TY - JOUR
AU - Selvey, Linda, A
AB - Abstract To investigate factors that enable or challenge the initiation and actioning of health and wellbeing policy in Australian local governments using political science frameworks. An online survey was distributed to staff and elected members of Australian local governments. The survey sought responses to a range of variables as informed by political science frameworks. Data were analysed using descriptive statistics and results were compared between local governments of different geographical sizes and locations using Kruskal–Wallis non-parametric testing. There were 1825 survey responses, including 243 CEOs, representing 45% of Australian local governments. Enablers for local government policy initiation and action included the high priority given to health and wellbeing (44%), local leadership (56%) and an organizational (70%) and personal obligation (68%) to the community to act. Less true is a favourable legislative environment (33%), leadership from higher levels of government (29%) and sufficient financial capacity (22%). Cities are better positioned to initiate and action health policy, regardless of the broader legislative environment. Health and wellbeing is a high priority for Australian local governments, despite lack of funding and limited lobbying and support from other sectors and higher levels of government. The insights from political science frameworks assist to understand the policy process, including the interrelatedness of enablers and challenges to initiating and actioning health and wellbeing policy. Further understanding the policy drivers would support practitioners and researchers advocating to influence local health and wellbeing policy. local government, health policy, determinants of health INTRODUCTION In Australia, the responsibility for health is largely the role of national and state tiers of government, both dominated by a biomedical model of healthcare (Keleher, 2016). Strong evidence suggests that to achieve major population health gains, the underlying determinants of health must be addressed (Marmot et al., 2008). In essence, addressing population health and wellbeing (HWB) relies on cross-sector collaboration and most often outside of the healthcare system, including investments in education, employment, early years development, housing and transport (Marmot et al., 2008). In practice, and despite the evidence, the required coordination to integrate HWB across different policy areas has proven challenging to facilitate across any tier of government (Clavier and de Leeuw, 2013). An integrated approach to HWB competes with the attention given to a biomedical approach to health (Baum et al., 2013) and raises difficulties in working collaboratively across government sectors (Exworthy and Hunter, 2011). With local government being the closest tier of government to the community (Rantala et al., 2014) and focused on a more social model of health (World Health Organisation, 2012), researchers have long proposed that local government may be the most feasible level of government to take action for underlying health determinants (Harris and Wills, 1997; de Leeuw and Clavier, 2011; Collins and Hayes, 2013). Whilst somewhat autonomous, Australian local governments are legislated by the senior State or Territory tier of Government. Therefore, the role of HWB in local governments vary, depending on their binding Local Government Act (Dollery et al., 2009). However, given that local governments have responsibility for a range of social, environmental and economic decisions, the question of where, or if, the determinants of health fit into these responsibilities continues to remain unanswered. Whilst evidence is growing at national and senior levels of government, recent reviews of the literature conclude there is a dearth of research at the local government level investigating the policy process addressing health determinants and health inequities (Baker et al., 2017; Guglielmin et al., 2018; Van Vliet-Brown et al., 2018). Within the limited research at a local level, the identified enablers to addressing health determinants include: having political will, involvement of media and community (Larsen et al., 2014; Rantala et al., 2014), commitment by local policy makers (Jansson et al., 2011), the capability to work across sectors (Larsen et al., 2014) and support from higher levels of government (Rantala et al., 2014). The challenges include lack of funding (Collins and Hayes, 2013; Larsen et al., 2014); absence of a policy entrepreneur (Hoeijmakers et al., 2007); siloed departments (Larsen et al., 2014; Rantala et al., 2014); perception of extra work; lack of measurable objectives and a lack of ownership by any one department (Larsen et al., 2014). Understanding the enablers and challenges that influence the likelihood of local government addressing determinants of health requires investigation into the complex policy process. In the absence of frameworks to navigate the complex policy process, health promotion has largely relied on rational frameworks such as the ‘stages heuristic’ that looks at policy identification, formulation, implementation and evaluation (Breton and de Leeuw, 2011; Buse et al., 2012), or influencing policy through awareness of research evidence and traditional knowledge translation strategies (Raphael, 2008; de Leeuw et al., 2014). Health promotion practitioners and researchers are largely aware of more complex policy influences, though are not exposed to policy frameworks (Breton and de Leeuw, 2011). The frameworks within political science shift the thinking of policy beyond a rational linear process to analyse the inter-relatedness of how and why policy issues are understood, the range and influence of policy actors involved, the broader politics around priorities and solutions and how external pressures influence the policy environment over time. There are few known studies using political science frameworks to investigate how and why health determinants end up in health policy or not (Embrett and Randall, 2014) and none in the local government setting. Notably, Hoeijmakers et al. (Hoeijmakers et al., 2007), who used stakeholder and network analysis as a framework to explore local health policy in the Netherlands, made a call to apply political science with more rigour in health promotion research more than a decade ago. This research aims to address these two research gaps by further investigating the factors that enable or challenge the current HWB policy process in local government, along with applying a theoretical lens from political science to further understand the complex policy process. METHODS Survey design An online questionnaire was designed using the combined constructs of four political science frameworks including Multiple Streams Framework (MSF) (Kingdon, 1995), Advocacy Coalition Framework (ACF) (Sabatier, 2007a), Punctuated Equilibrium (Baumgartner and Jones, 1993) and Analysis of Determinants of Policy Impact (ADEPT) (Rütten et al., 2011). These frameworks were chosen as they are comprehensible, tested in a research environment and proposed as useful to health promotion policy research (Sabatier, 