Advocacy Action Plan: policy proposal change for sexually transmitted infections in Harris County

1. Role of the Advanced Professional Nurse in Healthcare Advocacy
   Whether working in community settings or at the patient’s bedside, or in clinical settings,
   the role of advanced nurses in advocating for patient health is indispensable. The overarching
   goal usually remains the same: pushing for policy changes that would better the health of
   patients and the public. However, huge differences exist between community and bedside or
   clinical advocacy in terms of the objective, scope of advocacy, the approach, and the authorities
   that nurses pressurize to make the desired policy changes.
   Typically, in community settings, advanced professional nurses have one target: to lobby
   for community and environmental changes, known as the social determinants of health (SDOH),
   that affect the welfare of the general public or community. Social determinants of health are the
   settings or conditions in which people are born, live, grow, work, and age (Artiga & Hinton,
   2018). The role of MSN advanced nurses is to champion changes that affect economic stability,
   the physical environment and neighborhood, education, food, community and social settings, and
   the health system. This means that the scope of issues nurses advocate for in community settings
   is broader and all-encompassing. The objective is to pressure governments to make overall
   communal changes or institute new policies that positively impact the health of “at-risk”
   populations or the general population. These types of policies stretch from economic and fiscal
   policies to legislation that touches on environmental issues.
   At the community level, advanced professional nurses tend to focus on issues that extend
   beyond the usual clinical/medical issues, such as quality of care, health coverage, cultural
   competency, patient safety, and provider availability to include themes about food, education, the

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physical environment, the general economy, and social factors. For example, to address health
issues like inadequate access in impoverished communities, advanced professional nurses can
champion economic changes like raising income and creating employment for residents in these
regions. For neighborhoods facing nutritional-related health issues like obesity, overweight, and
diversity, advanced professional nurses can advocate for changes to increase the supply and
prices of healthy diets to improve access to local populations. Additionally, advanced nurses
might push for laws that address early childhood education, vocational training, and higher
education in neighborhoods with low literacy levels. Advocacy would target support systems,
social integration, community engagement, stress, and discrimination in the social context.
Another notable element of advocacy at the community level is that the voices are usually
directed towards lawmakers and stakeholders at the state or federal level. These powerful
institutions often have the Constitutional authority and mandate to institute changes that affect
the general livelihoods of large groups of people or communities. For example, politicians at
both Houses have the power to amend or enact health policies like the Affordable Care Act that
would ensure “at-risk” individuals (like low-income earners) and communities (such as
impoverished African American neighborhoods) can improve their access to healthcare services.
In the “economic” realm, lawmakers can also decide to provide tax breaks for people earning
below the country’s poverty line.
The scope and type of lobbying that advanced professional nurses perform at the bedside
or clinical settings contradicts the “community type” because it only focuses on the medical or
clinical aspects. Typically, the “clinical type” of advocacy focuses on patient and nurse (or
provider) outcomes. For example, for patient outcomes, advanced professional nurses might
champion hospital-wide changes (medical processes, safety rules, and medical procedures) that

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would improve the quality of care, reduce medical errors, improve patient safety, reduce hospital
stay, and lower the cost of care. For example, in case nosocomial infections (or hospital-acquired
infections) are on the rise in a particular hospital or healthcare facility, advanced professional
nurses might direct their grievances towards the management of this institution to institute new
safety protocols and implement standard operating procedures (SOPs) to lower patient-to-patient
or nurse-to-patient infections. Advanced professional nurses can also query the Board of Nursing
(BOD) to issue new regulations and policies to regulate nurse-related errors.
In addition, advanced professional nurses can advocate for nurse work-related changes
through their member associations, such as the American Nurses Association (ANA). This can
include lobbying for a salary increase, reduction of working hours, retirement benefits inclusion,
and insurance coverage. This type of advocacy usually arises when advanced professional nurses
feel that their colleagues’ work environment is inappropriate or is too risky and labor-intensive
but does not bring equal financial gains.
Interprofessional Collaboration within an Advocacy Action Team (AAT)
By their training, advanced professional nurses are equipped with skills to create and lead
teams that can effectively champion policy reforms to better the health of populations and
communities. Advanced nurses must form advocacy actions teams (AATs) and demonstrate
certain critical leadership skills to encourage teamwork and cohesion in championing the desired
change. As a team leader, team-building strategies can push AAT members to work together
toward a shared objective. These strategies include problem-solving, giving works autonomy,
organizing a get-together or bonding retreat, giving directions and setting boundaries, and
adopting an open-door policy. As a leader, there are several ways in which these strategies can
build my AAT. For example, the open-door policy can improve communication among team

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members because it opens the door for everyone (Moran, 2018). It will create the sense that
every team member is valued and their ideas are welcome. Providing a listening ear to the
concerns of members can improve the trust and morale of the AAT.

