Application of policy process theories in the development of Australian oral health and chronic disease policy

INTRODUCTION

The effect of bounded rationality on the decision-making process is a highly researched area and must be considered in the process of translating evidence to decision-makers.^[1] Randomized controlled trials and systematic reviews have long been acknowledged as producing the highest quality of evidence; however, this “hierarchy of evidence” established by science has less impact in policy development when considered against economic, ideological, and intergovernmental factors.^[2] Policy development theories regard bounded rationality and political factors in their explanations of the policy process.^[3,4] Theories of the policy process examine the associations between the goals, values, beliefs, and actions of potentially hundreds of policy actors, all interacting in the policy process. This is theorized to lead to particular policy outcomes and is of interest to policymakers, researchers, clinicians, and advocates seeking to inform policy.^[5] While policy theories do not offer specific actions for influencing the policy process, the application of these theories attempts to explain how policies are developed.^[6-8] The use of these theories can offer a range of approaches for those endeavoring to inform policy decisions.^[9] A proficient theory is imperative for the improvement of evidence-based policy research.^[6]

There is currently a gap in the chronic disease and oral health policy development process for the use of evidence-based research outcomes.^[10] Previous research has identified a number of political factors that affect the translation of oral health research into health policy.^[11] Research demonstrates that poor oral health increases an individual’s risk of cardiovascular diseases and cognitive impairment^[12,13] while diabetes and periodontal disease have a bidirectional relationship.^[14] Evidence demonstrates that the inclusion of this oral health research into health policy could be analyzed more systematically, and researchers could be guided by applying policy process theories to persuade policy change.^[15] Previous research conducted identifying the policy development process of oral health and chronic disease policy in Australia found that evidence-based, oral health research outcomes are rarely included in oral health and chronic disease policy.^[10] Further investigation revealed that only 27% of information used in policy development is from academic research.^[16] Identifying the political factors affecting the translation of research into policy may improve the implementation of oral health research into health policy. This study aimed to determine what could be learnt from policy process theories about the political factors affecting policy development. The establishment of this knowledge is hypothesized to provide guidance on how oral health and chronic disease policy can be influenced in the future.

MATERIALS AND METHODS

Numerous policy process theories have emerged from social and political science.^[3-6] Weible (2023) has identified eight of these theories as being established and endeavoring to progress a scientific theory over time with a focus on interrelated concepts involving actors, context, events, and outcomes surrounding policy.^[17] The first of these theories, the Multiple Stream Approach, states that three streams – the policy solutions stream, political stream, and policy stream – must come together at the same time creating a “policy window” when change will inevitably occur.^[18] The second theory, Punctuated Equilibrium theory, maintains that change in policy is incremental unless a major event occurs, causing dramatic shifts in public policy.^[19] Third, the Ecology of Games Framework argues that policy actors engage in policy debates and will cooperate to produce mutually beneficial outcomes.^[20,21] Next, diffusion and innovation scholarship considers that policies in one jurisdiction influence policy development in other jurisdictions.^[22] The fifth theory, institutional analysis and development framework, defines institutions as rules, norms, and relationships that determine the structure of interactions in the policy process.^[23,24] Next, Narrative Policy Framework explores the power of narratives in the policy process, where actors use stories to transfer knowledge, influence opinions, develop targets, build coalitions, and affect change.^[25] The Advocacy Coalition Framework is the seventh theory, which explains how people, organizations, and governments align with other policy actors with common beliefs and values to influence the policy development process.^[26] Finally, Policy Feedback Theory focuses on political considerations, assessing how policies affect the development of future policy.^[27] The interconnected elements of actors, context, events, and outcomes in these eight theories are the basis of this study.

1. Policy actors are any individual or organization involved in policy development who contribute to policy narratives, evidence, and policy implementation; these can be official actors who are involved in government or unofficial actors who do not have a legally mandated part of the process.^[28,29] They are interconnected with the context, events, and outcomes of the policy process.^[30] It is important to note that the possibility of who can be a policy actor is unlimited; in addition, new actors can emerge as systems change.^[31]

2. The context in which policy processes occur is a web of many factors, actors, and events that interact in a large and messy policy environment.^[32] This study adheres to current evidence stating that the context of the policy environment can change quickly. Therefore, a general definition of the context of each theory has been indicated.^[30] However, this does not disregard the knowledge that there are established laws, structures, institutions, and procedures that are ingrained in government that do not change.^[33]

3. An event is defined as an occasion, either expected or unexpected, that generates the attention of decision makers to a public problem or issue.^[29,34] These events can be intentionally created by policy actors or may unintentionally occur as a result of a natural disaster, for example.^[34]

4. Each policy process theory in this study combines the elements of actors, context, and events, which, if successful in eliciting policy change, produce an outcome.

