The fourth and final session of the June 2021 workshop featured a keynote speaker who offered reflections on the workshop and discussed equity-centered approaches for reducing the prevalence of obesity. Her remarks were followed by a panel discussion during which three of the workshop speakers answered questions from the audience. Melissa A. Simon, director of the Center for Health Equity Transformation at the Institute for Public Health and Medicine, and George H. Gardner Professor of Clinical Gynecology in the Feinberg School of Medicine at Northwestern University, moderated the session.
REFLECTIONS ON EQUITY-CENTERED APPROACHES TO REDUCING THE PREVALENCE OF OBESITY
Sarah de Guia, chief executive officer of ChangeLab Solutions, explained that ChangeLab Solutions is a national, nonpartisan, nonprofit organization that uses the tools of law and policy to advance health equity at the national, state, and local levels. Its interdisciplinary team of lawyers, planners, analysts, and other professionals works with community organizations, governments, and anchor institutions to develop and implement equitable policy solutions. According to de Guia, a focus of the organization is on demystifying law and policy, which she described as two powerful tools that are often inaccessible to the public yet hold strong potential both to help undo historical harms that affect large numbers of people and to engage change makers in the policy process. As ChangeLab works to connect stakeholders across sectors, she elaborated, a goal is to increase their understanding of equity issues and their ability to address them. She explained that ChangeLab pursues this goal by strengthening stakeholders’ leadership and capacity through training and technical assistance designed to help them leverage policy and legal tools that elevate practical, evidence-based, and community-centered solutions and successes.
As de Guia chronicled ChangeLab’s history, focusing on its efforts related to obesity prevention, she explained how the organization’s pivot to focus on fundamental drivers of health inequity has played out in its legal and policy solutions. The idea for ChangeLab Solutions arose in the mid-1990s, she recounted, when states had begun to win lawsuits against tobacco companies and found themselves with additional resources to support prevention of tobacco use. ChangeLab operated primarily as a provider of technical and legal assistance to local health departments in California, helping them use innovative legal and policy interventions—such as land use and zoning regulations, taxation, and First Amendment and consumer law—for tobacco control. According to de Guia, ChangeLab urged health departments to consider policy, systems, and environmental changes instead of the usual educational and outreach approaches, and
in the early 2000s began applying this perspective and its lessons from tobacco control to the topic of obesity prevention. She described initial efforts as being focused on downstream drivers of obesity, such as access to healthy foods and opportunities to be physically active, and as involving technical assistance as well as communication strategies to build the case for environmental change. In 2008, she continued, ChangeLab received a grant that enabled it to scale its policy and legal analysis efforts in obesity prevention to the national level. Yet despite the organization’s progress in addressing school environments and promoting healthy environments in other places, de Guia recalled, health disparities persisted and even widened among Black people, Indigenous people, other people of color, and low-income communities.
As ChangeLab considered how to integrate equity into its law and policy frameworks, de Guia reported, three resources, among many others, provided compelling data and evidence to support shifting its focus further upstream. The first was a framework for increasing equity in obesity prevention (Kumanyika, 2019), which is built on the premise that disparities related to health and obesity cannot be addressed adequately without attending to underlying health inequities (which are typically driven by upstream, systems-level factors). This framework, de Guia explained, includes policy solutions that incorporate traditional, downstream public health interventions, but also highlights the role of community engagement in the development of policies and practices. In addition to informing policies, she maintained, such engagement helps build social capital, increase community cohesion, build confidence and trust in government, and build on community strengths and assets. The second resource was an article on structural racism and health inequities in the United States (Bailey et al., 2017), which de Guia described as defining the systemic nature of structural racism and making the connection between historical racist laws and the policies and pathways that have led to disparities. The third resource was a trauma-informed approach (CDC, 2018) that encourages awareness of the impact trauma can have on communities and emphasizes principles of safety; trustworthiness and transparency; peer support; collaboration; empowerment; and cultural, historical, and gender issues.
