Intent to Advocate Before and After a Health Education Workshop Audrey R. MeCrary-Quarles, Michele L. Pettit, Fakmida Ralmman, and Stephen L. Brown Abatract This pilot study evaluated the influence of an advocacy training workshop sponsored by an Fi Sigma Garena chapter sifted wit large university inthe Midwest. The theory ‘ofplanned behavior (TPB) was utilized as a framework for ‘seating patcipans intentions to parepat in advocacy. Pasicipats completed pre-and post-test surveys o assess intent to advocate. Maltiple linear regression was executed to determine the extent to which participants’ attitudes, subjective noms, ad perceived behavioral conto predicted their behavior intentions to advocate, Only perceived ‘behavioral control significantly predicted participants’ ‘behavioral intentions to advocate, p = 009. Dependent f= tess showed that mean posttest scores were significantly Tower than pre-test scores for attitudes toward advocacy (= 11.39, A= 7.4), subjective norms (M = 1621, ‘M= 13.17), andbevoral intentions (M™ 18.55, M= 1350), There was no signifcat change for perceived behavioral contol (M = 37.65, M= 36.35). Partipuns' knowledge of the advocacy process was associated with greater inolvementin advocacy (M=5.10,M=6.15). Findings from this plot study suggest that participants’ perceptions regarding their capacity for advocacy influenced their intentions to engage in the process. Finding also indicate thatthe traning workshop improve participants" knowledge of advocacy, but not ther intent to advocate. Introdton ‘In additon to developing programs and filing other key responsibilities, health educators are increasingly involved in advocacy, a proces devoted to acing on bbl of individuals in need of resources and sll to support their health, Health eduestors can serve as instruments of change working closely with individuals and communities "+ Auiey McCrary Ques, MSA, CHES; Doctor Candie, ‘Soutien lio Universi, Department of Heth Easton ‘sod Reresion, Caron, 1 62901-4632; Teepe: 618- 509-4874 Ema sdgures@aolcom ‘bith Sto Univers, Suwa, OX 7078, Fatma Rahman, MA; Decal Candas; Souther ios ‘Universi, Crbowse I 62901. ‘Stephen {- Brown, FAD; Aisa Profesor esther Tinos ‘Unstable 62901-4632; Tepe 618453. 13 Fax 61845189; Eom rowndsie + comspening soar Pa 206, 38, Na 2 to facilitate the advocacy process (McKenzie, Neier, & Swe, 2005. ‘Advocacy hasbeen defined as an stem to influence ecsions that affect th health and welfire of vuemble indivdaas who nck power Sosin & Caukum, 200) Inotber ‘words an advocate sa person wo asserts or argues for a pariclar cause. Advocacy provides an opportunity for ‘nflencing the manner in whit the blew policymakers think about and vet on policies that affect health. Despite ‘common misconceptions about advocucy requiring special ‘metals and skills, advocacy en be performed by anyone ‘who has. desire to affect change for individual, families, communities, orgnizations, and other targeted entities (Cegisiaive Consulting, Ilinois Rural Health Assocation, ‘ertonal communication, Otober 15, 2004). Those who ‘engage in advocacy activities exercise ther rights to atcipte inthe democratic proces (American Public Health ‘Association, 199). There are many ways to be an active health advocate without making personal visits to policy makers, Writing eters to policy makers canbe very effective in influencing the outome of piece of legislation. Health educators can inform polieymakers about the impact particule bill would ‘ave on he, theircommnity, and ter sae. Utizing media coverage is one of the best ways to gain the atetion of ‘decision maker. The medi also can be used to publicize ‘community or tate level publi health events. Speaking at ‘own/public board meetings has the potential to impact the policymaking proces. Citizens who understand the needs ‘oftheir community and the rmieations of policy decisions ‘onthe heath and wel-being oftheir community ar essential to the success of any advocacy effort. Finally, coalition ‘buiding is one ofthe most effective vehicles for generating rss rot suppor fora public eath sue. Coalition billing involves activating local support through community ‘mobilization sound an ise, and voicing the support 10 policymakers (American Public Health Association, 1999), UUniortnately, few health estore ace atively involved in the advoetey proces Tappe & Galer-Unti, 2001). The ability to advocate for personal, family, and ‘community health represents an esenil sil fora beat literate individual and an integral part f the health education process. Advocating for bealth-related issues, needs, and esouresisnotonlya requisite sil, but also arespensiility ‘of health educators According othe National Commision {or Heath Edvation