Combining legal epidemiology and implementation science to improve global access to medicines: challenges and opportunities

Laws and policies affecting access to medicines have been in the global health spotlight for decades, yet our understanding of their effects remains substantially underdeveloped. The emerging field of legal epidemiology combined with the methods of implementation science presents an opportunity to help address this gap. Legal epidemiology refers to the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population. Legal epidemiology studies consist of a systematic collection and coding of laws and policies relating to a particular topic. Quasi-experimental or observational research methods can then be applied to take advantage of natural experiments resulting from heterogenous adoption and/or implementation of laws and policies. Often legal epidemiology studies fail to account for heterogenous law implementation processes, presenting a need and opportunity to integrate implementation science methods. Researchers may face challenges in integrating these methods for access to medicines studies, including data access issues and a complex legal and implementation environment. Yet, the opportunities presented by increasingly transparent legal environments, improved monitoring of medicine availability, universal health coverage expansion, and electronic health and insurance records integration may facilitate overcoming these challenges. Improved collaboration and communication between researchers, health authorities, manufacturers, and health providers from public and private sectors will be critical. In spite of the challenges, combining the fields of legal epidemiology and implementation science may present an important strategy toward creating a legal and policy environment that supports global and equitable access to medicines.

A Narrative Review of Literature Examining Studies Researching the Impact of Law on Health and Economic Outcomes

CONTEXT

Public health policy can play an important role in improving public health outcomes. Accordingly, there has been an increasing emphasis by policy makers on identifying and implementing evidence-informed public health policy interventions.

PROGRAM OR POLICY

Growth and refinement of the field of research assessing the impact of legal interventions on health outcomes, known as legal epidemiology, prompted this review of studies on the relationship between laws and health or economic outcomes.

IMPLEMENTATION

Authors systematically searched 8 major literature databases for all English language journal articles that assessed the effect of a law on health and economic outcomes published between January 1, 2009, and September 18, 2019. This search generated 12 570 unique articles 177 of which met inclusion criteria. The team conducting the systematic review was a multidisciplinary team that included health economists and public health policy researchers, as well as public health lawyers with expertise in legal epidemiological research methods. The authors identified and assessed the types of methods used to measure the laws' health impact.

EVALUATION

In this review, the authors examine how legal epidemiological research methods have been described in the literature as well as trends among the studies. Overall, 3 major themes emerged from this study: (1) limited variability in the sources of the health data across the studies, (2) limited differences in the methodological approaches used to connect law to health outcomes, and (3) lack of transparency surrounding the source and quality of the legal data relied upon.

DISCUSSION

Through highlighting public health law research methodologies, this systematic review may inform researchers, practitioners, and lawmakers on how to better examine and understand the impacts of legal interventions on health and economic outcomes. Findings may serve as a source of suggested practices in conducting legal epidemiological outcomes research and identifying conceptual and method-related gaps in the literature.

The Legal Needs of People Living with a Sexually Transmissible Infection or Blood-Borne Virus: Perspectives From a Sample of the Australian Sexual Health and Blood Borne Virus Workforce

Law and the legal environment are important factors in the epidemiology and prevention of sexually transmissible infections (STIs) and blood-borne viruses (BBVs). However, there has been no sustained effort to monitor the legal environment surrounding STIs and BBVs. This article presents the first data on the incidence and impacts of unmet legal needs for those affected by an STI or BBV in Australia using a survey administered to a sample of the Australian sexual health and BBV workforce. Migration, Housing, Money/Debt, Health (including complaints about health services), and Crime (accused/offender) were reported as the five most common legal need areas, with 60% of respondents describing these legal problems as generating a "severe" impact on health. These results indicate that unmet legal needs generate significant negative impacts in terms of individual health, on public health, and the ability to provide sustainable services such as testing and treatment to those facing unmet legal needs.

Impact of State Stroke Systems of Care Laws on Stroke Outcomes

Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003-2018), national stroke accreditation information (years 1997-2018), data from the Healthcare Cost and Utilization Project (years 2012-2018), and National Vital Statistics System (years 1979-2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610-1724 less per hospital stay), lower age-adjusted stroke mortality (1.0-1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6-5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality.

COVID-19 Vaccine Refusal and Medical Distrust Held by Correctional Officers

This study explores COVID-19 vaccine acceptance among prison security staff and the extent to which they trust varied sources of information about the vaccines. Cross-sectional survey data were obtained from a state-wide sample of corrections officers (COs, hereafter; n = 1208) in February 2021. Group differences, disaggregated by demographic characteristics, were examined using F-tests and t-tests. Despite the comparatively limited risk of contracting the virus, non-security staff reported they would accept a COVID-19 vaccine at no cost (74%), compared to their more vulnerable CO counterparts (49%). We observed vaccine refusal correlations between COs' reported gender, age, and length of time working as a CO, but none with their self-reported race. Vaccine refusal was more prevalent among womxn officers, younger officers, and those who had spent less time working as prison security staff. Our findings also suggest that the only trusted source of information about vaccines were family members and only for officers who would refuse the vaccine; the quality of trust placed in those sources, however, was not substantially positive and did not vary greatly across CO racial groups. By highlighting characteristics of the observed gaps in COVID-19 vaccine acceptance between COs and their non-security staff coworkers, as well as between corrections officers of varied demographic backgrounds, these findings can inform the development of responsive and accepted occupational health policies for communities both inside and intrinsically linked to prisons.

The Built Environment and Population Physical Activity: Methods for Mapping the Relevant Laws

BACKGROUND

The development of policies that promote and enable physical activity (PA) is a global health priority. Laws are an important policy instrument that can enable enduring beneficial outcomes for individuals, organizations, and environments through multiple mechanisms. This article presents a systematic process for mapping laws relevant to PA, which can be used to understand the role of laws as a powerful PA policy lever.

