"Health in All Policies": taking stock of emerging practices to incorporate health in decision making in the United States

Cultivating Health in All Policies Mindsets: An Ongoing Journey to Integrate Health and Housing in Georgia

This project report explores the use of a Health in All Policies (HiAP) approach by the Georgia Health Policy Center (GHPC) to integrate health perspectives into affordable housing policy and practice in Georgia. It focuses on five interconnected projects from over a decade-long collaboration to illustrate how the GHPC team started with a Health Impact Assessment (HIA) to seed cross-sector partnerships and then sustained them through subsequent collaborations. These projects included comprehensive-, intermediate-, and rapid-scale HIAs, as well as direct collaborations on housing development funding applications and a multidisciplinary research study on public housing renovations. This paper documents how HiAP tactics were applied across these projects to foster sustained collaboration and promote health equity. The insights offered highlight how the HiAP approach cultivated mindset shifts among public health practitioners, housing stakeholders, and policymakers, leading to a broader understanding of health and housing intersections. This synthesis contributes practical guidance for practitioners looking to advance the Vital Conditions for Health and Well-Being through housing policy initiatives.

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.

The power of partnerships: state public health department multisector collaborations in major chronic disease programme areas in the United States

BACKGROUND

Multisector collaboration between state public health departments (SHDs) and diverse community partners is increasingly recognized as important for promoting positive public health outcomes, addressing social determinants of health, and reducing health inequalities. This study investigates collaborations between SHDs in the United States and different types of organizations addressing chronic disease in and outside of the health sector.

METHODS

SHD employees were randomly selected from the National Association of Chronic Disease Directors membership list for participation in an online survey. Participants were asked about their primary chronic disease work unit (cancer, obesity, tobacco, diabetes, cardiovascular disease, and others), as well as their work unit collaborations (exchange of information/cooperation in activities) with organizations in health and non-health sectors. As a measure of the different organizations SHDs collaborated with in health and non-health sectors, a collaboration heterogeneity score for each programme area was calculated. One-way analysis of variance (ANOVA) with Tukey's post hoc tests were used to assess differences in collaborator heterogeneity between programme areas.

RESULTS

A total of 574 participants were surveyed. Results indicated that the cancer programme area, along with diabetes and cardiovascular disease, had significantly less collaboration heterogeneity with organizations outside of the health sector compared to the obesity and tobacco programme areas.

CONCLUSIONS

While collaborations with health sector organizations are commonly reported, public health departments can increase collaboration with sectors outside of health to more fully address chronic disease prevention.

Moderation of the Association between Primary Language and Health by Race and Gender: An Intersectional Approach

In the United States (US), limited English proficiency is associated with a higher risk of obesity and diabetes. “Intersectionality”, or the interconnected nature of social categorizations, such as race/ethnicity and gender, creates interdependent systems of disadvantage, which impact health and create complex health inequities. How these patterns are associated with language-based health inequities is not well understood. The study objective was to assess the potential for race/ethnicity, gender, and socioeconomic status to jointly moderate the association between primary language (English/Spanish) and having obesity and diabetes. Using the 2018 Behavioral Risk Factor Surveillance System (n = 431,045), weighted generalized linear models with a logistic link were used to estimate the associations between primary language (English/Spanish) and obesity and diabetes status, adjusting for confounders using stratification for the intersections of gender and race/ethnicity (White, Black, Other). Respondents whose primary language was Spanish were 11.6% more likely to have obesity (95% CI 7.4%, 15.9%) and 15.1% more likely to have diabetes (95% CI 10.1%, 20.3%) compared to English speakers. Compared to English speakers, Spanish speakers were more likely to have both obesity (p < 0.001) and diabetes (p < 0.001) among White females. Spanish speakers were also more likely to have obesity among males and females of other races/ethnicities (p < 0.001 for both), and White females (p = 0.042). Among males of other racial/ethnic classifications, Spanish speakers were less likely to have both obesity (p = 0.011) and diabetes (p = 0.005) than English speakers. Health promotion efforts need to recognize these differences and critical systems−change efforts designed to fundamentally transform underlying conditions that lead to health inequities should also consider these critical sociodemographic factors to maximize their effectiveness.

Grounding implementation science in health equity for cancer prevention and control

BACKGROUND

The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute's Consortium for Cancer Implementation Science convened an action group focused on 'health equity and context' to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions.

