How does local government use evidence to inform strategic planning for health and wellbeing?
© 2017 Dr. Geoffrey BrowneBackground: Globally, preventable non‐communicable diseases are on the rise and present a serious risk to the sustainability of health care systems. Many preventable diseases are determined by factors outside of the health system and so addressing the social determinants of health (SDH) has significant potential to reduce the global burden of disease. Local government (LG) is the level of government closest to the people. It has extensive interaction with its communities and this results in unique knowledge of contemporary health issues as they manifest locally. Internationally, it is understood that as a provider of social infrastructure and services, LG also has critical potential to enhance SDH. In Victoria, Australia, many communities are experiencing significant public health challenges such as inadequate physical activity, poor diets and social isolation, all associated with low land‐use densities, car dependence and poor access to healthy food. The Victorian Public Health and Wellbeing Act (2008), requires each of Victoria’s 79 LGs to develop an evidence‐based Municipal Public Health and Wellbeing Plan (MPHWP) aimed at improving the community’s health and wellbeing by addressing SDH. MPHWPs must also have regard to the priorities of the Victorian State Health and Wellbeing Plan. However, LG health plans are only as good as the effectiveness of their interventions and the evidence used to inform these interventions. Although there have been recent efforts to improve the use of evidence in Victorian MPHWPs, there has been no systematic analysis of the evidence used by LG to develop their MPHWPs. Similarly, to date, there has been no systematic analysis of the extent to which MPHWPs address SDH. Thus, using a comprehensive content analysis of all LGs’ MPHWPs, and via interviews with key informants in LG, this PhD study explored how LG interpreted and prosecuted its obligations under the Act. Specifically, it examined how LG has interpreted the Sections that require it 1) to use evidence to inform its strategic planning for health and wellbeing, 2) have regard to the state health plan, and 3) improve the social determinants of health. The aim was to make policy recommendations that will enable LG to be a more effective agent of public health. Methods: An analysis of the content of the 79 2013‐2017 MPHWPs and supporting documents was undertaken. The quantitative component involved an analysis of each occurrence of evidence in MPHWPs for its source, topic and type (descriptive or intervention). It also involved an assessment of whether the actions taken addressed State health priorities, and how they addressed SDH in two dimensions: policy area and distance ‘upstream’. The qualitative component sought to identify and analyse strategic statements describing LGs’ responsibility and goals in public health. Additionally, the experiences and perspectives of MPHWP managers from 16 LGs across Victoria were explored through semi‐structured in-depth interviews using an analytical framework of barriers to and enablers of evidence use. Results: MPHWPs cited evidence from numerous sources, covering a wide range of health issues and their determinants. However, much of this evidence was descriptive without defining effective interventions. Additionally, much of the documented support for actions in MPHWPs was sourced via community consultation rather than scientific research, resulting is some novel actions of unknown effectiveness. Key informants indicated that some intervention evidence diffuses into decision‐making via professional networks and a range of documented sources to become tacit knowledge that guides actions. In most cases however, evidence supporting actions taken by LG was lacking. Regarding actions, MPHWPs went well beyond the State Government’s public health priority areas to address a wide range of policy areas with a strong ‘upstream’ focus. Key informants indicated that this was because LG had strongly adopted the SDH model. The evidence suggests that LG has a high level of organisational efficacy to address health, but that LG would like to see more done to improve the environments that determine health. LG is therefore active both in working with partner organisations and in advocating ‘up’ to the state government to address SDH. Implications: The results of this research suggest that the Victorian Public health and Wellbeing Act’s requirement to address SDH is strongly integrated in the documentation that supports LGs’ MPHWPs. This has contributed to LG ‘punching above its weight’ to address SDH. In contrast, the requirement for MPHWPs to be evidence‐based has facilitated the use of descriptive evidence far more than it has intervention evidence. LG staff would benefit from increased evidence literacy – including the use of evidence typologies for appraising evidence – while MPHWPs themselves would benefit from improved evaluation, particularly of community‐derived actions. Recommendations for improving the evidence literacy of MPHWP planners, providing summaries of the latest intervention evidence and improving the evaluation of LG actions to create LG‐relevant intervention evidence were developed. These recommendations could be applied by both state‐level policymakers and LG level planners in Victoria and beyond to create more effective municipal health plans, and to make an important contribution to community wellbeing and the sustainability of health care systems