An investigation of the utilisation of health impact assessments (HIAs) in Irish public policy making

It is the aim of this thesis to investigate Health Impact Assessment (HIA) use in public policy formulation in Northern Ireland and in the Republic of Ireland. The influences affecting the use of HIAs will be examined in this study. Four case studies, where HIA has been conducted, will be used for research analysis. This includes HIAs conducted on traffic and transport in Dublin, Traveller accommodation in Donegal, a draft air quality action plan in Belfast and on a social housing regeneration project in Derry. HIA aims to identify possible intended and unintended consequences that a project, policy or programme will have on the affected population’s health. Although it has been acknowledged as a worthwhile tool to inform decision-makers, the extent to which it is used in policy in Ireland is subject to scrutiny. A theoretical framework, drawing from institutionalist, impact assessment and knowledge utilisation theories and schools of literature, underpin this study. The investigation involves an examination of the unit of analysis which consists of the HIA steering groups. These are made up of local authority decision makers, statutory health practitioners and community representatives. The overarching structure and underlying values which are hypothesized as present in each HIA case are investigated in this research. Chapters 2 and 3 outline the main literature in the area which includes theories from the public health and health promotion paradigm, the policy sciences and impact assessment techniques. Chapter 4 describes the methodology in this research which is a multiple case study design. This is followed by an analysis of the cases and then concludes with practical recommendations for HIA in Ireland and theoretical conclusions of the research.

The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.

Alcohol consumption among university students: a typology of consumption to aid the tailoring of effective public health policy

Objective: Elevated levels of alcohol consumption among university students are well documented. Policymakers have attempted to combat this issue at a university, national and international level. Tailoring public health policy to effectively tackle alcohol use is crucial. Using Q-methodology, the current study aims to develop a typology of alcohol consumption in the Irish university student population. Setting: A large Irish university. Participants Hundreds of possible statements on types of consumption were generated from a systematic review and a set of one-on-one interviews. These were reduced to 36 statements, 6 statements which define each of the 6 previously defined consumption types. Participants were advised to scan through the 36 statements and fill the statements into a ‘forced choice, standardised distribution’. Following this, a 45–90 min interview was conducted with students to illuminate subjectivity surrounding alcohol consumption. Analysis was conducted using PQ Method and NVivo software. Principal component analysis, followed by varimax rotation, was conducted to uncover the final factor information. Results: In total, 43 students completed the Q-study: 19 men and 24 women. A typology describing 4 distinct groupings of alcohol consumer was uncovered: the guarded drinker, the calculated hedonist, the peer-influenced drinker and the inevitable binger. Factor loadings of each of the consumer groupings were noted for type description. Conclusions: This is the first study to propose ideal types of alcohol consumption among a university student population. Further research is required to investigate the degree to which each of these ideal types is subscribed. However, this typology, in addition to informing public policy and strategies, will be a valuable analytic tool in future research.

Ireland's knowledge economy policy: beliefs, drivers and prospects

This dissertation critically examines Ireland’s knowledge economy policy, the country’s basis for economic recovery and growth, to enhance future policy decisions and debate. Much has been written internationally on the ‘knowledge economy’ with its emergence closely related to globalisation and technological progression in the 1990s. Since the late 1990s, Irish policy-makers have been firmly committed to positioning Ireland as a leading knowledge economy. Transforming the country’s competitive base to a knowledge economy is pivotal, directly shaping the course of Ireland’s economy and society. Given Ireland’s current economic crisis, limited resources, global competition from leaders in science and technology and growing challenges from emerging economies, a systematic study of Ireland’s major competitive policy is imperative. Above all, this study explores the processes behind the policy and the multiple actors from different institutions who follow and seek to influence decisions. The advocacy coalition framework is used to identify the advocacy coalition operating in the knowledge economy policy subsystem. The theoretical insights of this framework are also combined with other public policy approaches, providing complementary insights into the policy process. The research is framed around three elements - the beliefs underpinning the policy; who is driving the policy; and the prospects of the policy. Primary information is collected by way of semi-structured in-depth interviews with 49 Irish elites (politicians, senior bureaucrats, academics and business leaders) involved in the formation and implementation of the policy. This study finds that a strong advocacy coalition has formed in this policy subsystem whose members are collectively driving the policy. Both exogenous and endogenous forces help frame a common perception of the problems the policy addresses and the solutions it offers. Evidence suggests that this policy is a sustainable option for Ireland’s economic future and the study concludes with policy recommendations for advancing Ireland’s knowledge economy.

