Quantifying reciprocal relationships between poverty and health: combining a causal loop diagram with longitudinal structural equation modelling.

BACKGROUND: This study takes on the challenge of quantifying a complex causal loop diagram describing how poverty and health affect each other, and does so using longitudinal data from The Netherlands. Furthermore, this paper elaborates on its methodological approach in order to facilitate replication and methodological advancement. METHODS: After adapting a causal loop diagram that was built by stakeholders, a longitudinal structural equation modelling approach was used. A cross-lagged panel model with nine endogenous variables, of which two latent variables, and three time-invariant exogenous variables was constructed. With this model, directional effects are estimated in a Granger-causal manner, using data from 2015 to 2019. Both the direct effects (with a one-year lag) and total effects over multiple (up to eight) years were calculated. Five sensitivity analyses were conducted. Two of these focus on lower-income and lower-wealth individuals. The other three each added one exogenous variable: work status, level of education, and home ownership. RESULTS: The effects of income and financial wealth on health are present, but are relatively weak for the overall population. Sensitivity analyses show that these effects are stronger for those with lower incomes or wealth. Physical capability does seem to have strong positive effects on both income and financial wealth. There are a number of other results as well, as the estimated models are extensive. Many of the estimated effects only become substantial after several years. CONCLUSIONS: Income and financial wealth appear to have limited effects on the health of the overall population of The Netherlands. However, there are indications that these effects may be stronger for individuals who are closer to the poverty threshold. Since the estimated effects of physical capability on income and financial wealth are more substantial, a broad recommendation would be that including physical capability in efforts that are aimed at improving income and financial wealth could be useful and effective. The methodological approach described in this paper could also be applied to other research settings or topics.

Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences.

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

Strategies for public health adaptation to climate change in practice: social learning in the processionary Moth Knowledge Platform.

Social learning theory can support understanding of how a group of diverse actors addresses complex challenges related to public health adaptation. This study focuses on one specific issue of public health adaptation: oak processionary moth (OPM) adaptation. With a social learning framework, we examined how public health adaption strategies gradually develop and are adjusted on the basis of new knowledge and experiences. For this qualitative case study, data were collected through 27 meetings of the Processionary Moth Knowledge Platform in the Netherlands and six additional interviews. Results indicate that relations between stakeholders, including experts played a major role in the learning process, facilitating the development and implementation of OPM adaptation and connecting local challenges to national adaptation strategies. Uncertainties regarding knowledge and organization were recurrent topics of discussion, highlighting the iterative and adaptive nature of public health adaptation. The study emphasizes the importance of building relationships among stakeholders and small steps in the learning process that can lead to the creation of new strategies and, if successful, the prevention of negative health impacts.

Qualitative modelling of social determinants of health using group model building: the case of debt, poverty, and health.

BACKGROUND: Social determinants of health (SDoH) are known to have a large impact on health outcomes, but their effects are difficult to make visible. They are part of complex systems of variables largely indirect effects on multiple levels, constituting so-called wicked problems. This study describes a participatory approach using group model building (GMB) with stakeholders, in order to develop a qualitative causal model of the health effects of SDoH, taking poverty and debt in the Dutch city of Utrecht as a case study. METHODS: With GMB we utilised the perspective of stakeholders who are directly involved in policy and practice regarding poverty, debt, and/or health. This was done using system dynamic modelling, in three interactive sessions lasting three hours each. In these sessions, they constructed a model, resulting in a system of variables with causal relationships and feedback loops. Subsequently, the results of these GMB sessions were compared to scientific literature and reviewed by a panel of researchers with extensive experience in relevant scientific fields. RESULTS: The resulting model contains 71 causal relationships between 39 variables, 29 of which are present in feedback loops. The variables of participation in society, stress, shame, social contacts and use of services/provisions appear to hold prominent roles in the model's mechanisms. Most of the relationships in the model are supported by scientific literature. The researchers reviewing the model in the scientific meeting agreed that the vast majority of relationships would concur with scientific knowledge, but that the model constructed by the stakeholders consists mostly of individual-level factors, while important conditions usually relate to systemic variables. CONCLUSIONS: Building a model with GMB helps grasp the complex situation of a wicked problem, for which it is unlikely that its interrelationships result in a fully intuitive understanding with linear mechanisms. Using this approach, effects of SDoH can be made visible and the body of evidence expanded. Importantly, it elicits stakeholders' perspectives on a complex reality and offers a non-arbitrary way of formulating the model structure. This qualitative model is also well suited to serve as conceptual input for a quantitative model, which can be used to test and estimate the relationships.

Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity.

