[Improving national health-enhancing physical activity promotion policies]. / Améliorer les politiques nationales de promotion de l'activité physique favorable à la santé.

CONTEXT: In order to help states to develop policies and strategies impacting on all determinants of physical activity, the WHO has set up a policy analysis tool, the HEPA PAT (Health-Enhancing Physical Activity Policy Analysis Tool). This tool allows evaluation of national policies, while considering the complex network of determinants and influencing factors. This article has a double objective: firstly, to present this tool in order to define its specificity and utility in the development of HEPA national policies; secondly, to illustrate its application in the case of France. METHODS: The national HEPA policies and projects in France were identified and analysed using the HEPA PAT methodology and quality criteria to highlight the opportunities and to propose recommendations for improvement. RESULTS: HEPA promotion is a recent and fragmented process in France. Development is more intensive at the local level and needs stronger national support and coordination. The main problem seems to be the lack of long-term vision accompanied by a unified national strategy. Implementation is impaired by vaguely defined action plans, very often without any evaluation criteria or sustainable financing methods. CONCLUSION: The use of HEPA PAT provides a clear and complete overview of the political structure in the field of physical activity promotion. Further analysis of regional policies and projects is recommended to complete this work.

[The Ottawa Charter: 30 years without an action plan?] / La Charte d’Ottawa : 30 ans sans plan d’action ?

The Ottawa Charter is not an action plan, but rather a consensus document on the values and principles that should drive public health practice. It also provides, in the form of 5 lines of action, a map of the determinants of population health. In this paper, based on the lecture I delivered at the Université d’été francophone en santé publique de Besançon, I describe my vision of the Charter, what we have done with it and why it is about time we move on to operationalization of the project it embodies..

[Reflections on the evaluation and funding of complex public health interventions]. / Pistes de réflexion pour l’évaluation et le financement des interventions complexes en santé publique.

In France, in a context of growing health inequalities, the need for action on life settings and, more broadly, on the social determinants of health (SDH), requires a contribution from health promotion research. Today's challenge is not only to design interventions tailored to contexts and actively targeting SDH, but also to develop innovative evaluation strategies of these complex interventions. A group of researchers and representatives from funding agencies met in Paris on june 2nd, 2014 to discuss current experiences conducted in France. The debates yielded five conclusions: (i) the context of the intervention must be considered as one of its active ingredients, (ii) evaluation must be guided by a sound intervention logic (iii) randomized controlled trials cannot capture the complexity of the environment and evaluation must be designed using alternative models, including process evaluation, (iv) interventional research should be collaborative, or co-constructed, (v) public health training should cover the diversity of evaluative methods. The conclusions described here, in the context of France, stress that to address these challenges, funding agencies, researchers and stakeholders should further engage in discussions concerning the conduct of interventional research, evaluation and implementation of complex public health interventions.

Health policy--why research it and how: health political science.

The establishment of policy is key to the implementation of actions for health. We review the nature of policy and the definition and directions of health policy. In doing so, we explicitly cast a health political science gaze on setting parameters for researching policy change for health. A brief overview of core theories of the policy process for health promotion is presented, and illustrated with empirical evidence. The key arguments are that (a) policy is not an intervention, but drives intervention development and implementation; (b) understanding policy processes and their pertinent theories is pivotal for the potential to influence policy change; (c) those theories and associated empirical work need to recognise the wicked, multi-level, and incremental nature of elements in the process; and, therefore, (d) the public health, health promotion, and education research toolbox should more explicitly embrace health political science insights. The rigorous application of insights from and theories of the policy process will enhance our understanding of not just how, but also why health policy is structured and implemented the way it is.

[From behavior change to the improvement of living conditions. Toward ethical and effective health education]. / Du changement de comportement a l'action sur les conditions de vie.

Health education is the basis of all public health policies and programs. However, the fundamental principles of health education are often misunderstood by decision-makers and other key social actors, who often overestimate the impact of health education or overlook its benefits. This paper examines the benefits of health education from the point of view of preventive measures and health promotion measures. The paper highlights the tendency to restrict the theoretical perspectives underlying the development of programs to an examination of intra-individual factors, thus overlooking the constraining effects of the physical and social environment on health decisions. The paper concludes by recommending a form of health education aimed at individual and collective emancipation and by calling for the implementation of population health strategies based on tried and tested theoretical models of health promotion.

