Categorías de la educomunicación

I conducted a systematic literature review to better understand what evidence existed about specific barriers and facilitators to adopting Health-related policies at the state-level. I performed a single search in January 2016 of the English-language literature indexed in PubMed over the last 20 years (from January 1996 to January 2016) using a broad set of search terms to maximize sensitivity (Table 2). The search terms listed in Table 2 were combined for one single, complete search: (barriers OR challenges OR facilitators OR facilitating factors) AND (state OR state-level) AND health AND (policy OR legislation OR bill) AND (adoption OR adopting OR passing OR passage). First, I gathered studies from the peer-reviewed literature indexed in PubMed. Then, I used snowballing to identify additional relevant articles and related citations. I also included a few additional articles that were brought to my attention by separate sources. I developed a review form (an excel spreadsheet) to systematically record specific information from each article.

Table 2: Literature Review Search Terms

Barriers AND State AND Health AND Policy AND Adoption OR Challenges OR Facilitators OR Facilitating factors OR State- level OR Legislation OR Bill OR Adopting OR Passing OR Passage

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My initial PubMed search returned 187 articles. Snowballing resulted in the inclusion of 8 more articles, and 5 additional studies were included for review after they were brought to my attention. I reviewed titles and abstracts for relevance and identified 39 articles that I then retrieved in full text and reviewed for inclusion (22 from PubMed, 9 from snowballing, 8 from an outside source). Of the 39 articles that I reviewed fully, I found 24 to be relevant in terms of providing information about specific barriers and facilitating factors to adopting Health-related policies at the state-level (13 from PubMed, 8 from snowballing, and 3 from an outside source).

I included articles that specifically discussed barriers and/or facilitators to passing or adopting legislative or regulatory Health-related policies within U.S. states. I excluded articles if they discussed national-level policy or policies passed in other countries. I also excluded articles if they were too specific to be relevant to other health policy issues (e.g., cost as a barrier to vaccine coverage, or barriers to adopting electronic health records). I did include a few key articles that addressed the adoption of voluntary policies or policy adoption at the local level.

Findings

The articles that I reviewed considered barriers and facilitators to passing or adopting a number of different legislative or regulatory Health-related policies. Five studies were

specifically related to healthcare laws and policies, including two studies specific to Medicaid initiatives (Merryman, Miller, Shockley, Eskow, & Chasson, 2015; Sams, Rozier, Wilder, & Quinonez, 2013), one that looked at laws aiming to make mental health care more accessible for children with limited English proficiency (e.g., requiring language interpreter services in patient settings and multicultural staff training) (Schmeida & McNeal, 2013), one that identified barriers

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and facilitators to state-level implementation of primary stroke center (PSC) policies (O'Toole, Slade, Brewer, & Gase, 2011), and one that explored legislative efforts to attain direct access to a physical therapist without a physician referral or prescription (Shoemaker, 2012).

Seven studies explored barriers and facilitators to adopting tobacco control policies at the state or local level (Ahrens, Jones, Pfister, & Remington, 2011; Flynn et al., 1998; Francis, Abramsohn, & Park, 2010; Goldstein et al., 2003; Satterlund, Cassady, Treiber, & Lemp, 2011; Satterlund, Treiber, & Cassady, 2013; Satterlund, Treiber, Haun, & Cassady, 2014). Seven additional studies looked at factors that enabled, impeded, or predicted enactment of state legislative action to address obesity, including six articles that specifically addressed legislation aimed at preventing childhood obesity (Boehmer, Luke, Haire-Joshu, Bates, & Brownson, 2008; Cawley & Liu, 2008; Dinour, 2015; Dodson et al., 2009; Eyler, Nguyen, Kong, Yan, &

Brownson, 2012), and one article that looked at enactment of adult obesity prevention legislation (Donaldson et al., 2015). One additional study looked at policy changes to support breastfeeding, examining barriers and factors that facilitated the adoption and implementation of breastfeeding policy changes (Johnson, Lamson, Schwartz, Goldhammer, & Ellings, 2015)

Four articles looked at barriers and facilitators related to legislative health reform efforts, including three that specifically discussed the development and enactment of single-payer health care reform legislation in Vermont (Blanchet & Fox, 2013; Fox & Blanchet, 2015; Hsiao,

Knight, Kappel, & Done, 2011) and one article that reviewed the activities of seven states related to health care reform and the lessons learned from their activities (Paul-Shaheen, 1998). One final study explored tactics commonly used by groups that advocate for state laws to regulate firearm use, availability, or manufacture (Zakocs, Earp, & Runyan, 2001). I did not find any

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studies that were specific to the barriers or facilitating factors to adopting paid family leave policies.