METHODS

Building on methods used in public health law research, we developed a protocol for scientific mapping of laws influencing the built environment for PA in Australia. The MonQcle online legal research platform was used for data coding, analysis, and presentation.

RESULTS

We describe the 10 key stages of legal mapping that we applied to examine state and territory laws that influence walking and cycling in Australia.

CONCLUSIONS

Law is a neglected element of policy research for PA. There is a need for accessible legal data to drive the design, investment, and implementation of legal interventions to improve population PA. Legal mapping is a first step toward evaluation of such laws for PA. This paper provides a practical case study and guidance for the 10 stages in legal mapping of laws that influence the built environment for PA.

COVID-19 in the Americas: the role of collaborating centers in understanding lessons and best practices in pandemic preparedness and response

COVID-19 exposed major gaps in global, regional, state, and local responses to public health emergencies. In preparation for the WHA Special Session to consider the benefits of developing an international instrument on pandemic preparedness, the O'Neill Institute in partnership with Foundation for the National Institutes of Health convened 30 of the world's leading authorities on global health law, financing, biomedical science, implementation, and emergency response along with leaders from prominent international organizations. This meeting was followed by regional consultations convened in Latin America-Caribbean, Africa, and Southeast Asia. These high-level expert consultations generated in-depth discussions on weaknesses and persisting gaps in global pandemic preparedness and what a new international agreement might include to address them. Regional intergovernmental organizations like PAHO can work closely with related multilateral development banks to develop financial instruments that can smooth systemic economic disruption; and regional centers of research and manufacturing excellence can offer a strong front line for producing medicines and vaccines rapidly during a pandemic. With our research focused on the regional response to COVID-19 we are able to look at country responses individually and collectively to see how Latin America - Caribbean countries can capitalize and leverage their regional connections to strengthen their pandemic preparedness and response. By identifying existing gaps and examining the responses and approaches taken by PAHO, we can better understand the role of international and regional organizations and their collaborating centers in preparing and responding to pandemics.

Trends in Percentages of the US Population Covered by State-Issued COVID-19 Nonpharmaceutical Interventions, March 1, 2020-August 15, 2021

Trends in the percentages of the US population covered by state-issued nonpharmaceutical interventions (NPIs), including restaurant and bar restrictions, stay-at-home orders, gathering limits, and mask mandates, were examined by using county-specific data sets on state-issued orders for NPIs from March 1, 2020, to August 15, 2021. Most of the population was covered by multiple NPIs early in the pandemic. Most state-issued orders were lifted or relaxed as COVID-19 cases decreased during summer 2020. Few states reimplemented strict NPIs during later surges in US COVID-19 cases over the winter of 2020-2021. The exceptions were mask mandates, which covered about 80% of the population between August 2020 and February 2021, and the most restrictive gathering limits, which covered a maximum of 66% of the population in early 2020 and 68% of the population in winter 2020-2021. Most NPIs were lifted by the end of the analysis period.

Policy surveillance for a global analysis of national abortion laws

Policy surveillance offers a novel and important method for comparing law across jurisdictions. We used policy surveillance to examine abortion laws across the globe. Self-managed abortion, which generally takes place outside formal healthcare settings, is increasing in prevalence and can be safe. We analysed provisions that do not account for the prevalence of self-managed abortion and evidence of its safety. Such provisions require that abortion take place in a formal healthcare setting. We also analysed criminal penalties for non-compliance. Our method included development of a legal framework, an iterative process of refining coding schemes and procedures, and rigorous quality control. We limited our analysis to liberal abortion laws for two reasons. Abortion laws globally trend towards less restrictive. In addition, we aimed to focus on how laws relate to abortion outside a formal healthcare setting specifically and excluded laws that prohibit abortion more broadly. We found that in all countries with liberal national abortion laws, the law permits only healthcare professionals or trained health workers to perform legal abortion and the majority require the abortion to take place in a specified health facility. With policy surveillance methods we can illuminate characteristics of law across many jurisdictions and the need for widespread reform, toward laws that reflect scientific evidence and the way people have abortions.

A Legal Approach to Cancer Epidemiology in Public Health

The Public Health Act encompasses scientific research and law enforcement as causes, distributions, and preventive factors for diseases and injuries of a particular population. Today, the Public Health Law is growing into a field that expects to cultivate and utilize lawful practitioners who can apply specialized legal skills in health policy development and public health performance. The multidisciplinary approach of the Public Health Act integrates the legal and scientific elements of the field and the workforce, characterized by a more dynamic understanding of the health impact of legislation and the rapid deployment of effective policies. Thus, legal health interventions that manage and treat diverse populations need to be evaluated more rigorously and quickly. In addition, funding for policy surveillance and other legislation and policy mapping needs to be more sophisticated to maximize utility and avoid duplication. This study investigated legal interventions to manage and treat various groups of populations for health and discussed the necessity of public health laws.

Law and urban governance for health in times of rapid change

Governance is an important factor in urban health, and law is an important element of healthy governance. Law can be an intervention local government wields to influence behavior and shape environments. Law can also be an important target of health promotion efforts: Law and the enforcement and implementation behaviors it fosters can promote unhealthy behaviors and environmental conditions, and can act as a barrier to healthy interventions or practices. Finally, law is a design and construction tool for the organization of governance. Law is the means through which cities are formally established. Their powers and duties, organizational structure, boundaries and decision-making procedures are all set by law. Regardless of the form of government, cities have legal levers they can manipulate for health promotion. Cities can use tax authority to influence the price of unhealthy products, or to encourage consumption of healthy foods. Cities can use their legal powers to address incidental legal effects of policies that they themselves cannot control. Cities may also have the authority to use law to address deeper determinants of health. The overall level of income or wealth inequality in a country reflects factors well-beyond a local government’s control, but city government nonetheless has levers to directly and indirectly reduce economic and social inequality and their effects. A renewed focus on law and urban governance is the key to assuring health and well-being and closing the health equity gap.

