Abstract
Objectives. There is a shift toward a “health in all policies” approach in public health; however, most practitioners are not equipped with the necessary knowledge or skills to engage in and practice policy. This study explores how public health professionals can become policy practitioners and better engage in the policy process. This article also provides recommendations for training programs on how to increase students’ policy-related knowledge and skills. Method. We conducted in-depth interviews with 10 public health policy experts in the United States spanning academic, governmental, advocacy, and practice settings. Key informants provided perspectives regarding strengths and skill sets that practitioners need to better position themselves to do policy-relevant work and opportunities for public health programs to improve training. The research team conducted thematic analyses to determine commonality among expert responses. Results. Informants identified a number of strengths and skills that either support or impede practitioners’ ability to conduct policy work and proposed recommendations for public health curricula to integrate policy-related coursework or practical experiences to prepare practitioners for policy careers. Conclusion. Public health professionals need to become more politically astute to practice and advance public health policy. To facilitate the development of such skills, public health training and pedagogy must integrate policy practice into traditional public health coursework, include new policy-focused courses, and provide opportunities for real-world policy experience.
Background
In the past few decades, policy strategies have again become a predominant approach in addressing health issues plaguing the nation. Policy approaches to improving population-based health have remained at the forefront of the public health agenda, with policy reviews and recommendations from intervention guides, such as the federally funded Guide to Community Preventive Services (Community Guide; Zaza, Briss, Harris, 2005), serving as their evidence base. Example policy approaches from the Community Guide include active transportation policies to promote physical activity, laws mandating child safety seats to reduce motor vehicle-related injuries, and community water fluoridation policies to prevent dental caries (Zaza et al., 2005).
Although there is a strong evidence base that many policies can have a positive impact on population health, evidence from past health promotion studies suggests that public health professionals are minimally involved in policy activities, in part due to a number of perceived barriers (Holtrop, Price, & Boardley, 2000; Thompson, Boardley, Kerr, Greene, & Jenkins, 2009). Holtrop et al. (2000) found that most health educators working on policy voted, contacted public officials, provided policy-related information, and worked on coalitions, but nearly all (98%) reported barriers to other policy involvement, including lack of time, other priorities, and frustration with the process. Thompson et al. (2009) found that health commissioners’ public policy involvement was marginal and that only 15% perceived their knowledge related to the policy process as excellent.
The World Health Organization estimates that the field needs at least 1.9 million health workers with critical skills in health policy (Bailey & Dal Poz, 2010). The interaction of public health policy and politics is complex (Jansen, van Oers, Kok, & de Vries, 2010). Training in aspects of political science, economics, and sociology, including public policy theory, process, evaluation, and analyses strategies, as well the political system itself, may need to be incorporated into professional preparation (Atwood, Colditz, & Kawachi, 1997; Jansen et al., 2010; Lezine & Reed, 2007). Yet training of public health scholars as policy practitioners is falling short (Bailey & Dal Poz, 2010; Gebbie, Rosenstock, & Hernandez, 2003; Radius, Galer-Unti, & Tappe, 2009; Scutchfield, Spain, Pointer, & Hafey, 1995). Members of the public health workforce have consistently identified a need for skills development related to policy development, advocacy, implementation, and evaluation (Demers & Mamary, 2008; Kreitner, Leet, Baker, Maylahn, & Brownson, 2003; Scutchfield et al., 1995; Wilcox, Majestic, Ayele, Strasser, & Weaver, 2014).
The importance of policy-related knowledge and skills as a key component of public health training has been recognized for many years (Centers for Disease Control and Prevention & Office for State, Tribal, Local and Territorial Support, 2014; Gebbie et al., 2003) and continues to be a foundation of recommended curricula. The Canadian core competencies for public health include advocacy for health public policies and services as important (Public Health Agency of Canada, 2008). In the United States, the Association of Schools and Programs of Public Health (ASPPH) recently released a series of reports that recommend new frameworks for public health degree programs and other training. The first of these identified emerging trends in public health, including recognition that “law and policy are core tools for intervening to advance public health” (ASPPH, 2013). These reports also identified content domains deemed critical for public health training. Although details vary by degree program, foundational knowledge of public health policy—including skills related to its development and evaluation, in addition to basic understanding of involved organizations and actors—is uniformly recommended for all public health professionals.
