The implementation of Health in All Policies initiatives: a systems framework for government action

Trends in Suicides and Homicides in 21st Century America

BACKGROUND

Violent deaths, including suicides and homicides, pose a significant public health challenge in the United States. Understanding the trends and identifying associated risk factors is crucial for targeted intervention strategies.

AIM

To examine the trends in suicides and homicides over the past two decades and identify demographic and contextual predictors using the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System online database.

METHODS

A retrospective analysis of mortality records from 2000 to 2020 was conducted, utilizing multivariate regression analyses. Covariates included age, race, sex, education, mental health conditions, and time period. Age-adjusted rates were employed to assess trends.

RESULTS

Over the 20 years, there was an upward trajectory in suicide rates, increasing from approximately 10/100,000 to over 14/100,000 individuals, which is a notable increase among American Indians (100.8% increase) and individuals aged 25 years and younger (45.3% increase). Homicide rates, while relatively stable, exhibited a significant increase in 2019-2020, with African Americans consistently having the highest rates and a significant increase among American Indians (73.2% increase). In the multivariate regression analysis, Individuals with advanced education (OR= 1.74, 95% CI= 1.70 - 1.78), depression (OR = 13.47, 95% CI = 13.04 - 13.91), and bipolar disorder (OR = 2.65, 95% CI = 2.44 - 2.88) had higher odds of suicide. Risk factors for homicide include African Americans (OR = 4.15, 95% CI = 4.08 - 4.23), Latinx (OR = 2.31, 95% CI = 2.26 - 2.37), people aged 25 years and younger, and those with lower educational attainment.

CONCLUSION

This study highlights the changing demographic pattern in suicides and homicides in the United States and the need for targeted public health responses. Means restriction, universal suicide screening, addressing mental health stigma, and implementing broad interventions that modify societal attitudes toward suicide and homicides are essential components of a comprehensive strategy.

Wake-up call for HPPP - health promotion, prevention, and preparedness

The latest public health emergencies exposed urgent gaps in health promotion, prevention and preparedness (HPPP). Existing and new infectious diseases have gained far more prevalence than expected, and inequities in access to health care accounted for disturbing differences in the toll of these diseases in different populations. The COVID-19 pandemic not only demonstrated the need to prevent the onset and progression of non-communicable chronic diseases (NCDs) and promote healthy lifestyles, but also the need to prepare for new infectious diseases and their long-term effects on both physical and mental health. Preparedness was previously associated with natural disasters, with activities directed to developing emergency humanitarian action response resources. However, these actions are inadequate for the frequent natural disasters as the climate crisis intensifies. To reach effective actions in HPPP, we take a broad approach to HPPP components, identify the main stakeholders and suggest methods to change allocations for HPPP. We propose a call for action at global and national levels, involving strengthening the United Nations' Sustainable Development Goals and government commitment to HPPP.

Equilibrium in the governance of cross-sectoral policies: how does it translate into practice?

BACKGROUND

There is growing interest from health researchers in the governance of Health in All Policies (HiAP). Furthermore, the COVID-19 pandemic has re-ignited managers' interest in HiAP governance and in health prevention activities that involve actors from outside health ministries. Since the dynamics of these multi-actor, multi-sectoral policies are complex, the use of systems theory is a promising avenue toward understanding and improving HiAP governance. We focus on the concept of equilibrium within systems theory, especially as it points to the need to strike a balance between actors that goes beyond synergies or mimicry-a balance that is essential to HiAP governance.

METHOD

We mobilized two sources of data to understand how the concept of equilibrium applies to HiAP governance. First, we reviewed the literature on existing frameworks for collaborative governance, both in general and for HiAP specifically, in order to extract equilibrium-related elements. Second, we conducted an in-depth case study over three years of an HiAP implemented in Quebec, Canada.

RESULTS

In total, we identified 12 equilibrium-related elements relevant to HiAP governance and related to knowledge, actors, learning, mindsets, sustainability, principles, coordination, funding and roles. The equilibria were both operational and conceptual in nature.

CONCLUSIONS

We conclude that policy makers and policy implementers could benefit from mobilizing these 12 equilibrium-related elements to enhance HiAP governance. Evaluators of HiAP may also want to consider and integrate them into their governance assessments.

Health in All Policies at the Local Level: What Facilitates Success? Comment on "A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland"

The paper by Guglielmin and colleagues1 examines the implementation of Health in All Policies (HiAP) in a local government context in Kuopio Finland. The authors use a realist explanatory case study design to explore what has supported HiAP implementation with a focus on two specific hypotheses on what leads to success: common goals and committed leadership and staff. The paper is well argued using appropriate methodology and their findings support the importance of the success factors tested by their two hypotheses. However, the narrowed focus on just two hypotheses underrepresents the complexity of implementing HiAP at any level of government, including local government. Given its local government focus, the paper would have been strengthened by referencing the lessons gained from the Healthy Cities movement. Local government is a critical setting for action to address health and health equity and there is great potential to continue research that adds to the knowledge base on how to successful implement HiAP. Finally, it is important to acknowledge that Finland has a unique HiAP history. It is recognised as a global leader in the field, and the role of local government in Finland differs from many other countries. These factors may impact on the transferability of the case study findings.

Examining the influence of health sector coordination on the efficiency of county health systems in Kenya

BACKGROUND

Health systems are complex, consisting of multiple interacting structures and actors whose effective coordination is paramount to enhancing health system goals. Health sector coordination is a potential source of inefficiency in the health sector. We examined how the coordination of the health sector affects health system efficiency in Kenya.

METHODS

We conducted a qualitative cross-sectional study, collecting data at the national level and in two purposely selected counties in Kenya. We collected data using in-depth interviews (n = 37) with national and county-level respondents, and document reviews. We analyzed the data using a thematic approach.

RESULTS

The study found that while formal coordination structures exist in the Kenyan health system, duplication, fragmentation, and misalignment of health system functions and actor actions compromise the coordination of the health sector. These challenges were observed in both vertical (coordination within the ministry of health, within the county departments of health, and between the national ministry of health and the county department of health) and horizontal coordination mechanisms (coordination between the ministry of health or the county department of health and non-state partners, and coordination among county governments). These coordination challenges are likely to impact the efficiency of the Kenyan health system by increasing the transaction costs of health system functions. Inadequate coordination also impairs the implementation of health programmes and hence compromises health system performance.

