Public Policy and Global Health Trends

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Table of Contents

Policy Proposal
The Top-Down Approach to Policy Advocacy
The Bottom-up Approach to Policy Advocacy
Evaluating the Effectiveness of the two Approaches
References

Policy Proposal

Public Policy Issue

In health, public policy encompasses purposive decisions and actions intended to improve the outcomes of communities or populations. It is formulated to address emerging societal issues. Childhood obesity (BMI>30 kg/m²) is a pervasive public health problem that can be addressed through policy interventions. Its prevalence has tripled since the 1970s, and it affects an estimated 33% of American children (Centers for Disease Control and Prevention [CDC], 2018). An unhealthy diet and low physical activity are the main etiological factors of this multifactorial non-communicable condition. Integrated policy actions to reduce the sugar/calorie intake through food labeling and marketing restrictions could help curb this problem at the national, state, or community level.

Issue Selection

The writer selected childhood obesity as a public policy issue because of its profound physical and psychological effects on children nationally. It causes stigma, low self-esteem, financial burden, and higher cardiovascular risk (CDC, 2018). Additionally, obese or overweight children are likely to suffer from obesity and related comorbidities in the adult phase of a person, resulting in additional financial costs to society.

The financial burden is attributed to the high risk of developing type 2 diabetes and malignancies in obese children (CDC, 2018). Childhood obesity is considered a national epidemic; it affects 1 in 5 children and adolescents aged 6-19 years in 2014-2016 (CDC, 2018). Sugar-sweetened drinks and snacks are loaded with high calories that predispose children to obesity. A policy change to tackle modifiable risk factors that increase the intake of energy-dense beverages can yield significant per capita savings.

Issue Relevance

The high incidence rate of childhood obesity (one in every five youth) makes it an issue of significant relevance to the American public. In the US, the 2009-2010 data indicated that nearly 17% of the children and adolescents were at risk of morbid obesity with huge disparities among races and by socioeconomic status (Kristensen et al., 2014). Among the demographic groups, it was more prevalent in Hispanic children (21.2%) than in non-Hispanic youth (14%) (Kristensen et al., 2014). Moreover, overweight adolescents struggle with the condition into adulthood; hence, childhood is the appropriate period to control obesity. In this view, policymakers are mandated to develop policies with a broad reach to curb obesity/overweight in at-risk child populations.

The scale of the impact of childhood obesity justifies its prevention through public policies. Obese/overweight children often suffer from stigma and low self-esteem (Sahoo et al., 2015). They are also predisposed to poor health outcomes related to complications such as type 2 diabetes, cancer, and cardiovascular diseases that increase outpatient visits (Sahoo et al., 2015). Thus, the effects of obesity are associated with higher health care costs.

For these reasons, childhood obesity should be addressed through public policies to manage the financial burden of healthcare on American households. Federal or state legislation and related policy tools can be implemented to foster healthier lifestyles – diet and physical activity – in populations. They have a broader reach, and thus can promote public health and address risk factors in schools or at home, decreasing childhood obesity rates.

Financial Impact

Addressing childhood obesity can yield significant per capita financial savings to the economy. According to Finkelstein, Graham, and Malhotra (2014), “childhood obesity costs $19,000 per child” in lifetime medical costs (p. 858). Nationally, healthcare spending to manage this condition among obese/overweight children aged ten years is about $14 billion (Finkelstein et al., 2014). Thus, the financial impact of inaction is quite significant. Major medical savings can be made through policies that lower or defer the onset age of obesity.

The financial effect of this condition can be direct like hospitalization costs or indirect, for instance, absenteeism from work/school and reduced quality of life. The burden of childhood obesity on the US economy is about $14 billion in pharmacy costs, ED visits, and outpatient payments (Finkelstein et al., 2014). Further, one in three children remain obese in adulthood, and the estimated cost of managing adult obesity is over $150 billion (CDC, 2018). Therefore, a policy change to reduce sugar/calorie intake by children could yield substantial financial savings. Its positive impact over time will include lower childhood obesity rates, reduced expenditures on comorbidities, and efficient utilization of healthcare resources.

