an exploration of the factors influencing public health … · influencing public health nutrition...
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AN EXPLORATION OF THE FACTORS
INFLUENCING PUBLIC HEALTH
NUTRITION POLICYMAKING IN
AUSTRALIA
Katherine Cullerton
Master of Public Health, Grad Dip of Nutrition & Dietetics,
B. App Sci (Biochem/Micro), B. App. Sci (H.Ec)
Submitted in fulfilment of the requirements for the degree of
Doctor of Philosophy
School of Exercise and Nutrition Science
Faculty of Health
Queensland University of Technology
2017
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“The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the
best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.”
Signature:
Date: 28/06/17
QUT Verified Signature
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Keywords
Policy, nutrition, politics, advocacy, lobbying, interest groups, influence, power,
framing, public health, qualitative research, social network analysis, policy making,
policy process.
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Abstract
Background
Poor dietary intake is the most important behavioural risk factor affecting
health in Australia and makes the greatest contribution to Australia’s total disease
burden. There is a growing body of evidence that demonstrates that population-wide
or systems approaches requiring public policy change are the most cost-effective
solutions to address nutrition-related diseases (Cobiac, Veerman, & Vos, 2013;
Sacks, Veerman, Moodie, & Swinburn, 2010; World Health Organisation, 2003).
Despite this, limited national public policy action to address nutrition-related
diseases has occurred in Australia. Little is known as to why these evidence-based
solutions have not been translated into policy action. Additionally, minimal research
has been undertaken on the roles of individuals and organisations in enabling or
preventing such policy action. The primary aim of this research is to explore the
influences on the public health nutrition policymaking process in Australia, and to
explicate strategies that could be used by poorly-resourced health organisations to
gain traction in public health nutrition policymaking. It is anticipated that this
research will transform the way nutrition practitioners in Australia, and other high-
income countries with democratic governments, understand nutrition policymaking
in order to increase their influence over it.
Method
This research is informed by political science policy process theories and uses
a mix of qualitative and quantitative approaches designed to comprehensively
investigate the influential factors on public health nutrition policymaking in
Australia. Four studies were undertaken: a systematic literature review examining
use of policy process theory in nutrition policy literature (Study 1); a meta-synthesis
review of the enablers and barrier to nutrition policy change in high income,
democratic countries (Study 2); a social network analysis of the nutrition policy
network in Australia (Study 3); and in-depth interviews (n=37) with key influencers
and decision-makers in nutrition policy in Australia (Study 4).
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Results
The results of Study 1 demonstrate that there has been limited use of political
science policy process theories in nutrition policy literature in high income,
democratic countries. Study 2 built on the findings of Study 1 by reviewing the
barriers and enablers to nutrition policy change in the dataset. The key findings were
that for policy change to occur there needs to be political will, and preferably public
will, for the proposed policy problem and solution. The review documents a range of
enablers to assist health professionals in increasing their influence over nutrition
policy change. Together these studies highlight that there is significant benefit in
nutrition advocates developing a greater understanding of the policy process theories
to deepen their knowledge of the policymaking process and to assist in refining their
advocacy practice.
A significant and unique aspect of this research is that it included the first
network analysis of a national nutrition policy network (Study 3). Data was collected
directly from a wide range of nutrition policy stakeholders including bureaucrats,
non-government organisations, academia, the political sector, the media and the food
industry. A significant finding of the network analysis is that the food industry has
the greatest capacity to influence nutrition policy in Australia compared to all other
professional categories. While this outcome has often been speculated anecdotally,
this is the first time, internationally, that the food industry’s influence has been
empirically proven. Furthermore, the data highlighted that nutrition professionals are
far removed from key policy decision-makers, with limited strategic relationships.
Another important finding of the network analysis was that two dominant brokers
were identified within the nutrition policy network. Their position in the network,
however, means their brokerage roles have different purposes and different levels of
influence for policymaking. Additionally, the results indicate that a strategic
brokerage position within a decision-making network is not enough to influence
nutrition policy in Australia.
The results from Study 4, the in-depth interviews with key influencers and
decision-makers in nutrition policy in Australia, highlight that influencing nutrition
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policy in Australia is a complex and dynamic process with a series of inter-related
barriers and enablers. The majority of the barriers fell under the overarching
categories of: lack of political will; issue and/or organisation not top of mind, and the
complexity of the policymaking process. Crucial contextual factors that impact on
nutrition policymaking in Australia were also identified including: a neoliberal
ideology; a pressurised, risk-averse government; and the general system of
governance. A suite of enablers for influencing political and public will were
identified, including: investing in relationships and intelligence gathering; framing
problems based on values and emotion, and using real stories to gain traction;
ensuring the issue is top-of-mind for decision-makers and the general public; and
finally, ensuring there is a skilled policy entrepreneur and a policy champion to take
the issue forward. As per Study 2, no single enabling strategy will deliver results on
its own, and equally, utilising all the documented enablers will not necessarily result
in policy change. However, the findings from this study and the literature review
highlight that the greater the number of enabling strategies undertaken, the more
likely advocates will be able to affect policy change.
Conclusion
The research identified several enablers of policy change not previously
identified in the policy process theories and the literature. Firstly, the difference
between, and the need for, both a policy entrepreneur and a policy champion.
Secondly, a focusing event was not identified as a key enabler for policy change.
Finally, although the enablers had broad consensus with the policy process theories,
the findings identified specific micro-level enablers, which provide clear guidelines
for individuals wishing to influence the nutrition policymaking process.
The research findings in this thesis demonstrate that there are a number of
strategies advocates can use to increase their power and influence in the policy
process. A simplified model - synthesised from all four studies plus the policy
process theories - was developed to serve as a practical guide for poorly-resourced
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organisations, outlining key steps that can be taken to increase an individual’s or
organisation’s influence in policymaking.
For nutrition advocates, the data from this thesis raises significant challenges to
current practice, and highlights the need for individuals and nutrition associations to
invest in relationships strategically, while maintaining credibility. Additionally, a
focus on gathering intelligence as well as developing and amplifying effective frames
will assist in providing politically palatable policy solutions when policy windows
open. Finally, ensuring unity when voicing the problems and solutions, and
mobilising members of associations or coalitions to invest in relationships, gather
intelligence and amplify the frame will further increase advocates’ influence over the
nutrition policy process. If nutrition associations and nutrition professionals as a
whole can make these changes, this research suggests they will greatly contribute to
the effectiveness of future advocacy efforts.
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Published or Submitted Manuscripts resulting from the
PhD Research
Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2015). Using political
science to progress public health nutrition: A systematic review. Public Health
Nutrition 19(11), 2070-78.
Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2016). Playing the policy
game: A review of the enablers and barriers to nutrition policy change. Public Health
Nutrition 19(14), 2643-53
Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2016). Exploring power
and influence in nutrition policy in Australia. Obesity Reviews 17(12), 1218-25
Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2017). Joining the dots:
The role of brokers in nutrition policy in Australia. BMC Public Health 17(1), 307
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Presentations and Published Abstracts resulting from the
PhD Research
Invited speaker
Cullerton, K. (2016). Expert presentation on Working the Politics and
Reframing Issues at the Food Insecurity in High-Income Countries: an International
Research Forum. Warwick University, United Kingdom.
Cullerton, K. (2016). Taking Breastfeeding Advocacy to the Politicians.
Plenary speaker at the National Breastfeeding Advocacy Seminar. Brisbane,
Australia.
Cullerton, K. (2016). ‘Who has the power in nutrition policy in Australia’.
Invited speaker at the University College London Energy Balance Forum. London,
United Kingdom
Cullerton, K. (2016). Nurturing relationships with the community and
government. Plenary Speaker at Australian Breastfeeding Association Queensland
Branch Conference, Brisbane.
Cullerton, K. (2016). Who has the power in nutrition policy and how did they
get it? Invited to present at Community and Public Health Interest Group Workshop
at 33rd Dietitians Association of Australia National Conference. Melbourne,
Australia.
Cullerton, K. (2015). Effective ways to influence Aboriginal and Torres Strait
Islander national nutrition policy. Plenary speaker at Food and Nutrition: the gap in
health for Aboriginal and Torres Strait Islander People Symposium. Charles Perkins
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Centre, Sydney - subsequently asked to join the leadership group for the Network for
Healthy Food and Nutrition Futures for Australia’s First Peoples.
Cullerton, K. (2015). Policy process models – windows of opportunity. Invited
to present at the Food and Nutrition Special Interest Group Workshop. Population
Health Congress, Tasmania, Australia.
Cullerton, K. (2015). Effective ways to influence Aboriginal and Torres Strait
Islander nutrition policy. Invited speaker at Kimberly Public Health Nutrition
Planning day, Western Australia, October 2015
Cullerton, K. (2015). Who has the power in nutrition policy in Australia.
Invited speaker at the Australian Prevention Partnership Centre Research Network
in Melbourne, October 2015
Cullerton, K. (2015). Who has the power in nutrition policy in Australia.
Invited speaker at Queensland Health Population Health division, December 2015,
Brisbane.
Abstracts accepted – oral presentations
Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2016). Power and influence
in nutrition policymaking in Australia, International Health Conference, London,
United Kingdom
Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2016). How to win friends
and influence policy, Dietitians Association of Australia Conference. Melbourne,
Australia.
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Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2015). Who has the power
in nutrition policy in Australia? Population Health Congress. Tasmania, Australia.
Cullerton, K. (2014). Nutrition policy is not progressing, do we need to look
elsewhere? Emerging Health Policy Conference. Sydney, Australia.
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Table of Contents
Keywords ................................................................................................................................ iii
Abstract ................................................................................................................................... iv
Table of Contents .................................................................................................................. xiii
List of Figures ...................................................................................................................... xvii
List of Tables ........................................................................................................................ xix
List of Abbreviations ..............................................................................................................xx
Glossary ................................................................................................................................ xxi
Acknowledgements .............................................................................................................. xxii
Introduction ...................................................................................... 1 Chapter 1:
1.1 Background .....................................................................................................................1
1.2 Significance, scope and definitions ................................................................................2
1.3 Theoretical context .........................................................................................................4
1.4 Personal context ..............................................................................................................4
1.5 Conclusion ......................................................................................................................6
1.6 Thesis structure ...............................................................................................................7
Theoretical background to nutrition policymaking ...................... 9 Chapter 2:
2.1 The public health nutrition context .................................................................................9
2.2 Australian nutrition policy context ...............................................................................11 2.2.1 Public policy .......................................................................................................11 2.2.2 The federal system ..............................................................................................13 2.2.3 Food and nutrition policy ...................................................................................14
2.3 Theories of the policymaking process ..........................................................................18 2.3.1 Multiple Streams Theory ....................................................................................20 2.3.2 The Advocacy Coalition Framework .................................................................23 2.3.3 Punctuated Equilibrium Theory .........................................................................27
2.4 Similarities and differences of the three policymaking theories ...................................32 2.4.1 Individuals ..........................................................................................................33 2.4.2 Collective action .................................................................................................34 2.4.3 Institutional setting .............................................................................................34 2.4.4 Time....................................................................................................................35 2.4.5 Policy stasis ........................................................................................................35
2.5 Strengths and limitations of the three policymaking theories .......................................36
2.6 The role of power and influence in policymaking ........................................................38 2.6.1 Using political science policy process theories in public health nutrition ..........41
2.7 Summary and implications ...........................................................................................42
Research Design and Methods ...................................................... 43 Chapter 3:
3.1 Aim ...............................................................................................................................43
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3.2 Research questions ....................................................................................................... 43
3.3 Research paradigm ....................................................................................................... 44
3.4 Research plan ............................................................................................................... 45
3.5 STUDY 1: A systematic literature review ................................................................... 48 3.5.1 Scope of the review............................................................................................ 49
3.6 STUDY 2: A meta-narrative ........................................................................................ 49 3.6.1 Data analysis: the adapted Framework Method ................................................. 50
3.7 STUDY 3: A network analysis study ........................................................................... 52 3.7.1 A background to network analysis ..................................................................... 53 3.7.2 Network theory .................................................................................................. 53 3.7.3 Method ............................................................................................................... 56 3.7.4 Analysis ............................................................................................................. 59 3.7.5 Limitations ......................................................................................................... 60
3.8 STUDY 4: In-depth interviews .................................................................................... 61 3.8.1 Structure of interviews ....................................................................................... 61 3.8.2 Sampling ............................................................................................................ 63 3.8.3 Participants ........................................................................................................ 63 3.8.4 Interview process ............................................................................................... 64 3.8.5 Analysis ............................................................................................................. 64 3.8.6 Limitations ......................................................................................................... 66
3.9 Methodological Rigour ................................................................................................ 67 3.9.1 Reflexivity ......................................................................................................... 67 3.9.2 Triangulation ...................................................................................................... 67 3.9.3 Reliability check ................................................................................................ 68 3.9.4 Use of verbatim quotes ...................................................................................... 69
3.10 Ethical and Health and Safety approvals ..................................................................... 69
Systematic literature reviews ......................................................... 71 Chapter 4:
4.1 Paper 1: Using political science to progress public health nutrition: a systematic
review ..................................................................................................................................... 74
4.2 Paper 2: Playing the policy game: a review of the barriers and enablers of nutrition
policy change .......................................................................................................................... 99
4.3 Summary of systematic literature reviews ................................................................. 127
Social network analysis ................................................................ 128 Chapter 5:
5.1 Paper 3: Exploring power and influence in nutrition policy in Australia .................. 132
5.2 Paper 4: Joining the dots: the role of brokers in nutrition policy in Australia ........... 151
5.3 Summary of the social network analysis papers ........................................................ 170
The barriers to nutrition policy change in Australia ................ 172 Chapter 6:
6.1 Interview participants ................................................................................................. 173
6.2 Barriers to nutrition policy change ............................................................................. 174
6.3 Lack of political will .................................................................................................. 179 6.3.1 Beliefs .............................................................................................................. 179 6.3.2 Lack of public will ........................................................................................... 184 6.3.3 Lack of leadership ............................................................................................ 186 6.3.4 Power and influence of the food industry ........................................................ 193 6.3.5 Abdication of responsibility ............................................................................. 195
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6.4 Name/issue not top-of-mind .......................................................................................199 6.4.1 Competing for the attention of policymakers and the public ...........................199 6.4.2 Complex, multi-faceted problem ......................................................................202
6.5 Complexity of the policymaking process ...................................................................204 6.5.1 Evidence is only one factor ..............................................................................205 6.5.2 Priority of other portfolios ................................................................................206 6.5.3 Government silos ..............................................................................................207
6.6 Summary .....................................................................................................................208
6.7 Discussion ...................................................................................................................209 6.7.1 Policymakers accepting the frame: the policy monopoly .................................211 6.7.2 Ability of interest groups to organise opposition .............................................216 6.7.3 Democratisation of knowledge and the amplification of the ‘expert’ ..............221
Enablers for increasing nutrition policy action in Australia .... 225 Chapter 7:
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7.1 Invest in relationships .................................................................................................230 7.1.1 Intelligence gathering .......................................................................................231 7.1.2 Develop relationships at different levels ..........................................................231 7.1.3 Continuous engagement ...................................................................................233 7.1.4 Friendships .......................................................................................................234 7.1.5 Build/mobilise coalitions ..................................................................................235
7.2 Issue and/or organisation top-of-mind ........................................................................237 7.2.1 Able to create noise ..........................................................................................238 7.2.2 Appealing to beliefs ..........................................................................................242
7.3 Credibility ...................................................................................................................244 7.3.1 Representing many voices ................................................................................245 7.3.2 Trust .................................................................................................................245 7.3.3 Respect .............................................................................................................247 7.3.4 Expertise ...........................................................................................................248
7.4 Understand the policymaking process ........................................................................249 7.4.1 Increase/demonstrate public will ......................................................................249 7.4.2 Be alert for policy windows .............................................................................251 7.4.3 Play the long game ...........................................................................................253 7.4.4 Consider a different policy venue .....................................................................254
7.5 Additional characteristics for influential individuals ..................................................255 7.5.1 Communication skills .......................................................................................256 7.5.2 Having political clout .......................................................................................258
7.6 Discussion ...................................................................................................................259 7.6.1 Invest in relationships .......................................................................................260 7.6.2 ‘Irrational’ decision-making .............................................................................265 7.6.3 Your name/issue top-of-mind ...........................................................................269 7.6.4 Policy champion versus policy entrepreneur ....................................................272
7.7 Summary .....................................................................................................................275
Conclusion ..................................................................................... 277 Chapter 8:
8.1 Summary of key outcomes .........................................................................................278
8.2 Significance of outcomes ............................................................................................284 8.2.1 Previous concepts confirmed ............................................................................284
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8.2.2 New contributions to knowledge ..................................................................... 285
8.3 Synthesis of the findings and recommendations for advocates .................................. 287 8.3.1 Awareness of the policymaking environment .................................................. 292 8.3.2 Invest in relationships strategically .................................................................. 293 8.3.3 Develop a clear, unified solution ..................................................................... 296 8.3.4 Develop the skills/traits of a policy entrepreneur ............................................ 297 8.3.5 Reframe issues to appeal to values and beliefs ................................................ 298 8.3.6 Secure a policy champion ................................................................................ 299 8.3.7 Amplify the frame ............................................................................................ 300 8.3.8 Increase public will .......................................................................................... 302
8.4 Recommendations for further research ...................................................................... 304
8.5 Concluding statement ................................................................................................. 305
Appendices .................................................................................... 307 Chapter 9:
9.1 Sabatier’s criteria for a promising theory of the policy process ................................ 307
9.2 Resources of the ACF ................................................................................................ 308
9.3 Policy change – Punctuated Equilibrium Theory ....................................................... 309
9.4 Network analysis instrument ...................................................................................... 310
9.5 Interview guide .......................................................................................................... 312
References ...................................................................................... 313 Chapter 10:
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List of Figures
Figure 2.1. Diagrammatic representation of thesis ................................................. 8
Figure 2.1. Burden of disease attributable to 15 leading factors in 2010,
expressed as percentage of Australia DALYs (Institute for Health
Metrics and Evaluation, 2013a) ................................................................ 10
Figure 2.2: Adaption of Lasswell’s stages as the Policy Cycle (Palmer &
Short, 2000, p. 32) ...................................................................................... 18
Figure 2.3: Adaption of Kingdon’s Multiple Streams Theory and the
components that increase the chance of a policy window opening
(Zahariadis, 2007) ...................................................................................... 22
Figure 2.4: Advocacy coalition flow diagram (Weible, Sabatier, &
McQueen, 2009, p. 123) ............................................................................. 25
Figure 2.5: Policy stasis and the key concepts of the Punctuated
Equilibrium Theory ................................................................................... 28
Figure 3.1: Diagram of research design ................................................................. 46
Figure 4.1. PRISMA 2009 Flow diagram ............................................................... 80
Figure 4.2 Frequency of eligible nutrition policy articles (Jan 1986- Dec
2014) ............................................................................................................ 83
Figure 4.3 Nutrition policy topics ........................................................................... 84
Figure 4.4 Ebb and flow analysis of nutrition policy topics ................................. 84
Figure 4.5. Comparison of nutrition policy papers published and those
that use political science policy process theory (PPT) ............................ 85
Figure 4.6. PRISMA 2009 Flow diagram ............................................................. 103
Figure 4.7. The barriers and enablers of political and public will .................... 106
Figure 5.1. Cluster analysis of the nutrition policy network in Australia ........ 140
Figure 5.2. Comparative direct relationships between interest groups and
decision-makers ........................................................................................ 142
Figure 5.3 Relative capacity of stakeholder influence on decision-makers ...... 143
Figure 5.4. Network analysis of the overall nutrition policy network in
Australia.................................................................................................... 159
Figure 5.5. Direct ties from Brokers 1 and 2 ...................................................... 160
Figure 6.1. Barriers to nutrition policy change ................................................... 176
Figure 6.2. Summary of barriers to nutrition policy change ............................. 177
Figure 6.3: Representation of the barriers for nutrition policy change. ........... 178
Figure 7.1: Enablers to nutrition policy change .................................................. 227
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Figure 7.2 Summary of enablers for nutrition policy change ............................ 228
Figure 7.3: Representation of the enablers for nutrition policy change. .......... 229
Figure 7.4. Personal traits of influential advocates ............................................. 256
Figure 8.1 Model for increasing political will for nutrition policy change ....... 291
Figure 9.1: Policy change via the Punctuated Equilibrium Theory adapted
from Stachowiak (2013). .......................................................................... 309
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List of Tables
Table 2.1. A sample of Australian national government policies and
programs which include strategies targeting the food and
nutrition environment (1992-2013) .......................................................... 16
Table 2.2 Belief types in the ACF (Jenkins-Smith & Sabatier, 1993) ................. 26
Table 2.3. Comparison of the three theories of the policy process (Boin,
McConnell, & Hart, 2008; John, 2013; Sabatier, 1991; Schlager,
2007; Zahariadis, 2007) ............................................................................. 33
Table 2.4. Strengths and limitations of the three policymaking theories
(Boin et al., 2008; John, 2013; Kingdon, 1995; Mucciaroni, 1992;
Sabatier, 1991; True et al., 2007; Zahariadis, 2007) ............................... 36
Table 3.1 Research objectives and methods .......................................................... 47
Table 3.2 Categories and cases to be used in Study 4 (Halpin, 2014) ................. 58
Table 4.1 Summary of influential theories of the policymaking process ............ 78
Table 4.2 Inclusion and exclusion criteria for the identification of journal
articles reporting on policy research ........................................................ 81
Table 4.3 Summary of influential theories of the policy process (Cullerton
et al., 2016c) .............................................................................................. 101
Table 4.4. Inclusion and exclusion criteria for the identification of journal
articles reporting on policy research ...................................................... 104
Table 5.1. Seed sample for network analysis ....................................................... 135
Table 5.2. Categorisation of participants ............................................................. 136
Table 5.3. Number of respondents in each profession and response rates ....... 139
Table 5.4. Measure of centrality [24] .................................................................... 154
Table 5.5. Number of respondents in each profession and response rates ....... 157
Table 5.6 Betweenness centrality/ degree centrality of nutrition policy
network ..................................................................................................... 158
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List of Abbreviations
Abbreviation
ACF Advocacy Coalition Framework
PET Punctuated Equilibrium Theory
MST Multiple Streams Theory
PHAA
FANSIG
Public Health Association of Australia Food and Nutrition Special
Interest Group
DAA Dietitians Association of Australia
NATSINSAP National Aboriginal and Torres Strait Islander Nutrition Strategy
and Action Plan
OECD Organisation for Economic Co-operation and Development
SNA Social Network Analysis
NACCHO National Aboriginal Community Controlled Health Organisation
NHMRC National Health and Medical Research Council
WHO World Health Organisation
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Glossary
Terms Definition
Policy subsystem Defined by policy topic, geographic scope and
influencing actors.
Actors A participant in the policy process, may be an
individual or an organisation.
Institutions The arena in which policymaking occurs, for example,
organisations but also laws, rules and norms.
Elites A small group of people who control a disproportionate
amount of wealth or political power.
Framing The method of selecting an aspect of a perceived reality
to make it more salient, in such a way as to promote a
particular problem definition, moral evaluation, causal
interpretation, and/or treatment recommendation.
Reframing The method of changing the meaning of a concept and
thereby changing minds.
Structural position The location of an actor in a social network analysis.
This position often impacts an outcome, such as
performance, of that actor.
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Acknowledgements
I would firstly like to acknowledge the participants in this study, particularly
those who participated in the in-depth interviews. Thank you for your generosity of
time, frankness and insight into policymaking, this thesis would not have been
possible without it.
I would like to acknowledge the collective dedication of my supervisory team.
Special thanks to my principal supervisor, Professor Danielle Gallegos for your
supervision of this thesis over the years. For the guidance, trust, enthusiasm and
support you have provided for me, I am eternally grateful. I am also indebted to Dr
Timothy Donnet who introduced me to the world of social network analysis. Thanks
for your ongoing enthusiasm for my dataset and your insight into it. Thank you also
to Professor Amanda Lee for your expertise and providing a real-world lens on the
findings and for always being on the lookout for opportunities for me.
I was fortunate to complete this work alongside some wonderful PhD students
at QUT and interstate who provided support, mentoring and a laugh when needed,
thanks to you all, especially for the coffee breaks! Also thanks to Dr Martin Reese
from ALLS for his advice and enthusiasm and to Dr Christina Houen for editing this
thesis according to the guidelines of the Institute of Professional Editors (IPEd).
Particular thanks to the NHMRC for providing me with a Postgraduate Scholarship,
without which this research would not have been able to occur.
Most importantly, I would like to thank my family for their love, support and
encouragement over the period of this thesis and beyond. To my parents, thank you
for instilling a love of learning in me and for babysitting when needed! To my
partner Jonathan, thank you for putting up with the ups and downs of this thesis,
reading and re-reading many drafts and your constant support throughout the years.
Also a special thank-you to my two children, Jessica and Daniel, who have put up
xxiii
with a mummy who was often preoccupied reading literature or editing a draft, when
I should have been playing with them!
1
Introduction Chapter 1:
This chapter provides a background to public health nutrition and
policymaking in Australia (section 1.1) as well as the significance and scope of this
research (section 1.2). The theoretical context (section 1.3) and the personal context
(section 1.4) of the research are detailed followed by the potential impact of the
research (section 1.5). Finally, section 1.6 includes an outline of the remaining
chapters of this thesis.
1.1 BACKGROUND
Poor dietary intake is the most important behavioural risk factor affecting
health in Australia, contributing to 14% or more of Australia’s total disease burden,
which is double that of cigarette smoking (Institute for Health Metrics and
Evaluation, 2013b; National Health and Medical Research Council, 2013). A range
of effective, comprehensive strategies, from individual behaviour change approaches
to population-wide approaches, can be utilised to address nutrition-related diseases.
Current indications show that population-wide approaches are the most cost-effective
of the two, and potentially provide savings for both the Australian and global health
care systems (Cobiac et al., 2013; Colchero, Popkin, Rivera, & Ng, 2016; Sacks et
al., 2010; Waterlander, de Boer, Schuit, Seidell, & Steenhuis, 2013; World Health
Organisation, 2003). However, despite the evidence of the potential effectiveness of
these population-wide approaches to nutrition-related disease, limited federal policy
action and/or resources is directed to this area in Australia (Department of Health,
2016a; Lee, Baker, Stanton, Friel, & Weightman, 2013; Swinburn & Wood, 2013).
Implementing nutrition strategies at a population level is described as taking a
public health nutrition approach. Public health nutrition has been defined as the
“promotion and maintenance of nutrition-related health and wellbeing of populations
through the organised efforts and informed choices of society” (World Public Health
2
Nutrition Association, 2006). In 2016-17, the Portfolio of Health and Ageing
(Department of Health, 2016a) in Australia dedicated just 1.5% of its total budget to
spending for prevention (which includes nutrition among other areas). This level of
spending has declined since the mid-2000s when spending peaked at 2.2%, and is
significantly lower than most OECD countries (Willcox, 2014). This insignificant
expenditure could be indicative of a public policy focus on individual behaviour
change and personal responsibility that accompanies the philosophical approach of
the majority of neoliberal governments (Bambra, Fox, & Scott-Samuel, 2005; Lin &
Fawkes, 2007).
In Australia, public policies are those policies the government is primarily
responsible for and they are essential in determining where resources are directed
(Palmer & Short, 2000). Policy is defined as “a program of action (or inaction) of a
government to achieve specific goals” (Clavier & De Leeuw, 2013, p. 6). Public
policymaking is rarely a linear process and is formulated by interactions between
politicians, advisers, interest groups and public servants, as well as a range of other
participants (Bridgman & Davis, 2004). Many of the participants in the policymaking
process represent interest groups who work to promote particular outcomes for their
corporations, alliances, non-government organisations or unions. To understand why
nutrition is not addressed more fully in Australian public policy, the nutrition policy
process needs to be better understood, including how it is influenced and by whom.
In turn, this will allow stakeholders, especially those with limited resources, to
increase their capacity to advocate for political change.
1.2 SIGNIFICANCE, SCOPE AND DEFINITIONS
In public health nutrition, there are a range of diverse interest groups vying to
influence policy in Australia, including but not limited to: the different sectors of the
food and beverage industry; public health and foodservice associations and agencies;
non-government organisations; national, state and territory government departments
of health; agriculture; and consumer affairs. These interest groups, in different ways
and for different motives, seek to influence the Australian food and nutrition system
and what Australians eat through various advocacy strategies (Chapman, 1990). Very
3
little, however, has been written about this process of influence within the Australian
context.
Advocacy is used by these interest groups to generate change through a number
of mechanisms. It can enable advocates to gain access to, and have a voice in, the
decision-making process, and can change the power relationships between decision-
makers and the people their decisions will affect (Cohen, De la Vega, & Watson,
2001). Advocacy is defined as “active interventions by organisations on behalf of the
collective interests they represent, that have the explicit goal of influencing public
policy or the decisions of any institutional elite” (Onyx, Dalton, Melville, Casey, &
Banks, 2008, p. 632). The terms ‘advocacy’ and ‘lobbying’ often have the same
meaning and are used interchangeably, although advocacy tends to be used by health
professionals and lobbying tends to be used by private industry groups. A key
element of advocacy is the focus on collective interests, rather than the focus on
private benefits by lobbying (Onyx et al., 2008). It is important to note that this
definition does not exclude the private sector from advocacy, as there are many
examples of the private sector advocating for collective interests; for example, the
Australian Food and Grocery Council (AFGC). For the purpose of this document, the
terms lobbying and advocacy will be used interchangeably to describe the process of
influencing government policy in order to procure a specific outcome.
In Australia, there have been a small number of public health advocates
working at influencing public health policy over the years, however their practice is
often via an intuitive way of working rather than using an established evidence base
to achieve the maximum result for their efforts (Nutbeam & Boxall, 2008).
Internationally, a wide range of literature documents a variety of strategies for
influencing policy and/or decision-making in different fields, although comparatively
little has been written specifically about influencing public health policy, with even
less focus on the role of interest groups and advocates in influencing public health
nutrition policy (Bassett, 2003; Chapman, 2008; Jenkin, Signal, & Thomson, 2012).
Most of the evidence supporting this particular area has come from the United States
of America, where systems of government, the food system, the role of interest
4
groups and the historical contexts are significantly different to Australia, so it is
difficult to predict the potential transferability of findings. This gap in the research
and the transferability of the lessons from the literature will be explored as part of
this research.
1.3 THEORETICAL CONTEXT
An effective theory of the policy process would “explain goals and perceptions,
actions and events, among potentially hundreds of stakeholders in the process,
leading to specific sets of policy deliverables and outcomes” (Clavier & De Leeuw,
2013, p. 26). This study is particularly interested in theories of policy change. Policy
change theories usually focus on incremental policy change, significant policy
change or both, and identify the factors that will lead to this. Unfortunately, no single
theory offers a comprehensive description of the policymaking process, and there is a
lack of agreement over the precise components contributing to significant policy
change (Smith & Katikireddi, 2013). However, each theory offers its own unique and
valuable insights into the policy process. To gain a greater understanding of the
factors that may influence nutrition policymaking in Australia, this study will explore
and utilise three different policy process theories: the Multiple Streams Theory; the
Advocacy Coalition Framework; and the Punctuated Equilibrium Theory. While
there are many theories available that can provide insight into policymaking, these
three theories are the most widely cited internationally; they all focus on agenda
setting and policy change; they have complementary strengths; and they are
particularly pertinent to health policy development in Australia. By applying these
theories, different elements can be explored, and the possibility of whether any or all
of these theories are applicable to the Australian nutrition policymaking context can
be determined.
1.4 PERSONAL CONTEXT
Policymaking is a value-laden activity, and research on policymaking is no
different; as a result, researcher reflexivity is essential. Reflexivity is the process of
the researcher reflecting continuously on how their own actions, values and
5
perceptions impact upon the research setting and how this can affect data collection
and analysis (Gerrish & Lacey, 2006). Throughout the research process, I have been
undertaking reflexivity through regular entries into a research diary and debriefing
with my supervisors to ensure transparency and accountability and therefore reduce
potential research bias.
I will now outline my personal biography and values so the reader can better
understand the development of this research. I am a middle-class, Australian female
with dietetic and public health qualifications. I have worked in the field of
community and public health nutrition for the past 17 years, and this research is an
outcome of my frustration that public health nutrition solutions critical to the health
of Australians are not being acted on at a political level. This research topic
specifically grew out of my four years as the national policy officer working on the
National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan.
During this time, I was discouraged by the lack of evidence-based guidance for
advocates with limited resources, that is, time, money and influence. Simultaneously,
I watched the advocacy skills of certain representatives of the food industry with
envy and awe, and wondered how I, and my colleagues could advocate in the same
way and at the same level.
Adding to my curiosity around advocacy was the insight into ‘the other side’
that I have gained from talking with my partner, who has worked in advertising for
the past 18 years. I would often hear revealing stories of food company marketing
executives and political lobbyists. This made me realise that evidence was not the
whole story behind policy decisions, and how you framed your argument, the
influence of the general public and who you knew were powerful elements.
However, these strategies appeared difficult to undertake for an organisation with
only one or two advocates, which is often the case in public health nutrition. It also
made me realise that individuals from sectors outside our own hold powerful
information about effective routes and strategies of influence that would be useful for
nutrition advocates. In nutrition we have a tendency to demonise those with opposing
arguments. I wanted to use this research to access and value the opinions of all
6
players in the nutrition policy space. This will enable the exploration of strategies
and routes of influence that are most effective in Australian nutrition policymaking,
with a particular emphasis on what can be done by nutrition advocates with limited
resources.
1.5 CONCLUSION
This document outlines the research undertaken to add to the limited evidence
on the influential factors impacting on the public health nutrition policymaking
process in Australia. This work is timely, given that a prior federal government
commitment to developing a national nutrition policy in 2011(Department of Health,
2013) has now been watered down to a commitment to developing a national
nutrition framework. Even with this attenuation, limited progress has occurred on
this framework, with no end date in sight. The proposed research will use a
qualitative approach to understand the Australian nutrition policymaking process and
how best to influence it, particularly for health organisations with limited resources.
It will determine: whether political science policy process theories are applicable to
public health nutrition policymaking in Australia; identify key enablers and barriers
for influencing nutrition policy in Australia; and map individual positions of power
and influence in the Australian nutrition policy scene.
This research is significant because it aims to transform the way nutrition
practitioners in Australia and those working in other high-income countries with
democratic governments understand nutrition policymaking in order to increase their
influence over it. To date, little is known about the roles of individuals and
organisations and how they influence nutrition policy in Australia. This research will
identify these individuals and organisations and the strategies of influence they use.
It will also be the first study internationally to use network analysis to identify
influential actors in the nutrition policy space. The results and methodologies used
could be extrapolated to wider public health issues in Australia and other high-
income countries with similar neoliberal governments.
7
1.6 THESIS STRUCTURE
This thesis by published papers is prepared in accordance with the Queensland
University of Technology Thesis by Published Paper Guidelines. The thesis
comprises eight chapters arranged to reflect the emergence or flow of ideas
throughout the PhD program (Figure 1.1). Chapters that have been published as
journal articles, or are in submission, somewhat overlap in terms of theoretical
background and implications. Chapter 1 provides an overview of the research
background and outlines the purpose of the research and its significance. Chapter 2
sets the context of this research by providing a detailed overview of the background
evidence that informs this thesis. Chapter 3 provides an outline of the research design
and methods used for the four studies. Chapters 4 and 5 include each of the papers
derived from this thesis that are currently published, accepted or under review for
publication. The published papers include two systematic reviews examining use of
policy process theory in public health nutrition policy papers, and the subsequent
barriers and enablers to policy change identified in these papers. Two further papers
(one accepted and one under review) highlight the results from the network analysis
of the nutrition policy network in Australia. The findings from in-depth interviews
examining the key barriers and enablers of nutrition policy change with key
influencers and decision-makers are presented in Chapters 6 and 7. Finally, Chapter
8 provides a summary of the four studies, a synthesis of the research findings and
recommendations for advocates and the nutrition profession. It concludes with
proposed recommendations for further research and translation.
8
Introduction,
overview and
purpose of research
Two published systematic literature
reviews. Paper 1: Use of policy
process theories in nutrition policy
papers. Paper 2: Barriers and
enablers to nutrition policy change
Results and discussion of social network
analysis of nutrition policy in Australia
presented as Paper 3 examining direct
access to decision-makers (published) and
Paper 4 examining brokers (under review).
