The Use of Policy Frameworks to

Understand Public Health-Related

Public Policy Processes:
A Literature Review

Final Report
October 2012

Prepared for Peel Public Health

Prepared by Dr. Brent Moloughney

Public Health Consultant
ACKNOWLEDGEMENTS

The preparation of this literature review was facilitated by many individuals.

Several staff members at Peel Public Health contributed to the preparation of this literature
review. Rebecca Strange conducted the searches of the indexed databases. Rebecca Fortin was
the second reviewer applying the selection criteria and the quality assessment tool to a sample
of studies. Maria Gomes assisted with the retrieval of studies.

A number of policy process experts provided advice on the planned approach to this literature
review and suggested studies to be reviewed. These included Dr. Patrick Fafard (University of
Ottawa), Dr. Michael Rachlis (University of Toronto), and Professor Mark Exworthy (University
of London).

This report’s observations and conclusions are those of the author.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page ii
EXECUTIVE SUMMARY

Background

The burden of chronic diseases is of great concern particularly considering existing trends in
obesity and the projected rise in diabetes rates. Seeking change in public policy is a key public
health strategy to protect and promote the health of the public. The best available evidence
indicates a need to alter the social and physical environmental drivers of unhealthy eating,
physical inactivity and sedentary behaviours. This will require changes in public policies
affecting a wide range of stakeholders and settings. Much of the focus to-date for evidence-
informed public health policy processes has been on the review of evidence and its provision in
an appropriate format for decision-makers. However, a key challenge is that evidence is only
one of many inputs into policymaking and often not the most important. Public health requires
a more thorough understanding of the public policy development process in order to optimally
influence public policies that promote health and prevent disease.

Objective

To identify policy process frameworks that have been successfully applied to inform
understanding of and/or action on a public health-related public policy.

Search Methods

Policy analysis case studies were sought that focussed on a public health-related public policy
issue and applied one of five prominent policy process frameworks. The latter were identified
during the preliminary scan of the literature and by a leading authority as being among the
most promising frameworks. The following databases were searched for the years 2001-2012:
Medline, Psychinfo; Global Health; Sociological Abstracts, Healthstar, and CINAHL. Reference
lists of all relevant publications were followed up. Searches excluded non-English publications
and those addressing substantially different political contexts from Canada, as well as books,
book chapters and dissertations. Attempts were made to search the grey literature, but due to
the nature of the topic, this proved to be unhelpful. Contacted experts provided several
suggestions for potentially pertinent studies.

Data Collection and Analysis

The relevance of identified records was assessed. Information was captured for each included
study regarding the nature of the policy issue, context, and type of policy framework applied.
Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page iii
An assessment was also made regarding the extent the use of the policy framework assisted
understanding of the policy issue and/or action. It was also noted whether the study provided
concrete guidance on how the policy framework was applied. The methodological quality of
studies was assessed using a qualitative review form previously utilized by Peel Public Health. A
random sample of identified records was assessed by a second reviewer to assess the
application of the selection criteria. The second reviewer also applied the qualitative review
form to assess its inter-rater reliability.

Main Results

After the selection process had been completed, 21 policy analysis case studies were included
in this review. The policy process frameworks were applied to a wide range of policy issues
across the spectrum of public health practice including: chronic disease prevention (tobacco,
physical activity, obesity, alcohol); infectious diseases (global disease control, reporting of
healthcare infections, drug policy); healthy development (childhood health promotion;
emergency contraception); environmental health (urban policy, health impact assessments);
and health inequities and social determinants of health.

The majority (14) of the case studies utilized the Multiple Streams framework, while four
applied the Advocacy Coalition Framework (ACF). An additional two studies used the
Punctuated Equilibrium framework and one study used the Institutional Analysis and
Development Framework (IADF). While no studies used the Stages Heuristic in isolation, some
studies incorporated it into their preliminary descriptive analysis. The methodological quality of
studies was only moderate since many studies did not fully describe their approaches to data
collection and/or analysis. Nevertheless, several studies utilizing either the Multiple Streams
framework or the ACF provided useful insight into the policy process. Performing an adequate
descriptive policy analysis is important prior to applying one of the policy process frameworks.

Conclusion

Based on the findings of this review, a suggested approach is provided for conducting policy
analysis in a systematic way by a public health organization. The findings of this analysis can
then be used to inform subsequent policy engagement strategies.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page iv
TABLE OF CONTENTS
Acknowledgements..........................................................................................................................ii

Executive Summary.........................................................................................................................iii

Issue ................................................................................................................................................ 1

Context............................................................................................................................................ 1

Approach......................................................................................................................................... 3

Conceptual Framework ............................................................................................................... 3

Overview of Selected Policy Process Frameworks...................................................................... 6

Stages Heuristic ....................................................................................................................... 6

Institutional Analysis and Development Framework .............................................................. 7

Multiple Streams Framework .................................................................................................. 8

Punctuated-Equilibrium Framework ....................................................................................... 9

Advocacy Coalition Framework ............................................................................................. 10

Literature Review Question ...................................................................................................... 13

Literature Search ....................................................................................................................... 14

Relevance Assessment and Data Extraction ............................................................................. 15

Quality Assessment ................................................................................................................... 15

Results ........................................................................................................................................... 16

Search and Quality Assessment ................................................................................................ 16

Types of Policy Frameworks and Issues .................................................................................... 18

Summary of Included Studies ................................................................................................... 19

Stages Heuristic ..................................................................................................................... 19

Institutional Analysis and Development Framework ............................................................ 19

Punctuated Equilibrium Framework ..................................................................................... 19

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page v
 Multiple Streams Framework ................................................................................................ 20

Advocacy Coalition Framework ............................................................................................. 24

Discussion...................................................................................................................................... 28

Implications for Policy Analysis by Public Health Organizations............................................... 30

Descriptive Analysis ............................................................................................................... 30

Explanatory Analysis .............................................................................................................. 32

Implications for Policy Engagement.......................................................................................... 32

Summary................................................................................................................................ 36

Conclusion..................................................................................................................................... 38

Glossary......................................................................................................................................... 39

Appendix 1 – Search Strategy ....................................................................................................... 40

Appendix 2 – Quality Assessment Tool......................................................................................... 41

Appendix 3 – More Detailed Search Results................................................................................. 43

Appendix 4 – Included Policy Framework Case Studies ............................................................... 44

References .................................................................................................................................... 51

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 The Use of Policy Frameworks to
Understand Public Health-Related
Public Policies: A Literature Review

ISSUE
Seeking change in public policy is a key public health strategy to protect and promote the
health of the public. The policy advice and analysis provided by public health must be premised
on the best available evidence. However, “health is largely constructed outside the health
sector”1 such that the public policy decisions public health is seeking to influence often involve
multiple levels of government and other organizations. For example, efforts to increase
opportunities for physical activity will involve the policies of schools, workplaces and municipal
government, which themselves will be facilitated (or not) by provincial level policies.

In these policy contexts, evidence of health risk and benefit is but one of many considerations
of decision-makers. An evidence-informed policy development process needs to therefore not
only consider the evidence-base for public health advice and action, but also incorporate an
effective understanding of the policy process itself. A number of existing reports address the
retrieval and synthesis of evidence. The purpose of this review is to seek a greater
understanding of the policy process itself and how it is applied to public health-related public
policies. This understanding is fundamental for public health organizations to optimally
influence public policies affecting the health of the public.

CONTEXT
The burden of chronic diseases in Peel, as in Ontario and across Canada, is very large. In Peel,
obesity and diabetes rates are of particular concern. At current rates, diabetes prevalence is
projected to increase by 58% over the next 15 years.2 In addition to the personal effects on
health and wellbeing, such an increase is expected to place significant pressure on the
healthcare system and further threaten its sustainability. From a prevention perspective,
reducing or eliminating this projected increase in diabetes is dependent upon altering the social
and physical environmental drivers of unhealthy eating, physical inactivity and sedentary
behaviours. This will require policy change affecting a wide range of stakeholders and settings.
Table 1 provides selected examples of evidence-based population approaches for the
prevention of chronic diseases from a recent scientific statement of the American Health
Association (AHA).3 Implementation of every one of these approaches will require public policy
decisions.

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Table 1: Selected Evidence-Based Population Approaches for Preventing Chronic Diseases
Setting/Item Policy
Labelling and • Mandated nutrition fact panels or front-of-pack labels/icons to influence
Information industry behaviour and product formulations
• Point-of-decision prompts to encourage use of stairs
Economic • Subsidy strategies to lower prices of more healthful foods and beverages
Incentives • Tax strategies to increase prices of less healthful foods and beverages
Schools • Multi-component interventions focussed on improving diet and physical activity
including specialized educational curricula, trained teachers, supportive school
policies, a formal physical education program, healthy food and beverage
options, and a parental/family component
Workplaces • Comprehensive wellness programs with nutrition and physical activity
• Increased availability of healthier food/beverage options and/or strong nutrition
standards for foods and beverages served, in combination with vending machine
prompts, labels or icons to make healthier choices
• Improving stairway access and appeal, potentially in combination with ‘skip-
stop’ elevators that skip some floors (thereby making stair use necessary)
Local • Improved accessibility of recreation and exercise spaces and facilities (e.g.,
Environment building of parks and playgrounds, increased operating hours, use of school
facilities during non-school hours)
• Improved land use design (e.g., integration of and inter-relationships of
residential, school, work, retail and public spaces)
• Improved traffic safety
• Improved neighbourhood aesthetics to increase physical activity in adults
• Improved walkability, a composite indicator that incorporates aspects of land-
use mix, street connectivity, pedestrian infrastructure, aesthetics, traffic safety
and/or crime safety
Restrictions and • Restrictions on television advertisements for less healthful foods or beverages
Mandates advertised to children
• Restrictions of advertising and marketing of less health foods or beverages near
schools and public places frequented by youth
• General nutrition standards for foods and beverages marked and advertised to
children in any fashion, including on-package promotion
• Regulatory policies to reduce specific nutrients in foods (e.g., trans fats, salt,
certain fats)
3
Source: AHA Scientific Statement. Circulation 2012.

Existing public health tools focus predominantly on reaching evidence-informed decisions

regarding effective interventions such as those shown in Table 1. As part of a previous EXTRA
project, Peel Public Health has developed and is institutionalizing an evidence-informed public
health decision-making model. This model has proven to be extremely useful for the decision-
making by our organization. However, our experience with a range of public health policy issues
including the fluoridation of drinking water to improve oral health, workplace food policies, and

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land-use approval processes, indicates that public policy decisions are influenced by much more
than scientific evidence. Peel Public Health requires a theory and evidence-informed process in
order to optimally influence public policy development.

APPROACH
Conceptual Framework
Identifying a conceptual framework to guide this literature review was an initial challenge. We
readily found models whose primary focus was on evidence synthesis and knowledge
translation.4-7 While helpful, these models tend to treat the policy process as a ‘black box’
providing little insight into how and why certain policies are made or at times, not made.

