Meeting the Challenge: Using Policy to Improve Children’s Health

Abstract

We reflect on the proceedings of a symposium at a conference of the Centers for Disease Control and Prevention National Center on Birth Defects and Developmental Disabilities. We present examples of bridging the gap between science and policy to achieve improvements in children’s health through case studies in early hearing detection and intervention, folic acid fortification to prevent birth defects, sleep positioning recommendations to reduce infant mortality, and workplace lactation support programs.

We discuss case studies that present different policy strategies (public health law and voluntary practices) for improving public health. These case studies demonstrate both the power of policy as a tool for improving children’s health and the challenges of communicating public health research to policy decisionmakers.

ENSURING THAT CRITICAL public health research findings result in real benefit to the health of the public can be a challenge, and policy development is an important tool for ensuring that this translation occurs. In its 1988 report, The Future of Public Health,1 the Institute of Medicine confirms the importance of policy development, naming it, along with assessment and assurance, as 1 of the 3 core functions of public health. Policy development requires action by governmental agencies and the private sector,2 and public health professionals play an important role by conducting policy-relevant research, communicating findings in a manner that facilitates action, and encouraging the efficient use of resources through the promotion of evidence-based policies.1^–4 Policy development includes the advancement and implementation of public health law and voluntary practices that influence systems development, organizational change, and individual behavior. Simply put, public health policy results from any purposeful action by an entity—such as a government, company, or organization—to promote the health and welfare of its constituency.

Despite the important role of policy development in public health, numerous challenges limit the full use of these tools. The forces governing policy decisions are variable, uncertain, and complex. Although some argue that policy decisions are too often made in a way that contradicts available evidence, it is also true that policy decisions occur in a context governed by many factors, including those unrelated to science, such as values, precedent, and political will. Furthermore, policy decisions are often made in response to a perceived crisis, or to the concerns of vocal or powerful advocacy groups, and, as such, can result more from compromise and influence than from comprehensive assessment or objectivity.1^–3 Finally, evidence-based findings are not available to support every important policy decision.4 Even when available, evidence-based findings are often couched in terms of relative uncertainties or as part of inconclusive, ongoing scientific discourse.5 Even when decisionmakers look to the scientific community for answers, in the absence of clear, evidence-based solutions, they will be inclined to seek other answers.6

Public health professionals have a role in creating sound public policies. It is essential that public health professionals not only be familiar with the process and context of policymaking, but that they also engage with decisionmakers in developing strategies for using this process to improve the health of the public. However, such engagements present well-documented challenges for public health professionals, particularly in creating meaningful communication with policymakers.1^–3

In summarizing a symposium presented at the second conference of the Centers for Disease Control and Prevention’s (CDC’s) National Center on Birth Defects and Developmental Disabilities in July 2004,7 we present examples of bridging the gap between science and policy development to achieve improvements in children’s health. We introduce 4 case studies presenting different perspectives on both public health law and voluntary practices as policy tools for improving the health of the public. The case studies describe the role and impact of state and federal legislation in promoting early hearing detection and intervention (EHDI) programs and in implementing food fortification to prevent birth defects, the development of voluntary sleep positioning recommendations in the prevention of sudden infant death syndrome (SIDS), and workplace lactation support programs as a strategy to encourage voluntary wellness practices in the private sector (Figure 1 ▶).

FIGURE 1—

Policies as tools for improving children’s health.

^aEmployers constitute both decisionmakers and implementers.

PUBLIC HEALTH LAW AS A POLICY TOOL

In considering public health law as a tool for achieving public health goals, Congressional action most readily comes to mind, often to the exclusion of other important tools, such as regulation and state legislation. Certainly, federal public health law does have a role in public health policymaking, albeit inherently affected by politics and timing. The Children’s Health Act of 20008 solidified a federal response to persistent and emerging threats to children’s health by creating the National Center on Birth Defects and Developmental Disabilities at CDC. The act also authorized specific scientific studies on childhood disorders and authorized or reauthorized federal service delivery and research programs on a wide range of children’s health issues, including autism, fragile X, folic acid, childhood diabetes, asthma, newborn screening, hearing loss, oral health, lead poisoning, muscular dystrophy, Tourette syndrome, child care safety, adoption, and many others. Although federal legislation can have a far-reaching impact, public health professionals should also attend to state legislation, which establishes the details of many public health programs. The following case study explores the impact of state legislation on newborn hearing screening.