Credentialing, Ine. 2000), even entry level health educators have the responsibility of communicating health end health edvetion nents, cones, and resources. The competency-based framework for graduate level health educstors further expanded the ‘esponsibilites to incorporate health advocacy (NCHEC, 1989). For health educators to promote health literacy, ssdvocacy must be included inthe proces Tappe & Galen: Uni, 2000, “Health educators have the skills and experts, as well 1s the credibly to present informatio about wide aay ofheath issues. Educators may not know the species of every health policy, bu they can speak broly abou the Imporunce of prevention, suveillacs, data, and sound science (American Public Heath Assocation, 1999). Health ‘educators canbe found ina variety of setings, such a5 Schooluivesits,healthare organization, community ‘eat agencies and worksites. These diferent setings allow or many opportunities to advocate fr and educate others ‘on health elated issues. Advocacy can involve interaction ‘with eislatos, legislative sistant, school administrators, School board members, private sector leaders, parents, ‘community members, andlor faculty and staff members. ‘Advocecy interactions can be planed or cidentl cur ‘with one person ora group; and uke place during meeting, through the media, or at a public frum. Besause of the potential impact of successful advoracy, heath edvstors ‘must be prepared to leverage every opportunity available irk, 1985). "The success of health education programs depends, in ‘part onthe ability of health edseatrs influence te acons ‘of politicians, Politicians end to suppor programs they fel fate of greatest value to their constituents; they are not expected to know the value of community-based heath ‘education programs, unless heath advocates are able to take compelling cases for such programs. Therefore, politicians depend on advice fom those whohaveleptimate expertise such as health educators. The decisions thet legislators make have such a powerful effect on health ‘education that legislative advocacy canbe viewed as dre extension of he education process (Huntington, 2001). ‘Research has highlighted the noe fr health educators to master advocacy skills (Tappe & Galer-Unt, 200). ‘Moreover, the American Public Health Association (APH), ‘he Society for Public Health Edson (SOPHE),and other professional organizations have collaborated to support ‘voctcy education and skill development among health ‘educators (APHA, 1998). Despite widespread recognition (ofthe importance of advocacy and national initiatives to ‘develop advocacy skills among health educators, no research exists to address factor that contribute to health ‘educator intentions participate in advocacy activities This pilot study was designed to examine the effectiveness ofan advocacy tning workshop in relation to health educators" attitudes, social norms, levels of pereived contol and behavioral intentions. The warkshop, Sponsored by an Eta Sigma Gamma chapter, addressed ‘voceey lobbying, the law-making process, inplitions for health educators, methods for communicating with legislators, and tobacco contol as an example ‘Theoretical Framework, ‘The instrument for this study was developed using constructs from Ajzea and Fisbein’s Theory of Planned ‘Behavior (TPB) (isbein & Ajen, 1975; Glan, Rime, & ‘Lemis, 2002). The TPB is «value expectancy theory tht {oeuses onthe value atached to a behavioral outeome oF stbut. In essence, humans ae ational Beings who make ‘ecsions about engaging ina behavior a result he value associated withthe behavior (Ganz Rime, & Lewis, 2002) ‘The TB focuses on pediting human behavior trough ‘bchavioral intention. Behavioral intention is predicted by three consuct-atiudes toward the behavior, subjective ‘noms and perceived behavioral contol (Ganz, Rimes, & ‘Lewis, 2002). With regard o advocacy, atitude toward the ‘behavior is contingent upon perceptions regarding he rle ‘hat advocacy pays in one's profession life andthe extent to which advocacy makes e difference in the lives of the ‘people one serves. The key norms for advocacy come from beliefs and motivation to comply with the desires of supervisorfboses,co-worker/ollesgues, and tp level ‘ministre. Control issues rounding advocacy include valle resources, iflunce of sakeolders, knowledge ofthe advocacy proces, workplace environment, available ‘ine ifluenes rom ogaizatons, evel ofadvoeasy taining, and political atmosphere at work ‘Methods ‘The workshop consisted of lectured-based rsentatons, an open forum, an interactive discussion, and PowerPoint presentations. Guest speakers consisted of representatives om the Iliois General Assembly, Souther ino Uaiversiy Pubic Policy Insti, Minois Rural Healt ‘Association, andthe American Lung Assocation, “The moming session of the workshop addressed two major issues in advocacy including the use of media end advocacy versus lobbying. The afternoon session incorporated input fom sate representatives regarding whst is important esas Finally, the guest speakers focused ‘on te proces of advocacy utilizing bacco convo as an ccample Sample Finyfour individuals participated in the advocacy tuning workshop and completed pre-ests including 44 (6159) females and 10 (18.5%) males. The initial sample consisted of participant from the following work stings: (@elnial (11990), () school (12, 222%), (6) community (4, 183%) (@)universiy (18, 33.3%) () ober (6, 11.199), and (2 mahipl setings (7, 13.0%). ‘Twenty-two participants completed post ets incloding 14 (63.6%) females and 8 (364%) mals. The final sample consisted of individuals associated withthe following work sings () choo (4, 18290) () community (A, 182%), (3) al 206, 38 Na. 2 ‘university (10, 4.5%) () oer (1, 4.5%), and (9 multiple segs 3, 13.6%). Instrumentation ‘The research questions fr this plot study were as {llows (2) Do paticipant'atitdes, subjective noms, and percsived behavioral contol significantly peediet their ‘svocacy before and ater the advocacy taining workshop? (Does significant difference exist between participants subjective norm before and after the advocacy training ‘workshop? (f) Docs a sigaticantdierence exist berween parcpants'percived behavioral convol before and ater ‘he advocacy taining wokshop?; and (c) Does sigicant ference exist between participants’ behavioral intentions to advocate before and aftr the advocacy training workshop? ‘rot to developing the instrument fortis plot sty, the investigators conducted elicitation interviews among. potential parcpants of the advocacy taining workshop. Questions incorporated in the elicitation interviews were seviewed by an assistant professor of health education (se {wo repesenativs ftom local university for telephone interviews. Responses tothe elicitation interviews were sythesized anda formal instrument was developed based ‘on constucs fom Aen and Fishbeln's Theory of Planned ‘Behavior (TPB) (Fishbein & Ajen, 1975; Glan, Rimer, & Lewis, 2002). Specifically, survey items assessed ‘arcpants”atiudes about the importance and influence ‘fadvocacy, perceptions abou het support for advocacy involvement from individuals in the workplace (42. subjective norms), perceptions about facors tat inuence ‘heir capacity to affect change though advocacy (ie, etecived behavioral conto), and behavioral intentions 10 paripate in advocacy elated acvits. ‘Asitode 1 Whatrote has advocacy played in your professional ie? 2 Describe your perceptions ioward advocacy (Le, How do you feel about advoceey?, 4. Do you belive that doing more advocacy work will improve the lives of those you work with? ‘Why of why 20 Subjective norm TL By becoming involved in advocacy, whet individuals or groups do you fel will support or hinder your efforts? Plese explain, 2. How have your advocacy effors been affected ‘by individuals within your workplace? Pereived behavioral contol 1. What factors do you believe have fitted your ability to participate in advocacy activites? 2 What barriers do you believe have hindered your este to advocate? Figure |, Elichaton Interview Question Content and face validity forthe instrument was confimed by two heath education professors skied in insrumeatation Internal consistencyirelabiliy estimates ‘were conducted for each subecale ofthe instrument using at from the priest Resuls were as follows: (a atiudes toward advocacy (71), (b) subjective norms (89), (2) perceived behavioral contol (74), and (A) behavioral {nteations (32), ‘Responses to individual survey items were formated according to a 7-pint Liker-ype seale. For example, participants were asked torte the extent t9 which they ‘agreed (7) or disagreed (1) withthe statement, "Advocacy playsan important rosin my professional if.” Total scores were generated to measure participants” ates toward ‘Table Results ofthe Maliple Regression Analysis Predictors ‘ ' > Avsitudes oe “340 as Subjective norms 160 as 286 Pereived behavioral contol ao. 2041 09" *p<.0s a 206, 38, a2 The Heath éseae “a vocacy, subjective norms, perceived behavioral contol, fod behavioral intentions to advoete. Data Collection ‘Dat fr this pilot study were collected on two separate oceasions. Participants completed pre-ests during the registration process on the day of the advocacy traning ‘workshop Partcpans reviewed over eters ndieating that their prticistion was both voluniary and anonymous. By completing the survey and revealing their email eddess. 