This article describes some of the crucial theoretical, methodological and practical issues that need to be considered when evaluating Health in All Policies (HiAP) initiatives. The approaches that have been applied to evaluate HiAP in South Australia are drawn upon as case studies, and early findings from this evaluative research are provided. The South Australian evaluation of HiAP is based on a close partnership between researchers and public servants. The article describes the South Australian HiAP research partnership and considers its benefits and drawbacks in terms of the impact on the scope of the research, the types of evidence that can be collected and the implications for knowledge transfer. This partnership evolved from the conduct of process evaluations and is continuing to develop through joint collaboration on an Australian National Health & Medical Research Council grant. The South Australian research is not seeking to establish causality through statistical tests of correlations, but instead by creating a 'burden of evidence' which supports logically coherent chains of relations. These chains emerge through contrasting and comparing findings from many relevant and extant forms of evidence. As such, program logic is being used to attribute policy change to eventual health outcomes. The article presents the preliminary program logic model and describes the early work of applying the program logic approach to HiAP. The article concludes with an assessment of factors that have accounted for HiAP being sustained in South Australia from 2008 to 2013.
Health in All Policies (HiAP) is a policy development approach that facilitates intersectoral responses to addressing the social determinants of health and health equity whilst, at the same time, contributing to policy priorities across the various sectors of government. Given that different models of HiAP have been implemented in at least 16 countries, there is increasing interest in how its effectiveness can be optimized. Much of the existing literature on HiAP remains descriptive, however, and lacks critical, empirically informed analyses of the elements that support implementation. Furthermore, literature on HiAP, and intersectoral action more generally, provides little detail on the practical workings of policy collaborations. This paper contributes empirical findings from a multi-method study of HiAP implementation in South Australia (SA) between 2007 and 2013. It considers the views of public servants and presents analysis of elements that have supported, and impeded, implementation of HiAP in SA. We found that HiAP has been implemented in SA using a combination of interrelated elements. The operation of these elements has provided a strong foundation, which suggests the potential for HiAP to extend beyond being an isolated strategy, to form a more integrated and systemic mechanism of policy-making. We conclude with learnings from the SA experience of HiAP implementation to inform the ongoing development and implementation of HiAP in SA and internationally.
Aim To examine health worker–client interactions during care planning to understand processes that foster client empowerment and disempowerment. Background It is unclear how health worker–client exchanges and information sharing through chronic condition care planning currently operate in primary health care. Moreover, it is unclear how control in these exchanges either enhances collaborative decision‐making, partnership and client empowerment, or works to create client disempowerment and dependency on workers and health services. Design Critical discourse analysis of qualitative data from ethnographic observations and audio‐taped worker–client consultations. Method Multidisciplinary teams in two Australian community‐based primary healthcare sites participated. This included nurses, general practitioners and allied health workers and their clients who had a chronic condition care plan. Nineteen worker–client consultations were observed/recorded in 2011. Results Control was expressed through multiple processes inherent in the worker role and in their interactions with clients. When workers exercised disproportionate control and clients relinquished their own control, client disempowerment and dependency were evident. Clients' attempts to gain control and workers' attempts to relinquish control alleviated clients' disempowerment and dependency. However, structural features of information sharing systems and workers' care planning behaviours diminished such efforts. Conclusion Worker awareness of their communication style and the power of their role must improve for client chronic condition self‐care management to be achieved. Training on the impacts of control in worker communication and systems where they work must be provided if unbeneficial forms of client dependency are to be overcome and true self‐care management is to be realized.
BackgroundMental health recovery involves acknowledging the importance of building the person’s capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness.MethodsThis study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013–14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data.ResultsMoral framing was apparent in participants’ constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients’ positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients’ shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy.ConclusionsExperiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.
BackgroundPolicy decisions made within all sectors have the potential to influence population health and equity. Recognition of this provides impetus for the health sector to engage with other sectors to facilitate the development of policies that recognise, and aim to improve, population outcomes. This paper compares the approaches implemented to facilitate such engagement in two Australian jurisdictions. These are Health Impact Assessment (HIA) in New South Wales (NSW) and Health in All Policies (HiAP) in South Australia (SA).MethodsThe comparisons presented in this paper emerged through collaborative activities between stakeholders in both jurisdictions, including critical reflection on HIA and HiAP practice, joint participation in a workshop, and the preparation of a discussion paper written to inform a conference plenary session. The plenary provided an opportunity for the incorporation of additional insights from policy practitioners and academics.ResultsComparison of the approaches indicates that their overall intent is similar. Differences exist, however, in the underpinning principles, technical processes and tactical strategies applied. These differences appear to stem mainly from the organisational positioning of the work in each state and the extent to which each approach is linked to government systems.ConclusionsThe alignment of the HiAP approach with the systems of the SA Government increases the likelihood of influence within the policy cycle. However, the political priorities and sensitivities of the SA Government limit the scope of HiAP work. The implementation of the HIA approach from outside government in NSW means greater freedom to collaborate with a range of partners and to assess policy issues in any area, regardless of government priorities. However, the comparative distance of HIA from NSW Government systems may reduce the potential for impact on government policy. The diversity in the technical and tactical strategies that are applied within each approach provides insight into how the approaches have been tailored to suit the particular contexts in which they have been implemented.
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