Many of the barriers and facilitating factors outlined in these articles fit within one of Kingdon’s three streams, (problem, policy, or politics) or supported the concept of an open policy window. Additional barriers and facilitating factors supported Mintrom’s theory of policy entrepreneurs and the importance of dynamic political actors. Some of the factors identified from the literature did not fit neatly into one of these categories. These factors were primarily related to the socioeconomic and demographic (non-political) environment within the state that made it more or less likely to enact Health-related legislation. This is discussed in more detail below.

Environmental Context

Multiple state-level socioeconomic and demographic characteristics were associated with passing Health-related policies, including a higher percentage of college-educated adults, higher per capita income, a higher percentage of African Americans, more households that did not use English as their primary language at home, and anticipated issues related to population growth (Boehmer et al., 2008; Cawley & Liu, 2008; Schmeida & McNeal, 2013).

In a study looking at correlates of state legislative action to prevent childhood obesity, researchers found that wealthier states (based on per capita income) and states with a higher percentage of college-educated adults were more likely to introduce bills related to childhood obesity. State legislative action was also correlated with the racial composition of the state; anti- obesity policies were more likely to be enacted in states with larger African American

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populations. Additionally, state legislative action to address childhood obesity was more likely in states that reported a greater gap between adults’ actual and desired weight. Controlling for state- level adult obesity prevalence rates, greater deviation from desired weight may reflect greater dissatisfaction with being overweight among adults in the state, which may lead to more public support for policies to prevent childhood obesity (Cawley & Liu, 2008).

Schmeida and McNeal looked at 18 U.S. states that passed language laws promoting equitable mental health services for children with limited English proficiency, and 32 states that had not (Schmeida & McNeal, 2013). In this study, growth management innovation, an index based on the presence of programs to address the state’s ability to manage both growth and population decline, was used as an indicator of state agency resources and a measure of a state’s ability to anticipate and respond population growth and decline. Growth management innovation was positively associated with the adoption of children’s mental health language access laws, suggesting that states that anticipated problems related to population growth or decline were more likely to adopt children’s mental health language laws. Additionally, states with a higher number of residents that did not speak English as their primary language (ages 5 and over) were more likely to adopt and implement these laws.

Problem Stream

Kingdon’s problem stream includes the conditions or issues that present themselves as problems, and changes or circumstances that lead to the issue being viewed as something that requires the attention of policy makers. Misperceptions about the problem were commonly cited as barriers to passing a bill (Fox & Blanchet, 2015; Johnson et al., 2015; Merryman et al., 2015).

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For example, despite a window of opportunity to pass comprehensive health care reform in Vermont in the early 1990s, the attempt failed for a number of reasons. Multiple stakeholders that were interviewed discussed a misleading story in the media concerning a potential tax increase and a grassroots opposition campaign that developed in response to the perceived tax increase, which significantly weakened public support (Fox & Blanchet, 2015).

In a study looking at barriers and facilitating factors related to the adoption and implementation of breastfeeding policies in community health clinics, misperceptions about breastfeeding and available support were major barriers, including the perception that

breastfeeding did not need to be a focus of clinical care because it was being taken care of by staff from The Women, Infants, and Children (WIC) program (Johnson et al., 2015). An additional study investigated the primary success factors and barriers to adopting a Medicaid waiver that would allow state Medicaid agencies to create specific programs to serve individuals with Autism Spectrum Disorder (ASD). States that chose not to adopt an ASD-specific waiver perceived that children and youth with ASD were served sufficiently well through other

Medicaid benefits, and that intervention and monitoring would be more difficult than what they were currently doing (Merryman et al., 2015).

Being able to demonstrate clear evidence of the consequences of the problem and the ability to personalize health concerns were common factors that facilitated bill passage (Cawley & Liu, 2008; Goldstein et al., 2003; Satterlund et al., 2011). Additionally, national media

exposure around childhood obesity helped contribute to a growing awareness regarding the need to address the problem, and aided the passage of state-level childhood obesity prevention

legislation (Dodson et al., 2009). Notably, in two studies that looked at local-level tobacco control policy campaigns, arguments that were provided in opposition to the policies reduced the

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perceived significance of the problem and impeded bill passage (e.g., that there were other, more “pressing” issues, and that the need to address the problem did not outweigh perceived individual rights) (Satterlund et al., 2013; Satterlund et al., 2014).