CONCLUSION

The efficiency of the Kenyan health system could be enhanced by strengthening the coordination of the Kenyan health sector. This can be achieved by aligning and harmonizing the intergovernmental and health sector-specific coordination mechanisms, strengthening the implementation of the Kenya health sector coordination framework at the county level, and enhancing donor coordination through common funding arrangements and integrating vertical disease programs with the rest of the health system. The ministry of health and county departments of health should also review internal organizational structures to enhance functional and role clarity of organizational units and staff, respectively. Finally, counties should consider initiating health sector coordination mechanisms between counties to reduce the fragmentation of health system functions across neighboring counties.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

How to collaborate for health throughout the project timeline - a longitudinal study reflecting on implemented strategies in three projects for a healthy living environment

BACKGROUND

When improving the health of local and regional populations, cross-sector collaboration between different policy domains, non-governmental organisations and citizens themselves is needed. Previously, enabling factors and strategies have been identified to improve cross-sector collaboration for health. However, few longitudinal studies have been conducted to understand how the implementation of strategies for cross-sector collaboration changes throughout the collaboration process. The aim of this study is therefore to learn more about the different strategies that were implemented throughout three cross-sector collaboration projects for a healthy living environment.

METHODS

The realist evaluation approach was used to understand how the implemented strategies worked, in which context, why and with what outcomes. Project partners were asked to reflect on their implemented strategies at two different moments in the project timelines, and quarterly updates with project leaders were held. In addition two reference panels were organised for data triangulation.

RESULTS

Three key insights for successful cross-sector collaboration throughout projects for a healthy living environment were identified, namely 1. Investing in trust among the partners and faith in the project has a positive influence on continuing the collaboration throughout the project; 2. Making stakeholders actively participate throughout the project requires additional strategies after the onset of the project, and 3. Defining roles, tasks, and other prerequisites at the start of the project helps in pursuing the project over time, but needs re-examination throughout the project. These key insights were based on multiple examples of implemented strategies, linked to context, mechanisms and outcomes.

CONCLUSIONS

This study shows the different strategies that can be employed as the collaboration in projects for a healthy living environment progresses. We found that 'trust' does not merely include the relationships built between the partners, but at the onset of projects can also be based on faith in the project itself. In addition, as it can be difficult to foresee the right investments and strategies at the onset of the project, frequent reflection moments to choose fitting strategies might benefit regional partners in their cross-sector collaboration for health.

How effective is the health promotion policy in Sichuan, China: based on the PMC-Index model and field evaluation

BACKGROUND

Many countries around the world highlight the health in all policies (HiAP). However, most of the related research focused on the influential factors and implementation strategies, with less concern on the evaluation of HiAP. In response to HiAP's call, the Chinese government has proposed health promotion policies (HPPs) in counties or districts, the evaluation of HPPs in sample counties or districts of Sichuan province in China is an essential basis for optimizing policy content, improving policy implementation, and ensuring health promotion's continuous and efficient operation.

METHODS

This paper established an evaluation system for HPPs based on the PMC-Index model and then quantitatively analyzed 37 representative HPPs from the pilot areas in Sichuan province. In addition, a team of experts conducted a field assessment.

RESULTS

The results showed that the average PMC index of 37 HPPs was 7.091, and correlation analysis showed that there was a significant correlation between the PMC index and expert score.

CONCLUSIONS

This study indicates that the overall consistency of HPPs was good and proves a connection between the formulation and implementation of HPPs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

How and why buy-in for health in all policies was facilitated in Ecuador: a realist case study of Plan Nacional para el Buen Vivir

BACKGROUND

In 2008, Ecuador introduced Plan Nacional para el Buen Vivir (PNBV; National Plan for Good Living), which was widely recognized as a promising example of Health in All Policies (HiAP) due to the integration of policy sectors on health and health equity objectives. PBNV was implemented through three successive plans (2009-2013, 2013-2017, 2017-2021). In a time of widening global health inequities, there is growing interest in understanding how politics and governance shape HiAP implementation. The objective of this study was to test specific hypotheses about how, why, to what extent, and under what circumstances HiAP was implemented in Ecuador.

METHODS

An explanatory case study approach (HiAP Analysis using Realist Methods on International Case Studies-HARMONICS) was used to understand the processes that hindered or facilitated HiAP implementation. Realist methods and systems theory were employed to test hypotheses through analysis of empirical and grey literature, and 19 key informant interviews. This case study focused on processes related to buy-in for a HiAP approach by diverse policy sectors, particularly in relation to the strong mandate and transformative governance approach that were introduced by then-President Rafael Correa's administration to support PNBV.

RESULTS

The mandate and governance approach of the HiAP approach achieved buy-in for implementation across diverse sectors. Support for the hypotheses was found through direct evidence about buy-in for HiAP implementation by policy sectors; and indirect evidence about allocation of governmental resources for HiAP implementation. Key mechanisms identified included: influence of political elites; challenges in dealing with political opposition and 'siloed' ways of thinking; and the role of strategies and resources in motivating buy-in.

CONCLUSION

In Ecuador, political elites were a catalyst for mechanisms that impacted buy-in and government funding for HiAP implementation. They raised awareness among policy sectors initially opposed to PNBV about the rationale for changing governance practices, and they provided financial resources to support efforts related to PNBV. Specific mechanisms help explain these phenomena further. Future studies should examine ways that PNBV may have been an impediment to health equity for some marginalized groups while strengthening HiAP implementation.

From Health in All Policies to Health for All Policies

Worldwide responses to the COVID-19 pandemic have shown that it is possible for politicians to come together across departmental boundaries. To this end, in many countries, heads of government and their health ministers work closely with all other ministries, departments, and sectors, including social affairs, internal affairs, foreign affairs, research and education, transport, agriculture, business, and state aid. In this Viewpoint, we ask if and how the Sustainable Development Goals (SDGs) can support intersectoral collaboration to promote health, since governments have already committed to achieving them. We contend that SDGs can do so, ultimately advancing health while offering co-benefits across society.

