T17aP23 - Unintended Consequences of Policies

Topic : Sectorial Policy - Health

Panel Chair : Helen Jordan - h.jordan@unimelb.edu.au

Objectives and Scientific Relevance of the panel

Call for papers

Session 1 Unintended Consequences of Health Policies


Helen Jordan - h.jordan@unimelb.edu.au - Melbourne School of Population and Global Health, The University of Melbourne - Australia

Menu Labels, for Better, AND Worse? Exploring Socio-Economic and Racial-Ethnic Disparities in Menu Label Use in a National Sample

Wenhui Feng - wfeng@albany.edu - University at Albany, SUNY - United States

Ashley Fox - afox3@albany.edu - University at Albany, State University of New York - United States

Research Objective: Providing calorie information on restaurant menus aims to empower customers to make healthier food choices. The mandate of menu labeling has been one of the few obesity policies to become national law. However, researchers have questioned whether it will empower those with greater health literacy more, possibly reinforcing obesity disparities. Previous studies have not analyzed the change of disparities in menu label usage. To fill this gap, we investigate the change in race and socio-economic disparities in menu-calorie labeling usage, adjusting for gender, age and body weight.

Study Design: To describe the disparity change, we used a difference-in-differences approach. Survey wave was included both as an independent variable and as an interaction term with each major disparity variable (race/ethnicity, education and income) to assess whether differences among socio-economic and race-ethnic groups have gotten larger over time.

We examine change in disparities for four markers of menu label use- whether the respondent saw or used (if saw) menu labels in fast food restaurant and sit down restaurant. We hypothesized disparities should be the wider for using labels than seeing labels and in fast food restaurants since greater health literacy may be required to quickly process information about menu calorie labels and apply them to order decisions in a fast food setting.

Population Studied:  We used data from the 2007-2008, 2009-2010 and 2013-2014 rounds of the NHANES, Flexible Consumer Behavior Survey Module (n=19,015), a nationally representative sample of individuals of 16 years old or above.

Principal Findings: While seeing and using menu labels increased over time, not all groups increased the same. Blacks and low income individuals were less likely to use labels than Whites and higher income groups (odds-ratios 0.62 and 0.60, respectively; p<.05 for both). College graduates disproportionately increased label usage in progressive rounds compared with individuals only graduated high school (odds-ratio 1.55, p<.05).

Conclusions: Labels appears to have more influence on more empowered groups, who may be more ready to use them. This study reinforces concerns that there are exacerbated socio-economic and racial-ethnic obesity disparities in menu label usage. Labels themselves may not be sufficient to combat obesity in all populations, particularly those who are most at risk.

Implications for Policy or Practice: Disparities among different socio economic and race- ethnic groups have enlarged over time. The study found that the lower socio economic and minority groups, also have higher obesity rates, increased menu label usage at a slower pace than their counterparts. Labeling may have more influence on people who are already seeking nutrition information, although more causal studies are needed. As national implementation of menu labels is due to begin this year, researchers should explore ways to make the labels more visible and intuitive, so that at-risk groups can equally make use of menu labels. Researchers may also consider identifying policies that are less informationally-driven to address the structural causes of obesity disparities.

Exploring unintended consequences of policy initiatives in mental health: the example of Child and Adolescent Mental Health Services (CAMHS) in England

David Foreman - David_Foreman@doctors.net.uk - King - United Kingdom

Aims and Hypotheses
This study aimed to study service activity and capacity in CAMHS, in relation to policy decisions and professional attitudes, as a case study of policy and professional influences on mental health services, following an observation that CAMHS capacity in young children was falling, contrary to policy intentions.  Hypotheses were

1.     That well-intentioned policy initiatives could generate unintended, counterproductive consequences through perverse incentives

2.      That inadequate funding significantly contributed to policy failure

The focus was on pre-school (0-4) children, as both current and 2003 policy initiatives stressed the importance of “early intervention.”  The impact of policy and funding on Child and Adolescent Mental Health Service (CAMHS) activity and capacity, from 2003 to 2012, was assessed.  The Child and Adolescent Faculty of the Royal College of Psychiatrists surveyed its members about comparative 0-4 year service activity and attitudes in 2012.

CAMHS mapping data provided national estimates of total numbers of CAMHS patients, while HES data counted appointments or episodes of inpatient care.  The survey reported on Child Psychiatrists’ informal estimates of service activity, and attitudes towards 0-4 children. Funding details were obtained from CAMHS mapping and parliamentary reports. 

The association between service capacity and service activity was moderated by an interaction between specified funding and age, the youngest children benefiting least from specified funding, and suffering most when it was withdrawn (Pr=0.005). Policy review & significant differences between age-specific HES trends (Pr<0.001) suggested this reflected prioritisation of older children. Clinicians were unaware of this effect at local level, though it significantly influenced their attitudes to prioritising this group (Pr=0.02).  Overall funding had no effect.

Hypothesis 1 was supported, with prioritisation generating unintended consequences.  Professional opinions adapted to policy, rather than the reverse, consistent with perverse incentivisation.  Hypothesis 2 was not supported: hypothecation of funding was more important than funding totals. Appropriate, time limited prioritisation, with hypothecated funding, will improve the probability of success of mental health service initiatives. 


For further details see http://bmjopen.bmj.com/content/6/8/e010714.abstract

Health and Mental Health Effects of Local Immigration Enforcement Policies on Latino Immigrants in the US

Julia Shu-Huah Wang - jshwang@hku.hk - University of Hong Kong - Hong Kong, (China)

Neeraj Kaushal - nk464@columbia.edu - Columbia University  - United States

Backgrounds: This study examined the unintended health and mental health effects of local immigration enforcement policies on Latino immigrants living in the United States. In 1996, the US government passed the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA). Section 287(g) of IIRIRA grants state and local jurisdictions the choice to enter into agreements with Immigration and Customs Enforcement to participate in the enforcement of federal immigration laws. The number of localities pursuing 287(g) agreements has increased from two in 2002 to 76 in 2009 across 26 states. Since 2008, the Secure Communities Program (SC) gradually replaced 287(g) and was implemented in all counties nation-wide in 2013. As a result, tens of thousands of undocumented immigrants were removed annually from prison or during policing operations. There is limited national-level scientific research on how immigration policy environment affects immigrant health, in general, and how state- and local-activism on immigration enforcement in the US has influenced the health and mental health of immigrant families. This research bridges this critical knowledge gap and offers evidence to assess the full range of costs and benefits of immigration enforcement policies.

Data and Methods: This study used the restricted-use National Health Interview Survey (NHIS) data (2000-2012) and linked county-level 287(g) Task Force Enforcement (TF) and Jail Enforcement (JE) and SC policy variables to the NHIS data. Health was measured by self-rated health, and mental health is measured by Kessler-6 Psychological Distress Scale. The analytic sample was restricted to adults aged 18-60 born in Latin America living in households with at least one noncitizen family member. Ordinary least square models with county and year fixed effects were used to measure the health effects.

Results: This study found some evidence of local immigration enforcement policies adversely impacting mental health and self-rated health of Latino immigrants. Specifically, SC increased the proportion of Latino immigrants in households with non-citizens reporting fair or poor health by 1.5 to 2.8 percentage points (17 to 35 percent), and Jail Enforcement under Section 287(g) lowered the proportion reporting very good or excellent health by 3.7 to 7.5 percentage points (6 to 12 percent). Estimates also indicate that Task Force Enforcement under Section 287(g) deteriorated the mental health of Latinos immigrants in households with non-citizens by 19 to 40 percent. 

The effect of cost sharing on health utilization and financial risk protection

Haoran Peng - penghaoran@gmail.com - Sun Yat-sen University - China

Minhui Xiao - 170446659@qq.com - College of Public Management, Guangdong University of Finance and Economics - China

This paper exploits an adjustment in patient cost sharing in Ganzhou City, using administrative inpatient data to examine its effect on the use of health services and financial risk protection. Before 2012, Ganzhou's urban employees basic medical insurance (UEBMI) adopted different inpatient coinsurance rates for different age groups. In 2012, Ganzhou's UEBMI reduced its inpatient coinsurance rates and adopted the same coinsurance rate for all insured. We use this quasi-experiment and conduct cross-sectional and pre-post analysis. We find that reduced cost sharing for inpatient is associated with higher health expenditures and more inpatient days, but can not reduce the burden of patient  to our surprise. Further, we find that different age groups have different responses to this change. Our findings have important implications for China's health care reform. If China doesn't trully promote supply-side health reform, it can’t alleviate patients' financial burden only by reducing cost sharing in demand-side.


Unintended higher local suicide rate after suicide prevention law enactment in Korea

Iljoo Park - pij1@korea.ac.kr - Korea University - Korea, (South) Republic of

Recently Korea has higher suicide rate than other OECD countries do. Especially in the year of 2012, 28.1 per 100,000 people attempted suicide, which was the highest rate among OECD countries. According to the Korea Institute for Health and Social Affairs(2014), deaths by stomach cancer or cerebrovascular diseases which had been considered as diseases requiring highly advanced medical technology to cure has been decreased thanks to the development of advanced medical treatment skills and prevention policy from the year of 2002 to 2012. However, deaths by suicide in the past 15 years has risen by almost three times as of the year of 2012.   

For abovementioned reason, domestic and international efforts to contribute to identifying the cause of the increased suicide rate were substantial. Scholars point out that we should not limit the problem to certain parts since it is not helpful to mitigate the problem but see it as comprehensive social problem which cannot be overcome by individuals without governmental actions for preventing it.  

Korea has local autonomy system that allows a total of 227 towns to govern by themselves. A town is a smallest unit of territory to govern by itself. Each town can govern with planning and budgeting by itself. Recently, some towns have adopted and enacted the law for trying suicide prevention but there seems no clear impact on lowering suicide rate. This research aims to figure out if the law enactment helps to lower the suicide rate of the town in Korea. For the analysis, this article is structured as follows: First, other significant factors which are considered to impact on the suicide commitment are reviewed upon literature review. In this part, other factors are arranged into four parts: personal, economical, environmental and policy factors. Second, a quantitative analysis like multiple regression is conducted and the results are reviewed. Third, a qualitative analysis like interviewing with semi-structured technique is conducted for examining why the suicide rate has not been lowered even though they had an effort like legislation. Finally, the limitation and conclusion of the review are discussed.

As a result of the quantitative analysis, this research sees the possibility that the towns which adopted the suicide prevention law failed to mitigate the suicide rate or even worsening it. According to the qualitative analysis here, this unintended impact of policy effort is because the towns have implemented many unsophisticated policy actions like one-shot education, putting up a banner and employing only contract workers who cannot continue their job and so on without injecting sufficient fund to operate psychological autopsy which is revealed to help much on lowering suicide rate. Also the gap between towns which can govern with plenty of fund and those which cannot is somewhat significant. Finally those careless policy action make adverse reaction that people who are vulnerable mental condition from any reasons be exposed to suicide.  

In conclusion, this research sheds light on the local autonomy policy actions that aim to mitigate the suicide rate of towns should be followed with more sophisticated actions like conducting psychological autopsy, plenty of fund to operate and federal government’s support to economically vulnerable towns.

Consequences of Population Control Policies in Maharashtra (India), 1960-2010

Daksha Parmar - dakshacp@gmail.com - Tata Institute of Social Sciences, Mumbai - India

The state of Maharashtra has been a pioneer in the implementation of the family planning programme whose main objective was to limit the growth of population. One of the important features of the programme was to introduce the idea of small family norm. It was a dominant understanding that fewer numbers of children would improve the health of the women as well as lead to population stabilisation. The state of Maharashtra implemented the family planning programme with full vigour and enthusiasm by introducing various incentives and disincentives for contraception use and promotion and enforcement of the two child norm. However, there were unfavourable consequences in the form of sex selective abortion leading to masculinisation of the sex ratio in the state. The present paper analyses the state legislative assembly debates, the population policy of the state, secondary sources of census data and family health surveys as well data collected as in-depth interviews of few key government officials and health activists to understand how population policies combined with patriarchy and strong son preference  result in an adverse sex ratio in the state.



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