Developing Policy for Public Health Nutrition

What is Policy?

Policy – Webster’s

• Wise, expedient, or prudent conduct or management

• A principle, plan, or course of action, as pursued by a government, organization, individual, etc.

Policy Making – Webster’s

• The act or process of setting and directing the course of action to be pursued by a government, business, etc.

Policy = The Rules

Big “P” Little “p”

Legislation

Litigation

Regulation

Protocols

Procedure manuals

Organizational rules

Administrative rules

Incentives/disincentives

Examples of PoliciesState County MPO/RDC City

Legislation

Ordinance

Resolution

Tax Ordinance

Internal Policy

Plans

Design Manual

From Thunderhead Alliance: Complete Streets Report

Why do we need policy?

Intervention Categories with Strong Evidence of Effectiveness for the 10 greatest Achievements in Pubic Health: From IOM report: Preventing Childhood Obesity, 2005…

Community Wide Campaigns

School based intervention

Mass media strategies

Laws and regulations

Reducing costs to patients

Vaccination X X X X

Motor vehicle safety

X X X X

Safer work places

X X

Control of infectious disease

X X X X

Decline in deaths from CHD and stroke

X X X

Community Wide Campaigns

School based intervention

Mass media strategies

Laws and regulations

Reducing costs to patients

Safer and healthier foods

X X X X X

Healthier mothers and babies

X X X X

Family Planning

X X X

Water Fluoridation

X

Recognition of tobacco as a health hazard

X X X

How is policy developed?

Kingdon JW. Agendas, Alternatives, and Public Policies.

2002

Participants

The Streams

Agenda Setting

Alternative Specification

Coupling the Streams/ Windows

Participants

National Policy Participants

• President

• Members of congress

• Civil servants

• Lobbyists

• Journalists

• Academics

• Others

Basics

Kinds of Participants

• Visible: those who receive press and public attention – high level electeds and their appointees, the media, political parties, etc.– Affects the agenda

• Hidden: academic specialists, career bureaucrats, congressional staffers– Affects the choice of alternative solutions

Basics

Policy Entrepreneurs

• Willing to invest resources in return for future policies

• Can be elected officials, career civil servants, lobbyists, academics, journalists

• Entrepreneurs:– Highlight problem indicators to dramatize problem– Push for one kind of problem definition or another –

invite electeds to see for themselves– “Soften up” by writing papers, giving testimony,

holding hearings, getting press coverage, meeting endlessly…..

Food and Nutrition Policy Entrepreneurs

Food & Nutrition Policy

Health Professional Associations

Consumer Interest groups & Other NGOs

Government – at all levels

Farmers/Commodity groups

Food Industry

Scientific Bodies & Researchers

The “streams”

3 streams of processes

• Problem recognition

• Policies: proposal formation

• Politics

Problems

Why do some problems get attention?1. Indicators – large magnitude or change

2. Focusing event – disaster, crisis, personal experience

3. Feedback about existing programs – evaluation, complaints, etc.

Problem Recognition is Key

Policy entrepreneurs invest resources:– Bringing their conception of problems to

official’s attention– Convincing officials to see the problem the

way they want it to be seen

Framing the Problemhttp://www.frameworksinstitute.org/

• Problems with the Dominant Communications Approach to Childhood Obesity:

1. It focuses on the individual as the cause of the problem.

2. Parents are the only responsible actors in the frame.

3. The problem is overwhelming. 4. Behavior change by parents and children is

the solution to the problem.

Examples of Causal Sequences that Include Environments & Policies

• "Today's kids are generally getting less exercise as schools decrease the amount of phys ed and recess time offered each week, increasing their risk of becoming sedentary adults.”

• "When parents don't have access to healthy food because they live in a neighborhood where access to fresh produce and other healthy foods is limited, this makes it almost impossible to offer healthy diets at home. Initiatives such as community gardens can help make healthy food available to everyone."

• "The constant barrage of junk food ads directed at children shapes their food preferences, leading to an increase in consumption of unhealthy snacks, especially while watching television.”

Policy Proposals: Alternative Specification

• Narrows the large set of possible alternatives to that set from which choices are actually made.

