Joining the dots: the role of brokers in nutrition policy in Australia

Voice, access, and ownership: enabling environments for nutrition advocacy in India and Nigeria

What constitutes an enabling environment for nutrition advocacy in low- and middle-income countries? While a sizeable body of scholarship considers the enabling environment for nutrition policy, we focus specifically on the necessary conditions for advocacy. We argue that three factors-voice, access, and ownership-provide a useful lens into the advocacy enabling environment. These are operationalized, respectively, as the space to articulate and frame policy positions, entry points to interact with policy decision makers, and the existence of committed decision makers rather than those responding to pressures from external actors. These three factors are explored vis-à-vis a comparative analysis of two federal democracies-India and Nigeria-that each have vibrant advocacy communities confronting persistent malnutrition. Drawing on more than 100 structured interviews with nutrition advocates, government actors, donors, and researchers in the two countries, we highlight the ways in which voice, access, and ownership interactively shape advocacy efforts. In doing so, we find that Nigeria has a less ideological approach to certain nutrition issues than in India but also perceived to be more beholden to external actors in defining its nutrition actions. Recent restrictions on freedom of speech and association shrunk the civic space in India but these were less problematic in Nigeria. In both countries, the multi-tiered, multi-party system offers many different points of access into the policy arena, with sometimes negative implications for coordination. Overall, the paper contributes more broadly to the literature on enabling environments by highlighting potential indicators to guide nutrition advocates in other settings.

What works in advocating for food advertising policy change across an english region - a realist evaluation

BACKGROUND

With increasing recognition of the role of commercial determinants of health, local areas in England have sought to restrict the advertising of products high in fat, salt and sugar (HFSS) on council-owned spaces, as part of wider strategies to reduce obesity. While there is some evidence of the impact of such policy change on behaviour, little is known about what works in the process of implementing this policy change.

METHODS

Guided by a realist evaluation framework that explores the interaction between context, mechanism and outcomes, this study aims to investigate the factors that influence the restriction of outdoor advertising of HFSS products in one region in England. It refines a programme theory co-produced with stakeholders from 14 local authorities within a region and uses multiple data sources from each area with an in-depth examination of four case study sites. Data sources include longitudinal realist interviews, focus groups and surveys with policy advocates and policy stakeholders. Data were analysed retroductively to understand the causal link between context, mechanism and outcomes.

RESULTS

Outcomes were driven by five dominant mechanisms: a strategic and staggered approach to stakeholder engagement, gathering intelligence, identifying policy champions, building relationships, reframing the issue; and two secondary mechanisms of amplifying the issue and increasing public will. These led to varied outcomes with no changes in formal policy position within the evaluation period but draft policy guidance in place and changes in political will demonstrated. Dominant context factors influencing change included having a named and resourced policy advocate in place supported by an external Community of Improvement and having existing aligned local objectives. Organisational complexity and change, financial concerns, lack of local examples, ideological positions and the pandemic were also influencing contextual factors.

CONCLUSION

Effecting policy change in this area requires the commitment of an extended period and the valuing of short-term policy outcomes, such as increasing political will. The importance of a resourced and well-supported policy advocate to lead this work is fundamental and the commercially sensitive nature of this policy change means that a complex interplay of mechanisms is required which may be dominated by a strategically staggered approach to stakeholder engagement.

Public health practitioners as policy advocates: skills, attributes and development needs

Effecting policy change is a key strategy in tackling wider determinants of health. In England, public health sits within Local Authorities (LAs) and responsibility for ensuring health is considered across directorates increasingly falls to public health practitioners. While international professional standards expect competence in understanding policy processes, the advocacy role has been under-explored. This paper explores the professional skills, role characteristics and learning needs of practitioners advocating for the restriction of advertising high-fat, salt and sugar products in a region of England. A series of three interviews were conducted at three time points over 10 months with policy advocates leading this policy change from four LAs. Three focus groups were also held with 12 public health advocates from 10 LAs at the end of the 10-month period of data collection. Data were transcribed and analysed retroductively. Data showed that practitioners felt inexperienced as policy advocates and saw this work as different from other public health approaches. Successful advocates required interpersonal skills, knowledge of policy-making and local governance, determination, resilience, confidence, belief in their work's value and leadership. These skills were difficult to acquire through formal education, but advocacy training, mentorship and role modelling were seen as important for professional development. To successfully implement a Health in all Policies approach and address wider determinants of health, public health practitioners need to be equipped and supported as policy advocates. The advocacy role and the complex skills required need to be more fully understood by the public health profession and prioritized within workforce development at both local and national levels.

