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GOVERNMENT, POLITICS, AND LAW
Policy, Politics, and Collective Action
Understanding Evidence-Based Public Health Policy Ross C. Brownson, PhD, Jamie F. Chriqui, PhD, and Katherine A. Stamatakis, PhD, MPH
Public health policy has a
profound impact on health
status. Missing from the liter-
ature is a clear articulation of
the definition of evidence-
based policy and approaches
to move the field forward. Pol-
icy-relevant evidence includes
both quantitative (e.g., epi-
demiological) and qualitative
information (e.g., narrative
We describe 3 key domains
of evidence-based policy: (1)
process, to understand ap-
proaches to enhance the like-
lihood of policy adoption; (2)
content, to identify specific
policy elements that are likely
to be effective; and (3) out-
comes, to document the po-
tential impact of policy.
Actions to further evidence-
based policy include prepar-
ing and communicating data
more effectively, using exist-
ing analytic tools more ef-
fectively, conducting policy
surveillance, and tracking out-
comes with different types of
evidence. (Am J Public Health.
IT HAS LONG BEEN KNOWN
that public health policy, in the form of laws, regulations, and guidelines, has a profound effect on health status. For example, in a review of the 10 great public
health achievements of the 20th century,1 each of them was influ- enced by policy change such as seat belt laws or regulations governing permissible workplace exposures. As with any decision-making pro- cess in public health practice, for- mulation of health policies is com- plex and depends on a variety of scientific, economic, social, and po- litical forces.2
There is a considerable gap be- tween what research shows is ef- fective and the policies that are enacted and enforced. The defini- tion of policy is often broad, in- cluding laws, regulations, and ju- dicial decrees as well as agency guidelines and budget priorities.2–4
In a systematic search of ‘‘model’’ public health laws (i.e., a public health law or private policy that is publicly recommended by at least 1 organization for adoption by government bodies or by speci- fied private entities), Hartsfield et al.5 identified 107 model public health laws, covering 16 topics. The most common model laws were for tobacco control, injury prevention, and school health, whereas the least commonly covered topics included hearing, heart disease prevention, public health infrastructure, and rabies control. In only 6.5% of the model laws did the sponsors pro- vide details showing that the law
was based on scientific informa- tion (e.g., research-based guide- lines).
Research is most likely to influ- ence policy development through an extended process of communi- cation and interaction.6 In part, the research–policy interface is made more complex by the nature of scientific information, which is often vast, uneven in quality, and inac- cessible to policymakers. Several models for how research influences policymaking have been de- scribed,7–9 most of which involve moving beyond a simple linear model to more nuanced and indi- rect routes of influence, as in grad- ual ‘‘enlightenment.’’10 Such nonlin- ear models of policymaking and decision-making take into consider- ation that research evidence may hold equal, or even less importance, than other factors that ultimately influence policy, such as policy- makers’ values and competing sources of information, including anecdotes and personal experi- ence.11 Although not exhaustive, Table 1 highlights several important barriers that should be considered when one is attempting to develop effective policy.12–16
Although there have been many calls for more systematic and evidence-based approaches to policy development,5,6,17–21 miss- ing from the literature is a clear
articulation of the definition of evi- dence-based policy along with spe- cific approaches that will enhance the use of evidence in policymak- ing.
TYPES OF EVIDENCE FOR EVIDENCE-BASED POLICY
Policy change involves both science and art and, therefore, evidence for policymaking can take several forms. The concept of evidence often originates from legal settings in Western soceties. In law, evidence comes in the form of stories, witness accounts, police testimony, expert opin- ions, and forensic science.22 For policy-relevant evidence, both quantitative data (e.g., epidemiolog- ical) and qualitative information (e.g., narrative accounts) are impor- tant.
