Oral health policies and decision-making process in Brazil, Colombia and Chile

Public health policies are crucial for the well-being of the general population; however, the health systems of developed countries still do not include oral health in its system. Thus, it is necessary to understand the process of decision-making in oral health policies to create opportunities for countries to achieve an overall positive health outcome, including oral health. This study aimed to identify the factors influencing the inclusion of oral health on the political agenda in Brazil, Colombia, and Chile. The study sample involved decision-makers at political, technical, and academic levels. The extracted data were analyzed using the software Maxqda® and Kingdon´s theoretical model; defining interactive variables that produce a "window of opportunity" to define the agenda and the insertion of theme in formulating public policies. The decision-making process regarding oral health is influenced by many factors like the need to improve the overall oral health of the population, identified through national epidemiological studies, and the importance of individuals in positions involving political decision-making, who advocate for oral health. Strategies were developed in partnership with the academy that focused on the health rights of the population provided by law; territorial and national programs were also developed. The inclusion and creation of oral health policies depend on actors who advocate for thematic and scientific evidence to support decision-making. A close relationship between academia and stakeholders and knowledge translation is important for the development of public policies that can be effective for health systems.

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.

The emergence of political priority for addressing child sexual abuse in the United Kingdom

BACKGROUND

Child sexual abuse (CSA) is widespread. Few countries, however, prioritize the issue. The United Kingdom is an exception, ranked first in its response to the issue in a 2019 country comparison. In 2015, Prime Minister David Cameron designated the issue one of three national threats. Funding commitments and policies to address CSA followed.

OBJECTIVE

To investigate how CSA emerged as a national political priority in the United Kingdom, and to identify insights for proponents seeking to advance priority for addressing the issue.

PARTICIPANTS AND SETTING

Documents were analyzed and semi-structured interviews conducted with actors in the United Kingdom central to CSA advocacy, research, and/or programming, as well as with policymakers.

METHODS

Drawing on the multiple streams public policy model, a thematic analysis was conducted on collected documents (n = 160) and 21 interview transcripts.

RESULTS

Our analysis delineates three critical developments that led to national prioritization for addressing CSA. First, high-profile scandals and the re-framing of CSA survivors as deserving of support raised public awareness of the problem. Second, champions concerned with CSA developed evidence-based and politically-feasible solutions. Third, the Prime Minister's concern and other political developments opened a policy window.

CONCLUSIONS

The case provides insights for proponents on generating political priority for addressing CSA. Proponents need to (1) ensure survivors are not seen as culpable but rather as deserving of support, (2) be ready with solutions and (3) cultivate high-level political support, so that when policy windows open they can jump to push the issue onto the national agenda.

Two steps forward, one step back: the lead up to tobacco plain packaging policy in Turkey

The Turkish government first announced its intention to proceed with tobacco plain packaging legislation in 2011; however, it was 7 years before the legislation passed in December 2018. This study (conducted in 2018 before the legislation was passed) explored the policy context in Turkey between the first announcement that plain packaging legislation would be introduced and the passage of the legislation in 2018, and identified barriers and facilitators influencing its introduction. Publicly available documents relevant to plain packaging in Turkey were analysed. Interviews were conducted in 2018 with ten key informants including academics, bureaucrats in government ministries and leaders of non-government organizations (NGOs). Thematic analysis was undertaken, using a framework for systematically analysing how issues reach the policy agenda. The introduction of plain packaging legislation proved to be problematic, with many false starts and delays. Findings suggest these were mainly due to political barriers including changes in government, tobacco industry opposition and the national economic crisis. However, plain packaging legislation in Turkey managed to advance on the policy agenda, primarily through the collaborative advocacy efforts of NGOs, academics, and leadership from particular tobacco control advocates and politicians. Turkey's experience provides lessons for the wider uptake of tobacco plain packaging legislation, illustrating the critical importance of building effective coalitions between a range of stakeholders and political support within government while raising public awareness. Lay summary This research provides insights into the barriers and facilitators of decision making and action that shaped the process of introducing tobacco plain packaging legislation in Turkey. Major barriers that slowed Turkey's progress in enacting plain packaging included the financial and national economic crisis in 2018, changes in health ministers and opposition by the tobacco industry. A major facilitator of the policy process was the collaborative advocacy efforts of non-government organizations, academics, politicians and the leadership of certain tobacco control advocates. The insights from this case study may help other low- and middle-income countries to anticipate and successfully navigate the challenges involved in introducing tobacco plain packaging, an important policy measure for reducing the burden of tobacco-related disease in their populations, and its social and economic impacts. Building effective coalitions and fostering and supporting leadership are important strategies for the successful introduction of plain packaging legislation.

