'Including health in systems responsible for urban planning': a realist policy analysis research programme

Why is health improvement policy so difficult to secure?

Many governments seek to improve population health, and some seek to reduce health inequalities. Yet, there remains a large gap between their policy statements and actual outcomes. Perennial questions in public health research include: why is this gap so large, why does it endure, and what can be done to close it? This essay uses political science and policy studies insights to address these questions, focusing on the distinctive issues that relate to (1) broad aims like 'prevention', (2) specific strategies for health improvement, or (3) new events. On the one hand, the idea of 'prevention' has widespread appeal, when governments think they can save money or reduce inequalities by preventing problems happening or worsening. While health protection seeks to inoculate populations against communicable diseases, health improvement strategies, including 'Health in All Policies' (HiAP), primarily address non-communicable diseases (NCDs). Further, the coronavirus disease 2019 (COVID-19) pandemic highlights the unequal spread of ill health, showing that preventive health ideas should be at the core of policy. On the other hand, there is a large gap between rhetorical and substantive commitment to prevention, a continuous HiAP implementation gap, and a tendency for COVID-19 health protection to overshadow health improvement. Explaining each problem clearly helps to identify the factors that generally undermine prevention policies and those specific to more detailed strategies like HiAP or events like COVID-19. We do not prioritise leadership or 'political will' as the policymaking problem. Instead, we identify the systemic factors that apply to even the most sincere, competent, and energetic policymakers. Health improvement policy is typically undermined by a lack of: clarity about what prevention means in practice; congruity between the prevention agenda (emphasising the need for major change to policy and policymaking) and routine government business; and, capacity to overcome obstacles to policy change.

Qualitative Research Methods in Chronic Disease: Introduction and Opportunities to Promote Health Equity

Public health research that addresses chronic disease has historically underutilized and undervalued qualitative methods. This has limited the field's ability to advance (a) a more in-depth understanding of the factors and processes that shape health behaviors, (b) contextualized explanations of interventions' impacts (e.g., why and how something did or did not work for recipients and systems), and (c) opportunities for building and testing theories. We introduce frameworks and methodological approaches common to qualitative research, discuss how and when to apply them in order to advance health equity, and highlight relevant strengths and challenges. We provide an overview of data collection, sampling, and analysis for qualitative research, and we describe research questions that can be addressed by applying qualitative methods across the continuum of chronic disease research. Finally, we offer recommendations to promote the strategic application of rigorous qualitative methods, with an emphasis on priority areas to enhance health equity across the evidence generation continuum.

'Writing budgets for meetings and teas?': a multitheoretical analysis of intragovernmental coordination for multisectoral action for health in Uganda

Introduction

Coordination across policy domains and among government agencies is considered critical for addressing complex challenges such as inequities, urbanisation and climate change. However, the factors influencing coordination among government entities in low-income and middle-income countries are not well known. Although theory building is well suited to explain complex social phenomena, theory-based health policy and systems studies are limited. This paper examined the factors influencing coordination among government entities at the central government level in Uganda.

Methods

This theory-based case study used a qualitative approach. Primary data were collected through 26 national-level key informant interviews supplemented with a review of 6 national strategic and policy documents. Data were analysed abductively using a multitheoretical framework combining the transaction cost economics theory, principal–agent theory, resource dependence theory and political economy perspective.

Results

Complex and dynamic interactions among different factors, both internal and external to the government, were found. Interdependencies, coordination costs, non-aligned interests, and institutional and ideational aspects were crucial factors. The power dynamics within the bureaucratic structures and the agency of the coordinated entities influence the effectiveness of coordination efforts. New public management principles promoted in the 1990s by donor institutional strengthening projects (characterised by agencification and setting up of independent agencies to circumvent ineffective big line ministries) created further fragmentation within the government. The donors and international agendas were occasionally supportive but sometimes counterintuitive to national coordination efforts.

Conclusion

The multitheoretical framework derives a deep analysis of the factors that influence organisational decision-making to coordinate with others or not. Achieving intragovernmental coordination requires more time and resources to guide the software aspects of institutional change—articulating a shared vision on coordination across government. Shaping incentives to align interests, managing coordination costs and navigating historical-institutional contexts are critical. Countervailing political actions and power dynamics should be judiciously navigated.

