Background on Environment & Policy
What are environment and policy strategies?
- Intervention strategies used to create healthy places and practices to support prevention, management and rehabilitation behaviors for heart disease and stroke (e.g., lifestyle changes to reduce weight or increase healthy behaviors, monitoring and taking medications to regulate blood pressure and cholesterol).
- Environmental strategies are designed to modify structures and physical surroundings in ways that improve individuals’access to resources and overall capacity to address heart disease and stroke in order to affect their own health or the health of those around them.
- Policy strategies are laws or regulations that are put in place to achieve a goal, including organizational policies or public policies at the local, state or national levels. Policies are an important way to focus on the social, economic and environmental factors that serve to stimulate or enable individual behaviors.
- Through effective planning, implementation and enforcement, environment and policy interventions can:
- increase access to resources and support for enhancing detection of the signs and symptoms of heart disease, heart attack and stroke;
- instill practices and provide places that promote behavior change to prevent heart disease and stroke (e.g., increasing physical activity and healthy eating, quitting smoking);
- minimize the impact of heart disease and stroke by providing resources and support for management and rehabilitation (e.g., monitoring and taking medications to regulate blood pressure or cholesterol);
- create places and policies to support individual or group education programs, provider education or support groups and networks; and
- change community norms related to preventing or managing heart disease and stroke.
How can I use environment and policy strategies in heart disease and stroke interventions? How are they different from primary, secondary and tertiary prevention efforts?
- The goal of environmental and policy changes and other health promotion strategies is to prevent and reduce risk factors in the entire population and in high risk groups. Examples of environmental changes are establishing walking trails or creating bicycle lanes along highways etc. The goal of primary prevention is to reduce CVD risk factors among people who do not have a diagnosis of CVD, but are susceptible to CVD. Examples are smoking cessation, increasing physical activity and increasing consumption of fruits and vegetables. The goal of secondary prevention is to decrease the duration and severity of CVD through early detection of cardiovascular disease in asymptomatic people who have developed biological changes due to CVD. Examples are high blood pressure and cholesterol detection and control. The goal of tertiary prevention is to prevent the reoccurrence of CVD events and reduce the complications of this disease among the population with a diagnosis of CVD. A systemic change of the health care delivery system such as the Time Critical Diagnosis (TCD) system is an example of tertiary prevention. The goal of the new TCD system in Missouri is to prevent disability and death through the early identification and treatment of individuals with ST Elevated MIs sand Ischemic Strokes.
- Environmental policy strategies are attractive because they have the potential to reach most or all community members and create community changes that last much longer than most other types of interventions. Changes in environments and policies are critical to creating broad-based changes in heart disease and stroke prevention and management.
What are some types of heart disease and stroke environmental policies? What are some specific examples?
- In general, environmental policy interventions includes policies that support environmental changes in public or private places (e.g., parks, worksites, public transit systems, grocery stores policies to modify individuals’ lifestyle patterns by increasing access to resources (e.g., medications, nutritional foods, physical activity facilities), policies to reduce barriers to prevention and management of heart disease and stroke (e.g., cost of resources and transportation), and environmental changes to increase access to places that support healthy eating and physical activity as well as restrict tobacco use. Examples include:
- Increased access to health care services: There are also interventions that seek to enhance access to care by integrating environments with health care delivery (e.g., providing blood pressure screening at barbershops or in grocery stores, offering enabling services such as transportation services to medical facilities for those in rural areas, funding mobile health services units).
- Provision of medical supplies: Some clinics and individuals may not have the access to medical supplies required for self-management or clinical assessment related to heart disease and stroke. Some interventions have provided low cost or free medications for blood pressure control or cholesterol (lipid) management. Pharmaceutical companies often have programs for low-income populations.
- Changes in access to healthy foods: There are many different ways that people have suggested improving access to healthy foods (see Nutrition environmental and policy interventions). Some of these interventions have focused specifically on heart disease and stroke prevention and management. Others have attempted to improve access to healthy options, including increasing access to low fat and low sodium foods at cafeterias, restaurants, vending machines, grocery stores, schools, worksites, and community and faith-based functions; modifying recipes and preparation techniques so that the food provided at these venues is more heart healthy (e.g., lower in fat and sodium); and developing farmers’ markets and community gardens.
