Educating Health Care Professionals in Advocacy for Childhood Obesity Prevention in Their Communities: Integrating Public Health and Primary Care in the Be Our Voice Project

Abstract

Objectives. We assessed the perceived need for and the effectiveness of the Be Our Voice advocacy training. In this training, health care professionals learned public health strategies to advocate for environmental systems changes to prevent childhood obesity in their communities.

Methods. We assessed 13 trainings across 8 pilot sites. We conducted 2 rounds of surveys with participants—pre-training (n = 287, 84% response rate) and immediately post-training (n = 254, 75% response rate)—and semi-structured interviews with participants after training (n = 25).

Results. We uncovered essential and promising elements of the training. Primary care providers found the Be Our Voice training effective at building their comfort with and motivation for engaging in public health advocacy; they reported achieving learning objectives, and they had positive responses to the training overall and to specific sessions. They articulated the need for the training and plans for advocacy in their communities.

Conclusions. The Be Our Voice training provides an opportunity to integrate primary care providers into public health, community-based advocacy. It may be a model for future educational offerings for health care professionals in graduate and postgraduate training and in practice.

The effort to reverse the epidemic of childhood obesity in the United States provides a key opportunity to integrate public health and primary care by educating clinicians to be public health advocates in their communities. Obesity rates among the nation's children have tripled in the past 30 years.¹ As of 2008, over 30% of children aged 2 to 19 years had body mass indexes at or above the 85th percentile for their age.²

Public health strategies for community-level prevention and environmental change hold particular promise for positively affecting the environments in which children live, learn, and play, and ultimately, for reversing the obesity epidemic.^3,4 Integrating the clinical expertise of primary care providers with such public health approaches may further accelerate obesity prevention in communities. Through the approach of community-oriented primary care, there is longstanding precedent for efforts to bring together primary care and public health at the community level.^5–8

Health care professionals (HCPs) have daily exposure to the childhood obesity epidemic via the patients they treat, and they are trusted leaders in and resources for their communities.⁹ Their scientific and clinical knowledge of the epidemic coupled with this trusted community role positions HCPs to participate in community-based advocacy outside of their clinics.¹⁰ Expert committees and professional organizations have called on HCPs to collaborate with the public health community and to engage in community-based advocacy, and research has demonstrated that many clinicians are interested in advocacy.^11–13 Tobacco control, often cited by those engaged in reversing the obesity epidemic, is the most visible of several public health advances that benefitted from the active engagement of HCPs.¹⁴ For example, HCPs have been important participants in public health campaigns on issues including promotion of child safety seats and bicycle helmets.^15–17

Despite this potential role for HCPs as advocates, substantial barriers hinder clinicians becoming engaged in public health advocacy. Many medical schools include advocacy training in their curricula, and certain medical specialties, including pediatrics, require advocacy training as a part of residency training.^18,19 However, although some curricular programs are beginning to be tested, standard curricula do not yet exist to guide these requirements, and there is insufficient attention to advocacy in continuing medical education.^20,21 Additional barriers include clinical service delivery often being the sole determinant of payment, the time required to be involved in advocacy outside the clinic, and limitations in most clinicians’ knowledge of how to connect to their communities in public health advocacy.^4,10,22,23

In response to this opportunity, the National Initiative for Children's Healthcare Quality, in partnership with the American Academy of Pediatrics (AAP), the California Medical Association Foundation, and the Robert Wood Johnson Foundation Center to Prevent Childhood Obesity—the “National Partners”—created the Be Our Voice project with support from the Robert Wood Johnson Foundation. The project provides training and follow-up support to primary care providers to participate in community-based public health advocacy for childhood obesity prevention in their communities. This study examined the perceived need for this training and initial responses to it among HCPs in 8 pilot Be Our Voice communities.

METHODS

A major objective of the Be Our Voice project was to enable HCPs to become engaged policy advocates for environmental improvements in their communities. We intentionally defined HCPs broadly, to include a variety of disciplines that interact with and have an impact on and interest in children's health, including nurses, physicians, dentists, pharmacists, exercise physiologists, physician assistants, physical therapists, registered dietitians, promotoras, and medicine men or women. We defined advocacy as “speaking on behalf of a group of people within the public sphere around a particular issue.”

Overview of Educational Intervention

Specific objectives were to (1) recruit, train, and reinforce at least 160 HCPs—20 per site across 8 sites in the southern United States—to become change agents within their communities; (2) foster collaboration across multiple disciplines and sectors of health care to promote policy that supports obesity prevention; and (3) build organizational capacity and sustainability at the local level to continually promote a healthy environment. Be Our Voice aimed to enable HCPs, once trained in advocacy, to become engaged public health and policy advocates for environmental improvements in their communities and, in so doing, to contribute to reversing the trend of the childhood obesity epidemic. This study focused on the training elements of this project.

