Manifestations of integrated public health policy in Dutch municipalities

Manifestations of integrated public health policyin Dutch municipalities

DOROTHEE PETERS1*, JANNEKEHARTING1, HANS VANOERS2,3,JANTINE SCHUIT3,4, NANNEDE VRIES5 and KARIEN STRONKS11Department of Public Health, Academic Medical Center, University of Amsterdam, PO Box 22660,1100 DDAmsterdam, The Netherlands, 2Faculty of Social Sciences, University of Tilburg, PO Box 90153,5000 LE Tilburg, The Netherlands, 3National Institute for Public Health and the Environment, PO Box 1,3720 BA Bilthoven, The Netherlands, 4Department of Health Sciences and EMGO institute for Health andCare Research, VU University Amsterdam, De Boelelaan 1105, 1081 HVAmsterdam, The Netherlands and5Department of Health Promotion, CAPHRI School of Public Health and Primary Care, University ofMaastricht, PO Box 616, 6200 MDMaastricht, The Netherlands*Corresponding author. E-mail: [email protected] or [email protected]

SUMMARYIntegrated public health policy (IPHP) aims at integratinghealth considerations into policies of other sectors. Since thelimited empirical evidence available may hamper its furtherdevelopment, we systematically analysed empirical manifes-tations of IPHP, by placing policy strategies along a con-tinuum of less-to-more policy integration, going fromintersectoral action (IA) to healthy public policy (HPP)to health in all policies (HiAP). Our case study included34 municipal projects of the Dutch Gezonde SlagkrachtProgramme (2009–15), which supports the developmentand implementation of IPHP on overweight, alcohol anddrug abuse, and smoking. Our content analysis of projectapplication forms and interviews with all project leadersused a framework approach involving the policy strategiesand the following policy variables: initiator, actors, policy

goals, determinants and policy instruments. Most projectsshowed a combination of policy strategies. However, mani-festations of IPHP in overweight projects predominantlyinvolved IA. More policy integration was apparent in alcohol/drugs projects (HPP) and in all-theme projects (HiAP). Morepolicy integration was related to broad goal definitions, whichallowed for the involvement of actors representing severalpolicy sectors. This enabled the implementation of a mix ofpolicy instruments. Determinants of health were not explicitlyused as a starting point of the policy process. If a policyproblem justifies policy integration beyond IA, it might behelpful to start from the determinants of health (epidemio-logical reality), systematically transform them into policy(policy reality) and set broad policy goals, since this givesactors from other sectors the opportunity to participate.

Key words: determinants of health; government programs; healthy public policy; multisectoral policyresponse

INTRODUCTION

Public health issues are considered wicked pro-blems, as most of their determinants lie outsidethe health sector. Examples include environmen-tal determinants such as socio-economic, culturaland environmental factors, living and working

conditions, and community networks (Dahlgrenand Whitehead, 1991; Kickbusch, 2010). Giventhe importance of these social determinants ofhealth (SDH), policies that address them are con-sidered the most promising approach to promotehealth and achieve sustainable health outcomes(Kickbusch, 2008, 2010). These policies aim to

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integrate ‘health considerations into other pol-icies and sectors beyond the health sector’ [(Sihtoet al., 2006), p. 4]. Policy integration involves theinterrelation of the content (e.g. policy goals andpolicy instruments) of policies of several sectors(Shannon and Schmidt, 2002). Such integratedpolicies are referred to by different terms, e.g.governance for health (Kickbusch and Gleicher,2012), policies for better health (Kickbusch,2013) and integrated public health policy (IPHP)(Knutsson and Linell, 2010). Empirical evidenceon the way IPHP develops in practice is ‘scarce,preliminary or anecdotal’ [(Lin et al., 2012), p. 23].

The literature mainly explains what IPHP is orshould be (Ståhl et al., 2006; McQueen et al.,2012), and why it might be a necessary policystrategy (Kickbusch, 2010). Suggestions on howto develop IPHP are mainly derived from litera-ture on governance and policy development ingeneral (Kickbusch and Gleicher, 2012) and ex-amples given are primarily at a national level(Ståhl et al., 2006; Kickbusch and Buckett, 2010;McQueen et al., 2012, Leppo et al., 2013). Moredetailed insight into the empirical manifestationsof IPHP might bridge the gap between the theor-etical ideal of IPHP and daily practice, since itwill help to understand aspects of the policyprocess that enable the development of IPHP(McQueen et al., 2012). This would require evi-dence on policy variables such as who takes theinitiative to start IPHP, what other actors areinvolved in the policy process, what do they wantto achieve within the context of IPHP and withwhat type of policy instruments.

