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RESEARCH AND PRACTICE |
John N. Lavis, Suzanne E. Ross, and Gregory L. Stoddart are with the Centre for Health Economics and Policy Analysis and the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. John N. Lavis and Gregory L. Stoddart are also with the Population Health Program, Canadian Institute for Advanced Research, Toronto, Ontario. In addition, John N. Lavis is with the Institute for Work and Health, Toronto, and Gregory L. Stoddart is with the Department of Economics, McMaster University. Joanne M. Hohenadel is with the Department of Clinical Epidemiology and Biostatistics, McMaster University. Christopher B. McLeod is with the Institute for Work and Health, Toronto. Robert G. Evans is with the Population Health Program, Canadian Institute for Advanced Research, Toronto, and the Centre for Health Services and Policy Research and the Department of Economics, University of British Columbia, Vancouver.
Correspondence: Requests for reprints should be sent to John N. Lavis, MD, PhD, Centre for Health Economics and Policy Analysis, Health Sciences Centre, Room 2D3, McMaster University, 1200 Main St W, Hamilton, Ontario L8N 3Z5, Canada (e-mail: lavisj{at}mcmaster.ca).
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ABSTRACT |
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Objectives. This article describes Canadian civil servants’ awareness of, attitudes toward, and self-reported use of ideas about the determinants of health.
Methods. Federal and provincial civil servants in departments of finance, labor, social services, and health were surveyed.
Results. With civil servants in finance departments a notable exception, most Canadian civil servants see the health of populations as a relevant outcome for their sectors. Many (65%) report that ideas about the determinants of health have already influenced policymaking in their sector, but most (83%) say they need more information about the health consequences of the policy alternatives their departments face.
Conclusions. Civil servants should consider developing accountability structures for health and researchers should consider producing and transferring more policy-relevant research.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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But after all this time, we don’t know whether and how these ideas have taken root outside the health sector, where most of their policy implications lie. For example, tax policies, labor market policies, and early childhood development policies, while developed with explicit economic or social objectives, very likely have profound health consequences.5–7 This leads us to ask to what extent are civil servants in departments of finance, labor, and social services aware of and disposed toward these ideas, and whether they believe these ideas have influenced policies in their respective sectors.
Environmental impact assessments provide a helpful analogy. Civil servants have grown accustomed to considering the environmental consequences of public policies in addition to their explicit economic or social objectives. Are they considering health consequences in the same way? Many policy actors and social movements support a focus on the health of populations, although they are perhaps more preoccupied with vexing issues in their own sectors (such as access to health care) than those who support a focus on the environment.8 And in the case of some health problems, such as infectious diseases, the poor health of a fellow citizen can affect all of us in as direct a way as a polluted environment.
We believe that important lessons can be derived from an assessment of the extent to which Canadian researchers and civil servants in health departments have been able to transfer ideas about the determinants of health to civil servants outside the health sector. The systematic and widespread nature of these efforts makes Canada a helpful test case. Do these civil servants see the health of populations as a relevant outcome for their sectors? Are ideas about the determinants of health sufficiently well developed to have influenced sectors other than the health sector? If not, what is needed to increase the policy relevance and applicability of these ideas? The answers to these questions, which may differ by level of government or by sector, can inform decisions in other countries about whether and how to facilitate the further development and uptake of these ideas.
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METHODS |
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Survey instrument
The survey instrument consisted of a series of statements assessing civil servants’ awareness of, attitudes toward, and use of ideas about the determinants of health, as well as their sources of knowledge. All statements were derived from published interview and survey instruments, government documents, research papers, and our own interviews with civil servants and researchers.9–11 For example, the categorization of health determinants used in the awareness statements was developed by Canada’s federal government.12 All statements were followed by a 5-point Likert scale, with the scale for awareness statements defined by familiarity; the scale for attitude and use statements, by agreement; and the scale for knowledge sources, by importance. The survey instrument was pilot-tested with civil servants from both levels of government and all 4 sectors and was modified to reduce errors attributable to the way in which statements were worded or the order in which questions appeared. We cannot, however, fully address the concern that respondents may have provided answers that they perceived to be socially desirable.
