What factors affect the passage What factors affect the passage of state legislation to prevent of state legislation to prevent

childhood obesity?childhood obesity?

Ellen Jones, PhD

Elizabeth Dodson, MPH

CollaboratorsCollaborators Saint Louis Univ. School of Public Health

• Chris Fleming (Mathematica Policy Research, Inc.)• Tegan Boehmer (CDC)• Debra Haire-Joshu• Doug Luke• Ross Brownson• Ellen Jones• Amy Eyler• Leah Wentworth

Background Background

Childhood obesity epidemic

Environmental and policy interventions

Individual states have much of the authority over public health policy

4

Art and Science Art and Science

changing the physical and sociopolitical environments

opportunities, support, and cues may directly affect behaviors

• Influence of price of tobacco on consumption or may alter social norms

• Physically active people in public spaces Often more permanent than many public

health programs focused on individual-level behavioral change• Important complement to individual-level programs

Why Why policypolicy interventions? interventions?

Schmid, Pratt, and Witmer. Schmid, Pratt, and Witmer. J Physical Activity HealthJ Physical Activity Health 2006. 2006.

COPS:COPS:Childhood Obesity Policy StudyChildhood Obesity Policy Study Objective: Examine childhood

obesity prevention legislation in all 50 states, 2003-2005

Phases 1 and 2:1. Identify relevant legislation

describe patterns intro/adoption2. Explore predictors and contextual

factors affecting bill enactment

Results Summary: Objective 1Results Summary: Objective 1 Descriptive statistics to describe

patterns by time, place, and topic area

During 2003-2005• 123 of 717 (17%) bills were adopted• 71 of 134 (53%) resolutions were adopted

• Introduced legislation increased 70%• Adopted legislation increased 38%

Boehmer, et al. Preventing Chronic Disease 2007

10

700 bills 2003-2005!700 bills 2003-2005!

Fewer than 20% enacted More likely if bi-partisan sponsors More likely in 2 year sessions (Boehmer, 2007 and 2008)

Only 7% have a review of evidence base

(Hartsfield, 2007)

11

Mississippi 2009 provisionalMississippi 2009 provisional

HB=1,597 SB=3302 About 300 health About 60 made it out of committee About 10 passed into law

Bill Enactment (%) by Topic Bill Enactment (%) by Topic Area, 2003-2005Area, 2003-20050% 10% 20% 30% 40%

Nutrition/Vending

Physical Education/Activity

Health Education

Curriculum & Credit

Local Authority

Safe Routes to School

BMI Reporting

Model School Policies

Farmers Markets

Task Force/Study

Snack/Soda Tax

Walking/Biking Paths

Statewide Initiatives

Menu/Product Labeling

Bill Enactment (%) by State, Bill Enactment (%) by State, 2003-20052003-2005

Results Summary: Results Summary: Objective 2Objective 2

Bills were more likely to be introduced if:• Introduced in Senate vs. House• >1 sponsor from a single party

Bills were more likely to be enacted if:• Budget bills – enacted 75% of time• Involved community walking/biking paths

Bills were less likely to be enacted if:• Proposed a new law (vs. amendment)• Proposed to generate revenue through taxes or fines• Involved PE, health curriculum, nutrition/vending

regulations

Boehmer, et al. American J of Preventive Medicine 2008.

Phase 3: PurposePhase 3: Purpose

Objectives:• Identify factors of state legislative

environment important for successful childhood obesity prevention legislation

• Describe significant barriers to passing & adopting childhood obesity prevention legislation

Phase 3: MethodsPhase 3: Methods

Key informant interviews with state legislators and staffers

Interview questions Sample selection Telephone interviews conducted: Dec

05 – April 06 Qualitative data analysis

Results: SampleResults: Sample N=16: 11 legislators, 5 staffers

Political party: 80% Democratic

Backgrounds: law & ed (20% health)

Time in state legislature: range=4-21 years; mean=11.8 years

Legislative responsibilities

Interview Question #1Interview Question #1

In your view, what factors support or facilitate the introduction and adoption of childhood obesity prevention legislation?

Results: FacilitatorsResults: Facilitators

National Media Exposure

“[Which bills pass] depends on what makes it into the media.”

