A new approach to teaching public health advocacy

Public health leaders face many challenges in influencing policy and public opinion, especially in times of crisis such as the COVID-19 pandemic. However, public health training does not always prepare practitioners to advocate, communicate with the public or move beyond technocratic approaches to policy development. To address these challenges, we designed and delivered a new course on public health advocacy to help professional-stream doctoral students understand and use journalistic skills in developing a relationships-based approach to political and policy change. The course drew on students’ career experiences to anchor conversations that explored journalism as a novel approach for open-mindedness in public health advocacy, situated the political process as a legitimate democratic space for public health advocacy, and contextualized advocacy work in the broader context of relationship building and systems change. In this commentary, we share insights from the course to demonstrate how public health leaders can draw on journalism training to better shape and participate in public discussion.


ARTICLE INFO
Une nouvelle approche à l'enseignement de la défense de la santé publique T he COVID-19 crisis shone a spotlight on the complex links between how public health leaders make decisions and how they engage with, shape, respond to, and reflect public discourse.It also exposed the opportunity to better train public health leaders in the skills they need to influence change beyond their direct authority, to engage effectively in public debates about societal priorities, and to build trust on issues of equity and community engagement (Tam, 2021;Mulligan, 2022).We propose that public health leaders can draw on training in journalism disciplines to better shape and participate in public discussion.In this commentary, we share insights from our new graduate course on public health advocacy.The course, designed for graduate students pursuing a professional-based public health degree, is -as far as we know -the first of its kind in Canada.It combines journalism training with political, government, media and community relations capacity-building to enhance public health leadership and impact.It also integrates rigorous academic training with the professional experiences of working students, as well as our own lived experience of public health advocacy.By sharing our experience of expanding the accessibility of journalism education from schools of journalism and communications to a school of public health, we hope to stimulate a conversation about journalism's potential value in the toolkit of public health leaders, in a time of complex and overlapping public health crises.
Advocacy -political engagement to influence policy decisions at organizational and systems levels (National Collaborating Centre for Determinants of Health, 2015) -is a core competency of public health practice in Canada (Public Health Agency of Canada, 2007) and a fundamental component of health promotion (World Health Organization, 1986).But advocacy is not always taught in schools of public health, and when it is, it often focuses on technical skills for "policy development" rather than relational skills for dealing with politics and power -especially the speed, storytelling and savvy, or practical knowledge that supports good judgement -that journalism education teaches.As two public health faculty members with significant experience in public health advocacy at multiple scales of governance and action, we recognized this learning gap in the pro-fessional curriculum for students in the University of Toronto's professional Doctor of Public Health program (University of Toronto, 2023).To fill this gap, we developed and delivered an online elective course in public health advocacy in 2023.
Using Kania et al.'s (2018) "Water of Systems Change" framework, we posited that most professional-stream students work in the area of structural change (explicit changes to policies, practices and resource flows) in their everyday careers, and that most of their academic training was focused either at that same scale or in the abstract area of mental models (implicit paradigms) typically outside their daily scope of practice.We therefore concentrated the Public Health Advocacy course on the overlooked area of relational change -helping students develop advocacy skills by building their capacities to understand and influence power dynamics by developing ongoing relationships with public health decision-makers, communities, journalists and others who frame the public discussion.This decision was based in part on health promotion practice research showing that "within a systems approach to community-level health promotion, a practitioner's capacity to identify their role in complex adaptive systems and their ability to influence others are potentially powerful skills to facilitate change" (Bensberg, 2020, p. 1).
A key component of the course was the creation of a friendly and confidential classroom environment that respected the seniority and sensitivity of these working students, who are already leaders in their fields.Weekly online sessions combined practical training in journalism and advocacy skills, thoughtful engagement with academic theory and research, and shared discussion of real-time advocacy challenges faced by students or issues making headlines each week.

A NEW TOOLKIT IN FOUR PILLARS: ADVOCACY, JOURNALISM, POLITICS, AND COMMUNITY
T his course was based on the premise that policy experts need to generate trust in their ideas among other policy actors whose legitimacy reflects their own unique links to the public, including politicians and journalists.This requires a cognitive shift for public health leaders.Indeed, it challenges long-standing assumptions in public health that policies should "sell themselves" on nothing more than the quality of their evidence.By corollary, public health leaders often act as if communications failures reflect shortcomings in the public's understanding of evidence.Our approach challenged learners to understand that communications failures often reflect failures of trust, rather than understanding; and that they can build public trust by using a specific toolkit.That premise was translated into specific learning goals.We aimed for our students to: • Gain an introductory knowledge of the institutional and social contexts for their advocacy; • Use journalism disciplines to shape public environment within which advocacy happens • Shape the way political decision-makers discuss policy options • Use crisis management as a foundation for community trust in public health.
We advanced to those learning goals through four pillars delivered in a total of 12 two-hour sessions, each connected to specific professional competencies in public health.In this first offering of the course, two instructors taught seven doctoral students, enabling a high degree of engagement across the cohort.

