Article Text

Download PDFPDF

Teaching and learning about advocacy
  1. T Waterston
  1. Tony Waterston, Community Child Health, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK; a.j.r.waterston{at}ncl.ac.uk

Abstract

Advocacy is an essential skill in the practice of paediatrics, where much of the work covers aspects of health as well as disease and where cross-agency work is common. Educationally, advocacy is best taught using a competency based approach and the key knowledge, skills and attitudes are defined. Central to the knowledge field is the evidence base for advocacy, and the UN Convention on the Rights of the Child. It is desirable for advocacy skills to be learned through experiential learning and examples are offered including letter writing campaigns, an advocacy journal club and keeping a diary of cases seen in the clinic. Means are suggested for including advocacy training in the core teaching of paediatricians, through a combination of theoretical teaching and practical experience. It will be necessary also to include advocacy topics in examinations, if there is to be genuine prioritisation of this area of practice.

Statistics from Altmetric.com

Advocacy means speaking out on behalf of a particular issue, idea or person.1 Paediatricians advocate for children because they are vulnerable and not usually able to speak out for themselves. Advocacy differs from other areas of paediatric teaching and learning as it has a less secure knowledge base than a topic such as meningitis or cerebral palsy. The use of advocacy requires practical skills and an attitude of mind and has much in common with communication, as table 11 shows.

Table 1 Skills required for communication and for advocacy

Advocacy has always been a part of paediatric practice but in today’s world, when the public services that support children are much more complex, the requirement for it is much more frequent. Reasons why advocacy is more often needed in the modern world are shown in box 1, and an American view of advocacy is shown in box 2.

Box 1 Why child health advocacy is needed in the modern world

  • Interagency working is common (education, social services, housing).

  • Social determinants of health are better recognised (poverty, inequalities, environment).

  • Some modern epidemics are caused by environmental factors (obesity, accidental injury, conduct disorder).

  • Children’s rights are recognised as an underpinning principle for good health care.2

  • The expectations among families of high quality care are greater.

  • The profession has clearer standards for quality of care.

  • There are a number of vulnerable groups in the community whose needs are not adequately met, for example, adolescents, children with mental health difficulties, asylum seeker families, children in care, black and ethnic minority families and those living in poverty.

Box 2 An American view of advocacy3

Advocacy is many things. It is speaking out, speaking up, speaking for. In its simplest and most profound form, advocacy is giving voice to the questions, “What is wrong here? Couldn’t we do better?”. Advocates witness and bring to light abuses and inequities, unfair practices and dangerous conditions. Advocates take unpopular positions by questioning the status quo. They ask, “Why?” when others assert, “We have always done it this way”. Some advocacy involves taking serious risks, caring enough about a cause to question authority and even to court personal repercussions.

But other advocacy work is quiet, reformative and constructive – advocates who don’t simply wag their fingers and cry foul but figure out new ways of addressing serious problems and making a significant difference.

The paediatrician is well respected as being objective in providing care for the child, as not having financial interests and as possessing a high status in society.

Advocacy for children may lead to conflict with parents who do not always act in their child’s best interests. The UN Convention on the Rights of the Child (UNCRC)4 will provide direction in this situation.

Advocacy has been practised by paediatricians for many years and some examples are given in box 3.

Box 3 Examples of advocacy by paediatricians in child health5

  • Job Lewis Smith: promoted breast feeding of abandoned illegitimate children by wet nurses

  • James Spence: pressed for parents to be allowed to stay in hospital with their children

  • Donald Court: ensured that parents were represented on a committee for reforming children’s health services

  • Hugh Jackson: publicised the harm done by children ingesting adult medicines and became a fervent advocate of injury prevention

  • Murray Katcher: worked for legislation to prevent scalds by lowering water heater temperature settings

CHALLENGES AND PROBLEMS

While advocacy is not new to paediatrics, it has not yet been accepted by many UK paediatricians as an integral part of their work that can sit beside clinical skills and the acquisition of knowledge and evidence based practice as central to medical teaching. It will be important to identify methods of teaching about advocacy that will set the trainee alight with enthusiasm rather than douse their interest. Since advocacy is primarily a skill, it is this aspect that should be emphasised most during training.

STRENGTHS AND RICHNESSES IN THE PAEDIATRIC ENVIRONMENT

Paediatrics and child health lend themselves to teaching about advocacy. The characteristics of the environment that illustrate these strengths are shown in box 4.

