Journal of Nursing Education

Major Article 

Empowering Students and Influencing Policy Change Through Experiential Public Health Advocacy Education

Heather Morris, MN, RN; Les Hagen, MSM; Elaine Hyshka, PhD; Louis Hugo Francescutti, PhD, MD, MPH, FRCPC

Abstract

Background:

Public health advocacy is central to the work of many health professionals, including nurses. Although deemed to be a core competency for public health practitioners, courses described in the literature often lack a focus on experiential learning, which is an essential component to acquiring public health advocacy skills.

Method:

This article describes an innovative, 12-week graduate course that provides students with a combination of theory and experiential learning through an opportunity to engage in political advocacy, community mobilization, and media engagement on a current public health issue.

Results:

An advocacy campaign undertaken by students to increase community access to the overdose reversal medication naloxone is described in light of the current North American overdose epidemic. Key considerations for teaching public health advocacy to facilitate development of nursing courses elsewhere are highlighted.

Conclusion:

Public health advocacy education is important and needs to be expanded both within the nursing profession and across all disciplines. [J Nurs Educ. 2019;58(12):698–703.]

Abstract

Background:

Public health advocacy is central to the work of many health professionals, including nurses. Although deemed to be a core competency for public health practitioners, courses described in the literature often lack a focus on experiential learning, which is an essential component to acquiring public health advocacy skills.

Method:

This article describes an innovative, 12-week graduate course that provides students with a combination of theory and experiential learning through an opportunity to engage in political advocacy, community mobilization, and media engagement on a current public health issue.

Results:

An advocacy campaign undertaken by students to increase community access to the overdose reversal medication naloxone is described in light of the current North American overdose epidemic. Key considerations for teaching public health advocacy to facilitate development of nursing courses elsewhere are highlighted.

Conclusion:

Public health advocacy education is important and needs to be expanded both within the nursing profession and across all disciplines. [J Nurs Educ. 2019;58(12):698–703.]

Public health advocacy is considered central to the work of many health disciplines, including nurses; however, despite it being a core competency for public health practitioners (The Council on Linkages Between Academia and Public Health Practice, 2014; Public Health Agency of Canada, 2008), it often receives minimal attention in public health curricula. The World Health Organization defines advocacy 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” (World Health Organization, 1998, p. 5). Advocacy activities include, but are not limited to, meetings with government representatives or community or business leaders; creating coalitions of individuals and organizations interested in a particular issue; engaging in public mobilization activities; undertaking applied research to help advance an issue; and creating and disseminating strategic communication materials that convey information or a call to action (Canadian Public Health Association, 2009). News media engagement is another important advocacy activity that has been particularly effective at achieving public support for policies that improve the health of populations and influence law and policy makers (Chapman, 2004). Mass media campaigns have been found to positively influence health-related behaviors or prevent negative health-related behaviors at a population level (Wakefield, Loken, & Hornik, 2010). Such campaigns may also influence health policy making (Bou-Karroum et al., 2017). Activities such as organizing media events, writing letters to a newspaper editor, or requesting interviews or guest columns are some approaches that public health advocates may engage in when working with the news media.

The purpose of this article is to review public health advocacy education and present an example of an innovative public health advocacy course that may be used in undergraduate or graduate nursing education programs. We begin by describing the literature on teaching public health advocacy and identify limitations of the current state of advocacy coursework at the graduate level. To address these limitations, we offer a description of a unique, interdisciplinary public health advocacy course that incorporates both experiential learning and an opportunity to engage in an advocacy campaign that uses political advocacy, community mobilization, and news media engagement. We highlight key attributes of this course and provide an example of an advocacy campaign undertaken by one class in response to North America's opioid overdose epidemic. We analyze the successes, challenges, and key issues encountered in offering this course in an effort to highlight the importance of advocacy education and to help facilitate development of such a course elsewhere. Finally, we offer reasons why nursing advocacy is important in advancing health policy change and offer suggestions for different ways that advocacy education might be integrated into nursing curricula.

