working upstream skills for social change working upstream skills for social change a resource guide for developing a course on advocacy for public health developed by Lori Dorfman Berkeley Media Studies Group Public Health Institute Susan Sorenson School of Social Policy & Practice University of Pennsylvania Lawrence Wallack College of Urban & Public Affairs Portland State University supported by a grant from The California Endowment table of contents Acknowledgements . 7 Preface. 9 Introduction:Why this Resource Guide? . 11 Lesson 1: Concept and Mission of PH . 17 Lesson 2: Population Health and Determinants. 39 Lesson 3: Rationale for Advocacy & the Haddon Matrix. 57 Lesson 4: Policy Analysis . 77 Lesson 5:Advocating for Policy Change. 93 Lesson 6: Community Organizing . 137 Lesson 7: Coalition Building . 159 Lesson 8: Media Advocacy. 179 Lesson 9: Evaluating Advocacy. 203 Appendices: A:Vignettes & Lessons from Public Health Advocacy . 237 B:A Note on Service Learning. 269 C: Bibliography . 275 acknowledgements This work is dedicated to the memory of Ruth Roemer, 7 a tireless advocate for the health of the public. We would like to thank The California Endowment for understanding the need for this work, as well as for their fi- nancial and conceptual support. Barbara Masters and Gigi Barsoum, in particular, contributed to the success of this work. We express our appreciation to faculty members E. Richard Brown, David Dyjack,Vicki Ebin, John Elder, Stephanie Farquhar, Ralph Frerichs, John Froines, Mary Beth Love, Edward Mamary,David Michaels, Meredith Minkler, Sara Rosenbaum, Darleen Schuster, Harry Snyder, Jack Thompson, James Trussell, and WilliamVega,for their contributions during the initial meeting for this project. Thanks to the public health students attending, and graduates of, the public health programs at California State University,Northridge; Loma Linda University; San Diego State University; San Francisco State University; San Jose State University; University of California, Berkeley; Uni- versity of California, Los Angeles; and the University of Southern California, for offering their thoughts about how advocacy is — or isn’t — discussed in their programs. Thanks to advocates Mark Chekal-Bain, Larry Cohen, Donna Garske, Stefan Harvey,Kirsten Moore, Mark Pertschuk, Kathleen Rest, Susan West-Marmagas, Dan Wohlfeiler,Anthony Wright, and Ellen Wu, for their con- tributions during the second meeting for this project. Thanks to the reviewers for their cogent comments. In addition to the faculty and advocates mentioned above, we thank Elizabeth Burke Bryant, Carol Kamin, Justin Louie, and Makani Themba-Nixon who gave us valuable feed- back on various lessons. This work is a collaborative effort among Susan Sorenson, Lori Dorfman, Lawrence Wallack,and Sonja Herbert. Joining the collaboration were Sara Rosenbaum, who authored the lesson on Policy Analysis, Harry Snyder, who authored the lesson on Policy Advocacy with assis- tance from Tanecia Echols and Nadia Campbell,Vivian Chávez, who authored the lesson on Community Organiz- ing, Larry Cohen, Kate Pastor, and Sana Chehimi, who au- thored the lesson on Coalition Building, Julia Coffman, who authored the lesson on Evaluating Advocacy,and Stephanie Farquhar and Nancy Cuilwik, who authored the Note on Service Learning. Katie Woodruff and Liana 8 Winett edited theVignettes and Lessons from Public Health Advocacy.TheVignettes drew on lessons from Larry Cohen, Stephanie Farquhar, Donna Garske, Sonja Herbert, Kristen Moore, Mark Pertschuk, Liana Winett, and Ellen Wu; we thank them for sharing their stories. Julia Marcus and Jaimie Morse provided research assistance in the early stages of the project. Photographs in Lesson 5 were taken by Susan Duerksen. Special thanks to Steve Teret, whose conversations over the years with Lawrence Wallack provided the impe- tus for our efforts. preface During the last few years,The California Endowment has 9 placed increased focus on policy and advocacy work.We believe that for many societal challenges, creating policy change can have a more systemic and lasting effect on im- proving the health of Californians.And, we have seen the success of this strategy.We have supported advocates to bring to light many public health problems, and real change has resulted — from banning sodas in schools to improving access to interpretation services in the health care setting for people who don’t speak English. However, we know that continued success depends on having a large cadre sophisticated advocates that can effectively navigate the challenging terrain of policy advocacy. To answer this need,The California Endowment de- veloped advocacy training programs for our grantees deliv- ered through the Health ExChange Academy by our Center for