DISCUSSION

In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

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.

Health Impact Assessment: A Missed Opportunity for MCH Professionals in Their Quest to Address the Social Determinants of Health

Introduction

Public health professionals, especially ones concerned with maternal and child health (MCH), need to engage in cross-sector collaborations to address social determinants of health. Health Impact Assessment (HIA) systematically brings public health perspectives into non-health decision-making contexts that influence social determinants. Alignment of MCH and HIA practice has not previously been documented.

Methods

An exploratory review of HIAs conducted in the United States considered several dimensions of MCH-HIA alignment and produced data to test the hypothesis that HIAs involving MCH stakeholders are more likely to address MCH populations and relevant measures. The review examined three key variables for each HIA: inclusion of MCH-focused stakeholders, level of focus on MCH populations, and presence of MCH-relevant content.

Results

Of the 424 HIAs included in the database of US HIAs, 350 were included in this review. Twenty-four percent (84) included MCH-focused stakeholders, and 42% (148) focused on MCH populations. Ninety percent (317) included metrics or content relevant to at least one Title V National Performance Measure (NPM). HIAs that clearly included MCH stakeholders had seven times the odds of including both a focus on MCH populations and at least one NPM-relevant topic compared to HIAs that did not clearly include MCH stakeholders (OR 6.98; 95% CI 3.99, 12.20).

Discussion

Despite low engagement of MCH stakeholders in HIAs, many still consider MCH populations and measures. Intentional engagement of MCH workforce in HIAs could ensure greater alignment with existing MCH priorities (such as addressing the social determinants of health and equity) in a given jurisdiction.

Universal Health Coverage to counteract the economic impact of the COVID-19 infection: current practices and ethical challenges

In late December 2019, the first case of an emerging coronavirus was identified in the city of Wuhan, Hubei province, in mainland China. The novel virus appears to be highly contagious and is rapidly spreading worldwide, becoming a pandemic. The disease is causing a high toll of deaths. Effective public health responses to a new infectious disease are expected to mitigate and counteract its negative impact on the population. However, time and economic-financial constraints, as well as uncertainty, can jeopardize the answer. The aim of the present paper was to discuss the role of Universal Health Coverage to counteract the economic impact of the COVID-19 infection. Appropriate financing of the health system and ensuring equitable access to health services for all can, indeed, protect individuals against high medical costs, which is one of the most important goals of any health system. Financing profoundly affects the performance of the health system, and any policy that the health system decides to implement or not directly depends on the amount of available funding. Developed countries are injecting new funding to cope with the disease and prevent its further transmission. In addition to psychological support and increased societal engagement for the prevention, control, and treatment of COVID-19, extensive financial support to governments by the community should be considered. Developed and rich countries should support countries that do not have enough financial resources. This disease cannot be controlled and contained without international cooperation. The experience of the COVID-19 should be a lesson for further establishing and achieving universal health coverage in all countries. In addition to promoting equity in health, appropriate infrastructure should be strengthened to address these crises. Governments should make a stronger political commitment to fully implement this crucial set of policies and plans.

Aligning dissemination and implementation science with health policies to improve children's mental health

The prevalence of mental health problems among children (ages 0-21) in the United States remains unacceptably high and, post-COVID-19, is expected to increase dramatically. Decades of psychological knowledge about effective treatments should inform the delivery of better services. Dissemination and implementation (D&I) science has been heralded as a solution to the persistent problem of poor quality services and has, to some extent, improved our understanding of the contexts of delivery systems that implement effective practices. However, there are few studies demonstrating clear, population-level impacts of psychological interventions on children. Momentum is growing among communities, cities, states, and some federal agencies to build "health in all policies" to address broad familial, social, and economic factors known to affect children's healthy development and mental health. These health policy initiatives offer a rare opportunity to repurpose D&I science, shifting it from a primary focus on evidence-based practice implementation, to a focus on policy development and implementation to support child and family health and well-being. This shift is critical as states develop policy responses to address the health and mental health impacts of the COVID-19 pandemic on already-vulnerable families. We provide a typology for building research on D&I and children's mental health policy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Designing a toolkit for the assessment of Health in All Policies at a national scale in Iran