Background

The Ottawa Charter for Health Promotion identifies the imperative to advocate for health as one of the core pillars of health promotion (World Health Organization, 2017). Advocacy is also seen as a responsibility under the Code of Ethics by both the American Nurses Association (2015) and the Canadian Nurses Association (2017). More recently, the Council on Education for Public Health's (2016) accreditation criteria for schools of public health and public health programs identifies advocacy as part of the core competencies for master's and undergraduate public health students. Despite these value affirmations, advocacy is too often neglected as a legitimate skill worthy of development in public health training (Hines & Jernigan, 2012; Jernigan, 2010).

A number of authors have attempted to describe the current state of advocacy coursework offered in the fields of both public health and health education (Andrews, Jones, Tetrault, & Coontz, 2019; Blenner, Lang, & Prelip, 2017; deCastro & Levesque, 2018; Jernighan, 2010; Radius, Galer-Unti, & Tappe, 2009). Although public health educators and administrators acknowledge that public health advocacy needs to be included in the curriculum (Goodhart, 2002), this focus is often only addressed as a subtopic in broader community health courses (Blenner et al., 2017; Radius et al., 2009; Thompson et al., 2011). In a review of online course catalogues, Jernigan (2010) found that only one of 10 leading U.S. schools of public health provided advocacy training that covered what he refers to as “the trifecta of skills for change—community organizing, political advocacy, and media advocacy” (p. 22). A study conducted by Radius et al. (2009) determined that most undergraduate and graduate health education programs in the United States offer some degree of instruction in advocacy, but the majority of faculty surveyed lacked professional preparation and practical experience. This skills gap among faculty may reflect the observation that many public health higher education programs' tenure and accreditation process (or processes) have not historically recognized the significance of community activism or advocacy (Goodhart, 2002).

Several examples of health advocacy courses have been described recently in the academic literature (Galer-Unti & Tappe, 2006; Hines & Jernigan, 2012; Van Hoover, 2015). Class content varies, as do the methods of instruction. Galer-Unti and Tappe (2006) described a writing-intensive course with a particular focus on teaching students to develop clearly written advocacy messages while building advocacy skills. Van Hoover (2015) described an advocacy course that involves legislative engagement by students; however, there is no explicit involvement in media advocacy. Another group of authors recounted an online advocacy program that does not include practical experience (Hines & Jernigan, 2012). Blenner et al. (2017) and Andrews et al. (2019) both provided examples of advocacy training programs that use workshops to supplement practical community advocacy experiences, whereas de Castro and Levesque (2018) recounted a digital storytelling assignment that is used to teach advocacy to undergraduate nursing students. Although these public health advocacy courses and training programs have pointed to its value, lacking is an account of a public health advocacy course that incorporates experiential learning involving community mobilization, political advocacy, and news media engagement. To address this gap, we describe a 12-week advocacy course incorporating this full trifecta (Jernigan, 2010) of advocacy measures for public health graduate students.

Teaching Public Health Advocacy Using Experiential Learning

Two of the authors (L.H., L.H.F.) developed and co-teach the Advocacy for Public Health elective in the University of Alberta School of Public Health, a standalone faculty offering Master of Public Health, Master of Science, and PhD degree programs accredited by the Council on Education for Public Health. This interdisciplinary course is open to graduate students from within and outside of the faculty and is designed to improve students' understanding of public health advocacy and develop their competency and skills in advocating for improved population health policy. The detailed objectives of the course are outlined in Table 1. During the term, students are expected to select a public health issue and work together to execute an advocacy campaign that entails social media and media engagement, contacting elected officials and community-based organizations, producing evidence-based educational materials, and hosting a media event on their chosen public health topic. This serves a dual objective of providing students with an experiential learning opportunity while taking action to contribute directly to efforts to improve public health. The 3-hour, 12-week advocacy course includes seminars and class discussion on a broad range of topics, and guest lectures are provided by prominent national and international scholars and advocates who work in a variety of areas including injury prevention, tobacco control, Indigenous rights, and public health nutrition. Textbooks are not required for this course; however, students are provided with a reading list from the course instructors.