Personal Values

My personal and professional values are pertinent to the policy proposal. It espouses the instrumental value of responsibility, and, as a nurse, I feel obligated to alleviate health risks that contribute to childhood obesity.

I am passionate about this topic because our food environment is laden with unhealthy options that drive the obesity epidemic. My other core value is altruism. Helping families make healthy dietary choices can save children from the effects of childhood obesity. The policy is also predicated on nursing values, including the avoidance of suffering. Obese or overweight children are often victims of bullying and are predisposed to poor health outcomes that make life difficult. Addressing the factors that increase obesity risk is also consistent with my professional value of upholding human dignity. It will lead to lower BMI and high self-esteem in this population.

Ethical Principle or Theory

I believe that health a fundamental right to all citizens, including children. Being healthy and free of complications are indicators of a higher quality of life. Childhood obesity reduces the health and social outcomes of children, limiting their attainment of age-appropriate developmental milestones. A foundational principle underpinning this perspective is beneficence, which connotes an obligation to do good to the patient.

In my view, public policies ought to be formulated and implemented with the wellbeing of all citizens in mind. Reducing calorie/sugar intake both in school and at home are critical in the fight against childhood obesity and its consequences. It entails advocacy for the greater good since the aim is to alleviate poor health outcomes linked to comorbid disorders like type 2 diabetes, improve self-esteem, and reduce financial costs. My perspective is that acting with benevolence is a professional ethic that extends to the community. Consistent with the principle of beneficence, I believe that striving for high standards of health for populations (including children) is a core ethical imperative for nurses.

The Top-Down Approach to Policy Advocacy

Decision-Maker

The policy brief advocates for food labeling and restrictions on junk food commercials to tackle childhood obesity by reducing sugar/calorie intake. The appropriate decision-maker who will receive it is Doug Jones, the current Alabama senator. He is well-positioned to initiate a policy change in Congress.

Explanation

The proposed policy is essential as sugar-sweetened beverages (SSBs) constitute a significant component of children’s diets. SSBs have been associated with weight gain and an increase in obesity risk in children and adolescents (Keller & Torre, 2015). Therefore, reducing the amount of sugar/calories consumed will be critical in fighting childhood obesity. The policy requires the decision maker’s attention because Alabama has among the highest childhood obesity rates nationally. According to Ogden, Carroll, Kit, and Flegal (2014), 17.8% of Alabama’s children are overweight with a further 16.7% being obese.

Doug Jones will be interested in this policy to lower childhood obesity rates, contain healthcare costs, and prevent consequences like low self-esteem in children. Obesity is also a risk factor for chronic conditions such as type 2 diabetes and heart disease (CDC, 2016). The policy will address an existing inequality gap whereby minority and low socioeconomic status populations experience a higher burden of obesity than other groups in Alabama.

Challenges

Dealing with childhood obesity as a policy issue is likely to face some challenges. Sugar/calorie intake restriction through mandatory food labeling and controlling unhealthy food marketing to the youth could face political opposition because it may be considered an infringement on civil rights. The US is an open society that promotes free speech. Therefore, regulating the processed food industry may encounter criticism for infringing on this right and the freedom of choice. Rights activists and business actors may argue that the state is paternalistic.

A second challenge relates to the increased screen time of children. Robinson et al. (2018) found a relationship between more media exposure (television and computer screens) and childhood obesity due to “increased eating while viewing”, ads that feature high-calorie food, and less sleep time (p. 98). However, advancing a policy that may limit the extensive media advertising of SSBs may face stiff opposition from food companies.

Options/Interventions

The decision-maker has three primary options or interventions on receiving the policy brief. First, he can choose not to act and let the status quo prevail. However, this approach may not be the best option since current evidence links increased sugar/calorie intake to childhood obesity and a range of secondary comorbidities, including type 2 diabetes and cardiovascular diseases (Robinson et al., 2018). These conditions add to healthcare spending due to increased ED visits, prescription costs, and hospitalization. Therefore, the impact of inaction may be quite costly. Nevertheless, the lawmaker may ignore the policy proposal due to stiff political opposition. Corporate actors may oppose such an initiative because of its perceived detrimental impact on their economic interests.

