Policy
and Environmental Change: A Second Look
at Public Health Agency Involvement
Prepared for the Directors of Health
Promotion and Education
January 2006
Strategic
Health Concepts, Inc.
Policy and Environmental Change:
A Second Look at Public Health
Agency Involvement
Introduction
The health of the Nation falls far short of what it should be given the understanding and tools that science has provided us with. Diseases, particularly chronic diseases, continue to impose a terrible burden on the Nation. Far too many people die prematurely or are disabled from causes that are preventable. Many others prematurely die or suffer far more than they should because they were unable or unwilling to take advantage of systems that provide for early disease intervention, quality treatment, and follow up care. The burden of premature death and disability severely affect the psychological, social, and economic vitality of our citizens, families, communities, states and the Nation as a whole.
The problems of premature death and disability are compounded by the fact that certain segments of our population experience far worse health outcomes that do the population as a whole; a trend that appears to be getting worse in many instances. All of this is not to say that progress isn’t being made towards improving the health of the Nation; there has been progress, some of it remarkable. But the truth is that despite the progress made, our best efforts to continue making progress, and the tools at hand, we are simply not measuring up to the full potential we have to be a far healthier Nation.
The last decade and a half has seen a markedly increasing emphasis on policy and environmental change as major strategies for more fully realizing our potential for becoming a far healthier Nation. Policy and environmental changes, more often than not, are accomplished through the collaborative action of multiple organizations within communities where they have been successful. Government entities charged with protecting the public’s health can and have played a wide range of roles as this trend of collaborative action had unfolded. These government entities, which have a wide variety of official titles, are referred to in this report generically as ‘public health agencies’.
The capacity of public health agencies to effectively participate in policy and environmental change has been a priority for the Directors of Health Promotion and Education (DHPE) for some time. In particular, DHPE has been interested in tracking how public agencies fit into the total picture of policy and environmental changes and in identifying and improving the capacity of these agencies to do so.
To that end, in 2001, DHPE (then the Association of State and Territorial Directors of Health Promotion and Public Health Education) commissioned a study to identify the roles public health agencies play in policy and environmental change and to make recommendations regarding improving their capacity to do so. Many of the recommendations resulting from that study have been acted upon by DHPE and other agencies interested in capacity building.
In 2004, DHPE commissioned a follow up study to take a second look at the involvement of public health agencies in policy and environmental change and which included a greater emphasis on ‘how’ policy and environmental changes were accomplished. That study was completed in 2005.
This report reviews the context for studying policy and environmental change related to public health agency involvement, briefly summarizes the 2001 study, reports the methods and findings of the 2005 study, compares the results of the two studies, and makes recommendations for DHPE and others to consider regarding both continued capacity building and the conduct of future studies.
Project Scope
A case statement for public health agency involvement in policy and environmental change was developed for the 2001 study. It is repeated here in abbreviated form since it is applicable for the current study as well:
· Chronic diseases represent persistent public health problems.
· Great gains have been made in addressing these problems through interventions that focus on individual behavior change.
· The next major step forward will come from policy and environmental changes that can impact large segments of the population simultaneously.
· Public health agencies are the primary governmental institutions charged with protecting the health of the public.
· Public health agencies can play many different roles in advancing policy and environmental changes (e.g., providing data, educating the public and policy makers, coordinating efforts, etc.).
· For the most part, traditional public health practices, priorities, staff skills, and resource allocations do not reflect the capacity public health agencies need to aggressively pursue policy and environmental changes.
· Public health agencies make conscious choices about the degree of priority given to chronic disease programs, including policy and environmental changes.
· It is critical that these choices be well-informed decisions based on a solid understanding of best practices and the potential impact of policy and environmental change interventions.
This project looked at two types of public health interventions.
1. Policies, which include laws, regulations, and rules (both formal and informal). Examples include:
a. Laws and regulations that restrict smoking in public places;
b. Organizational rules that provide time off during work hours for physical activity.
2. Environmental interventions; which include changes to the economic, social, or physical environments. Examples include:
a. Incorporating walking paths and recreation areas into new community development designs;
b. Making low-fat food options available in cafeterias;
c. Removing ashtrays from meeting rooms.
