The Middle–Out Perspective — an approach to formalise 'normal practice' in public health advocacy

Background: The Middle–Out Perspective (MOP) provides a lens to examine how actors positioned between government (top) and individuals (bottom) act to promote broader societal changes from the middle–out (rather than the top–down or bottom–up). The MOP has been used in recent years in the fields of energy, climate change, and development studies. Public health practitioners involved with advocacy activities and creating alliances to amplify health promotion actions will be familiar with the general MOP concept if not the formal name. Methods: This paper introduces the MOP conceptual framework and customises it for a public health audience by positioning it among existing concepts and theories for actions within public health. Using two UK case studies (increasing signalised crossing times for pedestrians and the campaign for smoke–free legislation), we illustrate who middle actors are and what they can do to result in better public health outcomes. Results: These cases studies show that involving a wider range of middle actors, including those not traditionally involved in improving the public's health, can broaden the range and reach of organisations and individuals involving in advocating for public health measures. They also demonstrate that middle actors are not neutral. They can be recruited to improve public health outcomes, but they may also be exploited by commercial interests to block healthy policies or even promote a health-diminishing agenda. Conclusions: Using the MOP as a formal approach can help public health organisations and practitioners consider potential 'allies' from outside traditional health-related bodies or professions. Formal mapping can expand the range of who are considered potential middle actors for a particular public health issue. By applying the MOP, public health organisations and staff can enlist the additional leverage that is brought to bear by involving additional middle actors in improving the public's health.

An evaluation of the Victorian Salt Reduction Partnership’s advocacy strategy for policy change

Background Public health advocacy strategies facilitate policy change by bringing key health issues to the forefront of public and political discourse, influencing decision-makers and public opinion, and increasing policy demand. The Victorian Salt Reduction Partnership (VSRP) was established in 2014 in response to inadequate government action to improve population diets in Australia. This study aimed to evaluate the success of the VSRP’s advocacy strategy in achieving policy change. Methods Documentation of VSRP activities and outputs were collected, and semi-structured interviews conducted as part of a comprehensive process evaluation. For this study, the Kotter Plus 10-step public health advocacy evaluation framework was used to guide data extraction, analysis, and synthesis. Results A sense of urgency for salt reduction was generated by producing evidence and outlining the potential impact of a state-based salt reduction programme. This enabled the creation of a coalition with diverse skills and expertise, which facilitated the development of an innovative and collaborative advocacy action plan. A clear change vision was established, but communication of the vision to decision-makers was lacking, which reduced the impact of the programme as decision-makers were not provided with a clear incentive for policy change. As a result, while programme outputs were achieved, these did not translate to achieving broader strategic goals during a limited-term intervention in a political climate unconcerned with salt. Conclusions The Kotter Plus 10-step framework was a useful tool for evaluating the success of the VSRP advocacy strategy. The framework enabled the identification of key strengths, including the creation of the guiding coalition, and areas where efforts could be improved in future similar strategies, such as effective communication within partnerships and to decision-makers, to better influence policy and improve public health impact.

Patient-Planetary Health Co-benefit Prescribing: Emerging Considerations for Health Policy and Health Professional Practice

In addition to the importance of fostering and developing measures for better health-system resilience globally from the effects of climate change, there have been increasing calls for health professionals, as well as public health and medical education systems, to become partners in climate change mitigation efforts. Direct clinical practice considerations, however, have not been adequately fostered equitably across all regions with an often-confusing array of practice areas within planetary health and sustainable healthcare. This article calls for a more coordinated effort within clinical practice spaces given the urgency of global environmental change, while also taking lessons from Indigenous traditional knowledge systems—a viewpoint that is rarely heard from or prioritized in public health or medicine. Simpler and more coordinated messaging in efforts to improve patient and planetary health are needed. The creation of unifying terminology within planetary health-rooted clinical and public health practice has been proposed with the potential to bring forth dialogue between and within disciplinary offshoots and public health advocacy efforts, and within clinical and health-system policy spaces.

Understanding commercial actors’ engagement in policy debates on proposed e-cigarette regulation in Scotland

IntroductionThere is growing concern about transnational tobacco corporations’ (TTCs) and other commercial actors’ involvement in e-cigarette policy development. Previous analyses suggest that TTCs used e-cigarette debates to demonstrate alignment with public health and re-gain policy influence. Less is known about the engagement of other types of commercial actors in e-cigarette policy debates.MethodsThis paper is the first to empirically analyse commercial actors’ engagement in an e-cigarette policy consultation process and to examine their views on proposed regulation. It applies mixed methods, drawing on policy consultation submissions (n=32), semi-structured interviews (n=9) and a social network analysis of website links among 32 commercial actors.ResultsThe results show that commercial actors’ positions on e-cigarette regulation aligned with business interests. TTCs, independent e-cigarette manufacturers and other non-licensed commercial actors were opposed to most aspects of potential e-cigarette regulation (except for age of sale restrictions), whereas licensed commercial actors, including pharmaceutical companies, supported more stringent regulation. While collaboration was viewed as strategically important to gain policy influence, distinct commercial interests and concerns about TTC credibility led to strategic distancing and to collaboration being largely confined to sector boundaries. In addition to reiterating arguments employed by TTCs in previous regulatory debates, commercial actors focused on highlighting the technical complexity and harm reduction potential of e-cigarettes.ConclusionAwareness of the various commercial interests and strategic positioning of commercial actors in e-cigarette policy should inform public health advocacy and policy development, including managing conflicts of interest in the context of Framework Convention on Tobacco Control Article 5.3.

