Primary author: Karen Lazar

Public Health Advocacy
Public health advocacy involves the utilization of information and resources to improve the overall health of a group of people, thereby reducing the societal burden of public health problems. This is achieved by promoting efforts that focus on reducing death, disease or disability within these groups (Christoffel, 2000). Public health advocacy includes communicating about the pressing health issues in a community with government officials, media and the public. The goal of advocacy is to assist health professionals in overcoming barriers that inhibit the public health objective and to increase the capability and willingness of individuals and communities to actively participate in strategies that improve the public’s health (NC Public Health Academy, 2010). With the immense chronic disease burden on our country (cardiovascular disease, cancer and diabetes), public health advocacy plays a significant role in bringing attention to disease risk factors that commonly exist within our community life. Advocacy involves the determination of how life choices with regard to diet, exercise, and substance abuse can impact not only the health of an individual but the larger public. Government data on risk factors as well as disease rates helps communities act as advocates for their own health. However the basis for advocacy is not confined to only what we can quantitate. Often, it is life experiences that drive the commitment to seek changes in public health (Bassett, 2003).
A public health advocate is a supporter or a defender of health equity who works to influence the way the public and policy-makers think about certain health issues or policies. To be a representative of a public health issue for a group, an individual must be a good listener, and work to understand the groups feelings and concerns. They must also convey these issues effectively to institutions of power in a way that will be heard and considered. Health advocates often need to think outside the box and challenge the status quo (Avery and Bashir, 2003). Anyone can be a public health advocate. Examples of advocacy include: speaking to local groups about important health issues, writing an editorial in the local newspaper about a specific health issue, placing a public service announcement on television or radio to advertise for a free health clinic (NC Public Health Academy, 2010).

Christoffel (2000) suggests that advocacy has three stages: information, strategy, and action. These stages take place simultaneously. The information stage includes naming, describing and measuring the public health problem. Strategy stage involves using the above information to determine a plan of action for promoting public health. This stage involves communication of information to the public and health care professionals, assembling groups to work on the issue, and planning change. A strategy might be public education messages, campaigns, press conferences, news stories. The action stage involves the execution of the above strategies and might require fund raising, convincing individuals to change their lives, convincing legislators to get involved, and constructing regulations and legislation. To achieve action, changes in attitudes, habits and resource allocation and societal rules must take place.
Public health advocacy occurs at two levels: the individual/family level and on the larger community level (Christoffel, 2000). Advocacy that focuses on the interpersonal/intrapersonal level is often referred to as patient advocacy. Patient advocacy involves any "activity that benefits a patient" (Torrey, 2010). It can apply to caregiving for an individual patient, to groups that develop policies or lend advice to patients, to government groups that develop legislation to improve the health care system for patients. Some examples of patient advocacy organizations include government groups such as HHS, NIH, CDC and the FDA; not-for-profit groups like the American Cancer Society; for-profit groups that consist of health care professionals, lawyers, financial advisors (Health Advocate, Lynx care), hospital patient advocates (American Hospital Association), and individual patient advocates who act as healthcare assistants (Torrey, 2010).