2007b; Breton and de Leeuw, 2011; Clavier and de Leeuw, 2013). Each of the frameworks look at the policy process from different theoretical viewpoints, with their own strengths and limitations. In more recent literature, there is a move by researchers to apply multiple frameworks in recognition of their individual strengths to explain the policy process (Baker et al., 2017; Harris et al., 2017). A broad overview of the political science frameworks applied and how they informed the questionnaire are outlined in Table 1. The questionnaire included 13 overarching questions regarding local government healthy public policy processes and 5 demographic questions, including geographical region, size of local government and role of respondent. The questionnaire comprised 42 variables on a 5-point Likert scale that sought to identify how true a range of policy constructs are perceived, in addition to tick boxes and areas for free text including self-reported inclusion of HWB across several policy areas. The study was approved by the Curtin University Human Research Ethics Committee (SPH-88-2014), Australia. The full questionnaire tool is available on request from the corresponding author. Table 1: How the four frameworks of MSF, ACF, PEF and ADEPT inform the questionnaire to understand the policy process of local government MSF ACF PEF ADEPT Definition of the framework Theorizes that when three ‘streams’ of problem, policy and politics align, a ‘window of opportunity’ arises. The framework proposes that policy initiation is more likely where a policy entrepreneur manipulates the three streams (Sabatier, 2007a). Theorizes that it is largely individuals within a policy sub-system that influence policymaking. The framework proposes that individuals with similar values and beliefs form ‘advocacy coalitions’ that then compete for policy attention (Sabatier, 2007a). Theorizes that policy often has long periods of stability, that are then ‘punctuated’ by policy activists, events or heightened public awareness (Baumgartner and Jones, 1993) This model is adapted from a behavioural change theory. It identifies four organizational capacities that are considered to be required for policy implementation, including goals, obligations, resources and opportunities (Rütten et al., 2011) How the framework informed the questionnaire -Defining the problem of health and wellbeing for local government. -Problem ‘load’ and priority given to health and wellbeing. -Current solutions for health and wellbeing across local government policy areas. -Role of senior levels of government, including legislation. -Role of individual policy entrepreneurs. -Values and beliefs of elected and non-elected decision makers in local government. -Range of policy actors involved. -Competing and similar interests across policy actors. -Role of community in decision making. -Use of ‘evidence’ to inform decisions. -Level of advocacy efforts by different policy actors. -Problem ‘load’ and priority given to health and wellbeing. -Role of policy monitoring feedback. -Shared interests of policy actors and policy monopolies. -Role of external events. -Role of media and public concern. -Clarity of goals for health and wellbeing action. -Personal obligations of elected and non-elected members. -Organizational obligation by local government. -Use of performance indicators for measuring health and wellbeing. -Financial and staff resources. Strengths and limitations of the framework Strength Recognizes the inter-relatedness of a complex policy process.Limitation Focus is on policy initiation. It strongly implies the role of a policy entrepreneur to navigate and manipulate the three streams (Sabatier, 2007a). Strength Bases decision making on the underpinning individual or organization beliefs and values (Sabatier, 2007a).Limitation Focus is on policy initiation. Assumes that actors or coalitions will actively coordinate their behaviour or act on their beliefs (Sabatier, 2007a). Strength Focus on policy change and external influences on subsystem policy environments.Limitations Given the focus on uncertainty, the framework limits ability to predict policy priorities (Sabatier, 2007a). Strength Focus is beyond policy initiation and includes organizational capacities to action policy solutions.Limitations Limits to four concepts, adapted from a behavioural model of health (Rütten et al., 2011). MSF ACF PEF ADEPT Definition of the framework Theorizes that when three ‘streams’ of problem, policy and politics align, a ‘window of opportunity’ arises. The framework proposes that policy initiation is more likely where a policy entrepreneur manipulates the three streams (Sabatier, 2007a). Theorizes that it is largely individuals within a policy sub-system that influence policymaking. The framework proposes that individuals with similar values and beliefs form ‘advocacy coalitions’ that then compete for policy attention (Sabatier, 2007a). Theorizes that policy often has long periods of stability, that are then ‘punctuated’ by policy activists, events or heightened public awareness (Baumgartner and Jones, 1993) This model is adapted from a behavioural change theory. It identifies four organizational capacities that are considered to be required for policy implementation, including goals, obligations, resources and opportunities (Rütten et al., 2011) How the framework informed the questionnaire -Defining the problem of health and wellbeing for local government. -Problem ‘load’ and priority given to health and wellbeing. -Current solutions for health and wellbeing across local government policy areas. -Role of senior levels of government, including legislation. -Role of individual policy entrepreneurs. -Values and beliefs of elected and non-elected decision makers in local government. -Range of policy actors involved. -Competing and similar interests across policy actors. -Role of community in decision making. -Use of ‘evidence’ to inform decisions. -Level of advocacy efforts by different policy actors. -Problem ‘load’ and priority given to health and wellbeing. -Role of policy monitoring feedback. -Shared interests of policy actors and policy monopolies. -Role of external events. -Role of media and public concern. -Clarity of goals for health and wellbeing action. -Personal obligations of elected and non-elected members. -Organizational obligation by local government. -Use of performance indicators for measuring health and wellbeing. -Financial and staff resources. Strengths and limitations of the framework Strength Recognizes the inter-relatedness of a complex policy process.Limitation Focus is on policy initiation. It strongly implies the role of a policy entrepreneur to navigate and manipulate the three streams (Sabatier, 2007a). Strength Bases decision making on the underpinning individual or organization beliefs and values (Sabatier, 2007a).Limitation Focus is on policy initiation. Assumes that actors or coalitions will actively coordinate their behaviour or act on their beliefs (Sabatier, 2007a). Strength Focus on policy change and external influences on subsystem policy environments.Limitations Given the focus on uncertainty, the framework limits ability to predict policy priorities (Sabatier, 2007a). Strength Focus is beyond policy initiation and includes organizational capacities to action policy solutions.Limitations Limits to four concepts, adapted from a behavioural model of health (Rütten et al., 2011). Open in new tab Table 1: How the four frameworks of MSF, ACF, PEF and ADEPT inform the questionnaire to understand the policy process of local government MSF ACF PEF ADEPT Definition of the framework Theorizes that when three ‘streams’ of problem, policy and politics align, a ‘window of opportunity’ arises. The framework proposes that policy initiation is more likely where a policy entrepreneur manipulates the three streams (Sabatier, 2007a). Theorizes that it is largely individuals within a policy sub-system that influence policymaking. The framework proposes that individuals with similar values and beliefs form ‘advocacy coalitions’ that then compete for policy attention (Sabatier, 2007a). Theorizes that policy often has long periods of stability, that are then ‘punctuated’ by policy activists, events or heightened public awareness (Baumgartner and Jones, 1993) This model is adapted from a behavioural change theory. It identifies four organizational capacities that are considered to be required for policy implementation, including goals, obligations, resources and opportunities (Rütten et al., 2011) How the framework informed the questionnaire -Defining the problem of health and wellbeing for local government. -Problem ‘load’ and priority given to health and wellbeing. -Current solutions for health and wellbeing across local government policy areas. -Role of senior levels of government, including legislation. -Role of individual policy entrepreneurs. -Values and beliefs of elected and non-elected decision makers in local government. -Range of policy actors involved. -Competing and similar interests across policy actors. -Role of community in decision making. -Use of ‘evidence’ to inform decisions. -Level of advocacy efforts by different policy actors. -Problem ‘load’ and priority given to health and wellbeing. -Role of policy monitoring feedback. -Shared interests of policy actors and policy monopolies. -Role of external events. -Role of media and public concern. -Clarity of goals for health and wellbeing action. -Personal obligations of elected and non-elected members. -Organizational obligation by local government. -Use of performance indicators for measuring health and wellbeing. -Financial and staff resources. Strengths and limitations of the framework Strength Recognizes the inter-relatedness of a complex policy process.Limitation Focus is on policy initiation. It strongly implies the role of a policy entrepreneur to navigate and manipulate the three streams (Sabatier, 2007a). Strength Bases decision making on the underpinning individual or organization beliefs and values (Sabatier, 2007a).Limitation Focus is on policy initiation. Assumes that actors or coalitions will actively coordinate their behaviour or act on their beliefs (Sabatier, 2007a). Strength Focus on policy change and external influences on subsystem policy environments.Limitations Given the focus on uncertainty, the framework limits ability to predict policy priorities (Sabatier, 2007a). Strength Focus is beyond policy initiation and includes organizational capacities to action policy solutions.Limitations Limits to four concepts, adapted from a behavioural model of health (Rütten et al., 2011). MSF ACF PEF ADEPT Definition of the framework Theorizes that when three ‘streams’ of problem, policy and politics align, a ‘window of opportunity’ arises. The framework proposes that policy initiation is more likely where a policy entrepreneur manipulates the three streams (Sabatier, 2007a). Theorizes that it is largely individuals within a policy sub-system that influence policymaking. The framework proposes that individuals with similar values and beliefs form ‘advocacy coalitions’ that then compete for policy attention (Sabatier, 2007a). Theorizes that policy often has long periods of stability, that are then ‘punctuated’ by policy activists, events or heightened public awareness (Baumgartner and Jones, 1993) This model is adapted from a behavioural change theory. It identifies four organizational capacities that are considered to be required for policy implementation, including goals, obligations, resources and opportunities (Rütten et al., 2011) How the framework informed the questionnaire -Defining the problem of health and wellbeing for local government. -Problem ‘load’ and priority given to health and wellbeing. -Current solutions for health and wellbeing across local government policy areas. -Role of senior levels of government, including legislation. -Role of individual policy entrepreneurs. -Values and beliefs of elected and non-elected decision makers in local government. -Range of policy actors involved. -Competing and similar interests across policy actors. -Role of community in decision making. -Use of ‘evidence’ to inform decisions. -Level of advocacy efforts by different policy actors. -Problem ‘load’ and priority given to health and wellbeing. -Role of policy monitoring feedback. -Shared interests of policy actors and policy monopolies. -Role of external events. -Role of media and public concern. -Clarity of goals for health and wellbeing action. -Personal obligations of elected and non-elected members. -Organizational obligation by local government. -Use of performance indicators for measuring health and wellbeing. -Financial and staff resources. Strengths and limitations of the framework Strength Recognizes the inter-relatedness of a complex policy process.Limitation Focus is on policy initiation. It strongly implies the role of a policy entrepreneur to navigate and manipulate the three streams (Sabatier, 2007a). Strength Bases decision making on the underpinning individual or organization beliefs and values (Sabatier, 2007a).Limitation Focus is on policy initiation. Assumes that actors or coalitions will actively coordinate their behaviour or act on their beliefs (Sabatier, 2007a). Strength Focus on policy change and external influences on subsystem policy environments.Limitations Given the focus on uncertainty, the framework limits ability to predict policy priorities (Sabatier, 2007a). Strength Focus is beyond policy initiation and includes organizational capacities to action policy solutions.Limitations Limits to four concepts, adapted from a behavioural model of health (Rütten et al., 2011). Open in new tab Data collection The online questionnaire, using Qualtrics online software, was distributed to Chief Executive Officers (CEO), elected members, management and other staff in Australian local governments (individually referred to as a ‘council’) between June 2015 and May 2016. The Australian Capital Territory (ACT) was not included in the study given their different governance structure for the delivery of local government services. The survey was distributed via a personally addressed email and followed up with a reminder after 1 and 3 weeks. Where the email addresses were not publicly available a generic council email address was used, resulting in 461 CEOs, 440 mayors, 3532 elected councillors