Reviving health promotion in South Australia: The role of ideas, actors and institutional forces.

Globally health promotion has remained marginalized while biomedical health systems have maintained and even increased their dominance. During 2019-2021 we drew on the local and historical knowledge of actors from multiple sectors through semi-structured interviews and focus groups, to assess the implications of the withdrawal of the state from health promotion in a suburban region of South Australia. Institutional theory enabled in-depth analysis of the ideas, actors, and institutional forces at play in the institutional field, and how these elements come together to maintain the dominance of medicine. We found that the ideas, actors and institutional forces supporting health promotion in the study region have weakened and fragmented. This has happened as biomedicine has increased its dominance in the region's health system, mirroring international trends. The results point to a withdrawal of state and federal governments from health promotion, which has led to severe gaps in leadership and governance, and locally, to a decline in capacity and resources. The state health department reallocated resources to focus on individual behavioural change rather than more structural factors affecting health. While some activities aimed at the social determinants of health or community development strategies remained, these had minimal institutional support. The establishment of a state government wellbeing agency in 2020 prompted an exploration to determine whether the agency and the international wellbeing movement presents an opportunity for a revival of more comprehensive health promotion.

Health promotion has a rich history in South Australia. However, since government withdrew funding and institutional support, health promotion has become increasingly fragmented, unco-ordinated and targeted towards individual behaviour change activities. Analysis of the role of ideas, actors, and institutional forces, such as government policies, found that biomedical approaches to health and health care increasingly dominate the health system and health policy environment in the state and Australia wide. The establishment of a state government wellbeing agency in 2020 prompted optimism from participants that the government may once again take a leadership role in reviving health promotion and prevention strategies.

Conducting a rapid health promotion audit in suburban Adelaide, South Australia: Can it contribute to revitalising health promotion?

ISSUES ADDRESSED: How health promotion is implemented varies and it is often not clear what activities are in place in a region. Understanding the extent of health promotion activities helps planning activities. METHODS: This research involved a rapid audit of the types of health promotion activities in a suburban region of South Australia. This analysis was guided by the WHO Ottawa Charter's principles. To better understand population needs and which health promoting activities may help, an epidemiological, demographic and social determinants of health profile of southern Adelaide described disease patterns and health inequities. RESULTS: While there was evidence of a range of health promoting activities, most concerned individual or behavioural services. A key finding was the small number of activities that the state health department and local health system were responsible for. Alongside local government, NGOs provided the bulk of health promotion activities. In addition, there were no overarching health promotion strategies or coordinating bodies to evaluate the activities. The epidemiological, demographic and social determinants of health profile found persistent health and social inequities. CONCLUSION: This rapid audit of health promotion in a region enabled a quick assessment of the current health promotion situation and provided evidence of gaps and areas where policy change should be advocated. SO WHAT?: The key findings distilled from this research were designed to inform policy priorities to shift health promotion in southern Adelaide onto a trajectory consistent with the Ottawa Charter and prevent further focus on individualised behaviour change strategies known as 'lifestyle drift'.

Improving child literacy using South Australia's Health in All Policies approach.

The Health in All Policies (HiAP) approach aims to create coherent policy across government that will improve population health, wellbeing and equity while progressing the goals of other sectors. The quest to achieve policy coherence across government has focused interest on processes that facilitate collaboration between health and many other sectors. Health and education sectors have long been seen as natural partners with mutually beneficial goals. This article focuses on a case study of HiAP work, undertaken between health and education in South Australia to increase parental engagement in children's literacy among lower socio-economic families. It draws on a document analysis of 71 documents, seven in-depth interviews with senior policy actors and a programme logic model. The project began with the intention of using policy levers to improve long-term health outcomes through addressing child literacy, a proven social determinant of health. Because of the context in which it was operating, the project extended from a focus on policy to working directly with four schools implementing strategies to facilitate parental engagement, with the intention of finally influencing system-wide education policy. We use an institutional framework to support our analysis through a discussion of ideas, actors and institutions and how these influenced the project. The article provides insight into the facilitators and impediments to intersectoral efforts to progress shared educational and health goals and achieve sustainable change, and identifies lessons for others intending to use this approach.

To what extent can the activities of the South Australian Health in All Policies initiative be linked to population health outcomes using a program theory-based evaluation?

