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There is a dearth of advocacy training in graduate medical education in the United States. To address this void, the Legislative Education and Advocacy Development (LEAD) course was developed as an interprofessional experience, partnering a cohort of pediatrics residents, fourth-year medical students, and public health students to be trained in evidence-informed health policy making.
The objective of our study was to evaluate the usefulness and acceptability of a service-based legislative advocacy course.
We conducted a pilot study using a single-arm pre-post study design with 10 participants in the LEAD course. The course’s didactic portion taught learners how to define policy problems, research the background of the situation, brainstorm solutions, determine evaluation criteria, develop communication strategies, and formulate policy recommendations for state legislators. Learners worked in teams to create and present policy briefs addressing issues submitted by participating Illinois State legislators. We compared knowledge and attitudes of learners from pre- and postcourse surveys. We obtained qualitative feedback from legislators and pediatric residency directors.
Self-reported understanding of the health care system increased (mean score from 4 to 3.3,
Promising results were demonstrated for the LEAD approach to incorporate advocacy training into graduate medical education.
Since the 1970s, both US legislators and the public have shown diminished confidence in physician leadership [
There are very few published studies of curricula that train health care professionals in advocacy to provide optimal patient care [
To address this void in health professional education, a multidisciplinary faculty committee at the University of Illinois at Chicago, USA, created the Legislative Education and Advocacy Development (LEAD) course to train pediatrics residents, public health students, and fourth-year medical students to think critically about health care, analyze policy, and communicate effectively about policy through the method of legislative briefing. The LEAD course sought to help learners to discern the actors and institutions involved in the policy-making process; critically examine the context of policy developments; appreciate how issues are placed on the policy-making agenda; understand the process of policy development, implementation, and modification; and apply dominant conceptual theories of the policy-making process to a critical health issue.
The LEAD curriculum therefore drew from previously established advocacy training programs to provide learners with the tools to understand and engage in health policy making [
We used a single-arm pre-post study design to study the feasibility of the LEAD course and its impact on attitudes and knowledge among learners.
We purposively invited pediatrics residents, fourth-year medical students, and public health students by email to participate in the 2-week LEAD course. A pediatrics faculty member with 3 years of policy experience and a public health faculty member with 20 years of policy experience were the instructors for the course. The course and study were conducted in February 2016. We expected learners to spend about 40 hours per week on their work. This time was divided thusly: 30 hours per week spent on modules and preparation with the group, and 10 hours per week on lectures and mock panels. Learners’ pre- and postcourse surveys were printed, self-administered, and anonymous to ensure privacy, and therefore completion of the surveys did not affect learners’ grades in the course. Additionally, only approved members of the research team had access to the surveys to ensure confidentiality.
We received ethical approval from the Institutional Review Board of the University of Illinois at Chicago (December 21, 2015, Research Protocol # 2015-1084). The study was consistent with the ethical standards of the Declaration of Helsinki. All learners provided verbal informed consent to participate in the study; this was obtained by the lead author and not recorded.
The curriculum had two parts: didactics and experiential learning.
Learners participated in didactics, largely grounded in the works of Bardach, concerning background and landscape discovery, reiterative formulation of problem statements, and decision-making criteria [
Concurrently, learners worked in 4 independent interdisciplinary teams to create briefs based on specific child health queries submitted directly from the state legislators. Learners discoursed both in live groups and virtually by cocreating briefs through Google Docs (Google Inc). Some examples of queries are lead abatement, gun control, access to home care services for disabled children, and licensure of professional midwives. In creating these briefs, learners used legislator values to create decision-making criteria, which guided research and policy analysis.
We assessed knowledge with 15 questions on the pre- and postcourse surveys. These questions tested learners on factual data such as major US health care policies, components of a policy brief, and identification of state legislators and their governmental roles. Of these 15 questions, 13 were multiple choice questions with 4 to 12 answer choices, and 2 were free-response questions: “Who is your district’s state Senator?” and “Who is your district’s state Representative?” The highest possible correct total score was 15.
The pre- and postcourse surveys gave 13 attitude questions with possible answers ranging from 1=strongly agree to 5=strongly disagree. We analyzed each question separately. Content was adapted from 2 previously reported questionnaires on medical students’ and residents’ attitudes [
Learners were asked questions concerning quantity, quality, and engagement in past and present health policy instruction via the pre- and postcourse surveys. Questions 1 and 2 were rated from 1=excellent to 4=poor, questions 3 and 4 were rated from 1=excellent to 4=N/A (ie, not applicable), and questions 5 and 6 were rated from 1=strongly agree to 5=strongly disagree. To further measure feasibility and gauge interest among pediatric residency program directors, we presented the curriculum as a workshop at the Association of Pediatric Program Directors 2016 annual meeting and collected feedback. In addition to open-ended feedback, the 9 pediatric residency program directors who viewed the presentation were asked “Would you want this type of experience at your institution?” State legislators were queried in an open-ended format regarding their experience.
Due to an insufficient number of paired responses, we did not perform inferential statistical tests for the knowledge and attitudes questions. As applicable, we assessed program feedback data with a Wilcoxon signed rank test and otherwise assessed the feedback qualitatively for themes. We conducted statistical analyses using SAS version 9.4 (SAS Institute). All
A total of 10 learners provided pre- and postcourse surveys. We received 9 responses for demographic data (90% response rate), 5 precourse knowledge surveys (50% response rate), 7 postcourse knowledge surveys (70% response rate), 8 precourse attitude surveys (80% response rate), 7 postcourse attitude surveys (70%), and 10 sets of program feedback data (100% response rate). However, many of the pre- and postcourse attitude surveys were incompletely filled out by learners, and on further inspection it appeared this was partly due to secretarial issues, with some questions printed on the back of the page. We received qualitative feedback from 4 state legislators and 9 pediatric residency directors.
Demographics and characteristics of participants in the Legislative Education and Advocacy Development course (n=10).
Characteristics | n | % | |
Male | 6 | 60 | |
Female | 2 | 20 | |
No response | 2 | 20 | |
22-25 | 1 | 10 | |
26-29 | 2 | 20 | |
30-33 | 2 | 20 | |
>34 | 3 | 30 | |
No response | 2 | 20 | |
White (non-Hispanic) | 1 | 10 | |
Black (non-Hispanic) | 3 | 30 | |
Hispanic or Latino | 2 | 20 | |
Asian or Pacific Islander | 1 | 10 | |
Other | 1 | 10 | |
No response | 2 | 20 | |
MD/DO | 5 | 50 | |
Bachelor’s degree | 8 | 80 | |
Master’s degree | 2 | 20 | |
PhD | 0 | 0 | |
MPH | 2 | 20 | |
No response | 2 | 20 |
Learners’ scores improved from a mean of 6.8 out of 15 to 12.0 out of 15 by the end of the course (
Mean and 95% CIs of pre- and postcourse knowledge scores.
Mean pre- and postcourse attitude scoresa, with number of responders.
Statement | Pretest |
Posttest |
|
1 | It is part of my job as a physician to advocate for policy change on behalf of children. | 1.38 (0.74) |
1.29 (0.49) |
2 | I feel that my role as a health advocate extends beyond the individual patient(s) I am treating. | 1.25 (0.46) |
1.14 (0.39) |
3 | I plan to take leadership in health care policy issues as a physician. | 1.75 (0.71) |
1.57 (0.54) |
4 | I plan to support universal health care coverage as a physician. | 1.50 (0.54) |
1.29 (0.49) |
5 | I don’t expect to have any time to be active politically as a physician. | 3.75 (0.89) |
3.86 (0.90) |
6 | Health policy will have no effect on how I care for my patients. | 4.50 (0.58) |
5.00 (0.00) |
7 | The government should guarantee health care access for all citizens. | 1.25 (0.50) |
1.29 (0.49) |
8 | The government should provide health care access for all citizens, even if higher taxation is needed to generate sufficient revenue. | 2.00 (1.41) |
1.57 (0.54) |
9 | I would prefer my health care system to be “free market” rather than government controlled. | 3.00 (0.00) |
3.57 (0.79) |
10 | The government should regulate the prices of health care services. | 2.50 (1.00) |
2.29 (0.49) |
11 | Health care services would improve if the government had no involvement in health care. | 4.25 (0.50) |
4.29 (0.95) |
12 | All citizens should have access to the same standard of medical care without regard to their financial means. | 1.50 (0.58) |
1.71 (1.50) |
13 | All children should have access to the same standard of medical care without regard to their financial means. | 1.00 (0.00) |
1.43 (1.13) |
aAnswers ranged from 1=strongly agree to 5=strongly disagree.
Questions | Precourse |
Postcourse |
|
1. How would you rate your understanding of your health care system? | 3.00 (0.67) | 2.30 (0.48) | .01 |
2. How would you rate your understanding of health care systems in other “advanced/developed” countries? | 3.30 (0.05) | 3.00 (0.67) | .05 |
3. How would you rate the quantity of instruction on health care policy received in your current training program? | 2.70 (0.67) | N/Ab | N/A |
4. How would you rate the quality of instruction on health care policy received in your current training program? | 2.89 (1.27) | N/A | N/A |
5. The current likelihood of my engaging in health policy activity/activities has increased compared to 1 month ago. | N/A | 2.29 (0.82) |
N/A |
6. The current likelihood of my recommending that my colleagues engage in health policy learning has increased compared to 1 month ago. | N/A | 2.43 (1.41) |
N/A |
aQuestions 1 and 2 were rated from 1=excellent to 4=poor, questions 3 and 4 were rated from 1=excellent to 4=N/A, and questions 5 and 6 were rated from 1=strongly agree to 5=strongly disagree.
bN/A: not applicable.
We queried 4 state legislators about their experience with the LEAD course, and their responses were positive. Specifically, 2 state legislators expressed themes of efficacy. For example, 1 legislator wrote that this was “a thoughtful and well-researched brief that greatly improved my understanding in the area.” All state legislators expressed a desire to continue participating. For example, 1 legislator wrote, “I look forward to working with the learners again next year.” Of 9 pediatric residency program directors queried at the national conference, 8 (89%) said yes and 1 (11%) said maybe, regarding their desire for this type of course at their institution. Qualitatively, they found the experience insightful, were interested in viewing the didactics, and would like to incorporate LEAD into their training program.
The hypotheses for our LEAD course pilot study were all supported. We found that knowledge improved from pre- to postprogram. We found that attitudes were generally consistent from pre- to postprogram. We found that the pilot was well received by learners who took the course, pediatric residency program directors who may choose to implement the course, and the state legislators who participated in the course.
Knowledge improved meaningfully when learners’ scores improved (6.8/15 to 12.0/15) on the postsurvey questionnaire. Knowledge outcomes among health policy training programs for medical students and residents to date have been self-assessed [
As hypothesized, scores on attitude questions for LEAD learners did not generally change between pre- and postcourse. This was likely a product of the already extreme Likert responses at baseline and the small sample, which self-selected into a policy course. Categorically stable attitudes that are held over time tend to better predict behavior than attitudes that change [
Measuring attitudes is important, since attitudes may correlate closely with long-term behavioral outcomes in general [
Another focus of our study was to measure feedback from the 3 key types of players in the LEAD course: learners who took the course, pediatric residency program directors who may choose to implement the course, and the state legislators who participated in the course. There was broadly positive feedback from learners, pediatric residency program directors, and state legislators. More specifically, evaluative data from learners suggested that their understanding of the health care system improved, and prior to our course, their health care policy training was quite limited. In addition, the learners indicated a “good” likelihood of both engaging in health policy activities and recommending that a colleague engage in health policy learning. This is important because we know that learners’ subjective opinions about a course directly translate to both their long-term behavioral changes and their underlying satisfaction with their education [
Although legislators have previously signaled a desire to work with undergraduates, none have been surveyed in the context of graduate medical education [
This study has several limitations. First, the sample size was small. Second, we did not use a control group. This limited the ability to assess attitudes and knowledge of those medical students, residents, or public health students not participating in an intensive advocacy experience. Third, the lack of responses limited the ability to perform certain inferential statistical tests. Fourth, we did not collect data on how learners used their time; this would have been valuable to examine and perhaps compare with other advocacy training programs. Future research should study this topic with a larger sample and a control group.
There were promising results from the LEAD course as an acceptable and useful tool incorporating advocacy training into graduate medical education in the United States. The LEAD curriculum should be considered by institutions and programs seeking to help generate a new cadre of policy leaders from within the health professions.
Advanced organizer.
Course objectives.
Decision-making chart.
Legislative Education and Advocacy Development
The authors wish to acknowledge and thank Leana Wen, MD MSc, Health Commissioner of Baltimore City, and Fitzhugh Mullan, MD, Murdock Head Professor of Medicine and Health Policy, George Washington University, for their guidance in creating this course, and for their years of dedication to the health policy training of physicians and allied health professionals.
Funding for course development was provided by a grant from the Institute for Policy and Civic Engagement.
Financial support for the open access publishing fee for this article was provided by the Research Open Access Publishing (ROAAP) Fund of the University of Illinois at Chicago.
This topic was previously presented at the Association of Pediatric Program Directors Annual Meeting, New Orleans, LA, USA, April 2016.
None declared.