BACKGROUND: This meta-review investigated the context-related implementation determinants from seven domains (geographical, epidemiological, sociocultural, economic, ethics-related, political, and legal) that were systematically indicated as occurring during the implementation of obesity prevention policies targeting a healthy diet and a physically active lifestyle. METHODS: Data from nine databases and documentation of nine major stakeholders were searched for the purpose of this preregistered meta-review (#CRD42019133341). Context-related determinants were considered strongly supported if they were indicated in ≥60% of the reviews/stakeholder documents. The ROBIS tool and the Methodological Quality Checklist-SP were used to assess the quality-related risk of bias. RESULTS: Published reviews (k = 25) and stakeholder documents that reviewed the evidence of policy implementation (k = 17) were included. Across documents, the following six determinants from three context domains received strong support: economic resources at the macro (66.7% of analyzed documents) and meso/micro levels (71.4%); sociocultural context determinants at the meso/micro level, references to knowledge/beliefs/abilities of target groups (69.0%) and implementers (73.8%); political context determinants (interrelated policies supported in 71.4% of analyzed reviews/documents; policies within organizations, 69.0%). CONCLUSIONS: These findings indicate that sociocultural, economic, and political contexts need to be accounted for when formulating plans for the implementation of a healthy diet and physical activity/sedentary behavior policies.

Meta-review of implementation determinants for policies promoting healthy diet and physically active lifestyle: application of the Consolidated Framework for Implementation Research.

BACKGROUND: Although multiple systematic reviews indicate that various determinants (barriers and facilitators) occur in the implementation processes of policies promoting healthy diet, physical activity (PA), and sedentary behavior (SB) reduction, the overarching synthesis of such reviews is missing. Applying the Consolidated Framework for Implementation Research (CFIR), this meta-review aims to (1) identify determinants that were systematically indicated as occurring during the implementation processes and (2) identify differences in the presence of determinants across reviews versus stakeholder documents on healthy diet/PA/SB policies, reviews/stakeholder documents addressing healthy diet policies versus PA/SB policies targeting any population/setting, and healthy diet/PA/SB policies focusing on school settings. METHODS: A meta-review of published systematic scoping or realist reviews (k = 25) and stakeholder documents (k = 17) was conducted. Data from nine bibliographic databases and documentation of nine major stakeholders were systematically searched. Included reviews (72%) and stakeholder documents (100%) provided qualitative synthesis of original research on implementation determinants of policies promoting healthy diet or PA or SB reduction, and 28% of reviews provided some quantitative synthesis. Determinants were considered strongly supported if they were indicated by ≥ 60.0% of included reviews/stakeholder documents. RESULTS: Across the 26 CFIR-based implementation determinants, seven were supported by 66.7-76.2% of reviews/stakeholder documents. These determinants were cost, networking with other organizations/communities, external policies, structural characteristics of the setting, implementation climate, readiness for implementation, and knowledge/beliefs of involved individuals. Most frequently, published reviews provided support for inner setting and individual determinants, whereas stakeholder documents supported outer and inner setting implementation determinants. Comparisons between policies promoting healthy diet with PA/SB policies revealed shared support for only three implementation determinants: cost, implementation climate, and knowledge/beliefs. In the case of healthy diet/PA/SB policies targeting school settings, 14 out of 26 implementation determinants were strongly supported. CONCLUSIONS: The strongly supported (i.e., systematically indicated) determinants may guide policymakers and researchers who need to prioritize potential implementation determinants when planning and monitoring the implementation of respective policies. Future research should quantitatively assess the importance or role of determinants and test investigate associations between determinants and progress of implementation processes. TRIAL REGISTRATION: PROSPERO, # CRD42019133341.

Tunneling a crosstown highway: a natural experiment testing the longitudinal effect on physical activity and active transport.

BACKGROUND: In the city of Maastricht in the Netherlands, a highway crossing several deprived neighborhoods was tunneled in 2016. The vacant space on top of this tunnel was redesigned and prioritized for pedestrians and cyclists. The aim of this study was to evaluate the effect of this major infrastructural change, named the Green Carpet, on total and transport-based physical activity (PA) levels. METHODS: Participants (≥18 years) were part of one of three area-based exposure groups. The maximal exposure group lived in neighborhoods directly bordering the Green Carpet. The minimal exposure group consisted of individuals living at the other side of the city, and the no exposure group consisted of individuals living in a nearby city. Actual use of the new infrastructure was incorporated as a second measure of exposure. Data were collected before and 3-15 months after the opening of the Green Carpet. Device-based measurements were conducted to obtain PA levels and collect location data. Changes in PA over time and intervention effects were determined using linear mixed models. RESULTS: PA levels in the Green Carpet area increased for the maximal and minimal exposure groups, but did not lead to an increase in total or transport-based PA. For the no exposure group, transport-based MVPA decreased and transport-based SB increased. The significant interaction (time x exposure) for transport-based SB, indicated differences in trends between the no exposure and maximal exposure group (B=-3.59, 95% CI - 7.15; -0.02) and minimal exposure group (B= -4.02, 95% CI -7.85, -0.19). Trends in the results based on analyses focusing on actual use and non-use of the new infrastructure were similar to those of the area-based analyses. CONCLUSIONS: Results suggest that the Green Carpet led to more PA in this specific area, but did not increase the total volume of PA. The area-based differences might reflect the differences between users and non-users, but we should be careful when interpreting these results, due to possible interference of selective mobility bias. This paper reflects that the relationship between infrastructure and PA is not unambiguous. TRIAL REGISTRATION: This research was retrospectively registered at the Netherlands Trial Register ( NL8108 ).