Box 4 Strengths of paediatrics in relation to advocacy

  • Parents normally act as advocates for their child, hence paediatricians can provide support to such parents.

  • There is a large body of legislation to support advocacy, both nationally and internationally.

  • Specifically, the UN Convention on the Rights of the Child4 is the guiding light for advocacy on behalf of and with children and young people.

  • Paediatricians are seen as protagonists for children without a bias of self-interest.

  • Paediatricians work in an interdisciplinary, interagency environment where advocacy is likely to be needed and where the support of other disciplines can be obtained.

  • In relation to public health advocacy, paediatricians will find allies in children and young people themselves and they can be very effective advocates.

The ability of paediatricians to work both with parents and with children and young people makes for a particular richness, although there are times when the advocate may come into conflict with the parents on behalf of the child.

KEY EDUCATIONAL CONCEPTS

In this section I will explore the educational implications of advocacy. Like communication, it is a means to an end and cannot easily be taught on its own. Let me analyse the terms used in the definition above.

  • Advocacy is defined as arguing or speaking out on behalf of a particular issue, idea or person. Paediatricians advocate for children because they are vulnerable and not usually able to speak for themselves.

  • Advocacy may relate to a clinical encounter with an individual child or family, or to children’s health within society as a whole (child public health).6

“Arguing or speaking out” requires an evidence base (knowledge), presentation skills including both speaking and writing (skill), knowledge of the media and how to use it (knowledge and skill), understanding of the political process (knowledge), knowledge of the key children’s services (knowledge) and a commitment to the “cause” or “goal” of children’s health (knowledge and attitude). Successful advocacy also requires persuasion and persistence (skills) and a belief that change is possible (attitude).

“A particular issue, idea or person” requires an understanding of both paediatrics and child public health (knowledge) and an ability to prioritise (skill).

Hence one can derive the competencies that constitute the successful advocate. These are shown in box 5.

Box 5 Competencies of the skilled child health advocate

Knowledge

  • The evidence base of advocacy

  • The media and the political process

  • Children’s services

  • The “cause” of children’s health (eg, the UN Convention on the Rights of the Child)

  • Understanding of general paediatrics and child public health

Skills

  • Presentation skills and communication, including use of the media

  • Ability to prioritise, be persuasive and be persistent

Attitudes

  • Strong commitment to the “cause” of children’s health

  • Belief that change is possible

PRINCIPLES OF LEARNING AND TEACHING

A curriculum for advocacy training could be built on clinical practice, although certain competencies such as public health knowledge and use of the media require additional input.

Clinical and public health situations where advocacy is required are shown in boxes 6 and 7.

Box 6 Clinical situations where advocacy may be required

  • A young person whose consent has not been sought for a procedure

  • A child in hospital whose emotional needs have not been met

  • A child with special needs who is excluded from school

  • A child who is discriminated against

  • A child who has been abused or neglected but the services have not responded

Box 7 Public health situations where advocacy may be required

  • Children subjected to painful restraint in prison

  • Teenagers who are discriminated against in the media

  • Asylum seeker families who are refused access to health services

  • A law which permits corporal punishment of children

  • Inequalities in child health

  • Persistent bullying in schools

  • Lack of mental health services for young people

The individual clinical situations can be located in any hospital or (better) community practice. The public health scenarios are ever present but less familiar to most paediatric trainees.

TEACHING AND LEARNING IN PRACTICE

Knowledge

The knowledge areas described above are included in the competencies required at the end of paediatric training. However, they are unlikely to be included in bedside teaching. Most general paediatricians will not feel confident in covering them and they are more likely to be in the tool box of public health doctors. An on-line course is being prepared by the Royal College of Paediatrics and Child Health (RCPCH). If paediatric exams include questions in relation to the knowledge base, then trainees will make sure they learn it.

Skills and attitudes

These are best learned through practical experience, as for example through a project as is the case in the MMedSci course in Leeds.7 Here the students are asked to keep a diary of events over a 2-week period to identify topics requiring advocacy; nine paediatricians identified 60 problems. They then pursue one particular problem over a longer period to find a means of tackling it. Similar approaches are used in the American Academy of Pediatrics CPTI (Community Paediatric Training Initiatives) programme3 which provides excellent examples from the USA, some of which are shown in box 8.