In 2019, ChangeLab published A Blueprint for Changemakers, which posits that a focus on drivers of health inequities is critical for addressing health adequately and that unjust laws and policies are powerful risk factors for poor health given their historical perpetuation of racism, discrimination, and segregation. A Blueprint for Changemakers, de Guia elaborated, urges pursuing health equity by addressing five fundamental drivers of health inequity: structural racism and discrimination, income inequality and poverty, disparities in opportunity, disparities in political power, and governance that limits meaningful participation (Figure 9-1).
SOURCE: Presented by Sarah de Guia, June 22, 2021. Graphic from ChangeLab Solutions, 2019, used with permission. Design by Black Graphics.
As described in A Blueprint for Changemakers, these five co-occurring, overlapping drivers shape places, social environments, and living conditions, as well as individuals’ daily experiences and perspectives in those settings.
According to de Guia, ChangeLab’s recognition of these drivers has led it to adopt equity-centered frameworks and strategies that both enhance and go beyond its policy, systems, and environmental change approaches to improving public health. She explained that an equity-centered strategy for reducing health inequities addresses social and political pressures or promotes policies designed to change social determinants of health, applying a people-centered approach to identifying and prioritizing interventions that will most benefit underserved populations. A Blueprint for Changemakers offers several frameworks and approaches that spotlight people and communities most affected by injustice—for example, a “health in all policies” approach to government; ongoing, deliberate community engagement processes; and emphasis on local solutions. To highlight ChangeLab’s equity-oriented approach to changing policies, systems, and environments to reduce disparities in the prevalence of obesity while supporting and engaging communities most affected by structural barriers, de Guia offered three examples.
The first example was a systems change effort that applied a trauma-informed lens to an analysis of food policies in the U.S. Department of Agriculture’s (USDA’s) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The goal, de Guia explained, was to develop policy recommendations that might not be identified in a traditional public health analysis. Food insecurity is associated with traumatic experiences
that affect children’s development and health, de Guia pointed out; moreover, food assistance programs such as WIC are potential points of intervention to prevent trauma and retraumatization among individuals and families. According to de Guia, ChangeLab’s participant-centered approach and policy scan revealed that some WIC policies offer more generous food allowances for women who breastfeed fully or partially than for those who do not, although the policy does not necessarily consider that barriers to breastfeeding may be beyond a family’s control. She added that ChangeLab also found that few exceptions exist within WIC food packages for families of different cultural groups; de Guia asserted that a trauma-informed lens would seek to preserve WIC participants’ sense of control and choice. If these participants were invited to provide feedback on the program’s administration, she argued, their suggestions could improve its effectiveness and even identify community assets, such as stores offering cultural foods, that could be considered for inclusion in food packages.
With her second example—an effort to enact taxes on sugary drinks in Berkeley, California—de Guia highlighted advocates’ innovative approach that involved engaging community youth. The first step was to inform young people about the contribution of sugary drinks to diabetes, and then to alert them to such structural issues as targeted advertising of sugary drinks to Black and Latinx communities. Community members were also asked for ideas on how to spend revenues from taxes on sugary drinks, de Guia recalled, and an advisory board was formed to help distribute the funds. This example illustrates key components of the Kumanyika framework,1 de Guia pointed out; the change effort deters harmful products while also fostering community engagement and capacity.
The third example offered by de Guia also featured a community-centered approach, which grew out of a New Jersey documentary demonstrating how community assets could transform local structures and systems to enhance food security. ChangeLab identified legal barriers that communities needed to surmount in order to create and expand urban agriculture, farmers’ markets, and community gardens, de Guia said.
Shifting to reflect on the workshop presentations and discussions, de Guia offered a simple graphic (Figure 9-2) highlighting communications, data, community engagement, and equitable policy solutions, which she proposed are core, interrelated components in advancing efforts to reduce the prevalence of obesity.
The public and policy makers are two important audiences for communications, de Guia observed. She suggested framing messages with a
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1 The equity-oriented obesity prevention action framework is intended to assist in selecting or evaluating combinations of interventions that incorporate considerations related to social disadvantage and social determinants of health (Kumanyika, 2019).