What are the Tools Available for the Job? Coordination Instruments at Uganda's Central Government Level and Their Implications for Multisectoral Action for Health

Managing sectoral interdependences requires functional tools that facilitate coordinated multisectoral efforts. The pursuit of multisectoral action (MSA) for health is intrinsically linked to broader efforts in many governments to achieve greater internal coordination. This research explores the nature of coordination instruments for MSA at the national level in Uganda and the complexities of how these tools play out in implementation. Data was collected through 26 purposive in-depth interviews with national-level stakeholders, including government officials and non-state actors, and a review of selected government strategic documents. An adapted framework by Bouckaert and colleagues (2010) was used to establish a typology of coordination instruments (CIs) and break them down into structural and management tools, and infer their underlying coordination mechanisms based on their design and operational features. A multitheoretical framework guided the analysis of the factors influencing the implementation dynamics and functioning of the tools. The study found that the government of Uganda uses a range of structural and management instrument mixes mutually influencing each other and mainly based on hierarchy and network mechanisms. These instruments constitute and generate the resources that structure interorganisational relationships across vertical and horizontal boundaries. The instrument mixes also create hybrid institutional configurations that generate complementary but at times conflicting influences. This study demonstrated that a contextualized examination of specific coordination tools can be enhanced by delineating the underlying institutional forms of ideal type mechanisms. Such an approach can inspire more complex analysis and comparisons of CIs within and across government levels, policy domains or issues over time. Health policy and systems research needs to pay attention to the instrument mixes in government systems and their dynamic interaction across policy issues and over time.

Examining Intersectoral Action as an Approach to Implementing Multistakeholder Collaborations to Achieve the Sustainable Development Goals

Objectives: The Sustainable Development Goals (SDGs) re-orient action towards improving the social and ecological determinants of health and equity. SDG 17 calls for enhanced policy and institutional coherence and strong multi-stakeholder partnerships. Intersectoral action (IA) has a promising history in public health, including health promotion and global health. Some experts see IA as crucial to the SDGs. Yet less is known about how IA is conceptualized and what promising models exist with relevance to the SDGs. We sought to investigate how IA is understood conceptually and empirically.

Methods: We conducted a narrative review of global public health and political science literatures and grey literature on the SDGs to identify theoretical models, case studies and reviews of IA research.

Results: Multiple competing conceptualizations of IA exist. Research has focused on case studies in high-income countries. More conceptual clarity, analyses of applications in LMICs, and explorations of political and institutional factors affecting IA are needed, as is attention to power dynamics between sectors.

Conclusion: IA is required to collaborate on the SDGs and address equity. New models for successful implementation merit exploration.

Theory-based capacity building intervention for intersectoral action for health at local governments: An exploratory pilot study

Aim

To design, implement and evaluate a nurse‐led capacity building intervention (PromoGOB) for intersectoral action for health at local governments.

Design

The programme was based on theories of the policy process and organizational change and facilitated by a nurse developing a health broker role. A complex intervention perspective was adopted in carrying out the study. The intervention was evaluated using a mixed method embedded design.

Methods

Quantitative component relied on a specific questionnaire. This tool, designed and piloted ad hoc, measured the capacity in terms of knowledge, awareness, resources, skills, and commitment, both at sectoral and government levels. For the qualitative component, semi‐structured interviews were conducted. These explored the perceived capacity and feasibility and acceptability issues. The programme was initiated at the end of October 2019, and it lasted a total of 5 weeks. Nineteen individuals representing various sectors at a local government in northern Spain participated in the study. The data analysis was concluded by the end of March 2020.

Findings

PromoGOB positively influenced participants' capacity for addressing health promotion. Awareness component, intersectoral work and the nurse as health broker were essential in the programme. The necessity of political participation was identified as an issue to be prioritized in future studies.

Conclusion

This study highlights the relevance of capacity building at local governments and the role that nurses can play in it. Further work should be undertaken to continue developing Health in All Policies approach at local level.

Impact

This study offers a starting point for nurses to get involved in the policy process of health promotion, performing a specific role as health brokers, building capacity at local governments for addressing social determinants of health, and delving into theories and concepts of the Health in All Policies field.

Leveraging Social and Structural Determinants of Health at the Centers for Disease Control and Prevention: A Systems-Level Opportunity to Improve Public Health

CONTEXT

Social and structural determinants of health (SDOH) have become part of the public health and health care landscape. The need to address SDOH is reinforced by morbidity and mortality trends, including a recent multiyear decrease in life expectancy and persistent health disparities. Leadership on SDOH-related efforts has come from public health, health care, private philanthropy, and nongovernmental entities.

STRATEGY

The Centers for Disease Control and Prevention (CDC) has been addressing SDOH through both disease- or condition-specific programs and crosscutting offices. Guidance from public health partners in the field has led the CDC to consider more strategic approaches to incorporating SDOH into public health activities.

IMPLEMENTATION

The CDC's crosscutting SDOH Workgroup responded to external recommendations to develop a specific vision and plan that aims to integrate SDOH into the agency's infrastructure. The group also sponsors CDC forums for sharing research and trainings on embedding SDOH in programs. The group created a Web site to centralize CDC SDOH research, data sources, practice tools, programs, and policies.

PROGRESS

The CDC has shown strong leadership in prioritizing SDOH in recent years. Individual programs and crosscutting offices have developed various models aimed at ensuring that public health research and practice address SDOH.

DISCUSSION

Building sustainable SDOH infrastructures in public health institutions that reach across multiple health topics and non-health organizations could increase chances of meeting public health morbidity and mortality reduction goals, including decreasing health disparities. Although public health priorities and socioeconomic trends will change over time, experience suggests that social and structural factors will continue to influence the public's health. The CDC and state, tribal, local, and territorial public health institutions have played important leadership roles in the system of community and service organizations that interface with communities they mutually serve to address SDOH. Continued capacity-building could help grow and sustain an SDOH infrastructure that advances this work.

The Covid-19 pandemic reinforces the need for sustainable health planning

The 2030 Agenda for Sustainable Development highlighted the growing attention to the adequacy of health planning models to sustainable development. A re-reading of the results of a round table debate on "sustainable planning", which took place at the 5th National Congress of Tropical Medicine (Portugal, 2019) under a participant observation strategy, framed by the findings of a "synthesis of better evidence" literature review and cross-referenced with the reflections of different authors and experts about the momentum created by the COVID-19 pandemic, underlined the challenges to sustainable health planning that have emerged and are projected beyond the current pandemic context. Variable perceptions of the term "sustainable health development", leading to the potential loss of their relevance in guiding the elaboration of policies and strategic plans, and the potential higher effectiveness of the participatory approaches of health planning in achieving sustainable health were highlighted in the debate and literature, in general and in public health emergency contexts. Those results gained new relevance during the current COVID-19 pandemic, bringing back to the forefront a reflection of the inadequate planning framework that has usually been used to understand and respond to global health challenges, despite the already existing experience, evidence and support instruments.