Results and discussion of in-depth
interviews of influencers and
decision-makers (n=37) on the
barriers to nutrition policy change
in Australia
Summary of the four studies,
synthesis of the findings and
future directions
01 CHAPTER
Overview of nutrition policy in
Australia and policy process
theories
Research design and
methods used for the
four studies
Results and discussion of in-depth
interviews with influencers and
decision-makers (n=37) on the
enablers to nutrition policy
change in Australia
STUDY 1 & 2 STUDY 3 STUDY 4
03 CHAPTER
04 CHAPTER
05 CHAPTER
06 CHAPTER
08 CHAPTER
07 CHAPTER
02 CHAPTER
Figure 2.1. Diagrammatic representation of thesis
Chapter 2: 9
Theoretical background to Chapter 2:
nutrition policymaking
This chapter provides an overview of the public health nutrition policy context
in Australia (section 2.1) and the policymaking process (section 2.2), in particular
three political science theories that explain the policymaking process: the Multiple
Streams Theory; the Advocacy Coalition Framework; and the Punctuated
Equilibrium Theory (section 2.3-2.5). Framing will also be examined, as will theories
around power and influence (section 2.6). A summary of this chapter is provided in
section 2.7.
2.1 THE PUBLIC HEALTH NUTRITION CONTEXT
Public health nutrition takes into account the impact of the whole food system,
that is, food production, distribution and consumption, on the nutritional status and
health of the population, together with attitudes, behaviours, knowledge and skills in
the wider community (National Public Health Partnership, 2003). There have been
significant changes in dietary habits and physical activity levels worldwide as a
result of urbanisation, industrialisation, economic development and globalisation
(World Health Organisation, 2003). This change has increased the burden of disease
due to total dietary risks and high body mass index, which has now been estimated in
Australia to be at least 14% of the total disease burden, double that due to cigarette
smoking (Figure 2.1) (Institute for Health Metrics and Evaluation, 2013a).
10
Figure 2.1. Burden of disease attributable to 15 leading factors in 2010, expressed as
percentage of Australia DALYs (Institute for Health Metrics and Evaluation, 2013a)
Analyses of public health nutrition interventions, which target the population,
show that many interventions are cost-effective; that is, the intervention is judged to
be relatively inexpensive, yet has the potential to reduce the disease burden
substantially (Cobiac et al., 2013; Waterlander et al., 2013). Targeting the population
can bring larger and more sustained benefits at a lower cost to society than
individually targeted dietary interventions (Cobiac et al., 2013). Some examples of
population interventions most likely to be cost-effective include: the reduction of salt
in processed food; easy-to-understand, mandatory front-of-pack food labelling; and
an additional tax on unhealthy foods, particularly sugar-sweetened beverages
(Cobiac et al., 2013; Colchero et al., 2016; Eyles, Mhurchu, Nghiem, & Blakely,
11
2012; Sacks et al., 2010; Veerman, Sacks, Antonopoulos, & Martin, 2016; Wilson,
Blakely, Foster, Hadorn, & Vos, 2012).
Despite the cost-effectiveness of these interventions and the high profile nature
with which nutrition-related health issues are repeatedly referenced in the media and
public debate, few have been taken up by policymakers to be implemented at a
population level in Australia (Gollust, Niederdeppe, & Barry, 2013; Niederdeppe,
Porticella, & Shapiro, 2012; Shelley, Ogedegbe, & Elbel, 2014). A pervasive view
amongst public health nutritionists is that this inaction may be because many of these
interventions require the active engagement of private industry (Caraher & Coveney,
2004; Nestle, 2006; Swinburn & Wood, 2013; Vogel, 2010). The belief is that food
industry leaders are reluctant to make any changes to their modus operandi, and
prefer to advocate for interventions that focus on individual responsibility for
changing behaviour, usually through increasing physical activity rather than
improving nutritional status.
2.2 AUSTRALIAN NUTRITION POLICY CONTEXT
2.2.1 Public policy
In Australia, public policy is the process by which governments make decisions
in a consistent manner and in the perceived best interests of society as a whole
(Lester, 1994, p. 11). Public policymaking is rarely a linear process and is formulated
by interactions and negotiations between politicians, interest groups, advisers, and
public servants, plus an array of other participants (Bridgman & Davis, 2004).
Typically, nutrition practitioners have focused on policy documents as the
manifestation of a policy. However, policy action or inaction may or may not involve
documentation. This is particularly the case with policy inaction, where decisions
may be made behind closed doors. It is critical that nutrition practitioners realise
there is much more to public policy than documents fixed in time and content
(Clavier & De Leeuw, 2013). This narrow view of public policy diverts attention
from the complex and political nature of policymaking.
12
Public policy can be defined as “a program of action (or inaction) of a
government to achieve specific goals” (Clavier & De Leeuw, 2013, p. 6). This
definition prioritises the role of the government in making policy through a vertical,
hierarchical process. An alternative view of public policy is provided by Colebatch
(2006, pp. 39-40) who identifies three contrasting views of policy. The first view is
that policy is an ‘authoritative choice’ as described in the prior definition by Clavier
and De Leeuw, whereby policy is an expression of the electoral and program
priorities of ministers. The second view is policy as ‘structured interaction’, this view
does not assume a single decision-maker, addressing policy problems, instead it
recognises the wide range of actors that exist, the diversity of their understanding of
the problems, the ways in which they interact with each other and the outcomes of
this interaction (Colebatch, 2006). Government is seen as responding to the actions
of other participants in order to determine what issues will be considered and what
actions will be taken in response. The final view is policy as ‘social construction’,
which acknowledges the multiple ways in which problems are framed and
appropriate responses are devised and accepted (Colebatch, 2006).
Irrespective of the different definitions and views of public policy, policy
instruments are significant in the policymaking process as they are the techniques
through which governments attempt to attain their goals (Linder & Peters, 1990).
Commonly used policy instruments include:
Distributive policies: focusing on distributing new resources, for example,
providing diesel rebates for farmers;
Redistributive policies: modifying the distribution of existing resources, for
example, changing the conditions required to receive welfare benefits, and;
Regulatory policies: specifying conditions or constraints for individual or
collective behaviour, for example, food labelling requirements.
(Lowi, 1964)
13
Although this is a simplified way of categorising types of policy action, Lowi
(1964) believed that understanding the type of policy instrument allowed the
policymaker to predict the sorts of conflict that would precede the policy’s
enactment, and what sort of conflict might arise after the policy is adopted and
implemented. For participants in the policy process, this highlights that different
types of policy action will be associated with different levels of political conflict, and
explains why some groups potentially do better than others in achieving policy
change.
2.2.2 The federal system
The Australian government operates as a federal and decentralised system,
with power shared between the national government, state/territory governments and
local councils. Nationally, the Australian Department of Health is responsible for the
development and evaluation of national nutrition policy, resources and initiatives.
Each state and territory has a health department that is responsible for acute care in
hospitals (Australian Institute of Health and Welfare, 2012). These devolved
departments also have varying capacities to develop, implement and evaluate
nutrition policies, strategies and action plans in community and preventative health.
Local government in Australia is responsible for managing food safety in
commercial food premises and creating healthy environments for local communities,
although the level of engagement varies nationally (Australian Institute of Health and
Welfare, 2012). Constitutionally, the states have residual powers for health and the
federal government can only legislate or regulate in a policy area if it is mentioned in
the constitution. However, where the federal government does have power it
overrides the states and territories. Federal power has grown over the years, and
consequently it tends to assume a leadership role in areas of legislation and national
significance for population health (Duckett, 2004).
Of greatest significance is that through its use of constitutional powers,
including powers over corporations and taxation, the Australian Government is able
to legislate regulatory intervention for food producers, processors and retailers
(Crammond et al., 2013). However, this process is not simple. Within the federal
14
government, responsibility for food is divided between many portfolios, including
the Agricultural, Trade and Health portfolios. Furthermore the food standard
regulation system has been developed through an intergovernmental agreement
between the Australian Government, the States and Territories, and a treaty between
Australia and New Zealand which further adds to the complexity and difficulty in
progressing policy change (Crammond et al., 2013).
2.2.3 Food and nutrition policy
Until 1992, the focus of national food and nutrition activity in Australia was
educational and focused on individual behaviour change (Powles, Wahlqvist,
Robbins, King, & Hicks, 1992). This changed in 1992 with the release of Australia’s
first national Food and Nutrition Policy, which represented a change in focus away
from individual behaviour change towards a population health approach. This
national policy was developed to encourage and support action through the entire
food system, in order to achieve better nutrition for all Australians, especially those
most disadvantaged (Australian Institute of Health and Welfare, 2012, p. 52). In the
subsequent years, state and territory governments also released their own population-
focused nutrition policies reflecting the principles of the national policy, with
Tasmania and Victoria leading this movement (Lee et al., 2013). Unfortunately,
despite the system-wide focus, little action targeting the food environment occurred.
The majority of the outputs during phase one (1992-1996), were haphazard and
focussed on individual behaviour change, the development of teaching and learning
resources, and some joint promotional work with industry groups (Catford, 2000;
Department of Health and Family Services, 1998).
The Strategic Intergovernmental Nutrition Alliance (SIGNAL) was established
in 1998 to oversee the development of a national public health nutrition strategy
which would provide the implementation framework for phase two of the 1992
national Food and Nutrition Policy (Australian Institute of Health and Welfare,
2012). This was unique; never before had a nationally coordinated group
representing the states, territories and federal government authorities been
established. Their role was to oversee the development and implementation of a
15
national nutrition strategy with a formal reporting structure that fed back to the
Health Ministers’ Advisory Council via the National Public Health Partnership. Eat
Well Australia: An Agenda for Action in Public Health Nutrition 2000-2010 and the
companion document the National Aboriginal and Torres Strait Islander Nutrition
Strategy and Action Plan (NATSINSAP) 2000-2010, were released in 2001, and
achieved, for the first time, concerted joint commitment between the states,
territories and the federal government to achieve the objectives laid out in the two
documents, despite little funding (Catford, 2000). Following this, all states and
territories released their own strategic directions in nutrition which echoed the
priority action areas of the national documents (Lee et al., 2013). Whilst some gains
were made federally during this time, such as interventions to promote fruit and
vegetable consumption (SIGNAL, 2001) and the Remote Indigenous Stores and
Takeaway project (Gregoriou & Leonard, 2010), the coordinated federal action only
lasted until 2006, when SIGNAL and its parent committee the National Public Health
Partnership was dissolved by the Liberal-National government (Yeatman, 2008).
Eat Well Australia and NATSINSAP continued beyond 2006, officially
finishing in 2010, and were not replaced with any nationally coordinated strategy.
Regrettably, no national evaluation of the impact of Eat Well Australia occurred. An
evaluation of the NATSINSAP was undertaken by the Department of Health in 2010;
however, this evaluation was only released publicly in 2015 after a freedom of
information request (Lock, 2015). The national Food and Nutrition Policy, Eat Well
Australia and NATSINSAP were not the only policy documents released during this
time. Numerous national health policy documents were launched which included
public health nutrition strategies targeting the food and nutrition environment (see
Table 2.1). On face value, all of these documents cite credible evidence for the
effectiveness of the included strategies. While there was and continues to be
impressive policy action occurring at the state level, these strategies continue to be
overlooked or implemented on an ad hoc basis by the federal government with
investment instead focusing on individual behaviour change strategies (Lin &
Fawkes, 2007; Swinburn & Wood, 2013).
16
Table 2.1. A sample of Australian national government policies and programs which
include strategies targeting the food and nutrition environment (1992-2013)
Date Policy/program End date
1992 Australia’s Food and Nutrition Policy 2001
1996 National Public Health Partnership – strategic response to public
health priorities. Priority areas – healthy weight, child public
health, information development & workforce development
2006
1996 National health priority areas.
Cardiovascular health, cancer, injury, mental health, diabetes
mellitus (1997), obesity (1998)
2006
1997 Acting on Australia’s Weight: a strategic plan for the prevention of
overweight and obesity
2006
2001 Eat Well Australia: an agenda for action for public health nutrition
(2000-2010)
2010
2001 National Aboriginal and Torres Strait Islander Nutrition Strategy
and Action Plan
2010
2005 National Chronic Disease Strategy.
Priority areas: asthma; cancer; diabetes; heart, stroke and vascular
disease; arthritis; and osteoporosis
No set
end date
2008 National Partnership Agreement on Preventative Health
State and territory based programs for children and workplaces
targeting fruit and vegetable intake, obesity, alcohol and smoking.
2018
(was
abolished
in 2014)
2009 Food and Health Dialogue
Partnership between government, health groups and food industry
to encourage voluntary reformulation of food
No set
end date
2009 National Preventative Health Strategy
Priority areas: obesity, tobacco and alcohol misuse
2020
2009 National Strategy for Food Security in Remote Indigenous
Communities
2011
2009 Australian National Breastfeeding Strategy 2010-2015 2015
Federal nutrition policy action after 2010
Since the conclusion of Eat Well Australia and NATSINSAP, initiatives
supported by the Federal government have been ‘soft’ interventions, including
localised school cooking and gardening programs and social media campaigns
17
(Swinburn & Wood, 2013). However, one highlight of this time was the National
Partnership Agreement on Preventative Health (NPAPH) which provided significant
funding for the states and territories to address chronic disease (Council of Australian
Governments, 2008b). A key feature of the Partnership Agreement was the
establishment of the Australian National Preventive Health Agency (ANPHA), a
statutory authority in 2011. This agency had the remit to provide national capacity to
drive preventive health policy and programs with a focus on alcohol, tobacco and
obesity (Australian National Preventive Health Agency, 2014). However, the
existence of the NPAPH and ANPHA were short-lived; after the change of
government in 2013, the agency was dismantled the following year and the NPAPH
was abolished in 2014. The abolishment of the NPAPH had significant ramifications
for the states and territories with almost $400 million removed from their budgets,
resulting in a significant decrease in capacity to undertake prevention work (Reeve &
Jones, 2016).
Since the demise of Eat Well Australia there have been no legislative or
regulatory approaches to improving the food environment at the federal level, despite
these being identified as the most cost effective strategies to improve nutritional
status (Bastian, 2011; Caraher & Coveney, 2004; Colón-Ramos et al., 2007;
Swinburn & Wood, 2013). This has been exemplified in recent years with the only
federal systems-based policy actions being the voluntary front-of-pack food labelling
system and the Healthy Food Partnership (Department of Health, 2016b), a voluntary
collaboration between health bodies and food industry to reformulate key processed
foods. However, the effectiveness of voluntary food industry initiatives is
questionable; analysis demonstrates that they are frequently compromised by weak
commitments and standards plus a lack of transparency and enforcement
mechanisms (Magnusson & Reeve, 2015; Swinburn et al., 2015).
The lack of investment in legislative or regulatory approaches to improve the
food environment supports the notion widely held by public health researchers that it
is difficult to translate research findings and evidence into public policy action
(Brownson, Royer, Ewing, & McBride, 2006; Field & Gauld, 2011; Goldstein, 2009;
Hawkins, Holden, & McCambridge, 2012; Rychetnik & Wise, 2004). To better
18
understand why public health nutrition policy action in Australia is not informed by
evidence, it is necessary to examine the policymaking process and the actors
involved in it.
2.3 THEORIES OF THE POLICYMAKING PROCESS
Public health policy literature appears to predominantly focus on measuring
and evaluating policy impact and outcomes, paying little attention to the
policymaking process (Bernier & Clavier, 2011; Macintyre, 2012). Typically, public
health researchers tend to rely on a stages model of policymaking or one of the most
commonly utilised versions of the stages approach, the ‘policy cycle’ (Bridgman &
Davis, 2004) (see Figure 2.2). The stages model of policymaking was originally
devised by Lasswell in 1956, however, it has come under heavy criticism from
political and social scientists for being too simplistic. The model does not tend to
take into account the complex and iterative nature of the policy process (Bernier &
Clavier, 2011; Lewis, 2005). It also does not identify the underlying drivers that
govern the policy process within and across stages, and provides limited insight into
the policy change process (Sabatier, 2007).
Figure 2.2: Adaption of Lasswell’s stages as the Policy Cycle (Palmer & Short,
2000, p. 32)
19
Policymaking can involve sequential stages, from agenda-setting through to
decision-making and implementation; however, some stages may take longer than
others, the steps can occur in a different order or not at all, and several may occur
simultaneously. Since Lasswell, there have been other policymaking theories devised
by political and social scientists which have been empirically tested and are widely
used in the policymaking field (Sabatier, 2007). Unfortunately, no single theory
provides a comprehensive understanding or description of the policymaking process,
as each one answers somewhat different questions (Moloughney, 2012).
It is common for public policy studies to choose a single theory or to combine
the insights of multiple theories to guide the examination of the policy process
(Cairney, 2013). When determining which theory is the most appropriate for
examining influence in the nutrition policy process in Australia, various criteria have
been considered including Sabatier’s (2007) criteria for ‘promising’ policy process
theories (see Appendix 10.1). Using his criteria, Sabatier identified seven theories
and frameworks that allowed validated explanations of the policy process. It is not
within the scope of this literature review to examine all of these theories and
frameworks, so only the most widely cited theories with applicability to public health
nutrition will be examined. Understanding the complexity of the policy process
requires bringing together a range of theoretical and analytical perspectives (Peters &
Pierre, 2006). Accordingly, for this study, three theories will be explored separately
in this chapter and then used as a lens through which the nutrition policy process will
be viewed. As Peters and Pierre (2006, p. 1) stress understanding the complexity of
the policy process ‘requires bringing together a wide range of theoretical and
analytical perspectives.’
The theories that will be explored in this literature review are the Multiple
Streams Theory (Kingdon, 1984), the Punctuated Equilibrium Theory (Baumgartner
& Jones, 1993), and the Advocacy Coalition Framework (Sabatier & Jenkins Smith,
1993). These policy process theories have been selected because: they have been
validated empirically in multiple countries to explain and predict the policymaking
process; they are the most widely cited policy process theories internationally; they
all focus on agenda setting and policy adoption; they highlight the role of different
20
actors; they have complementary strengths; and they are particularly pertinent to
health policy development in Australia (Cairney & Heikkila, 2014; John, 2013;
Sabatier, 2007). Furthermore, these theories have been described in the literature as
superior to other policy process theories in providing an understanding of both policy
stasis and change (Cairney, 2012; Clarke, Swinburn, & Sacks, 2016). Another
possible key policy process theory, the Institutional Analysis and Development
Framework, has not been used because many of its concepts are broad and
unspecific, which makes them challenging to apply (Rutten, Gelius, & Abu-Omar,
2013). In the following section, the central tenets of each chosen theory will be
discussed, followed by a comparison of the theories across six dimensions of interest,
reviewing their strengths and limitations. Finally, the concepts of power and
influence will be interrogated.
2.3.1 Multiple Streams Theory
The Multiple Streams Theory (MST), developed by John Kingdon (1984), is
the most widely cited policymaking framework internationally (Zahariadis, 2007).
Kingdon developed this framework after completing hundreds of interviews over
four years with policymakers in Washington DC, USA. During this process he
identified that policymaking events do not proceed neatly in stages or steps and that
advocacy of solutions has often preceded the identification of problems. He
determined that the policy process comprised of three streams: a problem stream
consisting of various conditions that policymakers and the general public want
addressed; a policy stream involving the advocates of solutions to policy problems,
including politicians, bureaucrats, researchers, as well as interest groups; and a
politics stream which encompasses changes in the political environment, including
results of elections, changes in the administration and/or the ‘national mood’
(Kingdon, 1995).
Each of these streams are largely separate with their own dynamics and rules,
except when a ‘policy window’ opens, allowing a ‘policy entrepreneur’ to couple the
streams together, bringing about policy change. Sometimes the policy windows open
predictably, for example, during the budget cycle; at other times it can be
21
unpredictable. Kingdon (1995) notes that a window tends to open because of changes
in the political stream, or because a new problem captures the attention of decision-
makers or those close to them. Importantly, policy windows only open for short
periods of time; if advocates cannot or do not take advantage of these opportunities
they must wait until the next opportunity comes along (Kingdon, 1995).
Alternatively, a skilled policy entrepreneur may be able to link the three streams
together, increasing the likelihood of a policy window opening.
A key component of the MST is the ‘policy entrepreneur,’ whose defining
characteristic is a willingness to invest their resources – time, energy, reputation and
sometimes money – in the hope of further return (Kingdon, 1995, p. 122). Policy
entrepreneurs play a major role in ‘softening up’ both policy communities and the
general public, getting them used to new ideas and building support for their
proposals. Without this preliminary work, a proposal sprung at even the most
favourable time is unlikely to be heard (Kingdon, 1995). Policy entrepreneurs do
more than push for their proposal, they lie in wait for a window of opportunity to
open (Zahariadis, 2007). Their policy solutions and expertise must be prepared well
in advance in order to take advantage of the window opening. To increase the chance
of the streams coupling and a policy window opening, policy entrepreneurs hook
solutions to problems, proposals to political momentum, and political events to
policy problems (Kingdon, 1995, p. 182). Without a policy entrepreneur, the linking
of the streams may not take place and the opportunity for influencing the agenda may
be lost.
To increase the chance of the streams coupling and a policy window opening,
various strategies can be undertaken (see Figure 2.3). Firstly, in the problem stream,
Kingdon states that not all issues are considered problems. They only become a
problem when people in government become convinced that something should be
done about the issue. Getting policymakers to see new problems or to see old
problems in a new way is a major political accomplishment (Kingdon, 1995). It can
be achieved through focusing events, reframing, using feedback from previous
programs and the use of spillover. Spillover refers to the principle that the
appearance of a window for one issue often increases the probability that a window
22
will open for another similar subject; for example, warning labels on cigarette
packets increases the likely prospect of warning labels on alcohol being agreed to
(Kingdon, 1995). Importantly, problem load, that is, the number of difficult issues
occupying the attention of policymakers, has a significant adverse effect on the
efficient utilisation of information (Zahariadis, 2007). This has the potential to result
in policymakers shifting their attention rapidly and abruptly from one problem to
another and not giving a problem the attention it requires.
Figure 2.3: Adaption of Kingdon’s Multiple Streams Theory and the components that
increase the chance of a policy window opening (Zahariadis, 2007)
Secondly, the policy stream includes many ideas and proposals competing
simultaneously to win acceptance. Ideas are generated by experts and advocates from
policy communities and are considered in various settings and forms, such as
hearings, papers and conversations (Kingdon, 1995). To increase an idea’s chance of
survival it needs to be technically feasible and align with policymakers’ values. Ideas
that do not align with the prevailing ideology or those that may be evidence-based
but boring may not succeed (Greenfield et al., 2004).
Problem stream
Indicators
Focusing events
Feedback
Policy load
Reframing
Spillover
Policy Stream
Ideas
Proposals
Technical feasibility
Integration of
networks
Politics Stream
Party ideology
National mood
Interest group
pressure
Policy entrepreneurs
Softening up system
Investing resources
Coupling streams
Policy
window
Agenda
setting
23
Finally, the politics stream is influenced by public mood, changes in
government and interest group pressure. Public mood refers to the notion that many
individuals in a jurisdiction tend to think along similar lines and that the mood of
these individuals swings from time to time (Zahariadis, 2007). Consensus is built in
the political stream through persuasion, bargaining, and diffusion. Policymakers
constantly assess whether the balance of forces in the political stream favour action;
in particular, whether the general public will tolerate the suggested change of policy.
Of the three components in the political stream, the combination of public mood and
change in government has the greatest effect on policy agendas (Zahariadis, 2007).
2.3.2 The Advocacy Coalition Framework
The Advocacy Coalition Framework (ACF) was originally developed by
Sabatier and Jenkins-Smith in 1988 to deal with complex problems involving
significant conflict, technical disputes and multiple actors from several levels of
government (Sabatier & Weible, 2007). It is based on five premises:
Scientific and technical information are central in the policy process;
A period of 10 years or more is required to understand the process of
policy change;
A policy subsystem (defined by policy topic, geographic scope and
actors) is the primary unit of analysis;
Policy actors include officials from all levels of government, as well as
consultants, scientists, and journalists;
Policies and programs can be viewed as translations of beliefs.
(Sabatier & Jenkins Smith, 1999, p. 118)
Sabatier and his associates use the framework to explain policy change. At the
core of this framework are advocacy coalitions, each of which competes for
dominance in a policy subsystem.
24
Coalitions
Stakeholder beliefs and behaviours form the core of the ACF. They are
embedded within policy networks, and policymaking is influenced by the networks
among important policy participants (Sabatier & Weible, 2007). Therefore, to
succeed in achieving policy outcomes, stakeholders must seek allies, develop
complementary strategies and share resources. This can be achieved by the formation
of a coalition. Coalitions are alliances of people/organisations with similar policy
core beliefs that are coordinated (Sabatier & Weible, 2007). This is particularly
relevant for public health nutrition, which operates across a number of portfolios, and
involves people and organisations with diverse core beliefs, resulting in several
different coalitions competing in the nutrition policy subsystem.
The ACF highlights bounded rationality as an important theoretical construct.
Bounded rationality is defined as the notion that decision-makers have limited
resources and ability to process stimuli, therefore they will rely on shortcuts for
decision-making rather than comprehensive analysis (Simon, 1957). For example,
policymakers can only pay attention to a small percentage of the issues for which
they are responsible, therefore they ignore most and only actively focus on a few
select issues (Cairney, 2012). This concept is also referred to by the MST when
discussing policy load (Kingdon, 1995).
The other important construct in ACF is that actors from different coalitions
are likely to perceive the same information differently, this can lead to distrust.
Actors tend to view their opponents as less trustworthy, more evil, and more
powerful than they probably are; Sabatier and Weible (2007) refer to this concept as
the ‘Devil Shift’. This skewed perception increases the density of ties to members
within the same coalition, and intensifies conflicts across competing but potentially
aligning coalitions. We can see this happening in the nutrition field, where public
health nutrition advocates demonise and compete with food manufacturing groups
(Nestle & Rosenberg, 2015).
25
According to the ACF, the behaviour of policy participants within subsystems
is affected by two factors. Firstly, there are fairly stable parameters, such as
sociocultural values. These rarely change, but are important in determining the
constraints within which actors must operate. Secondly, there are dynamic external
factors, which include changes in the dominant coalition or socioeconomic
conditions and policy decisions from other subsystems. These are critical factors in
affecting major policy change. Figure 2.4 highlights these factors and how they
interact to create policy change or policy stability.
Figure 2.4: Advocacy coalition flow diagram (Weible, Sabatier, & McQueen, 2009, p.
123)
Belief systems
The concept of belief systems is critical to the ACF, it suggests that actors are
motivated by their beliefs, rather than by short-term self-interest, to form long-term
coalitions. Beliefs also relate to policy action, influencing which problems coalition
members consider should receive the highest priority, the causal factors that need to
be examined most closely, and government institutions most likely to be favourably
26
predisposed to the coalition’s position (Jenkins-Smith & Sabatier, 1993). There are
three types of beliefs: deep core; policy core; and secondary beliefs (See Table 2.2).
Table 2.2 Belief types in the ACF (Jenkins-Smith & Sabatier, 1993)
Types of
beliefs
Description
Deep core
beliefs
Broad, fundamental beliefs about human nature, values such as liberty and
equality, the role of the government versus the market. These can be seen as
traditional left/right scales and are very difficult to change.
Policy core
beliefs
Causal perceptions, basic strategies and policy positions for achieving deep
core beliefs in a policy subsystem, for example, disagreeing with front-of-
pack food labelling as it interferes with the free market. It is not always a
direct correlation but still very hard to change.
Secondary
beliefs
Narrow in scope and relate to the seriousness of the problem, budgetary
application within a specific program, the causes of problems in specific
locales, for example, whether $20 million should be spent on childhood
obesity initiatives in Queensland (Jenkins-Smith & Sabatier, 1994). As
these beliefs are narrower in scope, changing them requires less evidence and
fewer agreements among subsystem actors.
For policy change to occur, transformation of a belief system within a policy
subsystem must occur. This can be the result of four processes, listed below.
Policy oriented learning results from experience and/or new information
arising from policy implementation and may result in revision of policy objectives.
This is usually a slow change (may take ten years or more) and will most likely only
affect secondary beliefs.
External shock is when a coalition uses the experience of a major event, for
example, a global recession, to strengthen its position within the policy subsystem.
They do this by demonstrating that their belief system is best equipped to understand
and solve the policy problem. The external event is not responsible for an external
shock on its own, instead a competing coalition needs to exploit it successfully by –
27
using their resources to frame information, exploit public opinion and rally support
(Cairney, 2012).
Internal shocks refer to the effect of major external change on the coalition’s
belief system, analogous to a crisis of confidence; for example, a realisation by its
actors that existing policies have failed. It stimulates a coalition to revisit its core
policy beliefs.
A hurting stalemate is when all coalitions involved in a dispute view the
continuation of a stalemate as unacceptable. This provides an incentive for coalitions
to negotiate, resulting in change.
Resources policy participants can use to influence public policy
The ACF assumes that actors employ available resources to aid in the
transformation of belief systems and thereby bring about policy change. These
resources include public support, formal legal authority, mobilising the public,
technical information, financial resources, and skilful leadership (Sabatier & Weible,
2007). For more detail on resources used by policy participants see Appendix 10.2.
2.3.3 Punctuated Equilibrium Theory
For several decades, theories of agenda setting have highlighted the difficulty
that disfavoured groups and new ideas have in breaking through the established
system of policymaking (Sabatier & Weible, 2007). Interested in this concept,
Baumgartner and Jones (1993) analysed hundreds of US policymaking cases over ten
years and found that policymaking is characterised by long periods of incremental
change punctuated by brief periods of major policy change. This process involved
the interaction of policy images (how policies are discussed and understood by the
public, media and policy elites) and the existing set of policy venues (institutions
where policy can be made, for example, parliament, local government, and/or the
courts) (True, Jones, & Baumgartner, 2007). The interaction between policy images
and policy venues results in policy stability occurring for the majority of the time and
is the basis of the Punctuated Equilibrium Theory.
28
The key concepts of the Punctuated Equilibrium Theory (PET) are: bounded
rationality as in ACF and MST; policy monopolies; policy venue shopping; and
policy image (see Figure 2.5).
Figure 2.5: Policy stasis and the key concepts of the Punctuated Equilibrium Theory
Bounded rationality was discussed as an important construct of the ACF,
meaning that policymakers cannot consider all problems and their respective
solutions at all times (Cairney, 2012). The limited attention policymakers give most
issues helps explain why the majority of policies do not change. Baumgartner notes,
“a great number of worthy policy proposals go nowhere not because of active
opposition but because agenda gatekeepers and their allies have more urgent
concerns” (Baumgartner, Berry, Hojnacki, Leech, & Kimball, 2009, p. 114)
Subsystem
Policy
monopoly
Policy image
(Frame)
Policy Venues
(Institutions)
Issue
Definition
Agenda
Setting
Macropolitical
environment
29
Policy monopoly is when policymakers accept a group’s preferred way to
frame an issue for long periods, possibly even taking it for granted; for example,
framing obesity as an individual’s responsibility (Cairney, 2012). A policy monopoly
becomes ‘institutionalised’ when rules are created and resources are devoted to
solving the policy problem on those terms. This can be seen as a negative feedback
loop (Baumgartner et al., 2009). Policy monopolies typically limit the participation
and access of other participants. If the general public, who are normally excluded
from a policy monopoly remain apathetic, the institutional arrangement usually stays
in place with minimal policy change (True et al., 2007).
Policy image is how a problem is framed (understood, categorised, and
measured) and consequently solved by policymakers (Cairney, 2012). Groups
compete to influence the policy image of an issue; for example, it might be framed as
a problem that has been solved or as a crisis which would result in widespread media
attention and immediate action.
Venue shopping occurs when actors who have not been successful in pushing
their policy solution in one policy venue (such as the Australian Department of
Health), may seek an audience in another (such as a state health department or the
Australian Department of Human Services). In this search, image manipulation
(reframing) is essential to explain why an issue should be discussed in a particular
policy venue and attract the interest of individuals in that policy venue (True et al.,
2007).
The barriers to changing policy in this theoretical framework are that
policymakers are reluctant to focus on certain issues for pragmatic and ideological
reasons, for example, certain solutions may be too unpopular to consider or solutions
are in opposition to current political ideology; combined with the concept of bounded
rationality. A final but enduring barrier is the power of the status quo, whereby actors
are reluctant to change policy as it entails unknown risk and significant resources
(Baumgartner et al., 2009).
30
Insight can also be gained from the PET when looking at policy areas where no
opposing force is apparent, for example, Aboriginal and Torres Strait Islander
nutrition issues in Australia. Baumgartner et al. (2009) found in their study that a
lack of opposition was a good predictor of failure regarding policy change. This
appears to be because of the inability, unwillingness, or indifference of others to
engage in or consider an issue. By ignoring groups with little political visibility (or
power), decision-makers and interest groups can develop policy and allocate
resources in ways that serve their interests, without having to consider complicated,
longer term solutions and a politically unpopular use of resources (Baumgartner et
al., 2009). Advocates who draw opposition to their concerns have an advantage, as
conflict attracts attention. When interested others, including members of the public,
journalists, interest groups, and government decision-makers, become aware that an
issue is contested, they too may “choose sides,” increasing opportunities for greater
and more visible conflict (True et al., 2007).
Changing the status quo of a policy issue requires a critical mass of attention to
overcome the conservatism of decision-makers and to transfer their attention from
competing problems; Appendix 10.3 highlights these steps. Usually this requires a
substantial change in the policy image to drive positive feedback and hopefully
create the ‘bandwagon’ effect (Baumgartner et al., 2009). Media can play an
important role in this process by directing attention to different aspects of the same
issue. If levels of positive feedback reach a tipping point, major and infrequent
punctuations can occur rather than smaller and more regular policy changes. When
this occurs, new approaches and solutions are considered and different ‘weights’ are
applied to the same types of information; new actors can drive policy ideologically;
and/or the ‘new’ issue can stimulate new conflicts between political actors (Cairney,
2012). As the issue is redefined, new actors who previously were disengaged, feel
qualified to exert their authority and ‘jump on the bandwagon.’ The changes that
occur as the policy monopoly is broken up may remain in place for a significant time
as institutional reforms are put in place (True et al., 2007).
31
Framing/Reframing
Framing, or the policy image, plays a significant role in the process of change
as outlined by the PET. Baumgartner et al. (2009) believe that framing can have a
substantial impact on policy outcomes as the given issue is often associated with
dramatically different frames at different times and/or by different policy
monopolies. Framing is also referenced in the ACF as a resource that actors have to
influence policy change, and the MST uses framing as a way of getting people to see
new problems or to see old problems in a new way.
Frames help people make sense of what they see and hear by triggering
reference patterns that already reside within the neural circuits of our brains at a
conscious and pre-conscious level (Druckman, 2004). In other words, our brains link
new, incoming stimulus with knowledge and beliefs already imbedded in our brains.
Reframing occurs when small changes in the presentation of an event or an issue can
produce significant changes of opinion (Chong & Druckman, 2007, p. 103). The
theory behind this process is that the frame individuals use to make decisions is
controlled partly by the decision-makers’ set of available beliefs stored in their
memory, which includes norms, habits, and personal characteristics and partly by the
way a problem is presented. Framing can work in a number of different ways
including: making new beliefs available about an issue; making certain existing
beliefs accessible; or making beliefs pertinent or ‘strong’ in people’s evaluations
(Druckman, 2004).
Effective reframing requires a systematic approach in which the first decision
is about what change will advance the issue, followed by a clear analysis of what it
will take to create the change (Dorfman & Wallack, 2007). Strong frames often rest
on symbols, endorsements and links to ideology and partisanship; for example, using
war metaphors when describing health threats. Framing is important not only for
what it includes, but also for what it excludes, for example, excluding environmental
contributors (portion size, marketing, pricing) from obesity frames means that
strategies targeting environmental approaches will be less likely to be understood by
the public, and less likely to be supported by policymakers (Dorfman & Wallack,
32
2007). The effect of the frame depends on a range of factors, including the strength
and repetition of the frame, individual motivations, and whether other competing
frames are present (Chong & Druckman, 2007). Reframing can be a difficult process,
as it is hard to control the definition of the problem or the solution at hand, especially
as the media can be sceptical when presented with new frames (Baumgartner et al.,
2009).
2.4 SIMILARITIES AND DIFFERENCES OF THE THREE POLICYMAKING
THEORIES
These three theories have a lot in common and see changes in policy as the
result of the convergence of interests, ideas, institutions, and socio-economic forces.
