Enacting Sustainable School-Based Health Initiatives: A Communication-Centered Approach to Policy and Practice

Abstract

Communication plays an important role in all aspects of the development and use of policy. We present a communication-centered perspective on the processes of enacting public health policies.

Our proposed conceptual framework comprises 4 communication frames: orientation, amplification, implementation, and integration. Empirical examples from 2 longitudinal studies of school-based health policies show how each frame includes different communication processes that enable sustainable public health policy practices in school-based health initiatives. These 4 frames provide unique insight into the capacity of school-based public health policy to engage youths, parents, and a broader community of stakeholders.

Communication is often included as an element of health policy; however, our framework demonstrates the importance of communication as a pivotal resource in sustaining changes in public health practices.

The study of public health policy often reaches across disciplines and contexts.¹ Recent articles in the American Journal of Public Health, for instance, have demonstrated the relevance of communication to health policy issues. These essays have situated communication within the processes of policymaking,² and they have focused on issues of advocacy, ethics, and community participation.^3–5 However, this body of work lacks explicit statements detailing how communication helps translate policies into practices. Communication plays an important role in all aspects of the development and use of policy. Perhaps most important, communication grants insight into the process of enacting policy texts in everyday practice.^6,7 Accordingly, we present here a communication-centered perspective on public health policy.

To examine the relationship between communication and public health policy, we concentrated on school-based health initiatives because these efforts provide intriguing contexts for studying the relationship between policy and communication, particularly because the relevant concepts relate to processes and practices of change. In addition, public health policies are more than static sets of rules; they can also serve as new resources for coordinating change across schools. These resources may give a variety of stakeholders the opportunity to secure rights and promote sustainable changes within those schools.

ENACTING PUBLIC HEALTH POLICY THROUGH COMMUNICATION

Attempts to examine communication, enactment, and health policy are made more difficult by the ubiquity and ambiguity of these terms. To clarify these opaque concepts, we used structuration theory⁸ to focus on the use of rules and resources, such as policies, to enact changes in systems of practice, such as school-based health initiatives.

Positioning Policy Communication

Structuration theory offers a useful way to examine how individuals and institutions might use policy to institute new routines. More specifically, this theory presents the possibility of defining policies as rules and resources. Policies are rules in that they both proscribe and prescribe actions, but policies also are resources in that they serve as means for accomplishing specific goals (e.g., conducting health screenings in schools).^6,9 As such, policies operate as texts, decisions, and practices that provide documented postures for routine actions.^9,10

When policies are conceptualized not just as rules but also as resources, several insights about policy are possible. Initially, written policy operates to transform daily practice by lifting social relations, such as discussions about healthy eating, out of a local context and restructuring those relations across contexts and times.¹¹ In this way, policies provide new rules and resources for practice. With regard to school-based health initiatives, therefore, policies offer a way to initiate changes to health practices.

This process also involves the coordination of stakeholder activities across different contexts.^12,13 For example, Pike and Colquhoun found that school space configurations and school contexts made notable differences with regard to implementing school meal policies in the United Kingdom.¹⁴ This point is important to the study of school-based health initiatives because it enables a nuanced understanding of how policy texts weave throughout contexts (e.g., different school districts) to coordinate the actions of multiple stakeholders.

Viewing policies as communication resources also requires a more detailed definition of “communication.” We invoke this term to mean the process of sharing and constructing meaning among multiple stakeholders. From a structuration perspective, process, content, and outcome are all important when studying communication. This positioning of policy communication is similar to that advanced by Brownson et al. in their discussion of process, content, and outcome in evidence-based health policy.² Thus, both written and verbal policies are important components of policymaking processes. Policies serve as textual representations of common goals and shared meaning; at the same time, policy practices are also enabled and constrained by the ways in which stakeholders discuss them.

Policy text and talk are implicated in the ways that policies are made, enacted, and routinized. Policymaking processes address the formulation of policies through the strategic use of talk and text.^2,15 Policies also include processes of enactment, which involve ways that multiple stakeholders use policy talk and texts to make policy changes work in context.^16,17 Finally, policy routinization focuses on the regular and repeated use of policy talk and texts across time and space to structure practices.^1,8 In this essay, we focus explicitly on communication and processes related to enactment.