Learning to Teach and its Implications for the Continuum of Teacher Education: A Nine Country Cross-national Study.

The purpose of this Report is to inform discussions, policy formulation, and strategic planning on teacher education in Ireland. The research gives priority to initial teacher education (ITE) and induction, their interface, and implications for the continuum of teacher education, including continuing professional development (CPD). The study involved a two-pronged approach: a narrative review of recent and relevant literature and a cross-national review of teacher education policies in nine countries, namely, Ireland, Northern Ireland, Scotland, England, Finland, USA, Poland, Singapore and New Zealand. Adopting a broad, balanced and comprehensive understanding of the role of the contemporary teacher, it provides a framework for developing quality teacher education in Ireland. The Report incorporates exemplars of good practice and notes their implementation challenges for the Irish context.  Chapter One provides a framework for conceptualising quality teacher education and the continuum. Key features that emerge from the literature are discussed: teachers¿ practice, quality teaching, the professional life-cycle, teacher learning and relationships. With more specific reference to the continuum, Chapter Two overviews initial teacher education, induction, learning outcomes and accreditation in the selected countries, including Ireland. Key features of policy in the various countries are summarised. Individual country profiles, incorporating descriptions of socio-political, teaching and teacher education contexts, are further detailed in Appendix A. Chapter Three analyses relevant literature on initial teacher education, induction, learning outcomes/professional standards and accreditation. Along with previous chapters it provides the basis for recommendations for teacher education that are presented in Chapter Four. Chapter Four draws together the findings emerging from the cross-national review in terms of the contemporary context of teacher education in Ireland and identifies key challenges and possible lines of policy development as well as recommendations for the Teaching Council and other teacher education stakeholders. Each generation has an opportunity to provide the vision and resources for renewing teacher education in light of ambitious social, economic and educational aspirations to meet perceived societal and education challenges (as occurred in the 1970s). Despite the publication of two key reviews of initial teacher education a number of years ago, there is considerable scope for further reform of teacher education. However, significant changes have occurred to teacher education course provision and content over the last 100 years. In this report, we have stressed the need for, and called for investment in, greater system and programme coherence, mentoring to support assisted practice, knowledge integration, critical reflective practice, inquiry and the development of vibrant partnerships between higher education institutions and schools as the basis for teacher education reform across the continuum. This Executive Summary presents the Report¿s context, key findings and recommendations emerging from the analysis.  

Analysis of institutional arrangements and common pool resources governance: the case of Lake Tana sub-basin, Ethiopia

Although Common Pool Resources (CPRs) make up a significant share of total income for rural households in Ethiopia and elsewhere in developing world, limited access to these resources and environmental degradation threaten local livelihoods. As a result, the issues of management, governance of CPRs and how to prevent their over-exploitation are of great importance for development policy. This study examines the current state and dynamics of CPRs and overall resource governance system of the Lake Tana sub-basin. This research employed the modified form of Institutional Analysis and Development (IAD) framework. The framework integrates the concept of Socio-Ecological Systems (SES) and Interactive Governance (IG) perspectives where social actors, institutions, the politico-economic context, discourses and ecological features across governance and government levels were considered. It has been observed that overexploitation, degradation and encroachment of CPRs have increased dramatically and this threatens the sustainability of Lake Tana ecosystem. The stakeholder analysis result reveals that there are multiple stakeholders with diverse interest in and power over CPRs. The analysis of institutional arrangements reveals that the existing formal rules and regulations governing access to and control over CPRs could not be implemented and were not effective to legally bind and govern CPR user’s behavior at the operational level. The study also shows that a top-down and non-participatory policy formulation, law and decision making process overlooks the local contexts (local knowledge and informal institutions). The outcomes of examining the participation of local resource users, as an alternative to a centralized, command-and-control, and hierarchical approach to resource management and governance, have called for a fundamental shift in CPR use, management and governance to facilitate the participation of stakeholders in decision making. Therefore, establishing a multi-level stakeholder governance system as an institutional structure and process is necessary to sustain stakeholder participation in decision-making regarding CPR use, management and governance.