Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity.
The Lords Of Strategy Epub
Next, reliability of use by practitioners was assessed by asking two policy experts (the Department of Health Policy Lead for implementation of the 2010 English government tobacco control strategy and a tobacco researcher) to independently classify the 24 components of the strategy (see Additional file 1 for coding materials). Their coding data were compared with the 'gold standard.'
The initial coding of the intervention functions and policy categories of the 2010 English Tobacco Control Strategy was achieved with an inter-rater agreement of 88%. The inter-rater agreement for the NICE Obesity Guidance was 79%. Differences were readily resolved through discussion (see Additional file 8 for details of the analysis). The percentage agreement between the identified components and the 'gold standard' was 85% for the implementation lead for the 2010 English government tobacco control strategy in the Department of Health and 75% for the tobacco researcher.
It is imperative that planning for a COVID-19 vaccination uptake strategy begins in advance of vaccine availability for two reasons. First, countries will need to determine population sub-groups and build a consensus about the order in which these will get access to the vaccine. Second, we should reduce fear and concern and create demand for vaccines. A key part of this strategy is to counter the anti-vaccination movement that is already promoting hesitancy and resistance.
Those responsible for creating demand for the vaccine need to work with vaccine suppliers, administrators, and those delivering vaccination to bring together a full mix of demand-side and supply-side interventions. The intervention mix needs to include coordinated action in the fields of prioritization and access policy, supply systems, and promotions strategy. Prioritization is especially critical, given insufficient availability, especially after the initial months of vaccine launch. More important than building general demand are building awareness and support for COVID-19 vaccination prioritization plans and fostering high acceptance among people in priority groups.
Public health authorities need to build a proactive COVID-19 vaccine trust capacity for active engagement in the social media space as part of their overall promotional strategy [56]. Social media platforms are now the primary information source and communication channel for a large and growing number of citizens. Public health agencies need to invest in building teams of specialist staff trained and capable of understanding how to build and maintain social media presence.
Over the past decade, the Dutch government has pursued a research-based approach to tackle socioeconomic inequalities in health. We report on the most recent phase in this approach: the development of a strategy to reduce health inequalities in the Netherlands by an independent committee. In addition, we will reflect on the way the report of this committee has influenced health policy and practice.
A 6-year research and development program was conducted which covered a number of different policy options and consisted of 12 intervention studies. The study results were discussed with experts and policy makers. A government advisory committee developed a comprehensive strategy that intends to reduce socioeconomic inequalities in disability-free life expectancy by 25% in 2020. The strategy covers 4 different entry-points for reducing socioeconomic inequalities in health, contains 26 specific recommendations, and includes 11 quantitative policy targets. Further research and development efforts are also recommended.
Since then, the Dutch Ministry of Health has followed a systematic, research-based approach to tackling socioeconomic inequalities in health. An initial five-year research program mapped the nature and determinants of socioeconomic inequalities in health in the Netherlands [6]. A second six-year program launched in 1994 sought to gain systematic experience with interventions and policies designed to reduce socioeconomic inequalities in health. We report on the final phase of the second program: the development of a strategy to tackle health inequalities, and the production of a report containing recommendations for health policy making [7]. These recommendations were partly based on the results of the evaluation studies included in the second program. In addition, we will reflect on the way this report has influenced health policy and practice.
Subsequently, the committee overseeing the program held a number of plenary meetings to develop a comprehensive strategy to reduce health inequalities. Committee members were appointed by the Minister of Health, and they included former and active politicians of various political backgrounds, as well as a representative of the ministry of health and researchers. A conscious attempt was made to represent the whole (relatively narrow) political spectrum in the Netherlands. Members ranged from left (represented by the social-democrat mayor of the fourth largest city in the country) to right (represented by a former chairman of, and current House of Lords member for, the conservative party, who was later succeeded by another House of Lords member for the same party), and the committee was chaired by a former christian-democrat Minister of Social Affairs. Researchers had an important influence on the whole process: JM was secretary of the committee, and KS acted as co-ordinator of the program, and both were involved in writing draft versions of the final report. The committee reported directly to the Minister of Health.
The committee started from the assumption that existing inequalities in health at least partly rank as unjust and that the government is responsible for achieving a reduction of these health differences. This assumption was based on the argument that health should be seen as a condition for the options open to individuals to structure their own life as far as possible according to their own ideas. Those health differences that are the consequence of an unequal distribution of living conditions over which individuals have no control, were thus seen as health inequities, to be tackled by the government. It was argued that this would require a comprehensive strategy, given the persistent and widespread character of socio-economic inequalities in health.
The committee wanted its strategy for reducing health inequalities to be based on sound evidence. Ideally, factors targeted by the strategy should be known to contribute to the explanation of health inequalities, and interventions and policies should be known to diminish exposure of lower socioeconomic groups to these factors. While the first requirement could be met relatively easily (and documentation was provided, with references, in the final report of the committee), the second requirement was more difficult to meet. Although the program produced evidence on effectiveness of interventions and policies and showed some positive results, this left important gaps in the knowledge base, both in terms of coverage of various policy options and in terms of strength of evidence. This problem was also encountered in other countries [14]. The committee considered that one cannot expect further evidence to become available unless large-scale measures to reduce inequalities in health are taken. It therefore decided to recommend a combination of implementation of 'promising' interventions with continued evaluation efforts. For each of the interventions and policies that were recommended for implementation, it carefully listed the available evidence, plus references.
The committee decided to base its strategy on a number of quantitative targets, because these can aid in plotting a clear policy course and can function as milestones for interim assessments of the strategy. It took the World Health Organization target as its starting point [15], and reformulated it for the Netherlands as: "By the year 2020, the difference in healthy life expectancy between people with a low and people with a high socioeconomic status should be reduced from 12 to 9 years, due to a (stronger) increase in healthy life expectancy in the lowest socioeconomic groups."
In order to attain such an ambitious goal, major efforts are required, if only because during the last decades inequalities in health in the Netherlands have increased rather than decreased [16]. Although it was considered unwise to give up on the ambition laid down in this 'inspirational' target, the strategy focused on a set of 'intermediate' targets that seem feasible today or in the near future. These targets were chosen to represent each of the main entry-points for reducing socioeconomic inequalities in health, and were limited to intermediate outcomes for which quantitative data for the Netherlands are currently available.
Table 3 lists the interventions and policies constituting the strategy recommended by the committee. The strategy covers all four entry-points and spans the entire range between 'upstream' measures targeting socioeconomic disadvantage and 'downstream' measures targeting accessibility and quality of health care services. Where current policies were expected to contribute to reducing health inequalities (education policies, income policies, work disability benefit schemes, health care financing schemes), the committee explicitly recommended continuation. This is by no means trivial, because none of these achievements of the past can be considered safe for the future. For example, the Dutch government is considering a reform of the health care financing system that could lead to reduced coverage of health care for those insured under the current public scheme, and then would jeopardize equal financial accessibility. 2ff7e9595c
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