Between 2010 and 2011, Be Our Voice faculty provided advocacy training to over 300 HCPs representing a variety of clinical occupations and focused in the following pilot sites: Alabama, Arkansas, Kentucky, Mississippi, New Mexico, North Carolina (2 sites), and Texas. Each site was housed in an anchor organization (for 5 sites, the local AAP chapter) responsible for recruiting HCPs and holding local, 6-hour Be Our Voice training, with support from the National Partners. The curriculum for the trainings was based on an Advocacy Resource Guide jointly developed by the National Partners (available at www.nichq.org/advocacy), based on existing curricula, and customized to include site-specific data and resources.^24,25 All trainings included didactic and interactive components and time for participants, supported by training faculty, to create individual plans for community advocacy.

We used a train-the-trainer approach to train the leaders of each of the 8 pilot sites on essential elements of conducting the training, both in terms of process and content. Supported by the National Partners, each site then had flexibility in implementing the specifics of the training, including inviting faculty to join the local Be Our Voice site team presenters and the training date and location. The 6-hour trainings were held in a variety of settings, from a conference facility in a state park, to community-based facilities, to medical center facilities. With some variation, most trainings included sessions on defining advocacy, site-specific childhood obesity data, and addressing obesity prevention through policy. Physicians and nurses were eligible to earn continuing medical education credits, and HCPs from other disciplines earned certificates of participation to submit to their accrediting body.

Research Methods

In this article, we present data from the pre-training and post-training surveys of HCP participants across all sites to examine responses to the trainings. These activities were part of the larger longitudinal, mixed methods evaluation research of the Be Our Voice project conducted between March 2010 and July 2011. The Harvard School of Public Health institutional review board assessed all activities and deemed them exempt from further human subjects review.

Surveys.

Quantitative activities included 2 surveys—1 week before training (n = 287, 84% response rate) and immediately after training (n = 254, 75% response rate). The pre-training survey included demographic questions and items related to HCPs’ participation in advocacy-related activities. The post-training survey focused on training ratings as well as HCPs’ focus areas for advocacy. All participants who registered for Be Our Voice training were invited to take the surveys. We conducted analyses using SPSS software (PASW version 18; SPSS, Chicago, Illinois). Analyses primarily were descriptive, including obtaining frequencies and measures of central tendency.

Interviews.

We conducted qualitative interviews within 3 months after training (n = 25). Similar to the surveys, the interviews included questions regarding participants’ reactions to the training and Be Our Voice program. Participants were invited to interviews based on random selection using a random number generator and subsequent snowball sampling.

One of 2 interviewers conducted the telephone interviews according to a semi-structured interview guide. We obtained telephone informed consent at the beginning of each interview and stored detailed notes in a Microsoft Access (Microsoft, Redmond, Washington) database, where each interview question had its own field. Two members of the research team conducted analyses using inductive qualitative techniques to assess emerging themes from the data. Analyses were iterative and ongoing throughout the interview process.

RESULTS

The number of HCPs trained ranged from 15 to 50 across 13 trainings (4 of the 8 sites elected to hold more than 1 training). Two thirds of trainees reported their race/ethnicity as White, and 85% were women. HCP trainees had a wide variety of years of experience in their occupations, from less than 5 years to more than 21 years. Trainees represented more than 10 HCP occupations; a majority of trainees were physicians (more than 70% of whom were pediatricians) or nurses from specialties including school nursing, pediatrics, public or community health, and family practice (Tables 1 and Table 2).

TABLE 1—

Training Locations: the Be Our Voice Project, United States, 2010–2011

Training Locations	Trained, No.	Completed Pretraining Survey, No.
Total	340	287 (84%)
Alabama	21	17
Arkansas	25	20
Lucas, KY	50	40
Stanton, KY	25	22
Jackson, MS	33	27
Gulfport, MS	20	18
Cabarrus County, NC	32	28
Wake County, NC (2 trainings)	58	43
New Mexico	15	14
Austin, TX	26	28
Fort Worth, TX	15	15
Harlingen, TX	20	15

Note. 4 of the 8 pilot sites held more than 1 training.