and 1636 managers across a possible 545 councils receiving both initial and follow-up emails. To encourage responses, the questionnaire was promoted through newsletters and social media by three consenting local government associations. All of the emailed participants were encouraged to forward the survey to other council staff, particularly those in decision-making roles. Data analysis Descriptive analysis was conducted for variables related to the understanding and definition of HWB and the priority given to HWB by the council. In addition, the 42 variables that influence policy decisions were included in an exploratory factor analysis to narrow down the number of variables measured by Likert scale that explained most of the data variances within the dataset. Prior to conducting a factor analysis, the data were subjected to a Kaiser-Meyer-Olkin (KMO) Measure of Sampling Adequacy and Bartlett’s Test of Sphericity to determine if a factor analysis was suitable for the dataset (Williams et al., 2010). Both scores, including KMO of 0.960 and Bartlett’s Test of Sphericity significance at 0.000, indicated that the dataset was suitable. Factors were extracted using a principal component analysis method, with factors kept where the eigenvalue was >1 (Kaiser, 1960). This procedure was replicated to eliminate variables represented across more than one factor. Variables were analysed using descriptive statistics and non-parametric tests including Kruskal–Wallis post hoc testing for pairwise comparison between councils of varying size and location. The results were analysed using SPSS Version 22 (IBM Corp., 2016). RESULTS Of the 1825 responses to the survey, 243 CEOs responded, representing 45% of Australian councils. The respondents also included elected members, strategic and operational managers and other staff, representing all States and Territories in Australia (except ACT) and across rural, city and regional councils (Table 2). Table 2: Demographics of respondents to online questionnaire Role in local government% (n) Location by state/territory% (n) Size of local government% (n) Elected member 60.1% (n=1096) Western Australia 31.9% (n=583) Rural/shire 41.8% (n=761) CEO 13.3% (n=243) New South Wales 19.8% (n=362) City 30.6% (n=556) Strategic manager 7.5% (n=135) South Australia 15.2% (n=278) Regional 27.6% (n=502) Operational manager 8.8% (n=160) Victoria 14.7% (n=268) Other staff 10.5% (n=191) Queensland 10.6% (n=194) Tasmania 6.2% (n=114) Northern Territory 1.4% (n=26) Role in local government% (n) Location by state/territory% (n) Size of local government% (n) Elected member 60.1% (n=1096) Western Australia 31.9% (n=583) Rural/shire 41.8% (n=761) CEO 13.3% (n=243) New South Wales 19.8% (n=362) City 30.6% (n=556) Strategic manager 7.5% (n=135) South Australia 15.2% (n=278) Regional 27.6% (n=502) Operational manager 8.8% (n=160) Victoria 14.7% (n=268) Other staff 10.5% (n=191) Queensland 10.6% (n=194) Tasmania 6.2% (n=114) Northern Territory 1.4% (n=26) Open in new tab Table 2: Demographics of respondents to online questionnaire Role in local government% (n) Location by state/territory% (n) Size of local government% (n) Elected member 60.1% (n=1096) Western Australia 31.9% (n=583) Rural/shire 41.8% (n=761) CEO 13.3% (n=243) New South Wales 19.8% (n=362) City 30.6% (n=556) Strategic manager 7.5% (n=135) South Australia 15.2% (n=278) Regional 27.6% (n=502) Operational manager 8.8% (n=160) Victoria 14.7% (n=268) Other staff 10.5% (n=191) Queensland 10.6% (n=194) Tasmania 6.2% (n=114) Northern Territory 1.4% (n=26) Role in local government% (n) Location by state/territory% (n) Size of local government% (n) Elected member 60.1% (n=1096) Western Australia 31.9% (n=583) Rural/shire 41.8% (n=761) CEO 13.3% (n=243) New South Wales 19.8% (n=362) City 30.6% (n=556) Strategic manager 7.5% (n=135) South Australia 15.2% (n=278) Regional 27.6% (n=502) Operational manager 8.8% (n=160) Victoria 14.7% (n=268) Other staff 10.5% (n=191) Queensland 10.6% (n=194) Tasmania 6.2% (n=114) Northern Territory 1.4% (n=26) Open in new tab Integrating HWB in policy areas When asked to what extent HWB outcomes were considered in developing policies, 90% (n = 1329) of respondents reported that HWB was ‘always’ or ‘most of the time’ considered in the development of at least one of the listed policy areas of transport, urban planning, housing, energy and sustainability, sport and recreation, health care and economic development. Of these policy areas, respondents were most likely to report that HWB was integrated ‘always’ or ‘most of the time’ in sport and recreation (80%), urban planning (60%) and healthcare (60%). There were 295 respondents (16%) who reported HWB was considered across all listed policy areas ‘always’ or ‘most of the time’. There were no respondents that only reported HWB as ‘rarely’ or ‘never’ considered across all the policy areas listed. Understanding the policy problem From a list of varying definitions, a majority of respondents (58%, n = 984) reported that their council defined HWB as ‘Health is being not only free from disease, though a complete state of physical, mental and social wellbeing, stemming from built and social environments, family, individual circumstances and socioeconomic position’. Of the four listed, this definition was the most comprehensive, ecological approach to HWB. The responses were similarly distributed across all sizes of councils. Respondents were asked what policy areas they believe have the potential for improving their community’s HWB. A total of 62% (n = 1178) of all survey respondents answered the open-ended question. The most common policy areas reported included the built environment (n = 473), community development (n = 406), sport and recreation (n = 400), health behaviours and issues (n = 302) and the natural environment (n = 286). Of all responses, 6.5% (n = 75) indicated that ‘all policies impact’. Priority able to give to HWB as an issue When asked on a scale of 1–10 ‘Where does addressing HWB in your region fall among all of the other priorities your council have to consider?’, 44% (n = 421) of respondents reported an eight or above, including 43% of CEO’s. There was a significant difference by location of council (H = 9.332, p = 0.009), with respondents from rural and city councils reporting HWB as a higher priority than regional councils. Factor analysis A factor analysis resulted in four key factors over 30 variables. The four key factors were named ‘policy subsystem (16 variables)’, ‘resources and capacity (4 variables)’, ‘partnerships and actors (7 variables)’ and ‘policy initiators (4 variables)’ (Table 3). Variables related to the role of media and community, staff knowledge and skills, formal collaborative partnerships and the presence of a key champion did not group into any of the four factors. The responses related to the presence of a key champion were retained within the ‘policy subsystem’ factor as this was considered critical to at least one of the political science frameworks that informed the research. Table 3: Overall responses to how ‘true’ a range of variables in the policy process are, with demonstrated statistical significance by size of council Definitely true (%) Mostly true (%) Sometimes true (%) Rarely true (%) Not true at all (%) ** Policy subsystem Staff agree on what action needs to be taken to address HWB (n =1492) 12.5 42.6 34.1 7.9 2.9 City The approach to HWB is clear in the policy (n=1399) 17.0 36.3 32.2 10.6 3.9 City The goals for HWB are concrete enough (n=1398) 10.1 37.2 32.8 15.6 4.4 City The actions centre on improving the HWB of the community (n=1398) 19.5 39.3 28.8 9.9 2.4 City There is sufficient cooperation within the council during development of policy (n=1403) 14.1 40.4 30.6 10.9 3.9 City Rural There is current lobby for action on HWB within council (n=1398) 8.4 22.0 33.5 25.0 11.1 – There is sufficient evidence available to support council decisions (n=1397) 15.1 40.7 30.1 11.0 3.1 City There is strong support and leadership from within council (n=1367) 20.3 36.3 27.4 11.0 5.1 City Rural Various HWB strategies and/or activities are implemented (n=1370) 19.9 39.2 31.2 7.5 2.2 City There is clear council commitment (n=1368) 23.9 36.4 27.3 8.8 3.5 City There is sufficient cooperation within my council during implementation of policy (n=1367) 14.8 41.0 29.0 10.8 4.5 City There is ongoing monitoring and review of policy in council (n=1362) 22.0 36.7 25.0 12.2 4.1 City Policy reviews consider HWB impacts (n=1360) 17.7 33.5 29.7 13.8 5.2 City Council uses performance indicators to measure HWB impacts (n=1362) 15.3 26.0 27.5 20.6 10.6 City Considering cost–benefits, action to address HWB is worthwhile (n=1364) 24.0 35.9 25.2 10.0 4.9 City Rural There is a key leader/champion in HWB in our council (n=1494) 18.1 28.2 29.2 15.9 8.6 City Partnerships and actors There is strong leadership from other levels of government to act (n=1491) 7.4 21.8 38.2 24.3 8.2 – There is support from other sectors when developing policy (n=1400) 6.7 34.4 41.4 14.6 2.9 – There is cooperation between different political levels involved during policy development (n=1398) 4.1 25.6 42.2 21.8 6.2 – There is cooperation between public and private organizations (n=1398) 4.7 29.5 43.3 18.7 3.8 – There is support from other sectors when implementing actions (n=1361) 6.4 33.8 42.0 14.2 3.6 City There is cooperation between different political levels involved (during policy implementation) (n=1359) 4.2 24.7 41.9 22.7 6.6 – The legislative environment is favourable for HWB action (n=1361) 5.7 27.0 40.5 20.7 6.1 City Resources and capacity The council has the necessary staff capacity (n=1401) 8.9 28.8 30.0 21.6 10.7 City There are sufficient financial resources (n=1403) 5.1 17.2 30.3 31.8 15.6 City The council has the staff time and capacity to implement actions (n=1365) 8.6 28.1 36.0 19.4 8.0 City There are sufficient financial resources (n=1366) 4.7 17.6 29.4 32.0 16.3 City Policy initiators Personally I feel obliged to do something in the field (n=1492) 32.1 36.3 23.1 5.8 2.7 City The action is part of my professional duties (n=1490) 33.8 32.1 21.7 6.9 5.6 City Scientific results demand the action (n=1482) 21.7 31.5 34.0 8.7 4.0 City Regional The council is obliged to the community to act in this area (n=1497) 31.3 38.3 23.2 5.1 1.9 City Definitely true (%) Mostly true (%) Sometimes true (%) Rarely true (%) Not true at all (%) ** Policy subsystem Staff agree on what action needs to be taken to address HWB (n =1492) 12.5 42.6 34.1 7.9 2.9 City The approach to HWB is clear in the policy (n=1399) 17.0 36.3 32.2 10.6 3.9 City The goals for HWB are concrete enough (n=1398) 10.1 37.2 32.8 15.6 4.4 City The actions centre on improving the HWB of the community (n=1398) 19.5 39.3 28.8 9.9 2.4 City There is sufficient cooperation within the council during development of policy (n=1403) 14.1 40.4 30.6 10.9 3.9 City Rural There is current lobby for action on HWB within council (n=1398) 8.4 22.0 33.5 25.0 11.1 – There is sufficient evidence available to support council decisions (n=1397) 15.1 40.7 30.1 11.0 3.1 City There is strong support and leadership from within council (n=1367) 20.3 36.3 27.4 11.0 5.1 City Rural Various HWB strategies and/or activities are implemented (n=1370) 19.9 39.2 31.2 7.5 2.2 City There is clear council commitment (n=1368) 23.9 36.4 27.3 8.8 3.5 City There is sufficient cooperation within my council during implementation of policy (n=1367) 14.8 41.0 29.0 10.8 4.5 City There is ongoing monitoring and review of policy in council (n=1362) 22.0 36.7 25.0 12.2 4.1 City Policy reviews consider HWB impacts (n=1360) 17.7 33.5 29.7 13.8 5.2 City Council uses performance indicators to measure HWB impacts (n=1362) 15.3 26.0 27.5 20.6 10.6 City Considering cost–benefits, action to address HWB is worthwhile (n=1364) 24.0 35.9 25.2 10.0 4.9 City Rural There is a key leader/champion in HWB in our council (n=1494) 18.1 28.2 29.2 15.9 8.6 City Partnerships and actors There is strong leadership from other levels of government to act (n=1491) 7.4 21.8 38.2 24.3 8.2 – There is support from other sectors when developing policy (n=1400) 6.7 34.4 41.4 14.6 2.9 – There is cooperation between different political levels involved during policy development (n=1398) 4.1 25.6 42.2 21.8 6.2 – There is cooperation between public and private organizations (n=1398) 4.7 29.5 43.3 18.7 3.8 – There is support from other sectors when implementing actions (n=1361) 6.4 33.8 42.0 14.2 3.6 City There is cooperation between different political levels involved (during policy implementation) (n=1359) 4.2 24.7 41.9 22.7 6.6 – The legislative environment is favourable for HWB action (n=1361) 5.7 27.0 40.5 20.7 6.1 City Resources and capacity The council has the necessary staff capacity (n=1401) 8.9 28.8 30.0 21.6 10.7 City There are sufficient financial resources (n=1403) 5.1 17.2 30.3 31.8 15.6 City The council has the staff time and capacity to implement actions (n=1365) 8.6 28.1 36.0 19.4 8.0 City There are sufficient financial resources (n=1366) 4.7 17.6 29.4 32.0 16.3 City Policy initiators Personally I feel obliged to do something in the field (n=1492) 32.1 36.3 23.1 5.8 2.7 City The action is part of my professional duties (n=1490) 33.8 32.1 21.7 6.9 5.6 City Scientific results demand the action (n=1482) 21.7 31.5 34.0 8.7 4.0 City Regional The council is obliged to the community to act in this area (n=1497) 31.3 38.3 23.2 5.1 1.9 City ** Statistically significant p≤0.05. Open in new tab Table 3: Overall responses to how ‘true’ a range of variables in the policy process are, with demonstrated statistical significance by size of council Definitely true (%) Mostly true (%) Sometimes true (%) Rarely true (%) Not true at all (%) ** Policy subsystem Staff agree on what action needs to be taken to address HWB (n =1492) 12.5 42.6 34.1 7.9 2.9 City The approach to HWB is clear in the policy (n=1399) 17.0 36.3 32.2 10.6 3.9 City The goals for HWB are concrete enough (n=1398) 10.1 37.2 32.8 15.6 4.4 City The actions centre on improving the HWB of the community (n=1398) 19.5 39.3 28.8 9.9 2.4 City There is sufficient cooperation within the council during development of policy (n=1403) 14.1 40.4 30.6 10.9 3.9 City Rural There is current lobby for action on HWB within council (n=1398) 8.4 22.0 33.5 25.0 11.1 – There is sufficient evidence available to support council decisions (n=1397) 15.1 40.7 30.1 11.0 3.1 City There