Section One: Advocacy

Advocacy, often thought of as public support for a particular cause, is an important element in public health. It helps keep people healthy and safe by educating the public and lawmakers about different issues in the community. Some countries have improved traffic laws, health care resources, drinking water, and smoke-free public places through advocacy. Advocates, those who practice advocacy, have also helped to reduce pollution, child labor, and crime.

Advocacy usually involves getting the government, business, schools, or some other large institution to correct an unfair or harmful situation affecting people in the community.  The situation may be resolved through pressure, by compromise, or through political or legal action.

Suppose a community member learns that a public park will be closed but feels that the park is valuable to the community. She gets a group of local citizens together to educate city officials about this park and how important it is to the community. This is an example of advocacy. 

Health advocacy is “the processes by which the actions of individuals or groups attempt to bring about social and/or organization change on behalf of a particular health goal, program, interest, or population (National Association of County & City Health Officials, 2017).” Health advocacy includes educating policymakers and the public about evidence-based policy.

Example of Advocacy

One example of advocacy is the “Say YES for the children” campaign. It was launched on April 16th, 2001, in an effort to unite people behind ten principles (imperatives) that seek to improve and protect the lives of children.

Ten principles of the Say YES for the children:

1. Leave no child out

2. Put children first

3. Care for every child

4. Fight HIV and AIDS

5. Stop harming and exploiting children

6. Listen to children

7. Educate every child

8. Protect children from war

9. Protect the Earth for children

10. Fight poverty; Invest in children

This campaign was launched by the Global Movement for Children (GMC), which was created by the United Nations Children’s Fund (UNICEF).

After UNICEF researched the issue of child abuse, gathered data on public opinion, and conducted research to influence policy, the following strategies were used in India:

1.  Education and Encouragement

• Reframe the debate—UNICEF-India adopted the slogan from “Say YES for children,” which they feared might be interpreted as an encouragement to have more children, to a question: "If someone asked you ‘are children important?’ what would you say?"

2. Direct action campaign:

• Lobby decision makers and influential people in society— UNICEF-India initiated new partnerships with civil society organizations, celebrities, and politicians to help bring attention to the issue and gain influence.

3. Use media advocacy

• Use advertising: Popular television channels, from MTV to the state-run Doordarshan television network, have run free spots promoting the GMC and the campaign.

• Use cyber campaign: Cyber partnerships were developed with mainstream internet providers and popular websites such as Mantra Online to target wealthier children and professionals.

After much advocacy, the following results were achieved:

• The Education Ministry and a large youth union teamed up on “Say Yes for the Children” to distribute promotional material to children and young people, while the Tara Punjabi channel helped to collect 60,000 pledge forms. Throughout India, people at all levels, from Chief Ministers to local celebrities, pledged and supported the campaign. NGOs, youth clubs and others have made collaborative efforts to distribute and collect pledge forms.

• As a result, throughout India, parliamentarians joined local politicians, national celebrities, civic leaders, and sports stars to mobilize support for children. Momentum for the campaign also picked up following the creation of a National Commission for Children.

• Even the Prime Minister, Atal Behari Vajpayee, joined in during an Independence Day speech on August 15, 2001, in which he referred to children as "the most precious wealth of our nation.” The Prime Minister recalled having gone to the 1990 World Summit on Children and committed the Indian government to participate fully at the UN Special Session on Children back in May 2002.

Who Can Advocate?

Everyone should have the right to be an advocate or to be someone who is speaking, educating, and supporting positive or healthy changes in their community. Citizens can possess the power to educate and influence lawmakers. 

Advocates should educate policymakers about the latest information on public health issues and make sure that health-related legislation is based on current scientific evidence. This can be done through phone calls, letters, and email to legislators and their staff members. Advocates can also educate community members by raising awareness of health issues. This can be done through media, social media, fundraisers, classes, and community presentations. 

Five Advocacy Tips

(National Association of County & City Health Officials, 2017)

At the basic level, advocacy is building relationships, and the goal is to become a valuable resource for policymakers. No matter who the audience is, it would help if you  keep in mind the following: 

1. Be confident.
2. Frame your message to answer the question, “So what?”
3. Plan and practice your message.
4. Present a clear and compelling message; less is more.
5. Offer yourself as an expert resource and provide examples from your community; stories are more compelling than statistics.

