Advocacy Coalition Framework Application of the Advocacy Coalition Framework in the NOPRN restaurant project

County Public Health Departments Work to Improve Restaurant Food A case-study of three counties in Washington that took different approaches to providing nutrition information in restaurants identifying barriers and factors that enhance the development of policy related to the provision of nutrition information in restaurants highlight lessons learned in policy making process and implementation King County: menu labeling regulation implemented January 2009 requires chain restaurants with 15+ locations nationwide to provide calorie, saturated fat, carbohydrate and sodium information on menus Pierce County: voluntary pilot program for local restaurants. Participating restaurants got free nutrient analysis and advertising in exchange for putting nutrition information (calories, fat, carbohydrates and sodium) on their menus Thurston County: working with one chain restaurant owner to highlight the healthier kids meal items on menu boards through marketing and menu design

Advocacy Coalition Framework1 Policy Subsystem Relatively Stable Parameters System-wide with enduring/constraining effect Coalition A Policy beliefs Resources Strategy Coalition B Policy beliefs Resources Strategy Constraints & Resources Decisions by Governmental Authorities External Events - Change in socioeconomic conditions, public opinion, leaders - Policy decisions/impacts from other subsystems The Advocacy Coalition Framework (ACF) developed by Sabatier and Jenkins-Smith (1988) provides a theoretical tool for policy analysis and assessment, particularly relating the policy development process to outcomes. This type of policy analysis may facilitate developing awareness and capacity within public health to influence the policy process (Breton et al. 2008). The ACF adapts constructs from several disciplines and includes several specific components; some will be described here (figure one). The AFC can be combined with other policy frameworks including multiple streams models (Kingdon) and stages heuristic (Weible) Over 80 studies in diverse policy arenas have been conducted using the AFC. We chose the AFC for this analysis because of its inclusion of the impact of external influences, the important of policy beliefs and its non-linear perspectives on policy learning. Some key concepts are:   Relatively Stable Parameters: As set forth by the ACF, there are relatively stable parameters, attributes over which the policy actors have little control. In the case of restaurants these include the need for restaurants to remain profitable and the frequency with which American’s eat away from home. External Events: dynamic elements effecting policy change, including public opinion, legislation, elections, outcome of other policies. These events can influence whether an issue gets on the policy agenda. In the ACF external events are seen as necessary, but not sufficient to change policy Constraints and Resources: external factors (stable and dynamic) impact the constraints and resources of a policy subsystem. For example, elections can result in changes in leadership and/or funding. Policy Subsystems: the set of actors involved in a policy issue, including policy advocacy coalitions that form based on core beliefs or values shared by coalition members. Beliefs: The ACF identifies beliefs as the overarching driver for policy actors. These are categorized as (1) Deep core beliefs - basic personal philosophical beliefs that are very difficult to change; (2) Policy core beliefs – fundamental policy positions concerning the strategies for achieving core beliefs; and (3) Secondary beliefs that are specific to the topic and may be changed by interactions and learning within the policy sub-system. In some situations, policy-oriented learning can take place across coalitions and lead to changes in secondary beliefs. Policy-Oriented Learning: Policy-oriented learning occurs as a result of experience and involves changes in a coalition’s approach to attain policy outcomes consistent with the coalition’s core beliefs. Many policy processes take up to 10 years to mature. Policy Outputs & Impacts 1) 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.

Interview Guide Example ACF Construct Coalition beliefs Identification of social groups or other entities whose welfare is of greatest concern Overall seriousness of the problem Ability of society to solve the problem Interview Questions Public Health Employees Importance of menu labeling work: How important was it to tailor your approach to populations at high risk for obesity? How important do you think the quality of restaurant food is to the health of the population? To what extent do you think that the nutritional quality of restaurant food can realistically be improved?