Do State Comprehensive Planning Statutes Address Physical Activity?: Implications for Rural Communities

Less than one-quarter of U.S. adults meet physical activity (PA) recommendations, with rural residents less likely to be active than urban residents. The built environment has been identified as a potential facilitator of PA and local comprehensive plans are a foundational tool for guiding the development of the built environment. The purpose of this study was therefore to understand the current landscape of comprehensive planning state statutes related to PA and rural communities. We used primary legal research methods to identify, compile, and evaluate all 50 state comprehensive planning statutes for items related to PA and conditional mandates based on population size of local jurisdictions. The presence of population-conditional planning mandates and the inclusion of PA-related items was analyzed by state-level rurality using Fisher's exact tests. Our analyses demonstrated that (1) broader PA-related items were addressed in state statutes more often than more specific PA-related items; (2) when PA-related items were addressed, they were most likely to be mandated, subsumed elements; (3) several PA-related items were less likely to be addressed in the most rural states and/or conditionally mandated for jurisdictions meeting minimum population requirements; and (4) only two states addressed PA directly and explicitly in their comprehensive planning statutes.

A Legal and Epidemiological Consideration of the Causal Relationship between Tobacco and Lung Cancer

This study reviewed issues including causality among tobacco companies' illegal acts, smoking, and lung cancer occurrence. In tobacco lawsuits so far, the burden of proof regarding negligence and a causal relationship has fallen on plaintiffs, who are the injured party. However, since the legislation of the Product Liability Act, the possibility of mitigating plaintiffs' burden of proof has opened up. Nevertheless, this alone cannot prevent the immense socioeconomic cost incurred due to smoking. It is legislatively necessary to enact a tobacco management law so that the no-fault liability of tobacco companies, which are the defendants, for compensation can be acknowledged. However, it is necessary to take supplementary measures through the social security system such as establishing the upper limits for liquidated damages in lawsuits and creating a relief fund for the victims of smoking. In addition, it is fundamentally necessary for courts to accept the methods for inferring causality that are based on the natural sciences and epidemiology in situations such as tobacco lawsuits, where a causal relationship cannot be proven easily. In particular, jurists, too, must consider the application of population-based evidence presented by epidemiologists to lawsuits in a forward-looking manner for redressing damages to individuals with diseases; thus, bridging the gap between normative adjudication and scientific judgment to draw a conclusion about a causal relationship.

State laws matter when it comes to school provisions for structured PE and daily PE participation

The physical and mental benefits children receive from physical activity have been well documented, and physical education is a key way to ensure that physical activity opportunities are available during the school day. This study evaluates whether state PE laws are associated with school-level practices of requiring structured PE classes and whether students take PE classes daily. State laws were obtained as part of the National Cancer Institute's Classification of Laws Associated with School Students (CLASS) and were compiled for all 50 states and District of Columbia using Boolean keyword searches in LexisAdvance and WestlawNext. PE time requirements and state daily PE requirements in the laws were subsequently linked to school-required structured PE classes and daily PE in the School Nutrition and Meal Cost Study (SNMCS) Principal Survey. Logistic regression analyses were conducted while controlling for grade level, district child poverty rate, district race/ethnicity, school urbanicity, and school size. The state daily PE analysis also controlled for region. Schools located in a state that required at least 90 min of PE per week at the elementary level or 150 min of PE per week at the middle or high school levels had almost seven times higher odds of requiring structured PE. Schools located in a state that required daily participation of PE had almost five times higher odds of at least some students taking PE daily. State policymakers can utilize these findings to promote laws that require time for PE every week, daily if possible.

Translating Workforce Development Policy Interventions for Community Health Workers: Application of a Policy Research Continuum

CONTEXT

There is a need for knowledge translation to advance health equity in the prevention and control of cardiovascular disease and type 2 diabetes. One recommended strategy is engaging community health workers (CHWs) to have a central role in related interventions. Despite strong evidence of effectiveness for CHWs, there is limited information examining the impact of state CHW policy interventions. This article describes the application of a policy research continuum to enhance knowledge translation of CHW workforce development policy in the United States.

METHODS

During 2016-2019, a team of public health researchers and practitioners applied the policy research continuum, a multiphased systematic assessment approach that incorporates legal epidemiology to enhance knowledge translation of CHW workforce development policy interventions in the United States. The continuum consists of 5 discrete, yet interconnected, phases including early evidence assessments, policy surveillance, implementation studies, policy ratings, and impact studies.

RESULTS

Application of the first 3 phases of the continuum demonstrated (1) how CHW workforce development policy interventions are linked to strong evidence bases, (2) whether existing state CHW laws are evidence-informed, and (3) how different state approaches were implemented.

DISCUSSION

As a knowledge translation tool, the continuum enhances dissemination of timely, useful information to inform decision making and supports the effective implementation and scale-up of science-based policy interventions. When fully implemented, it assists public health practitioners in examining the utility of different policy intervention approaches, the effects of adaptation, and the linkages between policy interventions and more distal public health outcomes.

How Are Telehealth Laws Intersecting With Laws Addressing the Opioid Overdose Epidemic?

