A Mixed-Methods Exploration of the Implementation of Policies That Earmarked Taxes for Behavioral Health.

Policy Points Earmarked tax policies for behavioral health are perceived as having positive impacts related to increasing flexible funding, suggesting benefits to expand this financing approach. Implementation challenges related to these earmarked taxes included tax base volatility that impedes long-term service delivery planning and inequities in the distribution of tax revenue. Recommendations for designing or revising earmarked tax policies include developing clear guidelines and support systems to manage the administrative aspects of earmarked tax programs, cocreating reporting and oversight structures with system and service delivery agents, and selecting revenue streams that are relatively stable across years. CONTEXT: Over 200 cities and counties in the United States have implemented policies earmarking tax revenue for behavioral health services. This mixed-methods study was conducted with the aim of characterizing perceptions of the impacts of these earmarked tax policies, strengths and weaknesses of tax policy designs, and factors that influence decision making about how tax revenue is allocated for services. METHODS: Study data came from surveys completed by 274 officials involved in behavioral health earmarked tax policy implementation and 37 interviews with officials in a sample of jurisdictions with these taxes-California (n = 16), Washington (n = 12), Colorado (n = 6), and Iowa (n = 3). Interviews primarily explored perceptions of the advantages and drawbacks of the earmarked tax, perceptions of tax policy design, and factors influencing decisions about revenue allocation. FINDINGS: A total of 83% of respondents strongly agreed that it was better to have the tax than not, 73.2% strongly agreed that the tax increased flexibility to address complex behavioral health needs, and 65.1% strongly agreed that the tax increased the number of people served by evidence-based practices. Only 43.3%, however, strongly agreed that it was easy to satisfy tax-reporting requirements. Interviews revealed that the taxes enabled funding for services and implementation supports, such as training in the delivery of evidence-based practices, and supplemented mainstream funding sources (e.g., Medicaid). However, some interviewees also reported challenges related to volatility of funding, inequities in the distribution of tax revenue, and, in some cases, administratively burdensome tax reporting. Decisions about tax revenue allocation were influenced by goals such as reducing behavioral health care inequities, being responsive to community needs, addressing constraints of mainstream funding sources, and, to a lesser degree, supporting services considered to be evidence based. CONCLUSIONS: Earmarked taxes are a promising financing strategy to improve access to, and quality of, behavioral health services by supplementing mainstream state and federal financing.

Evaluating Policies of Expanding Versus Restricting First-Line Treatment Choices: A Cost-Effectiveness Analysis Framework.

OBJECTIVES: Healthcare payers often implement coverage policies that restrict the utilization of costly new first-line treatments. Cost-effectiveness analysis can be conducted to inform these decisions by comparing the new treatment with an existing one. However, this approach may overlook important factors such as treatment effect heterogeneity and endogenous treatment selection, policy implementation costs, and diverse patient preferences across multiple treatment options. We aimed to develop a cost-effectiveness analysis framework that considers these real-world factors, facilitating the evaluation of alternative policies related to expanding or restricting first-line treatment choices. METHODS: We introduced a metric of incremental cost-effectiveness ratio (ICER) that compares an expanded choice set (CS) including the new first-line treatment with a restricted CS excluding the new treatment. ICER(CS) accounts for treatment selection influenced by heterogeneous treatment effects and policy implementation costs. We examined a basic scenario with 2 standard first-line treatment choices and a more realistic scenario involving diverse preferences toward multiple choices. To illustrate the framework, we conducted a retrospective evaluation of including versus excluding abiraterone acetate plus prednisone (AAP) (androgen deprivation therapy [ADT] + AAP) as a first-line treatment for metastatic hormone-sensitive prostate cancer. RESULTS: The traditional ICERs for ADT + AAP versus ADT alone and ADT+ docetaxel were $104 269 and $206 324/quality-adjusted life-year, respectively. The ICER(CS) for comparing an expanded CS with ADT + AAP with a restricted CS without ADT + AAP was $123 179/quality-adjusted life-year. CONCLUSIONS: The proposed framework provides decision makers with policy-relevant tools, enabling them to assess the cost-effectiveness of alternative policies of expanding versus restricting patients' and physicians' first-line treatment choices.

Quantifying regulatory limits for multiple stressors in an open and transparent way.