Course Objectives for Advocacy for Public Health, University of Alberta, School of Public Health

Table 1:

Course Objectives for Advocacy for Public Health, University of Alberta, School of Public Health

Student evaluation consists of four assignments: an oral presentation relevant to a public health advocacy issue of their choice (30%); a class advocacy campaign project (40%); a peer evaluation of group participation (10%); and an oral final exit examination (20%). Since 2012, classes have undertaken campaigns on topics including improved refugee health care, safer cycling infrastructure, restricting public consumption of e-cigarettes, implementing a universal school nutrition program, and the reinvestment of tax revenue from planned national cannabis legalization toward addiction and mental health programs and services.

Student Advocacy Education in Action: Responding to Canada's Overdose Crisis

The 2016 Advocacy for Public Health class chose the topic of advocating for increased access to take home naloxone kits in the community as a tool for addressing Canada's overdose crisis. Naloxone is a medication that can help reverse respiratory arrest and assist in preventing death due to opioid poisoning (Carter & Graham, 2013). The 2016 group of graduate students debated a number of topics but chose to advocate for better access to naloxone because the advocacy objectives related to this topic were concrete, timely, and feasible to address in a 12-week period. Students used a structured process to determine their specific goals and objectives, map the opinions of key stakeholders, identify ongoing community initiatives that could support their advocacy work, and choose their advocacy approach and interventions (Canadian Public Health Association, 2009). Stakeholders included past and current medical officers of health, university researchers, representatives from the provincial nursing and pharmacist regulatory bodies, the provincial health authority, addiction physicians, academic experts, and a politician. The class also met with Petra Schulz, a local mother whose son died of an accidental fentanyl overdose in 2014, and a founding member of the family advocacy group, Moms Stop the Harm ( http://www.momsstoptheharm.com).

The class ultimately decided on three separate “Asks”:

  • Support for the federal government department of health proposal to make naloxone available without prescription (timing the media event to coincide with a public consultation process being undertaken by Health Canada around this issue) (Government of Canada, 2016a).
  • Request that Health Canada work with the pharmaceutical industry to facilitate better access to alternative delivery methods of naloxone (i.e., nasal spray or auto-injector) in Canada.
  • Support for the Good Samaritan Drug Overdose Act, Bill C-224 (Government of Canada, 2017a) that had been previously tabled in the federal Parliament as a private member's bill. The aim of this bill is to provide prosecution immunity related to simple possession charges to encourage more people to call 9-1-1 to report the overdose of illegal drugs (Government of Canada, 2017a). The ultimate goal was to move naloxone into the hands of more people in the community to help prevent opioid overdose deaths.

Tasks were divided among class participants, which included compiling literature and writing a position statement, coordinating logistics for the media event, developing a website and Facebook® page, developing a presentation for the advocacy media event, and writing letters to Health Canada and Sandoz Pharmaceuticals (a naloxone manufacturer). The media panel consisted of four invited guest speakers, including an addiction medicine specialist; Petra Schulz (described above); a researcher specializing in harm reduction strategies for substance use (E.H); and a graduate student representative from the class. One student also conducted an interview with a reporter from the Canadian Press the evening before the event.

The event was well attended by community members and media representatives and was covered extensively. Within 8 months of the media event, the three Asks had been realized. Health Canada announced in March 2016 that naloxone would have prescription-free status within Canada (Government of Canada, 2017b). In July 2016, the Federal Minister of Health signed an interim order authorizing immediate importation and sale of naloxone nasal spray in Canada (Government of Canada, 2016b). Also, in May 2017, Bill C-224, the Good Samaritan Drug Overdose Act, became law when it received Royal Assent by Parliament (Government of Canada, 2017a).

Although many factors produced these positive outcomes, the graduate students contributed to these policy decisions and the public discourse surrounding them by helping to keep the issue of community access to naloxone on the public agenda at a local, provincial, and national level. In the days following the media event, the story was featured in eight newspapers in four provinces across the country. Two television news items featuring the panel presentation were televised that same day locally. Petra Schulz, who was prominently featured in one of these television news reports, has since appeared in multiple news reports, drawing continued media interest.