City deals and health equity in Sydney, Australia

'City Deals' are new governance instruments for urban development. Vast evidence exists on the relationship between urban factors and health equity, but little research applies a health equity lens to urban policy-making. This paper does precisely that for the Western Sydney City Deal (WSCD) in Australia. We conducted a critical discourse analysis of publicly available documents and interviews with the WSCD's main architects, applying insights from relevant theories. We find 'pro-growth' discourse to encourage economic investment dominates any references to disadvantage. Interviewees maintained the WSCDs fundamental purpose is to rebalance urban investment toward the historically disadvantaged West. However, the WSCD makes limited reference to health and none to equity. Institutionalised governance practices that favour private investments in infrastructure remain the dominant force behind the WSCD. We document how a shift to 'place-based' infrastructure has promise for equity but struggles to overcome institutionalised approaches to urban investments.

European-wide policymaking at the urban level: a qualitative study

BACKGROUND

Inter-urban area (UA) health inequalities can be as dramatic as those between high and low-income countries. Policies need to focus on the determinants of health specific to UAs to effect change. This study therefore aimed to determine the degree to which policymakers from different countries could make autonomous health and wellbeing policy decisions for their urban jurisdiction area.

METHODS

We conducted a cross-sectional, qualitative interview study with policymakers recruited from eight European countries (N = 37).

RESULTS

The reported autonomy among policymakers varied considerably between countries, from little or no autonomy and strict adherence to national directives (e.g. Slovak Republic) to a high degree of autonomy and ability to interpret national guidelines to local context (e.g. Norway). The main perceived barriers to implementation of local policies were political, and the importance of regular and effective communication with stakeholders, especially politicians, was emphasized. Having qualified health professionals in positions of influence within the UA was cited as a strong driver of the public health (PH) agenda at the UA level.

CONCLUSION

Local-level policy development and implementation depends strongly on the degree of autonomy and independence of policymakers, which in turn depends on the organization, structure and financial budget allocation of PH services. While high levels of centralization in small, relatively homogenous countries may enhance efficient use of resources, larger, more diverse countries may benefit from devolution to smaller geographical regions.

A health political science for health promotion

If health promotion as a field of change for human and ecological health is to maintain its urgency, it needs to continue building its policy credentials. This paper charts the development of policy as a concern for IUHE/IUHPE (International Union for Health Education/International Union for Health Promotion and Education) from the mid-1970s when 'health education policies' were prominent issues, to the launch of Healthy Public Policy (in the 1980s) and Health in All Policy (in the 2000s). We argue that solid conceptual and theoretical foundations exist to frame and develop the relevance and connectedness of health promotion more prominently. We start off with a brief introduction into (health) political science, and then illustrate the urgency of the argument with three case studies. The first takes a critical realist perspective on 'closing the gap' in Australian Indigenous populations. With recent evidence it demonstrates that the core of the policymaking process needs to re-align itself with an Indigenous narrative. The second case study reviews the politics of healthy urban planning and health equity in cities. Taking a critical theory institutionalist view, the case describes how the political and narrative parallels between urban theory and health equity have gone underexplored. With an explicit gaze to connect the two, the field could become a large and influential driver of enhanced health promotion and public health policy. The third case describes the languages, policy frames, and distinctions, in four urban/health paradigms. It shows that unconscious policy and practice bias exists in policy priorities and processes. We conclude with observations and recommendations on the role of health promotion as a conceptual realm and field of activity. We show that all health promoters should be aware of the political nature of their enterprise. Tools and analyses exist to help further action.

