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1. Advancing knowledge
Bruce Maycock, Peter Howat, Terry Slevin
A decision-making model
for health promotion advocacy:
the case for advocacy of drunk
driving control measures*
This paper presents a decision-making model which can help public health professionals justify
their decision to advocate for a particular intervention. The model is demonstrated by a case
study related to advocacy of Random Breath Testing (RB1). For the purpose of this paper
advocacy is a "catch-all word for the set of skills used to create a shift in public opinion and
mobilise the necessary resources and forces to support an issue, policy, or constituency..."
(Wallack, Dorfman, Jernigan & Themba, 1994).
I In recent years, advocacy has become
recognised as a legitimate role of public
health practitioners in Australia. Indeed,
advocacy has become an expected
activity of health promotion
professionals (Howat, Maycock, Jackson
et al, 2000; Shilton, Howat, James, Lower
and Jeffery, 2000). Their advocacy role
was confirmed by the Ottawa Charter in
1986 (WHO, 1986), and more recently
reaffirmed by the Jakarta Declaration in
1997 (WHO, 1997). There are many
examples where such advocacy has
contributed to environmental and
legislative changes. These include issues
related to tobacco; alcohol; road safety;
swimming pool fencing; firearms;
nutrition; occupational safety and health;
and electronic gambling (Howat, Sleet
and Smith, 1991; Howat, O'Connor and
Slinger 1992; Productivity Commission,
1998; Productivity Commission, 1999).
Initiative for this advocacy has come
from a variety of sources with local
action groups, professional associations
and non-government agencies leading the
way. Increasing numbers of the
individuals who instigate the advocacy
on behalf of these organisations are
trained public health professionals.
These individuals have to justify the
promotion of a policy or measure and
are often faced with a dilemma of when it
is appropriate to undertake an advocacy
campaign. Not only is advocacy often a
time consuming and therefore potentially
costly activity, it also can enhance or
damage the reputation of the
organisation, the public health profession
and of those who undertake it (Becker
1993; Carey, Chapman and Gaffney 1994;
Engs 1991; Hawe and Shiell, 1995; Holder
and Treno,1997). Actions involving
community mobilisation, lobbying
politicians and other opinion leaders,
and gaining media coverage of an issue
inevitably involve the time, resources
and goodwill of many other people. It is
therefore wise to ensure there is a strong
case for advocating for the selected
environmental or legislative change.
Decision-making models
·. There is substantial literature that
provides guidelines for identifying
priorities for public health, and for the
introduction of measures that are likely
to benefit the health of communities
(Australian Institute of Health and
Welfare, 2000; Green and Kreuter, 1999;
Hawe, Degeling and Hall, 1990). Further,
there are numerous decision-making and
planning models that can be applied to
specific public health scenarios
(McLeory, Bibeau, Steckler and Glanz, 1
1988; van Beurden, 1995; Viney, 1996;
'"The term used in Australia is drink driving, however due to the common use of drunk driving or drinking and driving in
international settings the term has been rnodified.
IUHPE- PROMOTION & EDUCATION VOL Vlll/2. 2001
WHO, 1986). However, there is a paucity
of literature that guides public health
advocates as to when to undertake an
advocacy campaign for a specific issue
(Chapman and Lupton, 1994; Wallack,
Dorfman, Jernigan, and Themba, 1994).
Attempts to produce decision-making
models have been met with varying
effect. Some have been so complex that
their utility is severely compromised
while others have approached the
decision-making process from a limited
perspective (Viney 1996).
Decision-making in public health is a
complex and dynamic process, that is
influenced by science, epidemiology,
social, cultural, economic and political
factors. The experienced advocacy
campaigner usually has a set of criteria to
weigh up the pros and cons of
advocating for specific public health
measures. However, for the uninitiated
Bruce Maycock PhD, Seriiorlecturer;
Peter Howat PhD, Associate Professor;
·.Western Australian .. Centre .for····Health .•.
