The article, “Strengthening the implementation of Health in All Policies: a methodology for realist explanatory case studies,” was authored by Ketan Shankardass, Emilie Renahy, Carles Muntaner, and Patricia O’Campo, and was accepted for publication on March 7, 2014.
The paper addresses the increasingly vital role of Health in All Policies (HiAP) initiatives globally. HiAP involves governments using intersectoral action to address macro-social and economic determinants of health and equity. Unlike approaches focused solely on health services, HiAP initiatives employ cross-sectoral structures and relationships to systematically integrate health considerations into policymaking, targeting broad health determinants. This approach is crucial for narrowing widening health inequalities worldwide by tackling fundamental macro-social and economic determinants of population health. HiAP initiatives are often unique to their settings, with broad mandates that may involve various interventions and long implementation timelines, engaging diverse partners from government, the private sector, and civil society at multiple geographic levels.
Despite the growing prevalence of HiAP examples, the authors identify a significant research gap: there has been a notable lack of systematic study into why these initiatives succeed or fail. Consequently, rigorous evidence based on systematic research concerning the social mechanisms that consistently enable or hinder HiAP implementation across different jurisdictions remains sparse. The 2013 Helsinki Statement on HiAP underscored the importance of making HiAP implementation more effective, highlighting the need to study the implementation process itself, not just policy outcomes. Given the complexity of HiAP, which involves multiple activities, diverse partners, and different government levels, a robust methodology is needed to understand how institutionalized processes can support collaborative work and integrated solutions.
To address this critical gap, Shankardass et al. describe a novel methodology for explanatory case studies that adopts a scientific realist perspective to investigate HiAP implementation. This approach is grounded in the assumption that an external world of complex, changing phenomena exists, which can be understood through both transempirical concepts and factual data, acknowledging the interplay of agency and structural factors. The primary goal of this methodology is to build theory about successful practices by uncovering the social mechanisms that drive HiAP implementation within specific contextual conditions.
Key elements of this realist methodology include:
- Social Mechanisms: These are defined as interactive, often hidden processes involving at least two persons in a political, cultural, or economic relation, which initiate causal sequences in HiAP implementation. Mechanisms offer powerful explanations for how social systems, like policy implementation, function and are essential for generalizing explanations across different settings.
- Context-Mechanism-Outcome (CMO) Pattern Configurations: The methodology conceptualizes that mechanisms are “triggered” in relation to specific, conducive contextual conditions, leading to various outcomes such as the acceptability, feasibility, or sustainability of HiAP. This framework allows researchers to gain a rich understanding of how and why different sectors collaborate on health and equity, what approaches to HiAP implementation work, for whom, and in what types of settings.
The methodology proceeds through several structured steps:
- Conceptual Framework Formulation: It begins with developing a conceptual framework to describe the contexts, social mechanisms, and outcomes relevant to the sustainable implementation of HiAP. This framework, viewed as a “middle-range theory,” aids in systematically constructing CMOs. It defines the main outcome as sustainability, often indicated by successful or completed HiAP activities, and preconditions for sustainability as acceptability (willingness of sectors to collaborate) and feasibility (capacity of sectors to collaborate effectively). Contextual factors are categorized into those shaping HiAP initiation (e.g., cultural, economic, political context, international influences, specific policy problems, prior intersectoral action experience, ideology of health system) and those influencing implementation (e.g., political priority, formal enforcement processes, financial resources, capacity building activities). The framework is iteratively revised based on case study findings.
- Case Study Preparation:
- Case Identification: Cases of HiAP are selected based on a definition requiring intersectoral initiatives toward healthy public policymaking that address health upstream of inequities, conceive of health in multisectoral terms, and have mandates at high levels of government.
- Case Library and Key Informants: A preliminary understanding is developed by reviewing existing literature, creating a case summary, and identifying diverse key informants from various sectors and government levels using a snowball sampling strategy.
- Data Collection:
- Key Informant Interviews: Semi-structured telephone interviews explore informants’ roles, barriers, and facilitators, with specific probes to elicit explanations for “how” and “why” phenomena occur and the relevance of contextual factors.
