Learning in the zone: toward workforce development of evidence-based public policy communication

Learning in the zone: toward workforce development of evidence-based public policy communication Background: Evidence-based policy communication (EBPC) is an important, emerging focus in public health research. However, we have yet to understand public health workforce ability to develop and/or use it. The study objective was to characterize capacity to develop and use EBPC and identify cooperative learning and development opportunities using the case of Human papillomavirus (HPV). Methods: Vygotsky’s Zone of Proximal Development (ZPD) informed guided interviews with 27 advocates in Indiana from government, industry, research, state associations and individuals. Participants focused on HPV, cancer, women’s health, school health and minority health. Results: Capacity to develop and use EBPC was reported to develop through cooperative learning opportunities on the job or in advocacy focused coalitions. Coalition learning appeared to translate across health topics. Notably, policy experience did not assure understanding or use of EBPC. Conclusions: The ZPD framework can inform workforce EBPC interventions by focusing on actual development, potential development and factors for learning and development in the ZPD. Future studies should further clarify and evaluate emerging indicators in additional public health policy areas with a larger sample. Keywords: Health policy communication, Public health workforce development, Human papillomavirus, State policy development Background understood and deficits addressed. We know there is a Evidence-based policy communication (EBPC) is relatively substantial gap between public health workforce expertise new and is based on Brownson et al.’sconceptionof in specific areas and the ability to translate that expertise evidence-based policy: conveying evidence-based public into the policy domain, because policy development re- health interventions to policymakers [1–4]. EBPC is an mains the weakest of public health’s core functions [7–9]. important, emerging part of public health research in re- This gap persists even with wide acknowledgment that sponse to calls for empirically-based efforts to translate structural conditions, largely determined by policy, power- public health evidence for use in the policy arena [5, 6]. fully impact population health [10–12]. As Brownson and Successful EBPC has the potential to transform the colleagues noted, public health training programs do not health landscape by influencing the policy decision-making sufficiently focus on policy knowledge and skills develop- process. However, before such success can be achieved, the ment; [1] though this will likely change as accredited ability (or inability) of the public health workforce to schools of public health are required to offer policy learn- develop and use EBPC to advance policy goals must be ing opportunities to all students [13]. While this is good news, gains will be realized only in the future, and depend upon the quality of that education. Because the field of * Correspondence: bmeyerso@indiana.edu Rural Center for AIDS/STD Prevention, Indiana University School of Public public health is not comprised only of those with public Health-Bloomington, Bloomington, Indiana, USA health degrees, [14] efforts to develop EBPC capacity in Department of Applied Health Science, Indiana University School of Public the public health workforce must be bifocal: occurring Health-Bloomington, Bloomington, Indiana, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Meyerson et al. BMC Public Health (2018) 18:700 Page 2 of 9 through formal public health education programs and in and therefore do not speak to potential for future develop- the field. Understanding workforce capacity for EBPC, ment.Further,while theseindicators are examples of policy then, is a first step. behaviors, they are not necessarily evidence-based; which, A few studies have attempted to understand public according to Brownson, means that they express informa- health workforce policy capacity by examining policy tion grounded in both quantitative (e.g. scientific findings) behaviors. Examples of these behaviors are summarized and qualitative (e.g. narrative accounts) evidence, [1]and in Table 1, though it is important to note that a few ci- based on an awareness of the policy audience [2, 18]. tations are editorials and not studies. They are, how- A useful framework to help clarify and address the cen- ever, important contributions that point the way toward tral challenge of EBPC development over time is Vygotsky’s development of measurable policy behaviors. theory of the Zone of Proximal Development (ZPD). This The Meyerson [15] and Harris [16] studies used five learning/development theory presupposes a dynamic and policy behaviors measured by the National Association socially-oriented relationship between learning and devel- of County & City Health Officials in periodic surveys of opment [19]. Briefly put, ZPD theory seeks to define the U.S. local health departments. Meyerson et al.’s 2003 study upper boundary of the realm of abilities a person already measured similar behaviors among state sexually transmit- possesses and the lower boundary of abilities beyond that ted disease (STD) programs [17]. These local health depart- person’s capacity at the time. The gap between these two ment and STD program studies were limited by the unit of boundaries defines theZPD,thatis, thearea where aper- measure: one person reporting program or leadership be- son can learn new goals or, in this case, evidence-based pol- havior, and period of measure: they were snapshots in time icy behaviors with guidance. Vygotsky held that effective teaching targets the ZPD, with the teacher helping learners bootstrap their way dynamically to acquire greater skills Table 1 Examples of policy behaviors from the literature, 2016 and knowledge. In contrast, ineffective teaching aims too high (leading to frustration and a lack of development) Behavior Citation or too low (leading to disengagement and lack of devel- Prepare issue briefs for policy makers Harris and Mueller, 2013 [16] Meyerson and Sayegh, 2016 [15] opment). Identification of the ZPD essentially entails a defining of the potential level of development in order Publish a state policy agenda Meyerson et al., 2003 [17] to understand what maximally could be accomplished Publish consensus or other Friedlaender and Winston, 2004 [18] evidence-based document aimed through problem solving experience or guidance in social at policy change learning contexts [20]. Using ZPD theory, we argue that ad- Advance model public health Hartsfield et al., 2007 [25] vancing public health workforce EBPC skills requires more legislation, regulation or ordinance than an assessment of the current level of (EBPC) develop- Publish policy implications as Giles-Corti et al., 2015 [26] ment and knowledge, which simply provides a starting point part of research publications for intervention development. When applied to public Give public testimony to policy Harris and Mueller, 2013 [16] health workforce EBPC skills, the ZPD can help clarify makers Meyerson et al., 2003 [17] types of and platforms for workforce interventions (see Meyerson and Sayegh, 2016 [15] Fig. 1). Further clarity about optimum policy behaviors Communicate with legislators, Harris and Mueller, 2013 [16] and capacities will ultimately be necessary to fully articu- regulatory officials, or other policy Meyerson and Sayegh, 2016 [15] makers regarding proposed late EBPC behavior and capacity development expecta- regulations, legislation or ordinances tions. For now, however, Brownson’s definition of using a Provide technical assistance to a Harris and Mueller, 2013 [16] balance of peer reviewed quantitative and qualitative evi- legislative, regulatory or advisory Meyerson and Sayegh, 2016 [15] dence through a variety of behaviors (Table 1) based on group for drafting proposed audience preference is a good start. legislation, regulation or ordinance Using ZPD, the research task includes describing and Program disseminates STD related Meyerson et al., 2003 [17] information to policy makers characterizing current public health policy knowledge (e.g. epidemiologic reports) and behaviors (actual level), clarifying optimum EBPC Participate on a board or panel Harris and Mueller, 2013 [16] behaviors (potential level), and identifying situational or responsible for health policy Meyerson and Sayegh, 2016 [15] structural opportunities for learning and development Program works with a state Meyerson et al., 2003 [17] within the ZPD. coalition on STD related issues To explore the application of ZPD to EBPC skills and Staff contact policy makers as Meyerson et al., 2003 [17] development, an exemplar issue was chosen which is individual citizens frequently challenging in U.S. policy contexts: human Conduct policy surveillance Brownson et al., 2009 [1] papillomavirus (HPV). Specific study aims included the Conduct media advocacy Chapman ad Lupton, 1994 [27] conceptualization of policy