Promotion ·Research, Curtin>University, ｾ＠
·Perth, Western Australia, GPO Box 01987, 1
WA 6845. ·• .. •. .. i< < ,
Jerry Slevin, MPH, Senior Manager,
Education and Research, Cancer
Foundation of Western Australia.
Correspondence to Bruce Maycock,
•••b.maycock@curtin.edu.au
59!

2. this can be a daunting task. Hence, it is
useful to have some guidelines that can
provide a virtual checklist of steps to
follow when forced to make a decision
about whether a measure is worthy of
support. The PABCAR model was
designed to support this process.
PABCAR model
The PABCAR model described in this
paper evolved from the practice of health
promotion professionals in Australia.
The model was developed through
observation of decision-making in public
health settings, interviews with public
health practitioners, and the application
of the model by the authors (Maycock,
Howat and Martin 1996). Since that time
the model has continued to be refined
and used in Public Health decision-
making. It has proven to be useful for
those new to the field of Public Health or
those who have not been involved in the
development of new policy, health
interventions or advocacy activities.
The PABCAR model requires the
practitioners to answer five questions:
1. What is the problem and is it
significant?
2. Is it amenable to change?
3. Are the intervention benefits greater
than costs?
4. Is there acceptance for the
interventions?
5. What actions are recommended?
Under each of these questions the model
'directs the practitioner to collect or
examine a range of data (see Figure 1).
The first stage of the PABCAR model
requires the clear identification of the
problem and its significance to the
community. This includes a clear
description of how the problem
manifests within the community, the
incidence of the problem, information
about the target groupjs (number of
people affected and the social context of
the problem) and the cost of the problem
to the community. Integral to the
problem identification is the gathering of
the community's perceptions regarding '·
the problem and the identification of
how it impacts upon their lives.
The next step in the PABCAR Model is to
assess if the problem is amenable to
change. This step requires a review of
literature to ascertain the effects of
measures introduced in other
communities. It the data indicates that
the problem is amenable to change then
the practitioner moves to the next step.
However, if there is little evidence of
changeability, the option is to
discontinue or to carry out research to
find ways to increase the changeability.
In the third stage, the practitioner assess
the benefits and costs of implementing
the interventionjs. This includes the
impact upon the target group and the
community, ethical considerations
associated with the intervention, the
economic costs and the efficacy of the
interventions. Public health practitioners
can influence a nation's health culture
through legislation, education and
environmental changes. Over time, it
appears community standards evolve
that relate to a level at which people feel
public health decisions are justified.
These standards are not fixed and the
public health practitioner has to be
aware of them. The PABCAR Model
recognises this potential and requires
practitioners to consider the range of
social consequences, which may result
from the implementation of the change.
When considering the social impact of
interventions, the practitioner would
examine issues such as potential
unintended consequences of the
intervention and potential changes to
social structures and processes. The
ethical consequences of implementing or
not implementing the interventions are
also considered. The ethical conflict
often present in public health decisions
can be summarised as a dichotomy
between the paternalistic perspective
which could include beneficence and the
principle of respect for autonomy
(Caiman and Downes 1997; Yeo, 1993).
Beneficence refers to the prevention of
harm while autonomy relates to the
rights of the individual. The ethical
:Figure 1,
Public Health Decision Making Model (Maycock, Howat and Martin, 1996)
1. What is the problem
and is it significant?
Identification of the problem.
and target group
Epidemiology
Cost to the community
Community perceptions
Yes
Unknown
No
2. Is it amenable to change?
Develop interventions and
outcome based objectives:
Policy
Education
Environmental
3. Are the interventions benefits
greater than costs?
Assess the interventions
social impact
ethics
economic costs
efficacy
IUHPE- PROMOTION & EDUCATION VOL Vlll/2. 2001

3. Advancing knowledge
dilemma is between the rights of the
individual versus the needs of the
population in general. Generally this
implies that individuals have the right to
free choice of action, so long as they
bring no harm to others. The difficulty
comes in defining harm to others and
deciding what is acceptable. While both
are concerned with maximizing utility
(maximizing the total benefits for the
populations involved), they may
consider the issue from differing
perspectives and place different
emphasis upon criteria.
