Empirical Research And Advocacy

Shooting Themselves in the Foot: W hy Empirical Research is Essential to Advocacy Brad Wright, University of North Carolina – Chapel Hill

In the world of health policy, individuals and organizations tend to arrange themselves along a research-advocacy continuum. At the poles are the purists, who believe that health policy decisions should be driven by either empirical research or unabashed advocacy, but that the two should never meet. Between the two extremes, people seem to recognize that even the most objective researcher can never fully abandon his or her own personal biases. Unfortunately, when it comes to mixing research and advocacy, the focus always remains on advocacy’s ability to taint research, rather than on research’s ability to bolster advocacy. Charles Corry gives a thorough overview of what he calls “advocacy research,” which he defines as advocacy masquerading as research, with the results being clearly biased by the investigator’s preconceived agenda.1 Not surprisingly, the fear of being accused of conducting biased research has convinced most investigators that they must abandon advocacy altogether. Nothing could be further from the truth. This commentary aims to reframe the tension between research and advocacy in a positive light and explores the importance of research to advocacy efforts as it relates to a perennially important topic in health policy: federal funding for health professions training through the Title VII program. The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (DHHS) provides grants to support the training of health professions students through the Title VII program, so-called because it is authorized by Title VII of the Public Health Service Act. The Title VII label actually applies to a number of programs that provide scholarships, loan repayment, and institutionally-based training programs, many of which are used to increase the enrollment of underrepresented minorities in health professions schools. One well-known Title VII program is the National Health Service Corps, which works to target the distribution of the healthcare workforce by paying some or all of the costs of health professionals’ education in return for their fulfilling a commitment to work in an underserved area after graduation. The programs funded by Title VII are vital to the success of broader efforts to increase access to health care and reduce racial and ethnic disparities in health outcomes, and yet, the amount of funding authorized for Title VII programs annually is only a small fraction of the federal government’s spending on health care. Moreover, even this relatively small amount of funding is perennially threatened as presidential budget proposals look to the program for savings by drastically cutting—or even eliminating— funding for Title VII. The potential for lost funding motivates clinician advocacy groups to action. Governmental affairs arms of groups like the American Academy of Family Physicians, the National Association of Community Health Centers, and the Association of American Medical Colleges, among others, work diligently to lobby members of Congress in hopes of having Title VII funds restored in the final budget bill. Historically, these efforts have paid off. While Congress has made cuts to Title VII, the program has never been completely eliminated. This cycle repeats itself each fiscal year. Two important questions emerge from this scenario. First, why do presidential budgets so often look to cut Title VII? Second, why does Congress so often see fit to restore funding to the program?

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The reason why Title VII is targeted for reduction or elimination so frequently in presidential budgets is simple: evidence in support of Title VII programs is scarce. While there is a small body of literature that finds Title VII programs to be effective in increasing minority enrollment in medical schools and placing graduates in underserved areas, there is an equally small but opposite body of literature that finds Title VII programs to be ineffective. It comes as little surprise that an unproven program faces frequent scrutiny from the Office of Management and Budget, but given the dearth of evidence around Title VII, why does Congress choose to support the program? The reason for this is, again, simple: Congress typically responds to lobbying efforts from powerful, organized interest groups, especially when opposing these groups would be viewed unfavorably by the public. Granted, not many members of the public are aware of the Title VII program, but the organized interests that support Title VII could work very effectively with the media to get the word out that certain members of Congress oppose a program that helps recruit underrepresented minorities to health professions programs and place clinicians in underserved areas. It almost goes without saying that such exposure would be very unfavorable politically. This is a risk most members of Congress are unwilling to take. Still, this process is entirely inefficient. Advocacy organizations spend a considerable amount of time and resources to convince Congress to act in their favor. If instead, advocacy organizations worked to produce sound research on the effectiveness of Title VII, it is likely that the president’s budget would hesitate to cut the program, and thus, extensive lobbying of Congress would become unnecessary. Additionally, the programs housed under the umbrella of Title VII would become more efficient as research is able to distinguish best practices. So, what would this research advocacy look like and how would it work? Loosely speaking, all advocacy relies on some form of research. Organizations rarely go through the trouble of trying to push an agenda or convince policymakers to take their position on an issue without some sort of justification. The problem is, however, that the evidence they use to justify their claims is often weak and ineffectual. While isolated anecdotes and even public opinion can serve to influence policymakers, these types of evidence lack the strength and integrity of more rigorously collected data. Likewise, policymakers tend to be swayed less by organizations acting out of self-interest, unless it happens to coincide with the best self-interests of the policymaker (e.g., campaign contributions, voting support), and more by objective data that is perceived to be less biased in favor of organizational self-interest. Why, then, should advocacy organizations work diligently to incorporate sound research into their efforts? The answer is that advocacy organizations are in a unique position to assist researchers with study design, the conduct of research, and the dissemination of findings. The reward for advocacy organizations comes in the form of increased credibility, stronger arguments when appealing to policymakers, and better results on the issues the organization cares about. First, advocacy organizations tend to be more acutely aware of the unanswered questions in the field of study. Consequently, they know what research needs to be conducted, and what research will most directly influence policy. With this in mind, advocacy organizations can play a vital role in the design of research that is central to their organization’s interests. They can query their members to find out what needs they have, as well as what insights they can offer. Second, advocacy organizations represent a highly connected network of individual