Our goal is the achievement of public policies that create supportive environments to promote
health and prevent diseases. Our initial scan of the literature indicates that evidence-based
policy is qualitatively different from evidence-based medicine.8 Policy identifies a course of
action that sets priorities and guides resource allocation. It is a product of, and constructed
through, political and social processes.9 The reality is that politics and ideology are strong
drivers of policy decisions. Overall, decision-makers consider a wide range of factors of which
evidence is only one that includes: personal beliefs, values, evidence, external factors (e.g.,
recession, election), interest group pressure and institutional constraints.6

Despite this reality, there is often an implicit assumption by health professionals and
researchers of “a linear model of policy making where if good data are provided, good policy
decisions will follow.”10 However, the realities of decision making about policy are non-linear
and complex,10 and presenting it as a linear, rational process moving from formulation to
implementation… has been criticized as an over-simplistic view.”11

Fafard criticizes the underlying assumption that “policy will be based on evidence if researchers
can find the most effective ways of putting research into the hands of decision-makers. In other
words…if they have it (research), they will use it.’ This assumption is, however, not supported
by much of the available empirical evidence that points to the fact that many policy decisions
are based on considerations other than the best available evidence… [The] general reality [is]

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 3
that while policy-oriented researchers may want to ‘speak truth to power’, the powerful are by
no means obliged to listen and often do so when it best suits them.”12 Fafard further argues
that public health practitioners’ disappointment or frustration with policy decisions based on
‘politics’ and ‘ideology’ rather than science reflects “an inadequate theory of government
decision making and indeed of the nature of political power.”10

Typical knowledge translation models “tend to be silent on the complexities of cross-sectoral,

multilevel policy change and the implications of these complexities for evidence creation…
[and] have little to say about the influence of power, politics and social movements” in shaping
change.13 Even though “health promotion is an inherently political enterprise… the politics of
health promotion are rarely discussed.”14 As noted by Oliver, “Science can identify solutions to
pressing public health problems, but only politics can turn most of those solutions into
reality.”15

An editorial by Catford emphasizes the importance of political analysis for health promotion
practice,

Past experience of promoting public health, however, suggests that, while evidence is
important, it is not enough. The skills required in health promotion today are more than
the traditional specialist ones taught at university. Health promotion needs to be able to
work within existing political and economic systems, to understand how decisions are
made and then to know how to influence this decision making. This is the essence of
political analysis and strategy and a major ‘art’ of health promotion practice.16

Similarly, Breton and de Leuuw stress that “a sound theoretical repertoire can offer an
invaluable guide to policy advocacy practice.”17 Gilson states that “Effective policy change does
not simply require good technical design or using evidence to generate policy...It requires clear
attention to the processes by which change is brought about.”9

There are multiple existing theories of the policy process. Unfortunately, no single policy model
offers a fully comprehensive description or understanding of the policy process as each answers
somewhat different questions.11 Existing policy frameworks have complementary strengths
since policy dynamics are driven by a multiplicity of causal paths.18 It therefore seems
reasonable to apply multiple frameworks as ‘tools’ in order to assess and plan action
recognizing that some frameworks may be better suited for a particular situation.11,19 Once
greater understanding of the policy situation is achieved, then consideration can be given to
how public health might best improve the prospects of attaining the identified policy goals.

Figure 1 combines these two components of policy analysis and policy engagement strategies
with the foundation of public health advice and decisions informed by evidence.

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Figure 1: Conceptual Framework for Evidence-Informed Public Policy Analysis and Action

Adapted from: Buse 2008.20

It is beyond the scope of this project to consider the entire universe of policy frameworks and
theories. In the preliminary scoping of the literature, a limited number of policy frameworks
were repeatedly encountered.8,11,21,22 In addition, a key text by Sabatier, Theories of the Policy
Process, limits its consideration of frameworks to those that are the most promising.23 Based on
these sources, this project focuses on five policy process frameworks with complementary
strengths:

• Stages Heuristic: an ‘idealistic’ or ‘textbook’ approach to the policy process that divides the
process into a series of stages.
• Institutional Analysis and Development Framework: focuses on how institutional ‘rules’
alter or influence the behaviour of intendedly rational individuals motivated by material
self-interest.
• Multiple Streams Framework: explains how policies are made under conditions of
‘ambiguity’, where there are many ways of thinking about the same circumstance or
phenomenon.
• Punctuated Equilibrium Framework: policymaking is characterized by long periods of
incremental change punctuated by brief periods of major policy change.

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• Advocacy Coalition Framework: developed to address highly challenging problems in which
there are substantial goal conflicts, important technical disputes and multiple actors from
several levels of government.

Since understanding the results section is dependent on familiarity with these frameworks,
each will be briefly described.

Overview of Selected Policy Process Frameworks

Stages Heuristic
The stages heuristic is an ‘idealistic’ or ‘textbook approach’ to the policy process.8,24 It divides
the policy process into a series of stages:

• Agenda setting
• Policy formulation
• Policy adoption
• Policy implementation
• Policy assessment.

As an early ‘theory’, it divided a complex policy process into discrete stages and stimulated
research into specific stages.24 However, by the 1980s, it became increasingly criticized for a
number of limitations:

• It does not identify the causal drivers that govern the policy process within and across
stages. It offers little insight into the policy change process with an absence of causal
mechanisms. It is therefore not a theory with hypotheses than can be tested.
• A linear, systematic approach to solving policy problems is rarely found. Not all
problems go through the cycle in order or even use all stages. Furthermore, the inter-
linkages among stages is ignored (e.g., evaluation of existing programs affects agenda
setting and policy formulation occurs as bureaucrats attempt to implement vague
legislation).
• Evidence is ‘external’ to the policy cycle whereas other models incorporate it within
processes.
• It implies a top-down approach such as the passage and implementation of a single
piece of legislation. It neglects the interaction of the implementation and evaluation of
numerous pieces of legislation within a given policy domain and the reality that
multiple policies/legislative initiatives at varying stages may be occurring
simultaneously.8,24

Some advantages are offered by the stages heuristic. It is accessible and intuitive to the non-
specialist and disaggregates the policy process into manageable segments.25 Pragmatically, it

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can assist the public health practitioner to identify where in the policy cycle an issue is currently
situated as an initial part of their analysis and to describe what public health’s role could be.19 It
also highlights the “many points of influence on policy orientations.”26

While emphasizing that evidence is often not the primary driver of policymaking, Fafard notes
that the role of evidence varies at different stages of the policy cycle.12 Lavis explores this issue
in more detail identifying different types of systematic reviews for specific steps of the
policymaking process.4 Overall, while the stages heuristic does not provide insights into the
mechanisms of policymaking, it potentially aids practitioners to ‘get their bearings’ and to begin
to consider how they may contribute to the policy process.

Institutional Analysis and Development Framework

This framework focuses on how institutional ‘rules’ alter or influence the behaviour of
intendedly rational individuals motivated by material self-interest. 24 There are differing levels
of ‘rules’ from those that are mutually understood and predictably enforced to those that are
shared perceptions that tend to be enforced by participants themselves.27 The unit of analysis
and investigation is the ‘action situation’, which is the social space where individuals interact,
exchange goods and services, solve problems, dominate one another or fight. Analysis of the
situation involves several components:

• the set of participants (actors who may be individuals or groups)

• positions that exist (e.g., within an organization/association)
• allowable actions
• potential outcomes
• level of control over choice
• available information
• costs and benefits of actions and outcomes.28

The framework is multi-dimensional describing at least three levels of action:

• Operational tier: where actors interact in light of the incentives they face to generate
outcomes directly in the world
• Collective choice (policy) tier: where policy decisions are made within the constraints of
a set of collective-choice rules
• Constitutional tier: where decisions are made about who is eligible to participate in
policymaking and about the rules that will be used to undertake policymaking.28

A key strength of the framework is bringing an institutional perspective to policy analysis, which
tends to be weak/lacking in other frameworks. It considers ‘institutions’ as more than just a
government department, business firm, or political party, to apply the concept more broadly

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where people interact in a repetitive manner organized by rules, norms and strategies.27 For
example, the framework has been valuable in the study of common property regimes such as
the management of forestry resources.

Multiple Streams Framework

The Multiple Streams framework explains how policies are made under conditions of
‘ambiguity’, where there are many ways of thinking about the same circumstance or
phenomenon.29 This is different from ‘uncertainty’, which is the inability to accurately predict
an event. The distinction is such that more evidence may reduce uncertainty, but does not
reduce ambiguity. “For example, more information can tell us how AIDS is spread, but it still
won’t tell us whether AIDS is a health, educational, political or moral issue.”29

The framework is built on a garbage can model of choice in which participants drift in and out
of decisions, no one person controls the process of choice, and fluctuating attendance,
opportunities and attention give the process highly dynamic and interactive qualities. Time is a
limiting factor:

• Number of issues under consideration by policymakers at any one time is limited

• Number of pet projects a policy entrepreneur will push for adoption will be quite limited
• Policymakers often do not have the luxury to taking their time to make decisions
because many issues vie for attention with a need to strike when the iron is hot.29

Systems can do many things in parallel such that problems, solutions and politics each can be
conceived as having a life of its own. The concept of ‘agenda setting’ receives particular
attention since not all issues are problems. They need to be perceived as a problem, which will
involve values and framing. The problem recognition stream involves agenda setting, as well as
fluctuation in attention given to changing issues. The policy stream includes many ideas in
competition to win acceptance. Technical feasibility and value acceptance increase the chance
of survival. Ideas that do not align with prevailing ideological currents or those that may be
sound but boring may not succeed.30 The politics stream is influenced by public mood, shifting
public opinion, pressure-group campaigns and administrative/legislative turnover.29

This framework posits that policy choices are made when the three streams are coupled or
joined together at critical moments in time and these are referred to as ‘windows of
opportunity’. Opportunities may occur spontaneously due to a specific event or the presence of
a new administration. The framework emphasizes the importance of policy entrepreneurs.
These “are individuals or corporate actors who attempt to couple the three streams.”29 When a
window opens, the policy entrepreneur must immediately seize the opportunity to initiate
action to attach problems to their solutions and find politicians receptive to their ideas.

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The framework does not assume a rational sequence. A window may open because of a
problem that requires a solution. It may also open in the politics stream that prefers a particular
solution that then searches for a problem to couple with. In such circumstances, “what matters
more is the solution to be adopted rather than the problem to be solved.”29 The coupling of
windows provides an opportunity, but not certitude for policy change.

Concern has been expressed regarding this framework that the streams are often not
independent with often the same people participating in problem identification and suggesting
solutions. However, proponents counter that “stream independence is a conceptual device. It
has the advantage of enabling researchers to uncover rather than assume rationality.”29 The
framework tends to not address issues of collective action and coordination among participants
and deals with institutions unsystematically.

Punctuated-Equilibrium Framework
This framework argues that policymaking is characterized by long periods of incremental
change punctuated by brief periods of major policy change. 24 The concept was initially
developed in palaeontology to explain sudden bursts of change in the fossil record interspersed
among longer-term minor changes.31 It has been since applied to policymaking as similar
patterns were observed.32 A range of factors have been identified to resist and encourage large
scale policy change (see Table 2).

Table 2: Factors Encouraging and Resisting Major Policy Change

Resist Policy Change Encourage Policy Change

• Policy entrepreneurs • Exogenous shock resulting in tipping point

• Courts and rule of law • Elected officials & legislative committees
• Policy monopolies • Wars
• Bounded but not comprehensible rationality • New technologies and scientific changes
• Lack of acceptance of new policy ideas • Radical economic change
• Fragmented political jurisdictions between and • Reformist mobilizations by interest groups and
among levels of government. coalitions opposed to policy monopolies

Source: adapted from Givel 2010.31

In recent descriptions, considerable attention is given to fashioning a new ‘policy image’ and to
exploit multiple policy venues.32 The theory has been recently criticized for not apparently
applying to a number of major policy areas in the U.S. despite widespread disturbance to the
system.31 These include Pacific Northwest forest policy, state tobacco policy, and federal auto
efficiency standards.

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Advocacy Coalition Framework
The Advocacy Coalition Framework (ACF) was developed to address highly challenging
problems in which there are substantial goal conflicts, important technical disputes and
multiple actors from several levels of government.33 The framework focuses on the interaction
within a policy subsystem of a small number of advocacy coalitions comprised of actors from a
variety of institutions sharing a set of policy beliefs.24 The ACF purposely avoids a linear
depiction of the policy process and was designed as an alternative to the stages heuristic.34

While the ACF assumes a central role of scientific and technical information in the policy
processes, the ACF identifies beliefs as the causal driver for political behaviour.34 The ACF
describes three tiers of beliefs:

• Deep core beliefs: broadest and most stable and predominantly normative
• Policy core beliefs: moderate scope and span the substantive and geographic breadth of
a policy subsystem – ideal for forming coalitions and coordinating activities among
members. While resistant to change but more likely to adjust in response to verification
and refutation from new experiences and information than deep core beliefs.
• Secondary beliefs: more substantively and geographically narrow in scope and more
empirically based – most likely to change over time.34

The following table provides a more detailed breakdown of these three levels of beliefs.

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Table 3: Advocacy Coalition Framework Structure of Belief Systems
Deep Core Policy Core Secondary Aspects
Defining Fundamental normative and Fundamental policy Instrumental decisions and
Characteristics ontological axioms positions concerning the information searches
basic strategies for achieving necessary to implement
core values within the policy core
subsystem
Scope Across all policy subsystems Subsystem-wide Usually only part of
subsystem
Susceptibility to Very difficult; akin to Difficult, but can occur if Moderately easy; this is the
Change religious conversion experience reveals serious topic of most administrative
anomalies and even legislative
policymaking
Illustrative • The nature of man (e.g., • Orientation on basic • Seriousness of specific
Components inherently evil vs socially value priorities aspects of the problem
redeemable) • Identification of groups in specific locales
• Relative priority of or other entities whose • Importance of various
various ultimate values welfare is of greatest causal linkages in
(e.g., freedom, security, concern different locales and
health) • Basic causes of the over time
• Basic criteria for problem • Most discussions
distributive justice: • Proper distribution of concerning
whose welfare counts? authority between administrative rules
Relative weights of self, government and market (e.g., budgetary
primary groups, all • Priority accorded to allocation)
people, future various policy • Information regarding
generations, non-human instruments (e.g., performance of specific
beings, etc. regulation, insurance, programs or institutions
• Sociocultural identity education)
(e.g., ethnicity, religion, • Method of financing
gender, profession)
35
Source: Breton et al., 2007.

