Improving Population Health

Can We Find Political Common Ground to Improve Population Health?

By David A. Kindig, MD, PhD

The next two months will be filled with harsh and divisive campaigning, deepening the ideological divide that characterizes our politics these days. Both conventions seemed primarily designed to energize their bases, by emphasizing the sharpest differences between the political “tribes.” Perhaps this is necessary in today’s politics, but it doesn’t bode well for population health policy over the coming decade. Improving population health will require cutting health care costs while preserving access and quality, enabling better health behaviors, improving education, economic growth, and the physical environment while also increasing social support and social capital. These are decisions that will require careful, nuanced decisions that go far beyond simplified political exchanges. 

Last Labor Day I blogged on my summer read of Friedman and Mandelbaum’s book That Used To Be Us: How America Fell Behind in the World It Invented and How We Can Come Back, and their call for third party movement or even a new party which seeks to find common ground on such major challenges facing the country. This summer, I continued in this genre with Jonathan Haidt’s The Righteous Mind: Why Good People are Divided by Politics and Religion. Haidt is a social/moral psychologist, now at the NYU Stern School of Business. The book is a breathtaking synthesis of psychology, philosophy, evolutionary theory, anthropology, genetics, and political science. The book jacket poses these two questions: “Why can’t our political leaders work together as threats loom and problems mount? Why do people so readily assume the worst about the motives of their fellow citizens?”

Bloomberg and Sugar: Will Regulatory Incentives Be Effective?

By David A. Kindig, MD, PhD

In his current biography The Passage of Power, Robert Caro recalls how four days after the Kennedy assassination, Lyndon Johnson had to decide if he would make a major civil rights push in his transition address to Congress the following week. Cautioned by his aides that it might be too controversial, he said, "Well, what the hell’s the presidency for?"

I was thinking of this last week when the New York Times editorial page called last week’s proposed removal of sugary drinks larger than 16 ounces in restaurants, theaters, stadiums and food carts by Mayor Bloomberg and Health Commissioner Farley “A Ban Too Far.” They applaud other anti-obesity efforts but claim that “too much nannying with a ban might cause people to tune out.” That statement does not seem to be particularly compelling itself, but how should population health advocates evaluate when regulation is appropriate or not?

(How) Does Where You Live Get Under Your Skin?

By David A. Kindig, MD, PhD

Last week Kirstin blogged on an innovative housing project in the South Bronx that incorporated fitness promoting design principles. She cited the Robert Wood Johnson Foundation’s Commission to Build a Healthier America's Issue Brief on Housing and Health which identified three interrelated aspects of residential housing that influence health: (1) affordability, (2) the physical conditions within homes, and (3) neighborhood environments surrounding homes.

Last week there was significant media coverage (including the October 29 Economist!) of an article by Jens Ludwig and colleagues that was featured in the Oct 20 New England Journal of Medicine. The study reported that moving from a high poverty neighborhood to a lower poverty one showed substantial improvement in obesity rates and blood sugar levels. Why was this report deemed of such interest and importance, even by the mainstream press?

Can Policy Models be Helpful to Local Decision Makers?

By David A. Kindig, MD, PhD

Two recent posts have featured population health policy models (see Modeling Long Run Population Health Costs and Outcomes and A Population Health Opportunity Map). Such models will be increasingly important as we strive to effectively allocate resources appropriately across sectors to improve overall health outcomes and improve health equity. But to those in the local trenches, particularly in a time of resource reductions, models may seem abstract and irrelevant. What do we know NOW that can help communities make the best decisions possible in these challenging times? Can top down models or tools be helpful to communities looking for bottom up solutions?

A Population Health Opportunity Map

By David A. Kindig, MD, PhD

A commentary in the May 25 JAMA by Jonathan Fielding and Steve Teutsch caught my eye a couple of months ago. Both authors play influential roles in national population health policy, from their practice based experiences in the Los Angeles County Department of Public Health.

They begin by arguing that as we reform the health CARE system, complementary improvements are needed in community prevention programs and policies as well. The challenge for both national and local policy makers is to be able to “identify and implement those interventions that provide the greatest benefits and value,” including the relative effectiveness of both clinical and community prevention efforts. They suggest that a first step has to be a sound framework for “identifying and organizing” the universe of interventions which have been shown to have evidence of effectiveness.

