Working in the legislature: perspectives on injury prevention in the United States
- 1Department of Health Policy and Management, Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- 2Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and State Legislator, Maryland General Assembly, Baltimore, Maryland, USA
- Dr K M Pollack, Department of Health Policy and Management, Center for Injury Research and Policy, Johns Hopkins University Bloomberg School of Public Health, 624 N. Broadway, Room 557, Baltimore, MD 21205, USA;
- Accepted 12 February 2009
National, state, and local policies to prevent and control injury can benefit from the knowledge and expertise that researchers can bring to policymaking; however, researches are often absent from this process. The lack of interaction between researchers and legislators results in a chasm between two parties with a common interest in reducing injuries, and a potentially missed opportunity for injury prevention and control. The purpose of this paper is to describe two state-level injury-related bills that were considered during the 2008 Maryland General Assembly. Our goal is to illustrate one approach to translating and disseminating research findings to legislators. We describe how researchers contributed to the deliberative processes surrounding these two injury-related legislative proposals. We also discuss the critical role of researchers in the policymaking process, and conclude with recommendations for how researchers can be more involved with legislative initiatives to prevent and control injury.
Although legislators formulate policy interventions by passing laws, including those that address injury, their efforts are not always informed by the best available research. Legislators generally do not have access to research or the training needed to critically appraise and synthesise research findings accurately.1 In order to develop evidence-based policies, some legislators rely on researchers to synthesise and translate scientific literature into succinct points that can be shared with advocates and used to inform policy debates. Researchers can be an important information source in the legislative process. They have knowledge relevant to agenda setting; they can be advocates for empirically-based policies;2 and they can provide a level of depth that complements the broad knowledge base generally required of legislators.
Despite the potential benefits that can result from researchers interacting with legislators, direct and regular communication between researchers and legislators is uncommon. This lack of interaction has implications for public health. It results in a chasm between two parties with a common interest in reducing injuries, and a missed opportunity to create effective injury prevention and control policies. Advocacy organisations can and do serve to minimise this gap by serving as intermediaries between researchers and legislators. However, the contributions of effective advocates in this regard do not obviate the benefits that can result from direct researcher–legislator relationships.
In an attempt to minimise these missed opportunities, two authors of this paper (KP and SF) volunteered as staff for Maryland (MD) Delegate Dan Morhaim (11th District) during the 2008 legislative session. Delegate Morhaim is Deputy Majority Leader in the House of Delegates, a physician, an adjunct faculty member at the Johns Hopkins Bloomberg School of Public Health (JHSPH), and a co-author on this paper. Each year the MD General Assembly meets for 90 days, between January and April, to act on more than 2300 bills.3 During the session, we spent one day per week in Annapolis, Maryland where the General Assembly meets. Our activities were not conducted under the official aegis of our institution or the Center for Injury Research and Policy, nor were funds from sponsored research used to support our time in Annapolis.
Approximately 100 bills related to injury prevention were considered during the session.3 Experiences with two of these bills—one concerned all-terrain vehicle (ATV) safety, and another proposed an expansion of child passenger safety seat requirements—show how researchers can participate in formulating injury prevention legislation. The purpose of this paper is to describe how we contributed to the deliberative processes surrounding these two legislative proposals in order to illustrate one approach to translating and disseminating research to legislators. We also discuss the critical role of researchers in the policymaking process. We conclude with recommendations for how researchers can be more involved with legislative initiatives to prevent and control injury.
