PUBLIC HEALTH ADVOCACY

HEE 106
Course Objective

At the end of the course, students should be able to identify concepts in public
health advocacy, volunteer to be a public health advocate and use concerted
efforts to converse for public health.

Course outline

1. Concept of Public Health

2. Definition of Public Health Advocacy
3. Identified terms in Public Health Advocacy
4. Types of advocacy for Public Health
5. Roles of Advocacy groups in Public Health
6. Frameworks in Public Health Advocacy
7. Components of Public Health Advocacy
8. Strategies for evaluating Public Health Advocacy programmes

Continuous Assessment including Class Attendance = 30 marks

Examination = 70 marks
NOTE: STUDENTS ARE EXPECTED TO MAKE AT LEAST 70% ATTENDANCE IN THIS COURSE
History of Public Health
In some ways, public health is a modern concept, although it has roots in antiquity. From
the beginnings of human civilization, it was recognized that polluted water and lack of
proper waste disposal spread communicable diseases (theory of miasma). Early religions
attempted to regulate behaviour that specifically related to health, from types of food
eaten, to regulating certain indulgent behaviours, such as drinking alcohol or sexual
relations. The establishment of governments placed responsibility on leaders to develop
public health policies and programs in order to gain some understanding of the causes of
disease and thus ensure social stability prosperity, and maintain order.
By Roman times, it was well understood that proper diversion of human waste was a
necessary tenet of public health in urban areas. The Chinese developed the practice of
vaccination following a smallpox epidemic around 1000 BC. An individual without the
disease could gain some measure of immunity against it by inhaling the dried crusts that
formed around lesions of infected individuals. Also, children were protected by inoculating
a scratch on their forearms with the pus from a lesion. This practice was not documented in
the West until the early-1700s, and was used on a very limited basis. The practice of
vaccination did not become prevalent until the 1820s, following the work of Edward Jenner
to treat smallpox.
During the 14th century Black Death in Europe, it was believed that removing bodies of the
dead would further prevent the spread of the bacterial infection. This did little to stem the
plague, however, which was most likely spread by rodent-borne fleas. Burning parts of
cities resulted in much greater benefit, since it destroyed the rodent infestations. The
development of quarantine in the medieval period helped mitigate the effects of other
infectious diseases. However, according to Michel Foucault, the plague model of
governmentality was later controverted by the cholera model. A Cholera pandemic
devastated Europe between 1829 and 1851, and was first fought by the use of what
Foucault called "social medicine", which focused on flux, circulation of air, location of
cemeteries, etc. All those concerns, born of the miasma theory of disease, were mixed with
urbanistic concerns for the management of populations, which Foucault designated as the
concept of "biopower". The German conceptualized this in the Polizeiwissenschaft ("Science
of police").
The science of epidemiology was founded by John Snow's identification of a polluted public
water well as the source of an 1854 cholera outbreak in London. Dr. Snow believed in the
germ theory of disease as opposed to the prevailing miasma theory. Although miasma
theory correctly teaches that disease is a result of poor sanitation, it was based upon the
prevailing theory of spontaneous generation. Germ theory developed slowly: despite Anton
van Leeuwenhoek's observations of Microorganisms, (which are now known to cause many
of the most common infectious diseases) in the year 1680, the modern era of public health
did not begin until the 1880s, with Louis Pasteur's germ theory and production of artificial
vaccines.
Other public health interventions include latrinization, the building of sewers, the regular
collection of garbage followed by incineration or disposal in a landfill, providing clean
water and draining standing water to prevent the breeding of mosquitoes. This
contribution was made by Edwin Chadwick in 1843 who published a report on the
sanitation of the working class population in Great Britain at the time. So began the
inception of the modern public health. The industrial revolution had initially caused the
spread of disease through large conurbations around workhouses and factories. These
settlements were cramped and primitive and there was no organised sanitation. Disease
was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the
inhabitants.
Concept of Public Health
Public health is the study and practice of managing threats to the health of a community. It
is concerned with threats to the overall health of a community based on population health
analysis. The population in question can be as small as a handful of people or as large as all
the inhabitants of several continents (for instance, in the case of a pandemic).
Definitions
1. Public health is defined as "the science and art of preventing disease, prolonging life
and promoting health through the organized efforts and informed choices of society,
organizations, public and private, communities and individuals."(WHO)
2. It is the science and art of preventing disease, prolonging life and promoting
physical health and efficiency through the organized community efforts, for the
sanitation of the environment, the control of community infections, the education of
the individual in the principles of personal hygiene, the organisation of medical and
nursing service for the early detection and preventive treatment of disease, and the
development of the social machinery which will ensure to every individual in the
community a standard of living adequate for the maintenance of health.” (Winslow,
1920).
3. It is the “the science and art of preventing disease, promoting health and prolonging
life through organised effort of the society." (Acheson)
Essential Elements of Public Health
a. Collective responsibility
b. Prime role of the state in protecting and promoting the public’s health
c. Partnership with the population served
d. Emphasis on prevention
e. Recognising underlying socio-economic determinants of health and disease
There are 2 distinct characteristics of public health:
1. It deals with preventive rather than curative aspects of health
2. It deals with population-level, rather than individual-level health issues
Public health is typically divided into other important subfields of
a. Epidemiology
 b. Biostatistics and health services
c. Environmental Health
d. Social health
e. Behavioural Health
f. Occupational Health
Dimensions of Public Health
There are four commonly used terms to describe the dimensions of Public Health. These
are
1. Preventive Medicine: This is based on the scientifically proved and widely accepted
axiom that ‘prevention is better and cheaper than cure’. It differentiates public health
from the clinical disciplines that are primarily involved with the care of the sick.
Public health emphasises the avoidance of illness which moves from protective
measures like immunisation and improved nutrition to early diagnosis and prompt
treatment of sick persons with the aim of preventing progression. It also extends
into reversing damage and restoring function. This dimension led to the
classification of prevention into four levels of primordial, primary, secondary and
tertiary respectively and the five stages of prevention namely general health
promotion, specific prophylaxis, early diagnosis and treatment, limiting damage and
rehabilitation.
2. Social Medicine: This dimension is based on the popular belief that ‘the poor die
young’. The rise of social medicine coincided with the increasing realisation of the
links between social status and the health of individuals. The objective of social
medicine is to identify social determinants of health and illness in the community
and to devise mechanisms for alleviating suffering and ill-health through social
policies and actions.
Social Medicine is based on the following fundamental assumptions as contained in
Alma Ata declaration of Sept, 1978
i. Health as a birthright
ii. The responsibility of the state
iii. Development and health are inter-related
iv. Education promotes health
v. Social factors have a profound influence on health
vi. Health begins at home
vii. Poverty is a major underlying cause of ill health
3. Community Health: This dimension deals with the services that aim at protecting
the health of the community. The intervention varies from environmental sanitation
 including vector control to personal health care, immunisation, health education etc.
4. Community Medicine: This dimension refers to services that are provided at the
community level and is encompassed in primary care.