and organizational members that can assist in the conducting of a study in a variety of ways. Individual members may be considered the target population for a study, and thus, by working with the advocacy organization, researchers will gain easier access to their intended sample than they would if they had to contact all persons separately. Member organizations might also serve as study sites. For example, researchers might work with community health centers to survey patients who visit the center. Collaborations between research teams and advocacy organizations will facilitate these types of activities. Third, advocacy organizations are ideally situated to assist in the dissemination of research findings. Many research organizations are not structured with a clear tie to policymakers. Additionally, many research organizations—especially those that are publicly funded (e.g., state universities)—maintain policies that prohibit their staff from engaging in certain types of advocacy efforts. Thus, some of the best research studies are never translated into practice. Advocacy organizations, on the other hand, do maintain government affairs offices and can act as a bridge between research organizations and policymakers. Because of their familiarity with the topic and their knowledge of the policy process, advocacy organizations can interpret sophisticated research findings, translate these findings into more accessible language and concepts, and present this information to policymakers. Furthermore, while the law imposes limits on the amount of lobbying nonprofit organizations may engage in, and prohibits these organizations from endorsing particular political candidates, advocacy organizations do not face the types of apolitical and anti-advocacy policies that often constrain researchers. This greatly increases the likelihood that research findings will be understood correctly and acted upon appropriately. Fourth and finally, advocacy organizations that base their arguments on sound research findings are more likely to be taken seriously, as their claims will be considered more objective and therefore more credible. Advocating on the basis of isolated anecdotes and simply because “it’s the right thing to do” does not stand up well to counterarguments based on cost-effectiveness, technical feasibility, and political feasibility. The facts provided by research provide specificity to what would otherwise be a nebulous appeal for change, and can motivate individuals to take action in cases where they might remain passive if the debate was more vague or abstract. Promoting the findings of a research study also provides the organization with a valuable opportunity to make others aware of the organization and its mission, which can attract new members and additional external support to the organization’s cause. In sum, advocacy organizations need to become more involved in health services research, and researchers need to embrace the opportunity to support the efforts of advocacy organizations while remaining objective in their work. Ultimately, supporting the efforts of advocacy organizations must not necessarily equate to agreeing with the position of the advocacy organization. While some findings may support the advocacy organization’s position, findings which fail to support their position are still supportive insofar as they lead the organization to refine its focus and target only what has been to shown to work, rather than what they believe to work. Together, advocates and researchers working in conjunction with one another have the unique potential to improve the health care system via evidence-based health policy. Sources

Corry, Charles. “ Advocacy Research by Charles E. Corry, Ph.D..” Domestic Violence Against Men In Colorado. http://www.dvmen.org/dv-31.htm.

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