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.

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.

A glossary of policy frameworks: the many forms of 'universalism' and policy 'targeting'.

The recognition that certain characteristics (such as poverty, disadvantage or membership of marginalised social or cultural groups) can make individuals more susceptible to illness has reignited interest in how to combine universal programmes and policies with ones targeted at specific groups. However, 'universalism' and 'targeting' are used in different ways for different purposes. In this glossary, we define different types and approaches to universalism and targeting. We anticipate that greater clarity in relation to what is meant by 'universalism' and 'targeting' will lead to a more nuanced debate and practice in this area.

What is policy and where do we look for it when we want to research it?

Public health researchers are increasingly concerned with achieving 'upstream' change to achieve reductions in the global burden of disease and health inequalities. Consequently, understanding policy and how to change it has become a central goal of public health. Yet conceptualisation of what constitutes policy and where it can be found is very limited within this field. Our glossary demonstrates that policy is many headed. It is located in a vast array of documents, discussions dialogues and actions which can be captured variously by formal and informal forms of documentation and observation. Effectively understanding policy and its relevance for public health requires an awareness of the full range of places and contexts in which policy work happens and policy documents are produced.

Adaptive Policies for Reducing Inequalities in the Social Determinants of Health.

Inequalities in the social determinants of health (SDH), which drive avoidable health disparities between different individuals or groups, is a major concern for a number of international organisations, including the World Health Organization (WHO). Despite this, the pathways to changing inequalities in the SDH remain elusive. The methodologies and concepts within system science are now viewed as important domains of knowledge, ideas and skills for tackling issues of inequality, which are increasingly understood as emergent properties of complex systems. In this paper, we introduce and expand the concept of adaptive policies to reduce inequalities in the distribution of the SDH. The concept of adaptive policy for health equity was developed through reviewing the literature on learning and adaptive policies. Using a series of illustrative examples from education and poverty alleviation, which have their basis in real world policies, we demonstrate how an adaptive policy approach is more suited to the management of the emergent properties of inequalities in the SDH than traditional policy approaches. This is because they are better placed to handle future uncertainties. Our intention is that these examples are illustrative, rather than prescriptive, and serve to create a conversation regarding appropriate adaptive policies for progressing policy action on the SDH.

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.

Action on the social determinants of health: views from inside the policy process.

It is now well documented that many of the key drivers of health reside in our everyday living conditions. In the last two decades, public health has urged political action on these critical social determinants of health (SDH). As noted by the World Health Organisation, encouraging action in this area is challenging. Recent research has argued that public health researchers need to gain a deeper understanding of the complex and changing rationalities of policymaking. This, it seems, is the crucial next step for social determinants of health research. In this paper, we turn our attention to the practitioners of 'the art of government', in order to gain insight into how to secure upstream change for the SDH. Through interviews with policy actors (including politicians, senior government advisors, senior public servants and experienced policy lobbyists) the research sought to understand the nature of government and policymaking, as it pertains to action on the SDH. Through exploring the policy process, we examine how SDH discourses, evidence and strategies align with existing policy processes in the Australian context. Participants indicated that approaches to securing change that are based on linear conceptualisations of the policy process (as often found in public health) may be seen as 'out of touch' with the messy reality of policymaking. Rather, a more dialogic approach that embraces philosophical and moral reasoning (alongside evidence) may be more effective. Based on our findings, we recommend that SDH advocates develop a deeper awareness of the political and policy structures and the discursive conventions they seek to influence within specific settings.

Systems science and systems thinking for public health: a systematic review of the field.

OBJECTIVES: This paper reports on findings from a systematic review designed to investigate the state of systems science research in public health. The objectives were to: (1) explore how systems methodologies are being applied within public health and (2) identify fruitful areas of activity. DESIGN: A systematic review was conducted from existing literature that draws on or uses systems science (in its various forms) and relates to key public health areas of action and concern, including tobacco, alcohol, obesity and the social determinants of health. DATA ANALYSIS: 117 articles were included in the review. An inductive qualitative content analysis was used for data extraction. The following were systematically extracted from the articles: approach, methodology, transparency, strengths and weaknesses. These were then organised according to theme (ie, commonalities between studies within each category), in order to provide an overview of the state of the field as a whole. The assessment of data quality was intrinsic to the goals of the review itself, and therefore, was carried out as part of the analysis. RESULTS: 4 categories of research were identified from the review, ranging from editorial and commentary pieces to complex system dynamic modelling. Our analysis of each of these categories of research highlighted areas of potential for systems science to strengthen public health efforts, while also revealing a number of limitations in the dynamic systems modelling being carried out in public health. CONCLUSIONS: There is a great deal of interest in how the application of systems concepts and approach might aid public health. Our analysis suggests that soft systems modelling techniques are likely to be the most useful addition to public health, and align well with current debate around knowledge transfer and policy. However, the full range of systems methodologies is yet to be engaged with by public health researchers.

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.

Regulation to create environments conducive to physical activity: understanding the barriers and facilitators at the Australian state government level.

INTRODUCTION: Policy and regulatory interventions aimed at creating environments more conducive to physical activity (PA) are an important component of strategies to improve population levels of PA. However, many potentially effective policies are not being broadly implemented. This study sought to identify potential policy/regulatory interventions targeting PA environments, and barriers/facilitators to their implementation at the Australian state/territory government level. METHODS: In-depth interviews were conducted with senior representatives from state/territory governments, statutory authorities and non-government organisations (n = 40) to examine participants': 1) suggestions for regulatory interventions to create environments more conducive to PA; 2) support for preselected regulatory interventions derived from a literature review. Thematic and constant comparative analyses were conducted. RESULTS: POLICY INTERVENTIONS MOST COMMONLY SUGGESTED BY PARTICIPANTS FELL INTO TWO AREAS: 1) urban planning and provision of infrastructure to promote active travel; 2) discouraging the use of private motorised vehicles. Of the eleven preselected interventions presented to participants, interventions relating to walkability/cycling and PA facilities received greatest support. Interventions involving subsidisation (of public transport, PA-equipment) and the provision of more public transport infrastructure received least support. These were perceived as not economically viable or unlikely to increase PA levels. Dominant barriers were: the powerful 'road lobby', weaknesses in the planning system and the cost of potential interventions. Facilitators were: the provision of evidence, collaboration across sectors, and synergies with climate change/environment agendas. CONCLUSION: This study points to how difficult it will be to achieve policy change when there is a powerful 'road lobby' and government investment prioritises road infrastructure over PA-promoting infrastructure. It highlights the pivotal role of the planning and transport sectors in implementing PA-promoting policy, however suggests the need for clearer guidelines and responsibilities for state and local government levels in these areas. Health outcomes need to be given more direct consideration and greater priority within non-health sectors.

Policy change to create supportive environments for physical activity and healthy eating: which options are the most realistic for local government?

The objective is to identify and test regulatory options for creating supportive environments for physical activity and healthy eating among local governments in Victoria, Australia. A literature review identified nine potential areas for policy intervention at local government level, including the walking environment and food policy. Discussion documents were drafted which summarized the public health evidence and legal framework for change in each area. Levels of support for particular interventions were identified through semi-structured interviews conducted with key informants from local government. We conducted 11 key informant interviews and found support for policy intervention to create environments supportive of physical activity but little support for policy changes to promote healthy eating. Participants reported lack of relevance and competing priorities as reasons for not supporting particular interventions. Promoting healthy eating environments was not considered a priority for local government above food safety. There is a real opportunity for action to prevent obesity at local government level (e.g. mandate the promotion of healthy eating environments). For local government to have a role in the promotion of healthy food environments, regulatory change and suitable funding are required.

Taxing junk food: applying the logic of the Henry tax review to food.

The recent review of taxation in Australia - the Henry tax review - has recommended that the federal government increase the taxes already levied on tobacco and alcohol. Tobacco and alcohol taxes are put forward as the best way of reducing the social harms caused by the use and misuse of these substances. Junk foods have the same pattern of misuse and the same social costs as tobacco and alcohol. The Henry tax review rejects the idea of taxing fatty foods, and to date the government has not implemented a tax on junk food. We propose that a tax on junk food be implemented as a tool to reduce consumption and address the obesity epidemic.

Wanted: politicians to champion health (not obesity).

Because of the complex aetiology of modern obesity patterns, isolated therapeutic or public health measures will not solve the obesity problem. Consumers must be made aware of the ways in which the food industry influences their food purchases. Government needs to prioritise health ahead of industrial productivity and increased consumption. An obesity intervention wish list is presented as a suggested reform package: > prohibit all forms of marketing of energy-dense, nutrient-poor foods; introduce measures such as kilojoule caps, prohibition of bundling, and greater uniformity in packaging design to make energy-dense, nutrient-poor foods less enticing and less amenable to bulk purchase; redesign supermarkets to promote fresh rather than energy-dense, nutrient-poor foods; cease provision of government subsidies to food processing industries; tax energy-dense, nutrient-poor foods to create a disincentive to purchasing of these foods; and regulate the location and number of fast-food outlets by enacting urban planning laws.

Moving beyond 'rates, roads and rubbish': How do local governments make choices about healthy public policy to prevent obesity?

While the causes of obesity are well known traditional education and treatment strategies do not appear to be making an impact. One solution as part of a broader complimentary set of strategies may be regulatory intervention at local government level to create environments for healthy nutrition and increased physical activity. Semi structured interviews were conducted with representatives of local government in Australia. Factors most likely to facilitate policy change were those supported by external funding, developed from an evidence base and sensitive to community and market forces. Barriers to change included a perceived or real lack of power to make change and the complexity of the legislative framework. The development of a systematic evidence base to provide clear feedback on the size and scope of the obesity epidemic at a local level, coupled with cost benefit analysis for any potential regulatory intervention, are crucial to developing a regulatory environment which creates the physical and social environment required to prevent obesity.