Power and the people's health

Public policy plays a central role in creating and distributing resources and conditions of daily life that matter for health equity. Policy agendas have tended to focus on health care delivery and individualised interventions. Asking why there is a lack of policy action on structural drivers of health inequities raises questions about power inequities in policy systems that maintain the status quo. In this paper we investigate the power dynamics shaping public policy and implications for health equity. Using a Health Equity Power Framework (HEPF), we examined data from 158 qualitative interviews with government, industry and civil society actors across seven policy case studies covering areas of macroeconomics, employment, social protection, welfare reform, health care, infrastructure and land use planning. The influence of structures of capitalism, neoliberalism, sexism, colonisation, racism and biomedicalism were widely evident, manifested through the ideologies, behaviours and discourses of state, market, and civil actors and the institutional spaces they occupied. Structurally less powerful public interest actors made creative use of existing or new institutional spaces, and used network, discursive and moral power to influence policy, with some success in moderating inequities in structural and institutional forms of power. Our hope is that the methodological advancement and empirical data presented here helps to illuminate how public interest actors can navigate structural power inequities in the policy system in order to disrupt the status quo and advance a comprehensive policy agenda on the social determinants of health equity. However, this analysis highlights the unrealistic expectation of turning health inequities around in a short time given the long-term embedded power dynamics and inequities within policy systems under late capitalism. Achieving health equity is a power-saturated long game.

Including health impacts in environmental impact assessments for three Australian coal-mining projects: a documentary analysis

Notwithstanding the historical benefits of coal in aiding human and economic development, the negative health and environmental impacts of coal extraction and processing are of increasing concern. Environmental impact assessments (EIAs) are a regulated policy mechanism that can be used to predict and consider the health impacts of mining projects to determine if consent is given. The ways in which health is considered within EIA is unclear. This research investigated 'How and to what extent are health, well-being and equity issues considered in Environmental Impact Assessments (EIAs) of major coal mining projects in New South Wales, Australia'. To this end we developed and applied a comprehensive coding framework designed to interrogate the publicly available environmental impact statements (EISs) of three mines in New South Wales (NSW), Australia, for their inclusion of health, well-being and equity issues. Analysis of the three EISs demonstrates that: the possible impacts of each mine on health and well-being were narrowly and inadequately considered; when health and well-being were considered there was a failure to assess the possible impacts specific to the particular mine and the communities potentially affected; the cumulative impacts on human health of multiple mines in the same geographical area were almost completely ignored; the discussions of intragenerational and intergenerational equity did not demonstrate a sound understanding of equity and, it is essential that governments' requirements for the EIA include detailed analysis of the health, well-being, equity and cumulative impacts specific to the proposed mine and relevant communities.

Understanding Australian policies on public health using social and political science theories: reflections from an Academy of the Social Sciences in Australia Workshop

There is strong, and growing, evidence documenting health inequities across the world. However, most governments do not prioritize policies to encourage action on the social determinants of health and health equity. Furthermore, despite evidence concerning the benefits of joined-up, intersectoral policy to promote health and health equity, it is rare for such policy approaches to be applied systematically. To examine the usefulness of political and social science theory in understanding the reasons for this disjuncture between evidence and practice, researchers and public servants gathered in Adelaide for an Academy of the Social Sciences in Australia (ASSA) Workshop. This paper draws together the learnings that emerged from the Workshop, including key messages about the usefulness of various theories as well as insights drawn from policy practice. Discussions during the Workshop highlighted that applying multiple theories is particularly helpful in directing attention to, and understanding, the influence of all stages of the policy process; from the construction and framing of policy problems, to the implementation of policy and evaluation of outcomes, including those outcomes that may be unintended. In addition, the Workshop emphasized the value of collaborations among public health researchers, political and social scientists and public servants to open up critical discussion about the intersections between theory, research evidence and practice. Such critique is vital to render visible the processes through which particular sources of knowledge may be privileged over others and to examine how political and bureaucratic environments shape policy proposals and implementation action.

Healthy urban planning: an institutional policy analysis of strategic planning in Sydney, Australia

Rapid urbanization requires health promotion practitioners to understand and engage with strategic city planning. This policy analysis research investigated how and why health was taken up into strategic land use planning in Sydney, Australia, between 2013 and 2018. This qualitative study develops two case studies of consecutive instances of strategic planning in Sydney. Data collection was done via in-depth stakeholder interviews (n = 11) and documentary analysis. Data collection and analysis revolved around core categories underpinning policy institutions (actors, structures, ideas, governance and power) to develop an explanatory narrative of the progress of ‘health’ in policy discourse over the study period. The two strategic planning efforts shifted in policy discourse. In the earlier plan, ‘healthy built environments’ was positioned as a strategic direction, but without a mandate for action the emphasis was lost in an economic growth agenda. The second effort shifted that agenda to ecological sustainability, a core aspect of which was ‘Liveability’, having greater potential for health promotion. However, ‘health’ remained underdeveloped as a core driver for city planning remaining without an institutional mandate. Instead, infrastructure coordination was the defining strategic city problem and this paradigm defaulted to emphasizing ‘health precincts’ rather than positioning health as core for the city. This research demonstrates the utility in institutional analysis to understanding positioning health promotion in city planning. Despite potential shifts in policy discourse and a more sophisticated approach to planning holistically, the challenge remains of embedding health within the institutional mandates driving city planning.

