1. Policy & Nutrition Example: Obesity Conceptual Frameworks:
Kingdon Policy Model
IOM Obesity Prevention Organizing Framework

2. What is Policy?

3. 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.

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

5. Examples of Policies State County MPO/RDC City Legislation Ordinance
Resolution
Tax Ordinance
Internal Policy
Plans
Design Manual
From Thunderhead Alliance: Complete Streets Report

6. Why do we need policy?

7. Levels of Influence in the Social-Ecological Model
Structures, Policies, Systems
Local, state, federal policies and laws to regulate/support healthy actions
Institutions
Rules, regulations, policies & informal structures
Community
Social Networks, Norms, Standards
Interpersonal
Family, peers, social networks, associations
The outer layer of the model is the Structures, Policies and Systems that operate at local, state and Federal level to regulate and support healthy actions.
Individual
Knowledge, attitudes, beliefs

8. Intervention Categories with Strong Evidence of Effectiveness for the 10 greatest Achievements in Pubic Health: From IOM report: Preventing Childhood Obesity, 2005…

9. X Community Wide Campaigns School based intervention
Mass media strategies
Laws and regulations
Reducing costs to patients
Vaccination X
Motor vehicle safety
Safer work places
Control of infectious disease
Decline in deaths from CHD and stroke

10. X Community Wide Campaigns School based intervention
Mass media strategies
Laws and regulations
Reducing costs to patients
Safer and healthier foods X
Healthier mothers and babies
Family Planning
Water Fluoridation
Recognition of tobacco as a health hazard

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

12. Participants

13. National Policy Participants
President
Members of congress
Civil servants
Lobbyists
Journalists
Academics
Others
Basics

14. 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

15. 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…..

16. The “streams”

17. Problems
Policy Proposals
Politics

18. Legislation or Change in Policy
Problems
Policy Proposals
Politics
Legislation or Change in Policy

19. 3 streams of processes Problem recognition
Policies: proposal formation
Politics
Basics

20. 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.
Agenda Setting

21. 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
Agenda Setting

22. Google Hits for Obesity –
1/29/05
2/20/07
Obesity
8,650,000
31,100,000
Obesity and “New York Times”
214,000
932,000
Obesity and “Wall Street Journal”
49,300
386,000
Obesity and “Seattle Times”
13,100
91,700
Obesity and CBS
97,100
863,000

23. Decisions about Problem Recognition:
Made through persuasion
Use indicators to argue that conditions should be defined as problems
Argue that proposals meet tests of feasibility or value acceptability
Agenda Setting

24. Y O U R  T I M E / H E A L T H The Year of Obesity Our perennial interest in losing weight became a national obsession in 2004 By MICHAEL D. LEMONICK

25. 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
Agenda Setting

26. 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
Agenda Setting

27. Agenda Setting

28. Agenda Setting
Agenda = list of subjects to which officials are paying some serious attention at any given time
Basics

29. Kim Severson, Chronicle Staff Writer
Obesity 'a threat' to U.S. security Surgeon general urges cultural shift
Kim Severson, Chronicle Staff Writer
Tuesday, January 7, 2003

30. Alternative Specification
Narrows the large set of possible alternatives to that set from which choices are actually made.
Basics

31. 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
Alternative Specification

32. 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)
Alternative Specification

33. 2001
The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity

34. Ensure daily, quality physical education for all school grades
Ensure daily, quality physical education for all school grades. Currently, only one state in the country -- Illinois -- requires physical education for grades K-12, while only about one in four teenagers nationwide take part in some form of physical education.  
Ensure that more food options that are low in fat and calories, as well as fruits, vegetables, whole grains, and low-fat or non-fat dairy products, are available on school campuses and at school events. A modest step toward achieving this would be to enforce existing U.S. Department of Agriculture regulations that prohibit serving foods of minimal nutritional value during mealtimes in school food service areas, including in vending machines.  
Make community facilities available for physical activity for all people, including on the weekends.   
Create more opportunities for physical activity at work sites.  
Reduce time spent watching television and in other sedentary behaviors. In 1999, 43 percent of high-school students reported watching two hours of TV or more a day.  