At the centre of the theories is the concept of bounded rationality, the power of the
status quo, and policymaking and policy change as a complex process. They also
emphasise that dramatic events, changes in dominant coalitions, or changes in
government set the stage for major policy change, and that negative feedback results
in policy stasis. There are also key differences: MST highlights the role of individual
actors and argues that the policy, problem and political streams are relatively
independent; the ACF emphasises coalitions, and believes change is mostly
incremental; whereas the PET introduces the concept of policy venue shopping and
policy images, and highlights public agenda shifts. Importantly, none of these
theories suggest evidence alone can achieve significant policy change, and all
indicate power struggles and values/ideologies are important. Some important key
differences and terminology are highlighted in more detail below and summarised in
Table 2.3.
33
Table 2.3. Comparison of the three theories of the policy process (Boin, McConnell, &
Hart, 2008; John, 2013; Sabatier, 1991; Schlager, 2007; Zahariadis, 2007)
Unit ACF MST PET
Individual “Belief-er”
(belief system guides
choices and actions).
“Satisficer”
(searches through options
until an acceptable
solution is found).
“Selective attender”
(salience of an issue
depends on context).
Type of
Policy
Change
Policy oriented learning
or coalition turnovers
lead to incremental or
major change
respectively, depending
on the actors ability to
capitalise on chances.
Policy agenda attainment
leads to incremental or
major change depending
on entrepreneurial skills.
Public agenda shifts lead
to major change,
depending on
entrepreneurial skills to
create a positive
feedback process.
Networks Stable Dynamic Dynamic
Institutions Fixed;
Major role; Institutions
are more or less
susceptible to one
coalition’s belief.
Flexible but low priority;
Indirect role via position
of policy entrepreneur;
Institutions provide more
or less favourable access
points.
Flexible;
Major role via policy
venues;
Institutions hinder
collective action in
negative feedback &
facilitators in positive
feedback.
Scope for
action
Advocacy coalitions &
policy elites.
Policy windows. Policy monopolies &
public mobilisation.
Drivers of
policy
change
Coalitions.
Alignment and activity of
groups. Outside factors
realign beliefs and
generate change.
Implied serendipity.
Policy entrepreneurs.
Opening of policy
windows capitalised on
by policy entrepreneurs.
Serendipity.
Mobilised Public.
Public mobilisation can
establish a new policy
monopoly.
Entrepreneurs, interest
groups and serendipity
also play a role.
2.4.1 Individuals
When examining how individuals behave in the policy process, the three
theories rely on bounded rationality. In all three there is recognition that contextual
matters place boundaries on rationality (Boin et al., 2008). For MST, bounded
rationality incorporates a time-dependent flow of problems and solutions coming
through the streams, which act as major constraints on policymakers. With these
pressures, an individual is less able to choose the issues they would like to solve and
more concerned about addressing the multitude of problems thrust upon them
(Zahariadis, 2007). Therefore, the policymaker in MST is principally a ‘satisficer’
34
with independence in ideas, beliefs and preferences often pushed to the side
(Schlager, 2007).
In the ACF, individual choices and actions are determined by belief systems,
which form the basis for coalition creation. The individual has been classified as a
‘belief-er’ because when he or she is confronted with a new situation or new
information, the individual interprets it with their belief system as the benchmark.
(Schlager, 2007). The individual will refute or believe the information based on their
beliefs and potentially use the information to persuade others. For PET, the attributes
of the situation rather than the belief system are given greater priority, whereby the
policymaker can only pay attention to selective parts of the complex reality. For a
‘selective attender’ the decision-making setting is crucial, because it frames the
problem the individual confronts (Schlager, 2007). The PET ‘selective attender’
shares traits with the MST ‘satisficer’ in that the situation determines choice, rather
than the choice being influenced by the conviction of the individual. However, all
three theories support the view that beliefs, ideas, and preferences are difficult to
change.
2.4.2 Collective action
The three theories highlight different dynamics to account for collective action.
Collective action is paramount for ACF, whereas MST effectively disregards
collective action as a method for achieving policy change. When collective action is
mentioned in MST it is regarding the role a policy entrepreneur can have in driving
this process. Equally, PET shares the notion of a policy entrepreneur as a driver for
collective action although it more strongly highlights the important role of collective
action; for example, mass mobilisation and coalitions of interest groups, in policy
change.
2.4.3 Institutional setting
MST pays limited attention to institutional settings although the concept is
encompassed in the political stream through the traits of governing systems. It is also
35
touched on through the position of policy entrepreneurs in institutional settings, as it
affects their ability to influence the policymaking process (Schlager, 2007). To
achieve policy change in the PET, policy entrepreneurs need to disrupt the existing
institutional rigidity. This can be achieved by evoking interest from previously
uninterested actors in various settings and encouraging collective action (Boin et al.,
2008). The ACF shares the same view as PET, in that institutional settings are
susceptible to influence from coalitions or interest groups looking for suitable policy
venues to articulate their case. ACF also propounds the view that different
institutional arrangements powerfully affect the decision-making process, as they
may be more or less predisposed to one coalition’s beliefs.
2.4.4 Time
Time span plays an important role in the ACF and PET. Both theories argue
that what has happened around an issue for a very long period determines its chances
of reaching the policy agenda. An issue appears on the policy agenda because of a
shift in policy ideas and/or coalition turnover. MST does not focus on long time
spans, although it does show that repeated occurrence of events in the problems
stream increases the likelihood of agenda attainment.
2.4.5 Policy stasis
According to all three policy process theories, lack of change or preference for
policy stability can be associated with negative feedback mechanisms in a policy
system (Baumgartner & Jones, 1993). This incorporates three mechanisms. Firstly,
policymakers often accept a groups’ preferred way to frame an issue for long
periods, for example, framing obesity as an individual’s responsibility (Cairney,
2012; Gollust et al., 2013). The acceptance of a frame by policymakers is known as a
policy monopoly. This resulting policy monopoly becomes ‘institutionalised’ when
rules are created and resources are devoted to solving the policy problem on those
terms and other participants are excluded from the process (True et al., 2007). The
second negative feedback mechanism is the ability of interest groups or coalitions to
organise opposition to policy change (Sabatier & Weible, 2007). Finally, there is the
mechanism where policymakers make only marginal changes in existing policy
36
based on their limited ability to foresee the consequences of their changes because of
complexity and uncertainty.
2.5 STRENGTHS AND LIMITATIONS OF THE THREE POLICYMAKING
THEORIES
The three theories discussed all have different strengths and limitations. These
are outlined in Table 2.4. The limitations of the three theories will be elaborated on
below.
Table 2.4. Strengths and limitations of the three policymaking theories (Boin et al.,
2008; John, 2013; Kingdon, 1995; Mucciaroni, 1992; Sabatier, 1991; True et al., 2007;
Zahariadis, 2007)
Theory Strengths Limitations
Multiple
Streams
Theory
- Emphasis on role of human
agency.
- Provides simple and practical
applications in how alternative
policies are selected and
agendas are set.
- Fluid and flexible model.
- Emphasises the importance of
ideas in policy and how they
emerge by their adoption and
rejection by decision-makers.
- Does not address collective
action and coordination among
participants.
- Downplays the role of
institutions in the policymaking
process, believes institutions
make things possible, but people
make things happen.
- Does not fully explain the
independence of streams.
Advocacy
Coalition
Framework
- Explains how interested actors/
stakeholders interact to
influence public policy or
policy change within a specific
policy subsystem, over time.
- Highlights the role of scientific
and technical information.
- Explains why conflict is about
value differences rather than
technical deficiencies.
- Is a complex framework yet
does not fully explain policy
change, with little explanation
on the required conditions for
policy oriented collective action
to take place plus an over
emphasis on external shocks as
the main reason for policy
change.
- Neglects the role of individual
37
choice. Individuals do not act of
their own accord, only as part of
a coalition.
- Intergovernmental relations are
the only institutional choices
recognised.
- Concept of power not detailed.
Punctuated
Equilibrium
Theory
- Places dual emphasis on
political institutions and
boundedly rational decision-
making
- The attention paid to the
dynamics of problem
definition, policy images and
venues of action is helpful for
advocates.
- Ideas, individual actors and
their interests are crucial.
- Incorporates the role of power.
- A general, descriptive theory, in
that it does not make specific
predictions for particular policy
issues.
- Focuses on bottom-up
policymaking, neglecting how
preferences can be shaped from
above.
- Limited explanation for change
that is not punctuated.
Limitations of MST
As discussed previously, the MST disregards issues of collective action and
coordination among participants. It also has a limited focus on the role of institutions
in the policymaking process, believing “institutions make things possible, but people
make things happen” (Zahariadis, 2007, p. 84). A final limitation is that the treatment
of the streams is too independent; for example, Mucciaroni (1992) argues that they
cannot be that independent, as currently one cannot explain how new issues enter the
policy process when there are no policy windows.
Limitations of the ACF
Despite its complexity, the ACF has been criticised for not fully explaining the
process of policy change, with an overemphasis on external shocks as the primary
38
reason for policy change (John, 2013). It also neglects the role of institutions and
individual choice. The main institutional choices recognised are intergovernmental
relations, and that individuals do not act of their own accord, only as part of a
coalition. Finally, it does not acknowledge the conflictual nature of politics and the
power imbalances where certain types of actors and knowledge are favoured over
others (Boin et al., 2008).
Limitations of the PET
A shortcoming of the PET identified by scholars is that it is more a descriptive
than a causative model of policy change (John, 2013). It focuses on bottom-up
policymaking, neglecting the way in which political decision-makers can shape
preferences from above. It also has only a limited explanation for change that is not
punctuated.
It is important to recognise that a limitation of applying all three theories to
Australian policy change is that they were developed in the United States of
America, where there is a presidential form of government; that is, a republican
system whereby the head of government is democratically elected and leads an
executive branch that is separate from a legislative branch (Elijah Ben-Zion, 1997).
Despite this limitation, it is hoped that using these multiple theories to explore
nutrition policymaking in Australia will result in a greater understanding of the
policy process as well as identifying potential gaps specific to the nutrition context.
2.6 THE ROLE OF POWER AND INFLUENCE IN POLICYMAKING
The three policy process theories all identify different strategies interest groups
can use to influence the policymaking process. However, the theories provide limited
discussion around the machinations of interest group power and influence. It is
touched on by the ACF through its discussion of resources, and the MST highlights
the important characteristics of the policy entrepreneur which provides access to
decision-makers. Only the PET goes into more detail about the role of power and
influence in the policymaking process. This is particularly evident when discussing
39
the role of powerful forces to protect the status quo (Baumgartner et al., 2009). It
also notes that divided power and limited attention mean that it is in the best interest
of policymakers and interest groups to be working on the same issue that everyone
else is working on.
Power can be defined as control over outcomes; this can occur through control
over resources and/or control over actors (Hart, 1976, p. 289). Actors are powerful if
they are able to influence outcomes in a manner that brings them closer to their ideal
points (Dur & De Bievre, 2007). When examining the power and influence of
interest groups on policy outcomes, Dur and De Bievre (2007) suggest there are a
number of variables that need to be taken into consideration. The key variable is that
groups with more resources traditionally tend to have more influence than groups
with fewer resources. These resources can include: expertise on policy issues;
funding; information on the opinions of other policymakers; and information on the
opinions and interests of constituents (Hall & Deardorff, 2006). While policymakers
depend on resources, either to achieve their policy aims or for re-election, interest
groups will exchange their resources for influence over policy outcomes (Henning
2004).
The role of power in policymaking has been explored since the 1950’s by
political scientists; Lasswell and Kaplan note that ‘the political process is the
shaping, distribution, and exercise of power’ (1950, p. 50). Furthermore, Altensetter
(1987) argues that public policies reflect the values of those with the greatest
influence and are permeated with how those groups perceive how the world is, or
ought to be. Some consider that health policymaking, like policy in other sectors, is
determined by the accumulation and use of power by those involved in the policy
process (Lewis, 2006). Those who do not have access to decision-makers within
society rarely have a voice, and if they do, it is usually tokenistic in the form of
invitations for submissions or one-off public meetings (Bastian, 2011). Examining
the relationship between power and policy outcomes is far from straightforward,
even when power is used transparently.
40
Influence of interest groups also varies depending on whether the group
defends diffuse or concentrated interests. Those with diffuse interests, for example,
parents concerned about the food their children eat, would likely find it more
difficult to get organised than groups with concentrated interests such as the
Dietitians Association of Australia. The main problem is one of coordination; larger,
diffuse groups tend to be more difficult to organise. However, if there is an effective
leader, groups defending diffuse interests may be able to mobilise members and the
broader public and take possession of the “moral high ground” (Dur & De Bievre,
2007). The salience of an issue may also impact on the level of interest group
influence. The more attention the public pays to a particular issue, the more difficult
it should be for interest groups to influence outcomes, as governments fear
punishment at the next election (Dur & De Bievre, 2007). The technicality of an
issue may be a final factor which explains variation in influence across issues. As the
level of technicality of an issue increases, it is likely that decision-makers’ need for
involvement from ‘experts’ will also increase (Dur & De Bievre, 2007).
Measuring Power and Influence
The measuring of power and influence is problematic, as much of it is
unobservable. The most common ways of measuring influence in policymaking are
process tracing, attributed influence, and assessing the degree of preference
attainment. Process tracing attempts to determine the steps which affect outcomes;
this includes: access to decision-makers; scrutinising influence attempts; decision-
makers’ responses to influence efforts; and the degree to which the groups’
preferences are reflected in the outcomes (Dur, 2008). This usually takes the form of
case studies, which include interviews and text analyses. Attributed influence is
usually measured by surveys or network analysis, which allow individuals to provide
a self-assessment of their own influence or a peer assessment of the influence of
other individuals or groups (Henning, 2009). Assessing the degree of preference
attainment involves measuring the policy outcomes, compared with the ideal points
of actors (Dur, 2008). The influence of the actor is indicated by the distance between
an outcome and the ideal point of the actor.
41
Two separate factors can hinder the measurement of influence; these are the
existence of alternative channels of influence, and the occurrence of counteractive
lobbying. The different channels that interest groups use to influence and shape
policy include: direct lobbying of policymakers; outside lobbying aimed at
influencing public opinion through campaigns; and influencing the selection of
decision-makers that can wield structural power, such as the Minister of Health (Dur
& De Bievre, 2007). Influencing the selection of decision-makers can result in
influence that is almost impossible to observe, as little or no action is required of
those benefitting from the status quo (Bachrach & Baratz, 1962). Counteractive
lobbying can also hamper the measurement of influence; this is when an interest
group counters the lobbying efforts of another group or other groups (Dur, 2008).
Even if the interest group does not move the outcome in the preferred direction, if
they have avoided an even worse outcome, that is seen as a success.
Due to the problematic nature of measuring influence, it is recommended by
Dur (2008) that at least two methods are used for this. This research will use the two
most common forms of measuring policy influence: measures of attributed influence
(network analysis) and process tracing (case studies). The use of both of these
methodological approaches will ensure increased rigour in the findings.
2.6.1 Using political science policy process theories in public health nutrition
A preliminary review of the international literature from countries within the
Organisation for Economic Cooperation and Development (OECD), found that a
limited number of studies have examined nutrition policymaking using policy
process theories, thereby limiting insight into this important process. Importantly, the
majority of these studies occurred in the United States of America (Craig, Felix,
Walker, & Phillips, 2010; Gilson Sistrom, 2010; Hobbs, Ricketts, Dodds, & Milio,
2004; Johnson, Payne, McNeese, & Allen, 2012; Lyn et al., 2013; Mosier, 2013).
The most popular theory used was the MST in four of the papers, followed by the
ACF which was used in three of the papers. The only other OECD country to use
policy process theories when examining nutrition policymaking was Australia
(Caraher, Carey, McConell, & Lawrence, 2013; Yeatman, 2003). Both of these
42
papers used the MST when analysing the policymaking process. No studies were
found that used the PET, or theories around power and influence. With such limited
results, it was decided that a more systematic review of the literature should be
undertaken to confirm this paucity of data. In Chapter 4, two systematic reviews will
be presented. The first examines whether policy process theories informed public
heath nutrition policy scholars in high-income democratic countries. The second
review explores the same literature for the barriers and enablers to nutrition policy
change.
2.7 SUMMARY AND IMPLICATIONS
Theories of the policy process are able to provide insight and guidance on how
to influence the policymaking process. This is especially relevant in public health
nutrition where few studies seem to be using these theories, and little traction has
been gained in terms of policy action. Furthermore, without theoretical grounding,
policy success and failure cannot be satisfactorily explained and remain all but
anecdotal accounts (Breton & De Leeuw, 2011).
Research Design and Chapter 3:
Methods
This chapter outlines the purpose of the research (section 3.1), the research
questions (section 3.2) and research paradigm (section 3.3). The research plan is then
detailed (section 3.4) with the methods and methodology used for each study
(sections 3.5-3.8). The research methods utilised both a quantitative and qualitative
approach, including: two systematic reviews of the literature designed to determine
whether theories of the policy process are used in analysing nutrition policy
processes and an exploration of the barriers and enablers for nutrition policy change;
a social network analysis of influential actors in nutrition policy in Australia; and in-
depth interviews to aid interpretation of the quantitative measures from the social
network analysis, and to gain further understanding of the factors influencing public
health nutrition policymaking in Australia. This chapter describes the methodology
of each study, the relationship between these studies and how they address the
research questions. Finally, sections 3.9 and 3.10 discuss the methodological rigour
of the research and ethical considerations.
3.1 AIM
The primary aim of this research is to explore the influential factors impacting
on the public health nutrition policymaking process in Australia and to explicate
strategies that could be used by poorly-resourced organisations to gain traction in
public health nutrition policymaking.
3.2 RESEARCH QUESTIONS
1. What is the role of current policy process theory in public health nutrition
policymaking in high-income, democratic countries, particularly
Australia?
44
2. Who are the powerful and influential individuals and interest groups in
public health nutrition policymaking in Australia, and how do they
influence the policymaking process?
3. What are the barriers and enablers influencing public health nutrition
policy change in high-income, democratic countries, and particularly
Australia?
3.3 RESEARCH PARADIGM
This research study was influenced by a pragmatic philosophy. For
pragmatists, the research problem is more important than the methods used to
research it (Creswell, 2003). This means that questions of philosophy should not
impede the researcher’s quest, and that all avenues and methods should be available
when investigating the research. Therefore, pragmatists adopt a methodologically
eclectic, pluralist approach to research and focus on how their research may
contribute to improving the way things are currently done (Goldkuhl, 2012). In this
way, pragmatists support a critical knowledge interest, meaning they seek to question
the status quo (Morgan, 2014).
With regard to ontology, pragmatists consider that there may be singular or
multiple versions of the truth and reality, which may sometimes be subjective and
sometimes objective (Manion, Cohen, & Morrison, 2013). Dewey (1925, p. 47)
contends that pragmatism seeks to find ‘the truth’ whether it be an objective truth or
the relative truth of multiple realities. As knowledge can be considered personal and
subjective in pragmatism, it is necessary to examine interpretations of the world, as
seen through the eyes of multiple participants. Applying a mix of systematic reviews,
social network analysis, and triangulation via interview responses (discussed later)
helps to bolster the external and face validity of the research by providing a
consistent ontological lens to plan the program of research, frame the analysis and
explore findings for extended meaning within the context of nutrition policymaking.
45
3.4 RESEARCH PLAN
The research methodology was informed by pragmatism and underpinned by
the policy process theories discussed in the literature review. The combination of
multiple theories in policy studies is useful in providing insight, direction and a
useful list of initial concepts for research design and when collecting and analysing
data (Corbin & Strauss, 2008).
As this work was predominantly exploratory, a mix of qualitative and
quantitative approaches was chosen, in particular, social network analysis and in-
depth interviews. Qualitative approaches provide a deeper understanding of social
phenomena than would be obtained from quantitative methods (Silverman, 2006). In
contrast, quantitative methods (in this case social network analysis) can aid in
organising and mining data for insights that may be too subtle for some qualitative
methods to identify or interpret with confidence (Edwards, 2010). Furthermore,
using this mix of approaches can provide a unique insight into the structural aspects
of the nutrition policymaking process, as it allows an exploration of the structure of
policy networks from an ‘outsider’s’ perspective, and then explores the processes
which generate these structures from an ‘insider’s’ perspective (Heath, Fuller, &
Johnston, 2009). Together, the mix of qualitative and quantitative methods are well
suited for research that examines the policy change process, as it allows the
researcher to gain a rich understanding of the factors influencing the policymaking
process.
The research comprised four studies.
Study 1: Systematic literature review analysing whether political science
policy process theories are used in public health nutrition policy and if so,
which theories are used.
Study 2: Meta-narrative review exploring the barriers and enablers affecting
public health nutrition policy.
46
Study 3: Network analysis to identify influential actors in public health
nutrition policy in Australia, and identify key structural attributes of the
policymaking network.
Study 4: In-depth interviews with key stakeholders in the nutrition
policymaking space to determine the barriers and enablers of policy change in
public health nutrition.
Each study informed the subsequent study (see Figure 3.1). The study design
analyses the data from each study separately and then examines how their findings
relate to each other.
Figure 3.1: Diagram of research design
47
The comparison of findings from each study was used as a form of
triangulation. Table 3.1 outlines how each study answered the research questions by
addressing related objectives.
Table 3.1 Research objectives and methods
Research Question Objective/elements Studies
Do current political science
policy process theories
apply to public health
nutrition policymaking in
high-income, democratic
countries, and particularly
Australia?
1.1 Determine whether political science policy
process theories are being applied in the analysis
of the policy process in nutrition policy literature
in high-income, democratic countries.
1.2 Determine which strategies and structural
positions are most influential on the public health
nutrition policy process in Australia?
1, 3, 4
Who are the powerful and
influential interest groups
and how do they influence
the public health nutrition
policymaking process in
Australia?
2.1 Identify powerful and influential actors in
public health nutrition policy in Australia
2.2 Determine which structural positions are most
influential on the public health nutrition policy
process
2.3 Determine the most effective strategies
influential interest groups use to influence the
public health nutrition policy process in Australia?
3, 4
What are the barriers and
enablers of policy change
in public health nutrition in
high-income, democratic
countries and particularly
Australia?
3.1 Identify influential actors in public health
nutrition policy in Australia
3.2 Determine which structural positions are most
influential on the public health nutrition policy
process in Australia?
3.3 Determine the most effective strategies
influential interest groups use to influence the
public health nutrition policy process.
3.4 Identify the key skills and knowledge required
to be an effective nutrition policy entrepreneur.
2, 3, 4
48
3.5 STUDY 1: A SYSTEMATIC LITERATURE REVIEW
The purpose of Study 1 was to provide a greater understanding of the role of
political science policy process theories in nutrition policymaking in high-income,
democratic countries. To achieve this, a systematic literature review was undertaken.
This review was accepted and published by the journal Public Health Nutrition
(Cullerton, Donnet, Lee, & Gallegos, 2016c). Below is a brief outline of the method
used in Study 1 with greater detail provided in the published review in Chapter 4.1.
The methodology used for this systematic review was modelled on the
methodology used by Breton and De Leeuw (2011) who examined whether political
science theory was being utilised in health promotion; however, the review was
refined to focus on food and nutrition policy in high-income, democratic countries.
Five electronic databases (Pubmed, Informit, CinAHL, Pschinfo and SCOPUS) were
searched using the following keywords: “(politic* OR advoc* OR coalition OR
influenc*) AND (nutri* OR food OR obesity) AND (polic*) AND (government).”
The search was limited to peer-reviewed papers in the English language.
The selected papers were fully read by the researcher and assessed as to
whether insights from policy process theory have guided the research projects or the
theoretical reflections they reported. This was done initially by searching for
reference to political science theories and then determining whether the cited works
contributed to the writing on a specific policy or the policy process. Theoretical
concepts and results reported were also appraised against whether a framework,
theory or model had driven data collection, analysis or conceptual development. A
sub-set of coding was double coded by both researcher and principle supervisor. For
papers where there was uncertainty as to whether they fit the inclusion criteria, a
second independent reviewer scrutinised the papers. Disagreements between the
reviewers were resolved by discussion until consensus was reached.
49
3.5.1 Scope of the review
The scope of studies 1 and 2 was restricted to high-income, democratic
countries. This restricted scope was chosen to ensure similar policy contexts were
being compared. While a great deal of nutrition policy process learning has occurred
in low income countries and much has been written about this, policy scholars
indicate that the difference in health policy sectors between low and high-income
countries may be too great to allow meaningful comparisons (Geneau et al., 2010;
Levitt, Pelletier, Dufour, & Pell, 2011; Pelletier et al., 2013; Pelletier et al., 2012;
Shiffman, 2007; Spicer et al., 2014). Health policy environments in low income
countries may be characterized by weaker regulations, regulatory capacity and
monitoring systems; more patronage in political systems and more reliance on
external donor funds (Walt et al., 2008). With these differences in mind the focus
was narrowed to only high-income, democratic countries to ensure countries with
fairly similar governance structures and income levels were being compared. This
was undertaken in order to to reduce the number of variables examined and to ensure
the contexts of analysis were similar.
The results of the literature review informed the meta-narrative in Study 2 and
the study design for the Social Network Analysis (Study 3), and also informed the
questions for the in-depth interviews (Study 4).
3.6 STUDY 2: A META-NARRATIVE
After completing the initial coding for the systematic literature review (Study
1), it was evident that there was considerable data relating to the barriers and
enablers to nutrition policy change. To build on this, a meta-narrative was
undertaken to analyse these factors and to critically evaluate the data. This meta-
narrative was accepted and published in Public Health Nutrition (Cullerton, Donnet,
Lee, & Gallegos, 2016b). Below is a brief outline of the method used in Study 2 with
greater detail provided in the published review in Chapter 4.2.
50
A meta-narrative is a complete study that involves rigorously examining and
interpreting the findings of a number of qualitative research studies using a
qualitative method (Jensen & Allen, 1996). The goal of a meta-narrative is to
produce a new and synthesised interpretation of the findings that is more substantive
than those resulting from individual investigations (Finfgeld, 2003). Study 2 aimed to
provide new and integrative insights into the barriers to and enablers of nutrition
policy change in high-income, democratic countries using the dataset from Study 1.
The methodology for the examination and thematic analysis of the data was informed
by an adaptation of the Framework Method (Ritchie & Lewis, 2003).
3.6.1 Data analysis: the adapted Framework Method
Data analysis for the meta-narrative and the in-depth interview data (Study 4)
was undertaken using an adapted version of the Framework Method (Ritchie &
Lewis, 2003). This method utilises thematic analysis and involves identifying
commonalities, differences and relationships in qualitative data, while seeking to
draw descriptive and/or explanatory conclusions around themes (Gale, Heath,
Cameron, Rashid, & Redwood, 2013). The Framework Method is not affiliated with
a particular epistemological, theoretical or philosophical approach; rather it is a
adaptive tool that can be used with many different qualitative approaches that aim to
generate themes (Gale et al., 2013). The Framework Method provides seven clear
steps for the analysis and interpretation of data: transcription; familiarisation with the
interview/paper; coding; developing a working analytical framework; applying the
analytical framework; charting data into the framework matrix; and interpreting the
data (Gale et al., 2013).
Analysis commenced with uploading the applicable data, that is, journal
articles or interview transcripts, to the data management software program, QSR
NVivo 10TM
(QSR International, 2012). Following this, familiarisation with the data
occurred through reading the papers or listening to interview recordings. During this
stage, notes identifying ideas and recurrent themes were taken. Once the data had
been initially reviewed, coding began for each paper or transcript. Coding is a form
of content analysis used to find and conceptualise the underlying issues among the
51
“noise” in the data (Strauss & Corbin, 1997). Open codes were generated using
inductive and deductive iterative processes to identify the key issues, concepts and
themes. The inductive analysis involved generalising the experiences of the many
different participants. The deductive analysis incorporated the policy process theories
to assist with structuring and coding the data. Furthermore, codes from the meta-
synthesis subsequently informed the coding of the in-depth interviews (Study 4).
Open coding was used to form the initial categories about the phenomenon
being studied from the data gathered. This is “the process of breaking down,
examining, comparing, conceptualising and categorising data” (Strauss and Corbin,
1997 p. 61). It is vital in open coding to look out for the unexpected. For this reason,
the Framework Method recommends coding line by line and ensuring at least two
researchers independently code the first few transcripts (Gale et al., 2013). This
process was undertaken for the meta-synthesis and the in-depth interviews by the
researcher and the primary supervisor.
After coding six papers, a working analytical framework was developed,
informed by the deductive codes and the policy process theories. This provides a
thematic framework through which the data can be ‘sifted and sorted’ (Ritchie &
Lewis, 2003). The framework was developed through drawing on a priori issues,
emergent issues identified in the data, and analytic themes arising from the
recurrence or patterning of particular views or experiences (Ritchie & Lewis, 2003).
Ongoing refinement of the framework occurred while continuously looking for
conceptualisations which encapsulate and represent diversity of experience, attitudes
and circumstances (Ritchie & Lewis, 2003). This process required the researcher to
make judgements about meaning, about the relevance and importance of issues and
about the connections between ideas.
Following completion of the working analytical framework, it was then applied
by indexing subsequent transcripts into the existing codes and categories (Ritchie &
Lewis, 2003). Some passages were indexed to multiple codes which can highlight
patterns of association within the data (Ritchie & Lewis, 2003). The Framework
52
Method then recommends charting the data into a matrix; however, this step was not
formally undertaken due to the number of papers/transcripts being analysed and
because N-VivoTM
provides a structure whereby cases, categories and codes can
easily be compared and contrasted. The process followed for this final part of the
analysis included: firstly, comparing and contrasting perceptions and accounts;
secondly, searching for and seeking to explain patterns and connections within the
data; and finally, weighing up the salience and dynamics of issues (Ritchie & Lewis,
2003).
In line with the Framework Method, a log book was kept by the researcher
where impressions, ideas and early interpretations about the data were noted down.
This enabled characteristics of, and differences between the data to be identified. It
also allowed interrogation of the theoretical concepts and the mapping of connections
between categories to explore potential relationships and/or causality (Gale et al.,
2013).
The results of the literature review informed the study design for the Social
Network Analysis (Study 3) and also informed the questions for the in-depth
interviews (Study 4).
3.7 STUDY 3: A NETWORK ANALYSIS STUDY
After completing the systematic review and meta-narrative review, a social
network analysis of the nutrition policy subsystem in Australia was undertaken. This
study formed the basis of two papers; one has been accepted and published in
Obesity Reviews (Cullerton, Donnet, Lee, & Gallegos, 2016a), and the other has been
accepted and published with BMC Public Health (Cullerton, Donnet, Lee, &
Gallegos, 2017).
53
3.7.1 A background to network analysis
Several approaches targeting different aspects have been used to understand
power and policymaking. One approach that has been used to understand power in
health policymaking is network analysis, which includes policy networks and social
networks. Policy network analysis seeks to understand how interest groups control
the policy process (Marsh & Rhodes, 1992). This can be explored further by using a
social network approach, which focuses on interpersonal ties between individuals.
Using this approach generates a picture of influence and reveals the strengths of
certain positions in the policy process and alternative forms of influence wielded by
those in policy circles (Lewis, 2012). Influence can be gained both by inhabiting
important positions and by having the ability to make important connections through
the use of charisma or other personal resources (Lewis, 2005). Conversely, if
advocates do not inhabit important positions, it is difficult for them to be regarded as
influential, as they have limited power. By examining who is connected to whom, it
is possible to see who has high structural autonomy and who exercises control within
a social or policy network (Burt, 1992).
3.7.2 Network theory
There are many theories and concepts informing network analysis. This section
will discuss network theories and assumptions that are particularly relevant to
influencing policymaking in a policy network and are drawn from both the social
capital research tradition and the architectural perspective. Social capital in networks
is defined as “resources embedded in one’s social network that can be accessed or
mobilised through ties in the networks” (Lin, Cook, & Burt, 2001, p. 24). Studies
that employ social network analysis are based on several assumptions about
patterned relations and their effects. Knoke and Yang (2008) identified three
principal assumptions: firstly, relations are critically important when attempting to
explain behaviours or attitudes; secondly, social networks can affect beliefs,
perceptions and behaviours through a range of structural mechanisms that are
socially constructed by interactions among actors; finally, relations are not static but
occur as part of a dynamic process.
54
Importantly social capital is not the only perspective in network analysis. The
architectural model provides an alternative set of explanations for individual or group
success (Borgatti, Brass, & Halgin, 2014). In this model, network ties create
structures of interdependency and coordination. Theories based on this model explain
how the patterns of interconnections interact with contextual rules to generate
outcomes such as power and influence (Borgatti et al., 2014). Both the social capital
and architectural perspectives will be considered in this thesis to explain and
illuminate policy networks, as they highlight different but complementary
approaches to examining power and politics.
Structural-hole and weak tie theories
The ideas from social capital have been translated into an important approach
in social network theory, known as structural holes or brokerage (Burt, 1992;
Granovetter, 1973). Most social networks are characterised by dense clusters of
strong connections. Burt’s structural-hole theory (Burt, 1992) explains that in
competitive situations, other people’s cohesiveness is a disadvantage. People who are
embedded in a dense cohesive network all have access to the same information, and
each is constrained by the other; therefore, no one individual can gain an advantage.
However, if a person is a bridge or broker between denser sections of a network not
connected with another (a structural hole), the person gains information from diverse
clusters that do not have access to one another. Another theory similar to Burt’s
structural-hole theory is the “strength of weak ties” (Granovetter, 1973). This theory
argues that the stronger the tie between two people is, the more likely their contacts
will overlap so that they will have common ties with the same third parties.
Therefore those with strong ties are unlikely to transfer any novel information.
Consequently, Granovetter argues that weak ties (bridging ties) are a potential source
of new information. Both theories rely on the same underlying model; however,
Granovetter claims the strength of a tie determines whether it is a bridge or not.
Furthermore, an extension of tie strength research by Hebbert, Keast, and Mohannak
(2006) demonstrates that tie strength is not static and it can be wielded strategically
to ensure actors do not become overburdened by active relationships as they go about
their work.
55
Homophily
One reason people exist in dense, cohesive clusters with strong ties is the
principle of homophily, which is the tendency of individuals to associate, interact,
and bond with others who have similar backgrounds and characteristics (Robins,
2015). This key concept within social network analysis shapes the way networks
organise and reflects, as well as encourages, a sense of trust (McPherson, Smith-
Lovin, & Cook, 2001). Homophily shapes group formation and interaction in a wide
variety of settings, including work and social settings, in which similarity between
group members is observed across a wide range of characteristics, including
ethnicity, age, education, class, gender, social status, and organisational role
(Gompers, Mukharlyamov, & Xuan, 2016). Interaction, in turn, leads to a greater
influence over the ideas and values of interacting actors (Kadushin, 2012).
Granovetter (1973) warns that homophily has particular relevance to policymaking
whereby people of similar status or profession tend to cluster together, this can
inhibit the exchange of diverse viewpoints and opportunities for others, and preserve
the interests of elites.
Policy networks
A policy network describes the relations among collective political actors, that
is, political parties, interests groups and government bodies, participating in a given
policy domain (Fischer, 2013, p. 2). Network theory recognises that the traditional
boundaries between the different functions of state and private actors have become
less relevant over time (Laumann & Knoke, 1987). It also recognises that decision-
making authority is dispersed in modern political systems and involves the
interaction of many diverse participants. No actor alone has enough resources to
individually influence decision-making, and therefore cooperation among actors is
essential for influencing political decisions (Henry, 2011). This requirement to
collaborate and invest in relationships is consistent with the key tenet of social
capital.
Intense collaboration in a policy network leads to increased social capital
which facilitates communication and coordination as well as norms of reciprocity
56
and trust (Burt, 1992). However, it has been argued that only collaboration between
actors not otherwise connected allows for the spread of new information which can
result in policy change (Granovetter, 1973). Central to this concept are actors who
occupy potentially privileged positions in the networks structure, known as brokers,
who are often assumed to have a decisive impact on policy outcomes (Christopoulos
& Ingold, 2011).
3.7.3 Method
This section will provide a summary of the method used in the social network
analysis. This analysis explores which actors are perceived as influential in nutrition
policy, and how influence is structured in the nutrition policy space. A more detailed
description is provided in Paper 3 (Chapter 5.1).
Study 3 explored which actors are perceived as influential in nutrition policy,
and how influence is structured in the nutrition policy space. As knowledge of policy
influence is distributed among hundreds of individuals in a policy domain, a
previously used peer-nomination, reputational snowball method which asked
participants to nominate other influential participants in the network, was used
(Lewis, 2006). This technique assumes that groups of influential people know each
other, either personally or by reputation (Scott, 1991). Although any one respondent
is likely to have an incomplete view of the whole nutrition policy system, their
collective responses enable a reasonably accurate rating of group influence to be
determined (Heaney & Lorenz, 2013).