Modern Public Health

As the prevalence of infectious diseases in the developed world decreased through the 20th
century, public health began to put more focus on chronic diseases such as cancer and
heart disease. An emphasis on physical exercise was reintroduced.

In America, public health worker Dr. Sara Josephine Baker lowered the infant mortality
rate using preventative methods. She established many programs to help the poor in New
York City keep their infants healthy. Dr. Baker led teams of nurses into the crowded
neighbourhoods of Hell's Kitchen and taught mothers how to dress, feed, and bathe their
babies. After World War I many states and countries followed her example in order to
lower infant mortality rates.

During the 20th century, the dramatic increase in average life span is widely credited to
public health achievements, such as vaccination programs and control of infectious
diseases, effective safety policies such as motor-vehicle and occupational safety, improved
family planning, chlorination of drinking water, smoke-free measures, and programs
designed to decrease chronic disease.

Meanwhile, the developing world remained plagued by largely preventable infectious

diseases, exacerbated by malnutrition and poverty. Front-page headlines continue to
present society with public health issues on a daily basis: emerging infectious diseases such
as SARS, making its way from China to Canada and the United States; prescription drug
benefits under public programs such as Medicare; the increase of HIV-AIDS among young
heterosexual women and its spread in South Africa; the increase of childhood obesity and
the concomitant increase in type II diabetes among children; the impact of adolescent
pregnancy; and the ongoing social, economic and health disasters related to the 2004
Tsunami and Hurricane Katrina in 2005. There are other ongoing public health challenges
these days including the Ebola threat in west Africa, Lassa fever in Nigeria, insurgencies,
kidnapping, rape, all forms of slavery including child labour, and other forms of terrorism..

Since the 1980s, the growing field of population health has broadened the focus of public
health from individual behaviours and risk factors to population-level issues such as
inequality, poverty, and education. Modern public health is often concerned with
addressing determinants of health across a population, rather than advocating for
individual behaviour change. There is a recognition that our health is affected by many
factors including where we live, genetics, our income, our educational status and our social
relationships - these are known as "social determinants of health." A social gradient in
health runs through society, with those that are poorest generally suffering the worst
health. However even those in the middle classes will generally have worse health outcomes
than those of a higher social stratum. The new public health seeks to address these health
inequalities by advocating for population-based policies that improve health in an
equitable manner.

The modern public health includes all the elements in the dimensions – preventive
medicine, social medicine, community medicine and community health. Important features
of modern public health which are
1. Multidisciplinary in outlook: This involves contributions from other health
related disciplines other than the medical profession in achieving the goals of public
health. Thus the health team include doctors, nurses, midwives, dentists,
pharmacists, anthropologists, epidemiologists, economists, philosophers,
educationists, communication and legal experts as well as managers.
2. Multi-sectoral: The health sector has two distinct roles of primarily planning and
delivering health services as well as leadership function in mobilising intersectoral
action. Public health services engages the expertise of other ministries, departments
and parastatals such as public works on water and sanitation, environment on
refuse and sewage disposal, education in creating awareness, transport on the
control of road traffic accidents, agriculture on food security, nutrition, use of
pesticides and the control of zoonotic infections.
3. Evidence-based: Modern public health demands that decisions should be science
and knowledge based. Policy making should be made only after objective analysis of
relevant information. Where such information is lacking, data should be collected
and analysed to inform decision making.
4. Equity-oriented: Public health programmes must be designed to promote
impartiality as the ultimate goal of all health action. The aim is to ensure that each
member of the society attain the highest possible level of health. Public health
practitioners must adopt a strong advocacy role in persuading decision-makers and
influential members of the society.
Functions of Public Health
Public health services perform a wide range of functions. These include:
1. Health surveillance, monitoring and analysis
2. Investigation of disease outbreaks, epidemics and risk to health
3. Establishing, designing and managing health promotion and disease prevention
programmes
4. Enabling and empowering communities to promote health and reduce inequalities
5. Creating and sustaining cross-Government and inter-sectoral partnerships to improve
health and reduce inequalities
6. Ensuring compliance with regulations and laws to protect and promote health
7. Developing and maintaining a well-educated and trained, multi-disciplinary public
health workforce
8. Ensuring the effective performance of public health services to meet goals in improving
health, preventing disease and reducing inequalities
9. Research, development, evaluation and innovation
10. Quality assurance in public health function
Public Health Programmes
Governments in most countries of the world recognise the importance of public health
programmes in reducing the incidence of disease, disability, and mortality from preventable
causes among its population, although public health generally receives significantly less
government funding compared with medicine. In recent years, public health programmes
providing immunisations have made incredible strides in promoting health, including the
eradication of smallpox, a disease that plagued humanity for thousands of years.
One of the most important public health issues facing the world currently is HIV/AIDS.
Tuberculosis which claimed many lives in the past is also re-emerging as a major concern
due to the rise of HIV/AIDS-related infections and the development of tuberculin strains
that are resistant to standard antibiotics.
Some other major public health concerns are the debilitating chronic non communicable
illnesses such as the cardiovascular diseases, neuropsychiatric conditions, malignant
neoplasms (cancers) diabetes, hypertension, etc across the globe whose incidences are
increasing rapidly.
A controversial aspect of public health is the control of smoking. Many nations have
implemented major initiatives to cut smoking, such as increased taxation and bans on
smoking in some or all public places. Proponents argue that by presenting evidence that
smoking is one of the major killers in all developed countries, and that therefore
governments have a duty to reduce the death rate, both through limiting passive (second-
hand) smoking and by providing fewer opportunities for smokers to smoke. Opponents say
that this undermines individual freedom and personal responsibility. However, proponents
counter that inflicting disease on other people via passive smoking is not a human
right, .and in fact smokers are still free to smoke in their own homes.
Application of Public Health Principles to Healthcare

As well as seeking to improve population health through the implementation of specific

population-level interventions, public health professionals also seek to improve population
health by improving the contribution of medical care to life extension and quality of life. [19]

Such improvements could be identified by assessing what need for health services existed
within the population, and:

1. Assessing current services

2. Ascertaining requirements as expressed by professionals, public and other
stakeholders
3. Identifying the most appropriate interventions
4. Considering the effect on resources
5. Agreeing and implementing any necessary changes

In addition public health professionals can improve population health through:

1. Assessing evidence of effectiveness and cost-effectiveness for proposed
interventions
2. The evaluation of healthcare to determine whether the activity in question is
meeting its objectives
3. Supporting decision making in healthcare and planning health services

HEALTH PROMOTION

The first International Conference on Health Promotion took place in Ottawa,

Canada in 1986. The conference was a response to growing expectations for a new
public health movement around the world. Out of this conference came the Ottawa
Charter for Health Promotion, a framework for action to achieve 'Health for All by
the Year 2000' and beyond.