Understanding Public Health Adaptation to Climate Change: An Explorative Study on the Development of Adaptation Strategies Relating to the Oak Processionary Moth in The Netherlands.

Understanding of public health adaptation (PHA) to climate change and implementation is limited. This study therefore focuses on one specific PHA issue: adaptation to the oak processionary moth (OPM). The aim is to examine the development of OPM adaptation in order to offer a problem description of the complexities involved in OPM adaptation. In this explorative case study, we investigate adaptation strategies based on semi-structured interviews with 26 actors involved in OPM adaptation in The Netherlands. The results indicate that the context of OPM adaptation is relatively complex, given the involvement of many interdependent actors. OPM adaptation was developed with limited knowledge and strategies were based on ad hoc approaches in which there was ambiguity about tasks and expertise. In addition, different actors have different perceptions and values concerning health, sustainability, risks and responsibilities influencing decision-making processes, while also posing a challenge to collaboration and the development of a coordinated approach. The generation of knowledge and its translation into practical strategies calls for interdisciplinary cooperation in knowledge development. PHA adaptation involves more than technical and organisational solutions alone. It also entails the development of a shared problem perception and solution space in which citizens are also engaged.

A Scoping Review of Populist Radical Right Parties' Influence on Welfare Policy and its Implications for Population Health in Europe.

BACKGROUND: In light of worrying public health developments such as declining life expectancy gains and increasing health inequalities, there is a heightened interest in the relationship between politics and health. This scoping review explores the possible welfare policy consequences of populist radical right (PRR) parties in Europe and the implications for population health. The aim is to map the available empirical evidence regarding the influence of PRR parties on welfare policy reforms and to understand how this relationship is mediated by political system characteristics in different countries. METHODS AND ANALYSIS: A scoping review of peer-reviewed empirical literature addressing the relationship between PRR parties, political systems and welfare policy in Europe was performed using the methodology by the Joanna Briggs Institute. Data was charted on main study characteristics, concepts and relevant results, after which a qualitative content analysis was performed. The data was categorised according to the political system characteristics: constitution, political economy, interest representation and partisanship. Five expert interviews were conducted for validation purposes. Early evidence from 15 peer-reviewed articles suggests that exclusionary welfare chauvinistic positions of PRR parties are likely to have negative effects on the access to welfare provisions and health of vulnerable population groups. Differences in implementation of welfare chauvinistic policy reforms are partly explained by mediation of the constitutional order (judicial institutions at national and European Union [EU] level), political economy (healthcare system funding and European single market) and partisanship (vote-seeking strategies by PRR and mainstream parties). No clear evidence was found regarding the influence of interest representation on welfare chauvinistic policies. DISCUSSION: While early evidence suggests that the welfare chauvinistic ideology of PRR parties is harmful for public health, the possible mediating role of political system characteristics on PRR welfare policy influence offers risk and protective factors explaining why the PRR ideology plays out differently across Europe.

Health and well-being for all: an approach to accelerating progress to achieve the Sustainable Development Goals (SDGs) in countries in the WHO European Region.

BACKGROUND: Forty-three out of 53 of the WHO European Member States have set up political and institutional mechanisms to implement the United Nations (UN) 2030 Agenda for Sustainable Development. This includes governance and institutional mechanisms, engaging stakeholders, identifying targets and indicators, setting governmental and sectoral priorities for action and reporting progress regularly. Still, growing evidence suggests that there is room for advancing implementation of some of the Sustainable Development Goals (SDGs) and targets at a higher pace in the WHO European Region. This article proposes the E4A approach to support WHO European Member States in their efforts to achieve the health-related SDG targets. METHODS: The E4A approach was developed through a 2-year, multi-stage process, starting with the endorsement of the SDG Roadmap by all WHO European Member States in 2017. This approach resulted from a mix of qualitative methods: a semi-structured desk review of existing committal documents and tools; in-country policy dialogs, interviews and reports; joint UN missions and discussion among multi-lateral organizations; consultation with an advisory group of academics and health policy experts across countries. RESULTS: The E-engage-functions as the driver and pace-maker; the 4 As-assess, align, accelerate and account-serve as building blocks composed of policies, processes, activities and interventions operating in continuous and synchronized action. Each of the building blocks is an essential part of the approach that can be applied across geographic and institutional levels. CONCLUSION: While the E4A approach is being finalized, this article aims to generate debate and input to further refine and test this approach from a public health and user perspective.

