Developing Policy for Public Health Nutrition
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Transcript of Developing Policy for Public Health Nutrition
Outline
• What is policy? • Why we need policy? • A framework for policy work
– Policy identification– Policy development– Policy evaluation
• What can we do?
Policy – Webster’sWise, expedient, or prudent conduct or
managementA principle, plan, or course of action, as
pursued by a government, organization, individual, etc.
Policy Making – Webster’sThe 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”
LegislationLitigationRegulation
ProtocolsProcedure manualsOrganizational rulesAdministrative rulesIncentives/disincentives
Examples of PoliciesState County MPO/RDC City
Legislation
Ordinance
Resolution
Tax Ordinance
Internal Policy
Plans
Design Manual
From Thunderhead Alliance: Complete Streets Report
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
IOM report: Preventing Childhood Obesity
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
Purpose & ActionsTo describe opportunities to improve access to healthy foods in Washington State for the Access to Healthy Foods Coalition so that the coalition’s members and other stakeholders in Washington State can prioritize initiatives and integrate resources • Review of food system data• Interviews with 65 leaders from all food system sectors• Review of ~100 best practices documents• Integrated findings
Strategy Review in Full Report • Table of 400+ promising strategies &
categories • Sources, evidence & evaluation results to
support strategies• Cross referenced:
– Framework & components of food system
– Barriers, initiatives, opportunities from interviews
Strategies & RecommendationsEconomicProcurement standardsRetail quality & proximityTaxesRedevelopment/economic devel.
Direct Access to Foods Community gardensFood securityCommunity supported agricultureLocal kitchens/ processing unitsSchool foodFarmers marketsFarm-to-institution
Vitality of Farms/ FarmingCooperatives Supporting farms & farmersFarmland preservation
Organization & PlanningFood Policy CouncilsComprehensive PlansTransportation
Food IssuesFood safetyEmergency preparedness
Marketing
Policy Development Models to describe the process:
Stages HeuristicAdvocacy Coalition FrameworkKingdon’s Multiple Streams
EvaluationEvaluate the impact in terms of each
process and overall goal
ImplementationEnsure that enacted changes becomes
rule/processes/budgets
AdvocacyPromote the solution to decision-makers
Problem IdentificationClarify the problem & frame/ define it for Policy Agendas
Policy formulationConduct analyses to identify a
solution to promote
James Emery, MPH & Carolyn Crump, PhDUNC School of Public Health
Processes for Changing Policies, Environments and Systems
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 ParametersSystem-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
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
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
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
Kingdon JW. Agendas, Alternatives, and Public Policies.
2002
Participants
The Streams
Alternative Specification
Coupling the Streams/ Windows
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
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
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.”
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
Policy Evaluation
• To what extent are policies actually implemented?
• What are the impacts of policies?
School policy score versus exposure (total slots of SSB per student x 1000)
For each policy score, the same symbol indicates schools from same district.
SSB exposure at school versus percent of students drinking any SSB at school
(slots of SSB /per student x1000)
Reimbursement Level
Foo
d E
xpen
ditu
re($
/ch
ild*d
ay-1)
*
High reimbursement providers spent more per child per day
Expenditures on food
Reimbursement Level
Chi
ld M
AR
(%
)High reimbursement providers served more nutritious food
Nutritional Quality
*
Providers who spent more on food served more nutritious food
Nutritional Quality
Food Spending Level
Chi
ld M
AR
(%
)
*
Pre Post0
10
20
30
40
50
60
70
80
CorrectIncorrect
Pre-Post Education Curriculum
Q2 - “Lunch Meal that meets nutritional needs”Fr
eque
ncy
(%)
Chi-Sq: (p<.01)
Males Females0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Mea
n En
ergy
Den
sity
(cal
orie
s/g)
Males Females
Energy Density
Baseline Final
=3.2 calories/gram =.60 calories/gram
Taste
Cost
Conve
nienc
e
Nutrit
ion
Calorie
s2
2.5
3
3.5
4
4.5
5
0 =
Not
at a
ll Im
port
ant –
5 =
Ver
y Im
port
ant
Baseline Final
Taste
Cost
Convenience
Nutrition
Calorie
s
Factors That Influence Food Choices
This Year in Washington’s Legislature
• Coalition to Prevent Childhood Obesity– Healthy Food Procurement– Healthy Child Care standards
• Anti-Hunger Nutrition Coalition – Restore full benefits for families on the State Food
Assistance Program– Increase Emergency Food Assistance Program funds
for food banks Restore $500,000 to keep WSDA’s Farm to School and Small Farms programs running
– Support a balanced approach to the state budget
Hunger Action Day: February 22