Background: Equitable promotion of health indicators requires cooperation among different sectors more than ever. The "Health in All Policies" (HiAP) approach contributes to this process through strengthening intersectoral collaboration. To implement this approach at a national scale, indicators of health-oriented performance from various organizations, and their measurement methods, need to be precisely defined. The aim of present study was to design a toolkit for implementing HiAP in Iran. Methods: A review of literature and documents, as well as conducting semi-structured interviews and focus group discussions were undertaken to collect data for this qualitative study. Content analysis was applied to the collected data and the results were placed in three categories: criteria, sub-criteria and indicators; implementation processes; and implementation requirements. Results: The toolkit aims to achieve various objectives, including intersectoral excellence and the systematic development of intersectoral collaboration. In the process section, reports on measures taken by organizations are assessed by a three-member audit committee. The top three organizations, in terms of intersectoral cooperation in achieving public health goals, are introduced in a Health Week. Requirements for success in achieving the HiAP approach include financial resources to implement the HiAP, a database, an electronic method for submitting reports, training courses, monitoring and annual reporting of relevant indicators, and formulating regulations in order to assess organizations. Conclusion: Justification and training in various organizations to support the implementation of health-oriented measures, providing an annual ranking of organizations, and encouraging the organizations can contribute to the institutionalization of the toolkit through the SupremeCouncil for Health and Food Security. It is recommended that a Secretariat of sustainable development to be established under the Plan and Budget Organization (PBO) of the Islamic republic of Iran to monitor portfolio indicators.

Promoting equity at the population level: Putting the foundational principles into practice through disability advocacy

Rehabilitation psychology is based on foundational principles that can guide us toward health equity among disabled and nondisabled communities. We summarize the literature on disparities in the disability community and underscore the urgency to address underlying inequities to eliminate disparities. We include examples of population-level interventions that promote equity in the disability community. We conclude with a call for a broader mission for rehabilitation psychologists based on the field's foundational principles, and outline emerging opportunities to widen our impact and advance equity. Our foundational principles, built on systems theory, call on rehabilitation psychologist to work at macrosystemic levels. As rehabilitation psychologists, we need to widen our focus from the micro (individual) to the macro (population) level. We need to bring the respect, dignity, and collaborative spirit that inspire our work with individuals to the broader community by advocating for structures and policies that promote equity for disabled persons. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Methodological gaps and opportunities for studying multisectoral collaboration for health in low- and middle-income countries

The current body of research into multisectoral collaborations (MSCs) for health raises more questions than it answers, both in terms of how to implement MSCs and how to study them. This article reflects on current methodological gaps and opportunities for advancing MSC research, based on a targeted review of existing literature and qualitative input from researchers and practitioners at the 2018 Health Systems Research (HSR) Symposium in Liverpool. Through framework analysis of 205 MSC research papers referenced in a separately published MSC 'overview of reviews' paper, this article identifies six broad MSC question domains ('meta questions') and applies content analysis to estimate the relative frequency with which these meta questions and the research method(s) used to answer them are present in the literature. Results highlight a preponderance of research exploring MSC implementation using case study methods, which, in aggregate, does not seem to adequately meet policymakers' and practitioners' needs for generalizable or transferable insights. The content analysis is complemented by qualitative insights from HSR Symposium participants and the authors' own experience to identify six key methodological gaps in research on MSC for health. For each of these gaps, we propose areas in which we believe there are opportunities for methodological development and innovation to help advance this field of study, including: better understanding the role of power dynamics in shaping MSCs; development of a classification framework (or frameworks) of governance arrangements; exploring divergence of perspective and experience among MSC partners; identifying or generating theoretical frameworks for MSC that work across sectors and disciplines; developing intermediate indicators of collaboration; and increasing transferability of insights to other contexts. Collaboration with researchers outside of the health sector will enhance efforts in each of these areas, as will the establishment and strengthening of pluralistic MSC evidence networks also involving policymakers and practitioners.

Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy

Although cancer mortality rates declined in the United States in recent decades, some populations experienced little benefit from advances in cancer prevention, early detection, treatment, and survivorship care. In fact, some cancer disparities between populations of low and high socioeconomic status widened during this period. Many potentially preventable cancer deaths continue to occur, and disadvantaged populations bear a disproportionate burden. Reducing the burden of cancer and eliminating cancer-related disparities will require more focused and coordinated action across multiple sectors and in partnership with communities. This article, part of the American Cancer Society's Cancer Control Blueprint series, introduces a framework for understanding and addressing social determinants to advance cancer health equity and presents actionable recommendations for practice, research, and policy. The article aims to accelerate progress toward eliminating disparities in cancer and achieving health equity.

Do Healthy City Performance Awards Lead to Health in All Policies? A Case of Taiwan

The Healthy Cities (HC) Project, which was introduced by the World Health Organization (WHO) in 1986, has been recognized as the best setting approach for health promotion. However, very few studies have addressed how to use HC approaches to establish public policies in non-health departments in cities. This paper describes the strategies for the HC Performance Awards used in Taiwan to draw attention from different departments and to sustain intersectoral collaboration for the purpose of establishing Health in All Policies (HiAP). The methods include: (1) setting up the Taiwan Healthy City Alliance; (2) establishing HC Innovation Performance Awards; (3) reviewing the award applications according to seven criteria; and (4) analyzing the topic content of the award applications. We collected 961 HC award applications during 2013–2016 to analyze their content. The results showed that the number of applications increased nearly every year while significantly more non-health departments applied for the awards compared to health departments (73.3% vs. 26.7%). The award rates of non-health departments have also increased twice from 13.9% in 2013 to 25.8% in 2016. By examining the topics of the award winners, we concluded that “HC Innovation Performance Awards” indeed provide a role and opportunity for political involvement, intersectoral collaboration, co-opetition and capacity building that is necessary for establishing health in all policies.

Examining Whether The Health-In-All-Policies Approach Promotes Health Equity

Scholars and public health advocates have expressed optimism about the potential for the health-in-all-policies approach to address social disparities in health, but little research has been done on whether it promotes health equity in practice. Based on sixty-five in-depth interviews with US officials in the public and private sectors conducted in five states in 2016-17, we found a relationship between the use of the approach and the prominence of health equity as a policy concern. In emphasizing the social determinants of health, the approach gives public officials and policy entrepreneurs a framework for promoting this goal. In some areas, we found a gradual transition in focus from health generally to health equity. Overall, we found that practitioners of the approach introduce equity selectively and strategically.

Identifying health policy and systems research priorities on multisectoral collaboration for health in low-income and middle-income countries

Introduction

While efforts to achieve Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) have reinvigorated interest in multisectoral collaborations (MSCs) among the global health and development community, there remains a plethora of questions about how best to conceptualise, plan, implement, evaluate and sustain MSCs. The objective of this paper is to present research priorities on MSC for health from researchers and policymakers around the globe, with an emphasis on low-income and middle-income countries.

Methods

The authors identified 30 priority research questions from two sources: (1) 38 review articles on MSC for health, and (2) interviews and focus groups with a total of 81 policymakers, including government officials (largely from ministries of health and state/provincial departments of health, but also offices of planning, public service, social development, the prime minister and others), large multilateral or bilateral organisations, and non-governmental organisations. In a third phase, questions were refined and ranked by a diverse group of researchers from around the globe using an online voting platform.

Results

The top-ranked questions focused predominantly on pragmatic questions, such as how best to structure, implement and sustain MSCs, as well as how to build stakeholder capacity and community partnerships. Despite substantial variation between review articles, policymakers’ reflections and online ranking by researchers, two topics emerged as research priorities for all three: (1) leadership, partnership and governance structures for MSCs; and (2) MSC implementation strategies and mechanisms. The review articles underscored the need for more guidance on appropriate study designs and methods for investigating MSCs, which may be a prerequisite for other identified research priorities.

Conclusion

These findings could inform efforts within and beyond the health sector to better align research objectives and funding with the evidence needs of policymakers grappling with questions about how best to leverage MSCs to achieve UHC and the SDGs.