Policy windows for drug consumption rooms in Finland

Background: Use of drug consumption rooms is a novel harm reduction approach to reach marginalised and isolated people who used drugs, under the high risk of overdose deaths and infectious diseases. The aim of this article was to evaluate the policy opportunities and barriers of the Helsinki City initiative for establishing the first drug consumption room (DCR) in Finland from the multiple streams framework. Method: A qualitative interview research method is used to evaluate the perspectives of stakeholders. By including 23 participants, we analysed the political, social and policy level advantages and disadvantages of the current initiative. Findings: Our results show that the cost of DCRs, the COVID-19 burdens on public resources, the requirement of legislative change, public unawareness, potential policy failure of DCRs, and its impacts on electoral votes constitute the main policy barriers. On the other hand, an increase in drug-related deaths, economic benefits of DCR for society, its effects on street safety and public order, being a local initiative, prospectus change in national drug strategy plans and motivation to catch up with EU standards were underlined as policy opportunities. Four issues, leadership, moral perspective, social change and generational differences, act as mediating factors, which are fluctuated according to public opinions and political environment. Conclusion: By applying the multiple streams framework, our results show that experts’ DCR problematisation is still beyond the public and political interest, which needs additional effort around problem identification and prioritisation. Besides public unawareness, the COVID-19 situation seems to be postponing policy progress since the primary attention and available funds have already been dedicated to public health. Already having a local initiative and an upcoming drug strategy plan might be good formal leverage, but unexpected events might also trigger discussions.

Physical rehabilitation financing in Iran: a policy analysis using Kingdon's multiple streams

BACKGROUND

Adequate financing is a crucial function, securing that physical rehabilitation services (i.e., physiotherapy, occupational therapy, prosthetics and orthotics) are available with no financial hardship. Like many other countries, despite the adoption of various policies and strategies in recent decades, Iran enjoys no desirable physical rehabilitation financing (PRF). Accordingly, this qualitative study aimed to explore the PRF-related strategies and issues as well as their impacts on relevant policies in Iran.

METHODS

An analysis of PRF-related policies was conducted in Iran using semi-structured interviews and policy documents review. Purposive and snowball sampling techniques were employed to select key informants, including health-policy makers, civil society, rehabilitation-policy makers, university professors, and practitioners. Thematic analysis was used to analyze the collected data. The analysis was framed within Kingdon's multiple streams.

RESULTS

The hindering factors for desirable financing were weak insurance coverage, lack of sustainable financial resources, fragmented financing, lack of split between provider and financer, high-cost of physical rehabilitation services, low engagement of relevant experts in policy-making processes, and corrupt activities. In the policy stream, the following factors were highlighted: involvement of sustainable financial resources, the use of external revenue sources, allocated resources' earmarking, the integration of the current funds to have better pooling, the use of incentive and timely payment mechanisms, the implementation of strategic purchasing principals, and the employment of effective rationing strategies. Moreover, parliament support, changes in administrations, international effects, pressures from interest campaigns and NGOs, and international sanctions were found as factors affecting the politics stream.

CONCLUSION

The study findings revealed that a variety of national and international factors affect PRF-related issues in Iran. The recently enacted laws indicate that the PRF policies have already been on the national health political agenda. The study reflected the multifaceted nature of barriers to optimal PRF in Iran.

A narrative account of the key drivers in the development of the Learning from Deaths policy

Objective

In recent years there has been a proliferation of patient safety policies in the United Kingdom triggered by well publicized failures in health care. The Learning from Deaths (LfD) policy was implemented in response to failures at Southern Health National Health Service (NHS) Foundation Trust. This study aims to develop a narrative to enable the understanding of the key drivers involved in its evolution and implications for future national patient safety policy development.

Methods

A qualitative study was undertaken using documentary analysis and semi-structured interviews (n = 12) with policymakers from organizations involved in the design, implementation and assurance of LfD at a system level. Kingdon’s Multiple Streams Approach was used to frame the policymaking process.