These two types of interventions are not mutually exclusive and can occur simultaneously and/or precede each other. Indeed, one of the findings from the current study is that the line between these two types of interventions seems to be increasingly blurred. For example, one case story in the current study involves the passage of a special tax, a policy, from which the revenue generated was devoted to supporting the development of increased physical activity options (e.g., walking trails), an environmental change. The important point is that policies and environmental changes can work together in a mutually supportive fashion. While this report will treat them separately in parts of the analysis, in implementation they may well be combined.
The 2001 and 2005 studies focused on policy and environmental changes related specifically to chronic diseases. It should be noted that most of the case stories collected are policies and environmental changes that impact on risk factors for chronic diseases (i.e., tobacco use, poor nutrition, sedentary lifestyle) which also can impact on health issues other than chronic diseases.
Both the 2001 and 2005 study captured information on the current activities of public health agencies in policy and environmental change. Both studies collected information through on solicitations sent to state public health agencies; although states were encouraged to submit information on local policy and environmental change as well. There is an inherent selection bias in the results based on who chose to respond and what they choose to submit. The results are clearly informative, but are not necessarily representative of what may actually be occurring. Thus, conclusions relative to the numbers and types of interventions occurring should be seen as descriptive rather than definitive. On the other hand, “lessons learned” and other “how to’s” from the various case stories seem to be common across the different policy and environmental change strategies addressed and thus may have more common applicability.
The 2001 Study
The 2001 study was a first attempt to look at the state-of-the-practice and was responsive to a major reorientation of public health practice towards greater emphasis on policy and environmental change strategies for chronic disease prevention and control that emerged throughout the 1990’s. Many of the strategies implemented during that period were carried out by coalitions of various not-for-profit health organizations (e.g., the American Lung Association), public health agencies and, in some cases, for-profit organizations with an interest in health outcomes (e.g., hospitals, insurers). The two primary questions addressed in the initial study were:
1. What roles did public health agencies play in these broader strategies of policy and environmental change?
2. What was the capacity of public health agencies to fulfill these roles and what could be done to enhance that capacity?
Five mechanisms of data collection were used in the 2001 study:
1. A peer-reviewed literature search – some 700 articles were identified of which 58 yielded information relevant to the study.
2. Key informant interviews – with some 29 experts.
3. A review of “fugitive” literature (non peer-reviewed) – yielding 37 useful documents.
4. An Internet search - resulting in 52 relevant sites.
5. A nationwide “snapshot” assessment - based on information received from 40 states and three territories.
A comparison of the type and content of the policy and environmental interventions found in the 2001 study with those in the 2005 study will be presented later in this document.
Findings from the 2001 study:
· Identified critical success factors for the involvement of public health agencies in policy and environmental change work.
· Identified unique issues and barriers facing public health agencies as they engage in policy and environmental change work.
· Identified a wide range of roles and levels of involvement played by public health agencies.
· Were used to make summary conclusions about the state-of-the-practice of public health agency involvement in policy and environmental change.
Forty-one recommendations were made for enhancing the capacity of or supporting increased involvement by public health agencies in policy and environmental change work. These fell into eight categories as noted in Table 1.
Table 1
Categories of Recommendations from the 2001 Study of Public Health
Agency Involvement in Policy and Environmental Change Interventions
|
Recommendation
Category |
Number |
|
Leadership development |
8 |
|
Explaining the concept of policy and environmental change strategies |
6 |
|
Sharing experiences and information |
2 |
|
Skills development |
6 |
|
Funding |
5 |
|
Research |
10 |
|
Information management |
2 |
|
Regional cooperation (transcending state borders) |
2 |
An ASTDHPPHE (now DHPE) advisory group subsequently prioritized these recommendations for implementation purposes into primary recommendations (3), secondary (4), and tertiary (34).
An important conclusion from the 2001 study was the dearth of “how to” information found in the various sources of information. Interestingly, public health personnel are asking for this kind of information to complement a wide range of available information on the scope and content of policy and environmental changes.
One each of the primary and secondary recommendations from the 2001 study noted above addressed this dearth of “how to” information.
· Develop “what to do” models of successful policy and environmental change interventions…
· Develop concrete examples of how policy and environmental change interventions are started and completed. They should contain simple, real-life examples …
These two recommendations greatly influenced the scope and methods of the 2005 follow up study.