Nutrition policy reforms to address the double burden of malnutrition in Zambia: a prospective policy analysis

The evolution of nutrition patterns in Zambia has resulted in the coexistence of undernutrition and overnutrition in the same population, the double burden of malnutrition. While Zambia has strong policies addressing undernutrition and stunting, these do not adequately address food environment drivers of the double burden of malnutrition and the adolescent age group and hence the need for nutrition policy reforms. We conducted a theory-based qualitative prospective policy analysis involving in-depth interviews with nutrition policy stakeholders and policy document review to examine the feasibility of introducing nutrition policy options that address the double burden of malnutrition among adolescents to identify barriers and facilitators to such policy reforms. Using the multiple streams theory, we categorized the barriers and facilitators to prospective policy reforms into those related to the problem, policy solutions and politics stream. The use of a life-course approach in nutrition programming could facilitate policy reforms, as adolescence is one of the critical invention points in a person's lifecycle. Another key facilitator of policy reform was the availability of institutional infrastructure that could be leveraged to deliver adolescent-focused policies. However, the lack of evidence on the burden and long-term impacts of adolescent nutrition problems, the food industry's strong influence over governments' policy agenda setting and the lack of public awareness to demand better nutrition were perceived as critical barriers to policy reforms. In addition, the use of the individual responsibility framing for nutrition problems was dominant among stakeholders. As a result, stakeholders did not perceive legislative nutrition policy options that effectively address food environment drivers of the double burden of malnutrition to be feasible for the Zambian context. Policy entrepreneurs are required to broker policy reforms that will get legislative policy options on the government's agenda as they can help raise public support and re-engineer the framing of nutrition problems and their solutions in Zambia.

Systems Thinking and Complexity Science Methods and the Policy Process in Non-communicable Disease Prevention: A Systematic Scoping Review

BACKGROUND

Given the complex determinants of non-communicable diseases (NCDs), and the dynamic policy landscape, researchers and policymakers are exploring the use of systems thinking and complexity science (STCS) in developing effective policies. The aim of this review is to systematically identify and analyse existing applications of STCS-informed methods in NCD prevention policy.

METHODS

Systematic scoping review: We searched academic databases (Medline, Scopus, Web of Science, EMBASE) for all publications indexed by 13 October 2020, screening titles, abstracts and full texts and extracting data according to published guidelines. We summarised key data from each study, mapping applications of methods informed by STCS to policy process domains. We conducted a thematic analysis to identify advantages, limitations, barriers and facilitators to using STCS.

RESULTS

4681 papers were screened and 112 papers were included in this review. The most common policy areas were tobacco control, obesity prevention and physical activity promotion. Methods applied included system dynamics modelling, agent-based modelling and concept mapping. Advantages included supporting evidence-informed decision-making; modelling complex systems and addressing multi-sectoral problems. Limitations included the abstraction of reality by STCS methods, despite aims of encompassing greater complexity. Challenges included resource-intensiveness; lack of stakeholder trust in models; and results that were too complex to be comprehensible to stakeholders. Ensuring stakeholder ownership and presenting findings in a user-friendly way facilitated STCS use.

CONCLUSION

This review maps the proliferating applications of STCS methods in NCD prevention policy. STCS methods have the potential to generate tailored and dynamic evidence, adding robustness to evidence-informed policymaking, but must be accessible to policy stakeholders and have strong stakeholder ownership to build consensus and change stakeholder perspectives. Evaluations of whether, and under what circumstances, STCS methods lead to more effective policies compared to conventional methods are lacking, and would enable more targeted and constructive use of these methods.

Identifying important persons in the promotion of positive behaviour support (PBS) in disability services: A social network analysis

BACKGROUND

Little is known about networks for positive behaviour support (PBS) in disability services. This study explores a PBS network to identify influential persons in its promotion and communication.

METHODS

Quantitative sociometric methods were used to identify persons who occupy positions of either boundary spanning (those that link people and groups) and/or opinion leadership (those that are sought for advice).

RESULTS

Nineteen persons were identified. Boundary spanners met all criteria for the position while opinion leaders did not.

CONCLUSIONS

This is the first published study of a PBS network in disability services and provides insights into persons involved in its systemic promotion. Boundary spanners are effectively bridging the PBS network, yet persons seeking information about PBS are doing so from opinion leaders that do not display a requisite characteristic for this role. These results have implications for the wider utility of PBS within disability service systems.

