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Advocating for Children's Health at the State Level
Lessons Learned
Mary E. Aitken, MD, MPH;
Leigh Ann Rowlands, MPA;
J. Gary Wheeler, MD
Arch Pediatr Adolesc Med. 2001;155:877-880.
ABSTRACT
This article documents the successful creation and promotion of a bill
to fund a nurse home visitation program for high-risk mothers in Arkansas.
It illustrates several key factors in successful advocacy by pediatricians
working in an academic setting: a realistic time commitment; a community needs
assessment, data assimilation, and review of existing resources; the identification
and incorporation of stakeholders; a narrow focus on the area of greatest
need; the backing of political partners; and favorable opportunities to advance
child health issues.
INTRODUCTION
Since the beginnings of pediatrics as a distinct discipline within medicine,
advocacy has been an integral part of the profession. Recently, increased
advocacy has been encouraged by the American Academy of Pediatrics (AAP) through
its Department of Government Liaison and Division of State Government and
Chapter Affairs, its Web sites, and recent advocacy seminars and special articles.1, 2, 3
Academic departments of pediatrics have not commonly been centers of
state advocacy, with few activities originating from community pediatric leaders.
The following case study will provide an example of how an academic pediatric
program successfully advocated for the establishment of a well studied program
targeting at-risk children in the area of violence prevention and parenting
(Figure 1). This was accomplished
during a 1-year period with state AAP and state health official collaboration
and close adherence to fundamental principles of advocacy. Suggestions for
the initiation of similar projects in other communities will be proposed,
and lessons learned from this experience will be discussed.
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Figure 1. Steps to creation of a nurse home
visitation program in Arkansas.
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BACKGROUND
In 1997, the Department of Pediatrics of the University of Arkansas
for Medical Sciences, Little Rock, established a Center for Health Promotion
to advance the health of the children of Arkansas through program development,
education, and community outreach. This activity was developed in response
to a myriad of public health problems affecting children in Arkansas, including
high teenage pregnancy rates and increased rates of injury, obesity, hypertension,
school dropouts, gang violence, and overall poor health status. The center
was established using state funds and supported 2 part-time faculty and a
full-time coordinator. The faculty-level codirectors had worked in tobacco
use prevention and injury epidemiology and had established relationships with
the public health community. Under the direction of the department chair and
as a natural outgrowth of long-standing work by the department in pediatric
injury, the center undertook an in-depth review of child abuse and juvenile
violence.
As a starting point, a community needs assessment was formally undertaken.
The center set up a series of meetings with community organizations, political
groups, and health professionals. These were well attended, and there was
a general enthusiasm on the part of those involved to share ideas and experiences.
These meetings served as opportunities for learning more about available prevention
resources and to find service niches that needed to be filled. Groups invited
included local and state government, educational, faith-based, advocacy, and
nonprofit groups interested in children's welfare. One of these early meetings
was with members of the governor's staff, specifically his liaisons on health
and education. The purpose was to get to know the staff members and to offer
the Center for Health Promotion as an information resource on child health
issues. This early, agenda-less meeting laid the groundwork for later cooperation.
In all these meetings, the center explicitly promoted using evidence-based
knowledge, with a strong evaluation component to any intervention undertaken.
It was made clear that the center was not the beneficiary of the program but
simply sought to facilitate change.
A next step was to review and update the center's database using the
literature on child abuse and juvenile justice. This was done by review of
MEDLINE, Cochrane reviews, and other electronic resources, as well as personal
contact and consultation with experts in the field. Among the foci of the
review were models of child development explaining juvenile violence and interventions
to prevent violence. In addition, the center used local public health statistics
and programmatic histories on which to formulate local ideas for local intervention.
During the review process, the nurse home visitation model, developed
by Olds and colleagues,4, 5, 6
was identified as a rigorously studied intervention with evidence of effectiveness
in modifying important risk factors for the development of delinquency and
violent behavior. Subject families demonstrated reduced child abuse and arrest
rates and improved socioeconomic status in short-term and long-term follow-up.