Results

The publication of the Southern Health independent review and subsequent highlighting by the Care Quality Commission of a fragmented approach to learning from deaths across the NHS opened a ‘policy window.’ Under the influence of the families affected by patient safety failures and the then Secretary of State, acting as ‘policy entrepreneurs,’ recently developed methods for mortality review were combined with mechanisms to enhance transparency and governance. This rapidly created a framework designed to ensure NHS organizations identified remedial safety problems and could be accountable for addressing them.

Conclusions

The development of LfD exhibits several common features with other patient safety policies in the NHS. It was triggered by a crisis and the need for a prompt political response and attempts to address a range of concerns related to safety. In common with other safety policies, LfD contains inherent tensions related to its primary purpose, which may hinder its impact. In the absence of formal evaluations of these policies, deeper understanding of the policymaking process offers the possibility of identifying potential barriers to goal achievement.

Global Health Diplomacy (GHD) and the integration of health into foreign policy: Towards a conceptual approach

Since the end of the Cold War, health has gone from a peripheral concern in foreign policy negotiations to a prominent place on the global political agenda. While the rise of health onto the foreign policy agenda is by now old news, the driving forces behind its expansion into new political spheres remain understudied and undertheorized. This article builds on empirical findings from a four-country study of the integration of health into foreign policy, and proposes a conceptual approach to GHD to improve understanding of the conditions under which health is successfully positioned on the foreign policy agenda. Our approach consists of three dimensions: features of institutions and the interest various actors represent in GHD; the ideational environment in which GHD operates; and issue characteristics of the specific health concern entering foreign policy. Within each dimension, we identify specific variables that, in combination, make up the explanatory power of the proposed approach. The proposed approach does not relate to, or build upon, a single social sciences, public health, or international relations (IR) theory, but can be seen as a heuristic device to identify dimensions and variables that may shape why certain health issues rise onto the foreign policy agenda.

Stakeholder interactions with the federal government related to Bill S-228 and marketing to kids in Canada: a quantitative descriptive study

BACKGROUND

Canadian federal restrictions on food marketing to children (children's marketing) were proposed in 2016 as Bill S-228, the Child Health Protection Act, which subsequently died on the parliamentary table. This study quantified the interactions (meetings, correspondence and lobbying) related to Bill S-228 and children's marketing by different stakeholders with the federal government.

METHODS

Interactions between all stakeholders and government related to children's marketing and Bill S-228 (Sept. 1, 2016-Sept. 30, 2019) were analyzed. These included the "Meetings and correspondence on healthy eating" database, detailing interactions between stakeholders and Health Canada related to nutrition policies; and Canada's Registry of Lobbyists, reporting activities of paid lobbyists. We categorized the interactions by stakeholder type (industry, nonindustry and mixed), and analyzed the number and type of interactions with different government offices.

RESULTS

We analyzed 139 meetings, 65 lobbying registrants, 215 lobbying registrations and 3418 communications related to children's marketing and Bill S-228. Most interactions were from industry stakeholders, including 84.2% of meetings (117/139), 81.5% of lobbying registrants (53/65), 83.3% of lobbying registrations (179/215) and 83.9% of communications (2866/3418). Most interactions (> 80%) in the highest-ranking government offices were by industry.

INTERPRETATION

Industry stakeholders interacted with government more often, more broadly and with higher ranking offices than nonindustry stakeholders on subjects related to children's marketing and Bill S-228. Although further research is needed to analyze the nature of the discourse around children's marketing, it is apparent that industry viewpoints were more prominent than those of nonindustry stakeholders.

Scaling up population health interventions from decision to sustainability - a window of opportunity? A qualitative view from policy-makers

Background

While known efficacious preventive health interventions exist, the current capacity to scale up these interventions is limited. In recent years, much attention has focussed on developing frameworks and methods for scale-up yet, in practice, the pathway for scale-up is seldom linear and may be highly dependent on contextual circumstances. Few studies have examined the process of scaling up from decision to implementation nor examined the sustainability of scaled-up interventions. This study explores decision-makers’ perceptions from real-world scaled-up case studies to examine how scale-up decisions were made and describe enablers of successful scale-up and sustainability.

Methods

This qualitative study included 29 interviews conducted with purposively sampled key Australian policy-makers, practitioners and researchers experienced in scale-up. Semi-structured interview questions obtained information regarding case studies of scaled-up interventions. The Framework Analysis method was used as the primary method of analysis of the interview data to inductively generate common and divergent themes within qualitative data across cases.