is strong support and leadership from within council (n=1367) 20.3 36.3 27.4 11.0 5.1 City Rural Various HWB strategies and/or activities are implemented (n=1370) 19.9 39.2 31.2 7.5 2.2 City There is clear council commitment (n=1368) 23.9 36.4 27.3 8.8 3.5 City There is sufficient cooperation within my council during implementation of policy (n=1367) 14.8 41.0 29.0 10.8 4.5 City There is ongoing monitoring and review of policy in council (n=1362) 22.0 36.7 25.0 12.2 4.1 City Policy reviews consider HWB impacts (n=1360) 17.7 33.5 29.7 13.8 5.2 City Council uses performance indicators to measure HWB impacts (n=1362) 15.3 26.0 27.5 20.6 10.6 City Considering cost–benefits, action to address HWB is worthwhile (n=1364) 24.0 35.9 25.2 10.0 4.9 City Rural There is a key leader/champion in HWB in our council (n=1494) 18.1 28.2 29.2 15.9 8.6 City Partnerships and actors There is strong leadership from other levels of government to act (n=1491) 7.4 21.8 38.2 24.3 8.2 – There is support from other sectors when developing policy (n=1400) 6.7 34.4 41.4 14.6 2.9 – There is cooperation between different political levels involved during policy development (n=1398) 4.1 25.6 42.2 21.8 6.2 – There is cooperation between public and private organizations (n=1398) 4.7 29.5 43.3 18.7 3.8 – There is support from other sectors when implementing actions (n=1361) 6.4 33.8 42.0 14.2 3.6 City There is cooperation between different political levels involved (during policy implementation) (n=1359) 4.2 24.7 41.9 22.7 6.6 – The legislative environment is favourable for HWB action (n=1361) 5.7 27.0 40.5 20.7 6.1 City Resources and capacity The council has the necessary staff capacity (n=1401) 8.9 28.8 30.0 21.6 10.7 City There are sufficient financial resources (n=1403) 5.1 17.2 30.3 31.8 15.6 City The council has the staff time and capacity to implement actions (n=1365) 8.6 28.1 36.0 19.4 8.0 City There are sufficient financial resources (n=1366) 4.7 17.6 29.4 32.0 16.3 City Policy initiators Personally I feel obliged to do something in the field (n=1492) 32.1 36.3 23.1 5.8 2.7 City The action is part of my professional duties (n=1490) 33.8 32.1 21.7 6.9 5.6 City Scientific results demand the action (n=1482) 21.7 31.5 34.0 8.7 4.0 City Regional The council is obliged to the community to act in this area (n=1497) 31.3 38.3 23.2 5.1 1.9 City Definitely true (%) Mostly true (%) Sometimes true (%) Rarely true (%) Not true at all (%) ** Policy subsystem Staff agree on what action needs to be taken to address HWB (n =1492) 12.5 42.6 34.1 7.9 2.9 City The approach to HWB is clear in the policy (n=1399) 17.0 36.3 32.2 10.6 3.9 City The goals for HWB are concrete enough (n=1398) 10.1 37.2 32.8 15.6 4.4 City The actions centre on improving the HWB of the community (n=1398) 19.5 39.3 28.8 9.9 2.4 City There is sufficient cooperation within the council during development of policy (n=1403) 14.1 40.4 30.6 10.9 3.9 City Rural There is current lobby for action on HWB within council (n=1398) 8.4 22.0 33.5 25.0 11.1 – There is sufficient evidence available to support council decisions (n=1397) 15.1 40.7 30.1 11.0 3.1 City There is strong support and leadership from within council (n=1367) 20.3 36.3 27.4 11.0 5.1 City Rural Various HWB strategies and/or activities are implemented (n=1370) 19.9 39.2 31.2 7.5 2.2 City There is clear council commitment (n=1368) 23.9 36.4 27.3 8.8 3.5 City There is sufficient cooperation within my council during implementation of policy (n=1367) 14.8 41.0 29.0 10.8 4.5 City There is ongoing monitoring and review of policy in council (n=1362) 22.0 36.7 25.0 12.2 4.1 City Policy reviews consider HWB impacts (n=1360) 17.7 33.5 29.7 13.8 5.2 City Council uses performance indicators to measure HWB impacts (n=1362) 15.3 26.0 27.5 20.6 10.6 City Considering cost–benefits, action to address HWB is worthwhile (n=1364) 24.0 35.9 25.2 10.0 4.9 City Rural There is a key leader/champion in HWB in our council (n=1494) 18.1 28.2 29.2 15.9 8.6 City Partnerships and actors There is strong leadership from other levels of government to act (n=1491) 7.4 21.8 38.2 24.3 8.2 – There is support from other sectors when developing policy (n=1400) 6.7 34.4 41.4 14.6 2.9 – There is cooperation between different political levels involved during policy development (n=1398) 4.1 25.6 42.2 21.8 6.2 – There is cooperation between public and private organizations (n=1398) 4.7 29.5 43.3 18.7 3.8 – There is support from other sectors when implementing actions (n=1361) 6.4 33.8 42.0 14.2 3.6 City There is cooperation between different political levels involved (during policy implementation) (n=1359) 4.2 24.7 41.9 22.7 6.6 – The legislative environment is favourable for HWB action (n=1361) 5.7 27.0 40.5 20.7 6.1 City Resources and capacity The council has the necessary staff capacity (n=1401) 8.9 28.8 30.0 21.6 10.7 City There are sufficient financial resources (n=1403) 5.1 17.2 30.3 31.8 15.6 City The council has the staff time and capacity to implement actions (n=1365) 8.6 28.1 36.0 19.4 8.0 City There are sufficient financial resources (n=1366) 4.7 17.6 29.4 32.0 16.3 City Policy initiators Personally I feel obliged to do something in the field (n=1492) 32.1 36.3 23.1 5.8 2.7 City The action is part of my professional duties (n=1490) 33.8 32.1 21.7 6.9 5.6 City Scientific results demand the action (n=1482) 21.7 31.5 34.0 8.7 4.0 City Regional The council is obliged to the community to act in this area (n=1497) 31.3 38.3 23.2 5.1 1.9 City ** Statistically significant p≤0.05. Open in new tab Policy subsystem More than half of respondents reported that it was ‘definitely’ or ‘mostly true’ that their council have a clear commitment to HWB (60%, n = 824), strong support and leadership within council (56%, n = 773), sufficient cooperation within council when developing policy (54%, n = 764) and implementing policy (56%, n = 762) and that considering the costs, the benefits made it worthwhile (60%, n = 816). Respondents were less likely to report that it was ‘definitely’ or ‘mostly true’ that there was a key champion for HWB in the council (46%, n = 692), that the council uses performance indicators to measure HWB impacts (41%, n = 562) and that there is current lobby action for HWB within the council (30.4%, n = 424). Respondents from city and rural councils were more likely than their regional counterparts to report strong leadership and support from within council (H = 10.858, p = 0.004) and sufficient cooperation within council during development (H = 14.359, p = 0.001). Policy initiation Variables relating to initiators of policy were reported as ‘definitely’ or ‘mostly true’ by a majority of respondents, including an obligation by council to act (70%, n = 1043), a personal obligation to do something (68%, n = 1020) and that the action is part of their professional duties (66%, n = 981). Respondents from city councils were more likely than their rural counterparts to report a personal obligation to act (H = 9.827, p = 0.007), more likely than regional counterparts to report an organizational obligation to the community (H = 8.474, p = 0.014) and more likely than both regional and rural council respondents to report that the action is part of their professional duties (H = 26.420, p < 0.001). Partnerships and actors Less than half of respondents reported that it was ‘definitely’ or ‘mostly true’ that council have support from other sectors when either developing (41%, n = 574) or implementing policy (40%, n = 546), there is strong leadership from other levels of government in initiating HWB policy (29%, n = 434) and a favourable legislative environment for HWB action (33%, n = 444). Respondents from city councils were more likely than their regional and rural counterparts to report support from other sectors when implementing action (H = 11.866, p = 0.003) and that there is a favourable legislative environment (H = 14.367, p = 0.001). Across States and Territories, pairwise post hoc testing shows that respondents from the State of Victoria were more likely to report a favourable legislative environment compared with respondents from the States of New South Wales (p = 0.008) and Queensland (p = 0.014). Resources and capacity Less than half of respondents reported that it was ‘definitely’ or ‘mostly true’ that there is staff capacity (38%, n = 527), financial resources to develop HWB policy (22%, n = 303) and financial resources to implement policy actions (22%, n = 312). Respondents from city councils were more likely than their regional and rural counterparts to report sufficient financial capacity (H = 111.491, p < 0.001) and staff capacity (H = 81.197, p < 0.001). DISCUSSION The findings from this research in Australian local governments identify a range of enablers and challenges to addressing HWB in a local government context. Some factors confirm previous research, particularly having a strong commitment to HWB (Jansson et al., 2011), strong political will to act (Larsen et al., 2014; Rantala et al., 2014) and a lack of funding resources (Collins and Hayes, 2013). However, the intent of this research is not only to identify the enablers and challenges in the policy process, but also to demonstrate the policy constructs through the lens of political science to deconstruct an otherwise seemingly illogical policy process. When researching the literature on policy initiation and actioning of health inequity amongst all levels of government, Baker et al. (Baker et al., 2017) referred to this as not just interpreting enablers and challenges as stand-alone entities, but considering their inter-relatedness as increasing or decreasing the ‘probability’ of issues reaching the policy agenda. Policy problem The MSF (Kingdon, 1995) suggests that the three streams of policy problem, solution and broader politics need to align for policy to be initiated. According to the results of this study, the problem of HWB is clear to those in local government and defined from a socio-ecological perspective. Lawless et al. (Lawless et al., 2017) have previously surveyed local government staff in two Australian States and found similar findings, albeit with local government staff who already had public health responsibilities. In their study, the staff reported a reasonable understanding of health promotion theory and a self-reported personal obligation to improve HWB through policy work. The results of this survey support this level of understanding, focusing on decision makers across a range of local government responsibilities, including CEOs and elected members, and has found similar findings across all size councils in Australia. Policy solution In addition to a clear policy ‘problem’, a clearly agreed solution is needed to progress beyond a policy idea (Kingdon, 1995). The results from this survey indicate that local governments are integrating HWB across some known determinants, with some integrating HWB amongst a diverse range of policy areas, although the quality and extent to which this is done in local policy has not been explored as part of this research. Respondents agreed that there was sufficient cooperation during policy development and implementation, suggesting that internally there is at least some collaboration across departments. Whether decision makers within a single council collectively understand and define the problem of HWB similarly and agree on the solution is not known from these survey results. This is likely an enabler to local HWB policy given that the nature of addressing health determinants requires cooperation across a broad range of sectors (Marmot et al., 2008), with cross-sector communication considered a key enabler to adopting local health policy (Larsen et al., 2014; Hendriks et al., 2015). The ACF adds value to the understanding of this policy process by focusing on the role of different individuals and groups involved in influencing policy action (Sabatier, 2007a; Clavier and de Leeuw, 2013). However, the collaborative support of other sectors in actioning HWB was not always considered true by survey respondents. Given the experience by Corburn et al. (Corburn et al., 2014) whereby the not for profit sector triggered the initiation of local policy addressing health equity, the lack of other sector support reported by Australian local governments may be limiting health determinants reaching a higher priority on the local policy agenda. Politics The broader political environment is the third inter-related stream in the MSF (Kingdon, 1995). Previous research would agree that support from higher levels of government is an important enabler to local health policy initiation (Rantala et al., 2014). The results from the survey indicate this is not currently the case in Australia for a large majority of local governments, regardless of size and location. Whilst all Australian local governments have some responsibility and autonomy for how they respond to HWB, legislation for addressing health determinants only exists in two of the eight States/Territories. Respondents from city councils were most likely to report that a favourable legislative environment, yet there was little difference in response across different States or Territories of Australia. While there has been a legislative requirement for health plans in the State of Victoria for several decades and respondents of Victoria reported a more supportive legislative environment for HWB, these were only significantly different to two of the other five States and Territories included in the research. Our research findings suggest that local government are already actively considering HWB beyond their required legislation. Previous research has found local government policies, whilst somewhat responsive to broader political agendas, tend to give priority to local community needs (Jansson et al., 2011; Browne et al., 2019). For example, local policies in Swedish municipalities addressed determinants of health, though not to the extent of addressing health inequities as the national policy intended (Jansson et al., 2011). Research in Victoria, Australia, found that planners gave more emphasis on an upstream approach to creating wellbeing for their communities than the State legislation intended (Browne et al., 2019). The reported commitment to HWB by respondents, regardless of legislative responsibilities and measurable performance indicators, suggests that local government may not be driven by health