Public health professionals as policy entrepreneurs: Arkansas’ childhood obesity policy experience

Public Health Professionals as Policy Entrepreneurs:Arkansas’s Childhood Obesity Policy ExperienceRebekah L. Craig, MPH, Holly C. Felix, PhD, MPA, Jada F. Walker, MA, and Martha M. Phillips, PhD, MPH, MBA

In response to a nationwide

rise in obesity, several states

have passed legislation to

improve school health envi-

ronments. Among these was

Arkansas’s Act 1220 of 2003,

the most comprehensive

school-based childhood obe-

sity legislation at that time.

We used the Multiple Streams

Framework to analyze factors

that brought childhood obesity

to the forefront of the Arkan-

sas legislative agenda and re-

sulted in the passage of Act

1220. When 3 streams (prob-

lem, policy, and political) are

combined, a policy window is

opened and policy entrepre-

neurs may advance their goals.

We documented factors that

produced a policy window and

allowed entrepreneurs to en-

act comprehensive legislation.

This historical analysis and

the Multiple Streams Frame-

work may serve as a roadmap

for leaders seeking to influ-

ence health policy. (Am J

Public Health. 2010;100:2047–

2052. doi:10.2105/AJPH.2009.

183939)

IN AN UNPRECEDENTED RISE,

the prevalence of overweightamong US children has morethan tripled over the past 3 de-cades. Recent National Health andNutrition Examination Surveydata (2003 through 2006) esti-mated that 32% of children andadolescents had a body mass

index (BMI; defined as weight inkilograms divided by height inmeters squared) for age at orabove the 85th percentile.1 WhenOgden et al. used the 97th percen-tile as an identifier of those with thegreatest body mass for age, theyreported that more than 11% of USchildren and adolescents fit intothat category.1 Overweight in child-hood is likely to persist into adult-hood2,3 and obesity predisposes fora number of diseases of both child-hood and adulthood.4 Adolescentswith very high BMI have also beenshown to have adult mortality ratesup to 40% higher than those ob-served in adolescents with mediumBMI.4

Obesity interventions and pre-vention have, consequently, be-come a major priority for policy-makers, health care professionals,economists, and the general pub-lic.5 Prior to 2003, several statesand the federal government hadenacted limited legislation aimed atreducing and preventing childhoodobesity.6 Incremental school-basedprevention efforts were largely fo-cused on emphasizing and improv-ing nutrition and physical educationcurricula, reinforcing classroomlearning throughout the school en-vironment, rewarding voluntaryadoption of healthy nutrition andphysical activity standards, andproviding model vending policiesand toolkits.6,7 Arkansas

policymakers recognized that halt-ing the epidemic necessitated pro-gressive steps to outpace increasingdisease rates. With the passage ofAct 1220 in 2003, Arkansasenacted comprehensive legislationto combat childhood obesity.

Act 1220 included 6 compo-nents aimed at combating child-hood obesity. First, a 15-memberChild Health Advisory Committeewas created and tasked with mak-ing recommendations to the StateBoard of Education and StateBoard of Health regarding physi-cal activity and nutrition standardsin public schools. Further, Act1220 required school districts toestablish Nutrition and PhysicalActivity Advisory Committees toguide the development of locallyspecific policies and programs.With Act 1220, Arkansas becamethe first state to enact statewideschool-based BMI screening withreports to parents for all publicschool children in grades Kthrough 12. Act 1220 both re-stricted student access to vendingmachines in public elementaryschools and required that schoolsdisclose vending contracts andpublicly report vending revenues.Lastly, the Arkansas Departmentof Health was required to employcommunity health promotion spe-cialists to provide technical assis-tance to schools in formulatingand implementing the rules and

regulations.8 Thus, Act 1220 man-dated some limited immediate ac-tion while establishing the mecha-nisms for short- and longer-termchange at both state and local levels.