Advocacy is a tool utilized in behavior change theories such as Bandura's Social Cognitive Theory (SCT) and the Transtheoretical Model (TTM) or Stages of Change. Within the framework of these theories, advocacy can motivate the individual to change their behavior. According to SCT, social models through experiences encourage efficacy in individuals who may not be aware that their habits are unhealthy (Bandura, 1998). With increase in self-efficacy, or the belief that one can change their behavior, the motivation to make the healthier change increases. Self-efficacy is also an important concept in the TTM model. Additionally, advocacy encourages the key TTM concept of social liberation- the awareness and acceptance of alternative lifestyle options (Velicer et al, 1998). Advocacy helps create social solutions such as policy changes which may result in an environment more conducive to behavior change. For example, advocates might encourage policies that limit smoking in public places thereby creating an environment where a smoker feels more confident that they could succeed at quitting.Patient health advocates, also called care coordinators, are a relatively new profession. These individuals assist patients or family members with complex medical paperwork or insurance claims, help find community resources and give advice about questions they should ask physicians (Leibowitz, 2003; Brown, 2010). With the complexity of the healthcare system and the stress that individuals and families often face when dealing with a chronic disease, the health care advocate can be an extremely important resource.
Public health advocacy at the community level involves for-profit and non-profit organizations, academia & government agencies working together to create policies that will benefit the health of the public as a whole. Community-academic partnerships work together utilizing community-based participatory research (CBPR) to educate policy makers and promote health equity (Israel 1998; Izumi et al 2010). CBPR is focused on turning findings from research into action. This approach is a useful tool for advocates working with organizations or government agencies that desire to create policy changes that improve the fairness and quality of care for larger communities. Community-based organizations (CBOs) are called upon to use research evidence to inform their advocacy, program planning, and service delivery efforts. CBO’s use CBPR to translate knowledge into action by sharing the research results with appropriate health professionals, government officials and the public (Israel 1998;Wilson 2010).
The American Public Health Association (APHA) is the primary proponent for public health advocacy in the United States. Through education and advocacy promotions the APHA works to protect individuals and communities from preventable health threats and works to encourage disease prevention and community-based promotion (APHA, 2010 b). A large part of public health advocacy is education. In order to effect change the appropriate facts need to be communicated to the public and policymakers (APHA, 2010). These facts are often a product of community-based research efforts discussed above. Trust for America’s Health (TFAH) is a non-profit, non-partisan public health advocacy organization that focuses on prevention, protection and communities to make disease prevention a national priority in homes and in government (TFAH, 2010). Some of their policy activities include advocating for more funding for public health programs that involve preparedness, disease prevention and addresses the connection between the environment and our health, seeking to diminish health disparities, infectious disease prevention, disease prevention.

“Public health takes place in boardrooms, on street corners, in our homes, and in the legislature. So, too, does public health advocacy” (Bassett, 2003).

References
American Public Health Association, APHA (2010). Frequently asked questions. Retrieved online: www.apha.org/advocacy.

American Public Health Association, APHA (2010b). APHA public health advocacy process. Retrieved online: www.apha.org/advocacy/tips

Avery B and Bashir S (2003). The road to advocacy- searching for the rainbow. American Journal of Public Health 93(8): 1207-1210.

Bassett MT (2003). Public health advocacy. American Journal of Public Health 93(8): 1204

Bandura, A. (1998). Health promotion from the perspective of social cognitive theory. Psychology and Health, 13, 623-649.

Brown S (2010). What does a health advocate do? Health Contact Partners. Retrieved online:
http://healthcontactpartners.blogspot.com/2010/06/what-does-health-advocate-do.html

Christoffel, KK (2000). Public health advocacy: process and product. American Journal of Public Health 90(5): 722-726.

Israel BA, Schulz AJ, Parker EA, Becker AB (1998). Review of community-based research: assessing partnership approaches to improve public health. Annu. Rev. Public Health 19:173-202.

Izumi B, Schulz A, Israel BA, Reyes AG, Martin J, Lichetenstein RL, Wilson C, Sand S (2010). The one-pager: a practical policy advocacy tool for translating community-based participatory research into action. Prog. Community Health Partnersh 4(2): 141-147.

Leibowitz, A (2003). What do patient health advocates do? National Underwriter 3(2):1 Retrieved online: www.healthadvocate.com/downloads/articles/03_12-01LTCe-Wire.pdf

NC Public Health Academy (2010). Retrieved online: www.ncpublichealthacademy.org/AdvocacySection-2.pdf

Torrey T (2010). An overview of patient advocacy: patient advocate organizations, individuals, government, profit, not-for profits. About.com guide. Retrieved online: http://patients.about.com/od/caringforotherpatients/patadvocacy.htm updated Aug. 13, 2010.

Trust for America’s Health (TFAH), 2010. Retrieved online: www.healthyamericans.org/policy

Velicer, W.F., Prochaska, J.O., Fava, J.L., Norman, G.J., & Redding, C.A. (1998). Smoking cessation and stress management: applications of the transtheoretical model of behavior change. Homeostasis, 38, 216-233.

Wilson MG, Lavis JN, Travers R, Rourke SB (2010). Community-based knowledge transfer and exchange: helping community-based organizations link research to action. Implementation Science 5:33