In the literature, several different interpreta-tions of IPHP and related terminologies circulate.For the understanding of empirical manifestationsof IPHP, we consider the typology by Kickbusch(Kickbusch, 2010) as most suitable, because thisgives room for different interpretations to coexist.This typology distinguishes three intellectual pol-icy waves: intersectoral action (IA), healthy pub-lic policy (HPP) and health in all policies (HiAP).This typology is based on the development of hori-zontal policy approaches (WHO, 1978, 1986;Council of the European Union, 2006) and repre-sents a continuum of degrees of policy integration(Koivusalo, 2010). This continuum ranges from aone-directional, health-centred approach, involv-ing policy integration in the implementation stage(IA), to a multi-directional model, also involvingpolicy integration in decision-making and devel-opment processes (HiAP). The typology of policystrategies refers to a generally recognized shift

from government to governance (Kickert et al.,1997). This means that policy processes ‘are nolonger fully controlled by the government, butsubject to negotiations between a wide range ofpublic, semi-public and private actors’ [(Sørensenand Torfing, 2007), p. 4]. Whereas IA and HPPhave characteristics of ‘government’, and HiAPcould be typified as ‘governance’, the latter is notan end stage in policy making, rather part of alarger whole-of-government approach with oppor-tunities for synergistic policies in all directions(Kickbusch and Gleicher, 2012).

Since the three policy strategies can be placedon a continuum, the distinction between thesestrategies is not clear-cut. Although these strat-egies are interpreted differently in the literature(Kickbusch, 2013), common characteristics canbe derived. IA, proposed by the Alma Ata Dec-laration (WHO, 1978), involves efforts by thehealth sector to collaborate with other publicpolicy sectors to improve health outcomes (Kick-busch, 2010; Shankardass et al., 2011). Thisproject-based strategy is characterized by goalsnarrowly related to health and the use of commu-nicative policy instruments to tackle individuallifestyle determinants (Kickbusch, 2010; Kick-busch and Gleicher, 2012). HPP, introduced bythe Ottawa Charter (WHO, 1986), involves anexplicit concern for health in all areas of publicpolicy through accountability for health impact.It is characterized by the involvement of govern-mental actors of several policy sectors (Ståhlet al., 2006) and a mix of policy instruments ina settings approach (WHO, 1986; Kickbusch,2010). The main purpose is to create supportiveenvironments for health (Ståhl et al., 2006; Kick-busch, 2010). HiAP, a major theme during theFinnish Presidency of the EU, can be character-ized by a systematic examination of SDH, broadgoal definitions related to health, well-beingand equity, and a dynamic policy response acrossportfolio boundaries by governance networks,consisting of governmental (WHO, 2014) as wellas societal actors (Kickbusch, 2008, 2010; Shan-kardass et al., 2011). Health promotion pro-fessionals seem to have different roles in eachstrategy. They are implementers in IA and bro-kers for health in HPP strategies (Kickbusch,2010). Within HiAP, their role is not well defined.

The Dutch Gezonde Slagkracht Programme(Decisive Action for Health) (2009–15; ZonMw,2009) provides an excellent opportunity to sys-tematically study the empirical manifestations ofIPHP. This programme, initiated by the Dutch

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Ministry of Health, Welfare and Sports, providesfinancial and professional support for municipalauthorities to develop and implement IPHP onspecific health themes (or a combination ofthemes), i.e. overweight, alcohol and drug abuse,and smoking. Every Dutch municipality or col-laborating group of municipalities (referred tobelow as pilot projects) could apply for thissupport by completing application forms thatrequired them to specify their intended IPHPstrategy. Financial support depended on the levelof IPHP experience, for which the pilot projectswere purposively selected in different stages ofpolicy development. Professional support includedworkshops on national regulations affecting publichealth policy, interactive policy development andpolicy continuation. The examples of pilot projectsin Box 1 illustrate their diversity.

Box 1: Examples of projects in the Gezonde SlagkrachtProgramme

Obesity projectInitiated by the regional public health services, thisproject aims to promote a healthy lifestyle among children.The project uses a single lifestyle intervention in whichobese children attend special sports lessons. The actorsinvolved are from the policy sectors of public health andsports. Actors include both public (e.g. regional publicpolicy departments) and private organizations (e.g. sportsclub, health insurance company).