ALL-TERRAIN VEHICLE SAFETY IN MARYLAND: SENATE BILL 28/HOUSE BILL 114
The US Consumer Product Safety Commission (CPSC) and the Centers for Disease Control and Prevention define all-terrain vehicles (ATVs) as “off-road, motorised vehicles having three or four low pressure tires, a straddle seat, and handlebars”.45 ATV riding has become a popular recreational activity for children and adults in recent decades in the USA and Canada.6–8 Along with the increase in ATV popularity, the incidence of injury morbidity and mortality related to their use has also increased.910 ATV crashes can result in severe injuries to multiple body parts, death and disability, and significant costs to the healthcare system.59–11 Children under 16 in the USA suffer a significant portion of these injuries.1011 ATV injuries have also been documented in paediatric populations in Europe.1213
In Maryland, regulatory authority for the operation of off-road vehicles, including ATVs, resides with the Department of Natural Resources (DNR); however, their authority extends only to state land.14 The DNR requires ATV riders to wear helmets on land controlled by the DNR and operators to wear eye protection or have a windscreen on the vehicle. The agency also prohibits children under 12 from operating ATVs on public land.14 There is no law mandating helmet use on land outside DNR jurisdiction, despite epidemiological evidence establishing the effectiveness of helmet laws in preventing injury.15 To reduce the risk of injury, the US CPSC also recommends that ATV riders wear helmets.4
During the 2007 Maryland General Assembly, ATV safety was the subject of House and Senate bills to require ATV riders younger than 16 years of age to wear helmets. The lead sponsors of the bills, Senator Jennie Forehand and Delegate Sue Kullen, sought to address the growing number of Maryland youth who are injured in ATV crashes. In the Maryland legislative process (like most states), initial decision making rests with the committee to which bills are assigned, and it is in committee where bills can receive close scrutiny and analysis. Committee recommendations about bills are important. Although ATV helmet legislation for children was initially considered in the Senate and House (Senate Bill (SB) 482/House Bill (HB) 261), the House Bill was voted down in committee, and subsequently the Senate Bill was withdrawn.
At the end of the 2007 legislative session, the end-of-session Joint Chairmen’s Report requested that the Maryland Institute for Emergency Medical Services Systems (MIEMSS) compile data on ATV crashes in Maryland and offer recommendations to reduce injuries from off-road vehicle crashes.16 MIEMSS oversees and coordinates the statewide EMS system and maintains the Maryland State Trauma Registry. The report documented that between 2001 and 2005 there were 911 ATV-related injuries treated at trauma centres in Maryland.17 Among those patients where helmet use was determined, only 35% were wearing a helmet at the time of the crash. Although the low rate of helmet use among injured ATV riders is an important risk factor, the data also revealed that serious trauma does not always involve a head injury. In addition to injuries to the head (26% of all injuries), 46% of injuries were to the lower and upper limbs and 22% were to the chest, pelvis, spine and internal organs.17 The MIEMSS report also included a recommendation to establish an ATV Safety Task Force to develop a consensus approach to preventing these injuries.
During the 2008 legislative session, a bill to require that ATV riders under 16 years wear helmets was again proposed and considered (SB 28/HB 114). While in Annapolis serving as staff, we learned of the bill, met with the two lead sponsors, and shared information with them related to injury prevention and the availability of the JHSPH Center for Injury Research and Policy as a resource for information about ATV safety research. Opposition to the bill was present and resulted from at least three factors: concerns about civil liberties; the MIEMSS recommendation for further investigation of the topic; and evidence that many of the recent ATV deaths resulted from crushing injuries that would not have been prevented if the riders were wearing helmets. As a result, the sponsors amended their bills to propose the creation of an ATV Safety Task Force. It would exist for one year, include a diverse group of stakeholders, and make recommendations on a number of issues including, accurate methods of tracking ATV ownership, appropriate safety equipment, and training for ATV owners. The amended legislation received minimal opposition and favourable votes from their respective Committees. After passage in the Maryland House and Senate, Governor Martin O’Malley signed SB 28 into law on 13 May 2008.
In Maryland, there are several examples of policy that resulted from Task Force recommendations.18 We are optimistic that the recommendations resulting from this Task Force will yield future state policy that will result in fewer ATV-related injuries. Included in SB 28 was a provision that one member of the ATV Safety Task Force be from our institution. In August 2008, Dr Frattaroli was appointed as our institution’s representative. With her service on this Task Force, there is an opportunity to assure that injury prevention research informs Maryland’s future approach to ATV safety.