2. Description of the Health Issue, SDOH, and At-Risk Population in Harris County,

Texas

I. Health Issue
The primary health concern that affects Texans in Harris County is the high incidence
and prevalence rates of sexually transmitted diseases (STDs) or sexually transmitted infections
(STIs). A recent report released by the Texas Department of Health Services ranked Harris
County 1 st for the highest number of STIs across the state. In the 2018 document released by the
department titled “Texas STD Surveillance Report,” Harris County recorded approximately
26,540 Chlamydia cases with an incidence rate of 569.0. This represents a significant drop
compared to 2017 (number 27,408, rate, 592.1) and increase compared to 2016 (26, 231; 575.0).
For gonorrhea, a total of 8,448 cases were reported in 2018, compared to 8,408 and 7,515 in
2017 and 2016, respectively. For syphilis, the caseload stood at 2761, 2480, and 2278 in 2018,
2017, and 2016, respectively. Overall, Harris County’s data across the three STIs was the highest
in 2016, 2017, and 2018 (Texas Department of State Health Services, 2018).
Besides Chlamydia, syphilis, and gonorrhea, evidence from the Texas Department of
State Health (2021) shows that Harris County leads to HIV diagnosis. In 2019, a total of 1,172
new HIV cases were diagnosed. The County has also been recording significantly higher
numbers of new HIV infections compared to other counties, including 1194, 1098, 1257, 1266,
1256, 1226, 1277, 1227, and 1326 in 2018, 2017, 2016, 2015, 2014, 2013, 2012, 2011, and 2010,
respectively.

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II. Social Determinant of Health (SDOH)
Generally, a social determinant of health or SDOH is the overarching condition that
affects the quality of life, health, and wellbeing of residents living in a specific community or
neighborhood. According to the Healthy People 2020 report, SDOH can be categorized into five
broad classes: social and community context, health and health care, neighborhood and built
environment, and economic stability. These broad categories can be further split into specific
factors that determine or impact health within an area. For example, health and health care
include quality of care, provider cultural and linguistic competency, provider availability
(including nurse-to-patient ratios), and health coverage. At the same time, community and social
context encompass the absence of stress, discrimination, community engagement, support
systems, and social integration. Neighborhood and physical environment include zip code
geography, walkability, playgrounds, parks, safety, transportation, and housing. Economic
stability entails income levels, employment rates, debt, expenses, support systems, and medical
bills.
In the case of Harris County, the fundamental social determinant of health that drives
higher STIs/STDs incidence and infection rates is low income, implying that a majority of
community members live below the poverty line and, therefore, will engage in extramarital sex
or prostitution to fill their income deficits. Low-income rates also indicate that most Texans in
Harris County lack adequate funds to access advanced medical services to protect themselves
from contracting STIs, such as post-exposure prophylaxis antiretroviral drugs (PEP) after
engaging in unprotected sex with persons with HIV.
New evidence shows that Harris County’s income is disproportionately low compared to
other counties in Texas. For example, a comprehensive five-year survey (2006 and 2010) in 2012

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by the U.S. Census Bureau ranked Harris County’s average per capita income ($26,898), median
household income ($51,444), and median family income ($58,505) among the lowest in the
region. These figures were even below the national averages of $27,334, $51,914, and $ 62,982,
respectively. Other counties like Brazoria had incredibly higher income numbers, including
$27,529, $65,607, and $76,018, respectively (U.S. Census Bureau, 2020). These unreasonably
low-income metrics essentially expose Harris County residents to unhealthy sexual behavior,
such as prostitution and engaging in unprotected sex to earn additional income. It also plunges a
significant number of people into drug use and abuse, which can substantially double their
chances of getting STIs. Additionally, low earnings imply that a dozen residents are homeless or
fail to secure stable housing. This also heightens the risk of contracting sexually transmitted
diseases.
III. At-Risk Population
The main “at-risk” population for sexually transmitted infections in Harris County is the
African American, ethnic group. The risk is higher across all STI categories, including
HIV/AIDS, chlamydia, syphilis, and gonorrhea. For example, a 2021 HIV dossier issued by the
Texas Department of State Health shows that although the rates of new infections in the African
American community have been declining for the past few years, Blacks still register the highest
figures, compared to other racial groups. For instance, in 2019, the rate of new HIV diagnoses
per 100,000 people was 42.8 percent, although the figure dropped from the highest 58.5
registered in 2010. In comparison, the new HIV diagnoses among whites were 6.6 per 100,000
people in 2019. The Hispanic/Latino community came a distant second with 14.7. See table 1
below.