Biodiversity is confronted globally by multiple stressors. Environmental policies must regulate these stressors to achieve targets, but how should that be done when the outcomes of limits on one stressor are contingent on other stressors, about which there is imperfect knowledge? Deriving regulatory frameworks that incorporate these contingencies is an emerging challenge at the science-policy interface. To be fit for implementation, these frameworks need to facilitate the inherently sociopolitical process of policy implementation and account transparently for uncertainty, such that practitioners and other stakeholders can more realistically anticipate the range of potential outcomes to policy. We developed an approach to quantify stressor limits that explicitly accounts for multistressor contingencies. Using an invertebrate data set collected over 30 years throughout New Zealand, we combined ecological and ecotoxicological models to predict biodiversity loss as a function of one stressor, treating multistressor contingencies as a form of uncertainty about the outcomes of limits on that stressor. We transparently accounted for that uncertainty by presenting regulatory limits as bands bounded between optimistic and pessimistic views that practitioners may have about the local context within which limits are applied. In addition to transparently accounting for uncertainties, our framework also leaves room for practitioners to build stakeholder consensus when refining limits to suit different local contexts. A criticism of this open, transparent approach is that it creates too much scope for choosing limits that are lenient on polluters, paralyzing on-the-ground management of multiple stressors, but we demonstrate that this is not necessarily the case.

Cuantificación abierta y transparente de los límites regulatorios para varios estresantes Resumen La biodiversidad enfrenta a múltiples estresantes en todo el mundo. Las políticas ambientales deben regularlos para alcanzar los objetivos fijados, pero ¿cómo hacerlo cuando los resultados de la limitación de un estresante dependen de otros factores, de los que se conoce muy poco? La elaboración de marcos reguladores que incorporen estas contingencias es un reto emergente en la interfaz ciencia­política. Para aplicar estos marcos, se debe facilitar el proceso sociopolítico inherente a la aplicación de políticas y tener en cuenta de forma transparente la incertidumbre, de modo que los profesionales y otras partes interesadas puedan anticipar de forma más realista la variedad de posibles resultados de las políticas. Desarrollamos un método para cuantificar los límites de los estresantes que considera explícitamente las contingencias de múltiples factores. Usamos un conjunto de datos sobre invertebrados recolectados durante 30 años en toda Nueva Zelanda. Después combinamos modelos ecológicos y eco­toxicológicos para predecir la pérdida de biodiversidad en función de un estresante y tratamos las contingencias de múltiples estresantes como una forma de incertidumbre sobre los resultados de los límites de ese mismo estresante. Explicamos esa incertidumbre de forma transparente con los límites normativos como bandas delimitadas entre las opiniones optimistas y pesimistas que los profesionales pueden tener sobre el contexto local en el que se aplican los límites. Además de hacer lo anterior, nuestro marco también deja margen para que los profesionales lleguen a un consenso con las partes interesadas a la hora de perfeccionar los límites para adaptarlos a los distintos contextos locales. Una crítica a este enfoque abierto y transparente crea demasiado margen para elegir límites indulgentes con los contaminadores, paralizando la gestión sobre el terreno de múltiples estresantes, pero demostramos que no es necesariamente así.

Experiences of central child health services teams regarding a special governmental investment in child health services.

BACKGROUND: Historically marked by a high infant mortality rate, Sweden's healthcare reforms have successively led to a robust, decentralized universal child health system covering over 97% of the population 0-5 years. However, inequities in health have become an increasing problem and the public health law explicitly states that health inequities should be reduced, resulting in various government initiatives. This study examines the experiences of Central Child Health Services (CCHS) teams during the implementation of the Child Health Services Accessibility Agreement between the State and the regions starting in 2017. The agreement aimed to enhance child health service accessibility, especially in socio-economically disadvantaged areas, but broadly stated guidelines and the short-term nature of funding have raised questions about its effectiveness. The aim of this study was to understand the experiences of CCHC teams in implementing the Child Health Services Accessibility Agreement, focusing on investment decisions, implementation efforts, as well as facilitators and barriers to using the funds effectively. METHODS: CCHC teams were purposefully sampled and invited via email for interviews, with follow-ups for non-respondents. Conducted from January to October 2023, the interviews were held digitally and recorded with individuals familiar with the agreement's implementation within these teams. Both authors analyzed the transcripts thematically, applying Braun and Clarke's framework. Participants represented a cross-section of Sweden's varied healthcare regions. RESULTS: Three main themes emerged from the thematic analysis: "Easy come, easy go," highlighting funding uncertainties; "What are we supposed to do?" expressing dilemmas over project prioritization and partner collaboration; and "Building castles on sand," focusing on the challenges of staff retention and foundational program stability. Respective subthemes addressed issues like fund allocation timing, strategic decision-making, and the practical difficulties of implementing extended home visiting programs, particularly in collaboration with social services. CONCLUSIONS: This study uncovered the challenges faced in implementing the Child Health Services Accessibility Agreement across different regions in Sweden. These obstacles underline the need for precise guidelines regarding the use of funds, stable financing for long-term project sustainability, and strong foundational support to ensure effective interprofessional collaboration and infrastructure development for equitable service delivery in child health services.