Opioid-involved drug overdose deaths have been a growing concern in the United States for several decades. The Centers for Disease Control and Prevention identified several strategies to address the opioid overdose epidemic, including increased availability of and access to medication-assisted treatment and guidance on safer opioid prescribing practices. Telehealth offers the potential for increasing access and availability to these strategies, and laws governing telehealth have implications for their utilization. To understand how state telehealth laws intersect with the opioid overdose epidemic, we conducted a legal mapping study, a type of legal epidemiological assessment, of statutes and regulations that intersect at telehealth and opioids. This search yielded 28 laws from 17 states. These laws intersect both telehealth and the opioid overdose epidemic in different ways including prescribing limitations, opioid treatment through medication and counseling, patient plan review, and professional collaboration. Continued legal and policy surveillance is needed to be able to evaluate the impact of law in addressing opioid overdose outcomes.

Negative illness feedbacks: High-frisk policing reduces civilian reliance on ED services

OBJECTIVE

This paper demonstrates that localized and chronic stop-question-and-frisk (SQF) practices are associated with community members' utilization of emergency department (ED) resources. To explain this relationship, we explore the empirical applicability of a legal epidemiological framework, or the study of legal institutional influences on the distribution of disease and injury.

DATA AND STUDY DESIGN

Analyses are derived from merging data from the Philadelphia Vehicle and Pedestrians Investigation, the National Historical Geographic Information System, and the Southeastern Philadelphia Community Health database to zip code identifiers common to all datasets. Weighted multilevel negative binomial regressions measure the influence that local SQF practices have on ED use for this population. Analytic methods incorporate patient demographic covariates including household size, health insurance status, and having a doctor as a usual source of care.

PRINCIPAL FINDINGS

Findings reveal that both tract-level frisking and poor health are linked to more frequent use of hospital EDs, per respondent report. Despite their health care needs, however, reporting poor/fair health status is associated with a substantial decrease in the rate of emergency department visits as neighborhood frisk concentration increases (IRR = 0.923; 95% CI: 0.891, 0.957). Moreover, more sickly people in high-frisk neighborhoods live in tracts that have greater racial disparities in frisking-a pattern that accounts for the moderating role of neighborhood frisking in sick people's usage of the emergency room.

CONCLUSIONS

Findings indicating the robust association reported above interrogate the chronic incompatibility of local health and human service system aims. The study also provides an interdisciplinary theoretical lens through which stakeholders can make sense of these challenges and their implications.

Standards-based physical education in schools: The role of state laws

Purpose

Examine the association of state physical education (PE) laws (https://class.cancer.gov) with school policies addressing motor skill development, physical activity (PA) participation, and health-enhancing physical fitness (https://www.cdc.gov/healthyyouth/data/shpps/data.htm).

Methods

National school-level data on PE standards were obtained from the 2014 School Health Policies and Practices Study (SHPPS) of US schools for analytical samples of 408-410 schools in 43 states. These data were linked to Classification of Laws Associated with School Students (CLASS) data, which reflect the strength of state-PE curriculum laws and the associated state PE curriculum standards. Logistic regressions and generalized linear models with a complementary log-log link examined associations between state law and school-level standards.

Results

Compared to having no state law, weak law (OR: 5.07, 95% CI: 1.02-25.27) or strong law (OR: 2.96, 95% CI: 1.04-8.37) was associated with higher odds of school PE standards addressing motor skill development, while only strong state law was associated with higher prevalence of addressing achievement and maintenance of physical fitness (coefficient: 0.63, 95% CI: 0.12, 1.14). State laws were not associated with addressing PA participation.

Conclusions

Schools were more likely to address motor skills and physical fitness development when states had strong PE laws.

The importance of data source in prescription drug monitoring program research

OBJECTIVE

To develop a legal research protocol for identifying various measures of prescription drug monitoring program (PDMP) start dates, apply the protocol to create a useable PDMP database, and test whether the different legal databases that are meant to contain the same information produce divergent results when used in an illustrative empirical exercise.

DATA SOURCES

Original research from state statutes, regulations, policy statements, and interviews; alternative PDMP data from the National Alliance for Model State Drug Laws and Prescription Drug Abuse Policy System; claims from a 40 percent random sample of Medicare beneficiaries, 2006-2014.

STUDY DESIGN

Collaborative research effort among a group of lawyers to develop protocol. Legal research to produce an original database of dates state PDMP laws: (a) were enacted, (b) became operational, and (c) required query before prescribing controlled substances. Descriptive analyses characterize differences in dates of enactment, operation, and must query requirements. Regression analyses estimating, for each beneficiary annually any opioid prescription received in a calendar year, among other measures. Estimates conducted on under age 65 and full Medicare population.

DATA COLLECTION/EXTRACTION METHODS

PDMP legal databases were linked to annual Medicare claims.

PRINCIPAL FINDINGS

An original database differs from commonly used, publicly available data. Outcomes tested depend on the measure of PDMP date used and differ by data source. Must-query laws show the largest effects among all the laws tested.

CONCLUSIONS

Data choices likely have had large consequences for study results and may explain contradictory outcomes in prior research. Researchers must understand and report protocol for dates used in PDMP research to ensure that results are internally consistent and verifiable.

Developing a Database of Structural Racism-Related State Laws for Health Equity Research and Practice in the United States

OBJECTIVES

Although US state laws shape population health and health equity, few studies have examined how state laws affect the health of marginalized racial/ethnic groups (eg, Black, Indigenous, and Latinx populations) and racial/ethnic health inequities. A team of public health researchers and legal scholars with expertise in racial equity used systematic policy surveillance methods to develop a comprehensive database of state laws that are explicitly or implicitly related to structural racism, with the goal of evaluating their effect on health outcomes among marginalized racial/ethnic groups.

