State Legislators’ Work on Public Health-Related Issues: What Influences Priorities?

Abstract

Context

Policies are an effective way to influence population health and prevent disease. Unfortunately, public health research is often not well translated for policy audiences. Furthermore, researchers seeking to influence policy face an incomplete understanding of what influences legislators’ decisions regarding which issues will receive their limited time and focus.

Objective

The objective of this analysis was to examine various factors that may influence state legislators’ decisions about which health issues they address.

Design

Cross-sectional analysis of data collected from a randomized trial.

Setting

State legislatures.

Participants

State-level legislators.

Main Outcome Measure(s)

Measures included a rating of the influence of various factors on health policy priorities. A 7-point scale was used to measure political ideology on social and fiscal issues. Standard demographic questions were included on age, gender, and level of education.

Results

Seventy-five legislators completed surveys. Sixty-three percent were aged 55 years or older, and 76% male. When they were asked to rate factors according to importance in determining what health issues to work on, the top-rated factor was constituents’ needs or opinions followed by evidence of scientific effectiveness. Ratings were also examined by subgroups.

Conclusions

These findings point to several important applications for public health practitioners and researchers. Because legislators value constituents’ opinions, it is critical to inform and educate constituents about public health issues as well as policy options that may be effective in addressing problems. The results also highlight the importance of public health researchers and practitioners improving dissemination efforts to ensure that evidence-based scientific information is shared with policymakers in an effective and timely manner.

Health policies and allocation of public health re-sources can have substantial effects on public health.^1–3 Policy changes influenced each of the 10 great public health achievements of the 20th century.⁴ Health policies can be broad in scope (eg, state clean indoor air law) or may involve smaller-scale organizational practices (eg, a private worksite ban on smoking).

The nature of policy interventions makes them useful for several reasons. Unlike interventions designed to address specific individuals, policy interventions are aimed at changing the physical and sociopolitical environments; thus, policy interventions have potential to affect entire populations. Also, policy interventions are designed to provide opportunities, support, and cues to help people develop healthier behaviors and make healthy choices. Policies may directly affect behaviors or social norms and are often more permanent and far-reaching than many public health programs focused on individual-level behavioral change.⁵

Unfortunately, public health research is often not well translated for policy audiences. Also, research findings can be inconsistent or confusing and, even when clear, may present multiple policy implications.⁶ Indeed, many challenges exist in the development, communication, implementation, and evaluation of research-informed policies. For example, while researchers have longer timelines allowing for thorough study, legislators often need to make decisions very quickly, without the luxury of waiting for research to be completed.⁷ Also, the myriad demands competing for legislators′ time and attention are increasing.⁸ Researchers may not be trained to effectively communicate complex scientific information in a manner amenable to legislators′ limited time.⁷

Another challenge for researchers seeking to influence policy is an incomplete understanding of what influences legislators′ decisions regarding which issues will receive their limited time and focus. Individual states retain much of the power to influence policies and regulations in the United States over public health.⁹ However, while state legislators have considerable authority over which chronic disease interventions are funded, implemented, and evaluated, there is little empirical evidence on how policymakers assimilate a large body of health information to make decisions.^7,10,11 Therefore, the purpose of this study was to examine various factors that may influence state legislators′ decisions about which issues they address.

Methods

Sample

The current study was part of a larger project described in detail elsewhere that was designed to examine effective means of disseminating health information to state-level policymakers.¹² Data for the study described here were collected as part of the larger, randomized study, but analyzed cross-sectionally (ie, without respect to random allocation in the larger study). This analysis was restricted to state legislators, 1 of 3 groups in the larger study. (Other groups included state legislative staff and decision makers in state health departments.) State legislatures are the lawmaking bodies of the 50 states in the United States. They are the legislative branches at the state level of government and perform many of the same duties on the state level that the US Congress performs on the federal level.