Modeling Long Run Population Health Costs and Outcomes

By David A. Kindig, MD, PhD

The broad population health model that underpins this blog and the County Health Rankings must have long-term relevance because quick fixes are few and far between. There is an imperative to invest now in factors we know to be strong drivers of long-term health, such as early childhood interventions (see Can We Afford to Wait for Better Evidence on Improving Child Health? and Business Investment in Early Childhood: Making Future Workers Happier). There is also a need for more research which can better estimate such long-term impacts; the IOM’s recent report on Public Health Measurement and Accountability calls for advancing the use of predictive and system-based simulation models to understand the health consequences of the underlying determinants of health.

One such model does exist, and was reported on in the May 2011 Health Affairs issue on Environmental Health discussed last week. The article, authored by Bobby Milstein, Jack Homer and colleagues, focuses on the HealthBound policy simulation model which has been developed by the CDC over the past decade. This work seems and is ambitious, as any such analytic and projection tool has to be, but it also simplifies the sheer complexity of the U.S. health system into a tractable form that can be understood and studied by diverse stakeholders. It is built on the methodology of systems dynamics modeling, using several hundred interacting elements and differential equations tied to ten national data bases and many key reference studies.

Population Health and the Physical Environment: Beyond Air and Water

By David A. Kindig, MD, PhD

The population health model that underpins the County Health Rankings and this blog group the factors that drive health outcomes into four categories:

• Health Behaviors

• Clinical Care

• Social and Economic Factors

• Physical Environment

While we have discussed many aspects of the first three, we have (so far) focused little attention on the Physical Environment. This is partly justified; our model attributes only 10% of the total factor score to this area. But there is also the sense that environmental issues  – which we all intrinsically recognize as affecting health and quality of life -- often seem a bit remote or beyond our control.

Unpacking the Triple Aim Model

By David A. Kindig, MD, PhD

Many thanks to those who offered some great blog ideas for 2011 – reader suggestions are always welcome. Jay Gold’s question about the Triple Aim caught my eye because it’s something I’ve been giving a lot of thought to recently: “How in your view does population health tie in with the other two elements (quality of care, cost-effectiveness) of Berwick's Triple Aim?”

This is a relevant and timely question, since the Triple Aim is getting much more attention since Don Berwick became the Administrator of the Center for Medicare and Medicaid Services. In a blog interview with John Whittington last fall, we explored the origins of Triple Aim within the Institute for Healthcare Improvement and their emerging regional strategy beyond individual health systems or plans.

I am a big fan of Triple Aim and have been privileged to present at several of their recent meetings. My appreciation for this work is based in the belief that IHI/Triple Aim is one of the leading forces in the U.S. to motivate healthcare systems to stretch beyond traditional clinical roles and work towards broad population health improvement. In fact, population health is prominently featured at the top of the Triple Aim triangle:

It’s great to see population health front and center in a model. But there’s a communication problem here that needs to be acknowledged: what does “population health” in the Triple Aim model actually represent?

My concern is that people looking at the Triple Aim model won’t necessarily know what to make of the “population health” leg of the triangle. As a result, they may focus on the other two more concrete goals of improving the experience of healthcare and reducing per capita costs of healthcare. In no way do I want to diminish the importance the model’s clinical goals, which may represent our best short-term strategy. However, the reality is that even major progress in these two areas over the next decade will not help us achieve our goals related to healthy life expectancy and disparity reduction.

To achieve our broad population health goals we need to understand and intervene across the whole spectrum of determinants, not just health care. Triple Aim leaders understand and appreciate this, but I’m not sure this is clearly communicated by the Triple Aim model so I’ve drafted an alternate view that combines the Triple Aim model with our model of population health.

As the figure shows, two of the legs of the Triple Aim stool relate only to a single determinant, healthcare. I’d like to see the population health part of the Triple Aim model more clearly defined to make it clear that population health outcomes (among populations or individuals) are influenced by multiple determinants, most of which are beyond health care (note the reddish boxes in the figure above).

I have discussed this constructive criticism openly with Triple Aim leaders and will continue to do so. They have a powerful brand which is serving us well in many regards. But when Berwick and others talk about “better health” as a shorthand for “population health” in the Triple Aim model, let’s be certain that everyone understands this means actions beyond just health care. Several Triple Aim sites have developed impressive population health agendas and are moving forward with broad and ambitious health goals. But I can’t help but wonder if a revamped model might enhance existing efforts and spur new dialogue and action in AND out of the health care system to improve health.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Are We Individually Responsible for Our Health Behavior Choices?

