Understanding Political Priority Development for Public Health Issues in Turkey: Lessons from Tobacco Control & Road Safety
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UNDERSTANDING POLITICAL PRIORITY DEVELOPMENT FOR PUBLIC HEALTH ISSUES IN TURKEY: LESSONS FROM TOBACCO CONTROL & ROAD SAFETY by Connie H. Hoe A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland June, 2015 © 2015 Connie H. Hoe All Rights Reserved Abstract Background: In the last decade, tobacco control received political priority in Turkey while road safety did not despite the large health and economic burden road traffic injuries posed on the Turkish population. Political priority relates to the agenda-setting phase of the policy process and has been widely acknowledged as an important facilitating factor in the attainment of public health goals. Unfortunately, however, few studies currently exist to help us understand how it develops for public health issues in countries like Turkey. Objective: Using a framework adapted from John Kingdon’s Multiple Streams Theory, the primary objective of this study was to compare tobacco control with road safety for the purpose of assessing how political priority for public health issues develop in Turkey. Method: A comparative mixed-methods case study design was used. Qualitative data were gathered from key informant interviews (N=42), and documents (N=307) and quantitative data were collected from online self-administered surveys (N=153). For each case, qualitative data were analyzed using deductive and inductive coding and quantitative data were analyzed using descriptive statistics and nonparametric tests. All results were triangulated. Finally, cross-case analysis was employed such that the themes from the two cases could be compared. Results: Political priority emerged for tobacco control as a result of the development and convergence of four streams – problem, policy, political, and global – while a policy ii window was opened. Although the full development of all streams was found to be crucial, the transformation of the political stream appeared to be most significant. These streams were found to overlap at different points in time and influenced by an integrated group of diverse actors. Without all of these events and actors in place at the same time, the study showed that a public health problem is not likely to reach political priority in Turkey as seen in the case of road safety where only two of the four streams were developed, a policy window never opened, and many key actors were absent. Conclusion: The revised framework generated from this study could potentially help actors promoting public health issues in Turkey or other similar contexts. iii Committee of Thesis Readers Committee Members: Dr. Adnan A. Hyder Professor, PhD Advisor Department of International Health Dr. David M. Bishai Professor, Committee Chair Department of Population, Family and Reproductive Health Dr. Daniela Rodriguez Assistant Scientist Department of International Health Dr. Kent Stevens Assistant Professor School of Medicine, Surgery Alternate Committee Members: Dr. Abdulgafoor Bachani Assistant Professor Department of International Health Dr. Pierre-Gerlier Forest Professor Department of Health Policy and Management Dr. Ryan D. Kennedy Assistant Professor Department of Health, Behavior and Society iv Acknowledgements This dissertation would not have been possible without the invaluable support of many wonderful individuals. First and foremost, I would like to express my special appreciation and thanks to my advisor Dr. Adnan A. Hyder who has been a tremendous mentor to me. Thank you for giving me your full support during this PhD journey and for challenging me to be better. It has been a privilege to be your advisee. I would also like to acknowledge the intellectual contributions of numerous Johns Hopkins professors who have advised through this process. In particular, I would like to express my sincere gratitude for Dr. David Bishai, Dr. Daniela Rodriguez, Dr. Kent Stevens, Dr. Larissa Jennings, Dr. Joanna Cohen, Dr. Mark Boulay, Dr. Sara Bennett and Dr. David Peters. Your guidance and invaluable advice were instrumental to the design and implementation of this study. I would also like to thank Dr. Pierre-Gerlier Forest, Dr. Shivam Gupta, Dr. Timothy Baker, Dr. Abdulgafoor Bachani, Dr. Ryan D. Kennedy, Dr. Laura Morlock, Dr. William Reinke, Ms. Carol Buckley and Ms. Cristina Salazar. A heartfelt thank you to Dr. Türker Özkan and Dr. Timo Lajunen at the Middle East Technical University. You not only served as my mentors in Turkey but also made my stay in Ankara an enjoyable one. Thank you for you full support, generosity, hospitability and jokes! v Special thanks to the many students at the Middle East Technical University who generously offered