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Table 3 Reflection of aspects of program logic in SA HiAP action on the social determinants of health (2007–2016)

From: To what extent can the activities of the South Australian Health in All Policies initiative be linked to population health outcomes using a program theory-based evaluation?

Focus of action or intent Approach Reach Program theory: Immediate & Intermediate Outcomes Health and equity outcome contribution and likelihood
Utilisation of governance systems to support social determinants of health and equity
South Australia’s Strategic Plan (SASP) provided medium to long term goals for SA in identified priority areas SASP provided strong authorising environment for HiAP Whole population of SA A clear plan for improving the population’s health and wellbeing If government focus on achieving SASP targets maintained, likely to contribute to positive health and equity outcomes
HiAP initial activity focused on working with different agencies on health impacts of relevant SASP targets, many becoming focus of HLA work
Departmental Chief Executives held accountable for aspects of the plan, encouraging them to collaborate with HiAP
Assessment of extent to which SDH are presented in SA’s 7 Strategic Priorities for SA’s future HLA of SA’s 7 Strategic Priorities Reach varies depending on priority, but overall, whole of population Shorter term focus than that of SASP on strategic areas of significant government attention Enhanced whole of government responses to SDH
Legislative support for action on SDH through new Public Health Act HiAP reflected as a principle in the new legislation, and systematised in local government-led regional public health planning and establishment of Public Health Partner Authority (PHPA) agreements with interested government departments and other organisations Potentially whole of public sector and non-government organisations The PHPA provide basis for on-going action on SDH by gaining commitment from organisations to undertake such action Strong basis for improving health in the long term
Develop a statement to describe SA as a State of Wellbeing 2016 90 Day project – State of Wellbeing statement. Statement cites HiAP principles as underpinning statement and notes that wellbeing is most evident in equitable jurisdictions Whole of population Establishes aspiration for SA to be State of Wellbeing and positions equity as important to high wellbeing, which will encourage action across the state to advance wellbeing and equity The aspiration for wellbeing and as part of this equity to be a goal of state policy could, if enacted, result in improved health and equity
Development of relational systems to support action on social determinants of health
Changing culture of the SA public service to work collaboratively across sectors on social determinants of health Changing culture of public sector to understand role of social determinants and importance of cross-sector work Whole of public service Improved joined-up policy responses to complex multi-sectoral issues In long term public sector action more likely to work across silos and promote health (equity did not feature strongly)
Ideas about SDH have been dispersed across the public sector and are encouraging more focus on the broader implications of different agencies’ business (including the health implications) in some sectors
90 day project on Joined-Up policy delivery (2016)
Many departments have nominated policy champions to work on joined up policy through a policy network
Joint problem identification and decision making between HiAP and other sectors
Improving early literacy in children through increased parental engagement HLA on Parental Engagement in Literacy Initially 4 selected schools, then contributed to strategy for entire Education Dept. Improved literacy has been shown to have a positive impact on health If children more literate then they will have improved health when they are adults [27, 45]
Identifying strategies to improve the health, sustainability and economic positioning of communities in Upper Spencer Gulf HLA on Healthy Sustainable Regional Development: Upper Spencer Gulf Regional community of 53,000 people Including information about health and wellbeing in a regional plan will contribute to increased awareness in region and lead to improved policies Slight evidence of impact on region and likely to be very minor
Modest output of report and social health atlas and evidence of increased awareness from public servants
Improve the health and wellbeing of international students HLA on international student health and wellbeing International students in SA (more than 20,000 attracted to higher education institutions each year, however focus of HLA was on a sub-set of these, in Vocational Education and Training sector) Increasing students’ knowledge of Australian health system will enable them to gain care and stay healthy, but evidence on effectiveness of provision of information alone is not strong so unlikely to have big impact without more structural change [46]. For example, focus of information in fact sheets on general health and wellbeing is on individual behaviours such as smoking, alcohol, drugs, healthy diet etc. Very minor
The early stages of HLA suggested more wide-ranging outcomes whereas student fact sheets (reprinted and used interstate) focused mainly on behaviours, health insurance and available services
Support vulnerable young people to successfully transition from education to further training and employment HLA on Learning or Earning   No impact N/A – did not progress
Did not progress because health reorganisation slowed progress to extent that higher education dept. withdrew involvement
Increasing the proportion of the population in healthy weight range HLA on Healthy Weight which examined the potential contribution of every government dept. to encouraging healthy weight Whole of population Increase in healthy weight of population Improved population health outcomes [47, 48]
Increasing Aboriginal life expectancy by improving road safety through increasing safe mobility options HLA on Aboriginal Road Safety Aboriginal people in SA Increased number of Aboriginal people in urban, rural and remote SA who obtain and retain drivers’ licences Reduce number of Aboriginal people killed in motor vehicle accidents
HLA work informed 90 Day Project to frame Aboriginal drivers’ licensing as part of Public Sector Renewal Program, focused specifically on remote area with exclusively Aboriginal population
Reduce number of Aboriginal people incarcerated for traffic offences
Increase mobility, improved road safety and ultimately improved health and wellbeing [49, 50]
Making Adelaide a less carbon-dependent city and increasing healthy transport options 3 HLAs on: Detailed plans relevant to metropolitan region, and the active transport and cycling strategies relevant to whole Adelaide metropolitan area Denser cities are more carbon efficient and so healthier Health benefits likely over the long term from less carbon, more sustainable city and transport, and more active population [51, 52]
Transit orientated developments
Active transport reduces carbon and increases human activity, and encourages social interaction which is also good for health
Active transport
Increase the proportion of the community who visit parks, and increase the regularity of park visits Environment sector’s action under PHPA agreement on ‘Healthy Parks Healthy People’ with Health has led to strong focus on mental health and wellbeing impacts. Includes increasing green infrastructure in city. Whole of population and state, including special focus on Aboriginal people More people across all population groups use parks more often for a variety of activities If promotion of use of parks progresses as planned is likely to lead to improved mental and physical health outcomes as people get the benefits of exercise, social interaction and being in nature [33, 34]
Encouraging action on the social determinants of health in local government Local government Regional Public Health Plans mandated by SA Public Health Act 2011 Whole of state Immediate outcome is that all local governments in SA have had to produce public health plans and so focus on how they will contribute to health in the future. This may lead to improved infrastructure for health throughout the state
Local government reports that the process was useful and their plans will be more extensive in subsequent iterations
If the planning processes are effective and then implemented, health and wellbeing will be improved
Detailed analysis of plans indicates a fit between them and HiAP principles articulated in 2007
Extent of new action limited in first round but promising
  1. Abbreviations: dept. department, HiAP Health in All Policies, HLA Health Lens Analysis, PHPA Public Health Partner Authority, SA South Australia, SASP South Australia’s Strategic Plan, SDH social determinants of health