Interview Sample (n) Public Health Staff BOH Members Restaurant Owners Seattle-King 3 4 Tacoma-Pierce 5 Thurston 1 One interview with Washington Restaurant Association Representative

Coding Example: Beliefs ACF construct Characteristics Sample codes Deep Core Beliefs Fundamental values, unlikely to change Freedom, justice, health (priority of) Policy Core Beliefs Policy positions, strategies for achieving deep core values Education, regulation (priority of), role of government Secondary Aspects Implementation of policy core beliefs, easier to change Environment, behavior (change strategies), resources used

Preliminary Findings External Events Constraints & Resources Policy Beliefs Policy Oriented Learning Our analysis is not complete but it is clear that many of the constructs of the ACF are playing a role in the policy development process in each of the three case studies.

Examples of External Events CSPI & NYC helped set policy agenda Pushback from Restaurant Assoc in NYC Pierce: restaurants & their association very interested in partnering Thurston: avoided any regulations National legislation Preemption In all three counties the work was influenced by external events. Everybody was watching what was happening in NYC and with national legislation. Margo Wootan from the Center for Science in the Public Interest made visits to WA State to talk with state and local public health leaders about menu labeling. In King County, she testified at the Board of Health hearing about menu labeling. The push back from restaurants and legal action against the menu labeling regulations in NYC had different impacts in each of the three WA state cases. King County brought in legal counsel as they carefully worded their regulations. Thurston thought that their board and director would want to avoid what happened in NYC and they took a totally collaborative and voluntary approach to working with restaurants to improve the healthfulness of their offerings. In both Pierce and Thurston restaurant owners had been following what was happening in NYC and nationally so they were aware of the strong interest in the quality of their foods and public health staff thought that that made the restaurants more responsive to the initial requests from public health to work collaboratively with restaurants. Everybody is now watching the situation at the national level.

Examples of Constraints & Resources: Leadership King Co, new Director: policy as a public health tool championed the menu labeling policy despite industry pushback Pierce Co, budget cuts led to personnel changes: loss of several champions for menu labeling menu labeling policy development was put on hold during department restructuring As predicted by the Advocacy Coalition Framework, constraints and resources played important roles in the policy development process. For example: The new Health Department Director in King Co had strong focus on policy as a public health tool & the board of health initiated and championed the menu labeling policy despite industry pushback. In Pierce Co, budget cuts led to personnel changes at the health department including the loss of several champions for menu labeling. Menu labeling policy development was put on hold during the transition.

Examples of Coalition Beliefs Deep core beliefs Protection of freedom from regulation Protection of public health Policy beliefs: Role of Health Department Distribution of authority between government and marketplace Collaboration, voluntary approaches, regulation Both deep core beliefs and policy beliefs seemed to impact the kinds of initiatives that were conducted within each county. For example, In Thurston County Health Department staff felt that the County leaders would not support anything that interfered with the freedom of business owners to do what they wanted to do, Thurston County public health informants show a strong preference for a collaborative approach over an approach that requires restaurants to post this information. On the other hand, In King County informants felt that the health impact of eating less nutritious restaurant foods was serious and important and that restaurants would not change unless there was regulation.

Example of Policy-Oriented Learning King County WRA went to legislature in an attempt to get preemptive and less restrictive statewide regulations Forced a change to Health Department’s secondary beliefs (policy implementation) Health Dept and WRA negotiated modifications to regulation Key informants report increased understanding of opposing coalition’s perspective It is still early days for the kinds of policy oriented learning that is described in many of the other studies that have applied the ACF, and it is likely that the capacity of public health practitioners to work within the policy subsystem to develop policies that are effective for improving restaurant food choices will mature over time. In our study King County had most extensive policy oriented learning within the subsystem. For example in the initial regulations menu labeling was required if a chain had 10 franchises nationwide. After the King County regulations were passed the state Restaurant Association went to state legislature in an attempt to get preemptive and less restrictive regulations. The legislature instructed the Restaurant Association and King County to work collaboratively to modify regulation. That lead to a change that specified that the menu labeling only applied to franchises with 15 outlets.

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