The ACF assumes that policymaking in modern societies is so complex that participants must
specialize in order to be influential and that the vast majority of policy making occurs within
policy systems involving negotiations among specialists. The set of policy participants includes
not only legislators, agency officials and interest group leaders, but also researchers and
journalists writing in this area. It might also include judicial officials who regularly intervene in a
policy subsystem. The ACF assumes that policy participants hold strong beliefs and are
motivated to translate those beliefs into policy. Furthermore, the ACF assumes that
scientific/technical information plays an important role in modifying the beliefs of policy
participants and that researchers (scientists, policy analysts, consultants, etc.) are central
players.33 The use of evidence occurs within the context of advocacy coalitions and depends
upon how they use it to bolster their positions. Power and competition for power are critical to
explaining how research evidence is used and not used.

Figure 2 depicts the current flow diagram of the framework.

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Figure 2: 2007 Advocacy Coalition Framework Flow Diagram

Source: Weible et al., 2009.

The ACF continues to evolve since its first development. While the original framework identified
two causal pathways for major policy change, additional paths have been identified:

• External subsystem events resulting in shifts in the policy core attributes of the
subsystem. This may include broad changes in socioeconomic conditions, public opinion,
governing coalitions and other subsystems. These can foster change by shifting or
augmenting resources, tipping the power of coalitions, and changing beliefs.
• Internal subsystem events that indicate monumental failures of the policies and
behaviours of a dominant advocacy coalition. This directly questions the policy core
beliefs of the dominant coalition and confirms the policy core beliefs in minority
coalitions. A shift in critical resources such as public support and financial support may
result.
• Policy-oriented learning which is relatively enduring alternations of thought or
behavioural intentions that result from experience and/or new information and that are
concerned with the attainment or revision of policy objectives. Because of the rigidity of
belief systems, this learning primarily affects secondary beliefs.
• Negotiated agreements involving two or more coalitions. This includes the use of
professional forums that provide an institutional setting that allows coalitions to safely
negotiate, agree and implement agreements. Likelihood of change is affected by

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 presence of a hurting stalemate, effective leadership, consensus-based decision rules,
diverse funding, duration of process and commitment of members, a focus on empirical
issues, an emphasis on building trust, and lack of alternative venues.33,34

One concern raised in the literature is whether some public health issues such as obesity
prevention and physical activity may not easily reduce to a single policy sub-system. Another
concern is that institutions play a secondary role as targets of coalitions’ strategic behaviour.
Nevertheless, the ACF is a highly developed framework that has been usefully applied to public
health issues in which there are a small number of coalitions in conflict with highly divergent
perspectives.

Literature Review Question

The focus of this literature review is on the ‘policy analysis’ component of the conceptual
framework. The issue of evidence synthesis is well covered from a number of existing
sources.4,5 The ‘policy engagement strategies’ component cannot be addressed until the policy
analysis component is completed and will be addressed in the discussion section of this report
based on materials encountered during the literature scoping phase.

The literature review question is as follows:

“What policy process frameworks have been successfully applied to inform

understanding of and/or action on a public health-related public policy.”

P: public health-related public policy issue

I: application of a policy frameworki
C: nil
O: informed understanding of and/or action on issue

i
One or more of: Stages heuristic; Multiple Streams Framework; Advocacy Coalition Framework; Institutional
Analysis and Development Framework; Punctuated-Equilibrium Framework.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 13
Literature Search
Searches of the published and grey literatures were conducted in July 2012. Preliminary scans
of the literature were conducted to identify relevant studies and used to craft a more
comprehensive set of search terms. The search strategy included the following:

• Included years 2001 – 2012

• Indexed databases: Medline, Psychinfo; Global Health; Sociological Abstracts,
Healthstar, CINAHL
• Search terms (see Appendix 1)
• Grey literature: including public health sites and Internet search engine (Google)
• Contacting key informants that actively work in the area of public health-related public
policy.ii

Inclusion criteria for this review included the following:

a. Focussed on the application of one or more policy process frameworks of interest;

b. Focussed on a public health-related public policy issue; and,
c. Was a policy analysis case study in that it considers: content of the policy reform; actors
involved in the reform; processes contingent on developing and implementing change;
and, context within which policy is developed.36

Exclusion criteria included:

• Non-English language
• Political context substantially differing from Canadian context (e.g., developing country;
totalitarian regime)
• Books, book chapters and dissertations.

ii
Dr. Patrick Fafard (University of Ottawa); Dr. Michael Rachlis (University of Toronto); Professor Mark Exworthy
(University of London). An attempt was also made to contact Francois Benoit, the Director of the National
Collaborating Centre for Healthy Public Policy (NCCHPP), but summer vacation schedules did not allow for further
communication. However, a number of resources on the NCCHPP’s website were considered by this review.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 14
Relevance Assessment and Data Extraction
An initial assessment of the relevance of retrieved citations was conducted first by title and
then by abstract. If the relevance of the study was unclear from these two information sources,
the publication was retrieved for further assessment.

Information was captured for each included study regarding the nature of the policy issue,
context, and type of policy framework applied. An assessment was also made regarding the
extent the use of the model assisted understanding of the policy issue and/or action. Also
noted was whether the study provided any concrete guidance on how the policy framework
was applied.

Quality Assessment
Assessing the quality of studies is a key aspect of conducting a literature review. Inherently, all
of the included studies are qualitative in nature. As described by the UK Centre for Reviews and
Dissemination, there is a lack of consensus about quality assessment of such studies with
numerous existing tools, lack of agreement among different tools and different researchers,
and a lack of agreement as to how findings should be used.37 A Qualitative Review Form initially
developed by the Occupational Therapy Evidence-Based Practice Research Group at McMaster
University38 has been used previously at Peel Public Healthiii. While the focus of this project is
not on the effectiveness of an intervention applied in a clinical setting, the main features of the
tool appear to align with those of a 2008 literature review that assessed the health policy
analysis literature.9 Each of the items in the tool was scored equally with a maximum possible
score of 24.

Similar to the disagreement regarding quality assessment overall, there is also a lack of
consensus regarding the meaning and value of inter-rater reliability assessments.37
Nevertheless, a second reviewer assessed a random sample of included and excluded studies to
compare decisions on application of the inclusion/exclusion criteria. For the sample of included
studies, the second reviewer also applied the quality assessment tool.

iii
See Appendix 2 for a copy of the tool.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 15
RESULTS
Search and Quality Assessment
The search strategies produced three pools of citations for the relevance assessment:

i. Medline
ii. Other databases
iii. Cited references from retrieved studies identified in i. and ii. above, as well as
suggestions from contacted experts.

The grey literature search produced an unwieldly number of disparate responses that were not
useful. It did however, yield a website at the University of Denveriv that was potentially useful in
providing a list of applications of the Advocacy Coalition Framework. However, relevant
citations had already been identified from the indexed database searches.

As summarized in Figure 3, 376 records were identified in the searches of the indexed
databases. Of these, 63 full-text articles were retrieved for further assessment as were 25
additional studies identified from other sources. Overall, 21 studies met the selection criteria
for this review.

Figure 3: Overview of Systematic Search Process

iv
www.ucdenver.edu/academics/colleges/SPA/BuechnerInstitute/Centers/WOPPR/ACF/Pages/AdvocacyCoalitionApplications.a
spx

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 16
Common reasons for excluding studies included a focus on: health service design or funding,
clinical services, or broader health and social issues (e.g., human trafficking, housing co-ops).
Appendix 3 provides more detailed results from the search process.

Among the 21 studies that met the inclusion criteria, the average quality score was 10.8 out of
24, with a range of 4-19. The quality scores were limited for a variety of reasons. Many studies
did not describe their methodology very well. Lower quality studies tended to not describe the
sources of their data. In other studies that did provide this information, it was often unclear
how key informants were selected and their number was often arbitrary versus seeking
redundancy in the data. Quality control of data collection was not discussed in most studies.
The approach to data analysis also tended to be poorly described. With respect to the policy
analysis itself, many studies lacked sufficient description of the actors and setting to allow the
reader to fully understand the policy context. A final limitation of several studies was an only
superficial application of the policy framework.

For resource reasons, a single reviewer was relied upon to conduct this review. A random
sample of six included and six excluded studies were provided to a second reviewer blinded to
their inclusion status and quality assessment score. For the 12 studies, there was an initial rate
of agreement of 75% (9/12) for inclusion status. The items of disagreement raised two issues.
The first issue was how to address studies that did not identify their data sources, but
otherwise met the inclusion criteria. It was decided to include these studies since the purpose
of this review is to seek understanding of the application of the policy framework versus acting
upon the findings. These studies however, would score poorly on the quality assessment
related to sampling methodology.

The second issue was how to address studies that addressed a public health-related public
policy issue and mentioned a policy framework, but did not actually conduct a policy analysis.
Discussion of this issue led to providing explicit guidance in the inclusion criteria for this implicit
expectation.

For the six included studies that were quality assessed by both reviewers, the average
difference in scores was 3.5 points. For three of the studies, the quality assessment scores were
the same or differed by a single point. The remaining three studies had larger differences and
the reviewers’ scoring were compared. The score differences were predominantly due to
differences in judgement as to the adequacy of description of the policy actors and context, as
well as judgement regarding transferability of results. Following discussion of these studies,
adjustments of the quality scores for these studies was made.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 17
Types of Policy Frameworks and Issues
Table 4 summarizes the policy frameworks and policy issues addressed in the 21 included
studies. The Multiple Streams framework accounted for two thirds (14) of the studies with the
ACF the next most frequent with four studies. There were only two studies that used the
Punctuated Equilibrium framework and one study that used the IADF. No studies solely used
the Stages heuristic, although some studies used it as a narrative framework before utilizing
another framework for more detailed policy analysis.

A range of policy issues across the spectrum of public health practice were analyzed using the
frameworks including:

• Chronic disease prevention: tobacco control, physical activity, obesity, alcohol,

• Infectious diseases: global disease control, reporting of healthcare infections, drug
policy
• Healthy development: childhood health promotion, emergency contraception
• Environmental health: urban policy, health impact assessments
• Health inequities and social determinants of health.

Table 4: Summary of Public Health-Related Policy Issues to Which Selected Policy Frameworks
Have Been Applied
Policy Framework Number Policy Issue Average
Quality Score
(max 24)
Stages heuristic 0 Note: some studies used this framework to organize
the descriptive analysis before applying a policy -
framework
Institutional analysis and 1 • Tobacco control in hospitals 4
development framework
(IADF)
Multiple streams 14 • Physical activity in schools (3)
framework • Tobacco control (2)
• Health inequalities/social determinants (2)
• Health Impact Assessment (2)
• Urban policy
• Alcohol policy 11.6
• Obesity
• Reporting of healthcare infections
• Childhood health promotion
Punctuated-equilibrium 2 • Global disease control priorities 7.5
framework • State tobacco policy
Advocacy coalition 4 • Tobacco control (2)
framework (ACF) • Emergency contraception 11.3
• Drug policy

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 18
Summary of Included Studies
Appendix 4 provides a summary of the included studies clustered by the type of framework
used. For each case study, the Appendix describes key findings, the extent to which the study’s
use of the framework assists understanding of the policy issue and the quality assessment
score.

Stages Heuristic
There were no studies that meeting the inclusion criteria that relied on the stages heuristic for
their analysis. One study that applied the Multiple Streams framework utilized the stages
heuristic to provide a detailed narrative of the evolution of the policy for Health Impact
Assessment in Sweden.39 Use of the stages heuristic as a descriptive framework appears useful
in understanding where a policy came from, how it developed and was implemented, which is
key descriptive information for subsequent analysis.

