assessing decision-maker support for chronic disease prevention · 2019-03-20 · • community...

Assessing

Decision-Maker

Support for Chronic Disease Prevention

Effective Messages for Decision-Makers

Related to Healthy Eating and Active Living

June 2018

2 June 2018

Assessing Decision-Maker Support for Chronic Disease Prevention

Effective Messages for Decision-Makers Related to Healthy Eating and Active Living

Introduction to Policy Guides Lack of physical activity and poor nutrition drive poor health outcomes, such as obesity

and chronic disease, and cost the US billions of dollars every year. The Centers for

Disease Control and Prevention (CDC) has identified evidence-based strategies that

can help state and local public health partners promote increased physical activity and

healthy eating nationwide:

• Healthy foods: food service

guidelines and healthy food

retail (including corner stores

and farmers markets);

• Active friendly

communities: new or

improved pedestrian, bicycle,

or transportation systems

(activity-friendly routes) and

combining them with

implementing new or

improved land use or

environmental design (connected to everyday destinations); and

• Early care and education: improved physical activity and nutrition standards for

children in these settings.

Based on these three strategies, NACDD conducted a multi-pronged, qualitative

assessment to better understand state decision-makers' views related to policy

approaches to promote healthy eating and active living. A literature review was

conducted, followed by key informant interviews and focus groups including state and

local health department leaders, legislators, and public health advocates. The

information gathered during the assessment was used to develop content-specific

guides to assist in tailoring messages that reframe evidence-based approaches that

resonate with decision-makers.

Decision-makers:

• Prefer research that is: translated and delivered in short, concise formats; includes

cost data; is presented without bias; includes policy options; and is available at the

time decisions are being made.

3 June 2018



• Support obesity reduction policies that involve public schools and community-based

interventions; policies with positive implications for government finance; and policies

utilizing partnerships with community stakeholders.

• Look to voices from the business community, medical society, local voting boards,

grass roots organizations, and advocates for determining policy priorities. Credibility

and knowledge of the presenter was important.

• Want information on the potential impact of a proposed policy on business interests

and values related to local government control and decision making. They expect

measurable, immediate, and substantial returns on their investments.

When tailoring materials to state-level decision-makers, state and local public health can:

• Define and reframe obesity, using consistent messages.

• Communicate the economic perspective to move healthy eating and active living strategies forward.

• Focus on local data and solutions, rather than national statistics or problems.

• Discuss impact on specific populations of highest interest such as children, youth,

and older adults.

Key informants and focus group participants emphasized the critical role

fulfilled by the State Health Departments as:

• A convener and collaborative partner;

• A voice for supporting evidence based healthy eating and active living policy; and

• A source of expertise for implementing healthy eating and activity living

strategies.

• State Health Departments frequently are called upon to assist with convening

partners at the local level, providing subject matter expertise and technical

assistance to guide local agencies in initiating and implementing healthy eating and

active living strategies.

• Partnerships with State Health Departments were perceived to be important to

promote policy at the local level and inform policy at the state level through provision

of data and best practices and technical assistance to build capacity.

4 June 2018



Framing Messages Regarding

Healthy Eating

State and local decision-makers play an important role in supporting healthy

eating strategies where people live, learn, work, and play. The information in this

guide provides recommendations to help state and local public health reframe

messaging related to evidence-based approaches that will resonate with values of

decision-makers. Recommendations are based on a qualitative analysis that included a

literature review, key informant interviews, and focus groups conducted by the National

Association of Chronic Disease Directors.

Define and reframe obesity as it relates to healthy eating policy

Focus on lack of access to healthy foods and its impact on obesity. A barrier to

gaining support for healthy eating policies is the perception that obesity is entirely the

product of personal choice. Both the literature review and key informants identified that

a significant predictor for healthy eating is the availability and access to affordable

healthy food. Food service guidelines and the type of food available in retail markets

5 June 2018



have the potential to significantly expand food choices and, ultimately, to increase

healthy eating.

Discuss appropriate expectations for reductions in obesity-related chronic

disease and associated costs, including intermediate measures of success.

Legislators want more substantial results regarding obesity reduction rates than states

are currently reporting. Because it is unrealistic to assume that healthy eating policies

will result in significant reductions in obesity

rates within a short period of time, use specific

examples that are cited in the literature to

discuss the importance of changing the food

environment to encourage healthy eating.

Explain that policy and environmental

changes are more impactful than

individual approaches. Obesity is influenced

by multiple determinants that require

intervention and prevention strategies at both

individual and environmental levels. The

literature tells us that related contextual

features can dramatically influence a person’s

actions, thus, altering environments may be

an effective driver of individual behavior

change. For example, discuss how farmers

markets offer an access point for fresh

produce and a market for local growers.