and EBPC to advance HPV Wallack et al., 1993 [28] and cancer-related outcomes, identification of actual Meyerson et al. BMC Public Health (2018) 18:700 Page 3 of 9 Fig. 1 Zone of Proximal Development (adapted) for Evidence-Based Policy Behaviors (EBPC). Meyerson et al., 2016 and potential development levels for HPV EBPC, and independently coded data and met to compare and resolve identification of potential ZPD elements. conflicts after reviewing a sample of interviews (N =10). Final coding was then conducted using the agreed scheme Methods with theentiregroup of interviews.Coded data were In-person, 60-min interviews were conducted with indi- then classified as low, moderate and high for each of viduals engaged in HPV, cancer and public health policy the learning/development levels. Results are presented work in Indiana from October–December 2015. We fo- as theme-related tables and as interview quotations for cused on the state policy process because of its import- deeper understanding. The study was deemed exempt ance to public health policy [21]. by Indiana University Institutional Review Board. The interview guide contained 12 open-ended questions exploring conceptualization of policy, EBPC, reported cap- Results acity to develop and use EBPC, and reactions to a ‘mock’ The sample consisted of 27 individuals across various policy brief (“mock-up”). The mock-up was presented in public health and policy organizations. State association the third portion of the interview and written with anon- participants (25.9%, 7) included associations of school ymized text using a Lorem ipsum generator to allow the health nurses, rural health providers, local health depart- observation of participant reaction and developmental ments, action agencies focused generally on health and thinking when presented with a partial presentation of human services, and organizations focused on cancer, EBPC for HPV. Interviews were recorded and transcribed HPV or reproductive health. Community level organi- for analysis with Nvivo software (QSR International, v.9). zations (22%, 6) included those focused specifically on Purposeful sampling drew one individual from each of minority health, health care coverage, reproductive health the following types of organizations: state associations, services, cancer, and immunizations. Clinical care and re- community coalitions, clinical care research, local and state search participants (22%, 6) were focused on cancer or government agencies, state legislature, and individual advo- HPV specifically. Local and state government participants cates. All participants were previously observed by authors (14.8%, 4) included public health departments, state legis- as involved in HPV or cancer policy communication. lators and state programs focused on cancer. Industry par- Indicators of current knowledge and behavior mea- ticipants (7.4%, 2) were focused on HPV immunization, sured participant level of actual development for EBPC. testing or cancer treatment. Individual advocates (7.4% 2) Reported current or prior exposure to or participation in operated in the policy process focusing on HPV vaccin- collaborative policy learning environments, and response ation, screening and/or cervical cancer treatment. About to the mock-up characterized the ZPD. Ratings of “Low, one third of participants (33.3%, 9) focused specifically on Moderate, and High” were assigned for the potential to HPV or cervical cancer, 25.9% (7) on immunizations, and develop and use EBPC for HPV. Ratings were assigned 33.3% (9) on cervical screening; and 40.7% (11) had jobs based on researcher evaluation of knowledge accuracy, working directly in the policy process. the congruence between policy goals and audience, and the reporting of concrete examples of EBPC develop Level of Actual Development for EBPC and/or use. Table 2 displays the application of ZPD theory The level of actual development for EBPC was indicated with associated study measures and explanations. by reported knowledge and behaviors in the policy Coding was a priori, based on Table 2 indicators, and also process. Most participants misunderstood public policy, open to allow further study exploration. Two researchers policy audiences and what constituted policy behaviors. Meyerson et al. BMC Public Health (2018) 18:700 Page 4 of 9 Table 2 Evidence-Based Policy Communication (EBPC) Study indicators by Zone of Proximal Development (ZPD) Components, Level of actual development Zone of proximal development Level of potential development Accurate knowledge about policy Exposure to or participation in collaborative policy learning Rankings for potential to develop What policy is and where it happens Experience with policy learning on the job, in association EBPC for HPV context, other Researcher assigned: Low, Moderate, High Accurate knowledge about EBPC (what it is) Exposure to EBPC examples from others Rankings for potential to use EBPC: Using a balance of quantitative Reported exposure through peers, peer organizations, EBPC for HPV and qualitative information through a on the job, other Researcher assigned as Low, variety of policy behaviors to convey Moderate, High public health evidence to a policy audience based on their known preferences. Accurate knowledge about goals for policy Prior/current experience in environments which have communication and audience potential to enhance social learning about EBPC Policy communication informs decisions Reported experience (current or past) about administrative or legislative policy. Awareness of audience preferences for communication (how much narrative, how much data, what type of data). Reported policy behavior indicating Proximity to the policy process understanding and use of EBPC Working in state policy process full time, part time, Reported examples of past or current EBPC. sometimes, seldom within the last 3–5 years. Response to EBPC “mock-up” Recognition of this type of communication, impact of mock up on interview discourse, engaged discussion (participant driven) about EBPC based on mock up. Explanatory text in italics Job-related experience in the policy process appeared to focused on education such as state vaccine laws mandating correspond with the level of actual policy development. education of parents or providers. While some participants However, while participants with policy related jobs gen- believed that increased knowledge about HPV or cervical erally expressed correct conceptualizations of policy and cancer would generally lead to “better HPV policy,” the policy behaviors, they did not necessarily know what concept of “HPV policy” was never disentangled from constituted EBPC (Table 3). information about HPV or cervical cancer. Those with cor- As shown in Table 3, participants with low or moder- rect policy knowledge discussed policy behaviors akin to ate knowledge of policy tended to confuse policy with those listed in Table 1 such as advocacy or policy maker HPV information, hospital policy, or parent, physician or education, policy monitoring and the production of policy private payor behavior. For these participants, policy was communications for specific audiences. construed as education for these audiences to encourage them to vaccinate/screen or to underwrite services. Those We engage in the full array of policy advocacy demonstrating correct knowledge about policy primarily from monitoring bills to doing educational forums conceptualized it as state legislation, and only four partici- and we educate members to actively lobby, both at pants discussed policy as administrative action (funding, the grassroots level and direct lobbying of regulation, et cetera) by state agencies or the governor. A legislatures and administrators at the state and correct example of administrative policy was given by this federal level. participant: The confusion of policy and education appeared to be Medicaid made a change to their policy to cover all connected with an understanding that EBPC meant talk- adults in pharmacies….But what they did at the same ing only about cervical cancer or HPV epidemiologic time was (to require) all Medicaid eligible VFC evidence such as diagnosis or death rates, or information children to get their vaccines from a VFC provider, about the virus itself. There were, however, correct ex- which meant basically that the pharmacy could no amples of EBPC tools informed by such evidence and longer bill for it. developed to achieve policy goals. These included policy briefs or ‘report cards’ focused on a specific policy out- Those participants confusing HPV or cervical cancer come, the use of evidence in legislative testimony, or education with policy notably did not discuss policies evidence-based policy recommendations. Meyerson et al. BMC Public Health (2018) 18:700 Page 5 of 9 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � Table 3 Indicators and Levels of Actual Development for Evidence Based Policy Communication (EBPC) about Human Papillomavirus (HPV), 2016 (N = 27) Indicators Levels of actual development with reported examples from interviews High level Moderate level Low level Policy knowledge