Impact of Multilevel Health Policy Change
Globalization has resulted in the transnationalization of production and finance, which has fostered interdependent geopolitical and economic relations.1 As economic changes impact social conditions (inequities, social status) and affect health outcomes, health policy has to be seen not only in a global context but also as operating at national and municipal/local levels. Globalization also has consequences for health systems, in that the market-oriented initiatives of developed countries, such as the World Trade Organization and General Agreement on Trade in Services, can displace the promotion of social welfare and equity.2 Therefore, the need for creative thinking and action by governments and stakeholders is evident at multiple levels and needs to embrace the dimensions of a diverse set of stakeholders at each level, taking account of, and influencing, environmental, regulatory, and institutional policies.
At the community level, for example, partnership models that include government agencies, nongovernmental organizations, professional bodies, communities, and the private sector are necessary. Such models require networks, alliances, and coalitions, including philanthropic and public-private partnerships, and the cross-fertilization of ideas to raise awareness and to develop, implement, and share an agreed-upon set of "best practices," taking into account resources such as infrastructure support, including research capacity. Policy development at the global level usually involves larger networks.
At the global level, there is a need for a formal coalition, including, for example, the World Bank, International Monetary Fund, and finance ministries, most likely coordinated by the World Health Organization (WHO), to define a global agenda related to diet and physical activity. This might be done by linking the agenda to, and learning from, existing initiatives, such as the WHO policy on tobacco control and the Countrywide Integrated Noncommunicable Diseases Intervention program3 or the Wellness in the Workplace Initiative of the World Economic Forum and the WHO.3 The coalition will also need to build appropriate systems and infrastructures. A population strategy tackling the major social, economic, and cultural determinants of cardiovascular disease (CVD) at a societal level is paramount4 and involves educating the public about good cardiovascular health, changing public policy to create heart-healthy environments, and persuading industries to reduce the manufacture/sale of unhealthy products.
We must take account of the needs of developing countries, which are particularly vulnerable to the negative health effects of economic globalization. Poor health contributes to poverty at the individual and societal levels through reduced productivity, particularly for lower-income countries. It may be possible to improve health equity by harnessing the growing capacity of these countries for health innovation through networks.5
At any level, social rather than purely technical solutions are probably required, working with key players to develop an interactive model of what works best, drawing on systems theory. There is a need for coordinated multilevel interventions (programs and policies) and multisector partnerships that are culturally relevant and context-specific. Approaches should consider safety, accessibility, availability, affordability, and sustainability and should emphasize the return on investment through enhanced productivity and health and economic gains. The impact of this health policy change needs to be determined at interpersonal, organizational, and community levels by a well-developed public health surveillance system.6 Finally, the consequences of inaction should be stressed.
Lifestyle habits such as poor diet and physical inactivity are major factors in the cost of health care as well as morbidity and mortality. Indeed, the leading causes of death are related to lifestyle.7 Policies initiated at the societal level can impact these lifestyle habits, for example, restriction on added sugar and sodium to the diet and easy access to venues that facilitate physical activity, which in turn improve health behaviors and quality of life. Improved health and quality of life, reduced health care costs, and reduced morbidity and mortality are the goals of prevention and thus should drive the health-related policies at the societal level. The cornerstone of prevention is a healthy lifestyle, which can be impacted by well-thought-out policies.
Traditionally, the multiple levels of adherence are considered as 3 major components and include the patient, the provider, and the health delivery system.8 However, the multiple determinants of adherence can vary by the level of prevention. In the context of primordial and primary prevention, it may be the individual and personal-related factors, for example, social and economic factors such as affordability or access to healthy foods and nearness to safe sites for exercising. The provider and health delivery system may have nonexistent or minor roles.
The framework that seems to best fit the societal level approach to prevention is the social-ecological model (also see section II), a conceptual framework that can be used to examine the multiple effects and interrelatedness of social elements in an environment.9 The social-ecological model posits that individuals' behaviors are influenced by their surroundings-physical, social, and cultural environments.10 This suggests that the greatest impact of a policy is made when it optimizes the environments where people spend their time, that is, homes, workplaces, schools, and the greater community. This approach makes healthier behaviors the norm and healthier choices and places individual behavior in the context of multiple-level influences. It creates a supportive community and facilitates adherence to lifestyle recommendations.
