Healthy urban planning: an institutional policy analysis of strategic planning in Sydney, Australia.

Rapid urbanization requires health promotion practitioners to understand and engage with strategic city planning. This policy analysis research investigated how and why health was taken up into strategic land use planning in Sydney, Australia, between 2013 and 2018. This qualitative study develops two case studies of consecutive instances of strategic planning in Sydney. Data collection was done via in-depth stakeholder interviews (n = 11) and documentary analysis. Data collection and analysis revolved around core categories underpinning policy institutions (actors, structures, ideas, governance and power) to develop an explanatory narrative of the progress of 'health' in policy discourse over the study period. The two strategic planning efforts shifted in policy discourse. In the earlier plan, 'healthy built environments' was positioned as a strategic direction, but without a mandate for action the emphasis was lost in an economic growth agenda. The second effort shifted that agenda to ecological sustainability, a core aspect of which was 'Liveability', having greater potential for health promotion. However, 'health' remained underdeveloped as a core driver for city planning remaining without an institutional mandate. Instead, infrastructure coordination was the defining strategic city problem and this paradigm defaulted to emphasizing 'health precincts' rather than positioning health as core for the city. This research demonstrates the utility in institutional analysis to understanding positioning health promotion in city planning. Despite potential shifts in policy discourse and a more sophisticated approach to planning holistically, the challenge remains of embedding health within the institutional mandates driving city planning.

Including health impacts in environmental impact assessments for three Australian coal-mining projects: a documentary analysis.

Notwithstanding the historical benefits of coal in aiding human and economic development, the negative health and environmental impacts of coal extraction and processing are of increasing concern. Environmental impact assessments (EIAs) are a regulated policy mechanism that can be used to predict and consider the health impacts of mining projects to determine if consent is given. The ways in which health is considered within EIA is unclear. This research investigated 'How and to what extent are health, well-being and equity issues considered in Environmental Impact Assessments (EIAs) of major coal mining projects in New South Wales, Australia'. To this end we developed and applied a comprehensive coding framework designed to interrogate the publicly available environmental impact statements (EISs) of three mines in New South Wales (NSW), Australia, for their inclusion of health, well-being and equity issues. Analysis of the three EISs demonstrates that: the possible impacts of each mine on health and well-being were narrowly and inadequately considered; when health and well-being were considered there was a failure to assess the possible impacts specific to the particular mine and the communities potentially affected; the cumulative impacts on human health of multiple mines in the same geographical area were almost completely ignored; the discussions of intragenerational and intergenerational equity did not demonstrate a sound understanding of equity and, it is essential that governments' requirements for the EIA include detailed analysis of the health, well-being, equity and cumulative impacts specific to the proposed mine and relevant communities.

Climate change is a health issue: what can doctors do?

The visit to Australia by Dr David Pencheon, Founding Director of the National Health Service (NHS) Sustainable Development Unit, in April-May 2018 generated considerable interest and engagement. Dr Pencheon's overarching messages were that climate change is a health issue and that doctors and health systems have an opportunity, and responsibility, to lead climate action. This article distils Dr Pencheon's presentations into three themes: (i) carbon accounting; (ii) transformational change in our systems of healthcare; and (iii) a health system fit for the future. For each theme, we highlight promising initiatives that are already underway in Australia that are starting to transform our health system into one fit for a future environmentally sustainable world. We suggest practical ways in which doctors can lead the transformation through personal action and influence broader systems.

Creating 'healthy built environment' legislation in Australia; a policy analysis.

Influencing healthy public policy through health advocacy remains challenging. This policy analysis research uses theories of agenda setting to understand how health came to be considered for specific mention in legislation arising from land-use planning system reform in New South Wales, Australia. This qualitative study follows critical realist methodology to conduct a policy analysis of the case. We collected data from purposively sampled in-depth interviews (n = 9), a focus group and documentary analysis. We used three classic policy process (agenda setting) theories to develop an analytic framework for explaining the empirical data: Multiple Streams; Punctuated Equilibrium Theory and Advocacy Coalition Framework. The reform process presented a window of opportunity that opened incrementally over a 2 year period. The opportunity was grasped by individual policy entrepreneurs who subsequently formed a coalition of healthy planning advocates focused on strategically positioning 'health' as legislative objective for the new system. The actual point of influence seemed to appear suddenly when challenges to a perceived economic development agenda within the reforms peaked, and the health objective, see as non-threatening by all stakeholders, was taken up. Our analysis demonstrates how this particular point of influence followed sustained long-term activity by health advocates prior to and during the reform process. We demonstrate a theory-driven policy analysis of health advocacy efforts to influence an instance of major land-use planning reform. The application of multiple policy process theories enables deep understanding of what is required to effectively advocate for healthy public policy.