The data for this study were collected from semi-structured interviews conducted with 12 Australian oral health, cardiovascular disease, diabetes, and cognitive impairment policymakers from June 2021 to November 2021. Ethical approval was gained from the University of Newcastle: H-2020-0438. These data were previously investigated to determine the barriers and enablers policymakers experience during policy development.^[11] A consistent barrier identified by policymakers was the effect of political factors on policy development.^[11] This previous research employed an inductive approach in which the themes generated were data-driven, highlighting the importance of political factors to the policy development process as identified by policymakers.^[35] In this current study, the same data were coded according to actor, event, context, and outcome using deductive reflective thematic analysis. This approach offers a theoretical exploration of data where themes are generated through already established theory.^[36,37] As no validated framework for this research exists, these findings were then compared to each of the eight policy process theories to determine which aspects policymakers identify as active in Australian policy development and those unidentified elements which may indicate where a gap exists [Table 1].

RESULTS

The policy actors identified in this study included both official and unofficial policy actors. Official actors identified included: bureaucrats, policy brokers, policy entrepreneurs (within government), policymakers, and politicians. Unofficial actors were acknowledged as academics, advocates, clinical experts, consultants, individuals, institutions, interest groups, non-government organizations, policy entrepreneurs (outside government), private health insurers, professionals, researchers, resource users, and society. Policymakers in this study presented policy actors as either having the power to influence policy or as being a resource of knowledge that they approach for information. Policy entrepreneurs identified in this study were insurance companies, the food and beverage, tobacco, and alcohol industries, civil society, and non-government organizations.

The creation of a policy window by policymakers was the most frequently referred to event of any theory. Advocacy was stated as the main lever used to open a policy window, while the vulnerability of governments during an election campaign was also noted opportunity. However, this vulnerability was acknowledged as a time when the government may fund things that are not sensible.

“And then you have the election cycle, so the election cycle is a very powerful time when ministers like to really, they are very vulnerable at that time to people getting them to fund stuff which may or may not be sensible.”

Policymakers did not identify events from three of the policy process theories in their policy development. Each of these events is those in which policymakers have no control. This sentiment was expressed when one policymaker stated:

“I don’t have a choice what I can do, I work in the bureaucracy that supports the government of the day and that’s the policy positions.”

The context of three policy process theories was identified by policymakers. Policymakers spoke of their active role in the context of the multiple streams approach to create a policy window. The context of the Advocacy Coalition Framework was also highlighted, where evidence is only influential when it provides the opportunity to alter the beliefs of decision-makers.

“If you want to go down that big change kind of pathway then I need to convince my colleagues in the department, my minister, I need to convince peers, particularly in the finance department – I need to convince them both that the problem is worth solving and that the solution we propose is going to be effective in solving that problem.”

Policymakers also spoke of contextual factors affecting policy that do not change, such as Medicare and the Pharmaceutical Benefits Scheme. They stated the strength of these programs and their inability to be corrupted. Oral health policymakers highlighted the exclusion of oral healthcare from Medicare.

The outcomes of the Narrative Policy Framework were identified by policymakers, highlighting it as an effective approach when advocating to the government. Policy Feedback Theory was identified by policymakers where international policy was identified as influencing national policies. The outcome of Multiple Streams Framework was nearly identified; however, policymakers interviewed stressed the desire for specific solutions to specific policy problems. While the Ecology of Games Framework is not utilized by Australian policymakers interviewed in this study, the outcomes in which this theory operates were acknowledged as a possible policy solution to address the growing burden of poor oral health and chronic diseases.

“I think there is really strong evidence, that it would be better to get systems to work together, we would get better outcomes.”

Outcomes of the Ecology of Games Framework are produced when governments cooperate to deliver solutions to complex policy problems. When discussing the translation of oral health research into oral health and chronic disease policy policymakers stated that oral health is not a priority and therefore governments do not cooperate to find a solution.

“It’s not so much the ignorance it’s the choosing not to listen to the evidence around the connection between oral health and general health in policy or actioning it.”

The evaluation of the policy process is considered an important element of the policy process; however, it was identified as lacking in Australian health policy.^[38]

“Something I feel that is really a potentially powerful lever that is underutilized is the way that we use accountability around policy and the way that we use hard data and outcome measurements through an evaluation process to understand the impacts that policy can have.”

DISCUSSION

This research applied policy process theories to qualitative data collected from Australian policymakers to determine the political factors affecting policy development. The establishment of this knowledge could provide guidance on how and when oral health and chronic disease policy can be influenced. Consistent with previous research, a single policy process as seen in Figure 1 is unable to explain all policy outcomes.^[30] As demonstrated in this study, policymakers utilize multiple elements from different theories during policy development. There are consistencies in aspects policymakers did not apply at all, which highlights gaps in how policy may be influenced. The Narrative Policy Framework was the only theory where all elements were identified by policymakers. In this approach, the moral of a story offers a solution to the policy problem and intends to gain attention and influence policy outcomes.^[39,40] One policymaker spoke of two examples when individuals’ narratives were used to successfully advocate to government. Advocates of this theory argue that it is more powerful in influencing an individual’s view of policy than evidence-based research.^[41] As evidence is only effective if it changes the beliefs of decision-makers, narrative policy approach may be an influential approach to consider when endeavoring to inform policy decisions.^[8]

Close

Figure 1:

Actions recommended for mobilization of research into policy as informed by policy process theory.