A peer-nomination, reputational snowball method usually commences with one
actor and is represented as an egocentric network analysis. This type of network
begins with examining all of the direct relationships of one actor and then examines
the relationships of those surrounding the actor (Scott, 1991). Although Study 3
utilised an egocentric network analysis, it commenced with nine participants instead
of one. It was decided that nine participants would be used to commence the network
so that all policy actor categories as identified in the Advocacy Coalition Theory
(Sabatier & Weible, 2007) were represented. Additionally within these policy actor
57
categories, seed sample representatives were chosen to represent all domains of
Australia’s food and nutrition system. By purposively choosing representatives from
the different domains of the food and nutrition system, as well as the nutrition
policymaking process, it was hoped that their collective insight and responses would
lead to a more accurate and complete policy network. The participant representing
each category was purposively selected by the lead author (KC) and a co-author
(DG) as being the highest profile individual in Australia in each identified category
(see Table 5.1). This was based on their positional power, media presence or stated
organisational objectives. When the highest profile person was not available, the next
highest was contacted in their place, however, this only occurred on one occasion.
Participants in the seed sample were contacted by email or telephone and asked
to nominate individuals regarded as influential in nutrition in Australia, who
demonstrate a capacity to do one or more of the following:
shape ideas about policy;
initiate policy proposals;
substantially change or vet others’ proposals; or
substantially affect implementation of policy related to food and nutrition.
(Lewis, 2006, p. 2129)
The nomination request was asked firstly for nutrition policy generally and
then for three different case studies: Indigenous nutrition policy, school cooking and
gardening, and front-of-pack food labelling. Due to the large amount of network data
collected, these additional cases were not analysed further for this thesis. However
the initial exploration of multiple cases enabled greater understanding of general
contextual issues at play in national policy change. This strategy also enabled the
researcher to explore the subcultures of different nutrition issues and ensure that a
more complete representation of actors was included in the general nutrition policy
case study. Table 3.2 outlines the three categories chosen for maximum variation in
the unit of national policy change, and the cases that met the definition for each
category for the case studies. The rationale behind choosing these three different
58
areas will be discussed in the section 3.8 under Study 4. The remaining data for each
case study is available and will be published at a later date.
Table 3.2 Categories and cases to be used in Study 4 (Halpin, 2014)
Category Definition Case
Highly
contested
The issue has been publicly divisive
with clear opposing sides or differing
values/beliefs.
Front-of-pack food labelling
Neglected There has been little attention or
funding given to the issue.
National Aboriginal and Torres
Strait Islander Nutrition Strategy
and Action Plan
Party
political
initiative
A policy decision driven by ideology
or political interest.
Stephanie Alexander Kitchen
Garden Project
A snowball sampling process was used whereby each person named was
contacted and asked to make a list of influential people, noting who they were in
direct contact with and how frequently that contact occurred (see Appendix 10.4).
Then each new person nominated was asked to repeat the process. No set limit was
imposed, as this may have forced people to keep adding names who were not
especially influential or may have risked eliminating important people (Lewis, 2006).
No gratuity was provided to the participants.
Data collection occurred from November 2014 until October 2015. The
boundary of the network was defined by who nominated whom, and was limited only
by how many rounds were included before stopping the survey. For this study, the
survey went for four rounds when saturation was reached. This was in line with
previous studies (Lewis, 2006). In line with the Lewis (2006) methodology, initially
all those nominated were contacted. However, after the third round, only those with
more than two nominations were contacted, as limited new names were being
generated.
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3.7.4 Analysis
To analyse which actors had the greatest capacity to influence nutrition policy
in Australia, the data from the survey was entered into social network analysis
software, NodeXL (Smith et al., 2010). There are many different software packages
which can be used for network analysis however NodeXL was chosen for the
analysis of this data as it is an add-on to Excel making it very user friendly,
particularly for large datasets. Once the data was entered into NodeXL, network
graphs were generated using the Harel-Koren-Fast Multiscale algorithm (Chaturvedi,
Dunne, Ashktorab, Zachariah, & Schneiderman, 2014) as this algorithm provided the
best visualisation of the data. As direction of influence was taken into account, the
graphs were ‘directed’ networks.
The network data was then analysed using centrality measures, structural
equivalence and path distance. The centrality of an actor reflects their prominence or
importance to the network (Robins, 2015). There are several different measures of
centrality (see Table 5.4) including in-degree, out-degree and betweenness centrality
(Hanneman & Riddle, 2005). Each centrality index measures a slightly different
aspect of importance or influence in the network. Actors with large numbers of these
ties are more widely recognised as having influence of some kind (Krackhardt,
1990). The most common measure of influence is betweenness centrality, which
indicates the strategic importance of an actor within the network (Robins, 2015).
High betweenness centrality means an actor is in a position to act as a bridge or
gatekeeper for information flow through a network (Lewis, 2006). This acts as a
direct proxy for indirect influence, in that people with high betweenness centrality
connect actors who are otherwise not connected. Betweenness centrality measures
the extent of contact between the different subgroups and whether the pattern of
linkages differs as well as the homophily of the network (Robins, 2015).
The structural equivalence of actors within the network was examined using
cluster analysis. Structural equivalence refers to the extent to which two nodes are
connected to similar others, that is, having the same social environments (Sailer,
1978). Cluster analysis divides actors into structurally equivalent groups within a
60
network, based on regularities of patterns of relationships (ties) among the actors’
nominations of influence (Breiger, 1976). The Clauset-Newman-Moore algorithm
(Clauset & Newman, 2004) was used to undertake the cluster analysis as this
algorithm is designed to find community structure in large networks. The network
graphs were examined to identify the structure of the clusters and which categories of
individuals were positioned near decision-makers.
Path distance is a measure of how many steps an actor is away from another
actor. For this study, path distance between actors and decision-makers was
determined. This calculation enabled a comparison of the aggregate and relative
capacities of each stakeholder group to access decision-makers directly and
indirectly. Having direct access to policymakers has previously been shown to be a
significant factor in influencing public policy (Baumgartner et al., 2009; Beyers &
Braun, 2014; Henning, 2009).
3.7.5 Limitations
This method relied on key informants whose ability to provide accurate and
complete information may not be valid. Validity in the case of network analysis
studies refers to the extent to which a measure accurately measures what it is
intended to measure (Wasserman & Faust, 1994). To address this validity concern, a
wide seed sample including representatives from all sectors of the policymaking
process was used, ensuring that a more representative picture of power and influence
in nutrition policy was gained. Another limitation of this method concerns ethical
principles, such as securing informed consent, protecting anonymity, and assuring
confidentiality, which may become difficult when information is requested about
each person of influence (Borgatti & Molina, 2005). To address these concerns, all
participants were provided with a written statement explaining the purpose of the
research, the duration of participation, the methods used, and any foreseeable risks.
Furthermore participants were provided with a statement describing the processes in
place to ensure confidentially and the level of anonymity available to participants.
To protect the anonymity of participants, all participants were identified in terms of
their organisational category; for example, non-government organisation – nutrition
61
or journalist (as opposed to an individual’s name or rank). A final limitation was that
the data was collected at a single point in time. Since that time there has been a new
Prime Minister and Cabinet appointed, which may have changed the network and
key influencers over this time. Replicating the study over points in time would give
insight into the potentially changing network dynamics over time.
3.8 STUDY 4: IN-DEPTH INTERVIEWS
To gain a deeper understanding of the connections between individuals, the
reasons they are connected in a network, and the strategies they use to influence
policy outcomes within this network, 37 semi-structured, in-depth interviews were
conducted with key policy influencers and decision-makers. In-depth interviews
allowed us to gain a rich understanding of the interviewee’s perspective on
influencing the policymaking process (Ritchie & Lewis, 2003). They also served as a
vehicle to assist in piecing together the relationships and interactions that occur in
policymaking, as well providing access to institutional knowledge not otherwise
available (Signal et al., 2016).
3.8.1 Structure of interviews
In order for the depth and breadth of views and experiences to be explored,
participants were asked about their involvement in the three different cases used in
the social network analysis (see Table 3.2). Exploring multiple cases enabled greater
understanding of a central issue - the barriers and enablers to national policy change
generally, and the contextual issues involved in this. The selection of cases that vary
either on a key independent variable or dependent variable (policy change) but are
similar on other important explanatory variables (public health nutrition policy action
in Australia over the past eight years) can lead to valid causal inferences (Barakso,
Sabet, & Schaffner, 2013).
As discussed previously, the three cases represented very topical issues in
public health nutrition in Australia. Front-of-pack food labelling received extensive
press coverage, and received more than 6000 submissions through the Blewett
62
inquiry into food labelling in 2009/10 (Blewett, Goddard, Pettigrew, Reynolds, &
Yeatman, 2011). Equally, extensive information gathering and public statements of
support have occurred around Aboriginal and Torres Strait Islander nutrition,
highlighted by significant stakeholder consultation and media coverage for the
National Indigenous Health Equality Summit in 2008. The Close the Gap Indigenous
Health Equality Targets were developed from this summit and were designed to
close the health and life expectancy gap between Aboriginal and Torres Strait
Islander peoples and non-Indigenous Australians within a generation (Australian
Human Rights Commission, 2008). Subsequently COAG agreed to the National
Indigenous Reform Agreement in 2008. This agreement provided $4.6 billion
towards Closing the Gap however none of this money was specifically allocated for
nutrition initiatives (Browne, Hayes, & Gleeson, 2014). Furthermore, there was a
Parliamentary inquiry into remote Aboriginal and Torres Strait Islander stores in
2009, with 112 submissions, yet with minimal resulting policy action (Standing
Committee on Aboriginal and Torres Strait Islander Affairs, 2009). The final case,
the Stephanie Alexander Kitchen Garden project, has received considerable media
attention and has had continued federal funding support from 2008 until 2015
(Department of Health, 2016a; Yeatman et al., 2013). However, this initiative was
introduced as a federal policy without any prior recommendation from any of the
national nutrition groups/organisations in Australia.
It was not the intention of this study to gather specific information regarding
each case study. Instead the cases were used in an instrumental way to investigate the
broader phenomenon of how nutrition policy change can be most effectively
influenced in Australia. Accordingly, the cases were used to explore the strategies
participants used to influence policy outcomes, and the barriers they faced while
doing this (see Appendix 10.5 for interview guide). Furthermore, by exploring these
three cases through in-depth interviews, it was possible to assess whether the
influential participants identified in the network analysis in Study 3 were influential
in these different spaces, and if they were not active, why not?
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3.8.2 Sampling
The selection of interviewees was done in a purposeful manner designed to
obtain maximum diversity of viewpoints, enabling multiple ways of making sense of
what is important and valued in nutrition policymaking. Participants were either
decision-makers or key influencers who were able to provide real-world insights
about the barriers and enablers to public health nutrition policy change in Australia.
Initially, participants were recruited simultaneously from the social network analysis
seed sample (Study 3). The nine participants in the seed sample represented all
policy actor categories as identified in the Advocacy Coalition Theory (Sabatier &
Weible, 2007). Within these categories, were participants representing all domains of
Australia’s food and nutrition system. The participants had been purposively selected
by the researcher and principal supervisor as being the highest ranking individual in
Australia in each identified category (see Table 5.1). This was based on their
positional power, media presence or stated organisational objectives of their
employer. Subsequently, snowball sampling occurred with the seed sample interview
participants plus other participants in the network analysis, identifying
influential/decision-maker participants that the researcher was unaware of or could
not access. Furthermore, it should be noted, that the individuals originally nominated
in the seed sample were verified as key influencers or decision-makers by the social
network analysis. Recruitment and interviews continued until data saturation had
been reached.
3.8.3 Participants
Fifty-five people who were considered key influencers or decision-makers in
Australian nutrition policy were contacted to participate in the in-depth interviews.
The first participants interviewed were those identified in the seed sample (n=9) used
in the network analysis in Chapter 5. Additional participants were identified through
a process of purposive and snowball sampling. Participants were chosen purposively
to ensure maximum variation, with representation from all categories involved in the
nutrition policymaking process. Recruitment and interviews continued until data
saturation had been reached. Snowball sampling also occurred with the seed sample
participants plus other participants in the network analysis, identifying
influential/decision-maker participants that the researcher was unaware of or could
64
not access. All participants interviewed were also included in the social network
analysis.
Interview participants were asked four core questions: why certain issues in
public health nutrition failed to gain traction at the national policy level; what
strategies have they used or seen others use to influence policy change (or stability);
what makes someone influential and what makes them (the participant) influential?
Further clarifying questions were asked if needed or if interesting, or if novel
information was provided (see interview guide, Appendix 10.5). Their responses
were coded and analysed in QSR NVivoTM
using an adapted Framework Method, as
outlined in Chapter 3.6.1.
3.8.4 Interview process
Interviews were semi-structured and based on an interview guide, with themes
and questions developed from the policy process theories and nutrition policy
literature. The guide included four key open-ended questions, with additional
questions that could be used for prompting and expanding in order to obtain more
information and clarification if required (See Appendix 10.5). Consent was obtained
from all participants to allow the interview to be tape-recorded and later transcribed
verbatim by a transcription company. All interviewees were provided with an option
to receive copies of their interview transcripts to review the accuracy of the data and
report any inconsistencies (member-checking). However, only one participant took
advantage of this opportunity. All participants were offered the option to receive a
final copy of the thesis or a summary of the interview results.
3.8.5 Analysis
The Framework Method was adapted and used to guide the thematic analysis
of the data (full details of this process are outlined in section 3.6.1). The researcher
re-listened to all transcribed interviews at least twice and checked the transcriptions
for accuracy. This method allowed the researcher to develop a familiarity with the
data and assisted in the identification of common themes. Once accuracy was
65
confirmed the interview transcripts were uploaded to the data management software
program, QSR NVivo 10TM
(QSR International, 2012). After familiarisation, coding
occurred using QSR NVivo 10TM
for data management and the guidelines outlined
by the Framework method. As this study used inductive and deductive iterative
processes, the coding used ‘open’ coding as well as pre-defined codes gathered from
the policymaking theories and the systemic literature review (Study 2).
Coding was done line-by-line by the researcher, with a sub-set coded by the
principal supervisor, to ensure all issues were captured and there was intercoder
reliability. A working analytical framework was then developed by grouping codes
into categories. This framework was then applied by indexing subsequent transcripts
into the existing categories and codes. However, this did not limit new codes from
emerging and being incorporated into the framework. Further analysis was done
using a negotiated consensus process for emergent themes as well as connections
between emergent themes. This involved the researcher and the supervisory team
conceptually mapping and interrogating the relationships between the different
themes to understand the links and relationships across and between issues (see
Figures 6.1 and 7.1). These understandings were then further interrogated and refined
through a process of communal reflection about the reasons and, often, the
assumptions behind the construction of the maps (Daley, 2004). Disagreements over
the themes and relationships were resolved by discussion until consensus was
reached. The result of this process was the development of conceptual diagrams
which illustrate through directional arrows the inter-connecting relationships
between the themes and the overarching categories as well as illustrating the process
of synthesis (Figures 6.1 and 7.1 which became Figures 6.2 and 7.2).
As per Study 2, a log book was kept by the researcher, in which impressions,
ideas and early interpretations about the data were noted. This assisted the generation
of typologies and the mapping of connections between categories to explore
relationships and/or causality. After this analysis was completed, the results,
including verbatim quotes, were compared and contrasted with the network analysis
results and Study 1 and 2 to again explore relationships and/or causality. These
findings will be reported in the conclusion.
66
3.8.6 Limitations
The use of purposeful sampling to ensure maximum variation and wide
representation is associated with a probability of researcher bias. Although
considerable care was taken to develop a clear sampling frame and criteria, the
criteria, selection and categorisation of participants into nutrition policy sectors may
have occurred differently with a different researcher. Furthermore, while there was a
good response rate from participants, there were a few important political actors in
the policy process who declined to be interviewed, which may have influenced the
validity of the findings. However, interviewing such a wide range of other
participants and including alternative political actors mitigates the influence of these
missing actors.
In studies of power and influence involving in-depth interviews with elite
actors, there is often an asymmetric balance in favour of the respondent. This can
result in researchers overestimating the importance of what elites have to say (Welch,
Marschan-Piekkari, Penttinen, & Tahvanainen, 2002). Moreover, as elites are often
charged with representing and maintaining particular organisational policies and
objectives, they may be guarded in their responses or purposely not tell the ‘truth.’
However, Beyers, Braun, Marshall and De Bruycker (Beyers, Braun, Marshall, & De
Bruycker, 2014) advise that this is a minor limitation, in that it is natural for different
individuals to have different perceptions of the same event/issue, and this variation
can be very informative in itself. Interestingly for the researcher, it was noted that the
more senior an individual, the more open and frank their responses.
One final limitation is the risk of expansiveness bias, which refers to the
propensity of participants to over- or underestimate events or their ability (Fowler,
Heaney, Nickerson, Padgett, & Sinclair, 2011). This may include less powerful
actors inflating their status/actions and/or high status actors systematically under-
reporting their own influence/actions. To offset this form of bias, the researcher de-
emphasised the political and/or sensitive nature of the interview and took the
opportunity to clarify responses/actions and insights with subsequent participants.
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3.9 METHODOLOGICAL RIGOUR
Rigour in qualitative research includes the quality of the research process and
the ability to determine whether the conclusions drawn by the researcher are
trustworthy (Saumure & Given, 2008). To increase the rigour of the research and in
particular of the in-depth interviews, the researcher employed a variety of methods
including:
Reflexivity;
Triangulation;
Reliability check;
Use of verbatim quotes.
3.9.1 Reflexivity
Reflexivity is the process whereby the researcher reflects continuously on how
their own actions, values and perceptions impact upon the research setting and how
this can affect data collection and analysis (Gerrish & Lacey, 2006). Throughout the
research process, the researcher practiced reflexivity by keeping a research diary/log
book and debriefing with supervisors to ensure transparency and accountability, and
thus reduce research bias.
3.9.2 Triangulation
Triangulation involves the use of multiple methods, researchers, theoretical
perspectives or data sources to collect and interpret diverse viewpoints or standpoints
about a phenomenon (Denzin, 1978). Two forms of triangulation were used in this
research: data triangulation and methodological triangulation. Data triangulation
involves using multiple sources of data or information in order to increase the
validity of a study (Merriam, 2009). The different sources of data used in this study
comprise representatives from different sectors involved in nutrition policy,
including nutritionists, public servants, industry lobbyists and politicians. The results
were compared to assess whether similar results were found across all data sources.
If the conclusions from each of the methods are the same, then validity is more likely
68
(Patton, 2005). Furthermore, by gaining multiple perspectives the researcher is able
to gain a richer and more in-depth picture of the issue at hand (Denzin & Lincoln,
1994).
Methodological triangulation involves combining dissimilar research methods
to measure and interpret the same phenomenon (Denzin & Lincoln, 1994). The
rationale for this strategy is that the failings of each individual research method are
compensated for by the counter-balancing strengths of another, therefore by
combining methods, researchers can strengthen the outcome of the study and
overcome the weaknesses of an individual method (Denzin & Lincoln, 1994).
Furthermore, multiple methods can draw out greater meaning and understanding
around the phenomenon being investigated (Patton, 2005). For this study, literature
reviews, network analysis and in-depth interviews were used to investigate and then
confirm the level of influence and strategies of influence that interest groups use to
gain traction in nutrition policy. By using these multiple methods, validity is
increased. An example of this increased validity was the ability to verify individuals
originally nominated in the seed sample for Studies 3 and 4 as key influencers or
decision-makers by using the data obtained in the social network analysis. In
addition, using multiple methods not only increased validity but ensured a more
complete and contextual portrayal of the nutrition policy process was also obtained.
3.9.3 Reliability check
In qualitative research, transparency and replication are key to increasing the
reliability of the research (Gibbert & Ruigrok, 2008). This is particularly the case
when undertaking the coding of interview transcriptions or reviewed papers. To
increase reliability of coding in this study, coding of the interview transcripts and
literature review papers were tested through an intercoder reliability check. This
occurs when another researcher codes the same body of content. Ritchie and Lewis
(2003), who devised the Framework Method, agrees with this concept, and states that
at least two researchers should independently code the first few transcripts, if
feasible. These guidelines were followed, and the researcher and the principal
69
supervisor coded a random selection of the papers for the literature review and
interview transcripts.
3.9.4 Use of verbatim quotes
Using verbatim quotes is an important technique to ensure the credibility of
qualitative research findings. Verbatim quotes have been used in the chapters that
report the in-depth interview results (Chapter 6 and 7) to illustrate the themes and
linkages identified and deepen understanding. The inclusion of quotes also allows the
reader to evaluate whether or not the representation of the data fits the opinions of
the participants and whether the findings hold true (Hannes, 2011). Importantly,
when a quote has been attributed to a specific professional category, this category
had been agreed to by the relevant participant through a consent process.
3.10 ETHICAL AND HEALTH AND SAFETY APPROVALS
This study involved the active participation of those involved in trying to
influence nutrition policymaking in Australia as well as the nutrition policy decision-
makers. As mentioned in section 3.7.4 ethical principles, such as securing informed
consent, protecting anonymity, and assuring confidentiality, may become difficult
when information is requested about influential individuals (Borgatti & Molina,
2005). To address these concerns, all participants were provided with a written
statement explaining the purpose of the research, the duration of participation, the
methods used, and any foreseeable risks. Furthermore participants were provided
with a statement describing the processes in place to ensure confidentially and the
level of anonymity available to participants. To protect the anonymity of participants,
all participants were identified in terms of their organisational category; for example,
non-government organisation – nutrition or journalist (as opposed to an individual’s
name or rank). This was in compliance with the requirements of the National
Statement of Research involving Human Participants. Ethical clearance for this
research was granted by QUT University Human Research Ethics Committee,
Approval Number 1400000857. Health and safety risks for this research were
assessed and minimised in line with QUT Faculty of Health guidelines.
70
71
Systematic literature Chapter 4:
reviews
A preliminary review of the literature outlined in Chapter 2 found that only a
limited number of international studies have examined nutrition policymaking using
policy process theories; thus insight into this important process is limited. With such
limited results, a systematic review of the literature was needed to confirm this
paucity of data. Furthermore, the collection of this initial dataset provided an
opportunity to re-analyse the data in the nutrition policy peer-reviewed literature, in
order to gain an insight into the barriers and enablers to nutrition policy change in
high-income, democratic countries. A summary of the key findings from both papers
will be presented at the end of the chapter.
This chapter includes the following papers:
1. Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2015). Using political
science to progress public health nutrition: A systematic review, Public
Health Nutrition 19(11), 2070-78
2. Cullerton, K., Donnet, T., Lee, A., & Gallegos, D. (2016). Playing the
policy game: A review of the enablers and barriers to nutrition policy
change, Public Health Nutrition 19(14), 2643-53.
Paper 1 presents the results of a systematic review exploring whether nutrition
policy scholars in high-income, democratic countries are using political science
policy process theories to inform their analysis of nutrition policy. This paper
provides further evidence for research question 1: What is the role of current
policy process theory in public health nutrition policymaking in high-income,
democratic countries, and particularly Australia?
72
Paper 2 presents a re-analysis of the same dataset with a focus on examining
the barriers and enablers to nutrition policy change. This paper provides further
evidence for research question 3: What are the barriers and enablers influencing
public health nutrition policy change in high-income, democratic countries, and
particularly Australia?
These publications add to the existing body of literature by providing evidence
that nutrition policy scholars only use policy process theories in a very limited way.
The second article is the first systematic review to specifically examine the barriers
to and enablers of nutrition policy change in high-income countries.
Both papers have been published in the peer-reviewed journal Public Health
Nutrition, which is a Q1 journal in the discipline area and has an impact factor of
2.67. This journal is a highly respected peer-reviewed public health journal that
focuses on research with a specific focus on nutrition-related public health. It has a
wide readership including medical, policy and health professionals. Paper 1 has been
cited five times in Google Scholar and has an Altmetric Attention Score of 18. Paper
2 has been cited six times in Google Scholar and has an Altmetric Attention Score of
23. The Altmetric Scores received for both papers places them in the top 5% of all
research outputs scored by Altmetric. This chapter is presented according to the style
guidelines of the journal, using the Vancouver referencing style and American
English spelling.
QUT Verified Signature
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4.1 PAPER 1: USING POLITICAL SCIENCE TO PROGRESS PUBLIC
HEALTH NUTRITION: A SYSTEMATIC REVIEW
Abstract
Objective: Poor dietary intake is the most important behavioural risk factor affecting
health globally. Despite this, there has been little investment in public health
nutrition policy actions. Policy process theories from the field of political science can
aid understanding why policy decisions have occurred and identify how to influence
ongoing or future initiatives. This review aims to examine public health nutrition
policy literature and identify whether a policy process theory has been used to
analyse the process.
Design: Electronic databases were searched systematically for studies examining
policymaking in public health nutrition in high-income, democratic countries.
Setting: International, national, state and local government jurisdictions within high-
income, democratic countries.
Subjects: Individuals and organisations involved in the nutrition policymaking
process.
Results: Sixty-three studies met the eligibility criteria, most were conducted in the
USA and a majority focused on obesity. The analysis demonstrates an accelerating
trend in the number of nutrition policy papers published annually and an increase in
the diversity of nutrition topics examined. The use of policy process theory was
observed from 2003, however, it was utilised by only 14% of the reviewed papers.
Conclusions: There is limited research into the nutrition policy process in high-
income countries. While there has been a small increase in the use of policy process
theory from 2003, an opportunity to expand their use is evident. We suggest that
nutrition policymaking would benefit from a pragmatic approach that ensures those
trying to influence or understand the policymaking process are equipped with basic
knowledge around these theories.
Keywords: nutrition policy, political theory, advocacy
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Introduction
Poor dietary intake is the single most important preventable behavioural risk
factor affecting health globally (1)
. In high-income countries the burden of disease
due to poor dietary intake is at least 14% of the total disease burden, which is around
double that due to cigarette smoking (1, 2)
. There is evidence that a range of nutrition
strategies can effectively reduce diet-related disease, including individual focused
‘downstream’ approaches and more ‘upstream’ population-based approaches.
Downstream interventions often focus on adverse health behaviours through direct
dietary interventions and require active participation by individuals (3)
; upstream
interventions focus on the wider circumstances that produce the adverse health
behaviours. Intervening on the wider circumstances can be achieved through
implementing policies that improve the social or physical food environment, for
example, improving the availability and quality of healthy food choices, decreasing
the cost of healthy food choices or changing the socio-cultural norms around food
through public awareness campaigns (4)
. Regulatory actions from governments
combined with joint efforts from industry and society are often required to
implement these policies in order to create healthier food systems (5)
. There is
increasing evidence that upstream population approaches are more cost effective and
can provide larger savings to the health-care system than downstream individual
approaches (6-8)
. However, despite this, there has been limited progress towards
public policy action in many countries (9, 10)
.
Public policy is defined as “a program of action (or inaction) of a government
to achieve specific goals” (11)
, it is the bedrock of the political process and is essential
in directing investment (12)
. Public policymaking is rarely a linear process and is
informed by interactions between institutions, politicians, advisers, interest groups,
the public service plus a range of other participants (13)
. Current public policy to
address nutrition issues in high-income, democratic countries is inconsistent (14, 15)
.
Numerous hypotheses have been given for this inconsistency including the power of
vested interests, a lack of evidence, and that tackling nutrition issues is too expensive
and complex (14-16)
. To understand why nutrition is not addressed more fully in public
policy, the policy process needs to be better elucidated in terms of how it is
influenced and by whom. This does not mean a focus on the technical content and
76
design of policies rather it is the analysis of specific aspects of the policy process.
These include how ideas, knowledge, interests, power and institutions influence the
policy decision-making process (17)
. In analysing the policy process, stakeholders
may be able to use the findings to more effectively leverage for policy change.
Any discussion of the policymaking process needs to consider the nature of
power. Power can be defined as control over outcomes, and this can occur through
control over resources and/or control over actors (18)
. The role of power in
policymaking has been explored by political scientists since the 1950’s, with
Lasswell and Kaplan noting ‘the political process is the shaping, distribution, and
exercise of power’ (19)
. Public policies, it is argued, reflect the values of those with
the greatest influence and are imbued with how those groups perceive the world to
be, or ought to be (20)
. Some believe that health policymaking, like policy in other
sectors, rests on the accumulation and use of power by those involved in the
policymaking process (21)
. One way to increase one’s power in the policymaking
process is through effective advocacy. Advocacy is defined as “active interventions
by organisations on behalf of the collective interests they represent, that has the
explicit goal of influencing public policy or the decisions of any institutional elite”
(22).
Advocating for food and nutrition policy and government support to protect
and promote health has been identified internationally as a core function for the
public health nutrition workforce (23)
. However, research has shown that the current
workforce is largely disengaged from the advocacy component of the policymaking
process and is unprepared for this type of work (24)
. Nutrition practitioners and
researchers often embrace policy advocacy with the belief that a scientific approach
is all that is required, that is, providing high level scientific evidence is enough to
influence policy decisions. However, expecting a linear connection between
scientific results and policymaking reveals a misunderstanding of the political nature
of policy environments (25, 26)
. Whilst evidence is an important ingredient, it is only
one component in the inherently political policymaking process. Assuming that
policymaking is a linear, rational process ignores the broader influences of political
ideologies, institutions and powerful vested interests in shaping and selecting the
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‘knowledge’ provided in the formulation of public policy (27, 28)
. By relying solely on
scientific evidence as a platform for policy change and not acknowledging or
understanding the political dimension of policymaking, public health nutrition
practitioners and researchers are unlikely to fully appreciate why desired policy
outcomes fail to emerge and therefore, why nutrition is often not addressed at a broad
population level beyond the individual.
Conversely, the systematic study of the policymaking process has occurred in
the field of political science since the 1950’s where many theories have been
developed to explain the various components, including politics, process and power
(29). Applying political science policy process theories (PPT) retrospectively allows a
greater understanding of why particular policy decisions were made which can help
advocates understand the complexities of the policymaking process as well as
identify key actors and leverage points for power and influence in the process. An
understanding of PPT can also aid in predicting the outcomes of ongoing or future
initiatives (30, 31)
. Three commonly used PPTs that have been validated empirically in
multiple countries to explain and predict the policymaking process include: the
Advocacy Coalition Framework (32)
; the Punctuated-Equilibrium Theory (33)
; and the
Multiples Streams Theory (34)
(see Table 4.1 for a summary) (29)
. These PPT have
different components; they are however all theories of policy change which focus on
agenda setting and policy adoption. Despite this raft of knowledge, very few public
health experts utilise these empirically-based PPT when analysing or trying to
influence the policymaking process or the content of policies (35-37)
. Publications in
the public health policy area tend to focus on describing policy content and
evaluating policy impact and outcomes, paying little attention to the policymaking
process (27, 38, 39)
.
A review of peer-reviewed papers reporting on policy process or content in
2010 found only 18% applied a PPT (35)
. A systematic literature review of the health
policy literature in low and middle income countries between 1994 and 2007 found
that health policy analysis was in its infancy with the majority of studies being
descriptive and very few utilising PPT (37)
. While these reviews have been conducted
78
across health promotion and public health generally, to date, no systematic review of
public health nutrition policy papers has been undertaken.
Table 4.1 Summary of influential theories of the policymaking process
Advocacy Coalition
Framework
Multiple Streams
Theory
Punctuated
Equilibrium Theory
Summary Policymaking is
characterised by the
interaction of advocacy
coalitions within a
policy subsystem.
Policymaking is
composed of three
streams: problem;
policy; politics. These
streams come together
during windows of
opportunity to cause
major policy change.
Policymaking is
characterised by long
periods of incremental
change punctuated by
brief periods of major
policy change.
Individual
Motivation
Belief system guides
choices and actions.
Assesses options until
an acceptable solution is
found.
Salience of an issue
depends on context.
Drivers of
policy
change
Alignment and activity
of coalitions. Outside
factors can realign
beliefs and generate
change.
Opening of policy
windows capitalised on
by policy entrepreneurs.
Policy image and public
mobilisation can
establish a new policy
monopoly.
Entrepreneurs and
interests groups play a
role.
While reviews of health promotion and public health literature can provide
general insights, public health nutrition policy is a particularly unique field. Unlike
cigarettes or pathogens, the healthfulness of particular foods can be open to
individual interpretation. Adding to this, choosing food is a necessary, but complex
process. This complexity is due to food choices being deeply embedded in culture
and influenced by many factors internal and external to the person, including
biological, social, psychological, economic and environmental (40-43)
. Macro level
environmental factors, including social norms, economic price structures, food
marketing, agricultural policies and food production and distribution, play an indirect
79
role but have a substantial and powerful effect on what people eat (44)
. Successfully
impacting on these factors will often require a structural or political response. The
complexity of the issue is further exacerbated by the many different voices of interest
groups. These include not only those with obvious vested (social or financial)
interests such as public health groups and food industry groups, but also “alternative”
health practitioners as well as celebrities and even actors advocating dietary
recommendations. To advance our understanding of the unique field of public health
nutrition policy, we conducted a systematic review of peer reviewed literature to
determine whether PPT is ultilised to guide analysis in the literature.
Methods
The systematic review was conducted based on the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) statement (Figure 4.1)
and a review protocol used by Breton and De Leeuw (35)
which examined the use of
PPT in health promotion, refined to focus on food and nutrition policy. This review
included English language nutrition policy literature published between 1986 to
December 2014. The start date was chosen as this was the year the Ottawa Charter
(45), which recommended a focus on healthy public policy as an effective strategy of
health promotion, was released.
Five electronic databases (PubMed, Informit, CINAHL, PsycINFO and
Scopus) were searched using the following keywords: “(politic* OR advoc* OR
coalition OR influenc*) AND (nutri* OR food OR obesity) AND (polic*) AND
(government)”. To limit settings based approaches, on the two occasions when more
than 500 papers were retrieved from a search, the terms AND NOT agriculture* were
included. Reference lists of relevant articles were also searched for eligible papers.
Multiple papers referring to the same study contributed only once to the review.
80
Figure 4.1. PRISMA 2009 Flow diagram
The studies from the initial search (n=1932) were reviewed against the
inclusion criteria (see Table 4.2). Papers were excluded if they were not primarily
concerned with the food or nutrition policymaking process or policy content. In
addition, papers were excluded if they recommended developing a new policy but
provided no detail on how that should occur or if they only examined the views of
the community about general policy directions. The application of the criteria
resulted in 147 eligible papers.
All 147 papers were fully read by the first author and assessed as to whether
insights from any empirically tested PPT had guided the policy research or
Records identified through database
searching
(n = 1932)
Additional records identified through
other sources
(n = 9)
Records after duplicates removed
(n = 1442)
Records screened
(n = 1442)
Records excluded
(n =1299)
Full-text articles assessed
for eligibility
(n =147)
Full-text articles excluded,
with reasons
(n =83)
Studies included in
qualitative synthesis
(n = 63)
81
theoretical reflections they reported, consistent with the method in Breton and De
Leeuw (35)
. When there was uncertainty as to whether a paper fit the inclusion
criteria, it was reviewed by a second independent reviewer. Disagreements between
reviewers were resolved by discussion until consensus was reached. A second
screening was undertaken to exclude all papers concerning low income and/or partial
or non-democratic countries as defined by the Democracy Index 2014 (n = 19), as it
was felt these settings were too different from the health policy environments and
systems of government of prime interest/relevance in this study (46)
.
Table 4.2 Inclusion and exclusion criteria for the identification of journal
articles reporting on policy research
Inclusion criteria
The article:
- Is in a peer reviewed journal indexed in PubMed, Scopus, Informit, CINAHL,
PsycINFO;
- Is in English;
- Was published between January 1986 and December 2014;
- Features either in its abstract, title or subject headings the search terms:
“(politic* OR advoc* OR coalition OR influenc*) AND (nutri* OR food OR
obesity) AND (polic*) AND (government)”. When more than 500 papers were
retrieved from a search, the terms AND NOT (school* OR agriculture*) were
included.
- Either reports on issues at the supra-national, national, state or local government
level related to:
o The content or nature of a policy ie (foreseen) components;
effectiveness; impact; evolution;
o The policy change process ie advocacy intervention or strategy, capacity
building for advocacy, evidence and knowledge shaping in
policymaking, theoretical and methodological issues in policy analysis.
Address a policy or policy process that goes beyond the walls of a
specific workplace, school or other organisational settings.
