From rhetoric to reality: barriers faced by Health For All initiatives

Local public health projectification in practice: a qualitative study of facilitators and barriers to a public health plan implementation

AIMS

To identify factors perceived by local government employees to affect the implementation of a municipal public health plan.

METHODS

Qualitative individual interviews (n=13) were carried out. Participants were sampled from three districts in Oslo municipality, Norway, and asked about their experiences with an ongoing implementation of the Oslo Public Health Plan (2017-2020). The conceptual framework of public sector projectification - a growing reliance on project organisation of policies - informed the study. The consolidated framework for implementation research was used to aid data coding and subsequent thematic analysis.

RESULTS

Implementation facilitators included factors perceived to support flexibility, including plan adaptability to the local setting, and factors perceived to enable structure and control during the implementation process, such as the articulation of specific goals and a shared understanding of public health work. Barriers were mainly related to complex aspects of the plan, such as the need to involve multiple stakeholders and levels of governance, and to tensions between the time-limited implementation process and the permanent organisational structures.

CONCLUSIONS

This study has demonstrated how research-based methods can be used for the evaluation of a local community implementation process. It has identified implementation determinants using a predetermined taxonomy of operationally defined factors that are likely to influence implementation. However, while implementing a time-limited public health plan can be seen as 'taking action' in relation to multidimensional and complex problems, further research is needed to investigate whether plan implementation has a long-term impact on the surrounding organisation and, eventually, on public health outcomes.

Engaging Diverse Community Groups to Promote Population Health through Healthy City Approach: Analysis of Successful Cases in Western Pacific Region

Background: A substantial global burden of health can be attributed to unhealthy lifestyles and an unhealthy living environment. The concept of a Healthy City is continually creating and improving physical and social environments to enable healthy living. The aim of this paper is to investigate how the Healthy City concept would tackle the complexity of health by addressing the socio-economic and political determinants of health in the Western Pacific Region. Methods: The SPIRIT model adopted by the Alliance for Healthy Cities can provide a framework for an integrated and holistic approach to enable policy, environment, social matters, behaviours, and bio-medical interventions to take their rightful place side by side. The performance of cities awarded by the AFHC was analysed under each domain of the SPIRIT model to show the efforts striving to acquire the qualities of a healthy city. Findings: Two cities have incorporated the Healthy City concept in most of their policies outside the health sector, with a high level of commitment from city leaders and citizens, so the Health City activities were recognised as part of the means to advance the cityies’ general planning. One city has made use of its strong network of key stakeholders from different sectors and disciplines to establish a “Medical–Social–Community’ model. All three cities have collected health information to reflect health status, determinants of health and issues reflecting health promotion to enable the creation of a city health profile and show positive changes in health. The cities have engaged key stakeholders to launch a variety of health-promoting programmes according to the needs of the population. Conclusion: The AFHC can play an important role in linking the cities with strong action in Healthy City activities to support other cities in Healthy City development.

A Systematised Review of the Health Impact of Urban Informal Settlements and Implications for Upgrading Interventions in South Africa, a Rapidly Urbanising Middle-Income Country

Informal settlements are becoming more entrenched within African cities as the urban population continues to grow. Characterised by poor housing conditions and inadequate services, informal settlements are associated with an increased risk of disease and ill-health. However, little is known about how informal settlement upgrading impacts health over time. A systematised literature review was conducted to explore existing evidence and knowledge gaps on the association between informal settlement characteristics and health and the impact of informal settlement upgrading on health, within South Africa, an upper-middle income African country. Using two databases, Web of Science and PubMed, we identified 46 relevant peer-reviewed articles published since 1998. Findings highlight a growing body of research investigating the ways in which complete physical, mental and social health are influenced by the physical housing structure, the psychosocial home environment and the features of the neighbourhood and community in the context of informal settlements. However, there is a paucity of longitudinal research investigating the temporal impact of informal settlement upgrading or housing improvements on health outcomes of these urban residents. Informal settlements pose health risks particularly to vulnerable populations such as children, the elderly, and people with suppressed immune systems, and are likely to aggravate gender-related inequalities. Due to the complex interaction between health and factors of the built environment, there is a need for further research utilising a systems approach to generate evidence that investigates the interlinked factors that longitudinally influence health in the context of informal settlement upgrading in rapidly growing cities worldwide.

Determinants of an integrated public health approach: the implementation process of Greenland's second public health program

Background

Greenland struggles with a high prevalence of smoking, alcohol and drug abuse. In response to the increasing need for preventive initiatives, the first public health program Inuuneritta was introduced in 2007. Internationally, frameworks focus primarily on the implementation of a single, well-described intervention or program. However, with the increasing need and emergence of more holistic, integrated approaches, a need for research investigating the process of policy implementation from launch to action arises. This paper aims to augment the empirical evidence on the implementation of integrated health promotion programs within a governmental setting using the case of Inuuneritta II. In this study, the constraining and enabling determinants of the implementation processes within and across levels and sectors were examined.