In public health there exists a
precedence and mandate for the
community to be protected from
behaviour that may cause harm to either
the individual or others. In curative
health the principles of beneficence and
autonomy are less likely to come into
conflict due to the presence of illness.
However, in public health there may be
no symptoms, the disease may have an
aspect that is self-induced, the solutions
maybe coercive, could involve social
justice strategies that are re-distributive,
and the possibility of disease may be
well off in the future with no absolute
evidence that every individual will be
affected. Indeed there will always be
some that will not develop the illness or
problem. In some cases, the majority of
the population are unlikely to be directly
affected by the public health problem for
4. Is there acceptance for
the interventions?
Pilot interventions
No
C>B
Acceptance by
the target group.
community,
politicians.
industy
ＭＭＭＭｌＭＮＮＮＬＮＬＮｾＱ＠ Discontinue
which the measure is enacted (Gillon,
1990;''Skranbanek, 1990). Proposed
interventions may have different ethical
considerations and need to be weighted
against the size and severity of the
problem. Fundamental to this decision
would be the meaningful engagement of
the target group and those likely to be
affected by the intervention.
Part of the assessment of the benefits
and costs associated with the
interventions needs to include an
economic benefits and costs analysis.
Some of this data would have been
gathered in stages one and two when
examining the costs associated with the
burden of illness or the public health
problem, and the costs of implementing
various interventions and their
associated benefits (Viney, 1996). In this
section the practitioner needs to
consider any other unintended economic
benefits or costs that could result from
the intervention being implemented.
Finally, the efficacy of the interventions
are examined in relation to benefits and
costs. After weighing up the evidence
presented in this stage of the Model, it
should be possible to decide whether
the potential benefits of the advocated
policy or intervention are greater than
costs. If the benefits are greater than the
costs then it is recommended that the
decision making be taken to the next
stage, where an assessment is made of
5. What actions are
recommended?
Advocate for
Implement public
health measure
public health measure
Monitor the problem, evaluate
the interventions and change if required
IUHPE- PROMOTION & EDUCATION VOL Vlll/2. 2001
the level of acceptance or likely
acceptance of the advocated measure.
If the benefits are less than the costs it is
suggested that the proposed advocacy
be discontinued. If the answer is
unclear, then it might be appropriate to
advocate for pilot testing or a trial of the
proposed measure.
The fourth stage of the model examines
the acceptability of the proposed
measure. As Carey, Chapman and
Gaffney (1994) demonstrated in their
review of advocacy and swimming pool
fencing, there needs to be careful
consideration given to the framing of the
argument. Framing refers to the
maximisation of the affirmative and
minimisation of the negative case, for or
against, a particular intervention. In
many public health decisions there will
be those opposed to the implementation
of an intervention. The PABCAR model
requires the public health advocate to
consider the position of these groups or
individuals. These groups could include
the target group, the community,
politicians, and industry representatives.
The PABCAR model assists the public
health advocate to frame their arguments
for the implementation of the
intervention. It provides the practitioner
with the scientific and social evidence
that an intervention is required and that
it will be beneficial to the community.
Further, the constant engagement with
the affected groups provides a
mechanism for them to be included in
the advocacy process.
The final stage of the PABCAR model is
action and monitoring. If there is not a
significant level of acceptance for the
proposed measure then substantial
media and personal advocacy is
recommended. This advocacy should be
targeted towards those blocking the
implementation of the measure, as well
as towards those who support the
intervention to ensure that they continue
to advocate for its implementation.
In addition, ongoing media advocacy
aimed at the general public is
recommended. If there is a significant
level of acceptance then the measure
should be implemented by the
appropriate authorities.
The PABCAR model requires decision-
makers to examine a wide range of data
and consider potential social and ethical
impacts of proposed interventions.

4. Though the model is presented in a
linear format, experienced public health
decision-makers may simultaneously
consider many of these factors. The
model is not meant to be prescriptive,
but rather it is intended to be used as a
decision-making framework.