Development and oversight of ethical health promotion quality assurance and evaluation activities involving human participants.

ISSUE ADDRESSED: This paper considers the role of ethics and ethics review processes in the development of health promotion quality assurance and evaluation activities involving human participants. CONTENT: The Australian National Health and Medical Research Council (NHMRC) National Statement on Ethical Conduct in Human Research and associated documents provide the framework for the ethical conduct and independent review of research (including quality assurance and evaluation) involving humans in Australia. Identifying the level of risk to which participants may be exposed by participation in quality assurance and evaluation activities is essential for health promotion workers undertaking such activities. Organisations can establish processes other than review by a Human Research Ethics Committee for negligible and low risk research activities. Health promotion quality assurance and evaluation activities often involve negligible and low risk to participants. Seven triggers that indicate the need for ethics review of quality assurance and evaluation activities and a procedural checklist for developing ethical quality assurance and evaluation activities are provided. CONCLUSION: Health promotion workers should be familiar with the NHMRC's National Statement on Ethical Conduct in Human Research. When ethical considerations underpin the planning and conduct of all quality assurance and evaluation from the very beginning, the activity is the better for it, independent 'ethics approval' can mostly be secured without much trouble and workers' frustration levels are reduced. So what? Health promotion quality assurance and evaluation activities must be ethically justified. Health promotion workers should be familiar with the NHMRC's National Statement on Ethical Conduct in Human Research and should use it when developing health promotion quality assurance and evaluation activities.

Five urban health research traditions: A meta-narrative review.

Urban health scholars explore the connection between the urban space and health through ontological perspectives that are shaped by their disciplinary traditions. Without explicit recognition of the different approaches, there are barriers to collaboration. This paper maps the terrain of the urban health scholarship to identify key urban health research traditions; and to articulate the main features distinguishing these different traditions. We apply a meta-narrative review guided by a bibliometric co-citation network analysis to the body of research on urban health retrieved from the Web of Science Core Collection. Five urban health research traditions were identified: (1) sustainable urban development, (2) urban ecosystem services, (3) urban resilience, (4) healthy urban planning, and (5) urban green spaces. Each research tradition has a different conceptual and thematic perspective to addressing urban health. These include perspectives on the scale of the urban health issue of interest, and on the conceptualisation of the urban context and health. Additionally, we developed a framework to allow for better differentiation between the differing research traditions based on (1) perspectives of the urban system as complicated or complex, (2) the preferred locus of change as a function of structure and agency and (3) the geographic scale of the urban health issue that is addressed. These dimensions have even deeper implications for transdisciplinary collaboration as they are underpinned by paradigmatic differences, rather than disciplinary differences. We conclude that it is essential for urban health researchers to reflect on the different urban health approaches and seek coherence by understanding their similarities and differences. Such endeavours are required to produce and interpret transdisciplinary knowledge for the goal of improving health by transforming urban systems.

City deals and health equity in Sydney, Australia.

'City Deals' are new governance instruments for urban development. Vast evidence exists on the relationship between urban factors and health equity, but little research applies a health equity lens to urban policy-making. This paper does precisely that for the Western Sydney City Deal (WSCD) in Australia. We conducted a critical discourse analysis of publicly available documents and interviews with the WSCD's main architects, applying insights from relevant theories. We find 'pro-growth' discourse to encourage economic investment dominates any references to disadvantage. Interviewees maintained the WSCDs fundamental purpose is to rebalance urban investment toward the historically disadvantaged West. However, the WSCD makes limited reference to health and none to equity. Institutionalised governance practices that favour private investments in infrastructure remain the dominant force behind the WSCD. We document how a shift to 'place-based' infrastructure has promise for equity but struggles to overcome institutionalised approaches to urban investments.

Protocol for a meta-narrative review on research paradigms addressing the urban built environment and human health.

