The needs in the country’s healthcare system are constantly evolving, as well as the opportunities for meeting these needs. Still, many issues have not found a sufficient reflection yet, which increases the risks for critical situations in a variety of environments. One of the aspects requiring immediate consideration is the use of automated external defibrillators (AEDs) in schools. What follows is an analysis of the public health practice issue with a proposal to advocate for the suggested change from both the top-down and bottom-up approaches.
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Public Policy Issue
The suggested change is the proposal for a state policy to make the use of AEDs compulsory in every school. Currently, the State of Indiana imposes some demands on schools that have AEDs, but it does not require every school to keep an AED (Indiana State Department of Health, 2015). Meanwhile, the experience of other states, such as Iowa, indicates considerable improvements in cardiopulmonary resuscitation (CPR) education due to the implementation of AEDs at a state level (Hoyme & Atkins, 2017). It is necessary to note that according to the Indiana House Bill 1116 of 2007, any individual who wants to acquire a teacher’s license must hold certification in CPR training and AED (“Indiana,” n.d.; “The Indiana teaching and certification resource,” n.d.). This section will state the purpose of the policy proposal and present the background information necessary to understand the need for population-level advocacy.
The reason for selecting the public policy is that cardiac emergency preparedness is a crucial element of reaching the highest level of the nation’s health. Therefore, it is necessary to make the use of AEDs a legal requirement at a state level. Unequal distribution of AEDs can increase the incidence of sudden cardiac arrest among children and adolescents (White et al., 2016). According to the National Center for Health Statistics [NCHS] (2020a), Indiana is among the states with high heart disease mortality. Furthermore, heart disease is the most frequent cause of death in Indiana (NCHS, 2020b). The Centers for Disease Control and Prevention [CDC]) (n.d.) reports that as of 2015, about 357,000 Americans experienced out-of-hospital cardiac arrest. CDC also notes that nearly 70%-90% of people with such a condition die before being transported to the hospital, whereas the use of AEDs immediately following cardiac arrest can decrease the risk. Hence, the selected public policy issue is of great importance for Indiana and should be considered at the state level.
The relevance of the chosen public policy issue to public health is evident. The number of people suffering from heart disease and comorbid health issues in Indiana is too high to neglect it (NCHS, 2020a, 2020b). Meanwhile, scholarly investigations into the matter indicate that the likelihood of adverse outcomes of a sudden cardiac arrest among young people can be considerably decreased with equal distribution of AEDs (White et al., 2016). While in Indiana, all teachers are certified for AED use, not all schools have AEDs at their disposal.
The incidence of cardiac arrest among children and adolescents is low. Smith and Colquhoun (2015) note that school-based AEDs are not likely to be needed often. Thomas et al. (2016) agree that a sudden cardiac arrest is a rare occasion among young people. However, both studies note that the aftermath of the AEDs’ lack in schools can be devastating (Smith & Colquhoun, 2015; Thomas et al., 2016). Currently, small schools, those with a higher percentage of students with disabilities, and those with larger numbers of minority students rarely tend to possess AEDs (Thornton, Cicero, McCabe, & Chen, 2017). Therefore, the policy will make AEDs accessible to all Indiana schools, improving public health outcomes.
Since all teachers of Indiana schools are certified for AED use, the only financial burden to meet is the cost of AEDs. The average price per unit varied between $1,500 and $2,000 (American Heart Association, (2018). Thus, the resources needed to be spent will include this amount multiplied by the number of schools without AEDs in the state (also, it is necessary to consider the fact that some schools need more than one unit). Meanwhile, a positive financial outcome is the reduced cost of hospital stay of patients with a cardiac arrest that has not received help before getting to the hospital.
My position on the public policy issue is affected by such personal values as equality, security, and health. I am a strong believer that all children should have equal access to AEDs and should receive appropriate medical help immediately. Even if the incidence of cardiac arrest or heart disease is not high among school students, I consider every life valuable and deserving to be cherished. Furthermore, it is not only students whose health can be promoted but also their educators.
Ethical Principle or Theory
The ethical principle underpinning my perspective is that of beneficence. According to the American Nurse Association (2015), beneficence means compassion and willingness to help other people and do them good. I believe that the use of AEDs at schools will promote students’ health and help them avoid severe health implications that they might face if immediate help in case of a sudden cardiac arrest is not provided.
