II An approach to addressing healthy public policy
III Method for synthesizing knowledge relating to public policies
IV Workshops and conclusion
--submitted by Michael Keeling National Collaborating Centre for Healthy Public Policy
James Joyce’s To Do List
In a wonderful New Yorker cartoon which appeared in 1989, cartoonist David Jacobson imagined a to-do list on James Joyce’s refrigerator that read:
1. Call bank
2. Dry cleaner
3. Forge in the smithy of my soul the uncreated conscience of my race
4. Call mom 
Without trying to draw too strong a parallel, there is much here for our consideration as health promoters, public health actors, decision makers and those with an interest in public health more generally. First, let’s note the juxtaposition of the quotidian with the profound. Yes, it makes the cartoon funny. But there is also something in it for us. We are all probably awash in the day-to-day work and at the same time our jobs might call upon us to change the world. In Joyce’s case, these words, "forge in the smithy of my soul...," arrived during the epiphanic moment concluding A Portrait of the Artist as a Young Man, in which the character Stephen Dedalus realizes what his work must be. In spite of an ironic wink in the way in which he articulates the goal, Joyce the author later attempts and realizes something akin to this in his Ulysses and Finnegan’s Wake, two monumental works in English literature. 
What’s on Your List?
What might the lists on public health actors’ refrigerators look like? If you were to produce a list like James Joyce’s, what would it contain? Does it include reducing health inequalities? Advocacy? Influencing policy to put more health in all policies?
As the Commission on the Social Determinants of Health concluded in its 2008 report, health inequities caused by poverty and other social determinants are unjust, preventable, and pervasive. In Canada, some may see an advocacy role inherent in some of our provinces’ and territories’ public health laws. One might also see advocacy as a way to put healthy public policy on the agenda. In effect, tackling these issues amounts to changing the world. And we must not forget to attend to the dry cleaning. Which one gets put aside?
We do not need to go too far afield to learn that a great deal of health influencing is caused by policies outside of the health sector. Indeed, such policies have profound influence on income, transportation, workplaces, nutrition, housing, education, and so on; and these and other determinants are clearly linked to health. Acting to influence these policies so that they can favour the health of populations means working to produce healthy public policies.
Naturally, one cannot expect to do everything – and not all at once. Fortunately, no one is alone in taking responsibility for advancing the agenda. Over recent decades, there has been substantial movement towards recognizing the influence that policies outside of the health sector have on the health of populations and sub-groups, and this has produced some common will to produce change. There has been ever more awareness and emphasis on the fact that multisectoral approaches are necessary to address complex problems, and there have been ever-increasing efforts to build networks, tools, resources, awareness, examples of promising practices, an evidence base, and a climate for making change. All of these efforts have increased our knowledge and have also improved our ability to act. 
Another area in which there has been progress is in the policy arena. We are seeing a shift away from the idea that all we have to do is make evidence available to decision makers and they will then incorporate that into our health-influencing social structures, through policies and programs. Instead, as reflected in the linguistic shift from “evidence-based” to “evidence-informed” policy making, we find the idea that evidence is one dimension among many competing interests in decision-making.  Patrick Fafard notes the importance of paying attention to the decision-making context, claiming that “[a]llowing for context ... enables a consideration of issues of power in all its dimensions. If it is nothing else, the study of politics (and hence political science) is the study of power. This brings us to the ways in which policy making is understood by political scientists and other social scientists who share an interest in understanding (and perhaps even explaining) how policy decisions and non-decisions are made.” 
When we set out to work on public policies and on matters relating to the social determinants of health, the nature of the evidence we use changes. We cannot remove a policy from its social context – it is embedded in a complex, changing environment and it is thus difficult to isolate effects from that context. What evidence of effectiveness we can generate can be valuable, but it is by definition context- and time-specific, so its effectiveness when applied in other contexts may be compromised.
To summarize the story so far, our roles as citizens and as health promoters direct us to act on the social determinants of health. However, we are facing the difficulties of working in complex environments like the policy sector, trying to address complex social issues. As proponents of evidence-informed actions, we are additionally called upon to stay abreast of, and to advance, the best available evidence.
