For the Public's Health Revitalizing Law and Policy to Meet New Challenges (2011) / Chapter Skim
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4 Intersectoral Action on Health
4 Intersectoral Action on Health
Pages 73-110
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From page 73... ...
, exposure to a hazardous environment, or inadequate health care -- are themselves influenced by circumstances that are nominally outside the health domain, such as education, income, and the infrastructure and environment that exist in workplaces, schools, neighborhoods, and communities. In this chapter, the committee discusses the implications of the social determinants of health for the actions of various stakeholders, with a focus on non-health policies that affect population health (see Box 4-1 for a few examples)
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From page 74... ...
Research links social and economic features of neighborhoods "with mortality, general health status, disability, birth outcomes, chronic conditions, health behaviors and other risk factors for chronic disease, as well as with mental health, injuries, violence and other important health indicators" (Cubbin et al., 2008)
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From page 75... ...
Area-based or place-based conditions affect individuals and households throughout the neighborhood and community and are characteristics of a geographic area, such as a Census tract or block. Examples include ambient air pollution, crime rates, social cohesion, walkways and green space, the quality of local schools, health care facilities, access to healthful foods, the density of fastfood restaurants, marketing of tobacco and liquor, and access to affordable public transportation.
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From page 76... ...
Initiatives to promote jobs, corporate growth, transportation infrastructure, and community development are deliberated by officials, executives, and other decision-makers who often are unaware of or overlook the connection to health. School boards, educational agencies, and ballot initiatives determine funding for local schools and set policies that affect children's learning, educational attainment, physical activity, and diet.
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From page 77... ...
These include a rich evidence base that has demonstrated that the poor health outcomes in adulthood that is associated with disadvantage in childhood can be effectively prevented by policy interventions as varied as home health visiting programs, early stimulation in child care programs, and preschool settings (i.e., Early Head Start and Head Start) (Adler and Stewart, 2010; Braveman et al., 2010; Evans and Kim, 2010; Kawachi et al., 2010)
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From page 78... ...
The built environment is strongly linked with several types of health outcomes in the population (Bauman and Bull, 2007; Brownson et al., 2006; Communities Count, 2008; TRB and IOM, 2005)
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From page 79... ...
Too often, proponents of a policy overlook potential health benefits in making their case or in calculating the return on investment to argue the value proposition. Conversely, advocates of a policy do not always consider the potential 2 Originally denoted "Leadership in Energy and Environmental Design." 3 See, for example, Emerson et al.
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From page 80... ...
, and may present a risk for developing other poor health outcomes such as diabetes and heart disease -- requires synergistic changes in schools, workplaces, advertising, the food industry, restaurants, parks, public transportation, tax policy, and clinical care. A coordinated approach to this problem therefore requires policymakers in each of these sectors to consider their respective role in addressing obesity and how best to harmonize their efforts with other sectors.
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From page 81... ...
Health Care System: A Blueprint for Reform, as follows: National and local policies, programs, and funding allocations that support health -- not just health care -- must be realigned and prioritized in order to meaningfully improve population health. This process can be informed by examining the factors underlying the health status measure "life expectancy from birth" which incorporates the main causes of premature death.
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From page 82... ...
In February 2010, the governor of California issued Executive Order S-04-10, which authorized the California Strategic Growth Council (SGC) to establish a Health in All Policies Task Force as part of its larger mission to develop a sustainable economy for the state.
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From page 83... ...
These were based on a set of criteria, including population health impact, overlap with SGC objectives, availability of supportive evidence, ability to foster collaboration, equity impact, measurability, feasibility, and ability to transform state government culture (Health In All Policies Task Force, 2010a)
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From page 84... ...
HIAP: Some Findings from International Examples The pertinence of intersectoral policies to population health status was a key message of WHO conferences in the 1970s, 1980s, and 1990s. HIAP became a signature focus of the Finnish presidency of the European Union -- a significant fact because of Finland's North Karelia health promotion project, launched in 1972, which exemplified one of the early uses of a HIAP approach to address a major and pervasive health challenge.
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For example, researchers or decision-makers who are concerned about global climate change and its consequences for food, water, weather, and biodiversity may not consider health impacts as seriously or at all (McMichael et al., 2009)
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From page 86... ...
that are associated with poor population health outcomes. The first type of application for HIAP, that is, as an embodiment of the precautionary principle, is exemplified by California's Clean Air Act.
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In some cases this continuum of objectives is achieved through legislation, as illustrated earlier by the HIAP initiatives stipulated by Congress in the provisions of the Affordable Care Act and the Prevention Council, or through actions of the chief executive, as illustrated by the creation of the HIAP task force by California's governor. In other cases, the law invokes public health concerns as a basis for placing restrictions on commerce, transportation, and other domains outside the normal auspices of public health agencies.
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From page 88... ...
. Politics and political acceptability form an important backdrop to HIAP approaches, which seek to coordinate efforts to implement a policy.
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From page 89... ...
