National public health policy in a local context--implementation in two Swedish municipalities

TRIPLE C reporting principles for case study evaluations of the role of context in complex interventions

BACKGROUND

Guidance and reporting principles such as CONSORT (for randomised trials) and PRISMA (for systematic reviews) have greatly improved the reporting, discoverability, transparency and consistency of published research. We sought to develop similar guidance for case study evaluations undertaken to explore the influence of context on the processes and outcomes of complex interventions.

METHODS

A range of experts were recruited to an online Delphi panel, sampling for maximum diversity in disciplines (e.g. public health, health services research, organisational studies), settings (e.g. country), and sectors (e.g. academic, policy, third sector). To inform panel deliberations, we prepared background materials based on: [a] a systematic meta-narrative review of empirical and methodological literatures on case study, context and complex interventions; [b] the collective experience of a network of health systems and public health researchers; and [c] the established RAMESES II standards (which cover one kind of case study). We developed a list of topics and issues based on these sources and encouraged panel members to provide free text comments. Their feedback informed development of a set of items in the form of questions for potential inclusion in the reporting principles. We circulated these by email, asking panel members to rank each potential item twice (for relevance and validity) on a 7-point Likert scale. This sequence was repeated twice.

RESULTS

We recruited 51 panel members from 50 organisations across 12 countries, who brought experience of a range of case study research methods and applications. 26 completed all three Delphi rounds, reaching over 80% consensus on 16 items covering title, abstract, definitions of terms, philosophical assumptions, research question(s), rationale, how context and complexity relates to the intervention, ethical approval, empirical methods, findings, use of theory, generalisability and transferability, researcher perspective and influence, conclusions and recommendations, and funding and conflicts of interest.

CONCLUSION

The 'Triple C' (Case study, Context, Complex interventions) reporting principles recognise that case studies are undertaken in different ways for different purposes and based on different philosophical assumptions. They are designed to be enabling rather than prescriptive, and to make case study evaluation reporting on context and complex health interventions more comprehensive, accessible and useable.

How can we promote co-creation in communities? The perspective of health promoting professionals in four European countries

Purpose

The aim was to identify the competencies professionals need to promote co-creation engagement within communities.

Design/methodology/approach

Co-creation could contribute to building community capacity to promote health. Professional development is key to support co-creative practices. Participants were professionals in a position to promote co-creation processes in health-promoting welfare settings across Denmark, Portugal, France and United Kingdom. An overarching unstructured topic guide was used within interviews, focus groups, questionnaires and creative activities.

Findings

The need to develop competencies to promote co-creation was high across all countries. Creating a common understanding of co-creation and the processes involved to increase inclusivity, engagement and shared understanding was also necessary. Competencies included: How to run co-creation from the beginning of the process right through to evaluation, using feedback and communication throughout using an open action-oriented approach; initiating a perspective change and committing to the transformation of co-creation into a real-life process.

Practical implications

Overall, learning about underlying principles, process initiation, implementation and facilitation of co-creation were areas identified to be included within a co-creation training programme. This can be applied through the framework of enabling change, advocating for co-creative processes, mediating through partnership, communication, leadership, assessment, planning, implementation, evaluation and research, ethical values and knowledge of co-creative processes.

Originality/value

This study provides novel findings on the competencies needed for health promoting professionals to embed co-creative processes within their practice, and the key concerns that professionals with a position to mediate co-creation have in transferring the abstract term of co-creation into a real-world practice.

Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches

BACKGROUND

There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research.

METHODS

Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing 'hybrid papers' (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions.

RESULTS

We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently-respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of 'the case' and 'context' or considered the implications of such conceptualisations for methods and knowledge production.

CONCLUSIONS

Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.