Advocacy and Lobbying

Sometimes advocacy is confused with lobbying. Both are important in public health, but the two differ from one another.

Advocacy is public support for, or recommendations for, certain causes or policies. It is an action that educates, supports, or speaks in favor on behalf of others. It seeks to educate policymakers.

Lobbying is different because those who lobby are trying to influence lawmakers or decision-makers to add, change, remove, or enact laws. Advocacy, through education, can influence lawmakers and community leaders. Lobbying tries to convince those people to change laws or create new ones. 

Lobbying— “Attempts to influence a legislative body through communication with a member or employee of a legislative body, or with a government official who participates in formulating legislation. Lobbying can include written and oral communication for or against specific legislation.” (National Association of County & City Health Officials, 2017)

Here are some examples of the differences between advocacy and lobbying. 

1. Sam sends an email to city police officers about the many drivers that go over the speed limit on his neighborhood street. 

• This is an example of advocacy because Sam is not trying to change a law or to create a new one. He is educating the police about a possibly dangerous situation in his neighborhood.
  
  

2. Susan goes to a school board meeting to convince them to change the registration fees at her children’s school.

• This is an example of lobbying because Susan is trying to get the school board to change an existing policy.
  
  

3. Julie puts up a flier in the lunchroom about the dangers of drug use.

• This is an example of advocacy because Julie is not trying to create a new policy. She is letting people know about a health problem in her community.
  
  

4. Paul visits the city council members of his town and shares a factsheet containing important health data. He does this to get support to fund a new city park. 

• This is an example of lobbying because Paul is trying to influence public lawmakers to create a city park and provide funding for that park. 

Summary

Advocacy is education. It is an active promotion of a cause or principle that seeks to educate community and policy members. It does not try to convince lawmakers to create or change laws, nor does it seek out confrontation or conflict. Everyone can be an advocate and because of many efforts, advocacy has positively changed and improved many public health issues.

Section Two: Policy

Policies can be unwritten or written guidelines that people in different organizations or communities observe. Unwritten policies are similar to unwritten rules that people follow so that things are organized and run smoothly. 

For example, a company may not have a written policy that says employees must clean up if they make a mess in the lunchroom. Even though it is not written down as part of their contract, most employees clean up after themselves because there is an expectation to do that. 

Formal written policies have advantages over non-policy strategies. Though there is an expectation to clean up after making a mess, if the rule is not written down, some people may not feel they necessarily need to do it. 

However, if it is written that employees must clean up after using the lunchroom, all employees know they need to follow that rule. 

Another example of a written guideline is a business that sends out a memo encouraging employees to practice good hygiene. This encouragement may or may not result in the employees washing their hands after using the restroom.

However, suppose the business has a written policy that all employees must wash their hands before leaving the restroom. In that case, the employees are more likely to do it.

Policies can be public or private. 

Private policies are created by businesses, organizations, groups, or people to establish rules that shape how things are run. This includes regulations and contracts.

For example, all businesses, no matter their size, have policies about how they do business. They may have rules about store hours, what products are offered, how to hire people, compensation and salaries, vacation time, and how much paid maternity leave will be provided by the employer. 

Business owners may also put regulations on employer-employee relationships, employer-community relationships, and business practices and ethics. 

Public policy is created by public institutions such as local and national governments. These policies are usually discussed publicly and written down, either as or within laws and official regulations or as statements of policy in government documents. 

Examples of public policies are the amount of taxes people pay on food or property, environmental regulations, punishments for certain crimes, speed limits, rules on immigration, etc.   

This course refers to public policy as written statements that are binding and enforceable and broadly applicable to a geographic area, type of institution or physical space, and or a group of people. 

A public health policy has three components.

It is:
1. A written statement.
2. Binding and enforceable.
3. Broadly applicable to a geographic area, type of institution or physical space, or a group of people.  

Public health policy is critical because it takes health knowledge and applies it in the real world. Public health policies (rules and regulations) create action to improve the health and well-being of those living in communities. 

