Assigment 6 modules reflexion 2-3 pages.Apa seven . All instructions attached.

Module 5: Policy Innovations in Population Health

Slide 1: Policy Innovations in Population Health:

Welcome. Module 5 focuses on policy innovations in population health.

Slide 2: Acknowledgements:

As a reminder, this education module is made possible through a cooperative agreement between the Centers for Disease Control and Prevention and the Association for Prevention Teaching and Research.

I am Kristin Schneider from Rosalind Franklin University of Medicine and Science. I would like to acknowledge the other individuals and organizations who were instrumental in the creation of this training.

Slide 3: Population Health Modules:

This is the fifth module in this training series. After going over the objectives of this module, I will highlight how policy innovations in population health connect to the other modules you have completed.

Slide 4: Overall Learning Objective:

Together the 6 modules aim to provide foundational knowledge in population health science and best practices in population health, including the effective design, implementation, and evaluation of population health activities.

Slide 5: Objectives:

After completing this module, you will be able to:

1. Trace the recent trends in population health and the implications for policy.

2. Analyze the political and financial dimensions of policy formation and implementation with implications for public health professionals.

3. Explain the different governmental levels of population health policy formation and how public health’s role will differ depending on the policy level.

4. Apply interprofessional communication and coordination strategies to facilitate a ‘Health in All Policies’ approach.

Slide 6: Connection to Previous Modules:

Population health policies connect to content covered in previous modules in several ways. The social determinants of health discussed in module 1 need to be considered in policy development to ensure that policies can improve health for those who need assistance the most. For that reason, individuals and organizations from diverse communities have to be involved in the creation and evaluation of policies, to ensure that the policy will have the desired effect. Population health assessment and surveillance identify problems that could be addressed by policies. They might also provide insight into possible policy solutions to pursue.

Module 5 Transcript | 10

Lastly, population health interventions can provide evidence of possible solutions to problems that could inform the creation of policies to enhance or facilitate intervention implementation and sustainability.

Slide 7: What is a Policy?

Policy development is one aspect of public health practice and public health officials play a critical role in ensuring that policies will best serve their communities. Before we start diving into more content connected to this module’s objectives, I want to provide a broad definition of a policy. The CDC defines a policy as a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions. Population health is influenced by policies in a variety of sectors such as healthcare, transportation, education, and housing, to name a few. Ideally, policies are documented and written down in a way that is clear and accessible to everyone. However, that is not always the case. Policies are not always documented and having written documentation for a policy does not ensure that it is well- known and understood.

Slide 8: Objective 1:

Let’s begin with an examination of recent population health trends and the policy implications.

Slide 9: Three Significant Population Health Trends:

Over the last two decades there were three significant trends that influenced population health policy: the evolution of healthy people of the US department of health and human services, the signing of the patient protection and affordable care act by President Obama in 2010 and an increased focus on racial equity in policy development.

Slide 10: 1. Evolution of Healthy People:

The first major trend is the evolution of Healthy People. Healthy people refer to the US Dept of Health and Human Services identification of health objectives to be achieved during a 10-year period. The objectives are developed by national and state organizations, under the leadership of the US Surgeon General. In 1980, the first year of Healthy People, the objectives focused on national goals for reducing premature deaths and for preserving the independence of older adults. 10 years later, with Healthy People 2000, objectives connected to reducing health disparities are introduced, followed by objectives in Healthy People 2010 to eliminate health disparities. With healthy people 2010 there is a focus on enhancing quality of life, not just extending the lifespan. The focus on high quality of life and eliminating health disparities continues with Healthy people 2020, which also provides the first objectives connected to environments that promote health.

Slide 11: Healthy People 2030:

Many of the 2020 health people objectives and goals have continued in Healthy People 2030. The goals include a focus on attaining a high quality and disease-free life, elimination of health disparities, the creation of health promoting environments and health promotion across the lifespan. The focus on engaging leadership, constituents and the public to engage in policy

development is a unique aspect, which highlights the importance of collaboration among government, public health, industry partners, community organization and other relevant sectors.