Although the use of research- derived evidence may be a key feature of most policy models,7,9,23
it is not a certainty that scientific evidence will carry as much weight in ‘‘real world’’ policy- making settings as other types of evidence. Policymakers operate on a different hierarchy of evi- dence than scientists,17 leaving the 2 groups to live in so-called parallel universes.14 According to inter- views with policymakers, many re- spondents reported that they were
1576 | Government, Politics, and Law | Peer Reviewed | Brownson et al. American Journal of Public Health | September 2009, Vol 99, No. 9
not trained to distinguish between good and bad data, and were, therefore, prone to the influence of misused ‘‘facts’’ often pre- sented by interest groups.24 Sim- ilarly, McDonough reported that in policy debates in state legislatures, data were used as ‘‘rhetorical weapons used to bolster competing values.’’25(p210) Because numbers exert a powerful and widespread influence on policy debates, they can lose their objective meaning.26
Quantitative evidence for poli- cymaking (i.e., data in numerical quantities) can take many forms, ranging from scientific informa- tion in peer-reviewed journals, to data from public health surveil- lance systems, to evaluations of individual programs or poli- cies.27,28 Many consider the stron- gest evidence to be that from sys- tematic reviews (e.g., the Guide to Community Preventive Services29 or
the Cochrane Reviews30), which sum up the results of primary sci- entific studies that meet explicit criteria (i.e., decision rules). Using data from reviews of public health laws, Moulton et al. searched the English language literature over the past 5 years. They identified 65 systematic reviews and found that of 52 public health laws, 27 were found effective, 23 had insufficient evidence to judge effectiveness, 1 was harmful, and 1 was found to be ineffective.31 Yet single studies and evaluations are more com- monly used to support policy than are systematic reviews,32,33 in part because of the time and expense of conducting a systematic review or the insufficient number or quality of studies on a particular topic.
Other quantitative data can be collected from policymakers themselves to provide general guidance on policy approaches and strategic information on spe- cific public health issues. For ex- ample, in a survey of 292 US state policymakers,34 respondents expressed a strong preference for short, easy-to-digest data. Younger respondents were more likely to use electronic information than were older policymakers. The most trusted sources of information were those not having a stake in the outcome and those providing state- by-state comparisons. Surveys of policymakers can provide useful data on priorities and obstacles for specific health issues,35,36 attitudes and voting intentions,37 and per- ceptions of lobbyists and lobbying.38
Qualitative evidence involves nonnumerical observations, collected by methods such as
participant observation, group in- terviews, or focus groups. Quali- tative evidence can make use of the narrative form as a powerful means of influencing policy delib- erations, setting priorities, and proposing policy solutions by tell- ing persuasive stories that have an emotional hook and intuitive ap- peal. This often provides an an- chor for statistical evidence, which, in turn, offers the powerful persuasive impact of the law of large numbers, in addition to be- ing verifiable and having high credibility.39 In studying the impact of evidence on policy to address health disparities, qualitative data, such as the effects of policy initia- tives on children and families, has been persuasive and powerful in shaping the agenda.40
The incorporation of quantita- tive evidence within a compelling story can provide a powerful lever in the policy process. Studies from the communication field have ex- amined the effectiveness of using statistical data versus stories for persuasion. These have shown that, although quantitative evi- dence alone more frequently has a stronger persuasive effect than qualitative evidence alone,41 the combination of the 2 types of evi- dence appears to have a stronger persuasive impact than either type of evidence alone.42
Governmental policy systems vary widely in their structure and scope, ranging from totalitarian to democratic governments. We fo- cused the descriptions of evidence- based policy on multicentric (democratic) governments.
TABLE 1—Barriers to Implementing Effective Public Health Policy
Lack of value placed on prevention Only a small percentage of the annual
US health care budget is allocated
to population-wide approaches.
Insufficient evidence base The scientific evidence on effectiveness
of some interventions is lacking or
the evidence is changing over time.
Mismatched time horizons Election cycles, policy processes, and
research time often do not match well.