BACKGROUND: This paper reports on a five-year study using a theory-based program logic evaluation, and supporting survey and interview data to examine the extent to which the activites of the South Australian Health in All Policies initiative can be linked to population health outcomes. METHODS: Mixed-methods data were collected between 2012 and 2016 in South Australia (144 semi-structured key informant interviews; two electronic surveys of public servants in 2013 (n = 435) and 2015 (n = 483); analysis of state government policy documents; and construction of a program logic model to shape assessment of the feasibility of attribution to population health outcomes). RESULTS: Multiple actions on social determinants of health in a range of state government sectors were reported and most could be linked through a program logic model to making some contribution to future population health outcomes. Context strongly influences implementation; not all initiatives will be successful and experimentation is vital. Successful initiatives included HiAP influencing the urban planning department to be more concerned with the health impacts of planning decisions, and encouraging the environment department to be concerned with the health impacts of its work. CONCLUSIONS: The theory-based program logic suggests that SA HiAP facilitated improved population health through working with multiple government departments. Public servants came to appreciate how their sectors impact on health. Program logic is a mechanism to evaluate complex public health interventions in a way that takes account of political and economic contexts. SA HiAP was mainly successful in avoiding lifestyle drift in strategy. The initiative encouraged a range of state government departments to tackle conditions of daily living. The broader underpinning factors dictating the distribution of power, money and resources were not addressed by HiAP. This reflects HiAP's use of a consensus model which was driven by (rather than drove) state priorities and sought 'win-win' strategies.

Ideas, actors and institutions: lessons from South Australian Health in All Policies on what encourages other sectors' involvement.

BACKGROUND: This paper examines the extent to which actors from sectors other than health engaged with the South Australian Health in All Policies (HiAP) initiative, determines why they were prepared to do so and explains the mechanisms by which successful engagement happened. This examination applies theories of policy development and implementation. METHODS: The paper draws on a five year study of the implementation of HiAP comprising document analysis, a log of key events, detailed interviews with 64 policy actors and two surveys of public servants. RESULTS: The findings are analysed within an institutional policy analysis framework and examine the extent to which ideas, institutional factors and actor agency influenced the willingness of actors from other sectors to work with Health sector staff under the HiAP initiative. In terms of ideas, there was wide acceptance of the role of social determinants in shaping health and the importance of action to promote health in all government agencies. The institutional environment was initially supportive, but support waned over the course of the study when the economy in South Australia became less buoyant and a health minister less supportive of health promotion took office. The existence of a HiAP Unit was very helpful for gaining support from other sectors. A new Public Health Act offered some promise of institutionalising the HiAP approach and ideas. The analysis concludes that a key factor was the operation of a supportive network of public servants who promoted HiAP, including some who were senior and influential. CONCLUSIONS: The South Australian case study demonstrates that despite institutional constraints and shifting political support within the health sector, HiAP gained traction in other sectors. The key factors that encouraged the commitment of others sectors to HiAP were the existence of a supportive, knowledgeable policy network, political support, institutionalisation of the ideas and approach, and balancing of the economic and social goals of government.

Correction to: Ideas, actors and institutions: lessons from South Australian Health in All Policies on what encourages other sectors' involvement.

After publication of the article [1], it has been brought to our attention that Table 1 has been formatted poorly in the original version so that the columns are not aligned with their corresponding information. The correct version of the table is presented below. The original version of the article has now been revised.

Explaining health inequalities in Australia: the contribution of income, wealth and employment.

BACKGROUND: Studies show widespread widening of socioeconomic and health inequalities. Comprehensive primary health care has a focus on equity and to enact this requires more data on drivers of the increase in inequities. Hence, we examined trends in the distribution of income, wealth, employment and health in Australia. METHODS: We analysed data from the Public Health Information Development Unit and Australian Bureau of Statistics. Inequalities were assessed using rate ratios and the slope index of inequality. RESULTS: We found that the social gradient in health, income, wealth and labour force participation has steepened in Australia, and inequalities widened between the quintile living in the most disadvantaged areas and the quintile living in the least disadvantaged areas. CONCLUSION: Widening income, wealth and employment inequalities have been accompanied by increasing health inequalities, and have reinforced and amplified adverse health effects, leading to increased mortality inequality. Effective comprehensive primary health care needs to be informed by an understanding of structural factors driving economic and health inequities.

How do advisory groups contribute to healthy public policy research?

OBJECTIVES: This paper reflects on experiences of Australian public health researchers and members of research policy advisory groups (PAGs) in working with PAGs. It considers their benefits and challenges for building researcher and policy actor collaboration and ensuring policy relevance of research. METHODS: Four research projects conducted between 2015 and 2020 were selected for analysis. 68 PAG members from Australian federal, state and local governments, NGOs and academics participated in providing feedback. Thematic analysis of participant feedback and researchers' critical reflections on the effectiveness and capacity of PAGs to support research translation was undertaken. RESULTS: PAGs benefit the research process and can facilitate knowledge translation. PAG membership changes, differing researcher and policy actor agendas, and researchers' need to balance policy relevance and research independence are challenges when working with PAGs. Strategies to improve the function of health policy research PAGs are identified. CONCLUSIONS: The paper suggests a broader adapted approach for gaining the benefits and addressing the challenges of working with PAGs. It opens theoretical and practical discussion of PAGs' role and how they can increase research translation into policy.