For example, research is clear that smoking cigarettes is harmful not only to the health of the individual smoking them but to those around them. In many countries, public health leaders and government officials have created regulations for smoke-free areas. This policy has taken the health knowledge of smoking and applied it to laws and regulations to protect community members from secondhand smoke. 

Changing Policy

Sometimes, public policy needs to be created, updated or changed. Some of the factors that influence creating or altering public laws are; public opinion, changes in the economy, scientific findings, political changes, and new technologies.

For example, over the last 100 years, more and more people began to drive automobiles. As more cars and roads were created, more laws and regulations needed to be put in place to protect drivers and pedestrians. 

Changes in official policy, leading to changes in laws and regulations, are often brought about from new information being available or from public pressure.

Drunk driving laws are an example of regulations brought about by public pressure. In some countries, family members and friends of those killed or hurt by drunk drivers lobbied for tougher consequences for people who drive after drinking. As a result of this public pressure, legislators created these more severe drunk driving laws. 

Community policy is made by a combination of factors, but two are by far the most important. One is the opinions of community leaders - not necessarily those elected, but those whose opinions are listened to, because of their economic or political clout, or simply because of the respect they've earned. These may include influential business people, clergy, educators, or directors of organizations, among others.

The second factor influencing public policy is public opinion. Public opinion may be formed partially by the opinions of community leaders, but is also a product of people's own experiences, the media, and the long-time standards and practices of the community. Tragedies like oil spills and nuclear reactor accidents have generated public opinion about the environment, which has influenced public officials to create new rules and regulations. 

Reasons to Change Policies

As we've discussed, policies usually grow out of people's assumptions about the world. As a result, they're often difficult to change, and efforts to do so require patience, sensitivity, and hard work to succeed. Why go to all that trouble? Why not just try to get around or ignore policy in the particular instance you're concerned with and leave it at that?

There are several reasons why changing policies is worth the trouble. In general, it's the difference between sweeping problems under the rug and actually cleaning them up so they don't appear again.

• Policies are the basis for community decisions. If you can change the policy, you may be able to affect community decisions about an issue well into the future.

• Attempting to change policies can start a community conversation about the issues in question. Attempts at policy change make clear that current policies are inadequate to deal with the issues and start people thinking about why. The resulting discussions can change people's thinking about other issues and the direction of the community as a whole.

• Changing policy is easier in the long run than fighting the same battles over and over again. Even if you're successful in gaining concessions on a particular issue, if you haven't changed the policy, you may have to work to gain those concessions again each time the issue arises. 

• Changed policies can change people's minds and attitudes. Once an issue is addressed in particular ways, the new policies themselves become part of the community's self-image and lead to long-term change.

• Changed policies have effects on the next generation. Policy change may have its greatest effects on schoolchildren. A whole generation can grow up with better ideas for social change.

• Policy change is one path to permanent social change. For all of the reasons above, changing policies is a way to change society. The policies in question may come in the form of official government policies translated into laws or regulations. Or they may come from the grassroots, unions, workplaces, and social groups. Regardless of where they originate, policy changes that speak to the real causes of social issues and the real needs of the people involved lead to real and permanent social change.

Who Should Change Policies?

Anyone concerned can and should be involved in trying to change policies. However, some groups or individuals are more likely than others to be successful. Some of these are organizations and professional groups that work with the issue, citizen-led community groups, and concerned individuals. 

Another group that is generally successful at policy change is a coalition. In many ways, a coalition is an ideal group to address policy change because, compared to other groups, coalitions have some built-in advantages:

• Coalitions can - and should - represent a broad cross-section of the community, including all those affected by the issues and policies. The broad representation leads to various perspectives, which can generate more and better ideas about how to proceed.

• Broad representation also means that the community's history with the issue, personal conflicts that might affect its resolution, and other such details will come out and be dealt with as part of a plan for policy change.

• Coalitions have credibility because they represent all points of view and include leaders and spokespersons of all segments of the community.

• Coalitions, because they involve all segments of the community, generate plans that everyone can buy into and feel ownership of.

When Should You Try To Change Policies?