Olds visited Little Rock for public presentations shortly after the publication
of the 15-year follow-up5 of his group's intervention
studies, increasing local momentum for these interventions. During this time,
the center contacted other states that were implementing similar programs.
Each state had taken a different approach and provided good experiential advice
on legislative strategies.
In the midst of the study and review process, the state and the nation
were devastated in March 1998 by an elementary school shooting in Jonesboro,
Ark. Two boys, aged 11 and 13 years, lured their fellow elementary school
students from their classrooms with a false fire alarm and then attacked the
exposed children with a handgun and rifle barrage that left 4 girls and 1
teacher dead. This incident was followed by a series of high-profile incidents
in the US involving school violence and child fatalities. Several hypotheses
were put forth in the media and community to explain this event, and calls
came forth for all types of new legislation, from juvenile sentencing to firearm
restrictions. Because of prior work in the area of juvenile justice at a local
level, center staff were invited to discuss juvenile violence in "op-eds"
to the local media and by newspaper and television interviews.
IMPLEMENTATION
Academic Focus
The Jonesboro shooting prompted a local charitable organization connected
to the Arkansas Children's Hospital, Little Rock, to contact the center and
request the rapid submission of a proposal for violence prevention projects.
Because of its previous work in this field, the center was prepared for such
a request and was able to respond promptly. A menu of potential projects was
prepared: (1) a pilot of a nurse visitation program for high-risk mothers,
using the Olds model, (2) distribution of violence screening instruments to
primary care physicians in Arkansas, (3) conflict resolution curricula distribution
to elementary schools in Arkansas, and (4) training of mental health professionals
in the management of children with identified behavioral problems associated
with violence or aggression. These 4 juvenile violence prevention projects
were funded, allowing the center to develop direct experience with different
interventions.
State Focus
Another result of the Jonesboro shooting was the creation of a Governor's
Task Force on Juvenile Violence. Because of the center's previous contacts
in the governor's office, its directors were invited to make a presentation
to the task force early in its deliberations. The presentation to the task
force focused on the developmental models of juvenile justice and focused
on early childhood interventions to prevent later childhood violence. The
Olds model of nurse home visitation was one of several interventions described.
One of the members of the task force was a senior member of the State of Arkansas
House of Representatives, herself a former prosecutor and social worker. She
requested further meetings with the center, with the goal of writing a bill
to fund such a program. She also facilitated meetings with other legislators,
including the women's legislative caucus.
Coalition Building
Having identified a legislative champion, and with a legislative session
planned in 6 months, the center gathered stakeholders together for a candid
discussion of a possible bill to establish a nurse home visitation program
in Arkansas. The intention was to identify the level of support among stakeholders
and to try to obtain early critical thinking by potential opponents. Issues
debated included cost, competition with other worthy programs that affected
child welfare, other potentially less expensive models of home visitation,
and the appropriate size of such a program. Program size, scope, sustainability,
and administration were also discussed. An attempt was made to include all
interested parties in these meetings, and all comments were considered. Staff
from the governor's office and members of the legislature and state agencies
were in attendance at most of these meetings.
Once consensus was established, a bill, which included an advisory board
to oversee the implementation of the project, was drafted and submitted to
the legislature by Rep Rita Hale's office. The state AAP lobbyist was helpful
in developing strategy. Identifying a sustainable funding source for the program
was a clear problem throughout this process. Coincidentally, at this point,
a new director of the Department of Health was appointed, who embraced the
program, promised to attend the training, and with the center staff copresented
the bill in legislative committee meetings. Funding for the first stage of
the program (400 clients) was allocated from existing health department funds.
With this support, the bill was passed out of committee, the House and the
Senate unanimously approved it, and the bill became law in May 1999 (Figure 2).