The documentation of content domains and foundational areas by ASPPH underscores the importance of policy in the training of public health professionals but provides little details about the specific knowledge, skills, or abilities necessary to design, implement, or assess policy from a public health perspective. The Council on Linkages Between Academia and Public Health Practice, a collaborative of national organizations focused on public health education, practice, and research, has identified competencies organized into eight different skill domains. Within the policy development/program planning skills, there are 14 competencies, each of which are described at one or more of three tiers of practice (i.e., entry level, supervisory level, executive level). Within the health promotion field, the National Commission for Health Education Credentialing identifies seven core areas of responsibility for health educators and associated competencies for entry-level and advanced practice, and includes skills related to developing and implementing advocacy efforts, and assessing the health impacts of current or potential policies. Examples of policy-relevant domains and competencies recommended are available in Table 1.
Examples of Policy-Specific Content Areas and Competencies Recommended by the ASPPH and Council on Linkages Between Academia and Public Health
NOTE: ASPPH = Association of Schools and Programs of Public Health; MPH = Master of Public Health; DrPH = Doctor of Public Health; HR = human resources.
Despite the policy-specific domains and competency benchmarks outlined in the aforementioned reports, gaps may remain between the skills and tools public health practitioners currently possess and those needed to effectively practice and engage in policy. The purpose of this article is to qualitatively explore how public health professionals are currently able to engage in the policy process and to provide recommendations on how to better prepare public health professionals to understand, practice, and advance public health policy. More specifically, we aim to do the following:
Identify qualities and skills that public health practitioners currently possess and also need to advance public health policy that would better position them for this work
Formulate recommendations for enhancing public health training to better prepare students and practitioners to engage in policy-related public health work
Method
We conducted key informant interviews with professional experts working at the juxtaposition of public health and public policy. Our goal was to identify experts who had been involved in public health policy focused on a host of different topics in a variety of agencies. We created a matrix of several health topics (tobacco, alcohol, and substance use; obesity, diet, and physical activity; injury and violence; sexual behavior; maternal and child health; infectious disease; chronic disease, excluding obesity; and other) along one axis and four types of work environments (academia, government, advocacy/nongovernmental organization, and other practice) along the other. We consulted with faculty at three schools that train public health professionals and asked for recommendations of individuals to contact within each topic/institutional setting who currently do public health policy work, or train others to do so. From this process we identified 18 potential interviewees that we contacted to request their participation. We were unable to reach three people, and five were unavailable for an interview. We successfully interviewed 10 participants.
We developed an interview guide based on the study aims listed above. The guide consisted of two questions about the participants’ formal training and work experiences related to public health policy, followed by four open-ended questions designed to elicit opinions about the following: strengths or skills of public health practitioners in policy work; skills needed to enhance public health practitioners’ ability to engage in policy advocacy, development, implementation, and analysis; improvements that could be made to public health training programs to help students gain policy-relevant knowledge, skills, and experiences; and challenges and opportunities for public health practitioners interested in policy work. All interviews were conducted by telephone between October 2014 and February 2015 and lasted between 30 and 60 minutes. Interviews were recorded with permission of the participant and transcribed. The research team conducted thematic analyses to determine commonality among expert responses. Human subjects exempt approval was obtained from the Institutional Review Board of Washington University in St. Louis.
Results
Interviewee Demographics
Training, workplace, and policy topic backgrounds of the 10 interviewees varied—7 had formal public health training, 2 had law degrees, 1 had law and public health training, and the final interviewee was trained in economics. All interviewees indicated they gained their public health policy skills or training on the job. Interviewee job experience included informing federal legislative public health policy making; directing public health programs within federal government agencies; directing international, national, and state public health advocacy; and working in academic institutions as researchers and/or faculty. Three interviewees currently teach in public health programs.
Interviewee Perspectives
In the following section, we summarize expert opinions in four broad areas: current strengths that public health professionals contribute in policy work, additional skills public health practitioners need to engage effectively in the policy process, means through which public health curricula could be enhanced to better prepare students for policy-related careers, and additional challenges and opportunities that prevent or facilitate public health practitioners from establishing a credible role in policy. Table 2 provides a summary of overall findings.
Summary of Knowledge, Skills, and Recommendations for Improving Public Health Policy
Strengths of Public Health Practitioners in Policy Work
All of the experts believed that public health practitioners brought a wide variety of skills to policy work. Specifically, there was consensus among interviewees about public health practitioners’ ability to critically define and analyze population-based problems, identify evidence-based strategies for addressing public health problems, and consult multidisciplined stakeholders for designing a solution. One interviewee stated, Public health practitioners bring their surveillance skills to policy work. They might not necessarily know the policy approach to a problem but they can often identify what the public health problem is and where they want to be—even if they don’t know how to get there. And of course, once a policy is passed, they have strong evaluation skills.