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Several empirical studies have also ranked the African American race as one of the most
“at-risk” populations for new STI infections in Harris County. For example, a 2020 study by Hill
et al. found that African Americans recorded the highest new HIV infection rates between 2010
and 2017 in a screening exercise conducted by the emergency department (E.D.) in Harris
County. The researchers collected a dataset of 885,199 patients screened for HIV between 2010
and 2017 in the emergency department across the County. Out of the 1,795 positive cases,
African Americans represented 52.6 percent, Whites (46.6 percent), Natives (0.1 percent), and
Asians (0.7 percent). The Black community’s infection rate is alarming, considering that the
ethnic group only represented 16.8 percent of the 885,199 patients tested (Hill et al., 2020).
Table 1: Texas New HIV Diagnoses Rates by Ethnicity and Year, 2010-2019 (Texas Department
of State Health, 2021)

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3. Current Policy

Presently, Texas’s bare minimum income per hour is $7.25, equal to the national average
(U.S. Department of Labor, 2021). This is relatively low compared to other states like Virginia
(minimum hourly rate of $9.5), Vermont ($11.75), Washington ($13.69), and the District of
Colombia ($15.20). Like other states, Texas sets its “own” minimum wage, which should be at
par with the federal minimum or above it. In Texas, the 2009 Texas Minimum Wage Act
stipulates the liberties and rights assigned to employed individuals across all counties, including
Harris. TWC (Texas Workforce Commission) is the state body that supervises and regulates
work environments across the region. Formulated under the directions of the Act, TWC is
responsible for answering all questions employers and employees might hold concerning the
state’s minimum wages. Employees and employers can also forward their complaints to the
Commission. Currently, the Texas Minimum Wage Act does not cover employment subject to
FLSA (Fair Labor Standard Act). FLSA is legislation that establishes overtime pay, minimum
wage, youth employment standards, and recordkeeping impacting workers in local, state, and
federal governments and the private industry.
At the moment, the FLSA minimum hourly wage stands at $7.25. The FLSA Overtime
rule requires all covered nonexempt workers to receive overtime remuneration for hours worked
above 40 a week at a rate, not below 1.5 times the regular pay rate. The rule also exempts
overtime pay for work completed on regular days of rest, holidays, and weekends, unless these
days amount to overtime (U.S. Department of Labor, n.d.). The downside of paying workers a
$7.25 minimum federal wage and subjecting FLSA covered workers to the federal rules is that
most residents in Harris County are unable to increase their wages to meet the increasing

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inflation rates and snowballing prices of “basic” commodities like food, clothing, housing, and
medical insurance. This forces people in Harris County to look for alternative means to weather
the challenging economic times, resulting in some engaging in prostitution and other risky
behaviors, exposing them to STDs.

4. Proposed Policy Change

Firstly, I propose that the Texas Workforce Commission raise the state’s minimum wage
from $7.25 to $15.00. Secondly, I suggest that lawmakers in Texas repeal or amend the Texas
Minimum Wage Act by exempting all personnel from FLSA coverage, meaning that all workers
should be subject to state legislation, including state, federal, and local government employees
and those working in the private sector. The reasoning is that the FSLA minimum wage rules
were created in 2009 when the country’s inflation rate was at its lowest point, -0.36%. In April
2021, the national average stood at 4.2% (Wallheimer, 2021). The argument against subjecting
workers in Harris County to a similar FLSA’s minimum wage of 2009 is that commodity prices
have risen, and people now spend more compared to twelve years ago. It is illogical for
employers to pay workers a similar $7.25 per hour in 2021 as in 2009.
For Harris County, raising the state’s minimum hourly wage will automatically improve
the average per capita income and median household income above the current $32,765 and
$61,705, respectively (United State Census Bureau, n.d.). This can significantly improve the
purchasing power of people, including the “at-risk” African Americans, in Harris County. This
can reduce poverty rates and the potential of residents engaging in risky behaviors that might
predispose them to sexually transmitted infections. A likely protest from state policymakers is
likely to hamper the implementation of this policy. Employers are also likely to reject the

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minimum wage hike because it will eat into their profits. Passing such an ambitious bill will not
be a walk in the park.