Policy Stream

The policy stream includes feasible and acceptable policy solutions to the problem(s). Two specific barriers were identified that were related to the policy itself, or to potential policy alternatives. High costs associated with a bill (or a lack of financial resources to address the problem) and administrative concerns about additional reporting and monitoring that would be required were reported as significant barriers to passing strong, Health-related policies (Dinour, 2015; Johnson et al., 2015; Merryman et al., 2015; O'Toole et al., 2011; Sams et al., 2013).

Insufficient funding was the primary barrier to adopting a Medicaid waiver that would allow state Medicaid agencies to create specific programs to serve individuals with ASD (Merryman et al., 2015). Likewise, cost was a major barrier to adopting bills to limit the

availability and accessibility of competitive foods in schools (competitive foods are often of poor nutritional quality and sold in competition with reimbursable meal programs) (Dinour, 2015). Administrative issues were the most commonly reported barriers that kept state Medicaid programs from adopting initiatives to support the provision of preventive dental services by non- dental healthcare professionals. Policy adoption was more likely if the initiative was perceived to be simple and compatible with other Medicaid programs (Sams et al., 2013). Similarly, the adoption of breastfeeding policies in community health clinics was limited by the perceived need

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for organizational changes to accommodate actions like monitoring breastfeeding rates and allowing providers training time in response to new policies (Johnson et al., 2015).

Bill content was also critical, with bills related to more politically feasible and acceptable policy solutions (which varied by state) more likely to be adopted. For example, bills related to “safe routes to school” (programs that aim to make it safer for students to walk and bike to school), access to healthy food, physical activity, or educational programs, health and nutrition content, and those related to modifying rules and procedures (e.g., preemption) were more likely to be enacted than bills related to product or menu labeling, or food or beverage taxes (Boehmer et al., 2008; Donaldson et al., 2015; Eyler et al., 2012). Bills related to areas considered to be controversial by policymakers and their constituents, or by the business community or large industries (e.g., menu labeling) were less likely to be considered or adopted. Additionally, bills that were viewed as having the potential to create an unfavorable environment for business by imposing regulations or fees were less likely to pass (Satterlund et al., 2014).

Politics Stream

The politics stream comprises the political conditions in the environment, including public mood, ideologies of the current political leadership, and the presence and activities of a visible cluster of policy actors. A number of facilitators and barriers associated with the political conditions in the environment were identified within the literature outlined above, and state political climate strongly predicted legislative action. Bill passage was more likely in states with a Democratic governor, a unified Democratic government (or a legislature not controlled by Republicans), and term limits for offices held at the state level (Boehmer et al., 2008; Cawley &

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Liu, 2008; Eyler et al., 2012; Fox & Blanchet, 2015; Paul-Shaheen, 1998). Legislative power and influence have long been associated with legislative success, as measured by bills being passed into law. Legislators who held a formal office in the legislature (e.g., in the party leadership, as a committee chair, or as a ranking member), those within the majority party, and those from safe districts (those not facing strong competition for re-election) have been found to be more influential and effective (Ellickson, 1992). Having more than one sponsor or bipartisan

sponsorship increased enactment (Boehmer et al., 2008), as did more activity in general by civil rights and interest groups (Schmeida & McNeal, 2013) and the existence of relatively weak opposition (Fox & Blanchet, 2015).

Notable other facilitating factors included obtaining the support of influential or senior legislator(s) as well as other key players, including parents, physicians, school officials, and other influential champions (Dodson et al., 2009; Goldstein et al., 2003; Merryman et al., 2015; Satterlund et al., 2014). The ability to demonstrate constituent support for a proposed policy to policymakers was instrumental to passing tobacco control policies at the local level (Satterlund et al., 2011).

Prominent barriers to passing Health-related policies included having a small number of supporters with limited political influence, opposition by powerful lobbyists and/or a large number of opponents with greater political influence (Dodson et al., 2009; Shoemaker, 2012), and facing legislators in powerful positions who opposed a bill (Shoemaker, 2012). Additionally, tobacco control advocates reported multiple barriers specific to the policymaking process,

including a cumbersome, lengthy decision-making process, difficulty gaining access to policymakers, and difficulty understanding and effectively presenting the right information to policymakers (information they perceived as important) (Satterlund et al., 2011).