Results

A total of 31 case studies of public health interventions were described by interview respondents based on their experiences. According to the interviewees’ perceptions, decisions to scale up commonly occurred either opportunistically, when funding became available, or when a deliberate decision was made and funding allocated. The latter scenario was more common when the intervention aligned with specific political or strategic goals. Decisions to scale up were driven by a variety of key actors such as politicians, senior policy-makers and practitioners in the health system. Drivers of a successful scale-up process included good governance, clear leadership, and adequate resourcing and expertise. Establishing accountability structures and appropriate engagement mechanisms to encourage the uptake of interventions were also key enablers. Sustainability was influenced by evidence of impact as well as good acceptability among the general or target population.

Conclusions

Much like Kingdon’s Multiple Streams Theory of ‘policy windows’, there is a conceptually similar ‘window for scale-up’, driven by a complex interplay of factors such as political need, strategic context, funding and key actors. Researchers and policy-makers need to consider scalability from the outset and prepare for when the window for scale-up opens. Decision-makers need to provide longer term funding for scale-up to facilitate longer term sustainability and build on the resources already invested for the scale-up process.

The ethical, social, and cultural dimensions of screening for mental health in children and adolescents of the developing world

Despite their burden and high prevalence, mental health disorders of children and adolescents remain neglected in many parts of the world. In developing countries, where half of the population is younger than 18 years old, one of every five children and adolescents is estimated to suffer from a mental health disorder. It is then essential to detect these conditions through screening in a timely and accurate manner. But such screening is fraught with considerable ethical, social, and cultural challenges. This study systematically identifies, for the first time, these challenges, along with potential solutions to address them. We report on the results of an international multi- and inter-disciplinary three-round Delphi survey completed by 135 mental health experts from 37 countries. We asked these experts to identify and rank the main ethical, social, and cultural challenges of screening for child and adolescent mental health problems in developing nations, and to propose solutions for each challenge. Thirty-nine significant challenges emerged around eight themes, along with 32 potential solutions organized into seven themes. There was a high degree of consensus among the experts, but a few interesting disagreements arose between members of the panel from high-income countries and those from low- and middle-income nations. The panelists overwhelmingly supported mental health screening for children and adolescents. They recommended ensuring local acceptance and support for screening prior to program initiation, along with careful and comprehensive protection of human rights; integrating screening procedures into primary care; designing and implementing culturally appropriate screening tools, programs, and follow-up; securing long-term funding; expanding capacity building; and task-shifting screening to local non-specialists. These recommendations can serve as a guide for policy and decision-making, resource allocation, and international cooperation. They also offer a novel approach to reduce the burden of these disorders by encouraging their timely and context-sensitive prevention and management.

Defining the Benefit Package of Thailand Universal Coverage Scheme: From Pragmatism to Sophistication

Benefit package is crucial for implementing universal health coverage (UHC). This editorial analyses how the benefit package of the Thai Universal Coverage Scheme (UC Scheme) evolved from an implicit comprehensive package which covered all conditions and interventions (with a few exceptions), to additional explicit positive lists. In 2002 when the Thai UC Scheme was launched; the comprehensive benefit package, including medicines in the national essential list of medicines, formerly offered by the previous schemes were pragmatically adopted. Later, when capacities of producing evidence on health technology assessment (HTA) increased, rigorous assessment of cost effectiveness is mandatorily required for inclusion of new interventions into the Thai UC Scheme benefit package. This contributed to evidence-informed policy decisions. To prevent emptied promises, whichever policy choices are made about the benefit package, either using a negative or a positive list, developing country governments need to make quality health services available and accessible by the entire population. Political decision on benefit package should be informed by evidence on cost effectiveness, equity dimension and health system capacity to deliver equitable services. Low- and middle-income countries need to strengthen HTA capacity to generate evidence and inform policies.

Development and implementation of nutrition labelling in Iran: A retrospective policy analysis

BACKGROUND

Nutrition labelling is a strategy to promote healthy eating and combat non-communicable diseases (NCDs). The present study aimed to provide an analysis of the nutrition labelling policy and its opportunities to improve in Iran.

METHODS

Data were collected by 1) reviewing relevant documents and 2) semi-structured interviews with stakeholders through purposive and snowball sampling, continued until data saturation was achieved. A deductive content analysis was used by applying the policy triangulation framework and the Kingdon multiple stream theory. MAXQDA software was used to manage data analysis.

