Developing Policy for Public Health Nutrition

1. Developing Policy for Public Health Nutrition

2. Outline • What is policy? • Why we need policy? • A framework for policy work • Policy identification • Policy development • Policy evaluation • What can we do?

3. What is Policy?

4. 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.

5. Policy Making – Webster’s • The act or process of setting and directing the course of action to be pursued by a government, business, etc.

6. Policy = The Rules

7. Examples of Policies From Thunderhead Alliance: Complete Streets Report

8. IOM report: Preventing Childhood Obesity

10. Nutrition Policy Framework http://depts.washington.edu/nopren/

11. Policy Identification

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

13. Purpose & Actions To 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

14. 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

15. Strategies & Recommendations

16. Policy Development • Models to describe the process: • Stages Heuristic • Advocacy Coalition Framework • Kingdon’s Multiple Streams

17. Processes for Changing Policies, Environments and Systems Problem Identification Clarify the problem & frame/ define it for Policy Agendas Policy formulation Conduct analyses to identify a solution to promote Advocacy Promote the solution to decision-makers Implementation Ensure that enacted changes becomes rule/processes/budgets James Emery, MPH & Carolyn Crump, PhD UNC School of Public Health Evaluation Evaluate the impact in terms of each process and overall goal

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

19. Advocacy Coalition Framework Policy Subsystem Relatively Stable Parameters System-wide with enduring/constraining effect Coalition APolicy beliefsResourcesStrategy Coalition BPolicy beliefsResourcesStrategy Constraints & Resources Decisions by Governmental Authorities External Events - Change in socioeconomic conditions, public opinion, leaders- Policy decisions/impacts from other subsystems Policy Outputs & Impacts 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.

20. Three County Public Health Departments Work to Improve Restaurant Food

21. Approaches

22. 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.”

23. 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

24. Policy Beliefs

25. 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

26. Kingdon JW. Agendas, Alternatives, and Public Policies. 2002 Participants The Streams Alternative Specification Coupling the Streams/ Windows

27. 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

28. 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…..

29. Food and Nutrition Policy Entrepreneurs Consumer Interest groups & Other NGOs Government – at all levels Health Professional Associations Food & Nutrition Policy Farmers/Commodity groups Scientific Bodies & Researchers Food Industry

30. 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

31. Problem Recognition Policy Proposals Politics

32. Problems Why do some problems get attention? • Indicators – large magnitude or change • Focusing event – disaster, crisis, personal experience • Feedback about existing programs – evaluation, complaints, etc.

33. 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

34. Framing the Problemhttp://www.frameworksinstitute.org/ • Problems with the Dominant Communications Approach to Childhood Obesity: • It focuses on the individual as the cause of the problem. • Parents are the only responsible actors in the frame. • The problem is overwhelming. • Behavior change by parents and children is the solution to the problem.

35. 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.”

36. 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

37. 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)

38. 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

39. 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

40. Problem Recognition Politics Policy Proposals Legislation or Change in Policy

41. Policy Evaluation • To what extent are policies actually implemented? • What are the impacts of policies?

42. 64 Study Schools in 28 Districts

43. 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.

44. SSB exposure at school versus percent of students drinking any SSB at school (slots of SSB /per student x1000)

45. Expenditures on food High reimbursement providers spent more per child per day * Food Expenditure ($/child*day-1) Reimbursement Level

46. Nutritional Quality High reimbursement providers served more nutritious food * Child MAR (%) Reimbursement Level

47. Nutritional Quality Providers who spent more on food served more nutritious food * Child MAR (%) Food Spending Level

48. Pre-Post Education Curriculum Q2 - “Lunch Meal that meets nutritional needs” Frequency (%) Chi-Sq: (p<.01)

49. Energy Density =3.2 calories/gram =.60 calories/gram Mean Energy Density (calories/g) Baseline Final

50. Factors That Influence Food Choices 0 = Not at all Important – 5 = Very Important