METHODS

Legal scholars used primary and secondary sources to identify state laws related to structural racism pertaining to 10 legal domains and developed a coding scheme that assigned a numeric code representing a mutually exclusive category for each salient feature of each law using a subset of randomly selected states. Legal scholars systematically applied this coding scheme to laws in all 50 US states and the District of Columbia from 2010 through 2013.

RESULTS

We identified 843 state laws linked to structural racism. Most states had in place laws that disproportionately discriminate against marginalized racial/ethnic groups and had not enacted laws that prevent the unjust treatment of individuals from marginalized racial/ethnic populations from 2010 to 2013.

CONCLUSIONS

By providing comprehensive, detailed data on structural racism-related state laws in all 50 states and the District of Columbia over time, our database will provide public health researchers, social scientists, policy makers, and advocates with rigorous evidence to assess states' racial equity climates and evaluate and address their effect on racial/ethnic health inequities in the United States.

Connecting policy to licensed assisted living communities, introducing health services regulatory analysis

OBJECTIVE

To document dementia-relevant state assisted living regulations and their changes over time as they pertain to licensed care settings.

DATA SOURCES

For all states, current directories of licensed assisted living communities and state regulations for each year, 2007-2018, were obtained from state agency websites and Nexis Uni, respectively.

STUDY DESIGN

We identified multiple types of regulatory classifications for each state and documented the presence or absence of specific dementia care provisions in the regulations for each type by study year. Maps and summary statistics were used to compare results to previous research and document change longitudinally.

DATA COLLECTION/EXTRACTION METHODS

We used a policy analysis approach to connect communities listed in directories to applicable regulatory text. Then, we employed policy surveillance and question-based coding to record the presence or absence of specific policies for each classification and study year.

PRINCIPAL FINDINGS

Our team empirically documented provisions requiring dementia-specific training for administrators and direct care staff, and cognitive impairment screening for each study year. We found that 23 states added one or more of these requirements for one or more license types, but the states that had these provisions for all types of licensed assisted living declined from four to two.

CONCLUSIONS

We identified significant, previously undocumented, within-state policy variation for assisted living licensed settings between 2007 and 2018. Using the regulatory classification instead of the state as the unit of analysis revealed that many policy adoptions were limited to dementia-designated settings. This suggests that people living with dementia in general assisted living are not afforded the same protections. We call our approach health services regulatory analysis and argue that it has the potential to identify gaps in existing policies, an important endeavor for health services research in assisted living and other care settings.

State Wellness Policy Requirement Laws Matter for District Wellness Policy Comprehensiveness and Wellness Policy Implementation in the United States

Beginning with the school year 2006-2007, U.S. school districts participating in the federal Child Nutrition Programs were required to adopt and implement a local wellness policy (LWP) that included goals and/or standards for nutrition education, school meals, other foods sold or served in schools, and physical activity. A primary challenge with LWPs has been inconsistent implementation. This study examined whether state wellness policy requirement laws and district LWP comprehensiveness influence district level implementation, using law/policy data from the National Wellness Policy Study and school food authority (SFA)-reported district LWP implementation from the School Nutrition and Meal Cost Study. Generalized linear and structural equation models were used, controlling for SFA and district characteristics. SFAs in states with wellness policy requirement laws (vs. those in states without) reported implementing significantly more practices (59.56% vs. 44.57%, p < 0.01). State wellness policy requirement laws were associated with district LWP comprehensiveness (coeff.: 0.463; 95% CI: 0.123, 0.803) and district-level implementation (coeff.: 1.392; 95% CI: 0.299, 2.485). District LWP comprehensiveness was associated with district implementation (coeff.: 0.562; 95% CI: 0.072, 1.053), but did not mediate the state law-district implementation relationship. This study highlights the important role that state laws and district LWPs can play in facilitating wellness policy implementation.

Can Monitoring Make It Happen? An Assessment of How Reporting, Monitoring, and Evaluation Can Support Local Wellness Policy Implementation in US Schools

US school districts participating in federal child nutrition programs are required to develop a local wellness policy (LWP). Each district is allowed flexibility in policy development, including the approaches used for policy reporting, monitoring, and evaluation (RME). The aim of this convergent mixed-methods study was to quantitatively examine RME provisions in policies among a nationally representative sample of districts in the 2014-2015 school year in order to examine whether policies were associated with RME practices in those districts, and to qualitatively examine perceived challenges to RME practices. Data were compiled through the School Nutrition and Meal Cost Study and the National Wellness Policy Study. In multivariable regression models accounting for demographics, survey respondents were significantly more likely to report that their district had informed the public about LWP content and implementation, if there was a relevant policy provision in place. Having a strong policy (as compared to no policy) requiring evaluation was associated with reports that the district had indeed evaluated implementation. Having definitive/required provisions in policies was significantly associated with actual use of RME practices. RME activities are an important part of policy implementation, and these results show that policy provisions addressing RME activities must be written with strong language to require compliance. In interviews with 39 superintendents, many reported that RME activities are challenging, including difficulty determining how to monitor and show impact of their district's wellness initiatives. Furthermore, the qualitative results highlighted the need for vetted tools that are freely available, widely used, and feasible for districts to use in assessing their progress toward meeting the goals in their LWPs.

State Laws Matter When It Comes to District Policymaking Relative to the Whole School, Whole Community, Whole Child Framework

BACKGROUND

The Whole School, Whole Community, Whole Child (WSCC) framework supports the "whole child" across 10 domains. This study assessed state law and district policy WSCC coverage.