Communicate the economic perspective to demonstrate the value of healthy eating policy

Provide examples of how evidence-based policy approaches for healthy eating

will positively impact the economy and community. Key informants noted that

Legislators are particularly interested in policies that have the potential to positively

affect business and agriculture in the communities they represent. Because healthy

eating policy is typically first introduced and implemented at the local level, use local

success stories — such as development of farmers’ markets, local grocery stores,

community supported agriculture, farm to school, and/or community gardens — to

demonstrate potential outcomes for economic benefit from similar state-level policy.

6 June 2018



Focus on local data and solutions, rather than national statistics of problems

Use constituent support or stories. The

literature review identified constituent needs

or opinions as one of the most influential

factors for legislators when determining

health policy priorities. Key informant

interviewees also noted that when legislators

and other decision-makers are considering

healthy eating policy, personal interest and

strong constituent voices are influential. For

example, identify constituents who can

effectively support the evidence and discuss

food service guidelines that have benefitted

employees of local worksites. When

including data, make sure the data are

unbiased, timely, relevant, local when

possible, and linked directly to constituents

and community stakeholders.

Provide tangible solutions broken down

into actionable steps. The literature review,

key informants, and focus groups

participants said that focusing on the

solution, rather than the problem is

particularly effective. Discuss how financing

to establish local grocery stores in underserved areas can alleviate hunger, increase

self-sufficiency through job creation, and increase access to healthy food.

Discuss impact on specific populations of highest interest such as children, youth, and older adults

Discuss the impact of healthy eating policies on hunger and quality of life for

your community, especially for children, seniors, and individuals with disabilities.

Key informants noted that legislators tend to be supportive of policies that ensure the

health and safety of children, seniors, and individuals with disabilities. Additionally,

increased independence of seniors and individuals with disabilities is important to

legislators. A healthy diet is key to assuring the health and independence desired by

these vulnerable populations.

“Local government is getting

more interested in healthy

food access issues and they

see day to day the impact

that low access has on

people in their community.”

- State Health Department Leader

7 June 2018



Actions to effectively frame messages

about healthy eating policy to decision-makers

I. Consider decision-maker values that relate to healthy living

• Support for the business community, including agriculture’s

• Economic impact of policies on business

• Potential cost-savings to business

• Reduced employee absenteeism

• Reduced employee healthcare and health insurance costs

• Attracting new businesses and young workers

• Increased revenues for local businesses

• Support for individual responsibility for healthy behaviors

• Support for policy that reduces Medicaid and other publicly funded healthcare

costs for treating and preventing disease.

II. Develop messages that resonate with decision-makers’ values

• Discuss the potential economic impact of healthy eating policies on business and

agriculture.

• Discuss the impact of healthy eating policies on children’s brain development and

kindergarten readiness.

• Highlight examples of how healthy eating in schools has increased performance

and attention, while lowering behavioral issues.

• Discuss the impact of healthy eating policies on the quality of life and ability of

older adults and individuals with disabilities to live independently.

• Discuss the negative impact of hunger on children, older adults, and individuals

with disabilities, including increased medical costs and decreased independence.

• Provide specific examples of how obesity and associated chronic diseases are

negatively affecting the business community (reduced worker productivity,

increased absenteeism, increased healthcare costs, etc.).

• Provide examples of the impact of state programs and funding sources that have

shown outcomes to illustrate positive implications for government resources and

finances.

• Frame messages around chronic diseases such as cancer, diabetes, and heart

disease, a higher priority for decision-makers than obesity.

• Discuss how significant reductions in chronic disease rates require a combination

of policies that support and promote individual health behaviors over multiple

years.

8 June 2018



• Discuss how effective local policies can be replicated in other communities and

can be used in developing state-level policy.

• Share state and local data rather than national or regional data, when available.

• Share examples of success and/or need from the communities the legislator

represents.

• Showcase a comparable state or community that has adopted policies to

illustrate the potential impact.

• Use concrete examples to illustrate the decision-makers’ role in strengthening

healthy eating for children and youth.

III. Use effective messengers

• Strong constituent voices or vocal advocate groups can share examples and

success stories.

• Partners can cite examples of how partnerships between the state health

agency, healthy eating coalitions, other state agencies (education, agriculture,

and social services, etc.), large businesses, chambers of commerce and other

advisory or advocacy groups have improved food access and illustrate the “win-

win” of such collaborations.

• Schools and businesses can demonstrate their support for healthy eating

policies, as legislators consider them to be credible sources of information.

• The governor and current administration can be champions by demonstrating

how healthy eating policy can support their agenda.

• Local municipalities can adopt voluntary healthy eating guidelines that, if

successful, may be examples for local or state policy.

• Partners who share a common interest in healthy eating and/or hunger issues:

• Community stakeholders can gather evidence to supplement available

data.

• Hunger coalitions can speak to the challenges of healthy food access.

• Individuals and professional organizations representing the business and

medical communities can advocate for healthy eating policy.

• Grassroots advocates committed to reducing food disparities.

• Local government entities with authority to affect healthy eating policy.

• Local boards of health, city councils, and county commissions can share

their stories of successful healthy eating policy initiatives with state

decision-makers and to serve as models for state-level policies.

• State affiliates of national advocacy organizations, such as the American

Heart Association and American Cancer Society.

9 June 2018




Active Living State and local decision-makers play an important role in supporting active living

strategies where people live, learn, work, and play. The information in this guide

provides guidance to help state and local public health reframe messaging related to

evidence-based approaches that will resonate with values of decision-makers.

Recommendations are based on a qualitative analysis that included a literature review,

key informant interviews, and focus groups conducted by the National Association of

Chronic Disease Directors.

Define and reframe obesity as it relates to active living policy

Focus on obesity-related chronic disease and societal impact. Not only does

obesity decrease quality of life, it also increases one’s risk for multiple chronic

diseases—specifically high blood pressure, type 2 diabetes, heart disease, and certain

10 June 2018



cancers. Both the literature review and key informants identified a significant “predictor”

of decision-maker support for active living policies as the perception that chronic

disease is a serious societal problem.

Discuss appropriate expectations for reductions in obesity-related chronic

disease and associated costs, including intermediate measures of success. Key

informants said that legislators and other decision-makers tend to want more substantial

results regarding obesity reduction rates than states currently are reporting. Because it

is unrealistic to assume that active living policies will result in significant reductions in

obesity rates within one or two years, key informants recommended using intermediate

outcome measures to help decision-makers develop realistic expectations of the impact

of evidence-based policies on health outcome. For example, state and local sources of

population level data, such as the Behavioral Risk Factor Surveillance System

(BRFSS), can be used to describe the impact of active living strategies on healthy

behaviors and other potential benefits.

Explain that policy and environmental changes support individual healthy

choices. The literature indicates that related contextual features can dramatically

influence a person’s actions, thus altering environments may be an effective driver of

individual behavior change. Discuss how policies that assure walkability provide a safe

choice for children to walk to school and for seniors to exercise.

Communicate the economic perspective

to demonstrate value of active living policy

Provide examples of how evidence-based active living policy approaches will

positively affect the business economy. Key informants noted that most active living

policies are first introduced and implemented at the local level. Decision-makers are

particularly interested in policies that have the potential to positively affect businesses in

the communities they represent. Use local success stories to demonstrate potential

outcomes for similar state-level policy.

Focus on local data and solutions,

rather than national statistics or problems

Use constituent support or stories. The literature review identified constituent needs

or opinions as one of the most influential factors for decision-makers when determining

health policy priorities. Key informant interviewees also noted that when legislators and

11 June 2018



other decision-makers are considering health policy, personal interest and strong

constituent voices are influential. Therefore, identify constituents who are able to

support effectively the evidence and discuss

how policies that assure walkable

communities have benefitted local residents

and business. When including data, make

sure the data are unbiased, timely, relevant,

local whenever possible, and linked directly to

constituents and community stakeholders.

Provide tangible solutions broken down

into actionable steps. The literature review

as well as key informants and focus group

participants all noted that focusing on the

solution rather than the problem is particularly

effective. Discuss how trails connecting neighborhoods to schools, retail, and

community services can increase walking and biking in all age groups while also having

a positive effect on retail businesses. In addition, ensure that a “just-in-time” solution” is

available for policy action when the opportunity arises to promote walkability by laying

the groundwork early through public and decision-maker education.

“At the local level, active living polices are viewed

favorably as bringing in more jobs, more money

to local business with walkable, bikeable areas.”

– State Health

Department Leader

12 June 2018



Discuss impact on specific populations of highest interest

such as children, youth, and older adults

Discuss impact on safety and health, especially for children, seniors, and

individuals with disabilities. Key informants recommended that messengers provide

data and/or examples of outcomes such as brain development and kindergarten

readiness of young children. Increased independence of seniors and individuals with

disabilities also is important to legislators, as they tend to be supportive of policies that

ensure the health and safety of vulnerable populations.

Actions to effectively frame active living

policy messages to decision-makers

I. Consider decision-makers’ values that relate to active living

• Be aware that their values may include:

• Support for the business community;

• Support for children’s brain development and kindergarten readiness;

• Support for older adults’ and individuals with disabilities’ quality of life and their

ability to live independently; and

• Support for individual responsibility for health behaviors and health outcomes.

II. Develop messages that reflect decision-makers’ values

• Provide specific examples and share data of how obesity and associated chronic

diseases are negatively affecting the business community and, conversely, how

active living policies can decrease chronic disease rates.

• Share state-level data on obesity and associated chronic disease rates; describe the

estimated cost to the state Medicaid program for treating those conditions; and

provide examples of healthcare cost reductions to be achieved by lowering obesity-

related chronic disease rates.

• Frame the message around chronic diseases such as cancer, diabetes, and heart

disease, for which obesity is a contributing risk factor, using state and local data and

success stories.

• Provide examples of evidence-based active living policies in geographically and

demographically similar states.

• Discuss the economic impact of being an activity friendly city, where kids can walk

safely to school, crime is reduced with well-lit, well-marked paths, more people use

existing trails, and families are more engaged.

13 June 2018



• Describe how active living

policies help attract new

businesses and young

workers to communities and

can help local retail

businesses grow.

• Discuss how active living

policies improve the health of

children and youth. Use

concrete examples to

illustrate the decision-makers’

role in strengthening active

living for children and youth.

• Highlight solutions in plain

language in oral and written communications (e.g. briefs, infographics, website, etc.),

that are accompanied by clear actions that stakeholders can take to achieve them.

• Provide examples of the impact of state programs and funding sources that have had positive outcomes.

III. Use effective messengers

• Strong constituent voices and community stakeholders

• Individuals and professional organizations representing the business and medical

communities

• Grassroots advocates committed to increasing physical activity opportunities

• Local government entities that have authority to affect active living policy through

local planning, land use, transportation, recreation infrastructure, and zoning

• Local boards of health, city councils, and county commissions to share their stories

of successful active living policy initiatives and to lend support

• State affiliates of national organizations, such as the American Heart Association

and American Cancer Society

• Representatives of local chambers of commerce to share examples from their

respective communities

• Partners to cite examples of how partnerships between the State Health

Department, planning committees, other state agencies (education, housing,

transportation, etc.), large businesses, chambers of commerce, and other advisory

or advocacy groups have promoted physical activity and active friendly communities

• Schools and businesses to demonstrate their support for active living policies.

• The governor and current administration as champions.

14 June 2018




Policy in Early Care and Education (ECE) Settings

State and local decision-makers play an important role in supporting early

childcare and education (ECE) standards and practices for obesity prevention.

The information in this guide provides recommendations to help state and local public

health partners reframe messaging related to evidence-based approaches that will

resonate with values of decision-makers. Recommendations are based on a qualitative

analysis that included a literature review, key informant interviews, and focus groups

conducted by the National Association of Chronic Disease Directors.

Define and reframe obesity as it relates to ECE policy

Focus on both the immediate and long-term health impacts of obesity in children.

Not only can obesity have lifetime physical and psychological effects on children, it

poses an immediate increased risk for Type 2 diabetes, asthma, and depression. Young

15 June 2018



children who are overweight in kindergarten are four times more likely to have obesity in

the eighth grade than those not overweight. Childhood obesity is associated strongly

with chronic disease in adulthood.

Discuss appropriate expectations for reductions in obesity-related disease and

associated costs, including intermediate measures of success. Key informants

said that legislators and other decision-makers want more substantial results regarding

obesity reduction rates than states are currently reporting. Because it is unrealistic to

assume that changes to ECE systems and settings will result in significant reductions in

obesity rates within a short time period, promote other, more immediate benefits,

including improvement in behavior and ability of children to learn.

Explain that policy and environmental changes are more impactful than individual

approaches. Obesity is influenced by multiple determinants that require intervention

and prevention strategies at both individual and environmental levels. Most young

children spend time in care outside their home at least once weekly. ECE settings can

directly influence what children eat and drink and how active they are, building a

foundation for healthy

habits. Altering ECE

environments may be an

effective driver of

individual behavior

change for both the child

and their family. For

example, research

indicates that children

who participate in

gardening activities in a

childcare setting are

more likely to eat the

vegetables they have

grown and to request

them at home.

Communicate the economic perspective to move healthy eating

and active living strategies forward

Discuss impact of healthy diet and physical activity to prepare children for future

academic success. Key informants recommended that messengers provide data

and/or examples of outcomes such as improved brain development and kindergarten

16 June 2018



readiness of young children who are physically active and consume diets with nutritional

content appropriate for their age and stage of development. Because children spend a

large part of their day in ECE settings, there is a significant opportunity to influence child

growth and development by limiting sedentary behavior, encouraging physical activity,

and providing healthful food.

Focus on local data and solutions,

rather than national statistics or problems

Provide local examples and solutions or examples from similar states when

describing how evidence-based approaches in ECE settings will positively affect

children’s health and development. Key informants noted that decision-makers are

particularly receptive to considering successfully implemented guidelines in the

communities they represent when considering state policies that have the potential to

positively affect children. Decision-makers prefer stories

from people directly impacted by the issue. Use local stories

to describe how successful local ECE guidelines have

benefitted both the providers and the children in their care

and can serve as models for state-level policies. Share

stories about successful evidence-based early ECE policies

in geographically and demographically similar states that

he/she can then promote.

Use constituent support or stories. The literature review

identified constituent needs or opinions as the most

influential factor for legislators when determining health

policy priorities. Key informant interviewees also noted that

when legislators and other decision-makers are considering

health policy, personal interest, and strong constituent

voices are influential. Therefore, identify constituents who

can effectively support the evidence and highlight childcare providers who observed

improved behavior of children in their care following implementation of healthy eating

and active living guidelines. Share stories about successful evidence-based local ECE

policies in childcare, Head Start, preschool, and pre-kindergarten in communities

represented by the decision-maker that he/she can then promote.

Provide tangible solutions broken down into actionable steps. The literature

review, key informants, and focus groups participants said that focusing on the solution,

rather than the problem is particularly effective: For example, health departments can

“Healthy kids are

more productive

adults and that

has a positive

economic impact

on the state.”

- State Level Policy

Advocate

17 June 2018



provide evidence on the

impact of healthy eating and

physical activity (e.g.

improved academic

performance) and then

collect and share stories of

childcare providers who

implemented voluntary

guidelines for healthy eating

and physical activity in ECE

as an effective first step

toward development of

policy for ECE physical

activity and nutrition. Share stories about successful evidence-based policies co-

promoted by the State Health Department and other state agencies that support

physical activity and nutrition in early childcare settings while also meeting the desired

outcomes of the other agency sponsors – a “win-win.” Highlight the solution in plain

language in oral and written communications (e.g., briefs, infographics, website, etc.),

and accompanied by clear, actions that stakeholders can take to achieve the solution.

Actions to effectively frame early childcare and education policy messages to decision-makers

I. Consider decision-makers’ values that relate to the ECE setting

• Support for improving the state’s economy.

• Support for initiatives that help attract businesses and young workers.

• Support for policy that reduces Medicaid and other publicly funded healthcare costs.

• Support for academic performance of children.

• Support for investment in children that results in good outcomes and illustrates

positive investment of government resources and finances.

II. Develop messages that resonate with decision-makers

• Discuss the impact of ECE policies on children’s brain development and

kindergarten readiness.

• Ensure that a “just in time” solution is available for action when the opportunity

arises by laying the groundwork early through public and decision-maker education.

• Provide specific examples of how ECE policies can contribute to healthy children.

18 June 2018



• Discuss how significant reductions in chronic disease rates require a combination of

policies that support and promote individual health behaviors during multiple years,

starting in early childhood.

• Share state and local data rather than national or regional data when it’s available.

• Share examples of success and/or need from the communities the decision-maker

represents. • Highlight a comparable state or community that has adopted ECE policies to

illustrate the potential impact.

• Discuss specific issues related to ECE access and inequality for respective groups

of children.

V. Use effective messengers

• Community stakeholders to gather and share evidence to supplement available

data.

• Local municipalities and ECE sites to adopt voluntary ECE guidelines for healthy

food options, limited screen time, and/or minutes of physical activity in ECE settings

that, if successful, can serve as examples for local or state policy.

• Schools and businesses to demonstrate support for early childcare and education

policies, as they are considered credible sources of information by legislators.

• Partner organizations that can help deliver a unified message:

o Schools, Head Start, and childcare operators

o Individuals in and professional organizations representing the business and

medical communities that are involved in caring for children

o Grassroots advocates

o Local government entities

o Local boards of health, city councils, and county commissions to share their

stories of successful ECE policies initiatives and to lend support for similar

state-level policies

o Governor’s office for state leadership related to ECE policies.

This publication was supported by the Cooperative Agreement Number 5U38OT000225-05, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

assessing decision-maker support for chronic disease prevention · 2019-03-20 · • community...

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