Implementing cancer patient pathways in Scandinavia how structuring might affect the acceptance of a politically imposed reform

Through political decisions all three Scandinavian countries implemented national reforms in cancer care introducing cancer patient pathways. Though resistance from the professional community is common to top-down initiatives, we recognized positive receptions of this reform in all three countries and professionals immediately contributed in implementing the core measures. The implementation of a similar reform in three countries with a similar health care system created a unique opportunity to look for shared characteristics. Combining analytical framework of institutional theory and research on policy implementation, we identified common patterns of structuring of the initial implementation: The hierarchical processes were combined with supplementary structures located both within and outside the formal management hierarchy. Some had a permanent character while others were more project-like or even resembled social movements. These hybrid structures made it possible for actors from high up in the hierarchy to communicate directly to actors at the operational hospital level. Across the cases, we also identified structural components acting together with the traditional command-control; negotiation, consensus and counseling. However, variations in the presence of these did not seem to have significant impact on processes causing decisions and acceptance. These variations may, however, influence the long-term practice and outcome of cancer-care pathway-reform. Knowledge from our study should be considered when orchestrating future health care reforms and especially top-down politically initiated reforms.

Barriers, Facilitating Factors, and Intersectoral Collaboration for Promoting Active Mobility for Healthy Aging-A Qualitative Study within Local Government in Germany

The promotion of walking and cycling to stay active and mobile offers great potential for healthy aging. Intersectoral collaboration for age-friendly urban planning is required in local government to realize this potential. Semi-structured interviews were conducted with the heads of planning and public health departments in city and district administrations of a Metropolitan Region in Germany to identify factors influencing action on the cross-cutting issue of active mobility for healthy aging. Although some administrations are working on the promotion of active mobility, they consider neither the needs of older people nor health effects. A lack of human resources and expertise, mainly due to the low priority placed on the issue, are described as the main barriers for further strategic collaboration. Furthermore, the public health sector often focuses on pathogens as the cause of morbidity and mortality, reducing their acceptance of responsibility for the topic. Facilitating factors include the establishment of new administrative structures, projects with rapid results that create awareness and credibility among citizens and politicians, additional staff with expertise in health promotion, and political commitment. In the future, new administrative structures for intersectoral collaboration are needed in order to consider various perspectives in complex developments, such as healthy aging, and to benefit from synergies.

Insights into local health and wellbeing policy process in Australia

To investigate factors that enable or challenge the initiation and actioning of health and wellbeing policy in Australian local governments using political science frameworks. An online survey was distributed to staff and elected members of Australian local governments. The survey sought responses to a range of variables as informed by political science frameworks. Data were analysed using descriptive statistics and results were compared between local governments of different geographical sizes and locations using Kruskal-Wallis non-parametric testing. There were 1825 survey responses, including 243 CEOs, representing 45% of Australian local governments. Enablers for local government policy initiation and action included the high priority given to health and wellbeing (44%), local leadership (56%) and an organizational (70%) and personal obligation (68%) to the community to act. Less true is a favourable legislative environment (33%), leadership from higher levels of government (29%) and sufficient financial capacity (22%). Cities are better positioned to initiate and action health policy, regardless of the broader legislative environment. Health and wellbeing is a high priority for Australian local governments, despite lack of funding and limited lobbying and support from other sectors and higher levels of government. The insights from political science frameworks assist to understand the policy process, including the interrelatedness of enablers and challenges to initiating and actioning health and wellbeing policy. Further understanding the policy drivers would support practitioners and researchers advocating to influence local health and wellbeing policy.

Leaders' Future Orientation and Public Health Investment Intention: A Moderated Mediation Model of Self-Efficacy and Perceived Social Support

Prior studies have investigated the issue of public health and health policy from economic, environmental, and healthcare perspectives. Research on public health from leaders' perspective may also help to advance our knowledge about leaders' perceptions, attitudes, and behavioral intentions toward public health management. Therefore, this study is based on social ideal theory, social cognitive theory, and social trust theory to investigate the influence of leaders' future orientation on public health investment intention with the mediating role of leaders' self-efficacy and the moderating role of perceived social support. Using a structural equation modeling with a sample data of 381 leaders of government agencies in Vietnam, empirical results indicate that leaders' future orientation has a positive influence on public health investment intention. Furthermore, self-efficacy is found to have a positive mediating effect in the relationship between leaders' future orientation and public health investment intention. In addition, perceived social support positively moderates the link between leaders' future orientation and self-efficacy. Perceived social support also moderates the indirect effect of leaders' future orientation on public health investment intention through self-efficacy. On one hand, this study contributes to theoretical research by clarifying the effects of leaders' perceptions, and cognitive and behavioral intentions toward public health investment. Findings of this study may have implications for researchers who may have interest in studying the issue of public health management from leaders' viewpoints. On the other hand, this study contributes to practitioners since understanding how leaders' characteristics affect public health investment will enhance the quality of policy makers' decision-making in improving public health for citizens and society.

