Health advocacy, defined as healthcare professionals’ responsible use of “their expertise and influence to as they work with communities or patient populations to improve health” (Frank et al., 2015, p. 22), is increasingly recognized an integral part of a physician’s professional role and a core competency in residency training. The American Medical Association’s Declaration of Professional Responsibility has outlined health advocacy as one of the nine basic tenets of physicianhood (American Medical Association, 2001), and the Royal College of Physicians and Surgeons of Canada has officially adopted a physician competency framework that includes “health advocate” as one of seven essential physician roles to be emphasized in medical specialty training (Frank et al., 2015).

With the increasingly acknowledged importance of teaching health advocacy, researchers in medical education have started to examine advocacy attitudes, competencies, and participation in resident physicians (Verma et al., 2005; Leveridge et al., 2007; Stafford et al., 2010; Bachofer et al., 2011; Chamberlain et al., 2013; Long et al., 2014; Shepard et al., 2015; DeCesare and Jackson, 2016). However, there is, to our knowledge, no published data to date examining these attributes in psychiatric residents. This represents a gap in the current state of medical education knowledge and practice, especially given the significant societal and economic toll of mental illness worldwide. These factors speak to an ongoing need to train more psychiatrists and other healthcare professionals in health advocacy. The current study seeks to evaluate health advocacy attitudes, competencies, and participation in psychiatric resident physicians.

Participants and procedures

Participants were resident physicians from one US adult psychiatry residency program. There were 16 residents in the PGY-1, PGY-3, and PGY-4 classes and 17 residents in the PGY-2 class, comprising a total of 65 residents in the entire program who were eligible for the study. They were recruited through residency-wide emails, inviting them to respond to a confidential survey on psychiatry residents’ attitudes towards and competencies in health advocacy. Information on each resident’s postgraduate year of training was recorded, but in order to preserve confidentiality for the participants, who were providing quality improvement feedback to their residency program, no further demographic information was obtained. This project was undertaken as a quality improvement initiative within a hospital-based residency program, and, as such, the Institutional Review Board declined to review it as per hospital policy.

Measures

The Resident Physician Health Advocacy Questionnaire (R-PHAQ) is a 13-item, self-report measure designed to assess health advocacy attitudes and competencies in resident physicians. It was adapted from the Health Advocacy Questionnaire, a self-report tool for internists developed and validated by Stafford et al. (2010). Items 1-12 of the R-PHAQ are displayed in Table 1. The first 8 items are statements scored on a 5-point Likert scale (ranging from 1=strongly disagree to 5=strongly agree). Thematically, items 1-5 were intended to assess health advocacy competencies, and items 6-8 were intended to assess health advocacy attitudes. Items 9, 11, and 12 are multiple-choice items with “yes/no/unsure or undecided” responses assessing actual or planned participation in advocacy across time. Item 10 elaborates on when previous participation in advocacy occurred and asks respondents to “select all that apply.” Finally, Item 13 is a free-text area for additional comments (not shown in Table 1). Before it was administered to residents, this survey was validated for content by an expert in medical education and an expert in health advocacy, who recommended no additional changes.

Data analysis

Survey responses on the Likert scale were dichotomized as “disagree” (1 through 3) and “agree” (4 and 5) for purposes of statistical analysis, since not all items followed a normal distribution. Percentages were then calculated for these dichotomized responses. For items 9, 11, and 12, responses were also dichotomized into “yes” (yes) and “no” (no/unsure or undecided). Fisher’s exact tests were used to examine the association between advocacy attitudes and competencies (survey items 1-8) and previous, current, and planned future participation in advocacy. To assess whether dichotomization of the Likert scale responses into “disagree” (1 through 3) and “agree” (4 and 5), instead of separating 3 as a neutral value, had an impact on results, Fisher’s exact tests were also performed on responses dichotomized as “disagree” (1 and 2) and “agree” (3 through 5). Since this alternate method of dichotomization did not meaningfully impact the results, the original method of dichotomization was retained in the final analysis. The level of statistical significance was initially set to 0.05 (two-tailed) for all analyses. After a Bonferroni correction was made for the presence of multiple comparisons in a small sample, the final level of statistical significance was set to 0.002 (0.05/24 total hypotheses tested). Analyses were conducted using Stata/IC 14.2 statistical software (Stata, College Station, TX).

The R-PHAQ questionnaire was completed by 32 out of 65 residents in the four classes, for a response rate of 49%. There were 6 (19%) respondents from the PGY-1 class, 9 (28%) from the PGY-2 and PGY-4 classes, and 8 (25%) from the PGY-3 class.

Table 1 provides the characteristics of respondents, including postgraduate year of training, n (%) of respondents who expressed agreement with the Likert-scale items; n (%) of respondents who answered “yes” to questions about past, current, or planned future participation in advocacy; and when past participation in advocacy (if any) occurred.

In the statistical analysis examining the associations between advocacy attitudes and competencies and previous, current, and planned future participation in advocacy, endorsement of advocacy as an important part of one’s professional identity had a significant association with planned future participation in advocacy (38% vs. 9%, p < 0.001). No other associations reached statistical significance.

Nevertheless, several notable findings emerged from our survey that accord with the existing literature. These include that 1) training and competency in advocacy lags behind positive attitudes towards and professional identification with advocacy; 2) participation in advocacy drops off during residency; and 3) the perceived importance of advocacy is strongly associated with planned future participation in advocacy. Taken together, these data suggest that residents are interested in learning more about and participating in advocacy, and that curricula geared towards fostering a positive perception of advocacy may help in producing future advocates.