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Figure 2. The bill to establish a nurse
home visitation program in Arkansas became law in May 1999. Pictured from
left to right: Sarah Heffley, Gary Wheeler, MD, Rep Pat Bond, Rep Bobby Lee
Trammell, Gov Mike Huckabee (seated), Mary Aitken, MD, Martha Hiett, Rep Rita
Hale, Leigh Ann Rowlands, and Fay Boozman, MD.
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COMMENT
The success of the advocacy efforts was a combination of fortuitous
timing and adherence to some of the key principles of advocacy. Lessons learned
from our experience include these areas:
Commitment
The amount of time needed for advocacy work is great and will compete
with other professional activities. Establishment of clear priorities is therefore
of key importance. Development of expertise takes time, thought, and energy.
Pursuing small projects initially will help to establish experience and credibility
for larger projects as they arise. In this case, the formal support of the
Department of Pediatrics provided the necessary time and effort required for
success.
Needs Assessment
One should convene meetings that are educational, informational, fact
finding, strategic, or combinations thereof. Strategic meetings include neutral
introductory meetings with the political stakeholders in one's chosen advocacy
area, before asking for any support or assistance. It was in these meetings
that the legislative champion, the governor, and the director of the Department
of Health embraced the nurse visitation program and shepherded it.
Data Assimilation
Large amounts of data are available on every community in the nation
(from the Centers for Disease Control and Prevention, Atlanta, Ga; national
surveys; local health departments; and other sources). These data provide
the basis for the generation of logical hypotheses and, ultimately, for the
persuasion of legislators and stakeholders. These data should be compiled
and artfully presented. Most of our data were compiled from the literature
on child abuse and juvenile justice, with an emphasis on regional data from
reports of nurse home visitation program implementation in nearby Memphis,
Tenn. Local data on child abuse and teen pregnancy were also highlighted.
Existing Resources
Academic pediatricians may be a key group to carry out long-standing
advocacy efforts in each state. They can represent a cost-effective way to
promote children's health by having dedicated faculty and personnel available
to address children's policy issues. Use of existing resources, however, is
key to the success of any large program. Local and national AAP offices are
one such effective resource for advocacy activities. In our case, no member
of our team had legislative experience, but the local AAP and hospital lobbyists
were helpful in identifying potential supporters in the legislature and were
capable consultants on legislative rules and strategy. Academicians in state
institutions should be wary of issues in which advocacy by state employees
is limited under state or federal law. In this case, our center staff members
were summoned as experts to testify in committee hearings, while professional
lobbyists worked directly with legislators to promote this program.
Identification of Stakeholders
Pediatrician advocates should be aware that, in any important area of
advocacy, there will be many other individuals and groups with long-term investment
in the area and with credible, but sometimes differing, viewpoints. It is
critical in building a coalition to know all one's allies and opponents, most
of whom will share what they know, if asked. Advocates need to have an understanding
of the players in the targeted area, if they are to be taken seriously by
lawmakers, and need to know and respect their opponents, who will help by
being the best critics. In the center's meetings, 2 groups that preferred
directing the nurse home visitation monies elsewhere chose to stay neutral
because their philosophical hesitations were taken seriously and incorporated
into the long-range plans.
Focus
Where possible, it is most effective to choose a single program to advance.
The promotion of a program that has been well evaluated is most effective
in a legislative environment. The promotion of ineffective or unproven models
of intervention is risky and hinders one's long-term credibility. Presentation
of competing choices to a legislative group may also prove to be a disadvantage.
In our case, months of background work were needed to establish confidence
in the model proposed for legislation and to convince the coalition that this
was the single best model. Division was dealt with outside of the legislative
committee rooms. Another advantage was that hypotheses about its workability
were tested in a local pilot program before a legislative proposal was launched.
The Authority of the White Coat
Pediatricians are viewed as authorities in the resolution of children's
issues. This provides significant political capital that must be jealously
guarded and not wasted. Arkansas Children's Hospital, the practice site of
the coalition leaders, was well respected in the community and brought attention
to the presentations when they were made to the legislators.