SOURCE: Presented by Sarah de Guia, June 22, 2021. Reprinted with permission.
lens of fairness and justice, highlighting practices that drive disparities, and offering corresponding policy solutions. Communities want to see their assets and strengths uplifted in policy solutions, she maintained, instead of hearing only alarm bells and lectures about the problem.
According to de Guia, building intentional, deep relationships with communities engages them as cocreators—rather than mere recipients—of policies, which in turn increases the likelihood of developing optimal solutions for their needs. Such relationships also enhance policy evaluation by meaningfully soliciting community members’ experiences with and feedback on a policy—information that de Guia termed “community-defined data.” Stating that she was energized by the potential opportunities to engage schools and clinical settings in obesity prevention in new ways, de Guia underscored the value of multisector collaboration. She urged public health stakeholders to learn other sectors’ languages and to frame communications in a way that invites collaboration. She also urged mindfulness of potential biases in data sources and data collection methods, cautioning against introducing bias into such seemingly neutral tools as artificial intelligence and algorithms.
PANEL DISCUSSION
Following de Guia’s presentation, Simon moderated a discussion with three of the second workshop’s speakers: Colby Duren, director of policy and government relations at the Intertribal Agriculture Council (Chapter 8);
Jeff Niederdeppe, professor in the Department of Communication, director of the Health Communication Research Initiative, and codirector of the Center for Health Equity at Cornell University (Chapter 6); and Patrick O’Connor, senior clinical investigator and codirector of the Center for Chronic Care Innovation at HealthPartners Institute (Chapter 7). Panelists discussed topics that included laying the foundation for a successful communication strategy, using big data and clinical decision support tools, addressing climate change through agricultural policy, navigating gaps in data, implementing public health infrastructure initiatives that relate to obesity, and communicating about COVID-19 and obesity.
Laying the Foundation for a Successful Communication Strategy
In response to Simon’s question about successful two-way communications, Niederdeppe drew a contrast between interpersonal communication, in which exchange and feedback (both verbal and nonverbal) are available to enhance effectiveness, and organizational or community communication, in which the lack of direct feedback from various audiences creates a challenge. He cautioned that a communication strategy to achieve buy-in for a proposed policy will face an uphill battle if those at whom the policy is targeted have not been engaged in its development. He appealed for taking an inclusive approach to articulating shared goals and cocreating policies, explaining that including all stakeholders at the outset enables communication strategies to better reflect the interests of different groups and organizations.
Using Big Data and Clinical Decision Support Tools
O’Connor replied to Simon’s question about big data challenges and considerations by highlighting limitations of the data available in clinical decision support tools. These technologies are restricted to data that are included in an easily retrievable form in electronic medical records or other related big data systems, he explained, which are largely devoid of patient-reported outcomes, let alone information about the patient’s personal values and beliefs. According to O’Connor, it is a major challenge to obtain this type of data and incorporate it securely into clinical datasets so it can inform clinical decision making. Reiterating his presentation’s emphasis on shared decision making, he said a communication gap often exists between providers and patients because providers may have difficulty presenting information in a way that patients understand. He pointed out as well that providers tend to lack the training and skills that are often needed to counsel patients about health behavior change (e.g., smoking cessation) so that the potential benefits identified by clinical decision support tools can be achieved.
Addressing Climate Change through Agricultural Policy
Duren focused on climate change in his response to Simon’s question about additional outcomes that could be addressed through agricultural policy. Taking a broader perspective, he noted that large-scale entities often develop policies in silos, which results in approaches that are limited to their own departmental and issue area realms. A more inclusive approach, he suggested, would be to ensure representation of a broader group of stakeholders in policy initiation and development. One of the first hearings on climate change held by the agriculture community did not include producers of color, he recalled, who could have indicated how potential solutions would impact their communities and contributed their own ideas for solutions to serve their communities’ needs.
Duren highlighted as a further challenge that an issue initiative undertaken by a federal department may be discontinued when a new administration with different priorities takes control. This happened several years ago when the U.S. Department of the Interior’s Bureau of Indian Affairs allocated funding for tribes to formulate climate change actions and plans, he recounted, until the subsequent administration decided not to continue the program.