TABLE 2—

Profile of Health Care Professional (HCP) Trainees: the Be Our Voice Project, United States, 2010–2011

Characteristics	No. (%)
Gender (n = 270)
Female	230 (85)
Male	40 (15)
Race/ethnicitya (n = 247)
White	164 (66)
Black or African American	49 (20)
Latino or Hispanic	16 (6)
Asian, American Indian, Alaska Native, other Pacific Islander	12 (5)
Multiethnic	4 (2)
Other	2 (1)
Years in occupation (n = 243)
≤ 5	61 (25)
6–10	43 (18)
11–15	32 (13)
16–20	32 (13)
≥ 21	75 (31)
HCP type,a all sites (n = 232)
Physician (specialty below)	73 (31)
Pediatrics/pediatric subspecialty	53 (23)
Family practice	5 (2)
Joint internal medicine and pediatrics	3 (1)
Other/not specified	12 (5)
Nurse/nurse practitioner (specialty below)	70 (30)
School nursing	13 (6)
Pediatrics	11 (5)
Public health/Community nursing	7 (3)
Family practice	4 (2)
Other	5 (2)
Not specified	30 (13)
Health educator	39 (17)
Dietitian/nutritionist	35 (15)
Otherb	15 (6)

^aParticipants could check > 1 category.

^bIncludes physician assistant, psychologist, pharmacist, physical activity/recreation specialist, promotora, community health representative, dentist, and patient care assistant.

At baseline, 90% of participants reported some type of community engagement activity, and the most often cited activities were talking with community members about health issues (38%) and providing community education programs (37%). The least commonly identified activities were cultivating a long-term relationship with a decision-maker (13%) and writing a letter to the editor (18%).

Perspectives on the Training

Interviewees reported that they attended trainings for 1 or more of the following reasons:

• To gain advocacy skills: learning how to be effective at grassroots activities; learning how to expand reach into other communities; understanding what role in advocacy they could play; diversify personal skill set; and giving back to the community.

• To learn childhood obesity content: learning how to reduce childhood obesity; learning effective strategies in preventing childhood obesity; and becoming more competent speaking about obesity.

• Other reasons: networking; learning with colleagues; learning about the Be Our Voice project; and earning continuing education.

Interviewees described 4 ways in which the training meets an important need:

1. Helping HCPs recognize the importance of their role as engaged community advocates:

• “We need HCPs in the communities to step up in these [community] meetings and take roles as expert advocates.”

• “I wouldn't have thought that it's important for HCPs to be doing community based advocacy.… Having HCPs involved has tremendous impact, or at least has the potential to. We don't know enough about how to be effective advocates. Be Our Voice is trying to hit that mark.”

• “It's a call to action. We are a catalyst.”

1. Increasing HCPs’ comfort with and motivation for participating in community-based advocacy:

• “This is a serious issue. You, too, can go out and do something about it! It is simple.”

• “Be Our Voice engages HCPs and also increases their comfort.”

1. Providing support and resources from a national program to be an effective advocate:

• “We would not have had the ammunition. This is national … and gives credibility to my voice. Without it, I wouldn't have had that fortification.”

• “I can look on the Internet, but to have the Advocacy Resource Guide with the materials, best practices, resources, where to look—it is more ammunition in your belt.”

1. Fostering connections for childhood obesity prevention in the community:

• “Be Our Voice has … made me realize we can do more. I never thought about using the legislature, the city manager, the school district.… Be Our Voice made me think broader.”

• “It brings together different parts of the community.”

HCPs also reported on specific areas of the training they found particularly helpful. On post-training surveys, participants provided an average overall rating between 3.4 and 4.83 (out of 5) across the 13 trainings. The most highly rated sessions varied across trainings and included the intersection of obesity and advocacy (North Carolina, Mississippi), regional obesity statistics (Kentucky, Texas, and North Carolina), defining advocacy and your issue (Texas, Alabama, and Mississippi), media advocacy (Arkansas), and effective advocacy (New Mexico).

On average, participants reported achieving all learning objectives. They provided high ratings to training materials, and a majority of participants had future plans to use the materials, including their personal advocacy plans (Table 3).

TABLE 3—

Ratings of Learning Objectives and Training Materials, the Be Our Voice Project, United States, 2010–2011

Variable	Rating, Mean (SD)
Learning objectives achieved (scale = 1 [not at all] to 5 [extremely]; n = 185–186)
I can identify the social, economic, and environmental barriers that might affect childhood overweight and obesity and key policy interventions to address these issues.	4.45 (0.634)
I can describe the unique role and key qualities of physicians and other health care professionals for strengthening advocacy campaigns and advocacy partnerships.	4.37 (0.646)
I can communicate at least 2 key tips for establishing a successful child health advocacy partnership.	4.36 (0.685)
I can demonstrate effective techniques for delivering testimony to local government officials and interviews to key media outlets.	4.14 (0.714)
I can create a personal advocacy work plan.	4.13 (0.726)
Training materials’ ratings (scale = 1 [poor] to 5 [excellent]; n = 247–254)
Advocacy Resource Guide	4.22 (0.755)
Toolbox (resources accompanying Guide)	4.22 (0.721)
Presentation slide sets	4.10 (0.787)
Plans to use training materialsa (scale = 1 [definitely will not] to 5 [definitely will]; n = 252–254)
Advocacy Resource Guide	4.41 (0.652)
Toolbox (resources accompanying Guide)	4.39 (0.696)
Individual advocacy plan	4.23 (0.747)