Health promotion policies for elderly-Some comparisons across Germany, Italy, the Netherlands and Poland

OBJECTIVE

The aim of this study is to compare health promotion policies (HPP) for older adults in four European countries: Germany, Italy, the Netherlands and Poland. We focus on the design, regulations and implementation of policies in these countries.

METHOD

As policy relevant information is mostly available in national languages we have approached experts in each country. They filled in a specially designed questionnaire on the design, regulation and implementation of health promotion policies. To analyze the data collected via questionnaires, we use framework analyses. For each subject we define several themes.

RESULTS

Regarding regulations, Poland and Italy have a top-down regulation system for health promotion policy. Germany and Netherlands have a mixed system of regulation. Regarding the scope of the policy, in all four countries both health promotion and prevention are included. Activities include promotion of a healthy life style and social inclusion measures. In Poland and Italy the implementation plans for policy measures are not clearly defined. Clear implementation plans and budgeting are available in Germany and the Netherlands CONCLUSIONS: In all four countries there is no document that exclusively addresses health promotion policies for older adults. We also found that HPP for older adults appears to be gradually disappearing from the national agenda in all four countries.

Do the key functions of an intervention designed from the same specifications vary according to context? Investigating the transferability of a public health intervention in France

Background

The processes at play in the implementation of one program in different contexts are complex and not yet well understood. In order to facilitate both the analysis and transfer of interventions, a “key functions/implementation/context” (FIC) model was developed to structure the description of public health interventions by distinguishing their potentially transferable dimensions (their “key functions”) from those associated with their translation within a specific context (their “form”). It was used to describe and compare preschool preventative nutrition interventions routinely implemented across three territories, in accordance with same national specifications.

Methods

The interventions were independently described by researchers and intervention’s implementers using the FIC model, during several workshops. Their key functions were then classified into 12 themes and compared to assess the extent to which the three interventions were similar.

Results

Despite being produced from the same set of specifications and having similar objectives, the key functions of the interventions in the three departments mostly reflected the same major themes, they did not overlap and were in some cases very different. In one of the three departments, the intervention was markedly different from those of the other two departments. The historical context of the interventions and the specificities of the local actors appear highly determinant of the key functions described.

Conclusions

For the interventions that we studied, some of the key functions varied greatly and translated different concepts of health education and modes of intervention to the population. It now seems vital to improve the description of interventions on the ground in order to highlight the key functions on which they are based, which still often remain implicit. The FIC model could be used to complement other models and theories focusing on the description of the implementation process, its determinants or its evaluation. Its interest is to provide a structure for joint reflection by various actors on the transferable aspects of an intervention, its form and its interactions with the context, in order ultimately to analyse or to improve its potential transferability.

Do the key functions of an intervention designed from the same specifications vary according to context? Investigating the transferability of a public health intervention in France

BACKGROUND

The processes at play in the implementation of one program in different contexts are complex and not yet well understood. In order to facilitate both the analysis and transfer of interventions, a "key functions/implementation/context" (FIC) model was developed to structure the description of public health interventions by distinguishing their potentially transferable dimensions (their "key functions") from those associated with their translation within a specific context (their "form"). It was used to describe and compare preschool preventative nutrition interventions routinely implemented across three territories, in accordance with same national specifications.

METHODS

The interventions were independently described by researchers and intervention's implementers using the FIC model, during several workshops. Their key functions were then classified into 12 themes and compared to assess the extent to which the three interventions were similar.

