The fit between health impact assessment and public policy: practice meets theory

PURPOSE AND SETTING

The last decade has seen increased use of health impact assessment (HIA) to influence public policies developed outside the Health sector. HIA has developed as a structured, linear and technical process to incorporate health, broadly defined, into policy. This is potentially incongruent with complex, non-linear and tactical policy making which does not necessarily consider health. HIA research has however not incorporated existing public policy theory to explain practitioners' experiences with HIA and policy. This research, therefore, used public policy theory to explain HIA practitioners' experiences and investigate 'What is the fit between HIA and public policy?'

METHODS

Empirical findings from nine in-depth interviews with international HIA practitioners were re-analysed against public policy theory. We reviewed the HIA literature for inclusion of public policy theories then compared these for compatibility with our critical realist methodology and the empirical data. The theory 'Policy Cycles and Subsystems' (Howlett et al., 2009) was used to re-analyse the empirical data.

FINDINGS

HIAs for policy are necessarily both tactical and technical. Within policy subsystems using HIA to influence public policy requires tactically positioning health as a relevant public policy issue and, to facilitate this, institutional support for collaboration between Public Health and other sectors. HIA fits best within the often non-linear public policy cycle as a policy formulation instrument. HIA provides, tactically and technically, a space for practical reasoning to navigate facts, values and processes underlying the substantive and procedural dimensions of policy.

CONCLUSIONS

Re-analysing empirical experiential data using existing public policy theory provided valuable explanations for future research, policy and practice concerning why and how HIA fits tactically and technically with the world of public policy development. The use of theory and empiricism opens up important possibilities for future research in the search for better explanations of complex practical problems.

The essential elements of health impact assessment and healthy public policy: a qualitative study of practitioner perspectives

OBJECTIVES

This study uses critical realist methodology to identify the essential and contingent elements of Health Impact Assessment (HIA) and Healthy Public Policy (HPP) as operationalised by practitioners.

DESIGN

Data collection-qualitative interviews and a workshop were conducted with HIA and HPP practitioners working in differing contexts.

DATA ANALYSIS

Critical realist analytical questions identified the essential elements of HIA and HPP, the relationship between them, and the influences of public policy and other contingencies on the practice of both.

PARTICIPANTS

Nine interviews were conducted with purposively sampled participants working in Europe, USA and Australasia. 17 self-selected participants who worked in Europe, South East Asia and Australasia attended the workshop.

RESULTS

The results clarify that HIA and HPP are different but mutually supporting. HIA has four characteristics: assessing a policy proposal to predict population health and equity impacts, a structured process for stakeholder dialogue, making recommendations and flexibly adapting to the policy process. HPP has four characteristics: concern with a broad definition of health, designing policy to improve people's health and reduce health inequities, intersectoral collaboration and influencing the policy cycle from inception to completion. HIA brings to HPP prediction about a policy's broad health impacts, and a structured space for intersectoral engagement, but is one approach within a broader suite of HPP activities. Five features of public policy and seven contingent influences on HIA and HPP practice are identified.

CONCLUSIONS

This study clarifies the core attributes of HIA and HPP as separate yet overlapping while subject to wider influences. This provides the necessary common language to describe the application of both and avoid conflated expectations of either. The findings present the conceptual importance of public policy and the institutional role of public health as distinct and important influences on the practice of HIA and HPP.

Public health ethics: informing better public health practice

Public health ethics has emerged and grown as an independent discipline over the last decade. It involves using ethical theory and empirical analyses to determine and justify the right thing to do in public health. In this paper, we distinguish public health ethics from clinical ethics, research ethics, public health law and politics. We then discuss issues in public health ethics including: how to weigh up the benefits, harms and costs of intervening; how to ensure that public health interventions produce fair outcomes; the potential for public health to undermine or promote the rights of citizens; and the significance of being transparent and inclusive in public health interventions. We conclude that the explicit and systematic consideration of ethical issues will, and should, become central to every public health worker's daily practice.