Box 8 Some areas of focus of Community Paediatric Training Initiatives programmes3

  • Letter writing campaigns (Children’s Hospital of Philadelphia) (a letter on Medicaid cuts was presented before Grand Rounds and signed by over 100 physicians and other health care professionals8)

  • Advocacy Journal Club

  • Child advocacy reading list (University of Rochester)

  • Volunteering in a homeless shelter

  • Visiting community projects

  • Visiting a legislator on Capitol Hill

How do these ideas lie with the current competencies outlined by the RCPCH?

Box 9 lists those competencies which fall most clearly into the category of advocacy. Most of them are knowledge based competencies, but can be learned effectively during a project as described below.

Box 9 Competencies listed by the Royal College of Paediatrics and Child Health in relation to advocacy9

  • Understand the duties and responsibilities of a paediatrician in the safeguarding of babies, children and young people

  • Understand the responsibility of paediatricians to consider all aspects of a child’s well-being including biological, psychological and social factors

  • Develop a commitment to a policy of advocacy for a healthy lifestyle in children and young people and for the protection of their rights

  • Understand how national and local policy initiatives impact on medical practice and social health and well-being

  • Know the principles of the UN Convention on the Rights of the Child, apply these in your own practice and work for the protection of these rights

  • Be aware of the effect of the media on the public perception of health care issues

  • Be aware of the effect of non-health policies on child health

  • Be aware of child health exploitation issues including child prostitution, child labour and children in combat

  • Be aware of the effects of armed conflict on child health

  • Know about current government policies which relate to children

  • Understand the role of the paediatrician in advocating for children at individual, community, national and international levels

Note: these are some examples only, see full document for further information.

PUTTING ADVOCACY INTO PAEDIATRIC PRACTICE

In this section I look at how advocacy can enter the paediatric curriculum using examples of what has been done both in the UK and the USA.

Time

It is difficult to teach adequately about advocacy in a single session. With two or more sessions, work can be done in between to allow the student to apply what he or she has learned. If only one session is available, it is essential to give the students tasks to carry out in advance. It is best if the two sessions are 1 week apart so that the material remains fresh in the student’s mind. When material is available on the internet it is easier to give the students tasks outside a teaching session.

Learning about the UNCRC

The UNCRC is a UN document which uses quite dry language and can be difficult to read without preparation. However, as soon as the student sees how it applies to real situations, then it comes alive. Box 10 shows two examples of how the convention can be used in a small group setting in a more interactive way.

Box 10 Exercises on using the UNCRC

1. Each student is asked to pick a number between 2 and 40 (the key articles in practice). Then each is asked to read the relevant article and consider first whether it applies to health and health services, and second whether it is supported or breached in the UK. He or she is asked to present views to the others (this can be done in groups). This exercise leads the students to read the convention, examine its significance to health, and engage in a valuable discussion on the situation in their country.

2. (This exercise should be done in advance of the teaching session.) Pick one of the articles that refers best to clinical practice (5: respect for evolving capacities; 12: expressing a view; 13: freedom of expression (receiving and imparting information); 16: privacy and confidentiality; 19: protection from physical or emotional violence) and ask each person to look for a case over the following week which illustrates a breach or supports this right in clinical practice. This case is then presented at the session.

Both these exercises will lead the students to better understand the significance of the convention in clinical practice and will help them to see the rights basis of the clinical encounter. Further examples of teaching are in the child rights course on the European Society for Social Pediatrics and Child Health website (http://www.essop.org).

Using a diary to identify examples of advocacy

This technique requires time but as in the above, is very valuable in demonstrating the links between advocacy and real life. This technique has been used by students in the MMedSci in Paediatrics in Leeds, UK.7 Students keep a diary for 2 weeks to identify problems which might require an advocacy response. They then categorise the problems as follows:

  1. Family issue: where provision is available but not accessed by the family

  2. Within-agency issue: where a system has failed the child or family

  3. Interagency issue: where interaction between agencies has failed

  4. Inadequate or absent provision: where a problem has arisen which requires a political decision

  5. Discrimination: where a family suffers a racist or other discriminatory response from the service.

Sixty problems were identified over 2 weeks by nine paediatricians and these are summarised in box 11.