By David A. Kindig, MD, PhD

The answer is yes…and well, not really. This answer is often framed yes or no: either we have free-will,  “just say no” responsibility for our behaviors, or we have no responsibility because of the life situations we find ourselves in. Of course the truth is somewhere in between – but what is the balance between them? The answer has important policy implications, particularly with regard to informing investment priorities.

I’ve often noted (as in last week’s Child Health post) that currently available evidence is insufficient to effectively guide public and private policy makers’ investment decisions with regard to population health improvement. That said, we must recognize the cutting edge research being done in this area. For several decades, Paula Lantz and Jim House and colleagues at the University of Michigan have used a longitudinal database called the Americans’ Changing Lives Survey (ACLS) to explore answers to important questions using the most sophisticated social science methods available. The ACLS has tracked 3600 adults from 1986 to 2005, querying them 4 times over that period.

In their most recent paper (published in the May 2010 issue of Social Science and Medicine) they developed models to explore relationships among various factors (such as age, gender, ethnicity, education, income, smoking status, physical activity level, and many others) and risk of death. They were particularly interested in connections between income and behavior and wanted to determine if poor people have worse health because they have poor health behaviors – or if something else is going on.

Not surprisingly, the findings showed that people with lower incomes tended to have more unhealthy behaviors and people with higher incomes tended to have healthier behaviors. Regardless of income, smoking and low levels of physical activity were both associated with an increased risk of death. But more importantly for this blog, the findings revealed that unhealthy behaviors are far from the only reason low income populations are at increased risk of death. Independent of health-related behaviors and other control factors, the risk of death among those in the lowest income category was 76% greater than those in the highest income category (which was similar to the risk differential between smokers and nonsmokers). In addition, the independent effect of the lowest level of physical activity was nearly triple that of income and smoking.

The authors conclude with a call for health policy and clinical incentives to enhance income security, promote smoking cessation/prevention, and support physical activity. While these results do not tell us exactly what our population health investment strategy should be across behavioral and non-behavioral factors, they make clear that a balance is required. To improve population health, policy and programmatic resources are needed to help make the healthy choice the easy choice – not only with respect to health behaviors but for healthcare, employment, and education as well.

The concept of behavioral “choice” is often interpreted to mean individual choices independent of external (and often constraining) factors. Careful studies like this one provide evidence that keeps us from operating from such a simplistic perspective. To improve population health, we all need to make better health choices – but we also need to understand and remedy the economic and educational upstream factors which determine the extent to which this is possible.

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Can We Afford to Wait for Better Evidence on Improving Child Health?

By David A. Kindig, MD, PhD

I recently spent two days at a terrific small conference in Madison, sponsored by the Institute for Research on Poverty. The conference focused on Child Health and Well Being, with many leading thinkers and researchers on socioeconomic disparities in child health.  Researchers highlighted what we’re learning about the relationship among prenatal environmental factors, body system and brain development, and health outcomes over the life course. While I was extremely impressed with the meeting itself, I was quite frustrated by the lack of evidence regarding causal pathways and cost effectiveness of programs and policies. As a former pediatrician, many of these linkages seem...well...almost obvious. And they're gaining mainstream attention through popular media outlets. Time magazine recently ran a cover story on Annie Murphy Paul’s new book entitled Origins: How the Nine Months Before Birth Shape the Rest of Our Lives.

From a research perspective, these complicated relationships take enormous time and effort to untangle, and researchers venturing into the sphere of policy and practice is seldom encouraged or rewarded. We also can’t expect policy makers to invest resources and take political risks without sufficient evidence, especially in cases where there is a risk for potential harm. There are many examples where things we thought to be true were not, and people suffered. Remember that the first rule of medicine is “First Do No Harm.”

On the other hand, the reality is that many current policies emerge from political advocacy (often not even in the public interest) rather than on the strength of scientific evidence. Former Milbank President Dan Fox has noted that “policy is the sum of anecdote.” In the case of child and fetal health policy, failure to act on the best -- albeit imperfect -- evidence could potentially cause a great deal of harm. Public and private policy environments influencing maternal health, fetal development, and the first five years of life have substantial health and development ramifications over a lifetime. While we study and debate the causality and cost-effectiveness of our options over the next decade, the adult health of the 40 million children born in the United States during that time period will have already been determined. Investments in healthcare in middle and old age can only partly remedy poor health outcomes determined earlier, and often at great individual and social cost.

