Health inequalities in the UK are a major challenge, and they are growing. The apparent failure of policy efforts to reduce these inequalities often prompts calls for more public health ‘advocacy’ from researchers in the field. It is argued, first, that policies have failed because governments have been reluctant to draw on the available evidence, and second, that this reluctance stems from a perceived lack of public support for the kinds of upstream, redistributive policies this evidence often supports.
A proposed solution to this double-bind is ‘evidence-informed advocacy’. It is regarded by many as a critical step towards achieving a public mandate for policies which (in line with the conclusions of much public health research) seek greater redistribution of wealth and power within society. However, this approach is not un-controversial. Some critics feel health inequalities researchers ought simply to focus on improving the evidence available for policymakers. But for researchers who do support the need for ‘evidence-informed advocacy’ to reduce health inequalities, the question is, what might this involve (beyond trying to be a ‘bit more… sexy’, as one of our participants put it) and who should be doing it? Should researchers themselves be operating as advocates and what kinds of risks are involved when they do?
In the field of tobacco control, it seems relatively easy to answer these questions. Formal and informal relationships between campaigners and researchers help ensure that expertise readily flows between researchers and campaigners. A number of large NGOs actively campaign in this area, many of which have in-house teams of staff trained in research methods who are able to read and appraise relevant research (some even have in-house libraries). These kinds of relatively large, health-focused NGOs tend to be professionally run and politically savvy. In this context, public health advocacy seems relatively easy to manage as a researcher; link your research into the relevant NGO networks and, if your findings are relevant to issues NGOs are campaigning on, they may well use it. This is not to say that advocacy within tobacco control is problem-free; but it is organised into what others have described as a distinct ‘advocacy community’ and has achieved notable policy ‘wins’.
Public health advocacy looks very different, however, in the cross-cutting, contested field of health inequalities research. Whilst there are some active online groups (e.g. the Politics of Health Group and the Health Equity Network), it is much harder to identify organisations that consistently campaign to reduce health inequalities. Michael Marmot has recently established the UCL Institute for Health Equity which, , is intended to facilitate better links between researchers and policymakers working on health inequalities. Such efforts are, however, distinct from the large health-focused organisations mentioned in tobacco control, being largely academic-led (or at least research-orientated) relatively small and with only limited campaigning resources. It is therefore unsurprising that very few of the 44 journalists or policymakers we’ve interviewed about health inequalities over the past eight years could name any organisations actively campaigning to reduce health inequalities. As one ex-MP reflected, ‘there’s no big financial lobby for tackling inequality’. So where does this leave health inequalities researchers committed to achieving policy or societal changes that will reduce health inequalities?
For some, the answer is obvious: researching health inequalities is pointless unless that research is acted upon. Therefore, in the absence of other suitable actors, researchers ought to be acting as advocates. This view is gaining ground: one of the most notable differences between interviews undertaken with health inequalities researchers 2005-2007 and those undertaken in 2011-2012 was that more of those recently interviewed identified themselves as having an advocacy function. Yet, it seems clear from our research that there are risks involved in academic engagement in public health advocacy.
These risks relate to issues of the purported independence of the researcher. Advocacy can compromise a researcher’s actual and/or perceived independence (potentially reducing both their academic and their policy credibility). This is partly because developing and expressing a clear policy position can make it difficult to step back and consider other points of view as research evidence evolves. Additionally, academics who adopt public media profiles may risk criticisms and attacks from academic colleagues. (On the other hand, however, it may also contribute to the success of an academic career, depending on the context). More practically, if we take inspiration from the work of experienced advocates and popular, empirically-based theories of policy change, viable advocacy campaigns tend to focus on ‘winnable issues’. From a research perspective, this may mean putting more research effort into issues which are already on the policy agenda (and less on those that seem too challenging for the current policy context). This too can be seen as a threat to academic independence. In a health inequalities context, for example, this kind of approach could reinforce the persistent pull of research concerning downstream, behavioural interventions. Advocacy work can also be extremely time-consuming and therefore reduces the time available for research projects and other, more traditional, academic work. Finally, adopting a clear policy position on a research issue can implicitly suggest that the available research is sufficient (or at least that there is enough of a research basis to know what to do). This may limit a researcher’s ability to make a case for further research on a particular issue (‘if you’re already sure that we need to do X, why should we fund more research?’)
Despite all this, it is worth re-stating that there are also risks involved should researchers choose not to engage in public health advocacy. This is particularly true for health inequalities, where there are few organisations who effectively and consistently advocate for policies to reduce health inequalities and plenty of actors working to influence policy in ways likely to exacerbate health inequalities (e.g. alcohol, food, gambling and tobacco companies).
So where does this leave health inequalities researchers? For many of our interviewees, the tension seemed insurmountable. We suggest tobacco control may (despite being a rather different kind of problem from the complex, cross-cutting issue of health inequalities) offer some useful insights. This is because tobacco control usefully demonstrates how research and advocacy can be productively intertwined, mutually reinforcing and profile-raising. For example, from our own research and that of others, it is clear that many tobacco-control researchers are comfortable with the idea that some colleagues working to promote extremely radical policies, whilst others concentrate on more politically acceptable ideas. If this kind of spectrum could be better accommodated within the health inequalities research communities then it may help deal with at least some of the risks outlined above. At the very least (and in the absence of much training or guidance on advocacy within research contexts), it seems important for health inequalities researchers to start having more discussion and debate about balancing the research and advocacy functions of the work they do. So let’s start right here: should researchers be involved in public health advocacy? Does it depend on the issue, the context or the researcher? We’re keen to hear your views…
Some of this research is discussed in more detail in a new book by Katherine, ‘Beyond Evidence-Based Policy in Public Health: The Interplay of Ideas’ (Palgrave, 2013). We are continuing to research these issues via an ESRC grant entitled ‘A Risky Business? The Politics of Knowledge Transfer in Public Health’ (grant number ES/K001728/1).
About the Authors: Katherine Smith is Reader in the Global Public Health Unit, University of Edinburgh, where her research concentrates on the construction, circulation and policy impact of academic and other ‘expert’ knowledges. Ellen Stewart is Research Fellow in the Global Public Health Unit, and her research concentrates on the politics of health policy, with a particular focus on the interaction of ‘lay’ and expert knowledge.