The second option is that the decision-maker accepts the policy with slight changes. Instead of food labeling and marketing restrictions, the policymaker may implement an excise tax on SSBs to reduce consumption levels of sugar-sweetened drinks. However, this option is less tangible since there is no guarantee that costly SSBs would make the youth to opt for healthier alternatives. The third option for the lawmaker is supporting the policy as it is in Congress. Food labeling and the banning of SBB ads on television are likely to force food companies to improve the nutritional content of drinks. Additionally, the ban will provide an impetus for institutions to stock healthier food in cafeterias and vending machines.

Course of Action

Persuasive courses of action will be required to turn the policy proposal into a law. The public may not understand the risks of childhood obesity. The legislator can sponsor a bill requiring food labeling and banning SBB commercials targeting children in the Senate.

He will then invite the CDC obesity experts and other stakeholders to the Senate committee hearings to testify on the link between SBB ads and childhood obesity and create buy-in from the members. Addressing the challenges before the bill reaches the committee stage will be critical to its success. Critics may perceive the policy as an infringement on the freedom of choice. The decision-maker can avoid this challenge through public education in forums like town-hall meetings focusing on the dangers of SSBs. Another strong action to address the problem of increased screen time is social media campaigns to educate the public on the harmful effects of exposure to SBB commercials.

The Success of Policy Brief

A top-down approach involves evaluating decision-making from the highest authority downwards to its outcomes. The senator of Alabama is the decision-maker enlisted to assist with this process. The first success of this policy brief is that the lawmaker will sponsor a bill in Congress.

Further achievements will be realized when the proposal passes through the committee stage and Senate debates, and it is voted into a law banning SSB ads and requiring nutritional labels on all drinks. A long-term outcome of these measures includes reduced sugar/calorie intake by youths by 15% by 2020. Further, once the policy becomes law, it is expected that no SBBs will be stocked in cafeterias and vending machines. Instead, healthier alternatives, such as bottled water and fruit juices will be provided to children.

The Bottom-up Approach to Policy Advocacy

Identified Organization or Community

An endorsement of the childhood obesity issue from an organization would enhance the credibility of the workgroup. Walt Disney Company, a leading provider of children’s media content, may be interested in banning SBB ads and promoting nutritional labeling of food. The corporation can use its media resources to support the policy by conveying news of the ban. It can also intervene directly by requiring American food and beverage manufacturers such as Coca-Cola to market only healthier products through Disney channels.

Summary of Expressed Interest

Walt Disney has expressed interest in policies promoting healthy dietary habits in its young audience (children and adolescents). The corporation has already removed junk-food commercials from its TV and online programs for an audience aged below 12. It also launched its “Disney Check” label for food that meets its nutritional standards in grocery stores (Walt Disney World, 2018). For these reasons, collaborating with Disney is aligned with the proposed policy of marketing restrictions on SBBs and mandatory food labeling.

CBPR Principles

CBPR is critical in engaging the community to address a policy change for childhood obesity. The three CBPR principles that could be used are listed below.

Collaborative partnerships with community actors in the project from the start, including in formulating its objectives and design.
Building on community/local resources and strengths.
Co-learning and capacity development to empower community partners.

Approach and Collaboration

Approaching and collaborating with a big organization like Disney may be a difficult task if done without proper planning. Among the strategies I would use is teaching and creating awareness among key contacts in the corporation. The approach will entail regular meetings with Disney World Restaurants’ managers to gain buy-in and support for the policy. Community involvement in this bottom-up approach will require a coordinator who will promote the proposal among the members of the public. Grocery Manufacturers Association representatives will also be enlisted to develop the policy among industry players and encourage their participation in the process.

