Health advocacy training in undergraduate medical education over 20 years: A scoping review

INTRODUCTION: Health advocacy is recognised globally as a core physician competency yet remains one of the most challenging domains to teach, assess, and evaluate. Despite regulatory emphasis, integration into undergraduate medical curricula is inconsistent and poorly aligned with professional frameworks. This review maps and critically analyses how health advocacy has been conceptualised, implemented, and assessed in undergraduate medical education over the past two decades. METHODS: A scoping review following Arksey and O'Malley's framework and PRISMA-ScR guidelines was undertaken, incorporating critical interpretive synthesis to move beyond description towards theory development. Thirty-two studies (2003-2025) were identified from EMBASE, PubMed, Scopus, and Web of Science. Carlisle's advocacy domains, CanMEDS competencies, Van Melle's implementation components, and Kirkpatrick's evaluation levels were applied as complementary lenses. RESULTS: Advocacy education was most frequently framed as representation or community development, with limited engagement in community activism or policy reform. Programs were variably integrated, often elective or episodic rather than longitudinal. Implementation gaps were evident: only 56% articulated measurable advocacy competencies, 16% demonstrated sequenced progression, and 22% showed programmatic assessment alignment. Assessment was predominantly faculty-driven, with minimal community feedback and rare measurement of system-level impact. Evaluation focused largely on learner knowledge (Kirkpatrick level 2), with little evidence of behaviour change or structural outcomes. DISCUSSION: Advocacy education has advanced in visibility but remains conceptually under-specified, structurally fragmented, and weakly evaluated. By integrating complementary frameworks, this review identifies where breakdowns occur at the levels of meaning, design, and enactment. Educators should embed advocacy longitudinally, integrate community co-creation, and use assessment approaches that measure behavioural change and social impact. These findings are synthesised into five evidence-informed design principles presented as practice points to guide advocacy curriculum development and evaluation.