Katikireddi, Srinivasa Vittal (2013) The relationship between evidence and public health policy: Case studies of the English public health White Paper and minimum unit pricing of alcohol in Scotland. PhD thesis. http://theses.gla.ac.uk/4687/ Copyright and moral rights for this thesis are retained by the author A copy can be downloaded for personal non-commercial research or study, without prior permission or charge This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the Author The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the Author When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given Glasgow Theses Service http://theses.gla.ac.uk/ [email protected] The relationship between evidence and public health policy: Case studies of the English public health White Paper and minimum unit pricing of alcohol in Scotland Srinivasa Vittal Katikireddi BSc (Hons), MB ChB, MRCP, MSc, MFPH, PGCAP Thesis submitted for the degree of Doctor of Philosophy at the University of Glasgow MRC/CSO Social and Public Health Sciences Unit College of Medical, Veterinary and Life Sciences, University of Glasgow August 2013 © Srinivasa Vittal Katikireddi Abstract Background Public health researchers and practitioners have repeatedly called for policy to be informed by academic evidence. The rise of the evidence-based medicine movement has demonstrated the potential benefits of using evidence for clinical decision-making. Recently, politicians and policy documents have echoed these calls for increased use of evidence in policymaking by drawing upon the discourse of evidence-based policy. However, efforts to understand the relationship between evidence and public health policy are underdeveloped and often make limited use of knowledge from other fields, including political science and sociology. This thesis aims to explore the relationship between evidence and public health policy in the UK using two contemporary case studies: the English public health White Paper, ‘Healthy Lives, Healthy People’; and the development of minimum unit pricing of alcohol in Scotland. Methods The first case study: ‘Healthy Lives, Healthy People’ case study investigates the extent that three prominent discourses that draw upon academic work are reflected by the policy statements contained within the White Paper. The three areas examined include evidence on ‘what works’, the Nuffield framework on public health ethics and insights from behavioural science (‘nudge’). These discourses were chosen as they are not only rhetorically prominent in the White Paper, but also because they reflect the range of direct use of specific research findings and more conceptual use of research-derived ideas. To examine the extent that evidence on ‘what works’ has been incorporated into ‘Healthy Lives, Healthy People’, the research evidence for each of 51 specific policy actions described in the White Paper was reviewed. A critical analysis of ‘nudge’ and the Nuffield framework was conducted by contrasting their application with the authors’ original articulation. The second case study explores the development of the high-profile public health policy of minimum unit pricing of alcohol by drawing upon three different sources of data. First, a review of policy documents was conducted. Second, a systematic document analysis of evidence submissions that were received by the Scottish Parliament’s Health and Sport 2 Committee in response to its consultation on minimum unit pricing was performed. This analysis drew specifically on a framework for analysing political argumentation. Third, 36 semi-structured interviews were carried out with a broad range of policy stakeholders. Interviewees were purposively chosen to obtain diversity in supportiveness for minimum unit pricing, as well as by professional position (academic, advocate, civil servant, politician, industry representative). The evidence submissions and interview data were thematically coded and organised using NVivo 9. Results By systematically assessing the evidence underpinning the English public health White Paper, the study empirically established that public health policy does not meet conventional public health standards for being evidence-based. Similarly, the prominence of ‘nudge’ and the Nuffield framework in the text of ‘Healthy Lives, Healthy People’ do not appear to be matched by the actions suggested. However, this first case study finds that while evidence does have an influence, it does not determine policy. This relationship appears complex, partial and contingent rather than direct and instrumental, therefore necessitating a more detailed and focused case study. The second case study begins by providing a detailed description of the process by which minimum unit pricing developed in Scotland. It then draws on the analysis of evidence submission documents combined with interview data to identify a crucial role of public health advocates, who reframed the alcohol policy debate to bring about policy change. Epidemiological concepts were important in helping to achieve this shift in policy framing. Having investigated more conceptual influences of evidence, econometric modelling carried out by a team at the University of Sheffield is focused on as an example of a specific piece of research evidence that was perceived by interviewees to be influential in the policy debate. The different types of influence that the modelling study had on the policy process are determined and reasons for its influence investigated. The study also finds that interviewees believed econometric modelling could be more widely used to inform future public health policymaking. Lastly, a ‘multiple lenses’ approach builds upon these findings and political science theory to produce a comprehensive explanation of the policy process and describe the roles of evidence on the minimum unit pricing policy process. 3 Discussion Analysis of the ‘Healthy Lives, Healthy People’ White Paper shows that despite the prominent rhetoric for evidence-based policy, this is not reflected by the reality of current public health policy in the UK. The investigation of the development of minimum unit pricing of alcohol in Scotland demonstrates that evidence influences the policy process in a number of ways but these influences are heavily context-dependent. The role of evidence in changing the framing of the policy debate has been identified as of particular importance for this case study. The devolution process and evolving nature of political institutions also raises particular opportunities, but also challenges, for public health professionals. The strengths of the thesis include its use of two case studies to investigate the relationship between evidence and public health policy, the analysis of multiple sources of data in relation to minimum unit pricing policy and the application of political science theories that are typically underused in public health research. Limitations include the caution required when making generalisations from these data, particularly since these case studies have been purposively chosen. Drawing upon the two case studies, a conceptual model for the relationship between evidence and public health policy is articulated. The model suggests that evidence is likely to be used in different ways depending on the extent that the political values underpinning an issue are contested, with the importance of evidence for rhetorical purposes being a legitimate and helpful means of highlighting the health aspects of public policy issues. Lessons for public health researchers and practitioners, as well as directions for future research and theoretical implications, are considered and discussed. 4 Table of contents Abstract ........................................................................................................................ 2 List of Tables ............................................................................................................... 13 List of Figures ............................................................................................................. 14 Acknowledgements .................................................................................................... 15 Author’s declaration ................................................................................................... 17 Acronyms and Abbreviations ...................................................................................... 19 1 Introduction to the thesis .................................................................................... 20 1.1 Research question and aims ................................................................................ 20 1.2 Overview of the thesis .......................................................................................... 21 2 Literature review ................................................................................................. 23 2.1 Overview ............................................................................................................... 23 2.2 The nature of public health .................................................................................. 23 2.2.1 Health and its determinants ............................................................................ 23 2.2.2 What is public health? .....................................................................................