Legislators were randomly selected from 6 states. The states were identified by sorting them into a 6-cell matrix on the basis of the size of population (smaller or larger than median population size for all US states) and dominant party in state legislature (both houses Democrat, both houses Republican, or mixed). One state was then chosen to represent each of the 6 cells to maximize representation across regions of the United States. The states from which the sample was drawn were Mississippi, Missouri, New Jersey, Oregon, Pennsylvania, and South Carolina. During the period of data collection, state legislatures were both in and out of session as data were collected over the course of a full year. Participation by selected legislators involved reviewing a policy brief about access to breast cancer screening and responding to a short survey about factors influencing health policy priorities, political ideology, and the general composition and appearance of the brief. The institutional review board of Washington University in St. Louis approved research activities of this project.

Measures

The final survey tool contained 16 items and was designed for completion in approximately 10 minutes. Whenever possible, questionnaire items were based on previous research.^13–17 This analysis was based on a subset of items including a rating of priority issues in health in relation to other policy issues and the influence of various factors on health priorities.^18,19 A 7-point scale was used to measure political ideology on social and fiscal issues (ie, extremely liberal, liberal, slightly liberal, moderate, slightly conservative, conservative, extremely conservative).¹⁹ Standard demographic questions were included on age, gender, and level of education.

Data were collected from February to December 2009. The process of data collection included calling legislators′ offices to explain the study purpose and invite participation, mailing the policy brief and survey to each office, follow-up phone calls, and e-mailing a PDF of the policy brief and link for those who preferred an online survey. In 2 states (Mississippi and South Carolina), local constituents made personal phone calls and in-person visits with legislators to encourage survey completion. In additional 2 states (Oregon and New Jersey), personal visits were completed by project staff. The final response rate was 26%.

Analysis

The survey question most relevant to this analysis was, “How important are the following factors in determining what health issues you work on?” Legislators were instructed to rate each of the factors on a scale from 1 (unimportant) to 5 (very important). The factors were as follows: my personal interest in the health issue, data on health impact in my local area, a local leader I trust, constituents′ needs or opinions, position of advocacy groups, and evidence of scientific effectiveness. Mean scores for each factor were calculated for the full sample, as well as for a variety of subsamples. Differences between groups were tested using t tests and 1-way analysis of variance.

Results

In total, 75 legislators completed surveys. Sixty-three percent of legislators were aged 55 years or older, and 76% were male, which is representative of all state legislators.²⁰ The majority (75%) of respondents reported health status of very good or excellent, and over half (52%) indicated that they had a postgraduate degree. In terms of fiscal and social positions, 56% of legislators indicated that they considered themselves fiscally conservative, 40% reported being socially conservative, and 36% reported holding liberal social positions.

When legislators were asked to rate factors according to importance in determining what health issues to work on, the top-rated factor was constituents′ needs or opinions (Table 1). The second highest-rated factor was evidence of scientific effectiveness. When ratings were examined by subgroups, the same 2 factors emerged as most important for every group (eg, men, women, Democrats, Republicans, all ages). Some subgroup differences were statistically significant (Table 1).

TABLE 1.

Mean Importance of Factors Determining Health Priorities of State Legislators Participating in Study of Evidence-Based Policy Making, United States, 2009^a

	N	Scientific Evidence	Constituent Needs	Health Impact	Personal Interest	Local Leader	Advocacy Groups
Total	75	4.5	4.5	4.2	3.9	3.7	3.6
Gender
Men	57	4.4	4.5	4.3	3.9	3.7	3.6
Women	18	4.7b	4.8b	4.2	4.0	3.6	3.7
Political Party
Democrats	43	4.5	4.6	4.3	4.0	3.7	3.8
Republicans	32	4.5	4.4	4.1	3.8	3.7	3.4
Age, y
54 or younger	28	4.3	4.4	4.1	3.8	3.7	3.5
55 or older	47	4.7C	4.7b	4.3	4.0	3.7	3.7
Fiscal position
Liberal	9	4.8	4.4	3.8b	3.8	3.1	3.3
Moderate	23	4.4	4.7	4.5	4.1	4.0	4.1
Conservative	41	4.5	4.5	4.2	3.9	3.6	3.4C
Social position
Liberal	26	4.6	4.7	4.4	3.9	3.6	3.7
Moderate	18	4.3	4.5	4.0	4.0	3.9	3.9
Conservative	29	4.6	4.5	4.3	4.0	3.5	3.4

^aMean importance (1 = unimportant; 5 = very important).

