‘A drive to make change’ - exploring the views and experiences of medical students engaging in advocacy: a qualitative study in a UK medical school

ABSTRACT Background Advocacy is a recognised competency for medical graduates. Many medical students engage in advocacy, but research on this topic is limited. This study aimed to explore the views and experiences of medical student advocates. Methods Qualitative study using semi-structured interviews. Nine medical students from advocacy organisations were recruited by purposive sampling. Thematic analysis was used to generate codes and develop themes. Results There were five themes: triggers and enablers; barriers and disablers; knowledge, skills, and attributes; advocacy in the role of health professionals, and career aspirations; and teaching and assessment of advocacy. Triggers and enablers included internal drivers (e.g. experiencing injustice), and external drivers (e.g. role models). Obstacles included lack of institutional support, personal challenges, and discomfort around professionalism in advocacy. Student enhanced their knowledge of social issues and improved communication skills. Advocacy activities strongly influenced students’ future plans. Most agreed that advocacy is an important topic in medical education, suggesting teaching it early in medical school via small-group tutorials and role-modelling. For assessment, a reflective approach was preferred over written exams. Conclusion Medical students’ engagement in advocacy has complex facilitators and barriers, and the relationship between advocacy and professionalism requires clarity. Benefits of advocacy include fostering empathy and other transferable skills required of future doctors. Advocacy teaching was welcomed by students, with suggested approaches proposed. The optimal learning and assessment strategy remains uncertain, and further research is needed.


Context
Advocacy is an important component of medicine [1], and has been adopted into standards for doctors, such as the General Medical Council's (GMC) 'Outcomes for Graduates'. There is no universal definition of advocacy but, in this study, the following definition was devised: 'engaging in social actions to raise familiarity with a particular health issue, promoting health and access to quality health care and services, as well as gaining political support for a particular health issue'. Examples of student advocacy activities include holding committee positions on advocacy societies, participating in protests, raising awareness, and holding speaker events for other students.
Despite an abundance of research on the importance of advocacy in healthcare [1][2][3], it is seldom taught in undergraduate medicine [3,4]. The popularity of student societies such as Students for Global Health and Docs not Cops reflects the growing interest in advocacy amongst medical students. As advocacy becomes an increasingly recognised quality amongst doctors, it is important to understand medical students' experience of advocacy.

Project aim
This study aimed to explore the views and experiences of medical students engaged in advocacy activities.

Description
This was a qualitative study using semi-structured interviews. We recruited participants using purposive sampling; English-speaking medical students from a UK medical school were eligible for inclusion if they selfreported taking part in advocacy activities. There was no pre-existing relationship between participants and researcher.
The student researcher (MS) conducted one-on-one interviews following a pre-piloted topic guide on Zoom TM . Informed consent was obtained and the purpose of the study was discussed with the participants. This included an a priori definition of advocacy, which was used to sensitise participants to the aim of discussion.
Nine interviews were recorded, transcribed verbatim, and anonymised. Analysis was done iteratively using thematic analysis [5]. MS developed initial codes which were reviewed and refined with input from the project supervisors (DNB and AEW). Themes were then developed by MS and applied to the data set.
The study was reviewed by the University of Glasgow College of Medical, Veterinary & Life Sciences Ethics Committee.

Outcomes
The participants included 3 men and 6 women, from ethnically diverse backgrounds, who were part of advocacy societies tackling a range of issues. There were five main themes, presented along with illustrative quotes below.

Theme 1: triggers and enablers
Triggers included internal drivers (an intrinsic motivation to make a change, and personal experiences of discrimination and injustice), as well as external drivers (witnessing injustices, strong role models, finding community and support in advocacy networks) which were vital in attracting and retaining student advocates.

Theme 2: barriers and disablers
Lack of institutional support was an important barrier to advocacy, as some activities were considered 'unprofessional' and incompatible with the codes of conduct of medicine. Other disablers of advocacy included confusion and ambiguity surrounding the concept of 'professionalism', fear of clashing with regulatory bodies like the GMC, and personal factors such as limited time.

Theme 3: knowledge, skills, and attributes
Student advocates reported gaining deeper knowledge about social issues and the wider determinants of health, as well as developing skills in communication, leadership, and teamwork. Overall, advocacy was a positive experience for participants, and they felt it shaped them into more rounded and compassionate human beings, essential attributes for future doctors.

Theme 4: advocacy in the medical profession and career aspirations
Most students agreed that advocacy should be part of a medical professional's role. Many participants acknowledged the privilege granted to medical professionals in society, and felt a responsibility to leverage this influence constructively by advocating for issues of social inequality.

Theme 5: teaching and assessment of advocacy
Participants reported receiving limited teaching on advocacy and no assessment of advocacy in their undergraduate curriculum. Most respondents considered advocacy an important topic to teach at medical school, but some were sceptical about incorporating it as an assessed requirement into the curriculum.
Barriers to advocacy teaching identified by participants included prioritisation of clinical teaching above other 'softer skills' like advocacy, politicisation of advocacy, and a lack of time and space in the curriculum, but participants provided suggestions on how advocacy might be introduced and assessed at medical school, summarised in Table 1.

Conclusions
To our knowledge, this is the first study exploring the views and experiences of UK undergraduate medical students engaged in advocacy. The main barriers to medical students engaging in advocacy are similar to those experienced by physicians [6].
There were significant self-reported benefits from participation in advocacy, which could be explored further. There is a strong case for addressing the current lack of advocacy teaching in undergraduate curricula, but the methods for teaching and assessing advocacy require further research. The suggestions put forward by participants (presented in Table 1) provide a helpful starting point. Finally, there is scope to extend this research to other universities to assess transferability and to build a more comprehensive understanding of this subject.

Disclosure statement
No potential conflict of interest was reported by the author(s).