08 {he Instrument, participant agreed to be contacted for completion of follow-up survey. The follow-up suvey (Le, posttest) was administered to participants approximately Tour months after the advocacy training workshop. Participants received an initil email message and two subsequent follow-up messages Each message confined & Tink tothe survey Prcipants who failed to respond to the ‘mal survey received hard copes of the instrument though ‘he mal. The response rt fo the port test was 40.7% (n 22), Pre- and postiess were matched through participants’ ‘mal adresses. Data Analysis ‘Data wer analyzed using the Statistica Package forthe Social Sciences (SPSS) version 11.0. multiple linear ‘eqression analysis was used to examine the exen to which pancipans”attinds, subjective norms, and perceived ‘ehavioral contol predicted thei behavioral itentions to slvocate. The multiple regression analysis was based on {to compare mean responses to survey items before and ater the advocacy taining workshop. The Bonferroni procedure ‘was applied to minimize Type Tero for dependent ess. ‘Alpha levels were adjusted to.0128. Results ‘Results ftom the multiple linear regression analysis indicated thatthe linear combination of predictors (i, attudes, subjective norms, and perceived behaviors contol) was significantly relate tothe total score for ‘behavioral ineatins,F (3, 48)= 3.94, p= 01. The sample ‘multiple corelation coefficient was’ 46, indicating that approximately 21% (R= 21) of the variance ofthe toa ‘Store for behavioral intentions was explained by the linear combination of prediciors. ‘Table {presents results indicative ofthe stengh ofthe individual predictors. Only one predictor was sastically signfcantpeosived behavioral eon, p~009. Perceived ‘behavioral contol accounted for 18% of the variance of the total score for behavoralinetions while the other variables (Ge, atdes and subjective norms) contbuted only 3%. "Table 2 shows results fom th dependent ess. Mean postiest scores were significantly lower than the presest ‘subjective norms (.e, encouragement rom and compliance ‘withselected ets) 121) =2798,p intentions to advocate (17 ‘between the mean pre-and post-et scores for perceived ‘behavioral control (Le, factors that support or hinder participation in advocacy) (19) ~.832, p= 416. The data also revealed that upon completion of the workshop, patcpants’ knowledge of the advocacy process was mace Tikly to suppor their involvement in advocacy. Conctasons ‘Severs conclusions canbe drawn fom hsp stud. First, findings suggest that only factors that influence parcipans’ capacity to engage in advocacy effort (Lc, valle resources, fluence of stakeholders, knowledge ‘of advocacy process, workplace environment availble tine, influence from organizations level of advocacy taining, and political mosphere st work) influenced their intentions to ‘vocate. Consequently, health educators shoud sek to ‘dress these factors though collaboration with employers, ‘community agencies, and profesional organizations. Health ‘educators also must coordinate workshops and other ‘continuing education tivities that enhance perceived behaviors conto "A second conclusion from this pt study was that 2 single workshop characterized by presentations and <scusio is insuicient in improving participants atiudes toward advocacy, subjective norms, ereived behavioral ‘contol and behavioral intentions. Nonetheless, knowledge ‘of advocacy can positively affect individuals” perceptions about thet involvement in the process. Based on these ‘conclusions, efforts mst be made to ridge the gap between ‘vocacy knowledge and practice For example, continuing ‘education seminars tht incorporate role plays, scenarios, ‘ndoterineacive activites could be organized o promote ‘he practice of advocacy among health educators. Tneestigly, the vast majority (81.5%) of parcpants who chose o ated the workshop were females. However, ‘here was a greater response fate for the pos tst among, mals (80.090). The post-test response rate for females was 531.2%, These findings support a need to explore gender ‘differences related to interests and behaviors toward ‘advocacy. It also shouldbe noted that almost half (5.5%) of inividuals who completed the posttest were alited ‘witha university seting, These individuals might not have ‘hd opportunities fr profesional involvement in advocacy despite thee avid interest inthe proces, Sever limitations restricted the researches’ ability to ‘generalize findings and conclusions about the study. First fof all, the study design was non-experimental and all ‘measures relied on self-report. Thus, the extent to which partcpents provided socially desirable reaponses was not filly own. Seondly the total sample size and low response ‘ate from participants limited the type of data analyses al 206, 38 No.2 “Table? ‘Survey Questions and Ress of Dependent tists Constructs Prosest Postisst Hest value Asides case rate the extent which you agree or disagree with the following statements (scale: I= strongly disagree to ‘T= strongly agree). 