Nine questions to guide development and implementation of Health in All Policies

The pathway to health in all policies through intersectoral collaboration on the health workforce: a scoping review

The health workforce (HWF) is a critical component of the health sector. Intersectoral/multisectoral collaboration and action is foundational to strengthening the HWF, enabling responsiveness to dynamic population health demands and supporting broader goals around social and economic development-such development underpins the need for health in all policies (HiAP). To identify what can be learned from intersectoral/multisectoral activity for HWF strengthening to advance HiAP, we carried out a scoping review. Our review included both peer-reviewed and grey literature. Search terms encompassed terminology for the HWF, intersectoral/multisectoral activities and governance or management. We carried out a framework analysis, extracting data around different aspects of HiAP implementation. With the aim of supporting action to advance HiAP, our analysis identified core recommendations for intersectoral/multisectoral collaboration for the HWF, organized as a 'pathway to HiAP'. We identified 93 documents-67 (72%) were journal articles and 26 (28%) were grey literature. Documents reflected a wide range of country and regional settings. The majority (80, 86%) were published within the past 10 years, reflecting a growing trend in publications on the topic of intersectoral/multisectoral activity for the HWF. From our review and analysis, we identified five areas in the 'pathway to HiAP': ensure robust coordination and leadership; strengthen governance and policy-making and implementation capacities; develop intersectoral/multisectoral strategies; build intersectoral/multisectoral information systems and identify transparent, resources financing and investment opportunities. Each has key practical and policy implications. Although we introduce a 'pathway', the relationship between the areas is not linear, rather, they both influence and are influenced by one another, reflecting their shared importance. Underscoring this 'pathway' is the shared recognition of the importance of intersectoral/multisectoral activity, shared vision and political will. Advancing health 'for' all policies-generating evidence about best practices to identify and maximize co-benefits across sectors-is a next milestone.

Governance of Intersectoral Collaborations for Population Health and to Reduce Health Inequalities in High-Income Countries: A Complexity-Informed Systematic Review

BACKGROUND

A 'Health in All Policies' (HiAP) approach has been widely advocated as a way to involve multiple government sectors in addressing health inequalities, but implementation attempts have not always produced the expected results. Explaining how HiAP-style collaborations have been governed may offer insights into how to improve population health and reduce health inequalities.

METHODS

Theoretically focused systematic review. Synthesis of evidence from evaluative studies into a causal logic model.

RESULTS

Thirty-one publications based on 40 case studies from nine high-income countries were included. Intersectoral collaborations for population health and equity were multi-component and multi-dimensional with collaborative activity spanning policy, strategy, service design and service delivery. Governance of intersectoral collaboration included structural and relational components. Both internal and external legitimacy and credibility delivered collaborative power, which in turn enabled intersectoral collaboration. Internal legitimacy was driven by multiple structural elements and processes. Many of these were instrumental in developing (often-fragile) relational trust. Internal credibility was supported by multi-level collaborations that were adequately resourced and shared power. External legitimacy and credibility was created through meaningful community engagement, leadership that championed collaborations and the identification of 'win-win' strategies. External factors such as economic shocks and short political cycles reduced collaborative power.

CONCLUSION

This novel review, using systems thinking and causal loop representations, offers insights into how collaborations can generate internal and external legitimacy and credibility. This offers promise for future collaborative activity for population health and equity; it presents a clearer picture of what structural and relational components and dynamics collaborative partners can focus on when planning and implementing HiAP initiatives. The limits of the literature base, however, does not make it possible to identify if or how this might deliver improved population health or health equity.

Promoting children's sleep health: Intervention Mapping meets Health in All Policies

Background

To design a comprehensive approach to promote children's sleep health in Amsterdam, the Netherlands, we combined Intervention Mapping (IM) with the Health in All Policies (HiAP) perspective. We aimed to create an approach that fits local infrastructures and policy domains across sectors.

Methods

First, a needs assessment was conducted, including a systematic review, two concept mapping studies, and one cross-sectional sleep diary study (IM step 1). Subsequently, semi-structured interviews with stakeholders from policy, practice and science provided information on potential assets from all relevant social policy sectors to take into account in the program design (HiAP and IM step 1). Next, program outcomes and objectives were specified (IM step 2), with specific objectives for policy stakeholders (HiAP). This was followed by the program design (IM step 3), where potential program actions were adapted to local policy sectors and stakeholders (HiAP). Lastly, program production (IM step 4) focused on creating a multi-sector program (HiAP). An advisory panel guided the research team by providing tailored advice during all steps throughout the project.

Results

A blueprint was created for program development to promote children's sleep health, including a logic model of the problem, a logic model of change, an overview of the existing organizational structure of local policy and practice assets, and an overview of policy sectors, and related objectives and opportunities for promoting children's sleep health across these policy sectors. Furthermore, the program production resulted in a policy brief for the local government.

Conclusions

Combining IM and HiAP proved valuable for designing a blueprint for the development of an integrated multi-sector program to promote children's sleep health. Health promotion professionals focusing on other (health) behaviors can use the blueprint to develop health promotion programs that fit the local public service infrastructures, culture, and incorporate relevant policy sectors outside the public health domain.

Why is health improvement policy so difficult to secure?