Legislative decisions (HPV vaccination, School principal decisions about public information Public, parent or physician decision to Medicaid expansion, reproductive health in school vaccinate or access cervical cancer screening services access) Private insurer decision to require HPV testing Administrative decisions (Medicaid, VFC ) Goals of policy communication Remove barriers to access Support public discussion (school) about HPV, Increase knowledge of HPV and related cancer Invest in programming vaccination and/or screening Change opinion about benefit of screening or Require standard of care vaccination or Reimburse for screening (private insurers) vaccination among parents, teachers, providers screening Evidence Data from peer reviewed studies Stories from those affected (Only and not with Information about coalition messenger(s) Economic data other evidence) Any information about HPV or cervical cancer Epidemiologic data Some studies or information from CDC about Stories from those affected HPV or cancer EBPC knowledge Integrating evidence with desired policy Education about HPV and/or cervical cancer Not sure what it is, what it looks like, or how change for specific policy audience primarily for non-policy audience (what it is) to use Reported EBPC behaviors Use of: Public information about HPV and cervical cancer Giving testimony to legislature (The act but Policy report cards Screening and vaccination recommendations without quantitative or qualitative evidence) Policy briefs for doctors or insurers Grassroots coaching for letters, testimony, media contact, meetings VFC Vaccines for Children Program CDC Centers for Disease Control and Prevention Meyerson et al. BMC Public Health (2018) 18:700 Page 6 of 9 We have an annual report (which is) our ultimate Zone of Proximal Development policy brief ranking states in 11 different policy areas. Participants discussed how they obtained their policy It provides the background of what the problem is, a knowledge, learned policy behaviors, and learned about policy solution, and an issue overview that includes a EBPC. Every example was social and work-related instead lot of evidence in statistics about why that issue is of formal education-based; and each example included important. collaborative learning or policy modeling. Despite the reported policy awareness of some partici- (I learned) on the fly. You really learn how to put pants, most of the sample did not appear to understand together a good policy brief by trial and error, and EBPC. Only those that developed “policy briefs” reported through that communications process of giving that concepts about what EBPC might involve beyond pro- information to your various audiences and them viding written information specifically about cervical asking questions or telling you that they need more cancer or HPV as health issues. Those with stronger information. EBPC knowledge tended to have work-related experi- ence in the policy process and had some capacity to de- Over half of participants reported experience with velop EBPC. That said, experience working with the policy coalition work – whether led by the participant’s legislature was not sufficient to develop participant organization, or whether the participant was part of a knowledge or capacity to use EBPC. For example, one larger coalition focused on some aspect of health policy. participant with years of legislative experience stated These participants spoke about coalition experience as that the evidence informing any policy communication contributing to their policy learning. Notably, coalitions was about the coalition members themselves. discussed by participants were not necessarily focused on HPV or cervical cancer, as less than half reported being We try to develop a plan of what we can say (to part of such a coalition. However, the cooperative policy legislators) in a short amount of time, not more than learning environment from any policy-related coalition ex- one page, probably double spaced so that we can say perience appeared to be transferrable from issue to issue one, two, three, this is what we see, this is the facts we and endured over time. know, this is what we would like to see happen and this is why we’d like to see it happen. However, there Okay, here’s how I learned to [put together a good is evidence, which is that our members (as a policy brief]. Being part of the HIV Community profession) are trusted.….I have to say I don’t think Planning Group and at some sort of public forum, only I’ve taken any (data). having like a minute or less to talk about HIV, and trying to get a whole lot of important stuff into this What constituted public health policy evidence ranged minute or less. for participants. For those who functioned in the policy process, several indicated that a balance was needed One participant reported active engagement in the de- between research or studies about the effectiveness of velopment of EBPC communication skill and knowledge screening and follow-up investments and personal narra- with the organization’s coalition members in order to, in tives. Participants felt this was particularly the case for this example, further healthcare funding policy: HPV, given the tremendous social judgement about sexual activity. To navigate moral policy, one participant stated So I really say to (the coalition members): the first that “[Something] I’ve actually learned over the years is thing you need to have with you is data, so let’s talk that I sometimes am more powerful if I give anecdotes about the number of uninsured in your county. Maybe [rather] than evidence.” 2013 is a good benchmark ‘cause that was pre-ACA, Challenges identifying and presenting evidence were and then write down how many enrollments happened reported by several participants at all levels of development. in 2013 and 2014. The numbers really speak for Some participants felt the burden of “wading through CDC themselves. data” to identify the latest information about HPV when preparing to talk with state lawmakers. Others noted the While participants ranged in EBPC knowledge and challenge of synthesizing the most recent studies of HPV practice, everyone had a response to the EBPC mock-up. and cervical cancer, and translating the information into These responses ranged from conceptualizations of it as understandable concepts. Those rated as having high levels “another way to organize the information,” to active and of actual policy development were challenged to find policy evolving reflection about issues related to the gathering related evidence, such as the impact of vaccine policy, or and framing of evidence for policy argument. Partici- public funding for alternative screening venues. pants spoke of capacity (or lack of) to develop similar Meyerson et al. BMC Public Health (2018) 18:700 Page 7 of 9 material and the usefulness of it; especially with a moral Discussion policy issue such as HPV. Here, the challenge was one This exploratory study suggests that EBPC development of balancing evidence about policy effectiveness such as interventions for the public health workforce would bene- HPV vaccine policy with stories about human impact. fit by using the ZPD framework, because the ZPD helps to elucidate current activity (actual), facilitators of knowledge and skills development (zone), and estimates potential for Level of Potential Development future skills and knowledge. The ZPD framework also em- Levels of potential development began to arise after consid- braces the permanently iterative relationship between ering the actual level of development and emerging indica- learning and development. This is good in the long run, tors of the ZPD. We classified potential development levels because if one were to solely measure actual policy know- based on participant identification of zone indicators. For ledge and skill levels and presume that those rated high example, over half of the sample (60%) was categorized as for actual development were in no need for further devel- moderate to high potential to develop and or use HPV opment, we would miss an important observation from EBPC becausetheyreportedopportunityfor learning and this study: that those who were active in the policy process development through modeling, guided example in job or still did not necessarily understand, develop or use EBPC. coalition environments (see Table 4). Discussion emerging from encounters with the mock-up Those rated as having moderate and high EBPC po- provided a good opportunity to observe potential for future tential tended to have a job that required full-time development and knowledge; however, the estimates for participation in the policy process. An exception to potential development were limited because they are this involved- two participants who held jobs in orga- unverifiable without a retrospective study design relying nizations that limited their engagement with the policy on participant self-report of historical learning and develop- process; however, their role was to prepare coalition ment, or a prospective design over a longer period of time members for