35. Educate all expectant parents about the benefits of breast-feeding
Educate all expectant parents about the benefits of breast-feeding. Studies indicate breast-fed infants may be less likely to become overweight as they grow older.  
Change the perception of obesity so that health becomes the chief concern, not personal appearance.  
Increase research on the behavioral and biological causes of overweight and obesity. Direct research toward prevention and treatment, and toward ethnic/racial health disparities.  
Educate health care providers and health profession students on the prevention and treatment of overweight and obesity across the lifespan.

36. Preventing Childhood Obesity: Health in the Balance
IOM, 2005

37. Federal Government
Establish an interdepartmental task force and coordinate federal actions
Develop nutrition standards for foods and beverages sold in schools
Fund state-based nutrition and physical-activity grants with strong evaluation components
Develop guidelines regarding advertising and marketing to children and youth by convening a national conference
Expand funding for prevention intervention research, experimental behavioral research, and community-based population research; strengthen support for surveillance, monitoring, and evaluation efforts

38. State and Local Governments
Expand and promote opportunities for physical activity in the community through changes to ordinances, capital improvement programs, and other planning practices
Work with communities to support partnerships and networks that expandthe availability of and access to healthful foods

39. State and Local Education Authorities and Schools
Improve the nutritional quality of foods and beverages served and sold in schools and as part of school-related activities
Increase opportunities for frequent, more intensive, and engaging physical activity during and after school
Implement school-based interventions to reduce children's screen time
Develop, implement, and evaluate innovative pilot programs for both staffing and teaching about wellness, healthful eating, and physical activity

40. “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).
Alternative Specification

41. National Alliance for Nutrition and Activity
NANA promotes within the legislative and executive branches of government a better understanding of the importance of healthy eating, physical activity, and obesity control to the nation's health and health-care costs. One of the primary goals of NANA is to cultivate champions for nutrition, physical activity, and obesity prevention in Congress and federal agencies. Efforts include supporting effective education programs, advocating adequate funding for programs, and promoting environmental changes that help Americans eat better and be more active.
NANA is made up of more than 300 organizations.

42. NANA Priorities Model local school wellness policies
Strengthen national school lunch and other child nutrition programs
Strengthen national and state nutrition, physical activity and obesity programs

43. POLICY OPTIONS to promote nutrition and activity
Nutrition Labeling on Menus/Menu Boards at Chain Restaurants
Decrease Marketing of Low-Nutrition Foods to Children
Improve School Foods
Increase Physical Activity in Schools
Support Physical Activity through Transportation Policy
Promote Fruit and Vegetable Intake
Increase Resources for Nutrition and Physical Activity Programs (including Soft Drink Taxes)

44. 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

45. Coupling the Streams
The probability of rising on the agenda is increased if all 3 streams are joined
Partial couplings between 2 streams are less likely to result in policy changes

46. Problems
Policy Proposals
Politics

47. Legislation or Change in Policy
Problems
Policy Proposals
Politics
Legislation or Change in Policy

48. 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.

49. 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

50. Organizing Framework for Public Health Interventions (IOM, Preventing Childhood Obesity, 2005)
The information environment
Access and opportunity
Economic factors
The legal and regulatory environment
Prevention and treatment programs
The social environment

51. Information Environment Opportunities
Health ed campaigns and other persuasive communication
Require product labeling
Restrict harmful or misleading advertising

52. Access and Opportunity
Community environment
Restrict access like we have for tobacco?
School environment

53. Economic Factors Government has power to tax and spend
Taxes on calorie dense, low nutritional quality foods?
Incentives or subsidies for fruits and vegetables?

54. Legal and Regulatory Environment
Pubic health law is one of 8 emerging themes identified by IOM as important to the future of pubic health training. Three components:
Laws
Regulation
Litigation

55. State Nutrition and Physical Activity Legislative Database http://apps
2001
2002
2003
Nutrition bills introduced 88 58
174
Nutrition bills enacted 32 15 35
Physical Activity
Bills introduced
167
148
240
Physical activity bills enacted 28 33 55

56. State Nutrition and Physical Activity Legislative Database http://apps
2004
2005
2006
All States
WA State
All states WA
All
States
Nutrition bills introduced
172 8
280 4
220 1
Nutrition bills enacted 28 2 55 38
Physical Activity
Bills introduced
214
340 6
273
Physical activity bills enacted 50 72 47