Slide 12: 2. Patient Protection & Affordable Care Act (ACA) March 23, 2010:

The second significant health trend is the passing of the Patient Protection & Affordable Care Act or the ACA on March 23, 2010. The ACA represents the biggest federal health policy designed to transform healthcare in the last 45 years. It is an expansive piece of legislation that includes many components relevant to population health policy such as providing health insurance coverage to the uninsured. We’ll focus on one specific aspect of the Affordable Care Act: How the ACA established Accountable Care Organizations as a formal health care delivery arrangement as part of the Medicare Shared Savings Program. An Accountable Care Organization (ACO) is an integrated delivery system in which a group of health care professionals or organizations enters into a formal agreement with a payer such as Medicare to improve healthcare costs and quality, and patient health outcomes. The Medicare Shared Savings program rewards ACOs that lower their growth in health care costs while meeting performance standards on quality of care. These shared-savings arrangements require reaching specific quality and efficiency goals such as reducing emergency department visits or providing coordinated support to improve health. In doing so there is an emphasis on value- based care instead of the amount of care provided.

Slide 13: Public Health Can Work with Accountable Care Organizations (ACOs):

The creation of accountable care organizations provides a number of opportunities for public health to address population health. Public health agencies can connect accountable care organizations with relevant and diverse partners to address population health efforts. For example, a public health agency could partner with a ACO to conduct a community needs assessment to understand how the ACO could better serve their community. This would require connecting the ACO with a variety of partners such as community members, non-profit organizations, and local businesses. Public health agencies can also partner with ACOs to analyze population health data which can be used for population health assessment, surveillance and evaluation. Lastly, many public health departments provide healthcare services. As part of the ACO model, these public health departments can directly provide services to vulnerable populations and coordinate care with other ACOs.

Slide 14: 3. Increased Focus on Racial Equity:

The final trend is the increased focus on racial equity in population health policy.

As highlighted in the social determinants of health module, there are significant racial and ethnic disparities in health that are driven by institutional and structural racism. Throughout history, policies were developed that helped create and maintain racial disparities. The Homeowners Loan Corporation use of redlining provides an example of a policy that contributed to racial disparities. The Homeowners Load Corporation color categorized neighborhoods to indicate which neighborhoods provided the best home investment. The image on the right demonstrates how they did this. While green neighborhoods were

identified as the best investments, red neighborhoods were deemed bad investments. African American and Black residents typically resided in the red neighborhoods. Because their neighborhoods were labeled as poor investments by the Homeowners Load Corporation, African American and Black residents who wanted to buy homes in these neighborhoods were unable to get federal assistance with housing, which prevented them from accumulating wealth in the same way that white residents could who lived in the green and blue neighborhoods.

Slide 15: Policies Need to Address Structural Racism:

Historically, symptoms of health disparities were addressed with little success. There is growing acknowledgement that achieving racial equity will mean enacting policy changes that can address institutional and structural racism. On his first day in office, President Biden acknowledged the importance of considering equity in policies by signing an executive order that the Federal Government “should pursue a comprehensive approach to advancing equity for all, including people of color and others who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality.” Policies addressing equity require more than those spearheaded by the Federal Government. Broad collaboration across all levels of government and with public health, healthcare organizations, community agencies and community members are necessary for population health policies to address racial equity.

Slide 16: Objective 2:

The second objective of this module is to analyze the political and financial dimensions of policy formation and implementation that have implications for public health professionals.

Slide 17: Political Dimension: United States Culture:

The first political dimension to consider is the culture of the United States. Population health improvements require collective action by the population. The culture of the United States emphasizes individualism and personality responsibility, which can seemingly run counter to collective action. Population health policies can create concerns about governmental control and restrictions on liberty. How policies are structured and communicated can address this political aspect to increase the likelihood that legislative bodies and the public are in favor of the policy. Population health policies should be framed to highlight the right to self- determination, while promoting population health.

Slide 18: Political Dimension: Communication:

Communication is another political dimension. There are different ways of communicating population health priorities with policymakers: Non-partisan analysis, study and research; advocacy and lobbying. I will discuss each one.