Avenues of Influence: the Relationship between Health Impact Assessment and Determinants of Health and Health Equity

This study aims to identify perceived impacts of Health Impact Assessment (HIA) on decision-making, determinants of health, and determinants of health equity and outline the mechanisms through which these impacts can occur. The research team conducted a mixed-methods study of HIAs in the USA. First, investigators collected data regarding perceived HIA impacts through an online questionnaire, which was completed by 149 stakeholders representing 126 unique HIAs. To explore in greater depth the themes that arose from the online survey, investigators conducted semi-structured interviews with 46 stakeholders involved with 27 HIAs related to the built environment. This preliminary study suggests that HIAs can strengthen relationships and build trust between community and government institutions. In addition, this study suggests that HIA recommendations can inform policy and decision-making systems that determine the distribution of health-promoting resources and health risks. HIA outcomes may in turn lead to more equitable access to health resources and reduce exposure to environmental harms among at-risk populations. Future research should further explore associations between HIAs and changes in determinants of health and health equity by corroborating findings with other data sources and documenting potential impacts and outcomes of HIAs in other sectors.

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.

Emotional Well-Being and Public Health: Proposal for a Model National Initiative

In 2011, the National Prevention, Health Promotion, and Public Health Council named mental and emotional well-being as 1 of 7 priority areas for the National Prevention Strategy. In this article, we discuss emotional well-being as a scientific concept and its relevance to public health. We review evidence that supports the association between emotional well-being and health. We propose a national emotional well-being initiative and describe its 6 components: systematic measurement of emotional well-being, identification of the drivers of emotional well-being, formation of partnerships with diverse stakeholders, implementation and dissemination of evidence-based interventions to promote emotional well-being and its drivers, development of public health messaging, and identification of and strategies to address disparities in emotional well-being and its drivers. Finally, we discuss ways in which a national emotional well-being initiative would complement current public health efforts and the potential challenges to such an initiative.

Review of Education-Focused Health Impact Assessments Conducted in the United States

BACKGROUND

Health impact assessment (HIA) provides a structured process for examining the potential health impacts of proposed policies, plans, programs, and projects. This study systematically reviewed HIAs conducted in the United States on prekindergarten, primary, and secondary education-focused decisions.

METHODS

Relevant HIA reports were identified from web sources in late 2015. Key data elements were abstracted from each report. Four case studies were selected to highlight diversity of topics, methods, and impacts of the assessment process.

RESULTS

Twenty HIAs completed in 2003-2015 from 8 states on issues related to prekindergarten through secondary education were identified. The types of decisions examined included school structure and funding, transportation to and from school, physical modifications to school facilities, in-school physical activity and nutrition, and school discipline and climate. Assessments employed a range of methods to characterize the nature, magnitude, and severity of potential health impacts. Assessments fostered stakeholder engagement and provided health-promoting recommendations, some of which were subsequently incorporated into school policies.

CONCLUSIONS

Health impact assessment is a promising tool that education, health, and other stakeholders can use to maximize the health and well-being of students, families, and communities.

Collaborating for Health: Health in All Policies and the Law

This article introduces and defines the Health in All Policies (HiAP) concept and examines existing state legislation, with a focus on California. The article starts with an overview of HiAP and then analyzes the status of HiAP legislation, specifically addressing variations across states. Finally, the article describes California's HiAP approach and discusses how communities can apply a HiAP framework not only to improve health outcomes and advance health equity, but also to counteract existing laws and policies that contribute to health inequities.

Knowing Where Public Health Is Going: Levels and Determinants of Workforce Awareness of National Public Health Trends

CONTEXT

Several recent developments are trending in public health, providing an important window into the future of policy and practice in the field. The extent to which public health workforce is aware of these trends has not been assessed.

OBJECTIVE

This research examined the extent to which the public health workforce is familiar with 8 important developments and trends in public health and explored factors associated with variation in awareness levels.

DESIGN

This study characterizes an observational cross-sectional design, based on analysis of secondary data collected by the Association of State and Territorial Health Officials through the Public Health Workforce Interests and Needs Survey (PH WINS).

SETTING

Our study used data from those states for which representative samples for the local health department (LHD) employees were also available.

PARTICIPANTS

We included survey responses from employees of state health agencies' central offices and LHDs.

MAIN OUTCOME MEASURE

The primary outcome variable for the analysis was the level of awareness about emerging public health trends in the public health workforce.

RESULTS

Awareness of emerging trends was lowest for Public Health Systems and Services Research; roughly 1 in 4 employees were aware of this trend. The second least heard of trends were Health in All Policies, and cross-jurisdictional sharing. The public health trends about which the highest proportion of public health employees had heard were implementation of the Patient Protection and Affordable Care Act and evidence-based public health practice. Awareness about public health trends was generally higher among state health agency employees than among LHD employees. Work environment, supervisory status, employee education, and female gender were significantly associated with higher awareness levels for both state health agency and LHD employees.

