Public health terminology: Hindrance to a Health in All Policies approach?

"Health in All Policies" in Norwegian municipalities-Dilemmas and lack of legitimacy and capacity

According to the Health in All Policies (HiAP) approach, public health work in Norway is regarded as a multi-actor collaboration based on planning and partnership for the purpose of enabling people to increase their control over their health and its determinants. HiAP builds largely on the governance and communicative turn in the public sector and thus exists in the shadow of a vertical government structure with sectors, silos and a chain of command. In practice, HiAP challenges the established way of thinking and acting in the silos and tries to create a more holistic understanding and handling of problems and needs. In order to successfully involve different sectors and government levels in this work, HiAP requires strong democratic legitimacy and institutional capacity. In this article, we discuss the empirical research data on the HiAP approach in Norway within the context of theory on collaborative planning processes and legitimising political capacity to act. Our research question is whether the HiAP approach in Norwegian municipalities have sufficient democratic legitimacy and institutional capacity to achieve the purpose of public health work. In general, we find that HIAP as practised in Norwegian municipalities does not function as a complete political legitimising and capacity building process. The practice contains several dilemmas, and there is a need to distinguish between different forms of legitimacy and capacity.

Factors of the policy process influencing Health in All Policies in local government: A scoping review

Objectives

This review aimed to identify factors in the policymaking environment that influence a Health in all Policies approach in local government, how these vary across different municipal contexts, and the extent that theories of the policy process are applied.

Methods

A scoping review was conducted to include sources published in English, between 2001 and 2021 in three databases, and assessed for inclusion by two blind reviewers.

Results

Sixty-four sources were included. Sixteen factors of the policy process were identified, expanding on previously reported literature to include understanding and framing of health, use of evidence, policy priority, and influence of political ideology. Eleven sources applied or referred to theories of the policy process and few reported findings based on different local government contexts.

Conclusion

There are a range of factors influencing a Health in All Policies approach in local government, although a limited understanding of how these differ across contexts. A theory-informed lens contributed to identifying a breadth of factors, although lack of explicit application of theories of the policy process in studies makes it difficult to ascertain meaningful synthesis of the interconnectedness of these factors.

How to Evaluate Health in All Policies at the Local Level: Methodological Insights Within Municipalities From the WHO French Healthy Cities Network

BACKGROUND

This article proposes a method for analysing the degree of maturity of Health in All Policies (HiAP) among World Health Organization-French Healthy Cities Network (WHO-FHCN) as part of the GoveRnance for Equity, EnviroNment and Health in the City (GREENH-City) project. We focused on the creation or enhancement of health-promoting environments, and more specifically, public green spaces.

METHODS

We conducted a cross-sectional quantitative study guided by the evaluative framework of the HiAP maturity level developed by Storm et al mixed with a qualitative interpretation. A self-administered questionnaire was sent to elected officials and health department officers in the 85 member cities of the WHO-FHCN in 2017. Subsequently 58 cities were included in the analysis, which was based on a multiple correspondence analysis (MCA) and a hierarchical ascending classification (HAC).

RESULTS

Thirty-two criteria among a total of 100 were identified and were used to organize the cities into 8 groups which was then reduced to three profiles among the cities: a less advanced HiAP profile, an established HiAP profile and an advanced HiAP profile. This process allows us to identify 4 dimensions that make it possible to evaluate the level of maturity of cities in the HiAP process, namely: (1) the consideration of social inequalities in health and/or health issues in the policies/actions of the sector studied, (2) occasional intersectoral collaboration, ie, one-off initiatives between the health department and others sectors, (3) the existence of joint projects, ie, common projects between two or more sectors, (4) the existence of intersectoral bodies, in this case on the theme of urban green spaces including an intersectoral committee and/or working groups.

CONCLUSION

Four dimensions which allow to the measurement of the degree of progress in implementing health-all-policies are proposed. With a view to integrating knowledge into public action, this study carried out under real conditions offers a realistic method to evaluate HiAP.

General practitioners' experiences of being involved in local public health work in Norway. A qualitative study

AIM

The aim was to explore how general practitioners experienced being involved in local public health work and how they worked with prevention and health promotion clinically after the introduction of the Public Health Act in 2012.

DESIGN, SETTING AND SUBJECTS

Qualitative study with focus groups interviews with 18 GPs from different municipalities in Norway.

RESULTS

The GPs said that they either had not at all or only to a limited extent been involved in local public health work in their municipalities. They reported finding it hard to prioritize individual disease prevention and health promotion in their clinical work. GPs thought of health promotion as something that mainly concerned healthy people at a group level.

CONCLUSIONS

Based on the experiences of the GPs in this study, there is a gap between governmental expectations to the role of GPs in public health, and how it works in practice.KEY POINTSWith the Norwegian Public Health Act launched in 2012, GPs were expected to contribute to better population health in their clinical work and as data providers to local public health surveillance.The GPs interviewed in this study said they had not been involved in local public health work, and they found it hard to give disease prevention and health promotion priority in their clinical work.GPs expressed various perceptions of what prevention and health promotion entails.

