Research suggests that increased voting among adults is associated with improved child health. Despite the benefits of voting, the United States has low voter turnout compared with peer nations. Turnout is especially low among marginalized people in the United States. Voter registration is essential for increasing voter turnout, and registration efforts have been successfully carried out in clinical settings. Working with a nonprofit called Vot-ER, we advocated for nonpartisan voter registration efforts in pediatric settings nationwide preceding the November 2020 US elections. We describe lessons learned from these efforts. Using data obtained from Vot-ER, we also provide the first estimates of participation in a national voter registration campaign in pediatric settings. There was widespread engagement in voter registration efforts among pediatricians in 2020. Many lessons were learned from these efforts, including the benefits of advanced planning because registration deadlines can be up to 1 month in advance of Election Day. Obtaining buy-in from numerous stakeholders (e.g., health center leadership, public relations teams) supports widespread staff participation. Also important is to consider the tradeoffs between active voter registration (in which staff can broach the topic of voting with patients and families) and passive efforts (in which voting is discussed only if patients or families inquire about it). These and other lessons can inform future voter registration efforts in diverse pediatric settings across the country.
Multiple studies have found an association between voting among adults and improved pediatric health outcomes.1 In 1 study, laws granting women suffrage were associated with increased public health spending and decreased child mortality in the United States.2 In another study, increased census tract–level voter participation rates were associated with decreased pediatric inpatient bed-day rates.3 Additionally, voting during late adolescence and early adulthood is associated with fewer depressive symptoms later in life.4 Potential mechanisms linking voting and health include increased self-efficacy and political representation among voters and resultant policy changes that address the social determinants of health.1,4
Despite the benefits of voting, the United States has low voter turnout compared with peer nations.5 In presidential elections from 2000 to 2020, an average of only 62.8% of adult United States citizens voted.6 US voter turnout is generally lower among people who are racial minorities,7 Hispanic,7 or young adults.8 Turnout is also generally lower among people with disabilities,9 certain health conditions,1 or lower education6 or income levels.10 Factors contributing to these inequities include Jim Crow–era disenfranchisement of African Americans,11 present-day voter purges, and polling location closures12,13 that disproportionately affect African American and Hispanic individuals,14,15 and inadequate accessibility of polling locations for people with disabilities.9
Voter registration is essential for increasing voter turnout in the United States. Almost every state requires citizens to register before Election Day to vote.16,17 In presidential elections from 2000 to 2020, an average of only 71.1% of voting-age citizens were registered to vote.6 Turnout was on average 25.5% higher among these already registered citizens than among all voting-age citizens.5,18–24 Two randomized controlled trials demonstrated that interventions to encourage registration can increase voter turnout.25,26 Such interventions have been successfully implemented in clinical settings.27 Thus, voter registration efforts in clinical settings may increase voter turnout and thereby improve the health of pediatric patients.
Motivation and Goals
We advocated for nonpartisan voter registration in pediatric settings nationwide with a nonprofit called Vot-ER preceding the November 2020 US elections. Vot-ER’s national work across medical specialties has been previously described as helping more than 46 000 people start the process of registering to vote or requesting a mail-in ballot in the 2020 presidential election.28 The goals of our pediatric-focused advocacy efforts with Vot-ER in 2020 were to maximize the number of health professionals engaged in nonpartisan voter registration efforts in pediatric settings and the number of people these professionals helped register to vote. The specific objectives of this case study are twofold. First, we describe lessons learned from implementing voter registration efforts in pediatric settings across the country. Second, using data obtained from Vot-ER, we provide national-level estimates of participation in these efforts. To our knowledge, these are the first such estimates published for the United States.
Methods and Process
The Environment
Vot-ER was founded in 2019 by an emergency medicine physician (coauthor Dr Martin), with the goal of integrating voter registration into health care settings nationwide. Thus, as volunteers for Vot-ER, we supported voter registration efforts at diverse pediatric settings across the country, including academic and community-based primary care clinics, urgent care clinics, subspecialty clinics, emergency departments, and inpatient units. We also helped champion voter registration efforts at Boston Children’s Hospital (BCH) and Children’s Hospital of Philadelphia (CHOP). Given the national scope of our advocacy, this case study describes key elements of registration efforts common to BCH, CHOP, and other diverse pediatric institutions that received guidance and resources from Vot-ER.