Skills That Would Enhance Public Health Practitioners’ Abilities to Engage in the Policy Process
Interviewees identified several key skills and knowledge areas that are important to the policy-making process and that are sometimes lacking or underdeveloped in public health professionals. First, several interviewees noted that many public health professionals do not have a sufficient understanding of the policy-making process, both in general and specific to a particular context. This includes having an accurate definition for advocacy, and the conditions under which it is legal; identifying which political actors have the ability to move a policy forward and what motivates them; understanding the stages of policy implementation, including enforcement and review, and the resources needed to ensure they happen; and recognizing that all policy making involves a series of trade-offs, opportunity costs, and compromise.
One of our biggest problems is that we walk in and we don’t understand the policy levers we are trying to pull. We often infuse more granular experiences from on the ground than thinking about the broader intervention we are trying to build. We need more straightforward levers that are not nuanced.
Second, interviewees argued that public health professionals need skills in developing effective policy-related messages. Policy messages need to be clear and unequivocal, tell an effective story without over-reliance on nonrepresentative practice experiences, be based on accurate evidence and data, and be tailored in ways that resonate with policy makers and other specific audiences.
Third, two aspects of team building were highlighted by interviewees. Specifically, public health professionals need to be able to identify effective partners for specific policy work and how to motivate them to participate. Knowledge of key players, including those with history related to a policy across different levels of government, interpersonal skills, and the ability to engage diverse audiences, was underscored as important.
Finally, interviewees highlighted additional technical skills and personal characteristics that would enhance practitioners’ ability to engage in the policy process. On the technical side, skills included the following: writing policy briefs, conducting data management and analyses using mixed-methods approaches, engaging in systems-level thinking, and distilling complex scientific and legal information. Personal attributes considered essential included flexibility, creativity, and confidence, especially when speaking before policy makers and stakeholders.
How Public Health Education Programs Can Help Students Gain the Policy-Related Knowledge, Skills, and Experiences
Almost all interviewees believed that every student should be required to take fundamental courses in health policy regardless of specialization. Because policy and population-based interventions are leading strategies in public health, interviewees believed it was imperative to have at least a basic understanding of the role of policy and policy making in public health.
Even if you are a health behavior major or an epidemiology major or a nutrition concentration, everyone should have to take fundamental courses in health policy. There are just basics to know about the policy making and political process, which is different from making technical policies. For practitioners to understand the distinctions and how the policies that affect their work are born is very important.
Interviewees also suggested that foundational courses (i.e., biostatistics, epidemiology, health behavior) integrate policy into current competencies and class exercises. Several participants cited the “translation of research into action” as an opportunity that could be integrated into foundational courses. For example, students should be asked how the results from their data analyses exercises could be used to develop, implement, evaluate, and advocate for policy solutions.
Regarding specific policy specializations, interviewees noted that current courses related to public health policy are often housed within a health policy and management department and are primarily focused on major health care systems. Many believed that there should be a policy track separate from health system management that included competencies in public health law, policy advocacy, and governance.
Within each school, if their goal is to train students to work in the policy arena, there needs to be a multidisciplinary track so everyone interested in a policy trajectory could walk away with the necessary skills – like the legislative process, the regulatory process, how to build a policy brief, and how to analyze state and federal policy perspectives.
In addition, all interviewees believed that public health education should include practical policy experiences that involve students directly in the policy process. Suggested experiences included the following: holding mock policy exercises where students are asked to analyze a policy issue and present policy solutions; visiting a decision-making body such as a local-level school board meeting, city council hearing, or state legislative hearing; engaging in community-based policy research project; and participating in policy-based internships, ideally with a policy advocacy organization, locally, in Washington, D.C., or even internationally.
Take a field trip or two. Attend a school board meeting. Attend a state legislative session . . . get students to the state capital or to DC. Ideally, get people out of the classroom, even it is at the local level like a town council or school board meeting.
Additional Challenges and Opportunities for Public Health Practitioners Interested in Engaging in Public Policy Work
Interviewees noted several challenges and opportunities for public health practitioners who want to engage in public health policy work. One barrier noted was “fear” of engaging in policy work.
Practitioners often think of policy as unique outside of the other public health strategies, which make it challenging and scary. Instead they should think of it as just “another tool in the tool box.”
Interviewees admitted that changing administrations and policy agendas also present problems to long-term public health policy work, as these shifts can force public health professionals to switch gears and strategies at any given moment. In addition, limited funding in support of policy work, especially in government agencies, was noted as a challenge. Despite these challenges, interviewees underscored the need for increased opportunities for public health practitioners to engage in policy work. Because policy has become primary intervention strategy, practitioners who can conduct evaluation and system science research that links policies and outcomes are in demand. One interviewee summarized this perspective by saying: “Public health practitioners that know how to navigate the policy world are like unicorns.”
