Advocacy is an essential element of any strategy to effect changes required to improve health outcomes brought about by poor lifestyles. The complexity of the causes of chronic disease has been a barrier to advocacy and has resulted in criticism of the public health sector as being complacent in its response to this epidemic. ¹ Lang and Rayner² suggest that policy-makers have been slow to recognize the seriousness of the issue for a number of reasons because, for example:

• the public health movement has been slow or ineffective in its advocacy work;
  
• the evidence is not easily transferable into policy; or
  
• it lacks political champions.

How can those engaged with public health be more active and challenge vested interests, promote policy solutions, engage with government and challenge community norms? This chapter outlines a strategy to develop a plan of action to advocate for prevention.

Public health advocacy is increasingly recognized as a key element in the promotion of public health. The World Health Organization defines advocacy as “[a] combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular goal or program.”³

Simon Chapman, one of public health’s leading advocates, defines advocacy as a process to overcome structural (as opposed to individual or behavioral) barriers to achieving public health goals. ⁴ As such, it “aims to change the legislative, fiscal, physical and social environment in which individuals ’ knowledge and attitudes are developed and expressed, and in which behaviour changes take place.”⁴ This approach recognizes that improving population health requires more than just a focus on the individual and particular behaviors, but also on societal structures that work against improvements in public health.

Building healthy public policy is central to the prevention of overweight and obesity. The UK Foresight report outlines the complexity of the drivers of obesity, while highlighting that most are societal issues and, therefore, require a societal response.⁵ Unfortunately, action to address overweight and obesity often becomes tied up in the complexities of prevention, thereby resulting in a lack of action.

Yach⁶ identified three key levers to support health policy change:

• raising the profile of the issue in the minds and on the agendas of policy-makers
  
• providing policy-makers with the necessary evidence to support the case for prevention
  
• persuading them of the need for changes in the health system away from acute care to prevention.

Advocacy is an important strategy to effect policy reform and it is important that policy-makers are provided with clear and coherent directions on which they feel that they can deliver.² Advocacy can be influential in setting the agenda, shaping the debate (the media is critical here), and in advancing particular policy positions.

Public health advocacy requires careful planning to ensure effectiveness and often requires support from relevant organizational systems, managers and external funders—a case that, in itself, may require “advocacy”.⁷ It important to understand that facilitating structural change is a long-term proposition and this also needs to be considered when establishing and building capacity for advocacy. ⁸

Components of an effective advocacy campaign include:⁹

• Clear specific policy goals. It is important to identify the problem and then propose specific policy solutions (see Box 23.1).

A framework of questions is often used to design and develop an advocacy plan for public health issues. ^12–14 The main strategies of public health advocacy involve building coalitions and networks, political lobbying and media advocacy. ¹² These strategic planning questions provide a process for developing effective advocacy strategies, including media advocacy. ¹⁵

What are the goals of the advocacy effort?

Any advocacy effort must begin with a sense of its goals because government is more likely to notice clear, articulated messages. These will vary—the ultimate long-term objective is to achieve comprehensive, effective, enforced obesity-prevention policies and regulation. However, because this will take some time to achieve, it is also important to set ambitious, but realistic, short-term objectives. The more specific these are, the more concrete and effective the planning will be.

Planning will also have to develop content goals (e.g. policy change) and process goals (e.g. building coalitions). These goals need to be explored and defined at the start, in a way that can launch a program, attract supporters and sustain it over time.

Who has the authority to make it happen?

It is important to identify the key decision makers because they are the people that the messages need to reach. This includes the general public, because building political will requires both government leadership and public support.¹⁶ Government and politicians will be more likely to act if public opinion (i.e. the constituents who vote for them) is seen as supportive. Well-conducted opinion polls can provide critical evidence to persuade decision makers that proposed changes have broad community support.