II An approach to addressing healthy public policy
The dimensions that are touched upon above factor into an approach to addressing healthy public policies. The National Collaborating Centre for Healthy Public Policy (NCCHPP) has a mandate to increase the expertise of public health actors across Canada in healthy public policy through the development, sharing and use of knowledge.
The NCCHPP is one of six National Collaborating Centres (NCCs) for Public Health. The six centres promote and improve the use of scientific research and other knowledge to strengthen public health practices and policies in Canada.
Our challenge is to produce a variety of resources, theoretical and practical, that can help public health actors to be more effective in their efforts to advance healthy public policies. This includes developing networks, identifying research gaps, synthesizing knowledge relating to healthy public policy, based on the interests and needs that we hear expressed through a variety of means.
Based on the foregoing, we understand working on healthy public policy to include:
- Learning about public policies and their effects on health
- Generating and using knowledge about healthy public policies
- Identifying models and actors for intersectoral collaboration
- Influencing the development of healthy public policies. 
More specifically, our projects include work on:
- Health Impact Assessment as a means to incorporate health and equity into decision-making
- Deliberative processes as means to add context and depth to decision making
- Studying integrated governance (multisectoral) initiatives to better understand factors for their success in practice
- Understanding public policy processes
- Issue mapping in complex systems
- Problem framing as a way to better understand how organizations can work together
- Ethics in public health
For more on these and other projects, visit the projects page on our website. (http://www.ncchpp.ca/40/Projects.ccnpps)
III Method for synthesizing knowledge relating to public policies - One example of a recent project
Analytical Framework – dimensions studied
In order to respond to the need to have the best available knowledge about public policies to inform decision makers during the promotion, adoption and implementation of public policies, the Centre set out to develop a method for synthesizing knowledge specifically designed for public policies. The result is inspired by political science, by the literature on evidence-informed decision-making in public health, from work on evaluation, and on deliberative processes.
The analytical framework draws upon the best available effectiveness data, including failures of effectiveness. It also systematically considers the equity of the policy in question as well as issues relating to implementation, including cost, feasibility and acceptability. These latter are of particular interest to policy makers. Equity is also of interest: while policies may be shown to improve population health overall, this method focuses on differential effects resulting from a policy (i.e., identifying whether the distribution of effects will be equal or not). The relationships between the six dimensions for analyzing public policies are shown in Figure 1 below.
The overall goal is to “guide the collection and synthesis of knowledge about these various dimensions of the public policy being studied.”  To guide practitioners in applying the framework to the policies or programs of interest to them, we have produced lists of key questions relating to each dimension in the framework. These questions are available in the core document, Method for Synthesizing Knowledge about Public Policies.  Questions include, under feasibility for example, “Is the policy a follow-up to a pilot program?” and “Does the policy under study fall under the jurisdictional power of the authority that wishes to adopt it? Does it conform to existing legislation?”  Answers to these and the other questions could be built by consulting the scientific and grey literatures, through deliberative processes, and generally by taking stock of what is known in this area. The key questions, guided by the framework, can help to orient this data collection effort.
Four steps guide the method.
Step 1 - Inventory of policies and selection of subject of synthesis.
This is a preliminary exploration of the literature relating to a given health problem and the range of policies implemented to address it. From this review, one policy is chosen as the object of the knowledge synthesis.
Step 2 - Explication of the intervention logic.
Once the policy is selected, this step involves creating a logic model showing how the policy in question is intended to affect the targeted problem.
Step 3 - Synthesis of data drawn from the literature.
This involves the review of the scientific and grey literatures, including search, appraisal, extraction and synthesis according to specific criteria.
Step 4 - Enrichment and contextualization of the data.
This step involves organizing deliberative processes to bring together actors working in the context in which implementation of the policy is being proposed. The learnings from Step 3 will be furnished as a basis for discussion. The deliberative processes are intended to add experiential knowledge and to consider effectiveness and implementation issues relative to participants’ perspectives and context vis à vis the policy in question.
As the four steps outlined in Figure 2 show, the range of data considered is much broader than for a traditional approach to knowledge synthesis. While effectiveness data from experimental studies is an essential feature, this is not sufficient for the study of policies.
