Abstract
Legislators (i.e., elected Senators and House Representatives at the federal- and state-level) are a critically important dissemination audience because they shape the architecture of the US mental health system through budgetary and regulatory decisions. In this Point of View, we argue that legislators are a neglected audience in mental health dissemination research. We synthesize relevant research, discuss its potential implications for dissemination efforts, identify challenges, and outline areas for future study.
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Writing about the importance of translational science in 2009, Tom Insel (then Director of the National Institute of Mental Health [NIMH]) stated that “Both scientific and political efforts will be required to ensure that the fruits of research are disseminated efficiently to those who most need it” (Insel 2009). Since then, increased investments have been made in scientific efforts to help ensure that evidence reaches mental health clinicians and influences care. This is demonstrated in part by NIMH’s funding of 40 projects through Dissemination and Implementation Research in Health Program Announcements between 2007 and 2014—27 % of all projects funded through these announcements (Purtle et al. 2016b). But what about political efforts and activities to ensure that mental health evidence reaches legislators and does not get lost in the politics of policymaking? In this Point of View, we argue that legislators are a neglected audience in mental health dissemination research. We synthesize relevant research, discuss its potential implications for dissemination efforts, identify challenges, and outline areas for future study.
The Importance of Legislators
Legislators (i.e., elected Senators and House Representatives at the federal- and state-level) are a critically important dissemination audience because they shape the architecture of the US mental health system through budgetary and regulatory decisions. There are 7918 legislators in the United States—535 at the federal-level and 7383 at the state-level—and each has potential to affect the population-level determinants of mental health through the votes they cast and the legislation they introduce. For example, studies show that the success of efforts to increase access to evidence-based mental health services is dependent upon supportive legislation (e.g., parity laws that ensure insurance coverage, loan repayment programs that address workforce shortages) (Raghavan et al. 2008). Research has also identified how legislation can address the social determinants of mental health by preventing exposure to toxic stressors and providing buffering resources (Allen et al. 2014; Sederer 2015; Shern et al. 2016; Thoits 2010). In order for this knowledge inform legislative decisions, however, it must reach and be used by legislators.
Despite the importance of legislators as a dissemination audience, systematic reviews demonstrate that barely any empiric studies have investigated how mental health evidence can be most effectively disseminated to them (Goldner et al. 2011; Oliver et al. 2014; Purtle et al. 2016b; Williamson et al. 2015). These reviews do indicate, however, that disseminating research evidence to legislators is complicated because they are particularly susceptible to the politics of public opinion and have distinct information needs (Bogenschneider and Corbett 2011). Translating mental health research into legislation requires dissemination strategies that account for these complexities.
Policy Dissemination Research
Policy dissemination research—defined as the study of how, why, and under what circumstances scientific evidence is used by policymakers—offers potential to inform the design of these strategies (Purtle et al. 2016b). A transdisciplinary endeavor, policy dissemination research uses theories, concepts, and methods from disciplines such political science, communication, and implementation science to understand political contexts and develop dissemination strategies that are tailored to reflect them. Although policy dissemination research has primarily focused on physical health (Dodson et al. 2012), a synthesis of relevant research yields four themes that have implications for disseminating mental health evidence to legislators.
Four Themes from Research
The first three themes come from public opinion research on mental illness. Public opinion research elucidates the political context in which research evidence is interpreted by legislators and can thus inform how to effectively disseminate it (Corrigan and Watson 2003). The first theme is that notions of mental illness and inter-personal violence are intertwined in the minds of the US public. Americans implicate a failed mental health system as a primary reason for inter-personal violence and focusing events (e.g. mass shootings) sometimes spark political will for legislators to address mental illness (Barry et al. 2013; Metzl and MacLeish 2015; Saad 2013). Mass shooting might be an opportune time to disseminate evidence to legislators and correct the misconception that all people with mental illness are at increased risk for inter-personal violence perpetration (Swanson et al. 2015).
Second, many Americans hold stigmatizing attitudes towards people with mental illness (Parcesepe and Cabassa 2013; Stuber et al. 2014); and these attitudes are inversely correlated with public support for mental health legislation (Barry and McGinty 2014; Corrigan and Watson 2003; Corrigan et al. 2004; McSween 2002). For example, Barry and McGinty (2014) found that US adults who held stigmatizing attitudes towards people with mental illness were 29 % less likely to support mental health parity laws and 24 % less likely to support increased government spending on mental health services.