The Top-Down Approach to Policy Advocacy
The top-down approach to policy advocacy allows gaining full control of the whole process. By utilizing this method, it will be possible to address the person responsible for the implementation of the suggested change directly. This section will contain a discussion of the plan aimed at addressing the decision-maker and asking them to pass a bill for policy change. Potential challenges and ways of evaluating the policy brief’s success are also analyzed in the section.
The decision-maker that seems the most appropriate to address is the Governor of Indiana, Eric Holcomb. The rationale behind selecting Holcomb is that he holds the most power in the state. Since the suggested policy is to cover the whole state, it is necessary to address the Governor. The authority and influence of Holcomb cannot be doubted due to his numerous activities aimed at improving the state and the level of life for people in it. Since he was sworn in January 2017, Holcomb arranged many meaningful partnerships and launched important projects (“About Governor Eric J. Holcomb,” n.d.). One of the directions in which the Governor’s efforts are aimed is gaining an improvement of Indiana’s economic position. At the same time, Holcomb has done much in the spheres of child education and health care (“About Governor Eric J. Holcomb,” n.d.). Hence, addressing the Governor makes sense because he is genuinely interested in the state’s development in general and in the enhancement of citizens’ welfare in particular.
Addressing Governor Holcomb will increase the likelihood of the policy’s retrieval and acceptance. The Governor serves as a chief executive officer of his state, so there is no doubt that his authority is sufficient to implement the suggested change or reject with the request to make some amendments. In the least, the Governor will appoint someone else to help deal with the policy. However, since he is the most influential figure in the state’s administrative system, it is viable to address him as the most reasonable decision-maker.
There are several reasons why the suggested public policy requires the decision-makers attention. First of all, as of 2017, only in a small number of U.S. states ̶ 17 ̶ AED installation in schools was required by law (Sherrid et al., 2017). By 2019, only one state was added to this list; still, every state’s requirements are quite different from one another (Arabadjian, Stepanovic, & Sherrid, 2019). Indiana is not among these, which makes schoolchildren vulnerable to sudden cardiac attacks that will not be followed by immediate help. Additionally, the installation of AEDs in Indiana schools does not have public funding (Sherrid et al., 2017). Next, the American Heart Association (AHA) recommends making AEDs accessible in public places where the potential of a sudden cardiac arrest is high (Arabadjian et al., 2019). Meanwhile, even in the states with AED regulations present, not all schools are included in the system. For instance, in New York, schools AEDs are required in public schools but not demanded in private ones (Arabadjian et al., 2019). Each of these issues serves as a rationale for drawing the decision-maker’s attention to the public policy.
It is crucial to receive support from the Governor since heart disease is the most common death cause in Indiana. According to CDC (n.d.) and HCHS (2020a), it is of utmost importance to help individuals who experience an out-of-hospital cardiac arrest within the first few minutes following the accident since the majority of such people die before getting to the hospital. Since the Governor takes care of the state’s citizens’ health and welfare, he is a good fit for the proposed bill.
The most probable barrier the decision-maker is likely to face in trying to get the bill passed is the low incidence of sudden cardiac arrest among children and adolescents. As a result of a systematic review of school-based data, Smith and Colquhoun (2015) found that the annual incidence of cardiac arrest in schools constituted one case per 23.8–284.1 schools. Cardiac arrest incidence among school students was 17–4.4 per 100,000 students annually (Smith & Colquhoun, 2015). These data may serve as a basis for refusal to accept the policy and pass the bill by some legislators.
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Additionally, some obstacles may emerge at the point when financial support for the project is needed. Because of the pandemic, schools have been closed for several months, and there is a possibility that they will remain closed for at least some part of the next academic year. However, it is necessary to use this time as an opportunity and supply schools with AEDs. Smith and Colquhoun (2015) admit that sudden cardiac arrest in schools is “a rare, but devastating event” (p. 296). Thus, it is crucial not to allow challenges to restrict the possibility of the bill being passed.
