Introduction

A recent report from the Centers for Disease Control and Prevention (CDC) defines public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy” [1]. One need only examine the lack of universal health care coverage, the slow response to the HIV/AIDS epidemic, and the lightning rod issue of abortion to see how deeply politics affects public health in the United States. Health educators play a critical role in advocacy and policy involvement to make changes to improve the health of the public [2]. According to the American Public Health Association, “By sustaining a vocal and noticeable presence throughout the policy-making process, public health professionals can ensure that vital public health programs and services are protected and supported-both fiscally and politically” [3].

Many national professional health organizations echo this call for advocacy including the American Association for Health Education, the Society for Public Health Educators (SOPHE) and the American Public Health Association. The important role of health educators in advocacy is emphasized by the National Commission on Health Education Credentialing. One of their seven responsibilities for health educators is to “communicate and advocate for health and health education.” In the landmark publication, Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century, Gebbie et al. [4] state that while policy is recognized as being of vital importance in public health, education in policy matters in schools of public health is minimal. Further, if schools of public health wish to be significant players in the future of public health and health care, they need to pay attention to both politics and policy [4]. Although public health professionals are expected to be involved in advocacy and public policy as a means to improve the health of the public, there is a dearth of studies of advocacy efforts of public health professionals and particularly health commissioners in the professional literature. Holtrop et al. [5] conducted a survey research study of a random sample of 700 health educators listed in the CHES Directory or involved in prominent health education organizations. Results of this study found respondents performed a mean of 4.84 public policy activities and rated their overall involvement as 2.54 on a scale of 1–5. Health educators perceived lack of time (69.4%) as their greatest barrier to public policy involvement, followed by other priorities (43.3%) and frustration with the process (39%). The authors concluded that although health educators were involved in public policy activities, there was an opportunity for more involvement [5].

Using the same instrument, Oden et al. [6] examined the level and type of policy involvement as well as perceptions regarding policy involvement of nurse practitioners. The majority (59.6%) of nurse practitioners were involved in 3 or less public policy activities. The most frequent activities included voting and giving money to a campaign. Lack of time was the most frequently cited barrier to public policy involvement, while improving the health of the public was the most often cited benefit.

At the local level the responsibility for health advocacy falls to health commissioners, city and county health officials who often advocate for the most effective public health services [7]. Health commissioners are accountable for protecting the health and safety of all residents represented by their health department. Specifically, they are responsible for leading local health agencies in preventing the spread of communicable diseases, promoting healthy lifestyles, protecting against environmental hazards and working with other community officials to insure that the residents of the community have access to health information and preventative services. Health commissioners are the lead spokespersons for health departments and often are charged with developing local health policy and policy enforcement [7].

Most health commissioners are involved in the National Association of County and City Health Officials (NACCHO). NACCHO calls for public health advocacy and encourages their members to “take action to protect and improve the health of all people and all communities” on their website which also includes NACCHO positions, action, legislative resources and information, and a legislative action center [8]. As NACCHO members are key to local health advocacy efforts, and little is known about their advocacy efforts, this national study sought to determine NACCHO members’ advocacy and public policy involvement, perceived barriers and benefits of such involvement and perceived self-efficacy in performing these activities.

Methods

Subjects

A national sample of health commissioners was selected from the National Association of County & City Health Officials (NACCHO) database (N = 3000). Health commissioners were randomly selected using computerized random sampling. An a priori power analysis was completed for a one-way ANOVA to determine an approximate number in the sample required to minimize the Type II error rate. The sample size was determined by setting alpha at .05, the effect size at .20, and power at .80. The suggested sample size was 291.

Instrument

The survey instrument for this research was modified from a previously developed and validated instrument that was used to assess public policy involvement by health educators [5]. This instrument has also been used to determine public policy involvement of nurse practitioners [6]. A four page, 23-item survey instrument was designed to acquire health commissioners’ demographics, background characteristics, and involvement in public policy at the local, state and/or national level. The instrument examined public policy involvement in the last 4 years, perceived barriers, perceived benefits, perceived knowledge on how to change public policy, interest in changing public policy and self-efficacy regarding public policy. In this study public policy was defined as “any action taken by government to affect activities they choose to influence and that involve the expenditure of public funds.”