From the Ottawa Charter, health promotion was defined as the process of enabling
people to increase control over, and to improve, their health.

The Ottawa Charter identifies three approaches for health promotion. These are:

1. Advocacy to create the essential conditions for health

2. Enabling people to take control of the determinants of health in order to
achieve their fullest potential
 3. Mediating between different interests in society in the pursuit of health (WHO
1986)

Advocate: Good health is a major resource for social, economic and personal development
and an important dimension of quality of life. Political, economic, social, cultural,
environmental, behavioural and biological factors can all favour or harm health. Health
promotion action aims at making these conditions favourable through advocacy for health.

Enable: health promotion focuses on achieving equity in health. Health promotion action
aims at reducing differences in current health status and ensuring equal opportunities and
resources to enable all people to achieve their fullest potential. This includes a secure
foundation in a supportive environment, access to information, life skills (critical thinking,
conflict resolution, healthy eating, avoiding risks) and opportunities for making healthy
choices. People cannot achieve their fullest health potential unless they are able to take
control of those things which determine their health. This must apply to women and men
equally.

Mediate: The prerequisite for health cannot be ensured by the health sector alone. More
importantly, health promotion demands coordinated action by all concerned (government,
non-governmental and voluntary organisations, local authorities, industries and the
media). People in all walks of life are involved as individuals, families and communities.
Professionals and social groups including health personnels have a major responsibility to
mediate between different interests in the society in the pursuit of health.

WHAT IS MEANT BY "ADVOCACY"

If there is no struggle, there is no progress. Those who profess to favor freedom,
and yet deprecate agitation, are men who want crops without plowing up the
ground. They want rain without thunder and lightning. They want the ocean
without the awful roar of its many waters. This struggle may be a moral one;
or it may be a physical one; or it may be both moral and physical; but it must be
a struggle. Power concedes nothing without a demandi.

Advocacy can and does have multiple meanings throughout the literature whether in the
general, human service, or health promotion senses. Within the health promotion field
much attention has focused on advocacy for policy change: "public health advocacy" or
"healthy public policy" We will characterize this as "policy advocacy". As such, Advocacy
tends to focus on large-scale changes in policies, programmes, and environments and on
mobilizing resources and opinions to support them. The target audience tends to be
decision-makers, policy makers, programme managers, and more generally those that are
in a position to influence actions that affect many people simultaneously.
The key point is that advocacy seeks to increase the power of people and groups and to
make institutions more responsive to human needs. It attempts to enlarge the range of
choices that people can have by increasing their power to define problems and solutions
and participate in the broader social and policy arena.

It is “a deliberate effort to change private and public decision-making with respect to

policy, organizational and personal behaviours” Personal behaviours might range from
individual lifestyles to economic practices that create health threatening inequalities or
pollution. In many such instances, some stakeholders win while others might lose, and the
losers might not always be institutions.

Two main goals underpin health advocacy,

1. Protecting people who are vulnerable or discriminated against;

2. Empowering people who need a stronger voice by enabling them to express their
needs and make their own decisions
Levels of Orientations in Advocacy for Health

1. Micro level: A micro orientation focuses on individuals or particular vulnerable

groups. It involves development of their capacities to improve their health/well-
being, partly by intervening on their behalf with other institutions.
2. Macro level. A macro orientation, in contrast, focuses on structural changes to
achieve fundamental alterations of the determinants of the health of populations.
This orientation recognizes that barriers to health cannot always be dismantled by
individuals, or on a case-by-case basis.

Advocacy in the Health Promotion Literature

Advocacy for healthy public policy reached its adolescence as a crucial strategy for health
promotion with the release of the Ottawa Charter for Health Advocacy for healthy public
policy does seek to alter policies in order to achieve identified health and well-being
outcomes. But it is also about changing the means by which policy is made, in particular by:

 Advancing democratic values

 Empowering people as participants in the polity
 Facilitating the capacities of communities and vulnerable populations to make their
needs and interests known
 Increasing peoples’ participation more substantively in processes allocating societal
resources and values among its members.
This reflects this close correspondence between strategies of community mobilization,
empowerment, participatory action research, and advocacy.

Definition of Public Health Advocacy

Public health advocacy is the process of promoting education, processes and legislation
that are designed to improve the general health of people living within a defined
geographical location. The process of advocacy also involves identifying potential threats to
the health of people living in the community and alerting others to the seriousness of those
threats. Many different people can function in some capacity to support this effort, from
volunteers to health care professionals and lawmakers.

Advocacy is described as a combination of individual and social actions designed to gain

political commitment, policy support, social acceptance and systems support for a particular
health goal or programme. Such action may be taken by and/or on behalf of individuals and
groups to create living conditions which are conducive to health and the achievement of
healthy lifestyles. Advocacy is one of the three major strategies for health promotion and can
take many forms including the use of the mass media and multi-media, direct political
lobbying, and community mobilization through, for example, coalitions of interest around
defined issues. Health professionals have a major responsibility to act as advocates for health
at all levels in society

Community advocates:

 Work with local residents to refer them to local services and empower them to be
positive change agents in the community.
 Work with agencies to develop programs that will better serve needs of residents
 Develop and monitor local policies
 Work with community sectors to implement alternative activity programs for youth

It is possible to find people engaged in the work of public health advocacy in a number of
ways. Some choose to work through a non-profit organization and seek to educate people
on particular health conditions and risk, such as cancer, tobacco use, or diabetes. Others are
more involved in the research aspect of advocacy, actively raising funds and resources that
can be devoted to the creation of new medicines and treatments that will help alleviate
suffering. Still others function as part of government oversight of federal and local
programs, including monitoring the condition of city water and sewage systems and
inspecting foods that are prepared and offered to the general public.