Options and Interventions
The decision-maker may respond to the proposal in several different ways, depending on his view on the issue and current possibilities. The first option the Governor may choose is to leave the situation as it is. If he selects this variant, the likelihood of adverse outcomes for children and school staff resulting from a sudden cardiac arrest will remain high. Even though the incidence of such cases is low, the negative consequences are still highly possible. the Governor may select this option if there is no funding available or if he does not consider the issue significant enough.
The second option is accepting the proposal with some modifications. For instance, the Governor may promote the bill only for private or only for public schools. However, as Arabadjian et al. (2019) note, both types of schools require AEDs to the same extent. Thus, if the Governor agrees to promote the policy with this compromise, the expected outcome will not be achieved. The decision-maker may decide on this option if he realizes there is not enough support from legislators for the whole proposal or, again, if there are not enough funds to cover it.
Finally, the third option is for the decision-maker to adopt and support the bill proposal completely and carry it forward through the change process. The Governor may choose this variant if he fully understands the seriousness of the problem and if he feels secure about the support from legislators. He may also select this option if he finds sufficient funding and is confident about the possibility of completing the whole process of implementing the change.
Course of Action
The persuasive course of action for the decision-maker is a crucial aspect of gaining the proposal’s success. It is quite possible that lawmakers may not understand the health risks posed by the lack of AEDs in schools. To persuade them of the importance of the bill, the decision-maker could invite Judith Lovchik, the State assistant commissioner, public health preparedness, and state lab director. Ms. Lovchik could explain the severity of the issues related to the lack of AEDs in schools. For instance, she could give examples of positive changes in other states that were triggered by the AED installation requirement. Additionally, the assistant commissioner could provide statistics on how many children’s lives have been lost without timely assistance on the occasion of a sudden cardiac arrest in Indiana in comparison to other states.
Another idea is for the decision-maker to ask the State budget director, Zachary Q. Jackson, to present a brief report of the funds available. The Governor may then make a speech by himself, stating why he believes certain funds could be allocated to the proposal. The decision-maker can give examples of previously introduced bills or policies that turned out to have a positive financial impact on the state’s healthcare system and people’s health.
The success of the Policy Brief
|Table 1. Timeline for Evaluating the Success of the Top-Down Approach|
|1||The legislator’s agreement to sponsor the bill|
|2||The bill passes committee hearings|
|3||The committee marks up the bill|
|4||The majority vote in favor|
|5||The bill is sent to the other legislative chamber|
|6||The full chamber advances the bill and returns it to the house of origin|
|7||The Governor signs the bill into law|
|SMART goal||One year after the AED installation law is passed, the incidence of sudden heart arrest mortality-induced death among schoolchildren, teachers, and staff members decreases by 90%.|
The Bottom-Up Approach to Policy Advocacy
This section will describe a plan for working with a relevant stakeholder organization that can help to implement the suggested change via advocating it. Additionally, this organization will form a working group that will educate others about the issue and its relevance. The bottom-up approach is different from the top-down one, and it is necessary to consider both before selecting which of them is more suitable.
Identified Organization or Community
The organization that might be interested in the selected health public policy issue is the Indiana State Nurses Association (ISNA). This is the professional organization for Indiana State’s registered nurses (Indiana State Nurses Association [ISNA], n.d.). Being a branch of the American Nurses Association, ISNA sees its mission in promoting high-quality health care and nursing. ISNA will share resources and help make connections that will promote the credibility of the working group.
Summary of Expressed Interest
ISNA may be aligned with the bill proposal idea since it promotes the welfare of people living in the state. On the organization’s website, there is a bulletin of one of its partners, The American Academy of Nursing (ANA), with a description of top policy priorities for 2019-2020. ISNA aligns with these priorities as an advocate of public health initiatives. Specifically, ANA (American Academy of Nursing, n.d.) lists the reduction of patient burden as one of its core targets. Overall, despite a specific mentioning of ISNA’s interest in increasing AEDs in Indiana schools, one can notice that the organization is concerned with public health and will support and promote the bill.
Community-Based Participatory Research (CPBR)
The following CPBR principles may be applied by the working group:
- recognizing the community as a unit of identity (Frerichs, Lich, Dave, & Corbie-Smith, 2016);
- focusing on the local relevance of public health problems, as well as ecological perspectives attending to multiple determinants of health;
- integrating and gaining a balance between knowledge generation and intervention for the mutual benefit of all partners (The University of California, Berkeley School of Public Health, 2012).
Approach and Collaboration
To approach the organization, I would first of all contact Blayne Miley, Director of Policy and Advocacy of ISNA. I would ask for their support via email, but I would also request a personal meeting to discuss the details of the proposal. I would ask Mr. Miley to let me speak at a regular meeting of members to present the bill and ask for their collaboration.
The organization’s goals align with the purpose of the selected public policy issue. The alignment is reflected in ISNA’s foundational goal, which is “to protect the citizens of Indiana” (ISNA, n.d., para. 1). Also, the organization’s mission is related to the bill’s philosophy since “ISNA works through its members to promote and influence quality nursing and health care” (ISNA, n.d., para. 4). There is no direct indication of ISNA’s working with the proposed issue before, but it can be deduced from the available information that the organization will gladly participate in the promotion of change.
- Arrange contacts and meetings with organizations that may be interested in supporting the proposal.
- Performing research on the issue in the healthcare and financial dimensions.
- Preparing a report for potential sponsors.
- Presenting the proposal to the decision-maker.
Each of the mentioned steps will promote the state officials’ and potential benefactors’ understanding of the project and its support.
Roles and Responsibilities
|Table 2. Roles and Responsibilities of the Working Group Members|
|MSN||Meeting facilitator||MSN will arrange meetings, keep contacts in order, and address organizations and sponsors.||Developing a mission and vision of the proposal; creating an action framework; engaging all stakeholders and improving visibility|
|ISNA representatives,||Researchers||The research will promote the understanding of the issue by healthcare officials and financial leaders.||Arranging partnership and collaboration|
|ISNA treasurer||Report compiler and presenter||The treasurer will compile and present a financial report covering the needs for the project’s implementation.||Evaluating capacity needs and assets|
|LegisGroup Public Affairs – ISNA’s lobbyist partner||Proposal presenter||The lobbyist will present the proposal to the decision-maker and explain the significance of the bill.||Taking action; partnership development|
Key Elements of Evaluation Plan
The first CBPR principle is recognizing the community as a unit of identity. We will utilize it by involving all state schools in the policy. The principle applies to the evaluation plan because it will allow seeing whether all objects of change have been involved. The second principle is focusing on the local relevance of public health problems. It will be utilized by concentrating on Indiana State, and evaluation will show how concerned it is with the community’s health. The third CBPR principle is integrating knowledge for mutual benefit. We will use it by distributing information about the public health issue. It applies to the evaluation plan since we will be able to see whether all stakeholders can process data and generate knowledge for their benefit.
- At least 75%of those contacted agree to collaborate.
- Research produces reliable and valid results.
- The report is brief and contains all the necessary information.
- The lobbyist successfully presents the proposal to the decision-maker.
SMART goal: Within two months of collaboration with ISNA, all the members of the working group will have completed at least 70% of their duties. Within the third month of collaboration, each of them will finish their tasks.
Evaluating the Effectiveness of the Two Different Approaches
Strengths of Each Approach
The first strength of the top-down approach is the possibility of controlling the policy development first-hand. The second advantage is the cost-effectiveness of the procedure since we will communicate directly with the decision-maker. The first strength of the bottom-up approach is the possibility of networking, which will promote awareness about the policy. The second benefit is the ability to adapt to various needs.
Challenges of Each Approach
The first challenge of the top-down approach is that the target group may not consider the policy important enough for their approval. The second limitation is that we will not be able to control the process once we give the proposal to the decision-maker. The first barrier of the bottom-up approach is that arranging the network may be too complicated and may require additional resources. The second challenge is that we may have to pay the members of the working group, which will impose additional costs.
Most Effective Approach
In the paper, we have reviewed two alternatives to promoting a public health policy proposal. The specific details of each method, as well as their advantages and disadvantages, stakeholders, and supporters, have been discussed. Based on the analysis of the two approaches, we consider the bottom-up approach more viable. It seems reasonable that the healthcare organization will be more likely to support and promote our bill than the Governor.
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