METHODS

Primary legal research was used to compile relevant district policies and state laws for a stratified random sample of 368 public school districts across 20 states for school year 2017-18. Policies/laws were evaluated on 79 items across the WSCC domains (range: 3-14 items/domain). Multivariable regressions examined the relationship between state laws and district policies, controlling for district characteristics, and weighted to account for the sample design and non-response.

RESULTS

On average, district policies and state laws addressed 53% and 60% of the 79 items, respectively. State law predicted district policy WSCC attention across items (coeff. = 0.26, 95% CI = 0.14, 0.38) and 4 domains: physical activity (coeff. = 0.57, 95% CI = 0.29, 0.86); health services (coeff. = 0.50, 95% CI = 0.39, 0.62); social and emotional climate (coeff. = 0.34, 95% CI = 0.23, 0.45); and family engagement (coeff. = 0.41, 95% CI = 0.28, 0.54). State law was associated with lower district-level coverage in 3 domains (health education; counseling, psychological, and social services; and community involvement).

CONCLUSIONS

Although WSCC implementation is locally-driven, states have an active role to play in setting a policy "floor" for guiding district WSCC attention.

District Wellness Policy Nutrition Standards Are Associated with Healthier District Food Procurement Practices in the United States

Food procurement policies often exist to require that schools purchase foods with specific nutrient standards. Such policies are increasingly being used with the hope of improving access to healthier foods and beverages. Local wellness policies, required in any school district that participates in Federal Child Nutrition Programs, often contain specific nutrition standards that detail what can be sold to students during the school day. This study investigated the extent to which nutrition standards in wellness policies may be associated with healthier nutrition standards in district-level purchasing specifications. Cross-sectional data from the 2014-2015 school year for 490 school food authorities from 46 states and the District of Columbia were collected as part of the School Nutrition and Meal Cost Study and the National Wellness Policy Study. Survey-adjusted multivariable logistic regression models were computed to examine the association between district wellness policy nutrition standards and corresponding district food purchasing specifications. Results show that having a district wellness policy with corresponding nutrition standards and being in a rural area were associated with district food purchasing specifications for specific nutrients. These findings contribute to the literature to suggest that having a wellness policy with detailed nutrition standards may help to increase access to healthier foods and beverages.

Medical marijuana laws and driving under the influence of marijuana and alcohol

AIMS

Medical marijuana law (MML) enactment in the United States has been associated with increased cannabis use but lower traffic fatality rates. We assessed the possible association of MML and individual-level driving under the influence of cannabis (DUIC) and also under the influence of alcohol (DUIA).

DESIGN AND SETTING

Three cross-sectional U.S. adult surveys: The National Longitudinal Alcohol Epidemiologic Survey (NLAES; 1991-1992), the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2001-2002), and the NESARC-III (2012-2013).

PARTICIPANTS

The total n was 118 497: 41 764, 41 184, and 35 549 from NLAES, NESARC, and NESARC-III, respectively.

MEASUREMENTS

Across the three surveys, similar questions in the Alcohol Use Disorder and Associated Disabilities Interview Schedule assessed DUIC and DUIA. Ever-MML states enacted MML between 1991-1992 and 2012-2013 (overall period). Early-MML states enacted MML between 1991-1992 and 2001-2002 (early period). Late-MML states enacted MML between 2001-2002 and 2012-2013 (late period). MML effects on change in DUIC and DUIA prevalence were estimated using a difference-in-differences specification to compare changes in MML and other states.

FINDINGS

From 1991-1992 to 2012-2013, DUIC prevalence nearly doubled (from 1.02% to 1.92%), increasing more in states that enacted MML than other states (difference-in-differences [DiD] = 0.59%; 95% CI = 0.06%-1.12%). Most change in DUIC prevalence occurred between 2001-2002 and 2012-2013. DUIC prevalence increased more in states that enacted MML 2001-2002 to 2012-2013 than in never-MML states (DiD = 0.77%; 95% CI = -0.05%-1.59%), and in two early-MML states, California (DiD = 0.82; 95% CI = 0.06-1.59) and Colorado (DiD = 1.32; 95% CI = 0.11-2.53). In contrast, DUIA prevalence appeared unrelated to MML enactment.

CONCLUSIONS

Medical marijuana law enactment in US states appears to have been associated with increased prevalence of driving under the influence of cannabis, but not alcohol.

Meal Quality of Entrées That Can Be Sold as Competitive Foods in Schools and Potential Impact of the Proposed USDA Rollbacks

The Healthy, Hunger-Free Kids Act strengthened competitive food standards (i.e., Smart Snacks), but an exemption allows reimbursable meal entrées that do not meet Smart Snack standards to be sold as “competitive entrées” on the same day they are served in the reimbursable meal, and the following day. Proposed rollbacks would enable these competitive entrées to continue to be sold on a third day, increasing the availability of competitive foods exempt from Smart Snacks standards. This study compared the Healthy Eating Index (HEI) scores of potential competitive entrées alone versus full reimbursable school lunches, and examined the nutritional characteristics of potential competitive entrées. Data were from a national sample of 1108 schools from the School Nutrition and Meal Cost Study. Linear regression models, accounting for school-level and state and district policy characteristics, found that HEI scores of competitive entrées were an average of 30 points lower than HEI scores of reimbursable lunches, with greater differences in small and rural schools. Less than 1% of common potential competitive entrees met Smart Snack standards, primarily due to higher sodium and saturated fat levels. The proposed rollbacks are estimated to potentially add approximately 662 mg of sodium and 3 g of saturated fat over three days (1103 mg sodium and 5 g saturated fat over a week) on average relative to Smart Snacks limits. Instead of increasing opportunities to sell competitive entrées, their sales should be further limited.