PILLAR 1: ADVOCACY AND SYSTEMS CHANGE
In our first pillar, we placed policy advocacy in the context of larger systems change (Kramer and Senge, 2018) and discussions about the dynamics of group polarization currently shaping health policy debates (Brooks, 2022;Nyhan, 2014Nyhan, , 2015;;Ripley, 2019).Because these public health professionals and students are well-versed in structural change in their daily work and transformative change in their academic training, we focused this course on the missing level: relational change (Kramer and Senge, 2018).We aimed to help students use journalism skills to build and strengthen individual and institutional relationships, and to identify and challenge power dynamics, for the purposes of public health advocacy.

PILLAR 2: JOURNALISM
The two sessions of our second pillar focused on journalism as a novel framework for advocacy, building on existing work within our faculty.While journalism and advocacy are typically conceptualized as distinct projects, working "like a journalist" can help a policy entrepreneur seek fresh perspectives in their advocacy.Students learned how to interrogate their own disciplines with an open mind, as a journalist would.They also learned how journalists make a technical policy idea relevant to a wide spectrum of non-specialists by linking it to broader social themes, making it timely and exploring it in a non-partisan way.
We sought to introduce journalism principles very quickly by focusing strictly on the framework of story-pitches.Students learned that journalism depends on a collaboration between the journalist, representing a story, and an editor, representing an audience.That relationship mirrors the dynamic between public health leaders, who represent scientific evidence, and the audience -or public -itself.For public health actors, thinking like a journalist is not the same as engaging in public relations in order to protect an institutional reputation or advance an institutional agenda.
Rather, thinking like a journalist provides scaffolding against which these actors can link communications, context and evidence to action.
Just as a strong story pitch functions as the glue in that editorial relationship, students learned to formulate their public communications using pitching principles.Specifically, students were asked to identify a public health advocacy position in which they were involved, and then frame their evidence around three criteria of a compelling story pitch: why their approach was important (not just interesting) for their targeted population, how it challenged conventional wisdom, and why it was timely -even urgent.A fourth criterion, the scientific evidence driving their approach, was to be included only in the context of the first three criteria.This framework compelled students to think beyond just scientific evidence, and instead consider -and honour -the population with which they were communicating.Indeed, by using these criteria for a compelling pitch, students were expected to question their own understanding of an issue they thought they knew well.In their first assignment, we asked students to actually "pitch" their advocacy position in a 150-200-word pitch, formatted as a journalist would format a story pitch to an editor.We used a flipped classroom approach (Al-Samarraie et al., 2020) by workshopping each of their pitches in class, as a group, before the assignment was due.

PILLAR 3: POLITICS
Our third pillar focused on the legitimacy of politics in a democratic society and introduced students to the distinct qualities of political decision-making, especially in a post-pandemic environment.The COVID-19 pandemic "unmasked the politics of public health policies" even as it revealed "the absence of the politics of public health…in most definitions and framings of health and public health" (Daher-Nashif, 2021, p. 2).That gap was evident well before the pandemic; for example, a 2016 study of public health policy professionals suggested that public health students learn political skills such as "identifying which political actors have the ability to move a policy and forward and what motivates them… and recognizing that all policy making involves a series of tradeoffs, opportunity costs and compromise " (Moreland-Russell et al., 2016, p. 652).The study also suggested that public health policy students need "skills in developing effective policy-related messages" (Moreland-Russell et al., 2016, p. 652).
Pedagogically, the course sought to engage professional-stream students in those lessons as part-time adult learners who were already shaping advocacy in their own fields.Studies of advocacy teaching in medical education suggest that standardization does not work well with this material, and that adult learners best engage in advocacy learning when they can apply the material directly to their own work, in the context of their own values (McDonald, 2019).To underscore those connections, we began each two-hour session with 30 minutes discussing tensions arising from students' own policy experiences during the previous week.Those open-ended discussions in a small setting of seven graduate students provided a strong basis for shared learning and knowledge creation.
We drew on our own experiences in public health politics to teach these four sessions, locating them in theoretical frameworks of political change wherever possible.Students learned about politicians' need to link policy to public legitimacy and to their past public commitments.Students then learned how to translate a policy idea into a political "ask" by identifying a specific outcome an elected official could deliver -a statutory change, a regulatory change, a budget allocation, or an operational change in public services -and locating the specific politicians who could deliver that outcome.Finally, students learned how to engage in political consultations and shape their advocacy to specific politicians' decision-making models.

PILLAR 4: COMMUNITY
Our fourth pillar brought political advocacy into a community setting.Students revisited the relational change component of systems change (Kramer and Senge, 2018) and considered the power shifts and new relationships necessary to advance community participation in advocacy and decision making.Through guest lectures and case examples, students explored the advocacy work of community organizations, the necessity of including Indigenous governments and decision makers when considering advocacy work, and how public health researchers and decision makers have built and navigated public trust during crises.Students explored their own intersectional identities and learned how to build effective political alliances with community groups.