Analyses
Descriptive analyses were conducted for all civil servants together, then by level of government (federal or provincial) and by sector (finance, labor, social services, or health). For awareness statements, we calculated the proportion of respondents who were quite familiar or very familiar with a particular topic or document. For statements about attitudes toward and use of these ideas, we calculated the proportion of civil respondents who mildly or strongly agreed with a particular statement.
We hypothesized that a higher proportion of federal than provincial civil servants would be aware of and disposed toward ideas about the determinants of health and would report having used these ideas. Unlike their provincial counterparts, federal civil servants are not exposed to the demands of administering a health care system, and they are more likely to have been exposed to documents about the determinants of health produced by their own government. We also hypothesized that civil servants in the health sector would be more familiar with and disposed towards these ideas than civil servants in other sectors. We therefore performed pairwise t tests to assess differences by level of government, with federal as the reference category, and by sector, with health as the reference category. To identify differences across sectors and not just between health and other sectors, we performed F tests to determine whether the proportions for any sector were different from the mean proportion for all sectors.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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). Response rates were roughly similar across the 2 levels of government (federal and provincial) and across 3 of the 4 policy sectors (labor, social services, and health). The response rate for civil servants from finance departments was low (45%). Survey respondents had similar age, sex, work experience, and training profiles across the 2 levels of government, but different sex, work experience, and training profiles across sectors.
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). As well, more than half the respondents were quite familiar or very familiar with research related to the impact of specific "determinants of health" (as categorized by Health Canada) on the health of populations, with the exception of the category called biology and genetic endowment. Fewer than one third, and in some cases fewer than one fifth, reported being quite familiar or very familiar with landmark Canadian documents12–16 that have contributed to ideas about the determinants of health. These topics and documents were equally familiar (or unfamiliar) to federal and provincial civil servants, with the exception of the federal government’s Lalonde Report,1 which was better known to federal civil servants. Civil servants from finance departments had consistently lower awareness levels than those from health departments.
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). Most (83%) felt they needed more practical information about effective interventions that governments can undertake in order to give greater attention to initiatives that will improve the health of populations. Fewer than half the respondents felt that jurisdictional responsibility for government action to improve the health of populations should rest with government health departments. More respondents supported investments in the prekindergarten years and in data collection and research than supported other possible investments.
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Civil servants in finance departments were outliers in many of their attitudes. They were less convinced than their counterparts in other sectors that health determinants should be considered in all major government initiatives. They were more supportive than their counterparts of improving economic prosperity rather than reducing inequalities. Civil servants in finance departments were less supportive than those in other sectors about investments in any type of policy action.
Use in Policymaking
About two thirds of the respondents felt that knowledge about the determinants of health had influenced the development of policies or programs in their respective sectors (Table 4). The same proportion felt that they were always trying to improve the health of populations, even though they don’t use that language. A much higher proportion agreed with the positively framed statement about how this knowledge had been used within the health sector than agreed with the negatively framed statement. Federal and provincial civil servants shared similar views about whether and how these ideas have been used. Civil servants from departments of finance and labor tended to be less likely than their counterparts in social services and health to see themselves as always trying to improve the health of populations.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Civil servants in finance departments felt quite differently. While we expected civil servants in the federal government and in health sectors to be the outliers, civil servants in finance departments emerged as the outliers. Our follow-up telephone calls to them were often greeted with, "This isn’t relevant to me." The 45% of civil servants in finance departments who completed the surveys did not believe that they should consider health determinants in all major government initiatives. As well, compared with civil servants in other sectors, they were much less aware of ideas about the determinants of health in general and of research about the impact of specific health determinants on the health of populations. Civil servants in finance departments were also less likely to want to invest more in research and data collection or to undertake policy initiatives that could influence specific health determinants.