A Swedish study by Guldbrandsson and Fossom applying the Multiple Streams framework for
childhood health promotion initiatives conducted its preliminary descriptive analysis using a
two-dimensional matrix.40 One dimension was the stages heuristic and the other used an
actor/structural framework (context, institution, actor, performance). The content of the
published article, however, did not provide data organized by the stages heuristic. The
‘performance’ item is not typical of policy analysis but was added by the authors “to detect if
any municipal health promoting measure was empty talk rather than real action.”40

Institutional Analysis and Development Framework

Only one study used the IADF in studying the implementation of tobacco control policies in
hospitals in Spain.41 Overall, the study was methodologically weak and had the lowest quality
score reviewed in this review. The superficial use of the IADF did not appear to provide any
added value to the study’s analysis.

Punctuated Equilibrium Framework

The two studies applying the Punctuated Equilibrium framework were both relatively weak.
One of these studies addressed state tobacco policies42 and the other the emergence of global
disease control priorities.43 In neither instance did the applied framework seem to improve
understanding of what policy changes had or had not occurred. The reviewer’s impression for
both studies is that a different framework may have been preferable for the analysis. For
example, for the state tobacco control study, the ACF may have been a better choice since the
‘policy story’ was essentially one of the balance of power between the tobacco industry and
tobacco control proponents. For the global disease control priorities study, the Multiple
Streams framework may have been a better choice since there appeared to be constant
fluctuation in a range of infectious disease problems, what could be done about them, and the
perception of key decision makers until the three streams aligned and action was taken.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 19
The main point of the Punctuated Equilibrium framework is that a large shock can generate
policy change, unless, as in the case of the tobacco study, it does not generate change. The
framework does not appear to assist understanding of why change did or did not occur. In
contrast, both the ACF and Multiple Streams frameworks acknowledge the importance of large
system shocks to spur change and provide explanatory mechanisms. The ACF considers large
shocks as an opportunity for shifts in the balance of power among coalitions. The Multiple
Streams framework views shocks as an opportunity for coupling of the streams with changes in
how problems are perceived, solutions considered to be feasible, and/or shifts in public mood
or legislative/administrative changes.

Multiple Streams Framework

The majority of reviewed studies applied the Multiple Streams framework across the range of
domains of public health practice. The quality of studies varied markedly with scores ranging
from 4-19 out of 24. The quality score was not necessarily predictive of the useful application of
a framework to improve the understanding of the policy issue since the quality assessment tool
focuses primarily on the methodological rigor of studies.

While the Multiple Streams framework was the most commonly encountered framework in the
included studies, it did not always appear to have been the best choice for the topic under
consideration. For example, some studies were addressing circumstances in which there were
two or more groups with strong core beliefs that were in competition for political dominance.
In such circumstances, the ACF may have been a more appropriate choice. Examples include
the introduction of smoke-free legislation in a tobacco-growing county44 and the power issues
between public health and the alcohol industry regarding national alcohol control policies.45
Proponents of the Multiple Streams framework indicate that the framework is most useful for
ambiguous situations in which there is a lack of clarity regarding the nature of the problem
and/or policy solutions. Those case studies where the framework was most useful for
understanding the policy issue are described here in greater detail.

Three case studies from different countries applied the Multiple Streams framework to
examine physical activity policies for schools. Figure 4 illustrates the ambiguity that was
experienced in these studies regarding the framing of the problem, the types of solutions
proposed, and the extent of political interest.

The nature of the problem could be viewed in a variety of ways by different actors. Some actors
viewed it from a general health and well-being perspective where increased physical activity
leads to improved mental health and physical health, including reducing the risk of obesity.
Others however, were particularly interested in participation in sports and the need to support
this to occur. Those in the educational sector were particularly interested in the potential for

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 20
physical activity to improve academic performance and address behavioural issues, and less
interested in health-based perspectives.

Figure 4: Aligning the Streams for Increasing Physical Activity in Schools

46
Based on information from Gladwin et al., 2008.

Uncertainty also existed regarding how best to tackle the problem. A range of potential
solutions are possible including increasing physical activity throughout the school day. This
might also consider active transportation options for how children get to and from school.
Another approach is to mandate daily physical education within the curriculum. Building and
supporting sports infrastructure is yet another approach. As these solutions float around
waiting to be coupled to other streams, some solutions will be less attractive than others. From
a provincial or national perspective, active transportation as a policy solution is problematic
because it requires a tailored approach to each community/school and is not feasible for all
students. It also raises traffic safety concerns, and because it occurs outside of the curriculum,
education officials are less likely to be engaged on the issue. The framing of active
transportation can include its contribution to addressing other problems such as air pollution
and thereby is a way to engage other stakeholders. However, it also risks fragmenting the
description of the problem and provides a solution not salient to some key decision makers
(i.e., air pollution not considered a problem of the education sector). In contrast, physical
education is something to which schools have been familiar with for years.

The political stream is important in determining which solutions and associated problems may
receive attention. In the two case studies from Alberta and England, there was strong political

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 21
interest in taking action. In the third case study from Scotland, there was much weaker political
interest for this policy area with Ministers publicly articulating how they had disliked physical
education as students. This was identified as one of the reasons for the lack of successful policy
change in that country.47

The Multiple Streams framework highlights the importance of a policy entrepreneur to take
advantage of windows of opportunity to couple the streams. In both Alberta and England,
entrepreneurs existed and seemed to be particularly important in engaging the education
sector who were otherwise not enthused to address a health issue. In Alberta, it was the
Minister of Learning, who was a physician with personal beliefs about the benefits of physical
activity, who utilized his position as minister to actively seek a daily physical activity policy for
schools.46 He highlighted the benefits for educators based on the research evidence that daily
physical activity improves educational outcomes. In England, a non-political adviser to
government on school sport and physical education served as the entrepreneur. The case
study’s analysis indicated that “she managed to persuade civil servants and ministers of the
potential value of physical education and school sport, despite initial departmental scepticism…
[She] articulated an alternative view of school sport and physical education and skilfully
positioned it as particularly relevant to the government’s broader social and educational
objectives.”48

Analysis from both locations noted the lack of effective lobbying. In Alberta, proponents for
active transportation policies were locally based and relatively weak and unorganized. In
England, there was an absence of effective lobbying due to fragmentation among stakeholders
and their reluctance to define their objectives in terms of government priorities. The English
case study also noted the value of the steady accumulation of evidence that was persuasive to
more sceptical politicians and senior civil servants in the education sector.

Despite the success in policy adoption, one of the deficiencies in policy initiatives in Alberta and
England was the lack of attention to implementation. In Alberta, while the daily physical activity
policy was enacted, no funding for facilities or equipment was provided. In England, some key
informants expressed concern regarding the extent of change in schools, particularly in
elementary schools in which teachers were viewed to be less well prepared to teach physical
education than 20 years previously. Neither study addressed the actual implementation of the
policies.

The Multiple Streams framework was also usefully applied by Exworthy, Blane and Marmot to
identify the challenges of tackling health inequalities in the UK (see Figure 5).49 The authors
noted that considerable progress has been made through a series of landmark reports in
establishing health inequalities as a policy problem. However, the policy solution stream is
more problematic since evidence about the technical feasibility of policies remains limited.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 22
Acceptability of policies is also unclear since the authors’ perspective is that it barely registers
as a public issue. Within the politics stream, it is unclear whether a critical mass of civil servants
and Ministers across government exists that is committed to tackling health inequalities. Their
overall impression is that the policy window is partially open and the authors identify a number
of factors that will encourage its closure or opening.

Figure 5: Application of the Multiple Streams Framework to Health Inequalities in the UK

Series of landmark reports to establish issue of

health inequalities as a problem (e.g., Black
Problem Report, Acheson Report, Marmot)

E.g., UK
Technical feasibility, including demonstration Alignment?
of effectiveness, of policies remain limited Streams are somewhat aligned
Complex because often cross typical Potential Role with window partially open.
Policy government silos for a Number of factors could favour
Difficult to measure and attribute outcomes Policy window opening or closing further
Acceptability? (barely registers as public issue) Entrepreneur in future.

Government stated commitment to address

problem and initiation of some policies
Unclear whether critical mass of civil servants
Politics and Ministers across government exist to
tackle inequalities
Long time horizon for impacts does not align
with political terms
49
Based on information from Exworthy et al., 2003.

A case study from Arkansas illustrates the application of the framework for the passage of
childhood obesity legislation.50 Figure 6 shows key points within each stream. Gradual progress
over a period of years was occurring in each of the three streams. The Speaker of the House, as
a policy entrepreneur, personally intervened requesting that public health officials draft
legislation for a school-based policy to reduce childhood obesity. He furthermore personally
advocated for passage of the bill. The public health professionals not only drafted the
legislation, but had been providing information and raising awareness through the preceding
years until the streams converged. The legislation that was passed included six components:

• Child Health Advisory Committee created to make recommendations to State Board of

Education and Board of Health regarding physical activity and nutrition standards for
schools
• Nutrition and Physical Activity Committees established in each school district to guide
locally policies and programs
• Statewide school-based BMI screening with reports to parents

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 23
 • Restrict student access to vending machines in elementary schools and disclosure of
vending contracts and revenues
• Employ community health promotion specialists to provide technical assistance to
schools in formulating and implementing the rules and regulations.50

Figure 6: Multiple Stream-Based Analysis of the Development of Obesity Legislation in

Arkansas

Based on information from Craig et al., 2010.50

In summary, the Multiple Streams framework has been frequently applied to a range of public
health issues and appears to be useful in assessing the alignment of the problem, policy and
politics streams, and the value of a policy entrepreneur to actively couple the streams.

Advocacy Coalition Framework

The ACF was utilized in a total of four case studies. However, as previously indicated, the ACF
would have been a more useful framework for some of the studies applying other frameworks.
The best application of the ACF occurred in the two tobacco-related case studies from Quebec;
both of which were among higher quality studies in this review. The simplified version of the
ACF used by the authors is shown in Figure 7. Key features include identifying relatively stable
parameters, as well as external events that have the potential to influence the balance of
power among the coalitions. The key feature of the framework is weighing the beliefs,
resources and strategy of the coalitions.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 24
Figure 7: Simplified ACF Model

51
Source: Breton et al., 2008.

The authors use the ACF to analyze two time periods for tobacco policy in Quebec. The first is
the consideration of rolling back tobacco taxes in 1994 in response to a widespread increase in
contraband tobacco. Figure 8 provides their analysis using the ACF.

Figure 8: ACF-Based Analysis of 2004 Tobacco-Tax Rollback in Quebec

52
Source: Breton et al., 2006.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 25
The analysis indicates that the external events influencing the tobacco policy subsystem were a
steep rise in tobacco contraband activities and upcoming provincial elections in which public
opinion backs a tax rollback. Analysis of the two coalitions indicates the relative weakness of
the anti-tobacco coalition with low levels of organization and resources, reliance on a health-
based rationale and negative media coverage. In contrast, the promoters of the tobacco tax
rollback, which included local retailers and tobacco industry employers, had a well financed and
structured media campaign that framed the debate and focussed on economic arguments. Of
note, the health effects of tobacco were considered to be non-debatable and are therefore
included within the stable parameters domain. The prevailing perspective was that the
government could legitimately intervene on tobacco as long as it did not impact the economy
or employment within the province. The net result was the provincial government cut tobacco
taxes. However, a partial victory for public health occurred since the government also
established a tobacco control action plan that provided new tobacco control resources to public
health. This appears to have laid the foundation for the next stage.

As shown in Figure 9, within a few years, the policy context had changed. As per their nature,
the relatively stable parameters remained unchanged. However, several new external events
(to the subsystem) were in play. These included a steep increase in tobacco use in youth, the
election of a new government with a Minister of Health interested in tobacco control measures,
and new insights into tobacco industry practices from disclosures in court cases in the US.
When considered against the two advocacy coalitions, these events weakened the relative
strength of the pro-tobacco coalition and provided an opportunity for the tobacco-control
coalition. Learning from their previous experience, and taking advantage of their increase in
resources, public health had increased their tobacco control expertise and realized the need to
address the economic arguments of their opponents. For this reason and the highly negative
media coverage they had previously endured, public health organizations created a buffer by
contributing to the establishment of a NGO to advocate on their behalf.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 26
The net result was passage by the government of a comprehensive Tobacco Act.