Although a healthy lifestyle is the centerpiece of CVD prevention, adherence to prevention guidelines is also one of the most challenging tasks facing the population today. In the United States, less than 50% of the population achieves the recommended level of physical activity. On a more global basis, it is estimated that physical inactivity causes 1.9 million deaths per year.11 A universal recommendation is for increased consumption of fruits and vegetables; however, this goal is far from being realized in industrialized nations such as the United States.12 Among those with existing chronic disorders, only 11% of individuals with diabetes are reported to follow the dietary recommendations for saturated fat.13 The global epidemic of overweight and obesity presents an added burden of increased CVD risk. Thus, these facts suggest that adherence to prevention strategies is seriously deficient and that strategies are needed at the societal level if we are to be successful in preventing CVD.
Despite the numerous studies focused on adherence and the voluminous body of literature on the topic, adherence has not improved much over recent decades. Many interventions are available; however, many are intense and not practicable for delivery in a clinical setting,14 and moreover, most interventions at the individual level cannot be sustained after contact is discontinued. Often the focus is on the patient, which can be helpful but is not sufficient to make a major impact in a multidimensional problem. Multicomponent and multilevel strategies are more likely to have a positive effect on adherence.15 An extensive review of evidence-based strategies to promote a healthy diet and physical activity was published in 2010.15 This article also emphasized that policies are needed to ensure an environment that will support preventive interventions, interventions that can be delivered in numerous settings and over sustained periods.
Multilevel Risk Factor-Specific Strategies and Resources for Increasing Adherence
The prevention model that is cited most often as a multilevel approach to risk reduction and to behavior change at the societal level is the tobacco control program implemented in several countries.16 If a similar program could be implemented in terms of diet-related issues, for example, sweetened beverages, calorie-dense foods, and large portion sizes, it might be possible to reduce the obesity and type 2 diabetes epidemics. Attempts are being made to work with the food industry to modify food products, and initiatives are under way to restrict the availability of sweetened beverages in school settings; legislation at the local level is requiring restaurants to label menu items with the nutrient content.17 New York City was the first city to introduce menu labeling and the restriction of trans-fat in foods. These programs are in their early stages, and so far, the results have been mixed. Other organizations, such as the Centers for Disease Control and Prevention and the American Heart Association, are addressing the content of salt in foods as a means to reduce the incidence of hypertension and the associated sequelae.
Similar to the eating-related behaviors that are being reinforced by the changing environment, the reduction in physical activity in many countries is related to a migration to an urban or suburban setting that often does not provide opportunities for physical activity.18-21 It is extremely challenging to engage in behavior changes recommended by a provider (eg, reduce weight or become physically active) in an obesogenic environment that does not support healthful behaviors. To address this problem, some communities are reengineering the city to foster physical activity, for example, building parks and adding sidewalks. These initiatives are providing an environment that will support behavior change at both the societal and individual levels. Other problems that are being addressed include limited access to healthy foods and lack of safe physical areas for walking in impoverished areas; cities are negotiating with grocers to locate grocery stores in these urban areas and also to improve sidewalks and lighting.
Providing Incentives for Healthy Behaviors
Rewarding innovative approaches that lead to health gains and penalizing those who continue with practices that impede progress have been advocated.22 Rewards and incentives can increase participation and successful outcome rates and help employees who are having difficulty deciding to make healthy choices.23 An important point to bear in mind is that the costs of most unhealthy activities have an impact in the future, whereas the benefits of change occur in the present.23 Targeted schemes of incentives include central government support via matching grants to commissioners who fund health promotion or disease prevention programs, matching grants to employers, direct payments to individuals engaged in health promotion or disease prevention, and taxes on unhealthy behaviors.24
The use of financial incentives by public agencies and private employers to encourage healthy behaviors has increased significantly. Some evidence suggests that financial incentives, even relatively small ones, can have a positive influence on health-related behaviors such as low-cholesterol diets and enhanced physical activity, but the effects may diminish over time.25 Also, most of the evidence for using financial incentives to encourage exercise and weight control was carried out in work settings and is therefore more relevant for private-sector employers. Few studies conducted in the public sector have included long-term follow-up and have compared "positive" and "negative" incentives.25
It seems sensible that any system of incentives or rewards should take account of consumer characteristics such as health literacy, income, and self-efficacy, while recognizing that rewards might not necessarily be purely financial. Psychological and social strategies, such as receiving positive feedback to boost morale, instill confidence, increase satisfaction, and enhance self-esteem, may also be effective. Many community-based programs include reinforcement for progress, such as programs that set goals for weight loss or distance walked.
