A systems science leverage point analysis of climate change advocacy.

Failure of governments across the world to address climate change has fuelled social movements focused on climate-related policy and action. Research analysing these movements has focused mainly on the types of strategies employed including blockades and occupations, marches and petitions, divestment, boycotts and litigation as well as how groups are framing climate change as a problem. What has been largely missed are the ways these groups are framing the change they want to see, that is their demands to governments. Not all demands and actions have the same potential to create the changes needed to mitigate climate change. Used in public health and health promotion, the systems science Intervention Level Framework (ILF) is a tool that can help analyse to what extent different demands have the leverage to create change in a system. We use the ILF to analyse 131 demands from 35 different climate-related advocacy groups in Australia. Results show demands are more focused on lower system leverage points, such as stopping particular projects, rather than on more impactful leverage points, such as the governance structures that determine climate-related policy and decision-making mechanisms. Further, the results highlight the lack of attention on public health related topics of transport and food systems. This paper shows how a systems science framework used in health promotion, the ILF, could enable climate advocacy groups to more effectively target demands to achieve more impactful outcomes from governments, corporations and the public.

How personalisation programs can exacerbate socio-economic inequities: findings from budget utilisation in the Australian National Disability Insurance Scheme.

BACKGROUND: Researchers and policymakers are increasingly concerned that personalisation schemes in social and health care might be worsening social and health inequities. This has been found internationally, where better outcomes from such schemes have been found amongst those who have higher education and more household income. METHOD: This study looks at one of the world's largest personalisation schemes, the Australian National Disability Insurance Scheme. Using publicly available data we examine the allocation and utilisation of NDIS funds according to social gradient. RESULTS: We find that the rate at which people with disability 'spend' or effectively use their disability care funds follows a social gradient. That is, those in areas of higher socioeconomic disadvantage are not spending as much of their allocated budgets on care services across the year compared to people in areas of higher socioeconomic advantage. This represents a clear issue of equity in the use of public money to people with disability in Australia. CONCLUSION: We argue that this points to the need to provide targeted supports for the use of disability care funds in areas of higher socioeconomic disadvantage. Without effective supports for fund use, the NDIS and other personalisation schemes may be positioned to worsen existing social inequalities.

Application of theories of the policy process in research on consumption of sustainable diets: a systematic review.

BACKGROUND: There is a significant global lack of policy action on consumption of sustainable diets. Application of political science theories such as theories of the policy process can help in understanding policy inaction. Applying these theories could provide a more in-depth understanding of how various influences on the policy process shape decision making for consumption of sustainable diet policy. METHODS: A systematic review to examine application of eight key political science theories of the policy process to research on consumption of sustainable diets was conducted. RESULTS: The review identified no papers applying a theory of the policy process although 17 papers did mention or discuss influences on the policy process that are common elements within theories of the policy process. Most notably these elements were the influence of coalitions/networks, evidence use, narratives and framing, institutional and political system factors, and the importance of value and belief systems and socio-cultural norms. However, in most papers these influences were not examined in a detailed or in-depth way and often presented as suggestions for lack of policy action without the support of empirical data or application of any theory. CONCLUSIONS: Most research discussing policy inaction on the consumption of sustainable diets fails to utilise political science theories of the policy process, although a small number of papers include mention of or discussion of influences on the policy process. Application of political science theories could provide a more in-depth understanding of how different determinants might shape decision making at various points in the policy process. This could help identify key reasons for policy inaction on the consumption of sustainable diets and suggest possible ways to increase attention and action on the issue from policy decision makers.

Organisational structures and processes for health and well-being: insights from work integration social enterprise.

BACKGROUND: Previous research on employee well-being for those who have experienced social and economic disadvantage and those with previous or existing mental health conditions has focused mainly on programmatic interventions. The purpose of this research was to examine how organisational structures and processes (such as policies and culture) influence well-being of employees from these types of backgrounds. METHODS: A case study ethnographic approach which included in-depth qualitative analysis of 93 semi-structured interviews of employees, staff, and managers, together with participant observation of four social enterprises employing young people. RESULTS: The data revealed that young people were provided a combination of training, varied work tasks, psychosocial support, and encouragement to cultivate relationships among peers and management staff. This was enabled through the following elements: structure and space; funding, finance and industry orientation; organisational culture; policy and process; and fostering local service networks.. The findings further illustrate how organisational structures at these workplaces promoted an inclusive workplace environment in which participants self-reported a decrease in anxiety and depression, increased self-esteem, increased self-confidence and increased physical activity. CONCLUSIONS: Replicating these types of organisational structures, processes, and culture requires consideration of complex systems perspectives on implementation fidelity which has implications for policy, practice and future research.