CHILD SAFETY SEATS IN MARYLAND: SENATE BILL 789/HOUSE BILL 1312
Motor vehicle crashes are the leading cause of death among children between 2 and 14 years old in the United States.19 One effective strategy for reducing this injury risk is to increase proper restraint use, which includes child safety seats and booster seats. Laws that require children to ride in child safety seats and booster seats are generally viewed as an effective means of achieving high behavioural compliance; evaluation studies confirm this sentiment.20
As the use of child safety seats for infants and small children has increased in the USA in recent years (an estimated 98% of infants and 89% of toddlers aged 1–3 years are restrained in car seats),18 injury prevention efforts have expanded to include older, booster seat age children. Booster seats elevate children so that seat belts fit properly. They are generally recommended for children who have outgrown their child safety seats, at least up to age 8, to reduce motor vehicle crash-related injuries and eliminate injuries related to improperly fitting seat belts.21 Booster seats are an effective injury prevention strategy.22 As of February 2008, 38 states and the District of Columbia had passed laws mandating their use; however, not all of these laws require booster seats up to age 8.23
During the 2008 Maryland legislative session, Delegate William Bronrott and Senator Jennie Forehand introduced companion bills to expand Maryland’s child passenger safety seat law to include children up to age 8 (SB 789/HB 1312). The bills also included an exception for children taller than 4′9″ or weighing more than 65 pounds. Following introduction of the bills, individuals within Maryland’s trauma/injury prevention community began organising advocates in support of the bills. Integrating support for these bills into our schedules was a logical complement to the time that we were already spending in Annapolis.
We prepared testimony focusing on five points: (1) the strong empirical evidence demonstrating booster seat effectiveness; (2) the recommendations of several national organisations that children ride in booster seats up to age 8; (3) Maryland’s low rate of booster seat use and the role of legislation in increasing compliance; (4) the current height/weight/age requirements are confusing to parents but “up to age 8” is clear; and (5) the proposed law would allow Maryland to compete for new federal funds to promote booster seat use. When one of the child passenger safety seat technicians at our Children’s Safety Center learned of the bill and our plans to testify, she expressed an interest and spent a day of her vacation delivering testimony in support of the House and Senate bills. More than a dozen people offered oral and written testimony in support of the bills at the committee hearings. There was no opposition presented at these hearings. Ours was the only testimony delivered by a researcher.
Both the House and Senate committees passed their bills, and Maryland’s effort to expand its child safety seat law to include children up to age 8 appeared ready to pass. However, a Senate floor amendment threatened to weaken the bill by reducing the upper age requirement. Maryland’s trauma/injury prevention community responded and urged a constituent response, and with the support of astute lawmakers in both the House and Senate, the final bill that was passed retained the “up to age 8” provision. On June 30 2008, Maryland joined the growing number of states whose child passenger safety laws are consistent with the best available scientific evidence.
Throughout our experiences with these two legislative initiatives, we interacted with the lead sponsors of the bills, communicated research to them, attended Committee hearings, and provided testimony. Our regular presence in the state Capitol was helpful in understanding the politics that undergird the legislative process. We were able to identify those legislators with a strong interest and commitment to injury-related policy. We were also able to begin the process of building relationships with them, so that our interest in translating injury prevention research will be viewed as a resource for future injury prevention initiatives in the Maryland General Assembly. Towards that end, even through our limited commitment during the 2008 session (10 days), we became a known resource and legislators who were aware of our expertise and research skills contacted us. Although we highlighted only two examples that we were directly involved with during the session, we contributed to several public health-related bills on a variety of issues.
During the relatively short history of the field of injury prevention and control, researchers have made tremendous progress towards defining the problem of injuries and developing effective interventions to prevent and lessen their devastating and debilitating effects. These contributions are important and essential for the future of our field; however, we believe there is more that injury prevention researchers can offer. Only by assuring that research discoveries are shared and realised by the people whose lives will be measurably improved through injury prevention policies, and informed by the best available evidence, will we realise the true potential of our field. Some of the guidance for how to achieve such assurance already exists. Injury prevention research has its roots in an action-oriented style that resulted in remarkable achievements during a relatively short period of time.24 Consider modern car design, use of helmets in recreation and sports, and child passenger safety as a few examples of how injury prevention professionals have effectively translated research into policy.