RESULTS

Iran, is the first country in the Eastern Mediterranean region which has accomplished to implement nutrition traffic light labelling. The main contextual factors that affected nutrition labelling policy to become a national included health, political commitment, and international factors. Poor involvement of media for public awareness of nutrition traffic labeling, the inconsistency of nutrition traffic light color ranking using food standard guidelines, lack of consistency between nutrition traffic light colors and the healthy/unhealthy nature of some food products and the absence of a comprehensive evaluation plan were among the policy challenges identified.

CONCLUSIONS

Strengthening the governance for a healthy food environment is recommended to improve the program. Also, establishing national portion sizes for food labelling, initiating public awareness campaigns, evaluation of the policy effect and public perception of the labels and their application are recommended.

Opening the Policy Window to Mobilize Action Against Corruption in the Health Sector Comment on "We Need to Talk About Corruption in Health Systems"

Corruption in the health sector has been a "dirty secret" in the health policy and international development community, but recent global activities point to a day when it will no longer be neglected as a key determinant of health. To further explore next steps forward, this commentary applies the Kingdon's multiple-streams framework (MSF) to assess what opportunities are available to mobilize the global agenda to combat health corruption. Based on this analysis, it appears that Kingdon's problem, policy, and political streams are coalescing to create a policy window opportunity that can be leveraged based on recent developments in the global health and international development community around corruption. This includes the recent formation of the Global Network on Anti-Corruption, Transparency and Accountability (GNACTA) led by the World Health Organization (WHO), the Global Fund, and the United Nations Development Programme in 2019. It also includes bridging shared goals of addressing corruption in order to make progress towards health-specific goals in the United Nations (UN) Sustainable Development Goals (SDGs) and for achieving universal health coverage.

Entrepreneurialism and health-promoting retail food environments in Canadian city-regions

The retail sector is a dynamic and challenging component of contemporary food systems with an important influence on population health and nutrition. Global consensus is clear that policy and environmental changes in retail food environments are essential to promote healthier diets and reduce the burden of obesity and non-communicable diseases. In this article, we explore entrepreneurialism as a form of social change-making within retail food environments, focusing on small food businesses. Small businesses face structural barriers within food systems. However, conceptual work in multiple disciplines and evidence from promising health interventions tested in small stores suggest that these retail places may have a dual role in health promotion: settings to strengthen regional economies and social networks, and consumer environments to support healthier diets. We will discuss empirical examples of health-promoting entrepreneurialism based on two sets of in-depth interviews we conducted with public health intervention actors in Toronto, Canada, and food entrepreneurs and city-region policy actors in St. John's, Canada. We will explore the practices of entrepreneurialism in the retail food environment and examine the implications for population health interventions. We contend that entrepreneurialism is important to understand on its own and also as a dimension of population health intervention context. A growing social scientific literature offers a multifaceted lens through which we might consider entrepreneurialism not only as a set of personal characteristics but also as a practice in networked and intersectoral cooperation for public and population health.

The passage of tobacco control law 174 in Lebanon: reflections on the problem, policies and politics

Progress in tobacco control policy making has occurred worldwide through advocacy campaigns involving multiple players- civil society groups, activists, academics, media and policymakers. The Framework Convention on Tobacco Control (FCTC)-the first ever global health treaty-outlines evidence-based tobacco control policies. Lebanon ratified the FCTC in 2005, but until 2011, tobacco control policies remained rudimentary and not evidence-based. Beginning in 2009, a concerted advocacy campaign was undertaken by a variety of stakeholders with the aim of accelerating the process of adopting a strong tobacco control policy. The campaign was successful, and Law 174 passed the Lebanese Parliament in August 2011. In this article, we analyse the policy making process that led to the adoption of Law 174 using Kingdon's model. The analysis relies on primary and secondary data sources including historical records of key governmental decisions, documentation of the activities of the concerted advocacy campaign and in-depth interviews with key stakeholders. We describe the opening of a window of opportunity as a result of the alignment of the problem, policy and politics streams. Furthermore, findings revealed that despite the challenge of persistent tobacco industry interference and established power relations between the industry, its allies and policymakers; policy entrepreneurs succeeded in supporting the alignment of the streams, and influencing the passage of the law. Kingdon's multiple stream approach was useful in explaining how tobacco control became an emerging policy issue at the front of the policy agenda in Lebanon.