5. Diversity and Equitable Distribution of Resources

When implementing new policies, the onus is always on MSN advanced professional
nurse leaders to ensure that the voices of the weak and vulnerable populations are also
complicated or represented. This is part of advocating for the rights of these minority groups,
mainly if they cannot lobby for themselves. Factoring equity and diversity in the distribution of
new resources when designing new policies and programs is necessary to avoid creating new
health inequities or disparities. For example, advocating for a policy change to solve economic
issues facing women in a specific area might discriminate against men. This can ultimately
create wage gaps and conflicts between men and women.
In the same context, I believe the new policy change (raising the minimum wage to
$15.00) discriminates against one large and vulnerable group in Harris County: the unemployed.
The minimum wage policy proposal only applies to employment, whether working for the
government or private firms. As of July 2021, the unemployment rate in Harris stands at 6.8
percent (YCharts, 2021). Broadly, it is vital to consider that the policy change recommendation
might directly affect minority groups underrepresented in the County’s employment sector,
including African Americans, the elderly, women, and the disabled. For example, as evidenced
across other states across the U.S., the Black unemployment rate in Texas towers above all ethnic
groups, including whites and Hispanics. According to a 2021 report by the Economic Policy
Institute, Unemployment among African Americans was 5.5 percent in the Q1 of 2021,
compared to 2.0 percent and 2.9 percent among whites and Hispanics, respectively (Moore,

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2021). The new policy incorporates all diverse employed people, regardless of their age, physical
and mental disability, gender, sexual orientation, race, sex, and place of birth.

6. Ethical Implications of Proposed Policy and the ANA Code of Ethics Provisions
   As an advanced professional nurse, proposing an increase in the minimum hourly wage to
   $15 in Harris County can help me uphold two key “ANA Code of Ethics Provisions”: Provisions
   seven and eight. Provision seven requires nurses to advance the nursing discipline by creating
   health and nursing policy, engagement in scholarly inquiry and research and developing
   professional standards in all settings and roles. Championing an economic policy that would see
   employees earn better minimum wages in Harris County is part of my duty, as stipulated by the
   Code, to partake in policy generation. Provision eight requires nurses to collaborate with other
   care providers like physicians and the public to lower health inequities or disparities, promote
   health diplomacy, and safeguard human rights (American Nurses Association, 2015). Equally,
   there is no better way to exercise my mandate to reduce health inequities in Harris than
   recommending a policy amendment that would see vulnerable groups (low-income earners like
   African American workers) get a pay rise.
7. Identification of the Policy Maker

The policymakers that would be the most influential in the proposed policy change would
be the Texas Legislature, including the 31 senators and 150 house representatives. The Texas
Legislature is the only body with the Constitutional powers to amend the current Texas Minimum
Wage Act by incorporating a clause that raises the minimum hourly wage to $15 and repeal the
provision that exempts all employment covered by the Fair Labor Standards Act. Typically, the
legislature convenes every two years (odd-number) to develop new laws and propose policies to
issues facing Texans. A senator or a representative can introduce a motion or bill in any Houses

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after listening to issues raised by the electorate they represent (Texas House of Representative,
n.d.). Therefore, the best legislators to advocate for an income rise to tackle HIV in Harris
County are Representative Sheila Jackson Lee or Senator John Whitmire. Harris County
residents elected these two to legislate on their behalf and, thus, carry the Constitutional mandate
to introduce the bill in either of the Houses.