Parental perspectives on caring for a child with chronic kidney disease: an in-depth interview study

BACKGROUND

Children diagnosed with chronic kidney disease (CKD) depend on their parents for complex, continuous and intensive support. The study aimed to explore the experiences of parents who have children with CKD.

METHODS

Parents of 20 children with CKD, recruited from two paediatric hospitals in Australia, participated in an in-depth interview, qualitative study.

RESULTS

Four major themes were identified: (1) absorbing the clinical environment: parents struggled to accept the diagnosis and permanence of CKD, felt traumatized watching their child undergo invasive clinical procedures, battled to meet appointments, negotiated with staff for their child's needs and felt disempowered; (2) medicalizing parenting: parents became caregivers, a role which was stressful, exhausting and overwhelming. Dialysis was unrelenting and consumed the time, thoughts and energy of parents who felt at fault if their child developed infections and other complications. Parents struggled with their child's psychological problems and episodic aggressive behaviour; (3) disrupting family norms: CKD caused spousal tension, sibling neglect and influenced family planning; (4) coping strategies and support structures: Parents depended on support from their health care providers and valued meeting and learning from other parents of CKD children. Parents also expressed information needs and suggested methods of communicating information.

CONCLUSIONS

Despite facing profound and pervasive difficulties, parents strived to fulfil their dual parental and health care provider responsibilities. Parents appear to need better support structures to help them cope with the difficulties encountered during all stages of their child's illness.

Doing good qualitative research in public health: not as easy as it looks

In this paper, we discuss qualitative research for public health professionals. Quality matters in qualitative research, but the principles by which it is judged are critically different from those used to judge epidemiology. Compared to quantitative research, good quality qualitative studies serve different aims, answer distinct research questions and have their own logic for sampling, data collection and analysis. There is, however, no need for antagonism between qualitative research and epidemiology; the two are complementary. With theoretical and methodological guidance from experienced qualitative researchers, public health professionals can learn how to make the most of qualitative research for themselves.

Working in disadvantaged communities: What additional competencies do we need?

BACKGROUND

Residents of socioeconomically disadvantaged locations are more likely to have poor health than residents of socioeconomically advantaged locations and this has been comprehensively mapped in Australian cities. These inequalities present a challenge for the public health workers based in or responsible for improving the health of people living in disadvantaged localities. The purpose of this study was to develop a generic workforce needs assessment tool and to use it to identify the competencies needed by the public health workforce to work effectively in disadvantaged communities.

METHODS

A two-step mixed method process was used to identify the workforce needs. In step 1 a generic workforce needs assessment tool was developed and applied in three NSW Area Health Services using focus groups, key stakeholder interviews and a staff survey. In step 2 the findings of this needs assessment process were mapped against the existing National Health Training Package (HLT07) competencies, gaps were identified, additional competencies described and modules of training developed to fill identified gaps.

RESULTS

There was a high level of agreement among the AHS staff on the nature of the problems to be addressed but less confidence indentifying the work to be done. Processes for needs assessments, community consultations and adapting mainstream programs to local needs were frequently mentioned as points of intervention. Recruiting and retaining experienced staff to work in these communities and ensuring their safety were major concerns. Workforce skill development needs were seen in two ways: higher order planning/epidemiological skills and more effective working relationships with communities and other sectors. Organisational barriers to effective practice were high levels of annual compulsory training, balancing state and national priorities with local needs and giving equal attention to the population groups that are easy to reach and to those that are difficult to engage. A number of additional competency areas were identified and three training modules developed.

CONCLUSION

The generic workforce needs assessment tool was easy to use and interpret. It appears that the public health workforce involved in this study has a high level of understanding of the relationship between the social determinants and health. However there is a skill gap in identifying and undertaking effective intervention.