The target audiences may also include individuals, such as the chairperson of a parliamentary committee examining legislative reform, or members of cabinet who are examining legislation put forward by the health minister. It is also important to consider active and influential members of the community, as these people pay attention to public affairs and can also influence key decision makers. Finally, members of the public health community are important allies. These people can be opinion leaders and, as such, can be very influential. This influence applies not just to government, but also to the broader community as many people respect the views of doctors and other health professionals over and above those of vested commercial interests.

What messages are most likely to persuade the target audience to take the recommended action?

Consideration needs to be given to the value systems and political views of the target audience when developing persuasive messages. It is easier to convince someone to act on the basis of their existing beliefs, rather than trying to convince them of something new and different.¹⁷

Messages should include both a core message and tailored, secondary messages to address the self-interest and concerns of the target audience. Core messages are broad, simple and direct; their aim is to tie the advocacy campaign together. Tailored messages explain how the core message can be achieved. These messages can be used to motivate political leaders, as it will be necessary to convince government that there are good reasons for them to do something, particularly if it involves taking or changing their position.

As Yussuf Saloojee, a public health advocate from South Africa said: “The clearest antidote to lack of political support is to provide politicians and society with a convincing answer to the question—what interventions work and at what social and economic cost? If clear health benefits can be realised at a reasonable cost, most politicians will support health legislation.”¹⁸ Cost needs to be framed in a way which includes the political cost (such as going against the views of the food industry). This cannot be quantified but still needs to be acknowledged as part of the equation.

How do we develop messages that speak both to the head and the heart?

It is important to ensure that messages are more than just logically persuasive and morally authoritative. Such messages will be more compelling if they are capable of evoking passion. A campaign message must speak both to the head and to the heart. Effective messages must have a simple concept, which captures the essence of a scientific idea, and must be catchy enough to capture attention. The same message can then be delivered by various messengers and diffused through the community.

Effective messages can include statistics that are both truthful and emotionally moving, that is, “creative epidemiology”. How can stark, cold numbers from a study be translated into a message that evokes emotion and feeling? This is illustrated by the prevalence of Type 2 diabetes in adolescents. There are only a relatively small number of cases, but the concept that a disease stemming from unhealthy lifestyles in adults is now found in teenagers is shocking. This trend has created a much larger impact than that suggested by the data because of its emotional impact. Messages that are successful with one community may not always translate to another, owing to cultural and societal differences. To ensure success, the broader social and political cultures need to be considered when developing such messages, and it may be necessary to develop new messages that align with the values of that community.

Who can carry these messages to the target audience most effectively?

Persuading the target audience will rely as much on who delivers the message, as the message itself. Different people can have completely different credibility, power and effect. So a number of questions can be asked in order to determine the most effective messengers:

• Who is most likely to favorably influence the target audience?
  
• Who is the target audience politically responsive to?
  
• Who does that audience most want to please?
  
• To whom is that audience politically or financially obligated?
  
• Who does it respect?

For example, if the message is that “traffic light labeling on the front of packaged food will encourage healthier choices”, then who could take that message to the health minister? Probably not an epidemiolo-gist, maybe a consumer activist, but the head of the UK Food Safety Authority who has undertaken consumer research, developed a labeling system and implemented a strategy for uptake within their country, would be an ideal candidate.

It is also important to consider who the person you want to influence listens to and takes advice from, as they will also need to be reached. Often those you want to influence will be politicians so it is helpful to know how each level of government influences the policy-making process. Department staff and some ministerial advisers are extremely influential, as it is the cabinet that ultimately has to approve policy or legislative change.

Garnering support from the public health community, children’s rights groups, the consumer movement and the public—particularly parents—can also provide useful voices, so it is important to identify messengers that can reach these groups and help to raise awareness and support.

What medium will be most effective in delivering the messages to the target audience?

There are two key avenues to achieve this: first, directly through lobbying legislators to do what is recommended; and second, using the media to promote the message more broadly.

Direct lobbying

Lobbying is made up of two types of approaches: inside and outside. ¹⁹ Inside lobbying is that which takes place in and around the legislature and includes a mix of strategies including:

• meeting with politicians and legislative staff; delivering information face-to-face can be very powerful. Remember to think about what is in it for them;
  
• providing analysis and information to committees and legislative offices;
  
• testifying to committees;
  
• negotiating with policy-makers and other lobby groups.