Methods

Qualitative methods with a transdisciplinary approach were applied. Data collection consisted of six phases with different qualitative methods applied to gain a comprehensive overview and understanding of Inuuneritta II’s implementation process. These methods included: observations and focus group discussions at the community health worker (CHW) conference, telephone interviews, document analysis, and a workshop on results dissemination.

Results

Enabling determinants influencing the implementation process of Inuuneritta II positively were high motivation among adopters, local prevention committees supporting community health workers, and the initiation of the central prevention committee. In contrast, constraining determinants were ambiguous program aims, high turnovers, siloed budgets and work environments, and an inconsistent and neglected central prevention committee.

Conclusion

Inuuneritta II provided a substantial framework for an integrated health policy approach. However, having a holistic and comprehensive program enabling an integrated approach is not sufficient. Inuuneritta II’s integrated approach does not harmonise with the government’s inflexible organisational structure resulting in insufficient implementation.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6253-4) contains supplementary material, which is available to authorized users.

Keeping the Person in Personalised Healthcare

Proponents of personalised medicine believe that the involvement of the patients, including in "risk-sharing agreements," will result in cost savings, the use of the genetic makeup of an individual patient as the starting point will save resources and, indirectly, there will be great potential for startups and new business in many areas. But how can Europe ensure that the "person" is central stage and allow us to focus on the development of personalised medicine for his or her ultimate benefit? The EU has a clear role to play, argues the author. One way for this to happen is for the EU to focus investment in guidelines for governance. This will go a long way to ensuring that the citizen is the principal factor when it comes to utilising the new wealth of innovation in health. The citizen must always come first when innovation is harnessed.

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.

Beyond leadership: political strategies for coordination in health policies

Health in All Policies (HiAP) promises to improve population health by harnessing the energies and activities of various sectors. Nevertheless, it faces well-documented bureaucratic obstacles and appears to require intersectoral governance if it is to be established. The basic problems of establishing intersectoral governance for HiAP are known to public administration and political science. On reading that literature, we find that the difficulty of establishing intersectoral governance for HiAP breaks down into two kinds of problems: that of establishing coordinated actions at all (coordination); and ensuring that they endure in changed political circumstances (durability). We further find that policymakers' solutions fall into three categories: visible ones of political will (e.g., plans and targets); bureaucratic changes such as the introduction of Health Impact Assessment or reorganization; and indirect methods such as data publication and support from outside groups to put pressure on the government. It can seem that Health in All Policies, like much of public health, depends on effective and committed policymakers but is vulnerable to changing political winds. The three kinds of strategies suggest how policymakers can, and do, create intersectoral governance that functions and persists, expanding the range of effective policy recommendations.

[Conditions linked to the integration of the ecologic approach to the programming of prevention-promotion offered to elderly clients by the CSSS of Quebec: a case study]

This multiple case study investigates conditions influencing the integration of the ecological approach in disease prevention and health promotion (DPHP) programs offered to older adults by local health organizations in Quebec. Scheirer's (1981) implementation model guided the study of five Centres de Santé et Services Sociaux chosen in line with the ecological dimension of their DPHP programs. Documentary analyses were conducted along with thirty-eight semi-structured interviews among professionals and managers. Three categories of factors were explored: professional, organizational and environmental factors. Results indicate the ecological dimension of programs is influenced by organizational norms, competing priorities, team structure, external partnerships, preconceived ideas regarding DPHP for older adults, along with professional interest and training. These results provide levers for action toward optimizing services offered to the older population through disease prevention and health promotion programs.

Ecological models revisited: their uses and evolution in health promotion over two decades

Since the 1980s, ecological models of health promotion have generated a great deal of enthusiasm among researchers and interventionists. These models emerged from conceptual developments in other fields, and only selected elements of the ecological approach have been integrated into them. In this article, we describe the tenets of the ecological approach and highlight those aspects that have been integrated into ecological models used in health promotion. We also analyze how ecological models have been applied to the study of two important public health issues, namely physical activity promotion and the increased consumption of fruits and vegetables, by conducting an archival study of published research. Finally, we make a statement regarding the usefulness of ecological models for research and practice and propose recommendations for future research, program planning, and evaluation.

Integrating the Ecological Approach in Disease Prevention and Health Promotion Programs for Older Adults

The objective of this study was to identify contextual factors influencing the degree of integration of the ecological approach in disease prevention and health promotion (DPHP) programming initiatives for older adults in two public health organizations in Québec, Canada. A case study design was used and two organizations presenting contrasting profiles in the degree of integration of the approach in their DPHP programming for older adults were selected. Face-to-face interviews with professionals and managers and archival analysis were conducted. Several factors emerged as constraining the integration of the approach in both organizations, including the lack of data showing the effectiveness of DPHP interventions for older adults and the presence of macro-contextual political factors at odds with the ideology of DPHP. Resources and partnerships with academic milieus emerged as key factors distinguishing the two organizations. These results provide increased understanding of conditions required for planning DPHP programs for older adults.

Evaluating health impacts: Results from the neighbourhood renewal strategy [corrected] in Victoria, Australia

AIMS

Neighbourhood Renewal [NR] Strategy is currently underway in the Victoria's most disadvantaged neighbourhoods. Neighbourhood Renewal utilises an 'area-based' approach to reducing inequalities between NR sites and the Victorian state average across a range of social, educational and health outcomes. We examine the impact of this intervention on health and life satisfaction in the five metropolitan sites involved in first phase of the project.

