Teaching the Role of Health Advocate Reflections on two cross-cultural collaborative advocacy workshops for medical trainees and instructors in Oman

In March 2014, medical educators from Canada and Oman collaborated to shape the foundation of health advocacy training in Oman. Using existing research and innovative tools, two workshops were developed, representing the first formalised approach to health advocacy for medical trainees in Oman. The development and application of the workshops highlighted many unique challenges and opportunities in advocacy training. This article summarises the process of developing and implementing the workshops as well as feedback from the participants and short-term consequences. Furthermore, this article seeks to explore the complexities of designing a cross-cultural curriculum. In particular, it reflects on how the role of health advocate may be perceived differently in various cultural and societal settings. Understanding and adapting to these influences is paramount to creating a successful health advocacy curriculum that is relevant to learners and responsive to the communities in which they work.


H
ealth advocacy is a fundamental skill for physicians.Doctors have the potential to make a significant impact on policies and practices that affect societal wellbeing; indeed, it can be argued that doctors have a duty to act as advocates, especially in circumstances involving vulnerable populations or inequity. 1Several medical organisations worldwide have identified health advocacy to be an essential component within all levels of medical training.For example, the Royal College of Physicians and Surgeons of Canada designates 'health advocate' as one of the seven core roles of a physician within the CanMEDS framework. 2owever, it is only recently that most major medical schools have started to provide formal advocacy training and, as a result, the evidence for how to teach advocacy and what to include in an advocacy curriculum is still in its infancy.One of the major challenges in teaching advocacy is that it includes a skill set so broad and nuanced that it can be difficult to objectively quantify or evaluate. 3his article highlights some of the successes and challenges of developing two advocacy workshops for medical residents and instructors in Oman.These workshops were the first formalised exposure to advocacy teaching for most participants.Furthermore, the workshops involved the collaborative efforts of instructors from both Canada and Oman, creating a unique opportunity for cross-cultural learning as well as challenges in ensuring the relevance and applicability of the content to both settings.

Programme Setting
Oman is located on the southeast coast of the Arabian Peninsula.In 2010, the United Nations ranked Oman as the most improved country in the world in terms of development over the preceding 40 years. 4Additionally, Oman is categorised as a high-income economy and ranks as the 45 th most peaceful country worldwide.Life expectancy at birth was estimated to be 76.1 years in 2010. 4The healthcare system is government-operated and health services are free for nationals and all expatriate government employees.In 2001, Oman's healthcare system was ranked eighth by the World Health Organization. 5Major challenges include chronic lifestyle diseases (i.e.diabetes and obesity), mental illnesses, geriatric medicine, traffic-related injuries, the health of foreign workers and equitable access to healthcare services. 6

Oman Medical Specialty Board
The Oman Medical Specialty Board (OMSB) is a governmental organisation founded in 2006 to oversee the training of specialist physicians. 7Currently, there are approximately 600 medical residents in 18 different programmes, supervised by approximately 600 teachers of varying backgrounds.The OMSB provides training programmes modelled on the core competencies of a physician as identified by the CanMEDS framework. 2ost of these programmes are delivered as one-day workshops in collaboration with local and international experts.Limited follow-up in the form of a post-workshop evaluation is routinely completed.Longer term follow-up and more integrated training programmes are not yet commonplace.

Workshop Design and Implementation
Two four-hour workshops were held in Muscat, Oman, in March 2014.The first was titled 'Resident-as-health advocate' and included 148 medical residents in their fourth and fifth years of training.Similarly, a parallel 'Teaching and evaluating health advocacy' workshop was conducted involving 57 instructors.The workshops took place in a single morning or afternoon session.The materials for both workshops were distributed in printed format with links to websites and articles for further reading.
The workshops were led by two physicians.The first was an emergency medicine physician with a postgraduate doctoral degree in medical education who also served as a resource consultant for healthcare regulation and medical education issues in Oman.The other was an emergency physician who had advocated for injury control over the past 30 years and taught advocacy methodology and skills to students at the University of Alberta, Edmonton, Alberta, Canada.In addition, the latter physician was an international consultant and speaker on topics relating to safety culture, injury and wellness.

Basic components of advocacy
During the 'Resident-as-health advocate' workshop, a significant amount of time was devoted to establishing a common framework and language for advocacy work.Participants were provided with definitions and examples of advocacy.During the workshop itself, participants were given the opportunity to brainstorm different ways physicians could act as advocates.The CanMEDS competencies for the health advocate role provided the main backbone for outlining what is expected and included within health advocacy. 2These competencies were provided in printed format for the participants and reviewed during the workshop.
The next topic introduced was social determinants of health.Understanding and identifying these determinants is critical to health advocacy work.As such, a significant proportion of the workshop was spent solidifying these concepts using printed handouts, illustrative examples and discussions.The examples focused on diseases of particular relevance to Oman, especially chronic diseases and injury prevention, so that participants would learn to look beyond the immediate contributors of ill health and bring abstract concepts to life. 8n particular, one powerful exercise describing two different heart attack case studies gave participants the chance to reflect on how subtle differences in socioeconomic factors and access to healthcare resources can bring about radically different outcomes for patients who otherwise share similar physiological and demographic characteristics.