1. Advocacy plays an important ‘loin my professional ie 545106 386 20) 2 Advocacy makes a difference {in he ives ofthe people I seve. si4(7) 33870) ‘Toa 1139 (156) 74146) 4198 00 ‘Subjective Norms (Normative Beliefs) Please indicate the degree to which the following entities ar likey to discourage or encourage your involvement in advocacy (sale: I= very kel o discourage o 7 = very likly to ensourag). 1. Supervisorboss 5360153) $09.05) 2. Coworkerveoleagues 550106) 386 205) 3-Toplevel administrators 518053) 6180.48) ‘Subjective Norms (Motivation to Comply) ‘Please indicate how likly you are o comply withthe desires of each entity (scale: 1~not likly to comply to = very likely to comply). 1. Supervsorboss sassy 37320 2. Corworkerveolleagues 527035335092) 3. Toplevel administrators 56412) 382.@15) ‘Toul 162145) 13.1142) 2798 on Perceived Behavioral Control lease indcate how much each ofthe following factors support or hinder your participation in advocacy (eae: = very likely tinder to7= very likely to support. 1. Resources available 400056 310.59) 2 Infaence of stakebolders 51528) 338170) 3. Knowledge of advocacy process 10 (180) 615 (142) 4 Workplace environment S148) 613 (1.16) S.Avalabletime 43000) 29019) 6 Influence from organizations 445073) $90.7) 7. Level of dvocicy ting 475035 320.6) 8 Political atmosphere at work 47039 5401.03) “Tol 3765 (689) 3635 (400) 832 a6 Behavioral Intentions Please indicate the likethood of yur participation in each ofthe following advocacy-related activites within the ext 6 months (cle a satefeeral legislative body 2e8@0) 188.1 2. Writing aletersending an email message toa legislator 24052 33529 3. Making a telephone eal toa legislator sas@ay 2820174 4. Presenting infomation oa aca governing body 4mecy 55003) Toul 18462) 1350461) 330 08 a 206, el. 38, Na 2 The Heath éseae * ‘conducted by the researchers. Tit theresa possibility ‘hat participants were overwhelmed with iaformation about the complet ofthe advocacy process. Therefore, some participants interest in advocecy declined. Fourhly, the ‘workshop focused mostly on advocacy atthe sate evel as ‘opposed tothe local level, Thre is possibility that patcipants were expecting oe infomation aboutadvocacy a the grassroots level. Consequently, the content of the workshop did nt necessarily meet the needs and skils of ‘participants. This study involved oly one workshop in an nipated series of advocacy traning workshops. Lastly, the workshop did not include hands-on sctvities for engaging participants in the advocacy process. Paricipats were given an opportunity to evaluate the workshop by completing «form and providing writen ‘comments, Despite ts linatons, participants” comments bout the workshop reflected ther acknowledgement of the importance and relevance of advocacy in health eduction. "This pilot study provided planners with insights for improving future advocacy-traning seminars and an instrament io measure the effet of taining on advocacy involvement. Esseatally, those planning advocacy taining seminars should incorporate hands-on activites that ‘enhance participant self-efficacy, emphasize the impact of ‘vocecy a the local level, and fous onpatcpans’ special interests and work settings. Getting health educators involved at the grass oot level of advocacy scems to be @ favorable approsch for developing skills and gaining confidence towards advocacy activities. Thote planning ‘workshop also shold measure effect. The TPB my provide ‘famework for measuring this effect ‘Advocecy i an important aspect of health edvcaton, (Ope ofthe key responsibilities of «health educator sto ‘advocate for heath-elated issues a oa, state, and federal levels. The need for advocacy is Becoming increasingly secognized by health educators within school, university, ‘lineal, community and worksite etings. Health edvstos ‘must overcome bares for participating in the advocacy ‘roces and sve to Become a voice forthe people they References ‘American Public Health Association, (1999). APHA ‘advocates handbook: A guide for effective publie health advocacy. Washingion, DC: Author. ‘American Public Health Association (1998), Health ‘cats convene advoeay summit Nation’ Health 285,13. Birch, D. (1995). 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Advocacy: A. ‘concepalizaon for social work practice. Social Wark, wa ‘Tape, Me Galer-UntiR(200)- Health educators role in ‘omoting health literacy and advocacy for the 2Ist century. Journal of Schoo! Health, 71, 47-482 al 206, 38 Na. 2