82
Exclusion Criteria
The article refers to:
- Policies related to a specific setting, for example, workplace, school or other
organisational setting;
- Policies related to clinical nutrition issues, for example, hospital based or one to
one dietetic services;
- Policies related to general well-being, physical activity, tobacco or agriculture;
- An opinion piece, commentary, letter or book review.
The content of papers were scanned for topic areas, year of publication, use of
PPT, country of focus, and level of government, then results were tallied and
depicted graphically (Microsoft Excel version 2010). A data visualisation technique
known as ebb and flow analysis was conducted to examine graphically the thematic
changes over time. This enables readers to identify emerging, dominant, enduring
and transient themes within a field of literature, and in the case of this review,
highlight the evolution of a field of research as new areas of inquiry are developed
and gain traction over time (47)
.
The ebb and flow analysis was created through a process of thematically
coding articles to create a database that enumerated the number of articles published
per year for each theme identified (that is, for example, obesity, childhood obesity,
food security). This was transformed into a normalised dataset (percentage of a
theme’s publications compared to the total volume of publications for a given time
period – that is, for example, every year, 2 years, 5 years) and graphed in Microsoft
Excel (version 2010) using the ‘100% Stacked Area’ chart function. A line graph
representing the volume of publications per time period was overlayed to provide
additional context to the data.
Findings
After the full-text-review, 63 studies were selected for inclusion. The studies
focused on a variety of countries, settings and nutrition policy issues. Most studies
83
examined single cases of nutrition policy in one country although eleven studies
included multiple country comparisons or data. The number of nutrition policy
papers per annum increased over time; with a greater concentration occurring post
2007 (see Figure 4.2).
Figure 4.2 Frequency of eligible nutrition policy articles (Jan 1986- Dec 2014)
The majority of papers had a geographical focus on the United States of
America (n = 31, 49% of all papers), this accounted for more than double the papers
from the next most common geographical focus, Australia (n = 12, 19%). The
remaining countries or regions represented included the United Kingdom, Japan,
New Zealand, Canada, Norway, Finland and the European Union. A large number of
papers (n = 29, 46%) focused their attention on national nutrition policy. State
focused nutrition policy, then local and global focused nutrition policy were the next
most common (n=14, 22%; n=11, 17%; n=8, 13%) respectively.
0
2
4
6
8
10
12
Number ofnutritionpolicypapers
84
0 5 10 15
obesity
childhood obesity
community food movt
policy content or implementation
food/menu labelling
food security
interest group influence
local govt food policy
tv advertising to children
developing nutrition policy
school meal/drink reg
SSB tax
Salt reduction
F &V consumption
No. of papers
Nutrition policy topics
Figure 4.3 Nutrition policy topics
Figure 4.4 Ebb and flow analysis of nutrition policy topics
85
0
2
4
6
8
10
12
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
No
. of
pap
ers
pu
blis
he
d
Year
Number ofnutrition policypapers
political sciencetheory used
The topics covered in the nutrition policy papers were wide-ranging (see
Figure 4.3). Thirty-eight percent of the papers focused on obesity, divided into
general obesity (n = 15, 24%) and childhood obesity (n = 9, 14%). Other more
common topics were interest group influence (n= 14, 22%), local government food
policy (n=6, 9%) and the process of developing nutrition policy (n=6, 9%). The
popularity of these topics has changed over time which can be seen in the ebb and
flow analysis (Figure 4.4). Earlier papers focused more on general policy content and
implementation as well as school nutrition policy whereas more recently there has
been a stronger focus on obesity and the influence of interest groups in
policymaking. The ebb and flow analysis also illustrates the growing field of
nutrition policy research, and captures the fragmentation of the field as a wide
variety of nutrition issues have become more salient over time.
Use of political science policy process theories
There has been an increase in the use of PPT in the reviewed nutrition policy
papers in recent years (Figure 4.5). However, this increase is fairly small with only
14% (n=9) of all the nutrition policy papers reviewed using empirically tested PPT.
In 2014 there appeared to be a reverse of the slight upward trend with none of the
nutrition policy papers utilising PPT to analyse their papers.
Figure 4.5. Comparison of nutrition policy papers published and those that use
political science policy process theory (PPT)
86
Whilst papers were reviewed for all empirically tested PPTs, the only PPTs utilised
included Multiple Streams Theory (five papers) (48-52)
, the Advocacy Coalition
Framework (three papers) (9, 53, 54)
and one study used both Multiple Streams Theory
and the Advocacy Coalition Framework (55)
. Five papers referred to PPT in their
introduction or discussion but it was unclear whether they utilised theory in
analysing their data (56-60)
. Theory was used to retrospectively analyse a case
study/studies in all but one of these papers. Gilson Sistrom (55)
utilised PPT
prospectively, with the application of Multiple Streams Theory and the Advocacy
Coalition Framework to guide advocacy around regulating “junk food” in schools.
Seven papers (13%) referred to theories other than PPT. The theories used
included: Framing Theory (61)
, which looks at one component of the policy process;
the Health Belief Model (62)
and Stages of Change (Transtheoretical Model) (10)
, both
of which are theories related to individual behaviour change rather than policy or
system change. Three authors developed their own theories (63-65)
and one paper used
Walt and Gilson’s Health Policy Triangle which is a framework that identifies the
elements and relationships of the policy process. This framework is a useful starting
point for health policy analysts, however, the Health Policy Triangle does not explain
or predict behaviour and outcomes as do the PPT referred to earlier (66)
.
Discussion
The aim of this study was to explore nutrition policy studies in high-income
democratic countries and to examine whether political science policy process theory
was being used to guide or analyse the described policy process. The review resulted
in the inclusion of 63 papers although only nine (14%) of these utilised PPT. This is
a smaller percentage than the 18% found by Breton and De Leeuw in 2010 in their
review of health promotion policy literature. This limited use of political science
policy process theory may help explain the lack of progress in public health nutrition
policy action. Understanding these theories can help policy advocates understand the
complexities and identify the drivers and leverage points for influence in the
policymaking process.
87
The publication of general nutrition policy papers and those utilising PPT has
increased over time, with a greater concentration occurring post 2007, which is later
than the increase post 1999 identified in the review of health promotion papers (35)
.
This may be due to nutrition professionals becoming more aware of political science
theories because more are being published in the general health promotion literature.
Further, this heightened awareness of PPT may have led to increased opportunities
for collaboration or inter-sectoral approaches on nutrition issues with political
scientists. However, another reason is that there are increasingly more publishing
options available for health policy papers. Fifty eight percent (58%) of the journals
cited for this review were not in existence in 1986 and 30% of the journals only came
into being post 2000.
The ebb and flow analysis demonstrated the change in topics in nutrition policy
papers over time. Earlier papers focused more on general policy content and
implementation as well as school nutrition policy, whereas more recently there has
been a strong focus on obesity. Of note is the literature gap between 1996-2001. The
gap indicates a possible lack of research in this period. However, as the total
numbers of policy papers being produced at the time were so low, for example, one
or two per year, it is not unreasonable to assume that those early years did not
produce any nutrition policy papers. In more recent years, new policy topics emerged
which have expanded the field of literature, but obesity continues to rise to
prominence. This result is to be expected due to the worldwide trend and concern
about increasing obesity prevalence (1, 5, 8)
. The more recent diversification of topics
seems to be following the advent of state-based legislation in different countries
encouraging the exploration of specific themes and salient debates.
A progression from focusing mostly on the content or implementation of
nutrition policy to a greater focus on the policymaking process itself has been evident
within this review. This is positive progress as earlier criticisms of public health
policy research were that the focus was predominantly on policy content and
evaluating policy impact and outcomes, paying little attention to the policymaking
process (27)
. However, in line with the review of low and middle income country
healthy policy literature conducted by Gilson and Raphaely (37)
, most of the analyses
88
of nutrition policy were relatively intuitive and assumptions on which the analyses
were based were seldom identified. The majority of articles provided descriptions of
the policymaking process or described suggested barriers and facilitators to
policymaking as gleaned by policymakers. Most papers in this review relied on
anecdotes to explain what had occurred in the policy process or ignored the process
totally. Very few papers explained how the policy change happened (or did not
happen). This may be due to the authors’ lack of awareness around the complexity of
the policymaking process and where theories could help identify the discourse of the
different vested interests as well as system-wide events that could potentially shift
the balance in favour of one actor over another (67)
.
Another notable deficit is the lack of analysis around power. Power is not
simply about visible conflicts whereby one group wins and another loses, it can also
involve exercising power to reinforce social attitudes (68)
. If the weight of public
opinion is against government action, governments may not intervene. Interest
groups are also able to exercise power in keeping an issue off the government
agenda. This may occur by using their power to keep ‘safe’ issues on the agenda to
take up the attention of policymakers (68)
. In this review power is broadly discussed
in a range of articles, with some providing a description of influence strategies used
by vested interests to keep healthy food policies off the agenda. However, very few
articles explicitly explored the role of power in policymaking. Two papers that did
provide an exploration of power in the policymaking process were the paper by Field
and Gauld (69)
which does not use a theory or framework to analyse power but instead
uses the vested interest construct to explore how three different interest groups
influenced policy around marketing to children in New Zealand. Also, the paper by
Hobbs et al (53)
utilised an adaption of the Advocacy Coalition Framework to analyse
the policymaking process around federal school meals regulations by examining the
actions of different interest groups, their goals, resource base and strategies for
influence.
The majority of papers using PPT emerged from the United States of America
(USA). There is a long history of policy advocacy and some success in nutrition
policy action in the USA particularly at a state level. However, Scandinavian
89
countries have also been active in achieving nutrition policy action (70)
, yet they have
published comparatively little, with no studies found using PPT. This may be
because they are publishing in non-English language journals or because lobbying is
heavily embedded in the system of government in USA and therefore interest groups
are potentially more advanced in political lobbying. One other reason may be that the
USA has more pressure for academics to publish due to their public university
ratings system which has been active since the late 1980’s (71)
.
A large number of the nutrition papers reviewed (47%) focused their attention
on national nutrition policy. This may be representative of the traditional view of
government as having a directive, stewardship-like role in managing public health.
Although, for many of the countries represented in this review, the national level of
government is responsible for legislative or regulatory functions typically associated
with public health reform and so a focus on this level of government is to be
expected.
PPT was used to retrospectively analyse a case study/studies in all but one of
the papers that used policy process theories. There seems to be a missed opportunity
in utilising these theories prospectively to develop and inform policy advocacy
strategies. However, before practitioners and researchers can use these theories to
develop and inform policy advocacy strategies, they need to understand and be able
to apply them. Typically PPT are not covered in university training for public health
professionals, let alone those who specialise in nutrition. Including training around
these theories and the policymaking process in the curriculum would assist in
developing the core competency of advocacy for the next generation of public health
nutritionists. To better equip current nutrition professionals for future policy
advocacy work, better training and a stronger research focus on nutrition policy
processes is required.
Limitations
This review is subject to several limitations. It is possible that relevant articles
were not included in the review given the restrictions in the search terms and that
90
only English language literature was considered. In addition, although known to
exist, relevant book chapters, doctoral theses and grey literature were excluded from
analysis. We have accepted this limitation because, without peer-review, it is not
possible to verify the quality of the study, though we acknowledge that there is more
to be learnt from the grey literature. On both grounds, therefore, the review cannot
claim to be a comprehensive survey of all available nutrition policy work in high-
income, democratic countries conducted between 1986 and 2014. Despite these
limitations, this review contributes to improved recognition of the political
dimension of nutrition policymaking and can continue to stimulate critical thinking
about current and future policymaking.
Conclusion
The politics of agenda setting, policy formulation and implementation are
complex, with conflict and power being intrinsic elements. PPT can help a broad
range of health practitioners, including public health nutrition researchers and
practitioners, understand these complexities and identify leverage points for
influence. Oliver (72)
states that researchers and health professionals who understand
the political dimensions of health policy “can conduct more realistic research and
evaluation, better anticipate opportunities and constraints on governmental action
and design more effective policies and programs”. Whilst it is heartening to see a
small increase over time in the use of policy process theory when analysing nutrition
policy, this has been limited and wider use needs to be encouraged. More practical
measures could be taken to ensure those trying to influence or understand the
nutrition policymaking process are equipped with basic knowledge around these
theories which will enable them to become better advocates for policy change.
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4.2 PAPER 2: PLAYING THE POLICY GAME: A REVIEW OF THE
BARRIERS AND ENABLERS OF NUTRITION POLICY CHANGE
Abstract
Objective: To progress nutrition policy change and develop more effective advocates,
it is useful to consider real-world factors and practical experiences of past advocacy
efforts to determine the key barriers and enablers to nutrition policy change. This
review aimed to identify and synthesize the enablers and barriers to public policy
change within the field of nutrition.
Design: Electronic databases were searched systematically for studies examining
policymaking in public health nutrition. An interpretive synthesis was undertaken.
Setting: International, national, state and local government jurisdictions within high-
income, democratic countries.
Results: Sixty-three studies were selected for inclusion. Numerous themes were
identified explaining the barriers and enablers to policy change, all of which fell
under the overarching category, ‘political will’, underpinned by a second major
category, ‘public will’. Sub-themes, including pressure from industry; neoliberal
ideology; use of emotions and values, and being visible were prevalent in describing
links between public will, political will and policy change.
Conclusions: The frustration around lack of public policy change in nutrition
frequently stems from a belief that policymaking is a rational process in which
evidence is used to assess the relative costs and benefits of options. The findings
from this review confirm that evidence is only one component of influencing policy
change. For policy change to occur there needs to be the political will, and often the
public will, for the proposed policy problem and solution. This review presents a
suite of enablers which can assist health professionals to influence political and
public will in future advocacy efforts.
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Introduction
Improving the nutritional status of populations remains an urgent priority for
addressing the growing burden of obesity and chronic disease worldwide (1)
. Recent
papers advocate that the most effective way of achieving this involves the promotion
and implementation of public policy change, focusing on regulation, legislation and
public awareness campaigns designed to make healthy food choices, the preferred
choice (1, 2)
. However, relevant political science theory highlights that changing
policy at a national, state or local level of government is a slow and often challenging
process due to the complexity of the policy change process and the conservative
nature of political systems, which favour the status quo (3)
. Research from policy
process scholars suggest this preference towards the status quo is due to: institutions’
resistance to change; constraints on the rationality of decision-makers due to limited
time and the cognitive overload they face; and the power of vested interests in
maintaining their privileged position (3, 4)
. For change to occur, therefore, the power
of vested interests needs to be challenged and the policy problem, the policy solution
and the political climate all need to align (3, 4)
.
Nutrition advocates from non-government organisations, academia and government
bodies have taken up the challenge by attempting to influence policy positively
through a range of advocacy strategies with varied success (5)
. Advocacy is defined
as “active interventions by organisations on behalf of the collective interests they
represent, that has the explicit goal of influencing public policy or the decisions of
any institutional elite” (6p43)
. Some interest groups have greater power to influence
public policy and decision-making than others due to their organisational or personal
resources, including knowledge of effective advocacy strategies and how to apply
them. For groups in positions of low power and influence, improving knowledge of
effective advocacy strategies and how to apply them, particularly under resource-
constrained conditions, could change the power dynamic between policymakers and
the people affected by their decisions (7)
.
Internationally, a limited range of peer-reviewed literature documents effective
advocacy strategies for influencing public health policy in general, with even less
literature on influencing public health nutrition policy (8)
. Political science is one
101
field where a large volume of research has occurred in the study of the policy process
and influencing policy change (3, 4, 9)
. See Table 4.3 for a summary of influential
policy process theories. While theoretical models and frameworks from political
science can guide practitioners in influencing the policymaking process, only limited
numbers of nutrition policy advocates utilise these theories when championing policy
change (10)
. One criticism of these theories, which may explain their limited use, is
that they have been designed for an academic audience, rather than a practitioner
audience, with concepts that are often difficult to understand and translate to the real
world (11)
.
Table 4.3 Summary of influential theories of the policy process (Cullerton et al., 2016c)
ADVOCACY
COALITION
FRAMEWORK
MULTIPLE
STREAMS THEORY
PUNCTUATED
EQUILIBRIUM
THEORY
Summary Policymaking is
characterised by the
interaction of advocacy
coalitions within a
policy subsystem.
Policymaking is
composed of three
streams: problem;
policy; politics. These
streams come together
during windows of
opportunity to cause
policy change.
Policymaking is
characterised by long
periods of incremental
change punctuated by
brief periods of major
policy change.
Individual
Motivation
Belief system guides
choices and actions.
Assesses options until
an acceptable solution
is found.
Salience of an issue
depends on context.
Drivers of
policy
change
Alignment and activity
of coalitions. Outside
factors can realign
beliefs and generate
change.
Opening of policy
windows capitalised on
by policy
entrepreneurs.
Policy image and public
mobilisation can
establish a new policy
monopoly.
Entrepreneurs and
interests groups play a
role.
To progress nutrition policy change and develop more effective advocates, it is
useful to consider the real-world factors and practical experiences of past advocacy
efforts to determine the barriers and enablers to nutrition policy change.
Understanding these barriers and enablers may ensure future advocacy efforts of
health professionals are more targeted with interventions tailored to address specific
102
barriers and to make use of specific enablers. To date, there has been only one review
examining advocacy in nutrition policy undertaken, and it specifically focused on
obesity prevention (12)
. No systematic review of the barriers and enablers to nutrition
policy change has been conducted. To address this gap in knowledge this paper
presents a systematic review of the barriers and enablers to nutrition policy change,
with a specific focus on high-income, democratic countries.
Methodology
This review re-analyses the results of a previous systematic literature review (10)
to
answer a new question. These data were first used to determine whether policy
process theory had been used in nutrition policy papers. As the majority did not use
policy process theory, the data was re-assessed via interpretive synthesis (13)
to
determine the enablers and barriers to public health nutrition policy change. The
search strategy has been reported elsewhere (10)
and is summarised below.
The systematic review was conducted based on the PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-Analyses) statement (Figure 4.6) and a
review protocol developed by Breton and De Leeuw (14)
. Five electronic databases
(PubMed, Informit, CINAHL, PsycINFO and Scopus) were searched using the
inclusion and exclusion criteria specified in Table 4.4. The application of the criteria
resulted in 147 eligible papers progressing to the next stage in the screening process.
103
Figure 4.6. PRISMA 2009 Flow diagram
These papers were fully read by the first author (KC) and assessed as to whether
barriers and enablers to influencing public health nutrition policy were identified.
When there was uncertainty as to whether a paper fit the inclusion criteria, it was
reviewed by a second author (DG). Disagreements were resolved by discussion until
consensus was reached. As a means of controlling for comparable systems of
policymaking, a second screening excluded all papers focused on low income and/or
partial or non-democratic countries as defined by the Democracy Index 2014 (n = 19)
(15).
Records identified through database
searching
(n = 1932)
Additional records identified through
other sources
(n = 9)
Records after duplicates removed
(n = 1442)
Records screened
(n = 1442) Records excluded
(n =1299)
Full-text articles assessed for
eligibility
(n =147)
Full-text articles excluded,
with reasons
(n =83)
Studies included in
qualitative synthesis
(n = 63)
104
Table 4.4. Inclusion and exclusion criteria for the identification of journal articles
reporting on policy research
Inclusion criteria
The article:
Is in a peer reviewed journal indexed in PubMed, Scopus, Informit, CINAHL,
PsycINFO;
Is in English;
Was published between January 1986 and December 2014;
Features either in its abstract, title or subject headings the search terms: “(politic*
OR advoc* OR coalition OR influenc*) AND (nutri* OR food OR obesity) AND
(polic*) AND (government)”. When more than 500 papers were retrieved from a
search, the terms AND NOT (school* OR agriculture*) were included.
Either reports on issues at the supra-national, national, state or local government
level related to:
a. The content or nature of a policy ie (foreseen) components; effectiveness;
impact; evolution;
b. The policy change process ie advocacy intervention or strategy, capacity
building for advocacy, evidence and knowledge shaping in policymaking,
theoretical and methodological issues in policy analysis. Address a policy or
policy process that goes beyond the walls of a specific workplace, school or
other organisational settings.
Exclusion Criteria
The article refers to:
Policies related to a specific setting, for example, workplace, school or other
organisational setting;
Policies related to clinical nutrition issues, for example, hospital based or one to one
dietetic services;
Policies related to general well-being, physical activity, tobacco or agriculture;
An opinion piece, commentary, letter or book review.
Analysis
The Framework Method (16)
was adapted to guide the analysis of the data. This is a
systematic thematic analysis process which identifies commonalities and differences
in qualitative data before focusing on relationships between different parts of the data
105
(17). Papers were coded line by line by one investigator (KC). Initial codes were a mix
of open and pre-defined codes informed by the following political science policy
process theories: the advocacy coalition framework; the punctuated equilibrium
theory; and multiple streams theory (3, 4, 9)
. The pre-defined codes from the literature
included: policy entrepreneur; policy window; and coalition. The remaining codes
were deduced from the data. After coding six papers a working analytical
framework, which incorporated the codes, was applied to each paper. However, there
was flexibility to add new codes if needed. Nvivo (18)
was used to manage the data
and to generate the analytical framework .
Once the analytical framework had been applied, the characteristics of, and
differences between the data were identified. This was followed by mapping the
connections between these categories and identifying the central themes that
emerged which characterised and represented the key enablers and barriers.
Throughout this process, the range of attitudes and experiences, including deviant
cases for each theme were considered. As this was an interpretive review (13)
, no
attempt was made to undertake a content analysis in order to differentiate the themes
in terms of dialogue frequency and/or importance.
Results and Discussion
Screening resulted in 63 studies included for analysis. The characteristics of these
studies can be found in a previous paper (10)
. Numerous themes were identified
explaining the barriers and enablers to policy change, all of which fell under the
overarching category, ‘political will’. Political will reflects whether or not decision-
makers (politicians or senior bureaucrats) were supportive of policy change. This
was underpinned by a second major category, ‘public will’, which reflects the mood
and policy preferences of voters. Public will was a major component of political will,
as politicians were often not motivated to act on an issue that had little public interest
or could cause a backlash from wider society (19)
.
Four themes emerged as barriers and six as enablers for political will, whilst three
themes emerged as barriers and four as enablers for public will. There was high
106
concordance between the themes connected to influencing public and political will
(see Figure 4.7).
Figure 4.7. The barriers and enablers of political and public will
Barriers to change in policymaking
The barriers to policy change included: the rise of neoliberal ideology; pressure from
industry; lack of knowledge, skills and resources from health advocates; and
government silos. These themes all fell under the overarching theme of political will
107
and all, except government silos, were also applicable to the second overarching
theme of public will.
The rise of neoliberal ideology
The influence of neoliberal ideology in policy decisions was evident throughout the
literature. Several papers referred to the prioritising of economic prosperity as the
main barrier to policy change (19-24)
. This was demonstrated by a lack of support for
regulatory intervention, with the justification that it could interfere with market-
driven economies (25)
. Furthermore, the cost of implementing proposed solutions and
monitoring compliance was also cited as a concern to governments (21, 25, 26)
.
Specifically, many countries now require government departments proposing
regulation to demonstrate that they are cost-saving, that is, the health benefits
directly attributed to the regulation will exceed the direct or indirect costs to business
(25, 26). This was problematic for many public health nutrition initiatives as evidence
around cost-effectiveness did not exist or was difficult to determine due to the
complexity and multi-factorial nature of nutrition problems (26-28)
.
Prioritisation of government policies that resulted in short-term economic benefit,
over policies related to longer-term health outcomes was also evident in the
literature. This prioritisation was apparent when agricultural policies based on
subsidies raised the relative price of healthy foods and lowered the price of unhealthy
foods (19, 24, 25, 29, 30)
. In addition, conflicted decision-making was seen when the
government department responsible for protecting agricultural producers was the
same department advising the public about dietary intake (29)
. This conflict was
evident when the Department of Agriculture which had a dual mandate for health and
agriculture, under pressure from meat producers, changed federal dietary advice from
"decrease consumption of meat" to "have two or three (daily) servings." (29)
Even
within health departments, there were competing agendas which prioritised certain
nutrition issues over others, for example, food safety over food security (31)
.
Some authors identified the overriding desire by governments to ensure personal
freedoms was a driver in eschewing regulation or “nanny state” options. As
Campbell (32)
pointed out, proposing legislation as a solution creates tension within
nations with a liberal tradition of personal responsibility, individual choice and free
108
markets. This ideological conflict was identified by several authors who documented
a change in government resulting in food and nutrition policies being watered down
or rescinded on the basis of the revised policy being more industry friendly, or
because of personal responsibility arguments (23, 27, 33)
. It should be noted that the
ideology of personal responsibility is an entity in its own right albeit strongly
influenced by industry as a strategy to increase consumption (34)
.
Pressure from Industry
Pressure from industry was one of the main barriers cited for policy change not
occurring. This came in a number of forms, including intense lobbying; creation of
scientific uncertainty; industry-government or professional body partnerships; and
influencing cultural norms.
Intense lobbying
The most noticeable form of pressure from industry was ‘intense lobbying’ (23, 24, 27,
29, 32, 33, 35). Although, it should be noted that several authors referred to industry
‘using their influence’, there was no elaboration on what this involved (23, 24)
. Dodson
et al. (36)
elaborated by stating that lobbyists were ever present and that they ‘watch
for issues a lot more carefully than public interest groups’. Gilson Sistrom (35)
concurred with this and stated that through their higher capacity and resources,
industry lobbyists were able to ‘dog’ legislators every day. In addition, it was noted
that industry had a lot more points of interaction with government than health
organisations as: providers of tax revenue; major employers; through international
linkages; and as holders of specialised knowledge (37)
. Other food industry strategies
mentioned included directly contributing to political parties or individual politicians
(29, 38, 39) and utilising high level contacts
(25, 34).
Creation of scientific uncertainty
Another form of pressure evident in the literature was industry claiming there was
insufficient evidence on effective interventions and that more evidence was needed
before further action occurred (28, 34, 40, 41)
. This strategy generated a level of
uncertainty regarding evidence and tended to reduce the authority of health
professionals advocating for action (28, 34, 40)
. Another strategy was for industry to
fund scientific research to support their viewpoint or to spread unsubstantiated
109
misinformation (34, 41, 42)
. Consequently, this allowed industry to control how the issue
was portrayed to policymakers and the general public.
Industry-government or professional body partnerships
Forming associations with professional bodies and government agencies allowed
industry to build citizens’ trust in systems they perceived to be ethically flawed or
puzzling (43)
. Badging or developing a formal relationship with a nutrition
organisation was seen as a third party endorsement for a company and gave it
legitimacy to intervene in the regulatory environment (34, 43)
. Industry–government
partnerships allowed industry to shape a supportive regulatory environment that did
not impact on corporate profits (34, 37, 41, 43, 44)
. A more concerning aspect of this was
where public policy was not simply influenced but actually co-created and delivered
by the private sector, for example, the ‘Change4Life’ campaign in the United
Kingdom (44-46)
.
Influencing cultural norms
Industry’s pursuit of competitive advantage requires the active shaping of the cultural
environment in which food choices are made (43, 45)
. Consequently, industry invested
considerable resources to control the frame around nutrition problems and solutions.
Framing is how an issue is portrayed, often using media to influence popular and
elite opinion (42)
. One effective way issues were framed and reported in the media
was that regulation violates freedom of expression and limits personal responsibility
(34, 37). This effectively links in with the pursuit of the neoliberal agenda and increases
the value of industry as a government ally. A further strategy to influence cultural
norms was manufacturing public sentiment through the use of ‘fake’ citizen groups
funded by the food industry, for example ‘The Obesity Awareness and Solutions
Trust’(45)
. Miller (45)
concluded that this strategy was effective because it plays on the
fears of politicians of a backlash from wider society
Lack of resources, skills and knowledge from health advocates
The limited resources, money and time of health advocates were cited as significant
barriers to policy change (21, 36, 39)
. The volunteer advocates in the Oregon Healthy
Foods Schools Bill felt themselves to be at a distinct disadvantage against paid, full-
time lobbyists. They did not have the time or money to directly lobby decision-
110
makers and adding to this disadvantage was that they did not understand the policy
and political processes (35)
.
Confusion over the policymaking process was a key barrier for health advocates, and
components of this included: not knowing the entry point or responsibility of
government departments for certain nutrition issues (22)
; not understanding that
politicians usually decide on whether policy goes ahead, not the bureaucrats (26)
; the
importance of a uniform voice (35)
; the dogged persistence that is required (35)
; and the
hierarchy of power within government departments (25)
. Also, some advocates’
inability to compromise meant that they missed out on opportunities for policy
progression (35, 39)
.
Poor communication of the solution
The most commonly identified communication issue in the literature was advocates
not comprehending how little time policymakers have to understand an issue (21, 22, 47,
48). Food and nutrition policy is complex and multi-factorial, however, policymakers
are often required to make decisions with limited time. Providing reams of evidence
or using complex language was not helpful for policymakers, as most do not have the
time required to summarise and understand best practice solutions (21, 22, 48, 49)
.
Furthermore, ineffective framing of the issue weakened arguments and shifted the
focus away from interventions or policies of worth (42)
.
Government silos
Dietary intake is influenced by a complex set of factors and as a result the
responsibility is spread across different government departments and different levels
of government (24, 26)
. Co-ordinating various departments to work together can be
challenging as they tend to work in ‘silos’ and prioritise their own objectives (21, 25)
.
Furthermore, some government departments can take a narrow perspective of their
responsibilities, for example: local government identifying their sole role in food
policy as the regulation of food hygiene and safety; (22)
and Departments of
Agriculture seeing food only as a product to grow, sell and export (23, 30, 50)
. These
narrow perspectives were also reinforced by a broader societal mindset around a
biomedical approach to health, that is, that treatment and management take priority
over prevention (22)
.
111
Enablers of policy change
As highlighted in Figure 2, the literature pointed to a wide array of enablers that can
be harnessed to improve the likelihood of positive policy change. All were focused
on building political and/or public will, as detailed below.
Develop a well thought-through solution
A key enabler of policy change that emerged from the literature was providing
policymakers, and often the general public, with a well thought-through solution (12,
26, 51, 52). The most successful solutions had several components: clear, costed
strategies on how to solve the problem; single or incremental strategies; and a local
focus.
Clear, costed strategies on how to solve the problem (technical feasibility)
Many of the included studies described the importance of evidence in the
policymaking process. However, several caveats were provided regarding the need to
ensure evidence is useful for policymakers (see Table 4.5).
112
Table 4.5: Making evidence useful for policymakers
- Present practical and suitable solutions not just problems (12, 51, 54, 65)
;
- Highlight successful international implementation of the proposed solution (12, 50,
52).
- Explicitly describe the way an idea would be brought into practical use, including
all implementation issues and the potential impact of the policy (including cost to
business) (12, 26, 51)
;
- Keep documents brief, two pages or less (49)
;
- Include information on efficiency and whether benefits could be achieved
through less costly policy options to help combat the views of competitors (12, 26)
;
- Ensure solutions are aimed at a wide audience; and provide information on the
number, proportion and representativeness of individuals likely to be affected by
the proposed solution (12)
;
- Whilst it is important to seek out the best available evidence, it may be necessary
to include untested yet promising strategies (12)
.
Offer single or incremental solutions
A potential source of confusion for advocates in the complex field of public health
nutrition is whether to put forward a package of interventions which will have a far
greater impact on health status, or put forward one, manageable intervention, which
would have a more limited impact (26)
. All but one of the studies that examined this
issue suggested one single intervention or incrementalism had a far greater chance of
enactment (36, 53-56)
. Opposing this view was one study that suggested providing a
package of interventions was more effective, as the government requirements of cost
effectiveness could not be demonstrated with just one intervention (26)
. It was also
suggested that advocates should always have a list of back-up ideas to allow
flexibility during negotiations or when a different window of opportunity opens (12)
.
Start locally
Starting locally was found to be another way to present a more manageable proposal
to policymakers. Local advocacy initiatives were more effective in achieving their
objectives than national ones (54, 57)
. This success may be because they set more
113
modest goals, defined a more manageable scope of activities, or the institutional
structures of local government are not as complex with fewer vested interests than at
the state or national level. Compared to state and nationally focused initiatives, local
initiatives were able to leverage funding and support through different, often less
competitive routes (58)
. However, while this strategy can be successful at a local level
there was limited evidence of success at ‘scaling up’ to the national policy level (59)
.
Build relationships with key stakeholders
Gaining support from a wide range of policymakers and key stakeholders increased
the chance of legislation passing or a policy solution being supported (12, 36, 53, 57, 58)
.
Stakeholder support to which decision-makers responded positively included their
constituencies and colleagues, including public officials, community leaders, and
interest groups (12, 53, 56, 58)
. Consequently, those advocates who did not engage with
key stakeholders found their position was weakened (37)
. By building relationships
with key stakeholders, advocates developed a greater understanding of the wider
environment and were able to identify policy opportunities, tailor policy options to
the existing political environment, and gauge the likelihood of success (12, 60)
.
Form diverse and well-connected coalitions
Forming coalitions encompasses formally bringing together interest groups and
organisations, and sometimes politicians, to strengthen the voice on an issue and
influence policy change. Establishing broad engagement and commitment across a
mix of stakeholders, particularly non-traditional alliances, for example agricultural
and producer interests, contributed to the building of a strong coalition which was
able to exert prevailing influence on policy decisions (12, 31, 36, 50, 53, 54, 56, 57, 61)
. One
example of this was the Washington Nutrition Obesity Policy Research and
Evaluation Network which included researchers, public health practitioners, and
advocates from nutrition, agriculture, law, economics, public policy, epidemiology,
and urban design(61)
. Another advantage of fostering diversity was that all parties can
provide complementary skills, resources and new strategies and contacts to move
towards the common policy goal (12, 21, 54, 57, 61, 62)
. Furthermore, coalitions that
included groups with access to key points of government and decision-making were
more likely to have their issue placed on an agenda (12)
. Others highlighted the
114
advantages of the often contentious strategy of forming a coalition with industry to
reach mutually agreeable solutions on nutrition issues (52, 63)
.
Choose one common goal
When issues become linked based on a common goal, this creates synergy rather
than competition and increases the likelihood of policy change (62)
. Conversely,
disunity among interest groups creates confusion and weakens each interest group’s
position. Such disunity, and the ensuing lack of change, was evident in two papers:
the debate on a proposed tax on sugar sweetened beverages, where hunger activists
said the tax unfairly hurt the poor (62)
; and legislation to improve school meals in
Oregon, was met with opposition from parents, teachers and foodservice
professionals as they wanted to protect profits and keep local control (35, 36)
. Disunity
through a lack of coordination was identified as a barrier by Field and Gauld (37)
in a
government inquiry into food marketing to children where multiple advocacy groups
participated. However, there was little co-ordination in their advocacy efforts, which
weakened their overall position, resulting in failure to influence the outcome of the
inquiry.
Use emotion and values
While using evidence was cited as important, other factors, such as using stories and
emotion to engage values, can be equally, if not more, compelling (12, 42, 49)
. A
popular technique for building support and political will amongst policymakers and
the general community by way of emotion and values was framing. Small changes in
how an issue is presented can significantly alter how an issue is understood, which
can result in a change in public opinion as well as the policymaking environment (42,
49, 57, 64). The most effective frames relied on simple messages that were easy for the
general public and politicians to grasp (46, 48)
. Frames that advocates successfully used
to build policy support included: protecting the health of children; truth and honesty;
fairness and social justice; and urgent crisis or a looming evil (19, 57, 65, 66)
.
Safeguarding children seemed particularly effective with neoliberal governments
where there was concern about excessive government control over individuals and
food choices (66)
.
115
Be visible
To be effective, advocates must first have their issue acknowledged by policymakers
as a problem worthy of attention. Being visible is one way to get your issue
acknowledged. Visibility can come in a variety of forms but often requires high level
communication skills and creative solutions (67)
. The various techniques highlighted
in the literature are presented below.
High profile event or report
A large number of studies found that attendance by policymakers at a high-profile
event or policymakers reading a prominent, salient report was the trigger point for
initiating policy action on an issue (21, 27, 29, 48, 50, 54, 65, 66)
. Creating documents or
events that either raised awareness of an issue that policymakers previously were
unaware of and/or clearly outlined steps to solve the problem were considered most
effective. Effectively framing the problem and utilising international data or targets
as a comparison also came up as important ways to attract attention and encourage
action to be taken (12, 48, 50, 65, 66)
.
Media engagement or campaign
Advocacy coalitions that engaged with the media frequently were more likely to
achieve policy change (12, 36)
. However, it was noted that engaging the media can be
challenging for health advocates due to a lack of media skills and experience (12)
.