The goal of most organized public health advocacy efforts is twofold. First, the organization
seeks to present the general public with correct and current information regarding a
particular health condition or risk. This includes assisting persons suffering with the
condition in securing medical treatment, promoting research that will help minimize the
impact of the health risk, and alerting the public to situations within the community that
may increase the chances for spreading the health problem.

Second, public health advocacy goes behind education to promote action. This often takes
the form of encouraging the implementation of laws and standards that will pave the way
for better health conditions for all people in the community. From this perspective, the role
of a public health advocate is not just about pointing out the problem but also promoting
solutions.

Just about anyone can participate in the process of public health advocacy on some level.
Volunteers can support local non-profits that focus on one or more health issues with
donations of time and money. People who wish to make public health a career can become
inspectors or find work with educators who provide correct data about various public
health threats. There is also the option of working for an advocate program full-time,
possibly serving as a lobbyist that focuses on urging lawmakers to pass legislation that will
improve health conditions for the public.

Effective Advocacy

Effective advocacy involves identifying and assessing the power of opposition groups and
supporters as a basis for tagetting action to build support and develop coalitions. It relies
on tactical use of persuasive communication. Presenting the evidence is not enough.

Anyone can be an advocate, but to be an effective advocate requires practice, patience,

perseverance and professionalism. Here are a few tips to help you make a real impact when
advocating on any issue:

1. Be prepared. Know the facts and key points and try to understand the issue from
multiple viewpoints (arguments for and against). The more you know, the more
comfortable you will feel talking about the issue with anyone, including elected
officials and policy makers.

2. Be clear and concise. Know how to communicate your message quickly but effectively. A
few brief but well thought-out points always have more impact than a long rambling
statement. If you have a story to share, boil it down and practice making it clear and
compelling.

3. Reflect confidence. Do not be intimidated; if the issue is important to you, it is important

to many others as well. Convey your message with confidence and try to avoid
 sounding unsure or hesitant. If you do not know the answer to a question, say so,
and offer to find out; then follow-up later with the requested information.

4. Find your own voice. Know the facts and try to stay “on message,” but personalise it.
Weave in some personal examples and practice conveying key points in your own
words. Share your story or the stories of those around you (e.g. family, friends,
community members, patients, etc.) to help illustrate how the issue affects people.
Personal stories that evoke emotion are incredibly effective; people may not always
remember the facts, but they will always remember how you made them feel about
an issue.

5. Be an active listener. Listen with your eyes and ears. Look for visual cues (body
language) to see how receptive the other person is to your message; ask questions
and listen for the response; hear not only the words being spoken but also the
underlying message being delivered. These actions can help you to find common
ground even if the other person does not fully agree with your position on an issue.
By becoming a better listener, you can improve your ability to influence and
negotiate.

6. Manage your emotions. Draw on your passion and motivation to help drive your
advocacy work, but do not let anger or frustration about an issue overshadow your
message. Be calm and polite and always use “positive” language. Effective advocacy
is about building relationships, so keep an open mind and approach all
conversations on an issue as an opportunity to raise awareness and educate.

7. Reach out. Engage as many people in your advocacy work as possible. Look for
opportunities to raise awareness about the issue through networking or social
events, face-to-face meetings, emails, phone calls and social media. Talk about what
you are advocating for with others in your community. You will be surprised at how
quickly you can build a base of support once you begin reaching out.

8. Embrace technology. Social media can greatly enhance your advocacy efforts; embrace
it. If you are not yet active on social media, Get training and template posts
(Facebook) or tweets (Twitter) to help you get started. You are also encouraged to
actively participate in online advocacy campaigns to help raise awareness about
advocacy efforts and public policy recommendations.

Above all, remember that advocacy is a process, not a one-time event. One campaign or
meeting is usually not enough to influence change, so set realistic expectations and be
patient and persistent. Every time you speak out on an issue – in person, by email or phone,
through social media, or at community events – you are raising awareness, building
support and setting the stage for moving people to action. These are the building-blocks
that drive change.

Five Steps for Effective Advocacy

Five specific steps are recommended;

1. Complete data: Data must be as complete as possible. The data weaponry is not only
the information provided, but also the credibility of the data which needs to be
gathered systematically in a scientific way, and be seen to be so otherwise the public
and decision makers can select the data that they like when they view both parties
as biasing their data for partisan self-interest.

2. Coordinated action: There must be coordinated action around the issue area. This
provides some indication of the varying types of expertise that would be useful in an
advocacy effort, and an aid in the planning for coordinated action.

3. Specific goals: Advocates must define their efforts in terms of concrete, specific
goals. This would be aided if those opposing legislation face even worse
alternatives. The necessity for specific, well-defined goals has been frequently
stressed in the literature, despite the recognition that effective public health
advocacy involves multiple intermediate products (e.g., passage of seat belt laws,
increased traffic stops to screen for alcohol level), although strategies or tactics
often dictate a focus on a single product (e.g., mandated air bags in the 1980s)

4. Local/global coordinated action: Effective national advocacy requires simultaneous

advocacy in every state or province of a nation. While opponents of the advocacy
interests may be quite powerful at the national level, it is often more difficult for
them to impede efforts at lower levels. Building a local base of support, in turn,
increases political pressure at higher levels of government.

5. Public appeal: Ways must be devised to capture the imagination and attention of the
public media.

Barriers to Effective Advocacy

There is increased awareness about the importance of advocacy and changes have taken
place to enable increased participation. However, large barriers to effective advocacy
remain. Barriers can include:

1. Lack of credibility - Individuals may be judged as not accurately representing their

community’s concerns even when they have been invited to participate as a
‘community representative.
 2. Lack of organisation – Advocacy is more effective when there are many people who
feel strongly about the same cause and who are focused on the same goals and
activities.
3. Resistance to change – Change is difficult to implement. This is particularly true in
larger organisations with a well-developed organisational culture.
4. The nature of society – Information and education will help reduce prejudice. It is
important to recognise that there are forces, like the way the media portrays some
ethnic or faith groups that will influence community attitudes and reinforce
stereotypes.
5. Political will – Advocacy may not produce the desired change because of political
factors. Sometimes a good idea is just too challenging at that time or in that
situation.
6. Sustainability – Sometimes advocacy activity requires effort over a long period.
Energy or interest in a cause may not be sustained for a range of reasons.
7. Location – People living in rural communities have extra challenges in carrying out
advocacy because they may be more isolated and have fewer services.