Figure 9: ACF-Based Analysis of 2008 Decision to Implement Tobacco Act in Quebec

Relatively Stable Parameters Constraints and Resources Tobacco Policy Subsystem - 1998
Tobacco use entails substantial The lethality (for smokers) and
health risk for smokers addictive properties of tobacco can
Youth smoking is a problem hardly be contested Anti-tobacco coalition Opponents to tobacco control
A smoke-free environment is a The legitimacy of the province in measures
right tobacco control is difficult to challenge Increased resources available for
as long as it does not impact on the intervening in policy debate including As dubious conduct of the tobacco
Provincial government
economy expertise on advocacy and tobacco manufacturers during the contraband
intervention on tobacco is industry. Organizing and coordinating
Some local public health organizations crisis come under the limelight, they
legitimate as long as it does not resources based on past experience
acquiring expertise to address lost most of their credibility in the
impact on the economy of the environmental determinants of Constituency somewhat inflated to debate
province and employment tobacco use encompass representatives from Arguments against the Tobacco Act
With previous negative media healthcare and NGOs promoting sports almost exclusively centred on
coverage, public health organizations Advocacy rational encompasses not economic arguments (loss of
create a non-governmental only public health issues but economic manufacturing jobs and revenue for
organization for advocacy efforts – ones as well. For fear of engendering sports and cultural events relying on
particularly on non-health (economic) another tax debate, hardly address tobacco industry sponsorship)
concerns fiscal measures as a means to control
External Events tobacco use.
Tax rollback and resulting increase in
youth smoking have led to major
Election of a new provincial increases in provincial and regional Key Messages:
government with a new Minister of tobacco control budgets and to calls Prevalence of youth smoking has Key Messages:
Health advocating tobacco control for new tobacco control measures increased Only health education and the
measures An anti-tobacco advocate takes office There are effective measures to prohibition of the sale of tobacco
Steep increase in tobacco as the new Minister of Health and control tobacco use products work
tables a tobacco control bill There is a solution to alleviate the The tobacco control measures will
prevalence in youth
The federal restrictions on the impact of the Act on tobacco- have a huge impact on the economy of
Numerous instances elsewhere in sponsored events
Canada and abroad of successful promotion of tobacco products being the province
neutralized, the provincial government The tobacco industry is deceitful
implementation of tobacco control The population backs the measures
can now legitimately intervene in this
measures area
US administration proposed set of Readily available evidence that
measures to tackle youth smoking tobacco control measures are
Trials in US with disclosure of applicable, common sense and do not
confidential strategic documents harm the economy Government implements Tobacco Act as a means to tackle
from the tobacco industry The tobacco industry lies and deceives the high prevalence of youth tobacco use

52
Adapted from material presented in Breton et al., 2006 and Breton et al., 2008.51

In summary, the ACF appears to be useful in breaking down a complex policy situation where
there are two or more coalitions advocating for political dominance into a series of domains to
aid understanding.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 27
DISCUSSION
The intent of this project was to seek a greater understanding of the policy process related to
public health issues in order to inform the policy development processes at Peel Public Health.
A total of 21 case studies were retrieved applying one of the five policy analysis frameworks of
interest to a range of public health-related policies. While it is possible that additional case
studies may exist within the literature, this report represents the most comprehensive review
of published analyses of public health related public policies.

The overall quality of included studies was only moderate with many studies not addressing a
number of important methodological considerations. This is not dissimilar to a previous review
of policy analysis studies in low and middle income countries published in 2008 observing that
studies were “largely descriptive in nature, limiting understanding of policy change processes.”9
A previous review of the application of policy process frameworks in health promotion had
observed that many studies were atheoretical or utilized inappropriate types of frameworks.17
Since studies using specific policy frameworks was part of the selection process, this review
cannot comment on whether the proportion of studies using policy frameworks is changing.
Nevertheless, there is an accumulating body of literature applying such frameworks to public
health-related issues.

As indicated by previously noted commentary on the quality assessment of qualitative studies,

the quality assessment step was not straight forward. The quality assessment tool used in this
review had been previously used by Peel Public Health. Since it was originally developed for use
by a clinical service, some questions were oriented towards ‘participants’ and ‘study site’,
whereas for a policy case study, ‘actors’ and ‘context’ are more appropriate. Despite the
presence of a guidance document, considerable judgement was required in applying aspects of
the tool and was the source of scoring differences between the two reviewers.

The inter-rater differences in quality assessments have implications for the future conduct of
reviews of qualitative studies. Tailoring the selection of the tool to the nature of the studies
may be of assistance. Since the purpose of this review is on seeking understanding regarding
the application of policy frameworks versus directly applying the results of the analysis, the
quality scores are relatively less important. However, the quality assessment highlighted a
series of methodological gaps in many policy analyses that can be addressed in the application
of the frameworks at Peel Public Health in the future.

The reviewed case studies indicate that existing policy frameworks can assist with the
understanding of the policy process. While the descriptions of policymaking reinforce the sense
that the black box of policymaking is complex, chaotic and unpredictable with many factors

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 28
influencing policy decisions, at least two of the policy frameworks showed that they could
contribute to understanding the policy process.

There were indications in many of the case studies regarding the use of evidence. It tended to
play a supporting role and did not appear to be a primary or sufficient driver in any of the
studies. Nevertheless, public health officials and/or the use of evidence were key factors in
many studies. This included the use of evidence to achieve recognition of a problem (i.e.,
agenda setting), to refute opposing group’s messages, and to win over reluctant stakeholders.

A key learning from this review is the importance of conducting a policy analysis in two stages.
The first stage is descriptive in nature and needs to achieve a sufficient understanding of the
current status of the policy issue and the history of its development, as well as the various
actors and the policy context. When studies provided this descriptive analysis, it was much
easier to understand and apply the policy framework as part of the explanatory analysis.
Several studies tried to utilize one of the policy frameworks prematurely without providing a
sufficient understanding of the key elements resulting in a superficial and inadequate policy
analysis product.

The most frequently applied and useful policy process frameworks that fostered understanding
of the policy process were the Multiple Streams framework and ACF. These frameworks appear
to be complimentary having different strengths depending upon the type of issue and the
policy context. In general, the Multiple Streams framework is particularly useful for ambiguous
problems that are competing for attention with many other issues and for which solutions are
not clear. Encountered examples include the government response to obesity or health
inequalities.

In contrast, the ACF is particularly useful where two or more coalitions are competing on an
issue to have their positions be politically dominant (i.e., accepted, resourced, supported, etc.).
These coalitions are often based on differing strongly held core beliefs. Encountered examples
included drug policy (abstinence vs. harm reduction), tobacco control policy (individual choice
and economic benefit vs. health of the public), and emergency contraception (anti-abortion vs.
woman’s choice and health).

The implication is that deciding which framework to initially apply should be driven by the
nature of the issue and context. While not encountered in this set of case studies, there may be
circumstances in which both of these frameworks may provide complementary perspectives on
an issue. The study of school sport and physical education policy in England had intended to
apply both the Multiple Streams and Advocacy Coalition Framework. However, due to the
absence of effective coalitions, the latter was not particularly helpful.48

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 29
The case studies utilizing the other two policy process frameworks did not provide convincing
evidence for their usefulness. Nevertheless, these frameworks provide concepts that may be
useful to an analysis. For example, the IADF indicates that analysis should be conducted at
multiple system levels. In other words, whether the interaction between actors, institutions,
and content varies among local, provincial and national levels. With respect to the Punctuated
Equilibrium framework, it indicates that consideration should be given to noting whether or not
any major factors have or could occur that may encourage policy change.

Overall, the case studies indicated that the policy frameworks are suited to the study of policy,
but do not directly identify the actions for policy. In other words, they help to understand a
policy situation regarding what has happened, but not necessarily how to influence it. This is
consistent with our initial conceptual framework that separated out the steps of policy analysis
and policy engagement. The latter is not the focus of this literature review, but will be touched
upon later in this report.

Implications for Policy Analysis by Public Health Organizations

As shown earlier in the conceptual framework in Figure 1, prior to conducting a policy analysis,
public health staff should have an understanding of the issue and the existing state of evidence
for effective interventions. At a minimum, this would involve checking the latest available
health status information, retrieving a recent high quality literature review, and prioritizing
available policy options. Several existing resources address these steps and additional
considerations.

Once there is clarity of the nature of the problem, effective solutions and an identified policy
issue of interest, the next step is the policy analysis work, which should be divided into two
parts:

a. Descriptive analysis
b. Explanatory analysis.

Descriptive Analysis
The importance of conducting the descriptive analysis is that it provides the material for use in
the explanatory analysis. A variety of approaches to conducting the descriptive analysis appear
in the literature because there are different dimensions that need to be addressed. The case
studies that provided a narrative of the development of a policy were particularly helpful in
‘telling the story’ of where and how the policy issue emerged, how it has developed, and its
current status. To this end, the stages heuristic appears to be a useful tool to break down the
policy process into different stages or categories recognizing that policy processes do not follow
a clean linear process. The use of this framework is as a descriptive, and not explanatory, tool.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 30
Different sources use slightly different numbers and labels for the stages. Nevertheless, the use
of five stages is common:

• Agenda Setting: how have problems been recognized and received attention; how have
they been framed
• Policy Formulation: how were policy options considered and decided upon, how were
they communicated
• Policy Adoption: what decision was made
• Policy Implementation: what rules and procedures were established to implement the
policy; to what extent were they aligned with the initial intentions of the policy
• Policy Assessment: what has been the impact of the policy, how is it monitored, has it
achieved its objectives, are there unintended consequences.

Following this grounding in what has happened, more information is required to examine
several dimensions of the policy process. This includes:

• Actors: may be individuals or groups or organizations; who are the key actors, what are
their beliefs, their interests, and their influence (i.e., power)
• Context: what systematic factors (political, economic, social, other) have/may affect the
policy; are there external events that may influence or shock the policy context
• Institutions: what rules or norms are there for policy processes; what differences in
perspectives may there be by system level (local, provincial, national, international).

It should be noted that different authors have slightly different ways of lumping and splitting
these concepts. For example, the policy analysis triangle by Walt and Gilson includes content,
context and process with actors in the middle of the triangle.36 Several authors refer to the ‘3
I’s’ of ideas, interests and institutions. Ideas are the mental constructions and beliefs of policy
actors, while institutions are the rules, procedures and organizations that structure conduct.
Interests are what actors have at stake or are affected by an issue.53,54 Regardless of how these
inter-dependent concepts are labelled, a framework needs to be applied to seek explanation of
the policy process.

One additional integrative approach is worth noting. In the case study of childhood health
promotion initiatives in Sweden, the authors combined the stages heuristic with the
actor/structure elements generating a two-dimensional matrix for data collection and
organization.40 Since the authors did not provide the completed matrix, it is unclear whether it
would be useful to do so versus just having a listing of the completed elements. Applying the
proposed approach with real policy examples will help indicate which tools are most useful for
the public health context. For example, this could include piloting with staff separate and
combined templates of the stages heuristic and actor/context dimensions to assess what is
preferred.
Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 31
Explanatory Analysis
Once the raw material is available from the descriptive analysis, one or more of the policy
process frameworks can be used to seek greater understanding of what has or is occurring. This
literature review has found that the Multiple Stream framework and ACF have been most
useful for a range of public health-related policies. The one to start with depends upon the
issue and context. Since the two frameworks are complementary, an attempt at applying the
other framework should occur. Key concepts from the other two policy process frameworks
have been embedded within the descriptive analysis (i.e., looking for a major external event
that could shock the policy context (Punctuated Equilibrium) and the role of rules and norms,
and system levels (IADF)).

Application of the MS framework needs to consider:

• Problem stream: extent the issue is perceived to be a problem; how it is framed; extent
of attention it is receiving as it competes against other problems
• Policy/solution stream: technical feasibility; value acceptance; alignment with prevailing
currents; creates interest
• Politics stream: what is the public mood; influence of pressure-groups; administrative
change; legislative turnover
• Alignment of the streams: is there a window of opportunity
• Policy entrepreneur: is there someone influential that can couple the streams.

Application of the ACF needs to consider:

• Stable parameters: factors that do not change for a generation or more; e.g.,
constitution, economic system, well-established facts that are beyond debate (e.g.,
smoking causes cancer)
• Dynamic/new factors: external factors that may alter the policy environment e.g.,
business cycle, election, new disease (e.g., AIDS), new information (e.g., proof of
tobacco industry deception)
• Coalitions: what are the coalitions, what are their values, beliefs, interests, resources,
and strategies
• Information: how is information being used; what are the sources.

The application of one or both of these frameworks involves a mix of science and art. The latter
is hypothesizing how the different domains are interacting to produce the observed result. The
next section involves taking the next step of seeking to influence the policy.

