Formulation and implemention of evidence-based public health policy in political environments: the health trainer service initiative in England

Abstract

BackgroundCommentators have argued that we are witnessing an irresistible lifestyle drift that is focusing health equity policy, research, and practice on individual behaviours and is resulting in lifestyle interventions that are largely abstracted from the sociocultural contexts that affect behaviour and health. In England, the white paper Choosing Health: Making Healthier Choices Easier (2004) set the scene for public health policy in the following years. Choosing Health detailed a new public health workforce, health trainers, recruited from local communities to support people in disadvantaged circumstances to achieve lifestyle-focused behaviour change. In 2008, we were commissioned to undertake a review of the implementation of this policy. We aimed to understand the health trainer policy development and implementation, including local experience of delivery of health trainer services. MethodsOur review encompassed a theory-based mixed method evaluation with analysis of policy documentation, interviews with policy makers and the policy implementation team, in-depth qualitative case study work with stakeholders in six local health trainer services, and analysis of data held in the national health trainer service dataset. FindingsDocumentary review and interviews with the central policy team clearly show the constrained policy context for health trainers, and suggest that there were key assumptions and inherent tensions in the initial policy formulation. For example, a central assumption was that there would be significant unmet and easily accessible demand for (context-stripped) lifestyle-focused behaviour change interventions in target populations, while tensions included competing demands to adhere to the universal nature of NHS service provision versus targeted interventions to address inequalities. Our longitudinal case study work with local health trainer services shows that these assumptions were flawed and that the tensions that surfaced during service development and implementation were such that the long-term sustainability of services within NHS performance management and commissioning frameworks is threatened. Services have been incentivised to shift focus and move away from elements of service models that are theorised to facilitate impact in target populations. This situation results from a need to show value for money in narrowly conceptualised commissioning frameworks and understandings of legitimate evidence of effectiveness. InterpretationThis work provides a perfect illustration of the political nature of public health policy formulation and implementation, while reinforcing calls to acknowledge the sociocultural and economic contexts for the lifestyle behaviours that are targeted by policy interventions. Other themes that emerge from the research include the political nature and use of evidence by different stakeholder groups, including evaluations of public health policy interventions. FundingNIHR Policy Research Programme.