Alternative Specification

• Alternatives are generated and narrowed in the policy stream and by:

• Hidden participants: Loosely knit communities of academics, researchers, consultants, career bureaucrats, congressional staffers, analysts who work for interest groups who:

• Float ideas, criticize each other works, hone ideas, recombine ideas

Generation of Policy Alternatives

• Generation of policy alternatives analogous to natural selection

• Order developed from chaos

• Criteria include:– Technical feasibility– Congruence with values– Anticipation of future constraints (budget,

public acceptability, politicians’ receptivity)

Politics

Developments in the political arena are powerful agenda setters.– National mood– New administrations– New partisan/ideological distributions in

congress– Interest groups that press (or fail to press)

demands on government

Political Decisions

Consensus is built by bargaining– Trading provisions for support– Adding elected officials to coalitions by giving

concessions– Compromising from ideal positions to those

that will gain wider acceptance

National mood and elected officials more important than interest groups for political decisions

“Softening-up”

• Policy Entrepreneurs push for consideration in many ways and in many forums.

• Most proposed alternatives have long gestational period

• Recombination (coupling of already familiar elements) is more effective than mutation (wholly new forms).

Lives of the “Streams”

• The three streams have lives of their own.– Problems are recognized and defined– Policy proposals are developed according to

their own incentives and selection criteria and are often waiting for a problem or political event they can be attached to

– Political events flow along on their own schedule

Problem Recognition

Policy Proposals Politics

Problem Recognition

Policy Proposals Politics

Legislation or Change in Policy

2

Problem Stream

Policy Stream

Politics Stream

Figure 2: Kingdon’s Multiple Streams Model

No policy adoption

Problem Stream

Policy Stream

Politics Stream

A BC

B2

31

C

2

Scenario 1: No Coupling of Streams or Window Closed > Policy Proposal Not Adopted

Scenario 2: Coupling of Streams and Window of Opportunity Open > Policy Proposal Adopted

Policy Adoption

Window

• Window of opportunity open when policy advocates can push their solutions

• Advocates can wait for problems to “float” by that they can attach their solutions to or wait for the political stream to be advantageous.

• Windows do not stay open long.

Entrepreneurs Take Advantage of Open Windows

• Can make the critical couplings when policy windows open.

• Bring resources to the fray

• Bring claims to a hearing

• Political connections and negotiating skills add to ability to move policy forward

• Sheer persistence is essential

Local Policies Related to Restaurant Menu Labeling: Barriers, Facilitating Factors, and the Role of Local Health

Departments

Donna B. Johnson, RD, PhD, University of WashingtonElizabeth C. Payne, MPH, RD, University of Washington

Kirsten Frandsen, BS, Tacoma-Pierce County Health Department Deborah Allen, PhD, Thurston County Public Health & Social Services

Donna Oberg, MPH, RD, CD, Public Health-Seattle & King CountyMolly McNees, PhD, Public Health-Seattle & King County

Policy Development is a Function of Public Health

• Institute of Medicine– 1988: The Future of Public Health – 2011: For the Public’s Health - Revitalizing

Law and Policy to Meet New Challenges

Nutrition & Obesity Policy Research & Evaluation Network

NOPREN is funded by the Centers for Disease Control and Prevention under cooperative agreement number 1-U48-DP-001946.  The findings and conclusions are those of the authors and do not necessarily represent that official position of the Centers for Disease Control and Prevention.

Three County Public Health Departments

Work to Improve Restaurant Food

Approaches

King With support from Health Department staff Board of Health passed regulation; mandatory menu labeling for “chain” restaurants started January 2009

Pierce Health Department staff worked with non-chain restaurants to analyze recipes and facilitate menu labeling

Tacoma Health Department staff worked with one local franchise owner who offered healthier options in kids meals and posted some nutrition information

Design & MethodsMultiple-case, replication design

Data: documents and key informant interviews

• Interviews: public health practitioners (11), board of

health members (9) , restaurant owners and restaurant

association representative (10)

• Interview questions: explore themes related to policy

process and change as described by the Advocacy

Coalition Framework

Advocacy Coalition Framework

Adapted from: Breton E, Richard L, Gagnon F, Jacques M, Bergeron P. Health promotion research and practice require sound policy analysis models: The case of Quebec’s Tobacco Act. Social Science & Medicine 2008; 67:1679-1689.