In the policymaking process, in-cremental health policy change isthe norm, as opposed to innovative,comprehensive reforms such as Act1220. Legislators often face a mul-titude of issues, have little time toconsider all the data they need toaddress them, and may have tochoose from among a number ofpolicy alternatives to address anygiven issue. Zahariadis observedthat policymakers often ‘‘are lesscapable of choosing issues theywould like to solve and more con-cerned with addressing the multi-tude of problems thrust uponthem.’’9(p75) Arkansas is no excep-tion. In the 2003 Arkansas legis-lative session in particular, a largenumber of bills were introducedconcerning education. How, then,did the single issue of childhoodobesity rise to the forefront of anoverburdened legislative agenda?Who garnered political attentionfor this issue and formulated pol-icy solutions? What were the keyevents that led the Arkansas Leg-islature to abandon incrementallegislation and adopt a bold, com-prehensive policy initiative?

We sought to answer thesequestions by documenting thefactors and events that influenced

November 2010, Vol 100, No. 11 | American Journal of Public Health Craig et al. | Peer Reviewed | Government, Politics, and Law | 2047

GOVERNMENT, POLITICS, AND LAW

the policy process allowing thepassage of Arkansas’s school-based childhood obesity legisla-tion policy. This historical reviewand analysis of the policy processprovides a roadmap for publichealth advocates interested inpursuing policies directed towardcurbing the childhood obesity ep-idemic and other critical publichealth issues. By studying thispolicy process roadmap, publichealth advocates interested inshaping health policy can under-stand more fully their role in theprocess of setting agendas andformulating policy and can moreeffectively act when windows ofopportunity arise.

METHODS

In our policy analysis, we usedsecondary data collected as part ofa comprehensive evaluation ofArkansas Act 1220.10 Specifically,key informant interviews wereconducted by a research team atthe University of Arkansas forMedical Sciences (UAMS) Fay W.Boozman College of Public Healthwith persons knowledgeable of orinvolved in the passage of Act1220. Interviews were conductedin a semistructured format with 3questions aimed at understandingthe key events, policy entrepre-neurs, and processes that led to thedevelopment of Act 1220: ‘‘Howdid Act 1220 get started?’’; ‘‘Whohad the initial idea, and how did itget from that idea to a piece oflegislation ready for introductioninto the legislature?’’; and ‘‘How doyou see the early processes of policydevelopment for Act 1220?’’ Theopen-ended nature of the questionsallowed respondents to relate the

process of policy formation ina narrative format. When answerswere abbreviated or nonspecific,probing questions were asked toclarify or to obtain greater detail.

We used John Kingdon’s Multi-ple Streams Framework to guidethe review of interview transcripts.11

Kingdon said of the policy process:

[T]he development of policyproposals is a little bit like bi-ological natural selection. . . .Ideas float around in a policyprimeval soup. Much like mole-cules . . . ideas start, combine,recombine, and through this longprocess of evolution, some ideasfall away, while others will sur-vive and prosper.12(p333)

In the Multiple Streams Frame-work, the policy stream representsthe ideas towhich Kingdon referred(i.e., the policy alternatives andpossible solutions to a problem).The political stream represents themood, ideology, or attitudes of pol-icymakers and the public. Theproblem stream represents themany issues that may require gov-ernmental action. These 3 streamsflow independently until a policywindow (or window of opportunity)

is presented. Such windows openwhen changes occur in the problemor political streams, perhaps be-cause of new problem indicators,focusing events, or changes in po-litical parties or ideology. Feasible,acceptable, affordable proposalsfrom the policy stream then emergethrough the policy window withthe help of a policy entrepreneur.Such a person will invest his or herown resources to advocate a partic-ular policy leading to its adoption(Figure1).11,13

A research team at UAMS FayW. Boozman College of PublicHealth received training in theKingdon framework (e.g., 3streams, policy entrepreneur, andpolicy window) and then read thekey informant interview tran-scripts for overall content. Theythen reviewed the transcriptsagain to identify significant factors(e.g., person, idea, event, or pro-cess) in the policy formation pro-cess and to extract potentiallyrelevant quotes. Each transcriptwas assigned to a single reviewer;reviewers consulted with oneanother during the process to

facilitate consistency amongthemselves.