The 2005 Study – Scope and Methods
The 2005 study built on the 2001 study in that it provided a degree of comparable information on the level of involvement by public health agencies in policy and environmental change work. It differed from the earlier study in that it used only a case story approach. The primary purposes of this study were to describe the state-of-the-practice as in the 2001 study while gathering more in-depth, “how to” information that would inform decision making about future DHPE and other initiatives.
Two case story versions were solicited from state public health agencies:
1. Short case story – in which a structured set of questions was used to provide a 2-4 page summary of the initiative. The structured information requested included:
a. Title
b. Description of the policy/environmental change
c. How the idea for change was generated
d. Intended outcomes of the change
e. When the initiative was implemented (or if it was in progress)
f. Roles the public health agency played
g. Major partners involved
h. Public officials who supported the initiative
i. Tracking of outcomes
j. Lessons learned
k. Opposition encountered (added to the protocol after initial submissions were reviewed)
2. Long case story – in which the standard set of information was requested (see above) in a longer, more detailed, and personalized narrative description. These case studies were typically in the 8-12 page range in length. In addition to the standard information requested, submitters of detailed studies were asked to provide information in their narrative on the following topics:
a. Their agency’s skills for policy and environmental change
b. Partnerships and support
c. Key events in the initiative
d. Funding and resources
e. Obstacles
f. Modifications made during the initiative
The study protocol consisted of the following steps:
1. All state and territorial public health agencies were invited to nominate case stories for consideration as short case stories.
2. Nominations were requested in a shortened form of 1-page in length. In addition to submitting the information requested, those submitting nominations were asked to note whether they wanted their nomination to be considered for development as a long case story. Sixty-three nominations were received.
3. Nominations were reviewed by the study team for consistency with the study parameters. If needed, clarifications from those submitting the nominations were requested.
4. Forty nominations were accepted as short case stories and the submitters were given the standard format to submit the information on. In addition, the standard format was expanded to include information on opposition encountered during the policy or environmental change initiative.
5. Thirty-seven short case stories were subsequently accepted for inclusion in the study.
6. Ten nominations were accepted as long case stories and submitters were given the template with the information requested and asked to submit it in narrative style. Long case story submitters were offered $1,000 stipends to help in the preparation of the submission. Most accepted the stipend.
7. Eight long case stories were subsequently accepted for inclusion in the study.
8. The case stories were reviewed by the study team and edited as needed. The short case stories were all put in a standard format. Long case stories were standardized as much as possible without changing their narrative flow.
9. Edited case stories were returned to submitters for review and approval of changes made by the study team.
10. An analysis of the findings was prepared and incorporated into a draft report for DHPE review.
11. This final report was prepared for DHPE based on comments received.
12. The final versions of the case stories were submitted to DHPE for inclusion on their website.
In the course of carrying out the study protocol, some important lessons learned emerged. Among these are:
· Finding the right person(s) at the state public health agencies to solicit a response from was sometimes challenging. Personnel turnover, out-dated mailing lists, and varying levels of responsibility for responses among health agencies compounded the problem of finding knowledgeable and willing people to solicit submissions from.
· The time available for public health agencies to respond to requests for special studies such as these is very limited as increasingly these agencies seem to be asked to do more and more with less and less. The level of stress on the current public health system is extraordinary and must be factored into future plans for carrying out studies like these.
· The level of effort and time required to solicit and process information similar to that in these studies is extensive and in both 2001 and 2005 was greatly underestimated.
· The number of responses received was far less than the actual number of cases that exist even though extraordinary efforts were made to make the process as simple and user friendly as possible. This means studies using the approach that was used for both the 2001 and 2005 studies will almost always be illustrative snapshots of what is occurring rather than a representative picture. Nevertheless, the results are of great value given this limitation.
· The use of cash incentives ($1,000 per long case study) in the 2005 study undoubtedly helped in soliciting the cases but did not change the time or level of effort involved in actually getting them in hand and processing them.
While it was difficult to solicit a large response in the form of usable case stories, there was strong interest in the subject matter and many people who were not able to submit case stories requested that the information resulting from the study be shared with them.
The study team prepared a separate document describing in detail the issues encountered with implementing the study protocol and with recommendations and options for DHPE to consider for future studies of this type.