Slide 19: 1. Non-partisan Analysis, Study and Research:

A Non-partisan Analysis, Study and Research refers to an independent and objective report of a particular topic. The nonpartisan analysis, study, or research may advocate a particular position or viewpoint based on facts that enable the public or an individual to form an independent

opinion or conclusion. The report should be widely distributed to the public to facilitate awareness of the position and invite commentary. Presenting an unsupported opinion does not qualify as nonpartisan analysis, study, or research.

Slide 20: 2. Advocacy:

Advocacy is a second type of public health communication. Advocacy refers to “The application of information and resources (including finances, effort, and votes) to effect systemic changes that shape the way people in a community live.” Health advocacy, which is particularly relevant to population health policy, can be defined as the processes by which the actions of individuals or groups attempt to bring about social and/or organization change on behalf of a particular health goal, program, interest, or population. Advocacy includes educating policymakers and the public about evidence-based policy. Advocacy can be informed by a non-partisan analysis, study and research.

Slide 21: 3. Lobbying:

The third way of communicating about policy is lobbying. Lobbying has a specific definition so that it can be readily identified. Lobbying refers to Communication with a Government official or employee who participates in forming legislation that Reflects a point of view about Specific legislation.

Slide 22: Types of Lobbying:

There are different types of lobbying. Direct lobbying refers to Communicating about specific legislation with a member or employee of a legislative body or a government official or employee who may participate in formulating legislation. Indirect or grassroots lobbying is defined as Attempting to affect the public’s views about specific legislation AND encouraging the public to take action on specific legislation.

Slide 23: Advocacy vs. Lobbying Examples:

It is helpful to understand the differences between advocacy and lobbying because unlike advocacy, federal funds cannot be used for lobbying. Here are some examples from NAACHO, the national association of county and city health officials that highlight the differences between advocacy and lobbying. You can advocate for Zika funding when meeting with a member of congress by educating them about the rationale for providing funding to your community, but if you urge that member to vote for a specific bill to provide Zika funding to your health department, you are lobbying. You can engage in advocacy by posting statistics about health conditions like diabetes and the efforts of health departments to reduce diabetes rates on social media. However, posting a specific message encouraging Congress to vote against legislation that would impact health departments diabetes prevention programs constitutes lobbying.

In the third example, advocacy can entail sending a weekly email with education on opioid use and treatment to your organization’s members. Sending an email to members encouraging them to contact their representatives and vote in favor of opioid use prevention legislation is an

example of lobbying. This is a type of grassroots lobbying. The first two examples would be considered direct lobbying.

Slide 24: Public Health Lobbying is Limited:

Lobbying is an important aspect of population health policy work, yet public health lobbying is quite limited in scope. Health care lobbying expenditures totaled $237 million in 2000. These healthcare lobbying expenditures accounted for 15% of all federal lobbying and were larger than the lobbying expenditures of every other sector, including agriculture, communications, and defense. As the figure illustrates, pharmaceutical and health product companies spent the most on lobbying; 41% of all lobbying expenditures, followed by physicians and other health professionals at 19%. Disease advocacy and public health organizations spent the least on lobbying. Only $12 million. Lobbying by pharmaceutical and health product companies has increased over time. In 2019, pharmaceutical and health product companies spent over $250 million on lobbying.

Slide 25: Financial Considerations:

Since public health cannot compete with corporations on federal lobbying, other financial considerations are critical to facilitating policies that improve population health. The financial costs of policy implementation and sustainability must be considered during policy development. How much will policy implementation cost? Once implemented, what cost savings are expected? How will the costs be covered in the short and long term? One of the most important policy levers that impacts population health is the budget. And this will vary depending on the level of the government. For the federal government, political will for taxes and deficit spending, as well as the procedures and rules of the congressional budget process can create constraints. Majority of states need to balance their budgets by the end of the fiscal year, which can constrain their ability to implement programs that increase expenditures.