How can we remedy this?  Unfortunately, I don’t have any silver bullet answers. I’ve often lectured that if I were Czar, and if 25% of health care spending ($500 billion per year) is inappropriate or ineffective, I’d allocate $100 billion to covering the uninsured (we are now doing that), $100 billion to prevention and public health, and the remaining $300 billion to early childhood, prenatal, and K-12 education to have the most impact on later health. But at this point, nobody knows exactly what programs or policy packages are the most cost-effective to produce these results.

We of course need more research to figure this out – this was the point of my recent JAMA commentary with John Mullahy called Comparative Effectiveness – Of What? -- but not at the slow pace of the past several decades. An August New York Times article described the massive and coordinated public-private “moon-shot” approach in the last decade on Alzheimers research, which has led to many important recent discoveries in a challenging field. We should use a similar approach to understand what policy approaches are most cost-effective for improving the health of our children. Given the certain costs associated with inaction, we may, in the meantime, need to relax our policy investment standards somewhat. Such an approach is not without precedent. In the 1990s, while pharmaceutical researchers were working hard to develop HIV drug therapies, the seriousness of the disease resulted in conditional approval of some drugs pending more complete and relevant evidence.

We know enough right now to predict that doing nothing will result in poor adult health outcomes of babies being born today. Aside from the obvious moral dimensions, my main argument for expediency is pragmatic: the health and economic competitiveness of our nation over the next 50-100 years is at stake. Surely investing in maternal and early childhood health should be a priority. We should focus our research efforts on figuring out what approaches are most effective and waste no time in directing current investments based on the best available evidence.

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Can Community Health Workers Help Transform Healthcare and Community Health?

By Kirstin Q. Siemering, DrPH

In these last days of summer, Dave Kindig has quit town to go fishing. But out in the stream, his thoughts are still focused on improving population health. Lately we’ve been thinking about how to effectively bring attention to recent and relevant scientific publications in a way that’s interesting and appealing to people who aren’t necessarily academics. Your ideas and suggestions for how to do this are most welcome. Please send us an email or comment below and tell us what you think!

Speaking of literature, E. Lee Rosenthal and colleagues’ article Community Health Workers: Part of the Solution recently came across our desks. It appeared in the July issue of Health Affairs and brings attention to a topic that deserves attention in light of the recent achievements in healthcare reform. 

Those of you not very familiar with Community Health Workers (CHWs) should know that they are extremely diverse and therefore not so easily defined. While many have a role in healthcare delivery (such as in health education, case management, interpreting and patient advocates), they also engage in activities that broadly support community health (such as outreach, organizing, capacity building, and even research). CHWs are often recruited and hired on the basis of their relationships to and knowledge of underserved communities rather than their having specific health-related expertise or credentials.

One reason for the growing spotlight on CHWs is their potential to control costs while improving outcomes. CHWs are just one example of a larger trend towards decentralization that includes primary care providers doing specialty work in outpatient clinics, nurse practitioners based in retail clinics, and home-based diabetes self management.

But unlike most health professionals, CHWs have no universally accepted education or training program to formalize and legitimize their role. Training requirements vary from state to state and range from on-the-job training to very structured, state-supported credentialing programs.

The American Public Health Association’s position statement in support of CHWs points to research demonstrating CHWs’ effectiveness in improving healthcare access, quality, and outcomes. However, the wide range of CHW preparation, roles and activities makes evaluation of CHWs very difficult. We still have much to learn about their potential to improve the lives of underserved communities and to make public programs more effective.

The Patient Protection and Affordable Care Act of 2010 will add to our understanding by supporting the implementation and evaluation of CHW programs. Over $4 million is being made available in 2010 for Patient Navigator Outreach and Chronic Disease Prevention Demonstration projects (with additional annual allocations through 2014). Additional funds will likely be made available through other federal funding mechanisms, including Grants to Promote Positive Health Behaviors and Outcomes Community Transformation Grants.

The Health Affairs article noted above highlights the work of two states that have led the way on CHW policy issues. Both Massachusetts and Minnesota have implemented policies to facilitate utilization of CHWs (e.g., in Minnesota CHW services are reimbursable under Medicaid). CHW advocates have identified the following policy priorities: sustainable financing, workforce development resources, occupational regulation, and guidelines for common research and evaluation measures.