Advocacy spectrum
Following this, the participants were introduced to the many ways in which advocacy can be integrated into medical practice at the individual, institutional, community and societal/governmental levels, with examples discussed for each level.By presenting advocacy on a spectrum, participants were encouraged to make the connection between their work with patients and the broader context of issues facing their community.It also solidified the notion that not all physicians need to be community leaders or high-profile advocates.Instead, it gave equal importance to the many different styles of advocacy that exist.In addition, the spectrum exercise exposed participants to differing outlets for advocacy that might be more appropriate to the setting of Oman.In particular, there may be perceived or actual barriers to more outwardly active forms of advocacy due to the country's unique political and societal circumstances.Many Omani physicians may not feel comfortable taking a public advocacy role, especially with regards to controversial issues or projects that challenge certain societal norms.Such advocacy projects therefore require careful planning and implementation in order to mediate a conducive atmosphere for advocacy and change.

A step-by-step approach
The final exercise in the workshop involved developing an advocacy project.Using a step-by-step approach adapted from the Canadian Public Health Association Guide to Advocacy, participants went through the processes of recognising problems, developing position statements/goals, identifying opportunities/risks, mapping stakeholders, choosing an advocacy approach, developing key messages, creating an action plan and evaluating the project. 9The benefit of such a step-by-step approach means that large complicated tasks become easier to understand, particularly for novice advocates.
Participants were divided into small groups to discuss a health problem relevant to Oman, such as enforcing child car seats, substance misuse in schoolaged children, childcare facilities at workplaces or sports injuries among young athletes.They were then given approximately one hour to collaborate and create a hypothetical advocacy project using a step-by-step guide and special advocacy worksheet.Subsequently, each group presented their ideas to the rest of the participants, giving them the opportunity to practise their presentation and communication skills.The workshop then concluded with a review of the materials discussed, answering any questions and a brainstorming session to explore future directions and opportunities for participants to integrate advocacy skills into practice.

i n s t r u c t o r w o r k s h o p
The parallel workshop for instructors was tailored specifically to staff and teachers.It aimed to demonstrate how the role of health advocate could be integrated into a curriculum and how this role should be taught and evaluated.The structure of the workshop was similar to that given to the medical residents in that it began by providing basic information regarding advocacy and social determinants of health, as well as guidance on how to run an advocacy project.Thereafter, the Can-MEDS health advocate competencies were explored in more detail, with discussions on how to teach and evaluate each one. 2Various examples of successes in advocacy training at other medical schools and residency programmes were also highlighted.[3]

Workshop Feedback
All participants completed anonymous written evaluation forms immediately following the workshops.Information from these evaluation forms were used to improve teaching methods and materials for future workshops.They also provided some early insights into how advocacy teaching was perceived by the participants.For most participants, the workshops constituted their first exposure to the concept of health advocacy.A total of 93% and 89% of the medical residents and instructors, respectively, felt that the workshop met their expectations.Both the medical residents and teachers also felt that the workshop met the stated objectives (94% and 98%, respectively) and was relevant to their educational needs (93% and 91%, respectively).
In the comments section of the evaluation form, participants of both workshops shared an appreciation for the importance of advocacy work in medicine, with many listing possible advocacy issues to tackle in the future.Some participants also reported a strong sense of duty to become better advocates for their communities and patients.An informal follow-up within a month of the workshops indicated that two participants had taken on their own advocacy projects.In the first case, a faculty member had initiated a mobile phone-free driving campaign.In the second case, a medical resident had encountered a patient with suspected carbon monoxide poisoning due to poor ventilation in an industrial kitchen; the resident had then used skills and knowledge gained from the workshop to write a letter to the appropriate authorities to try to improve working conditions at this location.

