Advocacy for Health and Health Equity: A Call to Public Health Professionals Open Access

The world is confronted by complex challenges and crisis with impact on the health and well-being of communities and health inequities prevail. Almost 40 years after the Ottawa Charter for Health Promotion, we keep facing the inadequacy of usual approaches to health in addressing current public health challenges [1]. The Charter called for a shift from an individualistic approach, primarily focused on the individual risk factors and risk behaviours, to a context-based approach [1, 2]. In doing so, it included a focus on changing policies and the environments where people live, work, and play to improve health and well-being and reduce inequities [3].

It is now widely recognized that answering complex public health challenges requires addressing the wider determinants of health [4]. Policy and environmental changes are assumed to be more effective and equitable, once they reach a broad range of people and require less effort from them, making the healthy choice the easy choice [3]. Several success stories in public health reinforce the role of structural-level interventions and changes [5, 6]. However, these changes are extremely complex and hard to enact. In fact, over the years different authors have been raising attention to the paucity of published work examining efforts to modify policies and environments [7‒9], suggesting the maintenance of a stronger investment in individual interventions focusing on behavioural risks [10].

Efforts to make structural changes include a broad range of strategies and mechanisms, but gaining the support of individuals and organized groups has been pointed as a key ingredient for success [6]. Golden et al. [3] discuss the processes and ingredients that foster healthy policies and supportive environments, arguing that it takes organized and intentional human action at different levels. By using a social-ecological model “inside out,” they conceptualize that the development of healthy policies and environments is more likely when there are community champions putting health-promoting ideas in public debate and public support, organized groups united around common concerns (e.g., coalitions, interest groups) promoting the placement of key topics on policy agendas, informal or formal social networks well-positioned for organized structural action, and empowered individuals. Overall, the authors describe empowered communities, groups, and individuals as core conditions to influence and take part in decision-making and structural change.

Chapman [11] describes advocacy as seeking to “change upstream factors like laws, regulations, policies and institutional practices, prices, and product standards that influence the personal health choices of often millions of individuals, and the environments in which these are made.” Advocacy is recognized as a means of promoting policies that help improve health equity, by addressing the social determinants of health [12]. Health advocacy is one of the main strategies for health promotion – while calling for a shift to a context-based approach, the Ottawa Charter also suggested complementary processes, such as community mobilization and advocacy to produce social change and address the social determinants of health. The World Health Organization defines health 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” [13]. Such actions may be taken (a) on behalf of people unable to speak or act for themselves to defend their rights and needs and to create living conditions for health or (b) by empowering people and communities to gain a stronger voice to express their needs and participate in decision-making [13, 14]. Health advocacy is about organized social action for change, enabling the connection and collaboration with different audiences; it is about engaging others in some issues and getting listened by decision-makers to have a voice in decisions. Carlisle [14] suggests that advocacy can bridge the gap between policymakers and the lives and experiences of people.

Health advocacy can take many forms and involve a diverse range of people, including policy- and decision-makers, influential forces and relevant sectors of society, and the public. It encompasses several strategies, including communicating and bringing attention to issues, building consensus, and putting issues in public debate to advance initiatives in the pursuit of better health outcomes. Even though the overall aim of health advocacy is influencing decision-making regarding healthy policies and environments, advocacy is not only about direct political action. It can entail activating the media, building alliances with interest groups, taking more direct legislative action and political communication, or activating public demand through community-based and grassroots efforts and partnerships [13, 15]. Actually, community engagement and educating the public are central to advocacy efforts. By educating the public on the links between structural and environmental determinants and health outcomes, professionals can contribute to fostering public support and mobilization for policy and environmental change [10]. For these efforts, educating the public should go beyond ensuring individual behaviour change and include promoting the knowledge and skills in advocating for policies and environmental changes that foster communities’ health and well-being [6].

International frameworks on public health and health promotion capacities and practice include advocacy. The European Public Health Operations (EPHOs) by the World Health Organization Regional Office for Europe covers advocacy within EPHO9 – Information, Communication and Social Mobilization for Health – which states as purpose “to use modern communication methods and technologies to support leadership and advocacy for community engagement and empowerment” [16]. The Competency Framework for the Public Health Workforce in the European Region published by the World Health Organization and the Association of Schools for Public Health in the European Region refers to advocacy in competence 7.8 as “advocates for healthy public policies and services that promote and protect the health and well-being of individuals and communities” [17]. The IUHPE Core Competencies and Professional Standards for Health Promotion also includes advocacy within its 11 domains of core competencies, stating that health promotion practitioners are expected to “advocate with, and on behalf of, individuals, communities and organizations to improve health and well-being and build capacity for health promotion action” [18]. Advocating for health entails using advocacy strategies and techniques, engaging and influencing key stakeholders, raising awareness and influencing public opinion, advocating across sectors, and facilitating communities and groups to articulate their needs and advocate for answers [18].