Researching Healthy Public Policy: Navigating the 'Black Box' Means Thinking More About Power Comment on "Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia"

Lawless et al provide a valuable narrative of using program logic to develop an evaluation of Health in All Policies (HiAP) in South Australia. In this commentary I argue that the paper and analysis is an extremely useful example of navigating the supposed black box of policy-making. However the original makes the reader work too hard and is distracting from the main narrative of explaining the logic behind the HiAP approach in South Australia. My response covers avoiding epistemological traps and weighing up the pragmatics of collaborative policy research with more complex institutional policy issues like power.

Policies, Politics, and Paradigms: Healthy Planning in Australian Local Government

Local government in Australia is critically positioned to provide built environment initiatives that respond to the increasing prevalence of non-communicable diseases (NCD), climate change, and various other human and ecological health considerations. However, action on the ground has not been as widespread as might be expected, particularly in improving community health. This research explores the barriers to and enablers of the implementation of healthy planning and active living initiatives through in-depth interviews with healthy planning and active living advocates. Advocates are seen to promote healthy planning in relatively weak policy settings, where politicised, largely reactive decisions by individual politicians or practitioners are the main determinants of project success. The most important factor affecting project uptake and implementation is how the ‘problem’ of healthy planning, or what might be considered a healthy planning paradigm, is presented. Such a paradigm includes a strong reliance on the co-benefits of projects; it is also subject to the way that healthy planning is communicated and framed. Potential problems around such a setting are subsequently examined, identifying the potential reasons for the slow delivery of healthy planning.

Urban green spaces and cancer: a protocol for a scoping review

INTRODUCTION

Green space in the built environment is an important topic on the health agenda today. Studies have shown that access to green spaces is associated with better mental and physical health, yet green spaces can also be detrimental to health if they are not managed appropriately. Despite the increasing interest in urban green spaces, little research has so far been conducted into the links between green spaces and cancer.

OBJECTIVE

The purpose of this scoping review is therefore to map the literature available on the types of relationship between urban green spaces and cancer.

METHOD AND ANALYSIS

We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 guideline to report the protocol. To conduct this scoping review, we will use a structured search strategy based on controlled vocabulary and relevant key terms related to green space, urban space and cancer. We will search MEDLINE (PubMed), GreenFILE (EBSCOhost), Cumulative Index to Nursing and Allied Health Literature (EBSCOhost) and ScienceDirect as electronic database as well as hand-search publications for grey literature. This review will therefore provide evidence on this current topic, one which could have practical implications for policy-makers involved in choices which are more conducive to healthy living.

ETHICS AND DISSEMINATION

No primary data will be collected since all data that will be presented in this review are based on published articles and publicly available documents, and therefore ethics committee approval is not a requirement. The findings of this review will be presented at workshops and conferences, and will be submitted for publication in a peer-reviewed journal.

Including Health in Environmental Assessments of Major Transport Infrastructure Projects: A Documentary Analysis

Background: Transport policy and practice impacts health. Environmental Impact Assessments (EIAs) are regulated public policy mechanisms that can be used to consider the health impacts of major transport projects before they are approved. The way health is considered in these environmental assessments (EAs) is not well known. This research asked: How and to what extent was human health considered in EAs of four major transport projects in Australia.

Methods: We developed a comprehensive coding framework to analyse the Environmental Impact Statements (EISs) of four transport infrastructure projects: three road and one light rail. The coding framework was designed to capture how health was directly and indirectly included.

