology, advocacy has no journals dedicated to critical analysis of its methods, wins and losses. It has few textbooks7–11 and even fewer recognized training programmes, although in recent years an impressive body of scholarship has been published (see http://www.health.usyd.edu.au/resources/mchbib/index.html). Against the time and attention devoted to planning, implementing, and writing up research, the relative neglect of both the skills and analysis of advocacy is remarkable given its achievements. Every branch of public health can point to the critical role of advocacy in translating research into policy, practice and sea changes in supportive public opinion. In Australia, examples abound in areas such as tobacco control,12 injury prevention,13 and HIV/AIDS control.14 So why does the study and teaching of advocacy remain so neglected? Having worked in public health advocacy for over 20 years, I have come to see this as a reflection of advocacy's perceived incompatibility with the reductionist epistemology that underscores most public health enterprise. Academic public health has been most comfortable with those branches which go closest to satisfying criteria as science. While there are aspects of the advocacy process that are emerging as almost fail-safe ingredients in predicting the course of campaigns, much in the day-to-day practice of advocacy draws more on the less replicable truths of political science, and particularly on framing strategy.15 Epidemiology, with its aspirations to define nailed down notions of reality, demands precision in its specification of agent, host and environmental factors to satisfy these ambitions. Advocacy, by contrast, recognizes the dynamic interplay of a myriad of factors and influences which often lie well beyond the reach of the evaluator's desire for control. Many epidemiological findings with potential to improve health are welcomed by the public and decision makers alike. To generalize, in cases where there are no vested interest groups who stand to lose by policy or legislative changes; where these changes require little resource investment or might be commodified into profit making solutions; or where there is already overwhelming community support for implementing change, publicity rather than advocacy may be all that is required. Our emerging understanding of risk reduction in sudden infant death syndrome16 and of ways of reducing hip fracture in the aged and of folate in preventing neural tube defects17 are good examples of red carpet receptions being given to epidemiology. Advocacy seeks to change upstream factors like laws, regulations, policies and institutional practices, prices, and product standards that influence the personal health choices of often millions of individuals and the environments in which these are made. Advocacy shares strategies with public relations, but differs in that it invariably involves contested definitions of what is at issue. Advocates therefore often find themselves engaged in public conflict with sometimes powerful interest groups or governments determined to resist change. For the faint hearted, advocacy can take on the spectre of a fraught, politicized activity, threatening to make enemies particularly of retributive government figures and litigious industries. I have even received death threats over my gun control advocacy. This can seem a far cry from the mannered and often inconsequential exchanges in letters pages of journals. In the space available, I will examine three recurrent concerns about public health advocacy which seem to inhibit greater engagement by those in public health and epidemiology. The first of these is the often heated debate about when state regulation of the liberty of individuals is justified. While the Millean principle of preventing harm to others18 provides broad guidance in obvious examples like arguing the case for road rules and food safety laws, the principle is often contested by interest groups disputing the evidence on harm and/or the assumed primacy of health concerns over other values. This is particularly the case of interventions where Rose's prevention paradox applies (little benefit to individuals, but predicted benefits to whole populations).19 I will consider this problem through two case studies that illustrate different nuances: efforts to advance legislative reforms in gun control and reduce motor vehicle injury. The second problem is summed up in a question I am often asked by an uncomfortable person in an otherwise supportive audience: ‘do you believe that with advocacy it's a case of “anything goes” . . . that the end justifies the means?'. This question goes to the heart of the motivated intent of advocacy and its core strategies: of the way that advocacy sets out to be effective and the extent to which this can sometimes generate controversy about the ethical boundaries between information and persuasion. The core issue here concerns the ways in which problems are defined or framed and the naivete of assumptions that there is some ‘correct’ way of defining a problem. In this respect, epidemiological assumptions about the ‘reality’ of problems can again differ from those acknowledged as legitimate in advocacy. The third concern to be discussed is typically expressed through the question ‘what evidence have you that advocacy actually works?’. The attribution of effects to interventions in public health is subject to hierarchical models with the double blind randomized controlled trial enthroned as the emperor of evidence. By contrast, efforts to attribute causal effects from advocacy processes to their outcome objectives are fraught with problems, and therefore implicitly denigrated as soft or weak. This tends to mean that the most robust ‘truths’ about public health interventions tend to cluster around highly defined and interventions such as the of and to influence political decision making over years or even are about as far as can from such the rather that in public health, the only that should be those that can be and many case of public health be to the of I will the of in as a case Epidemiology is the on which advocacy should public health their they attract few people are to that from are that work environments should be or that it be good fewer people on the advocacy is when it out its strategies for these and for in and and or on the of for all attract protracted These strategies will often a concern to reach ever a risk more can be and in most of public health they should be to and advocate for the to The two case studies below illustrate that about the and of such In about all of both and at the that inform While there are and ethical for public health are by to will be or not on the way these are by and to these at a with no or and and people, the largest death ever in time involving a with the the people in in where or more people often with the and in the and a news of gun from the a to have been and the government to of and to national gun and require all gun to legitimate for a gun and but not The a gun for from on personal that to gun for the of their now there no national gun or there no national on the of individuals who the of on the of they the gun the and gun control all that it there well over a in the In from an of about an of in and require to and to at By this of such from the community the hope that such In the the not such has the that the gun reforms a In the to the and in the between the and the of the laws, advocacy efforts by those both promoting and to the gun hundreds of of in the gun to the as and I will two of the that the overwhelming