BACKGROUND: Urban health is a field of research and practice that has attracted the interest of various disciplines. While it is encouraged for diverse disciplines to contribute to a multidisciplinary field of study such as urban health, this often results in tensions, conflicts or competition between the different traditions that stem from different epistemological backgrounds. This meta-narrative review aims to identify and describe the multiple paradigms and articulate the underlying epistemological, ontological, methodological, and aetiological differences in their approaches. Articulating the paradigms not only contributes to the advancement of research, but also provides a framework for understanding the different policy beliefs and ideas policy actors hold and apply in the policy process. METHODS: We apply the meta-narrative method to systematic literature review which includes the following six iterative phases. The planning phase includes the finalisation of the review protocol and assembly of review team. The search phase includes a comprehensive literature search in key databases and a double-sided systematic snowballing method. We will search multidisciplinary databases including Web of Science, Scopus and ProQuest, and topic-specific databases including Urban Studies Abstracts (EBSCO), MEDLINE, and EMBASE from their inception onwards. Bibliometric analyses of this literature will be used to triangulate the mapping of the paradigms. The mapping phase includes identifying the dominant paradigms and landmark publications through agreement with the review team. In the appraisal phase, the literature will be assessed by their respective quality standards, followed by data extraction to identify the individual narratives in the conceptual, theoretical, methodological, and instrumental dimensions of each paradigm. The synthesis phase will review the data to compare and contrast and identify the overarching meta-narratives. The recommendation phase will include dissemination of the findings from the review. DISCUSSION: The meta-narrative review will reveal the how the different paradigms conceptualise, frame and prioritise urban health issues, their preferred methodologies to study the phenomenon, and the nature of the solutions to improve human health. This review will assist researchers and practitioners in understanding and interpreting evidence produced by other traditions that study urban health. Through this, urban health researchers and practitioners will be able to seek coherence in understanding, explaining, and exploring the urban health phenomenon. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework ( https://osf/io/tn8vk ).

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.

Patients' experiences and perspectives of living with CKD.

Explicit incorporation of patients' values and preferences is important in health care decision making. However, there are few data about this topic for patients with chronic kidney disease (CKD). We conducted 9 focus groups (3 each for CKD stages 1 to 5, CKD stage 5D, and CKD stages 1 to 5T). Five major themes were identified: (1) personal meaning of CKD, (2) managing and monitoring health, (3) lifestyle consequences, (4) family impact, and (5) informal support structures. Patients had to adjust to the disruptive and permanent implications of the illness on their physical health, identity, emotions, family, lifestyle, relationships, and employment. The overwhelming fatigue, complex treatment regimens, side effects, and liquid and diet restrictions constrained patients' lives. Patients appreciated specialist care, but described the health care system as nonintegrated and believed they received insufficient information and psychosocial support. Choice of treatments was based on lifestyle, family impact, and physical comfort, seldom on clinical outcomes. Time was needed to comprehend the diagnosis, cope with uncertainty, integrate their treatment regimen into their daily routine, and reestablish a sense of normality in their lives. Rather than focusing on clinical targets, greater attention may need to be given to providing information and psychosocial and practical support at a patient-level not organ-specific level, to maximize patient quality of life.

Working in disadvantaged communities: What additional competencies do we need?

BACKGROUND: Residents of socioeconomically disadvantaged locations are more likely to have poor health than residents of socioeconomically advantaged locations and this has been comprehensively mapped in Australian cities. These inequalities present a challenge for the public health workers based in or responsible for improving the health of people living in disadvantaged localities. The purpose of this study was to develop a generic workforce needs assessment tool and to use it to identify the competencies needed by the public health workforce to work effectively in disadvantaged communities. METHODS: A two-step mixed method process was used to identify the workforce needs. In step 1 a generic workforce needs assessment tool was developed and applied in three NSW Area Health Services using focus groups, key stakeholder interviews and a staff survey. In step 2 the findings of this needs assessment process were mapped against the existing National Health Training Package (HLT07) competencies, gaps were identified, additional competencies described and modules of training developed to fill identified gaps. RESULTS: There was a high level of agreement among the AHS staff on the nature of the problems to be addressed but less confidence indentifying the work to be done. Processes for needs assessments, community consultations and adapting mainstream programs to local needs were frequently mentioned as points of intervention. Recruiting and retaining experienced staff to work in these communities and ensuring their safety were major concerns. Workforce skill development needs were seen in two ways: higher order planning/epidemiological skills and more effective working relationships with communities and other sectors. Organisational barriers to effective practice were high levels of annual compulsory training, balancing state and national priorities with local needs and giving equal attention to the population groups that are easy to reach and to those that are difficult to engage. A number of additional competency areas were identified and three training modules developed. CONCLUSION: The generic workforce needs assessment tool was easy to use and interpret. It appears that the public health workforce involved in this study has a high level of understanding of the relationship between the social determinants and health. However there is a skill gap in identifying and undertaking effective intervention.

