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Structural interven-ons

David Jernigan, Ph.D.

“Saving lives millions at a -me”

How do we do this?

Structural interven-ons: examples

•  Water and sanita-on •  Housing •  Tobacco control •  Clean air •  Injury control •  Obesity •  Alcohol control •  HIV

Structural interven-ons: public health successes

•  Infant formula marke-ng code •  Smoke-‐free legisla-on •  Tobacco tax increases (Prop. 99 etc.) •  Reduc-ons in alcohol outlets •  Airbags in cars •  Limita-ons on handgun sales •  Dental care in Medicaid (“Molar Majority”) •  Withdrawal of dangerous products (Uptown, PowerMaster)

•  Removal of cigareUe and FLNV vending machines

The Frieden Pyramid •  Level five – counseling and educa-on

–  OZen viewed as the essence of public health –  Least effec-ve interven-ons

•  Need to do this is oZen symptoma-c of failure at level two

•  People don’t change behavior in response to knowledge –  Many failed aUempts

–  Brief advice in clinical se^ngs shows effect, but effect sizes small •  Smoking cessa-on •  Alcohol

–  Success story: HIV and MSMs

The Frieden Pyramid •  Level four – clinical – Evidence-‐based medicine can save and prolong life – Limited by: •  Lack of access

– Worse in countries without universal care (like the U.S.)

•  Erra-c or unpredictable adherence •  Imperfect effec-veness

The Frieden Pyramid •  Level three – long-‐las-ng protec-ve interven-ons (one-‐-me

or infrequent, individual-‐level but popula-on-‐wide) –  Immuniza-on –  Colonoscopy –  Smoking cessa-on

–  Male circumcision (HIV) –  Strong media campaigns

•  Downsides: –  Difficulty of reaching/securing agreement of many individuals

for individual ac-on

The Frieden Pyramid •  Level two – changing the context:

–  Clean air, water and food –  Iodine in salt –  Fluorida-on in water –  Reduced sodium in packaged foods

–  Designing communi-es to promote increased physical ac-vity –  Enac-ng policies that encourage public transit, bicycling, and walking instead of

driving

–  Designing buildings to promote stair use; –  Passing smoke-‐free laws

–  Taxing tobacco, alcohol, and unhealthy foods such as soda and other sugar-‐sweetened beverages.

•  Downsides: –  Poli-cally difficult to achieve –  Government interven-on/cultural imperialism

–  What will the “traffic” bear?

The Frieden Pyramid

•  Level one – socioeconomic factors: – Decrease inequality –  Reduce poverty (rela-ve and absolute) –  Increase educa-on –  Increase human rights – Downsides:

•  Risky behavior (tobacco, alcohol, unhealthy foods, driving) increases with development

– Upsides: •  Water, sanita-on, housing condi-ons etc. improve •  “Social injus-ce is killing people on a grand scale.”

Structural interven-ons: theore-cal basis

•  Ecological model: environmental (structural) factors are cri-cal determinants of individual behavior

•  Individuals also affect their environments

•  Structural interven-ons shiZ focus in public health to what enables individuals to affect our environments – Policy change – Structural change

Theore-cal basis: IOM 3 interven-ons

Structural interven-on: defini-on

•  Interven-ons that change condi-ons beyond individual control such as the social and physical environments (Cohen et al. 2000): neighborhood, worksite, community, etc.

•  I.e., factors that can change health behavior without being mediated by a change in individual beliefs, skills, a^tudes or knowledge

Community-‐level interven-ons

•  Individual •  Counseling or advice to get individuals to change their behavior, e.g. •  Use condoms •  Get a mammogram or HIV test

•  Lose weight •  Increase consump-on of fruits and vegetables

•  Structural •  Increase availability of condoms

•  Increase accessibility of mammograms by offering in mobile vans

•  Lower prices of fruits and vegetables

•  All these target condi-ons in the environment (i.e. price and availability)

Structural interven-ons: four categories

•  Availability/accessibility of consumer products –  Harmful: alcohol, tobacco, firearms, FLNVs –  Protec-ve: condoms, sterile needles, fruits & vegetables –  Availability/accessibility predicts consump-on (despite asser-ons to

the contrary…)