'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.

What key conditions and mechanisms generate health inequalities research in different contexts? Study protocol for two realist explanatory case studies

Evidence on health inequalities has grown in recent decades, however, the capacity to generate health inequalities research is uneven, worldwide. A recent bibliometric analysis found notable inequalities of the global production of health inequalities scientific research across countries. What determines the capacity to produce high volumes of health inequalities scientific research, in different settings? What mechanisms are involved? To answer these questions requires in-depth knowledge on the health inequalities research production process, in different settings. We plan to conduct two realist explanatory case studies, to understand why and how particular settings (e.g. the United Kingdom and the city of Barcelona) have generated high volumes of health inequalities research over past decades, and identify the potential key contextual conditions and causal mechanisms involved. This study protocol outlines the rationale and methodology involved, highlights the strengths and limitations of the approach, and provides guidance on how to overcome certain operational challenges and ensure validity of research findings. Valuable learning may be derived from these case experiences, with implications for research, policy and practice. This work can serve as a tool for researcher and planners to guide the development of further case studies to evaluate health inequalities research capacities in other settings.

'Health in All Policies'-A Key Driver for Health and Well-Being in a Post-COVID-19 Pandemic World

Policy in all sectors affects health, through multiple pathways and determinants. Health in all policies (HiAP) is an approach that seeks to identify and influence the health and equity impacts of policy decisions, to enhance health benefits and avoid harm. This usually involves the use of health impact assessment or health lens analysis. There is growing international experience in these approaches, and some countries have cross-sectoral governance structures that prioritize the assessment of the policies that are most likely to affect health. The fundamental elements of HiAP are inter-sectoral collaboration, policy influence, and holistic consideration of the range of health determinants affected by a policy area or proposal. HiAP requires public health professionals to invest time to build partnerships and engage meaningfully with the sectors affecting the social determinants of health and health equity. With commitment, political will and tools such as the health impact assessment, it provides a powerful approach to integrated policymaking that promotes health, well-being, and equity. The COVID-19 pandemic has raised the profile of public health and highlighted the links between health and other policy areas. This paper describes the rationale for, and principles underpinning, HiAP mechanisms, including HIA, experiences, challenges and opportunities for the future.

Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health

By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.

Opportunity for HiAP through a Healthy Cities initiative in Taiwan: a multiple streams analysis

Health in All Policies (HiAP) is an effective approach to promote population health through addressing comprehensive social determinants of health. In 1997, the World Health Organization designed a 20-step protocol for developing a Healthy Cities (HC) project to build healthy public policies. Taiwan adopted the concept of HC in 2002 and established the first demonstration project in Tainan City in 2003. This study explores the impact of the HC initiative on the development of HiAP, as well as how a window of opportunities for HiAP was opened through the HC movement, using Tainan City as an example. Tainan was selected as the case for this study because of its relative maturity in the development of an HC initiative. A theory-driven thematic analysis was conducted in the study with archived documents between 2003 and 2010. We first adopted a Multiple Streams Approach to examine how the city government opened a window for HiAP through the HC initiative and then drew on the Maturity Model to evaluate the stage of HiAP in the Tainan HC project. After analyzing all related documents, we concluded that HiAP in the Tainan HC project had reached Stage V Institutionalization after 7 years. Key contexts, factors, challenges and strategies were identified. This study suggests that the HC initiative can indeed contribute to the development of HiAP and that the window was opened for HiAP through a concurrence of the three streams of problem, policy and politics along with the HC movement process.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

Stakeholders' Perspectives on the Unmet Needs and Health Priorities of the Urban Poor in South-East Nigeria

Relatively little is known about readiness of urban health systems to address health needs of the poor. This study explored stakeholders' perception of health needs and strategies for improving health of the urban poor using qualitative analysis. Focus group discussions (n = 5) were held with 26 stakeholders drawn from two Nigerian states during a workshop. Urban areas are characterised by double burden of diseases. Poor housing, lack of basic amenities, poverty, and poor access to information are determinants of health of the urban poor. Shortage of health workers, stock-out of medicines, high cost of care, lack of clinical practice guidelines, and dual practice constrain access to primary health services. An overarching strategy, that prioritises community-driven urban planning, health-in-all policies, structured linkages between informal and formal providers, financial protection schemes, and strengthening of primary health care system, is required to address health needs of the urban poor.

Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis

BACKGROUND

Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the 'social value of health systems.'

METHODS

We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between 'health systems' and 'social values.' We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory.

RESULTS

We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen's understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups.

CONCLUSION

We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.

Multisectoral action for health in low-income and middle-income settings: how can insights from social science theories inform intragovernmental coordination efforts?

There is consensus in global health on the need for multisectoral action (MSA) to address many contemporary development challenges, but there is limited action. Examples of issues that require coordinated MSA include the determinants of health conditions such as nutrition (malnutrition and obesity) and chronic non-communicable diseases. Nutrition, tobacco control and such public health issues are regulated separately by health, trade and treasury ministries. Those issues need to be coordinated around the same ends to avoid conflicting policies. Despite the need for MSA, why do we see little progress? We investigate the obstacles to and opportunities for MSA by providing a government perspective. This paper draws on four theoretical perspectives, namely (1) the political economy perspective, (2) principal–agent theory, (3) resource dependence theory and (4) transaction cost economics theory. The theoretical framework provides complementary propositions to understand, anticipate and prepare for the emergence and structuring of coordination arrangements between government organisations at the same or different hierarchical levels. The research on MSA for health in low/middle-income countries needs to be interested in a multitheory approach that considers several theoretical perspectives and the contextual factors underlying coordination practices.