Patients' experiences and perspectives of living with CKD

Explicit incorporation of patients' values and preferences is important in health care decision making. However, there are few data about this topic for patients with chronic kidney disease (CKD). We conducted 9 focus groups (3 each for CKD stages 1 to 5, CKD stage 5D, and CKD stages 1 to 5T). Five major themes were identified: (1) personal meaning of CKD, (2) managing and monitoring health, (3) lifestyle consequences, (4) family impact, and (5) informal support structures. Patients had to adjust to the disruptive and permanent implications of the illness on their physical health, identity, emotions, family, lifestyle, relationships, and employment. The overwhelming fatigue, complex treatment regimens, side effects, and liquid and diet restrictions constrained patients' lives. Patients appreciated specialist care, but described the health care system as nonintegrated and believed they received insufficient information and psychosocial support. Choice of treatments was based on lifestyle, family impact, and physical comfort, seldom on clinical outcomes. Time was needed to comprehend the diagnosis, cope with uncertainty, integrate their treatment regimen into their daily routine, and reestablish a sense of normality in their lives. Rather than focusing on clinical targets, greater attention may need to be given to providing information and psychosocial and practical support at a patient-level not organ-specific level, to maximize patient quality of life.

Implementing a strategic plan for child health: a Sydney case study

AIM

The aim of this paper is to describe the implementation of a strategic plan, Health Gain for Children and Youth of Central Sydney, over a 10-year period to December 2005.

METHODS

Descriptive information was obtained from the records and minutes of all relevant committees, interviews with key workers who were involved with the committees, managers and senior health professionals, and from the involvement of the authors throughout the process of the implementation.

RESULTS

An implementation steering committee was established to oversee the implementation of the plan. Rather than adopting a uniform approach to assigning responsibility for the implementation of each strategy in the plan or developing specific costs and time frames for each strategy, a more pragmatic, flexible and opportunistic approach was taken. Most of the plan's strategies were implemented over a 7-year time frame using a combination of service reorientation and implementation of new programmes, some of which were funded from sources not anticipated during the development of the plan. Implementation required a dedicated driver, commitment at senior level and participation by many staff at many levels. Outcomes, monitored through data collected at 5-year intervals, revealed positive trends in a number of child and youth health indicators.

CONCLUSIONS

The successful implementation of the strategic plan required pragmatism, flexibility, opportunism and the commitment and involvement of staff at all organisational levels. It is envisaged that this approach provides a firm base for future evidence-based developments to benefit the health and well-being of children, youth and their families and reduce health inequities.

Support interventions for caregivers of people with chronic kidney disease: a systematic review

BACKGROUND

A growing number of patients with chronic kidney disease (CKD) rely on non-professional healthcare providers, such as family and friends, to manage their long-term condition throughout the trajectory of CKD. These informal caregivers can experience stress, depression, lack of confidence and poor quality of life. Yet, the needs of caregivers are often neglected and under-prioritized. The objective of this review is to evaluate the effectiveness of interventions aimed at providing support to caregivers of people with CKD.

METHODS

We conducted a systematic review of studies that evaluated any intervention for informal caregivers of CKD patients. We searched five electronic databases (up to January Week 5, 2008) including Medline, EMBASE, PsychINFO, CINAHL, Cochrane Central Register and reference lists of relevant articles.

RESULTS

Three studies were identified that evaluated an intervention for caregivers of CKD patients. All three only assessed the effect of educational material on caregivers' knowledge. Two evaluated information provided to caregivers of dialysis patients using a pre- and post-test study design. The other study used participatory action research methods to develop and evaluate an information handbook for transplant patients and their caregivers. Studies consistently found that the provision of information improved caregivers' knowledge. No other outcomes were reported.

CONCLUSIONS

Despite the growing recognition of the burden and adverse effects of CKD on caregivers, no high-quality evidence is available about the effect of information or support interventions on the physical or psychosocial well-being of informal caregivers and the patients. More attention towards the development and evaluation of services that respond to the support and informational needs of caregivers is needed, and this may also lead to improved outcomes for patients.

