Tag Archives: policy

Systems and self-esteem: Being helpful and constructive on obesity.

By Ashley White

I am not sure it’s possible to better articulate exactly how far off the mark anti-obesity campaigns tend to be that in the way Jezebel’s Lindy West has done right here:  It’s Hard Enough to Be a Fat Kid Without the Government Telling You You’re an Epidemic

She writes, “But first of all, though weight loss can certainly improve some people’s health, “fat” does not universally equal “unhealthy.” Health itself is a much more effective and specific goal. And campaigns like this—which target fat people instead of the system that makes them fat—do nothing but hurt that supposed cause. An anti-fat-people campaign is still an ANTI-PEOPLE CAMPAIGN.”

But, after this piece was published, West herself commented first, “Question. So, okay, if I’m saying that these ads are NOT HELPFUL–and a lot of you are agreeing with me–can anyone come up with a pro-health ad that would be genuinely helpful and constructive? Thoughts? What would that look like?

And so, I’ve been thinking on it.  Aside from killing subsidies to corn, boosting subsidies to a diverse array of plant crops, creating better ways to get good and affordable food to the North – which definitely must happen – and addressing poverty, education deficits, and infrastructure problems, what would be a radical approach to helping people attain healthy weights?
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Take This and Shut Up

By Kerry Porth

Earlier this year, I attended a talk on the Global Drug War.  After the talk, audience members were given an opportunity to ask questions and I was struck by a comment made by a member of the Vancouver Area Network of Drug Users (VANDU).  After introducing himself as a heroin user of some 35 years, he declared that “abstinence should not be viewed as a victory but rather, a defeat. It represents the complete and utter failure of self-will.” I was surprised to find myself in enthusiastic agreement with him.

For 23 years, my regular attempts to “recover” from addiction were facilitated by the 12-steps. This model posits addiction as a chronically relapsing disease. The medical detoxification facilities I attended (12 times in as many years) required daily attendance of Alcoholics Anonymous or Narcotics Anonymous meetings and group therapy sessions where we were told that the only positive outcome was complete abstinence from all drugs and alcohol.  We were told that we must no longer associate with anyone who uses drugs or alcohol and that we should avoid “slippery” places such as bars or areas where we used to score drugs.  We were told that we could never control our use or have just one drink. Drug addicts who had never abused alcohol were told they couldn’t drink and alcoholics were told they couldn’t smoke pot. To do so would mean an immediate relapse into hard-core addiction. We were told we couldn’t make any decisions for at least a year.  We were told we couldn’t enter into a romantic relationship.  Basically, we were told that we were an extreme danger to ourselves, we were sick, incurable, and would never have self control.  Indeed, the first of the twelve steps is an admission of powerlessness.

Well, I call bullshit. Continue reading

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What’s the evidence?

By Emily Groot

There has been a big push in public health to use the best available evidence to inform policy development.  When it comes to radical public health policy change, however, developing the evidence base for policy can be difficult.

In part, this is because randomized controlled trials (RCTs) are often considered the gold standard in health research.  When it comes to interventions that address the determinants of health, RCTs are often not feasible because the root causes of illness and well-being are interconnected and cannot be reduced to component parts (Norman, 2009).  Natural experiments are hard to come by.

Even when feasible, RCTs may not be preferred way to study systems change because the careful selection of the study population means that it is difficult to generalize the results to the broader population (Rockers et al., 2012).  As well, RCTs usually attempt to control the impact of historical, cultural, and political factors that are essential to understanding how an intervention will fare in a particular context (Best et al., 2009; Rockers et al., 2012).

Most RCTs only address single interventions, while in real life there are multiple policies already in effect.  These policies may interact in non-linear ways that are difficult to predict from the available evidence (e.g., a change to agricultural subsidies and a change to social assistance funding may both decrease the risk of obesity, but when both policies are implemented simultaneously, the total impact may be much greater than the sum of the impacts of both programs) (Peters & Bennett, 2012; Sanderson, 2009).

In essence, interventions addressing the determinants of health are often so context-dependent it is difficult to predict their effectiveness in a particular context.  That is not to say it is impossible.  What is necessary to change health systems to better address the determinants of health is a range of different types of evidence, including:

  • Information about overcoming local barriers to implementation;
  • Evidence from non-research environments;
  • Description of the unintended consequences or political ramifications of the intervention;
  • Evidence of the impact of the intervention on equity;
  • Assessments of the intervention’s technical feasibility; and
  • Assessment of the intervention’s acceptability to policymakers and stakeholders (Bosch-Capblanch et al., 2012; Peters & Bennett, 2012).

This can also include evidence of effectiveness from RCTs, when feasible.

References

Best, A., Terpstra, J. L., Moor, G., Riley, B., Norman, C. D., & Glasgow, R. E. (2009). Building

knowledge integration systems for evidence-informed decisions. Journal of Health Organisation and Management, 23(6), 627-641.

Bosch-Capblanch, X., Lavis, J. N., Lewin, S., Atun, R., Røttingen, J.-A., Dröschel, D., Beck, L., et al. (2012). Guidance for evidence-informed policies about health systems: Rationale for and challenges of guidance development. PLoS Medicine, 9(3), e1001185.

Norman, C. D. (2009). Health promotion as a systems science and practice. Journal of Evaluation in Clinical Practice, 15(5), 868-872.

Peters, D. H., & Bennett, S. (2012). Better guidance is welcome, but without blinders. PLoS Medicine, 9(3), e1001188.

Rockers, P. C., Feigl, A. B., Røttingen, J.-A., Fretheim, A., de Ferranti, D., Lavis, J. N., Melberg, H. O., et al. (2012). Study-design selection criteria in systematic reviews of effectiveness of health systems interventions and reforms: A meta-review. Health Policy, 104(3), 206-214.

Sanderson, I. (2009). Intelligent policy making for a complex world: Pragmatism, evidence and learningPolitical Studies, 57(4), 699-719.

 

Parts of this post were originally written for a paper submitted for CHL6020Y Y at the University of Toronto.

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