Chapter Two: Learning About Policy and Environmental Change

Key Topics

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Key Topics:

• Defining Advocacy and Lobbying
• Outlining the Policy Development Process
• Applying Policy and Environmental Change

Spotlight:

• Stroke
• High Blood Pressure
• Heart Disease

Individual changes in human behavior, including making better lifestyle choices, will not solve the public health challenges of our time. A complementary strategy also is needed: one that brings together many individuals and groups to encourage society to make healthy decisions. Many stakeholders — both public and private — can respond to these challenges with changes in policies and environments that affect populations and society as a whole. These stakeholders include, but are not limited to, legislators, regulators, school boards, health care providers, and business leaders.

Policy and environmental changes are integral in the lives of public health officials and individual citizens. Simply put, policy and environmental changes are defined as what an authority chooses to do or not do about a specific problem. This chapter provides a basic overview of the process by which public health problems can be addressed. The process is dynamic and complex, and each situation is unique. It is important to recognize that the steps in this process generally do not “just happen.” Action is needed to prompt discussion and to sustain sufficient momentum to ensure that ideas are implemented in policy or environmental changes.

This chapter also provides examples of interventions for policy and environmental change that can be used to address prevention and control of heart disease and stroke. It should provoke questions and ideas on how public health professionals and others can successfully influence the process through proactive communication activities that address policies and environments, educate the public, provide resources, and foster partnering with many sectors of society in pursuit of positive health benefits for the general public.

Shaping Policy and Environmental Change

1. Problem Recognition. Analyze the current situation and identify a problem that needs to be addressed. This process can be based on qualitative or quantitative research or on individual opinions. Health practitioners, community advocates, teachers, business leaders, legislators, or individuals can initiate this step, unveiling a problem for a larger debate.

Role for State Heart Disease and Stroke Prevention Programs. Identify a problem related to (1) cardiovascular health (e.g., lack of knowledge of signs and symptoms of cardiovascular disease, lack of emergency medical service protocols for stroke, or lack of insurance that covers prescriptions or prevention services) or (2) risk factors (e.g., high blood pressure [high blood pressure], high blood cholesterol levels, tobacco use, physical inactivity, poor nutrition, overweight, or diabetes), and provide real-life examples of the effect on the state’s citizens. You can do research or use data, case histories, and anecdotal evidence that strengthen the rationale for action and provide credibility to the debate.¹

2. Convergence of Interests. Once the problem is made public, stakeholders — those most affected by the problem — enter the debate. Advocacy groups with similar missions coalesce, as do those with opposing interests. Stakeholders will address the situation to determine the direct and indirect impacts on his or her organization or entity.

Role for State Heart Disease and Stroke Prevention Programs. Recruit additional stakeholders (e.g., contacts or partners in the advocacy group or in a business or government community with an interest in the issue), and educate them about the problem. To magnify the voice, you can create a consensus and communication workgroup in support of action. Identify experts and others who can speak knowledgeably about the issue.

See a more detailed, fold-out chart in Chapter 7: Tools and Resources.

3. Formulation of Proposal/Solution. Stakeholders, both supporters and opponents, should develop strategies to achieve appropriate solutions. Formulation of a solution hinges on getting the right information to the right people at the right time. Decision makers need to know what people think and feel about an issue. Hard facts are needed to help evaluate the efficacy of a course of action, and information may need to be packaged in a variety of ways to be appropriate for various audiences.

Role for State Heart Disease and Stroke Prevention Programs. Play an active role with stakeholders to help identify strategies and plans to address the problem. You should share promising practices. Identify and interpret facts to enable diverse audiences to understand them and take appropriate action. You also need to inform decision makers such as state insurance departments, medical societies, managed care associations, and legislators of what they can do about the issue.

4. Consideration by Authorities. The process is then brought before the proper authorities, such as a school board, legislature, court, board of directors, or county commissioners. During consideration of the problem, there are often opportunities for public comment.