Relatively Stable Parameters

System-wide with enduring/constraining effect

External Events

- Change in socioeconomic conditions, public opinion, leaders- Policy decisions/impacts from other subsystems

Co

nstrain

ts & R

esou

rces

Policy Subsystem

Coalition APolicy beliefsResourcesStrategy

Coalition BPolicy beliefsResourcesStrategy

Decisions by Governmental Authorities

Policy Outputs & Impacts

Common Agreement on Parameters

• Obesity rates are a concern

• Meals away from home are important determinants of food intake

• Restaurants need to be profitable

External Events

King •NYC precedent policy•Support from CSPI

Pierce •Industry push-back in NYC, King Co.•Federal legislation

Thurston •External funding for research with restaurants•Close association with Washington Restaurant Association

All: External funding for Policy, Systems & Environmental change; economic recession

Policy Sub-System Actors

King

Leaders: BOH, Public Health DirectorStaff: HEAL, environmental healthIndustry: restaurant owners, WRACommunity: health organizations & advocatesCenter for Science in the Public Interest

PierceLeaders: BOH, HD manager, PH Director Staff: HEALIndustry: restaurant owners, WRA

ThurstonLeaders: BOH, senior HD leadershipStaff: HEALIndustry: local franchise owner, WRA

BOH – Board of Health HEAL- Healthy Eating Active Living

HD – Health Department

WRA – Washington Restaurant Association

Boards of Health

King King County Council Members (3)

Seattle City Council Members (3)

Suburban City Mayors (2)

Health Professionals (2 voting/1 non-voting)

Director of the Public Health Department (1)

Pierce Pierce County Council (3)

Pierce County Executive (1)

Tacoma Mayor (1)

Tacoma City Council (1)

Pierce County Cities and Towns Association (1)

Health Professional (1)

Thurston The three elected Thurston County Commissioners

Policy Beliefs

ACF construct

Characteristics Examples

Deep Core Beliefs

Fundamental, unlikely to change

Freedom, justice, fairness, population health as priority

Policy Core Beliefs

Basic strategies for achieving core values

Roles of education v.s.regulation

Secondary Beliefs

Related to administration & implementation

Environmental & behavior change strategies

Policy Beliefs King All agreed it is an appropriate role of public health (PH) to use

regulation when necessary to protect the health of the community; population health is a priority; humans are resistant to change so we need environmental change; citizens entitled to nutrition information

Pierce Board of Health (BOH) and PH practitioners less united on need for regulation & roles of PH; one BOH member had strong anti-regulation beliefs; freedom was priority belief; people & industry will make the right choice if PH provides information

Thurston Role of PH is to collaborate with industry to assure the availability of healthy choices; priority value of freedom vs. regulation; inappropriate to take actions that could compromise industry profits

Policy Oriented Learning

• Ability of actors to learn how to find common ground to work together over time

• Strong demonstration in King County – – End result: ability to come together to modify

regulations to be in line with what federal regulations were expected to be after passage of ACA

Implications for Practice

1. Policy Development models can be helpful.

2. Core policy beliefs can be barriers or facilitators of the policy process.

3. Lessons learned can be applied to future nutrition policy development.

Models to Inform Practice

• Understanding processes– ACF used to describe over 80 other policy processes– Can learn from previous initiatives – Examples: external events, leadership, economic

context• Plan future strategies

– Constructs can guide planning • Flexibility in application

– Any given construct or theory does not apply to all situations

– Combine constructs and theories for a best fit explanation

Importance of core policy beliefs

• Industry freedom OR consumer’s right to know• Educate OR regulate• Environmental change OR individual responsibility

“…when society and communities and the environment are shaping people and encouraging people to be unhealthy, then it’s our role to step in- especially if there are societal consequences.”

“This is still a free country even after yesterday (ACA passed), you know. We still have choices to make. The less mandated the better.”

Lessons Learned: Use of law and policy to advance nutritional health of the population

• Facilitators– Leadership support– Policy-mentors – “strong support from the community, the BOH and the medical

community”– Resources for Policy, Systems and Environment work (PSE)

• The process unfolds over time– PSE work in King County going on for many years– Prepared policy advocates will look for favorable conditions and

be ready to move on policy when the context shifts in their favor

• External events have variable impact

• Local political context matters

What Can Nutrition Advocates Do?

Slides Courtesy of PolicyLink