A public health trainee’s guide Community Health Sciences Policy Advocacy A public health trainee’s guide Jason Cabaj, MD MSc PGY4 PHPM Resident May 28, 2014

Illustrate the relevance of policy advocacy in public health practice Session Objectives Illustrate the relevance of policy advocacy in public health practice Outline the knowledge gap in PHPM residency training Describe a potential solution for public health trainees: Learning module incorporated into a wiki-based knowledge management platform Purpose: Helping PHPM residents/future MOHs gain competencies for policy advocacy A consolidated document with most relevant public policy theories that apply to the public health practice context

Background Policy Advocacy Definite course of action selected from among alternatives to guide present and future decisions Public health policy Healthy public policy Advocacy Individual and social action designed to gain political commitment or support for a health goal or program Key method of achieving policy change and protecting/improving health Ottawa Charter strategy Both important Direct control over PH policy (in mandate) Less so for HPP But health constructed largely outside health sector Advocacy is core tool Ottawa Charter strategy Variety of methods jurisdictional, power governance structure Key Elements of Public Health Advocacy Focus on upstream factors (e.g. laws, regulations, policies, prices, product standards) to effect systemic change Emphasis on collective action Explicit recognition of the importance of engaging in political processes Employment of multiple tactics Public Health Policy Public health policy (sometimes called the backbone of public health) encompasses the rules, regulations and practices aimed at maintaining and improving overall level and equity of health of populations 3. Public health policy may refer to either all policies affecting the health of the public, or it may be used to refer more specifically to those policies developed and implemented by public health organizations. Healthy Public Policy Policy decisions affecting population health are not limited to policies in the health sector. Because policies from other sectors like housing, education, transportation, income, employment, social assistance, and others (social determinants of health) have a great influence on health, development and implementation of good policies in these areas is often great importance 4. Healthy public policy is characterized by an explicit concern for health and equity in all areas of policy and by an accountability for health impact 5 and building healthy public policy is one of the five action areas identified in the Ottawa Charter for Health Promotion "to achieve health for all" by the year 20006. As a means of pursuing this end, health impact assessments (HIA) can be used to understand (and influence) the health impacts of policies in diverse sectors using quantitative, qualitative and participatory techniques 7. One of the principle ways that public health professionals can seek to achieve policy change to protect and improve health is through advocacy. Policy advocacy is defined the active, covert, or inadvertent support of a particular policy or class of policies. For public health physicians, advocacy is a core competency 8. There is less consensus on how scientists in many fields can and should effectively contribute to policy development9.

Successful Policy Advocacy? - Advocacy seeking to implement specific policies > rather than general awareness raising. Won’t work if advocacy is not done in an informed way. - Need to think beyond just evidence > policy - Ways policy is assumed to be mobilized > useful in public health No focused resource on practice way of beginning it Effective advocacy requires evidence based approach Historical lack of translation to public health practice

PHPM Competencies RCPSC PHPM Objectives of Training 1.2. Identify opportunities for advocacy 2.1.1. Recognize situations where advocacy is required and define strategies to effect the desired outcome 3.3.3. Discuss mechanisms of policy development and methods of implementation, including legislation, regulation, and incentives 3.3.5. Conduct a policy analysis and policy evaluation 3.7.1. Demonstrate competency in advocacy skills 5.2.5. Contribute to the formulation of healthy public policy or legislation at local, provincial or federal level Minimum Competencies for MOHs in Canada (2009) MOH competencies similar but more advanced Highly required skills when working in a political environment Focus in both MOH and royal college PHPM objectives 24 mentions of policy and/or advocacy in RCPSC objectives ““Specialists apply strategies to influence and build healthy public policy, (as well as public health policy), and recognize the role of political factors and the political context, to make use of formal and informal systems to influence decision-makers and policy decisions” MOH Competency domain (Communication, collaboration, and advocacy for the public’s health) “MOHs are a primary source of information on public health matters to a range of audiences  and utilize their knowledge of communities to develop and shape strategies with partners to  mobilize action to identify inequities in health and build healthy public policy to reduce  them.” …But how does training prepare residents to attain these competencies

PHPM Training PHPM training requirements CanMEDS Knowledge, attitudes, skills Broad and location dependent Variation in academic curriculum Variation in opportunities for application Policy competencies Most residents have little background in political and social sciences Focus on the Policy Cycle and on KT Valuable but limited Policy development is black box Need to understand policy process itself to successfully engage and influence Guided by CanMeds. But varies by university department. Range from formalized training in full division of public health policy to exposure individual faculty interests. At Calgary, department has research focus and there are limited course offering for policy. Systematically very little to gain policy competencies mentioned on previous slide and there is a heavy reliance on the policy cycle. Policy work is complex and often proceeds non-linearly. However, a policy cycle provides a reference point for progressively advancing health policies. However, the policy cycle is the main framework, but insufficient. Does have role, but many criticisms. Need more substance. Analogy: Outbreak investigation without learning epidemiology or outbreak management strategies

