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You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010

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Tuesday, August 9, 2011

What is a Health Policy?

When my father was a teenager, the family decided it was time to get their first car.  Not only did they not have a car, but no one in the family had ever driven before.  It fell on my father to be the designated driver.  When he was handed the keys, he just got behind the wheel and taught himself to drive by trial and error.  He had no instruction, no formal public information about driving safety, and most people he knew were no help because they had never driven either.

Over the last 100  years there has been great progress in controlling deaths and injuries related to driving.

This progress is surely in part due to education to help youth learn to drive safely, and a lot of public education designed to help current drivers be mindful of safe driving practices.  However, we have not stopped there.  Since my father's early days of driving, a lot of policy solutions have been applied.

Traditionally, a lot of public health programming has been either informing the community about various health issues, such as what constitutes a healthy diet, or offering a service, such as a flu shot or a screening test.  Less often, public health and health promotion has tried to achieve its goals with policy solutions.  What I want to talk about in this posting is what is meant by a policy solution.  The emphasis placed on policy solutions to improve the public's health seems to be growing, so it is important to discuss what this really means and why it is important.  Complicating the discussion is the fact that there is no universal definition of the term.  We always have to clarify what people mean when they talk about health policy:  what is included, what is excluded, what do other people call the same thing?

Sometimes a policy is a way to enhance behavior change, to make the healthy choice easier.  This is sometimes called the "default" option.  In a generic sense, default is what will happen unless you take special steps to avoid it.  At one time auto companies were making automatic seat belts that would circle your waist to within inches of the buckling ratchet.  The idea was that this system made it easier to use a seat belt than to decline.  Using the seat belt became the default option.  This was brought about by a policy solution.  Automakers were incentivized by federal regulations and market forces to find ways to make it easier for people to use seat belts, and so they built them into the vehicles coming off the assembly line.  Another example is the tension between stairs versus elevators.  In most public buildings the elevator is the default option by virtue of its featured location, while those wanting to use the stairs have to look around or ask directions to find them.  What if we had a sweeping stairway located directly in front of a building's entrance, while you had to search around for an elevator?  The stairs would be a default option that more people would choose.  Default options are determined by policies.  Health promoters will sometimes label this type of policy solution an environmental strategy, because the changed circumstance or setting makes it more likely that healthful living is supported.

Other policy solutions have been to construct cars that better protect riders, and we've learned how to construct highways and roads that provide a safer driving experience.  These types of policies do not have a behavioral component, but simply promote health without any individual effort.  This is sometimes also called an environmental strategy, again meaning that we have changed something about circumstances that promotes health and safety.  Prohibiting public smoking is a policy solution that can also be called an environmental strategy because people are passively protected from exposure to tobacco smoke.  A non-policy solution to this same problem would be using education to persuade smokers to not smoke near nonsmokers.  Often we combine policy solutions with supportive education designed more toward behavior and decision making.  About ten years ago, policies were put in place requiring the posting of signs by cigarette vendors, notifying customers that it was illegal to sell cigarettes to minors.  This was an educational message brought about by a policy.

Some policies are government efforts with a requirement or mandate on individuals. State governments use highway policies that prohibit people from exceeding a posted rate of speed.  The speed laws compel people to obey, with a threatened penalty for noncompliance.

Some other types of policy solutions are instituted by organizations.  For example, some employers have the policy of rewarding employees for accumulating miles of walking or running.  This is a policy solution by virtue of creating a social circumstance that makes it more likely that people will exercise, above what could be expected if those same companies just relied on educational messages and communicated encouragement.

Part of the recent emphasis on health policy is because experience and evaluation show that education and communication alone, even when done according to best practice guidelines, often fall short of achieving desired health outcomes.   On the other hand, some segments of society have become very sensitive about policies that mandate or prohibit actions by individuals.  They see this as taking away personal freedom in an effort to build a "nanny state," which is seen as a futile effort to immunize the world against all threats to health.  Health promoters have to balance the use of best-practice policies with conflicting values in communities.  Unless a community is largely supportive of a policy solution, research evidence for effectiveness is irrelevant.  For this reason, policy solutions are more complex to apply because of the multi-step process of identifying effective policies, persuading policy decision-makers, and preparing the community.  With educational tools, we send out motivational messages and people take them or leave them.  More often than not they leave them, unless they are supported with simultaneous policy supports.

Next time I want to discuss the interaction of health policy with health disparities.



2 comments:

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