Many governments seek to improve population health, and some seek to reduce health inequalities. Yet, there remains a large gap between their policy statements and actual outcomes. Perennial questions in public health research include: why is this gap so large, why does it endure, and what can be done to close it? This essay uses political science and policy studies insights to address these questions, focusing on the distinctive issues that relate to (1) broad aims like 'prevention', (2) specific strategies for health improvement, or (3) new events. On the one hand, the idea of 'prevention' has widespread appeal, when governments think they can save money or reduce inequalities by preventing problems happening or worsening. While health protection seeks to inoculate populations against communicable diseases, health improvement strategies, including 'Health in All Policies' (HiAP), primarily address non-communicable diseases (NCDs). Further, the coronavirus disease 2019 (COVID-19) pandemic highlights the unequal spread of ill health, showing that preventive health ideas should be at the core of policy. On the other hand, there is a large gap between rhetorical and substantive commitment to prevention, a continuous HiAP implementation gap, and a tendency for COVID-19 health protection to overshadow health improvement. Explaining each problem clearly helps to identify the factors that generally undermine prevention policies and those specific to more detailed strategies like HiAP or events like COVID-19. We do not prioritise leadership or 'political will' as the policymaking problem. Instead, we identify the systemic factors that apply to even the most sincere, competent, and energetic policymakers. Health improvement policy is typically undermined by a lack of: clarity about what prevention means in practice; congruity between the prevention agenda (emphasising the need for major change to policy and policymaking) and routine government business; and, capacity to overcome obstacles to policy change.

'Writing budgets for meetings and teas?': a multitheoretical analysis of intragovernmental coordination for multisectoral action for health in Uganda

Introduction

Coordination across policy domains and among government agencies is considered critical for addressing complex challenges such as inequities, urbanisation and climate change. However, the factors influencing coordination among government entities in low-income and middle-income countries are not well known. Although theory building is well suited to explain complex social phenomena, theory-based health policy and systems studies are limited. This paper examined the factors influencing coordination among government entities at the central government level in Uganda.

Methods

This theory-based case study used a qualitative approach. Primary data were collected through 26 national-level key informant interviews supplemented with a review of 6 national strategic and policy documents. Data were analysed abductively using a multitheoretical framework combining the transaction cost economics theory, principal–agent theory, resource dependence theory and political economy perspective.

Results

Complex and dynamic interactions among different factors, both internal and external to the government, were found. Interdependencies, coordination costs, non-aligned interests, and institutional and ideational aspects were crucial factors. The power dynamics within the bureaucratic structures and the agency of the coordinated entities influence the effectiveness of coordination efforts. New public management principles promoted in the 1990s by donor institutional strengthening projects (characterised by agencification and setting up of independent agencies to circumvent ineffective big line ministries) created further fragmentation within the government. The donors and international agendas were occasionally supportive but sometimes counterintuitive to national coordination efforts.

Conclusion

The multitheoretical framework derives a deep analysis of the factors that influence organisational decision-making to coordinate with others or not. Achieving intragovernmental coordination requires more time and resources to guide the software aspects of institutional change—articulating a shared vision on coordination across government. Shaping incentives to align interests, managing coordination costs and navigating historical-institutional contexts are critical. Countervailing political actions and power dynamics should be judiciously navigated.

Supporting a Healthy Planet, Healthy People and Health Equity through Urban and Territorial Planning

The form of human settlements impacts on planetary health, population health and health equity. Yet goals for urban and territorial planning are only tangentially linked to public health outcomes. The WHO and UN-Habitat support actions to bring health to the fore in planning and design of human settlements, recently publishing 'Integrating Health in Urban and Territorial Planning: a sourcebook' focusing on 'why' action is needed, 'how' to initiate it; and curating several existing resources on 'what' to do. Recommendations for research, policy and practice include calls for rapid development of closer relationships between public health and spatial planning.

Does partnership diversity in intersectoral policymaking matter for health promoting intervention packages' composition? A multiple-case study in the Netherlands

Intersectoral policymaking to improve public health includes integrated health promotion (HP) intervention packages that address a variety of health behavior determinants. The involvement of different partners is assumed to be necessary to implement such integrated packages. We examined how partnership diversity was associated with the composition of intervention packages implemented in Dutch municipalities. In a longitudinal multiple-case study (2012-14), we collected questionnaire data among 31 project leaders and 152 intervention implementers in 31 (alliances of) municipalities. Package composition was assessed in terms of intervention strategies, implementation settings and targeted behavioral determinants. Partnership diversity during the adoption and implementation phases was assessed in terms of the actors and sectors, as well as private partners and citizens involved. The association between partnership diversity and package composition was examined using crosstabs. Almost all packages integrated multiple strategies, but mostly education, facilitation and case finding, in multiple, but mostly health and public settings, such as schools. The packages targeted diverse behavioral determinants, although mainly personal and social environmental factors. A variety of partners from multiple sectors was involved, during both adoption and implementation of the packages. However, partners from the health, welfare and education sectors were mostly involved. More partnership diversity, especially during implementation, was associated with more integrated intervention packages. In intersectoral policymaking, investment in diversely composed partnerships seems worthwhile for implementing integrated intervention packages. However, investments in other conditions, like framing health issues and network management, are also needed to make environmental determinants of health behavior the object of HP.

Social determinants of the Latinx diabetes health disparity: A Oaxaca-Blinder decomposition analysis

Latinx people living in the U.S. report a disproportionately high prevalence of diabetes. This project builds on the existing social determinants of diabetes literature by examining factors associated with a greater likelihood of diabetes and investigates factors correlated with the Latinx/non-Latinx disparity. This project studies the adult sample (18 and older) from the 2010–2018 IPUMS Health: National Health Interview Survey (NHIS) data. Logistic regression analyses are used to examine the patterns between reporting Latinx identity and reporting diabetes with additional subgroup analyses of the Latinx and non-Latinx groups. Then, Oaxaca-Blinder decomposition is used to examine the patterns explaining the difference in self-reported diabetes between the Latinx and non-Latinx population for the whole sample and by age group.

The logistic regression analyses show that after adjusting for age and other key social determinants of health, Latinx individuals are approximately 64.5% (OR 1.645, [95% CI, 1.536–1.760]) more likely to report being diagnosed with diabetes than non-Latinx individuals. Individual characteristics of age, race, and smoking behaviors are identified as suppressors of the gap, and conversely, characteristics of income, education, and BMI all contribute to the Latinx diabetes disparity gap. The Oaxaca-Blinder decomposition results show that the measured social determinants of health characteristics explain a meaningful amount of the Latinx diabetes gap. Importantly, differences in education and income (which are more immediately actionable policy areas) make larger contributions to the gap than BMI or other health behaviors.

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The Latinx diabetes disparity should always presented after adjusting for age.

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In the age-adjusted model, Latinx adults are 64.5% more likely to report diabetes.

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Oaxaca-Blinder decomposition analysis shows how factors such as income, education, and BMI drive the diabetes disparity.

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Income and education are identified as modifiable factors to be prioritized in policy interventions aimed at reducing the diabetes disparity.

Opportunity for HiAP through a Healthy Cities initiative in Taiwan: a multiple streams analysis

Health in All Policies (HiAP) is an effective approach to promote population health through addressing comprehensive social determinants of health. In 1997, the World Health Organization designed a 20-step protocol for developing a Healthy Cities (HC) project to build healthy public policies. Taiwan adopted the concept of HC in 2002 and established the first demonstration project in Tainan City in 2003. This study explores the impact of the HC initiative on the development of HiAP, as well as how a window of opportunities for HiAP was opened through the HC movement, using Tainan City as an example. Tainan was selected as the case for this study because of its relative maturity in the development of an HC initiative. A theory-driven thematic analysis was conducted in the study with archived documents between 2003 and 2010. We first adopted a Multiple Streams Approach to examine how the city government opened a window for HiAP through the HC initiative and then drew on the Maturity Model to evaluate the stage of HiAP in the Tainan HC project. After analyzing all related documents, we concluded that HiAP in the Tainan HC project had reached Stage V Institutionalization after 7 years. Key contexts, factors, challenges and strategies were identified. This study suggests that the HC initiative can indeed contribute to the development of HiAP and that the window was opened for HiAP through a concurrence of the three streams of problem, policy and politics along with the HC movement process.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

WITHDRAWN: The role of medical and health policies in the health risk management system

Ahead of Print article withdrawn by publisher.

Policy Adoption and the Implementation Woes of the Intersectoral First 1000 Days of Childhood Initiative, In the Western Cape Province of South Africa

BACKGROUND

There is a growing interest in implementing intersectoral approaches to address social determinants especially within the Sustainable Development Goals (SDGs) era. However, there is limited research that uses policy analysis approaches to understand the barriers to adoption and implementation of intersectoral approaches. In this paper we apply a policy analysis lens in examining implementation of the first thousand days (FTD) of childhood initiative in the Western Cape province of South Africa. This initiative aims to improve child outcomes through a holistic intersectoral approach, referred to as nurturing care.

METHODS

The case of the FTD initiative was constructed through a triangulated analysis of document reviews (34), in depth interviews (22) and observations. The analysis drew on Hall's 'ideas, interests and institutions' framework to understand the shift from political agendas to the implementation of the FTD.

RESULTS

In the Western Cape province, the FTD agenda setting process was catalysed by the increasing global evidence on the life-long impacts of brain development during the early childhood years. This created a window of opportunity for active lobbying by policy entrepreneurs and a favourable provincial context for a holistic focus on children. However, during implementation, the intersectoral goal of the FTD got lost, with limited bureaucratic support from service-delivery actors and minimal cross-sector involvement. Challenges facing the health sector, such as overburdened facilities, competing policies and the limited consideration of implementation realities (such as health providers' capacity), were perceived by implementing actors as the key constraints to intersectoral action. As a result, FTD actors, whose decision-making power largely resided in health services, reformulated FTD as a traditional maternal-child health mandate. Ambiguity and contestation between key actors regarding FTD interventions contributed to this narrowing of focus.

CONCLUSION

This study highlights conditions that should be considered for the effective implementation of intersectoral action - including engaging cross-sector players in agenda setting processes and creating spaces that allow the consideration of actors' interests especially those at service-delivery level. Networks that prioritise relationship building and trust can be valuable in allowing the emergence of common goals that further embrace collective interests.

Multisectoral action for health in low-income and middle-income settings: how can insights from social science theories inform intragovernmental coordination efforts?

There is consensus in global health on the need for multisectoral action (MSA) to address many contemporary development challenges, but there is limited action. Examples of issues that require coordinated MSA include the determinants of health conditions such as nutrition (malnutrition and obesity) and chronic non-communicable diseases. Nutrition, tobacco control and such public health issues are regulated separately by health, trade and treasury ministries. Those issues need to be coordinated around the same ends to avoid conflicting policies. Despite the need for MSA, why do we see little progress? We investigate the obstacles to and opportunities for MSA by providing a government perspective. This paper draws on four theoretical perspectives, namely (1) the political economy perspective, (2) principal–agent theory, (3) resource dependence theory and (4) transaction cost economics theory. The theoretical framework provides complementary propositions to understand, anticipate and prepare for the emergence and structuring of coordination arrangements between government organisations at the same or different hierarchical levels. The research on MSA for health in low/middle-income countries needs to be interested in a multitheory approach that considers several theoretical perspectives and the contextual factors underlying coordination practices.

The Rise of the Consucrat

Some agents representing the 'receiving end' of the medical-industrial complex could be called 'career consumers.' We identify these consucrats as a new class of intersectional representation of 'those affected' in healthcare delivery systems. We describe them in the context of (similar) abocrats and femocrats but show that consucrats face more complex and different level intersectional challenges. The designation, professionalization, and representation of consucrats are problematic, in particular for public policy change. We argue for an enhanced strategic and cautious role for the consumer health movement to support consucrats.

Cross-Center Virtual Education Fellowship Program for Early-Career Researchers in Atrial Fibrillation

BACKGROUND

It is estimated that over 46 million individuals have atrial fibrillation (AF) worldwide, and the incidence and prevalence of AF are increasing globally. There is an urgent need to accelerate the academic development of scientists possessing the skills to conduct innovative, collaborative AF research.

METHODS

We designed and implemented a virtual AF Strategically Focused Research Network Cross-Center Fellowship program to enhance the competencies of early-stage AF basic, clinical, and population health researchers through experiential education and mentorship. The pedagogical model involves significant cross-center collaboration to produce a curriculum focused on enhancing AF scientific competencies, fostering career/professional development, and cultivating grant writing skills. Outcomes for success involve clear expectations for fellows to produce manuscripts, presentations, and-for those at the appropriate career stage-grant applications. We evaluated the effectiveness of the fellowship model via mixed methods formative and summative surveys.

RESULTS

In 2 years of the fellowship, fellows generally achieved the productivity metrics sought by our pedagogical model, with outcomes for the 12 fellows including 50 AF-related manuscripts, 7 publications, 28 presentations, and 3 grant awards applications. Participant evaluations reported that the fellowship effectively met its educational objectives. All fellows reported medium to high satisfaction with the overall fellowship, webinar content and facilitation, staff communication and support, and program organization.

CONCLUSIONS

The fellowship model represents an innovative educational strategy by providing a virtual AF training and mentoring curriculum for early-career basic, clinical, and population health scientists working across multiple institutions, which is particularly valuable in the pandemic era.

Collaboration in health promotion for newly arrived migrants in Sweden

As a group, newly arrived migrants in Sweden face inequities in health compared to the general population. Successful promotion of population health requires awareness of and focus on health from several sectors of society. In light of this, the aim was to study the views of local authority officials on collaboration in health promotion activities for newly arrived migrants. Data was collected through five focus group interviews with 23 local authority officials working with the integration of newly arrived migrants in the Establishment Program in a municipality or at the Employment Services in northern Sweden. An inductive qualitative latent content analysis was performed, and the analysis showed that the participating officials considered health promotion as desirable in the Establishment Program, but it also raised complex issues within the existing organisations. The officials described unclear roles, but also possible changes to the organisation that would improve the possibility of working to promote health. The present study adds to the relatively limited knowledge of health promotion in integration activities and offers clinical relevance for policymakers through the officials' suggestions for improvements in the Establishment Program. It also raises important questions for further research.

Is an Iranian Health Promoting School status associated with improving school food environment and snacking behaviors in adolescents?

The Iranian Health Promoting Schools (IHPS) program was first piloted and then formally established in Iran in 2011 as a framework to promote healthy environment and behaviors such as proper dietary practice among adolescents. This study examined the role of IHPS in improving the school food environment and snacking behaviors among adolescents. In this cross-sectional study, 1320 eighth grade students from 40 middle schools with IHPS and non-IHPS program were selected using a proportional stratified random sampling method. A modified 55-item qualitative Food Frequency Questionnaire was used to assess the frequency of consumption of healthy and unhealthy snacks in the studied adolescents. Mixed effect negative binomial regression models were used to analyze the data. The association was also adjusted for individual variables, including gender, socio-economic status, pocket money, family structure and nutritional knowledge level. No significant difference was observed between the average of healthy and unhealthy snack items in IHPS and non-IHPS schools (p > 0.05). On the basis of adjusted analysis, being from/in IHPS was not associated with weekly frequency consumption of unhealthy [prevalence rate ratio (PRR) = 0.99; 95% CI: 0.85-1.16] and healthy (PRR = 1.08; 95% CI: 0.96-1.2) snacks among the adolescents. There was no difference regarding school food environment and snacking behaviors in IHPS and non-IHPS schools. This might indicate that there has been a weakness in institutionalizing the comprehensive concepts of the HPS approach in the studied schools. Addressing the proper understanding of HPS approach and the need for development of HPS through matching and adaptability with health promotion actions to reach defined standards, is necessary.

Health enhancing physical activity in all policies? Comparison of national public actors between France and Belgium

Despite evidence on the benefits of health enhancing physical activity (HEPA), only few countries have developed "health in all policies" and specifically integrated HEPA policies. Paucity of studies have questioned the role of public national actors in PA policies enactment and delivery, the barriers and levers for adopting cross-sectoral HEPA. The present work seeks at comparing France and Belgium in regard to their competencies of ministries promoting HEPA, the presence of leadership and coordination in HEPA policies implementation, their key public legal entities working on HEPA. Expert interviews and document analysis were realized to complete the HEPA policy audit tool in each country. Results have shown that HEPA cross-sectoral policies are at their early stage. A broad diversity of sectors was implicated in HEPA policies: sport, health, transport, environment, and education, but often with weak activity. No leadership or coordination exist to implement HEPA policies, although different public legal entities could work on this aim. Ministries relationships were principally coming from formal co-interventions mandated by national public plans in France, where in Belgium relationships were punctual. Lobbying within each sector and in key public legal entities to promote HEPA is needed, and the development of official national coordination is essential.

Policy, Theory, and Evaluation: Stop Mixing the Fruit Salad Comment on "Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia"

The study of Health in All Policies (HiAP) is gaining momentum. Authors are increasingly turning to wide swathes of political and social theory to frame (Program) Theory Based (or Informed) Evaluation (TBE) approaches. TBE for HiAP is not only prudent, it adds a level of elegance and insight to the research toolbox. However, it is still necessary to organize theoretical thinking appropriately. A commentary on a recent Int J Health Policy Manag paper argued that the framing of context and causality were hard to establish. This paper argues that this is not the most pressing issue. Rather, it claims we need to go back to basics to establish an appropriate HiAP evaluation paradigm. Such a basic paradigm would hinge on an understanding of power.

Evaluating Health in All Policies Comment on "Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia"

Health in All Policies (HiAP) has gained attention as a potential tool to address complex health and societal challenges at global, regional, national and subnational levels. In a recent article, Lawless et al propose an evaluation framework developed in the context of the South Australia HiAP initiative. Strategies, mediators, activities and impacts identified in the framework could potentially be useful for evaluating HiAP in other settings. Creating and sustaining political will, managing conflicts of interest and achieving financially, politically and conceptually sustainable HiAP initiatives are challenges that could be further strengthened in the current framework.

Intersectoriality in Danish municipalities: corrupting the social determinants of health?

Action on the social determinants of health (SDH) through intersectoral policymaking is often suggested to promote health and health equity. This paper argues that the process of intersectoral policymaking influences how the SDH are construed and acted upon in municipal policymaking. We discuss how the intersectoral policy process legitimates certain practices in the setting of Danish municipal health promotion and the potential impact this can have for long-term, sustainable healthy public policy. Based on ethnographic fieldwork, we show how the intention of intersectoriality produces a strong concern for integrating health into non-health sectors to ensure productive collaboration. To encourage this integration, health is often framed as a means to achieve the objectives of non-health sectors. In doing so, the intersectoral policy process tends to favor smaller-scale interventions that aim to introduce healthier practices into various settings, e.g. creating healthy school environments for increased physical activity and healthy eating. While other more overarching interventions on the health impacts of broader welfare policies (e.g. education policy) tend to be neglected. The interventions hereby neglect to address more fundamental SDH. Based on these findings, we argue that intersectoral policymaking to address the SDH may translate into a limited approach to action on so-called 'intermediary determinants' of health, and as such may end up corrupting the broader SDH. Further, we discuss how this corruption affects the intended role of non-health sectors in tackling the SDH, as it may impede the overall success and long-term sustainability of intersectoral efforts.

A Practice-Grounded Approach for Evaluating Health in All Policies Initiatives in the United States

OBJECTIVE

To address the social determinants of health, an increasing number of public health practitioners are implementing Health in All Policies initiatives aimed at increasing cross-sectoral collaboration and integrating health considerations into decisions made by "nonhealth" sectors. Despite the growth in practice nationally and internationally, evaluation of Health in All Policies is a relatively new field. To help inform evaluation of Health in All Policies initiatives in the United States, this study sought to develop a practice-grounded approach, including a logic model and a set of potential indicators, which could be used to describe and assess Health in All Policies activities, outputs, and outcomes.

DESIGN

Methods included (a) a review of the literature on current Health in All Policies approaches, practices, and evaluations; and (b) consultation with experts with substantive knowledge in implementing or evaluating Health in All Policies initiatives. Feedback from experts was obtained through individual (n = 11) and group (n = 14) consultation.

RESULTS

The logic model depicts a range of potential inputs, activities, outputs, and outcomes of Health in All Policies initiatives; example indicators for each component of the logic model are provided. Case studies from California, Washington, and Nashville highlight emerging examples of Health in All Policies evaluation and the ways in which local context and goals inform evaluation efforts.

CONCLUSION

The tools presented in this article synthesize concepts present in the emerging literature on Health in All Policies implementation and evaluation. Practitioners and researchers can use the tools to facilitate dialogue among stakeholders, clarify assumptions, identify how they will assess progress, and implement data-driven ways to improve their Health in All Policies work.

Ideas, actors and institutions: lessons from South Australian Health in All Policies on what encourages other sectors' involvement

BACKGROUND

This paper examines the extent to which actors from sectors other than health engaged with the South Australian Health in All Policies (HiAP) initiative, determines why they were prepared to do so and explains the mechanisms by which successful engagement happened. This examination applies theories of policy development and implementation.

METHODS

The paper draws on a five year study of the implementation of HiAP comprising document analysis, a log of key events, detailed interviews with 64 policy actors and two surveys of public servants.

RESULTS

The findings are analysed within an institutional policy analysis framework and examine the extent to which ideas, institutional factors and actor agency influenced the willingness of actors from other sectors to work with Health sector staff under the HiAP initiative. In terms of ideas, there was wide acceptance of the role of social determinants in shaping health and the importance of action to promote health in all government agencies. The institutional environment was initially supportive, but support waned over the course of the study when the economy in South Australia became less buoyant and a health minister less supportive of health promotion took office. The existence of a HiAP Unit was very helpful for gaining support from other sectors. A new Public Health Act offered some promise of institutionalising the HiAP approach and ideas. The analysis concludes that a key factor was the operation of a supportive network of public servants who promoted HiAP, including some who were senior and influential.

CONCLUSIONS

The South Australian case study demonstrates that despite institutional constraints and shifting political support within the health sector, HiAP gained traction in other sectors. The key factors that encouraged the commitment of others sectors to HiAP were the existence of a supportive, knowledgeable policy network, political support, institutionalisation of the ideas and approach, and balancing of the economic and social goals of government.

Structural integration and performance of inter-sectoral public health-related policy networks: An analysis across policy phases

BACKGROUND

Inter-sectoral policy networks may be effective in addressing environmental determinants of health with interventions. However, contradictory results are reported on relations between structural network characteristics (i.e., composition and integration) and network performance, such as addressing environmental determinants of health. This study examines these relations in different phases of the policy process.

METHODS

A multiple-case study was performed on four public health-related policy networks. Using a snowball method among network actors, overall and sub-networks per policy phase were identified and the policy sector of each actor was assigned. To operationalise the outcome variable, interventions were classified by the proportion of environmental determinants they addressed.

RESULTS

In the overall networks, no relation was found between structural network characteristics and network performance. In most effective cases, the policy development sub-networks were characterised by integration with less interrelations between actors (low cohesion), more equally distributed distances between the actors (low closeness centralisation), and horizontal integration in inter-sectoral cliques. The most effective case had non-public health central actors with less connections in all sub-networks.

CONCLUSION

The results suggest that, to address environmental determinants of health, sub-networks should be inter-sectorally composed in the policy development rather than in the intervention development and implementation phases, and that policy development actors should have the opportunity to connect with other actors, without strong direction from a central actor.

Why and How Political Science Can Contribute to Public Health? Proposals for Collaborative Research Avenues

Written by a group of political science researchers, this commentary focuses on the contributions of political science to public health and proposes research avenues to increase those contributions. Despite progress, the links between researchers from these two fields develop only slowly. Divergences between the approach of political science to public policy and the expectations that public health can have about the role of political science, are often seen as an obstacle to collaboration between experts in these two areas. Thus, promising and practical research avenues are proposed along with strategies to strengthen and develop them. Considering the interdisciplinary and intersectoral nature of population health, it is important to create a critical mass of researchers interested in the health of populations and in healthy public policy that can thrive working at the junction of political science and public health.

Using sustainability as a collaboration magnet to encourage multi-sector collaborations for health

The World Health Organization Commission on Social Determinants of Health (SDH) places great emphasis on the role of multi-sector collaboration in addressing SDH. Despite this emphasis on this need, there is surprisingly little evidence for this to advance health equity goals. One way to encourage more successful multi-sector collaborations is anchoring SDH discourse around 'sustainability', subordinating within it the ethical and empirical importance of 'levelling up'. Sustainability, in contrast to health equity, has recently proved to be an effective collaboration magnet. The recent adoption of the Sustainable Development Goals (SDGs) provides an opportunity for novel ways of ideationally re-framing SDH discussions through the notion of sustainability. The 2030 Agenda for the SDGs calls for greater policy coherence across sectors to advance on the goals and targets. The expectation is that diverse sectors are more likely and willing to collaborate with each other around the SDGs, the core idea of which is 'sustainability'.

Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action

Health is created largely outside the health sector. Engagement in health governance, policy, and intervention development and implementation by sectors other than health is therefore important. Recent calls for building and implementing Health in All Policies, and continued arguments for intersectoral action, may strengthen the potential that other sectors have for health. This review clarifies the conceptual foundations for integral health governance, policy, and action, delineates the different sectors and their possible engagement, and provides an overview of a continuum of methods of engagement with other sectors to secure integration. This continuum ranges from institutional (re)design to value-based narratives. Depending on the lens applied, different elements can be identified within the continuum. This review is built on insights from political science, leadership studies, public health, empirical Health in All Policy research, knowledge and evidence nexus approaches, and community perspectives. Successful integration of health governance, policy, and action depends on integration of the elements on the continuum.

Exploring the unanticipated effects of multi-sectoral partnerships in chronic disease prevention

Multi-sectoral partnerships are important parts of many public health efforts to address chronic diseases, such as cancer, diabetes, and cardiovascular disease. Despite the potential value of multi-sectoral approaches, uncertainty exists regarding their effects on individuals, organizations, communities and populations. This article reports on a study that examined the unanticipated effects (both positive and negative) of the Public Health Agency of Canada's (the Agency) Multi-sectoral Partnerships initiative, which supports more than 30 multi-sectoral partnership projects across Canada. Thirteen semi-structured interviews were conducted with staff from organizations participating in 3 diverse partnership projects as part of the Agency's multi-sectoral partnerships initiative. Multiple unanticipated effects were identified and organized into 4 themes: (1) insights about the flexibility and responsiveness of government; (2) access to new and valuable resources (people, skills, expertise); (3) opportunity to build new capacities; and (4) understanding realistic timelines for partnership activities and outcomes. While these effects were unanticipated for study participants, they resonate with insights from the literature on multi-sectoral partnerships. These results raise a number of questions for consideration as partnership initiatives continue to evolve, including the types of training that partners might need; the individual and organizational capacities required for partnership approaches; and the evaluation techniques that might be most useful to capture the non-linear effects of partnership approaches.

Integrierte Berichterstattung für ressortübergreifende kommunale Gesundheitspolitik

Durch integrierte Berichterstattung können spezifische Belastungsprofile einzelner Sozialräume auf kommunaler Ebene identifiziert werden. Im Idealfall wird ein ressortübergreifendes Handeln durch die politischen Entscheidungsträger gefördert und dessen Zielsetzung durch gemeinsame, auf das Allgemeinwohl abzielende Outcomes definiert. Eine etablierte kommunale Gesundheitsberichterstattung kann aber auch durch bilaterale Kooperationen mit anderen Ressorts dazu beitragen, dass Belange der Bevölkerungsgesundheit in die Kommunalpolitik einfließen.

Obstacles and Enablers on the Way towards Integrated Physical Activity Policies for Childhood Obesity Prevention: An Exploration of Local Policy Officials' Views

Background. Limited physical activity (PA) is a risk factor for childhood obesity. In Netherlands, as in many other countries worldwide, local policy officials bear responsibility for integrated PA policies, involving both health and nonhealth domains. In practice, its development seems hampered. We explore which obstacles local policy officials perceive in their effort. Methods. Fifteen semistructured interviews were held with policy officials from health and nonhealth policy domains, working at strategic, tactic, and operational level, in three relatively large municipalities. Questions focused on exploring perceived barriers for integrated PA policies. The interviews were deductively coded by applying the Behavior Change Ball framework. Findings. Childhood obesity prevention appeared on the governmental agenda and all officials understood the multicausal nature. However, operational officials had not yet developed a tradition to develop integrated PA policies due to insufficient boundary-spanning skills and structural and cultural differences between the domains. Tactical level officials did not sufficiently support intersectoral collaboration and strategic level officials mainly focused on public-private partnerships. Conclusion. Developing integrated PA policies is a bottom-up innovation process that needs to be supported by governmental leaders through better guiding organizational processes leading to such policies. Operational level officials can assist in this by making progress in intersectoral collaboration visible.

Cross-sector cooperation in health-enhancing physical activity policymaking: more potential than achievements?

BACKGROUND

The cooperation of actors across policy fields and the need for cross-sector cooperation as well as recommendations on how to implement cross-sector cooperation have been addressed in many national and international policies that seek to solve complex issues within societies. For such a purpose, the relevant governance structure between policy sectors is cross-sector cooperation. Therefore, cross-sector cooperation and its structures need to be better understood for improved implementation. This article reports on the governance structures and processes of cross-sector cooperation in health-enhancing physical activity (HEPA) policies in six European Union (EU) member states.

METHODS

Qualitative content analysis of HEPA policies and semi-structured interviews with key policymakers in six European countries.

RESULTS

Cross-sector cooperation varied between EU member states within HEPA policies. The main issues of the cross-sector policy process can be divided into stakeholder involvement, governance structures and coordination structures and processes. Stakeholder involvement included citizen hearings and gatherings of stakeholders from various non-governmental organisations and citizen groups. Governance structures with policy and political discussions included committees, working groups and consultations for HEPA policymaking. Coordination structures and processes included administrative processes with various stakeholders, such as ministerial departments, research institutes and private actors for HEPA policymaking. Successful cross-sector cooperation required joint planning and evaluation, financial frameworks, mandates based on laws or agreed methods of work, communication lines, and valued processes of cross-sector cooperation.

CONCLUSIONS

Cross-sector cooperation required participation with the co-production of goals and sharing of resources between stakeholders, which could, for example, provide mechanisms for collaborative decision-making through citizen hearing. Clearly stated responsibilities, goals, communication, learning and adaptation for cross-sector cooperation improve success. Specific resources allocated for cross-sector cooperation could enhance the empowerment of stakeholders, management of processes and outcomes of cross-sector cooperation.