In Centralized Health Systems, Much Is Left Out When Analyses of Local HiAP Strategies Are Limited to Public Administration Comment on "A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland".

We argue that the lessons drawn by Guglielmin and colleagues, from the Health in All Policies (HiAP) approach in the municipality of Kuopio, are of limited use to centralised health systems. There is a need for research more attuned to the circumstances of local governments that have little power over the provision of health programmes; yet can address a range of determinants of population health. In these cases, adopting a state-centric perspective may fail to capture the role of other actors such as non-governmental organizations (NGOs) and local branches of state agencies. Evidence from France shows that centralised health systems can foster HiAP locally through political commitment and dedicated coordination staff whose role is to mobilise and support NGOs, inhabitants, and other local branches of regional and central governments. We highlight, as three important challenges, the issue of legitimacy, funding and positioning of the HiAP instrument in the local government structure.

Public health lessons from the French 2012 soda tax and insights on the modifications enacted in 2018.

In 2016, the World Health Organization officially recommended sugar-sweetened beverage (SSB) taxation as a strategy to reduce purchases, stimulate product reformulation and generate revenues for health-related programmes. Four years before, France had been one of the first countries to tax SSBs. However, the design of this tax was not considered optimal: its rate was flat, low, identical for SSBs and artificially-sweetened drinks containing no added sugars, and its initial public health justification was set aside in favour of budgetary concerns. In 2018, a new taxation scheme was enacted. Integrated in the Social Security Finance Bill, the tax on SSBs is now linearly indexed to the quantity of added sugars in the drink. In this article, we summarize the lessons learnt from the 2012 soda tax and offer insights on the potential public health benefits of the new tax enacted in 2018. A multidimensional framework aimed at gathering evidence about SSB taxation for public health drove our rational so that we address: (1) the soda tax policy-change process; (2) its impact on price and purchases; (3) the consumer receptiveness to the tax and; (4) its legal framework. We also discuss the potential application of the tax to other foods/nutrients.

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 pre-defined 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.

Health Literacy: From a Property of Individuals to One of Communities.

Health literacy (HL) is increasingly hailed as a strategy to improve the control individuals have over their health. A central critic of HL intervention is its overemphasis on individual level factors, something recognised in the 2008 report of the Commission of Social Determinants of Health (SDoH) that recommended expanding the scope of HL to cover the SDoH. The objective of our study was to assess the extent to which recent progress on HL captures the need for collective action on the SDoH. We conducted a scoping review on PubMed looking for review papers published between 2013-2018 in English and French. Definitions of HL were analysed against two main dimensions (i.e., locus of change of HL strategies and foreseen outcome of HL improvements). Despite a number of authors calling for more research on HL interventions at the community level and an expansion of the definition to cover the SDoH, we found that the recommendation of the Commission has yet to be implemented. Even when the definitions include the capacities of individuals on distal determinants, both the locus of change and outcomes of HL improvement do not go beyond intra individual factors (knowledge, skills, etc.). It is noteworthy that communities were either framed as a setting outside of health care services or as an aggregate of individuals. We found no instance of HL intervention regarding communities as complex systems of actors sharing a common space and dynamic. We conclude by suggesting a new definition of HL and by drawing attention to the research gap in addressing the upstream SDoH through HL actions.

Collaboration of primary care and public health at the local level: observational descriptive study of French local health contracts.

AIM: In this paper, we report on a study investigating the involvement of primary care providers in French local health contracts. BACKGROUND: Worldwide actions are carried out to improve collaboration between primary care and public health to strengthen primary healthcare and consequently community health. In France, the local health contract is an instrument mobilising local stakeholders from different sectors to join in their actions to improve the health of the population. METHODS: We developed an instrument to analyse the frequency and nature of involvement of primary care providers in 428 action plans extracted from a sample of 17 contracts (one per French region). The number of primary care actions were counted, and thematic analyses were conducted to identify the nature and level of involvement of the professionals. FINDINGS: Primary care providers were involved in 20.1% (n = 86) of the action plans and were mostly described as a target of the action rather than leaders or partners. Within those action plans, 76.7% (n = 66) of these action plans aimed to improve access to care for local communities; an issue that appears as the main driver of collaboration between public health and primary care actors.