Doing good qualitative research in public health: not as easy as it looks.

In this paper, we discuss qualitative research for public health professionals. Quality matters in qualitative research, but the principles by which it is judged are critically different from those used to judge epidemiology. Compared to quantitative research, good quality qualitative studies serve different aims, answer distinct research questions and have their own logic for sampling, data collection and analysis. There is, however, no need for antagonism between qualitative research and epidemiology; the two are complementary. With theoretical and methodological guidance from experienced qualitative researchers, public health professionals can learn how to make the most of qualitative research for themselves.

How Local Health Districts can prepare for the effects of climate change: an adaptation model applied to metropolitan Sydney.

Climate change adaptation can be defined as a form of risk management (i.e. assessing climate change-related risks and responding appropriately so that the risks can be pre-emptively minimised and managed as they arise). Adapting to climate change by hospital and community health services will entail responding to changing health needs of the local population, and to the likely effects of climate change on health service resources, workforce and infrastructure. In this paper we apply a model that health services can use to predict and respond to climate change risks and illustrate this with reference to Sydney's Local Health Districts (LHDs). We outline the climate change predictions for the Sydney metropolitan area, discuss the resulting vulnerabilities for LHDs and consider the potential of LHDs to respond. Three 'core business' categories are examined: (1) ambulance, emergency and acute health care; (2) routine health care; and (3) population and preventative health services. We consider the key climate change risks and vulnerabilities of the LHDs' workforce, facilities and finances, and some important transboundary issues. Many Australian health services have existing robust disaster plans and management networks. These could be expanded to incorporate local climate and health adaptation plans.

Can health and health equity be advanced by urban planning strategies designed to advance global competitiveness? Lessons from two Australian case studies.

BACKGROUND: The purpose of this article is to investigate whether the neo-liberal goal of global economic competitiveness when included alongside image-inspired social goals such as liveability and environmental goals such as sustainability can lead to policies that impact positively on health and health equity. The paper presents an analysis of the content and intent of strategic planning and transport plans from two Australian state governments. METHODS: The analysis was undertaken using a thematic document analysis of each plan and interviews with agents (n = 21) directly involved in the preparation of each document. FINDINGS: Key strategic documents formulated under a neo-liberal hegemony simultaneously provided and reduced opportunities to promote and advance health. The policies viewed goals like liveability and sustainability as means of enhancing their cities' image in global competition for exogenous capital flows. Although liveability has many definitions, one definition was able to be used in one jurisdiction as an avenue to include a broad array of social determinants of health into urban planning policy. However, a productivity or a narrowly focussed image narrative can undermine the social determinants of health credentials of liveability. Overemphasising immediate city problems like road congestion as mechanisms to enhance global competitiveness can undermine necessary long-term strategies for city planning that are known to improve liveability and human health. Even where liveability is at the fore, there is a high risk of exacerbating spatial inequities through liveability investments for competitive advantage because they tend to flow to parts of cities with the greatest connections to the global economy, not those with the greatest social need. CONCLUSIONS: A neo-liberal-inspired competitive city paradigm provides opportunities for the advancement of health in urban development. However, when driven by the goals of productivity and/or liveability as image enhancement it can potentially exacerbate health inequities.

An analysis of media coverage on the prevention and early detection of CKD in Australia.

News media raise public awareness about health and can influence public policy agenda. Recently, nephrologists have sought to make prevention and early detection of chronic kidney disease (CKD) a health care priority. We assessed the extent and manner in which Australian television news and newspapers cover CKD prevention or early detection. Electronic news databases for print media and television programs were searched (May 2005 to March 2007) for items referring to CKD prevention or early detection. We analyzed all relevant items for spokespeople, main news frame, focus of responsibility, proposed solutions, and trigger/reason for publication. Of 2,439 newspaper articles and 10,430 television broadcasts retrieved, only 214 articles (8.77%) and 7 broadcasts (0.06%) were eligible. Kidney transplantation dominated CKD-related news. Lay person or high-profile advocates were virtually absent. Risks of cardiovascular disease and mortality conferred by CKD were not emphasized by news reports; instead, CKD received peripheral mention as a secondary consequence of diabetes or obesity. Few reports cited the economic consequences of CKD. The media focused on lifestyle causes and solutions, whereas nonlifestyle causes and screening and prevention strategies were rarely mentioned. Kidney health professionals need to actively engage with the media in efforts to amplify desired messages on CKD prevention or early detection. Medical journals, research institutions, universities, hospitals, and advocacy groups should issue press releases that highlight newsworthy aspects of this topic. Extending news media coverage can help exert an influence on health policies and agenda setting and increase public awareness to improve prevention and early detection of CKD.