Research from the fields of public health policy and communication has offered insight into how policies are enacted in everyday practices. Previous studies of health policies in schools have revealed inconsistent results of implementation efforts.^14,18,19 For example, Price and Rickard found that effective coordination between school staff members and public health administrators could reach a large number of children through the State Child Health Insurance Program.²⁰ However, Videto and Hodges found that after efforts to implement a Coordinated School Health Program, only 25% of schools reported improvements in the goal of family and community involvement.¹⁹ Often, such inconsistencies are not attributable to characteristics of the policies themselves or the individual stakeholders; rather, they can be traced back to enactment practices involving communication. Indeed, Pressman and Wildavsky noted in their foundational implementation work that “the apparently simple and straightforward is really complex and convoluted.”^21(p93)

These observations are consistent with communication research that has noted a disconnect between policies as written and policies as practiced.^6,7,22 For example, in their study of family-leave policies, Kirby and Krone⁷ demonstrated that a significant number of new fathers chose not to enact benefits granted to them under federal policy. Although these benefits had been formulated and implemented through federal policy, several stakeholders cited pressures from coworkers and pervasive policy talk as reasons for not enacting those benefits. Accordingly, the concept of enactment involves how stakeholders use communication to make policies meaningful through practice.

A Communication-Centered Conceptual Framework

Research has clarified the need for continued discussions of how policies are translated into practices. This translation is facilitated through the communication processes of enactment, and we propose a communication-centered conceptual framework that demonstrates this relationship. Our approach comprises 4 communication frames—orientation, amplification, implementation, and integration—through which stakeholders develop and apply policy knowledge, make connections between assumptions and practice, and use policy texts to institute change and integrate actions. These frames do not occur as mutually exclusive and linear stages; rather, like window frames, they constitute characteristically different ways of viewing policy and enabling sustainable changes. Table 1 presents the 4 frames, together with their subsidiary processes and examples of communication within each frame. The communication examples in Table 1 are taken from 2 qualitative studies of food and disability policies in K–12 schools.^23,24

TABLE 1.

A Communication-Centered Approach to Policy: 4 Communication Frames, Subsidiary Processes, and Examples

Frames	Subsidiary Processes	Examples
Orientation	Basic information dissemination	“The reason we are pushing this is because it's an enormous amount of money that the district gets reimbursed for stuff they're already doing for some kids.” (Medicaid billing administrator)
	Identifying policy priorities
	Asking questions
	Group/online formal training
Amplification	Multiple stakeholders constructing meaning	“When I listen to this discussion, I agree with [name 1]. I agree with [name 2] that if a psychologist leaves the district they should leave [the psychologist protocol reports] behind. I have a lot more questions now.” (special education administrator)
	Clarifications and explanations
	Asking questions
	Posing potential consequences
	Expressing differences
Implementation	Constructing meaning in action	“I guess I haven't taken the time to really look at these forms. Are we supposed to have parents sign them now?” (special education teacher)
	Asking questions
	Clarifications and explanations
	Expressing differences
Integration	Cross-context meaning construction	“I pulled several policies off the Web. They're not policies. They're more like guidelines and suggestions. I really think that we're further along than this.” (food service director)
	Identifying policy priorities
	Seeking external information
	Negotiation of interpretations

Note. Communication examples are taken from 2 qualitative studies of food and disability policies in K–12 schools.^23,24

Orientation.

The orientation frame introduces policy issues and develops general awareness for the stakeholders involved. This frame includes general information sessions, training meetings for staff members, public documents about policy provisions, and announcements made in person or via e-mail. Orientation involves basic information dissemination rather than mutually constructed meaning development. Table 1 presents an example of communication used in the orientation frame for school district staff members meeting about Medicaid changes.

Amplification.

Amplification involves developing more detailed knowledge about how policy provisions relate to stakeholders' everyday practices. This frame is critical for understanding how individuals draw upon structural rules and resources to transform policy processes. In this frame, stakeholders use communication resources to translate policies as written into policies as practiced. Table 1 presents an example of a summary statement made when school district staff members used the amplification frame to determine how to translate ambiguous policy into concrete job practices.