Limitations of Project

Offering this course is not without its challenges. First, the length of required participation in the advocacy campaign is limited to course duration. However, in reality, conventional advocacy projects may take longer to complete. Second, although a smaller class size (10 to 12) helps to ensure that all students participate equally, some students in larger classes may coast on the efforts of their classmates, contributing minimally. Third, although costs for holding a media event are typically under CDN $1,000 (e.g., for information technology support, room rental, printing, food), such costs should be defrayed by the institution when possible (as is the practice in our faculty).

Discussion

The Advocacy for Public Health course provided graduate students from different disciplines (including community health nursing) the opportunity to advocate directly for public health policy change. A key to the class's success was allowing students to choose a topic about which they were passionate. In the above example, students chose the issue of community access to naloxone in part because of a compelling presentation from Petra Schulz. Ms. Schulz's involvement with the class project was essential for educating and sensitizing class participants to the nature of the overdose crisis and helped heighten news media interest in the advocacy event itself. The literature highlights the importance of networking and working closely with community members in creating change (Canadian Public Health Association, 2009; Hoffman & Silverberg, 2015; Radius, Galer-Unti, & Tappe, 2009) and the significance of interdisciplinary and intersectoral collaboration when learning how to advocate (Reutter & Williamson, 2000). Students found the support of community agencies and government officials essential for learning about naloxone and developing targeted messages. Aligning with key stakeholders amplified their message and added credibility by association for the students.

Students taking a public health advocacy course benefit from faculty who are themselves actively engaged in advocacy work (Radius et al., 2009). The course instructors (L.H., L.H.F.) together have decades of experience advocating for better policy in tobacco control, injury prevention, health promotion, and poverty reduction. Student course evaluations for 2016 indicated that the hands-on nature of the advocacy course provided an opportunity to hone presentation skills and take ownership for advancing a chosen advocacy issue. Support from the School of Public Health (material and in-kind) in offering the course is also reinforced by the School's Faculty Evaluation Committee guidelines, which recognizes the public health advocacy activities of faculty as part of engaged scholarship criteria for tenure and promotion.

Few authors have evaluated health advocacy education programs and training empirically (Belkowitz et al., 2014; Hoffman & Silverberg, 2015; Huntoon et al., 2012; Rogo, Bono, & Peterson, 2014;Wu et al., 2018). As was the case with the participants from our course, students in two studies credited the practical nature of their advocacy training with helping them to enhance their advocacy skills (Belkowitz et al., 2014; Hoffman & Silverberg, 2015). Other benefits for students have included a greater understanding of community needs, organizations, and resources (Belkowitz et al., 2014), as well as increased knowledge, values, perceived likelihood of advocacy actions, and motivation and interest (Rogo et al., 2014; Wu et al., 2018). Despite this evidence, however, there remains an underlying tension related to advocacy education as many employers may restrict the advocacy practices of their employees (Hancock, 2015). This same dilemma at times extends to the question of whether university researchers also should be involved in advocacy work (Hancock, 2015; Polcin, 2014). One way of addressing this discomfort is for public health professionals to engage in advocacy outside of the workplace through community organizations and professional associations.

Advocacy Education and Nursing: Where Do We Go from Here?

Advocacy at a population level has been a cornerstone of the nursing profession dating back to its early days as a profession (Selanders & Crane, 2012). As the largest group of professionals within the health care workforce, nurses' voices are essential to advancing health policy (Nickitas, 2020). However, nurses face a number of barriers, some of which may include a lack of initiative, an absence of professional identity and autonomy, personal constraints (e.g., time) (Williams, 2018), and invisibility within the news media (Mason et al., 2018). Nurse educators, particularly those teaching community health courses, can help address such barriers and build capacity within the profession in many ways. First, nurse educators can and should incorporate discussions on public health advocacy in all courses, particularly those that pertain to community health. Community health nurses are particularly suited for undertaking media advocacy due to their role in promoting healthy public policies at a population level and their experience with coalition building (Flynn, 1998). Second, nursing students should not only be encouraged to work with their professional organizations but also take advantage of intersectoral opportunities during their clinical placements to help promote change from a grassroots level. Finally, we believe that a stand-alone advocacy course that includes community mobilization, political advocacy, and news media engagement, as described here, should be required of all nursing students, particularly at the graduate level. Such a course would empower nurses to overcome any reluctance to engaging in public health advocacy and provide the practical skills needed for changing health policies at a local, state/provincial, and national level.