Social support has been associated with a reduced risk of CVD.26 Available data clearly indicate that social relationships have potential for health-promoting and health-damaging effects in older adults and that there are biologically plausible pathways for these effects. Such evidence suggests that aspects of the social environment could play an important role in health promotion efforts for older adults, although careful consideration of both potentially positive as well as negative social influences is needed.27
Pay-for-performance programs instituted by health plans or by provider organizations in cooperation with health plans seem to produce improvement in selected quality measures, but the contribution of financial incentives to this improvement is unclear.28 Also, initial improvements in performance relative to quality measures may not necessarily reflect actual improvements in quality.28 Nevertheless, initiatives such as incentive-based online physical activity interventions result in smaller increases in health care costs for participants compared with those for nonparticipants.29 Consideration needs to be given to incentive strategies, types and amounts of rewards, and ethical and regulatory considerations. For example, holding employees accountable for their health behaviors, particularly through the use of penalties, may be perceived as violating individual liberties and discriminating against the unhealthy, and therefore ethical guidelines are necessary.30
Modifying Microenvironments to Increase Physical Activity
Urbanization has resulted in several environmental factors that may discourage participation in physical activity; these include population overcrowding, increased poverty, increased levels of crime, high density of traffic, low air quality, and absence of parks, sidewalks, and sports or recreational facilities.31 After adjusting for environmental factors, educational attainment is inversely directly associated with leisure-time physical activity.32
Many developed countries have initiated physical activity interventions at the national, state, and community levels. Countries that rapidly transitioned from an agricultural-based society to one that is highly mechanized are faced with the challenge of promoting healthy levels of physical activity and preventing the development of conditions associated with a sedentary lifestyle.33 However, often these countries do not have the resources to provide an environment that facilitates regular exercise. Societal efforts are needed to increase physical activity levels.34 One approach could include offering individuals exercise prescriptions or creating a walking or jogging track in local municipal parks.35 Whereas adults may respond to these types of interventions and feedback mechanism, children require different approaches. Providing playground markings or play equipment is not likely to increase activity levels during preschool recess; however, supervision that includes interaction with children and more structured physical activity seems to be needed.36
Commitment from powerful individuals in government is crucial, as it may drive the inclusion of physical activity promotion on the political agenda, particularly if the commitment is officially announced to the public. A network of relevant stakeholders (eg, ministries, private sector organizations, sports associations, schools, employers, parents, local community groups) is necessary for implementing physical activity interventions in specified settings (eg, school, community, workplace) and to disseminate intervention messages through relevant media (eg, television, radio, newspaper). Such networking and building of partnerships require shared values, mutual respect, and skillful articulation of arguments among stakeholders.33
National policies on physical activity should comprise multiple strategies that target supporting the individual and creating a supportive environment. A combination of different actions and programs is likely to be needed in different settings. The impact of physical activity interventions in developing countries needs to be better developed and examined through a systematic process and impact/outcome evaluation. To date, evaluation has been limited in developing countries.
Changes in the Food Supply and Population-Based Nutrition Education
Changes in diets and lifestyles that have occurred with industrialization, urbanization, economic development, and market globalization have accelerated in the past decade. These changes are having a significant impact on the health and nutritional status of populations, particularly in developing countries and in countries in transition. The pandemic of obesity and subsequent development of diabetes are of increasing concern; for example, in 2006, 1.6 billion people were overweight, and 400 million people were obese.