Implementation.

In this frame, people learn from “doing” policy, that is, implementing it. Through this process, what was abstract becomes concrete. Also through implementation, incompatibilities between policy texts and policy talk become apparent. Stakeholders use this frame to develop creative insights about policy processes that enable the restructuring of resources and sustainable policy changes. Table 1 presents an example e-mail sent when a teacher realized, on the job, that policy requirements were unclear in practice.

Integration.

Integration involves the specific practices related to coordination across contexts. As policies align actions across contexts, stakeholders often work to integrate ideas, share strategies and best practices, and demonstrate solidarity in using or resisting policy changes. In doing so, they engage in communication practices that can enable sustainable transformations within and across related systems. Table 1 presents an example of communication in the integration frame, as a committee member used other policy resources to shape how food policy would be enacted in her school district.

These frames illustrate ways policies are translated into practices through the communication processes involved in enactment. Figure 1 depicts the 4 frames as part of a larger policy process. The figure shows a recursive, rather than linear, relationship between policymaking (the formulation of policy texts through policy talk), policy enactment (the use of policy talk and texts by multiple stakeholders in context), and policy routinization (the routine use of policy talk and texts across time and space). The double arrows indicate the mutual influence of different sets of policy processes, which highlight particular policy decisions and involve different sets of stakeholders.²⁵

FIGURE 1.

Four frames of communication in the policy enactment process.

This figure represents a slight departure from more traditional models of policymaking that focus on policy formulation, implementation, and evaluation. The 4 frames call attention to the complex processes involved in taking policy in its textual form and translating it into more routine practices. Because our focus was on enactment rather than on the entire policy process, the frames are situated with policy enactment in Figure 1. However, this depiction does not dismiss the fact that elements of these frames also exist to varying degrees in policymaking (i.e., crafting the actual language of policy texts) and policy routinization (i.e., the routine use of those texts in specific contexts).

ILLUSTRATING THE FRAMEWORK

To illustrate how these frames can be used to identify ways in which communication processes enact sustainable policy practices in school-based health initiatives, we present empirical examples drawn from 2 studies conducted in school districts in the southwestern United States. One study concerned the development and implementation of 2 food policies for K–12 schools: (1) a statewide policy establishing the Arizona Nutrition Standards as the primary nutrition guideline for K–8 schools and (2) a federal-level requirement for local wellness policies in all K–12 school districts that participated in federal child nutrition programs.²³ The other study concerned changes in disability policies in K–8 schools, including the Individuals With Disabilities Education Act, Medicaid, and related policies.²⁴ Both studies extended over several months and used primarily qualitative methods to analyze policy texts, practices, interviews, and other relevant data (for a data summary, see the online article's supplemental appendix available at http://www.ajph.org).

Orientation

Orientation is the most commonly used communication frame for guiding school-based health policies. Federal, tribal, state, and local administrators often rely on mass-distributed policy briefs, informational packets, and print announcements to orient policy stakeholders to basic policy information. For example, to orient policy stakeholders to the Arizona Nutrition Standards, the state nutrition agency developed a series of textual resources to communicate basic information regarding how the standards operate. These resources included a quick guide that listed new food and beverage standards, portion sizes, and prohibited foods and beverages on campus. Another resource was a food wheel, a cardboard tool that food service directors could manually adjust to calculate how much fat, sodium, and calories an item should contain to qualify under the standards. Observational data from the food policy study demonstrated how the state nutrition agency relied heavily on the quick guide and the food wheel to orient food-service directors, lunchroom workers, teachers, and families to working with the nutrition standards.

School professionals often relied on such texts to determine how important a particular policy provision was in terms of everyday job practices. Interview and meeting data from the disability policy study indicated that specialists and teachers were more likely to focus on policy provisions when those in authority used handouts or other textual materials to stress the importance of specific aspects of a policy text. Staff members tended not to pay attention to provisions that were not explicitly stated as policy priorities by those in authority.