An Evaluation of the Victorian Salt Reduction Partnership’s Advocacy and Policy Strengthening Strategy

Background: Public health advocacy strategies facilitate policy change by bringing key health issues to the forefront of public and political discourse, influencing decision-makers and public opinion, and increasing policy demand. The Victorian Salt Reduction Partnership (VSRP) was established in 2014 in response to inadequate government action to improve population diets in Australia. This study aimed to evaluate the success of the VSRP’s advocacy and policy strengthening strategy.Methods: Documentation of VSRP activities and outputs were collected, and semi-structured interviews conducted as part of a comprehensive process evaluation. For this study, the “Kotter Plus” 10-step public health advocacy evaluation framework was used to guide data extraction, analysis and synthesis.Results: A sense of urgency for salt reduction was generated by producing evidence and outlining the potential impact of a state-based salt reduction program. This enabled the creation of a coalition with diverse skills and expertise, which facilitated the development of an innovative and collaborative advocacy action plan. A clear change vision was established but communication of the vision to decision-makers was lacking, which reduced the impact of the program as decision-makers were not provided with a clear incentive for policy change. Program outputs were achieved; however, these did not translate to achieving broader strategic goals during a limited-term intervention in an unsympathetic political climate.Conclusions: The “Kotter Plus” 10-step framework was a useful tool for evaluating the success of the VSRP advocacy and policy strengthening strategy. The framework enabled the identification of key strengths, including the creation of the guiding coalition, and areas where efforts could be improved in future similar strategies, such as effective communication within the partnerships and to decision-makers, to better influence policy and improve public health impact.

1.B. Workshop: Front-of-pack nutrition labelling: recent progress and remaining challenges

Front-of-pack nutrition labelling (FOPNL) is increasingly viewed as a central policy instrument in the fight against unhealthy diets, obesity, and noncommunicable diseases (NCDs), both for its direct effects on consumer behavior and for its potential to guide other effective nutrition policies (e.g. marketing restrictions, excise taxes). Major FOPNL schemes include the traffic-light system pioneered in the United Kingdom, warning labels as first introduced in Chile, the Australian Health Star Rating, and the Nutri-Score scheme developed in France. Countries that have already introduced mandatory FOPNL schemes include Chile, Israel, Peru, and Sri Lanka. Meanwhile, strong opposition from the food and beverage industry has prevented significant progress on FOPNL in many other countries. National developments have motivated several international initiatives. In 2019, the Codex Alimentarius Committee on Food Labelling began to formally negotiate guidelines for the development of FOPNL. Meanwhile, France and Australia have begun to convene a UN-supported Global Action Network on Nutrition Labelling. Understanding these national and international developments has become essential for effective public health advocacy in the field of FOPNL. The presentations in this workshop will therefore review recent key developments and identify major challenges to introducing effective FOPNL. The workshop will feature four presentations followed by an open discussion and exchange. Alexandra Jones will analyze key components of 31 existing FOPNL regulations and outline relevant best practice guidance. Tim Dorlach will explain why FOP warning labels first emerged in Chile and have subsequently diffused throughout Latin America. Chantal Julia will review the development of the Nutri-Score scheme in France and its adoption in other European countries. Anne Marie Thow will discuss how trade agreements and international standards can influence and potentially limit FOPNL schemes. Key messages Front-of-pack nutrition labelling (FOPNL) is a central policy instrument in the fight against unhealthy diets, obesity, and noncommunicable diseases (NCDs). Understanding recent national and international FOPNL developments is essential for effective public health advocacy for FOPNL and related interventions.

Picture of a pandemic: visual aids in the COVID-19 crisis

As a global crisis, COVID-19 has underscored the challenge of disseminating evidence-based public health recommendations amidst a rapidly evolving, often uncensored information ecosystem—one fueled in part by an unprecedented degree of connected afforded through social media. In this piece, we explore an underdiscussed intersection between the visual arts and public health, focusing on the use of validated infographics and other forms of visual communication to rapidly disseminate accurate public health information during the COVID-19 pandemic. We illustrate our arguments through our own experience in creating a validated infographic for patients, now disseminated through social media and other outlets across the world in nearly 20 translations. Visual communication offers a creative and practical medium to bridge critical health literacy gaps, empower diverse patient communities through evidence-based information and facilitate public health advocacy during this pandemic and the ‘new normal’ that lies ahead.

The Activist Lab and the MOULA Program

The Activist Lab at the University of South Florida College of Public Health is an exciting initiative that serves to build interdisciplinary advocacy and leadership skills for public health students and the community. The Lab is led by a very active student advisory group that with the Director develops the advocacy strategies and focus areas for change. The Activist Lab’s More Opportunities to Use Learned Advocacy, or MOULA program, allows students to work side by side with local agencies to support their advocacy efforts. A recent student works with the local Guardian ad Litem program to determine needs and services for children in the foster care system who have also been trafficked. The student is working with attorneys, social workers, families, advocates, and others so that the best needs of the children are met. Students must apply and be selected for the MOULA program based on their responses as to how they could meet the agency’s needs. The best responses and matches with the agencies are then determined. Students who participate in MOULA do midyear and final-year reports, evaluate their experiences, are evaluated by the agency mentor, develop a presentation on their experiences, and are interviewed on one of the Activist Lab podcast episodes. The Activist Lab and initiatives such as MOULA provide an opportunity for students to learn and advance critical public health advocacy skills and will help strengthen these skills for future success.