An exploratory study identifying where local government public health decision makers source their evidence for policy

The Western Australian (WA) Public Health Bill will soon replace the existing and antiquated Health Act 1911. One of the proposed clauses of the Bill is that all WA local governments will be required to develop a Public Health Plan. A Public Health Plan, though not defined in the Bill, is well known in the industry and is a comprehensive set of proposed activities that inform the way in which public health is managed within a local government.¹

The WA Public Health Bill acknowledges that local government needs risk-based and flexible mechanisms to undertake its role and to respond to community needs. It recognises that local government is the tier of government closest to the community and is a key advocate and protector of public health in the community. A long-standing criticism of public health legislation is that it tends to be reactive:² a problem is identified and a remedy is then defined to rectify the problem. This approach is rightly criticised as allowing little capacity for innovation or planning for a healthy environment in which the risk of future hazards is reduced. The draft Bill identifies a need to change the current approach and create a regulatory system that is flexible and proactive and where health planning is a key consideration for corporate strategy.

The WA Public Health Bill, in its current form, states that a local Public Health Plan should identify the public health needs of the local government district, include an examination of data relating to health status and health determinants in the local government district, and include a strategic framework for the identification, evaluation and management of public health risks in the local government district.² In other words, the Public Health Plans should be based on evidence from all levels, including national and statewide priorities, community needs, local statistical evidence, and stakeholder data. This exploratory study aimed to identify the sources of evidence used to generate the list of public health risks to be included in local government business and public health plans.

During 2012 and 2013, local government officers in WA were recruited (via a direct email approach) and invited to participate in an online survey requesting they identify the public health risks that affect their local community. The officers were asked to nominate the source (or sources) of evidence used to support their identification of local public health risks.

The survey consisted of three closed questions and one open-ended question, and asked respondents to rank a list of public health risks collated from a review of public health and chronic disease incidence data for their region. Categories of evidence, as indicated in Table 2, were presented as a closed question, with opportunities to add additional sources in an ‘other’ category. Descriptions of evidence sources were offered in the survey instrument.

There are 140 local governments in WA. From these, a total of five local governments were selected, representing three metropolitan Councils and two regional Councils. These Councils were selected as they had commenced the process of developing Public Health Plans. All professional staff members from these local governments were invited to participate in the survey (n = 1086). A total of 533 local government officers completed the survey, giving a response rate of 49%. The breakdown of responses was 50.7% from regional Councils and 49.3% from metropolitan Councils. As all WA local governments differ in their organisational structure, professional categories of respondents (rather than local government departmental categories) are indicated in Table 1.

Table 1.  Professional category of respondents

Table 2 shows the most important primary sources of evidence for local government officers when identifying public health risks relevant to their local community. The top four sources were: observing the consequences of the risks in the local community (24.5%), statewide evidence (17.6%), local evidence (17.6%) and coverage in local media (16.2%).

Table 2.  Primary sources of evidence for public health policy

Statewide evidence was defined as policies or plans that set strategic goals for the WA community. One example is the WA Health Promotion Strategic Framework 2012–2016³, which sets out WA Health’s strategic directions and priorities for the prevention of chronic disease and injury over the next five years. Another is the Environmental Health Directorate Yearbook, which outlines achievements and strategic directions.⁴

Local evidence varies considerably between Councils. However, it was generally defined as networking with key community groups and support services whose client base had identified risks, Public Health Unit data collations, and endorsed local government reports and plans.

