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Rural Health Information Hub

Policy, Systems, and Environmental Change

For health promotion and disease prevention strategies to be successful, policies, systems, and environments (PSE) must be supportive of health. Policy, systems, and environmental change strategies are designed to promote healthy behaviors by making healthy choices readily available and easily accessible in the community. PSE change strategies are designed with sustainability in mind.

Policy Change

Policy is a tool for achieving health promotion and disease prevention program goals. Policy decisions are made by organizations, agencies, and stakeholders. Policy approaches include legislative advocacy, fiscal measures, taxation, and regulatory oversight. Examples of health promotion and disease prevention policy approaches include:

  • Establishing policies for smoke-free zones and public events
  • Establishing healthy food options in vending machines in public places
  • Adding a tax to unhealthy food options
  • Requiring the use of safety equipment in a work setting to avoid injury

Additional considerations for implementing policy interventions are available in the Rural Health Policy topic guide.

Systems Change

Systems change refers to a fundamental shift in the way problems are solved. Within an organization, systems change affects organizational purpose, function, and connections by addressing organizational culture, beliefs, relationships, policies, and goals. Examples of systems change in health promotion and disease prevention include:

  • Developing plans for implementing new interventions and processes
  • Adapting or replicating a proven health promotion model
  • Implementing new technologies
  • Creating training or certification systems that align with policies

Environmental Change

Environmental change strategies involve changing the economic, social, or physical surroundings or contexts that affect health outcomes. Environmental strategies address population health outcomes and are best used in combination with other strategies. Examples of environmental strategies for health promotion and disease prevention include:

  • Increasing the number of parks, greenways, and trails in the community
  • Installing signs that promote use of walking and biking paths
  • Increasing the availability of fresh, healthy foods in schools, restaurants, and cafeterias

Examples of PSE Change Interventions

  • Kentucky Homeplace is a community health worker (CHW) initiative that addresses health through PSE changes. The initiative emphasizes care coordination and health coaching for diabetes, hypertension, and tobacco cessation, among other health topics. CHWs provide health information, screenings, and health coaching. The initiative also supports reduced or no-cost services and medications.
  • Healthy Adams County is an organization created by community members in rural Pennsylvania. The organization includes community task forces such as the Breast Cancer Coalition, Food Policy Council, Behavioral Health, Health Literacy, Oral Health, and Tobacco Prevention, among others. Activities are implemented to drive PSE changes in the community.
  • In Ohio, School as a Hub for Health, a project of the Athens Creating Healthy Communities Coalition, implements PSE changes within schools with the goal of achieving improvements in physical, mental, and social health. Examples of the services offered through the program include healthy vending machine options; dental sealants; integrated mental health services; and school-based gardens, food pantry, and community health clinics.

Considerations for Implementation

PSE change strategies have the potential to create positive changes in different settings. PSE change strategies are often complex, as they attempt to drive change at multiple levels (for example, within an organization, community, or state). PSE change strategies are therefore useful in addressing chronic diseases and other complex health problems, such as obesity and diabetes.

Programs seeking to implement PSE change strategies must have realistic expectations about the time and barriers that may be involved. Because PSE strategies seek to influence multiple factors and levels, it may be difficult to measure PSE changes.

To plan, develop, and implement PSE change strategies for disease prevention and health promotion, it may be important to:

  • Engage partners, stakeholders, and community members in the early stages of program development.
  • Understand the needs of the intended population to identify appropriate PSE change strategies.
  • Use health impact assessments to demonstrate the rationale for PSE changes.
  • Assess individual and organizational readiness for change, using the Stages of Change (Transtheoretical Model).
  • Provide education to the individuals (healthcare providers, managers, or teachers) and organizations (healthcare facilities, businesses, or schools) who will be involved in implementing PSE changes.
  • Foster partnerships and coalitions to support broader reach and sustainability.
  • Ensure enforcement of new policies.

Ensure regular review of PSE changes to evaluate effectiveness and impact on population health outcomes.

Resources to Learn More

Built Environment Approaches to Increase Physical Activity
Summarizes evidence-based recommendations for using one or more interventions to create or modify environmental characteristics in a community to encourage and improve physical activity and make it more accessible.
Organization(s): Community Preventive Services Task Force
Date: 5/2017

The Community Tool Box: Chapter 11 - Influencing Policy Development
Outlines in detail how to develop or modify policy within organizations and communities, and offers supporting resources.
Organization(s): Community Tool Box

Neighborhood and Built Environment
Describes with data and supporting resources the Healthy People 2030 objectives related to creating neighborhoods and environments to promote health and safety.
Organization(s): Health People 2030

Nutrition-Related Policy and Environmental Strategies to Prevent Obesity in Rural Communities: A Systematic Review of the Literature, 2002-2013
Presents the results of a literature review reporting on the evidence regarding the implementation and effectiveness of policy and environmental strategies for preventing obesity in rural settings.
Author(s): Calancie, L., Leeman, J., Pitts, S.J., et al.
Citation: Preventing Chronic Disease, 12
Date: 4/2015

Strategies to Repair Equity and Transform Community Health (STRETCH) Framework
Describes an equity-focused systems framework for use by public health entities when working to improve health outcomes in their communities.
Organization(s): CDC Foundation, Robert Wood Johnson Foundation
Date: 1/2022