Meyerson, Beth E. MDiv, PhD*; Chu, Bong-Chul MHA, PhD*; Raphael, Theresa L. MPH†
SEXUALLY TRANSMITTED DISEASE (STD) prevention programs are located in state, county, city, and U.S. territorial public health departments. These programs are expressions of the public effort to prevent and control diseases and conditions resulting from sexual exposure. STD prevention has been a governmental public health activity primarily since World War II, with initiation by a select few cities and counties before the war. 1,2
In 1997, the Institute of Medicine Committee on Prevention and Control of Sexually Transmitted Diseases argued that state-level public health policy leadership was needed in order to increase the contribution of state governments to STD prevention. The second of four recommended strategies to establish an effective national system to prevent STDs was to “develop strong leadership, strengthen investment, and improve systems for STD prevention.”3 Such a strategy involved, among other things, the development of strong advocacy for effective STD prevention by public and private organizations. Development of state and local electoral support was identified as being critical to resource development and policy support for STD prevention.
The opinion that policy activity was somehow related to policy outcomes and support for public health functioning was not new. The case was made formerly by the Institute of Medicine in 1988 that policy development was a core public health function. 4 Furthermore, and about STD prevention specifically, the mid-1990s was a period of emerging recognition that collective policy activity at local, state, and national levels would produce support for programming. The agenda of infertility prevention emerged in the early to mid-1990s at a federal level, the National Coalition of STD Directors was formed in 1997, and a national initiative to eliminate syphilis was implemented in 1998.
While public health policy activity was gaining importance and STD issues were finding policy agenda placement, there was little known about the activity of STD public health practitioners and programs in the state policy arena. An increased understanding of such activity was required to understand how STD programs were working at a state level to develop support for STD prevention programs and policies.
The objectives of this study included identification of an initial understanding of state-level policy behaviors by state STD programs for 1995 and 2000 and examination of potential associations between and among state-level policy behaviors and select state characteristics. Several recommendations are advanced to strengthen future evaluation, as this was the first assessment of state policy activity by public health programs.
State STD directors were surveyed in 2001 to identify the policy behaviors of their programs in state policy processes for 1995 and 2000. The survey was a component of a national STD program infrastructure needs assessment. 5 State STD directors are those persons responsible for the leadership of state STD programs. Recruitment of the state STD directors was achieved by the National Coalition of STD Directors (NCSD), an organization comprising health department STD programs in the 50 states, 7 cities, and the 8 U.S. territories.
By way of definition, the state policy process was understood as the state-level organizational arena in which policy-related activity occurred. The state policy process included a host of policy actors and organizations such as state legislatures, state-level coalitions, and other policy-makers who might impact the development of state-level policy and support for STDs. The conception of policy process grounding this study was consistent with a broad understanding of policy process. 6–9 Contrasting understandings construe policy process as component stages of policy development in a given policy arena, although there is considerable variation in the policy literature. 10–13
Information regarding the policy behaviors of STD programs was gathered through a written survey focused on STD program infrastructure need. Eight potential STD program behaviors in the state policy process were measured through recall and self-report for 1995 and for 2000. Several behaviors measured were identified as being important initiators of policy change in previous public health policy research. 5,14,15 The policy behaviors measured are listed in Figure 1.
In addition to those behaviors listed in Figure 1, survey respondents could indicate whether the state STD program lost contact with the policy process or whether the state STD program had no contact with the policy process for 1995 and for 2000. At the time of survey development, STD directors expressed the need to measure not only activity or lack thereof in the policy process but also the situation of transition from being active in the policy process to losing contact with the policy process. 5
Reported policy activity was also examined for association with several state characteristics theorized to have potential impact on the behavior of STD programs in the state policy process. 15 These characteristics included (1) geographic region of the United States, as defined by the Centers for Disease Control and Prevention 16; (2) type of STD program, whether “stand alone” or combined with an HIV program; (3) state population 17; (4) levels of reported state general revenue funding to the state STD program; (5) STD budget diversity, as measured by the percentage of federal funding in the state STD program budget 5,15; (6) per capita STD program spending; (7) state racial/ethnic diversity, measured by the proportion of whites in a state population; and (8) state general revenue strength, as measured by the balance of state general revenue as a percentage of general revenue expenditures. 17
This final characteristic was chosen on the basis of the premise that states experiencing financial austerity might contribute differently to their STD programs than states in other financial conditions, given budget requirements to spend on entitlement health services such as Medicaid. 15 A potential association between reported state STD program policy behaviors in state policy processes and the strength of the state general revenue budgets was also thought to exist; however, the direction of the relationship was not clear.