Overcoming COVID-19 vaccination resistance when alternative policies affect the dynamics of conformism, social norms, and crowding out.

What is an effective vaccination policy to end the COVID-19 pandemic? We address this question in a model of the dynamics of policy effectiveness drawing upon the results of a large panel survey implemented in Germany during the first and second waves of the pandemic. We observe increased opposition to vaccinations were they to be legally required. In contrast, for voluntary vaccinations, there was higher and undiminished support. We find that public distrust undermines vaccine acceptance, and is associated with a belief that the vaccine is ineffective and, if enforced, compromises individual freedom. We model how the willingness to be vaccinated may vary over time in response to the fraction of the population already vaccinated and whether vaccination has occurred voluntarily or not. A negative effect of enforcement on vaccine acceptance (of the magnitude observed in our panel or even considerably smaller) could result in a large increase in the numbers that would have to be vaccinated unwillingly in order to reach a herd-immunity target. Costly errors may be avoided if policy makers understand that citizens' preferences are not fixed but will be affected both by the crowding-out effect of enforcement and by conformism. Our findings have broad policy applicability beyond COVID-19 to cases in which voluntary citizen compliance is essential because state capacities are limited and because effectiveness may depend on the ways that the policies themselves alter citizens' beliefs and preferences.

Small Steps, Big Vision: using multi-stage qualitative research to develop a grab-and-go guide to support utilisation of the Ambitions for Palliative and End of Life Care framework.

BACKGROUND: The Ambitions for Palliative and End of Life Care is a national framework for local action in England co-produced by over 30 partners; little research has been conducted on how the Framework is received and used. This study sought to examine and support how people understand, interpret, and implement the Framework. METHODS: A multi-stage qualitative methodology involving four stages of data collection: (1) case study interviews, (2) focus groups, (3) interactive workshops, and (4) Evidence Cafés. From initial interviews, ongoing thematic data analysis informed the design and focus of subsequent stages as part of a process of knowledge transfer. RESULTS: A practical resource to support service provision and development was produced; a grab-and-go guide called "Small Steps, Big Visions". It focuses on the eight foundations in the Ambitions Framework, with additional guidance on collaboration and partnership working, and sharing learning. Each foundation is presented with a 'what' (definition), 'ask' (prompt questions), and 'examples in action' (drawn from case studies). CONCLUSIONS: Research can contribute to policy implementation to advance palliative and end of life care. The engagement and input of those responsible for implementation is key.

The workforce crisis in healthcare: Moving the debate to bridge evidence and policy.

This Special Issue aims to advance the healthcare workforce (HCWF) debate by directing its attention to the implementation of policy recommendations and identifying weaknesses. The selection of articles highlights a wide range of HCWF policies and interventions across various countries. The challenges faced often stem from policy failures and governance gaps at the macro-, meso- and micro-levels of health systems. Recommendations to mitigate the HCWF crisis include interconnected strategies, multi-/transsectoral policies, solidarity-based efforts, collaboration, skill-mix reforms, equity measures, global approaches, and crucially, strong political will. In addition, specific policy solutions are explored, such as community-centred action and employment of community health workers, mental health support initiatives, inclusion of refugees and displaced healthcare workers into the labour market, and preparing the HCWF for the impact of climate change. This Special Issue calls for transformative HCWF policies and multi-level transsectoral governance as essential components needed to effectively address the crisis. This will only be possible, if HCWF policy moves higher up in the public policy arena leading, among other things, to the establishment of HCWF research as a distinct academic field.