Health care workers and migrant health: Pre- and post-COVID-19 considerations for reviewing and expanding the research agenda

The main purpose of this article is to review several ways in which health care workers could either impact migrant health or be directly impacted by migration and, based on this, suggest the expansion of the current research agenda on migration and health to address a range of topics that are currently either neglected, insufficiently researched, or researched from different perspectives. To ground this suggestion and emphasize the complexity and significance of migrant health research, we start by briefly reviewing several migration-related notions including the process of migration and its key facilitators and benefits; existing barriers to the provision of migrant health care; and the intricate links between health systems, health professionals, and migrant health. The three areas of research examined in this article address (i) the specific role of health workers in providing care to migrants and refugees and their capacity to do so, (ii) the health problems experienced by health workers who become migrants or refugees, and (iii) the precarious employment conditions experienced by both migrant and non-migrant health care workers. After summarizing the current available evidence on these topics, we discuss key information gaps and strategies to address them, while also incorporating several relevant COVID-19 pandemic considerations and research implications. Expanding the focus of research studies on migration and health could not only enhance the results of current strategies by supplying additional information to support their implementation but also spearhead the development of new solutions to the migrant health problem.

Expanding Implementation Research to Prevent Chronic Diseases in Community Settings

Chronic disease prevention continues to be inadequate, overall and in achieving health equity, in spite of the many evidence-based practices and policies (EBPPs) available to address risk behaviors such as unhealthful eating, lack of physical activity, and tobacco use. Although clinical settings are needed for EBPPs that involve medical procedures such as immunization or early detection, dissemination of EBPPs can be effective in a variety of settings such as schools and childcare centers, worksites, social service organizations, and religious organizations. More implementation research is needed to meet challenges of effective application of EBPPs in such community settings, in which primary missions, capacity, cultures, and values do not focus on health services delivery. To address health equity, consideration of social and economic contexts of people reached in these settings is essential. This review presents lessons learned from past studies to guide future implementation research and practice across diverse settings and geographies.

Recommendations for Intersectoral Collaboration for the Prevention and Control of Vector-Borne Diseases: Results From a Modified Delphi Process

Background

Intersectoral collaboration in the context of the prevention and control of vector-borne diseases has been broadly described in both the literature and the current global strategy by the World Health Organization. Our aim was to develop a framework that will distill the currently known multiple models of collaboration.

Methods

Qualitative content analysis and logic modeling of data abstracted from 69 studies included in a scoping review done by the authors were used to develop 9 recommendation statements that summarized the composition and attributes of multisectoral approaches, which were then subjected to a modified Delphi process with 6 experts in the fields of health policy and infectious diseases.

Results

Consensus for all statements was achieved during the first round. The recommendation statements were on (1–3) sectoral engagement to supplement government efforts and augment public financing; (4) development of interventions for most systems levels; (5–6) investment in human resource, including training; (7–8) intersectoral action to implement strategies and ensure sustainability of initiatives; and (9) research to support prevention and control efforts.

Conclusions

The core of intersectoral action to prevent vector-borne diseases is collaboration among multiple stakeholders to develop, implement, and evaluate initiatives at multiple levels of intervention.

Evaluation of public health interventions from a complex systems perspective: A research methods review

INTRODUCTION

Applying a complex systems perspective to public health evaluation may increase the relevance and strength of evidence to improve health and reduce health inequalities. In this review of methods, we aimed to: (i) classify and describe different complex systems methods in evaluation applied to public health; and (ii) examine the kinds of evaluative evidence generated by these different methods.

METHODS

We adapted critical review methods to identify evaluations of public health interventions that used systems methods. We conducted expert consultation, searched electronic databases (Scopus, MEDLINE, Web of Science), and followed citations of relevant systematic reviews. Evaluations were included if they self-identified as using systems- or complexity-informed methods and if they evaluated existing or hypothetical public health interventions. Case studies were selected to illustrate different types of complex systems evaluation.

FINDINGS

Seventy-four unique studies met our inclusion criteria. A framework was developed to map the included studies onto different stages of the evaluation process, which parallels the planning, delivery, assessment, and further delivery phases of the interventions they seek to inform; these stages include: 1) theorising; 2) prediction (simulation); 3) process evaluation; 4) impact evaluation; and 5) further prediction (simulation). Within this framework, we broadly categorised methodological approaches as mapping, modelling, network analysis and 'system framing' (the application of a complex systems perspective to a range of study designs). Studies frequently applied more than one type of systems method.

CONCLUSIONS

A range of complex systems methods can be utilised, adapted, or combined to produce different types of evaluative evidence. Further methodological innovation in systems evaluation may generate stronger evidence to improve health and reduce health inequalities in our complex world.

Implications of a food system approach for policy agenda-setting design

A call to governments to enact a strategy for a sustainable food system is high on the global agenda. A sustainable food system presupposes a need to go beyond a view of the food system as linear and narrow, to comprehend the food system as dynamic and interlinked, which involves understanding social, economic and ecological outcomes and feedbacks of the system. As such, it should be accompanied by strategic, collaborative, transparent, inclusive, and reflexive agenda-setting process. The concepts of, directionality relating to an agreed vision for a future sustainable food system, and, reflexivity which describes the capacity for critical deliberation and responsiveness, are particularly important. Based on those concepts, this paper proposes an evaluative framework to assess tools and instruments applied during the agenda-setting stage. We apply the evaluative framework to recent food policy processes in Finland and Sweden, revealing that their agenda-setting design cannot be assessed as fully addressing both directionality and reflexivity, thus possibly falling short of the policy design needed for enable more transformative policy approaches.

Promoting Intersectoral Collaboration Through the Evaluations of Public Health Interventions: Insights From Key Informants in 6 European Countries

BACKGROUND

Intersectoral collaboration is critical to the successful implementation of many public health interventions (PHIs). Little attention has been paid to whether and how processes at the stage of evaluation can promote intersectoral collaboration. The objective of this study was to examine European experiences and views on whether and how the evaluation of PHIs promote intersectoral collaboration.

METHODS

A qualitative study design was used. We conducted semi-structured interviews with 15 individuals centrally involved in the evaluation of PHIs in 6 European countries (Austria, Denmark, England, Germany, Norway, and Switzerland). Questions pertained to current processes for evaluating PHIs in the country and current and potential strategies for promoting intersectoral collaboration. Transcripts were analyzed using thematic analysis to identify key themes responding to our primary objective.

RESULTS

Experiences with promoting intersectoral collaboration through the evaluation of PHIs could be summarized in 4 themes: (1) Early involvement of non-health sectors in the evaluative process and inclusion of non-health benefits can promote intersectoral collaboration, but should be combined with greater influence of these sectors in shaping PHIs; (2) Harmonization of methodological approaches may enable comparison of results and facilitate intersectoral collaboration, but should not be an overriding goal; (3) Involvement in health impact assessments (HIAs) can promote intersectoral collaboration, but needs to be incentivized and be conducted without putting overwhelming demands on non-health sectors; (4) A designated body for evaluating PHIs may promote intersectoral collaboration, but its design needs to take account of realities of policy-making.

