Theories of the policy process in health promotion research: a review

The Ottawa Charter laid the ground work for a new research and practice agenda by urging health promoters to advocate for healthy public policies. After more than 20 years, it is now time to reflect on the state of policy research in health promotion and to examine how rigorously theories are applied. The review of the literature was
conducted on 11 peer-reviewed journals. The journals were selected for their solid track record in publishing health promotion articles and by using a set of predefined
inclusion and exclusion criteria. The articles, published between January 1986 and June 2006, were searched using Medline and CINAHL databases. The selected papers feature search terms related to ‘politics’, ‘policy’, ‘advocacy’ and ‘coalition’. We examined the theoretical grounding of each paper and whether it focuses on policy content (e.g. nature, impact, evolution of the policy), policy processes (e.g. advocacy capacity building and strategies) or theoretical/methodological issues in policy analysis. This review demonstrates that policy research in health promotion is still largely an a theoretical enterprise. Out of the 119 articles that were found eligible, 39 did apply to some degree a theoretical framework, of which 21 referred to a theoretical framework from political science. We conclude that the field has yet to acknowledge critical concepts that would help to shed light on the policy process, and that validated rigorous theoretical frameworks to inform research and practice are hardly applied. Recommendations are formulated to improve policy research in health promotion.

Democratizing health : consumer groups in the policy process

This timely book examines the role of consumer organisations in the health policy process. In an age of shifting boundaries between state and civil society, consumer groups are potentially drivers of democratisation in the health domain. Their activities bring new dynamics to relations between service providers, the medical profession, government agencies, and other policy actors. This book is unique in comprehensively exploring the opportunities and dilemmas of this type of activism, including sometimes ambiguous partnerships between consumer groups and stakeholders such as the pharmaceutical industry. These themes are explored within an internationally comparative frameThis book examines the important role of consumer activism within health policy in different national contexts. In an age of shifting boundaries between state and civil society, consumer groups are potentially drivers of democratization in the health domain. The expert contributors explore how their activities bring new dynamics to relations between service providers, the medical profession, government agencies, and other policy actors. This book is unique in comprehensively analysing the opportunities and dilemmas of this type of activism, including ambiguous partnerships between consumer groups and stakeholders such as the pharmaceutical industry. These themes are explored within an internationally comparative framework, with case studies from various countries. work, with case studies from many countries.

Folate fortification : a case study of public health policy-making

Introducing Evidence Based Health Policy: Problems and Possibilities, Section 1: What is the Problem?, 1: Competing Rationalities: Evidence based Health Policy, 2: Beyond Two Communities, Section 2: What does Evidence Mean?, 3: Evidence based Medicine - The Medical Profession and Health Policy, 4: Mind The Gap: Assessing the Quality of Evidence for Public Health Problems, 5: Health Policy and Normative Analysis: Ethics, Evidence and Politics, 6: What is New in Health Information? Evidence for Health Consumers and Policy Making, 7: From Evidence based Medicine to Evidence based Public Health, Section 3: Policy Case Studies, 8: The Viagra Affair: Evidence as the Terrain for Competing Partners, 9: Folate Fortification: A Case Study of Public Health Policy-Making in a Food Regulation Setting, 10: The Supply and Safety of Blood and Blood Products - Evidence, Risk and Policy, 11: The Development of Nurse Practitioner Policy, 12: Creating Healthy Public Policy for Oral Health: How was the Evidence Used?, 13: Regulation of Traditional Chinese Medicine in Victoria, 14: The Victorian Primary Health Care Reforms: A Case Study of Evidence-based Policy Making, 15: Evidence-based Practice in the Australian Drug Policy Community, 16: Challenging the Evidence - Women's Health Policy in Australia, 17: Evidence and Aboriginal Health Policy, 18: The Limits to Technical Rationality in the Health Inequalities Policy Process, 19: Evidence-based policy: A Technocratic Wish in a Political World, Section 4: Is the transfer of evidence into policy possible?, 20: The Community Model of Research Transfer, 21: Getting Research Transfer into Policy and Practice in Maternity Care, 22: Improving the Research and Policy Partnership: An Agenda for Research Transfer and Governance, 23: Framing and Taming 'Wicked' Problems