Factors were mapped to com-ponents of the analysis framework(e.g., 3 streams, policy entrepreneur,and policy window), and all pas-sages coded to a specific compo-nent were merged into a singleframework component docu-ment. Secondary source docu-ments were used to confirm find-ings and to provide greater detailand context. A total of 23 infor-mants completed interviews, in-cluding policymakers such asArkansas legislators (n=8), gov-ernment-appointed advisors onhealth and education (n=11), andstate agency leaders (n=4).Twelve secondary source docu-ments salient to the Arkansasinitiative or addressing childhoodobesity through state educationpolicy were reviewed. Five ofthese documents were paperspublished in peer-reviewed jour-nals,14–18 3 were acts or resolutionsin the Arkansas Code,19–21 2 werearticles from the popular press,22,23

and 2 were state task force re-ports.24,25

FIGURE 1—Multiple Streams Framework.

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RESULTS

As complex as the MultipleStreams Framework concept maybe, it can elegantly help to describethe fast-paced and muddled expe-rience of a policy design and in-stallation such as the Arkansas Act1220 to combat childhood obesity.

The Policy Stream

As an informant commented,‘‘the Act represented the culmina-tion of a longer developmentalprocess around the policy optionsavailable to the legislature.’’ In thepolicy stream we found that

a policymaker was motivated toaction by concern about theamount of caffeine and sugar infoods and beverages available tochildren in school vending ma-chines. Determined to uncoverpossible solutions, the respondentled legislative hearings to raiseawareness of the issue and gener-ate policy alternatives during the1999 and 2001 legislative ses-sions (Figure 2). Respondentswere also familiar with the use ofschools as a venue for child healthscreenings. Knowledge of Arkan-sas’s long-standing history of pro-viding school health

services—including screening forscoliosis, vision, and hearing—andreporting adverse outcomes toparents was evident among poli-cymakers.19,20 Additionally, someschools in Arkansas routinely mea-sured student height and weight aspart of health, physical education,and other curricula. This practiceis not uncommon among schoolsnationwide. For example, Floridapublic schools began collectingheight and weight for students in3 grades in 1973.14 Story et al.reported that, as of 2000, 26% ofstates had requirements thatschools measure students’ height

and weight and 61% of those statesrequired parental notification ofresults.18

Policymakers nationwide recog-nized that only1additional stepwould be necessary for schools toconvert those measurements intoreportable BMI surveillance data. Asearly as1995, California imple-mented collection of BMI measure-ments for public school students in 3grades.14 During the 2000 to 2001academic year, Cambridge PublicSchools and the Institute for Com-munity Health, both in Massachu-setts, conducted a pilot study ofschool-based BMI screening with

Note. ACH = Arkansas Children’s Hospital; ADH = Arkansas Department of Health; AR PNPA = Arkansas Preventive Nutrition and Physical Activity Summit; ASTHO = Association of State and Territorial

Health Officials; BMI = body mass index; NCSL = National Conference of State Legislatures; NFWL = National Foundation for Women Legislators; NGA = National Governors Association; UAMS

COPH = University of Arkansas for Medical Sciences Fay W. Boozman College of Public Health.

Source. Felix HC.13

FIGURE 2—Application of Multiple Streams Framework to the enactment process for Arkansas Act 1220.



parental notification of results.15 Inthe same year, the Tennessee legis-lature authorized optional BMI sur-veillance for all public school stu-dents.14 The Michigan Departmentof Education recommended BMIscreening in 2001and about half ofschool districts elected to screensome or all of their students.22,24

The Political Stream

Prior to the passage of Act1220, several significant actionsoccurred in the political streamto influence the attitudes ofArkansas’s policymakers. In1999, the Arkansas Legislaturecommissioned the Arkansas De-partment of Health to establishan Obesity Task Force to studythe effects of obesity on childrenand adults and to make recom-mendations for future state ac-tion to reduce obesity.21 Thetask force findings were reportedpublicly and to the legislature in2000. Regarding childhood obe-sity, the task force recommendedlegislation to enact a comprehen-sive statewide program with 14specific aims to raise public aware-ness and enhance school policiesand practices for nutrition andphysical activity.25

Soon after, Arkansas legislatorsattended the 2001 National Foun-dation for Women LegislatorsConference where public healthadvocates made quite an impact.Their tactics of raising awarenessof state-specific childhood obesityindicators influenced a respondentto support efforts to combat theepidemic. This respondent noted,

All across the whole wall wasplastered ‘Little Rock, Arkansas—number 1 in the nation for child-hood obesity and type 2 diabetes.’