57. State Nutrition Legislation Enacted 2001-2006
Category
# Bills
Assistance Programs 12
Cafeteria Meals/Food Service (schools) 49
Nutrition Education 46
Farmers Market 9
Liability 22
Access to Obesity Treatment Services 13
Grocery Store/Food Market
Labeling (Ephedrine) 1
Restaurant (all about liability) 5
Worksite (tax credits for “certain benefits”)

58. SB
Requires state school directors convene advisory committee to develop model policy on: access nutritious foods and development, appropriate exercise. Policy to address nutritional content of foods and beverages and the availability and quality of health, nutrition, and physical education curricula. SPONSOR: Kohl-Welles

59. SB
No distributor, manufacturer or seller of food and non-alcoholic beverages will be held liable for claims resulting from weight gain, obesity or related health conditions due to long-term consumption of a product. SPONSOR: Brandland, Companion Bill: HB2994

60. HB
In regards to a specialized "Share the Road" license plate. Proceeds beyond costs of implementation will be used towards contracting with a qualified nonprofit organization to promote bicycle safety and awareness education in communities throughout Washington. The organization must promote bicycle safety and awareness education in communities throughout Washington. The Washington state traffic safety commission shall establish a program for improving bicycle and pedestrian safety, and shall cooperate with the stakeholders and independent representatives to form an advisory committee to develop programs and create public private partnerships which promote bicycle and pedestrian safety. Sponsor: Wood

61. HB 1413 and SB
Relates to expanding the criteria for habitat conservation programs, sets forth funding and guides the the interagency committee for outdoor recreation. Defines trail as a means public ways constructed for and open to pedestrians, equestrians, or bicyclists, or any combination thereof, other than a sidewalk constructed as a part of a city street or county road for exclusive use of pedestrians. Not less than twenty percent of appropriations for habitat programs must be used for the renovation, or development of trails. Sponsor: Dunshee Companion bill: SB5396

62. SB
Provides for county and city plans, wherever possible, to include urban planning approaches that promote physical activity. Transportation planning in cities, towns, and counties should incorporate policy and infrastructure changes that promote non-motorized transit. State agencies applying for loans or grants must have incorporated elements in their plans that increase access to walking and biking in their communities. Superintendent of Public Instruction to promote adoption of school-based curricula and policies that provide quality physical education for all students. Sponsor: Franklin

63. SB
Relating to commute trip reduction tax credit. Offered to employers and property owners who are taxable and provide financial incentives to their own or other employees for ride sharing, for using public transportation, for using car sharing, or for using nonmotorized commuting before July 1, 2013, are allowed a credit against taxes payable. Sponsor: Jacobsen

64. SB
Relating to funding and appropriations for transportation. Sponsor: Haugen

65. SB
Creates the Governor's Interagency Council on Health Disparities to create an action plan and statewide policy to include health impact reviews that measure and address other social determinants of health that lead to disparities as well as teh contributing factors of health care that can have broad impacts on improving status, health literacy, physical activity, and nutrition. SPONSOR: Franklin

66. Regulation
“If the tobacco experience is any guide, it is likely that the food companies will act just enough t o avoid government regulation…..to date companies have been much more comfortable with educational campaigns emphasizing personal responsibility and the need for increased physical activity, than proposing major policy or structural change.”
IOM, Preventing Childhood Obesity, 2005

67. Regulatory Options
FDA has authority to enforce laws about labeling and false claims, not to deal with nutritional adequacy.
IOM, Preventing Childhood Obesity, 2005

68. Litigation Powerful tool for tobacco, gun violence, lead paint
Initial attempts at fast food litigation have been “less than successful”
Future is unclear
Several states have passed legislation aimed at prohibiting lawsuits against food and beverage manufactures for obesity-related health problems.
Documents obtained through discovery could damage the public's perception of food companies.
IOM, Preventing Childhood Obesity, 2005

69. The Social Environment: Policy and Norms for Health Promotion
Norms are:
standards or models
Voluntary or expected way of behaving
Norms drive policy
Policy can also drive norms

70. Steps that previous efforts have taken before norms on the role of Government changed (Kersh and Marone, 2002)
Social disapproval
Medical science
Self-help
Demonize the user
Demonize an industry
Mass movement
Interest group action

71. Evaluation of Policy Change
Policy development should include plans for policy evaluation
Process evaluation: Was the policy actually carried out?
Outcome: Did the policy change have the intended outcome?