BRIEF APPLICATIONS
OF THE PABCAR MODEL
The next section illustrates three brief
applications of the PABCAR where the
strength of the advocacy case was strong,
moderate and weak respectively.
Strong evidence for advocacy
Intense advocacy was undertaken during
the 1980's in parts of Australia to
strengthen drunk-driving laws in an
attempt to reduce the significant
contribution of alcohol to traffic fatalities.
Random Breath Testing (RBD in Western
Australia was introduced due to
successful advocacy by a coalition of
community action groups and
professional associations. There was
strong evidence that RBT was a cost-
effective measure that could contribute
to a reduction in alcohol-related crashes.
The benefits were shown to outweigh
costs of the intervention, which was
widely accepted in the community. The
only significant opposition came from
sections of the alcohol industry and
some conservative politicians (Howat,
O'Connor and Slinger, 1992).
Moderate evidence for advocacy
Other measures aimed at reducing traffic
crashes included lowering the legal
drunk-driving limit from .08 to .05% Blood
Alcohol Concentration (BAC). This
measure was advocated nationally as
part of the Federal Government's 'Black
Spot' traffic safety initiative. Whilst most
States and Territories introduced the
measure by 1990, there was reluctance
by the Western Australian Government to
do so. There was also considerable
opposition from the alcohol industry,
which received some support from a
group of State conservative politicians.
The epidemiological evidence in support
of .05% BAC was equivocal and the
evidence of the effectiveness of this
intervention, unlike that for RBT, was not
as compelling (Howat, Sleet and Smith,
1991). However, the coalition of groups
advocating for its introduction were able
_,62
to present a case that eventually
/Convinced sufficient politicians that it
was a useful measure as part of a
comprehensive approach to reducing
alcohol related traffic injuries.
Weak evidence for advocacy
The .05% BAC was seen to be a realistic
compromise to the legal limit of 0% BAC
advocated by some of the 'temperance'
oriented community groups. The
coalition of community groups that
supported .05% BAC had considered the
.0% level, but quickly rejected it on
several grounds. There was little support
from the epidemiological evidence of its
appropriateness, and the majority of the
politicians, the alcohol industry and the
general public regarded it as being
unrealistic (Howat, O'Connor and Slinger,
1992). There is no doubt that advocacy
for a .0% BAC would have been
counterproductive. The credibility of the
individuals and groups involved would
most likely have been tarnished, making
it more difficult for them to get support
for subsequent public health
interventions. Future support by
politicians and the general public in
particular would have been
compromised. The cost of time and
resources needed for a .0% BAC
advocacy campaign would inevitably
have been diverted from other public
health activities. This is an example
where the application of the PABCAR
Model helped thwart inappropriate
public health advocacy.
A CASE STUDY USING THE
PABCAR DECISION MAKING
MODEL TO ASCERTAIN THE
APPROPRIATENESS FOR
ADVOCACY OF RBT
To illustrate the model in detail, the issue
of Random Breath Testing (RBT),
discussed briefly above has been
selected as an example. During the mid-
1980's, the State of New South Wales
enacted legislation to implement RBT as
part of a comprehensive approach to
reducing alcohol related traffic deaths.
In Western Australia, there was strong
opposition to such measures by the hotel
industry, which was supported by
conservative politicians. Although a
'defacto' type of RBT was introduced it
was regarded as ineffectual. Motorists,
who were stopped by police officers
checking on drunk-drivers, were often
not breath tested, and there was little
mass media publicity of the measure.
Hence, there was a very low perception
by drivers that they could be arrested for
drunk-driving.
Consequently a coalition of community
groups (People Against Drink Driving
{PADD}) was formed to lead an advocacy
campaign for the introduction of RBT in
1987. The following is an example of
how the PABCAR Model was used to
ascertain if there was a strong enough
caseforadvocatingfortheintroduction
of legislation supporting RBT in Western
Australia.
Stage 1. What is the problem
and is it significant ?
The public health problem was the
relatively high traffic injury and death
rates attributed to alcohol consumption.