An advocacy project

Probably the best way to develop the competencies required of a paediatrician-advocate is through undertaking an advocacy project. This means adopting a topic that requires advocacy and following the process through to completion which might take a period of 6 months.

An example of a project undertaken by a postgraduate student from the MMedSci course in Leeds is shown in box 12.

FURTHER DEVELOPMENTS

Advocacy for medical students

It seems entirely appropriate for advocacy education to start with medical students. They are often idealistic and will understand the point of advocacy to improve the health of children. Examples are essential and should relate to both advocacy for the individual child and public health advocacy. An example1 is given in box 13.

Box 11 Problems identified in paediatricians’ diaries7

  • Family issues: 15

  • Within agency issues: 24

  • Interagency issues: 13

  • Inadequate or absent provision: 7

  • Discrimination: 1

Box 12 An advocacy project6

A paediatrician was concerned about the poor toilet facilities for primary school girls who had reached menarche. Her audit of local schools found that over half required girls and boys to change together in the classroom for physical education lessons, and that over 40% of schools required menstruating girls to use the staff toilets. Focus groups held with the girls revealed that they were unhappy with this situation. The paediatrician discovered that there were no guidelines on acceptable practice either locally or nationally. The education department agreed to draw up local good practice guidelines and involved the healthy schools initiative officer in developing these. These guidelines, which included toilets with locks and sanitary disposal facilities for girls in Years 5 and 6, received a healthy schools award and funding was made available to implement them. The guidelines were then applied nationally.

Box 13 Child admitted to hospital after a fire

History: Ebrahim (aged 2 years), his two siblings and his mother were admitted to hospital with smoke inhalation. All four nearly died in a house fire because the smoke alarm did not activate. They are asylum seekers from Angola housed in dispersal accommodation. The house is in poor condition and is run by a notorious housing association that has a number of contracts with the Home Office, but which does not comply with the housing or health requirements of the contract. There had been many previous complaints from organisations working with asylum seekers about this housing provider.

Questions: What is the legal position here? Where should advocacy be directed? Who would be allies in taking advocacy forward?

International child health

The requirement for advocacy is paramount in international child health.10 Examples are in child prostitution, child labour, violence against children,11 child soldiers and children in war.12 Advocacy by paediatricians both as individuals and through their organisations is likely to be of benefit and there are also lobbying organisations such as Medact (Medical Action for Global Security, www.medact.org) to which the RCPCH is affiliated.

Advocacy in continuing professional development

In continuing professional development, understanding the relevance of the UNCRC is perhaps the best way to approach advocacy. Currently a yearly course on children’s rights is provided by the RCPCH which offers both a basic understanding of the relevance of children’s rights to child health, and an approach to advocacy and working with young people. (see http://www.rcpch.ac.uk/events)

Many opportunities are offered for advocacy through the RCPCH. In a recent UK campaign to end corporal punishment of children,13 paediatricians were asked to write to their MPs to support a change in the law, and many have done so.

The Equity Project (EP)

The EP is an example of international advocacy. It brings together paediatricians from the American Academy of Pediatrics and the RCPCH who aim to ensure that equity in child health forms a key goal for their organisation. Achievements of the EP so far have been the child rights course (see www.essop.org), a supplement in Pediatrics14 (September 2003) and a statement on equity and child health which is on the RCPCH website (http://www.rcpch.ac.uk/Policy/Advocacy). A collaboration is currently underway with the Open University to develop web based teaching under the OpenLearn system on children’s rights (www.open.ac.uk/openlearn).

RCPCH Advocacy award

The College is developing an annual award for the “Advocate of the year”. This will be open to paediatricians and trainees and will reward the person who has carried out the most effective advocacy project during the last year. The award will be presented by the President at the annual meeting.

CONCLUSION

Trainees who are introduced to advocacy in an insightful way will find that it improves their relationship with parents and children, assists them in understanding the workings of the system, and offers a means to help children and young people more deeply. It can also be fun, and provides a sense of achievement. Once started, you will never look back.

Acknowledgments

Sophie Haroon provided helpful comments on this paper. Jean Price, American Academy of Pediatrics, provided examples of the wide range of advocacy initiatives in the Academy. Elspeth Webb is a source of inspiration in relation to advocacy and the teaching of children’s rights.

REFERENCES

Footnotes

  • Competing interests: None.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.