Styles in Advocacy

Advocacy as a health promotion strategy has two inter-relating but somewhat different
facets:

• Prescriptive or campaign-style advocacy: A campaign message must speak at one and

the same time to the brain and the heart. Furthermore, effective advocacy campaigns often
use a simplifying concept (such as a catchy phrase) to communicate more complex ideas.
Symbolic representations can also be used such as Red Ribbon for HIV awareness, Pink
Ribbon for Cancer awareness or use of Wrist Band as symbol for ‘Make Poverty History.

• Empowering or community development-style advocacy: This approach seeks

participation and empowerment, which suggests that this type of advocacy would use a
social health promotion approach to health inequalities. Facilitating community definitions
of health and health problems is therefore a key role for the advocate who wishes to
practice social health promotion. Health promotion work on community development may
evolve into empowerment for action, which for some is the ultimate goal of practice

Types of Advocacy
Case Advocacy
 Listen
 Give opportunity for people to make their own case; self-advocate
 Help them to access legitimate authority
 Equalise power base
 Reinforce staff / management to use their authority appropriately; to act
responsibly
 Bring reality to the situation
 Persist in a consistent manner until meaningful resolution is gained
 Teach skilful ways to disagree with people; role model appropriate dispute
resolution
 Create safety, put in place safeguards
 Follow up
System Advocacy
Systems Advocacy, with a small "s", refers to advocacy initiatives in the context of
organizations/agencies or community that will influence programs and practices to benefit
children/youth. All systems advocacy is generated by case advocacy. When it is clear that
policies and practice in agencies interfere with the quality of life and development of
people especially children and youth, then systemic advocacy is required.

Policy Advocacy
Policy advocacy refers to advocacy tactics, strategies and initiatives which target changes
to policies and legislation. These advocacy initiatives seek to establish new policies,
improve existing policies or challenge the development of policies that diminish resources
and opportunities for vulnerable groups of people such as children and youth. Policy
generally refers to 'social' policy. Policy advocacy usually seeks to engage various sectors of
the government which includes: public servants, bureaucrats, political appointees, elected
officials and legislators. All policy advocacy should be generated by case and 's' systems
advocacy.

Benefits of Advocacy

Issues that people advocate about can be specific to an individual (self advocacy) or involve
an entire community or a group of people (collective advocacy). Collective advocacy often
attempts to influence or change society.

Advocacy is aimed at bringing change or reform. Advocacy challenges services, systems and
the broader community to respond genuinely to meet the expressed requirements or needs
of people. Effective advocacy will inevitably empower people in their everyday lives.
Advocacy and promoting the needs of your community can:

• Open doors to participation

• Right wrongs in the public health system

• Change the balance of power especially in health management and administration

• Address injustice in the health system

• Improve health services

• Alter health attitudes and values

Ways of Locating Advocacy practice in Health Promotion

Advocacy is the most political of health promotion strategies, risky both to practitioners
and agencies. Different ways have been identified in literature to determine whether what
is being carried out is advocacy or not. These include

1. Representational Advocacy: This involves representation of the underprivileged

(case advocacy) such as those who are disadvantaged or sick, with the aim of
promoting their rights and/or redressing imbalances in power. This has been
characterized as ‘case’ advocacy: Case advocacy is acting on behalf of a client
(individual, family or group) in order to access needed resources, services, or to
influence policy change. Keep in mind client consent and involvement in the process. It
also involves lobbying activity within public health which acknowledges that barriers
to health can lie beyond the control of individuals, and that structural factors need to be
addressed if health inequalities are to be reduced. This has been characterized as
‘cause’ advocacy . Most often, representational advocacy operates at the level of cases
rather than causes
2. Confrontational Activity or Community activism: it is about challenging powerful
anti-health interests such as tobacco policy. Activism therefore involves enabling
community to challenge the cause of poor health. Not every important public health
determinant can be attacked simultaneously. Priorities should be set, and changed, in
accordance with windows of opportunity. Therefore, this type of advocacy moves
beyond facilitating community definitions of need to enabling communities to challenge
the causes of poor health more directly at the policy-making and structural level, i.e.
social health promotion. Although the advocate operates at the level of ‘causes’, his or
her goals remain facilitative and empowering. This model of advocacy seeks to provide
communities with political advocacy skills rather than individualistic skills to make
‘better choices’. Greater levels of local community involvement in setting agendas for
action, and in the practice of health promotion, result in greater impacts on that
community
3. Community Development: In this type of health advocacy, the goals of health
promotion are enablement rather than protection/prevention. The practitioner's status
is likely to be that of a facilitative co-worker employing an egalitarian philosophy of
 practice. Advocacy activities are orientated towards ‘case’ level work with individuals
and groups, identifying their needs and seeking to address these at the local level.
Advocacy may also have a capacity building function, providing support for
disadvantaged individuals and/or communities to gain control over and improve their
own health by becoming effective policy advocates
4. Social Policy Reform: Social policy refer to guidelines, principles, legislation and
activities that affect the living conditions conducive to human welfare, such as a
person's quality of life. Social Policy Reform is a process in which changes are made to
the formal “rules of the game” – including laws, regulations and institutions – to address
a problem or achieve a goal such as economic growth, environmental protection or
poverty alleviation.
This type of advocacy is likely to require knowledge of local and national political
systems and other complex mechanisms. Work at this level demands that the advocate
practitioner possesses a degree of ‘expert’ knowledge and authority in order to have
credibility. Examples of this type of prescriptive advocacy may focus on legislative
reform relating to the availability of products perceived as antithetical to health such as
tobacco, alcohol or illegal drugs, or on the prevention of environmental hazards and
pollution, etc. The ‘champions’ of this type of social change in the interests of public
health are unlikely to be lone health promotion specialists working within local health
or social services, but are clearly drawing on a medically orientated view of health
promotion

Essentially, individuals have a different reason for engaging in advocacy. Some will
want to act at a local, personal level. Others will want to act at a higher level and
influence matters of national importance. There are many ways of undertaking
advocacy and promoting the needs of your community. Some examples include:
 Participating in community consultation about a decision through satisfaction
surveys, suggestion boxes, questionnaires, program evaluations or forums
 Joining advisory or reference groups to offer input from a community
perspective
 Holding full membership and voting rights on decision-making bodies
 Forming and operating self help and peer support groups
 Becoming involved in lobbying and advocacy activities
 Being employed to fill roles such as: consultants on projects, community
liaison in agencies and conducting social research
 Advocates may also work with training institutions, including universities, to
raise awareness about their community’s needs. They may also be contracted
to conduct training workshops with staff of particular services
Identified Terms in Public Health Advocacy

Public health advocacy plays an important role in the creation of public health policy,
including general health care policy. By educating the public, identifying threats to the
health of citizens in general, and promoting action to minimize or remove those threats, the
advocate joins with other public health professionals in making the quality of life much
higher for some people than it would have been otherwise.