INTEGRATING THE PILLARS INTO A CAPSTONE ASSIGNMENT
As a capstone assignment, students were asked to build an integrated advocacy plan for an issue on which they were working.The plan required them to deploy the full portfolio of skills they had learned in the course: formulating a policy idea as a focused political "ask," tailoring that ask to specific political decision makers, and using journalistic and community disciplines to mobilize public interest.
Students were asked to integrate the course's four learning goals by preparing a brief advocacy strategy written plan in four parts.First, rather than simply articulate an idealized, evidence-based policy, students described a more tightly focused, actionable policy request, with specific implementation advice, and identified the relevant, responsible political or public-service policy maker(s).Second, students assessed the political environment, identified pressures on their identified policy-maker(s), and considered supportive coalitions that could bolster successful implementation or decision-making.In this context, they produced an advocacy pitch sensitive to the policy maker's needs and goals.Third, students described how they would use their journalism skills to generate and direct public interest, where appropriate.
To underscore the applied nature of this work students were asked to sequence an execution plan with realistic and well explained time frames.The capstone project thus pushed students beyond traditional, evidence-based thinking about policy.They were expected to demonstrate an ability to also think politically and journalistically in order to build trust for new ideas that don't simply sell themselves.

REFLECTIONS
I n launching this new course, we aimed to address some of the failures we had seen in public health leadership during the height of the COVID-pandemic: a failure to connect with distressed populations and politicians, that arose because of an over-reliance on letting evidence speak for itself, and an under-appreciation of the tools necessary to build public trust.We recognized that in pre-senting those tools to emerging public health leaders, we were asking them to undertake a significant cognitive shift.Indeed, we were asking them to challenge the way more senior leaders in their own institutions tended to communicate.
In many respects, our students succeeded.We learned to use their ongoing, real-life experiences as a platform for applied learning, and students noted regularly that their approach to their jobs was changing week-by-week as the course progressed.In one class, students and instructors advised one student on how to advocate for an urgent change to the federal budget, weeks before the budget was due to be tabled in Parliament.In another, a student shared how they used course learnings and materials to turn their social media advocacy into a specific organizational change.
As instructors, we also learned that emerging and experienced public health leaders need to undertake a significant portion of this work inside their organizations.In some cases that is because they do not yet occupy public-facing positions; in others, it is because they are public servants and do not have independent public-facing mandates.Teaching advocacy in this way requires a high degree of engagement by instructors; in this case, two instructors taught only seven students, though we expect enrolment to grow as the course becomes established in the professional-stream curriculum.
Challenges in the capstone assignment, however, underscored just how difficult this kind of cognitive shift can actually be.Students diligently completed each component of the capstone, but both their written papers and their presentations continued to lean heavily on conventional, evidence-based arguments.Demonstrations of political, community, and journalistic thinking, for the most part, remained cautiously within the remit of mainstream public health policy approaches; that is, despite our focus on the connections and power dynamics of relational change, students stayed within their comfort zones in structural change, focusing on nuts-and-bolts scientific evidence and bureaucratic approaches over critical journalistic and community change.However, the students did successfully demonstrate their understanding of both the principles of relational change and the fundamentals of journalism that could support their traditional approaches.They also identified the structural barriers within their own positions that challenge their abilities to act on novel approaches and use their journalism training.
Our experience with these assignments as completed suggest that the course could do more to integrate the four pillars -advocacy thinking, journalism thinking, political thinking and community coalition building -rather than simply presenting them as a sequence of separate skills.In future course iterations, we plan to tie each session more explicitly to the final project in order to prompt a deeper cognitive shift and a more integrated approach to advocacy.We also plan to lean further into conversations about the support structures that public health professionals need to take intellectual and professional risks in advancing advocacy through relational change.The need, in a time of multiple public health crises requiring effective collaboration and communication, is clear.We hope that students can then use the course as a confidential, real-time journalism and advocacy lab, using feedback from instructors and peers to dig deeper into action on the relationships, connections and power dynamics involved in advocacy and systems change.

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FIGURE 1: "6 CONDITIONS OF SYSTEMS CHANGE" KANIA ET AL., 2018 Dr. Kate Mulligan is the senior director of the Canadian Institute for Social Prescribing, senior advisor on Knowledge Mobilization and Determinants of Health for the Canadian Red Cross, and assistant professor in social and behavioural health sciences at the University of Toronto's Dalla Lana School of Public Health.She is a former member of the Toronto Board of Health and a 2021 Healthy Debate/DLSPH/ Closing the Gap Healthcare Pillar of the Pandemic.Robert Steiner is the director of the Dalla Lana Fellowship in Journalism and Health Impact and an assistant professor in clinical public health at the University of Toronto's Dalla Lana School of PublicHealth.The fellowship is the first journalism program designed specifically to teach outstanding specialists with graduate degrees or professional experience in a field how to cover their own disciplines as freelance reporters for media around the world.