Do parties make a difference? A review of partisan effects on health and the welfare state.

BACKGROUND: Do political parties matter to health? Do they affect population health either directly or through welfare states' social policies and the eligibility, affordability and quality of health systems? And if they do, how? These are crucial questions if we are to understand health politics or shape public health policy, particularly given the changing landscape of political parties, party dominance in the executive and the mediating influence of the legislature. METHODS: Using a systematic approach, this review examines 107 peer-reviewed articles and books published after 1978 focusing on high-income countries asking the overarching question: Do political parties matter to health and the welfare state? RESULTS: The literature relating parties to health directly was surprisingly thin, thus, the welfare state was used as a 'proxy' variable. An overwhelming majority of the literature sample suggests that Left parties are inclined to expand the welfare state without cutting benefits, while the Right does not expand and tends to reduce benefits. There was an inflection in the 1980s when Left parties shifted from expansion to maintaining the status quo. CONCLUSION: Considering current health trends in the form of measles outbreaks, the 'Deaths of Despair', the rise of previous eradicated infectious diseases and the declining health expectancy rates in some Western countries as well as the rise of Populist Radical Right parties in office we question the current partisanship thesis that political parties matter less and less.

Comparative institutional analysis for public health: governing voluntary collaborative agreements for public health in England and the Netherlands.

Democratic institutions and state-society relations shape governance arrangements and expectations between public and private stakeholders about public health impact. We illustrate this with a comparison between the English Public Health Responsibility Deal (RD) and the Dutch 'All About Health…' (AaH) programme. As manifestations of a Whole-of-Society approach, in which governments, civil society and business take responsibility for the co-production of economic utility and good health, these programmes are two recent collaborative platforms based on voluntary agreements to improve public health. Using a 'most similar cases' design, we conducted a comparative secondary analysis of data from the evaluations of the two programmes. The underlying rationale of both programmes was that voluntary agreements would be better suited than regulation to encourage business and civil society to take more responsibility for improving health. Differences between the two included: expectations of an enforcing versus facilitative role for government; hierarchical versus horizontal coordination; big business versus civil society participants; top-down versus bottom-up formulation of voluntary pledges and progress monitoring for accountability versus for learning and adaptation. Despite the attempt in both programmes to base voluntary commitments on trust, the English 'shadow of hierarchy' and adversarial state-society relationships conditioned non-governmental parties to see the pledges as controlling, quasi-contractual agreements that were only partially lived up to. The Dutch consensual political tradition enabled a civil society-based understanding and gradual acceptance of the pledges as the internalization by partner organizations of public health values within their operations. We conclude that there are institutional limitations to the implementation of generic trust-building and learning-based models of change 'Whole-of-Society' approaches.

Policy, politics and public health.

If public health is the field that diagnoses and strives to cure social ills, then understanding political causes and cures for health problems should be an intrinsic part of the field. In this article, we argue that there is no support for the simple and common, implicit model of politics in which scientific evidence plus political will produces healthy policies. Efforts to improve the translation of evidence into policy such as knowledge transfer work only under certain circumstances. These circumstances are frequently political, and to be understood through systematic inquiry into basic features of the political economy such as institutions, partisanship and the organization of labour markets.

The construction of evidence-based local health policy through partnerships: Research infrastructure, process, and context in the Rotterdam 'Healthy in the City' programme.

Many authors in public health identify gaps between science, policy, and professional practice and seek to solve the problems by facilitating interactions between policymakers and researchers by creating partnership structures. Little empirical research indicates how these interactions contribute to use of research by policymakers, and under which conditions. We provide empirical information by analysing one project in an innovative partnership structure in the Netherlands. We show that although a partnership structure might facilitate interactions, it does not automatically render these interactions meaningful. To balance potential conflicts, careful issue management on a formal and informal level is needed. Partnership designs aiming to facilitate interactions between researchers and policymakers should pay attention to the role of knowledge brokers, expectations of science and policy actors, and the ways in which different perspectives can be helped to converge.