In view of the historic role of federal funding in state and local STD prevention programs, 1,5,15 it was hypothesized that state STD programs with more diversified budgets, in terms of state and federal revenue mix, would report greater involvement in state policy processes. This supposition was grounded in the historic presence of the federal government in state STD programs, as expressed through personnel and financial channels. In a federally focused organizational context, state agenda setting and policy development as indicated by reported policy activity was presumed to be minimal. 15
Policy behaviors were dichotomous, and the number and proportion of states reporting each behavior were calculated. The frequency of reported state STD program policy activity for 1995 and 2000 was examined, and the change in reported state STD program policy activity from 1995 to 2000 was analyzed with the McNemar test of change to establish whether any observed change between behaviors reported for 1995 and those reported for 2000 activity was statistically significant at the P ≤ 0.05 level. Pearson product moment correlations among policy behaviors were examined for potential associations between reported policy behaviors at the P ≤ 0.05 level.
Thirty-seven of the 50 state STD directors returned surveys and provided complete program-level financial data upon follow-up contact, for a response rate of 74%. While not an entire representation of state STD programs, the responding states encompassed the geographic and economic distribution of state STD programs in the United States. 5,15 Caution is suggested, however, vis a vis generalizing to the population of state STD programs in the United States.
A majority of state STD programs reported some level of state policy engagement, as 75.7% of responding state STD programs reported at least one policy behavior in the state policy process for 1995 and for 2000. Twenty-four percent of state STD directors reported that their programs either had no contact or had lost contact with the state policy process in 1995. The same number of states reported this circumstance for 2000. There was a discernible increase in certain state-level policy behaviors when we compared reported activity for 1995 and 2000.
The most frequent of policy activities reported for 1995 was dissemination of STD information to policy-makers. This activity was reported by 12 programs (32.4%) for 1995 and 19 programs (51.4%) for 2000 (P ≤ 0.05). Provision of testimony before the state legislature, whether about the state STD program budget or about an STD-related policy issue, was the type of behavior that increased most between 1995 and 2000. There was a 67% increase (P ≤ 0.01) in the provision of testimony on key STD policies before the state legislature, an increase of 63% (P ≤ 0.05) observed for reported state STD program work with a state coalition, and an increase of 58% (P ≤ 0.01) in the reported provision of testimony at state STD budget hearings. State STD programs also reported increased involvement with policy-related STD coalitions (Table 1).
Findings suggest potential continuity in state STD program policy behaviors, as certain policy behaviors reported for 1995 tended to be reported for 2000 as well. Moderate Pearson correlations (P ≤ 0.05) were found in comparison of the following five policy behaviors: the publishing of an STD policy agenda, the provision of testimony before the state legislature regarding the STD program budget, the provision of testimony before the state legislature regarding STD policy issues, STD program participation with an STD coalition, and STD program dissemination of STD-related information to policy-makers (Table 2).
There were a few noted bivariate correlations suggesting associations among several reported policy behaviors. The strongest correlations were found between policy behaviors involving the provision of testimony before state legislatures. State STD programs reporting testimony before the state legislature on budget issues tended also to report the provision of testimony regarding STD policy issues (P ≤ 0.01). State STD programs reporting policy and budget testimony also tended to report that the program disseminated information to policy-makers in 1995 and 2000 (P ≤ 0.05).
State STD programs reporting policy testimony in 2000 also tended to report that they participated in coalitions in 2000 (P ≤ 0.05). Furthermore, state STD programs reporting coalition work in 1995 and 2000 also tended to report that they disseminated information to policy-makers in 2000 (P ≤ 0.05;Table 3).
Several state characteristics were selected for comparison with reported state STD program activity. These characteristics included state population, state racial/ethnic diversity, whether the STD program was a “stand alone” or combined with an HIV program, state general revenue levels, the strength of state general revenue budgets, the proportion of federal funding in a state STD program budget, per capita STD expenditures, and U.S. region.