Although orientation includes formal training that conveys policy priorities and procedures, some stakeholders can experience a disconnect between the goals of the policy and the constraints of the local context. Participants in the disability study indicated that formal training sessions regarding Medicaid provisions often included information that contradicted the ways things actually worked at their schools. These training sessions generated more confusion than comprehension or policy compliance. In such instances, participants turned to their coworkers rather than training manuals to understand how to make Medicaid changes work in their schools.

Basic information dissemination and training sessions that characterize the orientation frame constitute necessary, but not sufficient, communication processes for effective policy practices. Proponents of sustainable policy changes in the example studies relied on a range of communication resources to orient stakeholders to policies and promote healthy schools. At the same time, simply exposing others to information is only a first step in using policy to transform practices for the benefit of students. Stakeholders must be prepared to engage in multiple rounds of shared meaning construction to make policy changes persist.

Amplification

Amplification is a process of clarifying what policy means, sharing diverse perspectives, considering potential consequences, and offering alternative suggestions for translating policy into practice. For example, participants in the disability study faced changing requirements for using Medicaid to provide services to children in public schools. Administrators used informational packets and formal training sessions to orient district staff members to the new requirements. Ultimately, stakeholders used amplification in school-level and district-level staff meetings to consider the specifics of how policy changes would work across time for specific schools and districts, predict potential problems arising from unintended consequences of policy interpretations, and resolve problems they faced as they developed new health-related practices. Staff members at one school site relied solely on formal training and existing practices to implement changes, which resulted in pervasive confusion among staff members, partial implementation of required changes, and questionable policy compliance. Students, staff, and the school district suffered when the amplification frame was ignored.

When the communication processes associated with amplification were present, however, this frame emerged in both studies as a key frame for transforming systems. For the stakeholders involved with the Arizona Nutrition Standards, amplification manifested when the state nutrition agency opened the state-level policy to a standard period of public commentary. Based on feedback from those comments, state agents made minor amendments to the policy text to allow sports drinks back on the menu. This public commentary introduced the policy to a wider range of stakeholders, giving them the opportunity to enter the amplification frame and directly engage in policy talk. Therefore, amplification constitutes a valuable resource for policy stakeholders who want to promote sustainable changes to school-based health initiatives.

Implementation

Implementation involves learning by doing. Data from both studies clearly indicate that participants in policy-related systems interpreted what policy meant and learned how to translate policy into practices by actively engaging in policy-led changes. This frame comprises several communication processes, such as identifying policy and procedural priorities, asking questions, providing explanations and clarifications within work groups, and expressing differences of opinion or interpretation as tensions emerge between policy requirements and work practices.

For example, the disability study revealed contradictions between existing school practices and Medicaid policy requirements that only became apparent during implementation. After receiving formal training about Medicaid changes, a school psychologist noted in an interview, “I see the mismatch with that, and I'm wondering how we're going to address that.” Participants attempted to resolve such contradictions by negotiating how to implement policy changes with their coworkers as they shared knowledge they had gained during training sessions, sought clarifications, and offered alternative suggestions. The Medicaid example illustrates the importance of each frame in that the lack of amplification regarding how to resolve the contradiction between policy and practice resulted in confusion about the policy and its implications for practice.

Policy implementers also used ongoing job activities as opportunities to restructure practices and construct shared meaning. In the school meal study, food service directors developed accessible ways of talking about policy changes with a wide range of stakeholders. The state nutrition agency formally trained food service directors regarding policy changes; however, those directors needed to convince lunchroom workers, food vendors, teachers, parents, and students that the policy could work for their district.

One food service director stated in an interview that she directly credited strategic communication as a crucial component of her school's success. She said,

Basically, the biggest thing I had to do was sell them on [the policy changes]. Because if I didn't have the support of the people that work under me, it was going to be complete chaos.

She offered samples of new foods to her staff and students as a way to build interest in the new cuisines to come. As they moved into implementation, the food service director developed greater knowledge about how stakeholders would actually use the policy texts. Through innovative restructuring of practices during implementation, stakeholders can construct the practical policy knowledge that they need to enact particular changes. In doing so, they work to ensure sustainable practices in school-based health initiatives.

