“The core value of public health remains its commitment to the health of populations.”[i] Health care costs are rising and chronic diseases continue to be the leading cause of death and disease, however, much of this burden is preventable. Research has evolved to identify that health outcomes are the products of multiple and overlapping determinants of health, including biological, social and environmental determinants. So how are those determinants addressed to improve health outcomes? Policy, systems, and environment change or PSE change as it’s known in the public health world, has shown to be an effective and necessary strategy to improve the health of all sectors in a community, including worksite, schools, and healthcare.
So what exactly is PSE change? While personal choice drives whether or not an individual engages in healthy behaviors, being healthy is not just about individual choice. PSE focuses on making the healthy choice the easy choice and is structured around “modifying the environment to make healthy choices practical and available to all community members. By changing laws and shaping physical landscapes, a big impact can be made with little time and resources. By changing policies, systems and/or environments, communities can help tackle health issues like obesity, diabetes, cancer and other chronic diseases.”[ii] Smoke-free tobacco policies, school nutrition programs, or healthy community design just some examples of PSE change approaches.
Policy change is an important component of PSE change that is becoming integral to improve population health, which are “interventions that create or amend laws, ordinances, resolutions, mandates, regulations, or rules.”[iii] Health in All Policies (HiAP) is a collaborative approach that “integrates health considerations into policymaking across sectors to improve the health of all communities and people.”[iv] This approach takes into account factors outside the health system and is strategy that can address the complex factors that influence health and equity, such as worksite environments, transportation options, or neighborhood safety. In addition, a HiAP approach ensures that decision-makers are informed about the healthy, equity, and sustainability consequences of various policy options during the policy development process.”[v]
Emerging trends in public health recognize the need to educate and prepare professionals in health and other fields to understand how their professional activities impact population health, including an understanding of systems thinking and health-across-all policies.[vi] In order to truly address the complex factors that affect health, innovative solutions, such as HiAP, a new policy paradigm, and structures that break down the siloed nature of government to advance collaboration.
Consider where you live, work, learn, and play…what policies are or are not in place that support or hinder your health? Worksite policies focused on smoke-free environments or nutrition and physical activity behaviors have shown to be effective interventions to reduce tobacco use, weight among employees, and overall healthcare costs. Does your worksite have policies in place to support a healthy environment?
How about where you live? Are there sidewalks and safe places to be active? Coordinated approaches shown to make physical activity easier and more accessible include policies that combine transportation systems and land use design to increase street connectivity, bicycle infrastructure, access to parks and access to local destinations.[vii] This approach takes policymaking to the local level, engaging city planning and transportation professionals. What if every new housing development built made sure that sidewalks are safe and accessible, people can walk to park and a grocery store with healthy foods, and people have the opportunity to be healthy right they live.
As a public health consultant, I have seen firsthand the benefit of policy to improve sun safety behaviors in children, worksite employees, and worksite administrators, as well as environment changes to support sun safe worksites and child care facilities. As a result of worksites and child care administrators recognizing the need to support healthy worksite and child care environments, each site now has a UV Protection Policy in place that encourages sun safety practices of staff and children, including wearing sun protective clothing, applying and re-applying sunscreen, and developing outdoor environments that support sun safe practices, such as shade structures. These are just some examples of how policy is an important strategy to improve the health of communities and all people.
State and local communities across the United States are engaging a HiAP approach, such as “the state of Vermont has established a cabinet level body for health in all policies when particularly target vulnerable populations or Boston’s Health in All Policies Task Force which brings together city agencies and community leaders to use health impact assessments to examine the impact of all decisions and policies on health.”[viii]
Research has identified the challenges with bringing health in all policies center the quality and quantity of evidence-based data, involving and convincing all stakeholders on the value of HiAP, given their differing points of view and different ways of understand the problem, as well as the latency of time between implementation of a policy and its effects in terms of health outcomes.[ix] After all it takes time to see shifts in health outcomes such as reductions in lung cancer or obesity rates, but prevention and HiAP do work.
Not sure where to start or what works? Leading public health organizations identified five key elements of Health in All Policies, including “1) promote health, equity, and sustainability, 2) support intersectoral collaboration, 3) benefit multiple partners, 4) engage stakeholders, and 5) create structural or process change. Addressing each element is important to garner support for an HiAP approach. The Community Guide, is leading source of evidence-based findings that highlight intervention approaches across a diverse range of topics and specific to groups, such as 24/7 smoke-free policies in schools shown to reduce and prevent tobacco use. In addition, resources and information is available from leading public health organizations, including the Centers for Disease Control and Prevention’s Health in All Policies and Health in All Policies Resource Center, or the Public Health Institute’s Health In All Policies guide for State and Local Governments.
[i] Association of Schools and Programs of Public Health. (2013, September 3). Public Health Trends and Redesigned Education. Blue Ribbon Public Health Employers’ Advisory Board: Summary of Interviews. Retrieved from https://s3.amazonaws.com/aspph-wp-production/app/uploads/2017/10/BlueRibbonPublicHealthEmployersAdvisoryBoard_Report_FINAL_09.06.13-SJC.pdf
[ii] American Planning Association’s Planning and Community Health Center. (2018). Policy, Systems, and Environmental Change Strategies, Plan 4 Health. Retrieved from http://plan4health.us/policy-systems-and-environmental-change-strategies/
[iii] National Association of County and City Officials. (2011, October). Healthy Communities, Healthy Behaviors: Using Policy, Systems, and Environmental Change to Combat Chronic Disease. Retrieved from http://archived.naccho.org/topics/HPDP/mcah/upload/issuebrief_pse_webfinal.pdf
[v] Rudolph, L., Caplan, J., Ben-Moshe, K., & Dillon, L. (2013). Health in All Policies: A Guide for State and Local Governments. Washington, DC and Oakland, CA: American Public Health Association and Public Health Institute.
[vi] Association of Schools and Programs of Public Health. (2015, March, 15). Population Health across All Professions Expert Panel Report. Retrieved from https://s3.amazonaws.com/aspph-wp-production/app/uploads/2015/02/PHaAP.pdf
[vii] Guide to Community Preventive Services. About The Community Guide. https://www.thecommunityguide.org/about/about-community-guide. Page last updated: October 19, 2017. Page accessed: February 21, 2018
[viii] American Public Health Association. (2018). Health in All Policies. Retrieved from https://www.apha.org/topics-and-issues/health-in-all-policies
[ix] Bert, F., Scaioli, G., Gualano, M., & Siliquini, R. (2015, February 1). How can we bring public health in all policies? Strategies for healthy societies. Journal of Public Health Research. 4:393, DOI: 10.4081/jphr.2015.393