Governance of Intersectoral Collaborations for Population Health and to Reduce Health Inequalities in High-Income Countries: A Complexity-Informed Systematic Review

A qualitative exploration of the coordinator's role in an intersectoral childhood overweight prevention programme in the Netherlands: 'a lot is expected from one person'

BACKGROUND

Intersectoral collaboration and its coordination are vital for community health promotion. Given the diverse organisational contexts in which local coordinators build intersectoral collaboration, training and support needs of coordinators may vary widely. To date, there is limited insight into how coordinators tasked with building intersectoral collaboration apply their role given their specific organisational context. A more detailed understanding of this process will provide valuable guidance for training and supporting local coordinators. In the current study we focussed on coordinators involved in building intersectoral collaboration within the 'Healthy Youth, Healthy Future' (JOGG) approach in the Netherlands. The organisational contexts in which these local coordinators operate vary considerably. The aim of this study was to explore how local coordinators of the JOGG approach apply their role in building intersectoral collaboration and the competencies they require, taking into account their organisational context.

METHODS

We conducted interviews with twelve local JOGG coordinators and two focus groups with eight community advisors from the national JOGG organisation. Data was analysed both inductively and deductively.

RESULTS

JOGG coordinators appeared to take on seven different roles over time: implementer, project manager, networker, matchmaker, linchpin, politician and programme manager. These roles required different competencies and varied according to the organisational context, including: available resources, the position of the employing organisation in existing local stakeholder networks, the coordinators' responsibilities in their employing organisation and professional background. In addition, the coordinators role depended on the implementation phase of the JOGG approach. During the first phase, roles at the operational level were more prominent, since they were important for engaging stakeholders and facilitating collaboration. In later phases, coordinators took on roles at a tactical and strategic level in order to mobilise their network.

CONCLUSIONS

This study highlights the diversity in how JOGG coordinators apply their role. Our findings highlight the importance of carefully selecting the organisation where coordinators are employed, as this influences their possibilities. In addition, our study provides directions for recruiting coordinators for an intersectoral health promotion approach and supporting them, taking into account the phase of the approach and organisational context.

Navigating the complexity of a collaborative, system-wide public health programme: learning from a longitudinal qualitative evaluation of the ActEarly City Collaboratory

BACKGROUND

Addressing the upstream social determinants of health (e.g. built environment, education) can reduce the burden of non-communicable diseases. To do so effectively often requires system-wide collaboration. However, collaborating across multiple sectors, organizations and disciplines within a complex system can be challenging. ActEarly was a public health research consortium that aimed to improve child health by building an interdisciplinary, cross-city partnership to develop and/or evaluate upstream interventions, increase research capacity and improve collaboration between researchers, local authorities and communities. This paper explores ActEarly's experiences of navigating complexity to identify mechanisms that supported its implementation and proposes recommendations for future intersectoral and interdisciplinary population health research collaborations.

METHODS

We conducted a longitudinal qualitative study of ActEarly, integrating findings from inductive documentary analysis of internal documents (mainly meetings minutes and reports) (n = 114) and interviews (n = 70) with 45 consortium members at three different timepoints (2018, 2021, 2023). Participants worked across different organizations, cities, roles and levels of seniority in the consortium.

FINDINGS

Clarity, Unity, Flexibility and Feasibility were seen as the key mechanisms required to support ActEarly's implementation. Clear aims, governance structures and communication were necessary to manage the uncertainty of the complex system. A unified approach, characterized by strong relationships, having a shared vision and communal access to resources supported effective collaboration. Flexibility was required to adjust to different ways of working, respond to wider system events and manage the consortium. Establishing feasible aims that responded to the limitations of the system, the available resources and research infrastructure was required for teams to deliver the work.

CONCLUSIONS

Implementing multi-faceted programmes in a complex system can be challenging. We recommend that future whole-systems consortia seeking to improve population health build Clarity, Unity, Flexibility and Feasibility into their programmes, noting the complex interrelationships between these factors. Iterative reflections from all parties should support delivery amidst the uncertainty that comes with running a population health research collaboration, and strong leadership and governance should play a key role in ensuring that these are built into foundations the programme.