The 2005 Study – Findings
This section presents the findings from the 2005 study in three parts:
· General Findings from the Short and Long Case Stories
· Additional Findings from the Long Case Stories
· Comparison of Findings from the 2001 and 2005 Studies
General
Findings from the Short and Long Case Stories
Respondents
Forty-five short and long case stories were received from 19 states:
California Florida Hawaii
Maine Missouri Mississippi
Montana North Carolina North Dakota
Oklahoma Pennsylvania Rhode Island
South Carolina Tennessee Texas
Utah Washington Wisconsin
West Virginia
State public health agencies were asked to submit case stories. Nineteen of the case stories were submitted by either a local organization or a state level organization other than the public health agency itself. In one case, a state public health agency and a local organization jointly submitted a case story (the only such joint submission received). This illustrates a healthy willingness on the part of some states to pass on a submission like this to some other group which may have greater awareness of the details and the full scope of the policy or environmental change intervention. The full breakdown of who submitted case stories is as follows:
· State level submissions (29)
o 27 by the state public health agency
o 2 by another state level organization
· Local level submissions (17)
o 6 by a local public health agency
o 11 by another local level organization
Policy and Environmental Changes Reported
An interesting array of policy and environmental change interventions were addressed in the case stories submitted. These are broken down separately in Table 2.
Table 2
Policy and Environmental Change
Interventions
Addressed in the 2001 Study
|
Intervention |
Number
Addressing Policy |
Number
Addressing Environmental Change |
|
Tobacco control |
15 |
0 |
|
Nutrition |
3 |
7 |
|
Oral health |
2 |
0 |
|
Physical activity |
1 |
10 |
|
Other Seat belts Bus idling School health Asthma inhalers Community engagement |
1 each |
0 |
In all, 26 policy-related case stories and 17 environmental change case stories were included in the study. In addition (and not included in the above table), there was one case story included that was both a policy change and an environmental change (a bed/occupancy tax that was used to support increased/enhanced recreational opportunities). And one case story was included that developed a tracking system for local policies. While not an intervention per se, a decision was made to include this story since the creation of such a system was intended to provide for more effective and timely policy analysis and development in the future.
Within these broad categories of interventions, there were a wide range of different policies and environmental change initiatives. Examples include:
· Tobacco control
o Clean indoor air ordinances
o Investment fund divestiture of tobacco stocks
o Tobacco-free beaches
o Tobacco-free campuses
· Nutrition
o Healthy snacks at events
o Healthy fundraising (no selling of junk foods)
o Healthy and culturally relevant food curricula
o Resolution supporting healthy foods and beverages in schools
o Healthy choices in vending machines
o Providing fruit and vegetable samples
· Physical activity
o Walking trails
§ For schools
§ In communities
o Exercise options embedded in regular school curricula
o Gardens
· Other
o Oral health eligibility guidelines changes
o Community engagement policies
Level of Society Intended to be Impacted
Of obvious importance is at what level of society are the policy and environmental changes intended to impact; which may be different from who submitted the case stories (see above). The case stories in this study show that the intended impact points were as follows:
· State level impact (10)
· City/county/organization impact (21)
· Individual school/school district impact (14)
Bearing in mind the issue of the representativeness of these case stories, it is fascinating that of 45 case stories submitted, 35 of them cover policies and environmental changes that impact at a local or organizational level, rather than at the state level. And, at least one of the state level impact stories was actually a statewide replication of a local policy which had proven successful. This supports the idea that much change in this country begins locally and has implications, discussed later, for what is done to support capacity building for policy and environmental change locally.
What Initiated the Policy or Environmental
Change
A number of factors were cited as the catalyst for the policies and environmental changes illustrated in the case stories. These are not mutually exclusive and a number of the case stories noted multiple reasons why a particular initiative came into being. These included
· The change being an add-on or an extension of previous efforts.
· The existence of compelling data to support change.
· Change in the environment/attitudes as a result of another policy.
· Peer/ constituent pressure for change.
· Seed money/funding available to support the initiative.
· A group, or an organization, and/or committed individual on a mission to effect a change they believe strongly in.
Worth noting here are those cases in which a policy or environmental change gets started because of other work being done (1st bullet above) or because attitudes or the environment has changed as a result of previous policy or environmental changes (3rd bullet above). There is now sufficient experience in policy and environmental change work to begin to see these kinds of impacts which may not have been foreseen or expected when the initial work began.