CONCLUSIONS

Public health trends that are important for health agencies should be brought to the spotlight in national dialogue in order to increase practitioner involvement in those initiatives.

Effectiveness of Health Impact Assessments: A Synthesis of Data From Five Impact Evaluation Reports

Introduction

Since the 1990s, the use of health impact assessments (HIAs) has grown for considering the potential health impacts of proposed policies, plans, programs, and projects in various sectors. Evaluation of HIA impacts is needed for understanding the value of HIAs, improving the methods involved in HIAs, and potentially expanding their application. Impact evaluations examine whether HIAs affect decisions and lead to other effects.

Methods

I reviewed HIA impact evaluations identified by literature review and professional networking. I abstracted and synthesized data on key findings, success factors, and challenges from 5 large evaluations conducted in the United States, Europe, Australia, and New Zealand and published from 2006 through 2015. These studies analyzed impacts of approximately 200 individual HIAs.

Results

Major impacts of HIAs were directly influencing some decisions, improving collaboration among stakeholders, increasing awareness of health issues among decision makers, and giving community members a stronger voice in local decisions. Factors that contributed to successful HIAs included engaging stakeholders, timeliness, policy and systems support for conducting HIAs, having people with appropriate skills on the HIA team, obtaining the support of decision makers, and providing clearly articulated, feasible recommendations. Challenges that may have reduced HIA success were poor timeliness, underestimation of time and resources needed, difficulty in accessing relevant data, use of jargon in HIA reports, difficulty in involving decision makers in the HIA process, and absence of a requirement to conduct HIAs.

Conclusion

HIAs can be useful to promote health and mitigate adverse impacts of decisions made outside of the health sector. Stakeholder interactions and community engagement may be as important as direct impacts of HIAs. Multiple factors are required for HIA success. Further work could strengthen the role of HIAs in promoting equity, examine HIA impacts in specific sectors, and document the role of HIAs in a “health in all policies” approach.

The development and achievement of a healthy cities network in Taiwan: sharing leadership and partnership building

The World Health Organization (WHO) Healthy Cities (HC) projects are the best known of the settings-based approaches to health promotion. They engage local governments in health development through a process of political commitment, institutional change, capacity-building, partnership-based planning and innovative projects. Many cities have promoted HC projects in Taiwan since 2002. In 2008, the Taiwan Alliance for Healthy Cities (TAHC) was launched to assist local governments in effectively establishing, operating and promoting HC projects. In this article, we share our experiences of establishing a platform and network to promote the HC program in Taiwan. Based on individual city profiles and governance in Taiwan, the TAHC developed a well-organized framework and model to encourage strong leadership in local governments and to promote participation and engagement in their communities. In the last 6 years, leaders from Taiwan’s local governments in HC networks have integrated the HC concepts into their governance models, actively engaging and combining various resources with practical expertise and private sectors. The network of health in Taiwan allows each city to develop its unique perspective on the HC projects. Using this method, not only local government meets its needs, but also increases governance efficiency and effectiveness, resulting in the promotion of its citizens’ overall sustainable urban health development. This HC network in Taiwan has partnerships with government and non-governmental organizations (NGOs), with academic support and citizen involvement, a dynamic data collection system and demonstrated leadership in the sharing of information in the Asian region.

Office for the Study of Aging at the University of South Carolina: Promoting Healthy Aging Through Program Development, Evaluation, Education/Training, and Research for South Carolina's Older Adults

The Office for the Study of Aging (OSA) at the University of South Carolina was established in 1988 in conjunction with the founding of the South Carolina Alzheimer's Disease Registry. Over the last 25 years, the Office for the Study of Aging has furthered its purpose through the development of research and programs for all of South Carolina's aging population. Examples include the Placemat Strength Training Program, the Dementia Dialogues education program, and the South Carolina Vulnerable Adult Guardian ad Litem program. The work of the office is sustained through a unique government-university-community partnership that supports innovative work and provides direct lines for dissemination, translation, and implementation of programs. The office's efforts have resulted in two state laws involving aging and older adults as well as recognition through awards and publications. The Office provides a partnership model that offers a dissemination and translation pipeline for programs to be developed, piloted, revised, and enacted into policy.