•  Physical structures (or physical characteris-cs of products) –  Protec-ve: well-‐lit streets, seat belts/airbags in cars, childproof

medicine containers –  Harmful: “broken windows” and crime

•  Cohen et al. 2000 (AJPH): Amount of abandoned or blighted housing, graffi-, abandoned cars, trash on street beUer predictor of gonorrhea rates than rates of poverty, unemployment or low educa-onal aUainment

Source: Cohen, Scribner & Farley 2000

Structural interven-ons: four categories (2)

•  Social structures •  Laws or policies that require or prohibit behaviors

•  Formal or informal enforcement

•  Changes in dynamics of situa-ons (reducing availability/accessibility of risky behaviors) •  E.g. youth risk behaviors

•  Increase aZer-‐school programs, midnight basketball

•  Improve teacher-‐student ra-os

•  Cultural and media messages •  E.g. Adver-sing/mandated counter-‐adver-sing

•  Why tobacco adver-sing on U.S. television ended

Axes and levels of structural interven-ons

•  Governmental •  Global •  Regional •  Na-onal •  State •  Local

•  Built environment •  Global •  Na-onal •  State •  Local •  Products •  Homes

Axes and levels of policy interven-ons

•  Governmental –  Global

•  World Trade Organiza-on –  Enforces 18 interna-onal trade agreements –  Disputes seUled by closed courts, with no conflict of interest rules, no outside appeal process

– WTO rulings can only be overturned by unanimous consensus (including the complainant na-on)

–  Health/environmental decisions have removed “precau-onary principle”

–  “…the trade and health debate outlined here suggests that health threats and opportuni-es for society will become increasingly globalized…When this next round of trade nego-a-ons is eventually launched, it is crucial that public health issues be given a higher profile in the delibera-ons.” -‐-‐ BeUcher, Yach and Guindon, 2000

Poten-al threats to alcohol policies from trade agreements

•  GATS (General Agreement on Trade in Services) – Ar-cle XVI:2(c) outlaws “limita-ons on the total number of service opera-ons” -‐ could undermine efforts to reduce outlet concentra-on

•  TBTs (technical barriers to trade) – Alcohol licensing restric-ons possibly threatened

11/2/10

Poten-al threats to alcohol policies from trade agreements

•  TRIMs (Trade-‐Related Investment Measures) –  Could affect restric-ons on alcohol sales in stadiums or restric-ons on exis-ng licenses since they may affect investors’ expected profits under contract

•  TRIPs (Trade Regula-on of Intellectual Property Agreement) –  Could affect restric-ons on alcohol adver-sing, in cases similar to Gerber’s successful campaign to force Guatemala to permit it to use its “Gerber baby” image on its products in that country by defining the image as intellectual property

11/2/10


•  Governmental –  Global

•  World Bank – Significant “health sector” – Prior to FCTC, passed ban on tobacco investments – Has similar policy discouraging alcohol investments

•  World Health Organiza-on – Governed by consensus among Member States – Framework Conven-on on Tobacco Control (FCTC) a significant watershed

– New global strategies just passed on harmful use of alcohol, NCDs


•  Governmental –  Regional •  European Union – Again, where do health issues fit in trade liberaliza-on?

– Widespread erosion of alcohol taxes

– Destruc-on of alcohol produc-on monopolies – “Race to the middle” in terms of other policies, e.g. adver-sing


•  Governmental

– Na-onal – state – local – Opportuni-es differ at each level – Possible to use change at one level to encourage change at another (fire-‐safe cigareUe)

– Pre-‐emp-on oZen an issue – Requires skills set oZen foreign to public health (e.g. legal exper-se)


•  Non-‐governmental

– Workplace safety –  Industry self-‐regula-on –  Insurance industry incen-ves – Professional peer groups (e.g. ABA) – Professional/clinical guidelines and best prac-ces

Case study: alcohol control •  Federal

•  Alcohol taxa-on •  Alcohol import/export •  Approval of new products, labels, adver-sing content •  Oversight of trade (FTC)

•  State •  Alcohol distribu-on

•  Three-‐-er system •  Control vs. license states •  Drinking age •  Service policies •  Taxa-on •  Adver-sing •  Hours and days of sale

•  Local •  Alcohol sales

•  Dry vs. wet coun-es •  Licensing/zoning •  Taxa-on •  Hours and days of sale

Case study: HIV

•  Coates (2004): 5 stages of HIV and public health •  Stage 1: Descrip-ve epidemiological inves-ga-ons determining prevalence and incidence of HIV and associated opportunis-c infec-ons, defining risk factors

