Case Studies

Population Health: The Translation of Research to Policy

September 17, 2018 | Robert Wood Johnson Foundation Health & Society Scholars, edited by Robert A. Hiatt

The Robert Wood Johnson Foundation Health & Society Scholars (HSS) program was designed to build the nation’s capacity for research, leadership, and policy change, while addressing the multiple determinants of population health. One of its goals was to produce a cadre of scientific leaders who could contribute to this research and spearhead action to improve overall population health and eliminate health inequities.

This report takes a case study approach using six diverse examples of science to policy translation generated by Scholars in the HSS program from 2003 to 2016. Because the HSS program was discontinued in 2017, the Milbank Memorial Fund published these case studies in the hope that many audiences, including students, would use them to learn about the connection between research, decision making, and policy.

In its work with health policy officials and as publisher of The Milbank Quarterly, the Milbank Memorial Fund improves population health by connecting leaders and decision makers with the best evidence and experience. With the publication of these case studies, the Fund extends its reach to students of health policy. The studies provide specific examples of the interdisciplinary and inter-sectoral challenges that come with addressing the factors that cause poor health—before individual patients arrive in waiting rooms with particular maladies. Besides chronicling the issues and skills required to address these challenges, the case studies also document the satisfaction that comes with thoughtful, persistent, collective action to improve the well-being of communities. We hope readers find them instructive.

 

Case Studies

Introduction


As an instructional tool, case studies teach by example rather than by the didactic conveyance of information. They provide a channel through which scholars learn by observing the successes and failures of those who came before them. The objective of a well-written case study is to stimulate independent thinking, discussion, and debate. In essence, case studies present problems to be solved but do not necessarily present answers.

The intent is for these case studies to be used for skill building at the undergraduate, graduate, and professional level. They are personal stories that can stimulate students to discuss the experiences relayed and to appreciate both the successes and challenges of integrating research into policy in all of its forms—laws, professional guidelines, or practices adopted by health departments, health systems, or local communities to improve the health of populations.

Download the Introduction (PDF)

Healthy and Unhealthy Food Sources in New York City


This case study traces the generation, evolution, and dissemination of policy-relevant research on the food environment. The study was conducted by the Built Environment and Health (BEH) Research Group at Columbia University. This interdisciplinary research team includes epidemiologists, sociologists, urban planners, and geographers. The Robert Wood Johnson Foundation Health & Society Scholars program played a vital role in the formation of this group by connecting researchers across the health and social sciences, providing seed funding for pilot research, and engaging scholars with a commitment to innovative, interdisciplinary research.

Learning Objectives

  • Explain why the food environment is an attractive target for policy intervention.
  • Describe and critically evaluate evidence for claims that either: (1) lowering the density of fast food outlets or (2) increasing availability of supermarkets is likely to reduce obesity rates.
  • Summarize the value of longitudinal data for understanding neighborhood effects on health.
  • Specify ways that city-specific population health research on the food environment can inform local policies in zoning, economic development, and health.

Download Case Study # 1 (PDF)

Fragile Health and Fragile Wealth


This case study aims to better understand relationships between the recent mortgage crisis and population health through in-depth interviews conducted among working-class African American homeowners who were experiencing difficulty paying their mortgages. These interviews showed how racial inequalities in health can intersect with other racially stratified sources of risk to put vulnerable homeowners at risk of mortgage strain.

Many participants in this study experienced mortgage strain following a health-related event that triggered a collapse of a fragile household budget. Like many working class African Americans, participants experienced poor health at relatively young ages. Additionally, they often lacked access to adequate personal and social safety nets that could buffer the consequences of illness.

This qualitative study was followed by an analysis of data from a nationally representative sample of homeowners. The quantitative analysis, like the qualitative one, found that the onset of illness or disability was associated with significant increases in the risk of mortgage strain, mortgage default, and foreclosure, and that these relationships were primarily mediated through job loss and health care costs.

Together, these studies suggest that the policy discussion around stable homeownership must go beyond the current focus on housing finance reform and financial literacy to include efforts that strengthen the broader safety nets available to homeowners who become ill or disabled.

Learning Objectives

  • Understand the intersection of mortgage strains and health inequity.
  • Examine the strengths and limitations of qualitative research methods in producing policy-relevant work.
  • Consider the intersections of health and social policies in efforts to improve population health.
  • Consider the challenges of translating social research into policy.

Download Case Study #2 (PDF)

Medical Marijuana as a Strategy to Reduce Opioid Overdose Deaths? Lessons from a Study of State Medical Marijuana Laws


This case study describes a collaborative project that combined the authors’ backgrounds in addiction medicine and health policy. They were led to this project through a shared interest in policy strategies to reduce opioid overdose mortality, which has more than quadrupled in the United States since the late 1990s. They hypothesized that access to medical marijuana, an alternative treatment for chronic pain, might reduce use of opioid painkillers at a population level and decrease overdose deaths. Using a quasi-experimental study design, the authors compared trends in overdose death rates in states that implemented medical marijuana laws to states that did not pass such laws. They found that enactment of a medical marijuana law was associated with a mean 24.8% lower opioid painkiller overdose mortality rate, relative to pre-enactment trends and trends in states without such laws. In 2013, when this study was conducted, it was the first study to link access to medical marijuana through changes in state laws to reduced mortality from opioid painkillers. In this case study, the authors present the collaboration that facilitated the study, the process of developing the study design, and the dissemination and policy impact of the findings.