CHWs could turn out to be an important piece in solving our healthcare and community health puzzle. Time will tell, given sufficient resources to develop and test innovative and resourceful policy and practice approaches.

Kirstin Q. Siemering DrPH is a researcher with the University of Wisconsin Population Health Institute.

Expanding the Scope of Comparative Effectiveness Research

By David A. Kindig, MD, PhD

We were originally going to take a break from the blog this week, assuming that many readers would be on vacation. But I have decided instead to tell you about a new commentary I wrote with my colleague, John Mullahy. It appears in this week’s issue of the Journal of the American Medical Association and is titled “Comparative effectiveness—of what? Evaluating strategies to improve population health” (subscription required).

The commentary is a call to broaden and provide dedicated resources for broadening comparative effectiveness research (CER) to help us better understand the relationship between our social investments and population health improvement.

As most of you know, the goal of most CER is to learn about the effectiveness, benefits, and harms associated with healthcare treatments such as drugs, medical devices, and even health systems. Although the emphasis in CER is currently on healthcare, there is tremendous potential for this type of research to contribute to a much deeper understanding of the many factors that influence health, including health behaviors, social, economic, cultural, environmental, and genetic factors.

I have mentioned before our need for a better understanding of how to accurately translate investments into length and quality of life. But we also need a framework to guide our spending decisions that’s based on a solid understanding of the total cost, overall effectiveness, and cost effectiveness of our strategies. To get these things done will require expanding—and funding—a comparative effectiveness research portfolio that addresses not only clinical care but the many other determinants of health as well.

Check out the article and let us know if you agree or have strategies to suggest to accomplish this goal.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Do Advance Directives Have a Place in Population Health Improvement?

One of the things we’re trying to accomplish with this blog is to provide insight into the many factors that influence health status and outcomes. These include health behaviors, the social, economic, and physical environments and, of course, healthcare. This week we’re focusing on the quality and cost of healthcare at the end of life, and thinking specifically about how advance directives apply to population health. To shed some light on the topic, we interviewed the University of Michigan’s Dr. Maria Silveira about her April 1, 2010 New England Journal of Medicine article (subscription required) on Advance Directives and Outcomes of Surrogate Decision Making Before Death.

What are advance directives?

Advance directives usually document patients’ wishes for life-sustaining treatment in a living will, as well as their choice of a proxy decision-maker in a durable power of attorney for health care. Advance directives are sanctioned in all 50 states and can be completed for free without the aid of an attorney.

What was the motivation for doing this research?

My experience in palliative care didn't jibe with the growing belief, reinforced during the recent “death panel” debate, that advance directives are not necessary or useful.

What were the main findings of your study, and how did they differ from previous work? 

A 1994 study indicated that only 21% of all seriously ill hospitalized patients had an advance directive. Our research shows that currently almost 60% of elderly have one. 

Prior to our study, no one knew how many elderly adults might need others to make complex medical decisions on their behalf at the end of life. 30% of older adults need someone else to make decisions (i.e., they had lost decision-making capacity) about whether aggressive, limited, or comfort care should be provided at the end of life. Subjects who had living wills were more likely to want limited care (93%) or comfort care (96%) than all care possible (2%). We also found that among people who had prepared living wills and had also expressed a preference for or against all care possible, there was a strong agreement between their stated preference and the care they received.

Fisher and colleagues at Dartmouth assert that end of life expenditures are one category of spending that increase costs without increases in outcomes or quality of care. Is it possible that advance directives could save resources by respecting patient preferences about care?

Absolutely – there’s no worse way to waste money as a health system than on care that is unwanted. Still, I'm not sure that the advance directives are as important as the conversations that take place about future care. Certainly I believe that when physicians (especially primary care physicians) have these conversations, patients are less likely to be hospitalized and to receive unwanted care. That should translate into cost savings for the system, but most importantly, it prevents undue suffering upon patients and his/her families.

What are the policy implications of your study? 

Our results suggest that helping patients prepare for a time when they cannot speak for themselves is important and worthwhile—policymakers  and insurers should consider reimbursing physicians appropriately for this effort. Currently, advance care planning is an activity that goes unreimbursed for most physicians. 