Power of vested interests Certain unhealthy interests (e.g., tobacco,
asbestos) hold disproportionate
Researchers isolated from
the policy process
The lack of personal contact between
researchers and policymakers can lead to
lack of progress, and researchers
do not see it as their responsibility to
think through the policy implications
of their work.
Policymaking process can be
complex and messy
Evidence-based policy occurs in complex
systems and social psychology suggests
that decision-makers often rely on habit,
stereotypes, and cultural norms for the
vast majority of decisions.
Individuals in any one discipline
may not understand the
policymaking process as a whole
Transdisciplinary approaches are more
likely to bring all of the necessary skills
to the table.
Practitioners lack the skills
to influence evidence-based
Much of the formal training in public
health (e.g., masters of public health
training) contains insufficient emphasis
on policy-related competencies.
GOVERNMENT, POLITICS, AND LAW
September 2009, Vol 99, No. 9 | American Journal of Public Health Brownson et al. | Peer Reviewed | Government, Politics, and Law | 1577
Whether at a local, state, or fed- eral level, the purpose of a rep- resentative body is to enact rules, laws, or ordinances that are in turn implemented by ex- ecutive or administrative agents. We focused primarily on ‘‘big P ’’ policies (e.g., formal laws, rules, regulations enacted by elected of- ficials) as contrasted with ‘‘small p’’ policies (e.g., organizational guidelines, internal agency deci- sions or memoranda, social norms guiding behavior).43,44
Evidence-based policymaking has largely been an incremental progression.45 For example, to- bacco control advocates have long sought comprehensive restrictions on tobacco use, access, and sec- ondhand smoke exposure. How- ever, public policies on these topics were developed over de- cades. In 1987, the US House of Representatives banned smoking on domestic flights of 2 hours or less; in 1992, Congress passed the Synar Amendment46 requiring states to adopt and enforce restric- tions on tobacco sales to minors; in 1996, the US Food and Drug Ad- ministration published a final rule that restricted youth access to to- bacco products (which was later overturned by the US Supreme Court)47,48; and in the past decade and a half, states and municipal governments have been extremely active in developing laws and reg- ulations aimed at smoke-free work- sites and public places.49–51
THREE DOMAINS OF EVIDENCE-BASED POLICY
We propose that evidence- based policy can be conceptualized as a continuum spanning 3
domains—process, content, and outcome (Table 2). Furthermore, as discussed earlier, there is no single, ‘‘best’’ type of evidence.
Recognizing and identifying key factors that inform the policy pro- cess is also critical to furthering evidence-based policy. Policymak- ing is complicated and the factors that inhibit or facilitate the process are equally complex.17 There are very distinct stages or ‘‘streams’’ as Kingdon noted that, when coupled together, increase the odds of a policy being adopted. The first stream is the problem––agenda setting and how certain problems or conditions come to be regarded as problems worthy of governmental intervention. The second stream is policy––the alternative policy approaches that may be taken to address those problems.4 The third stream, politics, recognizes those factors both inside and outside government that influence the
policymaking process. Public poli- cies must be not only ‘‘technically sound, but also politically and ad- ministratively feasible.’’52(p311)
Documenting influential politi- cal factors can comprise an evi- dence base for the process domain of evidence-based policy. Factors such as the national mood, orga- nized political forces (e.g., interest groups, lobbyists), changes in governmental participants such as legislative or administrative turn- over, jurisdictional boundaries or turf ‘‘wars’’ between governmental agencies, and the necessity of compromise or bargaining all affect the policy process.4,53
According to numerous accounts, one of the reasons that health care reform legislation failed in the early to mid-1990s was a failure to un- derstand the politics involved with policymaking.4,53 Furthermore, the approach taken by the executive branch at the time was very much a rational, comprehensive approach to policymaking that sought to
identify all of the possible alterna- tives, weigh the costs and benefits of each alternative, and choose the best approach among the alterna- tives. Proponents of that approach failed to learn from the lessons of past health care reform efforts, which indicated the need for an incremental approach to change rather than aiming for an all or nothing strategy.4,53,54
Many factors affect the policy- making process, including suc- cessful advocacy. In the study of social movements, progress hinges on the standing of those articulat- ing an issue and the presence of a policy ‘‘sparkplug.’’55,56 Case stud- ies show that policy entrepreneurs or champions (i.e., leaders from professional, political, or interest groups who effectively advocate policy) have played key roles in policy reforms, including making major reforms in the historically intractable arena of Chicago, Illi- nois, public schools57 and the rise of managed care as a dominating force
TABLE 2—Domains of Evidence-Based Public Health Policy
Domain Objective Data Sources Example
Process To understand approaches to
enhance the likelihood of
Key informant interviews Understanding the lessons learned
from different approaches and key
players involved in state health
Surveys of setting-specific
Content To identify specific policy
elements that are likely
to be effective
Systematic reviews Developing model laws on tobacco
that make use of decades
of research on the impacts of
policy on tobacco use.