Quality of life is defined as individual’s perceptions of their position in life in the context of
the culture and value system where they live, and in relation to their goals, expectations,
standards and concerns. It is a broad ranging concept, incorporating in a complex way a
person’s physical health, psychological state, level of independence, social relationships,
personal beliefs and relationship to salient features of the environment. This definition
highlights the views that quality of life refers to a subjective evaluation, which induces both
positive and negative dimensions, and which is embedded in a cultural, social and
environmental context. WHO identified six broad domains which describe core aspects of
quality of life cross-culturally: a physical domain (e.g. energy, fatigue), a psychological
domain (e.g. positive feelings), level of independence (e.g. mobility), social relationships
(e.g. practical social support), environment (e.g. accessibility of health care) and personal
beliefs/spirituality (e.g. meaning in life). The domains of health and quality of life are
complementary and overlapping.

Quality of life reflects the perception of individuals that their needs are being satisfied and
that they are not being denied opportunities to achieve happiness and fulfilment,
regardless of physical health status, or social and economic conditions. The goal of
improving the quality of life, alongside preventing avoidable ill-health, has become of
increased importance in health promotion. This is particularly important in relation to
meeting the needs of older people, the chronically sick, terminally ill, and disabled
populations.

Public Healthy Policy: Policy is used in a variety of ways. It could be used to describe a
very general statement of intentions and objectives or a set of actions of government in a
particular area. Health policy is therefore a set of standing rules that are intended to guide
health actions or inactions. Public health policy therefore is a formal statement or
procedure within institutions (notably government) which defines priorities and the
parameters for action in response to health needs, available resources and other political
pressures.

Equity means fairness. Equity in health means that people’s needs guide the distribution of
opportunities for well-being. The WHO global strategy of achieving Health for All is
fundamentally directed towards achieving greater equity in health between and within
populations, and between countries. This implies that all people have an equal opportunity
to develop and maintain their health, through fair and just access to resources for health.
Equity in health is not the same as equality in health status. Inequalities in health status
between individuals and populations are inevitable consequences of genetic differences, of
different social and economic conditions, or a result of personal lifestyle choices. Inequities
occur as a consequence of differences in opportunity which result, for example in unequal
access to health services, to nutritious food, adequate housing and so on. In such cases,
inequalities in health status arise as a consequence of inequities in opportunities in life.

Lifestyle is a way of living based on identifiable patterns of behaviour which are

determined by the interplay between an individual’s personal characteristics, social
interactions, and socioeconomic and environmental living conditions. These patterns of
behaviour are continually interpreted and tested out in different social situations and are
therefore not fixed, but subject to change. Individual lifestyles, characterized by identifiable
patterns of behaviour, can have a profound effect on an individual’s health and on the
health of others. If health is to be improved by enabling individuals to change their
lifestyles, action must be directed not only at the individual but also at the social and living
conditions which interact to produce and maintain these patterns of behaviour. It is
important to recognize, however, that there is no “optimal” lifestyle to be prescribed for all
people. Culture, income, family structure, age, physical ability, home and work environment
will make certain ways and conditions of living more attractive, feasible and appropriate.

Social capital represents the degree of social cohesion which exists in communities. It
refers to the processes between people which establish networks, norms, and social trust,
and facilitate co-ordination and co- operation for mutual benefit. Social capital is created
from the myriad of everyday interactions between people, and is embodied in such
structures as civic and religious groups, family membership, informal community
networks, and in norms of voluntarism, altruism and trust. The stronger these networks
and bonds, the more likely it is that members of a community will co-operate for mutual
benefit. In this way social capital creates health, and may enhance the benefits of
investments for health.

Social support is the perception and actuality that one is cared for, has assistance available
from other people, and that one is part of a supportive social network. It means having
friends and other people, including family, to turn to in times of need or crisis to give one a
broader focus and positive self-image. Social support enhances quality of life and provides
a buffer against adverse life events.

Types of Social Support

Emotional Expressions of empathy, love, trust and caring
Instrumental Tangible aid and service
Informational Advice, suggestions, and information
Appraisal Information that is useful for self-evaluation

Supportive environments for health offer people protection from threats to health, and
enable people to expand their capabilities and develop self reliance in health. They
encompass where people live, their local community, their home, where they work and
play, including people’s access to resources for health, and opportunities for
empowerment. Action to create supportive environments for health has many dimensions,
and may include direct political action to develop and implement policies and regulations
which help create supportive environments; economic action, particularly in relation to
fostering sustainable economic development; and social action.

Advocacy by an individual or by an advocacy group normally aim to influence public-

policy and resource allocation decisions within political, economic, and social systems and
institutions; it may be motivated from moral, ethical or faith principles or simply to protect
an asset of interest. Advocacy can include many activities that a person or organisation
undertakes including media campaigns, public speaking, commissioning and publishing
research or poll or the 'filing of friend of the court briefs'.

Lobbying (often by Lobby groups) is a form of advocacy where a direct approach is made
to legislators on an issue which plays a significant role in modern politics.

Types of Advocacy

There are several types of advocacy, which each represent a different approach in the way
change is brought into society. One of the most popular type is Social Justice Advocacy (the
way in which human rights are manifested in everyday lives of people at every level of the
society i. e equal distribution of wealth)

Social Justice Advocacy works for structural and enduring changes that increase the
power of those who are most disadvantaged politically, economically and socially. It tackles
the root and avoidable causes of inequalities for those who are systematically and
institutionally disadvantaged by their race, ethnicity, economic status, nationality, gender
expression, age sexual orientation or religion. It also aims for better participation in
alignments with and adherence to , international human rights.
Although, the initial definition does not encompass the notions of power relations, people’s
participation and a vision of a just society as promoted by social justice advocates should
be emphasised. For them, advocacy represents the series of actions taken and issues
highlighted to change the “what is” into a “what should be”, considering that this “what
should be” is a more decent and a more just society. Those actions, which vary with the
political, economic and social environment in which they are conducted, have several
points in common.

 Question the way policy is administered

 Participate in the agenda setting as they raise significant issues
 Target political systems “because those systems are not responding to people’s
needs”
 Are inclusive and engaging
 Propose policy solutions
 Open up space for public argumentation.