Outside lobbying also requires work outside, where legislation and policy is made. Some of these activities include:

• media activity including news conferences;
  
• building broad and diverse coalitions;
  
• visits to local elected representatives by their constituents;
  
• letter writing campaigns to legislators; and
  
• grass-roots activities such as rallies.

Media advocacy

Media advocacy is the “strategic use of mass media for advancing a social or public policy initiative.” ²⁰ It recognizes that publicity is not an end in itself, but asks, “How can this media initiative or opportunity best serve to advance our policy goals?”

Using the media is an extremely powerful way to advocate for change because to be successful, public health campaigns require cultural as well as political change.²¹ The media provides the key channels to promote these dual aims as it reaches the general public, opinion leaders and policy-makers.

Policies to prevent obesity, like tobacco and alcohol control, often involve issues that are contested, resulting in a struggle with opposing forces. As such, the media message has to play two roles—negating the position put out by the opposition as well as advocating the particular policy position. There is also a danger in thinking that success is getting media coverage: to effect change the media interest must be harnessed to advance public policy objectives, not merely to publicize the issue. ¹² A useful way to look at this is to ask three questions: What is wrong? Why does it matter? What should be done? ²²

A media advocacy campaign can be planned, but must also be flexible to enable advocates to react quickly and creatively to the changing news environment. For example, if the government releases a report on rising deaths from chronic disease, an advocacy group could put out a press release about what action government should take to address the problem.

It is important to identify the best spokesperson, which may not be the head of the organization.²³ As part of this, media training for spokespeople is a good idea; any adversaries put up by industry will be well prepared and very experienced in engaging with the media.

Media advocacy needs to be targeted to the media that is respected and used by the target audience. This is known as “narrowcasting” and is particularly useful once the campaign is advanced, such as, once you have public awareness of the problem of overweight and obesity. In order to do this it is important to know which media are most likely to influence the key decision makers and then to develop strategies to reach those media outlets. For example, politicians are more likely to read the news and editorial pages of the most widely circulated newspapers, followed by those from the region where their constituents are based. Community opinion leaders are more likely to read newspaper editorial pages, including letters to the editor and opinion editorials, than the general public.

How do we get the media to pay attention?

Stories must be newsworthy to generate media interest. Making it local and keeping it relevant are two strategies to do this. This can be done by bringing statistics from a national level down to the local level by using creative epidemiology—such as outlining the new cases of Type 2 diabetes by local government region, outlining “hot spots” and calling for action to address this problem.²⁴ Creating news with events is also another strategy; this can be used to launch reports, research findings, or to publicize the visit of an international expert. This will require creative expertise to develop a “hook” to entice the media to “bite” and cover the story in the way in which you require.

How do we make sure the media tells stories that communicate the advocacy messages effectively?

How advocates and the journalists frame the issue determines how the audience decides who is responsible for the cause and solution to a problem. This is important because research around media coverage of obesity shows that the way it is reported and framed can divert attention from the structural changes required for prevention. For example, in Australia, content and framing analysis of reporting of over-weight and obesity in television current affairs found that the media sees obesity as an individual problem with individual solutions.²⁵ The focus on the individual can give rise to a “blame the victim” approach, ignoring actions of food companies, advertisers and the effects of government policies. The emphasis on personal responsibility moves attention away from the broader environmental issues that are amenable to change.

There are several steps that advocates can take to ensure that the public health perspective resonates with the media.

• Translate the individual problem into a social issue. Rather than talking about behavior, talk about policies that will change the problem. The language must demonstrate that there is a wider environment in which people are trying to make healthy decisions.
  
• Assign primary responsibility. Most people assume that the individual or parents are responsible for the problem of overweight and obesity in children. However, if audiences are to understand the public health perspective, then advocates must outline the corporate, government or institutional responsibility for the problem. The body or individual responsible for taking action must be identified.
  
