Bradley R Crammond

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

BackgroundThe 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.MethodsIn 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.ResultsWe 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.ConclusionDrawing 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.

Moving beyond 'rates, roads and rubbish' : how do local governments make choices about healthy public policy to prevent obesity?

While the causes of obesity are well known traditional education and treatment strategies do not appear to be making an impact. One solution as part of a broader complimentary set of strategies may be regulatory intervention at local government level to create environments for healthy nutrition and increased physical activity. Semi structured interviews were conducted with representatives of local government in Australia. Factors most likely to facilitate policy change were those supported by external funding, developed from an evidence base and sensitive to community and market forces. Barriers to change included a perceived or real lack of power to make change and the complexity of the legislative framework. The development of a systematic evidence base to provide clear feedback on the size and scope of the obesity epidemic at a local level, coupled with cost benefit analysis for any potential regulatory intervention, are crucial to developing a regulatory environment which creates the physical and social environment required to prevent obesity.

Systems change for the social determinants of health

BackgroundInequalities in the distribution of the social determinants of health are now a widely recognised problem, seen as requiring immediate and significant action (CSDH. Closing the Gap in a Generation. Geneva: WHO; 2008; Marmot M. Fair Society, Healthy Lives: The Marmot Review. Strategic Review of Health Inequalitites inEngland Post-2010. London; 2010). Despite recommendations for action on the social determinants of health dating back to the 1980s, inequalities in many countries continue to grow. In this paper we provide an analysis of recommendations from major social determinants of health reports using the concept of ‘system leverage points’. Increasingly, powerful and effective action on the social determinants of health is conceptualised as that which targets government action on the non-health issues which drive health outcomes.MethodsRecommendations for action from 6 major national reports on the social determinants of health were sourced. Recommendations from each report were coded against two frameworks: Johnston et al’s recently developed Intervention Level Framework (ILF) and Meadow’s seminal ‘12 places to intervene in a system’ (Johnston LM, Matteson CL, Finegood DT. Systems Science and Obesity Policy: A Novel Framework forAnalyzing and Rethinking Population-Level Planning. American journal of public health. 2014;(0):e1-e9; Meadows D. Thinking in Systems. USA: Sustainability Institute; 1999) (N = 166).ResultsOur analysis found several major changes over time to the types of recommendations being made, including a shift towards paradigmatic change and away from individual interventions. Results from Meadow’s framework revealed a number of potentially powerful system intervention points that are currently underutilised in public health thinking regarding action on the social determinants of health.ConclusionWhen viewed through a systems lens, it is evident that the power of an intervention comes not from where it is targeted, but rather how it works to create change within the system. This means that efforts targeted at government policy can have only limited effectiveness if they are aimed at changing relatively weak leverage points. Our analysis raises further (and more nuanced) questions about what effective action on the social determinants of health looks like.

Systems science and systems thinking for public health: a systematic review of the field

Objectives This paper reports on findings from a systematic review designed to investigate the state of systems science research in public health. The objectives were to: (1) explore how systems methodologies are being applied within public health and (2) identify fruitful areas of activity. Design A systematic review was conducted from existing literature that draws on or uses systems science (in its various forms) and relates to key public health areas of action and concern, including tobacco, alcohol, obesity and the social determinants of health. Data analysis 117 articles were included in the review. An inductive qualitative content analysis was used for data extraction. The following were systematically extracted from the articles: approach, methodology, transparency, strengths and weaknesses. These were then organised according to theme (ie, commonalities between studies within each category), in order to provide an overview of the state of the field as a whole. The assessment of data quality was intrinsic to the goals of the review itself, and therefore, was carried out as part of the analysis. Results 4 categories of research were identified from the review, ranging from editorial and commentary pieces to complex system dynamic modelling. Our analysis of each of these categories of research highlighted areas of potential for systems science to strengthen public health efforts, while also revealing a number of limitations in the dynamic systems modelling being carried out in public health. Conclusions There is a great deal of interest in how the application of systems concepts and approach might aid public health. Our analysis suggests that soft systems modelling techniques are likely to be the most useful addition to public health, and align well with current debate around knowledge transfer and policy. However, the full range of systems methodologies is yet to be engaged with by public health researchers.

