1. Developing Policy for Public Health Nutrition

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. Policy = The Rules Big “P”Little “p” Legislation Litigation Regulation Protocols Procedure manuals Organizational rules Administrative rules Incentives/disincentives

6. Examples of Policies StateCountyMPO/RDCCity Legislation Ordinance Resolution Tax Ordinance Internal Policy Plans Design Manual From Thunderhead Alliance: Complete Streets Report

7. Why do we need policy?

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

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

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

11. How is policy developed?

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

13. Participants

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

15. 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

16. 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…..

17. Food and Nutrition Policy Entrepreneurs Food & Nutrition Policy Health Professional Associations Consumer Interest groups & Other NGOs Government – at all levels Farmers/Commodity groups Food Industry Scientific Bodies & Researchers

18. The “streams”

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

20. Problems Why do some problems get attention? 1.Indicators – large magnitude or change 2.Focusing event – disaster, crisis, personal experience 3.Feedback about existing programs – evaluation, complaints, etc.

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

22. Framing the Problem http://www.frameworksinstitute.org/ Problems with the Dominant Communications Approach to Childhood Obesity: 1.It focuses on the individual as the cause of the problem. 2.Parents are the only responsible actors in the frame. 3.The problem is overwhelming. 4.Behavior change by parents and children is the solution to the problem.

23. 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.”

24. Policy Proposals: Alternative Specification Narrows the large set of possible alternatives to that set from which choices are actually made.

25. 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

26. 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)

27. 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

28. 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

29. “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).

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. Problem Recognition Policy Proposals Politics Legislation or Change in Policy

33. 2 Problem Stream Policy Stream Politics Stream Figure 2: Kingdon’s Multiple Streams Model No policy adoption Problem Stream Policy Stream Politics Stream  A  B  C B 2 3 1      C 2 Scenario 1: No Coupling of Streams or Window Closed > Policy Proposal Not Adopted Scenario 2: Coupling of Streams and Window of Opportunity Open > Policy Proposal Adopted Policy Adoption

34. 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.

35. 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

36. Local Policies Related to Restaurant Menu Labeling: Barriers, Facilitating Factors, and the Role of Local Health Departments Donna B. Johnson, RD, PhD, University of Washington Elizabeth C. Payne, MPH, RD, University of Washington Kirsten Frandsen, BS, Tacoma-Pierce County Health Department Deborah Allen, PhD, Thurston County Public Health & Social Services Donna Oberg, MPH, RD, CD, Public Health-Seattle & King County Molly McNees, PhD, Public Health-Seattle & King County

37. Policy Development is a Function of Public Health Institute of Medicine –1988: The Future of Public Health –2011: For the Public’s Health - Revitalizing Law and Policy to Meet New Challenges

38. Nutrition & Obesity Policy Research & Evaluation Network NOPREN is funded by the Centers for Disease Control and Prevention under cooperative agreement number 1-U48-DP-001946. The findings and conclusions are those of the authors and do not necessarily represent that official position of the Centers for Disease Control and Prevention.

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

40. Approaches King 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

41. Design & Methods Multiple-case, replication design Data: documents and key informant interviews Interviews: public health practitioners (11), board of health members (9), restaurant owners and restaurant association representative (10) Interview questions: explore themes related to policy process and change as described by the Advocacy Coalition Framework

42. Advocacy Coalition Framework 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. Relatively Stable Parameters System-wide with enduring/constraining effect External Events - Change in socioeconomic conditions, public opinion, leaders - Policy decisions/impacts from other subsystems Constraints & Resources Policy Subsystem Coalition A Policy beliefs Resources Strategy Coalition B Policy beliefs Resources Strategy Decisions by Governmental Authorities Policy Outputs & Impacts

43. Common Agreement on Parameters Obesity rates are a concern Meals away from home are important determinants of food intake Restaurants need to be profitable

44. External Events King NYC precedent policy Support from CSPI Pierce Industry push-back in NYC, King Co. Federal legislation Thurston External funding for research with restaurants Close association with Washington Restaurant Association All: External funding for Policy, Systems & Environmental change; economic recession

45. Policy Sub-System Actors King Leaders: BOH, Public Health Director Staff: HEAL, environmental health Industry: restaurant owners, WRA Community: health organizations & advocates Center for Science in the Public Interest Pierce Leaders: BOH, HD manager, PH Director Staff: HEAL Industry: restaurant owners, WRA Thurston Leaders: BOH, senior HD leadership Staff: HEAL Industry: local franchise owner, WRA BOH – Board of Health HEAL- Healthy Eating Active Living HD – Health Department WRA – Washington Restaurant Association

46. Boards of Health King King County Council Members (3) Seattle City Council Members (3) Suburban City Mayors (2) Health Professionals (2 voting/1 non-voting) Director of the Public Health Department (1) Pierce Pierce County Council (3) Pierce County Executive (1) Tacoma Mayor (1) Tacoma City Council (1) Pierce County Cities and Towns Association (1) Health Professional (1) Thurston The three elected Thurston County Commissioners

47. Policy Beliefs ACF construct CharacteristicsExamples Deep Core Beliefs Fundamental, unlikely to change Freedom, justice, fairness, population health as priority Policy Core Beliefs Basic strategies for achieving core values Roles of education v.s.regulation Secondary Beliefs Related to administration & implementation Environmental & behavior change strategies

48. Policy Beliefs King 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

49. 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

50. Implications for Practice 1.Policy Development models can be helpful. 2.Core policy beliefs can be barriers or facilitators of the policy process. 3.Lessons learned can be applied to future nutrition policy development.

51. Models to Inform Practice Understanding processes –ACF used to describe over 80 other policy processes –Can learn from previous initiatives –Examples: external events, leadership, economic context Plan future strategies –Constructs can guide planning Flexibility in application –Any given construct or theory does not apply to all situations –Combine constructs and theories for a best fit explanation

52. 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.”

53. 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

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