8. Strategic Next Steps to Strengthen My Role as a Policy Advocate
   Across the active professional lives of nurses, the overarching duty always remains the
   same even as they increase their knowledge, experience, and qualification: advocating for the
   welfare and health of their patients and that of the profession. As life-long learners, nurses find
   themselves embroiled in a constant state of growth. Personally, this course has helped
   acknowledge the critical role advanced professional nurses, especially MSN-trained, can play in
   representing the voices of the vulnerable and at-risk groups in communities. I now know the
   critical role of indulging in politics as a nurse expert and social worker and how much it can
   change the social determinants of health of citizens, such as providing them with a safe
   environment free from toxic gases and water. I clearly understand my role as an advocate for
   changes that affect economic stability, the physical environment and neighborhood, education,
   food, community and social settings, and the health system. However, I have realized that
   effectively championing these changes takes more than just joining an association, such as ANA,
   or writing policy proposal letters to lawmakers. Therefore, I plan to take the following steps to
   strengthen my advocacy role and skills at the local, state, and national level:
   I. Pursue an MSN and a DPN
   Unquestionably, nurses can better their skills and experience, even in advocacy, by
   advancing their education and training. Therefore, I target to enroll in a Master of Science in

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Nursing immediately after completing my graduate education. I will take two or three years
practicing in clinical settings to gain the necessary experience before pursuing that Doctor of
Nursing Practice degree. These advanced courses will help me develop comprehensive clinical
instruction, critical thinking and problem-solving skills, research skills, and executive leadership
expertise (McCauley et al., 2020). The advanced training will also equip me with the most vital
leadership ingredients: people’s skills, such as good judgment, flexibility, empathy, active
listening, patience, strong communication skills, and connecting with others. These skillsets will
lay the background for the next massive step in my life: leadership and politics.
II. Join Leadership Positions, such as Board Membership, in Local Health Care
Facilities and Nursing Associations like ANA
After bagging a DNP, the most likely destination for me is leadership (like Board
membership) in health care institutions, such as hospitals, college training centers, or healthcare
insurance firms. I might also consider joining nursing associations like ANA, ABNS (American
Board of Nursing Specialties), and MLN (National League for Nursing). This will put me in a
better position to champion the rights of patients and nurses. Being at the helm of these national
institutions or public healthcare institutions will mean that I can directly communicate with those
in power to make effective changes that directly affect the health and wellbeing of communities.
Sitting at the Board also signifies I can vote or directly persuade my colleague to support policies
and programs I consider appropriate for the public or nurses (Institute of Medicine et al., 2011).
III. Join Politics
My ultimate goal is to join politics and represent the people at the bigger legislative stage.
According to Nickitas, Middaugh, & Aries (2016), nurses have a better chance of advocating for
quality care, better living standards, and safer and cleaner environments for the public by

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ascending to politics. As a politician (house representative or senator), I will have the voice to
raise issues on the floor and pass or fail bills.

(I)SBAR Summary of the Policy Proposal

Name of the Policy Maker: Sheila Jackson Lee
Title of the Policy Maker: House Representative, Harris County
Identity
I am an advanced professional nurse currently working in a local clinic in Harris County. I am
leading an action team advocating for African Americans at risk of contracting STIs in Harris
County.
Situation
I am disturbed by the alarming rates of new sexually transmitted infections in Harris, which is
ranked the highest in the state. Of more concern is the rates at which Blacks are
disproportionately affected by STIs, and this at-risk population is the most impoverished and
underemployed.
Background
STIs are infections that principally spread through unprotected sexual intercourse. It is prevalent
among low-income earners and poor households, and Black families have been forced to bear the
greatest brunt because most live below the poverty line. The current minimum wage of $7.25 set
by the Texas Workforce Commission is worsening the situation. It means that the already
disproportionately impoverished African Americans are earning less, pushing them into risky

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health behaviors like prostitution and drug abuse. This is what I think has been driving up the
rates of new STI diagnoses in Harris.
Assessment
I have come to seek your help to introduce a motion in the House to amend the Texas Minimum
Wage Act that will see the minimum hourly wage in the state rise to $15.
Recommendation
I recommend the House amend the bill to improve the purchasing power of all Texans.

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http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Co
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Artiga, S., & Hinton, E. (2018, May 10). Beyond health care: The role of social determinants in
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health-and-health-equity/
Hill, M. J., et al. (2020). Racial and sex disparities in HIV screening outcomes within emergency
departments of Harris County, Texas. Journal of the American College of Emergency
Physicians Open, 1(4), 476-483. doi: 10.1002/emp2.12046
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McCauley, L. A., et al. (2020). Doctor of nursing practice (DNP) degree in the United States:
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health professionals: Advocacy and action. Jones & Bartlett Publishers.

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Texas Department of State Health Services. (2018). 2018 Annual Report: Texas STD
Surveillance Report.
https://www.dshs.texas.gov/hivstd/reports/STDSurveillanceReport.pdf
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https://www.dol.gov/agencies/whd/flsa
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