The dynamic interplay of news media and bilingual education policy in Australia's Northern Territory 1988-2008

his study investigates the dynamic interplay between news media and the Northern Territory’s policy of bilingual education for indigenous children living in some remote communities. It provides evidence to support the argument that the media-related practices of a range of policy actors resulted in policy processes being shaped to a significant degree by ‘media logic’. The research is based on depth interviews and uses the spoken words of participants to gain access to the local experiences and perspectives of those invested in developing, influencing and communicating the bilingual education policy. Through the analysis of more than 20 interviews with journalists, public servants, academics, and politicians as well as indigenous and non-indigenous bilingual education advocates, I have identified a range of media-related practices that have enabled policy actors to penetrate the policy debate, define problems for policymaking and public discussion through the news media, and thereby exert particular forms of influence in the policy process. The study also provides a ‘southern theory’ analysis of the Yolngu public sphere and a Bourdesian understanding of the journalism sub-field of indigenous reporting in the Northern Territory. It shows that issues of physical and cultural remoteness and the need for journalists to develop cultural competence are the hallmarks of this reporting specialization. It also identifies marked differences in journalists’ relationships with government, academic and indigenous sources and how these differences play out in the way participants understand the production and reception of media texts. This research makes an innovative contribution to Australian Journalism Studies by demonstrating how indigenous epistemologies and knowledges offer fresh perspectives and insights about news media and indigeneity that can be brought into balance with northern theories to build what Connell (2007) has called ‘southern theory’. This dovetails with another key outcome, which is the development of an academic form of journalism that serves indigenous peoples’ self-determinist aims for scholarly research, based in indigenous perspectives and research methodologies.

External policy influence and higher education reform in Ethiopia : understanding symbolic power of the World Bank

Increasingly national policy processes are intersected with and affected by global policy actors and ideas. In aid-recipient countries such as Ethiopia, donors use financial and non-financial means to influence national policy decisions and directions. This paper is about the non-financial influence of the World Bank (WB) in the Ethiopian higher education policy reform. Using Pierre Bourdieu’s concept of symbolic power as a ‘thinking tool’, the paper aims to shed light on forms of symbolic capital that the Bank uses to generate a ‘misrecognisable’ form of power that regulates the HE policy process in Ethiopia. The findings show that the WB transforms its symbolic capital of recognition and legitimacy to establish a ‘shared misrecognition’ and thereby make its policy prescriptions implicit and hence acceptable to local policy agents. The Bank uses knowledge-based regulatory instruments to induce compliance to its neoliberal policy prescriptions. The paper therefore underscores the value of symbol power as an analytical framework to understand elusive but critical role of donors in policy processes of aid recipient countries.

The politics of developing reference standards for nutrient intakes : the case of Australia and New Zealand

Objective Nutrient Reference Values (NRV) are evidence-based benchmarks for assessing the dietary adequacy of individuals and population groups as well as informing public health nutrition policies and programmes. The present paper presents the findings of an analysis of the views of submitters to a draft document associated with the development of the 2006 NRV for Australia and New Zealand. The aim of the study was to explore how these views were reflected in the policy-making process and final policy document.

Design The information necessary to fulfil this aim required access to stakeholder submissions to the NRV development process and this necessitated exploiting the provisions of the Commonwealth of Australia’s Freedom of Information (FOI) Act 1982. We understand that the present research represents the first time that an FOI request seeking information about a National Health and Medical Research Council food and nutrition policy process has been made and therefore is novel in its approach to public health nutrition policy analysis.

Results The analysis of stakeholder submissions identified that stakeholders had particular concerns about the conduct of the review process and the future application of the nutrient values to policy and programmes. There is a lack of evidence that the majority of stakeholder comments were addressed in the final NRV document.

Conclusion Although these findings cannot be interpreted to assess the validity or otherwise of the set nutrient values, they do raise questions about the process for their development and the adequacy of the final document to reflect the views of key stakeholders.

'Build it, fill it and bill it' : how work in the public housing sector has changed (and stayed the same)

This paper is an ethnographic account of how 'wicked' (i.e. entrenched and enduring) problems with the 'building, filling and billing' of public housing have shaped and influenced the work of public housing workers in Victoria, Australia. With a few exceptions, the front line work of housing staff is represented in the literature as smaller, constituent parts of some larger policy process, organisational event or procedural reform. In order to understand how housing work has been constructed over time, this paper attempts to consolidate these fragmented narratives (contained in old documents, training manuals, news articles and reports) into an historical account of 'what it was like' to work in the public/social housing sector. In this paper, I will construct this 'historical account' with the stories I gathered over twelve months of field work in three different public housing offices. In their stories, public housing workers tell me how subtle and incremental has been the change to their work, how increasingly complex are the needs of tenants and how dfficult their work has become. Their stories illustrate the complexity of undersdanding and addressing these 'wicked' housing problems when tenants change, staff change and
the public housing sector has a history of frequent 'restructuring'. This contextualisation of 'old and new stories' will allow the reader to understand how the organisational reality of present day housing work has been socially constructed ('sedimented') by generation, of workers, managers and tenants.

