1. Policy, Systems, and Environmental Change in Cancer Control Maryland Cancer Collaborative Annual Meeting January 14, 2013 Meredith Truss, MPP Health Policy Analyst, Center for Cancer Prevention and Contro l Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration

2. January 14, 2013 2 Maryland Cancer Collaborative The goal of the Maryland Cancer Collaborative is to work with individuals and organizations throughout the state to implement the Maryland Comprehensive Cancer Control Plan. In addition, the Collaborative will bring together existing groups and new partners from across the state to collaborate on a common goal: reducing the burden of cancer in Maryland.

3. Prevention and Health Promotion Administration January 14, 2013 3 Given limited resources, how can we maximize our impact? Shift the focus of cancer control programs and interventions: Individual Behavior and Direct Services ↓ Infrastructure to Support Healthy Behavior Infrastructure includes public policy, healthcare systems, and physical environments

4. Prevention and Health Promotion Administration January 14, 2013 4 Policy, Systems, and Environmental Change Policy, Systems, and Environmental (PSE) changes enhance infrastructure PSE changes are interventions that modify environments to provide healthy options and to make healthy choices easy for everyone

5. Prevention and Health Promotion Administration January 14, 2013 5 PSE Change Cont. If we focus on adapting policies, systems, and environments, we can maximize resources by extending our impact to reach more people By modifying the environmental context, we can support healthy choices across a population vs. an individual

6. Prevention and Health Promotion Administration January 14, 2013 6 PSE Change Cont. Thomas R. Frieden, MD, MPH Am J Public Health. 2010 April; 100(4): 590–595. PSE Interventions

7. Prevention and Health Promotion Administration January 14, 2013 7 Individual = Counseling a 16-year old patient about sunscreen use and avoidance of artificial UVR PSE/Population = Legislation that bans tanning beds for minors

8. Prevention and Health Promotion Administration January 14, 2013 8 Policy Change Policies = Rules Legislation Regulations Ordinances Organizational Policy Corporate Policy Policy change can be large-scale (enactment of a federal law mandating that all health insurance plans cover cancer screenings with a USPSTF Grade A or B recommendation) or small-scale (a small business owner providing employees with paid time off for cancer screenings) Policy change can drive systems and environmental change

9. Prevention and Health Promotion Administration January 14, 2013 9 Systems Change Changes made to the rules and/or processes of an organization (often a type of policy change) Focuses on changing infrastructure within a school, park, community, worksite, or health care system (delivery or insurance) Health care system changes can ensure effective delivery and utilization of services to prevent, detect, and treat cancer

10. Prevention and Health Promotion Administration January 14, 2013 10 Environmental Change Changes made to the environment to promote health by making healthy behavior and choices easy (can be achieved through policy change) Environmental change can be large-scale (e.g. installing sidewalks throughout a community) or small-scale (e.g. installing signage to mark existing park trails) Includes physical, economic, and/or social environments

11. Prevention and Health Promotion Administration January 14, 2013 11 What’s the difference? PolicySystemsEnvironment DefinitionChanging laws, regulations, resolutions, ordinances, or rules Changing processes or rules of an organization, institution, or system Physically changing the environment SettingsLegislatures (national, state, local), government administrations, healthcare settings, schools, worksites, community organizations (faith-based, daycare, senior center) Healthcare delivery and insurance systems, schools, worksites, communities, parks Physical (stores, schools, worksites, parks, health clinics/offices), economic, and social environments ExamplesIncreasing tobacco taxes, implementing a smoke-free policy (hospital grounds, college campus, worksite, etc.), implementing a healthy meeting policy at work Developing a community plan that accounts for health impact of projects, reviewing and revising organizational procedures to increase cancer screening rates among patient population Constructing sidewalks to make roads pedestrian-friendly, designating a lactation room for nursing mothers at work, offering healthy vending machine options OverlapSmoke-free policy Healthy vending machine policy Adding night/weekend healthcare provider/clinic office hours Zoning restrictions/limitations on fast food establishments Farm-to-school program

12. Prevention and Health Promotion Administration January 14, 2013 12 PSE Change Vs. Programs SettingProgram/EventPSE Change SchoolCelebrate national nutrition month Add fruits and vegetables to cafeteria lunch options CommunityHost a community bike ride Implement a Complete Streets policy to ensure community roads are safe for biking, walking, and driving WorksiteHold a health fair for staff Implement a healthy vending machine policy that offers healthy, affordable snacks Radiology FacilityHold a low-cost mammography event Change operating hours to include night and weekend appointments HospitalHold free breastfeeding courses for new moms Implement WHO 10 Steps to Successful Breastfeeding Adapted from http://www.cookcountypublichealth.org/files/CPPW/PSE%20Change.pdf

13. Prevention and Health Promotion Administration January 14, 2013 13 Cancer Plan Examples- Prevention Tobacco and Lung Cancer Chapter: – Goal 1, Obj 2, Str 4: Engage with college and university administrators to ensure that all school campuses are tobacco-free at all times. – Goal 1, Obj 3, Str 1: Adopt state and local policies that prohibit the smoking of tobacco products inside multi-unit housing in MD. Ultraviolet Radiation and Skin Cancer Chapter: – Goal 2, Obj 1, Str 1: Encourage funding for the building of covered structures and implementing signage at public beaches and parks reminding people to wear sunscreen.

14. Prevention and Health Promotion Administration January 14, 2013 14 Cancer Plan Examples- Detection Colorectal Cancer Chapter: – Goal 1, Obj 1, Str 3: Increase the proportion of primary care providers and specialists who utilize evidence-based approaches such as physician recommendation for screening, client reminders, and chart review to ID patients appropriate for screening. – Goal 2, Obj 1, Str 4: Reduce barriers to CRC screening by utilizing strategies that facilitate primary care referral to specialists for screening, facilitate screening by use of patient navigators, community health workers, or lay health advisors, and/or encourage improved coordination between primary care providers and specialists. Breast Cancer Chapter: – Goal 2, Obj 1, Str 3: Support policies that allow work-time release to obtain cancer-screening services.

15. Prevention and Health Promotion Administration January 14, 2013 15 Cancer Plan Examples- Treatment & Survivorship Pain Management Chapter: – Goal 1, Obj 2, Str 1: Collaborate with pharmacies to ensure that pain medication is adequately stocked in all communities and explore legislation that would require pharmacies to stock pain medication. Palliative and Hospice Care Chapter: – Goal 1, Obj 2, Str 3: [Healthcare institutions] develop a strategic plan that incorporates goals and tactics to institutionalize palliative care. Nutrition, Physical Activity, and Healthy Weight Chapter: – Goal 1, Obj 5, Str 1 & 2: Implement programs in MD jurisdictions to promote access to healthy foods and physical activity in high- risk communities (virtual supermarkets, SNAP at farmers’ markets, partnership with park & recreation program, etc.)

16. Prevention and Health Promotion Administration January 14, 2013 16 Cancer Plan Example in Action: MCC Primary Prevention & Policy Committees Policy Tobacco Priority: Adopt state and local policies that restrict the sale, advertising, and promotion of tobacco products by… Prevention Tobacco Priority: Require that tobacco retailers: (a) display effective health warnings about the use of tobacco products; (2) display information on where to get help if you want to quit using tobacco; (c) ban so-called ‘power walls’ (large displays of tobacco products and ads; and (d) ban the distribution of ‘free- samples’ of all tobacco products.

17. Maryland Prevention and Health Promotion Administration Cancer and Chronic Disease Bureau Center for Cancer Prevention and Control Prevention and Health Promotion Administration [Date] 17 http://fha.dhmh.maryland.gov