The Innovation: Voter Registration Badges
The American Academy of Pediatrics (AAP) has led a longstanding nonpartisan Get Out the Vote campaign before major elections to encourage pediatricians to share the importance of voting with children’s and adolescents’ needs in mind. Campaign resources provided to AAP members have included shareable voting-related social media messages and graphics and a printable “prescription” to vote that pediatricians can give to families.29 In addition, staff at pediatric institutions have run in-person voter registration tables at their facilities using AAP- and institution-specific materials.
In 2020, the AAP partnered with Vot-ER to provide pediatricians with novel campaign resources to encourage eligible patients and families to vote. One such resource, the main innovation of Vot-ER, was a badge with a quick response (QR) code linking to a voter registration web site (Fig 1).28 Staff could wear a badge during their everyday clinical work and offer patients and families the opportunity to scan the QR code to register. Thus, the badge was a novel tool that digitized and streamlined voter registration.
The Vot-ER badge was also a departure from traditional voter registration tables. Voter registration tables passively engage only people who voluntarily visit them and can be supervised by government relations teams if available. In contrast, any staff member wearing a badge could proactively ask patients and caretakers about voter registration. Badges also enabled involvement by a potentially greater number of individual staff members, including those who lacked time to volunteer during designated tabling hours. Thus, badges were an innovation that democratized involvement in voter registration for pediatric staff.
In 2020, physical Vot-ER badges cost $8 to $10 each for bulk orders and were free for individual badges. Physical badges came with a lanyard displaying Vot-ER’s logo. Health centers could also obtain a free digital badge that they could print, laminate, and distribute to staff. Badge, printing, and lamination expenses could be paid for using hospital discretionary funds and/or small departmental grants. As of this writing, Vot-ER provides free digital and individual physical badges.30,31
Timelines and Buy-In
Timelines were an important consideration. Voter registration deadlines vary by state and can be up to 1 month in advance of Election Day.32 Thus, to do a month of preelection voter registration, many institutions had to complete their preparations by September. Additionally, time was needed to obtain institutional buy-in. For some pediatric staff members, institutional approval was not needed to use a Vot-ER badge independently as an individual. For large hospitals, it could take 3 or more months to obtain approval to launch institution-wide voter registration efforts using Vot-ER tools.
Especially for institution-wide efforts at large hospitals, buy-in often had to be obtained from multiple levels of stakeholders, including institution-wide leadership, departmental leadership, and front-line staff. Institution-wide leaders included staff in government relations, legal, and marketing/public relations departments. Initial conversations with institution-wide leadership could lead to requests to get buy-in from other teams in the hospital, ranging from nursing leadership to infection prevention and control. Materials on Vot-ER’s web site,33 including lists of participating institutions34,35 and Vot-ER’s terms of use,36 were helpful for answering stakeholders’ questions and demonstrating uptake by peer institutions.
Increasing Engagement
For larger scale voter registration efforts, institutional leadership support was helpful for obtaining buy-in from departmental leaders in areas ranging from the emergency department to affiliated primary care practices. Through means such as e-mails, intranet banners, informal conversations, and announcements at team meetings and academic conferences, staff from diverse disciplines were encouraged to participate in voter registration efforts.
In addition to Vot-ER badges, a range of voter registration materials was provided, including multilingual infographics (featuring a voter registration QR code) for fliers, posters, electronic elevator displays, computer screensavers, and smartphone lock screens, as well as electronic medical record text about voting that could be printed for patients and their caretakers. At larger institutions, the government relations and marketing/public relations departments could be engaged to ensure that materials complied with institutional branding requirements. Electronic drives were useful to compile all materials for easy accessibility by staff. Departmental clinical and administrative staff could be engaged to help with printing, lamination, hole punching, and distribution of materials.
Medical students, residents, and fellows were also important champions of this work. They developed and distributed materials, helped reach out to departmental leaders, and were frequent users of badges, even when the involvement of attending physicians was limited because of time constraints.37
Challenges Faced
Key concerns raised by stakeholders centered around issues of legality and nonpartisanship. In terms of legality, the National Voter Registration Act of 1993 states that “Each State shall designate as voter registration agencies…all offices in the State that provide public assistance.”38 Per Internal Revenue Code, 501(c)(3) nonprofits are allowed to engage in “voter registration and get-out-the-vote drives” that are strictly nonpartisan (i.e., that do not “have the effect of favoring a candidate or group of candidates”).39 These standards have been used to support nonpartisan voter registration efforts in healthcare settings.28,37,40–45 Because patients and caretakers who chose to register voluntarily input their own information on a voter registration web site, this information has not been considered subject to Health Insurance Portability and Accountability Act regulations.45–47
At some pediatric institutions, there were concerns raised regarding the potential for perceived or actual partisanship or bias in which patients were asked about voter registration and how they were asked. These concerns were addressed in a variety of ways. At least 1 institution did not allow Vot-ER badges to be used. Some institutions allowed staff to wear Vot-ER badges but encouraged them to focus on passively responding to patient and caretaker voter registration questions rather than actively broaching the topic of voter registration. Other institutions allowed staff to wear Vot-ER badges and proactively ask patients about voter registration.
One tool used to support nonpartisanship was an online form educating staff about nonpartisanship requirements and asking them to confirm their understanding of the requirements before obtaining a badge. Additionally, Vot-ER provides sample scripts48 for having nonpartisan discussions with patients and caretakers about voting, and the organization’s terms of use state that use of its tools must be nonpartisan.36
Defining and Measuring Success
We used 3 primary metrics to define success: (1) the number of individual pediatric staff members who ordered a Vot-ER badge; (2) the number of pediatric institutions that ordered Vot-ER badges and other Vot-ER materials; and (3) the number of individuals each pediatric institution registered to vote. Data on the number of registrants who voted were not available.
Institutions were defined as individual health centers, ranging from standalone pediatric clinics to large centers such as BCH and CHOP. Academic institutions were defined as those sponsoring a residency program or having a major relationship with a medical school as per the American Medical Association’s FREIDA Institution Directory.49 Institutions could request a unique QR code to enable tracking of the number of people their institution registered.
We obtained de-identified spreadsheets from Vot-ER with numbers of orders and numbers of voters registered using each unique institutional QR code from May 1, 2020, through November 5, 2020. In these spreadsheets, rows representing pediatric staff and institutions generally contained at least 1 pediatric-related word such as “children’s.” We filtered these spreadsheets using a list of pediatrics-related search terms and word stems to identify participating pediatric staff and institutions. The list was as follows: perinat, neonat, newbo, NICU, infan, baby, babies, toddler, preschool, preschool, kid, child, girl, boy, kinder, school, PICU, juvenile, teen, adolescen, young, youth, pedia, paedia, peds, AAP, parent. Our analysis of these outcomes was deemed exempt by the BCH institutional review board.
Outcomes
Badge orders came from 1490 individual pediatric staff members (Table 1). Of pediatric staff who ordered badges, 1132 (76.0%) were physicians or physicians in training and 228 (15.3%) were nurse practitioners, physician assistants, nurses, or social workers. Ninety-nine (6.6%) were pediatric staff with other roles, including child life specialists, dieticians, chaplains, scribes, interpreters, pharmacists, occupational therapists, and respiratory therapists. Staff who ordered badges were based at 353 separate pediatric institutions (Table 1) in 41 states and the District of Columbia (Fig 2). Of these institutions, 144 (40.8%) were academic.
. | n . | % . |
---|---|---|
Pediatric staff (including trainees) (n = 1490) | ||
Attending physicians | 780 | 52.3 |
Fellows | 70 | 4.7 |
Residents | 208 | 14.0 |
Physicians with unspecified trainee status | 59 | 4.0 |
Medical students | 15 | 1.0 |
Nurse practitioners | 38 | 2.6 |
Physician assistants | 12 | 0.8 |
Nurses | 114 | 7.7 |
Social workers | 64 | 4.3 |
Others (e.g., child life specialists, dieticians) | 99 | 6.6 |
Unspecified | 31 | 2.1 |
Pediatric institutions (n = 353) | ||
Academic institutions | 144 | 40.8 |
Nonacademic institutions | 209 | 59.2 |
. | n . | % . |
---|---|---|
Pediatric staff (including trainees) (n = 1490) | ||
Attending physicians | 780 | 52.3 |
Fellows | 70 | 4.7 |
Residents | 208 | 14.0 |
Physicians with unspecified trainee status | 59 | 4.0 |
Medical students | 15 | 1.0 |
Nurse practitioners | 38 | 2.6 |
Physician assistants | 12 | 0.8 |
Nurses | 114 | 7.7 |
Social workers | 64 | 4.3 |
Others (e.g., child life specialists, dieticians) | 99 | 6.6 |
Unspecified | 31 | 2.1 |
Pediatric institutions (n = 353) | ||
Academic institutions | 144 | 40.8 |
Nonacademic institutions | 209 | 59.2 |
Fifty-four (15.3%) of the 353 participating pediatric institutions had a unique QR code. People at 21 (38.9%) of these 54 institutions used the institution’s unique QR code to complete the voter registration process. Among these 21 institutions, a median of 2 (interquartile range, 1-13) people per institution completed their voter registration using the institution’s QR code. The maximum number of people who completed their voter registration using a single pediatric institution’s QR code was 118. In addition, there was a general QR code for AAP members that 127 people used to complete the voter registration process. In total, 389 people completed their voter registration using an AAP or pediatric institution’s QR code. These numbers are likely underestimates of registrations because they do not capture: (1) users from institutions that could not be unambiguously classified as pediatric; (2) people who completed their registration using Vot-ER’s general QR code that was not specific to the AAP or any pediatric institution; and (3) people who completed their registration offline or using a non–Vot-ER web site.
Lessons Learned
There was widespread uptake of Vot-ER resources at pediatric sites across the country. Based on the experiences of these sites, we share multiple lessons that could be useful for implementing voter registration efforts in pediatric settings.
Lesson #1
Start early and consider issues of scale. Starting to plan a voter registration effort months before Election Day maximizes the time available to build a large, diverse coalition of stakeholders to support the effort. With adequate time and buy-in from institutional leadership, more clinical sites and staff can get involved and more potential registrants can be reached. Additionally, distribution plans should make it easy for staff to participate (i.e., allowing staff to access digital and hard-copy materials at times and locations convenient for them). This work requires a core team of champions passionate about voter registration, with frequent communications and mutual encouragement.
Lesson #2
Build off small efforts. Even small-scale efforts with minimal advanced preparation can be valuable, forming the basis of future voter registration initiatives. Opportunities for voter registration arise every year. From midterm elections to primary elections to orientation days for new trainees and other staff, there are many opportunities to help people register. Ultimately, Vot-ER hopes that asking about voter registration will become a normalized element of clinical encounters, to be done even when there is not an immediately upcoming election.50
Lesson #3
Fully consider the tradeoffs between active voter registration (in which staff broach the topic of voting to patients and caretakers) and passive efforts (in which voting is discussed only if patients or caretakers inquire about it). If active efforts are used, concerns may be raised about potential partisanship or bias in whom staff ask about voter registration. However, one cannot know the political views of patients or families based solely on externally observable characteristics.
Furthermore, compared with active efforts, passive efforts may yield fewer conversations about voter registration. For instance, though badges and lanyards displayed Vot-ER’s logo and were designed to catch people’s attention, they were often covered by gowns worn by staff for patients on infection precautions. Additionally, patients may not have asked about badges because of lack of time, interest, awareness that they could register to vote at a health center, or confidence that the staff member wearing the badge would be willing and able to discuss voting with them. Though actively mentioning voter registration could overcome these barriers, certain patients (such as those presenting with very high acuity) may not be appropriate for discussions of voting. However, as with social work resources or clinical trial participation, voter registration could be viewed as a health promotion opportunity51 important enough to approach patients and caretakers about, even if one cannot approach everyone in a completely uniform way.
