Public policy and impact – suggestions for researchers who want to make a difference.

It is a privilege to be associated with the new Early Career Advocacy series in Health Promotion International, which I hope will encourage early career researchers to develop and continue their contributions to health promotion and public health advocacy.

In this brief paper, I will focus on some ways in which health promotion researchers can contribute to advocacy, but my starting point is to emphasise the impact that researchers and advocates can make from the early stages of their careers. I often reflect that some of the most significant contributions I was able to make to public health came in the early stages of my career. In the 1970s, I was one of a then small group developing new policy and media-oriented approaches to tobacco campaigning (we didn’t call it advocacy in those days) and then other health areas in the UK and internationally, including a focus on exposing and opposing the activities of harmful industries. Then as now, we would have got nowhere without the work and support of researchers who understood the importance of advocacy, and the needs of advocates.

So I will seek to set out some thoughts that may help to guide researchers who are looking to influence public policy, whether directly or indirectly.

1. Do research that aims to be useful.

As someone who has been active in public health advocacy and policy implementation for more than 50 years, I have only rarely been asked by researchers about what would be useful in terms of influencing public policy, or whether a particular research project could be developed or focused so as to be more helpful.

2. Even the best research achieves nothing if it just sits on the shelf and nobody knows about it.

For many years medical researchers were influenced by thinking encapsulated in advice from the great Canadian physician, Sir William Osler [1905], who said, “Do not dally with the Delilah of the press”. But times have changed, and even once-conservative research funders and academic institutions see the need for appropriate media communication. So a key part of any research program should be consideration around how the results can be presented for optimal impact in both traditional and new media.

3. Take time out to learn about those you are seeking to reach.

This includes colleagues, relevant organisations, media, politicians, decision-makers in government, and others. Learning about them and the way they work will help you to present your research and your objectives in ways that are most likely to influence them. And think about your messaging – especially getting across both the need for action and the action that is needed. All too often I have sat with ministers and premiers as they were lobbied by splendid researchers who spoke eloquently about the need for action, but didn’t follow up by clearly outlining the action that was needed, and then were disappointed when nothing further occurred.

4. Take time out to learn about those who may disagree with or oppose your approach and conclusions,especially harmful industries and their allies.

Their attitudes and interests need not affect your research or conclusions, but knowing about them and the way they operate should help you to develop your research program, frame your recommendations, and ensure that your phrasing, nuancing and overall presentation are meticulous and well-placed to withstand criticism.

5. Then look further into interests, declared or undeclared.

A disturbing feature of discussion on issues relating to harmful industries is the extent of comment, research, lobbying and trolling funded directly or indirectly by those industries or their allies and front groups.

6. Impact is about much more than traditional researcher metrics.

Citations and high-impact publications are important, but they are not the only – or even the most effective – means of influencing public policy. Many issues where research can be influential are likely to be under current discussion and/or debate, and as Lester-Irabinna Rigney has noted, public health researchers can play a role in reflecting and progressing “the mood of the nation” (Rigney 2023). Timing can be crucial. Terms of government vary from jurisdiction to jurisdiction: in Australia, federal elections are held every three years, with most key decisions likely to be taken in the first two years of any term, and major financial decisions are normally made months ahead of formal Budget statements. When I was Director General of Health for Western Australia, I found it hard to restrain my frustration when potentially valuable research was presented to us a week or two before the Budget, after all the decisions had been made and Budget documents printed.

When looking to publish, consider the timing of your publication (and where to publish), and then how best to promote it so that it will have a real impact. Journal publication may only be the starting point, and can be complemented by initial media coverage, further commentary, newspaper and website articles, submissions to governmental and parliamentary processes, and much more.

And just occasionally (with an apology for breaking one of the golden rules of academe), you may want to publish outside the formal academic publication process. D’Arcy Holman is rightly lauded as a stellar epidemiologist, with any number of publications, awards and achievements [The University of Western Australia 2023]. But throughout his career he has also been willing to carry out research projects and publish reports to meet advocacy deadlines and needs, finding new ways of demonstrating the present and future magnitude, impact and costs of health problems such as tobacco, alcohol, obesity (among many others) and the health and economic benefits of preventive action. Strong media coverage shortly before Parliamentary debates or Cabinet discussions will influence the outcome just a bit more than a journal paper six months afterwards.

7. Translation is about much more than the role some may envisage.

In commenting about obesity a few years ago the then Australian Chief Scientist said, “Two thirds of Australians are overweight or obese. In the last 20 years, there has been an explosion in the science underlying the genetics, basic biology and neuroscience regulating food intake and satiety. In the last ten years, we have spent almost $200 million on research. And yet such knowledge has not been translated to any new drugs that decrease weight safely and effectively” [Chubb 2012]. New drugs may well have a role to play in reducing obesity, but prevention matters too. Translating health promotion research into policy can bring enormous benefits to the community.