Slide 26: Funding for Public Health:

Financial considerations can vary depending on where in the US reside. While there is broad consensus that federal funding on public health is inadequate, there is variability in how much individual states allocate federal and state dollars to public health. In the map, states with darker colors are spending less per person on public health. State funding decisions will inevitably impact local public health funding since the state will distribute dollars to communities throughout the state.

Slide 27: Local Public Health Spending May Be Particularly Important to Population Health:

The variability in state funding is concerning from a population health perspective because local public health spending may be particularly important to population health improvements.

Several studies suggest that greater spending by local public health departments may directly translate to better health outcomes, compared to spending at the state or federal level. In one study, increases in local public health department spending over a 13-year period resulted in significant reductions in infant mortality and mortality from cancer, cardiovascular disease and diabetes. For each 10 percent increase in spending, infant mortality and cardiovascular disease

mortality, fell by 6.9 percent and 3.2 percent, respectively. These results should not be too surprising. Local public health departments are going to be more familiar with their communities and better able to identify and develop policies and interventions that will best facilitate population health improvements.

Slide 28: Reflection Question #1:

Before moving on to objective 3, take a moment to consider how political and financial factors impacted the health of your community. Pause the video if you want more time to consider this question.

Slide 29: Reflection Question #1 – ANSWERS:

Consider some of the possible factors that can influence the community’s health. In terms of financial factors, if you live in a state that spends less on public health, then you likely will have less available resources for implementing public health interventions. Within a state there may be variability in access to public health interventions. States that chose to expand Medicare increased healthcare coverage for their residents. A potential political factor may be the politicization of healthcare issues. Some healthcare issues like vaccination and requiring healthcare insurance have become politicized. This may impact the public’s interest in and support of population health policies. These are just a sample of the ways in which political and financial factors can influence population health. When working on population health policy, it is helpful to understand what constraints may exist that impact the likelihood of a policy being implemented.

Slide 30: Objective 3:

Moving on to objective three. Explain the different governmental levels of population health policy formation and how public health’s role will differ depending on the policy level

Slide 31: Population Health Policy Should Focus on All Government Levels:

The lines between federal, state, and local government authorities to influence population health are frequently gray, often due to shared responsibility. Policy levers that affect population health most commonly are discussed in the federal and state contexts, but the policy opportunities that exist in counties and municipalities, should be considered since they can impact policies in local communities. As I just discussed local policies may have an impact on specific populations of interest and may be more impactful for certain population health issues.

Slide 32: Policy Efforts – Federal Level:

Let’s begin by discussing some of the population health policy efforts that can occur at the federal level. One of the most commonly identified ways is by assisting with the creation of laws. Laws are an important public health tool towards improving the population’s health, especially when laws address public health priorities. Through research, advocacy, and lobbying, public health workers can assist with the development of laws that improve population health. The development of policies, strategies and interventions can connect to

federal policy efforts since policies can include funding strategies and interventions with health connections such as supplemental nutrition programs or housing programs. Educating policy makes about the importance of using credible evidence to identify what laws and policies will be effective is critical to assisting with the creation of laws and policies. Once federal policies and laws are enacted, program evaluation is necessary to demonstrate the initial and sustained impact, which justifies continued support.

Slide 33: Policy Efforts – State Level:

At the state level population health policies can be advanced by:

Adopting public health laws and regulations within a state such as laws to make streets and neighborhoods safter using speed limits and seatbelt laws, and

Assisting with establishing fees for service and eligibility for Medicaid.

Working with the Governor and other state and local agencies to implement and enhance public health programs like community violence prevention program.

Collaborating with other partners such as universities, schools, hospitals, cancer societies, health care providers, and health insurers to develop and evaluate programs and policies.

Slide 34: Policy Efforts – County/municipality Level:

At the levels of county and municipal government, health officials leverage their knowledge of and experience with their communities to facilitate population health policies. Local officials typically have authority for community health and assessment, planning, and public health enforcement which they can use in a variety of ways such as: identifying the key factors that impact their communities’ health, assessing the communities’ needs and available resources, prioritize problems that will have the largest impact, and identifying evidence-informed policies that will work for their community.