Results: FacilitatorsResults: FacilitatorsIntroduction by senior legislators & those

with personal interest “You need … committed legislators.

Legislators who are going to say, ‘I’m going to put myself on the line and push ...’”

“We said that we need to do something about the obesity issue instead of just inform the public…We just did basic fundamental thinking of, what can we do to help? And then: what can we do that will pass?”

Other Facilitators Other Facilitators

Gaining support of key players

Working in supportive political climate

Attempting incremental changes

Interview Question #2Interview Question #2

In your view, what factors oppose or inhibit the introduction and adoption of childhood obesity prevention legislation?

Results: BarriersResults: Barriers

Lobbyists “We cannot underestimate the power of the

food lobby, the soda lobby, the restaurant association…”

“You can’t blindside the lobbyists…I had this one…bill, we had as many lobbyists in the room as legislators…Lobbyists are there. They get paid and they can watch things a lot more carefully than public interest groups, which are not as well-funded.”

Results: BarriersResults: Barriers

“Representatives who voted no [on school junk food bill] indicated that their schools had encouraged them to vote no. Some of them implied that soft drink companies had put pressure on them as well. But most of them, even the ones who said they got pressure from the soda companies, all of them mentioned pressures from their school districts they represented, saying that their school districts feared they would lose money.”

Misconceptions - outcomes for schoolsMisconceptions - outcomes for schools

Interview Question #3Interview Question #3

Legislation sometimes passes in increments over a period of time, eventually leading to a comprehensive set of bills vs. the initial adoption of comprehensive bills. Do you think that childhood obesity prevention legislation is more likely to progress through (1) a series of several incremental bills or (2) a few comprehensive bills?

Question 3 ResultsQuestion 3 Results Childhood obesity prevention legislation is

more likely to pass through:• Series of incremental bills (73%)• One comprehensive bill (18%)

“I think incrementalism is the name of the game here in the legislature, given our fiscal constraints.”

So what?So what? What we already know:

• Lobbyists• Incrementalism• Political climate

What we can do: • Learn to work within the system• Learn from other areas of success (tobacco)• Train community advocates to use media• Educate constituents

Other needs & priorities• More on the evidence base for child obesity policy

e.g., IOM recommendations• Need for practice based evidence• Explore the generalizability of various policy approaches

RecommendationsRecommendations Build & advocate incrementally

“If you can get things into the media, it’s very helpful to legislators.”

“…to pass legislation like this, you really want to make sure that the people who are going to be implementing it and the people who are affected by it are involved in your legislative planning.”

Why do States Differ in the Level of Childhood Obesity

Legislation?

Ellen Jones, PhD

Objectives – to examine influence of

Type of legislature Legislator factors Political context Bill content Public support

Montana Capitol Rotunda

Factors in State Obesity Policy

Legislator Factors

Legislative Factors

2 x 2 TableLow Obesity High Obesity

SOUTH DAKOTAMONTANA

ARIZONA KANSAS

WASHINGTONMAINE

LOUISIANANEW YORK

Division of Legislation Tertiles:Low Legislation=0-3 Adopted Bills—17 statesMedian=4-7—16 statesHigh=8-30—17 states

Division of Childhood Obesity Tertiles: Lower Childhood Obesity=lowest (9.6%) to 13.2%—14 statesMedian=13.3% to 16%—21 statesHigh=16.1% to highest (21.9%)—15 states

Hig

h

Leg

isla

tio

n

Lo

w

Leg

isla

tio

n

35

Obesity Index Obesity Index

2003 and 2007 NSCH

Consistent Tertiles

9.6 - 13.2%

13.3 – 16%

16.1 – 21.9%

36

Ranking of Policy EnactedRanking of Policy Enacted

2006,2007,2008,2009 enacted

Low legislation = 0-3 bills Median legislation = 4-7 bills High legislation = 8-30 bills

Descriptive Analysis – Legislators

15 White, 3 Black, 2 Hispanic Children or grandchildren 9 Males, 11 Females 10 R, 10 D Senate Democrats 8 Chair, VC; 12 members

From left, New York’s Senator Joseph L. Bruno, Senator Hugh T. Farley, Gov. David A. Paterson and Assemblyman Sheldon Silver.