Conclusion
This article highlights perspectives from a panel of public health policy experts regarding how public health professionals can better understand and engage in public health policy. More specifically, this article outlines assets that public health practitioners currently contribute toward the advancement of public health policy, additional skills or knowledge that would better position them to become policy practitioners, and the challenges and opportunities for public health practitioners to engage in policy work.
Interviewed experts agreed both that people engaged in public health policy were not always adequately prepared for policy work and that schools of public health are important intervention points for developing public health practitioners’ abilities to successfully navigate and contribute toward the policy process. Although the five training areas currently required for accreditation as a school of public health by the Council on Education for Public Health (CEPH; 2011)—epidemiology, biostatistics, environmental health sciences, health services administration, and social and behavioral sciences—do not explicitly include public health policy, drafts of new proposed CEPH core training do (CEPH, 2016). As schools revise their competencies, our results suggest several specific knowledge areas and skills to consider, including understanding of the legislative process and ability to inform policy making. To do this with success, schools must employ faculty with policy experience. A 2009 study by Radius et al. supports this recommendation—study results demonstrated that the majority of health education faculty in their sample lacked policy advocacy-related preparation and development experiences and did not participate in policy advocacy training efforts or advocacy activities themselves. It is equally important for schools of public health to foster inter- or transdisciplinary collaboration among faculty in law, public policy, political science, economics, and public health.
In addition, our interviewees underscored the value of having public health schools and programs provide opportunities for real-world exposure to policy making and translating research into action. Internships that require attendance at legislative hearings, meetings with policy makers, campaigning for candidates supportive of public health issues, preparations of policy briefs and op-ed pieces for media advocacy, or collaborative work with advocacy organizations and coalitions could be incorporated (Galer-Unti, 2010; Galer-Unti, Tappe, & Lachenmayr, 2004). These opportunities not only educate public health practitioners on the legislative process but also allow them to gain skills necessary to be successful in translating complex issues into legislative, regulatory, and policy initiatives and to support decision makers.
Some training opportunities already embrace some of these recommendations. For example, Columbia University’s Mailman School of Public Health offers a Certificate of Health Policy and Practice. This certificate is designed to prepare MPH students to become effective policy practitioners by providing courses that allow students to gain the knowledge and skills necessary to understand public health challenges with the lens of political, social, and economic factors. Students are offered classes in public health law, economics, policy analysis, and the political system, learning from professors with firsthand experience in policy development. Another example is the American Public Health Association’s Fellowship in Government, which provides a yearlong public policy learning experience in a federal Congressional office. This fellowship program aims to increase the capacity of public health professionals to inform and influence policy decisions by providing access and exposure to the legislative process.
Opportunities also exist to look at policy training frameworks and approaches used by programs outside of public health education. Social work and other social welfare disciplines have already integrated the idea of policy practice into their curricula. This approach encourages practitioners to understand not only the mechanics of the policy system, which include the central, legal, economic, and organizational variables, but also the politics that make the process of adopting or amending policies so complex. Typical policy practice activities include defining problems; assessing needs; developing, advocating, and implementing programs; and forecasting future problems, needs, policies, and programs (Wyers, 1991). The integration of policy practice into public health curricula could support public health practitioners in understanding and addressing complex public health policy issues.
Some limitations of this study should be acknowledged. First, this research was conducted using a small convenience sample. While we chose experts whose work encompassed a host of different policy topics in a variety of agencies, the generalizability of the findings is limited. However, the same themes were identified for each of the questions across the panel of experts interviewed, stressing strong consensus regarding this topic. Furthermore, our study was designed to assess assets and challenges perceived by individuals currently practicing public health policy. Although we generate considerations for public health training programs from our results, we did not directly examine what is currently covered in public health curricula. Quantitative assessment of the curricula in the 107 certified schools or programs could lend important insight into whether the skill development needs that are perceived in the field derive from gaps in the quality or quantity of policy-relevant training in public health programs.
The next generation of public health leaders must be astute in navigating the field of policy and politics, especially in this era of public health when a majority of evidence-based public health interventions are those that can be implemented only through the development of policy. Public health policy progress will require new skills and “non-traditional” pedagogy that allows for closer linkages between the science of public health and policy making—teaching public health practitioners how to communicate with policy makers and build transdisciplinary partnerships. Only then will we truly be able to address issues of societal importance and thereby enhance the health of populations.