it. Participants reporting one or less than with focus on measuring knowledge and observing behav- one engagement in the policy process since 2013 were iors and EBPC tools used. We recommend both retrospect- rated as low for the capacity to develop and/or use ive and prospective study designs for this purpose. HPV EBPC because of the limited opportunity to learn The emergence of self-reported zone indicators such and practice it. Further, while coalition engagement as job focus, policy proximity, and coalition experience appeared to be a policy learning ground for many par- provide a starting point for further indicator characterization ticipants, being in a cancer-related or HPV coalition and evaluation. This is because, to our knowledge, there is did not necessarily translate to a high policy develop- no theory of policy learning and skills development beyond ment classification especially if participants did not the focus on the evolution of policy ideas [22, 23]. As ZPD report collaborative policy learning or development indicators are further developed, it will be important to ver- opportunities. ify their precise contribution to development and learning. Table 4 Zone of Proximal Development (ZPD) Indicators for Evidence-Based Policy Communication (EBPC) about Human Papillomavirus (HPV) by Levels of Potential Development, 2016 ZPD Indicators High level Moderate level Low level Exposure to or participation in � Is an advocacy coalition member � Has coalition experience, but � Has no exposure. Receives collaborative policy learning � Has a policy role in organization no recognized collaborative no coaching from others. learning Exposure to EBPC of others � Has developed or co-developed � Has used, but not developed � Has no exposure. EBPC � Has observed others using Prior/current experience in � Is a policy coalition member � Could join a policy coalition � Is a policy coalition member environments with potential � Has a work environment with with EBPC potential. (though unlikely that coalition for social learning about EBPC potential for EBPC learning (Awareness of such a coalition) has potential to develop or � Has potential to work with use EBPC) others through job (but not currently) Proximity to the policy process � Has full time policy job � Has periodic policy process � Gave policy testimony once � Has a policy role for organization engagement or twice before but not primary job Response to Mock-up � Has clear recognition of EBPC tool(s) � Demonstrated moderate � None to slight recognition of based on mock-up recognition of EBPC tool mock-up as an example of EBPC. � Demonstrated advanced thinking after exposure to mock-up Focused more on format than and conversation about EBPC and � Unclear how to use it concept. how tool might be used � Unclear whether could or would use Meyerson et al. BMC Public Health (2018) 18:700 Page 8 of 9 Their self-reported existence alone does not mean that who know about and engage in EBPC. Second, sampling EBPC related learning and development occurs or is even should include a variety of public health policy issue related to them. That said, participant meaning making areas to test whether the elements are shared widely or about their own policy learning journeys should not be are disease/condition specific. Finally, the next iteration devalued in the absence of studies about the associ- of studies should explore whether adaptation of EBPC ation between reported zone indicators and observed behaviors is acceptable and under what conditions. EBPC development. These findings would assist the selection of a dissemin- Similarly, there remains the challenge of knowing ation and implementation framework to guide policy when one encounters a correct reported example of capacity intervention design and testing. EBPC versus something incorrectly construed as EBPC. Abbreviations This is a study limitation, as we did not see examples of EBPC: Evidence based policy communication; HPV: Human papillomavirus; reported EBPC in the course of the study. All partici- ZPD: Zone of Proximal Development pants were asked to provide examples after their inter- Funding views, but only those who were coincidentally assessed This study was supported by a grant from the Anita Aldrich Foundation as developing and using EBPC actually did. Thus, there and a grant from Roche Diagnostics corporation. was no opportunity for content analysis verifying re- Availability of data and materials ported EBPC. Participant response to the mock-up did The datasets generated and/or analyzed during the current study are not facilitate observation of completely independent thinking publicly available as the interview transcripts contain information that will identify participants and their organizations. The corresponding author will about what an EBPC tool might look like and issues with consider reasonable requests. it; as if the opportunity to reflect on the mock-up was in and of itself a social learning opportunity for EBPC. That Authors’ contributions BM acquired the funding for the study. BM, GZ, KC conceived of the study. said, the vagueness (Lorem ipsum wording) might be BM and LH gathered and analyzed the data. BM led the writing of the considered a study weakness albeit developed to avoid manuscripts. All authors actively participated in the editing of the confounding. manuscript. All authors read and approved the final manuscript. Our observation that several participants confused policy Ethics approval and consent to participate with education for individual level behavior change reflects This study was deemed exempt by the Indiana University Institutional findings from our prior study of state comprehensive Review Board. Participants gave informed consent verbally. cancer plans. In the case of the cancer plans study, this Competing interests was likely because there were few policy related partners in- The authors declare that they have no competing interests. volved in the development of state plans [24]. Interestingly, in this EBPC study there was policy experience, and yet that Publisher’sNote did not necessarily mitigate the confusion of education Springer Nature remains neutral with regard to jurisdictional claims in about HPV/cervical cancer and policy. published maps and institutional affiliations. A remaining challenge is identifying what constitutes Author details evidence for policy communication. While a few partici- Rural Center for AIDS/STD Prevention, Indiana University School of Public pants reflected Brownson’s finding that evidence is a bal- Health-Bloomington, Bloomington, Indiana, USA. Department of Applied Health Science, Indiana University School of Public Health-Bloomington, ance of quantitative and narrative data, several participants Bloomington, Indiana, USA. Center for HPV Research, Indiana University felt that evidence was only about HPV or cervical cancer as School of Medicine, Indianapolis, Indiana, USA. The Polis Center, Indiana virus and condition. Only one participant identified the University Purdue University at Indianapolis, Indianapolis, Indiana, USA. 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J Public Health Manag Pract. 2013 Mar-Apr;19(2):E1–8. 17. Meyerson BE, Chu BC, Raphael TL. STD program activity in state policy processes, 1995 and 2000. Sex Transm Dis. 2003;18(8):614–9. 18. Friedlaender E, Winston F. Evidence based advocacy. Inj Prev. 2004;10:324–6. 19. Tharp RG, Gallimore R. Rousing minds to life: teaching, learning and schooling in social context. New York: Cambridge University Press; 1991. 20. Vygotsky LS. In: Cole M, John-Steiner V, Scribner S, Souberman E, editors. Interaction between learning and Development Mind and Society. Cambridge, MA: Harvard University Press; 1978. 21. Gostin LO. Public Health Law: Power, Duty, Restraint. California: Milbank Books; 2008. 22. Bennett CJ, Howlette M. The lessons of learning: reconciling theories of policy change. Policy Sci. 1992;25:275–94. 23. Mytelka LK, Smith K. Policy learning and innovation theory: an interactive and co-evolving process. Res Policy. 2002;31:1467–79. 24. Meyerson BE, Zimet GD, Multani GS, Levell C, Lawrence CA, Smith JS. Increasing efforts to reduce cervical Cancer through state-level comprehensive Cancer control planning. Cancer Prev Res. 2015;8(7):636–41. 25. Hartsfield D, Moulton AD, McKie KL. A review of model public health laws. Am J Public Health. 2007;97(Suppl 1):S56–61. 26. Giles-Corti B, Sallis JF, Sugiyama T, Frank LD, Lowe M, Owen N. Translating active living research into policy and practice: one important pathway to chronic disease prevention. J Health Policy. 2015;36:231–43. 27. Chapman S, Lupton D. The fight for public health. Principles and practice of media advocacy. London: BMJ publishing Group; 1994. 28. Wallack L, Dorfman L, Jernigan D, Themba M. Media Advocacy and Public health: power for prevention. Newbury Park: Sage; 1993. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Public Health Springer Journals

Learning in the zone: toward workforce development of evidence-based public policy communication