State Laws Governing Syringe Services Programs and Participant Syringe Possession, 2014-2019

OBJECTIVE

Law is an important factor in the diffusion of syringe services programs (SSPs). This study measures the current status of, and 5-year change in, state laws governing SSP operations and possession of syringes by participants.

METHODS

Legal researchers developed a cross-sectional data set measuring key features of state laws and regulations governing the possession and distribution of syringes across the 50 US states and the District of Columbia in effect on August 1, 2019. We compared these data with previously collected data on laws as of August 1, 2014.

RESULTS

Thirty-nine states (including the District of Columbia) had laws in effect on August 1, 2019, that removed legal impediments to, explicitly authorized, and/or regulated SSPs. Thirty-three states had 1 or more laws consistent with legal possession of syringes by SSP participants under at least some circumstances. Changes from 2014 to 2019 included an increase of 14 states explicitly authorizing SSPs by law and an increase of 12 states with at least 1 provision reducing legal barriers to SSPs. Since 2014, the number of states explicitly authorizing SSPs nearly doubled, and the new states included many rural, southern, or midwestern states that had been identified as having poor access to SSPs, as well as states at high risk for HIV and hepatitis C virus outbreaks. Substantial legal barriers to SSP operation and participant syringe possession remained in >20% of US states.

CONCLUSION

Legal barriers to effective operation of SSPs have declined but continue to hinder the prevention and reduction of drug-related harm.

Assessing the Relationship between District and State Policies and School Nutrition Promotion-Related Practices in the United States

School environments are an optimal setting to promote healthy student diets, yet it is unclear what role state and district policies play in shaping school contexts. This study examined how state and district policies are associated with school-reported practices for promoting student participation in school lunch programs. School nutrition manager data were obtained from the School Nutrition and Meal Cost Study’s (SNMCS) sample of 1210 schools in 46 states and the District of Columbia (DC) during school year 2014–2015. Relevant state laws and district policies were compiled and coded. Multivariable logistic and Poisson regressions, controlling for school characteristics, examined the relationship between state/district laws/policies and school practices. Compared to schools in districts or states with no policies/laws, respectively, schools were more likely to provide nutritional information on school meals (AOR = 2.59, 95% CI = 1.33, 5.05) in districts with strong policies, and to promote school meals at school events (AOR = 1.93, CI = 1.07, 3.46) in states with strong laws. Schools in states with any laws related to strategies to increase participation in school meals were more likely to seek student involvement in menu planning (AOR = 2.02, CI = 1.24, 3.31) and vegetable offerings (AOR = 2.00, CI = 1.23, 3.24). The findings support the association of laws/policies with school practices.

The Role of District Wellness Policies in Encouraging Student Participation in the School Breakfast Program, United States

Eating breakfast is associated with better academic performance and nutrition and lower risk of obesity, but skipping breakfast is common among children and adolescents, and participation in the U.S. Department of Agriculture's School Breakfast Program (SBP) is low. This study assessed the association between school district wellness policy provisions coded as part of the National Wellness Policy Study and student SBP participation and acceptance of the breakfasts provided using cross-sectional survey data from the School Nutrition and Meal Cost Study. Separate survey-adjusted multivariable logistic regressions were computed, linking students eating (N = 1575) and liking (N = 726) the school breakfast to corresponding district policy measures, controlling for school and student characteristics. Strong district policy, as opposed to no policy, was associated with significantly higher odds of students eating the school breakfast (odds ratio (OR): 1.86; 95% CI: 1.09, 3.16; p = 0.022), corresponding to an adjusted prevalence of 28.4% versus 19.2%, and liking the school breakfast (OR: 2.14; 95% CI: 1.26, 3.63; p = 0.005), corresponding to an adjusted prevalence of 69.0% versus 53.9%. District policy has the potential to play an important role in encouraging higher levels of SBP participation.

Comprehensive Policies to Support Comprehensive Practices: Physical Activity in Elementary Schools

BACKGROUND

Schools are a setting in which students learn about the importance of lifelong physical activity (PA). Best practice guidelines indicate that schools should provide students with adequate physical education (PE) minutes and opportunities to engage in PA throughout the school day.

METHODS

Data from the nationally representative School Nutrition and Meal Cost Study in 2014-2015 were utilized to assess PA practices (including PE) at 412 public elementary schools. These data were linked to state- and district-level policy data from the National Wellness Policy Study to examine the relationships between state law and school district policies and school practices.

RESULTS

Just over half of the schools were in a state with a policy regarding PE minutes. The comprehensiveness and strength of PA policies were higher at the district level than the state level, but were still low overall. Comprehensiveness of PA policies at the state level, but not at the district level, was related to schools within those states that provide more PA practices.

CONCLUSIONS

Existence of PE and PA policies at the state level appears to be an important predictor of school PA practices. Having more comprehensive policies at the state level may be an important facilitator of school implementation of comprehensive PA practices.

Mapping medical marijuana: state laws regulating patients, product safety, supply chains and dispensaries, 2017

AIMS

(1) To describe open source legal data sets, created for research use, that capture the key provisions of US state medical marijuana laws. The data document how state lawmakers have regulated a medicine that remains, under federal law, a Schedule I illegal drug with no legitimate medical use. (2) To demonstrate the variability that exists across states in rules governing patient access, product safety and dispensary practice.

METHODS

Two legal researchers collected and coded state laws governing marijuana patients, product safety and dispensaries in effect on 1 February 2017, creating three empirical legal data sets. We used summary tables to identify the variation in specific statutory provisions specified in each state's medical marijuana law as it existed on 1 February 2017. We compared aspects of these laws to the traditional Federal approach to regulating medicine. Full data sets, codebooks and protocols are available through the Prescription Drug Abuse Policy System (http://www.pdaps.org/; Archived at http://www.webcitation.org/6qv5CZNaZ on 2 June 2017).