Implementing Primary Care Reform in France: Bargaining, Policy Adaptation, and the Maisons de Santé Pluriprofessionnelles.

CONTEXT: The organization of primary care in France has long remained a secondary issue on the political agenda. The government began to address the difficulties of care access and coordination in the 2000s, when a seemingly viable solution emerged from the field: the Maisons de Santé Pluriprofessionnelles (MSPs). In a corporatist system and a predominantly private sector, the government chose an incentive-based, contractual policy to encourage providers to join these structures. This article analyzes the implementation of this policy which depends on private providers' commitment. METHODS: The article offers a comparative case study of six MSPs. Data were collected through semi-structured interviews, observation sessions, and document analysis. FINDINGS: First, the article shows that the emergence of MSPs has only been possible thanks to an unprecedented alliance between GPs, the state, and the health insurance fund. Second, it argues that MSP policy's implementation relies on a complex bargaining process between private providers and public authorities that enables the former to shape it to their local needs. CONCLUSIONS: MSP implementation experiences raise questions both about the understanding of medical corporatism in France and the assimilation of policy changes and local variation through implementation.

Discordance between farmers and scientists - Perspectives on nitrogen reduction measures in Denmark.

Mitigating nitrogen leaching from agricultural land is imperative for enhancing the ecological status of aquatic ecosystems. Incorporating the knowledge and perceptions of farmers regarding the feasibility and effectiveness of implementing nitrogen reduction measures is vital for increasing the adoption rate of such measures and related policies. Concurrently, the insights and perspectives of scientists advising policymakers on the implementation of these measures can facilitate a more comprehensive understanding of the barriers and potential for implementation. In this study, we employ Q methodology to elucidate the opinions of 11 farmers and 14 key scientists involved in providing contractual science policy advice to Danish ministries on nitrogen reduction measures. Results show that across the perspectives of farmers and scientists, four main factors (viewpoints) can be identified: 'Evidence-driven viewpoints', 'On-farm efficiency-driven viewpoints', 'Hydrological and landscape-scale viewpoints', 'Innovation-based viewpoints. From this, we suggest that within the field of nitrogen mitigation and implementation, there is a general broad division and opposing perspectives between scientists and farmers. The evidence presented here shows that scientists' viewpoints do not correspond to the viewpoints of farmers in most cases. Scientists broadly believe that landscape and long-term measures, especially wetlands, are most effective nitrogen measures, according to scientific evidence. This clashes severely with some farmer participants, who strongly believe that there should be more personal freedom and flexibility to make individual farm level management choices. This is a significant barrier to the uptake of the best possible measures.

Insights From a Community-Based Strategy to Assess Tobacco and Vape Shop Retailers' Implementation of Tobacco 21 Law in El Paso, Texas.

In 2019, the United States Congress passed Tobacco 21 (T21) legislation that raised the minimum legal sales age for tobacco products from 18 to 21. However, although the federal legislation superseded weaker state laws that were already in place in some states, including Texas, local guidance for retailers was inconsistent. Given that retailers are ultimately responsible for policy implementation, the American Heart Association (AHA) initiated a process of assessing retailers knowledge and perceptions of the law through a survey targeting all tobacco retailers and accompanying ethnography of a subset of vape shops in El Paso, Texas. The process yielded lessons learned for assessment of community-based policy implementation including key considerations for personnel and process that are applicable to other community-based assessment processes. While AHA considered an in-person approach ideal, having an alternate online response option was necessary. In addition, a focused approach and in-depth understanding of the purpose was key to responsiveness of the retailers.

The formative evaluation and pre-testing of a SunSmart policy implementation support toolkit targeting sun safe hat-wearing in NSW primary schools.