Specific strategies that were successful included leveraging media coverage off
national and international stories (58)
and using high profile organisations or
individuals to attract media attention (19, 65)
. Using high profile organisations or
individuals also provided credibility to issues with policymakers and the general
public (19, 59, 65)
.
Public mobilisation
Mobilising wider society to demonstrate support for an issue, led to increased public
and political will. Historically, this has been a frequently used strategy of health
advocates in the form of rallies, mass e-mail communications and boycotts (38, 57)
.
This is a very visible way of demonstrating public support to policymakers.
Alternatively, public surveys and interviews with key opinion leaders can also
demonstrate the support of the public (12)
. Providing public education or community
116
workshops about the topic at hand and policy solutions may be required before the
public engages and becomes mobilised (12, 21, 36, 50, 64)
. Conversely, failing to mobilise
community support was identified as a key reason for a policy issue not getting
policymakers’ support (35)
.
Engage a policy entrepreneur or develop skills of advocates
The value of a “policy entrepreneur”, described as an “advocate for proposals or for
the prominence of an idea, in progressing policy change” (4)
was highlighted in many
studies. Often the policy entrepreneur was in a position of power, for example a local
government CEO or a politician, (22, 31, 48, 58, 66, 68)
but not always (21, 36, 54, 69)
.
Regardless of position, policy entrepreneurs were seen as effective conduits for
disseminating evidence to legislators and promoting recommended strategies (21, 50, 53,
54, 65). The skills of the policy entrepreneur were often extolled in the literature, these
included: their analytical, strategic and political policy skills; high level
communication skills which enabled them to negotiate with, influence and encourage
consensus among high level stakeholders; and their general passion, enthusiasm and
vision for the issue at stake (21, 50, 54, 65, 68, 70)
.
Other attributes of a successful policy entrepreneur were the need to be flexible,
adaptive and persistent. Practically, this meant being able to refine policy solutions in
line with the politics of the time (23, 50)
and, being open to compromise by offering
alternative solutions that were mutually agreeable between interested parties (35, 39)
.
Moreover, this required policy entrepreneurs to be nimble enough to take advantage
of new political opportunities when they arose and to understand the strategies and
end-goal of their opposition (21, 35, 51)
. Finally, policymaking is a long process and so
persistence was required (50, 70)
.
Understand the policymaking process
Lack of understanding of the policymaking process emerged as a barrier to policy
change in the literature, however key strategies were identified to overcome this.
Ensure solutions are politically palatable
For a solution to be politically palatable it needed to align with at least one goal of
the government as well as the prevailing political ideology (26, 43, 51)
. If a policy does
117
not align with the prevailing neoliberal view, it is unlikely to make it on the agenda
despite the advocate’s best efforts. Additionally, interventions that are
‘announceable’ – that is, they are not contentious and the government received
favourable press coverage, needed to be offered (28, 58)
. Clearly demonstrating
community benefit increased the political palatability of a policy solution (22, 28, 58)
.
Finally, avoiding all conflict with, or criticism of, the policies of government ensured
an advocate or organisation remained politically neutral (58)
. However, as pointed out
by Bedore(58)
this strategy required advocates to relinquish the opportunity to be
critical of the ethics of decision-making and the existing power structures that impact
on the food system, social welfare and health.
Responding to the desire to keep wider society ‘on board’, policymakers tended to
choose interventions which were the least intrusive and thereby least likely to cause
disquiet among target populations (22)
. There was a preference for voluntary action
solutions to avoid battles between stakeholders and long regulatory processes to
enact such laws. In the studies reviewed, policymakers were more supportive of non-
legislative solutions, despite the effectiveness of these being limited (24, 25, 28, 40, 48, 55,
70, 71). Particularly popular solutions were: health and nutrition education in schools
(48, 53, 71); developing and promoting nutrition guidelines
(24) or taskforces
(28, 33, 48, 53);
cooking classes and community vegetable gardens (70)
; school canteen
recommendations/toolkits (28, 48)
; voluntary salt reduction(55)
; and collaborations with
industry (25, 37, 44)
.
Strategically target decision-makers
Advocates who did not understand the policymaking process often did not know who
to target. Several strategies were identified to overcome this (see Table 4.6).
118
Table 4.6: Strategies to strategically target decision-makers
- Develop knowledge of influential networks that elected and appointed
officials are situated within, including key decision-makers’ colleagues,
community and business affiliations, donors and political supporters (12)
.
- In these networks, identify the least resistant part of the policy nexus and
target evidence towards this entry point (22)
.
- Encourage support from a wide range of politicians as policy is more likely to
be enacted if there is bi-partisan support (53)
.
- Progressive parties are more likely to support public health nutrition
initiatives, this may mean waiting for a change in government or targeting a
different level of government which may have a more supportive political
environment (71)
.
- Target decision-makers as senior as possible as the higher level of
bureaucracy is where policy is being formed and they are more open to
innovation (51)
.
- Target bureaucrats and politicians with personal experience of the issue (48)
.
Be nimble (ready for the policy window)
Successful policy change often hinges on understanding how and when the processes
of problem recognition, policy development and political decision-making converge.
The coupling of these domains is commonly referred to as the opening of a policy
window, representing an advantageous time for policy change (12)
. A theme
throughout the papers was that advocates need to be nimble and ready for the policy
window (19, 23, 30, 35, 57)
. Identifying and being prepared to take advantage of new
political opportunities when they arise is crucial as missing that window will mean
the policy solution will fall on deaf ears (19, 23, 35)
. Alternatively, it was important to
be realistic when the timing was not right. In times of budget crisis at a local or
national level, there seemed to be little support for providing funding for nutrition
solutions (24, 30, 57)
.
119
Threaten litigation
If all else fails, three papers identified threatening corporations with litigation as a
powerful strategy to influence policy change (19, 38, 57)
. However, threat of litigation
usually results in policy change from private industry rather than mandated
government change.
Limitations
As with any systematic review, the scope of the initial literature search and
publication bias may have resulted in relevant papers being missed. In addition, only
papers that were peer-reviewed from high-income democratic countries were
included in the review. The authors acknowledge important work in policy advocacy
has occurred in developing countries and the grey literature, however, it was not
within the scope of this review to incorporate those findings.
Despite these limitations, a rapid appraisal of such alternative literature suggests that,
had the search been broadened, the results would not have altered in any significant
way. In addition we believe that the synthesised data present a compelling guide for
nutrition advocates who wish to better influence nutrition policymaking in the future.
Conclusion
The frustration expressed advocates around lack of policy change in nutrition
frequently stems from their belief that policymaking is a rational process in which
evidence is used to assess the relative costs and benefits of options (60)
. This synthesis
of the literature confirms that the reality is far from this. Consistent with the
perspectives of policy scholars, the findings from this review illustrate that evidence
is only one component of many influencing policy change. For policy change to
occur there needs to be political will, often underpinned by public will, for the
proposed policy problem and solution. This requires policy entrepreneurs to work
with coalitions of stakeholders to frame policy problems and communicate
politically-palatable solutions both to decision-makers and to the general public.
Many of the barriers identified in this review are consistent with those identified in
political science theories, particularly Multiple Streams, Punctuated Equilibrium and
the Advocacy Coalition Framework. Most of the barriers were macro or structural
120
issues, including the rise of neoliberal ideology; pressure from industry; and
government silos. These are issues that an advocate generally cannot change,
however, it is imperative to acknowledge and understand these issues and consider
how to work with them.
The suite of enablers presented in this review highlight several areas where
advocates can attempt to influence political and public will and ultimately change
policy. These include framing problems based on values and emotion, and effectively
coupling problems with well-considered solutions. It is important to appreciate that
no one method will give results on its own and equally, undertaking all the
documented strategies will not necessarily result in policy change, as policymaking
is often a complex and irrational process. However, the literature highlighted that the
greater the variety of enabling strategies undertaken, the more likely advocates will
be able to affect policy change. Further research into the effectiveness and impact of
these strategies, particularly around using values and emotion in the context of public
health nutrition policy, is warranted.
Despite the fact that few nutrition policy studies utilised political science theory in
their analyses (10)
, the enablers and barriers identified in this review are consistent
with political science theories which have been empirically tested in other fields of
policy. This review has demonstrated that these theories are relevant to public health
nutrition policy, therefore researchers and advocates are encouraged to incorporate
the use of these theories to assist in refining their advocacy practice.
Advocacy is frequently said to be a combination of science and art. This review has
considered the ‘science’ behind what barriers and enablers to policy change have
been identified in the nutrition policy literature. However, it has also identified that
effectively influencing policy change relies heavily on the ‘art’ of advocacy where
nimbleness, flexibility, persistence, communication skills and the ability to identify
the policy window opening, come to the fore. This review provides health
professionals with a greater understanding of the barriers and enablers to policy
change, so that future advocacy efforts are more targeted with interventions tailored
to address specific barriers and to make use of specific enablers.
121
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4.3 SUMMARY OF SYSTEMATIC LITERATURE REVIEWS
Paper 1 evaluates the current literature on whether nutrition policy literature in
high-income, democratic countries uses political science policy process theories to
inform their analysis of policy outcomes. Through systematic review, this study
demonstrates for the first time the limited use of policy process theories by nutrition
policy scholars. This paper identifies a small increase over time in the use of policy
process theory when analysing nutrition policy, although this was limited. The
recommendation from this study is that nutrition professionals would benefit from a
pragmatic approach that ensures those trying to influence or understand the
policymaking process are equipped with basic knowledge around the policy process
theories.
From the systematic literature review, it was evident that there was a
considerable body of data related to the barriers to and enablers of policy change in
this dataset. To build on the limited international evidence, a meta-narrative was
undertaken (Paper 2) to analyse these factors and to critically evaluate the data. Paper
2 provides the first systematic review of the barriers to and enablers of nutrition
policy change in high-income, democratic countries. The findings from this review
confirm that gathering and providing evidence is only one component of influencing
policy change. For policy change to occur there needs to be the political will, and
often the public will, for the proposed policy problem and solution. The review
presents a suite of enablers to assist health professionals to influence political and
public will in future advocacy efforts including working with coalitions of
stakeholders to frame policy problems and communicate politically-palatable
solutions both to decision-makers and to the general public.
Together these papers highlight that there is significant benefit in nutrition
advocates developing a greater understanding of the policy process theories to
deepen their knowledge of the policymaking process and to assist in refining their
advocacy practice.
128
Social network analysis Chapter 5:
In the previous chapter, the barriers and enablers to nutrition policy change
were identified in the literature as was the lack of nutrition policy scholars who are
using political science theory to analyse the nutrition policy process. This chapter
will explore the role that personal and professional relationships play in nutrition
policymaking in Australia through the use of social network analysis. The results will
be presented in the format of two publications. Following these two publications
there will be a summary of the major findings from both papers.
Within the policymaking process, direct connections to decision-makers often
result in greater visibility of ideas and potentially policy outcomes. This notion is
confirmed by network theory, which states that outcomes are affected by the
structure of relations among people (Robins, 2015). These relationships and the
interpersonal ties between individuals can be explored through social network
analysis. Uncovering these ties between individuals can generate a picture of
influence and reveal the strengths of certain positions in the policy process as well as
alternative forms of influence wielded by those in policy circles (Lewis, 2012).
This chapter includes the following two papers:
3. Cullerton, K., Donnet, T., Lee, A, Gallegos, D (2016) Exploring power
and influence in nutrition policy in Australia, Obesity Reviews 17(12),
1218-25.
4. Cullerton, K., Donnet, T., Lee, A, Gallegos, D (2016) Joining the dots:
the role of brokers in nutrition policy in Australia, BMC Public Health
17(1), 307.
These papers present the findings from Study 3, which aimed to answer the
research question: who are the powerful and influential individuals and interest
129
groups in public health nutrition policymaking in Australia, and how do they
influence the policymaking process?
The aim of Paper 3 was to map, for the first time, the structure of the nutrition
policy network in Australia and to identify which individuals and professional
categories have the greatest access to nutrition policy decision-makers. The structure
was explored using cluster analysis, and access was measured by determining who
had the shortest path to decision-makers. The aim of Paper 4 was to identify who
were the key brokers in the network as brokers can have another form of influence
and power in a policy network.
This analysis is the first time, internationally, actors and their structural
position in a nutrition policy network have been identified. This is significant as prior
to this study, advocates and scholars had only been able to hypothesise the role
certain actors had in influencing nutrition policy (Caraher et al., 2013; Ceccarelli,
2011; Swinburn & Wood, 2013). Furthermore, the dataset for this study is
unprecedented with respect to its scope and breadth across a range of general health,
industry, media, political and nutrition stakeholders. The closest comparative
network analysis was undertaken by Oliver (Oliver, de Vocht, Money, & Everett,
2013), who examined influence in public health policy. This study had 152
participants; however, they were all working in health policy either for the UK
National Health Service, the local council, the charitable sector, or academia.
Paper 3 has been published in Obesity Reviews as the results are able to inform
policymakers and researchers interested in obesity and chronic disease prevention.
Obesity Reviews is a Q1 journal for the discipline and has an impact factor of 7.51.
On Scimago Journal rank, it is the 4th
ranked journal out of 464 for Public Health,
Environmental and Occupational Health. The journal prioritises high quality peer-
reviewed manuscripts that provide needed new insight into all aspects of obesity and
its related comorbidities. Paper 3 has an Altmetric Attention Score of 51 which
places it in the top 5% of all research outputs scored by Altmetric. The paper is
130
presented according to the style guidelines of the journal and uses the Obesity
Reviews referencing style.
Paper 4 has been published in BMC Public Health, a journal that considers
articles on the epidemiology and understanding of all aspects of public health. BMC
Public Health is a Q1 journal for the discipline and has an impact factor of 2.209.
The paper is presented according to the style guidelines of the journal which includes
BMC Public Health referencing style.
131
QUT Verified Signature
132
5.1 PAPER 3: EXPLORING POWER AND INFLUENCE IN NUTRITION
POLICY IN AUSTRALIA
Abstract
The food industry is often described as having more power and influence in
nutrition policymaking than nutrition professionals, scientists and other practitioners
working for the public interest; yet authors often allude to this point as an assumed
truth, rather than an evidence-based fact. This paper applies social network analysis
techniques to provide a concise evidence-based demonstration of the food industry’s
capacity to influence nutrition policymaking networks in Australia. Network analysis
using four rounds of data collection was undertaken and the capacity of individual
actors and occupational categories to influence policy decision-makers were
analysed. Network graphs were developed using cluster analysis to identify the
structure of clusters and the path distance of actors from decision-makers. The
assumed advantage for the ‘food industry’ was present both strategically in overall
network position, and with respect to the number of direct access points to ‘decision-
makers’. Whereas ‘nutrition professionals’ were densely clustered together with
limited links to key ‘decision-makers’. The results demonstrate that the food industry
holds the strategic high ground in advocating their interests to policymakers in the
contexts studied. Nutrition professionals may be hampered by their reliance on
strong ties with other nutrition professionals as well as limited direct links to
‘decision-makers’.
Introduction
It is internationally recognised that governments need to actively improve food
environments through changes to public policy to halt the rise in obesity and chronic
disease.1 To date, most countries have favoured ‘soft’ approaches to address this,
including education and voluntary codes for the food industry in areas such as
advertising and product labelling, while ignoring ‘harder’ approaches such as fiscal
and regulatory interventions.1 Existing research suggests that one reason ‘harder’
approaches to food and nutrition policy are not pursued by governments is due to the
power and influence of the food industry.1-6
133
Proving the power and influence of the food industry on nutrition policy is however,
very difficult. Whether an interest group will succeed in its attempts to influence
policy depends on a group’s or individual’s influence among policymakers and this
influence can often rely on their direct interaction with policymakers.7, 8
While media
strategies and engaging the public are important, direct access to policymakers seems
to be significant in influencing public policy.7-9
Given policymakers limited capacity,
it is not possible for them to meet with every individual interest group. Consequently,
many individuals or groups rarely gain direct access to policymakers while some will
only gain access through intermediary actors.9 Health professionals may presume
that individuals from food industry have privileged access to key decision-makers,
while those from health do not share similar access.
Social network analysis is a methodology that can be used to gather and analyse data
to explain the degree to which policy actors connect to one another and the structural
makeup of relationships within a network.10
Critically, these networks are often
shaped by informal patterns of interaction rather than formal positional power.11
The
network approach emphasises both formal and informal relationships and
demonstrates that power and influence is inherently relational. An actor’s position in
the network is important because it can bring power and influence through its access
to information within the network,12
for its opportunities for brokerage in the
network,13
and for its status within the network.14
If advocates do not inhabit
important positions in a policy network, it is difficult for them to be regarded as
influential as they have limited power. By examining who is connected to whom, it is
possible to see who exercises power and influence within a policy network.13
There have been several attempts to map and understand network structures in public
health policy internationally15, 16
and in Australia,17-20
however, no study to date has
mapped the relationships and potential influence between decision-makers and the
different individuals involved in national nutrition policy. Furthermore, most
network studies have previously only examined actors on the ‘health’ side of the
policy network, excluding actors from other sectors. To gain insight into who has the
greatest capacity to be influential in nutrition policy, all sectors must be considered,
134
including the processed food and agricultural industry, the media, politicians and
traditional interest groups of academics, professional bodies and bureaucrats.
Australian case study
The Australian nutrition policy domain has been chosen as a case study to explore
the capacity of different interest groups to influence nutrition policy in a neoliberal
country where little recent policy action has occurred. In Australia, nutrition policy is
the responsibility of both Federal and State levels of government. However, this
study is focused on the Federal policy level as this is where the responsibility for
regulatory, legislative and nationally coordinated policy responses to nutrition reside.
Limited co-ordinated national nutrition policy action has occurred in Australia since
the end of the national nutrition strategy, ‘Eat Well Australia’, in 2010 and prior to
that a National Food and Nutrition Policy in 1992. Initiatives supported by the
Federal government have been ‘soft’ interventions including localised school
cooking and gardening programs and social media campaigns. The only systems-
based policy actions that have been introduced during this time are the voluntary
front-of-pack food labelling system and the Healthy Food Partnership21
; a voluntary
collaboration between health bodies and food industry to reformulate key processed
foods. While this is an Australian case study, the principles and applicability of
networks hold true across a variety of settings.
Method
As knowledge of policy influence is distributed among hundreds of individuals in a
policy domain, we adapted a previously used peer-nomination, reputational snowball
method which asked participants to nominate other influential participants in the
network.18
This technique assumes that groups of influential people know each other,
either personally or by reputation.10
Although any one respondent is likely to have an
incomplete view of the whole nutrition policy system, their collective responses
enable a reasonably accurate rating of group influence to be determined.22
The study commenced with an egocentric network analysis of nine participants
identified as being influential in nutrition policy in Australia. Each of the nine
participants represented a different policy actor category as identified in the
Advocacy Coalition Theory.23-25
Additionally within these policy actor categories,
135
seed sample representatives were chosen to represent all domains of Australia’s food
and nutrition system. By purposively choosing representatives from the different
sectors of the nutrition policymaking process it was hoped that their collective
insight and responses would lead to a more accurate and complete policy network.
The participant representing each category was purposively selected by the lead
author (KC) and a co-author (DG) as being the highest profile individual in Australia
in each identified category (see Table 5.1). This was based on their positional power,
media presence or stated organisational objectives. When the highest profile person
was not available, the next highest was contacted in their place, however, this only
occurred on one occasion.
Table 5.1. Seed sample for network analysis
Categories Chosen representative
Government Senior public health bureaucrat
Private industry Senior Executive Food industry – manufactured food
Senior Executive Food industry – agricultural
Academic Public health nutrition academic
Interest groups Non-Government Advocacy group – public health
Non-Government Advocacy group – nutrition
Non-Government Advocacy group – Indigenous health
Political sector Political Advisor
Journalists Journalist
The initial seed sample were contacted firstly by email or telephone and then asked
in-person or over the phone to nominate those regarded as influential in nutrition in
Australia, requiring that those nominated demonstrated a capacity to shape ideas
about policy; initiate policy proposals; substantially change or vet other’s proposals;
and/or substantially affect implementation of policy related to food and nutrition.18
As there are many aspects to nutrition policy, the authors did not want to limit
participant’s responses so no clarification of the term ‘nutrition policy’ was provided;
rather participants were encouraged to respond within the scope of their own
definition of the term. The survey question was asked for nutrition policy generally
136
in Australia and then in examination of different policy contexts. It was also asked
for three different case studies: Aboriginal and Torres Strait Islander nutrition; school
cooking programs; and front of pack food labelling. This paper presents only the
results for nutrition policy generally. All participants were also asked to note which
of the nominated individuals they were in direct contact with, as a means of mapping
the network of relationships within the policy domain. Snowball sampling allowed
all those nominated by the seed sample to repeat the same process. No set limit on
names was imposed as this may have forced people to keep adding names who were
not especially influential or risked eliminating important people.18
No gratuity was
provided to the participants.
Four rounds of data collection were included before data saturation was identified,
consistent with previous network studies.18
Initially, all those nominated were
contacted, although on the third round, only those with more than two nominations
were contacted to limit the number of outliers in the network. Some identified were
uncontactable due to insufficient contact information, turnover or absence (n=24).
Strong confidentiality measures encouraged participants to be more candid in their
responses. In order to maintain the highest level of anonymity of participants, all
participants were coded and referred to by the following categories – see Table 5.2.
Table 5.2. Categorisation of participants
Employer Role Examples
Non-government
organisation
General health
professional
CEO, Policy Officer, Government relations
officer, Medical officer
Nutrition specialist Nutritionist, Dietitian, nutrition policy officer
Academic General health
professional
Chronic disease, public health academic
Nutrition specialist Nutrition or obesity academic
Government General health
professional
Chief health officer, medical officer, policy
officer working in chronic disease, general
health.
Nutrition specialist Policy officer specialising in nutrition,
Dietitian, Nutritionist
137
Decision-maker
(GDM)
Senior policy officers responsible for general
health policy
Private Sector
(Food Industry)
n/a CEO’s, Chairs, nutrition managers,
government relations officers of
manufactured food companies/associations,
agricultural companies/associations and food
retailers.
Political sector Politician/advisor Politicians who don’t have a direct influence
on nutrition policy. All political advisors.
Decision-maker (PDM) Politician who has the power to directly
influence nutrition policy.
Journalist n/a Health journalists
Other Public figure Celebrities
Nutrition specialist Dietitians or nutritionists who are private
consultants.
Analysis
To analyse which actors had the greatest capacity to influence nutrition policy in
Australia, the data from the survey was entered into social network analysis software,
NodeXL,26
and network graphs were generated using the appropriate Harel-Koren-
Fast Multiscale algorithm.27
As direction of influence was taken into account, the
maps were ‘directed’ networks. The general structure of the nutrition policy system
was revealed by undertaking a ‘cluster analysis’ whereby the data is partitioned into
clusters consisting of individuals who closely interact with each other using the
Clauset-Newman-Moore algorithm.28
The network graphs were examined to identify
the structure of the clusters and which categories of individuals were positioned near
decision-makers. If an individual lies on the shortest path to a decision-maker, they
are more likely to gain access to timely and sensitive information and occupy high
status.29
To gain further insight into which individuals have the greatest capacity for influence
path distance for each node was determined by examining the location of individual
nodes and how many ‘steps’ a node is from a decision-maker in a network. The path
distance of the aggregate and relative capacities for each stakeholder group to
access/contact government decision-makers was calculated. Values for the fewest
“steps” between ‘government decision-makers’ (GDM) and ‘political decision-
138
makers’ (PDM) and every other node in the network were tabulated, allowing for
comparisons of ‘decision-maker’ access to be made between the different
stakeholders. To determine mediated relationships, a recalculation of the data was
performed by identifying wholly mediated relationships (where the ‘food industry’
wholly mediates another stakeholder’s ability to access GDM’s or PDM’s, or where
another stakeholder wholly mediates the ‘food industry’s’ ability to access GDM’s or
PDM’s) and removing them from path distance calculations.
Decision-makers
Decision-makers were classified as those politicians or bureaucrats who had the
power to make decisions about national nutrition policy. For the politicians this
included decisions around large funding investments, overarching policy, regulation
and legislative issues, whereas for the bureaucrats, their decision –making powers
were concentrated around comparatively smaller funding investments and policy
specifications. They were identified initially through the research team’s prior
knowledge and previous interactions with policymakers and confirmed during in-
depth interviews of the most influential people from different sectors in this network
analysis. The politicians included a number of cabinet ministers and junior ministers
across a range of portfolios. The bureaucrats were senior executives within the
Department of Health.
Results
Following the snowball sampling process, 283 invitations to participate were sent out
and 140 participants responded, giving a response rate of 49%. Individuals received a
wide range of nominations, ranging from one nomination to forty nine. The range of
job sectors for participants and their corresponding response rate are outlined in
Table 5.3.
139
Table 5.3. Number of respondents in each profession and response rates
Profession Number (Response rate
%)
Bureaucrat 38 (55)
Academic 38 (57)
Non-Government Organisation 37 (54)
Food Industry 16 (64)
Political 6 (18)
Public figures 2 (25)
Journalists 3 (23 )
Overall, 466 actors were nominated as influential in nutrition policy in Australia.
However this number also included organisations. Once organisations were removed
as well as those individuals who were nominated yet had no direct links with any
other individual in the network, the total number of influential individuals nominated
was reduced to 390. Within this policy network there were 1440 direct ties between
the nominated individuals.
Cluster analysis of the data identified 11 clusters consisting of individuals who
closely interact with each other in the network (see Figure 5.1). Qualitative
descriptors for each cluster identified in Figure 1 are provided in Box 1, providing
contextual insight to the attributes of different parts of the overall policymaking
network. Only three of the clusters will be discussed in this paper as they have the
greatest number of actors and also contain those with the greatest capacity to
influence decision-makers. Primary attributes of the clustered data show that
‘nutrition professionals’, both ‘academic’ and ‘government’, are predominantly
based in Cluster 1. There is only one ‘decision-maker’ in Cluster 1 who is in close
proximity to the ‘government nutrition professionals’. More ‘decision-makers’ (n=3)
can be found in Cluster 2 (The Activists) where there are many high –profile
individuals working in non-government organisations who often engage with the
140
media. Most are ‘general health professionals’ rather than ‘nutrition specialists’, with
‘food industry’ actors a prominent feature in this cluster.
Figure 5.1. Cluster analysis of the nutrition policy network in Australia
Key: NGO \ ACADEMIC \ GOVT \ FOOD IND \ DECISION MAKER \
POLITICIAN Public Figure\ Nutrition Specialist \ General Health\ Private Sector
* A green line indicates direct contact between individuals
* If an individual has many connections they are said to be prominent (have high betweenness
centrality). Nodes have been increased in size to indicate the individuals with higher prominence.
The greatest numbers of ‘decision-makers’ are in Cluster 3. This group also has a
large number of ‘food industry’ representatives as well as ‘government general
health professionals’ and ‘political representatives’. These ‘general health
professionals’ tended to be very senior, for example, Chief Health Officers of State
health departments. There are only two ‘nutrition specialists’ in this cluster – one
working for the government and one in academia. ‘Food industry’ and ‘political
advisors’ are in very close proximity to the key ‘decision-makers’. Additionally,
there are several ‘general health government’ officials who are also in close
proximity.
Cluster 1: Nutrition professionals Cluster 2: The activists
Cluster 3: The decision-makers
Outliers
Cluster 4: Industry - other
Cluster 5: The media
141
Box 1: Characteristics of Clusters
Cluster 1: Of the 106 individuals represented in this cluster, they are predominantly
nutrition professionals from government (n=28, 26%), academia (n= 25, 24%), and
non-government organisations (NGO’s) (n=12, 11%). The remaining individuals
include those from the general health sector in government, academia and NGOs as
well as a small number from food industry and the political sphere. There is one
government decision-maker present in close proximity to government nutrition
professionals.
Cluster 2: Consists of a large number of individuals who actively seek out the
media for nutrition issues or have an advocacy role as part of their job. This
includes general health individuals from NGOs (n=23, 26%) and nutrition
professionals in academia (n=19, 22%). The food industry represent 17% (n=15), all
of which are from the manufactured food sector and one from agriculture. The
remaining individuals include nutrition professionals from NGOs and those from the
general health sector in government and academia as well as a few politicians and
journalists. There are two political decision-makers and one government decision-
maker present. The political decision-makers are on the periphery however the
government decision-maker is more centrally placed with food industry actors in
close proximity.
Cluster 3: The largest number of decision-makers is present in this cluster, five
political decision-makers and two government decision-makers. The remaining
individuals in this cluster are very senior representatives of their respective
organisations. General health government officers are in the greatest number in this
cluster (n=31, 37%), with food industry the next highest (n= 20, 24%). Of these 20
food industry individuals, three represent the agricultural sector and the remainder
represent the food manufacturing sector. There is a high number of politicians and
advisors in this cluster (n= 16, 19%) as well as a few representatives from general
health NGO’s and two nutrition professionals, one from the government and one
from academia.
Cluster 4: This cluster was classified as the ‘industry - other’ as 50% (n=18) of the
individuals represented food industry staff who engage with nutrition professionals
as well as nutrition professional academics who work with food industry (n= 9,
25%). 44% of food industry individuals in this cluster were from the agricultural
sector. The remaining individuals represented government general health and
nutrition professionals and one general health NGO individual. No decision-makers
present.
Cluster 5: Consists predominantly of journalists (n= 13, 45%). Also present were
public figures (n= 3, 10%), individuals from the political sector (n=3, 10%) and the
remainder were from Government general health and nutrition and NGO general
health and nutrition. No decision-makers present.
Outliers: These individuals were on the periphery of the network, with limited
connections to others; resulting in little to no legitimacy/power in brokering
relationships or ability to contribute to nutrition policy discourse.
142
Capacity of stakeholder groups to influence decision-makers
Path distance calculations enabled a comparison of aggregate and relative capacities
for each stakeholder group to directly access/contact government decision-makers
(see Figure 5.2). This revealed that the ‘food industry’ has a distinct advantage in
their capacity to influence government and political decision-makers, with more
direct relationships with decision-makers than any other stakeholder groups (see
Figure 5.3). ‘General health’ individuals from ‘non-government organisations’ have
almost the same level of direct relationships with PDM’s; however their low level of
direct relationships with GDM’s decreases their aggregated relationships.
Figure 5.2. Comparative direct relationships between interest groups and decision-
makers
The relative capacity of stakeholder influence examined the aggregated share of
direct access stakeholders have to ‘decision-makers’. Again, it was demonstrated that
the ‘food industry’ has the greatest relative share of access to ‘decision-makers’, with
0%5%
10%15%20%25%30%35%
Shar
e o
f d
ire
ct a
cce
ss t
o d
eci
sio
n-m
ake
rs
Stakeholder Group
Direct Relationships Between Interest Groups and Decision Makers
Government Decision Makers
Political Decision Makers
AGGREGATED
143
‘general health NGO’s’ almost 12% behind. However, when we consider second
order relationships, representatives in ‘government general health’ are at almost the
same level as ‘food industry’ cumulatively.
Figure 5.3 Relative capacity of stakeholder influence on decision-makers
Discussion
The size of the studied nutrition policy network (n=390) is considerably larger than
previous studies (n=115-225);15, 17, 18
indicating a more complex policymaking
terrain, or more comprehensive methodology, or both.
Formal governance structures
The government general health officials are well represented in the most influential
cluster (cluster 3 - the ‘decision-makers’) in Figure 5.1. However this is to be
expected as there are many formal structures in place within the Australian
Government to ensure direct communication between state and federal Chief Health
144
Officers and other high-level bureaucrats and federal decision-makers. However,
what is unexpected is the degree to which food industry is represented in this group
(Figure 1). The only formal mechanism that currently exists for the food industry to
engage with health decision-makers is the Healthy Food Partnership. Yet despite this,
at face value it appears that the ‘food industry’ has a commanding position in the
network, with ‘decision-makers’ all but surrounded by ‘food industry’
representatives. However, the clustering of nodes can make it easier to overlook
some of the less obvious attributes of network relationships.
Influence of food industry
Path distance calculations enabled a comparison of aggregate and relative capacities
for each stakeholder group to access decision-makers directly and indirectly. This
revealed that the assumed advantage for the ‘food industry’ is present as determined
by their greater capacity to directly influence ‘decision-makers’ when compared to
the other stakeholder groups. Having direct access to policymakers has previously
been shown to be a significant factor in influencing public policy.7-9
‘General health’
individuals from non-government organisations had almost the same level of direct
relationships with PDM’s; however their low level of direct relationships with
GDM’s decreases their aggregated relationships. This could potentially mean the
message to decision-makers around nutrition policy may be diluted as it is coming
from ‘general health’ professionals in NGOs or that their strategy to influence
change is not gaining traction with PDMs.
The dominance of the ‘food industry’ in direct relations continued to be
demonstrated when we considered the relative capacity of stakeholders.
Representatives in ‘general health government’ come close to the ‘food industry’ in a
cumulative sense (as second order relationships are taken into account), but the ‘food
industry’ has a clear advantage in first order (direct) relationships with ‘decision-
makers’. This could be interpreted as the ‘food industry’ having superior ‘strength in
numbers’ to promote their interests directly to ‘decision-makers’. Whilst direct
relationships with ‘decision-makers’ are very important, network theory also
highlights the advantages of second order relationships (‘a friend of a friend’) in
being able to influence ‘decision-makers’.30
There are potential opportunities through
these second order relationships for the ‘nutrition’ and ‘general health’ communities
145
to seek new strategies to improve the effectiveness of their lobbying of ‘decision-
makers’ for national nutrition policy.
Influence of nutrition professionals
The dense cluster of ‘nutrition professionals’ with limited links to key ‘decision-
makers’ is of concern. These findings correspond with the Advocacy Coalition
Framework and Granovetter’s Theory of Weak Ties31
which predicts that actors
prefer and predominantly co-ordinate and develop strong ties with other actors if
they hold similar policy core beliefs or politically salient similarities. As a result,
strong ties tend to direct networks into tightly knit groupings, that is, clusters of
functionally and politically similar organisations.12
Information communicated by
strong ties – or within clusters – tends to be redundant and will tend to travel in short
distances relative to the size of the network as a whole and often leaves the group
isolated. In order to change this, Granovetter observed that the possession of links to
actors beyond one’s immediate close knit cluster can greatly increase opportunities
for new or distinct information.8 Previous studies have shown that organisations or
individuals with more investment in weak ties or acquaintances greatly improve their
access to the government.8, 12
Furthermore, a greater investment in strong ties does
not directly enhance and may even impair, access to government policymakers.12
Influence of medical officers
Previous network studies of health policy have found medical professionals to be
highly influential.18, 30
The presence of medical professionals was apparent in this
study in as much as the ‘general health’ positions positioned near ‘decision-makers’
tended to be medical officers. This may be related to the positional power of State-
based Chief Health Officers whereby those positions are only able to be held by
medical officers.
Influence of academics
Previous network studies have found academics to be influential in health
policymaking18
however this was generally not the case in this study. This may be
because academics in Australia do not have the time to devote to personal
relationships with decision-makers and/or do not see advocacy as an important part
of their role.
146
Limitations
The need to define the boundaries of the network in a manageable way restricted the
scope of the analysis. While such boundaries were necessary for this study, the real
world of nutrition policy is not artificially constrained in such a way. An additional
limitation was that, while the response rate was high for an elite network study of
this size, having a higher response rate, particularly from the political sector, would
have given us even greater confidence in our data. Further, we acknowledge path
distance is not the only measure of network influence; high “betweenness centrality”
whereby an actor controls the information flow and brokers contacts among other
players and, ultimately, decision-makers, is another important consideration.
Finally, there is a possibility that respondents suspected that their answers may have
political consequences. This may have resulted in expansiveness bias, whereby
respondents have a tendency to over- or under-report their ties with others.
Expansiveness bias is a problem if some low-status respondents attempt to raise their
status by over reporting their ties, while high-status respondents prefer to downplay
their influence by underreporting their ties. We propose the large number of
participants in this study minimises the influence of potential expansiveness bias,
particularly given that the network data is ‘directional’.
Conclusion
This study highlights that the ‘food industry’ does have a commanding position in
the nutrition policy network in Australia, both strategically in overall network
position, and with respect to the number of direct access points to ‘decision-makers’.