Alcohol projectInitiated by two policy departments, viz. public safetyand public health, and aimed at reducing excessivedrinking and changing the existing heavy drinkingculture in the village communities. The project uses amix of communication (e.g. instruction and education) andlegal instruments (e.g. covenants between municipality andsports clubs). Actors involved are both public (e.g. severalpolicy departments, police, fire-brigade), and privateactors (e.g. sports clubs, a discotheque).

All-themes projectAimed at creating a permanent level of instruments toprevent obesity, depression, alcohol abuse and earlyschool leaving, to enhance citizens’ ability to copeindependently. The project uses a mix of lifestyle inter-ventions, embedded in a permanent network of publicservices in policy sectors like education, public safety,social work and public health, with public, semi-publicand private actors involved. The initiator of this pro-ject is unknown.

The aim of this study was to systematically de-scribe the manifestations of IPHP in day-to-daypolicy practice and to evaluate how these mani-festations reflected the IA, HPP and HiAP policystrategies.

METHODS

Design and data collectionOur multiple case study encompassed all 34 pilotprojects of the Dutch Gezonde Slagkracht Pro-gramme (2009–15). Two different data sourceswere used. First, we collected the applicationforms (2009–10) in which the pilot projects moti-vated their participation in the programme andset out the aims of the projects and their plansfor collaboration, interventions, planning andfunding. Second, we interviewed the local projectleaders 6–12 months after the start of the pilotprojects (Spring, 2011). Topics discussed were themain issues addressed by the project plans (e.g.reasons for IPHP in general and content of spe-cific interventions in particular), as well as theposition of the project in the municipal organiza-tion (e.g. relations with existing municipal policyprograms and involvement of municipal actors)and the way IPHP was envisioned (what the char-acteristics of the intended IPHP were). The inter-views, which took ∼60–90 minutes each, wereaudio-taped with the respondents’ permission andsummarized by the researchers in interview re-ports. Four project leaders used the opportunity toread the reports for approval.

Data analysisOur qualitative content analysis used a deduc-tive framework approach, which is suitable forpolicy-relevant qualitative research (Srivastavaand Thomson, 2009) and includes a systematicanalysis of the data based on an analytical frame-work featuring key concepts and variables asinitial coding categories (Ritchie and Spencer,2004).

The three policy strategies, IA, HPP and HiAP,served as the basis for the analytical framework(Kickbusch, 2010). To make these strategies suit-able for empirical analysis, we operationalizedthem in terms of variables of the policy process.We adopted the variables of initiator and actorsfrom the policy network literature (Kickert et al.,1997). These variables refer to an individual,group, organization or group of organizations thattake action in the agenda-setting stage (initiator)or subsequent stages (actors) of the policy process.From public policy literature, we adopted thevariables of policy goals and policy instruments.Policy goals refer to situations that initiatorsand actors find important and think they can

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stimulate or actually want to achieve (Van deGraaf and Hoppe, 1996). We distinguished pro-cess and content goals. Process goals involvesector goals, i.e. goals that create conditions ne-cessary to realize central goals, whereas contentgoals involve central goals, i.e. what policy actorsactually want to achieve, and final formulations,i.e. the motives for the central goals (Van deGraaf and Hoppe, 1996). Policy instruments referto the resources that initiators and actors canuse to actually achieve the various predefinedgoals (Van den Heuvel, 1998). We subdividedthis variable into three types of policy instru-ments: communication (e.g. health education),economic (e.g. price mechanisms) and legal (e.g.covenants and laws) (Van den Heuvel, 1998).From the public health science literature, wefinally adopted the variable of determinants.Determinants refers to the causal factor policiesintend to address to improve health and health-related behaviours (Dahlgren and Whitehead,1991). These factors were further specified interms of the various health-related individual(e.g. motivation) and environmental determi-nants (e.g. social and physical factors) (Dahlgrenand Whitehead, 1991). Cross-tabulating the fivepolicy variables with the three policy strategiesresulted in the analytical framework presentedin Table 1 (Characteristics rows).

The data were coded using the framework vari-ables as the main codes and their further specifica-tions as sub-codes. To start with, D.P. and J.H.separately coded the data of three pilot projects.After discussing their results, they concluded thatthey agreed about the main codes but differedregarding the sub-codes. After further specifyingthe definitions of these sub-codes, the disagree-ment disappeared. The next step was to have theremaining pilot projects coded first by D.P. andthen by J.H., without major differences appearing.

Next, we rearranged the coded data accordingto the appropriate part of the analytical frame-work. That is, we decided for each of the fivevariables which of the coded text fragments exem-plified which of the policy strategies. This resultedin a summary of empirical manifestations for eachvariable and policy strategy. These empirical mani-festations were entered into the analytical frame-work (Table 1; Manifestations rows).

As we recognized different policy strategieswithin projects as well as within variables, wecreated the following scoring algorithm to system-atically interpret the data. Based on the empiricalmanifestations identified (Table 1), we assigned 0

points to a variable within a single project if thatparticular policy strategy was not apparent, 1 pointif the policy strategy was apparent but not domin-ant, 2 points if the policy strategy was dominantbut not exclusive and 3 points if the policy strategyhad been exclusively applied. The algorithm wasseparately applied by D.P. and J.H., after whichthey discussed their individual scores for each ofthe variables and projects. As a result, some char-acteristics (based on the literature) and manifesta-tions (based on the data) of the analyticalframework were further specified to reach consen-sus on the final scores. To protect the anonymity ofthe projects in this study, we decided to report theresults of our analysis without linking examples tothe specific projects in question.

RESULTS

For two of the pilot projects, insufficient informa-tion was available. Fifteen of the remaining 32 pro-jects focused on overweight, 2 on overweight andalcohol (referred to below as overweight projects)and 11 on alcohol and/or drugs (alcohol/drugs pro-jects), while 4 projects addressed all four themessimultaneously (all-theme projects). Due to insuf-ficient information, we could not assess initiatorand instrument variables for all projects, while thedeterminants variable could not be assessed forany of the projects. Determinants were eitherdescribed in general terms, e.g. attitude, lifestyle,social or physical environment, or implicitly re-ferred to by naming interventions without explain-ing their content and goals.

Mix of policy strategiesIn general, manifestations of IPHP predominantlyreflected IA, with HPP the second most commonpolicy strategy and HiAP the least common(Table 2). Some projects used an explicit IA, HPPor HiAP strategy, whereas most projects had char-acteristics of several policy strategies. This mix ofpolicy strategies was present across variables, e.g.predominantly IA regarding actors and HPPregarding policy goals, as well as within one vari-able, e.g. policy instruments with characteristics ofboth IA and HiAP.

InitiatorThe development of IPHP was most ofteninitiated by the public health sector (IA). This




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Table 1: Analytical framework: literature-derived characteristics and empirical manifestations of integrated policy strategies, by policy variable

Policy strategy Variables

Initiator Actor Policy goals Determinants Policy instruments

IACharacteristics Initiating policy sector

Primary health sectorand public healthsector (Kickbusch,2010).

Policy sectorHealth sector (mainly

government) and other sectors.Phase of policy process

Policy development (healthsector). Policy implementation(other sectors).

OtherHealth sector shows other sectors

how to contribute (Kickbusch,2010).

Goal definitionNarrow, health-

related (derivedfrom Kickbusch,2010; Shankardasset al., 2011).

Health determinantsaddressedFocus on individual

behaviouralchange; individuallifestyle factors(Kickbusch,2010).

InterventionsLifestyle intervention,

predominantlycommunicationinstrument.

Policy contextProject-based; policy

component notnecessary; rational policymaking (Kickbusch andGleicher, 2012).

Manifestations Initiating policy sectorPublic health sector

(e.g. regional publichealth service,department ofpublic health,Alderman for publichealth, based onresearch by regionalpublic healthservice), primaryhealth sector (e.g.addiction serviceprovider).

Policy sectorHealth sector, e.g. department of

public health, regional publichealth service, health serviceproviders, other policydepartments than publichealth.

Phase of policy processE.g. public health services

develop a specific interventionon exercise and healthy diet inschools and ask sports andeducation departments toimplement it.

Goal definitionIn terms of, e.g.

reduction ofobesity,development ofbalanced offer ofpreventioninterventions,increased healthylifestyle, i.e. centralgoals.

Not found in data. InterventionsE.g. health education,

coaching,implementation of oneexplicit health-relatedintervention, protocol forearly detection or chainapproach to health.

Policy contextProject-based, e.g.

temporary funding forthe implementation ofinterventions (<2 years).

HPPCharacteristics Initiating policy sector

Mainly public healthsector(government), butnot necessarily(Kickbusch andGleicher, 2012).

Policy sectorAny policy sector, including

public health (government)(Kickbusch and Gleicher,2012).

Phase of policy processPolicy development and policy

implementation (any policysector, including public health)(Kickbusch, 2010).

OtherRole of public health sector not

necessary.

Goal definitionMid-category,

predominantlyhealth related interms of creatingsupportiveenvironments forhealth (Kickbusch,2010)

Health determinantsaddressedProblems addressed

at the causal level:lifestyle,environment andpeople’sempowerment(Kickbusch andGleicher, 2012).

Start of SDHapproach.

InterventionsMix of strategies:

communication,economic and legalinstruments (Van denHeuvel, 1998; Kickbusch,2010).

Policy contextSettings approach, to get

same message to targetgroup in severallocations (Kickbusch andGleicher, 2012).

Incremental strategy; notproject based but policybased (Kickbusch, 2010).

Continued

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Table 1: Continued

Policy strategy Variables

Initiator Actor Policy goals Determinants Policy instruments

Manifestations Initiating policy sectorOther policy

departments thanpublic health,whether incollaboration withdepartment ofpublic health or not,or based on researchby department ofpublic safety.

Policy sectorOther policy departments than

public health, e.g. spatialplanning, education, welfare,employment, public safety.

Phase of policy processMultidisciplinary project groups

in which several policydepartments deal with policydevelopment.


creating healthyand physicalactivity friendlyenvironments,reducing nuisanceand criminality,changing mentalityand cultureregarding alcoholconsumption, i.e.central goals.

Not found in data. InterventionsMix of strategies:

communication (healtheducation), economic(fines), legal (covenants,ban on happy hour,changing local laws onalcohol distribution).

Policy contextPublic health related

message to target groupvia different actors andsectors, at severallocations in municipality.

If another policy departmentis involved with publichealth,environment-relatedinterventions.

Policy based: explicitlyrejecting temporaryinterventions.

HiAPCharacteristics Initiating policy sector

Any sector(government andsocietal actors)(Kickbusch, 2010).

Policy sectorAny policy sector, including

public health (government andnon-government).

Phase of policy processPolicy development and policy

implementation by any policysector, including public health:dynamic andpartnership-based policyprocess (includingcontributions by public healthto other sectors). Policynetworks include also othersocietal actors (governance)(Ståhl et al., 2006).

Goal definitionBroad, relating to

health, well-beingand equity.

OtherBenefits of improved

population healthfor the goals ofother sectors(Kickbusch andGleicher, 2012;McQueen et al.,2012).

Shared goals acrossall parts ofgovernment.

Health determinantsaddressedKey determinants of

health addressedin a moresystematicmanner(Kickbusch andGleicher, 2012).

Core is examiningSDH as startingpoint of policyprocess. Goesbeyond individualfactors andlifestyles (Ståhlet al., 2006).

InterventionsMix of HPP-related

strategies, but strategiesshow morecharacteristics of adynamic policy responseacross portfolioboundaries (Kickbusch,2010).

Policy contextEvidence-informed policy

making (Ståhl et al.,2006).

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Interdepartmental units andcommittees: administrativelevel and aim to reorient policydepartments around a sharedpriority (Greer, 2012).

OtherPolicy practice adopted by

politicians and policymakers.Manifestations Initiating policy sector

(Alliance of) citizens,governmental andsocietalorganizations, e.g.housingcorporations, police,welfareorganizations,several policydepartments,schools, health-careprofessionals.

Policy sectorInvolvement of private sector

organizations (e.g. sportsschools, supermarkets, cateringindustry, hospitals, welfareorganizations, health insurancecompanies), publicorganizations (e.g. schools,police, public prosecutor),societal organizations (e.g.churches, sports clubs), healthservice providers (if involvedin implementation process, e.g.addiction service providers,hospitals, general practitioners,physicians, dieticians,psychologists, home care) andcitizens.


reduction ofsocio-economichealth differences,investment incitizens’well-being,increased averagelife expectancy,increased ability ofcitizens to copeindependently,empowerment, i.e.final formulations.

OtherBenefits for goals of

other sectors: e.g.preventing earlyschool leaving,improving schoolachievements,reducing costsrelating toexcessive drinking,fighting disparities,increasing societalparticipation,counteractingsocial effects ofdrugsconsumption, i.e.sector goals.

Not found in data. InterventionsAcross portfolio

boundaries, e.g. if policyhas been initiated,developed andsupported by othersectors than publichealth, creation of ahealth-related policyumbrella under whichseveral policy sectorsdevelop and implementtheir policy, other policysectors explicitly payattention to public healthgoals, investment inpublic health by way oflower income policy.

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Table 2: Overall policy strategy scores and scores for each health theme, pilot project and policy variable(dominant strategy indicated by shading)

aCoded project names, due to anonymity of the pilot projects. Insufficient information was available to properly assess policystrategies applied in pilot projects AB and BG.




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was especially true for overweight projects, wherethe department of public health or the regionalpublic health service acted as the initiator, whilethe initiator in two of the projects was the munici-pal alderman for public health. In two of thealcohol/drugs projects, it were other policydepartments that took the initiative (HPP), suchas the department of public safety or the depart-ment of employment and social affairs. In one ofthe all-theme projects, the mayor, as representa-tive of the public safety department, acted as theinitiator (HPP). In one other project, the initiatorwas a working group formed by several policydepartments, citizens and societal actors (HiAP).

ActorsThe actors involved in the policy networks werepredominantly municipal departments represent-ing several sectors (HPP). Especially in alcohol/drugs projects, several policy departments wereinvolved in development and implementation ofIPHP. The department of public health or the re-gional public health services were involved inalmost all of these projects, as were societal ac-tors such as addiction service providers, schoolsand municipal policy departments (e.g. depart-ments of public safety, of public order and ofwelfare). All-theme projects were comparable toalcohol/drugs projects in terms of actors. In oneof these projects, IPHP was designed and imple-mented in an elaborate project structure con-sisting of a steering group, project groups andworking groups in which various organizations,e.g. policy departments, schools, sports clubs, li-brary, crèches and the police, participated (HiAP).Overweight projects showed a more mixed pat-tern of actor involvement. Public health sectororganizations were predominantly involved (IA),whereas other governmental policy departments,e.g. education, welfare and sports, were also in-volved, especially in the implementation phase ofIPHP.

Policy goalsThe most prevailing type of content goals werecentral goals narrowly related to health (IA).This was especially the case in overweight pro-jects. Policy goals were sometimes phrased interms of overweight reduction and achieving ahealthy lifestyle. Alcohol/drugs projects showed amixed pattern of types of policy goals. Next tocentral goals like reduction of alcohol or drugs

consumption by specified target groups (IA),many of these projects set final formulations interms of, e.g. the creation of safe environments(HPP) and the prevention of early school leaving(HiAP). All-theme projects set broader final for-mulations in terms of prevention of disparitiesand increased societal participation (HiAP),whether or not accompanied by central goalsregarding healthy lifestyle (IA) and revitalisingtown districts (HPP). Almost all projects formu-lated process-related sector goals predominantlyin terms of collaboration processes and createdsupport for the policy and implementation steps.

Policy instrumentsThe most common approach consisted of a mixof communication, legal and economic instru-ments in a settings approach (HPP). Alcohol/drugs projects as well as all-theme projects pre-dominantly developed and implemented such amix of policy strategies, for example covenantswith pubs to ban happy hours, combined withmeasures to correct the youths if they break thelaw on alcohol consumption. Some of these pro-jects implemented a settings approach in whichpublic health-related messages on alcohol anddrug abuse reached the target group viadifferent actors and sectors, and at various loca-tions. In overweight projects, communicationinterventions in terms of health education werethe most common type of policy instrument,while a settings approach was used to a lesser ex-tent. In the all-theme projects, some begandynamic policy responses across portfolioboundaries (HiAP). Such a policy componentarose, for example, when public health wasincorporated in the overall policy agenda of thelocal government as a topic of permanent policyattention, or when regulations were changed,such as rules to limit the time that bars mayserve alcohol and special arrangements foryoungsters who commit small crimes while beingunder the influence of soft drugs.

DISCUSSION

Summary of resultsThis study examined manifestations of IPHP inDutch municipalities participating in the GezondeSlagkracht Programme (ZonMw, 2009). We foundthat most pilot projects involved a combination of




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policy strategies. Overall, IA was the dominantpolicy strategy, especially in overweight projects.IAwas also clearly present in projects on alcoholand drugs, but HPP was the most common policystrategy here. In projects addressing all healththemes, HiAP was the most prominent strategy.

