Advocacy as a professional responsibility

Background

Health inequalities in Canada exist, are persistent and are growing. These gaps in health present as predisposition to disease, disease severity, complications, mortality, preventive screening, adherence and access to care. Many of these gaps are the result of social, political and economic disparities. They are seen with respect to race, ethnic group, immigrant status, ability, sexual orientation, gender identity, rurality and socioeconomic status.^1,2 In this era of heightened awareness of the impact of public policy on health outcomes, health inequalities are running rampant. ²

In the 19th century, Rudolf Virchow was one of the first to make a case for social origins of illness, public health reform and political engagement. He famously stated, “Physicians are natural attorneys of the poor and social problems should largely be solved by them.” ³ This call to advocacy came first to physicians, but as pharmacists increase their presence in direct patient care, the responsibility has extended loudly to us.

Advocacy is defined as speaking on behalf of another, to plead their cause. The American Pharmacists Association states that pharmacists must advocate for “changes that improve patient care” as well as “justice in the distribution of health resources.” The American Society of Hospital Pharmacists believes it is both a moral and an ethical professional obligation to advocate for these changes. This is to say that being an excellent clinician alone is insufficient. ⁴ In Canada, the National Association of Pharmacy Regulatory Authorities (NAPRA) has incorporated advocacy in their recently released standards for professionalism. This includes advocating for safe and effective medication for patients as well as helping patients navigate the health system. This professional principle calls for pharmacists to uphold “fair and equitable access to health care so that patient characteristics (e.g., finances, culture, language, ethnicity, gender identity, sexual orientation) do not serve as barriers to receiving quality care.” ⁵ The concept of advocacy has transcended into pharmacy education, as the Association of Faculties of Pharmacy of Canada (AFPC) has “health advocate” as a key competency for pharmacy graduates. AFPC calls on pharmacy graduates to be health advocates by demonstrating care, understanding health needs and advancing the health and well-being of others not just for individuals but also for communities and populations. AFPC extends the role of advocating for individuals’ health needs beyond the patient care environment and calls for social accountability to effect system-level change. ⁶

Health advocacy includes a broad number of activities and applications. Hubinette et al. ⁷ developed a Health Advocacy Framework to outline different types and approaches to advocacy and serve as a common pathway across health disciplines, as well as a teaching tool. They describe advocacy activities as 2 different types: agency and activism.

• Agency involves primarily helping a patient on an individual level to navigate the system. This may involve providing information, connecting patients to resources or making referrals to nonclinical professionals or resources.

• Activism occurs on a system level (institutional, community, population or policy levels) and entails increasing awareness, mobilizing resources and making changes.

Two main approaches are shared or directed. In shared advocacy, the expertise of the health care provider comes alongside the individual or population in collaboration. In contrast, in a directed approach, the needs are identified by the health care provider who advocates on behalf of an individual or population. This framework divides the types and approaches along 2 axes, creating 4 quadrants in which to reflect health advocacy activities (Table 1). ⁷

Table 1.

Health advocacy framework and examples^*

Shared activism	Directed activism
Community determines strengths, needs and opportunities. Health care providers support or join others in action.	Health care providers determine strengths, needs and opportunities and then lead, support or join.
Examples: - Support community-based organizations: donate, spread awareness, act as a clinical resource, be a volunteer or board member - Participate in events highlighting key populations and social justice - Amplify the voices of those with lived experience of health inequality - Get feedback from patient advisory committees - Make your practice site an inclusive space	Examples: - Assess health services for disparities in patient access and outcomes - Create quality improvement projects to improve care - Make changes at the pharmacy, chain, hospital or health-system level - Host a patient advisory committee - Voice policy concerns, written or oral, to your member of parliament and/or other stakeholders - Raise awareness for an issue by speaking with stakeholders, media or social media - Share your story - Get involved with professional organizations
Shared agency	Directed agency
Patient/family determines strengths and needs, patient acts, and health care providers join.	Health care providers determine strengths and needs and then lead action on behalf of patients.
Examples: - Listen - Go the “extra mile” in connecting patients to resources within and outside of the health care system - Be aware of community resources - Be informed of pertinent issues; stay up to date on current affairs through news and social media - Use preferred language to avoid stigmatization (patient first, proper pronouns, avoid terms associated with negative stereotypes) - Learn from your mistakes	Examples: - Be aware of community resources - Refer patients to resources within and outside the health care system - Be informed of pertinent issues; stay up to date on current affairs through news and social media - Recognize the power imbalances innate in health care and listen to the patient’s experience - Address misinformation - Proactively plan for addressing health equity within your organization or institution

^*Table completed from authors’ experiences and Knoer and Fox. ⁸

As advocacy is a core component of Canadian pharmacy practice, the profession needs to recognize opportunities at both individual and system levels to effect change. Doing so can elevate the voices of underserved populations and improve the disparities that exist within the health care system. The aims of this commentary are to critically reflect on the role and responsibility of pharmacists in advocacy and to provide guidance for pharmacists to practise shared and directed agency and activism within their own practices.