CONCLUSION

The full potential for promoting intersectoral collaboration through the evaluation of PHIs appears currently unrealized in the settings we studied. To further promote intersectoral collaboration, evaluators and decision-makers may consider the full range of strategies characterized in this study. This may be most effective if the strategies are deployed so that they reinforce each other, value outcomes beyond health, and are tailored to maximize political priority for PHIs across sectors.

Qualitative process evaluation from a complex systems perspective: A systematic review and framework for public health evaluators

BACKGROUND

Public health evaluation methods have been criticized for being overly reductionist and failing to generate suitable evidence for public health decision-making. A "complex systems approach" has been advocated to account for real world complexity. Qualitative methods may be well suited to understanding change in complex social environments, but guidance on applying a complex systems approach to inform qualitative research remains limited and underdeveloped. This systematic review aims to analyze published examples of process evaluations that utilize qualitative methods that involve a complex systems perspective and proposes a framework for qualitative complex system process evaluations.

METHODS AND FINDINGS

We conducted a systematic search to identify complex system process evaluations that involve qualitative methods by searching electronic databases from January 1, 2014-September 30, 2019 (Scopus, MEDLINE, Web of Science), citation searching, and expert consultations. Process evaluations were included if they self-identified as taking a systems- or complexity-oriented approach, integrated qualitative methods, reported empirical findings, and evaluated public health interventions. Two reviewers independently assessed each study to identify concepts associated with the systems thinking and complexity science traditions. Twenty-one unique studies were identified evaluating a wide range of public health interventions in, for example, urban planning, sexual health, violence prevention, substance use, and community transformation. Evaluations were conducted in settings such as schools, workplaces, and neighborhoods in 13 different countries (9 high-income and 4 middle-income). All reported some utilization of complex systems concepts in the analysis of qualitative data. In 14 evaluations, the consideration of complex systems influenced intervention design, evaluation planning, or fieldwork. The identified studies used systems concepts to depict and describe a system at one point in time. Only 4 evaluations explicitly utilized a range of complexity concepts to assess changes within the system resulting from, or co-occurring with, intervention implementation over time. Limitations to our approach are including only English-language papers, reliance on study authors reporting their utilization of complex systems concepts, and subjective judgment from the reviewers relating to which concepts featured in each study.

CONCLUSION

This study found no consensus on what bringing a complex systems perspective to public health process evaluations with qualitative methods looks like in practice and that many studies of this nature describe static systems at a single time point. We suggest future studies use a 2-phase framework for qualitative process evaluations that seek to assess changes over time from a complex systems perspective. The first phase involves producing a description of the system and identifying hypotheses about how the system may change in response to the intervention. The second phase involves following the pathway of emergent findings in an adaptive evaluation approach.

Social values and health systems in health policy and systems research: a mixed-method systematic review and evidence map

Because health systems are conceptualized as social systems, embedded in social contexts and shaped by human agency, values are a key factor in health system change. As such, health systems software-including values, norms, ideas and relationships-is considered a foundational focus of the field of health policy and systems research (HPSR). A substantive evidence-base exploring the influence of software factors on system functioning has developed but remains fragmented, with a lack of conceptual clarity and theoretical coherence. This is especially true for work on 'social values' within health systems-for which there is currently no substantive review available. This study reports on a systematic mixed-methods evidence mapping review on social values within HPSR. The study reaffirms the centrality of social values within HPSR and highlights significant evidence gaps. Research on social values in low- and middle-income country contexts is exceedingly rare (and mostly produced by authors in high-income countries), particularly within the limited body of empirical studies on the subject. In addition, few HPS researchers are drawing on available social science methodologies that would enable more in-depth empirical work on social values. This combination (over-representation of high-income country perspectives and little empirical work) suggests that the field of HPSR is at risk of developing theoretical foundations that are not supported by empirical evidence nor broadly generalizable. Strategies for future work on social values in HPSR are suggested, including: countering pervasive ideas about research hierarchies that prize positivist paradigms and systems hardware-focused studies as more rigorous and relevant to policy-makers; utilizing available social science theories and methodologies; conceptual development to build common framings of key concepts to guide future research, founded on quality empirical research from diverse contexts; and using empirical evidence to inform the development of operationalizable frameworks that will support rigorous future research on social values in health systems.

Health in All Policy Making Utilizing Big Data

INTRODUCTION

Health in all Policies (HiAP) is a valuable method for effective Healthcare policy development. Big data analysis can be useful to both individuals and clinicians so that the full potential of big data is employed.

AIM

The present paper deals with Health in All Policies, and how the use of Big Data can lead and support the development of new policies.

METHODS

To this end, in the context of the CrowdHEALTH project, data from heterogeneous sources will be exploited and the Policy Development Toolkit (PDT) model will be used. In order to facilitate new insights to healthcare by exploiting all available data sources.

RESULTS

In the case study that is being proposed, the NOHS Story Board (inpatient and outpatient health care) utilizing data from reimbursement of disease-related groups (DRGs), as well as medical costs for outpatient data, will be analyzed by the PDT.

CONCLUSION

PDT seems promising as an efficient decision support system for policymakers to align with HiAP as it offers Causal Analysis by calculating the total cost (expenses) per ICD-10, Forecasting Information by measuring the clinical effectiveness of reimbursement cost per medical condition, per gender and per age for outpatient healthcare, and Risk Stratification by investigating Screening Parameters, Indexes (Indicators) and other factors related to healthcare management. Thus, PDT could also support HiAP by helping policymakers to tailor various policies according to their needs, such as reduction of healthcare cost, improvement of clinical effectiveness and restriction of fraud.

Autonomous Vehicles and Public Health

Autonomous vehicles (AVs) have the potential to shape urban life and significantly modify travel behaviors. "Autonomous technology" means technology that can drive a vehicle without active physical control or monitoring by a human operator. The first AV fleets are already in service in US cities. AVs offer a variety of automation, vehicle ownership, and vehicle use options. AVs could increase some health risks (such as air pollution, noise, and sedentarism); however, if proper regulated, AVs will likely reduce morbidity and mortality from motor vehicle crashes and may help reshape cities to promote healthy urban environments. Healthy models of AV use include fully electric vehicles in a system of ridesharing and ridesplitting. Public health will benefit if proper policies and regulatory frameworks are implemented before the complete introduction of AVs into the market.