About a year ago, Representative Earl Blumenhauer (Oregon) proposed enhancing Medicare and Medicaid coverage of advanced illness management services and requiring physicians to provide Medicare beneficiaries with information on advance directives. The proposed legislation never made it out of committee (due to the controversy surrounding "death panels"). However, the Patient Protection and Affordable Care Act (PPACA) actually does contain a couple of small but relevant end of life provisions, including a 3-year demonstration project that will explore cost and quality implications of combining curative treatment and hospice care. Representative Blumenhauer is spearheading another effort to revive legislation that would allow for reimbursement of physician time to help patients plan for the future.

 

How Much Can Expanded Community Health Centers Do?

By David A. Kindig, MD, PhD

Many readers of this blog will not know that I “came of age” professionally as a Social Pediatric resident at the Martin Luther King Jr. Office of Economic Opportunity (OEO) Health Center in the South Bronx in the early 1970s. With vision and funding these health centers provided innovative primary care using interdisciplinary health care teams. 

What some may not know (or may have forgotten) is that such centers also provided an array of broader services such as job training, legal advocacy, and school health. We didn’t speak of epidemiology and disparities back then, but we understood that community health depended on more than the availability of healthcare services (and on the health of those who did not access them). I also learned an important policy lesson: grants go away—and when they do, many of the innovative services go with them.

The new Patient Protection and Affordable Care Act (PPACA) calls for a significant expansion of federal community health centers and the National Health Service Corps. In his important June 3 New England Journal of Medicine commentary, Dr. Eli Adashi and colleagues describe the current role and reach of such centers, including the PPACA’s plan to increase the number of patients served (to 40 million annually) while adding 15,000 new primary care providers by 2015.

While applauding this initiative, the authors cite numerous challenges to such an expansion, including state Medicaid cutbacks, lack of capital and information technology infrastructure, governmental administrative issues, and the limited production pipeline of primary care providers.

Last week I reported on a recent meeting at the Federal Reserve which highlighted potential partnerships between Community Health Centers (CHCs) and Community Development Financial Institutions (which address low-income housing, economic development, and other social services such as early childhood education).

Adashi and colleagues briefly mention the CHC role in “a broad swath of needs for coordinated disease prevention and health maintenance.” However, the authors fall short of calling for the broad interventions that the OEO provided and paid for 40 years ago. It is worth noting that one of the authors, Dr. Jack Geiger, successfully ordered groceries from the OEO central pharmacy for his malnourished patients in the Mississippi Delta!

In the end, this tremendous push for expanded healthcare access may require a focused, concerted, all-hands-on-deck approach. But we should keep in mind what the OEO knew in the 1960s--that healthcare is only one determinant of health with no clear accountability for the rest.

Some CHCs continue to offer a broad spectrum of services. With the White House and the Office of Management and Budget championing “place-based” initiatives, perhaps some funds can be set aside for pilot programs. For these pilots, CHCs (defined not only as federally qualified health centers but also community-funded safety net clinics, faith-based clinics, family practice residency programs, rural health centers and free clinics) could lead the integration all health promoting investments. However, without a permanent funding stream, even successful pilots (such as OEO) can regress. If successful, perhaps long-term funding streams from Community Benefit or Accountable Care Organization (ACO) savings could be attempted.

It worked once, but was not sustained. Isn’t it worth another try?

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

In the Literature: Comparing States' School Health Policies

About once a month, MATCH Project staff review a wide variety of academic journals to identify recent articles having particular relevance to population health policy, research, and practice. University of Wisconsin Robert Wood Johnson Health and Society scholars and faculty recommend an article or two to feature on the blog.

We recently connected with Professor Marilyn Nanney at the University of Minnesota to learn more about her recent research that examines the relationship between state school nutrition and physical activity environments and youth obesity.

What prompted you to do this research?

Our research team set out to explore the effectiveness of school nutrition and activity policies. This study just scratches the surface of this complex question. The daunting scale of the current childhood obesity epidemic has put tremendous pressure on policy makers to take action based on limited--but best available—evidence. Policy decisions are being made on evidence that is less than we would accept for other health interventions like drug therapy, for example. Since the problem requires that we take action now (rather than waiting until we have all the answers), I agree with this approach. However, evaluating the effectiveness, including negative consequences, of policies is important to do, especially with limited resources. This study is one tiny step towards building that evidence.

What do you think is particularly interesting and/or novel about your approach?