Caries indicators in relation to healthcare access and hygienic-dietary habits in Spanish preschoolers

INTRODUCTION

Dental caries continues to be a public healthcare problem due to its high prevalence and morbidity. It was proposed to evaluate caries indicators in relation to healthcare access and hygienic-dietary habits in Spanish preschoolers.

MATERIALS AND METHODS

A cross-sectional study was carried out on a random sample consisting of 343 patients ranging from 3 to 5 years of age in the primary care setting, the main measurements were: dental care access, hygienic-dietary habits, and caries registration according to WHO criteria.

RESULTS

The prevalence of caries was 35.3% and mean ± standard deviation (SD) dft was 1.51 ± 2.93. Preschoolers who had ever visited the dentist had a higher dft occurrence than those who had never attended the dentist. The lower prevalence of caries was significantly associated with the frequency of two daily brushings versus non-daily brushing (p = 0.007; 25.3% vs. 47.1%) and was 10.7% lower in patients who had the habit of night brushing (p = 0.041). The consumption of sugary liquids between meals implied a higher dft index.

CONCLUSIONS

The high prevalence of early childhood caries and the dental care access associated with poor oral health suggest the need to implement a multidisciplinary oral healthcare program that involves both healthcare and dental healthcare professionals in Primary Health Care Units without forgetting the participation of the community and local administrations.

Examining the Contextual Factors Influencing Intersectoral Action for the SDGs: Insights From Canadian Federal Policy Leaders

BACKGROUND

The interdependent and intersecting nature of the Sustainable Development Goals (SDGs) require collaboration across government sectors, and it is likely that departments with few past interactions will find themselves engaged in joint missions on SDG projects. Intersectoral action (IA) is becoming a common framework for different sectors to work together. Understanding the factors in the environment external to policy teams enacting IA is crucial for making progress on the SDGs.

METHODS

Interviews [n=17] with senior public servants leading SDG work in nine departments in the federal government of Canada were conducted to elicit information about issues affecting how departments engage in IA for the SDGs. Transcripts were coded based on a set of factors identified in a background review of 20 documents related to Canada's progress on SDGs. Iterative group thematic analysis by the authors illuminated a set of domestic and global contextual factors affecting IA processes for the SDGs.

RESULTS

The mechanisms for successful IA were identified as facilitative governance, leadership by a central coordinating office, supportive staff, flexible and clear reporting structures, adequate resources, and targeted skills development focused on collaboration and cross-sector learning. Factors that affect IA positively include alignment of the SDG agenda with domestic and global political priorities, and the co-occurrence of social issues such as Indigenous rights and gender equity that raise awareness of and support for related SDGs. Factors that affect IA negatively include competing conceptual frameworks for approaching shared priorities, lack of capacity for "big picture" thinking among bureaucratic staff, and global disruptions that shift national priorities away from the SDGs.

CONCLUSION

IA is becoming a normal way of working on problems that cross otherwise separate government accountabilities. The success of these collaborations can be impacted by contextual factors beyond any one department's control.

Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

Development of an action programme tackling obesity-related behaviours in adolescents: a participatory system dynamics approach

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10-14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

Assessing the effects of population-level political, economic and social exposures, interventions and policies on inclusive economy outcomes for health equity in high-income countries: a systematic review of reviews

BACKGROUND

A fairer economy is increasingly recognised as crucial for tackling widening social, economic and health inequalities within society. However, which actions have been evaluated for their impact on inclusive economy outcomes is yet unknown.

OBJECTIVE

Identify the effects of political, economic and social exposures, interventions and policies on inclusive economy (IE) outcomes in high-income countries, by systematically reviewing the review-level evidence.