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Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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Abstract

Background: Evidence-based policy communication (EBPC) is an important, emerging focus in public health research. However, we have yet to understand public health workforce ability to develop and/or use it. The study objective was to characterize capacity to develop and use EBPC and identify cooperative learning and development opportunities using the case of Human papillomavirus (HPV). Methods: Vygotsky’s Zone of Proximal Development (ZPD) informed guided interviews with 27 advocates in Indiana from government, industry, research, state associations and individuals. Participants focused on HPV, cancer, women’s health, school health and minority health. Results: Capacity to develop and use EBPC was reported to develop through cooperative learning opportunities on the job or in advocacy focused coalitions. Coalition learning appeared to translate across health topics. Notably, policy experience did not assure understanding or use of EBPC. Conclusions: The ZPD framework can inform workforce EBPC interventions by focusing on actual development, potential development and factors for learning and development in the ZPD. Future studies should further clarify and evaluate emerging indicators in additional public health policy areas with a larger sample. Keywords: Health policy communication, Public health workforce development, Human papillomavirus, State policy development Background understood and deficits addressed. We know there is a Evidence-based policy communication (EBPC) is relatively substantial gap between public health workforce expertise new and is based on Brownson et al.’sconceptionof in specific areas and the ability to translate that expertise evidence-based policy: conveying evidence-based public into the policy domain, because policy development re- health interventions to policymakers [1–4]. EBPC is an mains the weakest of public health’s core functions [7–9]. important, emerging part of public health research in re- This gap persists even with wide acknowledgment that sponse to calls for empirically-based efforts to translate structural conditions, largely determined by policy, power- public health evidence for use in the policy arena [5, 6]. fully impact population health [10–12]. As Brownson and Successful EBPC has the potential to transform the colleagues noted, public health training programs do not health landscape by influencing the policy decision-making sufficiently focus on policy knowledge and skills develop- process. However, before such success can be achieved, the ment; [1] though this will likely change as accredited ability (or inability) of the public health workforce to schools of public health are required to offer policy learn- develop and use EBPC to advance policy goals must be ing opportunities to all students [13]. While this is good news, gains will be realized only in the future, and depend upon the quality of that education. Because the field of * Correspondence: bmeyerso@indiana.edu Rural Center for AIDS/STD Prevention, Indiana University School of Public public health is not comprised only of those with public Health-Bloomington, Bloomington, Indiana, USA health degrees, [14] efforts to develop EBPC capacity in Department of Applied Health Science, Indiana University School of Public the public health workforce must be bifocal: occurring Health-Bloomington, Bloomington, Indiana, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Meyerson et al. BMC Public Health (2018) 18:700 Page 2 of 9 through formal public health education programs and in and therefore do not speak to potential for future develop- the field. Understanding workforce capacity for EBPC, ment.Further,while theseindicators are examples of policy then, is a first step. behaviors, they are not necessarily evidence-based; which, A few studies have attempted to understand public according to Brownson, means that they express informa- health workforce policy capacity by examining policy tion grounded in both quantitative (e.g. scientific findings) behaviors. Examples of these behaviors are summarized and qualitative (e.g. narrative accounts) evidence, [1]and in Table 1, though it is important to note that a few ci- based on an awareness of the policy audience [2, 18]. tations are editorials and not studies. They are, how- A useful framework to help clarify and address the cen- ever, important contributions that point the way toward tral challenge of EBPC development over time is Vygotsky’s development of measurable policy behaviors. theory of the Zone of Proximal Development (ZPD). This The Meyerson [15] and Harris [16] studies used five learning/development theory presupposes a dynamic and policy behaviors measured by the National Association socially-oriented relationship between learning and devel- of County & City Health Officials in periodic surveys of opment [19]. Briefly put, ZPD theory seeks to define the U.S. local health departments. Meyerson et al.’s 2003 study upper boundary of the realm of abilities a person already measured similar behaviors among state sexually transmit- possesses and the lower boundary of abilities beyond that ted disease (STD) programs [17]. These local health depart- person’s capacity at the time. The gap between these two ment and STD program studies were limited by the unit of boundaries defines theZPD,thatis, thearea where aper- measure: one person reporting program or leadership be- son can learn new goals or, in this case, evidence-based pol- havior, and period of measure: they were snapshots in time icy behaviors with guidance. Vygotsky held that effective teaching targets the ZPD, with the teacher helping learners bootstrap their way dynamically to acquire greater skills Table 1 Examples of policy behaviors from the literature, 2016 and knowledge. In contrast, ineffective teaching aims too high (leading to frustration and a lack of development) Behavior Citation or too low (leading to disengagement and lack of devel- Prepare issue briefs for policy makers Harris and Mueller, 2013 [16] Meyerson and Sayegh, 2016 [15] opment). Identification of the ZPD essentially entails a defining of the potential level of development in order Publish a state policy agenda Meyerson et al., 2003 [17] to understand what maximally could be accomplished Publish consensus or other Friedlaender and Winston, 2004 [18] evidence-based document aimed through problem solving experience or guidance in social at policy change learning contexts [20]. Using ZPD theory, we argue that ad- Advance model public health Hartsfield et al., 2007 [25] vancing public health workforce EBPC skills requires more legislation, regulation or ordinance than an assessment of the current level of (EBPC) develop- Publish policy implications as Giles-Corti et al., 2015 [26] ment and knowledge, which simply provides a starting point part of research publications for intervention development. When applied to public Give public testimony to policy Harris and Mueller, 2013 [16] health workforce EBPC skills, the ZPD can help clarify makers Meyerson et al., 2003 [17] types of and platforms for workforce interventions (see Meyerson and Sayegh, 2016 [15] Fig. 1). Further clarity about optimum policy behaviors Communicate with legislators, Harris and Mueller, 2013 [16] and capacities will ultimately be necessary to fully articu- regulatory officials, or other policy Meyerson and Sayegh, 2016 [15] makers regarding proposed late EBPC behavior and capacity development expecta- regulations, legislation or ordinances tions. For now, however, Brownson’s definition of using a Provide technical assistance to a Harris and Mueller, 2013 [16] balance of peer reviewed quantitative and qualitative evi- legislative, regulatory or advisory Meyerson and Sayegh, 2016 [15] dence through a variety of behaviors (Table 1) based on group for drafting proposed audience preference is a good start. legislation, regulation or ordinance Using ZPD, the research task includes describing and Program disseminates STD related Meyerson et al., 2003 [17] information to policy makers characterizing current public health policy knowledge (e.g. epidemiologic reports) and behaviors (actual level), clarifying optimum EBPC Participate on a board or panel Harris and Mueller, 2013 [16] behaviors (potential level), and identifying situational or responsible for health policy Meyerson and Sayegh, 2016 [15] structural opportunities for learning and development Program works with a state Meyerson et al., 2003 [17] within the ZPD. coalition on STD related issues To explore the application of ZPD to EBPC skills and Staff contact policy makers as Meyerson et al., 2003 [17] development, an exemplar issue was chosen which is individual citizens frequently challenging in U.S. policy contexts: human Conduct policy surveillance Brownson et al., 2009 [1] papillomavirus (HPV). Specific study aims included the Conduct media advocacy Chapman ad Lupton, 1994 [27] conceptualization of policy and EBPC to advance HPV Wallack et al., 1993 [28] and cancer-related outcomes, identification