Role for State Heart Disease and Stroke Prevention Programs. Work with stakeholders to identify the appropriate authorities. You should establish and maintain relationships with key individuals (e.g., legislators, legislative staff, school board members, business managers, leaders of medical and insurance associations, and state agency leaders). Know the process by which the problem will be considered (e.g., how a bill becomes a law, how school board decisions are made, how decisions from state agencies are influenced, and how business managers change policies). You must also understand any restrictions for state health officials, including lobbying restrictions. (See AR-12 Lobbying Restrictions in Chapter 7: Tools and Resources.) Provide policy and decision makers with data, tools, and resources to articulate the agenda. You will want to seek opportunities to testify or otherwise comment for the public record. In addition, work to educate those who are opposed or neutral to the proposed solution.

5. Decision and Articulation. Authorities render a decision, and numerous outcomes are possible — adopting a proposal or compromise, rejecting a proposal or compromise, or maintaining the status quo. Therefore, it is critical for the public and stakeholders to understand how the issue affects them.

Role for State Heart Disease and Stroke Prevention Programs. Once a proposal is in play, you need to take a position and publicly offer strong support. Work with partners to articulate your support to the public and other stakeholders. You will find it helpful to provide testimony and endorsements to write letters to decision makers, and to send letters to the editor and submit Op-Ed (opinion editorial) articles to newspapers. Prepare a statement for the media, hold a press conference, and speak with reporters to ensure that the public is aware of your position. You should establish feedback mechanisms through which actual policy consequences are examined for health, social, economic, and cultural impacts. Be prepared to respond to statements and other information from opponents of your proposal.

To avoid concerns about lobbying restrictions and other advocacy issues, State Program Directors may consider engaging their partners in any of these efforts. When partners are involved, states can provide funding information and data such as state documents on disease burden and data from the CDC, as tools.

6. Implementation.  After the formal decision has been made, the policy is implemented.  New rules, processes, and organizations often result.  The officials who will write the implementation documents need input and support, and public comments often are sought.

Role for State Heart Disease and Stroke Prevention Programs.  Make it happen!  You can provide expert input and comment on the optimal way to implement the new decision.  Ensure that public bodies are held accountable to deadlines and a transparent public process.  You must be ready to counteract negative statements or comments by opponents.  Provide data collection or other resources to ensure implementation, and work with implementers to track progress and results.  Ensure that stakeholders and the public understand their roles in the decision and that existing or potential legislation or policies are enforceable.

7. Evaluation. Outcomes of communication interventions are documented to examine whether the problem was properly addressed and the process achieved results.

Role for State Heart Disease and Stroke Prevention Programs. Work with stakeholders and related parties to identify whether desired outcomes have been met. Share promising practices. You should identify any issues or problems in the evaluation and note possible improvements.

The process described here leaves the door open for a number of communication activities that can target legislators directly.  Legal restrictions are noted for the following examples:

• Meeting with a legislator about possible solutions to health problems, as long as no specific policy or funding proposals are outlined;
• Publishing or verbally communicating nonpartisan analysis or research on specific legislation, including a view on the legislation under the conditions that (1) a full and fair review of facts is presented, (2) there is no call to action, and (3) the message is given to legislators on both sides of the issue; and
• Responding to requests for technical assistance or testimony from lawmakers, provided that the request is in writing on behalf of a full committee or subcommittee.

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Issues and Approaches for Prevention Through Policy and Environmental Change

The approaches and tactics for prevention of stroke, high blood pressure, and heart disease that are highlighted here can be used by State Program staff to promote primary and secondary prevention.  The legislative examples provide concrete ideas for state compliance with AR–12 Lobbying Restrictions and still provide information and ideas to legislators and their staff.  The nonlegislative examples emphasize that policy change goes beyond legislation and includes such elements as insurance regulations and accreditation, employer incentives for health insurance, individual behavior and healthy practices, and incentives of health care organizations for practitioners to improve standards of care.

