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

• Wise, expedient, or prudent conduct or management
• A principle, plan, or course of action, as pursued by a government, organization, individual, etc.

• The act or process of setting and directing the course of action to be pursued by a government, business, etc.

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

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
Individual
Knowledge, attitudes, beliefs

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

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

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

Participants
The Streams
Agenda Setting
Alternative Specification
Coupling the Streams/ Windows

Basics
• President
• Members of congress
• Civil servants
• Lobbyists
• Journalists
• Academics
• Others

• 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

• 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…..

Problems Policy Proposals
Politics

Problems Policy Proposals
Politics
Legislation or Change in Policy

• Problem recognition
• Policies: proposal formation
• Politics
Basics

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.
Agenda Setting

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

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

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

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

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

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

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

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

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

• 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

• 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

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

• 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.

• 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.

IOM, 2005

• 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

• 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

• 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

• 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

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.
http://cspinet.org/nutritionpolicy/nana.html
NANA is made up of more than 300 organizations
.

• Model local school wellness policies
• Strengthen national school lunch and other child nutrition programs
• Strengthen national and state nutrition, physical activity and obesity programs

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)

• 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

• 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

Problems Policy Proposals
Politics

Problems Policy Proposals
Politics
Legislation or Change in Policy

• 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.

• 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

(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

• Health ed campaigns and other persuasive communication
• Require product labeling
• Restrict harmful or misleading advertising

• Community environment
– Restrict access like we have for tobacco?
• School environment

• Government has power to tax and spend
– Taxes on calorie dense, low nutritional quality foods?
– Incentives or subsidies for fruits and vegetables?

• 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

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

2004 2005 2006
All
States
WA
State
172 8
All states
280
WA
4
All
States
220
WA
1 Nutrition bills introduced
Nutrition bills enacted
Physical Activity
Bills introduced
Physical activity bills enacted
28
214
50
2
8
1
55
340
72
0
6
6
38
273
47
1
6
2

Category # Bills
Assistance Programs 12
Cafeteria Meals/Food Service (schools)
Nutrition Education
Farmers Market
Liability
Access to Obesity Treatment Services
Grocery Store/Food Market
Labeling (Ephedrine)
Restaurant (all about liability)
Worksite (tax credits for “certain benefits”)
5
1
0
1
49
46
9
22
13

• 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

• 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

• 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

• 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

• 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

• 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

• Relating to funding and appropriations for transportation. Sponsor: Haugen

• 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

• “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

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

• 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

• Norms are:
– standards or models
– Voluntary or expected way of behaving
• Norms drive policy
• Policy can also drive norms

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

• 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?