^aPercent reporting “probably” or “definitely will” use: Advocacy Resource Guide, 90%; Toolbox, 88%, and individual advocacy plan, 82%.

Focus Areas and Planned Activities for Community-Based Advocacy

On post-training surveys, participants reported their planned foci for advocacy. Their priorities were roughly evenly divided among promoting active living in the community (26%); promoting healthy eating in the community (25%); promoting, strengthening, or enforcing school and worksite policies (25%); and other areas of focus, such as breastfeeding promotion (24%; Table 4). Additionally, 76% of participants reported feeling part of an advocacy team after the training.

TABLE 4—

Health Care Professionals’ Planned Focus Areas for Advocacy, the Be Our Voice Project, United States, 2010–2011

Advocacy Focus	No. (%)
Promoting active living in the community: included increasing access to physical activity offering and venues and promoting community safety for activity	61 (26)
Promoting healthy eating in the community	60 (25)
Increasing access to fresh fruits and vegetables	34 (14)
Decreasing access to sugar-sweetened beverages	17 (7)
Promoting community gardens, farmers’ markets, and acceptance of EBT cards at markets	7 (3)
Promoting healthy food access, general	2 (1)
Promoting, strengthening, and enforcing school and worksite policies	60 (25)
Promoting and enforcing stronger school wellness policies on increasing physical activity and healthier school meals	13 (5)
Promoting adoption of healthy worksite policies, including breastfeeding	10 (4)
Increasing opportunities for more frequent physical activity during and after school	10 (4)
Encouraging childcare centers to adopt policies that improve access to healthful food and physical activity within the centers	8 (3)
Encouraging youth-serving organizations to adopt a sports snack game plan and afterschool programs to adopt physical activity standards	8 (3)
Improving access to quality school meals	6 (3)
Increase appealing, healthy food and beverage choices offered outside of the school meal program	3 (1)
Supporting farm-to-school and school garden programs	2 (1)
Other advocacy areas	56 (24)
Increasing body mass index and physical fitness screening in schools	30 (13)
Promoting breastfeeding	20 (8)
Decreasing access to screen time	3 (1)
Community center revitalization	3 (1)

Note. EBT = electronic benefits transfer. The sample size was n = 237.

Participants reported on the advocacy activities in which they planned to engage. The most frequent responses included talking with HCPs and community members about advocacy issues (55%); connecting with other trainees interested in working within the community to pursue similar policy changes (36%); participating in a local board, forum, or committee meeting (34%); and serving on a committee, board, or coalition (34%). There were no significant differences in planned advocacy activities or focus areas for advocacy by participant characteristics, including gender, practitioner type, or years in practice. There was some variation by site, as some site leaders suggested advocacy focus areas for their trainees based on planned community activities and campaigns.

The following 2 examples illustrate vignettes of advocacy experiences unfolding in the communities of 2 Be Our Voice advocates:

A parish nurse advocate in North Carolina partnered with her local public health department to work towards improvements in nutritional standards for school foods in the county's elementary, middle, and high schools. She noted that Be Our Voice helped in “getting us together to identify the problem, [and] explaining how we will make a difference in policy.” This advocacy partnership of clinicians and public health officials has gathered community constituents, such as school board members, parents, and church members, and they have begun to see changes. She noted that “it was an eye opener to see school changed.” She plans to continue her advocacy work, saying, “I'm going to get involved with other health care providers in the future.”

In a small community in the deep South, a coalition of advocates led by 1 of the community's pediatricians developed several community gardens, walking trails, and is planning to revitalize a decommissioned middle school in a disadvantaged area of town into a community center housing free and low-cost healthy eating and active living programs for the community. A nutritionist who works at the local Women, Infants, and Children (WIC) program led the development of a community garden onsite at the public health department. WIC children help her plant and harvest the food. She described that this work is resulting in “getting everyone in the community involved for good health, [and] fighting chronic diseases that occur early on.” Partners in her work included senior citizens in the community, local physicians, and staff at the health department. “They've been very encouraging… [and the] health officer in the state has been very supportive.”

