Best practices in teaching/learning health advocacy in medical schools – a systematic review Dr Indira Samarawickrema Australian National University A/Prof Christine Phillips Australian National University Prof Donna Mak University of Notre Dame

Introduction Conventionally focused on individual patient care, access to care and direct socio-economic influences 1. Greater engagement in improving the health of populations and systems of care 2. Health advocate – Australia 3, USA, Canada 4 2

Knowledge and skills required for a generalist medical graduate “innovative, collaborative, participatory and transformative approaches” 5,6,7 –Identify, define, strategic partners, a strategic action plan, an effective message” 5 Need reasoning and communication skills 4. 3

Aims and objectives To systematically review publications on teaching/learning advocacy in medical schools –Identify best practice methods in developing skills in health advocacy among medical students. 4

Research question What are the best practice methods in developing skills in health advocacy among medical students? 5

PICOS Participants- medical students Intervention: health advocacy modules with hands-on experience Comparisons: health advocacy modules without hands-on experience Outcomes: Skills in advocacy as evident with evaluations Study design: experimental and/or evaluation 6

Methods We carried out a systematic review of publications Database: PubMed, ERIC via NLM Search terms: “advocacy” and “medic*” in the article Time period: 1 st Jan 2011 to 14 Sept

N=31 N=26 Initial screening N=1300 Duplicates = 96 N=1204 Does not mention medical students =1173 Not in English = 3 N=4 Commentaries = 2 Does not address teaching/learning in curriculum; exclude electives

Results Four from medical schools in North America –Three from USA –One from Canada None from Australia 9

Table 1: Summary of included studies Intervent ion Com paris on Outcome s Study design Findings Belkowitz, et al 2013 (Universit y of Miami Miller) 8 Y1&2 communit y health advocacy training in regional campus (RCM) Main camp us (MC) Attitudes, self- reported and objective knowledg e, and skills Cross- section al RCM higher scores>MC (p<0.01) Mean knowledge -community health needs (35 vs 31) -About CBOs (3 vs 2.7) -Community resources (5 vs 2) Mean skill scores -13 vs 11 Attitudes -Female>male 10

Table 1: Summary of included studies (contd.) Intervent ion Com paris on Outcome s Study design Findings Gill & Gill 2011 (Universit y of Alberta and University of Calgary) 9 Political Action Day with Members of Legislativ e Assembly (2-days) NoneAttitudes, self- reported knowledg e, and skills Pre- and post- survey Improved skills - Advocacy concepts - How to efficiently organize a meeting with an elected official - How to approach lobbying an issue at a population level Require - More in-depth Teaching 11

Table 1: Summary of included studies (contd.) Intervent ion Com paris on Outcome s Study design Findings Huntoon et al 2012 (AMSA at National Advocacy day) 10 ½ day advocacy experienc e at Capitol Hill NoneKnowledg e, skills and attitudes towards legislative advocacy Pre- and post- survey -Contact their legislators (p = 0.03) -Meet in person (p<0.01), -Advocate for population health needs (p = 0.04). -Role of a physician advocate (p = 0.03). -Formal curricula insufficient -Plan to engage in legislative advocacy activities in the future (p<0.01) 12

Table 1: Summary of included studies (contd.) Intervent ion Com paris on Outcome s Study design Findings Long et al 2011 (Universit y of Colorado Denver) 11 Leadershi p Educatio n Advocacy Develop ment Scholars hip program NoneKnowledg e, skills and attitudes towards legislative advocacy Pre- and post- summe r interns hip Empowerment, improved self-efficacy, and increased likelihood of future engagement in leadership and health Advocacy (p<0.05) 13

Discussion In-class + hands-on modules. Diverse experiential learning –Advocacy projects/internships with CBOs –Legislative advocacy Evaluation of hands-on modules –Improved skills –Empowerment –Likelihood of future engagement –Self-efficacy –Rated highly by students. 14

Discussion Small scale initiatives not integrated into the broader population health curricula. Lacks a more robust positioning of advocacy within the curriculum. 15

AMC new medical graduate outcomes and advocacy 3 One of the four domains Two of the first three outcome standards in that domain How to advocate for others (not only about populations and inequality) Knowledge, some exposure to the concepts and a public health responsibility 16

Challenges of teaching specialised skills to generalist medical graduates How a generalist could apply it in their normal daily practice. Ethics of advocacy –Potential to cause harm to people and communities Adaptability of focused skills No evidence that the education translated into better medical practice? 17

Limitations Grey literature not included Unpublished Teaching to the interested only Self-education 18

Conclusions Hands-on teaching/learning activities improved skills in advocacy among medical students in North America. More work is required to assess the breadth and effectiveness of medical school health advocacy teaching programs in Australia. 19

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