Goal Alignment

Walt Disney provides media content and restaurant services to children and families in the US and globally. Its philosophy of supporting healthy family lifestyles aligns with the proposed policy’s goal of reducing the calorie/sugar intake of children and adolescents. The organization has worked on the childhood obesity issue before. Food sold through the Disney World restaurants, its online channel (disneyworld.com), and Disney-licensed products in groceries bear the Disney Check label, an in-house marker of nutritional quality (Walt Disney World, 2018). Additionally, the organization has banned junk-food ads on its media networks for children (Walt Disney World, 2018). These actions are aligned with the ban on SBB ads and mandatory food labeling to curb childhood obesity.

Action Steps

Achieving the goal stated above will require our workgroup to gain adequate buy-in from stakeholders. In this regard, the following action steps will be taken:

Town-hall meetings with Walt Disney officials to educate them about the link between unhealthy food ads and childhood obesity.
A weekly online newsletter targeting consumers and parents to advocate for a policy change.
Forming a sub-committee of the workgroup to research on healthy sugar/calorie intake thresholds for children.
Collaborating with health centers to conduct community outreach programs that include patient education and screening.

Roles/Responsibilities

The goal of the policy is to reduce sugar/calorie consumption by children and adolescents. The workgroup will facilitate a change of policy to ban SBB ads on children’s media channels and introduce food labels indicating the calorie content of each product. The members of the selected group from Disney and other organizations supporting the proposal will play the following essential roles to realize the above goal:

Making consultations with Grocery Manufacturers Association (GMA) and industry players on calorie labeling guidelines for cafeterias and stores. The initial contact (an experienced GMA manager) who has worked with food makers will perform this role. Through the consultations, standards on calorie labeling – details about sugar/fat content, color codes, and presentation – will be developed to support a policy change. Thus, this function is a problem-solving role, i.e., it will address the challenge of calorie labeling standards to guide industry players.
Facilitation of bi-monthly town-hall meetings with Disney officials and media representatives to ensure strict restrictions on unhealthy food ads on digital platforms and the introduction of watershed periods on TV commercials. The MSN nurse leader will act as a facilitator of these meetings since she is experienced in patient education. A subject matter expert drawn from Disney will direct the public session. A report from the meetings will guide the development of restrictions on junk-food ads consistent with the policy’s goal of achieving SBB advert bans on children’s media. The facilitation of town-hall meetings is a problem-solving role since it entails brainstorming for watershed periods and standards for healthy food ads.
Organizing community outreach programs in collaboration with hospitals to educate consumers on nutrition and screen them for obesity, diabetes, and cardiovascular diseases. The RN is well-positioned to lead these initiatives. The RN’s function will enhance the awareness of the childhood obesity problem to create an impetus for a public policy change. This role is a capacity-building one.

Key Elements of Evaluation Plan

Our workgroup will apply the CBPR principles listed in section C2 in our work and to develop a collaborative evaluation plan. The first CBPR principle we selected to use is partnerships in all the stages of research. Our workgroup will utilize this standard in our project by involving the partners (families, Disney, and grocery stores) in the project from the start. It applies to the evaluation plan because member input is considered in the research priorities and design.

The second principle we will use is building community resources and strengths, including Disney’s media resources. We will utilize this tenet in the project by disseminating research findings to partners to support advocacy needs. It applies to the evaluation plan because of open communication (regular feedback) maintained will strengthen community assets to address childhood obesity. The third principle we will use co-learning and capacity-building efforts. We will utilize it to empower partners’ research and advocacy capacities. The principle applies to the evaluation plan because the empowerment of the members to solve their problems through research will begin at the start of the project.

Community/Organization Plan

A bottom-up approach enables a community or collaborating organization to give its views and participate in programs implemented in its locality in line with defined priorities and needs. Evaluating the action steps taken to achieve collaboration will indicate the success in meeting the goal mentioned above. The evaluation approach for each step is described below.