First, we were economical. Instead of collecting new data, we found data that already existed (from the Centers for Disease Control and Prevention) that could help us answer our research questions. Second, we took a comprehensive approach to evaluating the school obesity prevention policy environment. We looked at school vending and physical education policies, infrastructure and system supports, and expert certification and training to create as broad a picture as possible of the policy environment. We went beyond many other studies, which have tended to focus on one or two components of the school environment, such as vending or fundraising policies.  

Briefly describe your findings. Did you encounter any unexpected obstacles?

Our main finding is that the “fattest” states have more state driven school nutrition policies. It seems that as the number of school policies mandated by the state increases, youth weight increases! Since it’s highly unlikely that nutrition policies make kids fatter, our interpretation is that the “fattest” states (like Tennessee, Arkansas, Mississippi) are responding to the problem by instituting more state-level nutrition policies. But we need a different kind of study to test this assumption. 

What are the implications of this work either for further research or for practice?

This study offers many opportunities to move forward with this line of research. First, we need a better understanding of the relationship between school policies and weight –especially over time.  Second, we need to bring the focus down from the 30,000 foot view (i.e., state policies and state youth obesity prevalence) to the more proximal view (i.e., the effect of school policies upon students attending those schools). Answering these two questions will bring us closer to evaluating policy effectiveness. However, since kids’ spend much of their time in out-of-school environments, a significant challenge still remains in teasing out the contribution of school policies upon weight. Do school food policies promote better food choices when kids are away from school--or not?

In the Literature: Media Messages and Menu Labeling

Each month, MATCH Project staff review a wide variety of academic journals to identify recent articles having particular relevance to population health policy, research, and practice. University of Wisconsin Robert Wood Johnson Health and Society scholars and faculty recommend one or two articles to feature on the blog. The complete set of articles is archived here.

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News Media Messages and Public Perceptions of the Social Determinants of Health

We connected with Sarah Gollust, PhD, to learn more about her recent research exploring the relationship between media message framing and public perceptions on the issue of type 2 diabetes. Dr. Gollust received her graduate training in health services organization and policy at the University of Michigan and is currently a Robert Wood Johnson Health and Society Scholar at the University of Pennsylvania.

Improving Population Health (IPH): What prompted you to do this research?  

SG: I was motivated after taking many courses in graduate school at the University of Michigan in which I learned about health inequalities and the social factors—such as the neighborhoods we live in, our income and education—that influence population health.  In every class, I found myself wondering what the general public would have to say about these matters if they knew more about them. Would they be surprised? Upset? Would they be motivated to do more to support public health policy?

I discovered that there was little research in the U.S. on public attitudes and beliefs about health inequalities or how the news media present these issues for the public. So I decided to conduct a study about how U.S. newspapers describe type 2 diabetes and the effects of communicating about the social determinants of diabetes on Americans’ opinions about public health policy. I chose to examine type 2 diabetes for two reasons: it is a leading cause of death in the United States, so developing policies to prevent the disease is critical; and its causes can be portrayed in multiple ways, including strong epidemiological evidence of the influence of social determinants.  

IPH: What were your main findings? 

SG: In the study, members of the public were randomly assigned to read online versions of hypothetical news articles about type 2 diabetes that differed only in how they described the causes of diabetes. One version stated that behavioral choices influence diabetes, one stated that genetic predispositions influence diabetes, one stated that societal factors like impoverished neighborhoods and access to food influence diabetes, and another used no language about the cause of diabetes.

We observed that Republicans and Democrats responded very differently when they read the same information about the social factors that influence diabetes. Compared to their policy opinions after reading the article without any language about the cause of diabetes, Republicans expressed less support for public health policies to prevent diabetes and Democrats expressed more support for these policies when they read the social determinants article. This “polarization” finding signaled to us that everyone has different values and beliefs about who is responsible for improving health, and that certain ways of discussing these issues will resonate more or less with people’s prior values.  

IPH: Did you encounter any unexpected obstacles?  

SG: The research itself went quite smoothly, but in discussing the results I’ve discovered that talking about politics can be very tricky. It is all too easy to lapse into using caricatures and stereotypes to portray the two sides of the political spectrum. Even a topic as seemingly politically neutral as diabetes touches deeply felt values and political beliefs, which is important to recognize.

Since I published this work during the extremely politically polarized Congressional debates over health care reform, it received more press coverage than it might otherwise have gotten, but I wanted to be especially cautious to not over-extend the lessons we can learn from this study to the politics of health policy in general.  