Many civil servants outside the health sector reported that knowledge about the determinants of health has already influenced the development of policies in their sector. We cannot assess this influence relative to other factors, such as the values of the governing party, the power of interest groups, and the conditioning effects of particular institutional arrangements.16 That said, the correspondence between the particular expression of this knowledge in Canada and the particular types of influence reported by the civil servants we surveyed lends credibility to these findings. The focus in Canada on efficiency in the production of health8 (as opposed to the focus on the socioeconomic gradient in the United States17 and the focus on health inequalities in the United Kingdom18) appears to be reflected in the high proportion of civil servants agreeing that this knowledge pushed them to consider the value of health care spending practices. And the focus in Canada on early childhood development19–21 appears to be reflected in the high proportion of civil servants in social services departments agreeing that this knowledge has influenced the development of policies and programs in their sector.
Respondents to our survey generally agreed that they need more information about the health consequences of the policy alternatives that their departments face. While support for more research and data collection was lukewarm in finance departments, civil servants in other sectors appeared willing to make the necessary investments. Calling for more research is a familiar "tactical" use of research22; it suggests a commitment to action while removing the obligation for meaningful and immediate action. But at the same time, calling for more research indicates that, after more than 2 decades of exposure to ideas about the determinants of health, civil servants feel they need to signal something.23 Additional research is needed to ascertain whether elected officials feel similarly.
Our suggestions about what these survey results mean for civil servants are ambitious. Civil servants need to think seriously about how they can, through their influence on the economy, labor markets, social programs, and the health care system, affect the determinants of health and, through them, the health of populations. Perhaps there are lessons for these civil servants from the environmental field. Civil servants in the environmental sector have been far more successful at putting in place accountability structures that require their colleagues to make explicit the trade-offs between economic or social objectives and environmental consequences. Civil servants will be seeing more and more health research that has implications outside the health sector. It makes sense to begin thinking now about accountability structures for the health of populations.
Our suggestions about what these survey results mean for research and for knowledge transfer are equally ambitious. First, research funders should begin to support the evaluation of interventions and natural experiments that involve health determinants, at the same time as they continue to support research that explores relationships between possible health determinants and the health of populations. This research should attempt to identify the health consequences of policies as well as the extent to which the policies achieve their economic or social objectives. Second, researchers should begin to distill the key messages arising from research on the determinants of health and take concrete steps to use these messages to educate civil servants, especially in hard-to-reach finance departments. We recognize, however, that Homer Simpson’s adage may apply to civil servants in finance departments: "Just because I don’t care, doesn’t mean I don’t understand."
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Acknowledgments |
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Christel Woodward, an experienced survey researcher, assisted with the development of the survey instrument. Valerie Steep, an undergraduate student, followed up with French-speaking civil servants and conducted data entry and basic descriptive data analyses. Shirin Amarsi, also an undergraduate student, assisted with data entry. Christopher Sigouin, a doctoral student, assisted with the development of quality-checking and security provisions for data entry.
Many past and current civil servants in government and many researchers acted as informal advisors to the project, especially during the development and testing of the survey instrument and the survey follow-up. These informal advisors to the project include Jane Bartram, Lillian Bayne, Guy Bujold, Sheree Davis, Denise Kouri, Ron Labonte, Rejean Landry, Anne Larson, Steven Lewis, John Millar, Cameron Mustard, Michael Rachlis, and John Ronson. The authors take full responsibility for any remaining errors or omissions.
Human Participant Protection
The study protocol was approved by the research ethics board of McMaster University and the Hamilton Health Sciences Corporation.
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Footnotes |
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Accepted for publication April 1, 2002.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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23. Lavis JN. Ideas at the margin or marginalized ideas? Nonmedical determinants of health in Canada. Health Affairs 2002;21(2):107–112.
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