ISSUE ADDRESSED: Strategies that support the implementation of the SunSmart program in primary schools are essential to optimising policy uptake. Evidence outlining the type of support required, however, is lacking. This project explored the usefulness of an implementation support approach to sun safe hat-wearing in schools. METHODS: Formative research was undertaken with 16 primary schools in Greater Western Sydney to explore current sun protection behaviours and practices, perceived barriers and motivators of sun safe hat-wearing, and resource needs. Based on these insights, a resource toolkit was developed and tested in 14 demonstration sites. Follow-up interviews evaluated the usefulness of the toolkit and implementation support approach. RESULTS: Sun safe hat-wearing practices varied among schools. Commonly reported motivators included school policies, role modelling, incentives and knowledge. Commonly reported barriers included negative social norms, forgetfulness, cost and lack of understanding. Formative insights informed the development of the 'Motivation, Access, Triggers' Model and a 23-resource toolkit. Following toolkit rollout, champions reported that the ability to select resources according to local needs was useful, and most found that the toolkit supported their school with sun safe hat-wearing. CONCLUSIONS: A toolkit with local champions and leadership buy-in has the potential to improve policy implementation. The opportunity to prioritise resource selection enables schools to address their specific needs in line with their sun protection policy. SO WHAT?: The provision of policy implementation support can help schools overcome the challenges of transforming a written SunSmart policy into practice.

Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence.

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at the subnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.

"Listen with your ears and eyes and heart and your minds and your soul": Implications for decolonising consultation and occupational therapy from case studies on "Closing the Gap" policy implementation.

BACKGROUND: Including Aboriginal and Torres Strait Islander people and communities through consultation has been a key feature of policy implementation throughout the Australian Government's "Closing the Gap" (CTG) strategy. However, consultation often reinforces power imbalances between government and local community and can undervalue or marginalise Indigenous knowledge and leadership. Occupational therapy has a short history of examining colonial power structures within the profession, but there has been limited progress to decolonise consultation and practice. METHODS: Drawing on decolonising research methodology and positioned at the interface of knowledge, comparative case studies were used to understand policy implementation in two regions. In Shepparton, Victoria, CTG policy was implemented predominately through an Aboriginal Community Controlled Health Organisation, and in Southern Adelaide, South Australia, CTG policy was implemented through mainstream state government and non-government providers in the absence of a local Aboriginal-controlled organisation. Findings were examined critically to identify implications for occupational therapy. RESULTS: Our case studies showed that policy stakeholders perceived consultation to be tokenistic and partnerships were viewed differently by Aboriginal and non-Indigenous participants. Participants identified the need to move beyond a rhetoric of "working with" Aboriginal and Torres Strait Islander people, to promote Aboriginal leadership and really listen to community so that policy can respond to local need. The findings of this research show that Aboriginal-controlled services are best positioned to conduct and respond to community consultation. CONCLUSION: A decolonising approach to consultation would shift the status quo in policy implementation in ways that realign power away from colonial structures towards collaboration with Indigenous leadership and the promotion of Aboriginal-controlled services. There are lessons for occupational therapy from this research on policy implementation on authentic, decolonised consultation as a key feature of policy implementation. Shifting power imbalances through prioritising Indigenous leadership and honouring what is shared can drive change in CTG policy implementation processes and outcomes.

An Early Implementation Analysis of Syringe Services Programs in Kentucky: Barriers and Facilitators Identified by Program Operators and Local Officials.

Kentucky is one of ten states that require syringe services program (SSP) approval from local officials to operate legally. Public health leaders and local officials participated in semi-structured interviews in 2016 about the barriers and facilitators of SSP adoption and implementation (N = 22). Interviews were transcribed verbatim, and a thematic content analysis was conducted using Nvivo software. Political support, program champions who led education efforts, and access to resources and training facilitated SSP adoption. The most frequently reported barriers to adoption were often rooted in stigma and included the lack of political will to approve SSPs or lack of recognition of the need for a SSP. Requiring approval from local governing authorities could impose significant implementation delays, limits to the range of harm reduction services provided, and threaten harm reduction program sustainability. Removing barriers to the adoption and implementation of harm reduction programs is critical in order to effectively scale up harm reduction services to reduce the risks of infection and fatal overdose.

Incorporating Health Cobenefits into Province-Driven Climate Policy: A Case of Banning New Internal Combustion Engine Vehicle Sales in China.