of gun not and not any to the and the that gun death high to on the liberty of these The gun the of these of or with and that both groups or to be In the of been In those the gun that the of any gun and that therefore the government like a to a and the of by they not to be with these The gun much on that gun to of other that far more and that government in to make the community therefore and by wider political bound up with notions of being so many problems that more and more people why the government such attention to gun they They that the to reducing gun like in greater by and in those at risk of gun and repeatedly this as While the of gun and not they both that the average gun never use gun and that there to those who as and assume that all are of equal risk to the reducing gun which and on a large of For many these never to be and so gun control as a highly contested issue. This case a core for advocacy. The for of the advocacy for gun control not on any determined by of health epidemiologists and from that this a issue when all other health with many low such a have gun control to low which gun control gun to in the of political will to it in The of down the American the most expressed point to the This on a of epidemiological understanding that a with a high of gun and gun more to have a high of gun than where less from that with to gun of gun than those which not by that this like arguing that than For gun control the of framing the debate to the public at these and into the of defining the to the problem as involving gun rather than the gun of policies on their of and gun people. People of the for gun control with promoting the that with intent with many people The question for it to to or as with on to and should be framed as The to such a question will be by not epidemiology. 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I have often of advocacy efforts that that there are or ways of about problems, and in my the concern that is sometimes expressed that in advocacy. advocacy that is ethical never promote that are to be few areas in public health often than of public health policies will to often with the tobacco through for to reports to The for advocacy here is to being by by such to debate in research is policy at the time never beyond the that sound public health and often about epidemiological this can be concerns are expressed about the of into advocacy that is to be or involves choices about how and the information that to of what are to that is but that is not and in to a or around what are to be at issue. If it is that by this process of it is to that are not that when people information that they will find it in the ways If find the ways their this information are they to it in the hope that way To that there is some way of information is process is by on the of the as I have what is being in public health are the primacy of over it is that the of advocacy should to those values. This that it will often to its of what is at in a an and may well why an issue is the subject of advocacy in the first in debate is on but this is not how define problems, why they can about issues, remain to some or support some policy and not While the of public advocacy out on television news features in or the of a of news in public health over community health, the of public and out at risk to their these news conventions work to the meaning of public health issues, and to be rather than to have an understanding of the of their issues, as much as the of the in which they Many health where advocacy that are highly infant or in a that no is and any advocate who that they have little with such themselves from being an effective are a major of death in aged in who have the of these into standards have a in such as have those from the who for years and safety in these reforms volumes of on the epidemiology of on the health of for for from and on the of in reducing the of This published and for years the to to make the it preceded by many of of the case for by and sometimes public exchanges that to and and by the of news sound is like third . . . you the you the in and the core problem of has been as being of the for definitions of the To the tobacco a tobacco might be as a legitimate of a to inform its about its To to have tobacco the is by to with of an The interest that in its of these or by those to legislative or policy changes will be the that third problem advocacy in its academic within public health concerns the attribution of that advocacy are two major The first involves problems in what advocacy and the second concerns the of ways of its influence. in are and to be is to or for By contrast, advocacy ever in such environments, but seeks to and repeatedly to decision making environments that can change by the While the is in advocacy it is high and an quality in to the many and that in to promote change. not to strategies not out of some for the of the or in epidemiology on For public health often seem to be by interventions selected of interest our television change or the of on While studies abound of the influence of the of advocacy and there are few efforts at critical of the advocacy processes that to the of The of the advocacy process its in efforts to and I this as to and more as to be in critical analysis of how advocacy These that the over time of key and of the community to analysis of media and in efforts to around the and of the advocacy process by those in Australia, of are in where is by This has on that the research question has been is by on all public in all and public and in most in areas of will in and in of from to have been to have in the community by between and The tobacco are with and a recent that on have more to reduce tobacco in the than any other The and of tobacco efforts to the of environmental tobacco this is almost epidemiological reports on the health by with a public health to a growing community that and that being by the and most that the for who to These publicity by over health effects from publicity given to by the from a major case where the tobacco of the public on and large of Advocacy for not by any public health who by the of into the media or the of For of the there of letters to people up programmes on news in and individuals up in and people their when a or and causal about being and out in and advocacy into the media not or although analysis of news on to be the most issue in tobacco Tobacco control in all of these and often as or for a of that to attribute the to and which to factor in the to which advocacy the role of these more The strategies of advocacy are of course to good use by determined to public health as well as by risk on community about that any to The to recognize and the of such rather than in epidemiological study is than is a of effective advocacy. I have in advocacy are almost not about the being or about who has the or evidence. They are more about bound up in such as perceived out at the of and and and and The debate about high and is only at a debate between The with which those to at even the of risk in a a far meaning to the debate bound up with of the I have often these and as they can be with with epidemiology can be a in rather than to to policies that all hope public health policy be without advocacy the efforts of epidemiological efforts can in and academic and to be into reforms that can benefit the public health. The of academic public health to advocacy as a core will hopefully with the growing of the importance of analysis in reducing health problems and a growing of advocacy as a core in public health to in and