Policymaking through healthcare registries in Sweden

Healthcare registries, otherwise known in Sweden as national quality registries (NQRs), have progressed from being a patient-focused system supporting medical results to become the basis of a health policy steering instrument called regional comparisons (RCs). This article seeks to explain RCs as an unintended consequence of the NQR development, by utilizing the concepts of policy entrepreneurs and streams of impact: the problem stream (problem perceived), the policy stream (what is valid), and the political stream (governmental objectives). The empirical contribution lies in insights on how the RCs have developed as an unintended consequence of entrepreneurial deliberate action in the process of creating NQRs. These findings are based on documents, interviews, and previous research in the social sciences. The article also argues for a critical understanding of public knowledge management (PKM) related to experiences in the development of NQRs regarding how to use knowledge in healthcare government. This article highlights how knowledge generated in quality systems based on registries could imply a stronger role for authorities in exerting control over the medical profession. It also discusses the potential use of research evidence on NQRs as a base for more efficient policymaking.

Introduction of open visiting policy in intensive care units in Ukraine: policy analysis and the ethical perspective

Open visiting policy (OVP) in intensive care units (ICU) is considered a favorable visiting regime that may benefit patients and their family members as well as medical staff. The article examines the conditions and causes of OVP-making process in Ukraine and presents the ethical analysis of its implications with respect to the key stakeholders: ICU patients, family members, and medical staff. The OVP, established by the Ministry of Health in June, 2016, changes current approaches to the recognition of the role of families in critically ill patients' care dramatically; it does, however, have serious shortcomings. The analysis of risks and benefits showed that OVP does not adequately cater to the needs of all the key players-family members, patients, and medical staff. Moreover, there is no clear mechanism to control OVP implementation via feedback from all the key players (particularly patients and their families). These issues give rise to a concern that the implementation of OVP will die on the vine. In order to prevent this, a range of measures is required: the optimization of the ICU facilities and internal procedures, supervision of OVP implementation by policy-makers, training of medical staff, and providing family members with educational programs. Considering current shortcomings, it is crucially important to develop clear and consistent internal guidelines in hospitals that will guarantee the introduction of open ICU visiting and quality of critical care provisions.

Examination of the British Columbia influenza prevention policy for healthcare workers: Phase 1 qualitative case study

In August 2012, British Columbia became the first Canadian province to implement a province-wide Influenza Prevention Policy requiring all healthcare workers (HCWs) in residential and acute care facilities to either be immunized against influenza, or wear masks in patient care areas during the influenza season. This qualitative case study sought to understand the key facilitators and barriers involved in developing and implementing British Columbia's Influenza Prevention Policy. An explanatory qualitative case study approach was selected for this project. Data were collected through the review of 110 documents (policy and planning documents, implementation tools, press releases, communication materials, etc.), and through 7 focus groups with policy implementation team members (n = 48). Focus group interview transcripts were analyzed using Framework Analysis methods, and Prior's approach guided document analysis. Four themes were identified: (1) Clashing paradigms, (2) Policy implementation gaps, (3) Pathways of power, and (4) Personal impacts. Issues embedded in macro-, meso-, and micro-level contexts, and planning across the province, were identified as critical to policy implementation. A province-wide approach with senior-level engagement and dedicated resources is critical in a province-wide influenza prevention policy for HCW. Recommendations to improve large-scale implementation of condition-of-service influenza policies include: engaging stakeholders early, considering the complexity of political contexts, allotting time to plan appropriately, developing 'enforcement' plans, and providing education and skills to frontline providers.

Health Brokers: How Can They Help Deal with the Wickedness of Public Health Problems?

Background

The role of health broker is a relatively new one in public health. Health brokers aim to create support for efforts to optimise health promotion in complex or even “wicked” public health contexts by facilitating intersectoral collaborations and by exchanging knowledge with different stakeholders. The current study aimed to explore the role of health brokers, by examining the motivational, contextual, and behaviour-related factors they have to deal with.

Methods

Fifteen professionals from various backgrounds and from various policy and practice organisations were recruited for a semistructured interview. To structure the interviews, we developed the “Health Broker Wheel” (HBW), a framework we then specified with more details derived from the interviews.

Results

We identified seven primary types of behaviour that health brokers need to engage in: recognizing opportunities, agenda setting, implementing, network formation, intersectoral collaboration, adaptive managing, and leadership. Determinants of health brokers' behaviours were identified and categorised as capability, opportunities, motivation, and local or national contextual factors.