Integration

Integration focuses specifically on how policies weave together different contexts across time to coordinate policy initiatives and activities. Integration includes communication processes of identifying policy priorities, information seeking, and negotiation to coordinate activities across contexts and develop sustainable health policy changes over time. Integration was most apparent in the study of school meal policies, emerging in 2 ways.

First, individual policies exist within webs of other policy provisions, such as those advanced by a local school board or a federal health institution; therefore, stakeholders must make certain that their policy texts are not invalidated by policies that take precedence over them. One school district's wellness policy committee confronted a situation where their document needed to be integrated with other policy rules. For example, committee members had to consider how their local text was part of the district's general interest in health and wellness. At the second meeting of the policy committee, a representative from the school board became worried that they might be devoting a lot of work to developing policy that already existed for the district. Consequently, the subcommittee that focused on nutrition education and curriculum examined the governing board policy as a starting point for their own policy recommendations.

Second, integration was used to coordinate practices of multiple school districts in terms of healthy eating standards. One district committee consulted other local wellness policies as a way to gauge their own progress and generate new ideas to enhance their own policy. For example, a food-service director explained that she had surveyed other wellness policies. “I pulled several policies off the Web,” she explained. “They're not policies. They're more like guidelines and suggestions. I really think that we're further along than this.” By comparing the practices of local wellness policies across contexts, the members of this committee developed a sense of where their policy stood in terms of instituting healthy changes. Moreover, the committee borrowed from other model policies as a way to make their own text more innovative.

Using policy to coordinate actions across local, state, and federal contexts enables a new set of rules or innovative resources to reach stakeholders as they restructure school-based health practices. This conclusion corresponds with implementation research finding that policies are constantly transformed, or reinvented, through implementation.^2,26 Sustainable changes in school-based health initiatives are a multisite accomplishment, and public policies represent necessary resources for coordinating actions across sites.

CONCLUSIONS AND RECOMMENDATIONS

The 4 frames of policy communication we present provide a new lens for viewing enactment and connections between policies and practices. Communication is often included as an element of health policy; however, our framework demonstrates the importance of communication as a pivotal resource in sustaining changes in public health practices. This claim holds for school-based health initiatives as well as for other contexts. Indeed, Ratzan²⁷ noted that communication is a fundamental requirement for developing a health-competent society.

Health communication remains an important concept associated with federal-level goals such as Healthy People 2020.²⁸ Thus, we offer several recommendations for incorporating communication as a policy resource and promoting policy practices that are more collaborative, dialogic, and ultimately transparent:

1. Use a range of promotional resources to orient multiple stakeholders to policy changes. Stakeholders respond in different ways to various modes of communication texts and practices. Some stakeholders effectively orient themselves to a policy by simply reading the text and looking at a few handouts. Others require more interactive and dialogue-based approaches. Still others use their informal networks of colleagues to make sense of policy changes. Communication offers a rich range of resources (based in text and talk) that can assist school-based health practitioners in meeting the needs of multiple stakeholders.

2. Use the necessary time to develop sustainable practices. The injunction to recognize that sustainable changes take time is not a novel recommendation; however, stakeholders must actually use that time and the communication processes required to make policy changes persist. As made evident in our discussion of amplification, when this crucial frame was overlooked, stakeholders faced significantly more difficulty when implementing school-based health initiatives policies. These types of communication practices can help achieve a significant payoff with regard to how stakeholders actually use policy resources.

3. Construct shared knowledge about health practices by implementing policy. Incorporating communication as a policy-related resource might require some trial and error, especially as stakeholders search for more effective ways to implement policy initiatives. As stakeholders focus on strategic communication as a means to implement policies, opportunities to orient new stakeholders to policy changes and amplify the sustainable potential within those changes will arise.

4. Recognize how policies maneuver across contexts. Policies as communication resources do some of their best work between contexts. They provide stakeholders with a documented posture when it comes to charting a progressive path and providing support for stakeholders who want to implement larger systemic changes. In the pursuit of healthier students and healthier communities, this focus on communication as a resource for policy change can serve as a valuable means for enabling sustainable health practices.