Learning Objectives

  • Describe the epidemic of opioid misuse, addiction, and overdose and the hypothesized relationship between medical marijuana and use of opioid painkillers.
  • Compare the benefits of using natural experiments versus other potential study designs to measure the impact of medical marijuana on population health outcomes.
  • Explain some of the challenges in communicating study findings to the news media, and present some strategies that may be effective in improving communication.
  • Identify future directions for research on medical marijuana and opioid painkillers, and describe how current research can inform federal, state, and local policy.

Download Case Study #3 (PDF)

How Practitioners Bring Population Health Ideas into Other Policy Sectors: Lessons from Transportation


There are clear connections between population health, transportation, and equity. The transportation system—in combination with the larger built environment—supports the basic ability to carry out life’s activities. It provides access to jobs, education, health care, and natural places, but this access is often uneven. Moreover, transportation systems contribute to air and noise pollution, safety hazards, and social and economic isolation that result in adverse health outcomes and environmental justice concerns. Some of these connections have been well established in research and practice, but many are just emerging, including a deeper understanding of the distribution of the transportation system’s health costs and benefits across populations.

In this case study, the authors present the experience of a multidisciplinary group of practitioners and academics working together to bring population health into the mainstream of transportation. The group merges research and practice through its involvement in the Transportation Research Board, which is a Program Unit of the National Academies of Sciences, Engineering, and Medicine.

Learning Objectives

  • Describe how the process of bringing population health into a new sector, such as transportation, is tied to existing organizations and organizational structures within the field.
  • Identify how transportation practitioners learn about population health and how they apply this learning in their respective organizations to influence policy, analytical tools, and research.
  • Explain how peer networks facilitate the processes of learning and applying population health in the transportation sector and how these networks can be strengthened and maintained.

Download Case Study # 4 (PDF)

Forefront Suicide Prevention’s Wheel of Change: Catalyzing a Social Movement to Prevent Suicide


In the United States each year, over 44,000 people die by suicide. It is not widely recognized that, after cancer and heart disease, suicide accounts for more years of life lost than any other cause of death.1 Suicide deaths are the tip of the iceberg. Serious thoughts about suicide, plans, and attempts are common.2

Despite the magnitude of the problem, public resources and systems-oriented approaches to reducing suicide are in an early phase. Suicide prevention efforts are primarily based on a medical model leading to the development of clinical interventions that identify individuals who are at risk for suicide and then treat these individuals. However, to achieve a significant reduction in suicide rates, it will be necessary to impact multiple factors including changing: 1) hearts and minds—specifically, the culture and myths surrounding suicide; 2) behaviors—in particular, increasing the number of people who are equipped to help individuals at risk for suicide; and 3) systems and policies to bring about large-scale changes in the population health problem of suicide.

Forefront Suicide Prevention is leading a social movement in Washington State to implement a comprehensive approach to suicide prevention with the long-term goal of disseminating approaches developed in Washington to nearby states with the highest suicide rates. The conceptual model underlying Forefront’s work to make Washington a model suicide prevention state and its implications for the field of population health will be described in this case study.

Learning Objectives

  • Understand suicide as a significant population health problem.
  • Summarize the current state of the suicide prevention field including where opportunities for growth exist if we are to significantly reduce the suicide rate.
  • Learn the story of how one organization, Forefront Suicide Prevention, is providing leadership and building capacity to make Washington a model suicide prevention state.
  • Consider the catalysts that make policy and systems change possible.

1. Centers for Disease Control and Prevention: Web-based injury statistics query and reporting System. https://www.cdc.gov/injury/wisqars/index.html.
Accessed May 17, 2018.

2. About suicide/ statistics. American Foundation for Suicide Prevention website. www.afsp.org. 2014. Accessed February 13, 2018.

Download Case Study # 5 (PDF)

Exposure to Heat Waves: Making Film and Policy


This essay is both a professional and personal accounting of a topic that the author began to study as a Robert Wood Johnson Foundation Health and Society Scholar at the University of Pennsylvania. The health effects of heat waves and climate change began as a piece of research, became more central to her work in policy, and then became a story in a television series. Heat drives the most critical health impact of climate change. In the United States, exposure to heat waves kills more people than all natural disasters combined. However, identifying deaths caused by heat waves is a difficult and controversial issue. These estimations have policy ramifications at the federal level because the Environmental Protection Agency uses them as the central indicator for human health impacts of climate change. Paradoxically, health effects of heat exposure are largely ignored, even within the most vulnerable populations. Therefore, public education and education of policymakers is critical. The author produced a story for a Showtime television series on the effects of climate change, Years of Living Dangerously, with heat as the central story line and Matt Damon as the celebrity correspondent.

Learning Objectives

  • Understand the risk of heat exposure for health.
  • Identify the controversies regarding calculating death from heat exposure.
  • Understand how research can be of service to policy.
  • Become familiar with film as a tool for translating research.

Download Case Study # 6 (PDF)

Commentary


As a final step in exploring the translation of evidence to policy, following the compilation of the case studies, in November 2016, HSS’s National Program Office at The New York Academy of Medicine sponsored a workshop at the National Academies of Sciences, Engineering, and Medicine in Washington, D.C. The workshop brought together several of the program’s Scholars, including those who had produced the case studies, selected HSS faculty members, and leaders in science, policy, and the media who might be end users of the research findings. The goal of the meeting was to provide a platform to discuss the key elements of effective training for the translation of evidence into policy. Using three of the case studies as a point of departure, the participants engaged in a dialogue regarding the nature of evidence that is most useful in the policy making process and how best to communicate it. A summary of the key points from this lively and rich discussion can be found in this Commentary.

Download the Commentary (PDF)

Download all the Case Studies (PDF)