Conclusion

The health brokers' role can be seen as an operational approach and is visualised in the HBW. This framework can assist further research to monitor and evaluate this role, and health promotion practitioners can use it as a tool to implement the health brokers' role and to facilitate intersectoral collaboration.

Interpretation and use of evidence in state policymaking: a qualitative analysis

INTRODUCTION

Researchers advocating for evidence-informed policy have attempted to encourage policymakers to develop a greater understanding of research and researchers to develop a better understanding of the policymaking process. Our aim was to apply findings drawn from studies of the policymaking process, specifically the theory of policy windows, to identify strategies used to integrate evidence into policymaking and points in the policymaking process where evidence was more or less relevant.

METHODS

Our observational study relied on interviews conducted with 24 policymakers from the USA who had been trained to interpret scientific research in multiple iterations of an evidence-based workshop. Participants were asked to describe cases where they had been involved in making health policy and to provide examples in which research was used, either successfully or unsuccessfully. Interviews were transcribed, independently coded by multiple members of the study team and analysed for content using key words, concepts identified by participants and concepts arising from review of the texts.

RESULTS

Our results suggest that policymakers who focused on health issues used multiple strategies to encourage evidence-informed policymaking. The respondents used a strict definition of what constituted evidence, and relied on their experience with research to discourage the use of less rigorous research. Their experience suggested that evidence was less useful in identifying problems, encouraging political action or ensuring feasibility and more useful in developing policy alternatives.

CONCLUSIONS

Past research has suggested multiple strategies to increase the use of evidence in policymaking, including the development of rapid-response research and policy-oriented summaries of data. Our findings suggest that these strategies may be most relevant to the policymaking stream, which develops policy alternatives. In addition, we identify several strategies that policymakers and researchers can apply to encourage evidence-informed policymaking.

Mapping Priority Setting in Health in 17 Countries Across Asia, Latin America, and sub-Saharan Africa

Abstract-As more low- and middle-income countries (LMICs) commit to universal health coverage (UHC), there is a growing need for rational priority setting using health technology assessment (HTA) and other policy tools. We describe an approach for rapidly mapping LMICs' capacity and needs for rational priority setting, aimed at identifying candidate countries where technical assistance would be most viable, and present our findings from applying this approach to three continents. Drawing on the multiple streams theory and a conceptual model of HTA in health systems, we developed qualitative and quantitative indicators for political commitment, current position along UHC journey, institutional and technical capacity, health system financing characteristics, and potential economies of scale in rational priority setting and associated data collection tools. We additionally defined criteria for shortlisting countries, emphasizing feasibility of technical assistance. We purposively sampled 17 countries and gathered data up to May 2014 from various sources and applied the shortlisting criteria to these countries. The four shortlisted countries (Indonesia, Myanmar, South Africa, Ghana) had varying capacities for rational priority setting and shared clear demand for rational priority setting as a means of achieving UHC. Indonesia was the strongest candidate for technical assistance, given the potential scale of impact on its large population and potential lessons for LMICs transitioning from aid. We conducted additional in-country scoping, and technical assistance to support HTA development in Indonesia is now underway. Our approach is of potential value to development funders and initiatives seeking to maximize the impact of their aid investments in support of UHC.

Introducing New Priority Setting and Resource Allocation Processes in a Canadian Healthcare Organization: A Case Study Analysis Informed by Multiple Streams Theory

BACKGROUND

In this article, we analyze one case instance of how proposals for change to the priority setting and resource allocation (PSRA) processes at a Canadian healthcare institution reached the decision agenda of the organization's senior leadership. We adopt key concepts from an established policy studies framework - Kingdon's multiple streams theory - to inform our analysis.

METHODS

Twenty-six individual interviews were conducted at the IWK Health Centre in Halifax, NS, Canada. Participants were asked to reflect upon the reasons leading up to the implementation of a formal priority setting process - Program Budgeting and Marginal Analysis (PBMA) - in the 2012/2013 fiscal year. Responses were analyzed qualitatively using Kingdon's model as a template.

RESULTS

The introduction of PBMA can be understood as the opening of a policy window. A problem stream - defined as lack of broad engagement and information sharing across service lines in past practice - converged with a known policy solution, PBMA, which addressed the identified problems and was perceived as easy to use and with an evidence-base from past applications across Canada and elsewhere. Conditions in the political realm allowed for this intervention to proceed, but also constrained its potential outcomes.