Target groups
Primary target groups- Drunk-drivers
constituted the group that was likely to
be affected most from a measure aimed
to change their drunk-driving behaviour.
Secondary target groups - Members of
the public likely to be injured by drunk-
drivers and the victims' families and
friends were deemed to be the main
beneficiaries of a measure.
Epidemiology
Statistical data showed that over 40% of
all traffic fatalities were associated with
alcohol (Select Committee on Road
Safety, 1994; Kirov, Legge, and Rosman,
2000). The majority of drivers effected by
alcohol were males between the ages of
17 and 39 years with an over-
representation in the 17-20 year age
category (Howat, Sleet and Smith, 1991).
Cost to the community
Each alcohol related traffic crash
imposed substantial costs on the
community in the form of family trauma,
loss in productivity, health costs, and
property damage (Andreassen, 1992)
It was estimated that each person killed
in a road crash incurred a cost in excess
of $700,000, with each hospitalisation for
a non-fatal injury estimated at $125,000
(Andreassen, 1992; Kirov, Legge, and
Rosman, 2000)
Community perceptions
Parts of the community were very
concerned with the issue of drunk-
IUHPE- PROMOTION & EDUCATION VOL Vlll/2. 2001

5. driving. The community groups such as
People Against Drunk-Driving and
Mothers Against Drunk-Driving
represented a community coalition and
supported the effort to increase drinking
and driving control measures.
Stage 2. Is the problem
amenable to change?
There was evidence to indicate that
alcohol-related traffic injuries had been
reduced where interventions such as
Random Breath Testing (RBD had been
introduced (Home!, 1986; Howat, Sleet
and Smith, 1991).
Stage 3. Are intervention
benefits greater than costs?
Social impact
RBT was shown to influence a significant
reduction in road trauma resulting in
intangible savings of grief to family and
friends of potential victims (Home!,
1986). Further, RBT involved minimal
inconvenience to the community and
required no further increase in police
powers.
Ethical impact
The implementation of RBT would result
in a loss of freedom for a minority of
drivers who would be deprived of their
choice to be in charge of a vehicle while
intoxicated. There would be minor
inconvenience to members of the general
community when they were stopped to
be breathalysed. There would be some
loss of freedom by liquor retailers to ply
their product with drivers. On the other
hand, there would be an increase in
freedom of the community as a whole to
be able to drive, cycle or walk on the
roads with less risk of injury or death,
i.e. the society as a whole is the
beneficiary. There appeared to be few
ethical implications of randomly breath
testing drivers.
Economic costs
There were economic costs to the
community especially in the form of
public revenues required to promote
RBT on the media and its policing.
It was anticipated there would be some
down-turn in the bar trade which could
affect employment, and the decline in
alcohol-related traffic injuries could lead
to reduced work for vehicle repairers,
tow truck drivers, undertakers, health
professionals and hospitals.
Advancing knowledge
The benefits included health savings
from' the expected reduction in traffic
crashes. Some revenue could be
collected from traffic fines of drivers who
exceed the legal alcohol limits.
Industry
The alcohol industry and initially the
media who promoted their products,
were vigorous opponents to RBT. The
media soon become a major protagonist
of RBT with editorial comment becoming
increasingly supportive. The alcohol
industry remained as a critic of the
policy. There was undoubtedly a loss for
them with a significant decline in the
sales of alcoholic beverages across the
bar. As well as commercial outlets such
as taverns, hotels and sporting clubs are
also being affected.
Efficacy of the intervention
Evidence from NSW indicated that RBT
was an effective strategy to reduce drunk-
driving injuries. RBT was effective
wherever it was given substantial media
publicity and when enforcement was
implemented to a high level (Home!,
1986; Howat, O'Connor, and Slinger,
1992).
In the case of RBT, there was sufficient
clear evidence that benefits to the
community would likely outweigh the
costs.
Stage 4. Is there acceptance for
the interventions?
For the RBT case study there was strong
support from the target group, the
general community, and many politicians
for the introduction of the measure
(Howat, O'Connor and Slinger, 1992).