Lesson #4
Pilot and share innovative approaches. For instance, a brief question about voter registration status could be integrated into standard patient registration or screening processes. Patient portal and text messages could be sent to patients and families reminding them about voter registration. Adolescent medicine teams may be particularly well-suited to pilot voter registration innovations because many of their patients are nearly, or newly, eligible to vote.
Lesson #5
Support evaluation and research. Voter registration champions could consider applying for institutional review board approval to study their voter registration efforts. For tracking efforts using Vot-ER tools, it can be helpful to count the number of individuals registered using a unique institutional QR code. If the QR code is shared with another institution (such as an affiliated adult hospital), then QR code data can be difficult to interpret. Evaluation plans could also track total numbers of people who were engaged in a discussion about voting, who registered, and/or who voted, regardless of whether they used a QR code. Obtaining these data can be difficult. However, these data are important for assessing the impact of voter registration efforts and should be explored in future research. In addition, qualitative data on patient and family experiences should be captured to improve registration efforts and further assess their acceptability to patients and families.
More broadly, the intersection between voting and health is an area with great potential for future research. For instance, experimental studies are needed to delineate potential causal pathways between voter registration, voting, and various health outcomes and costs. Studies are also needed on barriers to implementing voter registration efforts in pediatric settings and how to overcome them.
Lesson #6
Support voter registration efforts outside of health care settings. Pediatric staff can encourage, learn from, and potentially partner with ongoing registration efforts in settings such as high schools and nonprofit organizations.52,53 In addition, pediatric staff can advocate for policies to facilitate voter registration, such as automatic voter registration54 and same-day voter registration.17 Both of these policies have been implemented in certain states and could be implemented more broadly to help increase voter registration.
Conclusions
Voter registration efforts have the potential to increase political representation among patients and families, thereby driving policy changes affecting virtually every aspect of pediatric health. Thus, no matter one’s issue of interest, from Medicaid reimbursement rates and research funding to pediatric mental health, firearm safety, and child poverty, voter registration and voting are important. Given this importance, there is widespread interest in voter registration in pediatric settings, as evidenced by our national-level data. Moving forward, we will focus on increasing staff, patient, and family engagement in voter registration nationwide, using tools such as freely available Vot-ER badges and AAP resources.29 We invite readers to lead their own voter registration efforts by drawing on the lessons presented in this case study.
Acknowledgments
The authors thank Aliya Bhatia, Dr Katelin Blackburn, Dr Stephanie Fong Gomez, and Dr Margaret N. Jones for their review of this manuscript and its applicability in various pediatric settings.
Dr Junior co-led voter registration efforts at Boston Children’s Hospital in 2020, conceptualized and designed the study, collected the data, analyzed the data, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Ha co-led voter registration efforts at Children’s Hospital of Philadelphia in 2020, conceptualized and designed the study, and reviewed and revised the manuscript; Ms Ruxin served as senior project manager for Vot-ER’s Healthy Democracy Campaign, conceptualized and designed the study, collected the data, analyzed the data, and reviewed and revised the manuscript; Ms Moore co-led voter registration efforts at Children’s Hospital of Philadelphia in 2020 and reviewed and revised the manuscript; Dr Grade is director of research at Vot-ER, collected the data, and reviewed and revised the manuscript; Dr Stewart co-led voter registration efforts at Boston Children’s Hospital in 2020 and reviewed and revised the manuscript; Dr Murray co-led voter registration efforts at Children’s Hospital of Philadelphia in 2020 and reviewed and revised the manuscript; Dr Martin founded and led Vot-ER, collected the data, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Results from this study were presented at the American Academy of Pediatrics 2022 National Conference and Exhibition; October 9, 2022; Anaheim, California.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: Dr Martin is the founder of Vot-ER. The other authors have indicated they have no potential conflicts of interest.
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