Implications for Policy Engagement

The preceding explanatory analysis involved the creation of hypotheses to explain the policy
process. Prospective analysis involves an even greater use of hypotheses to attempt to leverage
the existing understanding to identify what may or may not happen depending upon what

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 32
interventions or changes occur. To a large degree, the reviewed case studies focussed on
analyzing what had happened versus attempting to look forward to what might happen,
although some authors made high level suggestions regarding factors that may help create
policy change. This relative lack of prospective analysis does not appear to be unique for public
health related policies. According to Buse, there are few accounts in the overall policy literature
of prospective policy analysis.20

While not the focus of this review, the initial literature scoping identified a variety of tools and
checklists to aid in policy engagement strategies that will be noted recognizing that that this
area requires more in-depth information collection and analysis.

Public health authors tend to focus on the use of information and evidence. For example,
Benoit identifies possible public health roles depending upon the stage of the policy cycle (see
Table 5).

Table 5: Possible Public Health Roles for Stages in the Policy Cycle
Stage Description Public Health Role
Agenda Setting Problems are recognized and Problem structuring. Challenge assumptions underlying
discussed definition of problems. Influence what types of
evidence are used to look at the problem.
Policy Formulation Policy options (alternatives) are Forecasting. Determine the consequences of existing or
considered and evaluated proposed policies.
Policy Adoption A decision is made Recommendations. Reveals information and identifies
future benefits and costs under all policy scenarios
through information generated via forecasting.
Policy Rules and procedures are set out Monitoring. Provides information about the
Implementation consequences of previously adopted policies.
Policy Assessment Policy is evaluated, revised or Evaluation. Reveals discrepancies between expected
even terminated and actual performance.
19
From: Benoit, 2008.

Similarly, Lavis describes how systematic reviews addressing different types of questions can be
used to influence policymaking at different stages.4 Furthermore, engagement strategies such
as deliberative dialogues with decision makers can be employed in some situations to
encourage the transfer of information from researchers/practitioners to policymakers.6

There are many more options within public health’s policy engagement repertoire. These
include the establishment of community partnerships and coalitions, media advocacy,
community mobilization, and providing technical support and resources to community groups.
While not necessarily all applicable to public health action, Buse et al provide a more
comprehensive categorization of political strategies for policy change to shift position, power,
players, or perception (the 4 ‘P’s):

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 33
Position strategies – in general this is about changing the content of the proposed policy so that
it is more closely aligned to the interests of the some of the players:
• Making a deal with those in opposition or neutral to make them more supportive or less
opposed by altering a particular component of the policy
• Deals can be struck through which support is sought for one issue in return for concessions
on another
• Promises can be made
• Threats can be made

Power strategies – can be used to affect the distribution of political assets of the players
involved to strengthen supportive groups and undermine opposition groups:
• Providing supportive actors with:
o Funds, personnel and facilities
o Information to increase expertise
o Access to decision makers and the media
o Links to supportive networks
o Public relations materials which highlights supportive actors’ expertise, legitimacy,
victim status or heroic nature
• Limiting political resources of opponents by:
o Challenging their legitimacy, expertise, integrity or motives
o Reduce their access to decision makers
o Refuse to cooperate or share information with them or withhold information

Player strategies – attempt to impact the number of actors involved in a policy area:
• Mobilize those that are neutral (e.g., inform a group that an item is on agenda and what
their stake in the issue is)
• Undermine opponents (e.g., identify a sub-group within the larger group that might benefit
from your proposal and attempt to win them to your side)
• Change the venue of decision making

Perception strategies – use the force of ideas and the perceptions of a problem and its solution
• Use data and arguments regarding the relative importance of a problem or the practicality
of a policy solution
• Frame the problem in a manner to gain support (e.g., preventing congenital syphilis as
something inflicted on innocent infants versus treating mothers with sexually transmitted
diseases, which may raise moral challenges)
• Appeal to prevailing values – e.g., appealing to fairness and equity by comparison to other
issues/conditions
• Invoke symbols to change perceptions – e.g., use of celebrities, brand the initiative.55

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 34
The University of Kansas’ Community Tool Box applies a more pragmatic and process-oriented
approach providing a tool to influence policy development. High level categories include the
following with more detail available within the resource:

1. State why a policy needs to be developed or modified

2. Study the issue or problem a policy change would affect
3. Based on knowledge about the issue or problem and who it affects, indicate the type and
context of policies to be developed
4. State what your group will do to influence each of the stages of policy development (e.g.,
agenda setting)
5. Identify resources and assets to be used for policy development
6. Indicate potential allies and opponents of policy development efforts
7. Identify targets and agents of policy change efforts and their assets and interests.
8. Depending on the broad goal of your policy development efforts (see #3), choose the
strategies and action plan to be used
9. Review whether the planned policy goals, strategies and actions fit the situation
10. Create an action plan to carry out your policy efforts (who is going to do what by when)
11. Influence the adoption of a policy or how it will be implemented
12. Assess the evaluation of the policy development effort
13. (As appropriate) State the circumstances under which you will close out the policy
development effort.56

In contrast, Catfield focuses on generating political will for health promotion efforts:

• Issue:
o Vital that the intervention is seen to be responding to a perceived problem
o There needs to be a strong constituency of support both inside and outside
government advocating for the measure
o Need to give confidence that the intervention is possible and realistic
• Source:
o Advocates need to demonstrate their own credibility and status with community,
politicians and government – knowledgeable, legitimate and trustworthy?
• Benefits:
o Provide solutions, not more problems
o Create multiple ‘wins’ for different stakeholders
o Emphasize the consequences and risks from not acting are worse
• Timing:
o Build on existing policies and political ‘entry points’ that have already been agreed
o Place issues on political agenda before an election so can be included in policy
platforms
o Avoid major funding requests midway through term
• Methods:
o Develop supportive and constructive relationships – show empathy and realism

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 35
 o Show enthusiasm and commitment
o Use media creatively.16

In summary, Catfield’s five ‘P’s include:

• Position: what are you seeking; when do you want it to happen

• Perception: How does this fit within current context? What are the benefits?
• Players: Who are you? What credibility do you have? How united are you?
• Power: What resources and influence do you have to influence the agenda?
• Persistence: How determined are you? Will you stay the course?16

And finally, focussing on developing a policy strategic plan, Hoover outlines the following steps:

1. Who can make the change (city council, planning board, business owner)?
2. Who influences their decisions?
3. Why should this change be made?
4. What kinds of data and other information are needed?
5. What are arguments in favor? Against?
6. Who is likely to oppose?
7. How can you counter their arguments?
8. Do you have a media plan?
9. What actions will be taken?
10. Who will do them?
11. When?57

As indicated, the foregoing is a sample of existing tools to help inform action on public policy.
The source documents for these lists provide considerably more guidance.

Summary
Building on this review’s conceptual framework, it is envisioned that an evidence-informed
process to understand and influence public health-related public policies would involve several
inter-related components (see Figure 10).

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 36
Figure 10: Updated Conceptual Framework for an Evidence-Informed Approach to
Understanding and Influencing Public Policy

Interest in conducting a policy analysis will presumably be driven by the knowledge of a

particular health issue, existing evidence, and a particular policy area for further exploration.
Then one can proceed on conducting a descriptive analysis, which provides the raw material for
conducting the explanatory analysis. That understanding can then be leveraged to conduct a
prospective analysis to hypothesize potential opportunities for influencing the policy
environment. These can then be initiated and the impact monitored.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 37
CONCLUSION
This literature review sought, retrieved and reviewed the application of prominent policy
process frameworks to public health-related issues. A total of 21 case studies were reviewed
indicating that these policy frameworks can facilitate understanding of the process for public
policy. Based on the findings of this review, a suggested approach is provided for conducting
policy analysis in a systematic way by a public health organization. The findings of this analysis
can then be used to inform subsequent policy engagement strategies.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 38
GLOSSARY

Actor: any participant in the policy process that affects policy including individuals,
organizations, groups and even the government

Advocacy coalition: group within a policy sub-system distinguished by a shared set of norms,
beliefs and resources. Can include politicians, civil servants, members of interest groups,
journalists and academics who share ideas about policy goals and to a lesser extent about
solutions.

Agenda setting: process by which certain issues come onto the policy agenda from the much
larger number of issues potentially worthy of attention by policy makers.

Context: systematic factors which may have an effect on health policy, e.g., political, economic,
social or cultural.

Evidence: any form of knowledge, including but not confined to research, of sufficient quality to
be used to inform decisions.

Evidence-informed policy: movement within public policy to give evidence greater weight in
shaping policy decisions. ‘Evidence-informed’ more appropriate to ‘evidence-based’ since
evidence is only one factor influencing decision making.

Institutions: the ‘rules of the game’ determining how government and the wider state operate.
May be formal structures and procedures, but also informal norms of behaviour that may not
be written down

Policy formulation: how policies are arrived at, agreed upon and how they are communicated

Policy implementation: how policies are implemented and the extent of any diversion or
change from how formulated

Policy assessment: what happens once a policy is put into effect – how it is monitored, whether
it achieves its objectives and whether it has unintended consequences.

Power: the ability to influence people and in particular, to control resources to achieve a
desired outcome

From Buse, Mays and Galt, 201255

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 39
APPENDIX 1 – SEARCH STRATEGY
The following is the search strategy used for Medline:

1 stages.tw. (224983)
2 heuristic.tw. (3927)
3 1 or 2 (228846)
4 policy.tw. (89422)
5 3 and 4 (1024)
6 brewer.tw. (277)
7 deLeon.tw. (19)
8 6 or 7 (296)
9 5 and 8 (0)
10 policy.ti. (23968)
11 5 and 10 (141)
12 ostrom.tw. (7)
13 institutional analysis.tw. (151)
14 iad.tw. (451)
15 12 or 13 or 14 (608)
16 4 and 15 (6)
17 kingdon.tw. (20)
18 stream*.tw. (29931)
19 17 or 18 (29949)
20 4 and 19 (354)
21 10 and 20 (78)
22 sabatier.tw. (37)
23 advocacy coalition.tw. (22)
24 acf.tw. (1470)
25 22 or 23 or 24 (1524)
26 4 and 25 (17)
27 punctuated equilibrium.tw. (69)
28 4 and 27 (3)
29 11 or 16 or 21 or 26 or 28 (244)
30 limit 29 to yr="2001 -Current" (165)

A modified version of this search strategy was utilized in additional databases.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 40
APPENDIX 2 – QUALITY ASSESSMENT TOOL

The quality assessment tool for qualitative studies developed by Letts et al.38 was utilized in this
review. In the tool, Y=Yes; N=No; and, NA=Not Addressed. Minor modifications were made to
tailor the tool to the study issue – these are noted within questions through the use of italics
and underlining. The assessment tool included the following questions:

Study Purpose:
• Was the purpose and/or research question clearly stated? Y/N
o Outline the purpose of the study and/or research questions.

Literature:
• Was relevant background literature reviewed? Y/N
o Describe the justification of the need for this study. Was it clear and compelling?
o How does the study apply to your practice and/or to your research question? Is it
worth continuing this review?

Study Design:
• What was the design? (phenomenology; ethnography; grounded theory; participatory
action research; other)
o Was the design appropriate for the study question? (i.e., rationale) Explain.
• Was a theoretical perspective identified? Y/N
o Describe the theoretical or philosophical perspective for this study e.g.,
researcher’s perspective.
• Method used: (participant observation; interviews; document review; focus groups;
other)
o Describe the method(s) used to answer the research question. Are the methods
congruent with the philosophical underpinnings and purpose?

Sampling:
• Was the process of purposeful selection described? Y/N
o Describe the sampling methods used. Was the sampling method appropriate to
the study purpose or research question?
• Was sampling done until redundancy in data was achieved? Y/N/NA
o Are the participants described in adequate detail? How is the sample applicable
to your practice or research question? Is it worth continuing?
• Was informed consent obtained? Y/N/NA

Data Collection – Descriptive Clarity

• Clear and complete description of site (setting): Y/N; of participants (actors): Y/N
o Describe the context of the study. Was it sufficient for understanding of the
“whole” picture?

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 41
 • Role of researcher and relationship with participants: Y/N
o What was missing and how does that influence your understanding of the
research?
• Identification of assumptions and biases of researcher: Y/N
Data Collection – Procedural Rigour
• Procedural rigour was used in data collection strategies? Y/N/NA
o Do the researchers provide adequate information about data collection
procedures e.g., gaining access to the site, field notes, training data gatherers?
Describe any flexibility in the design and data collection methods.