METHODS

We conducted a review of reviews; searching databases (May 2020) EconLit, Web of Science, Sociological Abstracts, ASSIA, International Bibliography of the Social Sciences, Public Health Database, Embase and MEDLINE; and registries PROSPERO, Campbell Collaboration and EPPI Centre (February 2021) and grey literature (August/September 2020). We aimed to identify reviews which examined social, political and/or economic exposures, interventions and policies in relation to two IE outcome domains: (i) equitable distribution of the benefits of the economy and (ii) equitable access to the resources needed to participate in the economy. Reviews had to include primary studies which compared IE outcomes within or between groups. Quality was assessed using a modified version of AMSTAR-2 and data synthesised informed by SWiM principles.

RESULTS

We identified 19 reviews for inclusion, most of which were low quality, as was the underlying primary evidence. Most reviews (n = 14) had outcomes relating to the benefits of the economy (rather than access to resources) and examined a limited set of interventions, primarily active labour market programmes and social security. There was limited high-quality review evidence to draw upon to identify effects on IE outcomes. Most reviews focused on disadvantaged groups and did not consider equity impacts.

CONCLUSIONS

Review-level evidence is sparse and focuses on 'corrective' approaches. Future reviews should examine a diverse set of 'upstream' actions intended to be inclusive 'by design' and consider a wider range of outcomes, with particular attention to socioeconomic inequalities.

How can policy and policymaking foster climate justice? A qualitative systematic review

Background

Climate change research has established general requirements for policy and policymaking: transformational changes in policy and policymaking to foster 'climate justice', including a 'just transition' or movement towards environmental sustainability with equitable processes and outcomes. However, there is a major gap between these requirements and actual policies and policy processes. We identify how researchers use policy theories to understand this gap.

Methods

We conducted a qualitative systematic review (2022) to identify peer reviewed journal articles on climate change, policy, justice, and equity in three databases (Web of Science, Scopus, Proquest). Each article had to provide a non-trivial reference to policymaking concepts or theories. We used an immersive and inductive approach to identify key themes and show how the use of policy concepts and theories informs climate change research.

Results

A total of 108 texts meet the inclusion criteria (with some bias towards Global North research since all texts are in English). Most provide general definitions of climate justice, require fair outcomes and processes, and list what is required to meet those aims. However, they also identify unjust processes and outcomes in relation to who is recognised, gets to define the problem, and wins or loses from solutions. Researchers contrast their preferred social justice approach (informing 'civic environmentalism) to a dominant neoliberal approach (corresponding to weak 'ecological modernization').

Conclusions

Researchers focus on what they need from policy and policymaking to produce climate justice. Few engage meaningfully with policy theories to describe how policymaking actually works. More engagement would help to set meaningful expectations regarding policy change and avoid a needless tendency to treat policymaking like a 'black box'.

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.

Movement behavior policies in the early childhood education and care setting: An international scoping review

Background

Meeting 24-h movement behavior guidelines for the early years is associated with better health and development outcomes in young children. Early childhood education and care (ECEC) is a key intervention setting however little is known about the content and implementation of movement behavior polices in this context. To inform policy development this international scoping review examined the prevalence, content, development and implementation of ECEC-specific movement behavior policies.

Methods

A systematic literature search of published and gray literature since 2010 was conducted. Academic databases (EMBASE, Cinahl, Web of Science, Proquest, Scopus, EBSCO, PubMed) were searched. A Google search was undertaken and limited to the first 200 results. The Comprehensive Analysis of Policy on Physical Activity framework informed data charting.

Results

Forty-three ECEC policy documents met inclusion criteria. Most policies originated in the United States, were subnational and developed with government, non-government organizations and ECEC end-users. Physical activity was specified in 59% (30-180 min/day), sedentary time in 51% (15-60 min/day) and sleep in 20% (30-120 min/day) of policies. Daily outdoor physical activity was recommended (30-160 min/day) in most policies. No policy permitted screen time for children <2 years, with 20-120 min/day for children >2 years. Most policies (80%) had accompanying resources but few provided evaluation tools (e.g., checklists; action plan templates). Many policies had not been reviewed since the publication of 24-h movement guidelines.

Conclusion

Movement behavior policies in the ECEC setting are often vaguely worded, missing a comprehensive evidence base, siloed in development and often not tailored for the 'real world.' A focus on evidence informed ECEC-specific movement behavior policies proportionally aligned with national/international 24-h Movement Behaviors Guidelines for the Early Years is needed.