It has also shown that nutrition professionals may be hampered by their reliance on
strong ties with other nutrition professionals as well as limited direct links to
‘decision-makers’. However, ‘government general health professionals’ have the
capacity to influence in this space. For individuals or organisations wanting to
increase their influence in the nutrition policy space, the network structure needs to
change. Fortuitously, networks are dynamic, complex systems in which ties are
constantly evolving in conjunction with individual behaviours. Interested actors need
to increase their level of engagement with the health policy process and consider
building alliances with senior policymakers or politicians as well as with those
147
outside of nutrition. Although this study focused on the Australian nutrition policy
domain, the nature of lobbying and policymaking give the methodology and findings
merit across broader public health contexts.
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QUT Verified Signature
151
5.2 PAPER 4: JOINING THE DOTS: THE ROLE OF BROKERS IN
NUTRITION POLICY IN AUSTRALIA
ABSTRACT
Background: Poor diet is the leading preventable risk factor contributing to
the burden of disease in Australia. A range of cost-effective, comprehensive
population-focussed strategies are available to address these dietary-related diseases.
However, despite evidence of their effectiveness, minimal federal resources are
directed to this area. To better understand the limited public health nutrition policy
action in Australia, we sought to identify the key policy brokers in the Australian
nutrition policy network and consider their level of influence over nutrition
policymaking.
Methods: A social network analysis involving four rounds of data collection
was undertaken using a modified reputational snowball method to identify the
nutrition policy network of individuals in direct contact with each other. Centrality
measures, in particular betweenness centrality, and a visualisation of the network
were used to identify key policy brokers.
Results: Three hundred and ninety (390) individual actors with 1917 direct ties
were identified within the Australian nutrition policy network. The network revealed
two key brokers; a Nutrition Academic and a General Health professional from a
non-government organisation (NGO), with the latter being in the greatest strategic
position for influencing policymakers.
Conclusion: The results of this social network analysis illustrate there are two
dominant brokers within the nutrition policy network in Australia. However their
structural position in the network means their brokerage roles have different purposes
and different levels of influence on policymaking. The results suggest that brokerage
in isolation may not adequately represent influence in nutrition policy in Australia.
Other factors, such as direct access to decision–makers and the saliency of the
solution, must also be considered.
Key Words: nutrition policy, policy making, advocacy, food industry, social
network analysis, influence.
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Background
Poor diet is the leading preventable risk factor contributing to the burden of
disease in Australia [1, 2]. A range of cost-effective, comprehensive population-
focussed strategies are available to address these dietary-related diseases [3-5].
However, despite evidence of the effectiveness, minimal federal resources are
directed to this area in Australia [6]. This lack of action is occurring within a policy
space that is characterised by a range of diverse interest groups or actors vying to
influence public health nutrition policy, including: many different sectors of the food
and beverage industry; health and agricultural organisations; national, state and
territory government departments of health; agriculture; trade; and consumer affairs;
academics and popular media figures. In different ways and for different motives,
these interest groups seek to influence Australian food and nutrition policy and what
Australians eat [7]. To better understand the limited public health nutrition policy
action in Australia, we examined the power and influence of the actors involved in
the policymaking process.
Power is a contested concept amongst political science scholars and is often
conceptualized in a range of different ways, including ideational, structural and
relational [8]. Historically the most common understanding of power has been
relational where power is defined as the ability to achieve desired results; this can
occur through the utilisation of resources and/or influence over actors [9]. Actors are
powerful if they manage to influence outcomes in a way that brings them closer to
their ideal endpoints [8]. However, this can be achieved in a number of different
ways. A traditional view of power and influence in policymaking is that it comes
from the possession of important resources, such as positional power, for example a
Chief Executive Officer, or personal resources including education level or charisma
[10]. The relative possession of these resources is thought to provide actors with a
means of coercion or influence over others. However, some policy network scholars
believe this traditional view of resource-based power is limiting, as they believe
power is inherently a structural phenomenon within a network [10] [11, 12].
Accordingly, the authors view power within a policy network as being built upon
relationships between actors and the distance between actors and their resources.
153
Policy networks are linkages between government bodies and other actors
involved in public policymaking[13]. The networks are defined by geographic scope,
a substantive issue and may involve hundreds of active actors from all levels of
government, multiple interest groups, the media and research institutions [14]. These
actors compete for their specific policy objectives to be translated into government
policy. Some policy networks are considered “politically charged”, that is, they
contain both allies and adversarial actors vying for pre-eminence by both enhancing
their own position while also potentially subverting another’s outcomes [15]. This is
the case for the nutrition policy network in Australia [16, 17].
Mapping out a policy network using social network analysis allows for the
investigation of sometimes less obvious or hidden patterns in relationships that
transcend hierarchical structure and improve our understanding of an actor’s relative
power [18]. It has been used to examine a range of topics areas in health including
community health coalitions [19], physician collaborations [20], relationships
between tobacco control partners [21] and identifying the most powerful actors in
public health policymaking [22]. A network consists of ‘ties’ which are patterns of
association that link actors together; they can include informal linkages, based on
communication and trust, as well as links based on the traditional institutionalized
structures of co-ordination [23]. These connections can determine an actor’s ability
to project power, control information flows and attempts to influence political
outcomes or other actors. [11]. The way an individual is embedded in a policy
network can impose constraints on the individual as well as offer them opportunities
[24]. Opportunities and potentially influence can be gained by those individuals who
are well-connected to other informed individuals through their ability to access larger
stores of useful political information [25]. Those on the periphery of networks,
whose ties link them mainly to other marginal individuals, will encounter inadequate
quantities and qualities of information [26]. They are in uninformed, hence
uninfluential, locations.
Within social network analysis a range of different measures can be employed
to explore power and influence. Centrality measures in general and betweenness
centrality in particular are commonly used to identify influential individuals within a
154
policy network [18]. Those with the highest levels of betweenness centrality act as
brokers as they occupy a potentially privileged position in the networks structure and
are often assumed to have a decisive impact on policy outcomes [27]. Centrality
measures come in many forms including degree, closeness and betweenness (see
Table 5.4). The concept of closeness in the Australian nutrition policy network has
been explored by the authors in a previous paper [16]. This paper will explore power
gained by being a broker as well as degree centrality in the Australian nutrition
policy network.
Table 5.4. Measure of centrality [24]
Degree: the more ties (direct connections) an actor has, the more power they (may)
have. Actors who have more ties have greater opportunities because they have more
choices.
In-degree: the number of ties that lead into the actor directly from others, that is, the
number of respondents who identified a particular actor as influential.
Out-degree: the number of ties that lead out of the actor directly to others, that is,
the number of others identified by an individual actor as influential.
Closeness: If an actor is able to reach other actors at shorter path lengths, particularly
decision-makers they will have greater influence. This position means power can be
exerted by direct bargaining and exchange. Actors who are able to reach other actors
at shorter path lengths have greater power and capacity to influence.
Betweenness: If an actor lies between other actors, that is, they act as a ‘broker’ that
others must go through to reach a different group of people; they are in a position of
power.
*For detailed formulae for each of the above-used measures, please refer to Knoke
and Yang (2008) [28] or Wasserman and Faust (1994) [29]
Degree Centrality (in-degree and out-degree)
Power and influence can come from various sources within a network. One
measure is how highly nominated an individual is by others in the network (in-
155
degree). If an individual receives many nominations or ties (an indication of a
relationship or interactions) from others, they are said to be prominent or highly
visible and this may indicate their importance [24]. Individuals who are able to
nominate connections with a high number of people (out-degree) are able to
communicate with many others, or make others aware of their views. However,
network theorists note that simply having many connections is only one way to be
influential [30]. A person with fewer connections might have more ‘important’
connections than someone with a large number of connections. One connection can
be more important than another in different ways and in different contexts. Some
connections are better because they link to well-connected people [16], whereas
others are more important because they bridge across otherwise separated sections of
the network [30].
Betweenness centrality
Betweenness centrality is a measure that identifies individuals (brokers) who
bridge different parts of the network. It specifically measures the number of times an
actor is on the shortest path between two other actors [31]. Betweenness centrality is
the most prominent centrality measure used to study power and dominance, because
it indicates an actor's strategic position as a broker between other actors in the
network, thus enabling the spread of information [32]. Policy brokers can connect
subsystems when groups differ in their beliefs and conflict about policy preferences
exists [18].
Other actors in the network come to rely on brokers for indirect access to
resources beyond their reach [33]. The broker is pivotal within this configuration and
profits from others’ reliance on them. In turn, the group that emerges around the
broker benefits overall because the broker extends the group’s opportunities and
available resources [34]. Network analysis has demonstrated that brokers can have a
significant impact on decision-making and are thus able to shape outcomes
decisively at critical policy junctures [18], hence betweenness centrality is the
primary measure reported in this article.
156
Methods
A summary of the methods used is provided below; a more detailed description
of the methodology is described elsewhere [16]. The aim was to identify those
individuals who occupied structural positions of privilege in the nutrition policy
network in Australia. Privileged structural positions in a network include those actors
with high centrality, in particular betweenness centrality, and those with relatively
low path distance to decision-makers (compared to other actors in the network). A
previously used modified reputational snowball method [35] was undertaken to
identify the nutrition policy network of individuals in direct contact with each other.
This process began with asking a seed sample of nine leaders from diverse
backgrounds in the nutrition policymaking process to ‘list the people you regard as
influential in nutrition policy in Australia’. A definition of influence was provided
which required that those nominated could do one or more of the following:
demonstrate a capacity to shape ideas about policy; initiate policy proposals;
substantially change or veto other’s proposals; or substantially affect implementation
of policy related to food and nutrition [35]. Survey participants were required to note
whether they were in direct contact with those they nominated and how often this
direct contact occurred. The lead author then contacted all the nominees and asked
them the same question. This process occurred for four successive rounds as data
saturation was reached at this point.
All names received and their relationships with others were entered into social
network analysis software, NodeXL [36], for both network visualisation and
calculating centrality measures. Centrality measures were explored using in-degree
(number of nominations an individual receives from others), out-degree (number of
nominations of others an individual provides) and betweenness centrality (measures
the extent an individual lies on paths between other individuals). A visualisation of
the network was undertaken using the Harel-Koren Fast Multiscale algorithm with a
high level of repulsion between vertices (repulsion = 20) to visualise the network and
emphasise brokerage roles.
157
Results
Two hundred and eighty three individuals were invited to participate in the
study and 140 responded, providing a response rate of 49%. The response rates for
the different professional sectors are provided in Table 5.5.
Table 5.5. Number of respondents in each profession and response rates
PROFESSION NUMBER (RESPONSE RATE %)
Bureaucrat 38 (55)
Academic 38 (57)
Non-Government Organisation 37 (54)
Food Industry 16 (64)
Political 6 (18)
Public figures (celebrities) 2 (25)
Journalists 3 (23 )
Three hundred and ninety (390) individual actors with 1917 direct ties were
identified in the nutrition policy network, with the network density described as
relatively low at a measure of 0.009539 (potential actor relationships: actual actor
relationships) and an average geodesic path distance of 3.29007 (7 maximum). Table
5.6 highlights the top five Brokers ranked by betweenness centrality, which as
discussed above in Methods, is the lead indicator for power and dominance within
the nutrition network. Brokers’ degree, in-degree and out-degree are also reported in
Table 5.6 to provide additional context. Figure 5.4 presents a visual depiction of the
overall nutrition policy network in Australia, which at a glance shows academic and
government nutrition professionals congregating closely to Broker 2. Further
analysis of the direct ties from Broker 2 confirm a higher proportion of direct ties
with nutrition professionals compared to any other professional group (see Figure
5.5). This aggregation of nutrition professionals around Broker 2 was also confirmed
as a structural cluster within the network, via a cluster analysis conducted in a
previous interrogation of the data set (see [16]).
158
In the present analysis, we find that decision-makers are predominantly found
on the opposite side of this dense congregation with limited direct ties with the
nutrition professionals. In the middle of these two groups and with the highest
betweenness centrality (see Table 5.6) of all actors in the network is a General Health
Professional from a non-government organisation (NGO). This person is in a key
brokerage role (Broker 1). The authors acknowledge that the reported betweenness
centrality appears high at face value, but the size of the network, coupled with
relatively low density and modest average path distance make the resulting
betweenness less surprising. To make these reported figures more easily comparable
to other network studies, a column normalising (scaled between zero and one) the
reported betweenness centrality scores is also provided in Table 5.6, which further
illustrates the prominence of the two Brokers that are focused on in this paper.
Table 5.6 Betweenness centrality/ degree centrality of nutrition policy network
Top 5 brokers ranked by
betweenness centrality
Network
location
Degree Betweenness
centrality
Normalised
betweenness
centrality
In-
degree
Out-
degree
General Health NGO 1 76 25512 0.3381 49 53
Nutrition Professional
Academic
2 77 24039 0.3185 45 52
Nutrition Professional
Government
3 60 13930 0.1846 19 52
Food Industry 4 40 12017 0.1592 3 40
General Health
Government (decision-
maker)
5 30 10768 0.1427 10 24
159
Figure 5.4. Network analysis of the overall nutrition policy network in Australia
Key: NGO \ ACADEMIC \ GOVT \ FOOD IND \ DECISION MAKER
Public Figure\ Nutrition Specialist \ General Health\ Private Sector
NB: Nodes sized by betweenness centrality. Shapes represent actors in the network;
Lines between nodes represent reported interactions, with arrow specifying direction
of reported relationship.
1
2
3
5
4
160
Other actors with high betweenness centrality can be seen in Table 5.6. A
Nutrition Professional Academic has the second highest ranking (Broker 2);
however, when examining Figure 5.5 you can see this individual is surrounded by the
cluster of nutrition professionals. This indicates Broker 2 is taking on a brokering
role amongst nutrition professionals rather than brokering relations with decision-
makers. The three remaining actors in the top 5 brokers have much lower
betweenness centrality scores which correlate to their lower in-degree scores.
Figure 5.5. Direct ties from Brokers 1 and 2
Broker 1 Broker 2
Key: NGO \ ACADEMIC \ GOVT \ FOOD IND \ DECISION MAKER\ JOURNALIST\POLITICAL
Public Figure\ Nutrition Specialist \ General Health\ Private Sector
Discussion
Relationships between policymakers and interest groups can often occur
behind closed doors and are not easily visible. In this paper we have analysed data
from a range of nominated influential actors that make up the nutrition policy
network in Australia. There is a specific focus on brokers as their structural position
is assumed to give them a decisive impact on policy outcomes.
The network reveals two key brokers with the General Health NGO broker
(referred to as Broker 1) in a much more prominent (strategic) position for
161
influencing policymakers, than the Nutrition Professional Academic broker (Broker
2). The network data demonstrated that Broker 1 held a commanding position with
respect to network connections and strategic position within the network that no
other actor was able to match. This position gives this individual more power by
allowing them to better control the flow of important resources such as information
to and from other members of the network and brokering new relationships which in
turn can set and shape agendas. A potential downside of actors within centrally
located network positions is that while they can leverage their centrality to link actors
with resources and other constructive relationships within their network, they also
have the capacity to prevent other actors from participating in certain policymaking
decisions or agenda setting decisions [27].
Broker 2 (Public Health Nutrition Academic) has a clear brokering role among
nutrition professionals. This is an important role for ensuring the flow of information
between nutrition professionals in government, academia and within NGO’s.
However, the overall network position of Broker 2 is not as close to policy decision-
makers, meaning that it requires greater investment of time and relational capital for
Broker 2 to access and link information to decision-makers when compared to
Broker 1. So, while Broker 2 is highly prominent within the policymaking network,
Broker 2’s strategic position is not potentially as effective as that of Broker 1.
Other Brokers listed in Table 5.6 scored far lower in betweenness centrality
than the top two Brokers. This dramatically lower betweenness centrality is more a
product of their position in the network (with respect to the distance from central
decision makers) and their linking to fewer discrete sub-groups in the network (and
subsequently lower degree scores). This translates to a far lower visibility to others
within the nutrition network for these lower ranked Brokers. This reduced visibility
is further triangulated in the data from the imbalance between the lower ranked
Broker’s in-degree and out-degree. That is, a high out-degree demonstrates the
Broker identifies themselves as having active relationships with many others in the
network (typically across many categories of actors), whereas the lower in-degree
indicates that few in the network see the Broker as playing an influential role in the
policy making network (i.e. only seen as influential to particular categories within
162
the network). This highlights the value in the social network analysis methodology in
making the invisible networks visible. For example, Broker 4, from the food
industry, was well connected with decision-makers yet only one nutrition
professional nominated this person. While Broker 4 has fewer total connections, they
are extremely well-placed to access and potentially influence decision makers. Also,
a key government decision maker (Broker 5) had very few people in the network
nominate them as an influential direct connection, indicating a lack of awareness of
the importance of this individual in decision-making or an inability to develop a
relationship with a bureaucrat this senior. This presents an opportunity for actors to
review their network connections and their position within the policymaking
networks to ensure they remain effective within the network.
At face value, the network pictured in Figure 5.4 appears quite dense, which
makes the prominence of Broker 1 and Broker 2, as illustrated by their exceptionally
high betweenness centrality reported in Table 5.6, appear out of place. That is, a
relatively dense network would typically have many pathways available for actors to
access other actors in the network. This increased number of pathways would
normally result in downward pressure on the betweenness centrality for actors in the
network. However, the relatively low network density (0.009539) indicates that the
network is at least somewhat fragmented, with a previous analysis of the data [16]
confirming this by identifying several distinct clusters within the overall nutrition
policy network. Relationships between the clusters were often mediated by Brokers 1
and 2, helping to keep the average geodesic path distance (number of steps to get
from one actor to another) down to a modest 3.29007 (maximum of 7).
Consequently, Brokers 1 and 2 make it far easier for actors in one area of the
network to access actors in another, hence their extraordinarily high reported
betweenness centrality scores.
The two top-ranked Brokers have extremely high degree centrality (both in and
out degree) compared with the remaining participants. This demonstrates how well-
known these two Brokers are within the nutrition policy network, as well as how
effective they are at linking to others within the network, compared to the remaining
policy actors. This is a common phenomenon in SNA known as preferential
163
attachment [32]. Popular actors often tend to become more popular because they
have high visibility to begin with. This results in degree distributions which are often
positively skewed to a small number of actors with very high degree and many actors
with lower degrees [32].
Of interest, is that, despite Broker 1’s advantageous brokerage position, the
limited number of policy outcomes for nutrition suggests that the actor, and
potentially the network as a whole, has a limited impact on nutrition policy action at
a federal level on Australia. This may reflect the complexity of nutrition as an issue
or it may reflect the lack of focus on nutrition by Broker 1 due to competing
priorities associated with their general health role. It may also point to the fact that
brokerage in isolation may not be as influential in nutrition policy as other network
measures such as direct access to decision makers as discussed in a previous paper
by the authors. By extension, this indicates that a strategic brokerage position within
a decision making network is not enough to influence policy, and that many other
factors are likely at play including ideology and beliefs of decision-makers, the
salience of the issue, opposing pressure from the food industry, unsupportive
institutional norms and a lack of public will [17, 37, 38]. Furthermore despite the
close ties amongst the nutrition community in Australia, previous studies have shown
that this does not necessarily translate into expert consensus around nutrition issues
[17]. This lack of consensus hinders the development of strong, advocacy groups and
therefore decreases the likelihood of policy change [14].
Importantly these results show that brokers may perform different roles in the
network to what some scholars have traditionally assumed, which is that policy
brokers are synonymous with policy entrepreneurs [33]. Policy entrepreneurs act in
an opportunistic and strategic way to promote their interests so the final outcome
reflects their policy preferences [39]. However, the current role of the Broker 1 in
nutrition policy may be more in line with the policy broker definition provided by the
Advocacy Coalition Framework [14] where brokers are seen as actors that seek
stability through connecting interest groups that differ in their beliefs. In these
situations, policy brokers can intervene by promoting conciliatory policy solutions
and by mediating trust [40].
164
Another important role that brokers hold within policy networks is to steward
policy discussions of the more discrete actors that fall within their personal network.
Consequently, there is an opportunity for brokers in nutrition policy to act not only as
aggregators and conduits of information, but as mentors to their sub-networks as
well. It may be worth considering alternate ways to support key brokers in the
nutrition network or utilise their strategic position to improve the effectiveness of
nutrition advocacy and/or improve the ability of more discrete actors to align their
efforts in a more coordinated way. This could take the form of a broker mentoring a
group of actors to help them develop key relationships and share the burden of
linking discrete actors with decision-makers. Alternatively a good investment would
be creating more opportunities for establishing linkages between actors within the
network to provide better visibility of the range of initiatives taken by actors who
would identify as discrete.
Conclusion
This study has added value in terms of understanding influential actors and
power in an environment where policy is frequently made by a diverse range of
actors whose influence is often derived from access to political and social capital.
The results of this study suggest there are two dominant brokers of the nutrition
policy network in Australia. However their position in the network means their
brokerage roles have different purposes and different levels of influence for
policymaking. In the highly contested nutrition policy space, many other factors are
likely at play including ideology and beliefs of decision-makers, unappealing
solutions, lack of consensus from the nutrition community, opposing pressure from
the food industry and lack of public will. In addition, this study has also highlighted
that many nutrition advocates are not aware of and do not have direct links with other
key influential individuals. As networks are not static, there are opportunities for
advocates to change the current network by ensuring advocates for nutrition policy
change move into more advantageous positions. There is a role for the key brokers to
utilise their position to improve the effectiveness of nutrition advocacy and/or
improve the ability of more discrete actors to align their efforts in a more coordinated
way.
165
Limitation: This study has certain limitations. Firstly, brokerage is only one
aspect of actor influence in a policy network. Aspects beyond relationships can
impact on policy outcomes including public will, beliefs and values of decision-
makers, party policy, and media coverage of an issue. Incorporating qualitative data
from key network actors could provide further insight into power and influence in
nutrition policy. Secondly, this is a cross-sectional design and therefore limits the
ability to infer causality or temporality, and it may also mask potential shifts in
power over time as well as underlying power. If additional resources were available a
longitudinal analysis would improve the study. Finally, while the response rate for
this study was high for an elite network of this size, a higher response rate,
particularly from the political sector, would have provided greater confidence in our
data.
Abbreviations
NGO: Non-government organisation
Declarations
Ethics approval: this study obtained ethics approval from Queensland
University of Technology Human Research Ethics Committee, approval number:
1400000857. Informed written consent to participate was obtained from all
participants.
Consent for publication: not applicable as individuals are unidentifiable and
no specific details about individuals are reported within the manuscript.
Availability of data and materials: The datasets generated and/or analysed
during the current study are not publicly available due to confidentiality requirements
but are available from the corresponding author on reasonable request.
Competing interests: The authors declare that they have no competing
interests.
166
Sources of funding: K.C. is supported by an Australian National Health and
Medical Research Council (NHMRC) Postgraduate Scholarship. The NHMRC had
no role in the design of the study, the collection, analysis or interpretation of data or
in writing the manuscript.
Author contributions: All authors contributed equally to the study design, KC
did the literature search, collected the data and drafted the manuscript. TD and KC
analysed the data. KC, TD and DG interpreted the data. AL, TD and DG offered
valuable input and feedback on the manuscript. All authors have read and approved
the final version of this manuscript.
Acknowledgements: not applicable
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Additional files
Additional file 1.docx: Survey used to gather data regarding interest groups and
individuals and their influence on nutrition policy in Australia
170
5.3 SUMMARY OF THE SOCIAL NETWORK ANALYSIS PAPERS
The aim of Paper 3 was to map for the first time the structure of the nutrition
policy network in Australia and to identify which individuals and professional
categories have the greatest access to nutrition policy decision-makers. The structure
was explored using cluster analysis, and access was measured by determining who
had the shortest path to decision-makers. The analysis revealed the previously
assumed advantage for the ‘food industry’ was present both strategically in the
overall network position, and with respect to the number of direct access points to
‘decision-makers’. On the other hand, ‘nutrition professionals’ were densely
clustered together with limited links to key ‘decision-makers’. The results
demonstrate that the food industry holds the strategic high ground in advocating their
interests to policymakers in the contexts studied. Nutrition professionals may be
hampered by their reliance on strong ties with other nutrition professionals as well as
limited direct links to ‘decision-makers’.
The results presented in Paper 4 suggest there are two dominant brokers of the
nutrition policy network in Australia. However their position in the network means
their brokerage roles have different purposes and different levels of influence for
policymaking. Furthermore the results indicate that a strategic brokerage position
within a decision-making network is not enough to influence nutrition policy in
Australia.
These two papers have allowed an exploration of different measures of
influence within a policy network, direct access to decision-makers, and betweenness
centrality. Based on the limited progression of policy action in nutrition, it seems that
direct access may be the most influential measure of the two. However, many other
factors are likely at play, including the ideology and beliefs of decision-makers,
unappealing solutions and lack of public will. The findings from these papers have
implications for nutrition professionals in Australia, both nationally and
organisationally.
171
For nutrition advocates to have greater influence in nutrition policy, there is a
need to reach out to others and move beyond one’s comfort zone. To gain
information which may identify the opening of a policy window, connections with
decision-makers or to those who are connected to decision-makers are needed.
Alternatively, building relationships with other sectors can also provide new
information and intelligence, which can better prepare nutrition advocates and
thereby increase their influence. These implications will be discussed in more detail
in Chapter 9.
The findings from these two papers have been presented at the following
conferences:
Power and influence in nutrition policymaking in Australia, International
Health Conference, June 2016, London.
Who has the power in nutrition policy in Australia and how did they get it?
33rd Dietitians Association of Australia National Conference, May 2016,
Melbourne.
Who has the power in nutrition policy in Australia? Population Health
Congress, September 2015, Tasmania.
The presentations resonated with audiences and generated significant
discussion on the implications for organisations and professional groups. This
resulted in requests for information on concrete strategies for organisations to
improve their structural position, which led to further invitations to present my
findings at an organisational level.
The barriers to nutrition Chapter 6:
policy change in Australia
As stated previously, there is limited peer-reviewed literature on how to
effectively influence public health policy in general, and even less on influencing
public health nutrition policy (Jenkin et al., 2012). Previous research investigating
nutrition policy has mainly come from the United States of America, where systems
of government and the role of interest groups are significantly different to Australia,
so it is difficult to know how transferable the results are. Due to this dearth of
country-specific evidence, there is a limited understanding of the most effective
strategies for progressing public health nutrition policy change in the Australian
context. Therefore, to progress nutrition policy change in Australia and develop more
effective advocates, it is important to consider the practical experiences of key policy
influencers and decision-makers in Australia. These influential individuals are able to
provide real-world insight into the barriers and enablers to public health nutrition
policy change and therefore provide guidance on how to best influence the
policymaking process. Understanding these barriers and enablers is fundamental to
ensuring that the future advocacy efforts of nutrition professionals are more targeted,
with interventions tailored to address the barriers and to make use of specific
enablers.
The following chapters will address the following research questions:
1. What is the role of current policy process theory in public health
nutrition policymaking in high-income, democratic countries, particularly
Australia?
2. Who are the powerful and influential interest groups and how do they
influence the public health nutrition policymaking process in Australia?
3. What are the barriers and enablers influencing public health nutrition
policy change in high-income, democratic countries, and particularly Australia?
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These questions were answered through the analysis of in-depth interviews of
the key influencers and decision-makers in Australian nutrition policy. It was
important to have a wide range of policy actors from different levels and vantage
points to understand how they comprehend and navigate the nutrition policy space.
These key influencers and decision-makers were identified as part of the network
analysis described in Chapter 5. This chapter will present the findings, followed by a
discussion around the barriers to nutrition policy change, and Chapter 7 will present
the findings and discussion of the enablers to nutrition policy change.
6.1 INTERVIEW PARTICIPANTS
Fifty-five people who were considered key influencers or decision-makers in
Australian nutrition policy were contacted to participate in the in-depth interviews.
Of these, 37 participated (response rate 67%). The majority of those choosing not to
participate were politicians (11 of the 18 non-participants). Interviews took place
from November 2014 until October 2015, and were conducted face-to-face if
possible, by telephone if not. Participants came from a variety of sectors involved in
the policymaking process (see Table 6.1).
Participants were mostly from Canberra (n = 12) and Sydney (n= 11), with
smaller numbers from Victoria (n=7), Queensland (n= 6), and South Australia (n=1).
High numbers in Sydney and Canberra were to be expected, as most food industry
head offices are based in Sydney; and Canberra is the seat of the federal government
and home to many head offices of NGO’s, professional bodies and lobbyists. Fifty-
seven percent (n=21) of participants were female. A mix of face-to-face and
telephone interviews were conducted. Of the interviews that were conducted in
person, most were held at the participant’s place of work, either in their office or a
meeting room. The length of the interviews ranged in duration from 17 minutes to 58
minutes, with an average of 35 minutes.
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Table 6.1. Sector representation of participants
6.2 BARRIERS TO NUTRITION POLICY CHANGE
The systematic literature review of high-income countries in Chapter 4
identified that the barriers to nutrition policy change were mainly macro or structural
issues, including: the rise of neoliberal ideology; pressure from industry; and
government silos. Although an advocate generally cannot change these, it is
imperative to acknowledge and understand these issues and consider how to work
Category Chosen representative Number
Government Senior public health bureaucrat
(federal and state)
6
Food industry Senior executive food industry (manufactured food +
agriculture + food retailers)
10
Academic Public health and/or public health nutrition academic 2
Non-Government
Organisation
Nutrition 3
Public Health 7
Political sector Politician 3
Political advisor 2
Journalist Journalist 2
Public Figure Celebrity chef 1
Lobbyist Third party lobbyist 1
TOTAL 37
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within these contexts. This chapter presents the results of the in-depth interviews of
key influencers and decision-makers in nutrition policy in Australia on the subject of
the barriers to public health nutrition policy action in Australia. The findings were
analysed and will be discussed through the lens of the three political science policy
process theories identified in the introduction and the literature review (Chapters 1
and 2). By using these three theories, different elements can be explored, and the
possibility of whether any or all of these theories are applicable to the Australian
nutrition policymaking context can be determined.
The responses from participants regarding barriers fell into three overarching
categories:
Lack of political will;
Issue and/or organisation not top-of-mind; and
Complexity of the policymaking process.
Underneath these three inter-related categories were myriad intersecting
themes which demonstrate the complexity of influencing policy change at a federal
policy level. This complexity and the inter-related nature of the barriers is illustrated
in Figure 6.1, which identifies the barriers to influencing nutrition policy change with
key themes (in red) emanating from them.
Further analysis and synthesis (see Figure 6.2) revealed that surrounding these
themes was the macro-political environment and contextual influences on nutrition
policymaking in Australia. The macro-political environment contains uncontrollable
external forces that actors have no influence over: the neoliberal environment; the
system of governance; and the pressurised, risk averse environment within which
policymaking occurs. Figure 6.2 summarises and distils these key elements relating
to the barriers to influencing nutrition policy change in Australia. This figure was
subsequently sent to a graphic designer to represent the results in a clearer and more
stylised way. The resulting representation can be seen in Figure 6.3.
Lack of political appetite
beliefs
party policy
lack of public
appetitie
not our
responsibility
perceived failure of
nutrition prof's
beliefs & values of
ministers
everyone's an
expertideology
Power & influence
of food industry
strong vested
interests
agree to programs that
won't make a difference
money speaks
volumes
access to decsion
makers
'do-gooders'
loss of credibility
lack of unity
reactive rather than
proactive
lack of political
know-how
lack of flexibility
Nutrition prof's
guarding their patch
demanding
demonisation of
industrycan't pick their
battles
lack of investment in
relationships
shaming the govt
lack of personal stories
or personal experience
neoliberal ideologyacademics not seen
as practical
industry as experts
the market will
deliver
personal
responsibility
private consultant
driven policy
Complexity of thepolicymaking process
fear of backlash
from voters
lack of interest in
nutrition & prevention
minister not
receptive
short term funding cycles
for long term issues
long game
Govt silos
evidence is only
one factor
lack of undertsanding
PHN evidence
decisions in other health
areas impact on health
multiple decision
makers
serendipity
priority of other
portfolios
need to show solution
will work for industry
no champion
Competing for
attention & influence
competing for
attention of minister
name/issuenot
top-of-mind
complex,
multifaceted problem
academia doesn't
support advocacy
lack of leadership
requ expertise from
outside nutrition
'others' controlling
the narrative
results require a
long time
medical model
supported
contestable
evidence
interpretation of
evidence
cherry picking
evidence
hard to put tangible
costs on prevention
no clear solution
demonstrate
support of public
economic
argument
financial end-point
full cost of solution
return on
investment
cost-benefit
Figure 6.1. Barriers to nutrition policy change
177
Figure 6.2. Summary of barriers to nutrition policy
change
178
Figure 6.3: Representation of the barriers for nutrition policy change.
6.3 LACK OF POLITICAL WILL
Political will reflects whether or not decision-makers (politicians or senior
bureaucrats) are supportive of policy change. Underpinning this overarching
category were the following themes:
Beliefs;
Lack of public will;
Lack of leadership;
Power and influence of the food industry; and
Abdication of responsibility.
These themes emerged after iterative inductive and deductive analysis, using a
process of constant comparison of the codes and mapping the connections between
the codes to explore interconnectedness. Each theme will be explored by discussing
the relevant elements with exemplar quotes.
6.3.1 Beliefs
The theme ‘beliefs’ refers to a wide-ranging set of responses from participants
that related back to the personal and collective beliefs that shape values and attitudes
and drive decision-making processes. In this section on beliefs, the following
elements will be discussed: ideologies, party policy and personal beliefs and values.
Beliefs incorporate the concept of ideology, which is defined as “the mental
frameworks – the languages, the concepts, categories, imagery of thought and
systems of representation – which different classes and social groups deploy in order
to make sense of and render intelligible the way society works” (Hall, 1986, p. 29).
This definition incorporates many types of ideologies, including religious or
scientific; however, as ideology refers to the shared understanding of the way society
works, it is most often used as a central concept to politics. Most political parties
base their political action and policies on an ideology. Political ideology specifically
refers to a “shared set of ideas and beliefs about the proper order of society and how
180
it can be achieved” (Erikson & Tedin, 2003, p. 64). It is important to note that not all
political belief systems are ideological, some are driven by a party’s desire to
regain/gain governmental power (Nohrstedt, 2005).
For politicians in this study, personal beliefs often aligned with party policy
and therefore party ideology but this was not always the case. It was identified that
whilst individual politicians in a party may have different beliefs, they were often
required to support the party policy, particularly if they were members of the
Cabinet. The inability of politicians to progress issues because they went against
party policy was raised by those participants directly involved in politics.
As a Senator, I’m very privileged to be in a position where I can make a
decision based on what I think is the right thing to do, you know, whereas I
think a lot of politicians, particularly in the government today don’t have that
luxury.
Senator
The Senator went on later in the interview to explain how difficult it was for
him and others to be heard by the ruling political party, particularly when the issue of
concern went against party beliefs or policy. Of note, the Senator pointed to the
power of vested interests in informing the beliefs of politicians.
It’s very difficult to get your point across or your beliefs listened to, because
they’re so, I guess, dictated to by who’s funding them and of course, you know,
their party policies.
Senator
Furthermore, a journalist highlighted that when there is ‘consultation’ or
discussions occurring around certain policy issues, the government will include only
those stakeholders with compatible values and beliefs.
You often have one side of politics or another staking their claim along a
particular ideological agenda of how we should deal with a certain issue and
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then the people who ‘fit’ in that agenda are the people who get heard on that
issue.
Journalist 2
Shared ideology is the basis for much political party policy (Jost, Federico, &
Napier, 2009). The most common type of ideology expressed by participants when
discussing the barriers to nutrition policy action was a ‘neoliberal ideology’ or
‘neoliberalism’. Neoliberalism is a theory of economics that proposes that society
can best be advanced by “liberating individual entrepreneurial freedoms and skills
within an institutional framework characterised by strong private property rights, free
markets, and free trade” (Harvey, 2005, p. 2). The infiltration of neoliberalism as a
key influence on nutrition policymaking was noted by a wide range of respondents
from a variety of backgrounds, with the exception of the food industry. No
respondent from the food industry implicitly or explicitly identified neoliberal
ideology as a reason for the lack of progress in nutrition policy action. The neoliberal
ideology of the current government and its impact on policy was illustrated by a
General Health NGO Manager:
Some of this is still ideologically driven for the government, is nutrition a
public health issue or is it an individual’s responsibility, ‘just find out what‘s
good and eat right’, you know, and the current government tends to be in the
‘it’s your problem, so you can go for a walk’ or ‘you can eat Maccas if you
choose to eat Maccas, we’re not going to tell you what to eat’.