8. Pursue your research in ways that will add to its impact.

In research as in so many other areas, success takes time – but it is helped and supported when researchers understand the importance of following up their results with policy-relevant research and evidence-based advocacy. Carol Bower and Fiona Stanley first published research on the benefits of folate in preventing neural tube defects in 1989 [National Health and Medical Research Council 2021]. Having demonstrated those benefits, they followed up with research showing that educational approaches to promote dietary supplementation with folate would bring some benefits, but that these would be limited, and would fail to reach disadvantaged groups. Motivated by both health and social justice concerns, they then proceeded to carry out research demonstrating that the best approach to ensuring the benefits afforded by folate to the entire community would be mandatory fortification of breadmaking flour. There was fierce opposition from the food industry, which (in the best traditions of the Policy Dystopia Model [Ulucanlar, Fooks & Gilmore 2016]) claimed that this simple measure would be impossible, expensive, ineffective and catastrophic. But thanks to the researchers’ persistence and advocacy, mandatory fortification of breadmaking flour in Australia came into effect in 2009 – resulting in a dramatic fall in spina bifida and related birth defects, and virtually eliminating the disparity between Aboriginal and non-Aboriginal rates [ABC News 2015].

9. Choose the approach to media and policy advocacy that suits you.

If you feel comfortable about media and related coverage, go for it, from traditional mainstream media to the ever more influential world of social media – but make sure that you have taken on board some form of media training, and always, always, always ensure that your research and comments are based on sound science. There are also times when it may be appropriate for researchers not to be media-active, for example if they are advising governments. And researchers don’t have to be public advocates, and don’t have to be media stars. If you aren’t comfortable with media and publicity, there are plenty of other roles, from acting as reliable sources of information to working behind the scenes with professional and community organisations and committees. So if that is your preference, that’s fine. But do try to make sure that other people or organisations are aware of your work, well briefed and supported, and able to pursue it in the public arena.

10. Find mentors.

In the early stages of my career, I was privileged to be supported by some remarkable mentors, who encouraged and supported me, and tolerated any number of early morning and late evening ‘phone calls. They were advisers and sounding-boards, but much more – people who would come up with ideas that made semi-developed concepts fly, and who would also be there when times were tough. My experience is that there are many well-established researchers and others who will happily offer their time to mentor the next generations. And I have also learned that mentoring is a two-way street – experienced researchers can benefit enormously from input and advice from their younger colleagues!

11. Don’t be put off by critics (especially those with declared or undeclared interests).

We live in a world where communication can be instant, on a range of platforms, and presented from any number of perspectives, including those with commercial or related interests, trolls and anonymous tweeters. So you may find yourself the subject of personal criticism and even at times personal abuse. That is much more of a reflection on those who use this kind of approach than it is on you and your work, and indeed is likely to be an indication that you are having an impact. Researchers and others working on tobacco have long been familiar with the Scream Test – the louder tobacco companies scream, the more impact we know a measure will have. Don’t respond to the trolls and abusers – that simply encourages them - and don’t allow the bullies to intimidate you. Rather, seek out and listen to the colleagues and others who provide honest and constructive feedback, appreciating and supporting your work.

12. Don’t be satisfied with soft options

The approaches we seek should so far as possible be evidence-based, comprehensive and designed to achieve the best possible outcomes. We may have to accept that this doesn’t all happen at once, and we should certainly recognise and appreciate progress when it comes. But that doesn’t mean that we have to accept the soft options that harmful industries offer up as alternatives – voluntary codes, partial curbs, industry membership of advisory and oversight groups, low-key and minimally funded education, prevention messages that don’t prevent, heavy focus on personal responsibility – and so much more. Alongside the Scream Test, we should apply the Smile Test – if harmful industries are content with a proposed policy, it is unlikely to have any impact.

13. Support, don’t compete.

I have often been asked by media and others which is more important – tobacco, or alcohol, or obesity, or any number of other issues. I have always sought to explain that we aren’t in competition, any more than oncologists, cardiologists or psychiatrists compete with each other. In this complex world we seek to address a wide range of health and social problems.Calling for action on one issue absolutely does not and should not mean playing down the need for action on others.

14. We are parts of a team.

As in other areas, progress in health promotion rarely, if ever, occurs as a result of just one person’s work. We are all contributors to a team effort (admittedly, with some better at being team players than others – but still members of the team!). We should seek to work as closely as possible with those who share similar objectives – and when the successes come, as they do, make sure that the credit is shared. From researchers to advocates to supportive media to politicians and others involved in making the decisions we have been seeking –give credit where credit is due.

15. Stay with it.

Overnight success takes time, especially in prevention. However long it takes, always bear in mind the words of a great Aboriginal leader and campaigner, Rob Riley – “You can’t be wrong if you’re right…..just keep fighting” [Riley 1997].

Conflict of Interest

No conflicts to declare.

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