Case Study on State Legislation

Infant hearing loss is one of the most common birth defects, affecting 1 to 3 per 1000 live births.9^,10 Before newborn screening programs were widely implemented, the average age that hearing loss was detected was 1.5 to 3 years.10^–12 Studies have shown that children with a delayed diagnosis of hearing loss can suffer delays in speech, language, and cognitive development.13^–15 In response, a majority of states have established universal newborn hearing screening (UNHS) programs to identify infants and children with hearing loss. These programs are also referred to as EHDI programs and are based on the following three goals: screening all infants before 1 month of age, ensuring audiologic evaluation before 3 months of age for those who do not pass the screening, and enrolling those identified with hearing loss in early intervention services before 6 months of age. Collectively, these goals are known as the 1-3-6 plan, and, if followed, this plan has been linked to normal language development among children with congenital hearing loss.16

The practice of UNHS has been endorsed by professional organizations, including those at the National Institutes of Health Consensus Conference in 1993,17 the Joint Committee on Infant Hearing in 1997,18 and the American Academy of Pediatrics (AAP) in 1999.19 Although hearing screening is not mandated by federal law, provisions of the Children’s Health Act of 20008 authorized federal programs to support UNHS activities at the state level. To additionally emphasize the importance of UNHS and appropriate follow-up, the goals of the 1-3-6 plan were incorporated into Healthy People 2010, the nation’s health goals.20

As of 2003 UNHS-related legislation has been enacted by 37 states. The first states to pass UNHS legislation, Hawaii and Rhode Island, mandated that all infants be screened for hearing loss and helped establish the first EHDI programs in the United States. Although legislative requirements vary, 18 additional states had enacted some form of UNHS legislation by 2000 and another 17 by 2003. Currently, 13 states have not implemented such legislation.

Although the majority of states have legislation pertaining to UNHS, screening requirements vary by state. Twenty-three of the thirty-seven states with legislation require all babies to be screened for hearing loss. Of the remaining 14, some states require a certain percentage of newborns be screened (e.g., 85%) or limit screening to hospitals or counties with a certain birth size (i.e., more than 100 annual births) or population (i.e., more than 50 000 residents), and 3 states with UNHS legislation recommend hearing screening rather than require it.

To determine the independent contribution of legislation to attaining program goals, the CDC is evaluating the effectiveness of such legislation by examining screening differences among states. Preliminary analysis of data from the Directors of Speech and Hearing Programs in State Health and Welfare Agencies indicates that states with UNHS legislation may report higher newborn screening rates than states without legislation.

Hearing loss is a common birth defect, and legislation at the state and federal levels has played an important role in mitigating this condition in the United States. In addition to UNHS legislation, the work of dedicated state EHDI programs and the collaborative relationships among key stakeholders helps ensure that the goals of the 1-3-6 plan are met. Through these efforts, states are increasingly able to identify infants with hearing loss and ensure that affected infants receive appropriate intervention services to help them develop communication and social skills that match their cognitive abilities.

Case Study on Invoking Regulatory Authority

Although many public health interventions are not directly achieved through legislation, the authority to take action is often derived from legislation. Such is the case with regulation, the authority for which is established through the legislative process. Public health professionals are often called on to provide or interpret evidence for such decisions. The following case study on folic acid fortification of the food supply presents an example of the interplay between public health research and regulatory decisionmaking—both in determining regulatory strategy and in evaluating its impact.

In 1992, the US Public Health Service recommended that all women capable of becoming pregnant consume 400 μg of the B vitamin folic acid daily to reduce their risk of having a pregnancy affected by neural tube defects, severe birth defects of the brain (anencephaly) and spine (spina bifida).21 All infants with anencephaly die before or shortly after birth, and most babies born with spina bifida face lifelong disabilities. Three potential approaches for implementing the recommendation were listed: improvement of dietary habits, fortification of the US food supply, and use of dietary supplements. To reach the broadest number of women through a strategy requiring no individual behavior change, public health professionals engaged with policy decision makers at the US Food and Drug Administration and provided information useful for their deliberations regarding the possibility of food supply fortification.

Elsewhere in this issue, Grosse et al.7^,22 present information about the scientific findings and events leading up to fortification, as well as an economic evaluation of the policy. Fortification23 has clearly been a policy intervention effective in achieving positive public health outcomes. Since fortification, CDC has documented a 26% decrease in births affected by neural tube defects, reducing by 1000 the annual births affected by these fatal or debilitating anomalies.24 The story of folic acid fortification highlights an effective use of regulatory authority to impact population health.