Conclusion

Offering a full-credit, 12-week course involving a real-world public health advocacy campaign has provided an excellent opportunity for graduate students from a variety of disciplines, including nursing, to learn advocacy techniques aimed at promoting public health at the population level. Given today's political climate and the current emphasis on engaged research, it is our position that nursing students need to refine their skills, confidence, and abilities in public health advocacy. The time has come for nursing students, academics, and professionals to accept public health advocacy not only as a professional responsibility, but a moral and ethical one as well. Advocacy must be a key component of nursing practice, and our pedagogical efforts need to be commensurate with this objective as we educate nurses in the future.

References

Course Objectives for Advocacy for Public Health, University of Alberta, School of Public Health

Course ObjectiveActions or Skills to Be Demonstrated
1. Explore the evidence supporting the effectiveness of public health advocacy.Review empirical studies and policy documents that support the importance and effectiveness of public health advocacy. Explore public health advocacy frameworks and theories.
2. Identify appropriate opportunities to apply advocacy strategies.Review published case studies documenting advocacy projects. Identify common pitfalls in advocacy campaigns.
3. List knowledge to action used in public health advocacy, including health advocacy, engagement, and mobilization based on current evidence.Describe interventions and strategies undertaken by public health advocates Discuss when it is appropriate and not appropriate to engage in advocacy. Distinguish between lobbying, advocacy, and activism.
4. Review examples of past successful and unsuccessful advocacy campaigns.Discuss evaluation of advocacy projects.
5. Understand societal receptiveness, political processes, and other contextual factors that shape public health policy.Review political landscape both locally and nationally (e.g., how legislation is formulated, committee structures, political players, process of agenda setting). Learn how to address advocacy within environments that are resistant to change.
6. Describe and apply methods for effectively communicating and influencing the public agenda.Discuss a variety of methods including media and social media advocacy, engagement of politicians, organizing community events, and engagement with community policy actors. Review the importance and how to effectively frame one's messaging. Help students identify target audience for advocacy work.
7. Build experiential knowledge and skills for developing, implementing, and evaluating a public health advocacy campaign.Small group work to develop and implement an advocacy action plan including community engagement, lobbying, and media skills. Provide training in public speaking and presentation skills Informal media training provided by course instructors for students who will engage directly with members of the media.
8. Learn how to work in a team environment under time pressure, using peer-to-peer learning to address a real-world advocacy problem.Development of a work plan with specific tasks and responsibilities for each class member. Provide guidance through the ‘joining, storming, norming and performing’ stages of group dynamics.
9. Organize and deliver a live press conference focused on developing the ability to communicate the group's main messages with policy makers, members of the media, and the public.Live media event used to launch advocacy project and facilitate bringing a public health issue onto the political and public agenda. Continued follow-up with media and community members following media event as required to ensure advocacy issue remains on the public agenda.
Authors

Ms. Morris is PhD student, Mr. Hagen is Adjunct Professor, and Dr. Hyshka is Assistant Professor, School of Public Health, and Dr. Francescutti is Professor, School of Public Health and Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Petra Schulz of Moms Stop The Harm for her involvement with the 2016 class project and for reviewing this manuscript.

Address correspondence to Heather Morris, MN, RN, PhD Student, School of Public Health, University of Alberta, 3–300 Edmonton Clinic Health Academy, 11405 87th Ave., Edmonton, AB, Canada T6G 1C9; e-mail: hmmorris@ualberta.ca.

Received: January 09, 2019
Accepted: September 23, 2019

10.3928/01484834-20191120-04

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