IPH: What are the implications of this work either for further research or for practice?  

SG: With that caution in mind, I do think this work offers implications for future research and practice. First, the study provides an illustration of a phenomenon well-documented in the fields of communication and political psychology, but that has not been a central concern in public health—the idea that political values strongly influence how people process and respond, both cognitively and emotionally, to messages in the media. In particular, this study, along with my other work, demonstrates the important role of beliefs about personal and social responsibility for health in shaping Americans’ opinions about health policy. 

Second, advocates, researchers, journalists, and policymakers who want to publicize the social determinants of health and not face resistance from subgroups of the population might consider acknowledging both the roles of individuals (i.e., healthy behavioral choices) and the roles of societal forces that constrain people’s choices. However, these communication strategies should be empirically tested and grounded in theory. 

Third, and related to this last point, more research is needed to investigate how the public responds to alternative ways of presenting and framing the social determinants of health and health inequalities, with particular attention to the influence of social and political values.

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Showing Calories on Menus Could Make a Difference

Christina Roberto and her colleagues at the Yale University Rudd Center for Food Policy and Obesity have been engaged in both research and advocacy around restaurant menu labeling. In this post, Ms. Roberto highlights her recent article explaining the rationale and evidence for menu labeling legislation and discusses the new health reform law's national menu labeling requirement.

Restaurant menu labeling is a public health intervention aimed at improving poor diet and decreasing obesity. It requires chain restaurants to provide nutrition information (usually only calories, but some places also require information about saturated fat, sodium, etc.) on menus and menu boards so that the information is visible at the point-of-purchase. Restaurants with 20 or more locations are required to provide this information as part of the 2010 Health Care Reform bill.

Menu labeling makes sense. It provides people with information that allows them to make informed decisions about their eating. In the past, people ate at restaurants infrequently, so the occasional splurge was okay. Given how frequently people eat out today, however, the need for nutrition information about restaurant food has become more important. When we eat out, we tend to eat food that is higher in calories, of poorer nutritional quality, and served in larger portions, which promotes overeating.

How effective is menu labeling? Findings have been mixed but promising. One study conducted by researchers at New York University examined the impact of calorie labels among low-income individuals and did not see much of an effect. However, a larger study conducted by the New York City Department of Health observed reductions in calories purchased at several chain restaurants. These two studies looked at different restaurants and groups of people over varying time frames, which might explain the disparate results. Another recent study found that the calorie content of purchases at Starbucks was reduced in cities with menu labels versus those without. 

A recent study we published in the American Journal of Public Health involved people we recruited from the New Haven community and randomly assigned to receive one of three menus. Some participants received a menu with calorie labels on it, some received a menu without calorie labels, and the last group received a menu with calorie labels and a label that read: “The average daily caloric intake for an adult is 2000 calories.” Participants then ordered and ate a meal for dinner. We found that people ordered and ate fewer calories when given calorie information, suggesting that providing such information can encourage healthier food choices. In addition, this effect was maximized when people were given a menu which included a statement about recommended daily calorie intake. While our study was lab-based, unlike the other studies described, we actually measured calories consumed and were able to demonstrate a cause and effect relationship between menu labels and reduced food intake.

The menu labeling provision in the healthcare reform law is quite strong. It requires calorie labeling on chain restaurant menus and menu boards as well as on drive-through menus and vending machines. There is also a requirement that a brief statement regarding daily caloric intake be included. In addition, restaurants must provide more comprehensive nutrition information in a brochure upon request.  While the restaurant industry initially opposed menu labeling (it sued New York City twice, both times unsuccessfully), the National Restaurant Association supports national standards for menu labeling for a number of reasons.

Chain restaurants that operate in many different cities and states do not want to pay the cost of compliance with different regulations for each jurisdiction. Since this law will preempt local governments from creating their own standards, it will create certainty and uniformity that is helpful to the industry. In addition, the law allows for the error that accompanies routine differences in portion sizes and menu items by requiring restaurants to provide caloric information about restaurant items that is accurate within a reasonable range. Labeling also only applies to standard menu items and does not pertain to special dishes. Given those conditions, we can hope that any remaining backlash will not affect the upcoming Federal Drug Administration rulemaking process.

Christina Roberto, MS, is a doctoral student at Yale Univerity pursuing a joint degree in Clinical Psychology and Public Health.