Why Education and Choice Won't Solve the Obesity Problem

The authors express their opinion that governments must consider the environment that led to the obesity epidemic when proposing obesity prevention measures. They believe that proposals that focus on the willpower, knowledge, or decision-making ability of individuals will not be successful. They note that changing behavior is a challenge and that increasing levels of knowledge and awareness does not always result in change of behavior.

A glossary of policy frameworks: the many forms of ‘universalism’ and policy ‘targeting’

The recognition that certain characteristics (such as poverty, disadvantage or membership of marginalised social or cultural groups) can make individuals more susceptible to illness has reignited interest in how to combine universal programmes and policies with ones targeted at specific groups. However, ‘universalism’ and ‘targeting’ are used in different ways for different purposes. In this glossary, we define different types and approaches to universalism and targeting. We anticipate that greater clarity in relation to what is meant by ‘universalism’ and ‘targeting’ will lead to a more nuanced debate and practice in this area.

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.

Towards health equity: a framework for the application of proportionate universalism

IntroductionThe finding that there is a social gradient in health has prompted considerable interest in public health circles. Recent influential works describing health inequities and their causes do not always argue cogently for a policy framework that would drive the most appropriate solutions differentially across the social gradient This paper aims to develop a practice heuristic for proportionate universalism.MethodsThrough a review the proposed heuristic integrates evidence from welfare state and policy research, the literature on universal and targeted policy frameworks, and a multi-level governance approach that adopts the principle of subsidiarity.ResultsThe proposed heuristic provides a more-grained analysis of different policy approaches, integral for operationalizing the concept of proportionate universalism.ConclusionThe proposed framework would allow governments at all levels, social policy developers and bureaucrats, public health professionals and activists to consider the appropriateness of distinctive policy objectives across distinctive population needs within universal welfare state principles.

The possibility of regulating for obesity prevention - understanding regulation in the Commonwealth Government

A complex regulatory package is likely to be necessary to effectively reduce obesity prevalence in developed countries. This study investigated the barriers and facilitators to implementing regulatory interventions to prevent obesity within the executive arm of the Australian Commonwealth Government. Policy reviews were conducted on nine government departments to understand their roles and interests in obesity. From this process we identified regulatory review carried out by the Office of Best Practice Regulation as possibly posing a barrier to law reform for obesity prevention, along with the complexity of the food policymaking structures. The policy reviews informed subsequent in‐depth semi‐structured interviews with senior Commonwealth government officers (n = 13) focused on refining our understanding of the barriers to enacting obesity prevention policy. In addition to the two barriers already identified, interviewees identified a lack of evidence for interventions, which would reduce obesity prevalence, and the influence of politicians on executive decisions as posing obstacles. Most interviewees believed that the barriers to regulating to prevent obesity were strong and that intervention by elected politicians would be the most likely method of implementing obesity prevention policy.

Can the sociology of social problems help us to understand and manage ‘lifestyle drift’?

Lifestyle drift is increasingly seen as a barrier to broad action on the social determinants of health. The term is currently used in the population health literature to describe how broad policy initiatives for tackling inequalities in health that start off with social determinants (upstream) approach drift downstream to largely individual lifestyle factors, as well as the general trend of investing a the individual level. Lifestyle drift occurs despite the on-going efforts of public health advocates, such as anti-obesity campaigners, to draw attention to the social factors which shape health behavior and outcomes. In this article, we explore whether the sociology of social problems can help understand lifestyle drift in the context of obesity. Specifically, we apply Jamrozik and Nocellas residualist conversion model to the problem of obesity in order to explore whether such an approach can provide greater insight into the processes that underpin lifestyle drift and inform our attempts to mitigate it.