Intersectoral Collaboration to Promote Child Development: The Contributions of the Actor-Network Theory

An integrated intersectoral care model promises to meet complex needs to promote early child development and address health determinants and inequities. Nevertheless, there is a lack of understanding of actors' interactions in producing intersectoral collaboration networks. The present study aimed to analyze the intersectoral collaboration in the social protection network involved in promoting early child growth and development in Brazilian municipalities. Underpinned by the tenets of actor-network theory, a case study was conducted with data produced from an educational intervention, entitled "Projeto Nascente." Through document analysis (ecomaps), participant observation (in Projeto Nascente seminars), and interviews (with municipal management representatives), our study explored and captured links among actors; controversies and resolution mechanisms; the presence of mediators and intermediaries; and an alignment of actors, resources, and support. The qualitative analysis of these materials identified three main themes: (1) agency fragility for intersectoral collaboration, (2) attempt to form networks, and (3) incorporation of fields of possibilities. Our findings revealed that intersectoral collaboration for promoting child growth and development is virtually non-existent or fragile, and local potential is missed or underused. These results emphasized the scarcity of action by mediators and intermediaries to promote enrollment processes to intersectoral collaboration. Likewise, existing controversies were not used as a mechanism for triggering changes. Our research supports the need to mobilize actors, resources, management, and communication tools that promote processes of interessement and enrollment in favor of intersectoral collaboration policies and practices for child development.

Implementation of Health Impact Assessment in the Healthcare System of the Republic of Kazakhstan

The Health Impact Assessment (hereinafter referred to as HIA) is an effective method for predicting potential health impacts from decisions. Little is known about the implementation of the HIA in the Republic of Kazakhstan (further, RK). In addition, the Russian language literature has not yet been reviewed in terms of HIA-related knowledge. By conducting a literature review of enabling factors, including Russian language literature, on the implementation of the HIA and studying governance systems in RK, we aim to suggest an implementation process to implement the HIA in RK. After careful analysis of the governance system, we suggest set up of a HIA support unit under the National Scientific Center for Health Development and discuss the possible benefits. The proposed center should guide the implementation of the HIA in RK.

Evaluating ‘Health in All Policies’ in Norwegian Municipalities

The Health in All Policies (HiAP) approach has emerged as a central strategy for promoting health at local, regional, and state levels in different countries. Representing a complex and complicated strategy, evaluations of HIAP at the local level are scarce, and scholars call for more knowledge and critical discussions regarding how to evaluate at this level. In this conceptual paper, I discuss how summative and formative evaluation approaches might supplement each other when evaluating HiAP at the local level. First, I discuss the possibilities of using summative and formative evaluation of HiAP. Further, I discuss how formative-dialogue research might represent possibilities for evaluation by combining the two approaches. Finally, I ask if there has been a shift in the Norwegian evaluation discourse, from the promotion of summative evaluation alone to a combination of both summative and formative methods.

A Food Relief Charter for South Australia-Towards a Shared Vision for Pathways Out of Food Insecurity

Chronic food insecurity persists in high-income countries, leading to an entrenched need for food relief. In Australia, food relief services primarily focus on providing food to meet immediate need. To date, there has been few examples of a vision in the sector towards client outcomes and pathways out of food insecurity. In 2016, the South Australian Government commissioned research and community sector engagement to identify potential policy actions to address food insecurity. This article describes the process of developing a co-designed South Australian Food Relief Charter, through policy–research–practice collaboration, and reflects on the role of the Charter as both a policy tool and a declaration of a shared vision. Methods used to develop the Charter, and resulting guiding principles, are discussed. This article reflects on the intentions of the Charter and suggests how its guiding principles may be used to guide collective actions for system improvement. Whilst a Charter alone may be insufficient to create an integrated food relief system that goes beyond the provision of food, it is a useful first step in enabling a culture where the sector can have a unified voice to advocate for the prevention of food insecurity.