Creating change in government to address the social determinants of health: how can efforts be improved?

Background: The evidence base for the impact of social determinants of health has been strengthened considerably in the last decade. Increasingly, the public health field is using this as a foundation for arguments and actions to change government policies. The Health in All Policies (HiAP) approach, alongside recommendations from the 2010 Marmot Review into health inequalities in the UK (which we refer to as the ‘Fairness Agenda’), go beyond advocating for the redesign of individual policies, to shaping the government structures and processes that facilitate the implementation of these policies. In doing so, public health is drawing on recent trends in public policy towards ‘joined up government’, where greater integration is sought between government departments, agencies and actors outside of government. Methods: In this paper we provide a meta-synthesis of the empirical public policy research into joined up government, drawing out characteristics associated with successful joined up initiatives. We use this thematic synthesis as a basis for comparing and contrasting emerging public health interventions concerned with joined-up action across government. Results: We find that HiAP and the Fairness Agenda exhibit some of the characteristics associated with successful joined up initiatives, however they also utilise ‘change instruments’ that have been found to be ineffective. Moreover, we find that – like many joined up initiatives – there is room for improvement in the alignment between the goals of the interventions and their design. Conclusion: Drawing on public policy studies, we recommend a number of strategies to increase the efficacy of current interventions. More broadly, we argue that up-stream interventions need to be ‘fit-for-purpose’, and cannot be easily replicated from one context to the next

An analysis of potential barriers and enablers to regulating the television marketing of unhealthy foods to children at the state government level in Australia

Background In Australia there have been many calls for government action to halt the effects of unhealthy food marketing on children\u27s health, yet implementation has not occurred. The attitudes of those involved in the policy-making process towards regulatory intervention governing unhealthy food marketing are not well understood. The objective of this research was to understand the perceptions of senior representatives from Australian state and territory governments, statutory authorities and non-government organisations regarding the feasibility of state-level government regulation of television marketing of unhealthy food to children in Australia.Method Data from in-depth semi-structured interviews with senior representatives from state and territory government departments, statutory authorities and non-government organisations (n=22) were analysed to determine participants\u27 views about regulation of television marketing of unhealthy food to children at the state government level. Data were analysed using content and thematic analyses.Results Regulation of television marketing of unhealthy food to children was supported as a strategy for obesity prevention. Barriers to implementing regulation at the state level were: the perception that regulation of television advertising is a Commonwealth, not state/territory, responsibility; the power of the food industry and; the need for clear evidence that demonstrates the effectiveness of regulation. Evidence of community support for regulation was also cited as an important factor in determining feasibility.Conclusions The regulation of unhealthy food marketing to children is perceived to be a feasible strategy for obesity prevention however barriers to implementation at the state level exist. Those involved in state-level policy making generally indicated a preference for Commonwealth-led regulation. This research suggests that implementation of regulation of the television marketing of unhealthy food to children should ideally occur under the direction of the Commonwealth government. However, given that regulation is technically feasible at the state level, in the absence of Commonwealth action, states/territories could act independently. The relevance of our findings is likely to extend beyond Australia as unhealthy food marketing to children is a global issue.<br /

Action on the social determinants of health: Views from inside the policy process.

It is now well documented that many of the key drivers of health reside in our everyday living conditions. In the last two decades, public health has urged political action on these critical social determinants of health (SDH). As noted by the World Health Organisation, encouraging action in this area is challenging. Recent research has argued that public health researchers need to gain a deeper understanding of the complex and changing rationalities of policymaking. This, it seems, is the crucial next step for social determinants of health research.In this paper, we turn our attention to the practitioners of 'the art of government', in order to gain insight into how to secure upstream change for the SDH. Through interviews with policy actors (including politicians, senior government advisors, senior public servants and experienced policy lobbyists) the research sought to understand the nature of government and policymaking, as it pertains to action on the SDH. Through exploring the policy process, we examine how SDH discourses, evidence and strategies align with existing policy processes in the Australian context.Participants indicated that approaches to securing change that are based on linear conceptualisations of the policy process (as often found in public health) may be seen as 'out of touch' with the messy reality of policymaking. Rather, a more dialogic approach that embraces philosophical and moral reasoning (alongside evidence) may be more effective. Based on our findings, we recommend that SDH advocates develop a deeper awareness of the political and policy structures and the discursive conventions they seek to influence within specific settings