The town-hall meetings with Disney officials and the public will initially occur twice a month. The number of attendees and the frequency of the sessions will be indicators of the success of the project. Specifically, attracting over 800 people/supporters from the second gathering onwards or increasing the frequency of the meetings to once a week will be used in the evaluation.
Subscriptions to the free online newsletter will increase to 1,000 users within the first month. Referrals after the policy have been adopted will be an indicator of long-term success.
The sub-committee formed will report their findings on the legal calorie/sugar content in food and drinks sold to children. An indicator of long-term success will be reduced calorie/sugar in SBBs by 50% within six months.
The collaborative partnership with health centers is included to promote patient education on childhood obesity and its risk factors. The outreach programs should increase in number and be continued for over three years to indicate that the policy change has had long-term success.

Evaluating the Effectiveness of the two Approaches

Strengths of Each Approach

The top-down approach used in this paper involved enlisting a person of authority (Alabama Senator) to help with the policy change, i.e., banning SBB ads and introducing food labeling. One strength of this model is that the roles of the partners/participants are straightforward (Koontz & Newig, 2014). Consistent quality control is also possible when using the top-down approach since the decision-maker is one.

On the other hand, the strengths of the bottom-up model lie in its flexibility and collaboration component – it brings together multiple stakeholders (food manufacturers and Disney) and community members. It is also team-driven since different actors collaborate in the policy change process. In the proposal, the Grocery Manufacturers Association, Disney, and community members will work together in developing the calorie labeling standards and the watershed periods for SBB ads.

Challenges of Each Approach

The top-down approach has some weaknesses. First, the morale of the partners/participants may be affected since the decision-maker is one. Their opinion is only sought during public hearings at the committee stage. Second, the authority-directed leadership may not foster teamwork, increasing turnover or attrition of participants (Koontz & Newig, 2014). In contrast, the bottom-up approach requires that the project leadership alters the policy frequently to make headway. Additionally, the fact that the number of partners/participants is high may lead to high implementation costs. Consultations and meetings require significant resources and time. Thus, the bottom-up approach may be more costly than the top-down model of policy change.

Most Effective Approach

The top-down and bottom-up approaches provide a framework for policy change. While the first model involves formal policy directives originating from the decision-maker, the second approach begins with the people affected by the policy. I would recommend the bottom-up approach in developing a policy change for childhood obesity. The proposed ban on SSB ads and mandatory food labels would require working with the policy targets to achieve behavior change. Thus, collaborative partnerships are important not only in policy change but also in implementation. The bottom-up approach will ensure the inclusion of food manufacturers, media owners, and public health officials throughout the policy change process. In this regard, the model will encourage broad participation than a top-down approach.

References

Center for Disease Control and Prevention [CDC]. (2016). Alabama state nutrition, physical activity, and obesity profile. Web.

Center for Disease Control and Prevention [CDC]. (2018). Childhood obesity facts. Web.

Finkelstein, E. A., Graham, W. C. K., & Malhotra, R. (2014). Lifetime direct medical costs of childhood obesity. Pediatrics, 133(5), 854-862. Web.

Keller, A., & Torre, S. B. D. (2015). Sugar-sweetened beverages and obesity among children and adolescents: A review of systematic literature reviews. Childhood Obesity, 11(4), 338-346. Web.

Koontz, T. M., & Newig, J. (2014). From planning to implementation: Top-down and bottom-up approaches for collaborative watershed management. The Policy Studies Journal, 42(3), 416-442. Web.

Kristensen, A. H., Flottemesch, T. J., Maciosek, M. V., Jenson, J., Barclay, G., Ashe, M., … Brownson, R. C. (2014). Reducing childhood obesity through U.S. federal policy: A microsimulation analysis. American Journal of Preventive Medicine, 47(5), 604-612. Web.

Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association, 311(8), 806-814. Web.

Robinson, T. N., Banda, J. A., Hale, L., Lu, S. A., Fleming-Milici, F., Calvert, S. L., & Wartella, E. (2018). Screen media exposure and obesity in children and adolescents. Pediatrics, 140(2), 97-101. Web.

Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., & Bhadoria, A. S. (2015). Childhood obesity: Causes and consequences. Journal of Family Medicine and Primary Care, 4(2), 187-192. Web.

Walt Disney World. (2018). Restaurants – Frequently Asked Questions. Web.

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