State Heart Disease and Stroke Prevention Programs are not expected to implement all of these approaches but are encouraged to consider those that fit best within their state plans and meet state needs.

Key Definitions

• Lobbying.  "Lobbying is any attempt to influence any legislation through communication with legislators, staff persons, or any other government official who participates in the formulation of legislation, where the communication:
  (1) refers to a specific piece of legislation and
  (2) reflects a view on that legislation."⁵

Example:  Expressing support to a lawmaker for a specific piece of legislation or encouraging a lawmaker to take a position on a specific bill.

• Advocacy/Education.  "Advocacy is participating in the democratic process by taking action in support of a particular issue or cause.  Advocacy efforts such as education, awareness building, promotion, marketing, and/or social marketing do not constitute lobbying as long as a policy maker is not being urged to take a position or action on a specific piece of legislation."⁶

Example:  Educating lawmakers about the importance of stroke as a public health problem and the benefits of establishing stroke centers in their state to improve care for stroke victims.

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Spotlight: Stroke

Issues

• Stroke is the third leading cause of death in the United States.⁷
• 48% of all stroke deaths occur before transport or before emergency medical services arrive.⁸
• In 2001, only 46% of U.S. adults recognized the five key symptoms of stroke;  38% of Hispanics and 32% of African Americans recognized the symptoms.⁹

Approaches for Preventing Stroke

1. Promote policy and systems changes within health care systems to increase adherence to guidelines for primary and secondary prevention of stroke.
   Inform and educate hospital administrators and individual providers about guidelines and systems changes to ensure compliance with guidelines. (Nonlegislative)
    
2. Promote policies for treating stroke as an acute emergency.
   Meet with administrators from organizations of emergency medical service personnel and health care providers in the area to discuss adoption of guidelines for treating stroke as an acute emergency.  Present state data on stroke burden, and discuss the importance of policy and environmental change.  (Nonlegislative)
   
   Write an article about the importance of thrombolytic treatment for stroke and the role of stroke centers and neurologists in reducing death and disability from stroke.  Work with professional associations to get the article published in their member newsletters.  (Nonlegislative)
    
3. Strengthen prevention through increased awareness and education about risk factors and lifestyle changes that affect high blood pressure, high cholesterol, diabetes, and tobacco use, and through policy and environmental changes in a variety of settings that encourage healthy lifestyles.
   Develop a presentation about policy and environmental change using The Blue Book.  You can use strategies from projects on tobacco use, water fluoridation, and lead poisoning as talking points and examples.  Use this presentation with school boards, policy makers, hospital administrators, and leaders in other important settings.  (Legislative and nonlegislative)
    
4. Promote state–based policy development for enhanced 9–1–1 coverage.
   Work with partners to develop key messages on enhanced 9–1–1 coverage for distribution to policy makers in the form of a briefing document or fact sheet.  (Legislative and nonlegislative)
    
5. Increase the awareness of signs and symptoms of stroke and the need for people to act promptly by calling 9–1–1.
   Provide existing materials to policy makers and partner organizations that can educate people in different settings about the signs and symptoms of stroke.  (Legislative and nonlegislative)
    
6. Promote multistate and regional networks, such as the Tri–State Stroke Network, to share prevention strategies and partnership opportunities related to stroke.
   Host a conference call to introduce members of different stroke networks to facilitate information and idea exchanges.  (Nonlegislative)
   
   Work with other states to leverage resources and increase focus on stroke as a major health issue.  Prepare communication packets for use across states.  (Nonlegislative)
    
7. Develop a state-based registry to assess quality of care for stroke.
   Inform policy makers about the benefits of stroke registries.  (Legislative and nonlegislative)

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Spotlight: High Blood Pressure

Issues

• High blood pressure is the leading modifiable risk factor for stroke and a major cause of heart attack.¹⁰
• One in four adults in the United States has high blood pressure.¹¹
• Middle–aged Americans face a 90% chance of developing high blood pressure during their lives.¹²
• Effective strategies for prevention and control of high blood pressure are not widely used.¹³