LimitationsThe study had some limitations. First, the frame-work used to analyse the policy manifestations isone way of looking at IPHP (Kickbusch andGleicher, 2012). The pluralistic use of termin-ology in this respect (Kickbusch, 2013) indicatesthat alternative operationalizations are also pos-sible. One such an alternative could start withdeciding at which point on the continuum, fromIA to HiAP, policy integration becomes meaning-ful (Raphael, 2008). Another such an alternativecould start from a network perspective and includevariables such as actor interactions, decision-making and network management (Kickert et al.,1997). As recommended (Ritchie and Spencer,2004), we chose the analytical framework that atbest fitted the empirical policy manifestationsreflected by our data.

Second, the data did not always clearly reflectthe different policy variables. This indicates thatsome of the policy strategies may have remainedbeyond our view. Since the two types of datasource we studied (data triangulation; Polit andBeck, 2004) did not differ in the policy strategiesthey reflected, it is not very likely that missing in-formation has seriously biased our results.

Third, we operationalized the three policystrategies by giving the policy variables a distinctcontent for each strategy. This may not have donejustice to reality, in which the boundaries betweenthe strategies, covering a continuum of less-to-more policy integration, are not very clear-cut(Koivusalo, 2010). This may hamper the predict-ive value of the typology in future research. Weaddressed this by allowing different empiricalmanifestations of variables to coexist.

Fourth, we used a simple scoring algorithm todetermine the dominant policy strategy for eachproject. Although the use of the algorithm wasextensively discussed by two researchers (investi-gator triangulation; Polit and Beck, 2004), wecannot exclude that other evaluators would cometo different conclusions. As we consistently usedTable 1 as a guide for the analysis, we do not

expect, however, that accidental differences in in-terpretation would fundamentally alter the mixof policy strategies we found.

Finally, the projects included in our studymay reflect a selective sample. As the GezondeSlagkracht Programme purposively selectedpilot projects in different stages of policy devel-opment, we assume that our sample covered avariety of IPHP policies similar to that in allDutch municipalities. The inconsistent use of ter-minology in international literature and policydocuments makes it difficult to compare findingswith studies from other countries (Kickbusch,2013). Our operationalization based on Kick-busch could serve such kinds of comparisons withlocal or national initiatives elsewhere in the world,like those within the WHO European HealthyCities Network, the US Healthy CommunitiesProgram and the Australian Health Lens AnalysisProject.

Interpretation of the findingsManifestations of IPHP predominantly took theform of IA, involving a limited, though notnegligible degree of policy integration. IA isan improved policy approach compared withapproaches involving solely organizations fromthe public health sector in lifestyle-based healthpromotion interventions (Kickbusch, 2010). Inthe case of wicked problems, more sustainablehealth outcomes are theoretically expectedfrom HiAP, being the most integrated strategyon the continuum of policy integration (Sihtoet al., 2006; Kickbusch, 2010). As noticed be-fore (Raphael, 2008; Clavier et al., 2012), ourstudy indicates that HiAP, as a move towardsa whole-of-government approach (Kickbuschand Gleicher, 2012), seems to be more complexand more difficult to realize than IA and HPP.Besides, the nature of a health problem definesthe necessary level of policy integration totackle the problem (Smedley and Syme, 2000).In other words, an IA approach might suit somepublic health-related problems, while othersneed HPPor HiAP.

If, however, a policy problem justifies policy in-tegration beyond IA, our systematic analysis ofmanifestations of IPHP indicates that improvedintegration may be related to initiator, determi-nants of health, policy goals, policy instrumentsand policy coherence.




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InitiatorThe involvement of non-health sectors is re-garded as fundamental for public policy toachieve health benefits (Kickbusch, 2008, 2010).Becoming aware of this and of the benefits of ahealthy society for their own policy goals may bea prerequisite for other sectors to engage in oreven initiate IPHP (Provan and Milward, 2001).In our study, IPHP manifested itself predomin-antly as IAwith the health sector taking the lead.Achieving higher degrees of policy integration,such as HPP and HiAP, may require a differentrole for the health sector. One that is ‘outward-oriented, open to others and equipped with thenecessary knowledge, skills and mandate to takea systems approach to health’ [(Kickbusch andGleicher, 2012), p. 84]. This indicates that thehealth sector should act as agenda setter andbroker for health (Kickbusch, 2010; Kingdon2011) to create awareness among other sectors.