of actual Meyerson et al. BMC Public Health (2018) 18:700 Page 3 of 9 Fig. 1 Zone of Proximal Development (adapted) for Evidence-Based Policy Behaviors (EBPC). Meyerson et al., 2016 and potential development levels for HPV EBPC, and independently coded data and met to compare and resolve identification of potential ZPD elements. conflicts after reviewing a sample of interviews (N =10). Final coding was then conducted using the agreed scheme Methods with theentiregroup of interviews.Coded data were In-person, 60-min interviews were conducted with indi- then classified as low, moderate and high for each of viduals engaged in HPV, cancer and public health policy the learning/development levels. Results are presented work in Indiana from October–December 2015. We fo- as theme-related tables and as interview quotations for cused on the state policy process because of its import- deeper understanding. The study was deemed exempt ance to public health policy [21]. by Indiana University Institutional Review Board. The interview guide contained 12 open-ended questions exploring conceptualization of policy, EBPC, reported cap- Results acity to develop and use EBPC, and reactions to a ‘mock’ The sample consisted of 27 individuals across various policy brief (“mock-up”). The mock-up was presented in public health and policy organizations. State association the third portion of the interview and written with anon- participants (25.9%, 7) included associations of school ymized text using a Lorem ipsum generator to allow the health nurses, rural health providers, local health depart- observation of participant reaction and developmental ments, action agencies focused generally on health and thinking when presented with a partial presentation of human services, and organizations focused on cancer, EBPC for HPV. Interviews were recorded and transcribed HPV or reproductive health. Community level organi- for analysis with Nvivo software (QSR International, v.9). zations (22%, 6) included those focused specifically on Purposeful sampling drew one individual from each of minority health, health care coverage, reproductive health the following types of organizations: state associations, services, cancer, and immunizations. Clinical care and re- community coalitions, clinical care research, local and state search participants (22%, 6) were focused on cancer or government agencies, state legislature, and individual advo- HPV specifically. Local and state government participants cates. All participants were previously observed by authors (14.8%, 4) included public health departments, state legis- as involved in HPV or cancer policy communication. lators and state programs focused on cancer. Industry par- Indicators of current knowledge and behavior mea- ticipants (7.4%, 2) were focused on HPV immunization, sured participant level of actual development for EBPC. testing or cancer treatment. Individual advocates (7.4% 2) Reported current or prior exposure to or participation in operated in the policy process focusing on HPV vaccin- collaborative policy learning environments, and response ation, screening and/or cervical cancer treatment. About to the mock-up characterized the ZPD. Ratings of “Low, one third of participants (33.3%, 9) focused specifically on Moderate, and High” were assigned for the potential to HPV or cervical cancer, 25.9% (7) on immunizations, and develop and use EBPC for HPV. Ratings were assigned 33.3% (9) on cervical screening; and 40.7% (11) had jobs based on researcher evaluation of knowledge accuracy, working directly in the policy process. the congruence between policy goals and audience, and the reporting of concrete examples of EBPC develop Level of Actual Development for EBPC and/or use. Table 2 displays the application of ZPD theory The level of actual development for EBPC was indicated with associated study measures and explanations. by reported knowledge and behaviors in the policy Coding was a priori, based on Table 2 indicators, and also process. Most participants misunderstood public policy, open to allow further study exploration. Two researchers policy audiences and what constituted policy behaviors. Meyerson et al. BMC Public Health (2018) 18:700 Page 4 of 9 Table 2 Evidence-Based Policy Communication (EBPC) Study indicators by Zone of Proximal Development (ZPD) Components, Level of actual development Zone of proximal development Level of potential development Accurate knowledge about policy Exposure to or participation in collaborative policy learning Rankings for potential to develop What policy is and where it happens Experience with policy learning on the job, in association EBPC for HPV context, other Researcher assigned: Low, Moderate, High Accurate knowledge about EBPC (what it is) Exposure to EBPC examples from others Rankings for potential to use EBPC: Using a balance of quantitative Reported exposure through peers, peer organizations, EBPC for HPV and qualitative information through a on the job, other Researcher assigned as Low, variety of policy behaviors to convey Moderate, High public health evidence to a policy audience based on their known preferences. Accurate knowledge about goals for policy Prior/current experience in environments which have communication and audience potential to enhance social learning about EBPC Policy communication informs decisions Reported experience (current or past) about administrative or legislative policy. Awareness of audience preferences for communication (how much narrative, how much data, what type of data). Reported policy behavior indicating Proximity to the policy process understanding and use of EBPC Working in state policy process full time, part time, Reported examples of past or current EBPC. sometimes, seldom within the last 3–5 years. Response to EBPC “mock-up” Recognition of this type of communication, impact of mock up on interview discourse, engaged discussion (participant driven) about EBPC based on mock up. Explanatory text in italics Job-related experience in the policy process appeared to focused on education such as state vaccine laws mandating correspond with the level of actual policy development. education of parents or providers. While some participants However, while participants with policy related jobs gen- believed that increased knowledge about HPV or cervical erally expressed correct conceptualizations of policy and cancer would generally lead to “better HPV policy,” the policy behaviors, they did not necessarily know what concept of “HPV policy” was never disentangled from constituted EBPC (Table 3). information about HPV or cervical cancer. Those with cor- As shown in Table 3, participants with low or moder- rect policy knowledge discussed policy behaviors akin to ate knowledge of policy tended to confuse policy with those listed in Table 1 such as advocacy or policy maker HPV information, hospital policy, or parent, physician or education, policy monitoring and the production of policy private payor behavior. For these participants, policy was communications for specific audiences. construed as education for these audiences to encourage them to vaccinate/screen or to underwrite services. Those We engage in the full array of policy advocacy demonstrating correct knowledge about policy primarily from monitoring bills to doing educational forums conceptualized it as state legislation, and only four partici- and we educate members to actively lobby, both at pants discussed policy as administrative action (funding, the grassroots level and direct lobbying of regulation, et cetera) by state agencies or the governor. A legislatures and administrators at the state and correct example of administrative policy was given by this federal level. participant: The confusion of policy and education appeared to be Medicaid made a change to their policy to cover all connected with an understanding that EBPC meant talk- adults in pharmacies….But what they did at the same ing only about cervical cancer or HPV epidemiologic time was (to require) all Medicaid eligible VFC evidence such as diagnosis or death rates, or information children to get their vaccines from a VFC provider, about the virus itself. There were, however, correct ex- which meant basically that the pharmacy could no amples of EBPC tools informed by such evidence and longer bill for it. developed to achieve policy goals. These included policy briefs or ‘report cards’ focused on a specific policy out- Those participants confusing HPV or cervical cancer come, the use of evidence in legislative testimony, or education with policy notably did not discuss policies evidence-based policy recommendations. Meyerson et al. BMC Public Health (2018) 18:700 Page 5 of 9 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � Table 3 Indicators and Levels of Actual Development for Evidence Based Policy Communication (EBPC) about Human Papillomavirus (HPV), 2016 (N = 27) Indicators Levels of actual development with reported examples from interviews High level Moderate level Low level Policy knowledge Legislative decisions (HPV vaccination, School principal decisions about public