Slide 35: Example: Mental Health Policy Implemented at Different Governmental Levels: Let’s go through an example of what these efforts can look like at each governmental level. We’ll use population health efforts focused on mental health. At the federal level, a good example is the passing of the Affordable Care Act which expanded insurance coverage of

mental health treatment to provide greater access to care. At the state level, the enforcement of parity law has largely fallen to the states. Parity in mental health treatment helps ensure that insurers provide equal access to physical and mental health treatments, which is critical to improving access to mental health care. At the county level, a county health center could provide mental health services to uninsured individuals to help fill any gaps in access to affordable mental health treatment. Finally, the municipality, based on their understanding of the local community and pertinent mental health needs, can prioritize implementation of evidence-informed mental health programs that improve outcomes like quality of life, disability and depressive symptoms.

Slide 36: CDC Policy Process: Highlight Public Health’s Role in the Process:

Now that you have a sense of how public health can influence different levels of government, let’s discuss the policy process. The CDC created a Policy Analytical Framework, represented in

the image on the left, that outlines 5 policy process steps: problem identification, policy analysis, strategy and policy development, policy enactment and policy implementation. This process includes economic considerations and provides a method for identifying and implementing policies that can improve health. In looking at the figure, notice how stakeholder engagement and education is located in the center, which highlights the necessity of stakeholder engagement throughout the process. Public health officials are often key to ensuring appropriate stakeholder engagement, particularly from underserved populations. The circle surrounding stakeholder indicates how evaluation occurs during every step of this process. For step, problem identification, the goal is to clearly identify the problem as specifically as possible. Problem identification will likely be informed by the population health assessment so that you understand the problem from multiple dimensions such as who it affects, how many people, how common is the problem and how severe it is. Specifically defining the problem is critical to identifying possible policy solutions.

Slide 37: Step 2: Policy Analysis:

Step 2 focuses on policy analysis. Based on the problem identified, you identify and describe relevant policy options. Public health workers help identify policy options through strategies such as literature reviews, surveying best practices and conducting an environmental scan to understand what how others addressed the problem. Ideally, you will identify a range of options that may present opposing viewpoints. For each identified policy option, you will describe it by its public health impact, feasibility and economic and budgetary impact. The CDC created Table 1 on the right to guide this process. The table provides framing questions to generally describe the option such as What level of government will implement and what is the value-added of the policy. For each criterion of public health impact, feasibility and economic and budget impact, there are specific questions to help guide the description.

Slide 38: Step 2: Policy Analysis:

The next part of policy analysis requires assessing the relevant policy options. Based on the questions you completed from Table 1, you rate the possible policy options using Table 2, which is listed here. This table helps provide a way of identifying strengths and weaknesses connected to each policy, which assists with the final part of step 3: prioritizing policy options based on the ratings. Evaluate each policy alternative against each other and prioritize the policy options that maximize the three criteria of public health impact, feasibility and economic and budgetary impact. Remember the importance of ensuring that you have key stakeholders from the community involved in the rating and prioritization process. Their views about what policies might be impactful or feasible may be very different than others who are less familiar with the community.

Slide 39: Step 3: Strategy and Policy Development:

During step 3 you develop a strategy for furthering adoption of the policy solution. Once a policy solution has been prioritized, the next step is to define a strategy for getting the policy enacted and implemented. This typically entails three main components. One, clarifying operational issues to identify what is necessary for policy implementation. Two, providing

relevant information to key stakeholders, beyond the ones that have been involved in the policy process. Different types of communication may be necessary depending on the audience to ensure you are broadly reaching key stakeholders. Three, more background work may be necessary to address low feasibility, insufficient evidence of health impact, or low support. If so, you may need to identify incremental policies or development of a research policy agenda to fulfill gaps before moving forward with policy enactment.

Slide 40: Step 4: Policy Enactment:

Step 4 is policy enactment Where you seek the official go ahead to move forward with a policy. There may be multiple internal and external procedures for getting a policy enacted or passed. This may be required because the policy is enactment at multiple levels like a healthcare system, city legislature, state and federal government.