Health promotion research and practice require sound policy analysis models: the case of Quebec's Tobacco Act.

In this paper we illustrate how policy analysis models can deepen our understanding of the challenges facing health promoters advocating for policy change. Specifically we describe the factors underpinning the adoption of Québec's Tobacco Act (1998) and the role played by actors from governmental public health agencies (GPHAs). Data were collected through interviews (n=39), newspapers articles (n=569) and documents (n > 200) from GPHAs, NGOs, the Québec National Assembly, and opponents to the legislative measures. Data collection and analysis were based on Sabatier and Jenkins-Smith's Advocacy Coalition Framework (1999) and Lemieux's theorization of coalition structuring (1998). We explain the adoption of the Act by: (1) the broad recognition within the policy elite of the main parameters of tobacco use (i.e. lethality, addictive properties, and legitimacy of governmental intervention), (2) the impacts of a series of events (e.g. cigarette contraband crisis) that enabled tobacco control advocates to influence public debates, and the governmental agenda, (3) the critical contribution of a coalition of GPHAs pooling resources to address both the sanitary and economic aspects of the legislation while countering the opposition's strategy, and (4) the failure of the opponents to present an unified voice on the definition of the tobacco policy. This study illustrates the merits of applying a policy-change model to grasp the complexity of the process. Our findings call for the development of permanent policy analysis capabilities within public health agencies and for a broader scrutiny of the non-health-related dimensions of policy debates.

Dynamic Modeling of Crimean Congo Hemorrhagic Fever Virus (CCHFV) Spread to Test Control Strategies.

Crimean Congo hemorrhagic fever is a zoonotic disease which has emerged or re-emerged recently in Eastern Europe and Turkey. The causative agent is a virus, mainly transmitted by ticks of the species Hyalomma marginatum (Koch, 1844, Ixodida, Amblyommidae). To test potential scenarios for the control of pathogen spread, a dynamic mechanistic model has been developed that takes into account the major processes involved in tick population dynamics and pathogen spread. The tick population dynamics model represents both abiotic (meteorological variables) and biotic (hare and cattle densities) factors in the determination of processes (development, host finding, and mortality). The infection model consists of an SIRS model for the host part whereas a lifelong infectiousness was considered for ticks. The model was first applied to a zone in Central Anatolia (Turkey). Simulated dynamics represent the average reported level of infection in vectors and hosts. A sensitivity analysis to parameter value has been carried out and highlighted the role of transstadial transmission as well as acquisition of the pathogen by immature stages. Applying the model to different sites of Turkey shows different patterns in the dynamics of acarological risk (number of infectious questing adults). This model was thereafter used to test control strategies. Simulation results indicate that acaricide treatments and decrease in hare density could have valuable effects when combined, either on the acarological risk or on the prevalence in cattle. The kind of model we have developed provides insight into the ability of different strategies to prevent and control disease spread.

[The role of professionals in reducing social inequalities in health]. / Le rôle des professionnels dans la réduction des inégalités sociales de santé.

Inequalities in health stem from social mechanisms which for the most part operate outside the health care sector. By being aware of these inequalities and understanding them from the perspective of a gradient of resources, health professionals can intervene to improve equality in this field.

Banning shisha smoking in public places in Iran: an advocacy coalition framework perspective on policy process and change.

INTRODUCTION: Shisha smoking is a widespread custom in Iran with a rapidly growing prevalence especially among the youth. In this article, we analyze the policy process of enforcing a federal/state ban on shisha smoking in all public places in Kerman Province, Iran. Guided by the Advocacy Coalition Framework (ACF), we investigate how a shisha smoking ban reached the political agenda in 2011, how it was framed by different policy actors, and why no significant breakthrough took place despite its inclusion on the agenda. METHODS: We conducted a qualitative study using a case study approach. Two main sources of data were employed: face-to-face in-depth interviews and document analysis of key policy texts. We interviewed 24 policy actors from diverse sectors. A qualitative thematic framework, incorporating both inductive and deductive analyses, was employed to analyze our data. RESULTS: We found that the health sector was the main actor pushing the issue of shisha smoking onto the political agenda by framing it as a public health risk. The health sector and its allies advocated enforcement of a federal law to ban shisha smoking in all public places including teahouses and traditional restaurants whereas another group of actors opposed the ban. The pro-ban group was unable to neutralize the strategies of the anti-ban group and to steer the debate towards the health harms of shisha smoking. Our analysis uncovers three main reasons behind the policy stasis: lack of policy learning due to lack of agreement over evidence and related analytical conflicts between the two groups linked to differences in core and policy beliefs; the inability of the pro-ban group to exploit opportunities in the external policy subsystem through generating stronger public support for enforcement of the shisha smoking ban; and the nature of the institutional setting, in particular the autocratic governance of CHFS which contributed to a lack of policy learning within the policy subsystem. CONCLUSIONS: Our research demonstrated the utility of ACF as a theoretical framework for analyzing the policy process and policy change to promote tobacco control. It shows the importance of accounting for policy actors' belief systems and issue-framing in understanding how some issues get more prominence in the policy-making process than others. Our findings further indicate a need for significant resources employed by the state through public awareness campaigns to change public perceptions of shisha smoking in Iran which is a deeply anchored cultural practice.

Contribution des acteurs régionaux à la réduction des inégalités sociales de santé : le cas de la France.

Depuis le rapport de la Commission sur les Déterminants Sociaux de la Santé, plusieurs pays ont commencé à intégrer à leurs plans de santé la question des déterminants et de leur impact sur les inégalités de santé. En France, la création des Agences Régionales de Santé en 2009 est considérée comme une opportunité pour agir sur les inégalités sociales de santé (ISS) avec les instances régionales, départementales et locales qui détiennent les leviers appropriés. A la suite d'une analyse thématique des projets régionaux de santé, visant à identifier l'intégration des ISS ainsi que les approches retenues pour les aborder, quatre régions ont été étudiées plus finement. Des entretiens collectifs et individuels ( N = 45 interviewés) ont été menés auprès d'acteurs de terrain et institutionnels, afin de mieux comprendre et identifier les types de programmes et processus pour réduire les ISS. Nos analyses font ressortir une prise en compte généralisée des ISS dans les documents de planification et de programmation des instances régionales, des stratégies régionales qui restent centrées sur les populations vulnérables avec une faible considération du gradient social, l'existence d'instances de concertations intersectorielles dans les quatre régions qui constituent un potentiel de gouvernance important à mieux exploiter, l'existence de modalités de suivi et d'évaluation des ISS qui restent à consolider, et une forte mobilisation de plusieurs secteurs dans les processus régionaux de consultation des publics et des acteurs, mais des résultats variables, souvent reliés au niveau de ressources investies et des approches privilégiées. L'analyse de ces expériences françaises démontre un intérêt croissant pour l'action sur les déterminants sociaux de la santé et les ISS ; mais leur opérationnalisation, toujours en cours, appelle à des analyses plus fines qui permettront de mieux éclairer les politiques publiques.

Fighting a tobacco-tax rollback: a political analysis of the 1994 cigarette contraband crisis in Canada.

We identify factors that led a regional government (Quebec, Canada) to opt for a reduction of its tobacco tax to combat tobacco smuggling. Then we explore the fallout of Quebec's tobacco-tax rollback on its tobacco control policy. We conducted qualitative research using a case-study design and multiple sources of data. We applied the Advocacy Coalition Framework in respect of data collection and analysis. Advocates of the tobacco-tax rollback framed the contraband problem in a way that won the support of an array of actors. However, anti-tobacco activists succeeded in convincing the government to invest more in tobacco control. The new resources were instrumental in enhancing the activists' ability to promote legislative measures. Our approach sheds light on the tobacco industry's strategy to have governments reducing their tobacco tax. Quebec offers an example of how tobacco control activists can transform defeat into the cornerstone of a comprehensive tobacco control policy.

