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

Government, governance, and place-based approaches: lessons from and for public policy

BACKGROUND

Place-based approaches are increasingly applied to address the determinants of health, many of which are complex problems, to ultimately improve population health outcomes. Through public policy, government actions can affect the effectiveness of place-based approaches by influencing the conceptualisation, development, implementation, governance, and/or evaluation of place-based approaches. Despite the important role of public policy, there has been limited examination of public policy related to place-based approaches. We add to the limited knowledge base by analysing Australian national public policy, to explore: (1) the definitions, conceptualisations, and characteristics of place-based approaches in public policy; (2) the government's perception and communication of its role in place-based approaches; and (3) the extent to which government policy reflects the necessary conditions for successful place-based governance developed by Marsh and colleagues, namely localised context, embedded learning, and reciprocal accountability.

METHODS

This research was underpinned by the Theory of Systems Change and methodologically informed by the READ approach to document analysis. Ritchie and Spencer's framework method was utilised to analyse the data.

RESULTS

We identified and reviewed 67 policy documents. In terms of conceptualisation, common characteristics of place-based approaches related to collaboration, including community in decision-making, responsiveness to community needs, and suitability of place-based approaches to address complex problems and socio-economic determinants of health. Three roles of government were identified: funder, partner, and creator of a supportive policy environment. From the three criteria for successful place-based governance, localised context was the most dominant across the documents and reciprocal accountability the least.

CONCLUSIONS

Based on our findings, we drew key implications for public policy and research. There was a disproportionate emphasis on the bottom-up approach across the documents, which presents the risk of diminishing government interest in place-based approaches, potentially burdening communities experiencing disadvantage beyond their capacities. Governments engaged in place-based approaches should work towards a more balanced hybrid approach to place-based approaches that maintain the central functions of government while allowing for successful place-based governance. This could be achieved by promoting consistency in conceptualisations of 'place-based', employing an active role in trust building, advancing the creation of a supportive policy environment, and embedding 'learning' across place-based approaches.

Exploring views of members of the public and policymakers on the acceptability of population level dietary and active-travel policies: a qualitative study

BACKGROUND

There is limited evidence on what shapes the acceptability of population level dietary and active-travel policies in England. This information would be useful in the decision-making process about which policies should be implemented and how to increase their effectiveness and sustainability. To fill this gap, we explored public and policymakers' views about factors that influence public acceptability of dietary and active-travel policies and how to increase public acceptability for these policies.

METHODS

We conducted online, semi-structured interviews with 20 members of the public and 20 policymakers in England. A purposive sampling frame was used to recruit members of the public via a recruitment agency, based on age, sex, socioeconomic status and ethnicity. Policymakers were recruited from existing contacts within our research collaborations and via snowball sampling. We explored different dietary and active-travel policies that varied in their scope and focus. Interviews were transcribed verbatim and analysed using thematic reflexive analysis with both inductive and deductive coding.

RESULTS

We identified four themes that informed public acceptability of dietary and active-travel policies: (1) perceived policy effectiveness, i.e., policies that included believable mechanisms of action, addressed valued co-benefits and barriers to engage in the behaviour; (2) perceived policy fairness, i.e., policies that provided everyone with an opportunity to benefit (mentioned only by the public), equally considered the needs of various population subgroups and rewarded 'healthy' behaviours rather than only penalising 'unhealthy' behaviours; (3) communication of policies, i.e., policies that were visible and had consistent and positive messages from the media (mentioned only by policymakers) and (4) how to improve policy support, with the main suggestion being an integrated strategy addressing multiple aspects of these behaviours, inclusive policies that consider everyone's needs and use of appropriate channels and messages in policy communication.

CONCLUSIONS

Our findings highlight that members' of the public and policymakers' support for dietary and active-travel policies can be shaped by the perceived effectiveness, fairness and communication of policies and provide suggestions on how to improve policy support. This information can inform the design of acceptable policies but can also be used to help communicate existing and future policies to maximise their adoption and sustainability.

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.

Five-Year Trend of Adolescent Hospitalizations and Deaths in Thailand: A Secondary National Data Health Situation Analysis

Adolescence is a critical phase for achieving human potential, serving as the foundation for later health. In 2010, the major causes of hospital admissions and deaths in Thai adolescents were related to preventable causes, specifically engagement in high-risk behaviors such as unprotected sexual intercourse, substance use and unsafe driving. We retrieved data from 1,761,667 adolescent (10-17 years) hospital admissions and 6362 deaths between 2015 and 2019 from the National Health Security Office database. Trends of hospital admissions and deaths, length of stay and medical expenses by sex, age: early (10-13 years) and middle adolescents (14-17 years), and geographical regions were analyzed by ICD-10 disease group and single diagnosis. Hospital admissions increased in relation to the same age population from 2015 to 2019. Trends of the top 3 diagnoses shifted between disease groups from 2015 to 2019. Pregnancy retreated from the first (17.8%) to the third rank (12.2%), and arthropod-borne viral fevers advanced from the third (13.1%) to the first rank (17.1%). Injury and poisoning remained at the second rank (14.5-14.4%). Females were admitted more than males, but males had significantly longer hospital stays. Early adolescents were admitted less than middle adolescents and their hospital stay was significantly shorter. Trends of the top 3 diagnoses for deaths by disease groups remained stable: injury and poisoning (41.2%), neoplasms (10.2%), and respiratory infections (9.5%). The average direct health care cost utilized on adolescent health care was 3813 million Baht (115.54 million US Dollars) per year. Considering the top 3 disease groups, injury and poisoning had the highest average cost per hospital admission and net cost per year consuming 26.4% of the total cost. Our study highlights the cause of hospital admissions and deaths in Thai adolescents, which are mainly preventable. Adolescent health care will improve with more investment in prevention through policy, service, and education reform.