- Changes in access to places to be physically active: There are many different ways that people have suggested improving access to physical activity (see Physical Activity environmental and policy interventions). For example, some interventions have developed walking trails or new parks and recreation facilities to increase access to places for youth and adults to be physically active; created policies to increase the amount of time spent in physical education classes in schools or work sites; or improved transportation environments to encourage physical activity (e.g., sidewalk infrastructure, bike lanes or bike racks on public transit).
- Reduction in access to tobacco products and policies to reduce tobacco use in public places. There are many different approaches to reducing access to tobacco products (See Tobacco environmental and policy interventions). Some interventions have been conducted to increase taxes or costs of tobacco in order to reduce sales of tobacco, enforce restrictions on tobacco sales to minors, or create no-smoking policies in schools, worksites, restaurants and public buildings.
What are health care policy interventions? What are some examples?
- Health care policy interventions includes policies that support systemic changes in the health care delivery system that prevent disabilities, unnecessary hospitalizations and premature deaths, enhances the quality of care and reduces costs.
- Examples include: 1) the Missouri TCD system is an example of a health care policy intervention; 2) Electronic Medical Records (EMRs) or Electronic Health Records (EHRs); 3) Disease Management Protocols/Guidelines; and 4) Clinical registries for stroke . These interventions have been developed to enhance tracking and monitoring of individuals with heart disease and stroke. In addition, protocols for care can provide cues to alert physicians to check certain individuals at risk and to engage in particular clinical practices (e.g., check blood pressure, cholesterol and overweight/obesity). I would reference the Disease Management Protocols or Guidelines are available from a number of sources including the American College of Cardiology, JNC -7 etc.
What should I consider when developing environment and policy strategies for my heart disease and stroke intervention?
- Changes to the environment may require promotional or programmatic activities in order to increase awareness of these new or improved resources in the community. Likewise, promotional or programmatic activities may be helpful in sustaining use of the facilities or resources in the community over time.
- Policies should be monitored during development to ensure that the final policy is similar to the policy that was introduced.
- An Implementation Plan should be developed including an Evaluation Plan. Implementation planning may require additional funding and resources.
- Broad-scale environment or policy interventions are often more effective in changing large-scale population behaviors as well as maintaining behavior change over time, but are far more complex and costly.
- In some cases, environment and policy strategies may differ depending upon the target population. Therefore, these strategies may be intended for an entire community or they can be targeted to meet the needs or interests of a particular group. For example, the strategy may be geared toward communities with few resources for healthy lifestyles (e.g., lack of access to parks and recreation, lack of access to grocery stores) or reducing barriers to healthy lifestyles (e.g., signage promoting tobacco use, easy access to fast food restaurants with few healthy choices). Alternately, these strategies can also be designed to affect language or cultural barriers for different communities (e.g., increasing cultural competence of health care providers).
- Intervention strategies such as group education interventions and campaigns and promotions are often used in conjunction with environment and policy interventions. These strategies can be used to provide information to vendors, restaurants, schools, worksites or other groups on the benefits of proper oral care habits, guidance to encourage and enforce the desired policies and communication to let others know about the environmental interventions and or polices (e.g., newspaper, radio, television ads).
With whom should I work to develop and implement environment and policy strategies in my heart disease and stroke intervention?
- In order to create policies and environments that support prevention and management of heart disease and stroke in your organization, you will need to work with management, administrators and other decision-makers in the organization to decide what policy and environmental strategies make sense for the organization (e.g., policies on insurance and flex-time, on-site showers and locker rooms, types of foods and beverages available in cafeterias or vending machines, bike racks, polices restricting tobacco use on company property).
- Within the state, you will need to discuss the proposed policy with your organization’s state-wide external advisory group or steering committee. Examples of state-wide partners include the Missouri Department of Health and Senior Services, Heart Disease and Stroke Prevention Program, American Heart and Stroke Association, University Extension etc.
- In addition, you will need to meet with the local public health agency representatives and other local advocacy or community-based organizations (e.g., educational institutions, clean air or environmental organizations, or community development agencies) to decide what can be implemented as well as policy- and decision-makers (e.g., local elected or appointed officials, local civic organizations) to develop, enforce and evaluate these policies and changes to the environment.
- It is also critical to work with individual businesses and local business coalitions that can facilitate the implementation of these interventions (e.g., pharmacies, restaurant and grocery store owners and managers, food manufacturers and producers, parks and recreation, transportation, urban planning).
- Consider working with experts in public policy, law, advocacy, law enforcement, community organizing, insurance or other partners to decide what changes can be made to improve the community as well as how these interventions can be promoted.