RESULTS

Despite being produced from the same set of specifications and having similar objectives, the key functions of the interventions in the three departments mostly reflected the same major themes, they did not overlap and were in some cases very different. In one of the three departments, the intervention was markedly different from those of the other two departments. The historical context of the interventions and the specificities of the local actors appear highly determinant of the key functions described.

CONCLUSIONS

For the interventions that we studied, some of the key functions varied greatly and translated different concepts of health education and modes of intervention to the population. It now seems vital to improve the description of interventions on the ground in order to highlight the key functions on which they are based, which still often remain implicit. The FIC model could be used to complement other models and theories focusing on the description of the implementation process, its determinants or its evaluation. Its interest is to provide a structure for joint reflection by various actors on the transferable aspects of an intervention, its form and its interactions with the context, in order ultimately to analyse or to improve its potential transferability.

Evaluating China's mental health policy on local-level promotion and implementation: a case study of Liuyang Municipality

BACKGROUND

Since 2000, a series of national policies have been released to tackle mental health problems in China; however, their promotion and implementation at local level are under-evaluated. This study will evaluate the case of Liuyang Municipality, to present a deeper understanding of China's problems and lessons on implementation of mental health policy in developing countries.

METHODS

A rapid appraisal was conducted on Liuyang's mental health policy and plan, under two evaluation frameworks: (1) the WHO checklists for mental health policy and plan, (2) activities and time frames stated in Liuyang's mental health policy and plan. Documentation review, semi-structured interviews with nine key informants, and surveys on 32 front-line implementers were performed. Descriptive statistics and framework analysis were employed respectively to analyze quantitative and qualitative data.

RESULTS

As a local-level promotion of national mental health policies, Liuyang's mental health policy and plan had evidence base and received highest-level approval within local health system, but without stakeholders' consultation. The vision, principles and objectives were consistent with national policies. Twelve WHO-suggested areas for actions were unequally covered. Policy content had operational defects of lacking necessary details on evaluation, funding and activity. For implementation, health departments generally outperformed non-health ones. Discrepancies between planning and practices, and uneven regional implementation compromised implementation quality. Insufficient and poorly trained human resources, unguaranteed funding and low client acceptability were identified as implementation barriers.

CONCLUSIONS

The case of Liuyang is an active attempt to promote and implement national mental health policies at local level. As a reflection of mental health policy in China and developing countries, its highlights and problems demonstrate that evidence base, high-level approval, multi-sector involvement, operational content, and clear focuses promote policy implementation.

Not one Brexit: How local context and social processes influence policy analysis

This paper develops an empirical agent-based model to assess the impacts of Brexit on Scottish cattle farms. We first identify several trends and processes among Scottish cattle farms that were ongoing before Brexit: the lack of succession, the rise of leisure farming, the trend to diversify and industrialise, and, finally, the phenomenon of the "disappearing middle", characterised by the decline of medium-sized farms and the polarization of farm sizes. We then study the potential impact of Brexit amid the local context and those ongoing social processes. We find that the impact of Brexit is indeed subject to pre-Brexit conditions. For example, whether industrialization is present locally can significantly alter the impact of Brexit. The impact of Brexit also varies by location: we find a clear divide between constituencies in the north (highland and islands), the middle (the central belt) and the south. Finally, we argue that policy analysis of Brexit should consider the heterogeneous social context and the complex social processes under which Brexit occurs. Rather than fitting the world into simple system models and ignoring the evidence when it does not fit, we need to develop policy analysis frameworks that can incorporate real world complexities, so that we can assess the impacts of major events and policy changes in a more meaningful way.

A implementação do programa de saúde específico para a população em situação de rua - Consultório na rua: barreiras e facilitadores

Resumo O objetivo deste trabalho é investigar as razões da baixa adesão à implementação do programa de saúde específico para a população em situação de rua - Consultório na Rua - pela maioria dos municípios elegíveis. A partir da literatura contemporânea de determinantes da implementação de políticas públicas, a pesquisa, de caráter exploratório-descritivo, utiliza análise de conteúdo em documentos oficiais e, sobretudo, entrevistas com gestores federais e a aplicação de questionários aos gestores de municípios em ambas as situações, aderentes e não aderentes ao programa. Sob a ótica do governo federal, os resultados da investigação sugerem que a implementação do programa foi influenciada positivamente pelo alinhamento com uma política pública maior, com mais recursos e priorização governamental, embora as restrições fiscais, a partir de 2015, e as fragilidades do pacto federativo se apresentem como principais barreiras. Do ponto de vista dos gestores locais, as evidências empíricas demonstram percepções diferentes entre os municípios aderentes ao programa e os que não aderiram, porém há convergências quanto a relevância de um contexto favorável, do legado de políticas prévias e de fatores relacionados às competências e capacidades das prefeituras como determinantes à participação no programa Consultório na Rua.

Implementation of a web-based national child health-care programme in a local context: A complex facilitator role

Aim: The aim of this study was to investigate child health-care coordinators’ experiences of being a facilitator for the implementation of a new national child health-care programme in the form of a web-based national guide. Methods: The study was based on eight remote, online focus groups, using Skype for Business. A qualitative content analysis was performed. Results: The analysis generated three categories: adapt to a local context, transition challenges and led by strong incentives. There were eight subcategories. In the latent analysis, the theme ‘Being a facilitator: a complex role’ was formed to express the child health-care coordinators’ experiences. Conclusions: Facilitating a national guideline or decision support in a local context is a complex task that requires an advocating and mediating role. For successful implementation, guidelines and decision support, such as a web-based guide and the new child health-care programme, must match professional consensus and needs and be seen as relevant by all. Participation in the development and a strong bottom-up approach was important, making the web-based guide and the programme relevant to whom it is intended to serve, and for successful implementation. The study contributes valuable knowledge when planning to implement a national web-based decision support and policy programme in a local health-care context.

A scoping review of the implementation of health in all policies at the local level

OBJECTIVES

Health in All Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. HiAP implementation can involve engagement from multiple levels of government; however, factors contributing or hindering HiAP implementation at the local level are largely unexplored. Local is defined as the city or municipal level, wherein government is uniquely positioned to provide leadership for health and where many social determinants of health operate. This paper presents the results of a scoping review on local HiAP implementation.

METHODS

Peer reviewed articles and grey literature were systematically searched using the Arksey and O'Malley framework. Characteristics of articles were then categorized, tallied and described.

RESULTS

23 scholarly articles and four government documents were identified, ranging in publication year from 2002 to 2016 and originating from 14 countries primarily from North America and Europe. A wide range of themes emerged relating to HiAP implementation locally including: funding, shared vision, national leadership, ownership and accountability, local leadership and dedicated staff, Health Impact Assessment, and indicators.

CONCLUSION

Common themes were found in the literature regarding HiAP implementation locally. However, to better clarify these factors to contribute to theory development on HiAP implementation, further research is needed that specifically investigates the facilitators and barriers of HiAP locally within their political and policy context.

Implementation of health promotion programmes in schools: an approach to understand the influence of contextual factors on the process?

BACKGROUND

Implementing complex and multi-level public health programmes is challenging in school settings. Discrepancies between expected and actual programme outcomes are often reported. Such discrepancies are due to complex interactions between contextual factors. Contextual factors relate to the setting, the community, in which implementation occurs, the stakeholders involved, and the characteristics of the programme itself. This work uses realist evaluation to understand how contextual factors influence the implementation process, to result in variable programme outcomes. This study focuses on identifying contextual factors, pinpointing combinations of contextual factors, and understanding interactions and effects of such factors and combinations on programme outcomes on different levels of the implementation process.

METHODS

Schools which had participated in a school-based health promotion programme between 2012 and 2015 were included. Two sets of qualitative data were collected: semi-structured interviews with school staff and programme coordinators; and written documents about the actions implemented in a selection of four schools. Quantitative data included 1553 questionnaires targeting pupils aged 8 to 11 in 14 schools to describe the different school contexts.