RESULTS

Twenty-eight states (including the District of Columbia) have authorized medical marijuana. Twenty-seven specify qualifying diseases, which differ across states. All states protect patient privacy; only 14 protect patients against discrimination. Eighteen states have mandatory product safety testing before any sale. While the majority have package/label regulations, states have a wide range of specific requirements. Most regulate dispensaries (25 states), with considerable variation in specific provisions such as permitted product supply sources number of dispensaries per state and restricting proximity to various types of location.

CONCLUSIONS

The federal ban in the United States on marijuana has resulted in a patchwork of regulatory strategies that are not uniformly consistent with the approach usually taken by the Federal government and whose effectiveness remains unknown.

Medicaid Prior Authorization Policies for Medication Treatment of Attention-Deficit/Hyperactivity Disorder in Young Children, United States, 2015

OBJECTIVES

In 2011, the American Academy of Pediatrics updated its guidelines for the diagnosis and treatment of children with attention-deficit/hyperactivity disorder (ADHD) to recommend that clinicians refer parents of preschoolers (aged 4-5) for training in behavior therapy and subsequently treat with medication if behavior therapy fails to sufficiently improve functioning. Data available from just before the release of the guidelines suggest that fewer than half of preschoolers with ADHD received behavior therapy and about half received medication. About half of those who received medication also received behavior therapy. Prior authorization policies for ADHD medication may guide physicians toward recommended behavior therapy. Characterizing existing prior authorization policies is an important step toward evaluating the impact of these policies on treatment patterns. We inventoried existing prior authorization policies and characterized policy components to inform future evaluation efforts.

METHODS

A 50-state legal assessment characterized ADHD prior authorization policies in state Medicaid programs. We designed a database to capture data on policy characteristics and authorization criteria, including data on age restrictions and fail-first behavior therapy requirements.

RESULTS

In 2015, 27 states had Medicaid policies that prevented approval of pediatric ADHD medication payment without additional provider involvement. Seven states required that prescribers indicate whether nonmedication treatments were considered before Medicaid payment for ADHD medication could be approved.

CONCLUSION

Medicaid policies on ADHD medication treatment are diverse; some policies are tied to the diagnosis and treatment guidelines of the American Academy of Pediatrics. Evaluations are needed to determine if certain policy interventions guide families toward the use of behavior therapy as the first-line ADHD treatment for young children.

Policy Surveillance: A Vital Public Health Practice Comes of Age

Governments use statutes, regulations, and policies, often in innovative ways, to promote health and safety. Organizations outside government, from private schools to major corporations, create rules on matters as diverse as tobacco use and paid sick leave. Very little of this activity is systematically tracked. Even as the rest of the health system is working to build, share, and use a wide range of health and social data, legal information largely remains trapped in text files and pdfs, excluded from the universe of usable data. This article makes the case for the practice of policy surveillance to help end the anomalous treatment of law in public health research and practice. Policy surveillance is the systematic, scientific collection and analysis of laws of public health significance. It meets several important needs. Scientific collection and coding of important laws and policies creates data suitable for use in rigorous evaluation studies. Policy surveillance addresses the chronic lack of readily accessible, nonpartisan information about status and trends in health legislation and policy. It provides the opportunity to build policy capacity in the public health workforce. We trace its emergence over the past fifty years, show its value, and identify major challenges ahead.

A Scan of CDC-Authored Articles on Legal Epidemiology, 2011-2015

OBJECTIVE

The Centers for Disease Control and Prevention (CDC) conducts research on legal epidemiology, the scientific study of law as a factor in the cause, distribution, and prevention of disease. This study describes a scan of articles written by CDC staff members to characterize the frequency and key features of legal epidemiology articles and their distribution across CDC departments and divisions.

METHODS

CDC librarians searched an internal repository for journal articles by CDC staff published from January 1, 2011, to May 31, 2015. Researchers reviewed and coded the abstracts to produce data on key features of the articles.

RESULTS

Researchers identified 158 CDC-authored legal epidemiology articles published in 83 journals, most frequently in Preventing Chronic Disease (14 publications), Journal of Public Health Management Practice (10 publications), and Morbidity and Mortality Weekly Report (9 publications). Most articles concerned the use and impact of law as a deliberate tool of intervention. Thirteen articles addressed the legal infrastructure of public health, and 3 assessed the incidental or unintended effects of nonhealth laws. CDC-authored articles encompassed policy making, implementation, and impact. Literature reviews and studies mapping laws across multiple jurisdictions constituted one-quarter of all publications. Studies addressed laws at the international, national, state, local, and organizational levels.

CONCLUSION

Results of the scan can be used to identify opportunities for the agency to better support research, professional development, networking, publication, and tracking of publication in this emerging field.

A Transdisciplinary Approach to Public Health Law: The Emerging Practice of Legal Epidemiology

Public health law has roots in both law and science. For more than a century, lawyers have helped develop and implement health laws; over the past 50 years, scientific evaluation of the health effects of laws and legal practices has achieved high levels of rigor and influence. We describe an emerging model of public health law that unites these two traditions. This transdisciplinary model adds scientific practices to the lawyerly functions of normative and doctrinal research, counseling, and representation. These practices include policy surveillance and empirical public health law research on the efficacy of legal interventions and the impact of laws and legal practices on health and health system operation. A transdisciplinary model of public health law, melding its legal and scientific facets, can help break down enduring cultural, disciplinary, and resource barriers that have prevented the full recognition and optimal role of law in public health.