Public health partnerships to support effective policy

Helping countries combat junk food, obesity‍

“About 60% of what adults eat and 80% of what kids eat is ultra-processed,” says Barry Popkin, PhD. “It’s killing us.”

Popkin, the W.R. Kenan Jr. Distinguished Professor of Nutrition, was fresh off a trip that included stops in Brazil, South Africa and Colombia — just a few of the countries that are home to global partners who work closely with Popkin and his partners in the Global Food Research Program at UNC-CH.

They conduct and share research to help countries enact policies to reduce consumption of ultra-processed, high-sugar foods and beverages that lead to obesity and health problems among their populations. They also collaborate on evaluations they fund with these global research partners. Convincing policymakers to act can take years. For instance, Popkin had been working in Mexico for eight years before that country implemented a tax on sugary beverages. But once that happened and an evaluations article was published in BMJ, about 40 other countries followed suit over the next two years.

“Sometimes it felt like we were fighting a giant,” Popkin said. “But we’ve won.”

The group’s latest big project is in India, where for the past two years, Popkin and his Global Food Research Program partners Lindsey Smith-Taillie, PhD, associate professor of nutrition, and Shu Wen Ng, PhD, professor of nutrition, worked with medical groups, academic institutions, advocates, journalists and others to increase awareness of the health impacts of junk food. It’s been a huge but worthwhile task: India is now developing new food policies that are expected to include front-of-package warning labels, joining several other countries that have enacted similar policies based on the group’s research.

The group’s international work — and their proven results — are gaining traction here in the United States. “We’re involved in all sides of trying to cut unhealthy food consumption and reduce inequities,” Popkin said. “We are really at the forefront of the globe in providing research support for people trying to do healthy food policy.”

Pushing for equitable outcomes

Early in her public health career, Lindsey Yates, PhD, MPH, found herself working in Tarrant County, Texas, where infant mortality rates are especially high among Black pregnant women living in certain ZIP codes in the county.

“It was so discouraging to see that for Black women, even if they were educated, had good incomes and family support … their babies were still dying,” said Yates, an assistant professor of maternal and child health. “Something was happening at a broader policy and systemic level. It’s rooted in structural racism.”

As a health equity researcher focused on reproductive health services, maternal and child health, and implementation science, Yates works to improve outcomes through systemic change. She’s involved in a North Carolina initiative aiming to improve birth outcomes, reduce infant mortality, and improve health outcomes for children aged 0-5.

She also studies postpartum contraception, specifically when an IUD or birth control implant is inserted after a patient gives birth but before they are discharged. N.C. now covers this under Medicaid, but Yates found that patients had vastly different experiences in their contraception and counseling services — meaning there’s still work to do to improve systems and structures so they work for everyone.

N.C’s recent expansion of Medicaid services was a big win, Yates said. But she’s keeping a wary eye on how different states are reacting to the Supreme Court’s Dobbs decision and the concerning trend of rural hospitals closing their maternity care units. Such systemic and policy changes are especially important for historically marginalized populations, Yates said: “When bodies and minds encounter a system that’s not designed with their lived experiences in mind, that leads to harm, even death.”

It’s also important for policymakers to be mindful of “vital conditions” — factors like whether water is safe to drink, whether a community is walkable, and residents’ access to fresh foods or a local hospital. “These are all things out of any one individual’s control, but they are all things we need to be healthy — and a lot of that is set by policy,” Yates said. “If we want to have all our citizens thriving in strong communities, we need to pay attention to the equity implications of every policy.”

A passion project with policy results

One in four women are exposed to violence from their partners during pregnancy. Abigail Hatcher, PhD, associate professor of health behavior, has been trying to change that for years. Her studies of community and health interventions to prevent violence have been used to inform national law and policies in South Africa, as well as the World Health Organization’s care guidelines for maternal and child health care providers.

In South Africa, Hatcher worked on a study pairing gender training with microfinance — providing women with access to small loans that are secured through social relationships rather than high interest rates — and the team found it significantly reduced partner violence. A later clinical trial found that having nurses spend 30 to 45 minutes with women to talk about safety in relationships reduced partner violence by 48%. In her spare time, she got to know people and organizations who shared her interests in women’s safety.

“I’m curious about all the different ingredients, but I ultimately care about safer bodies and sounder minds for women,” she said. “For me, this was a passion project that happened to align with a policy window.”

A couple years later, South Africa saw a wave of student-led activism calling for more protections for women. Together with activists and civil society, Hatcher formed the Prevention Task Team to translate the evidence-base into outputs for policymakers. The team participated in multiple consensus-building events, writing parts of a declaration from a violence prevention summit that ended up being adopted by legislators. Two parts of that law harken back to Hatcher and others longstanding work — the central role of economic strengthening and health sector actors in ensuring women’s safety.

Once the law was in place, the health sector needed clear policies to put it into action with patients. Hatcher co-wrote South Africa’s national maternal health policy chapter on violence. Her team’s innovations around health worker training and patient assessment in pregnancy have now been incorporated into World Health Organization guidance.

In the coming years, Hatcher plans to translate these policy and programming insights into local settings. Approaches from elsewhere hold promise for the U.S. setting, where maternal mortality is higher than peer countries, in part due to violence in pregnancy.

“It’s fun as an academic to stretch my wings in an action-oriented way and feel like the work I’m putting in could impact daily lives,” Hatcher said.

Driving health behavior through policy

Lindsey Haynes-Maslow, PhD, MHA, is an expert on the intersection between public health and nutrition, and the impact government policies and programs have on health behaviors. Her work focuses mainly on lower-income families’ access to federal food assistance programs, a subject that first caught her interest over 15 years ago. The Affordable Care Act had not yet passed, and roughly 48 million U.S. adults lacked health insurance.

“I was looking for ways to prevent people from having to access the health care system if they couldn’t afford it. When I started examining the reasons people were going to the hospital, a common theme was that their visits were tied to complications from diet-related chronic disease like diabetes and hypertension,” said Haynes-Maslow, an associate professor of health policy and management and adjunct assistant professor of nutrition.

Knowing that a better diet could improve people’s health and reduce the cost of care inspired Haynes-Maslow to promote policies that would enhance access to healthier foods. For six years she led N.C. State University’s SNAP-Education program, managing a statewide nutrition education and obesity prevention program. She has also worked for UNC Health, the N.C. Institute of Medicine, the state’s Division of Public Health, and a nonprofit advocating for federal food and nutrition policies.

Today Haynes-Maslow teaches students, researchers and other scholars how to communicate with policymakers and the media. She advises them to know their topic and their audience and explain their work simply in a way that’s relatable.

“It’s easy to get frustrated by politics, but for those that are interested in policy, stay engaged and focus on playing the long game,” she said.

Breaking new ground in air quality policy

Barbara Turpin, PhD, professor in the Department of Environmental Sciences and Engineering, has co-authored a major new report outlining critical tools that could drive changes to air quality policies and practices across the country.

The Clean Air Act only authorizes regulation of outdoor air quality, even though the indoor environment is where people are primarily exposed to contaminants and toxic agents — both those of indoor and outdoor origin. But as outdoor air regulations are successfully reducing pollutants, unregulated indoor air pollution is becoming more and more of a problem. So in 2022, the American Thoracic Society invited Turpin and other experts to a major workshop to investigate how indoor pollution affects outdoor air quality.

They found that building operation and indoor activities also result in emission of pollutants like methane into the atmosphere, contributing to outdoor air quality problems and climate change. The experts concluded that using filtration and controlling indoor pollution at its source can effectively reduce outdoor air pollution and identified mitigation strategies like switching from natural gas stoves to electric ones and using scent-free consumer products.

“When you burn natural gas, methane leaks out. That’s a potent greenhouse gas and is really bad for the climate and contributes to ground level ozone regionally,” Turpin said. “There are health benefits to not burning things in your house — especially natural gas — and there are also climate benefits.”

States are required to comply with the federal Clean Air Act’s health-based standard for ozone. The FDA offers states a variety of compliance options they can implement to meet the standard. Now that scientists have shown how indoor-generated air pollution contributes to ozone, indoor pollution strategies can be added to the states’ options for compliance.

“Our department does a lot of policy-relevant work,” Turpin said. “I’m an engineer and I do public health, and for both those fields the point is to make a difference in practice.”

Policy prescription that makes a difference

The U.S. drug overdose crisis continues to be a major challenge. As providers and policymakers keep looking for solutions, it’s important to evaluate the steps that have already been taken.

Juan Hincapie-Castillo, PharmD, PhD, assistant professor of epidemiology, uses real-world data to evaluate and promote evidence-based policymaking. His focus is on improving prescribing policies so patients can safely access the medication they need to help manage their pain. “You can’t do pain management without thinking about opioids,” he said. “And you can’t address the opioid problem with a one-size-fits-all policy solution.”

Hincapie-Castillo was in pharmacy school in Florida when opioid prescribing began to peak. Wanting to make sure patients had access to safe, effective medication, he decided to pursue pharmacoepidemiology, which uses population-level research to examine medication use, safety, and effectiveness. Hincapie-Castillo did about a dozen studies analyzing Florida’s new opioid restrictions. He found that the laws, while well-intended, negatively impacted certain patients needing relief from chronic pain.

When similar legislation was introduced at the federal level, patient advocates cited his Florida studies as a cautionary tale in their meetings with legislators and staff members. The provision in question was removed from the legislation.

“I don’t want my papers to just sit in journals; I want them to be used to empower patient advocacy,” he said.

Today, Hincapie-Castillo is president of the board of directors for the National Pain Advocacy Center, a nonprofit working to advance the health and human rights of people living with pain.

At the Gillings School, he launched a class this semester on legal epidemiology, or how to evaluate the law’s effects on health behaviors and outcomes. He hopes to give students tools to identify important issues, evaluate policies, and interpret evidence to inform and persuade policymakers to support public health.

“We cannot do public health purely for academic purposes,” he said. “If our ultimate goal is to improve public health, we need to be honest — it happens through policy, though political leverage.”

Advancing methodologies that inform regulation, policy

Government agencies recognize the value that academic researchers bring to the policy and regulatory process. In some cases, they put academic consulting arrangements in place so the researchers — and their expertise — are close at hand.

Lisa LaVange, PhD, professor and chair emerita of biostatistics, has seen that relationship work from both vantage points. As former director of the Office of Biostatistics in the Center for Drug Evaluation and Research (CDER), which regulates over-the-counter and prescription drugs, she established one of the center’s earliest consulting arrangements (Interagency Personnel Act agreements, or IPAs) with a university researcher. Once LaVange returned to Gillings in 2018, she became an IPA consultant herself.

As a statistical advisor to the Office of the CDER Director, LaVange did not participate in individual drug approval decisions. She advised on statistical methods for drug testing and leveraged her academic expertise to identify ways in which those innovative methodologies could impact future drug development and regulatory oversight. She also worked with the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH), a group of regulatory bodies from countries around the world that works with industry to make new treatments available to consumers more quickly while maintaining scientific rigor and patient safety.

“I was there to advise as an academic, but I was also able to draw on my experience working inside FDA,” LaVange said.

The Food and Drug Administration relies on academic experts from both public and private universities to provide continuing education opportunities for agency reviewers and keep government officials abreast of cutting-edge research methods in academia. A programmatic example where such methods can have an impact is FDA’s Complex Innovative Trial Design (CID) Paired Meeting Program, which facilitates the use of complex clinical trial designs in drug development. LaVange was instrumental in launching this program while at FDA and continued to advise on its implementation after returning to academia.

Now retired, LaVange no longer consults with CDER, but she does stay engaged through FDA public meeting participation and other activities, and the FDA continues to lean on the department’s scientific experts for research and guidance through other research agreements. “Although biostatisticians tend to focus on methodological research,” said LaVange, “applications of those methods to real-world problems are just as important. Drug development and regulatory oversight are examples where those applications impact policymaking and, ultimately, public health.”  

‘Pracademic’ leadership to help meet crime victims’ needs

After a crime, victims may need help in a variety of ways, from short-term financial aid to long-term counseling and health care for conditions resulting from the crime. The Governor’s Crime Commission, which funds victim assistance programs, decided that a statewide assessment of victims’ needs would help the Commission optimize its resources.

Dana Rice, DrPH, assistant professor in the department of public health leadership and practice, and colleagues from the UNC School of Social Work led the assessment. Key to their work was creating a community advisory board to examine how victims’ needs, and their access to services, varied across populations.

“We really integrated the community advisory board as partners in the process,” Rice said. “They informed every phase of the needs assessment, from design to the interpretation of results and the final recommendations.”

The team undertook a comprehensive effort to better understand the scope of victims’ needs, making recommendations the Commission is now using to guide its funding decisions. But one of the most significant outcomes was that the Commission invited community advisory board members to be part of their new advisory board. “For the Commission to continue the relationships we’d built is a testament to the value of the community,” Rice said.

She also highlighted the role Gillings School students — including a capstone team from the health behavior and health equity and social justice concentrations and multiple practicum students from the Leadership in Practice concentration — played in the project. “From beginning to end, they were in it — they did all of it,” she said.

Rice, who uses the term “pracademic” to describe her academic and practice work, said impactful community engagement requires knowledge of the work and the ability to build relationships. “Without both the science and the art of public health work, policy change can’t happen,” she said.

Better outcomes for all

These are just a few of the outstanding leaders who exemplify that at the Gillings School, we strive to excel in both the art and the science of public health — working toward policy changes that improve equity and outcomes for families and communities in N.C. and across the world.