Results: We found that health was partially considered in all four EISs. In the three New South Wales (NSW) projects, but not the one South Australian project, this was influenced by the requirements issued to proponents by the government which directed the content of the EIS. Health was assessed using human health risk assessment (HHRA). We found this to be narrow in focus and revealed a need for a broader social determinants of health approach, using multiple methods. The road assessments emphasised air quality and noise risks, concluding these were minimal or predicted to improve. The South Australian project was the only road project not to include health data explicitly. The light rail EIS considered the health benefits of the project whereas the others focused on risk. Only one project considered mental health, although in less detail than air quality or noise.

Conclusion: Our findings suggest EIAs lag behind the known evidence linking transport infrastructure to health. If health is to be comprehensively included, a more complete model of health is required, as well as a shift away from health risk assessment as the main method used. This needs to be mandatory for all significant developments. We also found that considering health only at the EIA stage may be a significant limitation, and there is a need for health issues to be considered when earlier, fundamental decisions about the project are being made.

Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis

Background

Good governance may result in strengthened performance of a health system. Coherent policies are essential for good health system governance. The overall aim of this research is to provide the best available scientific evidence on principles of good policy related leadership and governance of health related rehabilitation services in less resourced settings. This research was also conducted to support development of the World Health Organization’s (WHO) Guidelines on health related rehabilitation.

Methods

An innovative study design was used, comprising two methods: a systematic search and realist synthesis of literature, and a Delphi survey of expert stakeholders to refine and triangulate findings from the realist synthesis. In accordance with Pawson and Tilley’s approach to realist synthesis, we identified context mechanism outcome pattern configurations (CMOCs) from the literature. Subsequently, these CMOCs were developed into statements for the Delphi survey, whereby 18 expert stakeholders refined these statements to achieve consensus on recommendations for policy related governance of health related rehabilitation.

Results

Several broad principles emerged throughout formulation of recommendations: participation of persons with disabilities in policy processes to improve programme responsiveness, efficiency, effectiveness, and sustainability, and to strengthen service-user self-determination and satisfaction; collection of disaggregated disability statistics to support political momentum, decision-making of policymakers, evaluation, accountability, and equitable allocation of resources; explicit promotion in policies of access to services for all subgroups of persons with disabilities and service-users to support equitable and accessible services; robust inter-sectoral coordination to cultivate coherent mandates across governmental departments regarding service provision; and ‘institutionalizing’ programmes by aligning them with preexisting Ministerial models of healthcare to support programme sustainability.

Conclusions

Alongside national policymakers, our policy recommendations are relevant for several stakeholders, including service providers and service-users. This research aims to provide broad policy recommendations, rather than a strict formula, in acknowledgement of contextual diversity and complexity. Accordingly, our study proposes general principles regarding optimal policy related governance of health related rehabilitation in less resourced settings, which may be valuable across diverse health systems and contexts.

Framing health for land-use planning legislation: A qualitative descriptive content analysis

PURPOSE AND SETTING

Framing health as a relevant policy issue for other sectors is not well understood. A recent review of the New South Wales (Australia) land-use planning system resulted in the drafting of legislation with an internationally unprecedented focus on human health. We apply a political science approach to investigate the question 'how and to what extent were health and wider issues framed in submissions to the review?'

METHODS

We investigated a range of stakeholder submissions including health focussed agencies (n = 31), purposively identified key stakeholders with influence on the review (n = 24), and a random sample of other agencies and individuals (n = 47). Using qualitative descriptive analysis we inductively coded for the term 'health' and sub-categories. We deductively coded for 'wider concerns' using a locally endorsed 'Healthy Urban Development Checklist'. Additional inductive analysis uncovered further 'wider concerns'.

FINDINGS

Health was explicitly identified as a relevant issue for planning policy only in submissions by health-focussed agencies. This framing concerned the new planning system promoting and protecting health as well as connecting health to wider planning concerns including economic issues, transport, public open space and, to a slightly lesser extent, environmental sustainability. Key stakeholder and other agency submissions focussed on these and other wider planning concerns but did not mention health in detail. Health agency submissions did not emphasise infrastructure, density or housing as explicitly as others.

CONCLUSIONS

Framing health as a relevant policy issue has the potential to influence legislative change governing the business of other sectors. Without submissions from health agencies arguing the importance of having health as an objective in the proposed legislation it is unlikely health considerations would have gained prominence in the draft bill. The findings have implications for health agency engagement with legislative change processes and beyond in land use planning.