Incorporating health cobenefits from coabated air pollution into carbon mitigation policy making is particularly important for developing countries to boost policy efficiency. For sectors that highly depend on electrification for decarbonization, it remains unclear how the increased electricity demand and consequent health impacts from sectoral mitigation policy in one province would change the scale and the regional and sectoral distributions of the overall health impacts in the whole country. This study chooses the banning of new sales of internal combustion engine vehicles in the private vehicle sector in China as a case. The results show that, without carbon neutrality and air pollution control goals in electricity generation, 53% of CO2 reduction and 65% of health benefits from the private vehicle sector would be offset by increased electricity demand. The regional distributions of CO2 reduction and health benefits due to a province-driven ban policy are greatly uneven, as the top five provinces take up over one-third of the total impact in China. Health benefits per ton of carbon reduction (H/C) may vary by up to 8 times across provinces. Finally, the provinces in southeast China and the Sichuan Basin, with their stably high H/C values, are suggested to enact the province-driven ban policy first.

Implementing front-of-pack nutrition warning labels in Mexico: important lessons for low- and middle-income countries.

OBJECTIVE: To analyse the implementation of front-of-pack nutrition labelling (FOPNL) in Mexico. DESIGN: Review of publicly accessible documents, including legislative websites, news sources, and government, intergovernmental, and advocacy reports. Usage of the policy cycle model to analyse the implementation and evaluation stages of Mexico's General Health Law, amended with FOPNL (2019-2022). RESULTS: In October 2019, the government published a draft modification of the Norma Oficial Mexicana (Official Mexican Standard) to regulate and enforce a new FOPNL warning label system. A 60-d public consultation period followed (October-December 2019), and the regulation was published in March 2020 and implementation began in October 2020. An analysis of nine key provisions of the Standard revealed that the food and beverage industry and its allies weakened some original provisions including health claims, warnings for added sweeteners and display areas. On the other hand, local and international public health groups maintained key regulations including the ban on cartoon character advertisements, standardised portions and nutrient criteria following international best practices. Early implementation appears to have high compliance and helped contribute to reformulating unhealthy products. Continued barriers to implementation include industry efforts to create double fronts and market their cartoon characters on social media and through digitalised marketing. CONCLUSION: Early success in implementing the new FOPNL system in Mexico was the result of an inclusive and participatory regulatory process dedicated to maintaining public health advances, local and international health advocacy support, and continued monitoring. Other countries proposing and enacting FOPNL should learn from the Mexican experience to maintain scientifically proven best practices, counter industry barriers and minimise delays in implementation.

Challenges faced by frontline health managers during the implementation of COVID-19 related policies in India: A qualitative analysis.

Background & objectives: The COVID-19 pandemic exposed the strengths and weaknesses of the healthcare systems across the world. Many directives, guidelines and policies for pandemic control were laid down centrally for its implementation; however, its translation at the periphery needs to be analyzed for future planning and implementation of public health activities. Hence, the objectives of this study were to identify the challenges faced by frontline health managers in selected States in India during the pandemic with regard to implementation of the COVID-19-related policies at the district level and also to assess the challenges faced by the them in adapting the centrally laid down COVID-19 guidelines as per the local needs of the district. Methods: A qualitative study using the grounded theory approach was conducted among frontline district-level managers from eight different States belonging to the north, south, east and west zones of India. The districts across the country were selected based on their vulnerability index, and in-depth interviews were conducted among the frontline managers to assess the challenges faced by them in carrying out COVID-19 related activities. Recorded data were transcribed verbatim, manually coded and thematically analyzed. Results: Challenges faced in implementing quarantine rules were numerous, and it was also compounded by stigma attached with the disease. The need for adapting the guidelines as per local considerations, inclusion of components of financial management at local level, management of tribal and vulnerable populations and migrants in COVID context were strongly suggested. The need to increase human resource in general and specifically data managers and operators was quoted as definite requirement. Interpretation & conclusions: The COVID-19 guidelines provided by the Centre were found to be useful at district levels. However, there was a need to make some operational and administrative modifications in order to implement these guidelines locally and to ensure their acceptability.

Towards Tobacco-Free Generation: implementation of preventive tobacco policies in the Nordic countries.