Some of the other types of advocacy include:

 Budget advocacy: Budget advocacy is another aspect of advocacy that ensures

proactive engagement of Civil Society Organizations with the government budget to
make the government more accountable to the people and promote transparency.
Budget advocacy also enables citizens and social action groups to compel the
government to be more alert to the needs and aspirations of people in general and
the deprived sections of the community.
 Bureaucratic advocacy: people considered “experts” have more chance to succeed
at presenting their issues to decision-makers. They use bureaucratic advocacy to
influence the agenda, however at a slower pace.
 Health advocacy: Health advocacy supports and promotes patient's health care
rights as well as enhance community health and policy initiatives that focus on the
availability, safety and quality of care.
 Ideological advocacy: in this approach, groups fight, sometimes during protests, to
advance their ideas in the decision-making circles.
 Interest-group advocacy: lobbying is the main tool used by interests groups doing
mass advocacy. It is a form of action that does not always succeed at influencing
political decision-makers as it requires resources and organisation to be effective.
 Legislative advocacy: legislative advocacy is the “reliance on the state or federal
legislative process” as part of a strategy to create change.
 Mass advocacy: is any type of action taken by large groups (petitions,
demonstrations, etc.)
  Media advocacy: is “the strategic use of the mass media as a resource to advance a
social or public policy initiative”. In Canada for example, the Manitoba Public
Insurance campaigns illustrate how media advocacy was used to fight alcohol and
tobacco-related health issues. We can also consider the role of health advocacy and
the media in “the enactment of municipal smoking bylaws in Canada between 1970
and 1995.”
 Social advocacy is recognized as part of a health professional's role. It is an effective
way to work for public policy reform. Health professionals can:
- act as advocates and lobbyists themselves, or
- encourage and support other community members to take up
advocacy and lobbying
There are a number of national and local organisations which could act to advocate for
better health for the community. Some examples are:
 the Consumers' Health Forum
 the Public Health Association
 The Nigerian Heart Foundation
 Nigerian School Health Association
 National association of Sports Science and Medicine
 Nutrition Foundation
 Tobacco Control Coalition
 Medical Services Alliance

Different contexts in which advocacy are used:

 In a legal/law context: An 'advocate' is the title of a specific person who is

authorized/appointed (in some way) to speak on behalf of a person in a legal
process. See advocate.
 In a political context: An 'advocacy group' is an organized collection of people who
seek to influence political decisions and policy, without seeking election to public
office. See Advocacy group and Lobbying.
 In a social care context: Both terms (and more specific ones such as 'independent
advocacy') are used in the UK in the context of a network of interconnected
organisations and projects which seek to benefit people who are in difficulty
(primarily in the context of disability and mental health).
 In the context of inclusion: Citizen Advocacy organisations (citizen advocacy
programmes) seek to cause benefit by reconnecting people who have become
isolated. Their practice was defined in two key documents: CAPE, and Learning from
Citizen Advocacy Programs.

Roles of Advocacy Groups in Public Health

Advocacy is led by advocates or, when they are organized in groups as is the case most of
the time, advocacy groups. Advocacy groups are different from political parties which "seek
to influence government policy by governing." They are "any organization that seeks to
influence government policy, but not to govern." This definition includes social movements,
sometimes network of organizations which are also focused on encouraging social change.
Social movements try to either influence governments or, like the environmental
movement, to influence people’s ideas or actions.

Today, advocacy groups contribute to democracy in many ways. They have five key
functions:

 Assist in the development of better public policy

 Ensure governments’ accountability to citizens.
 Give a voice to (misrepresented) citizen interests
 Mobilize citizens to participate in the democratic process
 Support the development of a culture of democracy

Advocates and advocacy groups represent a wide range of categories and support several
issues as listed on WorldAdvocacy.com. The Advocacy Institute, a US-based global
organization, is dedicated to strengthening the capacity of political, social, and economic
justice advocates to influence and change public policy.

The phenomenon of globalization draws a special attention to advocacy beyond countries’

borders. The core existence of networks such as World Advocacy or the Advocacy Institute
demonstrates the increasing importance of transnational advocacy and international
advocacy. Transnational advocacy networks are more likely to emerge around issues
where external influence is necessary to ease the communication between internal groups
and their own 1 government. Groups of advocates willing to further their mission also tend
to promote networks and to meet with their internal counterparts to exchange ideas.

Frameworks in Public Health Advocacy

The framework involves 3 main stages: information, strategy, and action. These stages are
conceptually sequential but, in practice, simultaneous. The work at each stage is
continually adjusted according to circumstances at the other stages.

The information stage refers to the activities that are involved in identifying,
describing, and quantifying the extent of a public health problem: its patterns of
occurrence, risk and protective factors, causal sequences, program effectiveness for
each level of prevention, barriers to effectiveness, and changes over time in all of these
 factors. The interim results of this stage generally appear as data reports, journal
articles, and the like.

The strategy stage refers to the activities that are involved in using the available
information to identify what needs to change to improve public health. This includes
accurately conveying the information to professional and lay audiences, specifying
discrete short-term objectives and time frames, mobilizing coalitions to work on the
issue and toward the objectives, developing means to foster needed changes, and
publicizing these elements. The interim results of this stage include policy statements,
public education messages and campaigns, fact sheets, press conferences, news stories,
strategy meetings, and networks of individuals and organizations.

The action stage refers to the activities involved in implementing specific strategies,
including raising funds, specifying tactics, formulating detailed time lines, shifting the
focus of staff in key organizations (e.g., local government) to the issue, convincing
individuals to change their lives, convincing individual policymakers to get involved,
crafting regulations and legislation, and pursuing the political activities needed to put
these activities into effect (including anticipating and addressing challenges). The
interim products of this stage include changes in attitudes, habits, resource allocation,
the physical and social environments, social interaction, and societal rules that can
affect the frequency or severity of public health problems.

Leading causes of mortality and morbidity affect not only individual health but also the
public health. As a result, they deplete social as well as personal resources. Leading among
these problems today are infections (e.g., HIV), chronic diseases (e.g., diabetes), and
injuries (e.g. those due to motor vehicles). Although the series of events leading to death
and disability from such problems is manifest in individuals, these events are usually
(perhaps always) fostered by psychosocial and physical phenomena that are key to disease
occurrence or severity and that operate in populations or subpopulations.

Contributing factors include prevalent toxic and addictive substances and products (e.g.,
cigarettes); cultural patterns (e.g., violence); and commercial promotion of personal
lifestyle options that involve self-destructive habits (e.g. sedentary living). Reducing the
societal burden of public health problems requires interventions designed to alter the
societal factors that foster these problems. Although such work is widespread, its processes
and products have not been well described.