The health and well-being impacts of a work integration social enterprise from a systems perspective.

Recent research has drawn upon the social determinants of health (SDH) framework to attempt to systematize the relationship between social enterprise and health. In this article, we adopt a realist evaluation approach to conceptualize social enterprises, and work integration social enterprises in particular, as 'complex interventions' that necessarily produce differential health outcomes for their beneficiaries, communities and staff. Drawing upon the findings from four social enterprises involving a range of methods including 93 semi-structured interviews with employees, managers and enterprise partners, together with participant observation, we demonstrate that these health outcomes are influenced by a limitless mix of complex and dynamic interactions between systems, settings, spaces, relationships and organizational and personal factors that cannot be distilled by questions of causality and attribution found in controlled trial designs. Given the increased policy focus on the potential of social enterprises to affect the SDH, this article seeks to respond to evidence gaps about the mechanisms and contexts through which social enterprises promote or constrain health outcomes, and thereby provide greater clarity about how research evidence can be used to support the social enterprise sector and policy development more broadly.

Work integration social enterprises (WISEs) are hybrid organizations that operate as businesses with a social purpose. WISEs focus on employment of people excluded from open employment, often as a result of discriminatory attitudes and practices of employers to people from minority groups and those experiencing disability or health-related problems. There is a lack of research on the ways in which a WISE could positively impact on individual health and well-being. We interviewed employees, managers and enterprise partners, together with participant observation, across four social enterprises to understand these dynamics. Through a number of strategies including flexible workplace structures, a culture of acceptance and support, encouragement to take risks and make mistakes and creative use of space, the participants described changes to health and well-being such as decreased symptoms of anxiety and depression, increased social connections, improved physical activity and increased confidence and self-esteem. Results show a mix of strategies combined with individually tailored support; this has implications for the type of research that is appropriate to understand these impacts. We conclude with suggestions on how future research could use complex research designs to understand how WISEs can influence health and well-being.

Women's experiences of accessing individualized disability supports: gender inequality and Australia's National Disability Insurance Scheme.

BACKGROUND: Care services in industrialized nations are increasingly moving towards individualized funding models, which aim to increase individuals' flexibility, choice and control over their services and supports. Recent research suggests that such schemes have the potential to exacerbate inequalities, however none has explored gendered dimensions of inequality. The Australian National Disability Insurance Scheme (NDIS) is a major individualized funding reform, and has a female participation rate of only 37%, despite women and girls making up half of the disability population. METHODS: The objective of the study is to explore possible gendered barriers to applying for and receiving adequate support through the NDIS, and to suggest directions for future research. We report on semi-structured interviews with 30 women with disability and explore their experiences with the NDIS and their perspectives on challenges associated with being a woman seeking disability support in Australia. We analyse the results using thematic analysis. RESULTS: Most women in our sample reported differences between the experiences of men and women seeking disability support in Australia. Commonly reported gendered barriers to women being able to access the right supports for their disability involve a) confidence, negotiation and self-advocacy, b) gendered discrimination in diagnosis and the medical system, which has implications for disability support access, and c) support for and recognition of caring roles. CONCLUSIONS: These results suggest that women are not receiving equitable treatment with regard to the NDIS, and that further research and policy reform are needed to ensure that women with disability are not further disadvantaged as a result of the move toward individualized funding models.

Community-based health promotion about alcohol and other drugs in a multicultural Australia-what works? A review of evidence.

Refugee and migrant communities from culturally and linguistically diverse backgrounds in Australia experience dependency, stigma, isolation, mental health issues, family issues and other problems associated with alcohol and other drugs. Yet, refugee and migrant communities also face major linguistic, cultural and technological barriers to health promotion about drug-related problems. The aim of this review is to identify effective techniques and approaches for health promotion that reduces the risk of problems with drugs in culturally and linguistically inclusive ways. To identify what is effective, the Medline/PubMed database was systematically searched for health promotion literature published between 2008 and 2018. Grey literature from relevant agencies was also searched. The review considered both quantitative and qualitative outcome measures, and assessed studies using the Critical Appraisal Skills Programme quality assessment tool. Three studies met inclusion criteria, with weak evaluations. The studies demonstrated effective community engagement, but do not provide conclusive evidence of what is effective drug-related health promotion. The review's findings point to an important knowledge gap. More rigorous research and evaluation are required to identify effective health promotion for reducing drug-related issues with a larger, more diverse range of refugee and migrant communities.

