Informing Public Health Policy

By Sami Jarrah

State legislatures often enact policies that greatly affect the public’s health. With this in mind, what kinds of information do legislators find compelling and helpful as they deliberate important public health initiatives?

To investigate this, the author surveyed Oregon legislators who had voted on House Bill 2726*. In 2009, Oregon legislators passed this bill, a menu-labeling law with significant health implications. The bill required chain restaurants to post calorie information for food items on menus, menu boards, or food packaging along with a statement describing the recommended daily nutrient intake. The goal was to enable healthy choices by providing Oregon consumers with point-of-purchase nutritional information.

To assist the passage of HB 2726, public health advocates mobilized voters and shared empirical evidence. Most often, this evidence focused on Oregon’s obesity and diabetes epidemics and how a menu-labeling law could reduce those population health problems.

Surveying Legislators

From August to November 2010, Oregon legislators completed online and paper surveys. The response rate was 55 percent, with 47 out of 85 legislators participating.

The survey invited the legislators to share information anonymously about their deliberations over HB 2726. The survey included eight questions and an “other comments” field. Questions asked legislators to identify their primary reasons for voting either in favor of or in opposition to HB 2726. Answer choices were based on policy research and reasons cited in the popular media. For legislators who voted in favor of HB 2726, options included empirical evidence describing the efficacy of menu labeling in reducing obesity rates, consumers’ right to know, the reliability of Oregon’s public health experts, and importance to constituents. Legislators also identified what evidence, if any, would have or did influence them to vote in favor of HB 2726.

Voting “Yay”

Among respondents, the two most common reasons legislators voted in favor of HB 2726 were a belief in consumers’ right to know point-of-purchase nutritional information and awareness of empirical evidence that suggests menu labeling decreases obesity levels.

Respondents from both parties and chambers listed these as their top two reasons.

Among respondents who voted in favor of HB 2726 (n=37), the third most commonly cited reason for doing so was that they believed that HB 2726 was important to their constituents.

Voting “Nay”

Among survey respondents who voted in opposition to HB 2726 (n=10), the most commonly cited reasons varied depending on political affiliation. Republican respondents generally opposed the legislation and most often reported that it was not the government’s role to influence individuals’ food choices. Another commonly identified reason among Republicans was that the government should not interfere with restaurant owners’ operations. Although only three Democrats in the study population opposed the legislation, these Democratic legislators each cited different reasons: insufficient empirical evidence, cost, and HB 2726 not being ambitious enough.

Convincing Opponents

Among opponents to HB 2726, respondents generally agreed that the most helpful decision-making resource would have been access to convincing empirical evidence suggesting the effectiveness of menu labeling. Importantly, among HB 2726 opponents, a face-to-face visit with public health leadership was the second most commonly identified decision-making resource that could have influenced a vote in favor of the legislation.

Other tactics that opponents listed as potential “game changers” included support for the bill from the Oregon business community, demonstration of constitutional authority by HB 2726 supporters, empirical evidence from other jurisdictions that had already implemented menu labeling, empirical evidence about the obesity epidemic, and testimony from consumer advocates.

Values vs. Information

According to the internationally known epidemiologist Alfred Sommer, legislators make policy decisions through the dual lenses of values and information. Values are formed through interactions of many factors, including belief systems, social and economic interests, ideology, and historical context. In this study, the data indicate that a significant percentage of policymakers, both HB 2726 supporters and opponents, valued empirical evidence. In fact, 60 percent (n=6) of HB 2726 opponent respondents indicated they might have supported the bill if they were presented with clear and compelling empirical evidence that menu labeling definitively reduces community obesity rates. In the end, evidence mattered.

The data illustrate that other legislators opposed HB 2726 because of values. This is likely the case for the 30 percent (n=3) of HB 2726 opponents who indicated no evidence could convince them to support the legislation, and also for the 60 percent (n=6) and 40 percent (n=4) of legislators who indicated, respectively, that the government has no role in influencing personal diet choices or in interfering with restaurant owners’ operations. The data suggest that opposition to HB 2726 was based primarily on ideological disagreements with the public health policy.

Implications

Evidence played a key role in influencing legislative support for HB 2726, but other factors—appealing to and mobilizing constituents, forming relationships with legislators, working with the business community—can be crucial for passing progressive public health policies. While a public health policy toolbox must include reliable and understandable evidence of efficacy, it must also include more. Evidence matters, but it’s not enough.

*HB 2726 has since been preempted by federal menu labeling provisions in the Patient Protection and Affordable Care Act.

Author

Sami Jarrah, MPH, is Strategy and Policy Analysis Manager for Integrated Clinical Services at the Multnomah County Health Department in Portland, Oregon.

Acknowledgments

Aaron Katz, CPH
Cindy Watts, PhD, MA

Resources

1. Sommer A. How public health policy is created: scientific process and political reality. Am J Epidemiol. 2001;154(12):S4-S6.
2. Wilensky, HL. Social science and the public agenda: reflections on the relation of knowledge to policy in the United States and abroad. J Health Polit Policy Law. 1997;22(5):1241-1265.
3. Stone DA. Causal stories and the formation of policy agendas. Polit Sci Q. 1989;104(2):281-300.