Ross C Brownson

Health policies, in the form of laws, regulations, and organizational practices, have a substantial impact on the health and well-being of the population. Policies can influence one or more of the following: (1) modifiable causes of disease, (2) early detection of disease in asymptomatic persons, (3) disease treatment in persons with symptomatic disease, and (4) rehabilitation and recovery. Formulation of health policies often depends on scientific, economic, social, and political forces (Terris 1980; Ibrahim 1985; Milio 1986; McKinlay 1993).

The influences of epidemiology on health policies are diverse and bidirectional. Epidemiologic studies are essential in the evaluation of new risk factors, therapeutic drugs, medical devices, and screening modalities. Results of these studies and public health surveillance data have been used frequently to inform health professionals, the public, and policy makers about the need for new or different health policies. This process is the translation of epidemiologic research into public health action. Conversely, health policies can have large impacts on the discipline of epidemiology and epidemiologic research (e.g., funding priorities or stringent confidentiality provisions).

Ideally, health policy-making should be based on weighing of societal risks and benefits, with a realistic model balancing special interests and divergent values through a political process (Fox 1977; Rothman and Poole 1985). Rational models of health policy formation are based on scientific inputs, systematic policy development, and comprehensive evaluation—yet are often not utilized in "real world" practice (Bots and Hulshof 1995; Brownson et al. 1997a). Health policy-making depends largely on a process of priority setting—public health and health care resources are limited and epidemiology can provide a reasonable basis for informing health priorities. Health policy development is seldom a straightforward, systematic process. Rather, it is a blend of science, politics, and sound judgment. The complexity of the process is embodied in the science of policy analysis and contains various categories and goals (Table 12-1).

Table 12-1. Seven Categories and Goals of Policy Analysis

Category Goal/Definition

Policy content To explain how a particular policy emerges and is im plemented

Policy process To analyze the stages through which issues pass and the influence of different factors

Information for policy- To marshal data from a variety of sources to assist making policy-makers in reaching decisions

Process advocacy To improve the nature of the policy-making system

Policy advocacy To press specific options and ideas, individually and as a group

Policy outputs To understand the results of policies in the context of social, economic, and other factors Evaluation studies To analyze the impacts of different policies on the population

Sources: Hogwood and Gunn (1981); Ham and Hill (1984); Orosz (1994).

It is unrealistic to expect that health policy making will be based solely on what epidemiologic science indicates. In discussing challenges facing epidemiology, it has been noted (Gordis 1988) that linking the science of epidemiology with the policy-making process is among the most challenging of public health issues. This challenge stems in part from the realization that epidemiology has been highly successful in identifying the large risk factors (e.g., smoking and lung cancer) yet is sometimes unable to clearly measure smaller, more subtle individual risks (e.g., diet and breast cancer) that may, nonetheless, have large impacts at the population level. Even when epidemiologic results are clear and consistent, there are multiple interpretations and multiple policy options (Yankauer 1984).

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