•  Stage 2: Interven-on research inves-ga-ng safety, efficacy and acceptability of individual-‐level interven-ons

•  Conclusion: Interven-ons CAN produce reduc-ons in high-‐risk sexual and needle-‐sharing behaviors; measurement of such behaviors is reliable and valid

•  Stage 3: Large-‐scale clinical trials of promising candidate interven-ons from stage 2

•  Stage 4: Dissemina-on and inves-ga-on of ways to beUer implement research findings

Case study: HIV (2) •  Coates (2004): 5 stages of HIV and public health –  Stage 5: Policy and structural interven-on research

1.  Comprehensive vs. abs-nence-‐only sex educa-on

2.  Children and families affected by HIV

3.  Resource mobiliza-on and advocacy at the local level

4.  Empirical legal research –  E.g. what effect do laws regarding IDU treatment, counseling and

referral have on HIV transmission?

5.  Redressing gender dispari-es in educa-on and the workplace –  Oxfam: $5.6 billion annually could ensure basic educa-on for every

boy and girl in developing world; would reduce HIV infec-on in 15-‐24 year-‐old age group by 700,000 to 1 million annually

6.  Dispari-es in access to care and preven-on services in the U.S.

7.  Sharing the wealth: mobilizing the popula-on in developed countries to support services and research in developing countries

Advantages of policy interven-ons

 Do not rely on individual behavior change  Can become permanent features of the environment

 Have the poten-al to reach millions of people, without their having to do anything

 Can be inexpensive to implement

Drawbacks of policy interven-ons

•  Can be difficult to achieve

•  Can be difficult to fund, and take a long -me •  OZen controversial •  An--‐status quo •  An--‐liberal individualism •  Crude and blunt instruments – difficult to separate out subpopula-ons – What level of inconvenience is the majority willing to suffer to protect the health of the minority?

How policy change occurs

Types of organizing

•  Grassroots •  Grasstops •  Astroturf •  Coali-on-‐building •  Labor •  Issue organizing •  Electoral organizing

Tac-cs •  Rela-onship-‐building – At every level

•  BoycoUs •  Informa-onal pickets •  Public shaming •  LeUer-‐wri-ng campaigns •  Electoral campaigns –  “Candidate surveys” etc.

•  One-‐to-‐one “educa-on of policy makers”

Listening dyad

Stages of community organizing

•  Listen •  Rela-onships •  Challenge •  Ac-on •  Evalua-on •  Reflec-on •  Celebra-on •  Listen

What it takes

•  Set of skills not generally taught as part of public health training –  Strategic communica-on –  Organizing – both community and poli-cal –  Legal exper-se

•  Willingness to be controversial, engage in public debate •  Accuracy •  Persistence •  Focus •  Message discipline •  Organizing/rela-onship building •  Rapid response

Structural interven-on: what it takes (2)

•  Long-‐term perspec-ve •  Data important –  Informa-on on extent of the problem, including how it is distributed across the popula-on

– Non-‐tradi-onal “data” •  Public opinion polling •  Candidate surveys •  “Opposi-on research”

•  Clear goals and objec-ves

Structural interven-on: what it takes (3)

•  Comfort with controversy: –  “A successful advocacy campaign doesn’t make friends. It makes

enemies. It points a finger, names names, and starts a fight. It tells us who’s responsible and how to fight back. It tells us which side we’re on.” -‐ Public Media Center

•  Comfort with unpopularity (“majority of one”)

•  Flexible strategies and broad-‐based coali-ons •  Clarity about targets •  Policy goals that are specific, clear and aUainable •  Willingness to focus on less “sexy” issues of

implementa-on and enforcement

BoUom line

“…poli-cs is an essen-al part of an effec-ve public health.”

-‐-‐ McKinlay and Marceau, IJHS, 2000

Par-ng thoughts

“I've been absolutely terrified every moment of my life -‐ and I've never let it keep me from doing a single thing I wanted to do.”

-‐-‐ Georgia O’Keeffe

“Hope is like a road in the country; there was never a road, but when many people walk on it, the road comes into existence.”

-‐-‐ Lin Yu Tang

Par-ng thoughts

“Never doubt that a small group of thoughwul, commiUed ci-zens can change the world.”

-‐-‐ Margaret Mead

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