Use of a knowledge broker to establish healthy public policies in a city district: a developmental evaluation

Background

Public health is to a large extent determined by non-health-sector policies. One approach to address this apparent paradox is to establish healthy public policies. This requires policy makers in non-health sectors to become more aware of the health impacts of their policies, and more willing to adopt evidence-informed policy measures to improve health. We employed a knowledge broker to set the agenda for health and to specify health-promoting policy alternatives. This study aimed at gaining in-depth understanding of how this knowledge broker approach works.

Methods

In the context of a long-term partnership between the two universities in Amsterdam and the municipal public health service, we employed a knowledge broker who worked part-time at a university and part-time for an Amsterdam city district. When setting an agenda and specifying evidence-informed policy alternatives, we considered three individual policy portfolios as well as the policy organization of the city district. We evaluated and developed the knowledge broker approach through action research using participant observation.

Results

Our knowledge brokering strategy led to the adoption of several policy alternatives in individual policy portfolios, and was especially successful in agenda-setting for health. More specifically, health became an issue on the formal policy agenda as evidenced by its uptake in the city district’s mid-term review and the appointment of a policy analyst for health. Our study corroborated the importance of process factors such as building trust, clearly distinguishing the knowledge broker role, and adequate management support. We also saw the benefits of multilevel agenda-setting and specifying policy alternatives at appropriate policy levels. Sector-specific responsibilities hampered the adoption of cross-sectoral policy alternatives, while thematically designed policy documents offered opportunities for including them. Further interpretation revealed three additional themes in knowledge brokering: boundary spanning, a ripple effect, and participant observation.

Conclusions

The employment of a knowledge broker who works simultaneously on both agenda-setting for health as well as the specification of health-promoting policy alternatives seems to be a promising first step in establishing local healthy public policies. Future studies are needed to explore the usefulness of our approach in further policy development and policy implementation.

We Need Action on Social Determinants of Health - but Do We Want It, too? Comment on "Understanding the Role of Public Administration in Implementing Action on the Social Determinants of Health and Health Inequities"

Recently a number of calls have been made to mobilise the arsenal of political science insights to investigate - and point to improvements in - the social determinants of health (SDH), and health equity. Recently, in this journal, such a rallying appeal was made for the field of public administration. This commentary argues that, although scholarly potential should justifiably be redirected to resolve these critical issues for humanity, a key ingredient in taking action may have been neglected. This factor is 'community.' Community health has been a standard element of the public health and health promotion, even political, repertoire for decades now. But this commentary claims that communities are insufficiently charged, equipped or appreciated to play the role that scholarship attributes (or occasionally avoids to identify) to them. Community is too important to not fully engage and understand. Rhetorical tools and inquiries can support their quintessential role.

Using Win-Win Strategies to Implement Health in All Policies: A Cross-Case Analysis

Background

In spite of increasing research into intersections of public policy and health, little evidence shows how policy processes impact the implementation of Health in All Policies (HiAP) initiatives. Our research sought to understand how and why strategies for engaging partners from diverse policy sectors in the implementation of HiAP succeed or fail in order to uncover the underlying social mechanisms contributing to sustainable implementation of HiAP.

Methods

In this explanatory multiple case study, we analyzed grey and peer-review literature and key informant interviews to identify mechanisms leading to implementation successes and failures in relation to different strategies for engagement across three case studies (Sweden, Quebec and South Australia), after accounting for the role of different contextual conditions.

Findings

Our results yielded no support for the use of awareness-raising or directive strategies as standalone approaches for engaging partners to implement HiAP. However, we found strong evidence that mechanisms related to “win-win” strategies facilitated implementation by increasing perceived acceptability (or buy-in) and feasibility of HiAP implementation across sectors. Win-win strategies were facilitated by mechanisms related to several activities, including: the development of a shared language to facilitate communication between actors from different sectors; integrating health into other policy agendas (eg., sustainability) and use of dual outcomes to appeal to the interests of diverse policy sectors; use of scientific evidence to demonstrate the effectiveness of HiAP; and using health impact assessment to make policy coordination for public health outcomes more feasible and to give credibility to policies being developed by diverse policy sectors.

Conclusion

Our findings enrich theoretical understanding in an under-unexplored area of intersectoral action. They also provide policy makers with examples of HiAP across wealthy welfare regimes, and improve understanding of successful HiAP implementation practices, including the win-win approach.

Health policy--why research it and how: health political science

The establishment of policy is key to the implementation of actions for health. We review the nature of policy and the definition and directions of health policy. In doing so, we explicitly cast a health political science gaze on setting parameters for researching policy change for health. A brief overview of core theories of the policy process for health promotion is presented, and illustrated with empirical evidence. The key arguments are that (a) policy is not an intervention, but drives intervention development and implementation; (b) understanding policy processes and their pertinent theories is pivotal for the potential to influence policy change; (c) those theories and associated empirical work need to recognise the wicked, multi-level, and incremental nature of elements in the process; and, therefore, (d) the public health, health promotion, and education research toolbox should more explicitly embrace health political science insights. The rigorous application of insights from and theories of the policy process will enhance our understanding of not just how, but also why health policy is structured and implemented the way it is.