There are particular times when the political or psychological climate is right for changing policies. That doesn't mean you can't work on policy change at any other time, but if it's a good time for change, you're more likely to be successful.

• Election years. Politicians are often more open to suggestions from constituents when an election - especially a close election - is on the line. If you're seeking a change in official government policy, close to an election may be the best time.

• When the issue first arises. Even though policies about the issue may already exist, it's sometimes easiest to change misguided ideas before there's been an investment of time and money in trying them out. Suppose you can convince policymakers or the public that there's a better way. In that case, they have less to lose by listening than they will after they've put their resources and reputations on the line backing something different.

• When there's a deadline for adding input to or making a policy decision. In 1995, for instance, when the federal Adult Education Act, which provided over $300 million for adult literacy, was up for renewal or discontinuation, adult educators and learners in many states mobilized to testify at public hearings, write to members of Congress, and otherwise try to influence the final decision.

• When a crisis is reached, and it's clear the current policy isn't working. Suppose the community has been responding to a drug problem with increased enforcement and punishment, and it's continuing to get worse. In that case, people may be willing to try alternatives. A government agency or foundation may be willing to try a new program or approach when it has become clear that what they've been funding hasn't been particularly effective.

• When a particular event or circumstance puts your target population at risk. A state fiscal crisis can often result in the threat - or reality - of a reduction in services, for example,  you may have to address policy to prevent the threat.

• When public opinion has reached critical mass. Policymakers can lag behind the public in their judgment of what people think and want. The public may be more progressive and support the change you advocate for. If that's the case, that support provides the perfect time for a policy-change campaign.

Another circumstance when public opinion can be your guide is when the public has become fed up with the policies of a particular business or institution. That entity might then be convinced to change its policies out of self-interest.

• When there's a specific debate about the issue. When policies are already under discussion, it's a good time to advocate for change. It may also be a necessary time to advocate for change to prevent a disastrous or badly flawed policy from being enacted.

• When new information changes perceptions about the issue. A study showing that particular methods do or don't work, a white paper contradicting current policies, evidence that an entity involved in an issue has been lying or behaving illegally or unethically - all these might serve to make it a good time to push policy change.

• When a publication or other source brings an issue to the public's attention. Articles in magazines or on social media can bring issues to the public’s notice and help to stir public opinion and change attitudes. 

How to Change Policies

All policy change starts with an assumption on someone's part that the current policy, or lack of policy, is not what's needed and that the current situation is unacceptable. Policy change is difficult and time-consuming, and it may look discouraging. But, with work and dedication, policy change is possible.

The fundamental guidelines for changing policies are the 8 Ps:

1. Planning, using a participatory strategic planning process.

2. Preparation, including doing all the necessary research and becoming an expert on existing policies.

3. Personal contact with policymakers, other change agents, and anyone else you have to deal with.

4. Pulse of the community: knowing what the community's attitudes are, what citizens will accept, and where to start to succeed.

5. Positivism, framing policy changes and their outcomes in a positive light.

6. Participation, including everyone affected by or concerned with the issue in planning and implementing policy change.

7. Publicity for your effort in general and your suggested policy changes - and the reasons for them - in particular.

8. Persistence, monitoring and evaluating your actions, and keeping at it for as long as necessary.

Those who successfully add or alter policies are usually good at emphasizing the benefits of policy change.

Here are some ways to emphasize the benefits of policy change.

• Economic: Recycling saves tax money and brings in income for the community. A healthy environment reduces medical costs. Attention to worker safety reduces time lost from accidents and injury and saves money in the long run.

• Social: Less violence and fewer drugs on the street lead to a more vibrant and satisfying community life, more recreational opportunities, and better opportunities for youth.

• Psychological: A safe working environment means less stress and greater feelings of security for workers, leading to greater productivity at work, and better family lives.

• Aesthetic: A cleaner environment, preservation of open space, and public art all bring people beauty in their daily lives.

• Physical and health: Lower stress, safer streets, less pollution, etc. all result in greater general health and physical well-being.

When trying to change policies, who should you stay in personal contact with?

Personal contact: Establish and maintain personal contact with those who influence or make policy. 