Personalisation schemes in social care and inequality: review of the evidence and early theorising.

BACKGROUND: Personalisation is a growing international policy paradigm that aims to create both improved outcomes for individuals, and reduce fiscal pressures on government, by giving greater choice and control to citizens accessing social services. In personalisation schemes, individuals purchase services from a 'service market' using individual budgets or vouchers given to them by governments. Personalisation schemes have grown in areas such as disability and aged care across Europe, the UK and Australia. There is a wealth of evidence in public health and health care that demonstrates that practically all forms of social services, programs and interventions produce unequal benefit depending on socio-economic position. Research has found that skills required to successfully negotiate service systems leads to disproportionate benefit to the 'middle class. With an unprecedented emphasis on individual skills, personalisation has even greater potential to widen and entrench social inequalities. Despite the increase in numbers of people now accessing services through such schemes, there has been no examination of how different social groups benefit from these schemes, how this widens and entrenches social inequities, and - in turn - what can be done to mitigate this. METHODS: This article presents a meta-review of the evidence on personalisation and inequality. A qualitative meta-analysis was undertaking of existing research into personalisation schemes in social services to identify whether and how such schemes are impacting different socio-economic groups. RESULTS: No research was identified which seeks to understand the impact of personalisation schemes on inequality. However, a number of 'proxies' for social class were identified, such as education, income, and employment, which had a bearing on outcome. We provide a theoretical framework for understanding why this is occurring, using concepts drawn from Bourdieu. CONCLUSION: Personalisation schemes are likely to be entrenching, and potentially expanding, social inequalities. More attention needs to be given to this aspect of personal budgets by policymakers and researchers.

Personalisation schemes in social care: are they growing social and health inequalities?

BACKGROUND: The connection between choice, control and health is well established in the literature on the social determinants of health, which includes choice and control of vital health and social services. However, even in the context of universal health and social care schemes, the ability to exercise choice and control can be distributed unequally. This paper uses the case of the Australian National Disability Insurance Scheme (NDIS) to examine these issues. The NDIS is a major policy reform based on an international trend towards personalisation in social care. It aims to increase choice and control over services and supports for people who have or acquire a permanent disability, thereby boosting citizen empowerment and improving health and social outcomes. METHODS: The research is a structured review of empirical evidence on the administration and outcomes of the NDIS to identify how social factors constrain or enable the ability of individuals to exercise choice within personalised care schemes. RESULTS: We show how social determinants of health at the individual level can collide with the complexity of policy delivery systems to entrench health inequalities. CONCLUSION: Many social policy reforms internationally focus on improving empowerment through enabling choice and control. However, if administrative systems do not take account of existing structural inequities, then such schemes are likely to entrench or grow social inequality. Our research indicates that more attention must be given to the design of policy delivery systems for personalisation schemes to ensure health equity.

Time to dismiss the idea of a structural fix within government? An analysis of intersectoral action for health in Danish municipalities.

AIMS: This paper examines the role of organizational structure within government(s) in attempts to implement intersectoral action for health in Danish municipalities. We discuss the implications of structural reorganization and the governance structures that are established in order to ensure coordination and integration between policy sectors. METHODS: The paper is based on 49 interviews with civil servants from health and non-health sectors of 10 municipalities. Based on participants' experiences, cases have been described and analyzed in an iterative process consulting the literature on Health in All Policies and joined-up government. RESULTS: Continuous and frequent processes of reorganizing were widespread in the municipalities. However, they appeared to have little effect on policy change. The two most common governance structures established to transcend organizational boundaries were the central unit and the intersectoral committee. According to the experiences of participants, paradoxically both of these organizational solutions tend to reproduce the organizational problems they are intended to overcome. Even if structural reorganization may succeed in dissolving some sector boundaries, it will inevitably create new ones. CONCLUSIONS: It is time to dismiss the idea that intersectoral action for health can be achieved by means of a structural fix. Rather than rearranging organizational boundaries it may be more useful to seek to manage the silos which exist in any organization, e.g. by promoting awareness of their implications for public health action and by enhancing the boundary spanning skills of public health officers.

