Understanding how laws affect public health: An update on legal epidemiology

Laws can have important effects on public health risks and outcomes, while research can provide key evidence to inform effective health-related laws and policies. An introduction to the increasingly influential field of legal epidemiology is presented in a special supplement to the Journal of Public Health Management and Practice (JPHMP).

The supplement is titled Advancing Legal Epidemiology—defined as "the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population." Assembling nine original research papers and three expert commentaries, the special issue presents "a compelling and diverse body of research that exemplifies how legal epidemiology can help public health practitioners and policy makers recognize opportunities for achieving better health outcomes through law and policy," according to an introduction by Betsy L. Thompson, MD, MSPH, DrPH, Director of the Division for Heart Disease and Stroke Prevention (DHDSP) of the Centers for Disease Control and Prevention (CDC); and supplement Guest Editors Lindsay K. Cloud, JD, and Lance Gable, JD, MPH.

Evaluating the Evidence for Policies on Community Health Workers

A paper by Erika B. Fulmer, MHA, of the DHDSP and colleagues reports on the use of a policy research continuum, including legal epidemiology, to support the development of a community health worker (CHW) workforce. Incorporating CHWs into healthcare teams is a promising strategy to prevent and control cardiovascular disease and type 2 diabetes—particularly in disadvantaged groups such as racial/ethnic minorities, people of lower socioeconomic status, and rural populations. "However, there is limited information examining the impact of state CHW policy interventions," the researchers write.

They applied the DHDSP's policy research continuum, which incorporates legal epidemiology, to CHW workforce development policies. An early-evidence assessment identified policy interventions with a strong evidence base, while policy surveillance provided an overview of the legal landscape supporting such policies. This enabled implementation studies showing how CHW workforce policies were carried out in different states, including qualitative information on early outcomes.

A future policy impact study will examine short- to long-term outcomes, helping to tailor workforce development strategies and maximize the public health benefits of the CHW approach. The DHDSP's policy research continuum "can speed development of tools and resources to enhance decision-making and identify interventions to improve public health impact, use resources wisely, and account for dollars spent," Ms. Fulmer and coauthors write.

Examining the Impact of Pregnancy-Specific Alcohol Policies

A paper by Sarah C.M. Roberts, DrPH, of the University of California, San Francisco and colleagues examines the impact of state-level pregnancy-specific alcohol policies on the health of infants. Using multiple data sources along with original legal research, the analysis included more than 40 years of data with more than 150 million births.

"State-level alcohol pregnancy policy environments have become more punitive over time," the researchers write. However, few studies have examined whether these policies actually improve health. The new study focused on whether health impacts of pregnancy-specific alcohol policies differ among women at different levels of education, as an indicator of socioeconomic status.

The results suggested that pregnancy-specific alcohol policies were more likely to have harmful health effects in women with higher educational status. More than half of policies studied were linked to increased rates of preterm birth and low birth weight for women who had at least a high school education. These included both supportive policies, such as Mandatory Warning Signs; and punitive policies, such as defining alcohol use during pregnancy as child abuse/neglect.

In contrast, policies related to reporting alcohol use during pregnancy—whether or not this information was used for child welfare purposes—were linked to lower rates of adverse birth outcomes among women with less than a high school education. "Public health professionals should take the lead on identifying and developing policy approaches that reduce harms related to alcohol use during pregnancy," Dr. Roberts and coauthors conclude.