DESIGN

We employed a before-and-after study design using two cross sectional community surveys to assess changes in health and life satisfaction. The study sample includes people living in NR areas and people living in other areas of the same Local Government Area (LGA). Survey responses from the five metropolitan NR and their surrounding were used in this analysis.

RESULTS

NR residents involved in the program had worse health than people living in the LGA in all analyses. There was no evidence of an NR effect at a whole of area level. However, the health (OR=2.15, 95%CI 1.23-3.74) and life satisfaction (OR=1.79 95%CI 1.38-1.52) of people living in NR areas who participated in the intervention improved relative to people in the LGA.

CONCLUSIONS

The results suggest that area-based health interventions are an important tool in the portfolio of strategies to reduce health inequalities.

Revisiting "Who gets care?": health equity as an arena for nursing action

This article revisits and reaffirms Patricia Steven's earlier work on access to healthcare as an important arena for nursing action. Many of the conditions that affect access to healthcare, such as racism and oppression, also shape inequities in health outcomes. We propose a conceptualization of social justice that is consistent with addressing the conditions that influence health inequities. We also discuss the implications of a critical and feminist conception of social justice for nursing action, education, practice, research, and policy.

Understanding the effectiveness of partnership-based early childhood interventions

In this paper, we seek to understand the relationship between partnership effectiveness and preschool enrolment in Best Start, an early childhood intervention for children living in disadvantaged areas in Victoria, an Australian State. We will examine the application of theories of partnership effectiveness at a whole of intervention level and in the context of local evaluation initiatives at the Broadmeadows Early Years Partnership. For the statewide intervention, partnership effectiveness was measured using the VicHealth Partnership Analysis Tool at 11 Best Start Sites. The dependent variable was preschool enrolment in Best Start local government area. For the Broadmeadows Early Years Partnership case study, partnership is conceptualised in terms of the Lasker and Weiss (2003) model of collaborative decision making. Scores rose significantly between the two applications of the VicHealth Partnership Analysis Tool at the beginning and end of the Best Start funding period on almost all of the dimensions of the VicHealth Tool. Support for ‘making partnerships work’, ‘minimising barriers to partnerships’ and the ‘total’ partnership scores were associated with increased preschool enrolments. The results of the case study supported the model for collaborative decision making with particular emphasis on the role of shared leadership, synergy and bridging social ties as crucial processes in improving service integration. The results of the statewide intervention and the case study both provide evidence of the value of partnership approaches in improving service uptake and integration for children living in disadvantaged areas. The study also supports current conceptualisations of partnership value and effectiveness.

The implementation of process orientation at a Swedish hospital

During the last decade, as a response to the need for inter- as well as intra-organizational integration, management models initially developed for industry have been spread to health care organizations. Based on 62 in-depth interviews, this qualitative study aims at describing and analyzing the limited success of implementation of process orientation at a Swedish hospital and in doing so, the traditional and the critical approaches are combined. Applying a traditional approach, the limited success of the implementation of process orientation is explained in terms of difficulties to challenge deeply institutionalized organizational routines and the inter-disciplinary boundaries. This might be condensed to the dilemma of how to maintain and develop the specialization of the medical profession while focusing process rather than function and how to enhance inter-organizational integration without hampering intra-organizational collaboration. Applying a critical approach, the limited success is explained in terms of a differentiated translation process and in terms of separation of talk and practice. This means that process orientation, notwithstanding that it might be an efficient tool for the type of integration needed, might be regarded as part of a change discourse, aiming at conveying a picture of an efficient and modern organization.

From rhetoric to reality: A systemic approach to understanding the constraints faced by Health For All initiatives in England

The increased appreciation of the effects socio-ecological factors have on health, witnessed over the last few decades, has given rise to many international, national, and local Health For All (HFA) initiatives tasked with addressing them. However, such initiatives have had to operate within environments which were not specifically designed for them or for the new social (rather than medical) perspective on health they were based upon. As a result, they have been facing significant barriers and constraints to fulfilling their mission. This paper explores the constraints which are imposed on such initiatives by the various environments within which they are nested. Drawing upon our experience in evaluating European Healthy City (HC) projects and English Health Action Zones (HAZs), we develop a dynamic conceptual model which shows how the national, governmental policy, interorganisational, organisational, and initiative environments relate with each other and their cumulative effects on initiatives. We argue that this model, and the principles on which it is based, can be used constructively to identify constraints facing HFA-type initiatives in many countries. We use our case study of English HCs and HAZs to illustrate the applicability of the model in a particular national context. We, first, interpret the model to reflect differences and similarities between their respective environments and trace the sources of the different constraints they encountered. We, then, show how an alternative structural configuration could enable some of these constraints to be eliminated. We argue that what is needed for HFA initiatives to be able to fulfill their brief in full is for governments to rethink existing organisational structures and update them to match the evolution of ideas on health which have emerged over the last decades.