Because public support influences legislators’ decisions, the effectiveness of legislator-focused research dissemination strategies might be maximized if implemented in conjunction with communication campaigns that reduce stigma among legislators and their constituents (Raghavan et al. 2008). Contact strategies, in which members of a stigmatized population (i.e., people with mental illness) meet and develop relationships with the general population, are also a relevant stigma reduction approach (Corrigan et al. 2012; Couture and Penn 2003).
Third, while Americans believe that mental illnesses adversely affect quality of life, they are less willing to pay for them than physical health conditions. In one study, US adults rated depression as being 19 % more burdensome than an amputated limb but were willing to pay 27 % less to prevent depression than amputation (Smith et al. 2012). Another study found that Americans were less supportive of requirements for insurance providers to cover mental health services than all other medical services (Maust et al. 2015). These findings suggest that messaging that emphasizes the social, in addition to the financial, costs of mental illness might be needed to foster support for spending on mental health legislation. Narrative dissemination techniques that utilize stories about people affected by an issue have demonstrated effectiveness at cultivating legislator support for physical health interventions and could also be effective at communicating mental health evidence to legislators (Brownson et al. 2011; Stamatakis et al. 2010).
Fourth, and finally, policy studies shed light on the sources from which legislators acquire research evidence. Studies of US state legislators have found that seeking research evidence from internal legislative staff is the practice legislators engage in most frequently, while contacting researchers directly and reading/watching media coverage is engaged in least frequently (Bogenschneider and Corbett 2011; Dodson et al. 2015; Purtle et al. 2016a). These findings suggest that mental health researchers should consider establishing relationships with, and disseminating research findings directly to, legislative staff.
Future Research
These four themes provide guidance about how mental health research might be effectively disseminated to legislative audiences, but do not obviate the need for future study. Formative assessments of legislators’ knowledge and attitudes about mental illness, similar to surveys conducted with the general public, are a critical first step to designing dissemination strategies which address knowledge deficits and correct misconceptions. These studies should examine nuances between legislators with different characteristics (e.g., federal vs. state, Democrat vs. Republican) so that dissemination activities can be tailored accordingly. There is also a need for studies that capture how mental health research evidence is, and is not, used in legislative processes. Qualitative case studies that utilize key informant interviews, document reviews, and media analysis offer an approach (Waddell et al. 2005).
Studies are also needed to determine the comparative effectiveness of different dissemination strategies on legislator support for evidence-supported mental health legislation. Randomized designs that test the comparative effectiveness of different dissemination materials (e.g., data-focused vs. narrative-focused policy briefs) on support for mental health legislation, introduction of legislation, and subsequent voting behavior are possible approaches.
Challenges
Policy dissemination research holds potential for bridging the gap between what mental health researchers know and what legislators do, but is not a panacea. Even if abundant knowledge existed about how to most effectively disseminate mental health evidence to legislators, many challenges would remain. After evidence reaches legislators, there is the risk of it being coopted and used to support pre-determined political positions (Haynes et al. 2011; Weiss 1979). For example, US state legislators have identified ‘using research to justify a decision’ as one of the most common uses of evidence (Purtle et al. 2016a).
Furthermore, policy dissemination research might inform how mental health research evidence can be effectively disseminated to legislators, but does not typically address who should do the disseminating. Researchers at academic institutions are generally not incentivized to engage in policy-focused dissemination activities. The strategies identified above (e.g., establishing relationships with legislative staff, rapidly disseminating research finding when focusing events occur) require time investments from researchers. Although policy dissemination activities may be considered “service” in academic settings, they are unlikely to substantially contribute to career development and influence promotion and tenure decisions (Brownson et al. 2006). Barriers also stem from the fact that many researchers feel uncomfortable engaging in legislative processes (Grande et al. 2014; Otten et al. 2015) and are uncertain about how to effectively do so (Trupin and Kerns 2015; Trupin et al. 1989).
Conclusions
The barriers to translating mental health research into legislation are formidable, but not insurmountable. As with other challenges facing the field of mental health research, these barriers can be overcome, or at least diminished, through systematic study. Policy dissemination research can help achieve this and should be a more prominent focus of translational science in mental health. Politics will never be taken out of the legislative process, but scientific evidence can be more effectively infused into it.
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JP conceptualized the manuscript and led the writing. RB and EP contributed to the conceptualization of the manuscript, reviewed, and revised drafts and revisions. All authors approved and are accountable for all aspects of the manuscript.
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Purtle, J., Brownson, R.C. & Proctor, E.K. Infusing Science into Politics and Policy: The Importance of Legislators as an Audience in Mental Health Policy Dissemination Research. Adm Policy Ment Health 44, 160–163 (2017). https://doi.org/10.1007/s10488-016-0752-3
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DOI: https://doi.org/10.1007/s10488-016-0752-3