Advocacy in practice

To better understand the roles of shared and directed agency and activism, we critically reflected on our roles as advocates within the profession (Box 1). Our differing perspectives as a frontline care provider and an academic involved in curriculum planning allowed us to identify specific examples of advocacy as part of our work, and we have translated these into examples provided in Table 1. Our conclusions from this process were that advocacy is a central component to a pharmacist’s role in patient care and that there are many ways to demonstrate shared and directed agency and activism in our daily activities. Furthermore, it was identified that advocacy was not limited to direct patient care settings, but that the reflections also highlighted the role of the system in facilitating the supportive environments required for pharmacists to effectively advocate for their patients. It is clear that by working collaboratively as a whole, professional stakeholders across different sectors can have great impacts for patient and population health and well-being.

Box 1. Critical reflections of pharmacists’ roles as advocates.

How has advocacy influenced my practice?

Advocacy is a term I have wrestled with as a pharmacist caring for patients with HIV. The history of HIV treatment is one of advocacy. Access to the first HIV treatment came as the result of gay communities across North America mobilizing efforts on behalf of people living with HIV (PLWH). The principles they fought for remain relevant today: patient-centred care, confidentiality, respect and quality treatment without discrimination. I began my career at St. Paul’s Hospital in Vancouver. It was one of the first hospitals in Canada to treat patients with HIV, and its legacy in advocating for PLWH carries on today. Working with this population, I learned early on that the success of my clinical interventions hinged on factors outside the drug-related problems I was trained to solve: stigma, intergenerational trauma, untreated substance use, to name a few. I felt unequipped as I grappled with how we could do better.

As a frontline health care worker, you bear witness to barriers to care. Over years of hearing patients’ stories and seeing challenges to engagement in care, I sought ways to help patients beyond my clinical workup. Patient care included agency—taking additional steps to connect patients to care and resources. Understanding the issues around unjust policies led to shared activism: joining with their voices by attending protests and writing letters to my members of parliament. I took on directed activism where my strengths lay, not in a loud voice but on my keyboard. We evaluated our services to assess for equitable access and outcomes by populations of interest and then adjusted services to improve care.

Advocacy is not meant to be done alone. Shared activism amplifies the voice of the community, and often community-based organizations (CBOs) represent that voice. As an individual, this shared activism can involve participating in and speaking at events organized by local organizations: in my world this meant the AIDS Walk, speaking at World AIDS Day activities and facilitating patient discussion groups. Shared activism implies a common goal and can be applied to an organizational level. Developing health services that use partnerships between the health care system and CBOs can meet the needs of some of the most vulnerable patients through outreach, peer support and community awareness.

I still wrestle with advocacy, but I see addressing health inequalities as a vital part of the professional I strive to be.

  —Caitlin Olatunbosun

How can we support advocacy at higher system levels?

I don’t think I truly understood the meaning of advocacy and the role of the “system” until I recently returned to Canada after spending 10 years working in largely academic settings in Ghana, Qatar and New Zealand. Despite having experience in both hospital and community settings in Canada, it was my time abroad that really exposed the need for the profession to work collectively to advocate for system-level change. I started to see similar patterns of issues facing the profession and the health of all patients across different countries. In particular, I noticed health care access and navigation difficulties for underserved populations as a whole.

Intersecting my personal and professional identities and establishing a research program in 2SLGBTQ+ health and education has truly enlightened me to the role that we have in dismantling systemic oppression and improving health care for all people. As education providers, we spend a lot of time working to ensure that students graduate as culturally competent, safe and responsive. Although this is important and core to our curricula, the onus for change is largely placed on the individual. Reflecting on my own experiences accessing health care as a gay man, I’ve experienced excellent care from many health care professionals but have just as frequently felt stigma or discrimination from factors mostly outside of their control (other staff attitudes, lack of representation, perceived stigma from other patients, etc.). How can one practise culturally safe care within a system that is not actively addressing these issues within its control?

System-level change through shared and directed agency and activism is not easy but can be accomplished when coordinated and well planned. As a lecturer and academic administrator, I’ve begun incorporating teaching on “the system” and its relation to health disparities for both entry-to-practice students and practising pharmacists. Equipping pharmacists with the knowledge and skills to address system-level factors may result in advocacy at broader levels. My research on 2SLGBTQ+ patients’ lived experiences in community pharmacies has brought to light many things that can easily be done to improve our relationships with underrepresented groups and reduce disparities in care. Interventions such as community engagement, direct displays of support and training for all staff may help to cut through systemic oppression and assist pharmacists in becoming the patient advocates we strive to be.

—Kyle Wilby

Call to action

Pharmacists are positioned to make a difference in health and health inequalities for patients and populations. There are many ways to advocate (Table 1). Knoer and Fox provided some tangible ways to get started:

• Choose an issue meaningful to you.

• Be informed.

• Identify your stakeholders and work together.

• Get involved with organizations at the local/provincial/national levels.

• Look for opportunities to amplify your voice or the voice of others to tell the story.

• Share your successes (and failures) so that others can learn. ⁸

Pharmacists have a professional responsibility as health advocates for patients, communities and populations. Health advocacy is multifaceted and includes various activities that need to be applied to practice, modeled for students and taught in our schools. This commitment requires us to work with our patients, community resources, professional organizations, educational institutions, companies and staff to practise agency and activism in both shared and directed approaches.