Discussion
1][12][13][14] At the University of Toronto, Ontario, Canada, emergency medicine staff conduct an annual Health Advocacy Day, bringing in guest speakers and conducting training sessions. 10Medical students at the University of Alberta can participate in a one-to-one longitudinal mentorship programme with a local leader in health advocacy. 12everal residency programmes in North America now also include a mandatory advocacy project to be completed during training as well as fellowship training programmes for physician advocacy. 11he advocacy workshops described in this article utilised a novel teaching approach specifically tailored to learners and teachers in Oman.However, it is important to distinguish between advocacy workshops and an actual advocacy curriculum.This workshop provided a basic set of tools for learning advocacy; nevertheless, ongoing opportunities are required for advocacy practice and reflection to be integrated within residency programmes.The authors therefore hope that these workshops will be the springboard for such a curriculum in Oman.The eventual goal is that Oman will develop a self-led and sustained advocacy programme that reflects and is relevant to the unique cultural and political climate of the country [Table 1].
Teaching the fundamentals of advocacy over the course of a four-hour workshop was an ambitious project.While some participants had previous experience with this topic, many did not.This variability in exposure also created challenges in ensuring that the workshop was engaging and useful to all participants.Additionally, while single-day workshops were logistically easier to organise, they are not an ideal format for effective learning.A series of shorter lectures or sessions separated by several weeks might allow participants time and space to process the information and integrate skills into practice.Moreover, previous research supports the notion that it is better to introduce key issues like social determinants of health prior to residency training. 15elkowitz et al. highlighted promising results from a longitudinal advocacy training intervention whereby medical students were given opportunities to partner with community agencies and put their advocacy skills into practice; this approach was associated with greater acquisition of advocacy skills and knowledge compared to students who did not participate in the intervention. 16 the current project, it was vital to ensure that the workshops reflected the needs and realities of Omani society.During the course of the workshops, it became clear that many of the North American constructs surrounding the role of health advocate did not easily translate to the Omani cultural setting.Although the workshops were designed and led by both Canadian and Omani physicians, most of the research and information used was from North American sources due to the lack of literature showcasing advocacy training from a Middle Eastern perspective.The researchers attempted to overcome this limitation by creating examples and engineering discussions relevant to issues within Oman.However, there were still major gaps in ensuring that the workshop was relevant and accessible to all participants.Nevertheless, as Omani faculty members are trained to teach and evaluate advocacy, it is hoped that they will be able to adapt the materials and concepts to better fit the needs of the community.Learning to adjust to unique setting-specific factors is pivotal to the success of an advocacy programme.
This unique cross-cultural teaching experience provided an opportunity to reflect on how advocacy is a culturally-bound skill that means different things in various social settings.In addition, the workshops reinforced the idea that advocacy cannot be taught in rigid or overly prescriptive ways.Instead, the role of a health advocate needs to be flexible and responsive to individual physicians or learners, the communities in which they work and the advocacy issues they face.Finally, advocacy training cannot be limited to a single workshop or printed handout.The most meaningful forms of learning advocacy occur outside the classroom, over time and practice. 17n retrospect, it would have been valuable to conduct a validated survey of participants with a prepost design to assess changes in advocacy-related attitudes, knowledge and skills after the workshops.The workshop evaluation forms focused on gathering useful feedback for improvement rather than a rigorous or quantifiable assessment of learning impact.Furthermore, the long-term effect and retention of the workshop materials was not measured.While informal reports of two participants taking on advocacy projects after the workshop are promising, such findings are anecdotal and further research is required to identify correlations between workshop sessions and measureable changes in advocacy-related attitudes, knowledge and skills.

Conclusion
This article describes the development and evaluation of two advocacy workshops for medical residents and • Health advocacy is one of the core roles of a physician and training in advocacy skills should be formally integrated across all levels of the medical curriculum.
• Social determinants of health form the backbone of effective health advocacy.
• Students should be given the opportunity to explore the wide spectrum of advocacy work, from the individual to community/governmental levels.
• Teachers and staff physicians should be prepared to model, explore and evaluate many forms of advocacy with medical trainees.
• Advocacy encompasses a wide range of skills and practices shaped by the cultural and political context in which they are employed.Related training should therefore take into account the unique social, cultural and political characteristics of Oman.

Teaching the Role of Health Advocate
Reflections on two cross-cultural collaborative advocacy workshops for medical trainees and instructors in Oman e290 | SQU Medical Journal, August 2018, Volume 18, Issue 3 instructors in Oman.This was the first formal approach to advocacy training of its kind in Oman and the experience of designing and presenting the workshops highlights opportunities and challenges to teaching health advocacy in Oman.Medical educators must continue to push for innovative curricula that provide the framework for integrating these skills into all levels of medical training.Dr Jessica Breton declares no conflicts of interest.Dr Louis H. Francescutti received an honorarium from the OMSB to develop and teach the advocacy workshops described in this article and to cover travel and accommodation expenses.Dr Yousef Al-Weshahi was working as a part-time visiting faculty member for the OMSB and also received an honorarium for leading the workshops.

Table 1 :
Practice points for health advocacy training in Oman