Help or hindrance? Social policy and the 'social determinants of health'

In recent years, public health research has become increasingly focused on issues of social inequality and social disadvantage. This is because social issues, such as poor housing and unemployment, have been found to impact health significantly, and are now referred to as �the social determinants of health�. As a result of this shift, public health is now principally concerned with what are historically considered to be social policy issues. This paper discusses the confluence of public health and social policy; it examines the opportunities and risks posed by this convergence for those working in social policy seeking to reduce poverty and inequality. We argue that, while much can be gained in the two fields by working more closely together, there remain fundamental differences in perspectives and approaches. In order to maximise benefits, these points of difference need to be thought through sooner rather than later

What do we mean by structure when we talk about structural influences on the social determinants of health and health outcomes?

Understanding and modifying the influence of structural factors on health is one of the core aims of contemporary public health. The currently dominant account in public health treats structure as being synonymous with indicators of social status such as income, education or occupation level. The unequal distribution of these indicators is further treated as the 'fundamental cause' of health inequalities. In this paper we build an account of structure which is grounded in social theory and responsive to the empirical evidence on health inequalities. We start with Bourdieu's model of habitus which positions social structures more proximally to the individual and redraws the hierarchy of up-, mid- and downstream influences. Bourdieu's theory does not adequately account for the role of public health interventions in changing attitudes and behaviours and it is particularly ill-suited to explaining the considerable reductions in smoking prevalence seen in industrialised countries. For these reasons we supplement habitus with Foucault's notion of governmentality. Structural influences on health behaviour are understood to combine equally with the myriad individual concerns of daily life. Describing some structures as being 'fundamental causes' owing to their distant position from the individual leads to misunderstanding the crucially important roles of all levels of structure

What works in joined-up government? An evidence synthesis

While coordination across departments has long been a goal of government, since the late 1990s joining-up (in various forms) is now viewed as essential to the core business of government and public administration. However, research is still catching up on the expansion of joined-up working, and there continues to be no specific body of evidence upon which judgments about its success, or which can be drawn on in the planning and implementation of new initiatives. This article draws together peer-reviewed, empirical investigations of joined-up government, synthesizing available exploratory evidence on the process of creating joined-up government

Policy change for the social determinants of health: The strange irrelevance of social epidemiology

The considerable evidence base linking social conditions to population health has spurred many in public health to call for political action. Most of these conditions fall outside the purview of health departments, meaning that advocates are increasingly calling on other government sectors to improve health. Whether levelled at the whole-of-government or individual departments these calls seek a paradigm shift in governmental goals. Paradigmatic political change is an essentially normative process – one based upon ethical, rather than empirical, reasoning. Successfully achieving political change requires that public health advocates improve their normative justification for change and reduce their reliance upon evidence-based arguments

What is policy and where do we look for it when we want to research it? A Glossary

Public health researchers are increasingly concerned with achieving ‘upstream’ change to achieve reductions in the global burden of disease and health inequalities. Consequently, understanding policy and how to change it has become a central goal of public health. Yet conceptualisation of what constitutes policy and where it can be found is very limited within this field. Our glossary demonstrates that policy is many headed. It is located in a vast array of documents, discussions dialogues and actions which can be captured variously by formal and informal forms of documentation and observation. Effectively understanding policy and its relevance for public health requires an awareness of the full range of places and contexts in which policy work happens and policy documents are producedThis study is funded by National Health and Medical Research Council

Implementing Joined-up Government: Lessons from the Australian Social Inclusion Agenda

‘Joined-up government’ (JUG) approaches have emerged in many industrialized countries as a means to tackle persistent ‘wicked’ public and social policy problems (Pollit 2003). Despite this, limited evidence exists concerning their implementation or effectiveness. ‘JUG’ was popularized by the Blair Government (UK) with its focus on addressing social exclusion. Following in these footsteps, in 2007 the Australian Government launched the Social Inclusion Agenda: a joined-up approach to improving the wellbeing of all Australians and addressing disadvantage. This paper focuses on findings from a study that examined the SIA as a natural experiment in JUG. Drawing on the implementation experiences of federal policy makers, our findings lend weight to emerging research into JUG that suggests that compatibility and consistency between goals, instruments, and processes is critical to success. We argue that closer attention needs to be given to developing ‘supportive architecture’ around joined-up initiatives to facilitate implementation