DISCUSSION

The Be Our Voice trainings provided an opportunity to integrate clinicians into community-based public health advocacy for the prevention of childhood obesity. Essential elements of the training included both didactic and hands-on sessions to provide HCPs with childhood obesity-related and advocacy-specific content. Participants left the training with individual plans for advocacy in their communities. Three quarters of participants reported feeling part of an advocacy team after training; subsequent research must assess the extent to which they follow through on advocacy plans.

HCPs rated the training highly; they reported achieving all learning objectives and were particularly positive about “how-to” sessions on advocacy and applying local childhood obesity data in advocacy. There was high variation in ratings across trainings, which might, in part, be explained by the variation in the implementation of the trainings. Although unified around the same curriculum and overall approach, no 2 training sites had the same faculty (although most faculty attended the kick-off train-the-trainer meeting), and all trainings included data and resources specific to each site's own state or county.

HCPs described ways in which Be Our Voice training filled a need, specifically by increasing comfort with and motivation to engage in advocacy, and by providing high-quality resources and tools to employ in advocacy. They also believed that the training might promote community collaboration for childhood obesity prevention. These responses confirmed rhetoric regarding the importance of and potential role for HCPs integrating into community-based public health advocacy.

This training might also fill a need in the larger medical education space to provide both content and advocacy skills-based training for clinicians both in training (graduate and postgraduate) and in practice (continuing medical education). Two of the sites offered additional Be Our Voice trainings for medical residents or medical students. Challenges in integrating advocacy training into medical curricula include the need for longitudinal (not one-time) education in advocacy coupled with service learning opportunities, mentorship from skilled clinician advocates, and institutional recognition of the importance of and financial support for advocacy in medical education.²³ Be Our Voice trainings included obesity-related data specific to each site and advocacy skills on a local level (e.g., presenting to a local school board, in addition to state or national-level advocacy activities). In the future, the training could be adapted to other topics at the intersection of public health and primary care (e.g., breastfeeding promotion), while continuing to include a variety of advocacy activities at multiple governmental levels.

Study Limitations

Nonresponse bias was a potential concern. Although response rates were high (84% pre-training, 75% post-training), participation fell off at the post-training survey. Participation rates were also somewhat lower than desired in interviews. We aimed to interview 3 to 5 HCPs per site, for a total of interview sample of between 24 and 40; we had 25 interviewees. Additionally, all data were self-reported. Future research may incorporate perspectives from community members with whom HCPs are engaged after training.

Although the positive results from the training represent an important first step, the long-term success of this educational intervention will be assessed by participants’ engagement in their communities and the associated impact on environmental systems changes and, ultimately, on obesity rates. Additional Be Our Voice research activities not presented here will assess follow-up at 12 to 18 months after training, including specific details of advocacy activities (type, frequency, collaborators) and preliminary community impacts. However, even those activities may have a timeline too short to detect policy changes and certainly too short to detect changes in obesity rates. Furthermore, it will be difficult to attribute causality to 1 particular educational intervention in a climate of significant activity around childhood obesity prevention. Future research must address issues of timing and attribution.

Conclusions and Future Directions

The HCPs who participated in Be Our Voice advocacy trainings were extremely positive about their training experiences, and they affirmed the role for HCPs as advocates in the public health space. Future work will need to assess whether their positive responses to training translate into sustained action for childhood obesity prevention as well as evaluate the effect of advocacy in the community. Researchers could interview individuals advocating in coalitions with HCPs and from those “receiving” advocacy (e.g., school board members hearing testimony) regarding the frequency and amount of HCPs’ participation in advocacy (e.g., number of HCPs participating on community coalitions and in what roles), information on policy changes related to obesity prevention that were proposed or passed, and community members’ perceptions of the effect and success of HCPs as advocates.

Across the Be Our Voice trainings, the majority of trainees (85%) were women. By comparison, 55% of pediatricians and 70.5% of pediatric residents are women.²⁶ Future research could explore whether it is a trend for women to be overrepresented in advocacy trainings, and if so, whether that is indicative of the feminization of medicine in general, of women generally taking more interest than men at participating in advocacy, or of some other factor.

The Be Our Voice training included elements that other scholars have identified as important to include in medical education advocacy curricula, such as clear learning and advocacy objectives, attention to community partnerships (and associated opportunities for service learning), and concrete advocacy skills and tools.^21,27 This training may thus serve as a model for graduate, postgraduate, and continuing medical education, integrating clinical and public health advocacy on a variety of health topics. Our research pointed to a promising educational intervention for integrating primary care clinicians into public health advocacy in their communities for addressing childhood obesity.