Slide 41: Step 5: Policy Implementation:

The final step is implementing the identified policy or policies and evaluating the implementation of the policy. There may be steps you need to take to translate the policy into operational practice and define implementation standards. Simultaneously, you’ll want to coordinate resources and build personnel capacity to implement policy. These first two steps are key to the success of implementation. The translation of the policy and identification of resources will then guide the implementation of regulations, guidelines, recommendations, directives and organizational policies to ensure the policy is implemented as intended. Policy evaluation is an important aspect of policy implementation to ensure that the policy is implemented properly and it as the desired impact. Indicators and metrics need to be identified to facilitate policy evaluation. Those identified indicators and metrics are then used to assess implementation and ensure policy compliance. Any issues that interfere with implementation should be addressed to support post-implementation sustainability of policy. During this step it is particularly important to understand the extent to which the policy impacts the populations that are at greatest risk and whether they are deriving greater benefit. If those at greatest risk are not benefiting, the population health impact will be limited, and you may need to restart the policy process.

Slide 42: Objective 4:

The final objective of this module aims to enable you to Apply interprofessional coordination and communication strategies to facilitate a ‘Health in All Policies’ approach.

Slide 43: Health in All Policies (HiAP):

Let’s first discuss what is meant by Health in All Policies. Health in all Policies refers to a collaborative approach to considering health at all levels of policymaking to improve the populations’ health. Collaboration is expected across federal, state and local government, as well as across different sectors such as education, industry, healthcare, public health and community organizations. Essentially, HiAP postulates that to improve the populations’ health, any decisions that impact the community in areas such as transportation, education, or housing must consider health to ensure that the decision will facilitate disease prevention and health

promotion. A health in all policies approach is consistent with Healthy People 2030, which was discussed earlier, and the National Prevention Strategy represented in the figure. The overall goal of the National Prevention Strategy is represented in the center of the circle—to increase the number of Americans who are healthy at every life stage. Surrounding the circle are the four strategic directions necessary to focus on prevention: healthy and safe communities; clinical and community preventive services, empowered people and elimination of health disparities. The outermost circle reflects the seven priorities that are most likely to prevent disease and promote health and well-being: tobacco free living; preventing drug abuse and excessive alcohol use; health eating; active living, Mental and Emotional Well-Being, Reproductive and Sexual Health and Injury and Violence Free Living. The National Prevention Strategy aims to guide our nation in the most effective and achievable means for improving health and well-being. The strategy promotes a Health in All Policies approach to prevention by integrating recommendations and actions across multiple settings to improve health and save lives.

Slide 44: Key Elements of HiAP Practice:

The Association of State and Territorial Health Organizations has created a framework for facilitating a HiAP approach. The first component of the framework includes key elements of Health in All Policy Practice. First, HiAP is built on defining mutual goals, or “win-wins.” All partners must listen and engage one another to ensure that the policy will improve health and well-being. Typically, a HiAP approach will building upon existing partnerships or relationships; otherwise, it can take time to build the trust required for ensuring mutually beneficial goals.

Partnerships across sectors are another key. In population health, key sectors include the healthcare system and public health agencies, but other sectors may be involved depending on the policy goals. In addition to collaboration across pertinent sectors, key stakeholders from the community should participate to ensure that the policy will meet the community’s needs.

Stakeholders could include state, local, or federal agencies, community members, nonprofits, faith-based organizations, academic institutions, or businesses, depending on the policy goals and approach. Another key element is the potential opportunity for policy change.

Unfortunately, even effective policy solutions may not be implemented if the current problems, policies and politics are not aligned. With a HiAP approach, you will want to seek political windows of opportunity to facilitate policy implementation. Finally, consistent with a population health approach, HiAP practice should promote health and equity, such that they are integrated into all decisions. Evidence-based solutions and community-defined practices that encourage health, equity, and sustainability should be the desired goal.