While central to health promotion action and recognized within professional frameworks, it has been suggested that advocacy is an under-explored area in public health and health promotion practice, and several calls to action have been issued. For example, Golden et al. [3] argue that health promotion practitioners have a role in promoting the conditions for healthy policies and environments, which involves (a) communicating the role of the social determinants of health as well as the needs and opportunities regarding policy and environmental changes, (b) mobilizing social action by building partnerships, and (c) exerting an advocacy role regarding structural changes and health equity. Several others have urged public health professionals to take an active role in advocating for healthier policies and environments [15, 19‒22].

Available examples illustrate how public health professionals can transform their practice to contribute to structural change, by joining forces with individuals and groups in advocacy efforts [10, 21]. These alliances may not be systematically documented in scientific papers but are not new to public health and have contributed to improving population health through advancements in sanitation, housing, working conditions, and environmental justice. In some of these partnerships, community organizations and social movements took the lead, and public health professionals took a supportive role, by providing evidence, evaluating strategies, mediating interests, and educating the public.

However, some evidence suggests that public health professionals may feel responsible for health advocacy and yet not engage in advocacy actions [23, 24]. In fact, several barriers to advocacy action have been identified [19] with the lack of training and experience being emphasized and the need for shifting the culture of public health pointed out [15, 20, 25]. The study from Sykes et al. [15] with practitioners advocating for restrictions in advertising high-fat, salt, and sugar products in England showed that they felt inexperienced and under-trained for a role requiring complex skills – interpersonal skills, knowledge of the policy process, determination, autonomy, integrity – and organizational support.

Changing professionals’ engagement in advocacy action demands more training, more opportunities for learning in practice, but also more acceptance and trust in public health professionals’ advocacy role [15, 20, 21]. Hancock emphasizes that while public health advocacy has always been part of public health practice, it has also always been unpopular, with many considering it to be inappropriate and others feeling uncomfortable in speaking out about the evidence and implications for health and well-being [21]. The author makes a call to public health professionals, academics, and professional organizations to stand up for the protection of the role of public health professionals in exerting their advocacy “right and duty.”

Some specialists made suggestions to public health professionals to improve their role as advocates. Regarding training, it is suggested that professionals identify good role models to observe or to have as mentors [15, 26, 27]. Strong evidence and expertise for crafting messages are central for credibility and trustworthiness [15, 26‒28], while also ensuring that data are adapted to the specific audiences and that messages are clear and concrete – providing clear and well-selected data (killer facts) supported by compelling, value-based narratives, and case studies is better than having arguments backed up by extensive sets of numbers, statistical details, and abstractions [26, 28]. Developing unified arguments and actions by identifying organizations and individuals with common priorities to build coalitions is also a strong suggestion [26, 27]. Engaging with the media to amplify the reach of public health evidence and arguments is mandatory and each public health professional should find out their preferred ways, study the media to take advantage of opportunities, and be accessible [11, 26‒28]. Social media transformed advocacy opportunities, and using it amplifies the reach of advocacy efforts unprecedentedly [28]. Beyond these elements, public health professionals must also gather the courage and confidence to be unpopular and the patience and persistence to wait for the advocacy outcomes [21, 22, 26, 28]. Above all, professionals must be always ready to communicate their killer facts and arguments [28].

Public health professionals want to make a difference in the world, by addressing complex and always-evolving challenges that threaten the health and well-being of populations and communities. They have the knowledge and skills to design, implement, and evaluate effective and evidence-based interventions and policies. However, as stated by Kickbusch [29], we may have the knowledge and technologies to improve health and create more equitable societies, but ensuring their wide use in the interest of the public requires transformation. Health advocacy intends to produce transformation in the ways people live by bringing to the decision-making process and public debate the population needs and evidence-based policies and interventions. Engaging in policy and environmental change is within the core functions of public health and health promotion professionals. Despite the challenges and barriers, public health professionals are well-positioned to contribute to more upstream structural action, by having an active role in advocacy efforts. Integrating health advocacy into the public health training, practice, research, and culture remains an invaluable contribution to address the wider determinants of health. Public health professionals in the present may have a unique role in accelerating communities’ empowerment and structural change for healthier, sustainable, and equitable communities.