The Next Step in SDOH Education – Training Health Professionals to be Change Agents

After witnessing and experiencing the trauma of dual pandemics on ourselves and on communities of color, it has become apparent that simply teaching our learners to recognize the impact of racism and other social determinants of health on health outcomes is insufficient. Educators must help learners develop skills in advocating for transformational change of our health system and society. Engaging in advocacy can provide a sense of purpose, a strong identity, a common goal, and community, all of which can bolster resilience and healing¹.  In this blog post, I’ll discuss why health professionals in particular should engage in advocacy and how to get started.

Advocacy is a deliberate process based on demonstrated evidence, to directly or indirectly influence decision makers, stakeholders, and relevant audiences to support actions that contribute to the fulfillment of human rights².  Advocacy creates greater awareness and public support around specific causes, can amplify marginalized voices, and build community.  At first glance, this may feel out of the scope of many health professional’s practice, which often focuses on the individual patient. However, numerous professional organizations such as the American Medical Association and American Nurses Association endorse advocacy as a professional responsibility^3,4 and altruism often motivates students to pursue careers in healthcare⁵. Health professionals’ status in society makes us trusted and authoritative sources. In addition, clinical work allows us the privilege to get to know individuals across race and class boundaries in a society that is often highly segregated, and to bear witness to the impact of unstable housing, immigration status, and other social determinants on their lives and health. However, few health professionals actively engage in societal discourse or advocacy; for example, physicians are less likely to volunteer or to vote than the general population^6,7.  Barriers to developing advocacy skills include the lack of formal training or mentorship as well as the long and arduous training that effectively removes physicians-in-training from the community^8,9.

Advocacy can take the form of writing an op-ed for a local newspaper, sharing posts on social media, setting up a meeting with a local legislator or joining a lobby day in your state’s capitol. There have been numerous examples of healthcare advocacy happening right now- from front lines providers joining Black Lives Matter protests, to efforts to make our academic institutions more antiracist, clinic-based voter registration campaigns, and collaborations to address specific SDOH such as housing or food instability and gun violence (#ThisIsMyLane).

That’s exactly what my friend Stella Safo was aiming for when she co-founded Vote Health, a non-partisan coalition of health professionals and students committed to helping peers and patients register to vote and vote safely this November. The organization aims to address systemic oppression that makes it harder for some populations to vote, as well as the historically low voting rates among physicians. Stella joined the VoteHealth 2020 team “because the care of my patients doesn’t stop in the clinic; it has to continue to include all forms of civic engagement, from voting to protests. Covid-19 has shown us over and over again that public health is local and voting for strong local leadership is one of the ways I can help my patients and peers stay safe.”

But you don’t need to found an organization in order to get started engaging in advocacy yourself or with your learners.  Here are a few tips for getting started:

1. Clarify your vision early. Spend a few minutes to consider what topic you’d like to address and explore how your topic of interest is impacting you and the community you serve. Solicit the perspective of patients or community members.
2. Identify and partner with local organizations engaging in advocacy around your topic of interest. For example, a community-based housing organization will likely be aware of proposed legislation to extend Covid-era eviction protections, have identified legislators supportive of the cause, and have amassed evidence in support of their position. You can amplify advocacy efforts by highlighting their health-related impacts, such as the positive impact of stable housing on health. Health professional organizations often also have an advocacy branch and are happy to work with you to maximize your impact.
3. Use storytelling and empathy to support evidence-based points. Storytelling that combines emotions and facts, human narrative and numbers in compelling ways is key to engaging audiences, triggering connections, changing attitudes and inspiring action. Of course, if you are taking inspiration from patient experiences, stories should be sufficiently anonymized so as not to breach HIPAA privacy regulations.
4. Be mindful when engaging as an ‘expert’ to not subvert expertise of community partner’s lived experience and expertise. For example, providers should take a supporting role to people with criminal justice experience when advocating for decarceration and other changes to address the lasting impact of mass incarceration on communities of color.

Erin Goss, MD, AAHIVS, Community of Practice Member

Dr. Goss is an Assistant Professor in the Departments of Medicine and Family & Social Medicine at the Albert Einstein College of Medicine in Bronx, NY and a core faculty member for the Primary Care/Social Internal Medicine residency program at Montefiore Medical Center. She has developed, implemented, and assessed curriculum focused on the care of marginalized populations, community engagement and health advocacy.

References:

1. Pinderi, K. ( 2017, May 11) When advocacy work builds resilience, everyone benefits. Available from:  https://www.openglobalrights.org/when-advocacy-work-builds-resilience-everyone-benefits/
2. (2010) Advocacy Toolkit. Available from: https://unicef.org/evaluation/files/Advocacy_Toolkit.pdf
3. Association, A.M. (2018 ,February 15)Declaration of professional responsibility: medicine’s social contract with humanity.  Available from: http://www.cms.org/uploads/Declaration-of-Professional-Responsibility.
4. American Nurses Association. (2015). “Code of Ethics for Nurses with Interpretive Statements.” Silver Spring, MD: Available from: nursesbooks.org.
5. Roseamelia, C., J.A. Smith, and A.L. Villarreal, Decline of medical student idealism in the first and second year of medical school: a survey of pre-clinical medical students at one institution AU – Morley, Christopher P. Medical Education Online, 2013. 18(1): p. 21194.
6. Grande, D. and K. Armstrong, Community volunteerism of US physicians. J Gen Intern Med, 2008. 23(12): p. 1987-91.
7. Grande, D. and K. Armstrong, WIll physicians vote? Annals of Internal Medicine, 2016. 165(11): p. 814-815.
8. Luft, L.M., The essential role of physician as advocate: how and why we pass it on. Can Med Educ J, 2017. 8(3): p. e109-e116.
9. Institute of Medicine (US) Committee on Enhancing Environmental Health Content in Nursing Practice; Pope AM, Snyder MA, Mood LH, editors. Nursing Health, & Environment: Strengthening the Relationship to Improve the Public’s Health. Washington (DC): National Academies Press (US); 1995. F, Nursing Advocacy at the Policy Level: Strategies and Resources. Available from: https://www.ncbi.nlm.nih.gov/books/NBK232398/