outcomes. Previous literature has also observed that local government staff and elected members perceive that they have limited responsibility for reducing health inequities (Collins and Hayes, 2013) and tend to focus on health policy for their own interests, such as quality of life or social connection, rather than for health outcomes (Hoeijmakers et al., 2007; Steenbakkers et al., 2012). The results of this survey, combined with findings of previous research, queries whether involvement or incentive by higher tiers of government are required to initiate or action local HWB policy, or whether the strong leadership and commitment within the local subsystem of local government withstands any broader political pressures. Policy entrepreneur The MSF considers policy entrepreneurs as a critical element to being able to influence the policy process, by recognizing and acting on a ‘window of opportunity’ (Kingdon, 1995). Over half of the respondents to the survey indicated that the presence of a key champion was sometimes, rarely or not true. This is consistent with research by Hoeijmakers et al. (Hoeijmakers et al., 2007) who found no key champion for health policy in the four local governments of the Netherlands that they followed over several years. Political science frameworks, particularly the ACF, would suggest that combined with the lack of lobbying efforts within councils, as reported by respondents in this study, this could potentially challenge the attention given to HWB when competing with other priorities (Sabatier, 2007a). Policy priority Despite the impacts of addressing health determinants being long term and difficult to measure (Bauman et al., 2014; Larsen et al., 2014) and amongst all other priorities that local governments are responsible for, HWB is still reported as a high priority by Australian councils across all sizes and locations, something not previously documented in research to date. As local governments deal with many competing community and senior government demands, one of the enablers to keeping HWB a priority is likely the shared obligation amongst decision makers. This is a key enabler to the initiation and stability of the policy environment raised within policy frameworks, including the MSF, ACF, PEF and ADEPT (Kingdon, 1995; Rütten et al., 2003; Sabatier, 2007a). Whether this strong obligation to address HWB is indicative of the type of staff and representatives elected into or employed in local government, whether the drive is to address other issues beyond health outcomes, whether the results are driven by respondent selection bias, or whether this is something that is part of organizational and professional duties (or all of these) is not able to be derived from the results of this survey. Funding The ADEPT framework is slightly different to other policy frameworks in that it considers the implementation, action and evaluation of health policy once it is initiated (Rütten et al., 2011). In the initial testing of the framework, having sufficient resources was found to be a key factor in generating policy outcomes (Rütten et al., 2011). Consistent with literature, funding is reported by respondents as one of the biggest challenges in the policy process (Collins and Hayes, 2013; Larsen et al., 2014). This was reported across councils of all sizes, though particularly rural councils. Local government have such limited opportunities to raise funding, apart from accessing grants or raising rates paid by property owners (Collins and Hayes, 2013). Smaller local governments find revenue raising more difficult, given the low property numbers and higher infrastructure costs associated with remote locations (Tan and Artist, 2013). However, despite insufficient financial capacity, a majority of respondents agreed that the investment in HWB was cost-effective. This suggests that local governments may be considering the benefits of HWB policy beyond addressing health outcomes. Applying the theories Applying political science theories to these findings, local government demonstrate an understanding of the problem and policy solution of determinants of health, and to some extent at least, these are actioned in policy. According to the MSF, the broader political environment would need to be supportive, which is also the case within the subsystem environment of local government. However, the central role of the policy entrepreneur to manipulate the three streams is mostly absent in many local government settings. As theorized by the ACF, and PEF, the strong values and obligations to act on HWB of communities are likely causing a stable policy monopoly by a group of local government policy actors. This maintains the attention and priority that can be given to HWB. These policy decisions are actioned within the resources and capacity available to the different sized local governments, with larger, city councils in a better financial position to enable this. Limitations The reliance on voluntary, self-reported responses may create a bias in the results as those most interested or active in the field of HWB were more likely to respond. However, there were a high response of CEO’s and a wide range of respondents across different states, territories and geographical sizes of local government in Australia. HWB is a broad topic area and whilst respondents defined HWB as a socio-ecological perspective, it is unknown what context some of their responses were considering. In addition, for many of the responses, there were reports of the variables being ‘somewhat true’. The use of a factor analysis to reduce the number of variables demonstrating the key variances in the dataset have meant that the role of the community and media in the policy process have not been included in this analysis. As part of the growing literature in addressing health determinants, supported by political science theory, more investigation is required through qualitative research to further demonstrate the inter-relatedness of the policy constructs. CONCLUSION The results of the study add to the argument that local government can address the determinants of health and certainly have local political will to do so, particularly in larger city councils. The personal obligation, commitment by council and local leadership are likely to increase the initiation and action of local HWB policy. Local governments report incorporating HWB across a range of policy areas, despite limited funding, absence of broad political support and at times without a policy entrepreneur or other sector support and lobbying efforts. Further research should investigate what HWB outcomes local governments are interested in, as this has practical implications for the framing of future health promotion advocacy efforts, legislative requirements and policy monitoring measures. 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TI - Insights into local health and wellbeing policy process in Australia
JF - Health Promotion International
DO - 10.1093/heapro/daz082
DA - 2020-03-13
UR - https://www.deepdyve.com/lp/oxford-university-press/insights-into-local-health-and-wellbeing-policy-process-in-australia-pCeDECYgYa
SP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -