Policy, Systems, and Environmental Change in Cancer Control

Maryland Cancer Collaborative Annual MeetingJanuary 14, 2013

Meredith Truss, MPPHealth Policy Analyst, Center for Cancer Prevention and Control

Maryland Department of Health and Mental HygienePrevention and Health Promotion Administration

Prevention and Health Promotion Administration January 14, 2013 *

Maryland Cancer CollaborativeThe goal of the Maryland Cancer Collaborative is to work with individuals and organizations throughout the state to implement the Maryland Comprehensive Cancer Control Plan.

In addition, the Collaborative will bring together existing groups and new partners from across the state to collaborate on a common goal: reducing the burden of cancer in Maryland.

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Given limited resources, how can we maximize our impact?Shift the focus of cancer control programs and interventions:

Individual Behavior and Direct ServicesInfrastructure to Support Healthy Behavior

Infrastructure includes public policy, healthcare systems, and physical environments

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Policy, Systems, and Environmental ChangePolicy, Systems, and Environmental (PSE) changes enhance infrastructure

PSE changes are interventions that modify environments to provide healthy options and to make healthy choices easy for everyone

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PSE Change Cont.If we focus on adapting policies, systems, and environments, we can maximize resources by extending our impact to reach more peopleBy modifying the environmental context, we can support healthy choices across a population vs. an individual

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PSE Change Cont.Thomas R. Frieden, MD, MPHAm J Public Health.2010 April;100(4): 590595.

PSE Interventions

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Individual = Counseling a 16-year old patient about sunscreen use and avoidance of artificial UVRPSE/Population = Legislation that bans tanning beds for minors

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Policy ChangePolicies = RulesLegislationRegulationsOrdinancesOrganizational PolicyCorporate PolicyPolicy change can be large-scale (enactment of a federal law mandating that all health insurance plans cover cancer screenings with a USPSTF Grade A or B recommendation) or small-scale (a small business owner providing employees with paid time off for cancer screenings)Policy change can drive systems and environmental change

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Systems ChangeChanges made to the rules and/or processes of an organization (often a type of policy change)Focuses on changing infrastructure within a school, park, community, worksite, or health care system (delivery or insurance)Health care system changes can ensure effective delivery and utilization of services to prevent, detect, and treat cancer

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Environmental ChangeChanges made to the environment to promote health by making healthy behavior and choices easy (can be achieved through policy change)Environmental change can be large-scale (e.g. installing sidewalks throughout a community) or small-scale (e.g. installing signage to mark existing park trails)Includes physical, economic, and/or social environments

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Whats the difference?

PolicySystemsEnvironmentDefinitionChanging laws, regulations, resolutions, ordinances, or rulesChanging processes or rules of an organization, institution, or systemPhysically changing the environment SettingsLegislatures (national, state, local), government administrations, healthcare settings, schools, worksites, community organizations (faith-based, daycare, senior center)Healthcare delivery and insurance systems, schools, worksites, communities, parksPhysical (stores, schools, worksites, parks, health clinics/offices), economic, and social environments ExamplesIncreasing tobacco taxes, implementing a smoke-free policy (hospital grounds, college campus, worksite, etc.), implementing a healthy meeting policy at workDeveloping a community plan that accounts for health impact of projects, reviewing and revising organizational procedures to increase cancer screening rates among patient populationConstructing sidewalks to make roads pedestrian-friendly, designating a lactation room for nursing mothers at work, offering healthy vending machine optionsOverlapSmoke-free policyHealthy vending machine policyAdding night/weekend healthcare provider/clinic office hoursZoning restrictions/limitations on fast food establishmentsFarm-to-school program

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PSE Change Vs. ProgramsAdapted from http://www.cookcountypublichealth.org/files/CPPW/PSE%20Change.pdf

SettingProgram/EventPSE ChangeSchoolCelebrate national nutrition monthAdd fruits and vegetables to cafeteria lunch optionsCommunityHost a community bike rideImplement a Complete Streets policy to ensure community roads are safe for biking, walking, and drivingWorksiteHold a health fair for staffImplement a healthy vending machine policy that offers healthy, affordable snacksRadiology FacilityHold a low-cost mammography eventChange operating hours to include night and weekend appointmentsHospitalHold free breastfeeding courses for new momsImplement WHO 10 Steps to Successful Breastfeeding

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Cancer Plan Examples- PreventionTobacco and Lung Cancer Chapter:Goal 1, Obj 2, Str 4: Engage with college and university administrators to ensure that all school campuses are tobacco-free at all times.Goal 1, Obj 3, Str 1: Adopt state and local policies that prohibit the smoking of tobacco products inside multi-unit housing in MD.Ultraviolet Radiation and Skin Cancer Chapter:Goal 2, Obj 1, Str 1: Encourage funding for the building of covered structures and implementing signage at public beaches and parks reminding people to wear sunscreen.