information Public, parent or physician decision to Medicaid expansion, reproductive health in school vaccinate or access cervical cancer screening services access) Private insurer decision to require HPV testing Administrative decisions (Medicaid, VFC ) Goals of policy communication Remove barriers to access Support public discussion (school) about HPV, Increase knowledge of HPV and related cancer Invest in programming vaccination and/or screening Change opinion about benefit of screening or Require standard of care vaccination or Reimburse for screening (private insurers) vaccination among parents, teachers, providers screening Evidence Data from peer reviewed studies Stories from those affected (Only and not with Information about coalition messenger(s) Economic data other evidence) Any information about HPV or cervical cancer Epidemiologic data Some studies or information from CDC about Stories from those affected HPV or cancer EBPC knowledge Integrating evidence with desired policy Education about HPV and/or cervical cancer Not sure what it is, what it looks like, or how change for specific policy audience primarily for non-policy audience (what it is) to use Reported EBPC behaviors Use of: Public information about HPV and cervical cancer Giving testimony to legislature (The act but Policy report cards Screening and vaccination recommendations without quantitative or qualitative evidence) Policy briefs for doctors or insurers Grassroots coaching for letters, testimony, media contact, meetings VFC Vaccines for Children Program CDC Centers for Disease Control and Prevention Meyerson et al. BMC Public Health (2018) 18:700 Page 6 of 9 We have an annual report (which is) our ultimate Zone of Proximal Development policy brief ranking states in 11 different policy areas. Participants discussed how they obtained their policy It provides the background of what the problem is, a knowledge, learned policy behaviors, and learned about policy solution, and an issue overview that includes a EBPC. Every example was social and work-related instead lot of evidence in statistics about why that issue is of formal education-based; and each example included important. collaborative learning or policy modeling. Despite the reported policy awareness of some partici- (I learned) on the fly. You really learn how to put pants, most of the sample did not appear to understand together a good policy brief by trial and error, and EBPC. Only those that developed “policy briefs” reported through that communications process of giving that concepts about what EBPC might involve beyond pro- information to your various audiences and them viding written information specifically about cervical asking questions or telling you that they need more cancer or HPV as health issues. Those with stronger information. EBPC knowledge tended to have work-related experi- ence in the policy process and had some capacity to de- Over half of participants reported experience with velop EBPC. That said, experience working with the policy coalition work – whether led by the participant’s legislature was not sufficient to develop participant organization, or whether the participant was part of a knowledge or capacity to use EBPC. For example, one larger coalition focused on some aspect of health policy. participant with years of legislative experience stated These participants spoke about coalition experience as that the evidence informing any policy communication contributing to their policy learning. Notably, coalitions was about the coalition members themselves. discussed by participants were not necessarily focused on HPV or cervical cancer, as less than half reported being We try to develop a plan of what we can say (to part of such a coalition. However, the cooperative policy legislators) in a short amount of time, not more than learning environment from any policy-related coalition ex- one page, probably double spaced so that we can say perience appeared to be transferrable from issue to issue one, two, three, this is what we see, this is the facts we and endured over time. know, this is what we would like to see happen and this is why we’d like to see it happen. However, there Okay, here’s how I learned to [put together a good is evidence, which is that our members (as a policy brief]. Being part of the HIV Community profession) are trusted.….I have to say I don’t think Planning Group and at some sort of public forum, only I’ve taken any (data). having like a minute or less to talk about HIV, and trying to get a whole lot of important stuff into this What constituted public health policy evidence ranged minute or less. for participants. For those who functioned in the policy process, several indicated that a balance was needed One participant reported active engagement in the de- between research or studies about the effectiveness of velopment of EBPC communication skill and knowledge screening and follow-up investments and personal narra- with the organization’s coalition members in order to, in tives. Participants felt this was particularly the case for this example, further healthcare funding policy: HPV, given the tremendous social judgement about sexual activity. To navigate moral policy, one participant stated So I really say to (the coalition members): the first that “[Something] I’ve actually learned over the years is thing you need to have with you is data, so let’s talk that I sometimes am more powerful if I give anecdotes about the number of uninsured in your county. Maybe [rather] than evidence.” 2013 is a good benchmark ‘cause that was pre-ACA, Challenges identifying and presenting evidence were and then write down how many enrollments happened reported by several participants at all levels of development. in 2013 and 2014. The numbers really speak for Some participants felt the burden of “wading through CDC themselves. data” to identify the latest information about HPV when preparing to talk with state lawmakers. Others noted the While participants ranged in EBPC knowledge and challenge of synthesizing the most recent studies of HPV practice, everyone had a response to the EBPC mock-up. and cervical cancer, and translating the information into These responses ranged from conceptualizations of it as understandable concepts. Those rated as having high levels “another way to organize the information,” to active and of actual policy development were challenged to find policy evolving reflection about issues related to the gathering related evidence, such as the impact of vaccine policy, or and framing of evidence for policy argument. Partici- public funding for alternative screening venues. pants spoke of capacity (or lack of) to develop similar Meyerson et al. BMC Public Health (2018) 18:700 Page 7 of 9 material and the usefulness of it; especially with a moral Discussion policy issue such as HPV. Here, the challenge was one This exploratory study suggests that EBPC development of balancing evidence about policy effectiveness such as interventions for the public health workforce would bene- HPV vaccine policy with stories about human impact. fit by using the ZPD framework, because the ZPD helps to elucidate current activity (actual), facilitators of knowledge and skills development (zone), and estimates potential for Level of Potential Development future skills and knowledge. The ZPD framework also em- Levels of potential development began to arise after consid- braces the permanently iterative relationship between ering the actual level of development and emerging indica- learning and development. This is good in the long run, tors of the ZPD. We classified potential development levels because if one were to solely measure actual policy know- based on participant identification of zone indicators. For ledge and skill levels and presume that those rated high example, over half of the sample (60%) was categorized as for actual development were in no need for further devel- moderate to high potential to develop and or use HPV opment, we would miss an important observation from EBPC becausetheyreportedopportunityfor learning and this study: that those who were active in the policy process development through modeling, guided example in job or still did not necessarily understand, develop or use EBPC. coalition environments (see Table 4). Discussion emerging from encounters with the mock-up Those rated as having moderate and high EBPC po- provided a good opportunity to observe potential for future tential tended to have a job that required full-time development and knowledge; however, the estimates for participation in the policy process. An exception to potential development were limited because they are this involved- two participants who held jobs in orga- unverifiable without a retrospective study design relying nizations that limited their engagement with the policy on participant self-report of historical learning and develop- process; however, their role was to prepare coalition ment, or a prospective design over a longer period of time members for it. Participants reporting one or less than with focus on measuring knowledge and observing