An analysis of media coverage on the prevention and early detection of CKD in Australia

News media raise public awareness about health and can influence public policy agenda. Recently, nephrologists have sought to make prevention and early detection of chronic kidney disease (CKD) a health care priority. We assessed the extent and manner in which Australian television news and newspapers cover CKD prevention or early detection. Electronic news databases for print media and television programs were searched (May 2005 to March 2007) for items referring to CKD prevention or early detection. We analyzed all relevant items for spokespeople, main news frame, focus of responsibility, proposed solutions, and trigger/reason for publication. Of 2,439 newspaper articles and 10,430 television broadcasts retrieved, only 214 articles (8.77%) and 7 broadcasts (0.06%) were eligible. Kidney transplantation dominated CKD-related news. Lay person or high-profile advocates were virtually absent. Risks of cardiovascular disease and mortality conferred by CKD were not emphasized by news reports; instead, CKD received peripheral mention as a secondary consequence of diabetes or obesity. Few reports cited the economic consequences of CKD. The media focused on lifestyle causes and solutions, whereas nonlifestyle causes and screening and prevention strategies were rarely mentioned. Kidney health professionals need to actively engage with the media in efforts to amplify desired messages on CKD prevention or early detection. Medical journals, research institutions, universities, hospitals, and advocacy groups should issue press releases that highlight newsworthy aspects of this topic. Extending news media coverage can help exert an influence on health policies and agenda setting and increase public awareness to improve prevention and early detection of CKD.

Democracy: the forgotten determinant of mental health

ISSUE ADDRESSED

Promoting mental health is a relatively new initiative being taken across the world, stimulated by concerns about the global burden of mental illness, inequalities in mental health and debate about the relationship between quality of life and economic growth. Social factors influence the health of populations but the distribution of these is determined by people who exercise political power through societies' institutions of governance. Inequalities in health (and mental health) arise from the unequal distribution of these social determinants of health. This paper aims to stimulate interest and debate on the role of democracy, a mechanism for allocating political power, as a determinant of health and of mental health in particular.

METHODS AND RESULTS

Drawing principally on the political science literature, we briefly describe the development of democracy in some of its commoner current forms and relate this to the spread of political power and participation in collective decision making and improvements in public health over the past 200 years. We conducted a non-systematic literature search and identified 34 studies examining the link between democracy and health. Despite methodological weaknesses, these papers suggest that there is a weak empirical link between democracy and health, including mental health. We suggest mechanisms that might account for this.

CONCLUSIONS

Historical, theoretical and empirical evidence suggests that democracy is a (frequently forgotten) determinant of health.

Experiences of parents who have children with chronic kidney disease: a systematic review of qualitative studies

OBJECTIVE

The objective of this study was to describe the experiences of parents who have children with chronic kidney disease.

METHODS

We conducted a systematic review and meta-ethnography of studies that had used in-depth interviews or focus groups to explore experiences of parents with children who have chronic kidney disease (predialysis, hemodialysis, peritoneal dialysis, or after kidney transplantation). We searched 5 electronic databases (through to August 2005), Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Sociofile/Sociological Abstract, and reference lists of relevant articles.

RESULTS

Sixteen articles that reported the experiences of parents of 358 children with chronic kidney disease were included. Ten themes emerged, which we grouped into 3 interrelated clusters: intrapersonal (living with constant uncertainty, stress, and maintaining vigilance despite experiencing fatigue), interpersonal (medicalization of the parental role, dependence on and conflict with staff, and disrupted peer relationships), and external issues (management of the medical regimen, pursuit of information, organizing transportation, accommodation and finances, adhering to the child's liquid and diet restrictions, and balancing medical care with domestic responsibilities).

CONCLUSIONS

In addition to "normal" parental roles, being a parent of a child with chronic kidney disease demands a high-level health care provider, problem solving, information seeking, and financial and practical skills at a time when the capacity to cope is threatened by physical tiredness, uncertainty, and disruption to peer support within and outside the family structure. Parents of children with chronic kidney disease need multidisciplinary care, which may lead to improved outcomes for their children.

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups

BACKGROUND

Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of qualitative design.