Senators Being Led in Physical Exercises by Physultopathy Founder Bernarr Macfadden, 1924: Black and White Photograph  from the Library of Congress features American Work Outs throughout history

Descriptive Analysis – Legislative Factors

3 R Gov, 5 D Gov Party in House 3 D and 3 R Party in Senate 4 D and 3 R Term limits gov - 5 yes Term limits leg – 5 yes 1 professional legislatures 3 hybrid legislatures 4 part time legislatures

Washington Capitol Building

40

Red StatesRed StatesTime 80%Time 80%

Comp $68,599Comp $68,599

Staff 8.9Staff 8.9

White White StatesStates

Time 70%Time 70%

Comp $35,326Comp $35,326

Staff 3.1Staff 3.1

Blue StatesBlue StatesTime 54%Time 54%

Comp $15,984Comp $15,984

Staff 1.2Staff 1.2

NJNJ

CA NY CA NY

IL OHIL OH

FL PAFL PA

NA WINA WI

MI MI

www.ncsl.orgwww.ncsl.org

AL KY ORAL KY OR

AZ LA SCAZ LA SC

AK MD TNAK MD TN

CO MN TXCO MN TX

CT MO VICT MO VI

DE NE WADE NE WA

HA NC ARHA NC AR

IA OKIA OK

GA WVGA WV

ID MTID MT

IN NHIN NH

KS NDKS ND

ME SDME SD

MS UTMS UT

NV WYONV WYO

NM RI VTNM RI VT

41

LegislaturesLegislatures

CategoryCategory Time Time CompensatiCompensationon

StaffStaff

RedRed 80%80% $68,599$68,599 8.98.9

WhiteWhite 70%70% $35,326$35,326 3.13.1

BlueBlue 54%54% $15,984$15,984 1.21.2NCSL, 2008NCSL, 2008

Introduction Results

Legislator role (in and out of session) influences intent

Impetus for action not articulated Discomfort in state policy role Discomfort with evidence and results Philosophical support vs. policy action

Introduction Quotes “there’s support for prevention, but not for

legislation”

“In 10 yrs debate, several (bills) introduced but none passed…”

“can you legislate obesity?”

“well aware there is a problem; but the question is how to address it”

Bill Content Results

Unclear cost or new cost is barrier Need for immediate results No consensus around role of legislature Different definitions Different expectations of evidence/science

Bill Content Quote “not a whole lot of it is science….I think a lot

of it is anecdotal…”

“the science is hard because policies are so new”

…any proposed policies with start up money will be hard pressed”

“cost is a make or break issue”

Political Context Results

Legislators expect but don’t act on public health message

No compelling social movement Opposition viewed as well

planned Loss outweighs gain It’s the economy…

Maine’s Speaker of the House, Hannah Pingree announcing policies to curb obesity

Political Context Quotes “several people introduced bills but no one is

consistently pushing and prodding”…

“no one comes to mind”

“are you kidding me? Cost is a very critical issue – a deciding factor”

“overwhelming budget deficit makes funding obesity policy difficult”

Different Motivators End User: Researcher Legislator Staff

Time in Job long shortest short

Accountability university voters decision makers

Constituents funders

publishers

voters, party, supporters

Chair, VC,

Members, party

External factors funding, teaching, writing

media, money, public support

habit, relationships, culture

Time on issue long shortest short

Data used peer reviewed Stories, real life, testimony, results

internal/ external support, data

Public Support Results

Lack consensus on state role

Unclear wishes of

constituents

Uncertain evidence will work

Not tied to current priorities

Media messages inconsistent

No tie to policy actions Engagement not seen as a

desire of constituents Nonprofit Day in Montana Capitol Rotunda

Public Support Quotes

“…interest in home level, NOT the government…”

“1) economy, 2) jobs, 3) housing market”

“Messages would be important as long as they are giving me specific ideas what to do”

“even if it saves money, it wouldn’t be now, we have to balance a budget now…”

High Leg vs Low legHigh Leg vs Low leg

So What? Importance of non-modifiable factors

Legislator discomfort with role and science

Political context inhibits passage

Philosophical support vs. policy action

Kansas Capitol Rotunda

Factors in State Obesity Policy

Legislative Factors

Legislator Factors

54

Art and Science Art and Science Next Study:

Advocates in • LA• WA• CO• NY• CA• ME