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Cancer Plan Examples- DetectionColorectal Cancer Chapter:Goal 1, Obj 1, Str 3: Increase the proportion of primary care providers and specialists who utilize evidence-based approaches such as physician recommendation for screening, client reminders, and chart review to ID patients appropriate for screening.Goal 2, Obj 1, Str 4: Reduce barriers to CRC screening by utilizing strategies that facilitate primary care referral to specialists for screening, facilitate screening by use of patient navigators, community health workers, or lay health advisors, and/or encourage improved coordination between primary care providers and specialists.Breast Cancer Chapter:Goal 2, Obj 1, Str 3: Support policies that allow work-time release to obtain cancer-screening services.

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Cancer Plan Examples- Treatment & SurvivorshipPain Management Chapter:Goal 1, Obj 2, Str 1: Collaborate with pharmacies to ensure that pain medication is adequately stocked in all communities and explore legislation that would require pharmacies to stock pain medication.Palliative and Hospice Care Chapter:Goal 1, Obj 2, Str 3: [Healthcare institutions] develop a strategic plan that incorporates goals and tactics to institutionalize palliative care.Nutrition, Physical Activity, and Healthy Weight Chapter:Goal 1, Obj 5, Str 1 & 2: Implement programs in MD jurisdictions to promote access to healthy foods and physical activity in high-risk communities (virtual supermarkets, SNAP at farmers markets, partnership with park & recreation program, etc.)

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Cancer Plan Example in Action: MCC Primary Prevention & Policy CommitteesPolicy Tobacco Priority: Adopt state and local policies that restrict the sale, advertising, and promotion of tobacco products by

Prevention Tobacco Priority: Require that tobacco retailers: (a) display effective health warnings about the use of tobacco products; (2) display information on where to get help if you want to quit using tobacco; (c) ban so-called power walls (large displays of tobacco products and ads; and (d) ban the distribution of free-samples of all tobacco products.

Maryland Prevention and Health Promotion Administration

Cancer and Chronic Disease Bureau

Center for Cancer Prevention and ControlPrevention and Health Promotion Administration [Date] *http://fha.dhmh.maryland.gov

**However, given that we have limited resources and increasing expectations, how can we maximize our impact?Im going to talk a little today about one approach,which is a shift thats already taking place within several CDC-funded cancer programs away from interventions that aim to alter individual behavior or provide direct services, toward interventions that enhance infrastructure to support healthy behavior. *Environments: include any environment where someone lives, works, or accesses health services, including communities, neighborhoods, schools, businesses or workplaces, & healthcare settings.*Population- small or large, could be as small as 10-20 employees of a small business, or as large as the residents of an entire state, in the case of the OTP tax increase that we saw last year.*Dr. Frieden (Freeden) director of Centers for Disease Control & PreventionAnd he explains that interventions that focus on lower levels tend to be more effective because they reach broader segments of society and require less individual effort. PSE interventions target the second level of the pyramid, changing the context to make individuals default decisions healthy.*What CDC is promoting is infrastructure enhancement through PSE change to reach populations.This is the cancer control continuum, and I included this to point out that PSE change is applicable to all stages of the continuum. I though that it might be helpful to show an example of the difference between an intervention that focuses on individual behavior and a PSE intervention. So if we look at prevention and sun exposure in particular...

Ill provide some more PSE examples from the Cancer Plan later in the presentation.*So- what does policy, systems, and environmental change really mean?***This chart explains different definitions, settings, and examples of PSE changes, but the take away point here is that theres quite a bit of overlap.

Im not going to talk through the entire chart, but the examples may be helpful.

Down at the bottom of the chart there are examples that illustrate the overlap of the 3 PSE categories.

Its not as important to designate one PSE category to a given intervention, because all 3 categories are reaching a larger population, which is key.*I like this chart, which I took from another PSE presentation, because I think that it pretty clearly shows the difference between a program and a PSE change.*I pulled out some examples from the Cancer Plan, and our hope today is that this will give you some inspiration for PSE interventions or projects that could be implemented in your individual organizations, systems and communities.*The colorectal cancer control program at DHMH is helping healthcare systems to implement some of these changes.*These are just a few examples, there are many more in the cancer plan and in the coming months DHMH will work on developing a Cancer Plan Companion Document that includes a more comprehensive list. In addition to taking this back to your organizations as inspiration, were hoping that as you work within your Collaborative committees to implement priorities, that you keep in mind the bigger impact of PSE interventions and incorporate as you can.

*Kathleen Hoke- Policy Chair, Elizabeth Platz- Primary Prevention ChairThey will talk about how theyre working together to implement PSE strategies from the Cancer Plan.**