Using evidence to inform policy is not new. Evidence-based policy making is an approach that ‘helps people make well-informed decisions about policy, programs and projects by putting the best available evidence from research at the heart of policy development and implementation’⁵ (p. 3). More recently, Oxman and colleagues state that evidence-informed health policymaking is an approach to policy decisions that is intended to ensure that decision making is well informed by the best available research evidence, and is characterised by systematic and transparent access to, and appraisal of, evidence as an input into the policymaking process.⁶

Evidence-informed public health calls for a solid knowledge base for disease frequency and distribution, for the determinants and consequences of disease, and for the safety, efficacy and effectiveness of interventions and their costs.⁷

The challenges highlighted in this study lie in the definition or constitution of evidence. In the public health planning process, local government decision makers must address complex questions about the nature and significance of a public health problem to be addressed, and the nature of proposed interventions (together with their differential impacts, cost-effectiveness, acceptability and evaluation). This exploratory study found that the four most common sources of evidence used to identify local public health risks for inclusion in a Public Health Plan were: observing the consequences in the community, statewide evidence, local evidence, and media reporting. There is no doubt that local and statewide evidence contained in published reports and including reflections from stakeholders are both useful when contributing to the development of policy. However, a review of the trustworthiness and reliability of media and personal observations as a source of evidence reveals that these are less acceptable, and in fact are considered to be ‘soft’ sources.

Contemporary public health practitioners accept and advocate for mixed methods that include a balance of qualitative and quantitative data, practice-based wisdom, self-reflections by practitioners, and community aspirations.

Of particular concern from this exploratory study was that the fourth most common source of evidence on which public health decisions and priorities were based for public health planning processes in WA was reliance on mass media. Mass media strategies have been used in public health to educate and advocate for opinion and behavioural changes at individual, social and community levels.^8–10,11 This study indicates that in over 16% of cases, local government officers make real-world health-risk policy decisions based on information reported in the media. Although newspapers reflect community attitudes, actions and (in some cases) opinions, relying on this information is in itself a risky behaviour. A systematic and unbiased sample of every health-related story appearing in the top 10 best-selling UK newspapers every day for one week was collated, coded and checked to identify the evidence behind every claim.¹² Of the 111 claims reviewed, using the WCRF grading system it was found that 69 claims (62%) were rated to have an insufficient evidence base. Seventeen claims (15%) were based on convincing evidence and 24 claims (22%) fell into the combined middle probable/possible evidence categories. The remaining 1% was unclassifiable.

It is clear that different types of evidence are relevant to different questions and public health issues. However, evidence-informed policymaking aims to ensure that relevant evidence is identified, and that judgements about issues such as what evidence is relevant, and the reliability and applicability of identified evidence, are made systematically and transparently. Another essential characteristic of evidence-informed policymaking is that policymakers access relevant information and research and ensure it is appraised and used appropriately.¹³

Given the time and resource constraints within the local government sector, it is difficult to encourage rigorous and transparent systematic systems at the local level and local government officers tend to use what is available, easily accessible and locally applicable. It is clear from this exploratory study, that for local government decision makers to develop effective policy, they need to be basing their decisions on good information. To achieve this, they require access to a synthesis of high-quality evidence that includes qualitative and quantitative data, including statewide and local evidence, community aspirations and concerns, and perceived needs from Elected Members and key stakeholders.

With the exception of those who work in an extremely narrow field, it is difficult for local government officers, whose role, amongst many others includes policymaking, to read the vast amount of information that has been published in their area of expertise. For those who are committed to the notion of evidence-informed policymaking, as advocated within the WA Public Health Bill, this presents a considerable challenge. This study has highlighted the range of sources of evidence currently used to identify public health risks by a select group of local government officers in WA. The results indicate that a range of data sources are used when identifying public health priorities and risks, with personal observation, state and local sources of evidence, and media being the most frequently reported sources. Yet, to ensure well-informed decisions about public health risks, local government policymakers need access to robust evidence. Evidence is needed to clarify what services and programs are needed, how to effectively deliver those services at the local level, budgeting and resource implications, governance arrangements, and how to implement strategies to mitigate or reduce public health risks. With the use of personal observations and media reporting as the first and fourth most common sources of evidence on which to identify local public health risks, there is room for improvement regarding what constitutes ‘evidence’. Further research to explore more fully the definition and breadth of evidence sources used in the local government sector, the constraints under which the sector operates, and any required sector-specific tools, may guide how best to bridge the gap between research findings and policy development.

Ethics approval has been granted through Curtin University – Research with a low risk.