^bP < .10.

^cP < .05.

Discussion

This study was designed to enhance an understanding of what factors state legislators consider when evaluating health issues and developing their agenda. Overall, legislators in this sample indicated that the most important factors to them were evidence of scientific effectiveness and the needs and opinions of their constituents. These findings point to several important applications for public health practitioners and researchers.

Because legislators value constituents′ opinions, it is critical to inform and educate constituents about public health issues as well as policy options that may be effective in addressing problems. Furthermore, where the public holds misconceptions about policies that may protect or improve public health, practitioners and researchers should work to clarify and communicate the evidence. For example, school boards and parents are often opposed to interventions involving school vending machines for fear of losing money for schools.²¹ Improving public education about such topics can both help constituents become informed voters and positively influence the public will.²² This, in turn, can dramatically affect political will and policy decisions. Moreover, because legislators also noted the importance of scientific evidence, well-informed constituents bearing scientific evidence to support their needs and opinions may be one of the most effective means of influencing state legislators′ health policy priorities. Therefore, efforts should be aimed at debunking myths and educating constituents and stakeholders about public health issues and possible policy solutions.

This study also shows that state legislators value evidence of scientific effectiveness when considering health issues. This highlights the importance of researchers learning to disseminate scientific findings in a clear, concise, and timely manner. Special attention should be paid to who delivers health messages to policymakers and how they can most effectively do so. Some studies have examined the relative effectiveness of policy dissemination through various communication methods. Sorian and Baugh²³ reported on a survey of nearly 300 state government policymakers who sought to understand their methods of obtaining information about policy topics. Respondents in the study discussed being overwhelmed with information and therefore never reading 35% of what they receive.²³ Policymakers also reported finding summaries and brief reports more useful than e-mail lists, conferences, and press releases.

Another possible implication of these findings is the idea that specific factors may have unique influences on different types of legislators′ decision making. Therefore, the method of persuasion or communication used by advocates and researchers may change, depending on the legislative audience. For example, while both men and women rated it highly, a higher percentage of women legislators in this sample rated the role of constituents′ needs and opinions as very important in determining what health issues they work on; therefore, communication targeted to women legislators might incorporate a message about constituents′ opinions (Table 1). Similarly, more than 50% of social conservatives reported that data on health impact of an issue in their local area were very important in determining what health issues they work on compared with only 33% of social moderates. Thus, when communicating with social conservatives, including data on local health impact may prove more persuasive in helping a legislator decide to work on a particular issue. Overall, these findings point to the need for personalized or tailored communication with legislators as opposed to using a “one-size-fits-all” generic communication approach.

Several limitations warrant mention. Because the most commonly cited important factors of evidence of scientific effectiveness and constituents′ needs and opinions are socially desirable, it is difficult to discern if legislators truly value these factors more highly than others. Also, participants consistently rated the importance of advocacy groups as low (often last place, Table 1). This, too, may be seen as a more acceptable answer and might not accurately represent the role of advocacy groups in determining what health issues receive legislators′ focus. Also, there are several important factors that were excluded from the list of options, such as funding, fellow legislators, and lobbyists. Had these factors been included in the lists, the ratings may have been different. Finally, despite months of a variety of data collection efforts, the sample size of legislators was still quite small, which limited statistical analyses. While response rates were small compared with many population-based surveys, they were congruent with studies in similar policymaker populations.²⁴ Low rates may partly be explained by our inability to offer participant incentives due to state ethics laws. Similar rates of nonresponse across study conditions and a variety of variables indicate that any selection bias was evenly distributed across conditions.

Policy interventions hold promise for effectively and efficiently improving public health.²⁵ Policymakers at the state level are in positions to affect the funding and implementation of public health policies. Furthermore, they are influenced by the needs and opinions of their constituents as well as indication of scientific effectiveness of interventions. Therefore, public health researchers and practitioners must improve dissemination efforts to ensure that evidence-based scientific information is shared with policymakers in an effective and timely manner, using localized information wherever possible. They should also educate constituents about public health problems and policy solutions and encourage constituent advocacy.