That really woke me up and wasone reason that I spoke out.

Subsequently, legislators werepresented with a health resolutioncalling on them to take personalaction and serve as role models inthe state’s efforts to combat child-hood obesity.

Further support for state policyefforts to combat childhood obe-sity was garnered in January 2002when Arkansas legislators andother policymakers, includingrepresentatives from the Gover-nor’s Office and the Arkansas De-partment of Health, attendeda meeting sponsored by the Na-tional Conference of State Legis-latures, National Governors Asso-ciation, and Association of Stateand Territorial Health Officials. Atthe meeting, attendees from 6contiguous states considered dif-ferent approaches to addressinghealth issues in their states, in-cluding childhood obesity.23 Re-spondents noted interventions forchildhood obesity as a primarytopic of discussion within theArkansas delegation.

Public health professionals fromthe Arkansas Department ofHealth’s Cardiovascular HealthProgram and the UAMS hostedthe first Arkansas Preventive Nu-trition and Physical Activity Sum-mit in March 2002. Leaders whowere thought ‘‘most able to initiateand implement change’’ were in-vited to attend the 1-day confer-ence.16 Attendees were divided intowork groups, 1 of which was taskedwith devising practical, achievablepolicy alternatives for education,including school environment. Arespondent from the health com-munity summarized the Summit’s

impact: ‘‘The [Arkansas PreventiveNutrition and Physical Activity Sum-mit] set the framework for thinkingabout what the problems are, thescope of the problem, and possibleinterventions.’’ The Summit’s work-ing recommendations includedschool-based BMI surveillance withparental notification for all publicschool students and creation of anoffice devoted to nutrition andphysical activity.16

The Problem Stream

Throughout that time, publichealth leaders from the UAMS FayW. Boozman College of PublicHealth and the Arkansas Depart-ment of Health presented annualupdates to legislators about theburden of obesity in Arkansas.Multiple policymakers interviewedrecounted health information theylearned during those updates. Evi-dence of obesity’s consequences forthe state made a strong impressionon legislators. One respondent,whose remark is representative ofseveral others, recalled learningthat because of earlier onset ofobesity and diabetes, ‘‘40-year-oldpeople are getting their feet andlegs cut off.’’ The informationhelped focus the attention of poli-cymakers on the obesity issue.

Annual updates to the ArkansasLegislature often included indica-tors of the severity of childhoodobesity. By 2002, for example, anestimated 31% of American chil-dren aged 6 to 19 years wereoverweight or obese, and physi-cians at the Arkansas Children’sHospital began discussing thesharp rise in the number of casesof child and adolescent onsetof type 2 diabetes seen in theirclinics.17 A fitness clinic was

planned at Arkansas Children’sHospital to provide behavioral andsurgical weight-loss interventionsfor children with a BMI measure-ment greater than the 95th per-centile.

Prior to the Arkansas 2003 leg-islative session, then-Speaker of theHouse Herschel Cleveland, a Demo-crat, and then-Arkansas GovernorMike Huckabee, a Republican, eachexperienced serious obesity-relatedpersonal health problems. Thoseexperiences, made public becauseof their offices, served as focusingevents that brought attention to theseriousness of the issue and made itclear that the battle against obesitywas bipartisan.

The Policy Window and Policy

Entrepreneurs

Because of these changes inthe political and problemstreams, a temporary policy win-dow opened, providing the op-portunity for comprehensivepolicy changes to combat child-hood obesity. After summarizingsome events in the 3 streams,a respondent aptly described thisphenomenon:

It just happened to be that thelegislators were interested inhearing about ways to improvechild health and were willing tostick their neck out with a bill thatwas really different from any-thing that had been done in therest of the United States.

Speaker Cleveland was broadlycredited by respondents as the pri-mary policy entrepreneur. Onepolicymaker remarked, ‘‘I think[Speaker Cleveland] had a personalexperience, professional interest,and a legislative responsibility thatcame together.’’ Speaker Cleveland

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requested that the Arkansas De-partment of Health draft potentiallegislation for school-based policychanges to reduce childhood obesityand then invested himself person-ally in advocating the bill’s passage.

Public health professionals actedas secondary policy entrepreneursby coupling the problem with via-ble alternatives from the policystream. Several of those individualshad been involved in the eventsnoted in the political and problemstreams and were ready with prac-tical, achievable policy optionsgenerated at the Arkansas Preven-tive Nutrition and Physical ActivitySummit and other venues. Thetimely coupling of streams by pol-icy entrepreneurs led to the passageof Arkansas Act 1220 of 2003.

DISCUSSION

In the political stream, advocacyby public health professionals atnational legislative conferencesand state-level meetings influ-enced policymakers’ beliefs aboutchildhood obesity. In the problemstream, focusing events, namelythe personal health problemsof 2 policymakers, paired withthe changes in indicators pre-sented at local and national meet-ings, turned attention and focusto the issue. Arkansas Speaker ofthe House Herschel Clevelandand Arkansas’s public health pro-fessionals were most frequentlynoted by key informants to bethe primary policy entrepreneurs.Public health advocates whoparticipated in the ArkansasObesity Task Force and theArkansas Preventive Nutritionand Physical Activity Summitgenerated policy alternatives and

formulated the legislation, whichwas then sponsored by colleaguesof Speaker Cleveland, at his urg-ing.

Kingdon’s Multiple StreamsFramework continues to be auseful model for understandingmany cases of health policy re-form, particularly comprehensivereforms such as Arkansas Act1220. It is notable that during thepolicy process in Arkansas, somepublic health leaders advocatedan incremental approach toaddressing school-based obesitypolicy. Several respondentsremarked about the many ver-sions drafted before the bill wasfiled. Key elements that werefeared to diminish political feasi-bility, such as vending restrictionsand the BMI initiative, were de-bated, eliminated, and then addedback into the proposal as keypublic health professionals tire-lessly advocated comprehensivelegislation.

Kingdon asserted that althoughgeneration of policy alternativesmay be incremental, as was thecase for Act 1220, agenda changeis nonincremental and occurswhen a combination of the 3streams opens a policy window.11

During that short window of time‘‘there is often sufficient ambiguityin the nature of the problem orwhat can be done about it so thata leader can offer his or her pro-posal as a plausible solution.’’26(p216)

Speaker Cleveland was a policyentrepreneur; thus, his experience,interests, and responsibility to thestate of Arkansas poised him toadvocate policy change when hewas presented with a window ofopportunity. Public health pro-fessionals, armed with policy

alternatives, found that legislatorswere willing to take bold stepstoward eliminating childhoodobesity in Arkansas. The processwas described, even by a pro-ponent of incrementalism, as ‘‘awonderful progression of compro-mise, of discussion, of verythoughtful people being passionateabout it and it’s turned out to be anoutstanding piece of legislation.’’

The Arkansas law known as Act1220 of 2003 provides an illus-trative example of comprehensivepublic health policy on a state level.When Act 1220 is viewed throughthe lens of the Multiple StreamsFramework, the influence of publichealth professionals is clearly seenin raising awareness and proac-tively generating policy alternatives.The Multiple Streams Frameworkincorporates the important role ofchance in the policymaking process.Policy windows are short andoften unpredictable. Whether atthe federal, state, local, or agencylevel, public health professionalsmust understand their policy en-vironment and not lose a momentin recognizing the convergence ofthe 3 streams and ‘‘champion’’policy entrepreneurs. With thecorrect balance of strategicplanning and timely responses topolicy windows, public healthprofessionals can use Kingdon’sMultiple Streams Framework asa roadmap for improving thehealth and well-being of thepopulation. j

About the AuthorsAt the time of the study, all authors werewith the Fay W. Boozman College of PublicHealth, University of Arkansas for MedicalSciences, Little Rock. Martha M. Phillipswas also with the Department of Psychiatry,

College of Medicine, University of Arkansasfor Medical Sciences.

Correspondence should be sent to JadaWalker, MA, University of Arkansas forMedical Sciences, Fay W. Boozman Collegeof Public Health, 4301 W Markham St,Slot 863, Little Rock, AR, 72205 (e-mail:[email protected]). Reprints can be or-dered at http://www.ajph.org by clicking the‘‘Reprints/Eprints’’ link.

This article was accepted on April 5,2010.

ContributorsR. L. Craig synthesized concepts, inte-grated research findings, and led thewriting. H. C. Felix assisted with thepolicy theory specifics and analyses. J. F.Walker assisted with the research andenvisioned the policy implications. M. M.Phillips originated the research and su-pervised all aspects of its implementa-tion. All authors helped to conceptualizeideas, interpret findings, and reviewdrafts of the article.

AcknowledgmentsThis work was supported by the RobertWood Johnson Foundation (grants051737, 60284, and 30930).

The authors thank James M. Raczynski,PhD, for his support, as well as BritniMitchell and Matilda Louvring for assis-tance in preparation of this article.

Human Participant ProtectionThis study was approved by the Univer-sity of Arkansas for Medical Sciencesinstitutional review board.

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5. Paxson C, Donahue E, Orleans T,Grisson JA. The Future of Children.2006;16:9–10. Available at: http://www.aecf.org/upload/publicationfiles/obesity.pdf. Accessed July 27, 2010.

6. Rosenthal J, Chang D. State ap-proaches to childhood obesity: a snapshotof promising practices and lessonslearned. Portland, ME: National Academyfor State Health Policy; 2004. Availableat: http://nashp.org/sites/default/files/childhood_obesity.pdf. Accessed July 27,2010.

7. National Conference of State Legisla-tures. Childhood obesity—An overview ofpolicy options in 2003–2004. Availableat: http://www.ncsl.org/default.aspx?tabid-14112. Accessed August 29, 2009.

8. Arkansas Act 1220 of 2003 toCombat Childhood Obesity. ArkansasCode Annotated, 20-7-133-135 (2003).

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10. Raczynski J, Phillips M, Bursac Z, et al.Establishing a baseline to evaluate Act1220 of 2003: an act of the ArkansasGeneral Assembly to combat childhoodobesity. Little Rock, AR: University ofArkansas for Medical Sciences College ofPublic Health; 2005:1–32.

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13. Felix HC. The rise of the community-based participatory research initiative atthe National Institute for EnvironmentalHealth Sciences: an historical analysisusing the policy streams model. ProgCommunity Health Partnership. 2007;1(1):31–39.

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Utilization of Research in Policymaking for Graduated Driver LicensingReece Hinchcliff, PhD, Rebecca Q. Ivers, PhD, MPH, Roslyn Poulos, PhD, and Teresa Senserrick, PhD

Young drivers are overrep-

resented in road trauma and

vehicle-related deaths, and

there is substantial evidence

for the effectiveness of gradu-

ated driver licensing (GDL)

policies that minimize young

drivers’ exposure to high-risk

driving situations. However, it

is unclear what role research

plays in the process of making

GDL policies.

To understand how research

is utilized in this context, we

interviewed influential GDL

policy actors in Australia and

the United States. We found

that GDL policy actors gener-

ally believed that research

evidence informed GDL policy

development, but they also be-

lieved that research was used

to justify politically determined

policy positions that were not

based on evidence.

Further efforts, including

more effective research dis-

semination strategies, are re-

quired to increase research

utilization in policy. (Am J Pub-

lic Health. 2010;100:2052–

2058. doi:10.2105/AJPH.2009.

184713)

YOUNG DRIVERS (AGED 17-25

years) are overrepresented in roadtrauma, and vehicle-related

crashes are a leading cause of

death among young people.1,2

Governments in many high-income

countries, including Australia and

the United States, have addressed

this problem by developing gradu-

ated driver licensing (GDL) sys-

tems.1 GDL systems minimize

young drivers’ exposure to high-risk

driving situations and may use any

of a variety of policies, such as

minimum age of licensing and speed

limitations. Research has shown that

such systems can be very effective

in reducing crashes and injuries,

although their effectiveness depends

on the inclusion of several key fac-tors.3

Restrictions on night drivingand on the ages of passengers areamong the most effective ways toreduce crash involvement.4 How-ever, policymakers in many statesand jurisdictions have opposedthese restrictions for a number ofpolitical (e.g., electoral support) andideological reasons, and because ofconcerns regarding the legitimacyof using evaluations from otherjurisdictions to determine appropri-ate policies.5 Such widespread gov-ernmental opposition to these re-strictions indicates that, despite the

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Public health professionals as policy entrepreneurs: Arkansas’ childhood obesity policy experience

Health & Medicine

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