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Getting Health Profession Workforce Diversity on the Public Agenda: A Communications Toolkit

Introduction

For more than a year, a multi-disciplinary team of researchers examined health professions workforce diversity (HPWD) in California from virtually every aspect of the issue. This Public Health Institute initiative, Connecting the Dots: California Initiative to Increase Health Professions Workforce Diversity (http://www.calendow.org/Article.aspx?id=2290), included an examination of K-12 challenges and promising practices, a range of post secondary and workplace issues and practice as well as issues in strategic communications and HPWD.

As part of the research to support strategic communications, a report was developed by The Praxis Project titled, If It’s a Pipeline, Why Isn’t There More Diversity At the Other End? Framing the Agenda for Health Professions Workforce Diversity (www.thepraxisproject.org) that examined current challenges in framing HPWD and made recommendations for advocates working to advance HPWD issues in the policy arena.

This guide is based on the report’s findings and is designed to help you tell the story of why health profession workforce diversity is important, how key institutions like government, schools and hospitals have affected diversity in the health professions and what can be done to make a difference. The guide focuses on news media and public education as the primary vehicles for engaging potential stakeholders on these issues. The emphasis of this guide is on communications to support changing policy and practice and not as much on increasing awareness about opportunities in the health professions. Although making people aware of health profession opportunities is important, this guide focuses on building public support for more effective programs and dedicated resources to HPWD as an important way to ensure that we have enough competent health professionals with the experience they need to effectively care for everyone in our communities.

The guide is in three parts. The first section provides a brief summary of the issues and the findings that frame the communications strategy overall outlines messages and framing opportunities. The second section focuses on preparation for engaging the media and overall goal setting. The third and final section includes resource materials including a template for a media plan, a sample spokesperson practice exercise, tips on working with journalists and other ideas for strengthening your media infrastructure.

HPWD Communications Toolkit (www.thepraxisproject.org) - 1 - WHAT’S AT STAKE: Ensuring Quality Health Care for All Californians

As an advocate, you already know that California, like the rest of the nation, is facing an acute shortage in health professionals and that the health workforce we have is not diverse enough to adequately serve California’s current population – much less the even more diverse state we will have in the future.

The data confirms what we know from experience: the higher up you go on the health professional continuum, the whiter the field. People of color are mostly in support professions as assistants and Whites (and to a much lesser extent, Chinese, Asian Indians and Pakistanis) comprise the vast majority of the physician/surgeon workforce.1

For those unfamiliar with the issue, the lack of HPWD diversity may seem natural, even unavoidable. Misconceptions about race, culture and ability shape how many see these issues. Lack of awareness of the barriers facing underrepresented communities (like racism, economic issues and inequitable funding for public schools) exacerbate these misconceptions.

Figure 1 (below) examines some of the many “stories” that shape how people “hear” what we have to say about HPWD issues.

Concepts of diversity, multiculturalism Concepts of the changing Concepts of proper role for demographics fairness re: government and affirmative action public investment special programs – especially re: for recruitment/ creating equity retention post-12

Concepts of Health Associations between quality fairness re: equal Professions access to quality care and diversity Workforce (patient-provider education for Diversity concordance, race children of color relates to… and competence)

Concepts of access Concepts of gender to equity, and race inequity: opportunity, degree of belief equality: degree of that it needs to/can Concern about support for be addressed access to quality, intervention, $ culturally competent health care now and in the future

1 Data from Bates, T., Hailer, L., et.al. Quantitative Assessment of Diversity in Selected Health Professions in California, UCSF Center for Health Professions, San Francisco, September 2007 http://www.calendow.org/uploadedFiles/Publications/By_Topic/Culturally_Competent_Health_Systems/Workforce _Diversity/SelectedHealthProfessionsinCA.pdf

HPWD Communications Toolkit (www.thepraxisproject.org) - 2 - I. Getting Ready for Media Advocacy

"The idea is to link it to the problems that are already being covered…how is it affecting what the rest of us are getting?” - Jim Brewer, reporter, San Francisco Chronicle

Using the media to tell stories for policy change is often called media advocacy. Media advocacy is just one part of a comprehensive change strategy that should also include mobilization and community organizing to build public support for change; and research and policy development to help identify the most effective policies and decisionmaking structures with which to work.

Know your territory. When we asked health journalists for advice on effectively framing health professions workforce diversity, we heard again and again how important it was to link our stories to issues of current interest. There is only one way to connect or piggyback on existing news and that is to pay attention to what is being reported.

Imagine driving cross country and having no idea what direction to go, what month it is or what the weather will be. Framing your issue without first monitoring media coverage of it is much the same thing. Good media advocacy requires some surveying of the terrain and a system for tracking coverage and media outlets.