Duren encouraged those considering large-scale changes to address such issues as climate change to adopt a perspective that considers the issue in the context of the entirety of a government department’s programs. As an example, he pointed to USDA, whose provision of funding to producers is contingent on certain requirements. Duren suggested that those requirements could be adapted to empower producers who want to venture into an innovative practice such as regenerative agriculture.
Navigating Gaps in Data
A participant asked panelists what they should do if data they need are not available. In the clinical context, replied O’Connor, provider–patient conversations can elicit patient priorities and guide shared decision making about behavior change and other treatment options. Such an exchange can be difficult in the face of communication barriers related to culture or language, he pointed out, and even more so if a patient’s conception of a health condition deviates from a Western biomedical perspective. He added that most EMR systems have a patient portal where information can be exchanged between patient and provider, but at present, this pathway is often limited to one-way sharing of laboratory results and visit summary notes with patients. Enabling patients to self-report their beliefs, values, and preferences and provide information about symptoms or lifestyle, he argued, would greatly expand the scope of clinical decision support systems. Simon pointed to the concept of a learning health care system designed to enable a patient’s preferences and values to drive the clinical care team’s learning.
In Niederdeppe’s experience, data are rarely available at a level needed to predict the outcomes of systems-level changes. A wide range of relevant data with a high degree of confidence related to effects on health, economic, social, or equity outcomes may be needed, he elaborated, and he echoed Duren’s call to solicit the input of a broad, diverse group of stakeholders to identify some of those potential effects based on their lived experiences. He also stressed the importance of consistent evaluation of systems change interventions to assess their implementation and compile lessons that can be applied the next time a similar intervention is implemented in a different community.
Implementing Public Health Infrastructure Initiatives That Relate to Obesity
A participant asked whether any public health initiatives in the U.S. Congress’s infrastructure bill have the potential to influence the prevalence of obesity. Duren responded that the final provisions and specific language of the bill are still uncertain, but from his perspective, an important public health support would be to improve access to potable water in homes and other community settings. A more tangential yet relevant public health support would be to increase access to broadband, he suggested, which would provide opportunities for telemedicine and support the building of additional health facilities in rural areas and throughout Indian country.
Communicating about COVID-19 and Obesity
Niederdeppe shared two observations about health communication regarding COVID-19 and obesity. First, he stated that mixed messages from a government agency about what is considered evidence-based practice result in public confusion in the short term and erosion of trust in public health institutions in the longer term. He added that the perception of mixed messages may be accurate, particularly if messages have been politicized, or less accurate, if changing guidance reflects an evolving evidence base used to inform best practice.
This issue reflects a broader communication challenge, Niederdeppe said in introducing his second observation: that complex, dynamic concepts cannot always be distilled into simple, definitive messages and that doing so may risk causing public distrust in the longer term. He referenced the example of face mask guidance early in the COVID-19 pandemic, recounting the shift in public messaging that paralleled emerging science but was perceived by many to represent an abrupt turnaround. Niederdeppe encouraged those responsible for health communication to raise awareness that science is a process that results in an evolving understanding of the truth—and thus in the evolution of public health guidance—as the evidence base grows.
To respond to Simon’s follow-up question about whether the emphasis on protecting others as the public health rationale for mask wearing was in-congruent with the individualistic culture of the United States, Niederdeppe observed that public health messaging is often based on fear and defaults to the concept of “protect yourself.” He urged improvements in communicating the value of individual actions in influencing collective benefits.
O’Connor asked Niederdeppe for advice on how to improve provider–patient communication. Niederdeppe suggested striking a balance between talking and attentive listening, offering qualitative explanations of risks and benefits that are typically provided in quantitative terms, and considering how to provide communication opportunities outside of the clinical encounter with the primary care provider.
O’Connor addressed the final question from a participant, who asked about the role of obesity treatment in relation to efforts to change systems to reduce the prevalence of obesity. According to O’Connor, it is important to pursue both as part of a holistic approach to addressing the root causes of the problem, and the most effective way to combat the obesity epidemic may be to coordinate public health, environmental policy, public policy, and clinical approaches.