Roles Played by Public Health Agencies
As was the case in the 2001 study, public health agencies played a wide variety of and multiple roles in support of policy and environmental changes. The reported roles are presented here in descending order of mention among the case stories:
· Resources (funding, donations, staff time, other in-kind resources)
· Education (forums, materials, campaigns)
· Partnering/collaborating (strategizing together, coordinating action, helping link to resources, maintaining partnerships)
· Technical assistance (training, planning, skills development)
· Providing information (data, information on potential impact of interventions)
· Program development, management, facilitation
· Assessment and evaluation
· Key leadership
· Providing regulatory language
· Marketing and public relations
This list is similar to that reported in the 2001 study. The implications of this list presented in descending order of mention, is that public health agencies are much more often behind the scenes in policy and environmental changes that out in front. In some cases, this may be necessitated by legal restrictions and/or it may be the result of a traditionally conservative view of the role of public health agencies generally in such initiatives.
Major Partners
It is not surprising that a wide array of major partners were identified given the range of policy and environmental changes contained in the case stories. On the other hand, the degree to which the reported major partners in these case stories extends beyond the “usual suspects” in public health is encouraging. Major partners included:
· Elected officials (state, local, school)
· School districts (superintendents, administrators, teachers, school nurses)
· Other state agencies (Education, Parks, Aging, Environment, Conservation, Highways)
· National agencies (ACS, AHA, ALA, DHHS, USDA)
· Local public health agencies; local clinical organizations
· Coalitions, community based organizations, clubs, etc.
· Private companies (grocery stores, banks, concrete companies, quarries, landscaping firms, baseball teams)
Opposition
The question of opposition to the policy and environmental change initiatives was added after the original submissions. Some of the submitters did not reply to this additional question. Of the 45 total submissions, 33 addressed the question of opposition with the following results:
· Opposition encountered:
o No – 17
o No formal opposition; but disagreements arose – 4
o Formal opposition – 12
· Formal opposition by topic:
o Nutrition – 3
o Tobacco – 6
o Physical activity – 2
o Seat belts – 1
· Results of countering formal opposition:
o Overcame – 6
o Compromised – 5
o Lost – 1
o Ignored – 1
About 1/3 of the policy/environmental change initiatives encountered some type of formal opposition. It is not surprising that ½ of those related to tobacco control efforts. Very encouraging is the finding that only one of the 12 cases stories where formal opposition occurred resulted in a defeat. That one was related to a school policy. This has implications for capacity building in terms of preparing to anticipate opposition, determining what strategies to employ when opposition is encountered, and when to compromise and when not to. Special note should be made of the one case where the opposition was “ignored”. In this case, city officials opposed a proposed change to the point that they refused to approve grant applications to support the effort submitted through the city. The community response was to ignore city complaints and continue the initiative by setting up a separate 501(c)(3) through which the resources needed for the project could be received and managed – a strategy that proved successful.
Evaluation
The case story templates asked submitters to identify the intended outcomes of their policy and environmental change and their plans/activities for tracking those outcomes. A review of the reported outcomes and the types of tracking methods resulted in the following breakdown:
· Types of evaluation/tracking reported
o Both outcome and process evaluations – 16
o Process evaluations only, qualitative evaluation, and/or indirect monitoring in place – 21
o No evaluation reported – 5
o Specific evaluation plan identified, to be implemented – 1
o Not applicable – 2
· Types of information being collected
o Policy enactment and/or environmental change completed
o Baseline data (e.g., public attitudes and support, etc.)
o Process data during the initiative (e.g., number of meetings of coalition, media coverage, etc.)
o Post-policy enactment or environmental change implementation processes and intermediate outcomes (e.g., proportion of people complying with a policy, number of people using new services/facilities, proportion of people covered by the new policy, etc.)
o Health/disease/risk factor outcomes
It is encouraging that the majority of cases have some active evaluation underway. The specific methods being employed range from a few simple types of data collection (e.g., small user intercept surveys) to sophisticated surveys and secondary data analysis. To some extent the selection of methods depends on the availability of resources and expertise. Nevertheless, there is a high level of awareness among this group regarding the use and need for evaluation and they seem to be making serious attempts to fulfill that need and show progress towards and achievement of outcomes.
Lessons Learned