behav- one engagement in the policy process since 2013 were iors and EBPC tools used. We recommend both retrospect- rated as low for the capacity to develop and/or use ive and prospective study designs for this purpose. HPV EBPC because of the limited opportunity to learn The emergence of self-reported zone indicators such and practice it. Further, while coalition engagement as job focus, policy proximity, and coalition experience appeared to be a policy learning ground for many par- provide a starting point for further indicator characterization ticipants, being in a cancer-related or HPV coalition and evaluation. This is because, to our knowledge, there is did not necessarily translate to a high policy develop- no theory of policy learning and skills development beyond ment classification especially if participants did not the focus on the evolution of policy ideas [22, 23]. As ZPD report collaborative policy learning or development indicators are further developed, it will be important to ver- opportunities. ify their precise contribution to development and learning. Table 4 Zone of Proximal Development (ZPD) Indicators for Evidence-Based Policy Communication (EBPC) about Human Papillomavirus (HPV) by Levels of Potential Development, 2016 ZPD Indicators High level Moderate level Low level Exposure to or participation in � Is an advocacy coalition member � Has coalition experience, but � Has no exposure. Receives collaborative policy learning � Has a policy role in organization no recognized collaborative no coaching from others. learning Exposure to EBPC of others � Has developed or co-developed � Has used, but not developed � Has no exposure. EBPC � Has observed others using Prior/current experience in � Is a policy coalition member � Could join a policy coalition � Is a policy coalition member environments with potential � Has a work environment with with EBPC potential. (though unlikely that coalition for social learning about EBPC potential for EBPC learning (Awareness of such a coalition) has potential to develop or � Has potential to work with use EBPC) others through job (but not currently) Proximity to the policy process � Has full time policy job � Has periodic policy process � Gave policy testimony once � Has a policy role for organization engagement or twice before but not primary job Response to Mock-up � Has clear recognition of EBPC tool(s) � Demonstrated moderate � None to slight recognition of based on mock-up recognition of EBPC tool mock-up as an example of EBPC. � Demonstrated advanced thinking after exposure to mock-up Focused more on format than and conversation about EBPC and � Unclear how to use it concept. how tool might be used � Unclear whether could or would use Meyerson et al. BMC Public Health (2018) 18:700 Page 8 of 9 Their self-reported existence alone does not mean that who know about and engage in EBPC. Second, sampling EBPC related learning and development occurs or is even should include a variety of public health policy issue related to them. That said, participant meaning making areas to test whether the elements are shared widely or about their own policy learning journeys should not be are disease/condition specific. Finally, the next iteration devalued in the absence of studies about the associ- of studies should explore whether adaptation of EBPC ation between reported zone indicators and observed behaviors is acceptable and under what conditions. EBPC development. These findings would assist the selection of a dissemin- Similarly, there remains the challenge of knowing ation and implementation framework to guide policy when one encounters a correct reported example of capacity intervention design and testing. EBPC versus something incorrectly construed as EBPC. Abbreviations This is a study limitation, as we did not see examples of EBPC: Evidence based policy communication; HPV: Human papillomavirus; reported EBPC in the course of the study. All partici- ZPD: Zone of Proximal Development pants were asked to provide examples after their inter- Funding views, but only those who were coincidentally assessed This study was supported by a grant from the Anita Aldrich Foundation as developing and using EBPC actually did. Thus, there and a grant from Roche Diagnostics corporation. was no opportunity for content analysis verifying re- Availability of data and materials ported EBPC. Participant response to the mock-up did The datasets generated and/or analyzed during the current study are not facilitate observation of completely independent thinking publicly available as the interview transcripts contain information that will identify participants and their organizations. The corresponding author will about what an EBPC tool might look like and issues with consider reasonable requests. it; as if the opportunity to reflect on the mock-up was in and of itself a social learning opportunity for EBPC. That Authors’ contributions BM acquired the funding for the study. BM, GZ, KC conceived of the study. said, the vagueness (Lorem ipsum wording) might be BM and LH gathered and analyzed the data. BM led the writing of the considered a study weakness albeit developed to avoid manuscripts. All authors actively participated in the editing of the confounding. manuscript. All authors read and approved the final manuscript. Our observation that several participants confused policy Ethics approval and consent to participate with education for individual level behavior change reflects This study was deemed exempt by the Indiana University Institutional findings from our prior study of state comprehensive Review Board. Participants gave informed consent verbally. cancer plans. In the case of the cancer plans study, this Competing interests was likely because there were few policy related partners in- The authors declare that they have no competing interests. volved in the development of state plans [24]. Interestingly, in this EBPC study there was policy experience, and yet that Publisher’sNote did not necessarily mitigate the confusion of education Springer Nature remains neutral with regard to jurisdictional claims in about HPV/cervical cancer and policy. published maps and institutional affiliations. A remaining challenge is identifying what constitutes Author details evidence for policy communication. While a few partici- Rural Center for AIDS/STD Prevention, Indiana University School of Public pants reflected Brownson’s finding that evidence is a bal- Health-Bloomington, Bloomington, Indiana, USA. Department of Applied Health Science, Indiana University School of Public Health-Bloomington, ance of quantitative and narrative data, several participants Bloomington, Indiana, USA. Center for HPV Research, Indiana University felt that evidence was only about HPV or cervical cancer as School of Medicine, Indianapolis, Indiana, USA. The Polis Center, Indiana virus and condition. Only one participant identified the University Purdue University at Indianapolis, Indianapolis, Indiana, USA. Department of Adolescent Medicine, Center for HPV Research, Indiana challenge of not having a body of evidence about HPV and University School of Medicine, Indianapolis, Indiana, USA. cervical cancer policy, such as the impact of vaccine fund- ing regimes, state policy incentives for HPV vaccination, Received: 12 October 2017 Accepted: 28 May 2018 cervical screening and follow-up in alternative settings, or related structural incentives such as insurance requirements References to achieve vaccine and screening outcomes. The challenge 1. Brownson RC, Chriqui JF, Stamatakis KA. Understanding evidence-based public health policy. Am J Public Health. 2009;99(9):1576–83. is for all public health policy researchers to contribute to a 2. Brownson RC, Dodson EA, Stamatakis KA, Casey CM, Elliot MB, Luke DA, body of evidence for EBPC. Wintrode CG, Kreuter MW. Communicating evidence based information on cancer prevention to state level policy makers. JNCI. 2011;103(4):306–16. 3. 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Mays GP, McHugh MC, Shim K, et al. Identifying dimensions of performance in local public health systems: results from the National Public Health Performance Standards Program. J Public Health Manag Pract. 2004;10(3):193–203. 8. National Association of County and City Health Officials. 1990 National Profile of local health departments. Washington, DC: National Association of County and City Health Officials; 1990. 9. Williams-Crowe SM, Aultman TV. State health agencies and the legislative policy process. Public Health Rep. 1994;100(3):361–7. 10. Viruell-Fuentes EA, Miranda PY, Abdulrahim S. More than culture: structural racism, intersectional theory and immigrant health. Soc Sci Med. 2012;75(12):2099–106. 11. Blankenship KM, Reinhard E, Sherman SG, EL-Bassel N. Structural interventions for HIV prevention among women who use drugs: a global perspective. J AIDS. 2015;69(sup 2):s140–5. 12. Biradavalo MR, Blankenship KM, Jena A, Dhugana N. 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BMC Public HealthSpringer Journals

Published: Jun 5, 2018

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