to assist me with the endless translations, document review, and note taking during interviews. In particular, I would like to thank Yeşim Üzümcüoğlum, Hande Ağca, Pınar Bıçaksız, and Zümrüt Yıldırım-Yenier. I am so grateful for all of your help and, more importantly, your friendships. It was because of all of you that data collection in Turkey was fun. I would also like to give a special thanks to Dr. Laila Martinussen at Danmarks Tekniske Universitet. My first stay in Ankara would not have been the same without you! This project was conducted during the Bloomberg Philanthropies’ Road Safety in 10 Countries Project in which I was a research assistant. I would like to give a special thanks to Bloomberg Philanthropies. Being a part of the project gave me a better understanding of the Turkish context. I am sincerely grateful for all the key informants and survey respondents who participated in this study. Thank you for taking time out of your busy schedule to contribute to this research. My gratitude is also extended to the World Health Organization for their assistance and support during the data collection process. In particular, I would like to thank the staff at the Turkey Country Office for their hospitality, generosity and friendship. Data collection would not have gone as smoothly if it were not for your full support. vi I would like to give special acknowledgement to the Association for Safe International Travels, Global Road Safety Partnership, Turkey’s General Directorate of Security, General Directorate of Highways, Ministry of Health, Kocatepe University and Hacetteppe University for their generous support during the data collection process. A special thank you is extended to all the staff at the Johns Hopkins International Injury Research Unit. Thank you all for your encouragement and for making the unit such an enjoyable place to work! I am also indebted to my brilliant friends who were always a source of laughter, happiness and support. In particular, I am grateful for Aarushi Bhatnagar, Jonathan Akuoku, Aisha Jafri, Ligia Paina, Fayrouz Ashour, Kareshma Mohanty, Alexandria Appah, Jennifer Lee, Bryan Shaw, Nathan Miller, Afsan Bhadelia, Pooja Sripad, Nasreen Jessani, Krit Pongpriul and Julia (Xiaoge) Zhang. I would like to take this opportunity to thank Jason Wilcox who has been a constant source of strength and inspiration. These past few years have not been an easy ride and I truly thank you for sticking by my side. Your support and motivation allowed me to finish this journey. Finally, I would like to thank my parents, Jack and Pamela Hoe, my sister, Alice Hoe and my grandparents for all of their love and encouragement. Words cannot express how vii thankful I am for the sacrifices you have made on my behalf. I would not have made it this far without you. Thank you from my bottom of my heart! viii This dissertation is dedicated to a safer and healthier Turkey daha güvenli ve daha sağlıklı bir Türkiye için ix Table of Contents Abstract ii Committee of Thesis Readers iv Acknowledgements v Acronyms xvii 1. Overview of Thesis 1 Introduction 1 Rationale 2 Literature Review 4 Political Priority Development Theories 4 A Review of Political Priority Development Studies 9 Methods to Investigate Political Priority Development for Public Health Issues 13 Background 15 Republic of Turkey: Country Profile 15 Burden of Tobacco Use in Turkey 18 Burden of Road Traffic Injuries in Turkey 20 Study Objectives 22 Research Methods 22 Organization of the Study 25 2. “Quitting Like A Turk:” How Political Priority Developed for Tobacco Control in Turkey 45 Abstract 45 Introduction 47 Conceptual framework 49 Methods 52 Qualitative Research Methods 52 Data Collection 52 Data Analysis 55 Quantitative Research Methods 57 Data Collection 57 Data Analysis 59 Within-Case Analysis 60 Ethical Approval 61 RESULTS 61 Characteristics of the Data Sources 61 History of Tobacco Control in Turkey 1980 - 2002 63 Key Actors 64 Governmental Actors 64 Civil Society Actors 67 International Actors 71 x Streams 73 Problem Stream (1980s) 73 Political Stream (2002) 76 Global Stream (2003) 81 Policy Stream (2006) 85 Policy Window and the Joining of the Streams 90 Sustaining the Momentum 93 Discussion 97 Key Findings 98 Limitations 105 In-depth Interviews 106 Documents Review 108 Survey 109 Reflexivity 112 Implications for Action and Policy 113 Future Research 115 Conclusions 116 Appendix 2.1a Field Guide for Tobacco Control - English 144 Appendix 2.1b Field Guide for Tobacco Control -Turkish 147 Appendix 2.2a Codebook Draft 150 Appendix 2.2b Codebook Final 152 Appendix 2.3 Document Review Summary 155 Appendix 2.4a Tobacco Control Survey in Turkey - English 158 Appendix 2.4b Tobacco Control Survey in Turkey - Turkish 162 3. The Unfinished Agenda: An Analysis of Why Political Priority Did Not