A Sophisticated Architecture Is Indeed Necessary for the Implementation of Health in All Policies but not Enough Comment on "Understanding the Role of Public Administration in Implementing Action on the Social Determinants of Health and Health Inequities".

In this commentary, I argue that beyond a sophisticated supportive architecture to facilitate implementation of actions on the social determinants of health (SDOH) and health inequities, the Health in All Policies (HiAP) project faces two main barriers: lack of awareness within policy networks on the social determinants of population health, and a tendency of health actors to neglect investing in other sectors' complex problems.

A health equity impact assessment umbrella program (AAPRISS) to tackle social inequalities in health: program description.

BACKGROUND: The failure to simultaneously address two objectives (increasing the average health of the population and reducing health inequalities) may have led to what has been observed in France so far: an overall decrease in mortality and increase in inequality. OBJECTIVE: The Apprendre et Agir pour Réduire les Inégalités Sociales de Santé (AAPRISS) methodology is to analyze and modify interventions that are already underway in terms of their potential impact on health inequalities. It relies on partnership between researchers and actors in the health field, as well as policy makers. In this paper, we describe the program and discuss its feasibility and acceptability. METHODS: This program is not a single intervention, but a process aiming at assessing and reshaping existing health programs, therefore acting as a kind of meta-intervention. The program develops scientific and methodological support stemming from co-construction methods aimed at increasing equity within the programs. Stakeholders from prevention policy-making and the health care system, as well as researchers, collaborate in defining interventions, monitoring their progress, and choosing indicators, methods and evaluation procedures. The target population is mainly the population of the greater Toulouse area. The steps of the process are described: (1) establishment of AAPRISS governance and partnerships; (2) inclusion of projects; and (3) the projects' process. DISCUSSION: Many partners have rallied around this program, which has been shown to be feasible and acceptable by partners and health actors. A major challenge is understanding each partner's expectations in terms of temporality of interventions, expected outcomes, assessment methods and indicators. Analyzing the projects has been quite feasible, and some modifications have been implemented in them in order to take inequalities in health into account.

The concept of mechanism from a realist approach: a scoping review to facilitate its operationalization in public health program evaluation.

BACKGROUND: Public health interventions are complex by nature, and their evaluation requires unpacking their intervention logic and their interactions with open social systems. By focusing on the interrelationships between context, mechanism, and outcome, Pawson and Tilley's realist approach appears a promising innovation for public health-related evaluation works. However, and as expected of any methodological innovation, this approach is being constructed gradually by answering the multiple challenges to its operationalization that fall in its path. One of these challenges, users of this approach agree on, is the necessity of clarifying its key concept of mechanism. METHOD: We first collected the definitions of mechanism from published works of Pawson and colleagues. Secondly, a scoping review was conducted to identify the ones quoted by users of the realist approach for evaluating public health interventions (1997-2012). We then appraised the clarity and precision of this concept against the three dimensions defined by Daigneault and Jacobs "term, sense and referent." RESULTS: Of the 2344 documents identified in the scoping review, 49 documents were included. Term: Users of the realist approach use adjectives qualifying the term mechanism that were not specifically endorsed by Pawson and colleagues. Sense: None of the attributes stated by Pawson and colleagues has been listed in all of the documents analyzed, and some contributions clarified its attributes. Referent: The concept of mechanism within a realist approach can be ascribed to theory-based evaluation, complex social interventions, and critical realism. CONCLUSION: This review led us to reconsider the concept of mechanism within the realist approach by confronting the theoretical stance of its proponents to the practical one of its users. This resulted in a clearer, more precise definition of the concept of mechanism which may in turn trigger further improvements in the way the realist approach is applied in evaluative practice in public health and potentially beyond. A mechanism is hidden but real, is an element of reasoning and reactions of agents in regard to the resources available in a given context to bring about changes through the implementation of an intervention, and evolves within an open space-time and social system of relationships.