Dissemination, Implementation, and Improvement Science Research in Population Health: Opportunities for Public Health and CTSAs

IMPORTANCE

The complex, dynamic nature of health systems requires dissemination, implementation, and improvement (DII) sciences to effectively translate emerging knowledge into practice. Although they hold great promise for informing multisector policies and system-level changes, these methods are often not strategically used by public health.

OBJECTIVES AND METHODS

More than 120 stakeholders from Southern California, including the community, federal and local government, university, and health services were convened to identify key priorities and opportunities for public health departments and Clinical and Translational Science Awards programs (CTSAs) to advance DII sciences in population health.

MAIN OUTCOMES

Participants identified challenges (mismatch of practice realities with narrowly focused research questions; lack of iterative learning) and solutions (using methods that fit the dynamic nature of the real world; aligning theories of change across sectors) for applying DII science research to public health problems. Pragmatic steps that public health and CTSAs can take to facilitate DII science research include: employing appropriate study designs; training scientists and practicing professionals in these methods; securing resources to advance this work; and supporting team science to solve complex-systems issues.

CONCLUSIONS

Public health and CTSAs represent a unique model of practice for advancing DII research in population health. The partnership can inform policy and program development in local communities.

The State of Evaluation Research on Food Policies to Reduce Obesity and Diabetes Among Adults in the United States, 2000-2011

INTRODUCTION

Improvements in diet can prevent obesity and type 2 diabetes. Although policy changes provide a foundation for improvement at the population level, evidence for the effectiveness of such changes is slim. This study summarizes the literature on recent efforts in the United States to change food-related policies to prevent obesity and diabetes among adults.

METHODS

We conducted a systematic review of evidence of the impact of food policies. Websites of government, academic, and nonprofit organizations were scanned to generate a typology of food-related policies, which we classified into 18 categories. A key-word search and a search of policy reports identified empirical evaluation studies of these categories. Analyses were limited to strategies with 10 or more reports. Of 422 articles identified, 94 met these criteria. Using publication date, study design, study quality, and dietary outcomes assessed, we evaluated the strength of evidence for each strategy in 3 assessment categories: time period, quality, and study design.

RESULTS

Five strategies yielded 10 or more reports. Only 2 of the 5 strategies, menu labeling and taxes on unhealthy foods, had 50% or more studies with positive findings in at least 2 of 3 assessment categories. Most studies used methods that were rated medium quality. Although the number of published studies increased over 11 years, study quality did not show any clear trend nor did it vary by strategy.

CONCLUSION

Researchers and policy makers can improve the quality and rigor of policy evaluations to synthesize existing evidence and develop better methods for gleaning policy guidance from the ample but imperfect data available.

What makes health impact assessments successful? Factors contributing to effectiveness in Australia and New Zealand

BACKGROUND

While many guidelines explain how to conduct Health Impact Assessments (HIAs), less is known about the factors that determine the extent to which HIAs affect health considerations in the decision making process. We investigated which factors are associated with increased or reduced effectiveness of HIAs in changing decisions and in the implementation of policies, programs or projects. This study builds on and tests the Harris and Harris-Roxas' conceptual framework for evaluating HIA effectiveness, which emphasises context, process and output as key domains.

METHODS

We reviewed 55 HIA reports in Australia and New Zealand from 2005 to 2009 and conducted surveys and interviews for 48 of these HIAs. Eleven detailed case studies were undertaken using document review and stakeholder interviews. Case study participants were selected through purposeful and snowball sampling. The data were analysed by thematic content analysis. Findings were synthesised and mapped against the conceptual framework. A stakeholder forum was utilised to test face validity and practical adequacy of the findings.

RESULTS

We found that some features of HIA are essential, such as the stepwise but flexible process, and evidence based approach. Non-essential features that can enhance the impact of HIAs include capacity and experience; 'right person right level'; involvement of decision-makers and communities; and relationships and partnerships. There are contextual factors outside of HIA such as fit with planning and decision making context, broader global context and unanticipated events, and shared values and goals that may influence a HIA. Crosscutting factors include proactive positioning, and time and timeliness. These all operate within complex open systems, involving multiple decision-makers, levels of decision-making, and points of influence. The Harris and Harris-Roxas framework was generally supported.