Health problems represent the range of physical and mental dysfunctions that reduce life
duration, create sufficient acute or chronic disability to impede personal and community
functions (including work and social interactions), and/or are treated by medical and allied
care providers. Health problems become public health problems when they actually or
potentially affect a substantial portion of a community (or a much higher proportion than
in other communities), involve the use of substantial common resources, or alter the way
the community functions or allocates its resources.

Ethical Framework for Advocacy

There is no formal ‘code of ethical conduct’ for advocates and leaders in the community
sector. But there are a number of clear principles about what are decent and proper ways
to work as a community advocate, leader, or as a representative organisation. Since
advocacy often focuses on justice and equity, advocacy activities are strongly influenced by
an understanding of what makes up ethical behaviour. Advocacy is about all members of
the community being empowered and valued as equal citizens.

Deciding what to do and how: Before you advocate on behalf of others you should have a
clear understanding of what your community thinks the issues of concern are, as well as
the actions that will best address them. Consultation and meetings with your community
will enable you to decide as a group what the main issues are and how to respond to them
in a planned way. This process will also enable members of your community to have a say
and become involved in the process of change. This is a great way to empower people.
There may be different views in your community. It is important to acknowledge this. The
challenge in advocacy is to maintain a strong sense of the views of the majority of people
within your community. You also need to respect and be sensitive to other people who may
have a different point of view to you.

Confidentiality: If you are advocating on behalf of someone else, it is vital that you are
aware of issues concerning confidentiality. Confidentiality is about having control over who
has access to information about people and in what form. There are many issues about
confidentiality that are not as simple or obvious as they appear. Some of the basic issues to
consider include:

• What consumers of services mean by confidentiality can be quite different to what service
providers mean

• Confidentiality means that information is not discussed with others

• Confidentiality means you do not identify a person to a third party (or parties) without
that person’s permission

• Confidentiality means that you do not discuss another person’s affairs where you could be
overheard by those not directly concerned

• Confidentiality means treating any information you have about another person with
respect for their privacy – do not discuss a person’s information with others without that
person’s permission.
Accountability and responsibility: Being accountable means that you need to be able to
justify your words and actions. In some cases you may be required to be formally
accountable to an employer, funding body, group, or person (for such things as reports or
invoices). In other cases, accountability may mean taking responsibility for your role in a
less formal or structured way. You may find yourself in a situation where you are
accountable to more than one person or group and there is a conflict. First, consider your
own conscience and whether you believe that your actions are morally right. Second,
consider how your actions may be interpreted in the worst possible way by an objective
onlooker. Make sure that your actions cannot be interpreted as foolish or self-interested
and that they can be defended

Representing the community – your role on committees: Advocacy can sometimes

involve representing a group or a cause, for example, when acting as a community
representative on a committee of management. It is important to be clear about the intent
or purpose of representation. You may be being asked to represent your own views as an
individual, the views of your community, or of an organisation you are associated with. If a
community leader or advocate is going to represent the views of their community, it is
important that they fully understand the opinions, views and perceptions of their
community

Appointees: Sometimes community leaders are asked to sit on special advisory

committees because they are well known or have particular expertise or experience. These
people are in a position of great responsibility as community leaders. A lot of what they are
asked to discuss will be confidential and they will not be able to share it with others. They
are oft en selected because they come from an organisation that has access to a network of
people or organisations in their community. Although they are not representative (in the
usual sense), a part of their responsibility is to think about how they frame the information
and advice they put forward within the committee.

Tokenism: Tokenism is the inclusion of a representative from a socially marginalised

group into a mainstream body to satisfy anti discrimination legislation or to take advantage
of targeted funding opportunities. Community representatives can be included in a token
way as researchers or as members of advisory and evaluation boards or during
consultation. Where this occurs there may not be a genuine attempt to listen and learn how
to respond better to the expressed needs of the communities. Tokenism could be addressed
by:

• Seeking to have at least two (preferably more) community representatives present

to avoid being the lone voice when decisions are made

• Ensuring that clear and understandable information relevant to your community’s

concerns is available to all participants to assist with decision-making
 • Seeking to ensure that the perspectives communities are fully integrated into
training programs. Community representatives should be included during the
planning stages of programs in which they are to participate

Components of Public Health Advocacy

Informal discussions of public health advocacy often assume that one or another specific
action (e.g., legislation) constitutes its unique product or process. But a closer look shows
that there are many products and processes involved.

Products

2. The final products of effective public health advocacy are reduced morbidity and
mortality.
3. Intermediate products include the bringing together of disparate forces to work for a
common goal and changes in the conduct of individual and community life from
behaviours that impede health to ones that promote it (or from behaviours that
promote health problems to ones that do not). In efforts to reduce motor vehicle
injuries, for example, intermediate goals have included a reduced frequency of drunk
driving and increased safety belt use (at the individual level), along with improved
vehicle construction standards and a reduced tolerance of drunk driving (at the
community level).
Effective reductions in public health problems usually require multiple changes at each
level. Therefore, effective public health advocacy involves multiple intermediate products
(e.g., passage of seat belt laws, increased traffic stops to screen for alcohol level), although
strategies or tactics often dictate a focus on a single product (e.g., mandated air bags in the
1980s).

Processes

Public health advocacy activities include

1. Problem identification;

2. Research and data gathering;

3. Professional and clinical education, as well as education of those involved in the

creation of public policy (including media coverage);

4. Development and promotion of regulations and legislation;

5. Endorsement of regulations and legislation via elections and government action;

6. Enforcement of effective policies; and

7. Policy process and outcome evaluations.

All of these activities occur in a situation in which many groups and individuals are
involved, often from distinct functional perspectives, including governmental (executive or
legislative branch), geographic, religious, racial or ethnic, family, professional, and
personal. The participants in public health advocacy work on its processes in distinct and
overlapping ways, depending on their positions in society and the health care environment.

Strategies for Evaluating Public Health Advocacy

Because of the various features of public health advocacy, evaluation could be done using
the following:

• The current staffing of a particular public health advocacy effort, to assess whether
it can effectively carry out each stage on the assembly line and the steps at each
stage.

• The staffing of an organization that is involved in several public health advocacy

efforts and how it allocates attention and energy along the assembly line to each
effort.

• The most productive role of an individual in a particular public health advocacy

effort or group of efforts, given that person’s knowledge, skills, talents, and
preferences.

• Any gaps in knowledge, skills, attention, or staffing that need to be corrected to

enhance the quality and pace of public health advocacy product creation by any
group or coalition.

• Funding needs, to ensure that each stage of the public health advocacy assembly line
is fully staffed (in one enterprise or across several enterprises).
i