Approaches for Preventing High Blood Pressure

1. Promote policy development for increased adherence to national guidelines for the prevention and control of high blood pressure.
   Work with managed care companies in your state to create incentive programs for physicians who comply with national guidelines for managing high blood pressure.  This could include a certificate or other public or professional recognition.  (Nonlegislative)
    

2. Continue to inform the public that high blood pressure is a major modifiable risk factor for heart disease and stroke.  Encourage having high blood pressure checked as an important first step in identifying and controlling high blood pressure and reducing the risk of heart disease and stroke.
   Work with your workgroup partners to develop consistent messaging about high blood pressure and its effect on public health.  Have partners develop public education materials containing key messages.  (Nonlegislative)
   
   Develop materials for various audiences that present high blood pressure as an urgent health issue.  For example, compare the cost of treating high blood pressure with that of treating heart disease or stroke.  (Nonlegislative)
   
   Track outreach efforts to ensure that the messages are culturally appropriate and consistently delivered to populations at risk for high blood pressure.  (Nonlegislative)
    

3. Collaborate on education and policy intervention programs to detect and control high blood pressure in high–risk groups.
   Work with a nurses' association to create a communications initiative that encourages and enables nurses to clearly and briefly explain to patients the meaning of their blood pressure readings obtained during a health care visit.  (Nonlegislative)
   
   Develop handouts and talking points about high blood pressure prevention and control.  Ask partner organizations active with your priority populations, such as interfaith associations and community service organizations, to speak with groups in their communities.  Also ask these partners to distribute educational materials about high blood pressure.  (Nonlegislative)

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Spotlight:  Heart Disease

Issues

• Heart disease remains the single most common cause of death in the United States.¹⁴
• Most of the death and disability from heart disease can be prevented.¹⁵
• 60% to 70% of cardiac deaths occur outside the hospital.¹⁶
• Out–of–hospital deaths have increased among women.¹⁷
• The leading cause of disability among Americans is heart disease.¹⁸

Approaches for Preventing Heart Disease and Deaths From Heart Attack

1. Increase awareness and sense of urgency about out–of–hospital cardiac deaths.
   Use data from CDC or state surveillance to develop a fact sheet on the number of cardiac deaths and the importance of addressing out–of–hospital deaths.  Share this information with policy makers and health care providers.  (Legislative and nonlegislative)
   
   Develop a PowerPoint presentation about policy and environmental change using The Blue Book.  Deliver a presentation in discussions with school boards, policy makers, hospital administrators, and leaders in other priority settings.  (Legislative and nonlegislative)
    

2. Encourage health care systems to increase adherence to guidelines for primary and secondary prevention of heart disease.
   Circulate information on the latest guidelines for prevention of heart disease to hospital personnel, administrators, and individual health care providers.  Meet with administrators of large health care systems to design communication programs to encourage compliance with guidelines.  (Nonlegislative)
    

3. Promote development of state policy for enhanced 9–1–1 coverage.
   Work with your workgroup partners, develop key messages on enhanced 9–1–1 coverage for distribution to policy makers in the form of a briefing document or fact sheet.  (Legislative and nonlegislative)
    

4. Promote education at schools and work sites on the use of defibrillators.
   Provide educational materials that explain to employers and school sites how to use defibrillators and emphasize their importance in these settings.  Meet with school boards and major employers to discuss the need for defibrillators.  Provide printed information on the purchase of defibrillators and training for their use.  (Nonlegislative)
    

5. Increase awareness of the signs and symptoms of heart attack and of the need to act promptly by calling 9–1–1.
   Inform policy makers and partner organizations about health education materials that can be easily obtained and distributed in their communities.  (Legislative and nonlegislative)

   Develop educational materials on the signs and symptoms of heart attack (using CDC and Behavioral Risk Factor Surveillance System (BRFSS) data).  (Nonlegislative)
   