. Keep an updated media list with names. You can start with the many published media lists available online, through bookstores or nonprofit associations. Calls should be made to local outlets that are important to your efforts to get the names of key contacts. Routine calls should be made to update lists as personnel moves frequently.

. Track coverage at least monthly. Some electronic services will track major news outlets in online databases for a fee. Many local papers, especially ethnic and other community press, are not a part of these services but can often be tracked using google or other search engines. It makes sense to regularly monitor (i.e., read, watch, subscribe to) key outlets in your area.

. Monitor with a mission. Look for how HWPD and the related issues in Figure 1 are covered in papers or on broadcast news. Look at who’s quoted, how are they quoted and how much; whether the reporter had a grasp of the issue’s complexity/importance; and the overall angle or frame of the story.

Map out key reporters and outlets. Review your monitoring and identify the media outlets and reporters that are covering related issues. If there are key outlets that are missing, note that, too. The sample chart below offers one, relatively simple way to organize your findings. The grade allows you to summarize the overall impression of the coverage as it relates to what you are trying to communicate. Outlets and/or journalist can be prioritized by a combination of grade and outlet importance in your communications plan. When prioritizing, outlets that already have a good track record are important to cultivate. Outlets that have been resistant may be lower priority, unless they are critical to your efforts. In cases of negative or resistant outlets, be sure

HPWD Communications Toolkit (www.thepraxisproject.org) - 3 - to identify whether it’s the outlet or the reporter and plan education and relationship building efforts accordingly.

Figure 2: Media Monitoring Analysis Outlet/Reporter Issues Covered Trend Grade Next Steps Eagle News/Joe Race and Does a good B Send information Smith education, job/gets it. No on education and population health issues yet HPWD and call to changes follow up Daily Sheet No local Only reprinting F Look at who is coverage of wire stories left on staff and related issues in identify potential last year. Lost people to health reporter in cultivate. Perhaps staff cuts talk with editor.

Identify clear issues and solutions. Be prepared to talk about what’s at stake and the solutions we are offering to address this crisis – especially given the public funding crunch.

Journalist Interviews’ Key Take Home Lessons for HPWD Advocates

Provide clear examples of what is at stake/why HPWD matters for as broad an audience as possible. Journalists are often writing for multiple audiences and these audiences should be kept in mind when framing and pitching news stories. Always ask, why should someone care about this? The answers should inform story development at its core.

Identify diverse spokespersons that illustrate the stories we are trying to tell. Journalists want to tell compelling, visually rich stories. Although data is important, we need to convey what the data mean in human terms with good stories and compelling characters -- and without losing our focus on the role of institutions and public policies. The key is to ensure that spokespersons tell their story in ways that complement and elucidate the larger context.

Develop relationships with journalists over time by providing information and sources they can use – even when the story is not directly about HPWD. Journalists need good, reliable information and sources. Many of us are well connected to a wide range of helpful sources, especially on health and education issues. With consistent, strategic relationship building, advocates can expand the ranks of journalists who understand HPWD and its relationship to a number of important issues they cover.

HPWD Communications Toolkit (www.thepraxisproject.org) - 4 - II. Framing Our Message

A pipeline conjures up images of fluid, uninterrupted movement from point A to B – nearly the opposite of what is actually occurring with regard to HPWD. Truth be told, with navigating the rules, the schools, the costs and the pressure, the road to becoming a health professional (especially at the higher echelons) looks more like an obstacle course than a pipeline.

Of course, we want a pipeline. We need a pipeline – a set of networks so interconnected, sturdy and efficient that everyone who chooses can flow through this system and have the necessary support to come out the other end ready to serve. Still, it will be important to convey that the pipeline is a work in progress. It is a goal, not yet a reality. However, there is an upside to this message: we already possess most of the know-how we need to make it a reality. We just need to come together and make it a priority.

In addition to re-examining our metaphors, there is also the need for clearer, simpler language to describe HPWD efforts – especially to those outside of the field. This will require taking a break from the level of detail and precision required for generating policy briefs or research and focusing instead on language that speaks to people at the level of their emotion. This does not mean developing emotive messages in isolation from policy goals. On the contrary, it is important to maintain consistency between each level of communication; meaning, communication messages should not contradict messages at the level of policy detail and vice versa.

It is important to note that a message is not a soundbite but an overarching theme that can be communicated using soundbites. For example, a soundbite might be, "We roll the dice hoping that we’ll end up with enough doctors from the small pool of people who can afford to prepare for and pay for medical school. But it isn’t good policy and it isn’t good sense.” The message, in this case, is that current policies to address the physician shortage are short sighted, impractical and puts us all at risk. The underlying values communicated are the need we all share for security, to have the services we need when we need them and to have sensible public policy.

Following (Figure 5) is a chart of message examples at each level of discourse along four message themes.

