Taking Action

The Journey into the Hallowed Halls of Politics: How Nurse Practitioners Changed Pennsylvania Policy

Norma Alicea-Alvarez and Susan D. Hellier

“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.”

—Niccolo Machiavelli

We were merely completing an assignment during the second year of our Doctor of Nursing Practice program at Waynesburg University in Pennsylvania—or so we thought. We had conducted a pilot study on a high school screening program for Chlamydia. We both had an interest in adolescent health and worked in the same county. Our professors had given us the go-ahead to work on a practicum assignment together.

The Pilot Study

A literature review revealed that Chlamydia is prevalent in sexually active adolescents with rates ranging from 3% to 12.4% among 15- to 19-year-old adolescents (Wang, Burstein, & Cohen, 2002). Chlamydia is known as the silent epidemic; more than 75% of cases are asymptomatic. Up to 40% of cases that are untreated or undertreated will result in pelvic inflammatory disease with the risk of infertility, pelvic pain, ectopic pregnancy, and abscess. We also learned that the screening rate for Chlamydia in the United States was 41.6% and that Pennsylvania’s was 39% (CDC, 2009). Protecting the reproductive health of young women and the prevention of sequela were the goals of our screening program.

We first had to find a school for a study site, gain approval for screening for a sexually transmitted disease (STD)—viewed as a “sensitive” topic by many parents and teachers, and arrange for an educational session for the school prior to the actual screenings. Finding a laboratory to take the samples was a challenge. Some labs charged up to $80 per sample, but after many phone calls we found one that charged $12.50.

The study site was grades 10 through 12 at the vocational high school in the rural county where we worked. Before we could walk through the doors of the school, our study had to be approved by the Institutional Review Board, the director of the high school, the principal, the school board, the teachers, the school nurse, and parents of the students who would consent to participate in the study. The process was completed with the help of our collaborating physician Dr. Carlos I. Flores and the director of the vocational school, who was also a doctoral student at a different university. We were on our way!

Grant writing was a challenge that we met both head-on and with trepidation. We found the appropriate organization and began the elaborate process of writing a grant to cover the cost of the urine screening for Chlamydia. We wrote and rewrote the grant several times. We had two conference calls with the director of the organization and our program director, and we had to defend our study, present the literature, and explain why we needed the grant. After several months, we were finally informed that due to the economy, the organization had decided not to provide funds to any applicants for the fiscal year but had they decided to give money away, we would have received it.

We entered through the doors of the high school and were handed badges from the principal’s office. We presented a PowerPoint lecture about Chlamydia and its etiology, treatment, and prevention, and then we spoke about our study. This took place in the lunchroom, which doubled as the auditorium. Students were aware that parents had to consent to the study in order for them to be screened. Screening would take place by a urine sample that was sent to an independent laboratory and tested for Chlamydia. We mailed 165 consents and waited, expecting to get about 3 back. We received 51 consents! The mailbox was full each day for a week.

On 2 separate days, we went to the school and collected urine samples from the students. They provided some basic demographic information. Of the 51 girls, 2 received positive results, and we later found out that 1 was also pregnant. Parents were informed first, and then the students were informed. The adolescent girls were aware of this protocol, as it was a requirement by the school board for participating in the study.

The Capstone Project

Once our pilot study was completed, we hoped that two Capstone Project ideas would emerge for our final year as doctoral students. We met again with our professor to ask for guidance, and she recommended that we work together and take the pilot study to the next level. We weren’t really sure what the “next level” was, and being doctoral students she obviously wanted us to decipher her “coded” language. The Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT), a medical assistance program for children from infancy to 21 years, did not require yearly urine screening for any STD. The screening for STDs in the EPSDT program was based on symptoms. Since the majority of Chlamydia cases are asymptomatic, this was the “light-bulb moment” that acted as the springboard for the Capstone Project. We decided to change the current policy of the EPSDT program and require the state’s Medicaid program to adopt a new policy that requires adolescents, regardless of sexual history, to be screened for Chlamydia. We also wanted to disseminate information about the risks of Chlamydia to health care providers and the community.

We became educated in the legislative process and politics; policy change theories; and orchestrating the collaboration of politicians, colleagues, and the community to influence patient care outcomes. We used Kingdon’s Agenda Setting Theory to ground our policy aims in theory. Kingdon’s Theory seeks to develop structure for successful policy change and explain the political factors that influence legislative action and how an advocate of a cause can bring attention to a societal problem.

Our pilot study metamorphosed into a Capstone Project with three aims: (1) a policy change to increase Chlamydia screening for 15- to 21-year-old adolescents enrolled in a Medicaid program, (2) the support of House Bill 1163: The Healthy Youth Act (making all public high schools teach a comprehensive sex education class), and (3) the institution of Chlamydia Awareness Day in Pennsylvania to bring attention to the disease (Figure 46-1).