   Distribute "live read" radio Public Service Announcement scripts to news radio stations that appeal to policy makers.  (Legislative and nonlegislative)
    

6. Strengthen prevention through increased awareness and education about risk factors and lifestyle changes that affect high blood pressure, high cholesterol, diabetes, and tobacco use.
   Work with a local hospitals to write an article educating physicians about the guidelines for putting patients on cholesterol–lowering statin drugs and the importance of statin treatment.  Work with the hospitals to include this information in the communication vehicles they use to reach admitting physicians, such as physician newsletters.  (Nonlegislative)

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Chapter References

1. Cockrel J. Public Policymaking in America, University of Kentucky Cooperative Extension Service [online]. 1997. (cited 2003 December 1). Available from URL: http://www.ca.uky.edu/agc/pubs/ip/ip19/ip19.pdf
2. National Center for Chronic Disease Prevention and Health Promotion. Exemplary state programs to prevent chronic disease and promote health [online]. Winter 2002. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/nccdphp/exemplary/pdfs/State_Examples.pdf
3. National Center for Chronic Disease Prevention and Health Promotion. Exemplary state programs to prevent chronic disease and promote health [online]. Winter 2002. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/nccdphp/exemplary/pdfs/State_Examples.pdf (PDF 133K)
4. Centers for Disease Control and Prevention, AR-12 Lobbying Restrictions, CDC Program Announcement 02045 Cardiovascular Health Programs. 2002.
5. Vernick JS. Lobbying and Advocacy for the Public’s Health: What Are the Limits for Nonprofit Organizations? American Journal of Public Health, 1999;89(9):1425-1429.
6. Vernick JS. Lobbying and Advocacy for the Public’s Health: What Are the Limits for Nonprofit Organizations? American Journal of Public Health, 1999;89(9):1425-1429.
7. Centers for Disease Control and Prevention. Leading Causes of Death [online]. September 2002. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/nchs/fastats/lcod.htm
8. Centers for Disease Control and Prevention. State-Specific Mortality from Stroke and Distribution of Place and Death. MMWR [online]. 1999;51(20):429-433. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5120a1.htm
9. Pancioli AM, Broderick J, Kothari R, et al. Public perception of stroke warning signs and knowledge of potential risk factors. JAMA 1998;279:1288–1292.
10. American Heart Association. High Blood Pressure: Why Should I Care? [online]. 2003. [cited 2003 December 1]. Available from URL: http://www.americanheart.org/presenter.jhtml?identifier=2129*
11. American Heart Association. High Blood Pressure Statistics. [online] 2003. [cited 2003 December 1]. Available from URL: http://www.americanheart.org/presenter.jhtml?identifier=2139*
12. National Heart, Lung, and Blood Institute. Your Guide to Lowering Blood Pressure. [cited 2003 December 1]. Available from URL: http://www.nhlbi.nih.gov/hbp/*
13. National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2000 Chart book on cardiovascular, lung, and blood diseases. Washington, DC: The Institute; 2000.
14. Centers for Disease Control and Prevention. Leading Causes of Death [online]. September 2002. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/nchs/fastats/lcod.htm
15. Centers for Disease Control and Prevention. Heart healthy and stroke free: An orientation and reference manual for the cardiovascular health state program. Washington, DC: The Center; 2002.
16. American Heart Association. Out-Of-Hospital Deaths by State – 1999. [cited 2003 December 1). Available from URL: http://www.americanheart.org/presenter.jhtml?identifier=3008698*
17. Centers for Disease Control and Prevention. MMWR [online]. [cited 2003 December 1]. Available from URL: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5106a3.htm
18. National Heart, Lung, and Blood Institute. Women’s Heart Health Education Initiative: Cardiovascular Disease and Women (online). 2003. (cited 2003 December 1). Available from URL: http://hin.nhlbi.nih.gov/womencvd/wrkshp/ontime.htm*

Date last reviewed: 05/12/2006
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion