Title: Advancing Understandings of Policy Implementation and Sustainability to Address Health Equity
Description: Public health and social policies are often debated, designed, and adopted without implementation, sustainability, or equity in mind, which can generate profound uncertainty about how to equitably deliver them initially and over time. Although sustainability and equity considerations are sometimes considered in post-hoc policy analysis and evaluation, little is known about how to plan for and track planned and unplanned adaptations to policy implementation, as well as the ways that key sustainability factors and strategies can relate to the equitable delivery or relative effectiveness of policies on the ground and in community settings. The purpose of this dissertation was to explore the long-term sustainability and equity of tobacco control policies and programs in New York City to understand and contextualize their limited reach and impact on persistent smoking and tobacco-related health disparities in underserved Asian American communities. The specific aims were to: 1) conceptually specify an operational definition of policy sustainability and its key dimensions, including health equity, and to refine this using a mixed methods single case study of tobacco policies in New York City; 2) use the case study approach to describe the extent to which tobacco policies have been sustained and adapted in New York City; and 3) to use the case study to identify key multi-level factors that influence the long-term sustainability and equity of tobacco policies in New York City.

Using a single, in-depth, convergent-parallel mixed methods case study design, data were collected, analyzed, and integrated across five key primary and secondary sources: 1) Policymaking documents – text of key tobacco bills and statutes, as well as transcripts from when they were first proposed, amended, debated, and adopted; 2) Local newspaper coverage – articles from a database of 29 major newspapers in New York State on the policies and their impacts on communities and businesses over time; 3) Key informant interviews – conducted with community members and community leaders at local health and advocacy organizations in New York City that primarily serve Asian American and immigrant communities (n = 21); 4) Direct observation periods – conducted within and around the health and advocacy organizations, as well as in majority Asian neighborhoods and Asian ethnic enclaves (n = 15); and 5) the New York City Community Health Survey (2012-2017) – conducted annually by the New York City Department of Health and Mental Hygiene.

The integrated study findings point to the importance of understanding policy sustainability not as a static end goal, but rather as a dynamic set of processes and outcomes that impact health and health equity. Findings from this case study clustered across three key themes: 1) since the initial adoption of comprehensive local tobacco control measures in New York City in 2002, broad “one-size-fits-all” approaches to policy implementation and monitoring have been sustained, which have had and continue to have limited reach and impact within underserved Asian American and immigrant communities; 2) two delayed adaptation efforts were made by policymakers during the sustainability phase, one in 2012 and another in 2018, were intended to improve on prior uneven implementation to better reach Chinese-speaking communities, with the 2018 adaptation demonstrating significant improvements from the 2012 effort; and 3) community-based organizations have played a direct role in functioning not just as key stakeholders but also as key implementers to ensure that tobacco and other health policies are reaching communities that the designated or official implementers cannot reach.

This suggests the need for further study of unofficial implementers in implementation science – those who have not been formally designated as the ones responsible for ensuring that implementation takes place, but are still delivering implementation strategies to ensure adoption, integration, and sustainment. Overall, this case study points to the potential for policy sustainability research to advance health equity by identifying factors and mechanisms that can be improved to maximize and sustain the equitable reach and impact of social and public health policies. By focusing on dynamic contextual factors and sustainability as a set of processes and outcomes, the findings from this case study raise critical questions about the criteria typically used to evaluate whether policy interventions are deemed evidence-based and effective by asking: 1) effective for whom?; 2) based on what evidence?; and 3) what happens as dynamic populations and contexts change over time? These questions highlight how the tobacco control success story was largely constructed around broad population-wide implementation and benefits, while overlooking underserved Asian American communities who continue to disproportionately bear the brunt of smoking and tobacco-related health disparities in New York City.