The NCCHPP has recently published four documents relating to this proposed method for analyzing public policies. The central document outlines and describes the method in detail. To complement this, the Centre has produced an example of a knowledge synthesis using nutrition-labelling policies as a case study. This synthesis is primarily intended to serve as an illustrative example of the method and the kind of results it can produce, but it contains material that will likely be of interest to public health actors concerned with labelling as a policy option for reducing obesity in Canada. In addition, there is an 8- to 10-page summary version of each, to provide an overview and highlights.
Method for Synthesizing Knowledge About Public Policies
Summary - Method for Synthesizing Knowledge About Public Policies
Public Policies on Nutrition Labelling: Effects and Implementation Issues, A Knowledge Synthesis
Highlights - Public Policies on Nutrition Labelling: Effects and Implementation Issues, A Knowledge Synthesis
IV Workshops and conclusion
The NCCHPP is looking ahead to providing training in how to apply this method and discussing it with our colleagues across Canada. Two events are already planned, including a pre-conference session at the Canadian Public Health Association (CPHA) 2011 Conference in Montréal. Click here to see the Program, on the site of the CPHA (see page 21 for our workshop description). We will also offer a workshop at the JASP, les Journées annuelles de santé publique in November 2011. More events will be announced for different regions of Canada as they arise. Florence Morestin, the lead author of the four papers, will be available on April 6 and 7, 2011 at the Ontario Public Health Convention (TOPHC). You can find Florence at the NCCHPP’s booth in the exhibitors’ hall. (Conference website: http://www.tophc.ca/).
Our recent work on a method for synthesizing knowledge about public policies is a small part of a very big picture. It is one response to the seemingly too vast, systemic, and enduring social phenomena that confound our progress. Ideally, this and other tools, ideas, networks, and solutions of various kinds will allow us to see the ways that we can put the big picture and the ambitious goals that it entails on our to-do lists.
The NCCHPP would love to hear from you. Please send a note with your feedback, ideas, requests or suggestions to firstname.lastname@example.org.
(1) The cartoon is under copyright, but you may view it on the site of The Cartoon Bank, at: http://www.cartoonbank.com/1989/james-joyces-refrigerator/invt/113810/
(2) For those unfamiliar with Joyce’s (b. 1882, d. 1941) work, he was an Irish novelist whose later work in particular was revolutionary for its stream of consciousness approach, for its blending of allusion, thought, and conversation within single discursive strands, and for its seminal place in the development of modernist literature in English. For a general background on Joyce, try Wikipedia.
(3) For further reading on healthy public policy, social determinants of health, inequalities and inequities, we suggest that you consult the links to resources compiled on the following page of the NCCHPP’s website: http://www.ncchpp.ca/62/What_We_Do.ccnpps. Besides some orientation on the NCCHPP’s work, we have links to a variety of papers, including the World Health Organization’s Ottawa Charter for Health Promotion, the final report of the Commission on the Social Determinants of Health, Trevor Hancock’s Beyond Health Care: From Public Health Policy to Healthy Public Policy, several key readings on the determinants of health, and some recent reports on health inequalities and inequities.
(4) Fafard, P. (2008) Evidence and Healthy Public Policy: Insights from Health and Political Sciences. National Collaborating Centre for Healthy Public Policy, pp. 5-7. Online at: http://www.ncchpp.ca/165/Publications.ccnpps?id_article=160
(5) Ibid., p. 8.
(6) To learn more or to link to further reading, try the following web pages:
Learn about public policies and their effects on health
Generate and using knowledge about healthy public policies
Identify models and actors for intersectoral collaboration
Influence the development of healthy public policies
(7) Morestin, F. (2011). Summary - Method for Synthesizing Knowledge About Public Policies. National Collaborating Centre for Healthy Public Policy, p.2. Online at: http://www.ncchpp.ca/172/Publications.ccnpps?id_article=576
(8) Text boxes with examples of key questions relating to each dimension for analyzing policies may be found in: Morestin, F., Gauvin, F.-P., Hogue, M.-C., & Benoit, F. (2011). Method for Synthesizing Knowledge About Public Policies. National Collaborating Centre for Healthy Public Policy, pp.6-11. Online at: http://www.ncchpp.ca/docs/MethodPP_EN.pdf
(9) Ibid., p. 9.