DeterminantsDeterminants are an important starting pointfor better health outcomes (Kickbusch, 2008,2010). However, our data indicate that thesedeterminants were not the basis of the IPHPprocess in the pilot projects. Instead of an epi-demiological reality (Plochg et al., 2013), we pre-dominantly saw a policy reality (Shaw, 2012) witha prominent role for sector goals on aspects likecollaboration with other sectors. Domination ofthe policy reality may have a distracting effect onthe systematic transformation of determinants ofhealth into public policy. Experiences with inter-vention mapping indicate that this protocol maybe helpful in such a transformation process(Bartholomew et al., 2011).

Policy goalsActors are willing to contribute to policy pro-cesses when they have the opportunity to safe-guard their own interests (Provan and Milward,2001). Our findings for alcohol/drugs and all all-theme projects show that broad policy goals interms of final formulations on well-being andequity can accommodate these interests andbridge a presumed gap between policy sectors.This trend can possibly be explained by the factthat alcohol- and drugs-related problems, whichare also present in all-theme projects, seem todirectly impact other objectives than public

health, e.g. public safety or economic prosperity.This creates possibilities for cross-sectoral col-laboration. Although overweight is predomin-antly considered an individual lifestyle problem(Raphael 2008), it impacts other sectors as well(Cawley, 2004). This may result in a commoninterest in addressing overweight. Final formula-tions offer the opportunity to accommodatemultiple central goals of several policy sectors(Van de Graaf and Hoppe, 1996) and can facili-tate coherent policy to meet common interests.Overweight projects may thus also be able toovercome the dominance of IA.

Policy instrumentsDeterminants and policy goals determine thechoice of policy instruments (Van den Heuvel,1998). The dominance of IA in our study resultedin a focus on communication instruments in theform of individual lifestyle interventions in a ma-jority of the projects. However, lifestyle interven-tions are not appropriate for every problem. Forwicked problems, a setting approach could bemore effective (Smedley and Syme, 2000). Ifvarious sectors are involved in IPHP, they bringalong their own resources (Provan and Milward,2001). This may lead to the development and im-plementation of a mix of communication, legaland economic instruments as characteristics ofthe HPP and HiAP strategies. If this is the policyambition, policymakers should be familiar withdifferent types of policy instruments and knowwho possess what instruments.

Coherence between policy strategiesSome projects showed a mix of policy strategiesacross and within the variables. Such a mixwithin variables does not seem problematic. Itseems reasonable to formulate policy goals nar-rowly related to health (IA) and final formula-tions related to health, well-being and equity(HiAP). However, such a mix across variablesmight have unfavourable consequences if thismix displays incompatible aspects. For example,it seems impossible for policy goals stated interms of final formulations (HiAP) to be rea-lized with communication instruments (IA). Thequality of a policy theory, by which we mean‘the total of causal and other assumptions under-lying a policy’ [(Hoogerwerf, 1990), p. 285],affects the results of this policy (Hoogerwerf,1990). Although, such understanding of policy




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theories may contribute to the necessary policyintegration, it may not be easy to preciselyspecify these causal theories for the wicked pro-blems that many public health issues in fact are.This may at least partly explain why IPHP mani-fests itself predominantly as IA in the pilot pro-jects. A systems perspective might be helpful tosupport a transition from government-relatedIPHP such as IA to governance-based IPHP likeHiAP (Richmond, 1993).

CONCLUSION

Manifestations of IPHP in Dutch municipalitieshave more characteristics of IA than of HiAP. IA,meaning a limited though not negligible degreeof policy integration, is a step forward comparedwith previous public health policies, but it maynot be sufficient to tackle wicked public healthproblems. If a policy problem justifies policy inte-gration beyond IA, combining an epidemiologic-al and a policy reality might be helpful. Thismeans taking determinants as the starting pointfor the policy process, as well as translating theminto policy. Setting broad policy goals might alsobe helpful, since this gives actors of other sectorsthe opportunity to participate, and bring alongseveral other types of policy instruments. Furtherresearch on the actual development of these em-pirical manifestations of IPHP should providegreater insights into these processes.

FUNDING

This work was supported by Zonmw (grant no.201000002).

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Manifestations of integrated public health policy in Dutch municipalities

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