How and why do win-win strategies work in engaging policy-makers to implement Health in All Policies? A multiple-case study of six state- and national-level governments

Background

Much of the research about Health in All Policies (HiAP) implementation is descriptive, and there have been calls for more evaluative evidence to explain how and why successes and failures have occurred. In this cross-case study of six state- and national-level governments (California, Ecuador, Finland, Norway, Scotland and Thailand), we tested hypotheses about win–win strategies for engaging policy-makers in HiAP implementation drawing on components identified in our previous systems framework.

Methods

We used two sources of data — key informant interviews and peer-reviewed and grey literature. Using a protocol, we created context–mechanism–outcome pattern configurations to articulate mechanisms that explain how win–win strategies work and fail in different contexts. We then applied our evidence for all cases to the systems framework. We assessed the quality of evidence within and across cases in terms of triangulation of sources and strength of evidence. We also strengthened hypothesis testing using replication logic.

Results

We found robust evidence for two mechanisms about how and why win–win strategies build partnerships for HiAP implementation — the use of shared language and the value of multiple outcomes. Within our cases, the triangulation was strong, both hypotheses were supported by literal and contrast replications, and there was no support against them. For the third mechanism studied, using the public-health arguments win–win strategy, we only found evidence from Finland. Based on our systems framework, we expected that the most important system components to using win–win strategies are sectoral objectives, and we found empirical support for this prediction.

Conclusions

We conclude that two mechanisms about how and why win–win strategies build partnerships for HiAP implementation — the use of shared language and the value of multiple outcomes — were found as relevant to the six settings. Both of these mechanisms trigger a process of developing synergies and releasing potentialities among different government sectors and these interactions between sectors often work through sectoral objectives. These mechanisms should be considered when designing future HiAP initiatives and their implementation to enhance the emergence of non-health sector policy-makers’ engagement.

Addressing Health and Well-Being Through State Policy: Understanding Barriers and Opportunities for Policy-Making to Prevent Adverse Childhood Experiences (ACEs) in South Carolina

PURPOSE

As adverse childhood experiences (ACEs) become increasingly recognized as a root cause of unhealthy behaviors, researchers, practitioners, and legislators seek to understand policy strategies to prevent and mitigate its effects. Given the high prevalence of ACEs, policies that address ACEs can meaningfully prevent disease in adulthood and improve population health. We sought to understand barriers and opportunities for policies to prevent and mitigate ACEs by exploring state legislator perspectives.

SETTING AND PARTICIPANTS

Twenty-four current state legislators in South Carolina.

DESIGN

In 2018, we conducted semistructured interviews with 24 state legislators. Participants were recruited using maximum variation sampling. The researchers individually analyzed each interview transcript using focused coding qualitative techniques. A high inter-rater agreement was demonstrated (κ = .76 to .87), and discrepancies were resolved through discussion.

METHOD

The data collection and analysis were guided by Multiple Streams Theory, which identifies 3 key components (attention to the problem, decisions about policy options, and the impact of political landscape) that can lead windows of opportunity for passing policies.

RESULTS

Legislators identified several factors that can influence the passage of legislation on ACEs: awareness of ACEs; gaps in understanding about what can be done about ACEs; the use of data and stories that contextualize the problem of ACEs; capitalizing on the bipartisanship of children's issues; and linking to current ACEs-related issues on the policy agenda, such as school safety and violence prevention and the opioid epidemic.

CONCLUSION

Public health researchers and practitioners should focus on the factors identified to advocate for policies that prevent ACEs and/or address their health consequences.

National Health Policies in Practice: An Explorative Analysis for India

The health ministry of India has released three National Health Policies (NHPs) since independence. These are guiding documents for the government for their health-related expenditure. Till 2017, India allocated central resources through five-year plans (FYPs) formed by the Planning Commission. Thereafter, the newly formed National Institution of Transforming India or the National Institute for Transforming India (NITI) Aayog released its first 3-year action agenda for different sectors. We study the translation of these policies in practice, by comparing policy recommendations with the FYPs. This article also compares the recommendation of the NHP, 2017 with the first 3-year agenda of the NITI Aayog. This explorative analysis also studies the cohesion between the three policies. Hence, it helps to identify five key issues in translating these policies to practise for and provides suggestions. Our study indicates that the NHPs in India need to be released frequently while incorporating tools of accountability, need to generate evidence on which policy decisions can be made, need to be inter-sectoral, but coordinated within different agencies of the government and need to have cohesion with budgetary allocations for allowing a better analysis.

Considering health and health disparities during state policy formulation: examining Washington state Health Impact Reviews

BACKGROUND

As part of efforts to expand Health in All Policies (HiAP) in Washington State in the U.S., the Washington State Board of Health (BOH) received statutory authority in 2006 to conduct Health Impact Reviews (HIRs). HIRs analyze the potential impacts of proposed legislation and budget decisions on health and health disparities. Public health professionals who are aware of HIRs are interested in adopting a similar process in their states; however, there is limited information about HIRs, how they are perceived, and how they could advance HiAP.

METHODS

This research involved a descriptive analysis of a sample of HIRs and semi-structured interviews with a purposive sample of 17 key informants. For the descriptive analysis, all HIRs requested or completed between January 1, 2007 and April 1, 2016 that had a request form submitted by a legislator or the governor that was available in the BOH's online database were reviewed. Information was collected on several variables including the bill number and title, sponsor and political affiliation, and the sector to which the bill or budgetary proposal pertained. A purposeful sample of legislators, staff, advocates, and lobbyists who were involved with HIRs during the study period were invited to participate in semi-structured interviews. Topic coding was used to identify key themes from the qualitative data.

RESULTS

During the study period, 20 legislators requested 36 HIRs; 32 HIRs were completed. HIRs were requested for several bill topics, including education (11/36) and labor and employment (9/36). Legislators who requested HIRs felt they provided valuable data on health and health disparities for proposed bills. Individuals who were less supportive of HIRs perceived them as an advocacy or political tool. The main barrier to widespread use of HIRs in Washington was a lack of awareness among legislators.