Personal relationships are the key to successful advocacy, and changing policy is no exception. If you can make a personal connection, not only with policymakers but with opinion leaders and political opponents, you can get your phone calls returned, make your voice heard and maintain a level of credibility greater than you could if you were only a name or a face.

Some of those with whom you might want to establish personal contact:

• Legislators

• Local elected and appointed officials. Especially in small communities, this is easy to do - in general, these people are your neighbors. Even in large communities, officials are usually interested and are willing to meet with you.

• Individuals at regulatory and funding agencies. They can provide information, speed up applications or complaints, and make your life easier.

• Key individuals and contacts at groups and institutions in the community. Opinion leaders, clergy, business leaders, members of target populations, and members of service clubs. The more people you know, the more community support you'll be able to generate when you need it.

• Directors or others at other community-based organizations, initiatives, and coalitions. Maintaining personal contact with organizations with which you already have a common purpose is particularly important. 

• The media.
  

(Chapter 34, Section 1. Working with the Media, n.d.)

Communication Tools: SBAR

When communicating with others, it is important to have a clear message. This can be especially important in the context of lobbying.  When lobbying, an individual tries to persuade someone with decision-making authority to adopt or change something.  Communicating the public health and community health message briefly yet completely is essential.

Using an established framework or communication tool can frequently help both the party trying to communicate a message and those hearing the message.

One such communication framework is SBAR, which stands for situation, background, assessment, and recommendation.  Using a tool like SBAR can help individuals prepare their message, knowing the person who will hear the message is often bombarded with many daily requests.  The clearer the communication, the less likely the hearer will be distracted or disinterested.

The elements of the SBAR framework and what should be communicated with each element are described below:

Situation:  Briefly describe the situation. Identify the problem and describe the negative effects and problems the situation is creating.

Background:  Describe the context in which the problem is occurring, the duration of the problem, and other pertinent information the decision maker will need to know to make a decision.

Assessment: Provide an interpretation or summary of what you think is going on. 

Recommendation: State a clear request with a time frame.  Be direct, but respectful of what you are asking for.

The following is an example of an SBAR in an advocacy or lobbying situation:

Situation: The southeast portion of the county is experiencing a higher incidence of malaria.

Background: This began two years ago. The population of that area has steadily been increasing during the same period. The new residents are in a much lower socioeconomic status and are experiencing extreme poverty. They do not have resources such as mosquito nets. Significant standing water exists throughout the area, and insecticide spraying has stopped over the past few years.

Assessment: The citizens of the southeast portion of the county are at risk for increased rates of contracting malaria due to decreased management and prevention efforts by the government.

Recommendation: Institute an oversight committee to confirm the causes of the increased malaria rates in this region and make the correct preventative interventions to solve this problem within the next six months.

In Summary

Every organization, governing body, and other group has a set of policies. Policies  generally based on a combination of logic and people's assumptions, correct or incorrect, about how the world is and works - dictate how those groups operate and can have a great deal of influence over community health and development.

When the policies of governments, funders, corporations, or other groups stand in the way of beneficial interventions or necessary fundamental community change, you may need to change the policies themselves. Changing policy is a step toward changing social conditions and real community development. It saves you from constantly repeating your effort, and, over the long term, changes people's minds and attitudes. 

The ideal policy change agents are broad-based coalitions. However, organizations that work with those affected by the policies in question, grassroots community initiatives, concerned professional groups, and determined individuals can all be effective in the right circumstances. The best times to try to change policy are when something important is at stake, either for policymakers (for example, an election) or for you (loss of funding, the imminent passage of a disastrous law or regulation); when the issue is at a crisis point; when it's already under discussion, when public opinion is behind you; or when new information or a new publication draws attention to it. 

References

Chapter 34, Section 1. Working with the Media. (n.d.). Community Tool Box. https://ctb.ku.edu/en/table-of-contents/advocacy/media-advocacy/working-with-media/main

National Association of County & City Health Officials. (2017). Building Your Advocacy Toolbox: Advocacy vs. Lobbying. https://www.naccho.org/uploads/downloadable-resources/flyer_advocacy-vs-lobbying.pdf