- Systematic Literature Search: The case library is updated with peer-reviewed and grey literature, including sources mentioned during interviews.
- Coding and Analysis:
- CMO Pattern Configuration Coding: Interview data are systematically coded to identify outcomes (sustainability, acceptability, feasibility), mechanisms (basic causal processes related to outcomes), and contextual factors that condition the mechanism-outcome relationship. Independent coding by multiple team members ensures rigor.
- Thematic CMO Summarization: Coded mechanisms are discussed in team meetings to reach consensus on their causal pathways and contextual relevance. Unique CMO texts are grouped by patterns and themes into higher-level summaries, with continuous “interrogation” of the data for alternative explanations.
- Literature Review for Evidence: All relevant literature is examined for strong confirmatory or contradictory evidence regarding the articulated mechanisms, which is then integrated into the case summaries.
- Case Report Generation: The final product for each case is a comprehensive report that narrates the success of HiAP implementation, detailing how and why specific factors and strategies were relevant to sustainability. These reports include citations to informants and literature, enriched with key quotes.
The article illustrates this methodology with a comparative example of Health Impact Assessment (HIA) tools in Sweden and Quebec, where the team applied this approach.
- In Sweden, where HIA is not a legal requirement [Context], its use was hindered by a lack of understanding of the tool and insufficient financial capacity [Mechanisms]. However, the introduction of a public health perspective was more acceptable [Outcome] when activities could be easily integrated into pre-existing structures, like the mandatory Environmental Impact Assessments (EIA), leveraging existing experience and capacity. This highlights a mechanism of “automaticity” or “conformity” where new policies can use existing administrative structures, facilitated by pilot projects that allow actors to draw on existing experience.
- In Quebec, this specific mechanism was not observed due to distinct contextual differences. Firstly, Quebec’s Public Health Act (2001) mandates HIA use [Context], unlike Sweden’s non-legislated, occasional use. Secondly, Quebec established a detailed inter-ministerial process with multiple structures to guide and support ministries in HIA, while Sweden relied mainly on its National Public Health Institute for evidence support. The authors suggest that Quebec’s legislation and detailed processes likely persuade ministries and facilitate tool use, making the need for “conformity” and “automaticity” less critical compared to Sweden, where such detailed intentional processes are absent. This comparative analysis demonstrates how contextual factors shape the relevance and effectiveness of mechanisms.
The strengths of this research approach include:
- Triangulation: It uses multiple sources of evidence (literature, interviews, documents), diverse methodological approaches (explanatory case study, realist evaluation), and a team-based approach with multiple raters to interpret evidence. This yields rich data about mechanisms and causal linkages, enhancing construct and internal validity.
- Theory Building: It supports theory and learning about causation by providing clear temporal sequences, accommodating the complex interplay of macro- and micro-social factors, and iteratively refining causal linkages.
- Transparency and Systematism: The methodology emphasizes transparency in reporting research processes, documenting decisions, and systematically following detailed protocols across case studies.
Acknowledged limitations include the potential for incomplete revelation of mechanisms due to reliance on key informant recall, challenges in recruiting diverse participants from all relevant sectors/levels, time constraints in interviews, and the inherent subjectivity of individual perspectives. While contradictory evidence may arise, the research team aims to resolve disagreements through further discussion and document review.
In conclusion, this methodology provides a robust and novel approach to identify and triangulate rich evidence describing social mechanisms and salient contextual factors that characterize successful HiAP practices. It is applicable to diverse jurisdictions and can be used to study HiAP and other forms of intersectoral action for reducing health inequities, serving as a building block for multiple case studies to examine the broader generalizability of successful practices.
Reference: Shankardass, K., Renahy, E., Muntaner, C., & O’Campo, P. (2014). Strengthening the implementation of Health in All Policies: a methodology for realist explanatory case studies. Health Policy and Planning, 29(7), 896–907. doi:10.1093/heapol/czu021