Several factors are contributing to the increasing prevalence of obesity, including the increased consumption of food through larger portion sizes, increased caloric density, and increased consumption of sweetened beverages.37 The structure of the diet has changed with a higher consumption of fat, sugars, and saturated fat and a reduced intake of complex carbohydrates, fiber, fruits, and vegetables. In the past 15 years, there has been an increase of 250 kcal per capita per day. Similarly, in the past 3 decades, the per capita fat intake per day has increased by 14 g in Eastern Europe and 31 g in the European community. In 2 of the most affluent regions (North America and Europe), the intake of saturated fat is at or greater than 10% of total energy intake. In other regions, the intake of saturated fat is lower, ranging from 5% to 8 %. Only in recent years has fish consumption increased to the recommended twice a week, and this is in only a few countries.38
Recommendations have been made to improve dietary habits and nutrition at the population level.39,40 The Mediterranean dietary pattern has been shown to improve CVD risk factors.41 As nutritional habits are influenced by several factors, nutritional education needs to start early and target the family.42,43 Each country needs to select the optimal mix of actions according to their populace, use of food products, and capability of the country and its laws and realities.38 The government can take a strong steering role in developing strategies and interventions for promoting a healthy diet, restricting the marketing of unhealthy foods, and promoting effective food labeling.38 Population subgroups need extra attention: children during the fast-growth periods of infancy and adolescence44 and families with a low income.38 Health care professionals also need to be better educated about nutrition and how to counsel patients about lifestyle changes. This has implications for the curriculum of schools educating health professionals.
Economic Incentives for Organizations, Businesses, and Individuals
Macroenvironmental factors include not only air and water pollution, sanitation, nutrition, physical activity, and hygiene, but also the built environment and level of urbanization and land-use patterns. Thus, urban planning and design and building features in the home, school, and workplace can impact accessibility to recreational activity facilities, which, in turn, impacts the physical activity of the citizens and, consequently, lifestyle patterns and risk factors such as weight gain.21 Political or legislative action may be required to modify recreational facilities and reduce population density and improve air quality. Legislation may be required to improve access to healthy foods and accurate labeling and to increase the numbers of foods with reduced salt, sugar, and saturated fats.45 Lobbying and working in partnership with the tobacco and food industry may be useful but are likely to be more effective if accompanied by incentives for organizations, businesses, or individuals. At the organizational level, this may mean providing resources or expert consultation to monitor health improvement. At the individual level, this may mean exploiting opportunities for structural change, such as ensuring that schoolchildren can conveniently access vendors who sell fruits and vegetables. In essence, these measures are about giving stakeholders something they want to obtain buy-in. When salutary change is sought and achieved at community and national levels, we will begin to see improvements in disease prevention and public health.
Summary and Conclusions
The focus of this section has been on the development of health-related policies that support the primary prevention of CVD. Creating an environment that is supportive of healthful lifestyle habits promotes adherence to population-based health recommendations, such as those outlined in Healthy People 201046 and the WHO goals.47 Increasingly more organizations are publishing health-oriented goals, for example, the American Heart Association.48 As noted previously, the social-ecological model focuses on the greater environment such as the diet and physical activity programs discussed in this section, for example, reducing sodium from the food supply.49 This approach can have a major impact on a large segment of the population. Moreover, it can lead to significant improvements in the population's cardiovascular health.
Although significant changes are occurring as a result of major initiatives to improve health at the societal level, a great deal remains to be done at multiple levels, which will only reinforce the sustainability of healthy lifestyle habits. At the level of health care delivery, reimbursement policies that support individual interventions to improve lifestyle will provide assistance to those who need more than what is provided in the community. At the community level, numerous stakeholders, from industry to health care professionals to citizens/patients, need to work together to promote legislative initiatives that will correct the obesogenic environment of today and modify it so that the default is healthy habits. An example of where more work needs to be done is the overwhelming amount of diet-related information that is presented to the public as well as the overwhelming array of food products that hype their healthful nutrients. Legislative initiatives could be undertaken to provide more helpful information that could guide the consumer in food choices, as well as initiatives to limit the use of certain food components.15 Similarly, initiatives need to be undertaken to improve the environment of communities and the workplace.
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