Redressing or entrenching social and health inequities through policy implementation? Examining personalised budgets through the Australian National Disability Insurance Scheme.

BACKGROUND: Increasing attention is being given to political agenda setting for the social determinants of health. While designing policies that can improve the social determinants of health is critical, so too is ensuring these policies are appropriately administered and implemented. Many policies have the potential to entrench or even expand inequities during implementation. At present little attention has been given to this in the social determinants of health literature. There is an international trend in the personalisation of funding for care services, from the National Health Service in the England to the Brukerstyrt Personlig Assistanse in Norway. Part of this trend is the Australian National Disability Insurance Scheme (NDIS). The NDIS has the potential to secure gains in health for hundreds of thousands of Australians living with a disability. However, policies are only as good as their implementation. METHODS: As part of a longitudinal study on the implementation of the Australian NDIS, we conducted a systematic document search of policy documents pertaining to the Scheme on the websites of government departments with auspice over the design and implementation of the scheme with the aim of examining issues of equity. RESULTS AND DISCUSSION: Scheme architects have argued that the NDIS has the potential to replace a piecemeal and fragmented set of state-determined services with an empowering model of user choice and control. However, without careful attention to both existing inequities and, diversity and difference across populations (e.g. different disability types and different localities), market based approaches such as the NDIS have the serious potential to entrench or even widen inequities. CONCLUSIONS: The research concluded that 'personalisation' approaches can widen inequities and inequalities unless careful consideration is given at both policy design and implementation stages.

A longitudinal study of the implementation experiences of the Australian National Disability Insurance Scheme: investigating transformative policy change.

BACKGROUND: Internationally there has been a growth in the use of publicly funded service markets as a mechanism to deliver health and social services. This has accompanied the emergence of 'self-directed care' in a number of different policy areas including disability and aged care - often referred to as 'personalisation' (Giaimo and Manow, Comp. Pol Stud 32:967-1000, 1999; Needham, Public Money Manage 30:136-8, 2010; [Hood], [The Idea of Joined-up Government: A Historical Perspective], [2005]; Klijn and Koppenjan, Public Manage 2:437-54, 2000, Greener, Policy Polit 36:93-108, 2008). These reforms are underpinned by an idea that individuals should be placed in control of their own service needs, given funding directly by government and encouraged to exercise choice and control through purchasing their own services. A major challenge for governments in charge of these reforms is determining the best way to structure and govern emerging service markets markets. Given the growing international embrace of market-based reform mechanisms to provide essential services to citizens, finding ways to ensure they promote, and not diminish, people's health and wellbeing is vital. METHODS: The Australian National Disability Insurance Scheme (NDIS) is Australia's first national approach to the use of personalised budgets. The program of research outlined in this paper brings together streams from a range of different studies in order to investigate the implementation of the NDIS longitudinally across different administrative levels of government, service providers and scheme participants. CONCLUSION: This programme of research will make a contribution to our understanding of the Australian scheme and how individualised funding operates within this context, but will also generate much needed evidence that will have relevance to other jurisdictions and help fill a gap in the evidence base.

Can the sociology of social problems help us to understand and manage 'lifestyle drift'?

Lifestyle drift is increasingly seen as a barrier to broad action on the social determinants of health. The term is currently used in the population health literature to describe how broad policy initiatives for tackling inequalities in health that start off with social determinants (upstream) approach drift downstream to largely individual lifestyle factors, as well as the general trend of investing a the individual level. Lifestyle drift occurs despite the on-going efforts of public health advocates, such as anti-obesity campaigners, to draw attention to the social factors which shape health behavior and outcomes. In this article, we explore whether the sociology of social problems can help understand lifestyle drift in the context of obesity. Specifically, we apply Jamrozik and Nocella's residualist conversion model to the problem of obesity in order to explore whether such an approach can provide greater insight into the processes that underpin lifestyle drift and inform our attempts to mitigate it.

Evaluating for impact: what type of data can assist a health promoting school approach?

There is debate within the health promoting school (HPS) movement on whether schools should monitor health behaviour outcomes as part of an evaluation or rely more on process type measures, such as changes to school policies and the physical and social environment which yield information about (in)effective implementation. The debate is often framed around ideological considerations of the role of schools and there is little empirical work on how these indicators of effective implementation can influence change at a policy and practice level in real world settings. Information has potentially powerful effects in motivating a change process, but this will vary according to the type of information and the type of organizational culture into which it is presented. The current predominant model relies on process data, policy and environmental audit monitoring and benchmarking approaches, and there is little evidence of whether this engages school communities. Theoretical assertions on the importance of monitoring data to motivate change need to be empirically tested and, in doing so, we can learn which types of data influence adoption of HPS in which types of school and policy contexts.