Outcome To document the potential
impact of policy
Surveillance systems Tracking changes in rates of
self-reported seat belt use in
relation to the passage of seat
Natural experiments tracking
Describing the cost-effectiveness
of child immunization requirements.
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GOVERNMENT, POLITICS, AND LAW
in the US health care system.58
From the health policy field, several authors20,59–62 describe successful examples of evidence-based advo- cacy and provide a guide for those who seek to move from research to advocacy. A strong partnership of researchers and advocates ensures that policies are grounded in sci- ence, so messages are tailored to the target audience, and models of persuasive communication (e.g., social marketing) are applied.
Policy content focuses on iden- tifying the specific policy elements that are likely to be effective. As noted earlier, both quantitative and qualitative data can be used by policymakers to determine the appropriate policy intervention. Such information may be gleaned from systematic reviews and other scientific research including con- tent analyses that offer an evidence base to inform decisionmaking.29
For example, the Institute of Medicine has recognized that trans fatty acids (trans fats) do not pro- vide any known health benefit and that they are linked to coronary heart disease.63 One way to reduce or eliminate exposure to trans fats is to regulate their inclusion in food products.64 As of August 2008, 7 US cities or counties had limited or restricted trans fats65,66 and Cali- fornia is the first state to enact a law banning trans fats.66
We need to better understand and describe evidence-based ele- ments within existing or proposed policy. For example, in examining 6.5 years of state legislation on physical education, Eyler67 used systematic reviews and national standards to identify 4 specific bill
components that are scientifically supported (i.e., minutes in physical education, physical education ac- tivity, teacher certification, and an environmental element including facilities and equipment).68–70
Eyler conducted a content analysis and found that 28% of state laws had at least 1 evidence-based element yet only 0.5% had all 4 evidence-based elements.67
Documenting the effects of implemented policies (policy out- come) is equally important in supporting evidence-based policy. Policy evaluations are critical to the understanding of the impact of policies on community- and indi- vidual-level behavior changes. They should include ‘‘upstream’’ (e.g., presence of zoning policies supportive of physical activity), ‘‘midstream’’ (e.g., the enrollment in walking clubs), and ‘‘down- stream’’ (e.g., the rate of physical activity) factors.71 By far, the ma- jority of quantitative measures are available for downstream out- comes.71 One evaluation frame- work, the RE-AIM framework,72
can be applied to evaluations of a policy and its impact.73 RE-AIM has 5 dimensions: (1) reach (who or how many will be affected by the policy), (2) effectiveness (proximal or distal impacts and unintended consequences), (3) adoption (policy diffusion and participation level), (4) implementation (costs as well as enforcement and compliance), and (5) maintenance (institutionalizing the policy or program).