Global health governance : framework convention on tobacco control (FCTC), the Doha Declaration, and democratisation

Global public health agreements are heralded as a success for the affirmation of the right to health within a complex and contested political landscape. However, the practical implementation of such agreements at the national level is often overlooked. This article outlines two radically different global health agreements: The Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement and Public Health; and the Framework Convention on Tobacco Control (FCTC). We identify significant challenges in their implementation, particularly for low and middle income countries. Shifts in the policy network constellations around these two agreements have allowed for some positive influence by civil society. Yet industry influence at the national level constrains effective implementation and those affected by these policies have largely been left on the periphery. The broader provisions of these two agreements have been watered down by vested interests and donor conditions. We advocate for both activist and academic actors to play a significant role in highlighting the consequences of these power asymmetries. Deliberative democracy may be the key to addressing these challenges in a way that empowers those presently excluded from effective participation in the policy process.

Evidence-based clinical policy: case report of a reproducible process to encourage understanding and evaluation of evidence

We report within a case study a reproducible process to facilitate the explicit incorporation of evidence by a multidisciplinary group into clinical policy development. To support the decision-making of a multidisciplinary Intersectoral Advisory Group (IAG) convened by the Royal Australasian College of Physicians Health Policy Unit, a systematic review of randomized controlled trials about environmental tobacco smoke and smoking cessation interventions in paediatric settings was first undertaken. As reported in detail here, IAG members were then formally engaged in a transparent and replicable process to understand and interpret the synthesized evidence and to proffer their independent reactions regarding policy, practice and research. Our intention was to ensure that all IAG members were democratically engaged and made aware of the available evidence. As clinical policy must engage stakeholder representatives from diverse backgrounds, a process to equalize understanding of the evidence and 'democratize' judgment about its implications is needed. Future research must then examine the benefits of such explicit steps when guidelines, in turn, are implemented. We hypothesize that changes to future practice will be more likely if processes undertaken to develop guidelines are transparent to clinicians and other target groups.

Media/ting change: the print media's role in mediating education policy in a period of radical reform in Victoria, Australia

This paper draws upon critical discourse analysis, cultural studies and communication theory, studies on media and educational reform, and the work of Bernstein, Bourdieu and Luhmann in particular, to explore how the print and media 'mediated' a period of educational change marked by moves to self-management in schools in Victoria, Australia. It considers how the media was mobilized by various education stakeholders, and in turn informed relations between schools and government, through policy discourses and texts. It considers why and how particular themes became media 'issues', how schools and teachers responded to these issues, and how the media was used by various stakeholders in education to shape policy debates. It is based on a year-long qualitative study that explored critical incidents and representations about education in the print media over a year in the daily press. It illustrates the ways in which a neo-liberal Victorian government mobilized the media to gain strategic advantage to promote radical education reform policies, considers the media effects of this media/tion process on schools and teachers, and conceptualizes how school and system performance is fed from and into media representations, public perceptions and community understandings of schools and teachers' work.

`Building bridges`: a case study of a collaborative research process

'Building bridges' is a metaphor we have used to describe a collaborative research process involving social work academic and senior practitioners from government and non-government child protection and family service organizations in Victoria, Australia. The purpose of the research was to develop a 'practice-generated approach to policy implementation' in child protection practice. The research sought to explore the appropriateness of social constructionist approaches for child protection practice that might enhance the existing risk paradigm. This article aims to critically evaluate the process of 'building bridges' and its outcomes, by focusing on how potential and actual differences between organizational contexts, namely universities and various serviceproviding organizations, may influence relationships between theory and practice. We critically reflect on our research process comparing it with idealized forms of collaborative research discussed in the literature.

From policy to practice: the development of an integrated health promotion plan for children's services at Plenty Valley Community Health Inc.

Current changes in the funding of health promotion in community health in Victoria require community health agencies to integrate health promotion with service delivery. This provides both opportunities and challenges for community health staff. Members of the Children’s Service Team at Plenty Valley Community Health Inc. addressed these changes by developing an integrated health promotion plan. The approach used involved identifying client pathways and then integrating opportunities for health promotion interventions into these pathways. Staff perceptions of the process involved in developing the plan were examined. The use of client pathways to integrate health promotion into everyday practice proved a successful approach for members of the Children’s Services Team, and provides a useful model for health promotion planning in community health that helps staff to see the relevance of health promotion to their practice, and engages staff in the planning process. Members of the Children’s Services Team reported that the process involved in developing their integrated health promotion plan was a very worthwhile experience that allowed them a strong sense of ownership of the plan.

Incorporating community objectives in improved wetland management: the use of the analytic hierarchy process

Wetlands in Australia provide considerable ecological, economic, environmental and social benefits. However, the use of wetlands has been indiscriminate and significant damage to many Australian wetlands has occurred. During the last 150 years one third of the wetlands in Victoria have been lost. A conspicuous problem in wetland management is the paucity of involvement by stakeholders. This paper uses the Analytic Hierarchy Process (AHP) to incorporate stakeholder objectives in the ‘Wonga Wetlands’ on the Murray River. The study shows that the AHP can explicitly incorporate stakeholder preferences and multiple objectives to evaluate management options. The AHP also provides several approaches for policy makers to arrive at policy decisions.