1. Fifolt, Matthew PhD
  2. Graham, Tessa MPH
  3. McMahon, Sean MPH
  4. McCormick, Lisa C. DrPH


Policy surveillance is becoming an increasingly powerful tool in public health to identify policies and programs that influence individual and community health. However, not many systems exist to track or facilitate greater understanding of policies at a city or county level. Furthermore, relatively little is known about which policies are being implemented and how they relate to population health goals. In 2019, the University of Alabama at Birmingham School of Public Health joined a consortium of universities to specifically track municipal policies in Birmingham, Alabama. Since its inception, the Birmingham Policy Surveillance Initiative has identified 443 policies and program initiatives related to 6 key areas of focus. The purpose of this article is to describe a policy surveillance system in Birmingham, Alabama. Results are intended to raise the profile of policy surveillance and inform policy makers of opportunities and gaps in policies that influence individual and community health.


Article Content

According to Carter and colleagues,1 one of the primary challenges to health promotion is "insufficient, incomplete evidence to guide decision making about population level intervention(s)."(p467) To begin to remedy this deficiency, Burris et al2 advocated for rigorous surveillance systems in public health to help monitor patterns and trends in policies. Accordingly, findings from policy surveillance can be used to expand the geographic reach of successful policies and laws by identifying unmet needs for policy development and advocacy strategies.3 The purpose of this article is to describe a public health policy surveillance initiative in Birmingham, Alabama.



Most public health policy is enacted at the state or federal level; however, cities play a crucial role in implementing policies and programs that impact population health. Nevertheless, not many systems exist to track or facilitate greater understanding of policies at a city or county level. In 2017, the Urban Health Collaborative (UHC) at Drexel University's Dornsife School of Public Health initiated the Policy Surveillance Project, which focused on monitoring city policies in 4 major US cities: New York, Philadelphia, Los Angeles, and Washington, District of Columbia. The impetus of this policy surveillance project was to "identify best practices in select cities around the United States that are employing promising or effective policy, programmatic, and budgetary initiatives to promote health equity despite actions or inaction at the federal policy level."4(para2)


In 2019, 3 other cities joined the project, including Louisville, Kentucky; St Louis, Missouri; and Birmingham, Alabama. The University of Alabama at Birmingham School of Public Health (UABSOPH) was invited to join this consortium to specifically track municipal policies in Birmingham, Alabama. The UHC's stated goal for expanding the consortium was to include cities from US regions (eg, Midwest, Southeast) not captured in the first round of surveillance.5 For the purpose of this project, participating cities limited the definition of policy to include legislation, regulations, major programs, and budget plans that occurred within the jurisdiction of the municipality.


Areas of focus

The initial areas of focus for the UHC were education, housing, and the environment. However, 2 primary adaptations were made to the Birmingham Policy Surveillance Initiative (BPSI) due to demographic and economic differences between the 4 major US cities and Birmingham, as well as the implementation of Live HealthSmart Alabama, a pilot project designed to target policy, system, and environment changes to improve Alabama's health.


Adaptation 1 expanded areas of focus to include (a) prevention and wellness, including nutrition, physical activity, and other factors aimed at improving health; (b) crime reduction efforts, such as capital expenditures and amending municipal criminal codes; and (c) economic development opportunities, such as workforce training programs and redevelopment efforts. Adaptation 2 was intended to review nonprofit and private sector initiatives; however, it was eliminated in August 2020 due to the impractical nature of monitoring organizational-level policy implementation and limited access to materials.


Policy framework for the BPSI

The BPSI was informed by the ecological model, which suggests that individual, social, and contextual factors influence health.6 Although public policies are not considered public health services, they frequently influence health outcomes by affecting the social determinants of health (SDoH), which HealthyPeople 2030 identified as economic stability, education access and quality, health care access and quality, neighborhood and built environment, social and community context.7



The process of weekly surveillance of the 6 public health areas of focus (education, housing, environment, prevention and wellness, crime reduction, and economic development) began in October 2019. Program administrators adapted the UHC policy surveillance process developed by Drexel University, which outlines a step-by-step process for scanning, monitoring, recording, and interpreting surveillance sources. This process includes general inclusion/exclusion criteria to guide policy reviewers in determining whether or not to record enacted legislation, regulations, programs, or budget plans. The process of policy surveillance was predicated on the following conditions:


* Synthesize information on selected topics to identify current trends and highlight promising urban action.