Policy evaluations may employ both qualitative and quantitative methodologies and may make use of ‘‘natural experiments’’
surrounding the adoption and implementation of the policy. These evaluations involve natu- rally occurring circumstances where different populations are exposed or not exposed to a po- tentially causal factor (e.g., a new policy) such that it resembles a true experiment in which study participants are assigned to ex- posed and unexposed groups. For example, scientific evidence led to the change in polio vaccination policy in the United States from that of an entirely oral poliovirus vaccine prior to 1997, to a sched- ule of inactivated poliovirus vac- cine followed by oral poliovirus vaccine in 1997 through 1999, to a schedule of entirely inactivated poliovirus vaccine in 2000. When the policy changed from oral po- liovirus vaccine only to inactivated poliovirus vaccine followed by oral poliovirus vaccine, the mean number of cases of vaccine-associ- ated paralytic poliomyelitis de- clined by 54%. Since the conver- sion to an entirely inactivated poliovirus vaccine schedule in 2000, no cases of vaccine-associ- ated paralytic poliomyelitis have been reported in the United States.74
Feedback Among the
Making public policy is a con- tinuous or recursive process that relies heavily upon scientific evi- dence and other influences (Figure 1).75,76 Scientific evidence that ex- amines the impact of public policies on systems and individual-level be- havior change is one possible source of feedback. ‘‘Policy rein- vention’’ is another step in the feedback loop—i.e., policies evolve
as they diffuse.77 The development and diffusion of smoke-free air laws in states and municipalities in the United States began with restricting smoking to designated areas, fol- lowed by restricting smoking to separately ventilated and separately enclosed areas, and, in the past several years, to complete bans on smoking.50,51
In addition, how the policy issue is framed is as important as the process and content. As Jewell and Bero recently noted, research- based evidence
must be packaged to incite and persuade, to translate that knowledge into something that is understandable by the average legislator, average citizen.24(p196)
For example, efforts to ban or restrict the content of vending machines in schools did not mo- bilize until the issue was framed in a way such that vending machines were considered a vector for risk factors and behaviors that may be linked to obesity (such as the re- lationship between soft drink consumption and childhood over- weight and obesity).24 The feed- back and framing processes are enhanced by partnerships among researchers, practitioners, and policy- makers.
A WORKING DEFINITION TO MOVE THE DEBATE FORWARD
This short review of the nature of evidence-based policy sets the stage for 6 issues that will help in advancing the field, organized across the 3 domains of process, content, and outcome. Although the list that follows is not exhaus- tive, it involves the themes that we
September 2009, Vol 99, No. 9 | American Journal of Public Health Brownson et al. | Peer Reviewed | Government, Politics, and Law | 1579
GOVERNMENT, POLITICS, AND LAW
believe are among the highest priorities. Building on our review and past literature,32,33,78 we pro- pose the following working defini- tion: to improve public health out- comes, evidence-based policy is developed through a continuous process that uses the best available quantitative and qualitative evi- dence.
Prepare data for quick and proactive dissemination. Seneca, a philosopher in ancient Rome, noted that ‘‘luck is what happens when preparation meets opportu- nity.’’79 This notion applies to modern-day policymaking. Luck and timing undoubtedly play im- portant roles in policy success and we know that scientific studies are not always conducted at the right time to influence policy deci- sions.80,81 For success in the pro- cess, one often needs to proactively
analyze and assemble data so that evidence is ready when a policy window or opportunity emerges.82,83
Seek new ways of communicating data. Although it is well estab- lished that data can be powerful in shaping policy decisions,84 they are sometimes not in the form most useful for policymakers.85 One study of long-term care policymak- ing indicated ‘‘loud and clear, that academic-quality research is not reaching’’ policymakers.86(p320) For example, surveillance data often provide disease or risk factor data at the national or state level, yet these reports can be lengthy and are often lacking local-level data on health disparities.87 Data need to be in a form that (1) shows public health burden, (2) demonstrates priority of an issue over many others, (3) shows relevance at the local (voting district) level, (4) shows benefits (or sometimes harms88) from an
intervention, (5) personalizes an is- sue by telling a compelling story of how peoples’ lives are affected,14
and (6) estimates the cost of in- tervention. Such data need to be presented in short and concise formats (e.g., issue briefs) that di- rectly address the issue that is being debated.