Slide 45: Foundations of HiAP:

When pursuing a HiAP approach, there are key resources or foundations critical to success. On the previous slide, I mentioned how cross-sector collaborations and stakeholder engagement are key elements of HiAP. Having established relationships with policymakers, community groups, healthcare organizations, public health agencies help facilitate collaboration.

Community relationships can assist with cultivating public support, which may be integral to developing the political will for policies. Relationships with policymakers and federal agencies

may be required to advance policy initiatives. Informational resources include the evidence about the impacts of policies on the social determinants of health, state and local data about the extent to which there is a problem impacting the population’s health and quantitative tools to analyze the local health impacts. Information includes existing health promoting evidence- based policy alternatives that could be pursued. People are a key resource. Having a HiAP champion, spokesperson and leadership support ensure that the HiAP is implemented. Having a health-focused staff helps secure a commitment to the HiAP approach, while having staff with diverse skills and resources helps with managing all of the different tasks required for policy implementation. Funding can be a challenge. A combination of federal and private grants may be necessary to support HiAP efforts. State general funds can be used for HiAP efforts when the activities are consistent with current roles and activities. A final foundation, legal resources are critical to any policy initiatives since there may be laws that require considering health, at least in certain sectors. Understanding the legal aspects can be helpful in securing partners, political well and other relevant relationships.

Slide 46: HiAP Strategies:

There are a variety of strategies to assist state and territorial health agency in pursuing HiAP. The model organizes activities into informational, consultative, engaging, and collaborative strategies with the activities flowing from least to most collaborative. There are four main ways opportunities for impact and change can occur. Informational strategies support the sharing of information between partners to facilitate engagement, build relationships and provide education on health connections to policy. Information strategy examples include conducting trainings, providing resources and sharing information. Consultative strategies involve soliciting input from collaborators. Often one partner may be the one soliciting information rather than a bidirectional sharing of information. Engaging strategies support greater involvement by collaborators in the HiAP process and may encourage partner engagement in policy selection and implementation, though there typically is one group primarily responsible for overseeing the process. Finally, collaborative strategies incorporate shared partner involvement in all aspects of the health policy decision making. Workgroups or task forces that include members from all sectors may be created to ensure equal involvement in the process.

Slide 47: Goals for HiAP Practice: Identify Outcomes:

The final component of this framework is the expected outcomes from HiAP initiatives. Clearly defined and measurable outcomes are critical to evaluation and defining success. These are potential outcomes that partners should strive to achieve when implementing HiAP initiatives. Identifying specific short, intermediate, and long-term outcomes is ideal for evaluating progress over time. Examples of short-term goals include defining common goals, building staff and leadership capacity for HiAP, increasing understanding of the social determinants of health that impact the population the most and increasing engagement with stakeholders, community members and relevant sectors. Intermediate goals focus on building stakeholder capacity to promote healthy policy. During this stage, health should be considered more routinely in decisions. Policies or legislation may be implemented to support common health goals across sectors. Formal agreements may be created with other sectors to secure their commitment to

considering health routinely. The long-term goal of HiAP is to create sustainable structures and mechanisms among partners that support considering health in all policymaking and implementation. Sustainability, public support, and effective policies that improve population health are core aspects of achieving this long-term goal.

Slide 48: Example: Successful HiAP Implementation:

Let’s review an example of how health in all policies can be successfully implemented. ASHTO described how the Arizona Department of Health Services created the Childhood Lead Poisoning Prevention Program to conduct state-level lead poisoning prevention activities. The childhood lead poisoning prevention program consisted of a small team who provide education about lead poisoning, encourage blood testing in high-risk areas and support environmental sampling when a child has elevated blood lead levels. In 2018 a lead poisoning coalition was established which included partners from a variety of sectors such as county health departments and Arizona’s Medicaid agency, refugee resettlement programs, HeadStart programs, lead testing providers and tribal liaisons. This coalition helped facilitate increased collaboration within and outside of the coalition though use of an online community portal.

Increased collaboration provided opportunities to expand testing of blood lead levels. Partnerships with healthcare organizations enhanced provider education on blood lead screening, and partnerships with health departments and community organizations enhanced lead poisoning prevention outreach, especially to underserved communities. Collaboration and greater testing supported several initiatives that improved sharing of heath data and metrics.