RESULTS

The comparison between what was expected from the programme (programme theory) and the outcomes identified in the field data, showed that some of the mechanisms expected to support the implementation of the programme, did not operate as anticipated (e.g. inclusion of training, initiation by decision-maker). Key factors which influenced the implementation process included, amongst other factors, the mode of introduction of the programme, home/school relationship, leadership of the management team, and the level of delegated power. Five types of interactions between contextual factors were put forward: enabling, hindering, neutral, counterbalancing and moderating effects. Recurrent combinations of factors were identified. Implementation was more challenging in vulnerable schools where school climate was poor.

CONCLUSION

A single programme cannot be suited or introduced in the same manner in every context. However, key recurrent combinations of contextual factors could contribute to the design of implementation patterns, which could provide guidelines and recommendation for grass-root programme implementation.

Implementation of a health promotion programme: a ten-year retrospective study

Purpose

Implementing health promotion programmes in schools is key to improving children’s health and well-being but difficulties in achieving expected results are often reported in the research literature. Discrepancies between expected and achieved outcomes can originate from differences in contexts. Understanding how interactions between contexts and programmes generate variable outcomes is, therefore, critical. The purpose of this paper is to explore the outputs of a programme implemented in different school contexts. The focus is to pinpoint outputs, understand the involvement of combinations of contextual factors and identify recurrences in these combinations.

Design/methodology/approach

This retrospective study covers a period from 2006 to 2016. Data collection includes two sets of data in eight high schools in the Rhône-Alpes Region in France: written documents and interviews with school staff. Realist evaluation is used to attempt to pinpoint outputs and relating contextual factors.

Findings

Results highlight the limited outputs of the programme. Differences between schools appear to originate from existing school policy prior to participation, existence of a project team, identification of the issue as priority and staff turnover. Analysis of contextual factors led to considering the implementation process as enabling health capacity building and enhanced the capacity of settings and communities to promote health.

Research limitations/implications

The data provided remain partial as there was high staff turnover, reluctance to participate due to failure to implement the project, and schools being over burdened with other requests.

Originality/value

Previous research suggests that top-down implementation of a standard programme is not an efficient strategy for all schools to engage in the development of suitable health promotion policies. A potential way forward is to base support for the local development of health promotion in schools on a better understanding of the contexts in which implementation occurs.

Moving towards a new vision: implementation of a public health policy intervention

Background

Public health systems in Canada have undergone significant policy renewal over the last decade in response to threats to the public’s health, such as severe acute respiratory syndrome. There is limited research on how public health policies have been implemented or what has influenced their implementation. This paper explores policy implementation in two exemplar public health programs -chronic disease prevention and sexually-transmitted infection prevention - in Ontario, Canada. It examines public health service providers’, managers’ and senior managements’ perspectives on the process of implementation of the Ontario Public Health Standards 2008 and factors influencing implementation.

Methods

Public health staff from six health units representing rural, remote, large and small urban settings were included. We conducted 21 focus groups and 18 interviews between 2010 (manager and staff focus groups) and 2011 (senior management interviews) involving 133 participants. Research assistants coded transcripts and researchers reviewed these; the research team discussed and resolved discrepancies. To facilitate a breadth of perspectives, several team members helped interpret the findings. An integrated knowledge translation approach was used, reflected by the inclusion of academics as well as decision-makers on the team and as co-authors.

Results

Front line service providers often were unaware of the new policies but managers and senior management incorporated them in operational and program planning. Some participants were involved in policy development or provided feedback prior to their launch. Implementation was influenced by many factors that aligned with Greenhalgh and colleagues’ empirically-based Diffusion of Innovations in Service Organizations Framework. Factors and related components that were most clearly linked to the OPHS policy implementation were: attributes of the innovation itself; adoption by individuals; diffusion and dissemination;the outer context – interorganizational networks and collaboration; the inner setting – implementation processes and routinization; and, linkage at the design and implementation stage.

Conclusions

Multiple factors influenced public health policy implementation. Results provide empirical support for components of Greenhalgh et al’s framework and suggest two additional components – the role of external organizational collaborations and partnerships as well as planning processes in influencing implementation. These are important to consider by government and public health organizations when promoting new or revised public health policies as they evolve over time. A successful policy implementation process in Ontario has helped to move public health towards the new vision.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3056-3) contains supplementary material, which is available to authorized users.