Towards health equity: a framework for the application of proportionate universalism.

INTRODUCTION: The finding that there is a social gradient in health has prompted considerable interest in public health circles. Recent influential works describing health inequities and their causes do not always argue cogently for a policy framework that would drive the most appropriate solutions differentially across the social gradient This paper aims to develop a practice heuristic for proportionate universalism. METHODS: Through a review the proposed heuristic integrates evidence from welfare state and policy research, the literature on universal and targeted policy frameworks, and a multi-level governance approach that adopts the principle of subsidiarity. RESULTS: The proposed heuristic provides a more-grained analysis of different policy approaches, integral for operationalizing the concept of proportionate universalism. CONCLUSION: The proposed framework would allow governments at all levels, social policy developers and bureaucrats, public health professionals and activists to consider the appropriateness of distinctive policy objectives across distinctive population needs within universal welfare state principles.

Systems change for the social determinants of health.

BACKGROUND: Inequalities in the distribution of the social determinants of health are now a widely recognised problem, seen as requiring immediate and significant action (CSDH. Closing the Gap in a Generation. Geneva: WHO; 2008; Marmot M. Fair Society, Healthy Lives: The Marmot Review. Strategic Review of Health Inequalitites in England Post-2010. London; 2010). Despite recommendations for action on the social determinants of health dating back to the 1980s, inequalities in many countries continue to grow. In this paper we provide an analysis of recommendations from major social determinants of health reports using the concept of 'system leverage points'. Increasingly, powerful and effective action on the social determinants of health is conceptualised as that which targets government action on the non-health issues which drive health outcomes. METHODS: Recommendations for action from 6 major national reports on the social determinants of health were sourced. Recommendations from each report were coded against two frameworks: Johnston et al's recently developed Intervention Level Framework (ILF) and Meadow's seminal '12 places to intervene in a system' (Johnston LM, Matteson CL, Finegood DT. Systems Science and Obesity Policy: A Novel Framework for Analyzing and Rethinking Population-Level Planning. American journal of public health. 2014;(0):e1-e9; Meadows D. Thinking in Systems. USA: Sustainability Institute; 1999) (N = 166). RESULTS: Our analysis found several major changes over time to the types of recommendations being made, including a shift towards paradigmatic change and away from individual interventions. Results from Meadow's framework revealed a number of potentially powerful system intervention points that are currently underutilised in public health thinking regarding action on the social determinants of health. CONCLUSION: When viewed through a systems lens, it is evident that the power of an intervention comes not from where it is targeted, but rather how it works to create change within the system. This means that efforts targeted at government policy can have only limited effectiveness if they are aimed at changing relatively weak leverage points. Our analysis raises further (and more nuanced) questions about what effective action on the social determinants of health looks like.

Creating change in government to address the social determinants of health: how can efforts be improved?

BACKGROUND: The evidence base for the impact of social determinants of health has been strengthened considerably in the last decade. Increasingly, the public health field is using this as a foundation for arguments and actions to change government policies. The Health in All Policies (HiAP) approach, alongside recommendations from the 2010 Marmot Review into health inequalities in the UK (which we refer to as the 'Fairness Agenda'), go beyond advocating for the redesign of individual policies, to shaping the government structures and processes that facilitate the implementation of these policies. In doing so, public health is drawing on recent trends in public policy towards 'joined up government', where greater integration is sought between government departments, agencies and actors outside of government. METHODS: In this paper we provide a meta-synthesis of the empirical public policy research into joined up government, drawing out characteristics associated with successful joined up initiatives.We use this thematic synthesis as a basis for comparing and contrasting emerging public health interventions concerned with joined-up action across government. RESULTS: We find that HiAP and the Fairness Agenda exhibit some of the characteristics associated with successful joined up initiatives, however they also utilise 'change instruments' that have been found to be ineffective. Moreover, we find that - like many joined up initiatives - there is room for improvement in the alignment between the goals of the interventions and their design. CONCLUSION: Drawing on public policy studies, we recommend a number of strategies to increase the efficacy of current interventions. More broadly, we argue that up-stream interventions need to be 'fit-for-purpose', and cannot be easily replicated from one context to the next.