Policy design for territorial equity in multi-level and multi-sectoral political systems: Comparing health and education strategies

The EU has many plans to foster equity and spatial justice. However, each has separate reference points, and it is difficult to find an overall vision. To demonstrate, we analyse two sectoral strategies to identify their implications for spatial justice strategies. Education focuses on early investment and public service reform. Health prioritises intersectoral action to address the 'social determinants' beyond the control of health services. Both warn against equating territorial cohesion or spatial justice with equal access to public services. These findings could inform European Commission strategy, but it tends to respond with renewed rhetoric rather than reconsidering its approach.

Evaluating ‘Health in All Policies’ in Norwegian Municipalities

The Health in All Policies (HiAP) approach has emerged as a central strategy for promoting health at local, regional, and state levels in different countries. Representing a complex and complicated strategy, evaluations of HIAP at the local level are scarce, and scholars call for more knowledge and critical discussions regarding how to evaluate at this level. In this conceptual paper, I discuss how summative and formative evaluation approaches might supplement each other when evaluating HiAP at the local level. First, I discuss the possibilities of using summative and formative evaluation of HiAP. Further, I discuss how formative-dialogue research might represent possibilities for evaluation by combining the two approaches. Finally, I ask if there has been a shift in the Norwegian evaluation discourse, from the promotion of summative evaluation alone to a combination of both summative and formative methods.

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.

Give Older Persons a Voice in the Society-By Using Information Compiled during Preventive Home Visits on a Societal Level

Preventive home visits (PHVs) are offered to older persons with the purpose of promoting health and preventing risks on an individual level. However, aspects of health need to be considered on a societal level as well. This study aims to get a deeper understanding of perceptions of the usability of the information compiled during the PHVs to promote health, among older persons, on a societal level. Three online focus groups were conducted with heads of unit of PHVs, heads of department, and politicians responsible for health and welfare in seven municipalities in Sweden (n = 12). The findings were visualised in the core category Enable an inclusive society and the interrelated categories Monitoring determinants of health and Enabling exchange of information. The information from the PHVs could be used to monitor determinants of health by identifying assets, challenges, shifts, trends, and future needs in the society. Moreover, exchange of information from the PHVs could occur within and outside the health and welfare organisation. However, the potential use was affected by hindrances illustrated in the category Obstacles to interpreting and communicating the information. To conclude, using the information from the PHVs could possibly contribute to an inclusive society, where persons not usually represented in decision making are given a voice.

How and why do win-win strategies work in engaging policy-makers to implement Health in All Policies? A multiple-case study of six state- and national-level governments

Background

Much of the research about Health in All Policies (HiAP) implementation is descriptive, and there have been calls for more evaluative evidence to explain how and why successes and failures have occurred. In this cross-case study of six state- and national-level governments (California, Ecuador, Finland, Norway, Scotland and Thailand), we tested hypotheses about win–win strategies for engaging policy-makers in HiAP implementation drawing on components identified in our previous systems framework.

Methods

We used two sources of data — key informant interviews and peer-reviewed and grey literature. Using a protocol, we created context–mechanism–outcome pattern configurations to articulate mechanisms that explain how win–win strategies work and fail in different contexts. We then applied our evidence for all cases to the systems framework. We assessed the quality of evidence within and across cases in terms of triangulation of sources and strength of evidence. We also strengthened hypothesis testing using replication logic.

Results

We found robust evidence for two mechanisms about how and why win–win strategies build partnerships for HiAP implementation — the use of shared language and the value of multiple outcomes. Within our cases, the triangulation was strong, both hypotheses were supported by literal and contrast replications, and there was no support against them. For the third mechanism studied, using the public-health arguments win–win strategy, we only found evidence from Finland. Based on our systems framework, we expected that the most important system components to using win–win strategies are sectoral objectives, and we found empirical support for this prediction.

Conclusions

We conclude that two mechanisms about how and why win–win strategies build partnerships for HiAP implementation — the use of shared language and the value of multiple outcomes — were found as relevant to the six settings. Both of these mechanisms trigger a process of developing synergies and releasing potentialities among different government sectors and these interactions between sectors often work through sectoral objectives. These mechanisms should be considered when designing future HiAP initiatives and their implementation to enhance the emergence of non-health sector policy-makers’ engagement.

Rethinking the Theory of Change for Health in All Policies Comment on "Health Promotion at Local Level in Norway: The Use of Public Health Coordinators and Health Overviews to Promote Fair Distribution Among Social Groups"

This commentary discusses the interesting and surprising findings by Hagen and colleagues, focusing on the role of the public health coordinator as a Health in All Policies (HiAP) tool. The original article finds a negative association between the employment of public health coordinators in Norwegian municipalities and consideration of a fair distribution of social and economic resources between social groups in local policymaking and planning. The commentary contemplates whether this surprising negative association should be interpreted as a failure of implementation, as suggested by the authors, or whether it might be the theory of change that has failed. On this basis, it is suggested that the very notion of HiAP could be flawed by the assumption that health should function as an overarching aim across government sectors. Potentially, the social determinants of health (SDH) might be more efficiently addressed by means of sectoral action by the corresponding sectors, emphasizing equity rather than health.