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 Big “P” Little “p” Legislation Litigation
Regulation
Protocols
Procedure manuals
Organizational rules
Administrative rules
Incentives/disincentives

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

8. 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
IOM report: Preventing Childhood Obesity

9. 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

10. Nutrition Policy Framework
WA-NOPREN:
-NOPREN is a thematic research network of the CDC Prevention Research Centers Program. Its mission is to conduct transdisciplinary nutrition- and obesity-related policy research and evaluation along a policy change continuum (policy identification, policy development, policy evaluation). 

11. Policy Identification

12. http://depts. washington

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
Economic
Procurement standards
Retail quality & proximity
Taxes
Redevelopment/economic devel.
Direct Access to Foods
Community gardens
Food security
Community supported agriculture
Local kitchens/ processing units
School food
Farmers markets
Farm-to-institution
Vitality of Farms/ Farming
Cooperatives
Supporting farms & farmers
Farmland preservation Organization & Planning
Food Policy Councils
Comprehensive Plans
Transportation
Food Issues
Food safety
Emergency preparedness
Marketing

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
After pilot testing the Kingdon Model as a framework for monitoring policy development in NPAO healthy communities, we decided that although it contains useful elements, it did not provide enough detail on steps required in the problem/ agenda setting-setting process or in the proposal (model policy development) process. It was a bit too abstract for communities who were doing the work—they felt it did not capture the work they were doing. We also felt the model didn’t go far enough in monitoring the quality of policy implementation, or measuring policy impacts.
So, we turned to the Policy development model developed by James Emery and Carolyn Crumb of UNC, which is supported by the Directors of Health Promotion Education. This is the model we use to train our HC grantees.
In this model, policy making is seen as a process that occurs in 5 domains: problem identification, policy formulation, advocacy, implementation, and evaluation.
This model is laid out in linear fashion—which makes each step easy to understand. While it is true that some things “ought to” happen sequentially, we know the reality is that many processes may occur simultaneously—are iterative—and basically, messy and unpredictable.
For that reason, we decided to draw on both models for our evaluation.
The DHPE model will be used for defining milestones in the policy development process as we collect data from our HC grantees in the form of progress reports. We will use this data to document what happened We will bring the Kingdon framework in as we evaluate why things happened the way they did. Our evaluation framework actually draws on both models.

19. Advocacy Coalition Framework
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
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 (chapter on policy oriented belief systems from the Sabatier book). 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 change occurs through 2 processes- changes in external events and 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
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:

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

21. Approaches King Pierce Tacoma
With support from Health Department staff Board of Health passed regulation; mandatory menu labeling for “chain” restaurants started January 2009
Pierce
Health Department staff worked with non-chain restaurants to analyze recipes and facilitate menu labeling
Tacoma
Health Department staff worked with one local franchise owner who offered healthier options in kids meals and posted some nutrition information

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 King Pierce Thurston
All agreed it is an appropriate role of public health (PH) to use regulation when necessary to protect the health of the community; population health is a priority; humans are resistant to change so we need environmental change; citizens entitled to nutrition information
Pierce
Board of Health (BOH) and PH practitioners less united on need for regulation & roles of PH; one BOH member had strong anti-regulation beliefs; freedom was priority belief; people & industry will make the right choice if PH provides information
Thurston
Role of PH is to collaborate with industry to assure the availability of healthy choices; priority value of freedom vs. regulation; inappropriate to take actions that could compromise industry profits

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 Problem http://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. Legislation or Change in Policy
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 * Reimbursement Level Food Expenditure
High reimbursement providers spent more per child per day *
Food Expenditure
($/child*day-1)
Reimbursement Level

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

47. Nutritional Quality * Food Spending Level Child MAR (%)
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 Baseline Final =3.2 calories/gram =.60 calories/gram
Mean Energy Density (calories/g)
For Woodinville females, energy density of foods consumed does drop, while at Bothell, it went up.
Baseline
Final

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

51. What Can Nutrition Advocates Do?
Slides Courtesy of PolicyLink

57. This Year in Washington’s Legislature
Coalition to Prevent Childhood Obesity
Healthy Food Procurement
Healthy Child Care standards
Anti-Hunger Nutrition Coalition
Restore full benefits for families on the State Food Assistance Program
Increase Emergency Food Assistance Program funds for food banks Restore $500,000 to keep WSDA’s Farm to School and Small Farms programs running
Support a balanced approach to the state budget
Hunger Action Day: February 22