Policy, Systems, & Environmental Change Approaches

What is PSE Change?

Policy, systems, and environmental (PSE) change strategies are a way of making sustainable, lasting change within a community to support healthy environments and behaviors across populations. These strategies create or change infrastructure and modify the contexts in which people live to improve community conditions that promote health. PSE changes are often made in combination with each other.

Figure 1. The relationship between Policy, system, and environmental changes

Policy Change

Policy change includes the passing or changing of laws also known as legislation, as well as ordinances, resolutions, mandates, regulations, or rules. Government bodies, park districts, healthcare organizations, worksites, and other community institutions (schools, jails, daycares, etc.) all make policies. Policy change strategies include advocacy & education, civic engagement, and power building.

Examples of Policy Change:

A state institutes a policy requiring Black History to be included in its educational curriculum.
Changing local zoning ordinances so that corner markets can display produce outdoors.
A park district adopts policy to prioritize investments in park-deficient neighborhoods.

Systems Change

Systems change creates fundamental shifts in how problems are solved and how resources and services get distributed. It involves changes made to the policies, processes, power structures, and relationships within an organization or across organizations. Systems changes can be unwritten, ongoing, often qualitative organizational decisions/changes. They might precede or follow written policies.

Examples of System Change:

Redesigning power structures within institutions to center community voice & decision-making.
Establish guidelines for low vision awareness in all age-friendly planning work.

Environmental Change

Environmental changes involve the economic, social, or physical surroundings or contexts that affect health outcomes. Environmental strategies create more lasting change when paired with systems and policy changes.

Examples of Environmental Change:

Incorporating pedestrian-friendly intersections and recreation areas into community design.
Provision of health insurance discounts or bonus dollars for those who exercise frequently.
Education and awareness campaign to destigmatize domestic violence/sexual violence survivors seeking services.

PSE strategies work together.

Scenario: A youth development organization wants to provide mental health support to its youth.

Program approach: Hire a mental health counselor at the organization.

PSE approach:

Policy: Create a policy to include mental health awareness in all staff training to increase staff members’ knowledge and skills.
Systems: Create a coalition with teachers, youth with lived experience, mental health counselors, and other partners to determine youth need and how to help, while using a training curriculum developed for staff to equip teachers and health care providers.
Environment: Create a permanent and physical room for mental health counseling that is welcoming and comfortable for youth.

Characteristics of Program vs. PSE Change

Adopted from the Food Trust

Figure 2. Characteristics of program approach vs. PSE change approach

Programmatic Approach VS. PSE Change Approach Examples

PSE Strategies & Root Cause Analysis

PSE Case Study Reflection Guide (Click to download)

PSE Strategies & Root Cause Analysis

Root Cause Analysis is a technique that can help answer the question of why a problem is occurring. It works to identify the source of a problem so that we can identify the most appropriate solutions. There are several tools and processes you can use to conduct a root cause analysis, but the basic approach is to simply ask “Why?” working backwards from the problem until you identify the deeper causes. Policy, systems, and environmental changes are a valuable tool to address those deeper root causes and improve conditions that impact population health.

Scenario: In a rural community, a pregnant woman named Sarah has limited access to maternal care. She lives in a remote area with no nearby maternity clinic or hospital. The nearest maternity care facility is a two-hour drive away. Sarah doesn’t own a car, and public transportation options are scarce. She has Medicaid coverage, but she is concerned about the cost of transportation and potential childcare expenses for her other children while she attends prenatal appointments. As a result, Sarah’s access to essential prenatal care is severely limited, which can have negative implications for her health and the health of her baby.

What’s happening: Pregnant women living in rural areas, who do not have access to transportation, experience negative health outcomes.

Root cause question: What is the root cause of the negative health outcomes for rural pregnant women?

Root causes analysis:

Pregnant women in rural areas experience disproportionate negative health outcomes. Why?
They are unable to access prenatal care. Why?
Rural areas commonly experience shortages of obstetricians, gynecologists, and other maternal healthcare professionals, resulting in limited access to specialized care. Why?
Rural areas are geographically isolated and lack healthcare facilities, leading to limited access to healthcare facilities. Why?
Limited public transit options and long distances to healthcare facilities make it difficult to access care. Many lack reliable personal transportation and/or the means to afford travel to healthcare appointments. Why?
Low wages, housing & food insecurity, etc. limit income available to spend on transportation and childcare required to travel.

PSE Change options:

Work with the government to revise regulations to enable healthcare providers to deliver prenatal consultations through telehealth option. (Policy change)
Introduce mobile maternity equipped with healthcare professionals, ultrasound machines, and essential medical equipment. They travel to rural communities to provide care and education on a regular schedule. (System & Environmental change)
Work with organizational partners to increase sustainable funding for transportation services. (Policy & Environmental change)

Community Engagement: Collaborate with local community organizations and leaders to gather data and share testimonies from impacted individuals to raise awareness about this issue.