Creating a whole-of-government approach to promoting healthy weight: What can Health in All Policies contribute?

OBJECTIVES: This paper examines the opportunities and barriers that the South Australian Health in all Policies (SA HiAP) approach encountered when seeking to establish a whole-of-government response to promoting healthy weight. METHODS: The paper draws on data collected during 31 semi-structured interviews, analysis of 113 documents, and a program logic model developed via workshops to show the causal links between strategies and anticipated outcomes. RESULTS: A South Australian Government target to increase healthy weight was supported by SA HiAP to develop a cross-government response. Our analysis shows what supported and hindered implementation. A combination of economic and systemic framing, in conjunction with a co-benefits approach, facilitated intersectoral engagement. The program logic shows how implementation can be expected to contribute to a population with healthy weight. CONCLUSIONS: The HiAP approach achieved some success in encouraging a range of government departments to contribute to a healthy weight target. However, a comprehensive approach requires national regulation to address the commercial determinants of health and underlying causes of population obesity in addition to cross-government action to promote population healthy weight through regional government action.

Health in All Policies in South Australia-Did It Promote and Enact an Equity Perspective?

Mobilising cross-sectoral action is helpful in addressing the range of social determinants that contribute to health inequities. The South Australian Health in All Policies (SA HiAP) approach was implemented from 2007 to stimulate cross-sector policy activity to address the social determinants of health to improve population wellbeing and reduce health inequities. This paper presents selected findings from a five year multi-methods research study of the SA HiAP approach and draws on data collected during interviews, observation, case studies, and document analysis. The analysis shows that SA HiAP had dual goals of facilitating joined-up government for co-benefits (process focus); and addressing social determinants of health and inequities through cross-sectoral policy activity (outcomes focus). Government agencies readily understood HiAP as providing tools for improving the process of intersectoral policy development, while the more distal outcome-focused intent of improving equity was not well understood and gained less traction. While some early rhetorical support existed for progressing an equity agenda through SA HiAP, subsequent economic pressures resulted in the government narrowing its priorities to economic goals. The paper concludes that SA HiAP's initial intentions to address equity were only partially enacted and little was done to reduce inequities. Emerging opportunities in SA, and internationally, including the UN Sustainable Development Goals, may revive interest in addressing equity.

Evaluating health system change--using focus groups and a developing discussion paper to compile the "voices from the field".

The authors describe the contribution of a series of focus groups and a progressively revised discussion paper to the evaluation of health care reform in South Australia. The focus groups informed the evaluation about participants' experiences of the impact of reform on their agencies while enabling increased understanding about change in the health system. A discussion paper describing global health service trends and emerging findings from our evaluation was prepared prior to the first focus group and subsequently revised to incorporate participants' comments before being sent to the next group. The results was a paper that enhanced participants' discussion, and reflected their views. As an action research-based method, this iterative process was valuable for participants and the evaluation, and supported organizational learning.

Learning about interagency collaboration: trialling collaborative projects between hospitals and community health services.

Interagency collaboration has increasingly been viewed as an important strategy to encourage the co-ordination of healthcare. It is seen to have a number of positive outcomes, including: improved service delivery for people requiring multiple services; more efficient use of healthcare resources; and a means for managers to share the responsibility of community care and reduce organizational stress caused by pressures of increasing demand for services within a climate of cost containment. However, establishing collaborative interagency relationships can be a challenging, long-term and complex process. The present article describes some of the findings of a research project that evaluated collaborative strategies adopted and trialed by a group of four publicly funded healthcare agencies in the southern metropolitan area of Adelaide, South Australia. Key findings from the literature about the factors supporting and impeding collaboration are discussed in the light of some of the findings from the evaluation project. Some of the themes emerging from the Adelaide study include: the need for resources for change; experience of multidisciplinary work; professional barriers to collaboration; the importance of agreed aims, agendas and project ownership; and the importance of supportive leadership. This article concludes with a discussion of the difficulties and opportunities for collaboration between community-based primary healthcare agencies and acute care hospitals. The development of partnerships which are either based on trust, or on the open negotiation of power differences and professional territories, and the management of mistrust are found to be important foundations for achieving greater genuine collaboration between primary and tertiary level healthcare.