Facilitators for the development and implementation of health promoting policy and programs - a scoping review at the local community level

BACKGROUND

Health promotion, with a focus on multidimensional upstream factors and an ecological, life-course approach, is establishing itself as the guiding philosophy for addressing public health. Action at the political and programmatic level on the Social Determinants of Health has proven effective for promoting and building public health at all levels but has been particularly evident at the national and international levels - due in large part to available documents and guidelines. Although research and experience establish that health promotion is most effective when settings-based, the development of health promoting policies and programs at the local level is still difficult. This study intended to investigate available knowledge on the development and implementation of health promoting policies and programs at the local level and identify factors most important for facilitating capacity building and outcome achievement.

METHODS

We used a scoping review in order to review the current literature on local policy development and program implementation. Keywords were chosen based on results of a previous literature review. A total of 53 articles were divided into two categories: policy and implementation. Critical analysis was conducted for each article and a summary assembled. Data was charted with specific focus on the aims of the study, data acquisition, key theories/concepts/frameworks used, outcome measures, results, and conclusions.

RESULTS

The articles included in this study primarily focused on discussing factors that facilitate the development of health promoting policy and the implementation of health promotion programs. Most significant facilitators included: collaborative decision-making, agreement of objectives and goals, local planning and action, effective leadership, building and maintaining trust, availability of resources, a dynamic approach, a realistic time-frame, and trained and knowledgeable staff. Within each of these important facilitating factors, various elements supporting implementation were discussed and highlighted in this study.

CONCLUSION

Our results indicate that clear and consistent facilitators exist for supporting health promoting policy development and program implementation at the local level. These results offer a starting point for local action on the Social Determinants of Health and have the potential to contribute to the development of a framework for improving action at the local level.

Are equity aspects communicated in Nordic public health documents?

Aims: To explore if the term equity was applied and how measures for addressing social inequalities in health and reducing inequity were communicated in selected Nordic documents concerning public health. Methods: Documents from Denmark, Finland, Norway, and Sweden were collected and analysed by Nordic authors. Data included material from websites of ministries and authorities responsible for public health issues, with primary focus on steering documents, action programmes, and reports from 2001 until spring 2013. Results: Most strategies applied in Danish, Finnish, and Swedish documents focused on the population in general but paid special attention to vulnerable groups. The latest Danish and Finnish documents communicate a clearer commitment to address social inequalities in health. They emphasise the social gradient and the need to address the social determinants in order to improve the position of disadvantaged groups. Norwegian authorities have paid increasing attention to inequity/social inequalities in health and initiated a new law in 2012 which aims to address the social gradient in a more clear way than seen elsewhere in the Nordic countries. Conclusions: In the Nordic countries, redistribution by means of universal welfare policies is historically viewed as a vital mechanism to improve the situation of vulnerable groups and level the social gradient. To establish the concept of equity as a strong concern and a core value within health promotion, it is important to be aware how policies can contribute to enable reduction of social health differences.

The health-promotion perspective in public-health plans in a Swedish region over three decades

The trend away from a health and medical care-based policy to a healthy public policy has taken place in Sweden rather later than in other West European countries. One of the first county councils to establish health-promotion plans was Västernorrland. The aims of this study are to describe the contents of and analyze the changes over time in the five public-health plans in the county. The object of study for the policy analysis consists in these plans between 1978 and 2004. A deductive thematic content analysis was performed for each plan on the basis of the central determinants of health promotion. The positioning of the plans was determined using a theoretical framework (Beattie's modified model) founded in the dimensions of power (individual and collective) and governance (local, i.e. the municipalities, and central, i.e. the county council). The results show that the value attributed to good health was consistently high, but the means for attaining this goal have varied over time. The policy focus of the measures in the plans have taken a cyclical path--from individual empowerment to empowerment from a societal perspective, and back prioritizing of actions at an individual level. On the governance dimension, there has been a corresponding positional change over time--from regional to local and then back to regional. Promoting the health of a population requires mutual interaction between the regional and local levels, in which both societal and individually oriented actions are prioritized.