Development of single consolidated resource Proposed Solution Development of single consolidated resource Focus on informing public health practice Learning module for PHPM residents Potential utility for other public health trainees Process Two month rotation guided by academic public health physician preceptor (Dr. Lynn McIntyre) Targeted readings Environmental scan Policy briefs and analyses Policy scans Module development Information overload

Learning module content Policy science overview (i.e. policy 101) Policy process theories PHPM physician roles in policy advocacy Advocacy methods, skills, tactics Key policy concepts Competency application opportunities Policy briefs, policy analyses Links to external resources NCCHPP, NCCMT, PHPC, CPHA Knowledge translation overview

Theories of policy process Policy Science Theories of policy process Policy Cycle i.e. Stages Model/Heuristic “Textbook approach” Advocacy Coalition Framework Paul Sabatier Multiple Streams Framework John Kingdon Relatively Stable Parameters External Subsystem Events Long Term Coalition Opportunity Structures Short Term Constraints and Resources of Subsystem Actors Policy Subsystem - Coalition A - Coalition B https://www.peelregion.ca/health/library/pdf/Policy_Frameworks.PDF Public Health-Related Policy Issues to Which Selected Policy Frameworks Have Been Applied (2001-2012) – literature (grey and published) review by Peel Region Stages = 0 Institutional analysis and development framework = 1 Punctuated equilibrium framework = 2 Advocacy coalition framework = 4 Multiple streams framework = 14 Policy Window Problems Proposals Politics

Public health physicians have many potential roles Physician Roles Public health physicians have many potential roles Decision maker/policy maker Policy entrepreneur Advisor Coalition member Honest broker Medical doctor Government employee Expert Private citizen Association member Role analysis is important. Need to be clear on which hat to wear (effective, ethical, transparent) Particularly important for MOHs – potential conflict between role as MD and government official

Key Policy Concepts Framing Agenda Setting Policy Implementation Valence Policy Entrepreneurs Different than text – speak to application Practitioner centred – not off the shelf. I.e. roles only for PHPM (explore. And interrogate practice). Module includes information on key policy concepts, such as those included here Framing, entrepreneur, implementation were key areas of focus Framing particularly important because policy isn’t made value free. Which frames/values we choose to emphasize is of paramount important (i.e. climate change) and can overcome political, ideological, or other worldview differences Rhetoric Policy Implications Policy Window

Module Don’t have time to show the module contents, but here’s a screenshot of module.

Wiki Module part of a closed wiki that serves as a knowledge management platform for UofC residents, which I built several years ago with Dr. David Strong (PD) Core royal college study notes Problem based learning and applied scenarios Academic half day curriculum content and document repository

Applications for Module Two models for use Stand alone resource Self-learning module for PHPM resident policy and knowledge translation competency acquisition Elective rotation/directed study course guide Core or supplementary resource guidance document Recently used to good effect by CHS graduate student As part of that, the module will be used in two ways Wiki reference for residents Self-directed/guided learning (PhD student elective - directed study course; used module tools and NCCPH resources) Future work to be done in terms of other professionals, broadening resources

The world of policy is complex Summary The world of policy is complex Lack of existing practice focused learning resources Custom learning module provides a concise entry point Sipping from the fire hydrant

Thank you Questions? Show and tell about decision making process Explicit call for more Practitioners or those in training may need for tailoring in preparation. Piecemeal Policy and advocacy are part of practice (distilling it to what is essential) Questions?

References and Resources Baumgartner, F.R. (2013). Ideas and policy change. Governance: An International Journal of Policy, Administration, and Institutions. 26:2, 239-258. Canadian Public Health Association - Policy and Advocacy page Moloughny, B. (2012). The use of policy frameworks to understand public health-related public policy processes: a literature review. Prepared for Peel Public Health. Learn about public policies and their effects on health. National Collaborating Centre for Healthy Public Policy National Collaborating Centre for Healthy Public Policy National Collaborating Centre for Methods and Tools Public Health Physicians of Canada - Advocacy Documents Sabatier P. (ed) (2007). Theories of the policy process. Westview Press. Cambridge. Scott, J.M, Rachlow, J.L., Lackey, R.T. (2008). The science-policy interface: What is an appropriate role for professional societies. BioScience 58:9, 865-869. Acknowledgements: Dr. Lynn McIntyre Dr. David Strong

Key Policy Concepts Agenda setting Framing Policy entrepreneur Policy agenda is the issues/problems that decision makers are paying attention to Framing How actors seek to understand and act on complex situations Policy entrepreneur Individuals who may influence policy processes due to position, network, and persistence Policy implementation The process of turning policy into practice Policy implications Social, legal, ethical, environmental, economic, political, and organization factors Policy window Critical period of time when policy streams converge to facilitate policy change Rhetoric The art of effective or persuasive speaking or writing used in policy debates Valence The emotional quality of an idea that makes it more or less attractive Different than text – speak to application Practitioner centred – not off the shelf. I.e. roles only for PHPM (explore. And interrogate practice). Module includes information on key policy concepts, such as those included here Framing, entrepreneur, implementation were key areas of focus Framing particularly important because policy isn’t made value free. Which frames/values we choose to emphasize is of paramount important (i.e. climate change) and can overcome polictical, ideological, or other worldview differences