• Present a solution. It is not enough to speak about the problem and who is responsible. The action required also needs to be articulated in a simple and effective way.
  
• Make a practical appeal. Public health policies are usually much more effective at changing behavior than education alone. If you can demonstrate that they are also cost-effective, particularly in the short-term, that is also beneficial and worth highlighting. Outline how the policy will address the basic cause of the problem and how it will save money, enhance productivity, save lives or protect children.
  
• Counter the food and advertising industry frames. It is necessary to develop media frames to counter those of the opposition, and counter messaging is essential with an adversarial issue such as overweight and obesity. A number of common arguments are used by adversaries in the debate such as: “Parents are responsible for overseeing their children’s health, particularly their diet”; “Obesity prevention is complex and there is still a lot of debate about what causes it”; “There is no evidence that food marketing is the cause of the problem or that bans on marketing are the cure”; “There are no good or bad foods, just good or bad diets”; “Individual responsibility is the key to the problem, not a heavy-handed nanny state”.²⁶
  
• Use media bites. These are short quotes which reporters find so appealing that they want to use them in their stories. Ideally, they provide a simplifying concept for the policy objective, they grab the attention of a journalist and gain access to a news story and they help frame the issues that points towards the policy objective. Once the media outlets have worked up the background for the story, they will look for quotes to best illustrate a particular aspect. This will often take the form of about 15 seconds in a television story, a few sentences in an article or a one-sentence grab for radio. They need to be short and sharp so that they succinctly frame the issue, for example: self-regulation of junk food marketing by the advertising and media industry is “like leaving the fox in charge of the hen house”; decisions not to regulate junk food marketing are “putting corporate wealth ahead of children’s health”; high sugar breakfast cereals are “confectionery dressed up as breakfast cereal”.²⁷

Advocacy is an essential driver of meaningful change for obesity prevention. Developing a plan of action starts with a critical understanding of the problem and the solutions, identifying those who are involved with the issue, recognizing the policies related to the issue (either implemented or not), the organizations engaged with it, and the channels (including the media) that will provide access to those who make decisions, or can influence decisions.

Many countries have published expert reports, which outline the problem of overweight and obesity, along with potential solutions. These recommendations have no force unless they are implemented, which will not happen without advocacy. The public health community must acknowledge and recognize the important role that advocacy plays in the prevention of overweight and obesity. As experts, those engaged in the issue make credible spokespeople, have links to the research and evidence for obesity prevention, and are in a position to encourage others to join up and support change.

More critically, industries that may be threatened by policies and regulation to prevent obesity are, themselves, actively engaged in lobbying to ensure that their views are heard and that their economic and other contributions are recognized and supported. The alternative views on protecting the health and wellbeing of children need to be communicated and promoted to both decision makers and to the wider community. Without this action, effective policies that challenge the status quo are unlikely to be implemented and the epidemic will continue to escalate unchecked.

1 The Lancet. Editorial—The catastrophic failures of public health. Lancet 2004; 363: 745.

2 Lang T, Rayner g: Overcoming policy cacophony on obesity: an ecological public health frameworke for policymakers. Obes Rev 2007; 8(Suppl. 1): 165–181.

3 World Health Organization: Development Communication in Action. Report of the Inter-agency Meeting on Advocacy Strategies for Health and Development. HED/92.5. Geneva. WHO, 1995.

4 Chapman S, Lupton D: The Fight for Public Health: Principles and Practice of Media Advocacy. London: BMJ Publishing Group, 1994.

5 UK Government Office for Science: Tackling Obesities: Future Choices—Project Report, 2nd edn. London: UK Government Foresight Programme, Government Office for Science, 2007.

6 Yach D, Hawkes C, Gould CL, Hofman K: The global burden of chronic diseases—overcoming the impediments to prevention and control. JAMA 2004; 291: 2616–2622.

7 Public Health Alliance for the Island of Ireland (PHA): Public Health Advocacy Toolkit. Ireland: PHA Belfast, 2007.

8 Gray M: Forty years of plotting for public health. MJA 1997; 167: 587–589.