* Develop methods that can be replicated in other cities and for other topics.


* Disseminate information and methods to advocates, researchers, and other stakeholders who can use it to improve public health and promote health equity.4



Graduate student internships

To date, UABSOPH has recruited and trained 7 graduate student interns to conduct weekly searches of available data sources for evidence of policies and programs related to public health and SDoH. Data sources include newsletters, city media/social media/Web sites (eg, press releases), city legislation databases, city council meeting agendas/minutes, local news agencies, and county agency sources. Interns record policy findings in an internal database based on topic area; policy description; lead agency; timeline; budget; and partnerships. Once student interns complete this initial round of coding, they revisit the policy or the program and record whether or not it includes a health equity frame. If health equity is in question, the student intern shares the policy with 2 program administrators and other reviewers to reach consensus during their weekly meeting. Interns periodically review and remove data records when a policy initiative is started but later abandoned or not funded. In addition to keeping the database current, this recursive process helps UABSOPH refine its inclusion/exclusion criteria.



Since 2019, the UABSOPH has reviewed 203 meeting agendas, recordings, and minutes, and identified 443 policy and program initiatives related to public health and SDoH. The greatest number of policy and program initiatives (n = 107) correspond to issues related to crime reduction, with funding for technology and personnel as the primary drivers. Policy and program initiatives for remaining areas of focus include prevention and wellness (n = 83), education (n = 82), economic development (n = 71), environment (n = 52), and housing (n = 48). See the Table.

TABLE Breakdown of A... - Click to enlarge in new windowTABLE Breakdown of Areas of Focus by Policy and Program Initiatives

The UABSOPH staff members and interns are currently in the process of reviewing and analyzing policies related to COVID-19 mitigation efforts as well as policies intended to address racial inequity in the city. Next, the team intends to qualitatively assess areas of focus for potential gaps in policy and program coverage. Further analysis may also include financial modeling of policy impact between short- and long-term projects and a review of policies by underserved communities. Initial policy analyses are currently available on selected topics and trends through the Lister Hill Center for Health Policy. The long-term goal of the BPSI is to develop a Web-based portal to make data and analyses more widely available to researchers, advocates, and other stakeholders.


Policy surveillance is becoming an increasingly powerful tool in public health to identify policies that influence individual and community health. Despite identified benefits of policy surveillance, relatively little is known about which policies are being implemented and how they relate to population health goals. The intent of this article was to raise the profile of policy surveillance and describe its utility. We suggest that the BPSI is one example of a municipal-level policy surveillance initiative that could be replicated in other settings.


Implications for Policy & Practice


* The BPSI is a tool that allows UAB and other key stakeholders to monitor and catalog programs and policies in Birmingham that are intended to improve population health, enhance SDoH, and promote health equity.


* Findings from the BPSI can be shared with researchers, policy makers, and program developers to identify areas of unmet needs and implement programs and initiatives to improve the lives of Birmingham residents.


* Moreover, systematically recording data through the BPSI and sharing results with other metropolitan cities through the UHC allow city managers the opportunity to benchmark challenges and share strategies for successfully resolving common issues.




1. Carter SM, Rychetnik L, Lloyd B, et al Evidence, ethics, and values: a framework for health promotion. Am J Public Health. 2011;101(3):465-472. [Context Link]


2. Burris S, Hitchcock L, Ibrahim J, Penn M, Ramanathan T. Policy surveillance: a vital public health practice comes of age. J Health Polit Policy Law. 2016;41(6):1151-1173. [Context Link]


3. Institute of Medicine. For the Public's Health: Revitalizing Law and Policy to Meet New Challenges. Washington, DC: The National Academies Press; 2011. [Context Link]


4. Urban Health Collaborative (UHC). Urban policy and program surveillance project. Accessed May 8, 2022. [Context Link]


5. Urban Health Collaborative (UHC). Policy surveillance project expanded. Accessed June 15, 2022. [Context Link]


6. Department of Health & Human Services (HSS). Theory at a Glance: A Guide for Health Promotion and Practice. 2nd ed. Washington, DC: Department of Health & Human Services; 2005. [Context Link]


7. HealthyPeople2030. Social determinants of health. U.S. Department of Health & Human Services. Accessed June 14, 2022. [Context Link]


ecological model; policy surveillance; population health; social determinants of health