Target group
Increasing numbers of the target groups,
as indicated through the results of
community polls, supported the proposal
for the introduction of RBT (Howat,
O'Connor and Slinger, 1992). However,
some drivers, especially those with
drinking problems remained antagonists
of RBT.
Community
There was increased readiness of the
community to accept the intervention.
The media had saturated the community
with information about alcohol and road
safety. This made such a significant
impact on the drunk-driving attitudes of
Western Australians that by the mid-
1980's the WA community was receptive
to interventions like RBT (Howat,
O'Connor and Slinger 1992; Kirov, Legge,
and Rosman, 2000).
Politicians
Politicians tend to follow the feelings of
the community rather than lead when it
comes to health-related policy. With
regard to this issue and many others,
politicians appear to initially operate from
the ethical principle of respect for
autonomy that is the belief that
individuals are responsible for their own
health and safety. One implication of this
perspective is that it results in less service
provision. This required a re-framing of
the issues as politicians raised concerns
and as they responded to concerns raised
by the alcohol industry. For example, the
industry criticised the measure on the
grounds that it infringed on individuals'
rights and freedoms. Drivers, they
claimed, would be denied their rights and
freedoms to attend social functions and
partake in alcoholic beverages, which was
central to them having a good time.
By re-framing the argument public health
advocates were able to say that the
introduction of the measures would
contribute to the freedom of families to
travel on the roads without the great risk
of being injured by a drunk driver. As the
community mood changed with
increasing disapproval of drunk driving,
politicians became increasingly receptive
to supporting RBT (and this happened
again later with the lowering of the legal
BAC from .08 to .05%). Politicians also like
to be seen to be associated with 'popular
causes', and hence being aligned with pro-
RBT was probably eventually regarded as
a political gain.
Stage 5. What actions are
recommended?
In the case of RBT in Western Australia,
there was very strong community
support for the measure. People in WA
had become aware of the major role
alcohol played in traffic deaths, and
understood that evidence in other parts
of the country supported it as an
effective way to reduce the drunk-driving
problem. The majority of State Members
of Parliament were also made aware of
the efficacy of RBT, along with the
publics' opinion on the issue.
Consequently, the WA Government
eventually introduced legislation
IUHPE- PROMOTION & EDUCATION VOL Vlll/2. 2001

6. whereby RBT became a part of a
comprehensive approach to dealing with
alcohol related traffic crashes. The
coalition of groups supporting the
introduction of RBT in WA was therefore
effective in their advocacy. Based on the
evidence outlined above, their decision
to advocate for RBT was well founded,
and supported by the PABCAR decision
making process. The Government's
decision to support the introduction of
the measure was similarly based on
sound evidence.
CONCLUSIONS
Besides use with these alcohol issues,
the PABCAR Model has been developed
through the authors' experiences with
many other public health advocacy
issues during the last two decades and
has been presented to public health
professionals for modification and
comment (Maycock, Howat, and Martin,
1996). Unlike some other 'decision-
making models' it is relatively simple and
straightforward to use. A value of the
model is that it provides a logical and
systematic process to determine whether
a public health issue is worthy of
advocacy efforts. Its use should help
minimise the criticism that can result
from advocating for measures that are
inappropriate.
The PABCAR Model leads the advocate
through a series of questions and steps,
which requires consideration of the
problem from a broad perspective.
It assists advocates in the framing of
their arguments and in anticipating the
framing of the arguments of opposition
groups. Importantly, it helps ensure that
public health professionals have
considered relevant evidence prior to
advocating for measures and that they
have engaged with and involved those
likely to be affected by the problem
and the solution.
The evidence presented here shows
unequivocally that there was a strong
case for mounting an advocacy campaign
in support of the introduction of RBT.
On the other hand, the case for the
introduction of the .05%BAC legal limit
was less compelling and the case for
.00%BAC was very weak. The Model
provided useful guidelines that led, in
our opinion, to appropriate decisions
about which of the drunk driving control
measures to advocate for.
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