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?

What is Policy?

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

Nutrition Policy Framework

http://depts.washington.edu/nopren/

Policy Identification

http://depts.washington.edu/waaction/tools/featured_resources/access_report.html

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

DHPE Model with Steps in the Policy, Systems, and Built Environment Change Approach

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

Problem Recognition

Policy Proposals 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.”

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

Problem Recognition

Policy Proposals Politics

Legislation or Change in Policy

Policy Evaluation

• To what extent are policies actually implemented?

• What are the impacts of policies?

64 Study Schools in 28 Districts

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

What Can Nutrition Advocates Do?

Slides Courtesy of PolicyLink

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