Data Analysis – Analytical Rigour

• Data analyses were inductive? Y/N/NA
o Describe method(s) of data analysis. Were the methods appropriate? What were
the findings?
• Findings were consistent with and reflective of data? Y/N

Data Analysis – Auditability

• Decision trail developed? Y/N/NA
o Describe the decisions of the researchers re: transformation of data to
codes/themes. Outline the rationale given for development of themes.
• Process of analyzing the data was described adequately? Y/N/NA

Data Analysis – Theoretical Considerations

• Did a meaningful picture of the phenomenon under study emerge? Y/N
o How were concepts under study clarified and refined, and relationships made
clear? Describe any conceptual frameworks that emerged.

Overall Rigour
• Was there evidence of the four components of trustworthiness? Credibility: Y/N;
Transferability: Y/N; Dependability: Y/N; Confirmability: Y/N
o For each of the components of trustworthiness, identify what the researcher
used to ensure each.
o What meaning and relevance does this study have for your practice or research
question?

Conclusions and Implications

• Conclusions were appropriate given the study findings? Y/N
o What did the study conclude? What were the implications of the findings for
occupational therapy (policy analysis of public health-related public policies)
(practice and research)? What were the main limitations in the study?
• The findings contributed to theory development and future OT (policy analysis of public
health-related public policies)practice/research? Y/N

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 42
APPENDIX 3 – MORE DETAILED SEARCH RESULTS
Table 6 provides a more detailed breakdown of the search results.

Table 6: Summary of Search Results

Source Medline Additional Databases** Other (Cited references;
Contacted experts)
Total identified 165 211* 25
Primary relevance 45 18 -
assessment (retrieved)
Met inclusion criteria 10 4 7
*Originally 442 items, but obvious duplicates from Medline search were detected and removed.
**Includes: Psychinfo; Global Health; Sociological Abstracts, Healthstar, CINAHL

Among the Medline search, reasons for rejecting records for further review are summarized in
Table 7.

Table 7: Reasons for Rejecting Medline Citations for Further Assessment

Reason #
Health service design/funding 22
Focus on clinical service 21
Broader health/social issue (e.g., 17
human trafficking, housing co-
ops)
Modelling/KTA 12
Markedly different contexts (e.g., 10
sub-Saharan Africa)
Non-English 8
Discussion documents 6
Focus on researcher/KT 4
Disease control 4
Methodology focus 3
Focus on lab procedures 3
Other 10

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 43
APPENDIX 4 – INCLUDED POLICY FRAMEWORK CASE STUDIES
Table 8: Summary of Case Studies Applying Policy Framework to Public Health-Related Issue
Framework Issue (Author) Key Findings Model Application Guidance on Quality Comments
Assisted Understanding How to Apply Assessment
and/or Action Model
Stages heuristic Health impact The ‘problem’ Helps understand the No (refers to 8/24 (Kingdon More detail provided with
assessment in relating to time sequence (i.e., Buse) focus) this framework than with
Sweden inequalities seems to where idea came from), Kingdon.
(Mannheimer have opened a how policy proposal came
39
2007) window for HIA, but to be, and problem with
lack of attention to implementation
implementation and
differing political
perspectives has
hampered progress
Institutional Tobacco control Implementation has No No 4/24 Impression is that could
Analysis and policy been incomplete with have likely come to the
Development implementation five key management same conclusions without
Framework in Catalan and executive mentioning the IAD model.
hospitals outcomes impeding (i.e., what are the typical
(Martinez 2009)41 successful barriers to implementing
implementation. hospital-based tobacco
control policies) unclear
how collected or analyzed
data
Multiple Physical activity Streams became Shows alignment for one Partial. Use of 13/24 Stream model useful to
streams policy in schools linked for daily policy option and not questionnaire seek understanding in
in Alberta physical activity but another. However, structured by situation where there was
(Gladwin et al, not walk-to-school relationships unclear agenda setting, ambiguity (ie, what to do
46
2008) initiatives. Minister among values, beliefs and policy about physical activity in
who was physician as political context. Action formulation and children). Lack of coalitions.
policy entrepreneur of policy entrepreneur decision-making. But, needed more data to
not described. Findings then improve understanding of
analyzed via context and process.
streams model.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 44
 Framework Issue (Author) Key Findings Model Application Guidance on Quality Comments
Assisted Understanding How to Apply Assessment
and/or Action Model
Evolution of Politician interest in Yes – ambiguous situation No 12/24 Authors considered ACF,
school sport and finding a policy of what should be done but found no evidence of
physical solution, but none with key role by policy effective coalition. Was
education policy obvious. Key role of entrepreneur ‘policy learning’ but this
(Houlihan and policy entrepreneur was leveraged by the
48
Green, 2006) to couple streams entrepreneur.
assisted by context
that favoured action
by politicians,
increasing evidence
of benefit, and
alignment with
broader political
aims.
School sport and Ambiguous problem Yes – analysis broken No 12/24 Narrative indicates how
physical with different down by streams. there were challenges
education policy problem perspectives within all of the streams
(Reid and and solutions and and without entrepreneur
Thorburn, without strong to help coupling.
47
2011) political interest and
focus on
implementation.
Social Cities that recognize Somewhat, although Not in any detail. 13/24 Stream appears potentially
entreneurship in three Kingdon insufficient data provided useful for local policy
urban policy (de streams more likely for each stream within context, but more data
58
Leeuw 1999) to influence policy individual cities. Actual needed. Institutionalized
agendas. actions of entrepreneurs entrepreneur interesting
Institutionalized not described. concept (very public health
entrepreneurs more relevant), but little info
likely to have impact provided on actual actions.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 45
 Framework Issue (Author) Key Findings Model Application Guidance on Quality Comments
Assisted Understanding How to Apply Assessment
and/or Action Model
Tackling health Made progress Yes, in terms of need At high level yes, 11/24 Value of looking at an
inequalities in getting inequalities positive response to all but not in any ambiguous issue along
the UK (Exworthy viewed as a problem. three streams and have detail three streams.
et al, 2003)49 However, limitations them aligned.
regarding solutions
and politics to make
progress.
Tackling health Policy alternatives No No 5/24 Limited data gathering;
inequalities in must be advocated unclear methodology;
Norway (Strand for a long period insufficient description of
and Fosse, before an context and actors
59
2011) opportunity presents
itself
Introduction of Legislation resulted Yes can see how three Yes, sample 17/24 Shows alignment of the
childhood from alignment of streams aligned. questions streams with practical
obesity the three streams provided and example.
legislation (Craig and the leadership of diagram showing
50
et al, 2010) policy entrepreneur. alignment helpful
Key supporting role
for public health
Health impact The ‘problem’ Somewhat – model Initial data 12/24 Data collection approach
assessment in relating to seems insufficiently collection to seems inadequate.
Sweden inequalities seems to applied with data sources include content, Application of model seems
(Mannheimer have opened a limited to documents. actors, processes superficial (e.g., clarity of
39
2007) window for HIA, but Not clear there was and context of the ‘problem’ seems
lack of attention to agreement to ‘the policy-making. critical).
implementation and problem’, and blending No guidance
differing political politics and policy regarding
perspectives has streams not helpful. No Kingdon model
hampered progress mention of policy application itself.
entrepreneur.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 46
 Framework Issue (Author) Key Findings Model Application Guidance on Quality Comments
Assisted Understanding How to Apply Assessment
and/or Action Model
Health impact Multiple windows No. Insufficient No. 9/24 Insufficient descriptive
assessment in opened: problem descriptive information is analysis in order to support
Slovakia (deteriorating health provided in order to be the analysis by the multiple
(Mannheimer et status; lack of able to fully understand streams.
60
al, 2007) intersectorality); the analysis. In addition,
politics (transition in much more attention
approach to given to implementation
government); policy than policy itself
(HIA was favoured by
WHO and EU)
Childhood health In 9 case studies, Yes. Demonstrated Conceptually yes. 19/24 Very good methods.
promotion outlined policy, analysis in two stages. List of interview Somewhat weak in
initiatives in problem, politics and One to describe in two guide items applying enough detail
Sweden role of policy dimensions (stages and provided in around context to fully
(Guldbrandsson entrepreneur structure/actor) and then earlier understand what
61
and Fossum, apply streams publication happened.
40
2009)
Contraband Nature of the Yes, showed how No. 11/24 Shows need alignment of
tobacco in contraband problem problem has changed and the three streams. Doesn’t
Canadian context has changed such that while understood, no address how to make this
(Schwartz and that there is no agreement on what to so. Also tends to mix policy
Johnson, 2010)62 political agreement do. and political streams
on a feasible solution. together.
Mandatory Three streams not Yes, although limited by No 4/24 Methodology unclear. Poor
reporting of fully aligned; concern lack of information description of context and
health-care for problem is there, actors. Detectable bias
associated but different towards reporting.
infections solutions possible,
(Odom-Forren and political stream is
and Hahn, unclear
63
2006)

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 47
 Framework Issue (Author) Key Findings Model Application Guidance on Quality Comments
Assisted Understanding How to Apply Assessment
and/or Action Model
Smoke-free Number of events Yes, although model No 6/24 Methodology unclear.
legislation in and trends provided limited to explain ‘why’. Advocacy coalition may
tobacco county window of have been more
(Greathouse et opportunity. appropriate framework to
44
al, 2005) apply
Alcohol policy Findings generally No No 18/24 Recurrent theme is that of
(Greenfield, consistent with a power struggle between
Johnson & Kingdon, although two groups with quite
Giesbrecht, not clear how different core beliefs. ACF
30,45
2005) windows of may have been better
opportunity occur choice. Use of science
mainly to bolster existing
views
Advocacy Drug policy in Existing competition Incompatible deeply held None. Narrative 7/24 Good example of how
Coalition Switzerland between coalitions beliefs: drug use as a description. Non- external event shifted
64
Framework (Kubler 2001) advocating different deviant behaviour and systematic power balance between
belief systems individuals need help to application of the belief-based coalitions. Not
externally shocked by get back on track; vs, ACF domains a single decision, but series
AIDS epidemic harm reduction model. of issues as both sides
causing a shift in their With AIDS, prevention adapted to previous
power distribution became more important decisions. Also, coalitions
than abstinence with shift morphed and aligned with
in power balance; other networks to pursue
coalitions not fixed but their core beliefs. Major
fluid depending on issue limitation is lack of
specifics methodology description.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 48
 Framework Issue (Author) Key Findings Model Application Guidance on Quality Comments
Assisted Understanding How to Apply Assessment
and/or Action Model
Fighting a Tax reduction Analysis of power balance Yes, ACF-based 15/24 Very good example of how
tobacco-tax coalition was between coalitions diagrams show external events shifted
rollback stronger due to more providing understanding analysis at two power balance between
secondary to financial resources, why lost initial fight about points in time coalitions. Diagrams quite
tobacco better use of media, tax rollback. when tax helpful to distill what was
smuggling and more reduction won going on.
(Breton et al, heterogeneity. and when later
52
2006) Change in resources tobacco strategy
and loss of influence won.
of industry later
shifted balance.
Tobacco control Adoption of Quebec Impact of contraband Uses ACF 16/24 Very good example of
policy in Quebec Tobacco Act crisis enabled influencing components of application of the ACF.
(Breton et al, explained using ACF. of government agenda. ‘relatively stable Cannot leave unaddressed
2008)51 Importance of Advocates addressed parameters’ and concerns for non-health-
external events and economic aspects of ‘external events’ related policy impacts.
recognition that most industry’s strategy & to identify Authors note that more
important issues failure of opponents to constraints and complex issues such as
were not the health present a unified voice. resources of obesity and physical
impacts, but subsystem activity attract more
potential economic actors. complex constellations of
ones. Strategically, policy actors that will
public health transcend a ‘policy
organizations subsystem’.
created an NGO
to do advocacy
work, particularly
to address the
non-health
issues.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 49
 Framework Issue (Author) Key Findings Model Application Guidance on Quality Comments
Assisted Understanding How to Apply Assessment
and/or Action Model
Emergency Considering the two Two main coalitions of No, but use of 7/24 Value here is use of ACF to
contraception for coalitions with deep proponents and ACF theory to understand the situation
sexual assault beliefs, analysis opponents and their suggest ways to and suggest the potential
victims in suggests need to being driven by their core address the routes of policy change to
Tennessee frame the issue as beliefs. power balance shift the balance.
65
(Schorn 2005) one of the health and between the two Weakness is lack of
well-being of women coalitions information on
and on pregnancy methodology (data sources,
prevention analysis, etc.).
Punctuated- State tobacco Despite widespread No, other than that No. 8 Not entirely clear whether
Equilibrium policies in US disturbance of the shocks by less powerful it is the lack of depth within
42
Theory (Givel 2006) system through won’t always be the theory or the lack of its
coalitions of health successful. Seems as application is the issue in
advocates and though ACF would have this paper. Since two
Master Agreement, been better model to coalitions with strong core
no major change in apply to this issue. beliefs, ACF might have
policy been better choice.
Emergence of Global disease No – doesn’t really seem No other than 6 Seems to fit Kingdon
disease control control priorities to be a model. looking at image streams. No methodologic
priorities experience long Description of factors fits (way in which a description.
(Shiffman et al, periods of Kingdon streams given problem
2002)43 incremental change and set of
and then bursts of solutions are
activity. Change conceptualized)
related to and venue (set of
convergence of actors and
agreement of institutions that
problem, solution make decisions)
and political interest

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 50
REFERENCES

(1) Ollila E. Health in All Policies: from rhetoric to action. Scand J Public Health 2011;
39(6 Suppl):11-18.

