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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