Identify the elements that lead to evidence-based policy. On the basis of credible evaluations, it is possi- ble to sift apart the ‘‘active ingre- dients’’ of various policy interven- tions (i.e., the essential elements that contribute to effectiveness). Thus, the content of legislation can be developed based on the key elements that are likely to have the greatest public health impact, bal- ancing effectiveness and popula- tion impact. This is the concept underpinning model legislation, yet even when model language exists, it is often lacking a scien- tific basis or has not been widely tested.5
Effectively use existing tools. A diverse and rich set of tools puts information at the fingertips to shape the content of evidence- based policy. These tools include meta-analysis, decision analysis, cost-effectiveness analysis, and simulation modeling; all are underutilized.89,90 The existence of the tool alone is not enough; often training and technical assis- tance are needed to enhance uptake among potential users.
Develop systems for policy surveillance. To examine the adoption, implementation, and impact of evidence-based policy,
we need systems in place to help us monitor patterns and trends in policies.91–93 A few early efforts are underway to develop public health policy surveillance systems. For ex- ample, a group of federal and vol- unteer-based agencies have devel- oped policy surveillance systems for tobacco, alcohol, and, more re- cently, school-based nutrition and physical education.94–97
Rely upon numerous forms of evidence for tracking outcomes. Ev- idence comes in numerous forms. It may be helpful to consider pol- icy evidence in a typology rather than a hierarchy because adher- ence to a strict hierarchy of study designs may reinforce an ‘‘inverse evidence law’’ by which interven- tions most likely to influence whole populations (e.g., policy change) are least valued in an evidence matrix emphasizing ran- domized designs.98,99 In addition, policy outcomes can be monitored with triangulated methods (accu- mulation of evidence from a variety of sources to gain insight into a particular topic, often combining quantitative and qualitative data) to understand content and track progress. Successful monitoring of outcomes will also require sources beyond the usual public health data sets (e.g., tax revenue data, polling data, marketing information).
Policy has had, and will con- tinue to have, a vast impact on our daily lives and on public health indicators in part because of its long-term effects and relative low cost. Many of the public health programs now being implemented have a significant focus on policy
FIGURE 1—The interplay of factors influencing evidence-based
public health policy.
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GOVERNMENT, POLITICS, AND LAW
change. To improve these pro- grams and to further evidence- based policy, we need to use the best available evidence and ex- pand the role of researchers and practitioners to communicate evi- dence packaged appropriately for various policy audiences; to un- derstand and engage all 3 streams (problem, policy, politics) to im- plement an evidence-based policy process; to develop content based on specific policy elements that are most likely to be effective; and to document outcomes to improve, expand, or terminate policy.
Governments spend significant sums on health-related research (about $30 billion annually in the United States) with the implied obligation that this investment will improve the health of the public. Better application of the tenets of evidence-based policy is likely to accelerate this improvement. j
About the Authors Ross C. Brownson is with the Prevention Research Center in St Louis, the George Warren Brown School of Social Work, and the Department of Surgery and Alvin J. Siteman Cancer Center, School of Medicine, Washington University, St Louis. Jamie F. Chriqui is with the Health Policy Center, Institute for Health Research and Policy, University of Illinois, Chicago. Katherine A. Stamatakis is with the Department of Sur- gery and Alvin J. Siteman Cancer Center, School of Medicine, Washington Univer- sity, St. Louis.
Correspondence should be sent to Ross C. Brownson, PhD, Washington University in St Louis, 660 S Euclid, Campus Box 8109, St Louis, MO 63110 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ link.
This article was accepted January 20, 2009.
Contributors R. C. Brownson conceptualized the ori- ginal project, led all phases, wrote
sections of the article, and edited the entire article. J. F. Chriqui and K. A. Stamatakis helped to conceptualize ideas, wrote sections of …
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