HPWD Communications Toolkit (www.thepraxisproject.org) - 5 - Figure 5: Examples of Communicating at Levels 1-3

Message Themes Level 1 (values) Level 2 (issue) Level 3 (policy) There is a lot at stake. We Every community matters The future of our health Policy goals and must act now to avoid a care depends on how we recommendations re: health care crisis and Safety, valuing face this challenge improving networks and ensure that there are community, fairness, together (set aside bias, collaboration; funding enough providers for every caring for others, etc.) equity community. compassion, etc.

Our solution is fair, This is about Californians We need a health Policy goals and practical and sensible: we caring for California workforce that is truly recommendations re: must increase the number representative. Achieving improving support of providers from our Local pride, common this means we have to systems/policies to communities so that we heritage, caring for clear the road blocks to increase the number of have a knowledgeable neighbors, common sense opportunities in the health students, professionals, [could also use culturally professions faculty, etc., along the competent] health “pipeline” workforce that reflects our state. (A health workforce that looks like California)

We have the know-how to Ingenuity, initiative, All over the state, there are Communicating about get this done rolling up our sleeves, success stories. With the successful programs and “just do it” right investment, we can pilots take success to scale Working together, we can Sharing the work, taking The Legislature, health Communicating about do it. responsibility, also rolling care sector, etc. all have successful collaborations up our sleeves important roles to play. and targeted briefings on We need you to play them. policy options

These simplified messages for conveying issues around HPWD are grounded in change communications principles that prioritize communicating action2. Messages to advance policy and/or institutional change must focus on the institutional roots of the issue and offer concrete, understandable “solutions” with change actors in mind. It does no good to develop messages promoting individual responsibility for an effort that requires action by legislators. Actions and messages must reinforce one another.

Good messages are affective -- they touch us emotionally. They are effective -- they convey what we need them to. They connect with shared dreams and beliefs. They surface the promise and possibilities in our coming together. Good messages also communicate "what can be done" so that those who are normally outside the process understand what they can do to have more power inside the process. Again, this requires that communication and strategies are integrated.

Communicating Along the Pathways of Change

2 For more on change communications, see Wallack, L. and Woodruff, K., et.al. News for a Change: An Advocate’s Guide to Working With the Media, Sage Publications, 1999 and Themba, M. “The Bridge Just Beyond: Constructing Communications for Social Change,” www.thepraxisproject.org.

HPWD Communications Toolkit (www.thepraxisproject.org) - 6 - The first step in developing an integrated, action oriented communications strategy is to identify actions and decision pathways where change must likely occur. We began mapping change agents by examining the core group of informants for the other inquiries and developing a list of corresponding key decisionmakers to implement emerging recommendations from the informants and researchers in each of the inquiries (Figure 6 below).

Figure 6: Moving From Informant Audiences to Decisionmaker Audiences

Informant Audiences: Stakeholders Corresponding Decisionmakers: Actors With Critical Perspectives With Power to Shape the Issue

Health professions educators at Faculty Senate, Department Chairs, academic institutions Administrators, Chancellor, President, Trustees/Regents, Accreditation Faculty members who take on “diversity enriching courses”

Health professions educators at Professional Associations, Provider Boards provider organizations

Health professions students from Campus and Statewide Student Associations community college along the continuum through medical school

Pre-health and non-health related declared underrepresented minority students from each of the public university and college systems, private college and high schools

Entry to mid-level professionals such as Unions and Professional Organizations community health workers, associate degree nurses or medical assistants;

Practicing underrepresented minority graduates from California health profession schools.

Health/Public Health Departments County Board of Supervisors, Health Directors, City Council, State Director

Community Health Centers Directors, Community Boards, Boards of Directors, Accreditation and Licensing

HPWD Communications Toolkit (www.thepraxisproject.org) - 7 - Informant Audiences: Stakeholders Corresponding Decisionmakers: Actors With Critical Perspectives With Power to Shape the Issue

Health plans (Senior Administrators and CEOs, Boards of Directors, Senior Human Resource Directors) Administrators and Human Resource Directors

Programs and Regulatory Agencies Commissioners, Boards of Directors, Senior Administrators, Legislature

Teaching Hospitals Boards of Trustees, President, Senior Administrators,

News Media Editors, Publishers, Community Affairs Directors, Editorial Boards, Media Associations and Professional Organizations including ethnic media formations

Legislators/Elected Officials Governor, State Legislature, City Councils, County Boards, Mayors, Legislative Caucuses, State Congressional Delegation, Elected Official Associations (ethnic and affinity)

Accreditation Bodies Governing Boards, Senior staff, Legislative Oversight Committees, Legislature, Governor

K-12 Programs to support students School Boards, Superintendents, Accreditation, going into health careers State Board, State Legislature and City Councils

Surfacing the Change Model. The project design implies a change model or approach to addressing these issues that has at least four elements:

1) Connecting practitioners/administrators with effective practice and other resources;

2) Connecting health related faculty, health workers and potential health workers with recruitment and retention resources;

3) Through media, research dissemination and other communications strategies, help build political will by investing HPWD issues with a sense of public urgency and priority; and

4) Connecting policymakers at all levels with good information and policies/models that increase funding and other supports for HPWD initiatives.