Export to PPT

Policymakers did acknowledge that information is sifted through a belief system, as in the Advocacy Coalition Framework. This is an advantage if decision makers’ beliefs align with the proposed policy solution, as this can form influential collaborations that affect policy change.^[42] However, it is also a hindrance when the evidence does not align with decision-makers’ beliefs, and policymakers stated there was no point presenting the evidence at all. Advocacy was identified as a powerful lever to open a policy window in which evidence may be better received as advocates make the problem recognizable.^[43] Research has demonstrated that the translation of evidence could be improved if policy windows were more easily anticipated and utilized.^[44] While policymakers did state the effectiveness of identifying a policy window, they more frequently referred to creating a policy window through evidence and advocating. This study indicates that creating rather than waiting for a policy window is an effective strategy for influencing the policy process.

Policymakers acknowledged a number of actors; however, this list is not exhaustive, as the possibility of who can be a policy actor is unlimited; in addition, new actors can emerge as systems change.^[31] This establishes the need to map policy actors pertinent to a policy issue when advocating for its solution. It is important to map which policy actors are at play and their level of power. For example, policymakers interviewed identified the strong influence of private health insurers in some states, whereas they indicated to have no influence in other states. It would benefit oral health and chronic disease researchers to identify the power dynamics in the policy process, as failing to do so can misidentify why policy development and implementation may fail.^[45]

The success of a policy solution will depend largely on the institutional context, as stated in the Institutional Analysis and Development Framework.^[46] The exclusion of oral health from Medicare was identified by policymakers in this study; however, there was hesitation to propose funding oral health through Medicare due to the failure of the Chronic Disease Dental Scheme. The Chronic Disease Dental Scheme was administered from 2007 to 2012 and was considered a policy failure. Retrospectively, this failure can be attributed to politics, economics, timing, and a lack of intergovernmental collaboration.^[47,48] Although this program has not been continued, it did acknowledge the effects of oral health on chronic disease and focused on treating the most prevalent oral health conditions.^[48] The contextual factors identified in the failure of this program should be reflected on with the development of a new approach. The alignment of diverse stakeholders, such as dental clinicians, policymakers, and patients, could form important coalitions that drive policy change and find solutions, as seen in the Advocacy Coalition Framework, and work together to avoid the downfalls of previous schemes. While it may be controversial, the inclusion of oral health into Medicare is a recommendation of this study based on the significant need for oral healthcare and the identification of political factors that negatively affected previous implementation efforts.^[47,48] Reflecting on the Chronic Disease Dental Scheme, funding of oral health through Medicare could focus on preventive services utilizing dental hygienists and oral health therapists whose scope includes preventive services when treating adult patients.^[48] Creating a narrative around the benefits stakeholders receive from the inclusion of oral health funding through Medicare could contribute to and maintain policy momentum based on the success of the Narrative Policy Framework.

Policy evaluation strategies should be incorporated into all oral health and chronic disease policy development on a more methodological basis. While policy implementation and outcome evaluation are integral components of the policy process, the policymakers we interviewed identified a lack of evaluation processes in Australian health policy.^[49] The integration of policy evaluation into the oral health and chronic disease policy process is recommended as policy evaluation directs responsible decision-making around how policies are implemented, scaled, and funded.^[50] Policymakers expressed frustration around the lack of cooperation and accountability among the government, indicating the importance of an intergovernmental approach. This aligns with The Ecology of Games Framework where the focus is on complex policy problems.^[21] The benefits of this approach are seen in the successes of tobacco control where the consolidation of political will occurred internationally and produced change.^[51] The translation of oral health research into chronic disease policy requires collective action.

The jurisdiction of each policymaker and their area of policy were not revealed, and while this could be considered a limitation, it was important to maintain policymakers’ anonymity. While the initial investigation and application of policy process theories were completed by the lead author, all four authors reviewed the application and agreed on the findings recorded. Limitations of this study include the number of policymakers interviewed. Given the specificity of this study and the limited number of oral health, cardiovascular disease, diabetes, and cognitive impairment policymakers in Australia, data were analyzed during collection to ensure saturation was achieved.

CONCLUSION

This study aimed to determine the political factors affecting policy development. The establishment of this knowledge provides guidance on how oral health and chronic disease policy could potentially be influenced. The use of a narrative policy framework is considered a persuasive approach when endeavoring to influence the policy process. Combining evidence and advocacy may result in the creation of a policy window, which was the most frequently referred to event in this study. Actors hold a range of power and may or may not affect the policy process; it is imperative that they are mapped and considered. A lack of policy evaluation has been identified where policies could be better assessed for implementation, scaling, and funding. Intergovernmental cooperation is critical to the development and implementation of policies that address complex problems. Government collaboration and reflection of past programs to develop an approach to incorporate oral health funding into Medicare is imperative for the improvement of those living with poor oral health, cardiovascular disease, diabetes, and cognitive impairment.

The application of policy process theories has produced recommendations researchers, policymakers, and advocates can apply when endeavoring to inform the policy process. Influencing this process is critical to translating oral health research into oral health and chronic disease policy. While this study has demonstrated actions that can be taken in oral health and chronic disease policy development, these results can be applied to other complex policy problems within Australia and globally.