To improve the translation of research and realise greater population-level improvements through sound injury prevention policies, we advocate for a direct role of researchers in the policymaking process. Granted, many researchers are already translating and disseminating their research to injury-prevention advocates, advocacy organisations, and coalitions. However, the benefits of effective policy advocacy to legislative bodies by injury advocates do not supersede those that could also result from direct researcher-legislator relationships.
We recognise that many researchers have a desire to engage in direct interaction with legislators. Yet when we ask our colleagues why they do not engage in these activities, the most often cited barriers are time constraints, feeling that such activities are not valued in the appointments and promotions processes, and unfamiliarity with how best to communicate science to legislators. Depending on the structure of one’s academic position, faculty are faced with competing demands to conduct research, teach, advise and engage in service to their institution and field. These time issues are magnified for tenure-track faculty, particularly junior faculty, who are also expected to compete for grants and contracts to cover some part of their salary. In our case, activities with the state legislature were not conducted under the official aegis of our institution. Our time in Annapolis was voluntary in that we were not compensated by our institution for the time we spent working on these issues. However, we do enjoy flexibility in setting our schedules, which makes participation in these activities possible.
Based on our experience, and conversations with colleagues, we have identified a few strategies to address the aforementioned concerns. As participants in the peer-review process, we can contribute manuscripts that document efforts to translate research into policies, and value such contributions during the review process. Practice-based legislative activities should be included as translation scholarship in the peer-review literature. Such contributions can provide researchers who chose to engage in legislative work with a product that is recognised in the promotions process. If the scholarship on researchers translating science to legislators is expanded, there will be greater congruence with academic measures of productivity and the time challenge is minimised.
Establishing valued measures to assess the contributions that researchers make to the policy process, and including those metrics as part of the appointments and promotion process would address concerns that some may have about promotion. Policy activities are important and necessary to practice-oriented public health education and research.25 One way to document faculty time in policy and practice activities is through a practice portfolio. Including a practice portfolio, which details faculty contributions to applying scientific findings to policies and programmes, as part of a promotion packet is one mechanism that is available for faculty at our institution. Practice portfolios include descriptions of practice-based activities, influential practice reports, participation on practice-related advisory panels and committees, and testimonies given.
Finally, training researchers who are interested in interacting directly with policymakers could address concerns about how best to communicate science to them. The effective communication of science to policymakers is a skill that requires practice, and, to be effective, should not include scientific jargon. Opportunities should be increased for researchers to learn about policy advocacy, media advocacy, and other salient communication and policy topics. These activities could even be included in professional development activities.
Recognising that there are several challenges to the activities that we described, how can researchers better engage with legislators? Based on our experiences during the legislative session, we suggest the following strategies to guide how researchers can directly engage with legislators and legislative initiatives to prevent and control injury:
Summarise and translate the research literature into pragmatic evidence-based recommendations, via short (1-page) policy briefs.
Communicate information to policymakers clearly and without scientific jargon and abbreviations (eg, legislators are not concerned with p values).
Provide testimony that highlights scientific evidence during committee hearings on legislative bills.
Participate in educational forums for policymakers to provide information about the burden of injury in specific localities.
Familiarise yourself with and understand the legislative process in your state or nation; visit your national, state or local legislators and staff.
Almost 30 years ago, a group of injury prevention researchers and practitioners gathered to discuss their efforts to reduce injury through state-level policy. The introduction to the proceedings from that meeting offers this bold reflection: “It is a truism that politicians have the capacity to save many more lives than physicians and other health professionals”.23 Therefore, we conclude that researchers who are interested in moving their science into the policy arena, should have a deliberative role in the processes of creating legislative proposals to prevent and control injury. Such efforts will increase the likelihood that resulting policies are based on the best available evidence. We advocate for more direct interactions between legislators and researchers that are value-congruent, built on partnership, and consistent with the goal of protecting the public’s health from injuries and related sequelae.
We would like to thank Associate Deans Thomas Burke and Stephen Teret of the Johns Hopkins Bloomberg School of Public Health for their comments on this manuscript, and support of our public health practice activities.