Expertise and Politics
Politics is for the politicians. One should identify a capable lawmaker
to make the case, negotiate the deals, and build the political alliances.
The legislature is a unique world with its own customs and rules. Unless one
is a member (certainly an effective option), one should avoid being a player.
Basic courtesy, including follow-up and thank-you letters, is important in
establishing relationships with politicians. It is also important not to offend
any politician, remaining neutral in public settings.
Carpe Diem
One may need to work for years before the political environment is right
for one's issue. However, if prepared, the right timing will allow successful
advocacy. Our center was fortunate in having had prior preparation to act
quickly after the Jonesboro shooting. Clearly, there was great support and
pressure in our state to do something in the area of juvenile violence. Even
though the center's timetable was to approach lawmakers 2 years later, when
its own demonstration projects were evaluated, the opportunity forced the
early submission of a bill that was ultimately successful.
CONCLUSIONS
Advocacy is a rewarding activity that requires energy, time, and experience.
The effectiveness of our center's activities has reinforced the observations
that pediatricians can be effective advocates for children and that important
changes in public health can be brought about by changes in public policy.
As in the past, advocacy is a legacy of our specialty that needs continuation
as we chart our course in this new millennium.
AUTHOR INFORMATION
Accepted for publication February 2, 2001.
This study was funded by Child and Family Life Institute.
We gratefully acknowledge the contributions of Debra Fiser, MD; Fay
Boozman, MD; Nick Long, PhD; Jerry Jones, MD; Karen Worley, PhD; Amy Rossi,
Sherri Jo McLemore, Rep Lisa Ferrell, Don Smith, Blanche Moore, Suzette Schutze,
Sarah Heffley, and Gov Mike Huckabee in the implementation of this program.
We also greatly appreciate the advice and technical support provided by David
P. Racine, Replication & Program Strategies Inc, Philadelphia, Pa.
Arkansas State House Representative Rita Hale, the legislative champion
described in this article, had a stroke shortly before the legislative session
of 1999. Partially recovered, she took the floor to introduce and speak on
behalf of HB 1613, the Prenatal and Early Childhood Nurse Home Visitation
Bill. She suffered a fatal stroke after the legislative session closed. The
Rita Rowell Hale Prenatal and Early Childhood Nurse Home Visitation Program
began operation in the fall of 1999.
From the Center for Health Promotion, Department of Pediatrics, University
of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock.
Corresponding author and reprints: Mary E. Aitken, MD, MPH, Center
for Health Promotion, Department of Pediatrics, University of Arkansas for
Medical Sciences, Arkansas Children's Hospital, 800 Marshall St, Little Rock,
AR 72202.
REFERENCES
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1. Berman S. Training pediatricians to become child advocates. Pediatrics. 1998;102:632-636.
FREE FULL TEXT
2. Mercy JA. Advocating for children: the pediatrician's role in violence prevention
[comment]. Pediatrics. 1999;103:157.
FREE FULL TEXT
3. Skaug WA. The Jonesboro school shootings: lessons for us all. Pediatrics. 1999;103:156.
FREE FULL TEXT
4. Rivara FP, Farrington DP. Prevention of violence: role of the pediatrician. Arch Pediatr Adolesc Med. 1995;149:421-429.
ABSTRACT
5. Olds DL, Eckenrode J, Henderson CR Jr, et al. Long-term effects of home visitation on maternal life course and child
abuse and neglect: fifteen-year follow-up of a randomized trial. JAMA. 1997;278:637-643.
ABSTRACT
6. Kitzman H, Olds DL, Henderson CR Jr, et al. Effect of prenatal and infancy home visitation by nurses on pregnancy
outcomes, childhood injuries, and repeated childbearing: a randomized controlled
trial. JAMA. 1997;278:644-652.
ABSTRACT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Pediatric Advocacy: More Lessons
Aitken et al.
Arch Pediatr Adolesc Med 2001;155:1390-1390.
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