HPWD Communications Toolkit (www.thepraxisproject.org) - 8 - Practitioners, mostly captured in the left column (above), play a critical role in implementing HPWD practice and policies and advancing these issues from the “ground up” as identified in Change Model elements 1 and 2.

Given the set of findings from each of the inquiry areas, it is clear that actors in the left column believe dedicated funding and policy priorities are critical to moving HPWD issues forward, therefore helping to articulate an agenda for the audiences on the right. As a result, communication strategies targeting “practitioner” audiences should focus on engaging them in public agenda setting. In addition, a number of recommendations focus on strengthening practice in ways that lead to increased coordination and capacity across a variety of networks including K-12, the private sector, academia and so forth. This points to another critical communication objective: connecting these practitioners with good practice and practitioner networks.

The audiences on the right, then, constitute primary decisionmaker audiences with whom to communicate and engage mostly around change model Components 3 and 4. As decision makers, they will need a range of materials, resources and contacts in order to facilitate informed policymaking across the policy spectrum. Not shown here, but critically important are other, broader publics discussed above who have an important role to play in agenda setting as well.

In this framework, key communications objectives would look much like those outlined in Figure 7 (below).

Figure 7: HPWD Communications Objectives for Change Agents

Practitioners* What We Need to Policymakers Communicate Where on the support Where on the support continuum continuum

Unaware/on the fence and it’s important, it matters, it’s Unaware/on the fence overall reasonable, necessary, fair and practical

Contemplating action/ ready Who else has done it, how Contemplating action/ ready to to act they did it (political and act programmatic details), jump in the water is fine

Actively engaged in HPWD Kudos, support, affirmation Actively engaged in HPWD efforts that they are part of a efforts growing movement

Opposed to HPWD efforts This is an unreasonable, Opposed to HPWD efforts outmoded and marginalized position * Of course, there are practitioners that also set policy

HPWD Communications Toolkit (www.thepraxisproject.org) - 9 - PLANNING RESOURCE MATERIALS

HPWD Communications Toolkit (www.thepraxisproject.org) - 10 - MEDIA PLANNING CONSIDERATIONS: A Checklist

Write here your main three program goals:

List three goals for your work with the media. At least one should be related to your program goals:

Whom do you want to reach? Remember any targets you identified.

Organization/ Why do we want What do we want What do they What/whom Constituency them? them to do? care about? do they read, watch, (values, listen to? vulnerabilities)

HPWD Communications Toolkit (www.thepraxisproject.org) - 11 - What are you trying to communicate? Try to distill your message into a 25-word (maximum) statement that will get the point across. Remember: a message is not the same as a soundbite. It is the overall theme you are trying to communicate.

What are good images for conveying this message?

Who are good spokespeople for conveying the message?

What are the best media for conveying this message for each target? (List targets and choose one or more that fit. Try to focus on not more than three)

 Large Academic Publications

 Professional development or journal articles

 News media: ___ print ___ radio ___ television __ on-line __ opinion

HPWD Communications Toolkit (www.thepraxisproject.org) - 12 -  Entertainment media

 Other on-line media

 Personal networks

 Other ______

List arguments of the opposition:

Develop two soundbites that convey your message and address important issues raised by the opposition. (Remember: you are not debating them. You are delivering the message.)

HPWD Communications Toolkit (www.thepraxisproject.org) - 13 - Planning

List upcoming events and products, date they are scheduled to be completed and whether they have any piggybacking opportunities:

Event/Product Date to be done Media opportunities

List other events and products you know about (annual conferences, anniversaries, etc., that provide opportunities to communicate with others and advance your goals:

HPWD Communications Toolkit (www.thepraxisproject.org) - 14 - Organize these events in chronological order and prioritize which are the communications opportunities you’d like to follow up on.

Identify what tasks need to be done and by whom in order to complete the follow up:

HPWD Communications Toolkit (www.thepraxisproject.org) - 15 - About The Praxis Project

The Praxis Project is a non-profit organization based in Washington, DC. We are an intermediary working to support local policy advocacy as part of a comprehensive strategy for change. Our emphasis is on developing fields of work in ways that encourage multi-level, trans- disciplinary learning and collaboration. We work to identify "fulcrum" points, approaches that help lift and advance a wide range of work like meta-messaging -- communication strategies that cut across campaigns and issues for greater "echo" and impact. For more information or questions about this toolkit, please contact us at (202) 234-5921 or visit us on the web at www.thepraxisproject.org

HPWD Communications Toolkit (www.thepraxisproject.org) - 16 -

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