AIMS: Europe's Beating Cancer Plan set a goal of creating a Tobacco-Free Generation in Europe by 2040. Prevention is important for achieving this goal. We compare the Nordic countries' preventive tobacco policies, discuss the possible determinants for similarities and differences in policy implementation, and provide strategies for strengthening tobacco prevention. METHODS: We used the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) to identify the key policies for this narrative review. We focused on Articles 6, 8, 9, 11, 13 and 16 of the WHO FCTC, and assessed the status of the required (core) and recommended (advanced) policies and their application to novel tobacco and nicotine products. Information on the implementation of strategies, acts and regulations were searched from global and national tobacco control databases, websites and scientific articles via PubMed and MEDLINE. RESULTS: The WHO FCTC and European regulations have ensured that the core policies are mostly in place, but also contributed to the shared deficiencies that are seen especially in the regulations on smokeless tobacco and novel products. Strong national tobacco control actors have facilitated countries to implement some advanced policies - even as the first countries in the world: point-of-sale display bans (Iceland), outdoor smoking bans (Sweden), flavour bans on electronic cigarettes (Finland), plain packaging (Norway), and plain packaging on electronic cigarettes (Denmark). CONCLUSIONS: Collaboration and participation in reinforcing the European regulations, resources for national networking between tobacco control actors, and national regulations to provide protection from the tobacco industry's interference are needed to strengthen comprehensive implementation of tobacco policies in the Nordic countries.

Tools for local health in all policies implementation: evidence from an explanatory case study of Kuopio, Finland.

AIMS: This paper describes the use of three governance tools for health in all policies utilised to facilitate implementation in the municipality of Kuopio, Finland: impact assessments, a city mandate (the Kuopio strategy), and shared budgets. METHODS: An explanatory case study was used. Data sources included semistructured interviews with 10 government employees and scholarly literature. Realist scientific methods were used to reveal mechanisms underlying the use of tools in health in all policies. RESULTS: Strong evidence was found supporting initial and new theory/hypotheses regarding the use of each tool in achieving positive implementation outcomes. Impact assessments facilitated health in all policies by enhancing understanding of health implications. The Kuopio strategy aided in implementation by giving credence to health in all policies work via formal authority. Shared budgets promoted intersectoral discussions and understanding, and a sense of ownership, in addition to allowing time to be spent on health in all policies work and not financial deliberation. CONCLUSIONS: Findings confirm the efficacious use of three governance tools in implementing health in all policies in Kuopio. Knowledge and evidence-based guidelines on local health in all policies implementation are needed as this policy approach continues to be recognised and adopted as a means to promote population health and health equity.

Advertisement of unhealthy commodities in Bristol and South Gloucestershire and rationale for a new advertisement policy.

BACKGROUND: Bristol City Council introduced a new advertisement policy in 2021/2022 which included prohibiting the advertising of unhealthy food and drink (HFSS), alcohol, gambling and payday loans across council-owned advertising spaces. This mixed methods study is part of the BEAR study, and aimed to explore the rationale and the barriers and facilitators to implementing the policy, and describe the perceived advertising environment prior to implementation. METHODS: Semi-structured interviews were carried out with seven stakeholders involved in the design and implementation of the advertising policy. A stakeholder topic guide was developed before interviews took place to help standardise the lines of inquiry between interviewees. A resident survey was developed to collect socio-demographic data and, for the purpose of this study, information regarding observations of advertising for HFSS products, alcohol and gambling. RESULTS: Fifty-eight percent of respondents residing in Bristol and South Gloucestershire reported seeing advertisements for unhealthy commodities in the week prior to completing the survey. This was highest for HFSS products (40%). 16% of residents reported seeing HFSS product advertisements specifically appealing to children. For HFSS products in particular, younger people were more likely to report seeing adverts than older people, as were those who were from more deprived areas. An advertisement policy that restricts the advertisement of such unhealthy commodities, and in particular for HFSS products, has the potential to reduce health inequalities. This rationale directly influenced the development of the advertisement policy in Bristol. Implementation of the policy benefitted from an existing supportive environment following the 'health in all policies' initiative and a focus on reducing health inequalities across the city. CONCLUSIONS: Unhealthy product advertisements, particularly for unhealthy food and drinks, were observed more by younger people and those living in more deprived areas. Policies that specifically restrict such advertisements, therefore, have the potential to reduce health inequalities, as was the hope when this policy was developed. Future evaluation of the policy will provide evidence of any public health impact.