Moderate bivariate correlations were observed (Table 4) and suggest a potential relationship between three characteristics and select policy behaviors of state STD programs: state general revenue strength (fiscal strength), per capita STD program expenditure, and geographic region of the country. State fiscal strength in 1995 and 2000 was associated with whether a state STD program published a policy agenda in 2000; STD programs with higher per capita expenditures in 2000 tended to report that individual staff members contacted policy-makers as individual citizens in 2000, and Midwestern state STD programs tended to report the provision of budget testimony and policy testimony before state legislatures.
When reported policy activities were combined to express state-reported STD program policy activity in the aggregate for 1995 and for 2000, it was found that states with more diversified STD program budgets in 2000 tended to increase their activity in the state policy process in a comparison of reported activity for 1995 and 2000 (P ≤ 0.05). In terms of state fiscal strength generally, it was found that states reporting higher aggregated policy activities in 2000 tended to report stronger state general revenue budgets for 1995. (State fiscal strength was measured by the balance of state general revenue as a percentage of general revenue expenditures [personal communication with S. Patteson and S. Mazer of the National Association of State Budget Officers, December 12, 2001].)
The findings of this initial study of state STD program activity in the state policy process revealed that state STD programs are engaged in their state policy processes in some way, as three quarters of the respondent states (75.7%) reported at least one activity to engage in the state policy process. The engagement was found to increase for certain activities when activity reported for 1995 was compared with activity reported for 2000. These activities included state STD policy coalition involvement, the provision of testimony on budget or STD policy, and the dissemination of STD information to policy-makers. Further, state STD programs reporting state policy activity in 1995 tended to report maintained or increased policy activity for 2000.
These findings are surprising, particularly given a prevailing sense that policy activity among state STD directors is generally low. Opinions aside, there is evidence of a recent and emerging environment enabling state STD directors to engage in public policy activity. This environment includes such forces as federal STD-related policy initiatives and the 1997 formation of the National Coalition of STD Directors. While an association could not be found between policy activity and whether an STD program was combined with an HIV program, it is important to note that 18 of the 37 respondents (or 48.6%) were programs that combined STD/HIV. The history of HIV policy involvement would lead one to suspect that HIV policy enablers also functioned to reinforce STD policy activity.
The STD program policy behaviors of information dissemination, both forms of testimony and coalition participation, were found to increase when those reported for 1995 were compared with those reported for 2000. Moreover, a relationship was found among them. Certain activities could potentially be linked to exogenous policy factors. For example, federal initiatives for syphilis elimination were in place between 1995 and 2000 in several states, and infertility prevention initiatives were being rolled out in the mid to late 1990s. Both initiatives called for increased community coalition activity around STD issues.
Perennial policy issues related to sexual health agenda setting and morality policy 18 discussions at the state level may also have facilitated increased testimony by STD programs and increased dissemination of program related information. Examples of such policy issues are condoms in schools, access to school health clinics, and age of consent policies for STD and family planning treatment.
The ability to associate fiscal characteristics and policy activities is valued but not always possible. In this study, certain financial characteristics were found to be related to state STD program policy behavior. The specific characteristic of interest to the authors was the relationship between policy activity in aggregate and state STD program budget diversity. Specifically, did state STD programs with more diverse budgets report greater policy activity? The question could not be answered at this time.
The lack of an observed relationship between state policy involvement and STD program budget diversity could well be tempered by the fact that in the late 1990s, states that were flush with cash tended to spend it on programs as opposed to putting the resource into “rainy day funds.”19 As such, it could be argued that programs across the board, irrespective of policy involvement, benefited from increases in state general revenue contributions. Future and more careful fiscal analyses should be conducted over a longer period of time. The continued attention to budget mix and its potential relationship with policy outcomes will be of importance, given the emergence of state fiscal austerity and federal government reductions to grant programs.
The initial surprise about the reported policy behavior of state STD programs leads to a central limitation in the study. The measures of policy behavior, while noted as being important for policy change, were not themselves indicators of the level or intensity of policy involvement. Though measuring policy behavior generally and across several behaviors, the measurement approach prevented the opportunity to differentiate states in terms of the frequency and concentration of particular policy behaviors.
Likewise, as policy activities for 1995 and 2000 were recalled by memory from the year 2001, the study was challenged in terms of the ability to ensure accuracy. Limitations notwithstanding, given recall challenges particularly related to 1995 activity, it would be more likely that STD directors would have the capability of reporting that an activity occurred rather than the concentration or frequency of the activity. In short, the weakness of general measurement might actually serve the challenge of recall for 1995 activity.
This initial understanding of state STD program policy behaviors in state policy processes can inform state STD policy leadership development. Future policy leadership development could focus on how state STD programs can enter their state policy processes, how state STD programs can improve the dissemination of policy-related information, and how STD programs can develop strategy to increase the provision of testimony on budget or policy issues.
As this study was the first of its kind, the findings may appear unsatisfying, particularly as policy behaviors themselves could not be directly and strongly related to outcomes such as state general revenue funding levels for STD programs, STD program standing in the state policy process, or other desired public health policy outcomes. Observing such relationships would require several years of data points to account for the time lag between any policy activity and outcome and to allow for more complex and nonlinear analyses.
Nevertheless, this study does establish an initial understanding of STD program behavior in state policy processes and suggests several potential associations between policy behaviors and state characteristics for future examination. Theoretically, one could conceptualize the relationship between and among policy behaviors, state characteristics, and policy outcomes simply as follows (Figure 2).
As in Figure 2, it is theorized that policy behaviors are influenced by state characteristics and potentially other factors. More complex figures would suggest potential intervening or interruptive factors. The purpose here is to clarify the conceptualization of the primary potential relationships. State characteristics influence policy outcomes, as do policy behaviors. The lever for policy leadership and development is that of policy behaviors, given the opportunity to affect change at this level. Bidirectional relationships are presumed to exist between policy behaviors and policy outcomes, and potentially (though perhaps less clearly) between policy outcomes and selected state characteristics.
Several improvements should be implemented for the future study of state STD program policy activity. As it is critical to understand the relationship between policy behaviors and desired outcomes such as program funding or policy support, it is necessary to gather several years of data to observe patterns between policy behaviors and particular outcomes. Several data points would also permit nonlinear and complex or lattice analysis of the patterns among state policy behaviors, outcomes, and potentially intervening variables related to state characteristics.
Furthermore, gathering data in “real time,” in contrast with the reliance on STD director recall, may improve data accuracy. Continuing to measure the same state policy–related behaviors over time would allow for the observation of patterns in state-level policy activities.
The policy activity of state STD programs is potentially influenced by several factors that were not measured in this study. These factors should be considered in future research. Factors specific to the STD program leadership and the prevailing administrative view and/or skill level about policy issues and activities may play a role in whether and how a state STD program functions in the state policy process.
For example, a state health department director may choose to limit the activity of public health programs in the state policy process, or the department itself may not have the policy standing to have presence in the state policy process unless responding to an emergent public health crisis (another potential factor). Understanding more about the context of STD program policy behaviors and understanding STD policy behaviors in a comparative context vis a vis other state public health programs (such as family planning, breast cancer, or HIV) would improve public health strategic considerations.
Changes in the state policy climate such as the liberalization of agendas or the changing of state leadership (governor, health director) may also play a role in determining whether and how a state STD program functions in state policy processes. Exogenous factors such as disease outbreaks or media agenda setting may also inform future variables selected for research. Figure 3 identifies potential issues that may serve to inform the development of future variables to study STD program policy behaviors.
The relationship of state and federal STD policy activity remains to be evaluated. Several national level policy activities involving STD prevention were presumed to form an enabling environment for state STD program policy behavior; however, this has not been empirically established.
One of the greater challenges associated with the increase of STD program activity in state policy processes appears to be the attitude of STD directors themselves toward policy processes. Though not directly measured in this study, in a recent needs assessment, several STD directors offered written comments regarding their attitudes about policy involvement by STD programs. Concern was expressed that STD programs function best from below the political radar, for fear that engagement in the state policy process might serve to decrease support for STD programs, given the sociopolitical challenges facing issues of sexual health in state policy processes. 5
There appeared to be a perception that public health did not belong in the policy process or that STD programs had few options to engage in the policy process, given their location in the public sector. It is possible that any policy-related activity is understood as “lobbying.” These perceptions lend explanatory power to the prevailing view that STD programs are not involved in the policy process in spite of data indicating otherwise.
An opportunity exists to improve the policy standing of STD programs and to enhance the state and local policy support of these programs and their public health missions. It is important to continue the study of public health program policy activity, as such inquiry will inform the development of policy leadership in public health for the benefit of communities.