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Timing was also found to strongly influence bill passage (Fox & Blanchet, 2015; Paul- Shaheen, 1998). In the case of health reform, the defeat of the Clinton Administration’s health care reform package at the national level in 1993 weakened support for the state-level effort in Vermont later that year. Seventeen years later, the passage of the Patient Protection and

Affordable Care Act (ACA) in 2010 helped raise the saliency of health care reform as a political priority issue, and in May 2011 Vermont became the first state to lay the groundwork for a single-payer health care system (Fox & Blanchet, 2015). The state-level policy process can be viewed as a continuum, with major reforms being the product of earlier, smaller efforts at the state and local level (Paul-Shaheen, 1998). Pursuing a statewide policy prematurely can result in a weak policy that has the ability to stymie local efforts and delay the adoption of a more

meaningful statewide policy (Francis et al., 2010). The influence of timing can be viewed both as a political condition and as the opening of a policy window.

The Policy Window

As stated above, an issue is most likely to make it onto the policy agenda when all three streams (problem, policy, and politics) converge, creating a window of opportunity for the policy to pass (Kingdon, 1997). Policy proposals may exist but may not be viewed as feasible,

acceptable, or affordable until conditions in one of the three streams change. In 2003, despite a packed legislative agenda focused primarily on education, the state of Arkansas enacted innovative, comprehensive legislation to combat childhood obesity. Specific changes in the problem and political streams helped to open a window, providing the opportunity for policy change (R. L. Craig, Felix, Walker, & Phillips, 2010).

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In the problem stream, Herschel Cleveland who was the Speaker of the House at the time (and a Democrat) and then-Governor Mike Huckabee, a Republican, both experienced serious personal health problems related to obesity. Their experiences brought attention to the issue and made it clear that the fight against obesity was bipartisan. Additionally, several significant actions occurred in the political stream leading up to the 2003 legislative session that greatly influenced the attitudes of Arkansas policymakers. In 1999, the Legislature commissioned an Obesity Task Force to study the effects of obesity and make recommendations for state action. In 2000, the task force recommended legislation to enact a comprehensive statewide program to raise public awareness and enhance school policies and practices related to nutrition and physical activity.

Arkansas legislators attended a series of meetings and conferences in 2001 and 2002. At the 2001 National Foundation for Women Legislators Conference, one legislator recalled that “all across the whole wall was plastered ‘Little Rock, Arkansas–number 1 in the nation for childhood obesity and type 2 diabetes,” noting that seeing this really woke them up and

influenced them to speak out. In early in 2002, Arkansas legislators and other policymakers met with leaders from six neighboring states and discussed potential approaches to addressing health issues in their states, including childhood obesity. Later in 2002, leaders were invited to a one- day summit to develop practical, achievable policy alternatives related to nutrition and physical activity in the school environment (R. L. Craig et al., 2010). These activities set the parameters for defining the problems and helped legislators develop realistic, feasible interventions.

It is important to note that an open policy window is not always enough. Legislators and advocates in Vermont they had an open policy window to pass a comprehensive health reform bill in 1991. They had elected a Democratic governor who was also a physician, the state had

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already established a commission on health care to make recommendations, they had multiple single-payer champions and policy entrepreneurs in the state, a progressive social movement around the issue, and heightened attention was being paid to health reform efforts at the national level. This momentum led to the development of three different proposals that were all too costly for the fiscally conservative governor, and no single plan rose to the top for advocates and

supporters to rally behind (Fox & Blanchet, 2015).

A crisis (real or perceived) and media attention (due to a crisis or on its own) can also serve as a facilitator and create a window of opportunity for policy change. National media exposure was found to influence the passage of legislation intended to prevent childhood obesity in a number of states (Dodson et al., 2009). Additionally, the perception of a crisis alone was able to create a window of opportunity for legislation and serve as a catalyst for political action. The escalating cost of health care in the states served as the key “crisis” (in terms of costs to the middle class, the government, and the business community) that influenced state-level health reform efforts (Paul-Shaheen, 1998).

Policy Entrepreneurs

Policy entrepreneurs are political actors who seek to initiate dynamic policy change, and who are responsible for promoting policy innovations and energizing the diffusion process