(2) Peel Public Health. A picture of health: A comprehensive report on health in Peel.
Brampton, ON: Peel Public Health, 2008.

(3) Mozaffarian D, Afshin A, Benowitz NL, Bittner V, Daniels SR, Franch HA et al.
Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A
Scientific Statement From the American Heart Association. Circulation 2012;
126(12):1514-1563.

(4) Lavis JN. How can we support the use of systematic reviews in policymaking? PLoS
Med 2009; 6(11).

(5) Morestin F, Gauvin F-P, Hogue M-C, Benoit F. Method for synthesizing knowledge
about public policies. National Collaborating Centre for Healthy Public Policy, 2010.

(6) Lavis, J. N. Organizing and evaluating deliberative dialogues in Canada and elsewhere.
2010. Available from: www.ncchpp.ca/docs/DeliberationJASP2010_LAVIS_EN.pdf.
Accessed: 28-5-2012.

(7) Dobbins M, Ciliska D, Cockerill R, Barnsley J, DiCenso A. A framework for the

dissemination and utilization of research for health-care policy and practice. Online
Journal of Knowledge Synthesis for Nursing 2002; 9:7.

(8) Lomas J, Brown AD. Research and advice giving: a functional view of evidence-
informed policy advice in a Canadian Ministry of Health. Milbank Q 2009; 87(4):903-
926.

(9) Gilson L, Raphaely N. The terrain of health policy analysis in low and middle income
countries: a review of published literature 1994-2007. Health Policy Plan 2008;
23(5):294-307.

(10) Fafard P. Public health understandings of policy and power: Lessons from INSITE. J
Urban Health 2012.

(11) Exworthy M. Policy to tackle the social determinants of health: using conceptual
models to understand the policy process. Health Policy Plan 2008; 23(5):318-327.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 51
 (12) Fafard, P. Evidence and healthy public policy: insights from health and political
sciences. National Collaborating Centre for Healthy Public Policy, 2008. Available
from: www.cprn.org/documents/50036_EN.pdf. Accessed: 22-5-2012.

(13) Murphy K, Fafard P, O'Campo P. Introduction-knowledge translation and urban health

equity: Advancing the agenda. J Urban Health 2012.

(14) Signal L. The politics of health promotion: insights from political theory. Health
Promotion Inter 1998; 13:257-263.

(15) Oliver TR. The politics of public health policy. Annu Rev Public Health 2006; 27:195-
233.

(16) Catford J. Creating political will: moving from the science to the art of health
promotion. Health Promot Int 2006; 21(1):1-4.

(17) Breton E, De LE. Theories of the policy process in health promotion research: a review.
Health Promot Int 2011; 26(1):82-90.

(18) Real-Dato J. Mechanisms of policy change: a proposal for a synthetic explanatory

framework. J Compar Policy Analysis 2009; 11(1):117-143.

(19) Benoit, F. Policy frameworks and public health influence. National Collaborating
Centre for Healthy Public Policy, 2008. Available from: www.ncchpp.ca/docs/FB-
SI2008ang-pp.pdf. Accessed: 22-5-2012.

(20) Buse K. Addressing the theoretical, practical and ethical challenges inherent in
prospective health policy analysis. Health Policy Plan 2008; 23(5):351-360.

(21) Zahariadis N. Comparing three lenses of policy choice. Policy Stud J 1998; 26(3):434-
448.

(22) Nowlin MC. Theories of the policy process: state of the research and emerging trends.
Policy Studies J 2011; 39(S1):41-60.

(23) Sabatier PA. Theories of the policy process. 2nd. Boulder, CO: Westview Press, 2007.

(24) Sabatier PA. The need for better theories. In: Sabatier PA, editor. Theories of the policy
process. Boulder, CO: Westview Press, 2007.

(25) Exworthy M, Peckham S, Powell M, Hann A. Shaping health policy: case study
methods and analysis. Chicago, IL: The Policy Press, 2012.

(26) Bernier NF, Clavier C. Public health policy research: making the case for a political
science approach. Health Promot Int 2011; 26(1):109-116.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 52
 (27) Ostrom E. Institutional rational choice: an assessment of the Institutional Analysis and
Development Framework. In: Sabatier PA, editor. Theories of the policy process.
Boulder, CO: Westview Press, 2007.

(28) Ostrom E. Background on the Institutional Analysis and Development Framework.

Policy Studies J 2011; 39(1):7-27.

(29) Zahariadis N. The Multiple Streams Framework: structure, limitations, prospects. In:
Sabatier PA, editor. Theories of the policy process. Boulder, CO: Westview Press,
2007.

(30) Greenfield TK, Giesbrecht N, Kaskutas LA, Johnson S, Kavanagh L, Anglin L. A study
of the alcohol policy development process in the United States: Theory, goals, and
methods. Contemporary Drug Problems: An Interdisciplinary Quarterly 2004;
31(4):591-626.

(31) Givel M. The evolution of the theoretical foundations of Punctuated Equilibrium

Theory in public policy. Rev Policy Research 2010; 27(2):187-198.

(32) True JL, Jones BD, Baumgartner FR. Punctuated-Equilibrium Theory: explaining
stablity and change in public policymaking. In: Sabatier PA, editor. Theories of the
policy process. Boulder, CO: Westview Press, 2007.

(33) Sabatier PA, Weible CM. The Advocacy Coalition Framework: innovations and
claifications. In: Sabatier PA, editor. Theories of the policy process. Boulder, CO:
Westview Press, 2007.

(34) Weible CM, Sabatier PA, McQueen K. Themes and variations: taking stock of the
Advocacy Coaltion Framework. Policy Studies J 2009; 37(1):121-140.

(35) Breton E, Richard L, Gagnon F. The role of health education in the policy change
process: Lessons from tobacco control. Crit Public Health 2007; 17(4):351-364.

(36) Walt G, Gilson L. Reforming the health sector in developing countries: the central role
of policy analysis. Health Policy Plan 1994; 9(4):353-370.

(37) Centre for Reviews and Dissemination. Systematic reviews: CRD's guidance for
undertaking reviews in health care. York, UK: CRD, University of York, 2008.

(38) Letts, L., Wilkins, S., Law, M., Stewart, D., Bosch, J., and Westmorland, M. Guidelines
for critical review form: qualitative studies (version 2.0). 2007. Available from:
www.srs-mcmaster.ca/Portals/20/pdf/ebp/qualguidelines_version2.0.pdf. Accessed: 18-
7-2012.

(39) Mannheimer LN, Lehto J, Ostlin P. Window of opportunity for intersectoral health
policy in Sweden--open, half-open or half-shut? Health Promot Internation 2007;
22(4):307-315.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 53
 (40) Guldbrandsson K, Fossum B. An exploration of the theoretical concepts policy
windows and policy entrepreneurs at the Swedish public health arena. Health Promot
Internation 2009; 24(4):434-444.

(41) Martinez C. Barriers and challenges of implementing tobacco control policies in

hospitals: applying the institutional analysis and development framework to the Catalan
Network of Smoke-Free Hospitals. Policy, Politics, & Nursing Practice 2009;
10(3):224-232.

(42) Givel M. Punctuated Equilibrium in limbo: the tobacco lobyy and U.S. state
policymaking from 1990 to 2003. Policy Studies J 2006; 34(3):405-418.

(43) Shiffman J, Beer T, Wu Y. The emergence of global disease control priorities. Health
Policy & Planning 2002; 17(3):225-234.

(44) Greathouse LW, Hahn EJ, Okoli CT, Warnick TA, Riker CA. Passing a smoke-free law
in a pro-tobacco culture: a multiple streams approach. Policy Polit Nurs Pract 2005;
6(3):211-220.

(45) Greenfield TK, Johnson SP, Giesbrecht N. The alcohol policy development process:
policymakers speak. Contemporary Drug Problems 2004; 31(4):627-654.

(46) Gladwin CP, Church J, Plotnikoff RC. Public policy processes and getting physical
activity into Alberta's urban schools. Canadian Journal of Public Health Revue
Canadienne de Sante Publique 2008; 99(4):332-338.

(47) Reid G, Thorburn M. Analysing policy change in Scottish physical education and
school sport. J Policy Res Tourism Leisure Events 2011; 3(3):298-315.

(48) Houlihan B, Green M. The changing status of school sport and physical education:
Explaining policy change. Sport, Education and Society 2006; 11(1):73-92.

(49) Exworthy M, Blane D, Marmot M. Tackling health inequalities in the United Kingdom:
the progress and pitfalls of policy. Health Serv Res 2003; 38(6 Pt 2):1905-1921.

(50) Craig RL, Felix HC, Walker JF, Phillips MM. Public health professionals as policy
entrepreneurs: Arkansas's childhood obesity policy experience. Am J Public Health
2010; 100(11):2047-2052.

(51) Breton E, Richard L, Gagnon F, Jacques M, Bergeron P. Health promotion research and
practice require sound policy analysis models: the case of Quebec's Tobacco Act. Soc
Sci Med 2008; 67(11):1679-1689.

(52) Breton E, Richard L, Gagnon F, Jacques M, Bergeron P. Fighting a tobacco-tax

rollback: a political analysis of the 1994 cigarette contraband crisis in Canada. J Public
Health Policy 2006; 27(1):77-99.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 54
 (53) King A. Ideas, institutions and the policies of governments: a comparative analysis:
part III. Br J Pol Sci 1973; 3(4):409-423.

(54) Humpage L. Institutions, interests and ideas: explaining social policy change in welfare
states incorporating an indigenous population. J Europ Soc Policy 2010; 20(3):235-247.

(55) Buse K, Mays N, Walt G. Making health policy. 2nd ed. New York: Open University
Press, 2012.

(56) University of Kansas. The Community Tool Box: Influencing Policy Development.
2012. Available from: http://ctb.ku.edu/en/dothework/tools_tk_11.aspx. Accessed: 27-
8-2012.

(57) Hoover, S. A. Media advocacy. Community Prevention Institute, 2012. Available from:
http://www.ca-cpi.org/docs/publications/TARP/TARP_MediaAdvocacy.pdf. Accessed:
27-8-2012.

(58) de Leeuw E. Healthy Cities: urban social entrepreneurship for health. Health Promotion
Inter 1999; 14(3):261-269.

(59) Strand M, Fosse E. Tackling health inequalities in Norway: Applying linear and non-
linear models in the policy-making process. CRIT PUBLIC HEALTH 2011; 21(3):373-
381.

(60) Mannheimer LN, Gulis G, Lehto J, Ostlin P. Introducing Health Impact Assessment: an
analysis of political and administrative intersectoral working methods. Eur J Public
Health 2007; 17(5):526-531.

(61) Guldbrandsson K, Bremberg S, Back H. What makes things happen? An analysis of the
development of nine health-promoting measures aimed at children and adolescents in
three Swedish municipalities. Soc Sci Med 2005; 61(11):2331-2344.

(62) Schwartz R, Johnson T. Problems, policies and politics: A comparative case study of
contraband tobacco from the 1990s to the present in the Canadian context. J Public
Health Policy 2010; 31(3):342-354.

(63) Odom-Forren J, Hahn EJ. Mandatory reporting of health care-associated infections:

Kingdon's multiple streams approach. Policy Polit Nurs Pract 2006; 7(1):64-72.

(64) Kubler D. Understanding policy change with the advocacy coalition framework: an
application of Swiss drug policy. J Europ Public Pol 2001; 8(4):623-641.

(65) Schorn MN. Emergency contraception for sexual assault victims: an advocacy coalition
framework. Policy, Politics, & Nursing Practice 2005; 6(4):343-353.

Application of Policy Frameworks for Public Health-Related Public Policy Processes – Final Report Page 55