Notwithstanding the dramatic reductions in affected pregnancies in the span of 5 years, the observed decrease in neural tube defects falls short of the 50% to 70% decline predicted by epidemiological models before fortification.21^,25 Thus, opportunities remain for the use of strategies (policy and otherwise) to maximize the prevention potential of this important vitamin and bring the benefits of folic acid to more women and children.

VOLUNTARY PRACTICES AS POLICY TOOLS

Public health law can indeed promote, support, and even create positive public health outcomes for children; however, as stated previously, these tools are vulnerable to complex and uncertain political forces. The success of legislation in changing individual behavior, including laws aimed at reducing smoking rates by increasing cigarette taxes26 and laws that appear to be reducing automobile accident fatalities by requiring seat belt use,27 is well documented. Nevertheless, in a culture placing a high value on individual freedom, mandatory solutions can be unpopular. To create and support environments that encourage health, the promotion and adoption of voluntary practices by individuals, groups, and organizations constitute another important policy tool for public health professionals. The following case studies illustrate successes and opportunities in translating scientific knowledge into voluntary practices to be adopted by individuals, groups, or institutions. Although both case studies describe efforts to change individual behavior, the first describes an intervention delivered primarily by clinicians, whereas the second explores the potential benefits and challenges of improving maternal and child health by promoting changes in the workplace.

Case Study on Voluntary Practices

The development and adoption of sleep positioning recommendations by physicians and other health care professionals for infants, made well known through the Back to Sleep Campaign, is a successful public health initiative and a clear example of public-private collaboration. In 1991, SIDS was responsible for 4660 deaths per year in the United States and represented the largest portion of infant mortality beyond the neonatal period.28 Published epidemiological studies from other countries documented a considerably higher risk for SIDS among babies placed to sleep prone (on stomach) rather than supine (on back).29

By 1991, the growing body of evidence led key decisionmakers at the AAP to from a task force and begin reviewing the data. This task force recommended that babies be placed down for sleep supine rather than the traditional custom of placing them prone.30 Officials from the National Institute of Child Health and Human Development (NICHD), an institute of the National Institutes of Health, learned of the pending recommendation through a past AAP president and rapidly organized and funded a scientific meeting in 1992 to review the evidence. NICHD also initiated an annual survey to assess changes in infant sleep habits, including sleep positioning, and worked with the National Center for Health Statistics to track monthly and annual SIDS rates.

When it became evident that rates of both SIDS and prone positioning were dropping, AAP and NICHD joined with the National Heart, Lung, and Blood Institute and a coalition of other federal and private agencies in 1994 to launch the Back to Sleep Campaign to disseminate the sleep positioning recommendations to all parents of infants.30 By 2000, the rate of prone infant sleeping had fallen 77% (70 to 14%) and coincided with a 53% reduction in the US SIDS rate (1.2 to 0.56 per 1000 live births). This represents 2827 fewer deaths per year.31

The success of this collaborative endeavor was because of several overlapping and orchestrated factors. First, several epidemiologists in Europe, New Zealand, and Tasmania made the initial observations of the relationship between sleep positioning and SIDS. Responsive national organizations were willing to work together to expedite an organized effort, including funding a scientific review and tracking system. Also, a healthy competitive spirit among federal and private organizations provided the impetus to join the coalition once the intervention was proven valid. Physicians, health care professionals, and public health professionals quickly adopted the promotion of this recommendation. The resulting intervention was effective and simple, and, as a result, communicated well to parents and was quickly adopted.

Case Study on Working With the Private Sector

As the SIDS case study demonstrates, encouraging the adoption of public health interventions by individuals can be successfully supported by the private sector. The SIDS intervention is highly conducive to private sector support because it is not costly, and the benefits are quickly realized. However, because few preventive measures realize direct cost savings,32 a thoughtful approach to lowering private-sector barriers is needed when encouraging the private sector to implement health interventions. The foremost barrier is one of costs. Will an intervention reduce profitability? Time is the second critical barrier, because researching, designing, negotiating with contractors, and implementing a new preventive service takes time that managers may lack. A third major barrier is that some health improvements provide externalized benefits; they occur years after intervention, after which time many employees have left an organization. Other barriers to private sector support include the perception that health concerns are not problems; competing priorities and limited resources; insufficient demand from employees, consumers, or plan enrollees; an unconvincing evidence base; timing problems; and how executives view employees (e.g., as long-term investments vs short-term and easily replaced assets).