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.

A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland

BACKGROUND

Health in All Policies (HiAP) encompasses collaboration across government and the consideration of health in various governmental sector's policies and decisions. Despite increasing advocacy, interest, and uptake in HiAP globally, empirical and evaluative studies are underrepresented in this growing literature, particularly literature on HiAP implementation at the local level. Finland has been a pioneer in and champion for HiAP.

METHODS

A realist explanatory case study design was used to test hypotheses about how HiAP is implemented in Kuopio, Finland. Semi-structured interviews with ten government employees from various sectors were conducted. Data from interviews and literature were analyzed with the aims of uncovering explanatory mechanisms in the form of context-strategy-mechanism-outcome (CSMO) configurations related to implementation strategies. Evidence was evaluated for quality based on triangulation of sources and strength of evidence. We hypothesized that having or creating a common goal between sectors and having committed staff and local leadership would facilitate implementation.

RESULTS

Strong evidence supports our hypothesis that having or creating a common goal can aid in positive implementation outcomes at the local level. Common goals can be created by the strategies of having a city mandate, engaging in cross-sectoral discussions, and/or by working together. Policy and political elite leadership led to HiAP implementation success because leaders supported HiAP work, thus providing justification for using time to work intersectorally. How and why the wellbeing committee facilitated implementation included by providing opportunities for discussion and learning, which led to understanding of how non-health decisions impact community wellbeing, and by acting as a conduit for the communication of wellbeing goals to government employees.

CONCLUSION

At the municipal level, having or creating a common goal, leadership from policy and political elites, and the presence of committed staff can facilitate HiAP implementation. Inclusion of not only strategies for HiAP, but also the explanatory mechanisms, aids in elucidating how and why HiAP is successfully implemented in a local setting.

Fuzzy Win-Win: A Novel Approach to Quantify Win-Win Using Fuzzy Logic

The classic notion of a win–win situation has a key flaw in that it cannot always offer the parties equal amounts of winningsbecause each party believes they are winners. In reality, one party may win more than the other. This strategy is not limited to a single product or negotiation; it may be applied to a variety of situations in life. We present a novel way to measure the win–win situation in this paper. The proposed method employs fuzzy logic to create a mathematical model that aids negotiators in quantifying their winning percentages. The model is put to the test on real-life negotiation scenarios such as the Iraqi–Jordanian oil deal and iron ore negotiation (2005–2009), in addition to scenarios from the game of chess. The presented model has proven to be a useful tool in practice and can be easily generalized to be utilized in other domains as well.

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.

College Students' Experiences of Race-Related Bias or Hatred in Their Lifetimes and COVID-19 Era

OBJECTIVE

The primary aim of this study was to investigate whether students in minority race categories are more likely to experience race-related bias and hatred in their lifetime and since the onset of COVID-19, after controlling the effect of demographic and other variables.

METHODS

This quantitative study used primary data from the survey of 1249 college students at one of the universities in Georgia during April and May 2020. We performed multinomial logistic regression, computing 2 models for the 2 ordinal dependent variables concerning students' experience of race-related bias and hatred-(a) during their lifetime and (b) since the onset of COVID-19 in March 2020-both measured as "never," "rarely," "sometimes," and "fairly often or very often."

RESULTS

During their lifetime, 47.5% of students had experienced some level of bias or hatred, ranging from "rarely" to "very often." Since the onset of COVID-19 on March 2 in Georgia, in a short period of 1 to 2 months, 17.6% of students reported experiencing race-related bias or hatred. Univariate statistics revealed substantial differences in race-related bias and hatred by race, experienced during students' lifetime as well as since the onset of COVID-19. Results of multinomial logistic regression showed that the odds of having experienced bias or hatred during their lifetime were significantly higher (P < .05) for the Black students than for White students (adjusted odds ratio [AOR] = 75.8, for very often or often vs never; AOR = 42 for sometimes vs never). Compared with White students, the odds of hatred and bias were also significantly higher for students who were Asian, multiple races, or another non-White race. The odds of having experienced race-related bias and hatred since the onset of COVID-19 were also higher for Black Asian, multiple races, and other non-White students.

CONCLUSIONS

This study adds critical scientific evidence about variation in the perception of bias and hatred that should draw policy attention to race-related issues experienced by college students in the United States.

Four normative perspectives on public health policy-making and their preferences for bodies of evidence

Calls for evidence-informed public health policy-making often ignore that there are multiple, and often competing, bodies of potentially relevant evidence to which policy-makers have recourse in identifying policy priorities and taking decisions. In this paper, we illustrate how policy frames may favour the use of specific bodies of evidence. For the sixth Dutch Public Health Status and Foresight report (2014), possible future trends in population health and healthcare expenditure were used as a starting point for a deliberative dialogue with stakeholders to identify and formulate the most important societal challenges for the Dutch health system. Working with these stakeholders, we expanded these societal challenges into four normative perspectives on public health. These perspectives can be regarded as policy frames. In each of the perspectives, a specific body of evidence is favoured and other types of evidence are neglected. Crucial outcomes in one body may be regarded as irrelevant from other perspectives. Consequently, the results of research from a single body of evidence may not be helpful in the policy-making processes because policy-makers need to account for trade-offs between all competing interests and values. To support these policy processes, researchers need to combine qualitative and quantitative methodologies to address different outcomes from the start of their studies. We feel it is time for the research community to re-politicise the idea of evidence use and for policy-makers to demand research that helps them to account for all health-related policy goals. This is a prerequisite for real evidence-informed policy-making.