CONCLUSION

We have confirmed previously identified factors influencing effectiveness of HIA and identified new factors such as proactive positioning. Our findings challenge some presumptions about 'right' timing for HIA and the rationality and linearity of decision-making processes. The influence of right timing on decision making needs to be seen within the context of other factors such as proactive positioning. This research can help HIA practitioners and researchers understand and identify what can be enhanced within the HIA process. Practitioners can adapt the flexible HIA process to accommodate the external contextual factors identified in this report.

Education Improves Public Health and Promotes Health Equity

This article describes a framework and empirical evidence to support the argument that educational programs and policies are crucial public health interventions. Concepts of education and health are developed and linked, and we review a wide range of empirical studies to clarify pathways of linkage and explore implications. Basic educational expertise and skills, including fundamental knowledge, reasoning ability, emotional self-regulation, and interactional abilities, are critical components of health. Moreover, education is a fundamental social determinant of health - an upstream cause of health. Programs that close gaps in educational outcomes between low-income or racial and ethnic minority populations and higher-income or majority populations are needed to promote health equity. Public health policy makers, health practitioners and educators, and departments of health and education can collaborate to implement educational programs and policies for which systematic evidence indicates clear public health benefits.

Review of state legislative approaches to eliminating racial and ethnic health disparities, 2002-2011

We conducted a legal mapping study of state bills related to racial/ethnic health disparities in all 50 states between 2002 and 2011. Forty-five states introduced at least 1 bill that specifically targeted racial/ethnic health disparities; we analyzed 607 total bills. Of these 607 bills, 330 were passed into law (54.4%). These bills approached eliminating racial/ethnic health disparities by developing governmental infrastructure, providing appropriations, and focusing on specific diseases and data collection. In addition, states tackled emerging topics that were previously lacking laws, particularly Hispanic health. Legislation is an important policy tool for states to advance the elimination of racial/ethnic health disparities.

Estimating the costs and benefits of providing free public transit passes to students in Los Angeles County: lessons learned in applying a health lens to decision-making

In spite of increased focus by public health to engage and work with non-health sector partners to improve the health of the general as well as special populations, only a paucity of studies have described and disseminated emerging lessons and promising practices that can be used to undertake this work. This article describes the process used to conduct a Health Impact Assessment of a proposal to provide free public transportation passes to students in Los Angeles County. This illustrative case example describes opportunities and challenges encountered in working with an array of cross-sector partners and highlights four important lessons learned: (1) the benefits and challenges associated with broad conceptualization of public issues; (2) the need for more comprehensive, longitudinal data systems and dynamic simulation models to inform decision-making; (3) the importance of having a comprehensive policy assessment strategy that considers health impacts as well as costs and feasibility; and (4) the need for additional efforts to delineate the interconnectivity between health and other agency priorities. As public health advances cross-sector work in the community, further development of these priorities will help advance meaningful collaboration among all partners.

Health in All Urban Policy: city services through the prism of health

In April, 2014, the City of Richmond, California, became one of the first and only municipalities in the USA to adopt a Health in All Policies (HiAP) ordinance and strategy. HiAP is increasingly recognized as an important method for ensuring policy making outside the health sector addresses the determinants of health and social equity. A central challenge facing HiAP is how to integrate community knowledge and health equity considerations into the agendas of policymakers who have not previously considered health as their responsibility or view the value of such an approach. In Richmond, the HiAP strategy has an explicit focus on equity and guides city services from budgeting to built and social environment programs. We describe the evolution of Richmond's HiAP strategy and its content. We highlight how this urban HiAP was the result of the coproduction of science policy. Coproduction includes participatory processes where different public stakeholders, scientific experts, and government sector leaders come together to jointly generate policy goals, health equity metrics, and policy drafting and implementation strategies. We conclude with some insights for how city governments might consider HiAP as an approach to achieve "targeted universalism," or the idea that general population health goals can be achieved by targeting actions and improvements for specific vulnerable groups and places.

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

Based on the policy science literature, we formulate nine core questions that can guide the formulation, negotiation, development and implementation of Health in All Policies (HiAP). Each question is grounded in the political and policy science literature and culminates in checklist items that HiAP developers must consider.