CONCLUSIONS

HIRs are one strategy to advance HiAP for state policy decisions. HIRs are a potentially effective tool for highlighting how legislative proposals and budgets positively and negatively impact health and health disparities. Future efforts should promote awareness and highlight shared benefits of HIRs among legislators and their staff, as well as their scientific integrity, methodological rigor, and objectivity.

Do Healthy City Performance Awards Lead to Health in All Policies? A Case of Taiwan

The Healthy Cities (HC) Project, which was introduced by the World Health Organization (WHO) in 1986, has been recognized as the best setting approach for health promotion. However, very few studies have addressed how to use HC approaches to establish public policies in non-health departments in cities. This paper describes the strategies for the HC Performance Awards used in Taiwan to draw attention from different departments and to sustain intersectoral collaboration for the purpose of establishing Health in All Policies (HiAP). The methods include: (1) setting up the Taiwan Healthy City Alliance; (2) establishing HC Innovation Performance Awards; (3) reviewing the award applications according to seven criteria; and (4) analyzing the topic content of the award applications. We collected 961 HC award applications during 2013–2016 to analyze their content. The results showed that the number of applications increased nearly every year while significantly more non-health departments applied for the awards compared to health departments (73.3% vs. 26.7%). The award rates of non-health departments have also increased twice from 13.9% in 2013 to 25.8% in 2016. By examining the topics of the award winners, we concluded that “HC Innovation Performance Awards” indeed provide a role and opportunity for political involvement, intersectoral collaboration, co-opetition and capacity building that is necessary for establishing health in all policies.

Blending integrated knowledge translation with global health governance: an approach for advancing action on a wicked problem

BACKGROUND

The persistence of health inequities is a wicked problem for which there is strong evidence of causal roots in the maldistribution of power, resources and money within and between countries. Though the evidence is clear, the solutions are far from straightforward. Integrated knowledge translation (IKT) ought to be well suited for designing evidence-informed solutions, yet current frameworks are limited in their capacity to navigate complexity. Global health governance (GHG) also ought to be well suited to advance action, but a lack of accountability, inclusion and integration of evidence gives rise to politically driven action. Recognising a persistent struggle for meaningful action, we invite contemplation about how blending IKT with GHG could leverage the strengths of both processes to advance health equity.

DISCUSSION

Action on root causes of health inequities implicates disruption of structures and systems that shape how society is organised. This infinitely complex work demands sophisticated examination of drivers and disrupters of inequities and a vast imagination for who (and what) should be engaged. Yet, underlying tendencies toward reductionism seem to drive superficial responses. Where IKT models lack consideration of issues of power and provide little direction for how to support cohesive efforts toward a common goal, recent calls from the field of GHG may provide insight into these issues. Additionally, though GHG is criticised for its lack of attention to using evidence, IKT offers approaches and strategies for collaborative processes of generating and refining knowledge. Contemplating the inclusion of governance in IKT requires re-examining roles, responsibilities, power and voice in processes of connecting knowledge with action. We argue for expanding IKT models to include GHG as a means of considering the complexity of issues and opening new possibilities for evidence-informed action on wicked problems.

CONCLUSION

Integrated learning between these two fields, adopting principles of GHG alongside the strategies of IKT, is a promising opportunity to strengthen leadership for health equity action.

Reducing Health Inequities Through Intersectoral Action: Balancing Equity in Health With Equity for Other Social Goods

Significant attention has been devoted to developing intersectoral strategies to reduce health inequities; however, these strategies have largely neglected to consider how equity in health ought to be weighted and balanced with the pursuit of equity for other social goods (eg, education equity). Research in this domain is crucial, as the health sector’s pursuit of health equity may be at odds with policies in other sectors, which may consider the reduction of health inequities to be peripheral to, if not incompatible with, their own equity-related aims. It is therefore critical that intersectoral strategies to reduce health inequities be guided by a more general account of social justice that is capable of carefully balancing equity in health against the pursuit of equity in other sectors.

The 2007 Caribbean Community Port-of-Spain Declaration on noncommunicable diseases: an overview of a multidisciplinary evaluation

OBJECTIVES

Noncommunicable diseases (NCDs) are a threat to social and economic development, including in the Caribbean. In 2007 the Caribbean Community (CARICOM) held the world's first-ever summit of heads of government on NCD prevention and control and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. The objectives of this paper are to provide an overview of a formal evaluation of the Declaration and to highlight key findings that could inform further implementation of the Declaration's 15 mandates.

METHODS

The evaluation's six research objectives were decided through stakeholder engagement and assessed by concurrent quantitative and qualitative research methods, using the following four themes: 1) trends in risk factors, morbidity, and mortality; 2) national and Caribbean-wide policy responses, and factors associated with policy successes and difficulties; 3) the international impact of the Declaration; and 4) the potential for raising revenue from tobacco and alcohol taxation in order to support NCD prevention and control.

RESULTS

There are marked disparities in NCD mortality and trends among the 20 CARICOM member countries and territories. No CARICOM member had fully implemented all of the Declaration's 15 mandates (which were monitored by 26 indicators), with 10 CARICOM members implementing fewer than half of the indicators, and with most members lacking a well-functioning multisectoral NCD Commission. Larger CARICOM members tended to have higher levels of implementation than did smaller members. Mandates that received active support from regional institutions tended to be better implemented by the CARICOM members than did mandates that lacked that kind of support. Feasible national tobacco and alcohol tax increases could more than cover the cost of implementing the World Health Organization NCD "best buy" interventions in the CARICOM member countries and territories.

CONCLUSIONS

Priorities for further implementation of the mandates from the Port-of-Spain Declaration include establishing throughout the CARICOM member countries and territories fully functioning national bodies to support multisectoral action for NCD prevention; greater regional support in policy development and implementation for smaller countries; and greater targeted use of taxes on tobacco and alcohol to support NCD control and prevention.

"First, Do No Harm": Have the Health Impacts of Government Bills on Tax Legislation Been Assessed in Finland?

As taxation is one of the key public policy domains influencing population health, and as there is a legal, strategic, and programmatic basis for health impact assessment (HIA) in Finland, we analyzed all 235 government bills on tax legislation over the years 2007–2014 to see whether the health impacts of the tax bills had been assessed. We found that health impacts had been assessed for 13 bills, bills dealing with tobacco, alcohol, confectionery, and energy legislation and that four of these impact assessments included impacts on health inequalities between social classes. Based on our theoretical classification, the health impacts of 40 other tax bills should have been evaluated.