Creating a business case is a good strategy for encouraging voluntary practices in the private sector. Doing so requires translating public health information into business terms and formats.33 The business case must encompass benefits, risks, and costs—including projected impact on the bottom line—and, if possible, should provide evidence of effectiveness and return on investment. Although public health impact is a sufficient motivator for pubic health professionals, taking the time to create a business case (from outcome studies, applied research, and cost—benefit analyses) is often necessary when convincing decisionmakers in the private sector.

Workplace lactation support programs provide a relevant example of the impact and challenges of working the private sector to adopt voluntary practices. The benefits of breastfeeding for infants and mothers are well documented, and this strong evidence base contributed to the inclusion of breastfeeding goals in the nation’s health agenda, Healthy People 2010 (to increase the proportion of mothers who breastfeed their babies to age 6 months from 29% in 1998 to 50% by 2010).20 Since these health goals were developed, additional benefits from breast-feeding have continued to be discovered, including recent studies documenting reduced risk for postneonatal death34 and reductions in pediatric overweight.35 Although the science points to breastfeeding as a simple and effective intervention for improving maternal and child health, data show a significant drop in the proportion of mothers breastfeeding by the sixth month postpartum.20

A mother’s return to work is a documented barrier to the continuation of breastfeeding.36 However, workplace breastfeeding support programs can help reduce this barrier; women who participate in such programs have been shown to continue breast-feeding for 6 months or longer.36 The private sector is clearly an important partner in ensuring both the existence and promotion of such support programs. Encouraging private sector decision-makers to adopt voluntary practices, such as workplace breastfeeding support programs, challenges public health professionals to effectively articulate to the private sector the benefits of adopting such practices, and private sector policymakers are challenged to prioritize investments in such programs.37

In the case of breastfeeding, research has demonstrated the potential for billions of dollars in cost savings if breastfeeding rates were to increase to recommended levels.38 Other research has shown that workplace lactation support programs provide direct medical cost savings, support lower maternal absenteeism because of infant illness, increase employee loyalty and productivity, and enhance corporate public image.39 In addition, studies have demonstrated that significant proportions of sampled employers would be willing to support workplace lactation programs,40 yet surveys also demonstrate that many employers remain unaware of the benefits of such support programs.37 Clearly, there is a role for public health professionals to engage with workplace decisionmakers to effectively communicate the value of workplace lactation programs—both to their employees’ health and to the bottom line of the company—and to help companies adopt and evaluate such programs.

As the example of workplace lactation support programs reveals, private sector partners, like other policy decisionmakers, constitute an important audience whose actions affect public health. Taking the time to prepare information in a way that meets their needs can improve their willingness to use such information in decisionmaking.

CONCLUSION

In summary, policy development is a critical tool for ensuring that public health research findings result in meaningful improvements to children’s health. Although policy development presents challenges for public health professionals, such as communicating scientific evidence to nonscientific audiences, these case studies show that such challenges can be overcome. Specific opportunities include not only adapting the traditional style and tone of scientific discourse to more effectively communicate scientific information to policy decisionmakers but also creating the types of information needed by those decisionmakers.

In many cases, epidemiologists and other public health professionals are already generating this type of information but might not fully realize the importance of their data for informing new policy decisions and for evaluating the effectiveness of those already in place. For example, CDC used birth defects surveillance data to document the impact of the policy decision to fortify grain products with folic acid. Such documentation not only provides important information on the effectiveness of interventions but also highlights the relevance to policy decisions of public health data and the infrastructures that support their collection, analysis, and reporting.

In addition to being responsive to requests for information from decisionmakers, public health professionals also can further the use of policy development to impact public health by seeking and creating opportunities for meaningful engagement. Public health professionals are often government employees and, as such, are limited in their role as direct advocates for specific policy initiatives. Nonetheless, as we have shown, policy development extends well beyond legislation, and public health professionals play a critical role in identifying possible policy interventions. By considering the communication styles and needs of policymakers (for example, providing easy-to-understand and timely data), as well as the context in which policymaking occurs, public health professionals can take a more active role in ensuring that important public health research findings are acted on by decision makers.