Support interventions for caregivers of people with chronic kidney disease: a systematic review.

BACKGROUND: A growing number of patients with chronic kidney disease (CKD) rely on non-professional healthcare providers, such as family and friends, to manage their long-term condition throughout the trajectory of CKD. These informal caregivers can experience stress, depression, lack of confidence and poor quality of life. Yet, the needs of caregivers are often neglected and under-prioritized. The objective of this review is to evaluate the effectiveness of interventions aimed at providing support to caregivers of people with CKD. METHODS: We conducted a systematic review of studies that evaluated any intervention for informal caregivers of CKD patients. We searched five electronic databases (up to January Week 5, 2008) including Medline, EMBASE, PsychINFO, CINAHL, Cochrane Central Register and reference lists of relevant articles. RESULTS: Three studies were identified that evaluated an intervention for caregivers of CKD patients. All three only assessed the effect of educational material on caregivers' knowledge. Two evaluated information provided to caregivers of dialysis patients using a pre- and post-test study design. The other study used participatory action research methods to develop and evaluate an information handbook for transplant patients and their caregivers. Studies consistently found that the provision of information improved caregivers' knowledge. No other outcomes were reported. CONCLUSIONS: Despite the growing recognition of the burden and adverse effects of CKD on caregivers, no high-quality evidence is available about the effect of information or support interventions on the physical or psychosocial well-being of informal caregivers and the patients. More attention towards the development and evaluation of services that respond to the support and informational needs of caregivers is needed, and this may also lead to improved outcomes for patients.

Patients' priorities for health research: focus group study of patients with chronic kidney disease.

BACKGROUND: The inclusion of consumer preferences in prioritizing research topics is widely advocated, but prioritization is driven largely by professional agendas. METHODS: Patients with chronic kidney disease (CKD) were purposively sampled from four kidney dialysis and transplant centres in Australia to participate in nine focus groups (three each for pre-dialysis, dialysis and transplant patients), which were conducted from July 2006 to September 2006. Each involved 6-8 participants. Transcripts were coded and thematically analysed to identify recurrent research topics and the participants' reasons for their choices. RESULTS: Participants suggested eight research priorities: prevention of kidney disease, better access to and improvement in kidney transplantation, reduction of symptoms of CKD and complications associated with treatment, new technological therapies, psychosocial aspects of living with CKD, whole body not organ-specialized care, and improvement in dialysis and caregiver support. Five major reasons for the selections were identified: normalization of life (developing therapies and regimens that fit into daily living), altruism (considering the welfare of others before personal needs), economic efficiency (channelling resources for maximum economic gain), personal needs (preferences based on feelings, values, personal needs) and clinical outcomes (improving health states and the physiological condition of patients with CKD). CONCLUSIONS: A patient-focused research agenda is possible to elicit for CKD, and by inference for other healthcare issues. Unlike researchers who focus on specific interventions and questions, consumers think in terms of broad themes and quality of life outcomes. Effective methods for translating a patient-focused agenda into research priority setting and resource allocation are now needed.

Implementing a strategic plan for child health: a Sydney case study.

AIM: The aim of this paper is to describe the implementation of a strategic plan, Health Gain for Children and Youth of Central Sydney, over a 10-year period to December 2005. METHODS: Descriptive information was obtained from the records and minutes of all relevant committees, interviews with key workers who were involved with the committees, managers and senior health professionals, and from the involvement of the authors throughout the process of the implementation. RESULTS: An implementation steering committee was established to oversee the implementation of the plan. Rather than adopting a uniform approach to assigning responsibility for the implementation of each strategy in the plan or developing specific costs and time frames for each strategy, a more pragmatic, flexible and opportunistic approach was taken. Most of the plan's strategies were implemented over a 7-year time frame using a combination of service reorientation and implementation of new programmes, some of which were funded from sources not anticipated during the development of the plan. Implementation required a dedicated driver, commitment at senior level and participation by many staff at many levels. Outcomes, monitored through data collected at 5-year intervals, revealed positive trends in a number of child and youth health indicators. CONCLUSIONS: The successful implementation of the strategic plan required pragmatism, flexibility, opportunism and the commitment and involvement of staff at all organisational levels. It is envisaged that this approach provides a firm base for future evidence-based developments to benefit the health and well-being of children, youth and their families and reduce health inequities.