Procedures

To account for possible non-response from health commissioners, 700 surveys were mailed to those who were randomly selected in hopes of attaining the suggested sample size of 291. Multiple techniques were utilized to increase the response rate of the study [9, 10]. Questionnaires were sent through the mail using a three-wave mailing, a hand-signed cover letter, and a self-addressed, stamped return envelope with first-class postage stamps. Data was collected in Fall, 2007. Prior to beginning the study, approval was granted from the University Human Subjects Committee.

Data Analysis

Survey data were entered into the computer using SPSS 13.0. Descriptive statistics (frequencies, range of scores, means, standard deviations) were utilized to describe the respondents in terms of their demographic and background characteristics, participation in various advocacy activities, and perceived barriers and benefits of engaging in advocacy related activities. To assess the variations of participation in advocacy related activities and self-efficacy between the demographic variables of sex, race/ethnicity, geographic location, and level of education, a series of chi squares and regression analyses were performed. In cases where respondents had missing data, the analyses were conducted based on responding individuals’ responses to that item.

Results

Demographics of Respondents

A total of 700 surveys were mailed to a random sample of health commissioners. Fifty-two of the surveys were undeliverable, therefore 648 actually received the survey. Of the 648 surveys potentially received, 327 were returned for a 50% response rate. Of these respondents, the majority (60%) were female and (88%) Caucasian (Table 1). The mean age of the respondents was 52 (range 26-83; SD 8.8). Respondents reported their primary educational training as nursing (27%), health education/public health (17%), environmental health (12.5%), business (12%), and medicine (11%). Less than 1% had educational training in the fields of epidemiology, biostatistics, and animal science/veterinary. Seventeen percent of the respondents indicated other educational training such as administration, anthropology, dietetics, health policy, and urban planning. This sample appears to be representative of NACCHO membership as the demographics of this study are similar to those of commissioners included in the local health department profiles on the NACCHO website. Interestingly, only five individuals in our sample reported that they were Certified Health Education Specialists (CHES). Political affiliations included 42% Democrats, 26% Republicans, 21% Independents, 5% Other, and 6% did not identify their political affiliation.

Table 1 Respondent demographic characteristics
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Health Commissioners’ Involvement in Public Policy

Overall, 15% of health commissioners reported being very involved in influencing public policy in the last 4 years and 25% indicated they were somewhat involved. The most common reported activities engaged in by health commissioners included voting (84%), contacting public officials regarding policy (76%), and providing policy information to consumers or other professionals (65%). The least reported activities included volunteering for a public official (6%), participation in a public demonstration (8%) and lobbying in front of a policy-making body (11%) (Table 2). There was a positive correlation (r = .71; P < 0.0) between the self-rated level of involvement and the number of health policy activities in which the health commissioner participated. An analysis of demographic variables regarding self-rated involvement yielded a significant difference by gender (X2 = 17.4; df = 4, P = .002) with men reporting a higher mean score of involvement (M = 3.4; SD = 1.2) than women (M = 2.9, SD = 1.1). There was no significant difference by race, political affiliation or employment setting.

Table 2 Respondent public policy activities
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Barriers and Benefits to Participation in Public Policy

Perceived barriers to influencing policy were time, (64%), other priorities (46%), and lack of money or resources (41%). Perceived benefits to influencing policy included improving the health of the public (94%), making a difference in others’ lives (87%) and improving the situation (77%) (Table 3).

Table 3 Barriers and benefits to public policy activities
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Self-Efficacy and Public Policy Involvement

Our instrument measured two components of self efficacy: efficacy expectations, and outcome expectations (see Fig. 1). For the eight items that assessed efficacy expectations, respondents had an overall mean efficacy score of 3.76 (SD = 0.79) (potential range 1–5 with higher scores indicating higher efficacy scores). The mean score for the six efficacy outcome items was 3.71 (SD = 1.2) (potential range 1–5 with higher scores indicating higher efficacy scores). The activities that yielded the highest self-efficacy scores included voting in an election (M = 4.8; SD = .54), contacting a public official (M = 4.3, SD = .99), and providing information for a proposed policy (M = 4.0;.SD = 0.97). The activities that yielded the lowest self efficacy scores included lobbying a public policy making body (M = 2.9; SD = 1.3), working on a campaign for a candidate or proposal (M = 3.0; SD = 1.3), and organizing people for action through a committee or coalition (M = 3.3; SD = 1.21).

Fig. 1
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Self-efficacy questions

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Outcome expectation scores revealed that respondents believed that the greatest impact was made by voting (M = 4.0; SD = 1.03), followed by organizing people for action (M = 3.8; SD = 2.4), providing information about proposed policies (M = 3.8; SD = 0.93), providing written reports, consultation or research (M = 3.7; SD = 0.99), contacting a public official (M = 3.7; SD = 1.0), and working on a campaign for a candidate or proposal (M = 3.3; SD = 1.1).

Perceptions of the Value of Public Policy in Influencing Health

Two questions were used to examine the perceived influence that public policy may have on the health of the public. The first question specifically asked respondents how important are the results of the public policy makers’ actions on the health and well being of the public (potential range 1–5). Sixty-three percent of respondents (n = 205) said that the results of public policy makers’ actions were important (M = 3.5; SD = .78). The second question asked how much the actions of the policymakers influence the health and well being of the public (potential range 1–5). Forty-three percent of respondents (n = 141) felt that public policy makers have great influence on the health and well being of the public, while less than one percent (0.6) felt there was no influence (M = 4.2;SD = .89).

Perceived Knowledge, Interest, and Training in Public Policy

Respondents rated their level of knowledge regarding how to change health policy on a 1–5 likert type scale. The ratings were as follows: 15% (n = 49) rated their knowledge as excellent, 41% good (n = 134), 26% neutral (n = 85), 11% fair (n = 37), and 6% poor (n = 18) (M = 3.5; SD = 1). Interest regarding efforts to influence health-related public policy was measured. Overall 37% stated they were interested (n = 120), while 2% said they were not interested (N = 8) (M = 4; SD = 0.93).

The majority of health commissioners (62%) reported that they had received some type of information regarding how to change public policy (n = 203). The most commonly reported source of education information was conference sessions (43%), followed by professional colleagues (38%), on the job experience (35%), workshop materials (32%), journals (28%), materials from professional organizations (27%), college course work (19%), the mass media (13%), and participation in a non professional political group (10%).

Health commissioners rated their level of personal involvement in public policy over the last 4 years. Sixty-nine percent of respondents (n = 227) indicated that they had not been involved in changing public policy at all. Sixty-five percent (n = 214) reported they had not been involved in changing public policy as a health commissioner and 62% said they had not been involved in changing public policy as a citizen, taxpayer, or parent (n = 204). To assess social norms regarding health commissioners’ involvement in public policy, a survey item was included that asked if they personally knew another health commissioner who had been involved in public policy. Seventy-nine percent of respondents believed they knew someone (n = 257), while 14% said they did not know someone (n = 47), and six percent were unsure (n = 19).

Factors Predictive of Public Policy Involvement

A stepwise linear regression was conducted to determine the effect of number of perceived benefits, number of perceived barriers, total confidence score, total opinion of impact score, number of different education/training sessions, knowing other involved health commissioners (dummy coded), age, sex (dummy coded) and race (dummy coded) on the total number of public policy activities in which respondents participated. Four variables (total confidence score, training, perceived benefits and perceived barriers) predicted 50% of the total variance (Table 4). Variables that were not significant predictors included opinion of impact, knowing other involved health commissioners, age, sex, and race.

Table 4 Regression of independent variables on total level of public policy activity
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Discussion

Our findings indicate that many health commissioners appear to have minimal understanding of public policy matters. Only slightly over half of the respondents (56%) rated their knowledge of policy matters as good or excellent. In addition, only 62% reported having some kind of education regarding policy matters. Most of this education was obtained at conference sessions. This lack of advocacy and policy education may be compounded by the many different educational backgrounds of the health commissioners and a lack of policy and advocacy education in many of their degree programs. Although schools of public health recognize the importance of education about policy in public health, even these schools give minimal coverage to addressing policy issues as part of their curricula [4].

Although health commissioners reported voting as their number one advocacy activity (84%), and their involvement in voting is higher than the percentage of US citizens who voted in the last presidential election (68%) [11], there is still room for improvement. Voting has a major effect on public policy and should be an activity that health commissioners value and participate in consistently. In addition, the fact that only 15% of the health commissioners reported being very involved in public policy in the past 4 years and 69% reported not being involved at all is a cause for concern. As leaders of the public health community, health commissioners should serve as a resource in developing policy and a catalyst for implementing policy to improve the health status of their communities. Advocacy and policy involvement are clearly priorities of NACCHO.

Health commissioners identified several barriers to engaging in public policy including lack of time, other priorities, and lack of money or resources. Interestingly, our regression analysis found that those respondents who identified more barriers to engaging in public health policy were more likely to engage in policy-related activities. Perhaps those individuals who are active in public policy activities perceived more barriers merely because of their experience with these barriers in attempting to perform policy-related activities. Holtrop et al. [5], had a similar finding in their study of health educators where those who perceived more barriers were more involved in policy-related activities.

Lack of time was cited as a major barrier to advocacy and policy activities, just as it was in studies of health educators and nurses [5, 6]. While lack of time is a real barrier, it is often given as a rationale for choosing not to participate in activities. In addition, perhaps some of the commissioners’ lack of involvement may be attributed to perceived deficiencies in their advocacy and policy skills, a lack of education about these skills, and decreased self-efficacy in performing these skills, particularly in the areas of lobbying, working for a candidate, or forming a coalition.

The major benefits health commissioners reported in participating in public policy change activities was improving the health of the public, making a difference in others’ lives and improving a situation or issue. These perceived benefits were predictive of the health commissioners’ involvement in public policy issues.

Holtrop et al. [5], found that working in a government setting was a significant predictor of policy involvement and that it was understandable that those who work in this setting (e.g. health commissioners) would be most involved in public policy being that their focus audience is the public. This study did not support that premise.

Certainly Schools of Public Health should prepare public health educators with advocacy and policy skills. As Gebbie et al. [4] state, “Should schools wish to be significant players in the future of public health and health care, dwelling on the science of public health without paying appropriate attention to both politics and policy will not be enough”. In addition, given that many health commissioners have nursing backgrounds, Schools of Nursing should also require education on policy and advocacy issues.

Conclusion and Recommendations

Although NACCHO emphasizes the importance of communicating and advocating for health issues and policies, participation in public policy activities among health commissioners is only moderate. As health commissioners are in a unique role to influence public health policy, efforts should be focused on increasing their level of involvement by increasing knowledge about the public policy making process, removing perceived barriers, and increasing awareness of perceived benefits. New venues for distribution of advocacy and public policy knowledge need to be explored. At a minimum, professional preparation programs for physicians, nurses, public health and environmental health professionals should require advocacy and policy courses. Sadly, only 19% of commissioners indicated this was their source of education information on advocacy and policy. In contrast, conference sessions were identified by the commissioners as their main means of acquiring advocacy and policy information. These sessions should be continued with an emphasis on advocacy and policy skills.

According to Gebbie, et al. [4], these skills include “understanding the dynamics of community politics, identifying and working with stakeholders, identifying legal and policy structures currently influencing community health, and motivating and educating stakeholders and officials”. Other methods for delivery of educational programs could include peer instruction by colleagues including on the job experiences, and workshops, journal articles, and materials developed by professional associations as these were the next-ranking sources of information on advocacy and policy. Web-based courses (such as NACCHO “webinars”) offered for continuing education credits may be effective for providing advocacy and policy education to busy professionals with a variety of educational backgrounds. In addition, NACCHO should provide sessions on advocacy at their conference venues. These sessions should address areas of lowest self-efficacy scores including lobbying a public policy making body, working on a campaign for a candidate or proposal, and organizing people for action through a committee or coalition. Coalition development should receive particular attention since health commissioners felt the second greatest impact was made by organizing people for action through a committee or coalition, yet it was a skill they felt low self-efficacy about performing.

Recommendations for future research include the following: (1) investigation of participation in personal versus professional/workplace advocacy, (2) advocacy and policy training in professional preparation programs, (3) advocacy training via conferences, and journal articles (content analysis/bibiometric studies) and (4) perceived public health policy expectations of employers.

Limitations

This study was delimitated to health commissioners in the United States who were listed in the NACCHO national database. Although a random sampling method was employed, a stratified random sample may have been more representative as some states have hundreds of health commissioners while other states have only one. Because the survey instrument was formatted for forced choice responses, respondents did not have the opportunity to provide additional information that may have been pertinent to our research. Self-reported data may be over or under reported based on the nature of the survey. Finally, the monothematic design of the questionnaire may have elicited responses that were socially desirable.