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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 them-
selves 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. Depart-
ment 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 insti-
tutionally-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 distribu-
tion of the healthcare workforce by paying some or all of the costs of health profes-
sionals’ 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 in-
crease 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 pro-
posals 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. Gov-
ernmental 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 ef-
forts 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 effec-
tive 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 pro-
gram 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 lobby-
ing 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 consider-
able 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-inter-
est, 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 dis-
semination 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
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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. Collabo-
rations 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 organiza-
tions 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 under-
stood correctly and acted upon appropriately.
Fourth and finally, advocacy organizations that base their arguments on sound re-
search 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 anec-
dotes and simply because “it’s the right thing to do” does not stand up well to counter-
arguments 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, support-
ing 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.