No major public health success has been attained without the use of legislation and its associated enforcement. We’ve recently witnessed this at hyper speed during COVID-19, when legislative action has been quickly enlisted to prevent the spread of this infectious disease – from mask mandates to quarantine, isolation and other lockdown measures enforced through criminal sanctions.
Legislation and policy have always been the most powerful interventions to improve population health. They are important tools to assist in the creation of environments that support and encourage healthier behaviours. Major public health successes built on a legislative approach have also required the support of education, awareness campaigns and services. This has been demonstrated in our response to COVID-19 and other communicable diseases as well as other examples including:
- Tobacco control with taxation, advertising bans and indoor smoking bans supported by health services and campaigns.
- Injury prevention with seat belt legislation, bicycle helmets, speed and drink driving legislation, gun control and various Australian Standards for products all supported by campaigns.
Such legislation has ordinarily been implemented in a staggered fashion, adding individual new pieces of legislation over the course of many years. Notably, legislative change for public health is only possible where the majority of the community is voluntarily complying with the matter to be legislated and the majority of the community supports a regulatory approach. Legislation is then a tool used to nudge and support the behaviour of those who are not voluntarily adopting healthy behaviours. This incremental approach to legislation is best approached alongside substantial community awareness, knowledge and engagement.
The rapid pace with which legislative changes were made for public health orders on COVID-19 may well give the impression that change can happen quickly. But outside the circumstances of a pandemic, the wheels of change move much more slowly. Through my experience in public health from practitioner to researcher to policymaker, I have been fortunate to identify the considerations and tools that can be used to support the process of legislative or policy reform.
A certain series of events may make an intervention more palatable to decision makers and help garner more community support for the passage of new legislation or policy that might otherwise not have been possible.
In the early stages of the COVID-19 pandemic in Australia, for example, legislation was used with public health orders limiting individual movement or business operations. Timing and political will is now turning to how public health orders may address issues regarding mandatory COVID-19 vaccinations in certain workplaces. While these issues remain contentious, it is hard to imagine what the public or political appetite would be in other circumstances for any other communicable disease.
‘Political will’ is an interesting concept to comprehend for researchers, and even policy makers at certain times. We need to look at practical solutions rather than perfect solutions. Politicians generally reflect the will of the population, and it is important for researchers and policy makers to be well prepared when proposing public health interventions or reforms.
Any final legislation or policy is always a compromise between the best evidence, feasibility constraints, political constraints and readiness of the population to adopt the reform. This should be seen as part of the process of reform that is incremental and acceptable to the community and represents progress.
The role of politicians is to reflect and represent the general public’s views. The role of public health is therefore to understand the sentiment of the community.
Legislative interventions will not occur without clear support from the majority of the community. We must continually ask how we know a majority of the community supports a proposed intervention and this highlights an ongoing reliance on a range of consultation approaches.
Community surveys using robust epidemiological methods for sample selection, data collection and analysis can provide clear evidence of community sentiment. This can be particularly helpful when there is a vocal minority opposed to the reform, but who have traction in the media or with decision makers.
Deliberative democracy is a process whereby a group of people, considered representative of the community, gather to deliberate a topic. The group actively seeks the information or expertise that they determine is necessary to assist in the deliberation and finally decide on their position on the topic. This methodology can demonstrate clearly what the community thinks about a topic once informed and can help to influence key decision makers to adopt the policy, should it be broadly supported by the community.
This form of consultation was used effectively with a Citizen Jury in South Australia in 2017 regarding proposed amendments to the Dog and Cat Management Bill. I was involved in presenting evidence to the jury as part of my role as SA Health Director of Epidemiology with a study on how desexing dogs reduced aggression and the associated risk of dog bites. The legislation change was subsequently adopted and mandatory desexing of dogs (with some exceptions) has been implemented with little of the community outrage orginally expected because of the key steps we followed as outlined here.
The signifigicance of coalitions of stakeholders cannot be over-emphasised. While not all stakeholders will share the objectives of a proposed reform, it is important to note that reform will work best when all relevant stakeholders support the reform effort or agree not to thwart it.
When it came to pushing for reforms with mandatory pet desexing, although our study supported the Dog and Cat Management Board advocacy position, we needed to enlist the support of other key stakeholders such as animal welfare groups and councils. These differing stakeholders wanted to tackle a range of other issues in the bill such as mandatory microchipping, increased penalties for dangerous dogs or puppy “farming”. While we may have come to the coalition with differing advocacy or interest, we were all working towards the same outcome.
It is important to appeal to a wide variety of stakeholders, keeping in mind that a different emphasis may need to be placed on some aspects of the reform versus others for some stakeholders. Of course, this is while remaining transparent to all stakeholder partners on all aspects of the reform. When it comes to contentious matters, a coalition that is prepared to publically or privately support the reform is vitally essential.
All policy and legislation should be grounded in high quality peer-reviewed evidence. In public health, there is frequently little high-quality evidence on interventions, such as cluster randomised trials. There is, however, a large body of high-quality evidence on how to shift behaviour at the population level and this should be the framework for all proposed interventions in public health.
Where observational study designs are used to guide a reform, it is important to triangulate this with other sources, such as different study designs, using different disciplinary knowledge or effectiveness of the intervention in different populations. If there is consistency across this multiple lens view of the data, there can be more confidence that the intervention may be effective if applied at the population level.
There are many instances when there is good evidence for the need for an intervention without tranlsation into real-world legislation or policy. These situations should be examined carefully to identify the enablers and barriers to implementation, with a focus on finding solutions. This might be a missing piece of information from a data perspective, a missing tool, stakeholder engagement or other barrier that can be overcome with adaptation. A pilot intervention may be feasible in order to demonstrate the intervention is effective in generating positive outcomes or not generating negative outcomes.
I am pleased to note the great deal of work the Prevention Centre has been doing in this area of implementation science and scale up.
The significance of ‘story’ is another factor that cannot be understated. When presenting evidence, verbally or in writing, it is important to appreciate the power of stories. For the Citizen’s Jury, we presented quite graphic but emotive photographs of child victims of dog bites. This had the impact on jury members you would expect.
Such anecdotes help the audience to recognise themselves in the issue and become more engaged than they would typically be. This strategy is well used by politicians and leaders, and, although it can be difficult for epidemiologists to incorporate, they must.
All stories have a beginning, middle and end, as is the case for all major interventions which must have a rigorous plan for evaluation. This often means clear baseline data collections and substantial pre-planning are required in the beginning well before the intervention is in place.
It is critical to understand that reform is a multi-year process so we celebrate our small wins, redirect when facing barriers, and, most importantly, persevere.