Adolescent Medicine Physicians As Reproductive Health Advocates

A Dissertation Presented to the Faculty of The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.

Adolescent reproductive health (ARH) policies often impact the practice of adolescent medicine.  Examples of such policies include parental notification for abortion and over-the-counter access to emergency contraception.  In the U.S., ARH is intensely political, and ARH policy decisions often are driven as much by political agendas as by medical and public health evidence.  This particularly was the case under President Bush (2000-2008). However, President Obama recently encouraged a shift in practice through a memorandum to Executive agencies calling for science as opposed to politics to guide public policy.  Adolescent medicine physicians are experts in the health issues at stake in ARH policy, and they have regular contact with the teenagers whom those policies most directly impact.  Yet little is known about the extent to which these physicians may act as policy advocates and/or have a voice in ARH policy.  Additionally, there is no consensus definition for physician advocacy to guide such inquiry.

This mixed methods research explores the ways in which adolescent medicine physicians define professional advocacy for ARH. Additionally, it reflects on how a wider array of potential advocacy activities relate to ARH policy.  The primary research questions are, “How do adolescent medicine physicians define physician advocacy, and in what contexts do they report acting as advocates for adolescent reproductive health?” 

Two theories guide this research—Richmond and Kotelchuck’s theory for influencing health policy and Palfrey’s theory for child health advocacy.  Richmond and Kotelchuk present factors to which advocates must attend in order to affect health policy.  Palfrey’s theory is based on Richmond and Kotelchuk’s work and formed the basis for the interview guide in the qualitative study.  According to Palfrey, activities constituting physician advocacy include formal legislative advocacy activities such as lobbying and individual advocacy activities on behalf of specific patients, yet advocacy also extends beyond those two categories.

The qualitative study included thirty-nine in-depth interviews with adolescent medicine physicians and fellows-in-training. The quantitative study was a survey with 273 board-certified adolescent medicine physicians in the U.S. (response rate 52%); the survey was developed, in part, based on results of the qualitative study.  Both the interviews and the survey included questions related to the conceptualization of physician advocacy, participation in a variety of potential advocacy activities, role of advocacy in ARH, barriers to advocacy, self-identification as an advocate, and ARH advocacy priorities, e.g., abortion, emergency contraception.  The survey also included the presentation of four ARH policy scenarios related to over-the-counter access to emergency contraception, refusal of federal funds for abstinence-only education, statewide legislation strengthening parental notification for minors seeking abortion, and policies for parental consent for adolescents receiving oral contraceptive pills.

All physicians cited a need for advocacy within adolescent medicine despite significant barriers such as time, lack of advocacy training, lack of an organizing presence for adolescent-focused advocacy, and financial disincentives to advocate. Physicians look to professional organizations for training in advocacy as well as opportunities to advocate, yet they also described ways in which those organizations are falling short of their expectations. Participants' advocacy priorities ranged from seeking healthcare coverage and insurance reforms, to implementing policies fostering increased access to emergency contraception and abortion, to re-envisioning the ways teenagers are viewed in the public sphere.

Data from both research activities contributed to the development of a new model that details characteristics of physician advocacy. The model specifies goals of advocacy as well as the special role of physician as advocate. It also identifies a broader array of activities as advocacy, e.g., research, committee work, than are usually found in existing, legislative-focused models. Applying this new model to the activities of physician participants revealed that although physicians are extensively engaged in activities related to adolescent medicine and ARH, they do not necessarily identify these efforts as advocacy. For example, they most often participate in activities individually rather than joining coordinated advocacy efforts. Also, they are most involved on the community level rather than on statewide or national levels. Thus their advocacy falls under the radar both within their professional communities and in policy analysis research.

The new model for physician advocacy for ARH presented here expands the theoretical discourse regarding physician advocacy. In addition, this work has implications for public policy. If health policy decisions increasingly are guided by scientific evidence, as indicated by the new administration, then physicians as scientific experts should play a greater role in the policy arena. Physicians who labeled their individual patient and community-level work as advocacy were more inclined to do advocacy work on more macro levels. The expanded definition of physician advocacy created by this research may help physicians recognize that they already are acting as advocates and thus may make them more likely to continue this important work. Additionally, the results of this research regarding barriers to advocacy and ARH priorities may help groups that organize advocacy efforts (e.g., professional medical groups) to better respond to the advocacy needs and priorities of their member physicians. These results illustrate the possibility for physician advocacy for ARH to become more organized and focused, and thus potentially more effective and relevant in guiding future policies.