OBJECTIVE

To develop a checklist for explicit and comprehensive reporting of qualitative studies (in depth interviews and focus groups).

METHODS

We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed.

RESULTS

Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting.

CONCLUSIONS

The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups

BACKGROUND

Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of qualitative design.

OBJECTIVE

To develop a checklist for explicit and comprehensive reporting of qualitative studies (in depth interviews and focus groups).

METHODS

We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed.

RESULTS

Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting.

CONCLUSIONS

The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.

Vision for a global registry of anticipated public health studies

In public health, the generation, management, and transfer of knowledge all need major improvement. Problems in generating knowledge include an imbalance in research funding, publication bias, unnecessary studies, adherence to fashion, and undue interest in novel and immediate issues. Impaired generation of knowledge, combined with a dated and inadequate process for managing knowledge and an inefficient system for transferring knowledge, mean a distorted body of evidence available for decisionmaking in public health. This article hopes to stimulate discussion by proposing a Global Registry of Anticipated Public Health Studies. This prospective, comprehensive system for tracking research in public health could help enhance collaboration and improve efficiency. Practical problems must be discussed before such a vision can be further developed.

In what ways does the mandatory nature of Victoria's municipal public health planning framework impact on the planning process and outcomes?

Background

Systems for planning are a critical component of the infrastructure for public health. Both in Australia and internationally there is growing interest in how planning processes might best be strengthened to improve health outcomes for communities. In Australia the delivery of public health varies across states, and mandated municipal public health planning is being introduced or considered in a number of jurisdictions. In 1988 the Victorian State government enacted legislation that made it mandatory for each local government to produce a Municipal Public Health Plan, offering us a 20-year experience to consider.

Results

In-depth interviews were undertaken with those involved in public health planning at the local government level, as part of a larger study on local public health infrastructure and capacity. From these interviews four significant themes emerge. Firstly, there is general agreement that the Victorian framework of mandatory public health planning has led to improvements in systems for planning. However, there is some debate about the degree of that improvement. Secondly, there is considerable variation in the way in which councils approach planning and the priority they attach to the process. Thirdly, there is concern that the focus is on producing a plan rather than on implementing the plan. Finally, some tension over priorities is evident. Those responsible for developing Municipal Public Health Plans express frustration over the difficulty of having issues they believe are important addressed through the MPHP process.

Conclusion

There are criticisms of Victoria's system for public health planning at the local government level. Some of these issues may be specific to the arrangement in Victoria, others are problems encountered in public health planning generally. In Victoria where the delivery structure for public health is diverse, a system of mandatory planning has created a minimum standard. The implementation of the framework was slow and factors in the broader political environment had a significant impact. Work done in recent years to support the process appears to have led to improvements. There are lessons for other states as they embark upon mandated public health plans.

Diseases of comfort: primary cause of death in the 22nd century

CONTEXT

The world has started to feel the impact of a global chronic disease epidemic, which is putting pressure on our health care systems. If uncurbed, a new generation of "diseases of comfort" (such as those chronic diseases caused by obesity and physical inactivity) will become a major public health problem in this and the next century.

OBJECTIVE

To describe the concept, causes, and prevention and control strategies of diseases of comfort.

METHODS

Brokered by a senior research scientist specialised in knowledge translation, a chair, a president, and a past president of national public health associations contributed their views on the subject.

RESULTS

Diseases of comfort have emerged as a price of living in a modern society. It is inevitable that these diseases will become more common and more disabling if human "progress" and civilisation continue toward better (more comfortable) living, without necessarily considering their effects on health. Modern technology must be combined with education, legislation, intersectoral action, and community involvement to create built and social environments that encourage, and make easy, walking, physical activity, and nutritious food choices, to reduce the health damaging effects of modern society for all citizens and not only the few.

CONCLUSIONS

Public health needs to be more passionate about the health issues caused by human progress and adopt a health promotion stance, challenging the assumptions behind the notion of social "progress" that is giving rise to the burden of chronic disease and developing the skills to create more health promoting societies in which individual health thrives.