CONCLUSION

Understanding in a theoretically-informed way how change occurs in healthcare management practices can provide useful lessons to researchers and decision-makers whose aim is to help health systems achieve the most effective use of available financial resources.

Upgrading Preschool Environment in a Swedish Municipality: Evaluation of an Implementation Process

Redesigning outdoor preschool environment may favorably affect multiple factors relevant to health and reach many children. Cross-sectional studies in various landscapes at different latitudes have explored the characteristics of preschool outdoor environment considering the play potential triggering combined physical activity and sun-protective behavior due to space, vegetation, and topography. Criteria were pinpointed to upgrade preschool outdoor environment for multiple health outcomes to be applied in local government in charge of public preschools. Purposeful land use policies and administrative management of outdoor land use may serve to monitor the quality of preschool outdoor environments (upgrading and planning). This study evaluates the process of implementing routines for upgrading outdoor preschool environments in a medium-sized municipality, Sweden, 2008-2011, using qualitative and quantitative analysis. Recorded written material (logs and protocols) related to the project was processed using thematic analysis. Quantitative data (m(2) flat/multileveled, overgrown/naked surface, and fraction of free visible sky) were analyzed to assess the impact of implementation (surface, topography, greenery integrated in play). The preschool outdoor environments were upgraded accordingly. The quality of implementation was assessed using the theory of policy streams approach. Though long-term impact remains to be confirmed the process seems to have changed work routines in the interior management for purposeful upgrading of preschool outdoor environments. The aptitude and applicability of inexpensive methods for assessing, selecting, and upgrading preschool land at various latitudes, climates, and outdoor play policies (including gender aspects and staff policies) should be further discussed, as well as the compilation of data for monitoring and evaluation.

Policy development and implementation in health promotion--from theory to practice: the ADEPT model

There is a growing interest among health promotion researchers to better understand and influence the policy process. However, at this point in time, theoretical concepts enabling researchers to do so are still rare and underused, suggesting a need for new, easy-to-use concepts to explain successes or failures of health promotion policies. This article presents the ADEPT (Analysis of Determinants of Policy Impact) approach, which aims to explain and influence policy development and policy impact implementation with four determinants: goals, obligations, resources and opportunities. ADEPT provides a detailed operationalization for both quantitative and qualitative use. An empirical test of the ADEPT model using a quantitative survey of 719 policy-makers from four health promotion policy fields and six European nations indicated that both policy outputs and policy outcomes are influenced by the four determinants. The approach has, in the meantime, been successfully utilized to analyze and initiate policy development in a number of health promotion projects. Despite a number of limitations, ADEPT provides an easy-to-use, theory-based and parsimonious tool for understanding and influencing policy processes in health promotion. Moreover, as it identifies potential 'levers of influence' and can easily be connected to existing methods of community development or capacity building, it is a particularly powerful tool for policy development.

Health promotion at local level: a case study of content, organization and development in four Swedish municipalities

BACKGROUND

Several health determinants are related to local conditions and prerequisites at community level. For this reason, strengthening community action has been one of five strategies implemented in health promotion since the end of the 1980s. Such action includes setting priorities, making decisions, planning strategies, and implementing them to achieve better health. The aim of this paper is to obtain a deeper understanding of content, organization and processes in the development of local health promotion.

METHODS

A qualitative multiple case study of four Swedish municipalities. The cases were analyzed in accordance with the principles of cross-case study analysis, and a content analysis of documents and interviews was conducted in two steps. First, a manifest content analysis was performed to identify present and former actors and measures. Thereafter, a latent content analysis was performed to investigate structures and processes in local contexts.

RESULTS

The results of the inductive content analysis showed development of local health promotion in three phases: initiation, action, and achievement. Strengthening factors were local actors, health statistics and events. Hindering factors were lack of resources and vague objectives. External factors, e.g. national policies, were not perceived as prominent influencing factors. Media reports were regarded as having had an influence, but only to some extent. The content of local health promotion has developed from ad-hoc lifestyle and behaviour-related actions into structural, intersectoral actions related to determinants of health.

CONCLUSIONS

The municipalities have organized and developed their health promotion targets, actions and priorities on the basis of local needs and prerequisites. The three phases in the identified health promotion processes were experienced and documented as being subject to greater influence from internal rather than external strengthening and hindering factors in their local contexts.