Governing ultra-processed food and alcohol industries: the presence and role of non-government organisations in Australia

OBJECTIVE

The roles of non-governmental organisations (NGOs) in regulating harmful commodity industries (HCIs) are understudied. The aim of this paper is to identify the NGOs and the roles that they play in the governance of the ultra-processed food and alcohol industries in Australia.

METHODS

We undertook an exploratory descriptive analysis of NGOs identified from an online search based on the typology we developed of type, issue area and governance function.

RESULTS

A total of 134 relevant Australian NGOs were identified: 38 work on food issues, 61 with alcohol issues and 35 are active in both. In the food domain, 90% of NGOs engage in agenda setting, 88% in capacity building, 15% in implementation and 12% in monitoring. In the alcohol domain, 92% of NGOs are active in agenda setting, 72% in capacity building, 35% in implementation and 8% in monitoring.

CONCLUSIONS

Australian NGOs are active actors in the food and alcohol governance system.

IMPLICATIONS FOR PUBLIC HEALTH

There are many opportunities for NGOs to regulate HCI practices, building on their relative strengths in agenda setting and capacity building, and expanding their activities in monitoring and implementation. A more detailed examination is needed of strategies that can be used by NGOs to be effective regulators in the governance system.

A guide to policy analysis as a research method

Policy analysis provides a way for understanding how and why governments enact certain policies, and their effects. Public health policy research is limited and lacks theoretical underpinnings. This article aims to describe and critique different approaches to policy analysis thus providing direction for undertaking policy analysis in the field of health promotion. Through the use of an illustrative example in nutrition it aims to illustrate the different approaches. Three broad orientations to policy analysis are outlined: (i) Traditional approaches aim to identify the 'best' solution, through undertaking objective analyses of possible solutions. (ii) Mainstream approaches focus on the interaction of policy actors in policymaking. (iii) Interpretive approaches examine the framing and representation of problems and how policies reflect the social construction of 'problems'. Policy analysis may assist understanding of how and why policies to improve nutrition are enacted (or rejected) and may inform practitioners in their advocacy. As such, policy analysis provides researchers with a powerful tool to understand the use of research evidence in policymaking and generate a heightened understanding of the values, interests and political contexts underpinning policy decisions. Such methods may enable more effective advocacy for policies that can lead to improvements in health.

Who Are the Key Players Involved with Shaping Public Opinion and Policies on Obesity and Diabetes in New Zealand?

There is an urgent need for strategic approaches to address the high prevalence of obesity and diabetes in New Zealand. Such approaches rely strongly on input from multiple actors in the diabetes and obesity policy space. We conducted a social network analysis to identify influential actors involved with shaping public opinion and/or policy regarding obesity and diabetes in New Zealand. Our analysis revealed a diverse network of 272 individuals deemed influential by their peers. These individuals represented nine professional categories, particularly academics (34%), health service providers (22%), and government representatives (17%). The network included a total of 17 identified decision-makers. Relative capacity of professional categories to access these decision-makers was highest for representatives of the food and beverage industry (25%), compared with nongovernment organisations (9%) or academics (7%). We identified six distinct brokers, in academic (n = 4), government (n = 1), and nongovernmental (n = 1) positions, who could play a key role in improving communication and networking activities among all interest groups. Such actions should ultimately establish effective networks to foster evidence-based policy development to prevent and reduce the burden of diabetes and obesity.

Effective advocacy strategies for influencing government nutrition policy: a conceptual model

Influencing public policy change can be difficult and complex, particularly for those with limited power and resources. For any one issue there may be several groups, including the commercial sector and public health advocates advocating from different policy perspectives. However, much of the public health advocacy literature and tools available for those wanting to improve their practice is based on research from one specific perspective of an issue. This approach deprives advocates of potential insight into the most effective levers for this complex and difficult process. To provide a more comprehensive insight into effective levers for influencing public health policy change, a conceptual model for poorly-resourced advocates was developed. The model was developed through the integration and synthesis of policy process and network theories with the results from three studies conducted previously by the authors: a systematic literature review; a social network analysis of influential actors in Australian nutrition policy; plus in-depth interviews with a sample of these actors who had diverse perspectives on influencing nutrition policy. Through understanding the key steps in this model advocates will be better equipped to increase political and public will, and affect positive policy change.