Healthy Communities.That training series is helping practitioners and community leaders across Cali- fornia become active on local, state, and national policy. Still, there was more to do. Policy leaders advocating for change on our most difficult issues — health care, asthma, obesity prevention, and more — needed reinforce- ments. A logical place to look was to the public health programs in the state’s universities, since they are training the very people who will staff the organizations seeking to create healthier communities in California. Public health programs train masters degree students for positions in community-based organizations and gov- ernment agencies.The programs tend to focus on research and intervention but generally lack systematic training for students in policy advocacy despite the fact that advocacy is a central strategy in translating science into public policy. The Resource Guide you now hold is a first step toward addressing that educational need. The process Berkeley Media Studies Group and their colleagues used to develop the Resource Guide drew on public health faculty and advocates from California and across the nation.They have devised a comprehensive yet flexible compendium of course work that can be adapted in public health programs everywhere. We look forward to seeing these materials used to pre- pare public health students for the escalating challenges they will face in advocating for the policies that will bring health to every population in California. 1010 Barbara Masters Gigi Barsoum Public Policy Department The California Endowment February 2009 introduction “The key challenge facing public health 11 education today is reconciliation of the academic environment in which most public health education takes place with the practice environment for which students are destined.” KM Gebbie, L Rosenstock, LM Hernandez WhoWill KeepThe Public Healthy? Washington,DC: National Academies Press, 2003 background Degree-granting public health programs typically focus educational efforts on research and practice. Considerable resources are invested in creating competent consumers and producers of research. Course offerings and internships also emphasize practice, includ- ing program planning, health education, and policy.However, the connection between research and practice is sometimes not as well developed or fully articulated in academia as are research and practice, alone. Public health needs more practitioners who can bridge the gap between research and practice, people who can take research findings and use them to inform policymak- ers and influence the development and implementation of policy.Public health students need to understand the process of social change and, when indicated, be able to advocate for social change. Unfortunately,many public health faculty do not possess the skills or experience to teach advocacy effectively.Faculty surveys show,for example, that despite advocacy for 12 health being recognized as an ethical responsibility and required competency of health educators, many health education faculty do not see themselves as competent for teach- ing advocacy and lack instructional materials to do so (see Radius et al 2009). Degree- granting programs in public health need to provide systematic training in social advocacy. In the absence of formal training in social change, public health graduates must learn this information and develop these skills on a catch-as-catch-can basis.Working in this way means that some will be less effective than they otherwise could be in advancing the health of the public. Our objective in developing this resource guide is to provide tools and examples to help public health faculty instill skills in their students for working upstream where, by doing advocacy,they can improve the environments that cause unnecessary morbidity and mortality. the current project Process In recognition of this curricular gap, present in many universities that educate students in public health, we enlisted the participation of faculty from across the nation, as well as that of leaders in nonprofit public health organizations and current students and recent graduates from several degree-granting public health programs and schools, in order to develop this resource guide.To recount briefly,we: Reviewed existing courses on social advocacy in public health programs. Through an online search and addi- tional information provided by multiple instructors, we found that about half of the universities (20 of 42) sur- veyed nationally offer one or more relevant courses.After obtaining and reviewing the syllabi for 28 of the 29 cur- 13 rently offered courses, we concluded that only a handful of courses emphasized skills-building, and even fewer empha- sized the skills