Thoughtful reflection on the statutory and professional responsibilities of governmental public health requires these organizations to communicate about data and evidence, and convene other sectors and stakeholders toward health-supporting policy action that extends beyond the historical arenas in which these institutions have worked. Apart from politics and philosophical questions, the fragmented structure of government is itself an obstacle to the HIAP approach.
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From page 90... ...
STRUCTURES TO SUPPORT COLLABORATION IN PROMOTING HEALTH IN ALL POLICIES In its purest form, the HIAP approach entails collaboration among multiple sectors, reaching beyond the government, to foster the conditions for good health. Public health agencies or, more broadly, government, cannot alone be effective in helping a community to address tobacco use, reduce obesity, redesign the built environment, produce jobs, and improve children's education.
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From page 91... ...
The question the committee seeks to answer in this section is how do legal, or more broadly, policy frameworks, inform the structures needed for effective multi-sector engagement on population health, where there are and where there are not statutory or funding relationships that serve as the natural bases for holding participants accountable? Despite the fact that an estimated half the overall public health expenditures are incurred by nongovernmental actors (see Mays et al., 2004)
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From page 92... ...
* Gov Public Health Other Gov Community Media Level C: Organizations Academia Medical Care Figure 4-2 broadside Employers/Business Level B: Microsystem (programs, interventions, evidence base on specific areas of population health)
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From page 93... ...
Level B refers to microsystems, which in the context of population health6 are programs, policies, and interventions that may be thought to refer to the points of contact or interactions between community groups, local businesses, others in the neighborhood, and their local public health agencies and allied entities. An example of microsystems is an interaction among a health department, a local medical care provider, community coalition, or local business concerning a particular health outcome.
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From page 94... ...
The organizations include the local public health agency, hospitals and other clinical-care entities, community organizations, schools, businesses, religious congregations, and many others that perform roles that influence health outcomes. Level D refers to the environment, which includes a variety of social, physical (both naturally occurring and constructed)
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From page 95... ...
. Some of the strongest examples are found in the work of the Task Force on Community Preventive Services and of the Cochrane Collaboration, both of which use the approach of systematic assessment of the effectiveness of certain laws and their enforcement on behaviors with health consequences.
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From page 96... ...
Health Impact Assessments "In the environmental field, new construction projects are required to file an environmental impact report. In the health field, there should be a similar health impact report that makes explicit what effect new social policies will have on population health and how negative results could be mitigated," wrote Schroeder and Hughes (2008, p.
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From page 97... ...
Although HIAP and HIAs are closely related concepts, the former refers to a broad approach to public policy and the latter to a decision-support tool that may be used in evaluating that approach. It has been asserted that the health consequences of policies can be predicted, and tools such as the health impact assessments and simulation modeling can be used to enable policymakers to foresee the outcomes of choosing different options (Burris et al., 2010; Kemm, 2006)
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From page 98... ...
requirements, or by the public health agency. There are several existing models for requiring and conducting assessments of health policy impact (see Box 4-3 for examples of tools available to support implementing health in all policies)
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From page 99... ...
Assessing the impact of public health laws requires careful measurement and analytic strategies that take these details into consideration. Also, the work of the Task Force on Community Preventive Services indicates that multiple, different, and ongoing interventions are sometimes necessary to achieve a substantial and sustained effect on health outcomes and health behaviors (this was the case with tobacco, as discussed in Chapter 3, and similarly multifaceted interventions are likely needed to address physical activity, high school graduation rates, and living wages)
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From page 100... ...
Although the committee accepts the principle that all population health interventions, including laws, should be based on the best evidence available, it notes that the policy context determines the level of acceptable uncertainty in the data. In particular, the risk of harm (economic or health-related)
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From page 101... ...
. Research on the comparative effectiveness and health impact of public health laws and policies could be conducted by documenting geographic variation and temporal change in population exposure to specific policy and legal interventions.
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economic activity is in the private sector, formal and informal policies adopted by business, foundations, and others have the potential to profoundly influence health. However, public health practitioners have limited knowledge of policy development and implementation in the nongovernmental sectors.
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From page 103... ...
Such a system would gather information on the geographic reach, scope, and timing of significant new laws and policies designed to promote health and prevent disease and disability at the population level. The surveillance system could include such health-related laws and policies adopted at federal, state, and local government levels, including laws that define regulatory and enforcement powers and duties for public health agencies and for other governmental entities.
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Preventing Chronic Disease Public Health Research, Practice, and Policy 7(5)
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American Journal of Public Health 100:S186-S196. Braveman, P., S
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2010. Building multi sectoral partnerships for population health and health equity.
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Health Impact Assessment Collaborative-San Francisco Bay Area.
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2006. Health impact assessment and health in all policies.
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American Journal Public Health:e1-e6, http://ajph.aphapublications.org/cgi/content/ abstract/AJPH.2010.300023v1 (May 12, 2011)
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2008. Menu Labeling as a Potential Strategy for Combating the Obesity Epidemic: A Health Impact Assessment (HIA)
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