Formal data sharing agreements were created between health departments and housing agencies to identify homes requiring lead inspections. Improved surveillance occurred via an electronic health record database of blood lead levels which triggered additional follow-up when necessary. Increased data sharing resulted in the creation of a lead risk map to identify high-risk areas for lead poisoning and encourage residents to complete lead exposure testing.

Slide 49: Communicating about HiAP: Key Aspects:

Communication is a critical aspect of Health in All Policies since good communication facilitates successful collaboration among partners and helps secure political will for Health in All Policies approaches. The first step is to define the target audience for the message so that the communication can be appropriately tailored. Communication with stakeholders likely will require different messaging than communication with the community. You also want to consider what you want to communicate to your target audience. Framing the environment is the next step. Earlier in this presentation I discussed that one of the political factors influencing policy work, it the United States cultural focus on individuality and personal responsibility.

While individual decisions certainly affect health, a Health in All Policies approach posits that the environments in which we live, work, and play matter for health too, and thus policy decisions that affect environments should consider health. Thus, communications need to counter the personal responsibility narrative by framing the environment and reminding the audience of the way the environment affects health. Framing the environment lays the groundwork for the next step: building on shared values. Finding shared values that connect to the policy helps ensure that the message will be well-received. You may need to spend time

identifying values that are addressed by the policy and are shared by your targeted audience. Common shared values often linked to Health in all Policy approaches include opportunity and equality. You may need to reach out to your partners to ensure that you understand your audience’s values to support crafting a message around shared value. The final step in communicating about policy is to state the solution clearly. Ensure that the solution is easily understood by your targeted audience and that you spend as much time communicating about the solution as you do on describing the problem.

Slide 50: HiAP Communication: Example:

Here is an example of how HiAP communication can look. Rudolph and colleagues provided this example for the American Public Health Association and Public Health Institute. This example about poorly maintained sidewalks begins by framing the environment and illustrating how the environment impacts health-safe sidewalks make it easier to engage in physical activity, which helps families be healthy. This first statement also references commonly shared values that may speak to the audience—prioritizing our families’ health. In the second section, the solution is clearly identified. Two agencies have to work together to identify solutions for fixing the sidewalks. Values connected to child safety, collaboration and equity are referenced in the solution description. Values can appear anywhere in a message to help garner support for the approach.

Slide 51: Reflection Question #2:

For reflection question number 2, consider What facilitates implementation of a Health in All Policies (HiAP) approach? You may want to think about what would facilitate a health in all policies approach for your community or with your organization.

Slide 52: Reflection Question #2 – ANSWERS:

Here are just some of the ways to facilitate a health in all policies approach. Relationships and collaboration are key. Strong partnerships between multiple sectors including public health, healthcare, government, nonprofits, faith-based organizations, education, industry to name a few are important. In part strong partnerships are going to be founded on mutual respect among partners. While there likely will be disagreements and conflicts, mutual respect helps address any conflicts that arise. For collaborators, a health in all policy approach focuses on shared goals. Agreement on goals is crucial to identifying policy solutions. Any approaches or solutions that are identified should be achievable to ensure that there is a path to implementation. Inability to implement a particular strategy or approach will foster frustration and could harm the partnership. Lastly, any approaches must address health inequities by considering social determinants of health.

Slide 53: Policy Resources:

You have completed the content presentation for module 5. There are some resources that I would like to highlight. A list of these resources and references are available for download from the training website. Here are specific policy resources to access that are relevant to policy at the federal, state, and local level.

Slide 54: Advocacy Resources:

Here are two terrific toolkits for more advocacy guidance.

Slide 55: Health in All Policies Resources:

And lastly, a number of resources to support a health in all policies approach.

Side 56: References:

I also want to acknowledge the references that were used to create this presentation.

Slide 57: References (part 2):

Again, a list can be downloaded from the training website.

Slide 58: References (part 3): Thank you for your attention.