General Health NGO 5
The influence of neoliberal ideology in underpinning public policy was also
supported by a Federal Bureaucrat:
The coalition policy tends to be one of minimal regulation, allowing people to
make decisions for themselves. So that would influence the policies too.
Federal Bureaucrat 3
182
It was highlighted that ideology, including neoliberalism, is complex and not
always unequivocal and can change, depending on the issue. This was expressed by a
third-party lobbyist:
You’ve clearly got people who are essential free marketers as a dominant
philosophy; so decreasing red tape is really important, but then the moment
you switch into an area that’s politically sensitive for conservatives like
biosecurity, they’re the first ones arguing for regulation and supporting the
system. So in fact there are complex and at times contradictory threads that
run through all of that behaviour, and it’s always important to understand that.
And usually what I find certainly with senior politicians and bureaucrats is
they have much more complex and nuanced positions around a lot of these
issues, they’re neither free marketers nor are they completely interventionist or
regulatory either.
Lobbyist
While ideology and party policy made up a significant component of the
beliefs theme, participants remarked that it was essential to consider and possibly
leverage the specific personal beliefs and values of the Minister for Health (and other
more senior Cabinet ministers) as decision-making ultimately rests with them. These
values and beliefs may have been informed by a wide range of determinants; for
example, schooling, peer groups, parental values and beliefs, religion, and the media.
Ministers make policy, and ministers are individuals with their own set of
prejudices and beliefs. They will be influenced by a bunch of things, and the
bureaucracy is only part of what would influence them. So if you think about
ministers they all have different education backgrounds and different career
backgrounds before they're coming to Parliament.
Federal Bureaucrat 3
A common area of agreement between participants was that if a proposition
does not resonate with the beliefs and values of the Minister, the proposition will not
progress. Several participants re-iterated that the Health Minister is the ultimate
183
decision-maker for health policy, only overruled by more senior members of
Cabinet; for example, the Prime-Minister, the Treasurer, or the Finance Minister.
So if the Minister is not on board, you’ve got no hope.
Food Industry 8
It was not just the beliefs of ministers and bureaucrats that were highlighted by
participants as barriers to progressing nutrition policy action; all nutrition
professionals interviewed expressed great frustration around the belief that ‘everyone
is an expert’ in the field of nutrition. However, no-one outside of nutrition mentioned
this as a barrier. Nutrition professionals were particularly concerned that the beliefs
and opinions of individuals who did not have nutrition qualifications were being
given equal weighting with those of academic experts/scientists by the media. There
was a concern that this equal weighting of opinions also occurred at the policymaker
level, as one respondent explained:
But also because everyone’s an expert in nutrition so it’s hard for scientists in
the area to get traction because everyone’s opinion seems to be given equal
weight on the web, and there are people out there who are really quite
adamant that their belief systems are the ones we should be following, such as
the Paleo people.
Public Health Academic 2
There was also the recognition that, unlike other public health fields, most
people have a vested interest in food, because everyone eats. This again can result in
some members of society feeling that they are, or have the right to be, an expert in
nutrition.
Nutrition is also one of those very emotional things where there’s a lot of
personal investment in it, and you get prominent public figures making
personal statements that they should not make. It’s about how they feel about
food and how they feel it should be approached and there is some of that
personal take as well…
NGO Nutrition 3
184
This notion of ‘everyone being an expert’ around food and nutrition was
demonstrated during the interviews by several of the general health professionals
with no nutrition qualifications, who stated their own personal belief about what
would work and what would not in public health nutrition policy, despite prevailing
evidence:
I just don’t believe that the health star rating system or any amount of
information on the labels or even a tax is going to help them change their mind
about whether they take the 10 bottles of coke home, that’s their way of life and
until perhaps they get a health scare or something, they need that trigger that
convinces them that if they keep on doing what they’ve always been doing
they’ll get the same results.
Federal Bureaucrat 1
Participants identified beliefs as a key barrier to nutrition policy change. These
beliefs were wide ranging; however, there was a strong emphasis by participants on
the increasing prevalence of neoliberal ideology as a barrier to policy change.
6.3.2 Lack of public will
Participants in this study identified the ‘lack of public will’ as a key barrier to
nutrition policy change. Public will reflects the mood, preferences and belief systems
of voters towards a policy. It is a major component of political will, as politicians are
often not motivated to act on an issue that has little public interest or could cause a
backlash from wider society (Kersh & Morone, 2002). Public will took on several
different facets, the most concrete being ‘there are no votes’ in the issue, as
highlighted by the following participants:
Often it's because it's all down to what's the bottom line, how much is the
margin … what's going to get us <political party> a vote, you know.
Food Industry 1
185
It absolutely has everything to do with the government that is so interested in
the voting public and what, you know, what community wants. And, so, I think
if they don’t see communities really embracing the concept of good nutrition
then they won’t show the leadership either.
NGO General Health 3
The food industry was noted to be very competent at capitalising on the ‘no
votes in it’ sentiment to highlight to the government not only the lack of interest from
the general public but potentially the active opposition of the public around
suggested policy changes. A common strategy the food industry uses was highlighted
by a Federal Bureaucrat:
You <food industry> will go straight to the minister or the PM and you'll tell a
story about how it’s going to impact jobs or drive up the grocery prices or a
story so that the minister would believe that consumers won’t like this at the
end of the day, that consumers will blame government at the end of the day.
Federal Bureaucrat 1
Media was reported as a crucial component not only in reporting but also in
shaping the public will around a policy issue. This ability to shape public opinion
through the media could be taken advantage of by skilled vested interests, including
the government, to decrease support for policy change.
I just think that the media will definitely play up things that sell newspapers or
air time or whatever. But the reason why it sells is because there is an appetite
for it in the community. And part of shaping that, part of being in politics is
about trying to have an influence over that.
Advisor 1
While the media was noted as a key factor in shaping public will, respondents
noted that a lack of public will may be due to the complexity around nutrition, the
186
perception that the ‘nutrition message’ was constantly changing, and that some
things just did not make sense for the general public.
It is important to know if you’re expecting government to spend a large amount
of money there needs to be community support, because there’s more projects
than there are dollars as we all know. So looking for stuff that the community
would say, “I get that.” And they get vegetable gardens.
Food Industry 7
However, it was noted that having a perceived high level of public will still did
not mean that policy would change.
Public opinion is important but we’ve got really high public opinion around
what to do about overweight and obesity. It’s not really a public opinion
problem it’s a political will problem and industry make it really hard.
NGO Nutrition 2
6.3.3 Lack of leadership
The lack of leadership in public health nutrition was highlighted on numerous
occasions by a range of participants as a barrier to policy change. This related to the
limited number and capacity of individuals and organisations to engage, unify and
champion public health nutrition issues with policymakers and to successfully
compete for their attention.
So we have fewer champions, and when we come to nutrition, we have fewer
champions across the board in the nutrition space.
NGO General Health 6
A lack of ‘clinical champions’ was cited as a barrier to public health nutrition
policy action. Clinical champions are typically doctors, nurses or other health
professionals who work in a hospital setting seeing patients on a one-to-one basis.
These individuals are often highly regarded within the traditional biomedical model
of health.
187
I think for nutrition it’s much harder to push that because it’s not an immediate
thing or something politicians can push, it’s long term, it’s got long term
outcomes and it doesn’t have as many super-duper clinical champions that
drive it.
NGO General Health 5
The lack of leadership in nutrition, and resulting lack of a unified solution, was
particularly noted around Aboriginal and Torres Strait Islander nutrition policy.
Participants identified that no one was providing leadership in this area and clearly
explaining what policy actions were required.
I don't think anyone actually knows how to do it and that makes it very difficult
to argue for change. So one of the really key things generally <in Aboriginal
and Torres Strait Islander health policy is> you've got a much better chance at
getting action when it's clear what the action should be. In the nutrition case,
it's not at all clear what the action should be.
Federal Bureaucrat 3
One Federal Bureaucrat explained that Aboriginal Community Controlled
Health Services are often expected to assume the leadership role across all health
areas, including public health nutrition. However, the reality is that due to funding
restrictions, they are predominantly concentrating on the promotion of their services
that focus on primary health care to ensure their own survival and continuity of these
services.
I think that they're in an awkward situation in that they want to claim that they
are the preeminent expert on Indigenous health, but in reality, their primary
reasons for being and their primary goal is around the promotion of their
services.
Federal Bureaucrat 3
188
Perceived failure of nutrition professionals
A consistent theme throughout the interviews from almost all participants was
criticism of individual nutrition professionals or their profession as advocates. These
criticisms included: poor resourcing or limited prioritisation of advocacy within the
profession coupled with a lack of skills to undertake advocacy; a lack of unity around
messaging; concerns around credibility, particularly in terms of one of the
associations that represents nutrition professionals.
While advocacy is a core competency for public health nutritionists and
dietitians in Australia, it tends to be undertaken mainly at very local or individual
levels; for example, advocating for individual patients or community groups. Only
limited numbers of nutrition professionals undertake advocacy work targeting the
state or national levels of government, since finding the time and resources to
undertake or prioritise these advocacy activities can be difficult (Hughes, 2004).
There were particular challenges noted for the nutrition professionals in academia,
where it was suggested the academic environment does not encourage or reward
advocacy.
In academia, it’s actually harder to collaborate…. because academia is set up
in the current environment particularly as a competitive situation….I don’t
think there’s much opportunity to be proactive as an individual but there’s
opportunities to be reactive as one.
Public Health Academic 2
A further impediment to progressing policy change was the perceived
inflexibility and demanding nature of nutrition advocates. Whether this was because
of their lack of skills in advocacy or a preferred way of advancing their issue, this
way of working was not well received by the decision-makers interviewed, as
highlighted by this Federal Bureaucrat:
I was in Rome recently at the ICM2 and you had all these public health
advocates sitting in their room saying “get the industry out of here, they’re the
bad guys, we can’t deal with them, they should be regulated, they should be put
in a box and told what to produce and what to do and how they can market
189
their product”. So I had all of these crying industry people coming to the room
and say “I’m from the seafood industry” “I’m from the meat and livestock
industry” or “I’m from the dairy industry”… “We’re not bad, we produce
good products and we do so in a sustainable way as much as we can… and you
need us” and I say “Absolutely, I am not going to make a policy decision
around food without you being actually consulted.” You’ve got to be in the
tent. You are not the tobacco industry. The way that that group approached
that preliminary meeting, I think is basically counter to the way that the
Australian government and this department wants to approach things, but
that’s where groups are going.
Federal Bureaucrat 2
This inflexible approach was also thought to show a lack of political know-how
from some advocates.
Whereas the xxxx have a much different approach and they’re much harder to
work with in government because they have this kind of ‘this is our policy and
we are just going to keep shouting this policy’ in the hope that it will get
through but without talking and understanding some of the nuances, like if the
timing is right and those subtleties that are all about the politics and the
concerns other than health.
State Public Health Nutritionist
The food industry joined in the criticism of nutrition professionals as being too
demanding and idealistic. Two food industry participants described why nutrition
professionals have not succeeded in gaining traction on nutrition policy action with
the government:
Health advocates have a tendency to have a win - lose outcome. We <the
health professionals> have to go and bash up the government to tell them what
dreadful people they are and that sort of stuff.
Food Industry 7
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Generally you'll get people that have an almost idealistic view of what happens
and are not prepared to let go of bits of that in order to achieve anything and
so therefore you achieve nothing.
Food Industry 4
A wide range of stakeholders identified a lack of unity in the nutrition message
and no ‘clear voice’ as to what the solutions are, as a key reason why there was
limited action in nutrition policy. This was articulated by Federal Bureaucrats,
Nutrition Professionals, Politicians and NGOs.
Well frankly if you have a range of different organisations talking about
different things, you really can’t do it very well or very effectively. It’s best to
get a commonality of purpose….that strengthens it.
State Politician
So, it’s really important to collaborate, because if you’re saying different
things, it’s easy for politicians, and Nicola Roxon said this in her public
speaking since she was a minister, that around obesity, she found it difficult to
act or she said she found it difficult because she was being told different things
by different groups. There was no consensus of what are the priorities in
obesity.
NGO General Health 6
I think that this market is not cohesive and the other thing is amongst the key
public health organisations that have led prevention in tobacco control like
heart, cancer and now diabetes….there’s not a consistency of message with
those groups as well. So that undermines it.
NGO Nutrition 2
The final aspect of the criticism of nutrition professionals was the belief of
several participants that the profession lacks credibility. In contrast to earlier
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comments about the perceived inflexibility of nutrition professionals and their
perceived demonisation of the food industry, this criticism was particularly focused
on dietitians and the Dietitians Association of Australia and their perceived alliances
with industry.
The other semi-influential people are the nutrition people, the dietitians, but
they are not trusted. The dietitians are certainly not trusted, have a look at
their funding, its industry funding, totally apologetic around sugar and things
like that. Nutrition…a bit different but nevertheless because a lot of them work
in that industry, people are wary.
Federal Bureaucrat 4
The British DAA have a position around sugary drinks, I would be very
shocked if the DAA here ever did something like that because they are clearly
funded and supported by industry. A lot of the people that are in that
organisation work in industry, they’re probably the majority.
NGO Nutrition 2
So the Dietitians Association is a good example. It can be a very influential
body. Why do we not have it in the inner circle? Because they take a huge
amount of money from the industry.
NGO General Health 4
Researchers also came in for criticism for taking money from the food
industry, especially when they were not transparent in their declaration of funding
support.
There’s a lot of people who take funding from xxxx and those companies and
you don’t always know where their interests lie and they get used by the
companies to present their research or to go on panels and you don’t know
who funds who. You do in an academic paper but in a forum you don’t know,
it’s not disclosed. I think it’s a huge issue that there’s not that transparency.
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And there’s huge amounts of influence through funding and just through those
spheres of influence.
NGO Nutrition 2
However, there was some acknowledgement by decision-makers that the
current funding environment made it difficult for research to be done without
funding from the food industry. Despite this, there was still an admission from a
Federal Bureaucrat that it weakened an individual’s and/or organisation’s credibility.
Same with academics, they might do some fantastic research but if it was
partially financed by xxx or something, people won’t believe it... It can be very
unfair that they're criticised for taking money from whoever it is that they're
taking money from. And particularly where else would they get money from?
More and more the government is not funding that kind of thing so where are
they going to get money from? It’s a real difficulty. But any of those
organisations that's taking money from the other side if you like, it does
weaken their credibility.
Federal Bureaucrat 1
The final component of this perceived failure of nutrition professionals was a
concern around nutrition professionals ‘guarding their patch’ and insisting that only
they were able to work in the nutrition space. This was perceived as nutrition
professionals protecting their profession, possibly due to limited funding and a desire
for self-preservation, rather than working towards the common good for the
population.
People in the professions spend a lot of time guarding their patch rather than
working for a common good. So I think all of us in the professions need to have
the ability to think about health outcomes more and our careers less ... I think
it's a thing that’s stopping us at the moment.
NGO General Health 5
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6.3.4 Power and influence of the food industry
All participants, except perhaps unsurprisingly, those from the food industry,
noted the power and influence of the food industry as a reason why public health
nutrition policy does not progress. Notably, the Federal Bureaucrats were most
expressive in this area. The food industry were said to be using their power and
influence to resist change to public health nutrition policy action as this would
potentially impact on their profit margin. As mentioned previously, participants
identified that a common strategy deployed by the food industry, is to play to the
fears of politicians regarding voter backlash and lack of public will for an initiative.
What they’ll be saying to government is, as I said, you lose jobs over the years
or the price of basic food will go up or whatever, or fortification of flour and
things like that. There was a lot of discussion there about how the price of
bread will go up and all that kind of thing. So that’s what they said in the
government, they talk about the cost and the impact. But they’ll always be
drawing a line to it and people won’t like if the price goes up or whatever.
Federal Bureaucrat 1
Another strategy the food industry used when communicating with Ministers
and Bureaucrats was to continuously challenge the evidence for public health
nutrition action. This strategy raises questions in the mind of the decision-makers, so
there is reasonable doubt about proceeding.
Even now, you’ll see various industry and interest groups try and dismantle
what that evidence says. The sugar industry hates the fact that we’re saying
limit. So small words, they’ll say ‘show us the evidence as to how you arrived
at that’?? It’s bloody… its difficult stuff!
Federal Bureaucrat 2
Other reported techniques the food industry used to exert power and influence
included agreeing to programs that would not make a difference to their product
sales, such as the voluntary front-of-pack food labelling scheme, and using their
financial and organisational position to access and persuade the government. This
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increased likelihood of open doors was capitalised on by the food industry who
invest time and effort in building relationships with key decision-makers and their
advisors which can then be used to their advantage. Federal Bureaucrats explained
this increased level of access available to the food industry.
Now the food industry is clearly a very powerful industry and they go to a lot of
effort to be connected politically.
Federal Bureaucrat 3
I think people that come on a large industry base, governments have to listen to
them. Xxxx can bang on any door and get access to ministers at any time and
so can xxxx, incredibly influential, an absolute operator. The head of
Woolworths, Westfarmers, Coles, Metcash, Aldi, the Farmers’ Federation,
Andrew…the chief advisor to the head of the xxx bank and ..people like him are
able to knock on any doors. People who come from a large industry base, big
employers, government has to listen to them – very influential people.
Federal Bureaucrat 2
This privileged access to decision-makers was highlighted by another
Bureaucrat, who also pointed to the food industry’s salient framing of the ‘personal
responsibility’ message to decision-makers and the general public. This was aided by
the synergy between the financial endpoints of both the government and the food
industry.
The industry, primarily in the form of the AFGC, but there are other players
there as well, like other food companies, are in and out of the minister’s
offices. They have a lot of influence not only in the background, they have a lot
of overt influence, if I could put it that way, in the public domain particularly
around their due regulatory rhetoric and the rhetoric of non-interference and
of letting the markets work blah blah blah. So they’re a major influencer.
Federal Bureaucrat 4
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One of the senior Federal Bureaucrats admitted to struggling with the high
level of influence of the food industry, due to their ability to consistently fall back on
the financial endpoint argument and the success they have in ensuring their
arguments gain traction with the Minister.
I think that the Food and Grocery Council because they talk about jobs, they
talk about the economic impact, they potentially are more influential than we
<Senior Bureaucrats> are, and this is something that I’ve struggled with over
the last four years.
Federal Bureaucrat 2
6.3.5 Abdication of responsibility
The final theme under ‘lack of political will’ is the concept that intervening in
public health nutrition is not the responsibility of the federal government.
Participants reported that this sentiment within government had increased over the
years, due to the influence of the food industry, the neoliberal ideology of the
government in power, the complexity and cross-departmental nature of public health
nutrition action, and the perceived lack of interest from the general public, all of
which has resulted in the government stepping away from public health nutrition
policy action.
I think that’s been the problem with nutrition policy because it is cross-
jurisdictional, there has to be buy-in from everyone. If it sits in health,
everyone ignores it because everyone ignores health. If you try and do it in
food, it gets hijacked by trade, which we saw with the food policy <National
Food Plan>. It got totally hijacked by the trade agenda and the agriculture
production agenda and nutrition which had a little bit of a leg-in initially,
whole thing got dumped and it all got moved to a completely economic and
terms of trade and agriculture agenda. There is no acknowledgement in the
food policy that it has anything to do with human health and this is where the
problem lies. To me that’s what I see as being one of the issues.
NGO Nutrition 3
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The neoliberal ideology that is promoted by the food industry and is
particularly espoused by conservative governments in Australia encourages personal
responsibility when it comes to food choices. During their interview, several food
industry participants championed the personal responsibility argument as a way of
questioning why the government should be getting involved in food and nutrition
policy.
I have a personal issue with the amount of personal responsibility that
consumers seem not to want to take. At the end of the day what you put in your
mouth is your responsibility.
Food Industry 5
Federal bureaucrats were also concerned about ‘intervening’ too much into
people lives:
I think there needs to be more… they need to find the middle of the road
solution. And it’s a struggle, for a lot of choices that the individual makes, how
much government intervention should there be.
Federal Bureaucrat 1
The rise of neoliberal ideology and the consequent fear of political parties
being accused by the media and general public of going down the ‘nanny state’ route
was also identified by participants. This fear of being criticised as a ‘nanny state’ was
reported to intensify if the government had recently passed a large public health
initiative such as plain packaging for cigarettes. It was perceived by an NGO
participant that all good will for any other public health initiatives was ‘used up’ for
many years following such an event.
Within the government, there is a very strong anti-red tape push. It’s almost
like a Tea Party influence and it’s that influence that extends into the Labor
party. The Labor party is anxious not to be seen to be pushing the nanny state.
I think they felt that Nicola Roxon had her fun <with plain packaging for
cigarettes> and now we really can’t go any further, you know.
NGO General Health 6
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The nanny-state rhetoric of some participants revealed a fear of being regarded
as too overprotective or as constraining individual liberties. This was highlighted by
one of the politicians:
There's this reluctance on the part of government to get involved in this area to
make a broad policy across the country because you revert to this notion of
self-responsibility and how much do you intervene.
State Politician
Further exhortation of the neoliberal sentiment that ‘the market will deliver’
and that nutrition policy is not the responsibility of government was evident when
discussing food security policy in Aboriginal and Torres Strait Islander communities
with a federal government representative. On numerous occasions throughout the
interview he reminded me that the preferred option for the government is for the ‘the
market to deliver.’
And by and large, you know, that is a market. And so the normal approach is
that, you know, the market will…the best thing is when the market can respond
to that, the provision or supply of food, then that’s the preferred
approach…..Our idea is what you need is a business, and government does not
run businesses, it’s reliant on the market, but through xxxx we’ve set up an
institution that can help the market deliver services.
Federal Bureaucrat 5
Another Federal Bureaucrat echoed this position, which they were critical of,
and associated it with neoliberal ideology:
The overall flavour of government matters as well and the mood we have
politically, it’s an almost neoclassical model, and that’s very much a model
which says if you have the right conditions and place, the market will deliver.
Now we know without any doubt and any analysis will tell you that the serious
market failure both in the general market and the Indigenous market it’s a
rampant failure and that won’t do the trick but when you put it beside some
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type of potential regulation then it’s extremely difficult to get anything up, even
with the kind of results we’ve got.
Federal Bureaucrat 1
It is important to note however, that even when participants attempted to align
with the neoliberal ideology to gain traction with policymakers, it still failed if the
strategy did not comply with party policy. This was demonstrated by one example
from an NGO Health participant, who expressed their exasperation that despite
having a viable business plan and a business model that would result in long-term
profit of a community business as well as support the health of a remote Aboriginal
community, it did not correspond with the policy of the government and therefore
got no traction.
I met with the department last year, the Department of Communities, with a
group from APY lands (remote Aboriginal homelands in the centre of
Australia), who ran stores there and the person who ran the stores was a
nutritionist, she was the CEO and they were making sure they were doing all
the right things but they were running at a loss, initially, and that would have
picked up over time because they understood the business model, but the
government said ‘no, we have another store chain we prefer xxx because they
have a better business model’. So we sat there and honestly,…. they ended up
talking to a 28 year old girl, who had no experience in anything but who was
an advisor, who talked down to them and had no idea about remote or
Aboriginal or nutrition and said ‘no, no, the current government’s policy is
blah blah..’ and we said we could provide the evidence of the long term gains,
the investment will be worth it, you can invest in us now to prevent this or you
can invest in emergency departments to prevent heart attacks, so what would
you like to do? ‘The policy of this government is…’ So the issue there was
there was there was a business agenda they were putting ahead of the health
agenda, which I understand because there is cost effectiveness, but this was in
place where you know that nutrition would be a total failure unless you did
something radical like this.
NGO General Health 5
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Lack of political will was identified by participants in this study as an
overarching barrier to nutrition policy action. Encompassed within this overarching
category were the inter-related themes of: beliefs; lack of public will; lack of
leadership; the power and influence of the food industry; and abdication of
responsibility.
6.4 NAME/ISSUE NOT TOP-OF-MIND
Policymakers and in particular politicians are often overwhelmed with constant
requests from constituents, vested interests and other colleagues to prioritise certain
problems and solutions. For an issue to get adequate attention from policymakers it
must be ‘top-of-mind’. The key reasons nutrition issues were not ‘top-of-mind’ fell
under the following themes:
Competing for the attention of decision-makers;
Lack of leadership; and
Complex, multi-faceted problem.
Lack of leadership has been discussed in the previous section lack of political
appetite (Chapter 6.1), therefore this section will discuss the results from two themes,
competing for the attention of decision-makers’ and complex, multifaceted problem.
6.4.1 Competing for the attention of policymakers and the public
Some groups were considered better than others at competing for the attention
of policymakers and the general public. This was due to their resources and
expertise, but also to their understanding of the daily reality for those in federal
decision-making positions.
Remember information overload affects us all. It certainly affects bureaucrats
and ministerial staffers, they just get shit loads… They’ve also got 50 million
people in their faces all wanting something.
Food Industry 7
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A policy advisor explained that parliamentary friendship groups, dinners and
breakfasts were very common strategies interest groups used to compete for the
attention of policymakers. However, as these are now numerous, they can often
become overwhelming.
It’s a much more common tactic in the parliament now that we sort of joke
about dining out on disease….it really is like every week, there’s at least one in
health, or more than that. Look, it’s not dining out on disease. Often, it’s
different groups like it’s – I mean, for example, last week, there was an ovarian
cancer breakfast. There was an organ donation that was more of a walk, a
charity walk but there was an organ donation walk in the morning. I think the
rural doctors have something on this week….
Political Advisor 2
The ability of the food industry to use their economic power, for example their
tax revenue, employment figures or political donations, to gain extra access and the
attention of policymakers above and beyond other groups was highlighted by an
NGO Nutrition participant.
The power of industry, the ability of them to advocate at all levels, they’re very
well connected through sports sponsorship and through advertising agencies,
they’re connected through the peak bodies, they’re connected through the
companies themselves, they’re connected….and that’s where the changes
happen so the opposition they do that very well. They’re funded with a lot of
money to do that, so there’s lots of influence through those connections.
NGO Nutrition 2
In comparison, it was believed that lack of funding and resources made it
difficult for nutrition advocates to access federal policymakers generally, let alone a
senior level policymaker that the food industry can access through their resources
and political clout.
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And money makes that happen as well, having people to do the work. Public
health doesn't make money and therefore its power to influence is less, by virtue of
lack of people on the ground.
Public Health Academic 1
A further factor in competing for the attention of policymakers was identified
by public health nutrition advocates. They felt their voices were drowned out by the
emergence of everyone being an expert, as explored previously in the section on
beliefs. All the nutrition professionals interviewed were concerned that non-nutrition
specialists, for example bloggers and celebrity chefs, were able to engage with
decision-makers and the general public through effective use of social and
mainstream media, and because of this there was concern that others were
influencing public will and the policy agenda.
Because everybody’s an expert in nutrition….So it’s hard for scientists in the
area to get traction because everyone’s opinion seems to be given equal weight
on the web.
Public Health Academic 2
Furthermore, there was a concern raised that nutrition advocates were not
engaging with the media as a form of advocacy. One participant felt that they were
alone in speaking up about nutrition policy issues, and claimed:
People aren’t brave, they’re reluctant to do advocacy. I’m out there on my own
talking about a GST <goods and services tax> not being applied to fruit and
veg, by myself. No other groups came out and spoke to that.
NGO Nutrition 2
However, this may be a case of this participant working in a silo and not being
aware of who was speaking up on this issue. Interviews with other participants
identified that a number of them had in fact spoken to the media about GST on
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healthy foods. This lack of awareness of who is advocating for an issue again
highlights the lack of leadership and unity of voice for nutrition professionals.
Using the media was identified as a strategy that advocates could use to
increase attention to their issue. However, it was highlighted by journalists that the
‘unsurprising nature’ of most public health nutrition stories was a barrier to getting
this coverage. Society understands that there are public health nutrition problems, but
the solutions that advocates propose are well known and not new; therefore they’re
not considered ‘newsworthy’ by the media. This barrier was identified for obesity,
which was described by journalists as ‘boring’; but also for Aboriginal and Torres
Strait Islander nutrition issues, which had the added complexity of being seen as
unsolvable for many:
People (need to) feel in some way it affects them or affects their life, I think
that’s particularly difficult for Indigenous health issues because people see
Indigenous health as something that’s separate from their own health. And it’s
something that’s also very unsurprising, so they know that there's a lot of
health problems in Indigenous communities, so saying ‘Oh look here’s another
one’, it’s not seen as an urgent or like a new problem, its seen as an intractable
long term problem that everyone knows about.
Journalist 2
6.4.2 Complex, multi-faceted problem
The nature of nutrition-related diseases is that they are complex in aetiology
and often multi-faceted. As a result of this complexity, many participants noted that
the area had become a contestable space, which made it difficult to attempt to
identify solutions and the best way forward. This complexity, with no easily
identifiable solution meant that limited attention was given to nutrition policy, as it
was considered ‘too hard’.
Nutrition is a bit different because you're talking about longer term objectives
and almost hard work in a sense
Federal Bureaucrat 1
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This complexity also made it much harder to ‘sell’ nutrition policy action to
policymakers:
In nutrition it all depends, it's a much more complicated story, much harder to
tell that story, much harder to provide convincing evidence, yeah. I think it's a
complex issue and I think it's also so much less immediate...
NGO Nutrition 1
Due to the complex aetiology of nutrition-related diseases, policy outcomes for
public health nutrition usually take longer than the three year political cycle;
therefore, there is a reluctance by politicians to engage in issues that are unable to
deliver tangible outcomes in that three year timeframe.
It really needs a lot of strategic planning and the timeframes involved go
beyond the time periods of government, so it’s always put into the too hard
basket.
Public Health Academic 2
We’re looking at changing food habits in a country which is a long term
process with long term results. But, yet, we operate within a funding cycle that
is short term with political motivation and a political agenda.
NGO Nutrition 1
Another barrier highlighting the complexity of nutrition was the lack of skills
of individuals in the bureaucracy to understand the complex evidence around
nutrition.
At the bureaucratic level, there's a similar set of factors...not all public
servants are good at understanding evidence or effective evidence. In fact, I
sometimes kind of despair for the lack of evidence based approaches, so in the
public service we're not always as focused on evidence or as good at assessing
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evidence as we should be. Sometimes we're good at it and sometimes we're
really crap.
Federal Bureaucrat 3
One way to increase attention to an issue is to work collaboratively to be the
only voice or a united voice speaking about an issue. However, it was identified that
the field of nutrition has many voices and many different opinions on what the
priorities should be and how issues should be progressed. This was identified as one
barrier to progressing nutrition policy.
Well look, the whole nutrition policy area is fragmented, partly fragmented.
There are a lot of players in it.
Food Industry 9
Obviously in the obesity game there’s not a consistency of message with those
groups as well. So that undermines it. Its complex, multi-factorial, and its
complex….So you’ve got a fractured, not a strong face and that adds to the
lack of ability to progress things.
NGO Nutrition 2
6.5 COMPLEXITY OF THE POLICYMAKING PROCESS
The making of public policy is often a slow, complex, political process. This
complexity was seen by participants as a barrier to progressing policy change.
Underpinning this complexity were the following themes:
Evidence is only one factor;
Priorities of other portfolios;
Government silos.
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6.5.1 Evidence is only one factor
A common misconception about health policymaking is that evidence is the
starting point for developing new policy or revising existing policy (Bernier &
Clavier, 2011; Clavier & De Leeuw, 2013). As acknowledged by many policy
scholars as well as the participants in this study, the reality is that evidence is only
one component in a complex, dynamic, multi-faceted policymaking process.
You could have all the evidence in the world and it won’t get you action. And
sometimes you can get action without any evidence. They're really important
factors to think about at the political level.
Federal Bureaucrat 3
You'd like to think that it’s based on evidence, but I don’t think there's much
evidence that things get supported based on evidence. Things often get
supported because they seem okay at the time and that doesn’t necessarily
mean that it’s not because people aren’t trying to do the right thing. I think it
grows out of a sense of frustration… we’ve got this problem, where do we
start? What do you do? It sounds okay, let’s do it in schools and see if it works
and then you allocate the funds.
State Politician
It was reported that as the policymaking process was dynamic with no orderly,
linear process it presented additional challenges for advocates with limited
experience of policymaking at the federal level or limited inside intelligence of
where potential opportunities and barriers may lie.
One day it could be the governments getting a lot of bad publicity about
something and they’re looking for an announcement, an easy announcement.
So it could just be circumstance and happenstance and right place, right time. I
don't think it’s some linear, sensible orderly process unfortunately.
Journalist 1
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Adding to the challenge is that making or changing policy at a federal level in
Australia was reported by many participants as a slow and complex process which
often takes a long time. Several participants pointed to the risk-adverse nature of the
public service, which limits innovation and large-scale policy change.
If you have expectations that you’re going to change things overnight, you’re
going to be disappointed.
Federal Politician
Changes in government or changes in other key actors such as senior
executives in the food industry or senior Bureaucrats, can also influence the
policymaking process and can result in previous policy decisions being overturned.
You can see that when governments change, interests groups switch their view
and they may have agreed to a particular position we thought we had them
locked down, but they see an opportunity to back track out of it and they do it.
All that it takes is the Food and Grocery Council to change their Chair, change
their CEO, change their advisor on something and the whole dynamic changes.
So, how policy is made in the food space is it’s fluid, it’s dynamic and it’s just
not linear.
Federal Bureaucrat 2
As well as the complexity of the nutrition issue, it was noted by the politicians
in this study that due to the complex, dynamic policymaking environment, it is
difficult for any individual or group, no matter what their issue, to change policy.
It is hard. It’s exhausting, exercising influence is hard. If it was easy, everyone
would always get what they wanted!
Federal Politician
6.5.2 Priority of other portfolios
Whilst the Health Minister is responsible for many policy decisions within the
health portfolio, there are some policy decisions that need to be approved at a
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Cabinet level. These are usually policy decisions which impact on other portfolios.
For public health nutrition many of the recommended policy actions potentially
impact negatively on other portfolios, for example, the industry portfolio, may
typically oppose the action suggested. The priority and trade-offs between portfolios
was explained by one Federal Bureaucrat.
The more competitive you can make the food industry, the better for exports
and trade. So it’s constantly playing off trade versus public health versus
industry interests, so this again is a huge complexity in a way that ultimately a
minister makes a decision. You also have within Cabinet the views of trade
ministers, of industry ministers, of agriculture ministers, of then sectional party
interests and depending on group cliques, where political parties come from,
whether they’re rural or urban based, they’ll have a particular view on things.
Federal Bureaucrat 2
With all those competing views within Cabinet it was pointed out that there
was a hierarchy around policy decisions where certain portfolios or Cabinet positions
will trump others but also that ministers are in a position to champion certain policy
issues no matter what their portfolio.
Because at the end of the day, clearly, the treasurer has greater sway than the
health minister or the agriculture minister or the industry minister but if any of
those ministers can come up with a very convincing argument about something
and the timing is right, then you can convince either the majority of your
ministry or Cabinet or party room or the leader and affect policy in that way.
Political Advisor 2
6.5.3 Government silos
The most effective public health nutrition policy often requires action across a
range of different divisions and departments within the federal and state governments
(Swinburn et al., 2013). The problem of government silos, whereby different
departments and divisions fail to speak and/or collaborate with each other to develop
approaches that would tackle complex problems, was mentioned by a few different
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participants from the food industry, as well as health advocates, as a barrier to
progressing food and nutrition policy.
Often you needed state and federal and the private sector around the same
table. It proves a problem in Australia and I don’t know why. It really does.
To get the states and feds around one table is hard enough, but bringing in the
private sector as well is often seems to be a step too far for many governments.
Food Industry 7
The problem of government silos was particularly evident in Aboriginal and
Torres Strait Islander nutrition policy, especially around the issue of food security.
So that’s a possibility because it's…look if it was community health, you know,
if they wanted to talk about an Aboriginal health service, you know, that
clearly sits with health but if they wanted to talk about stores licensing that
clearly sits with us, but there are other policy areas where those conditions
aren’t quite so neat. And, you know, in terms of…it depends what subsidies
you’re talking about. If you’re talking about freight subsidies there are
different areas of government that deal with freight subsidies. You know, you
might be looking at an entirely different agency coming in.
Federal Bureaucrat 5
6.6 SUMMARY
Participants engaged in the nutrition policymaking process in Australia
identified a wide range of barriers to policy change which were dynamic and inter-
related. These barriers fell under the three overarching categories of: lack of political
appetite; issue and/or organisation not top of mind, and the complexity of the
policymaking process. Furthermore, surrounding the categories and underling themes
were the contextual factors that frame nutrition policymaking in Australia, that is: a
neoliberal ideology; a pressurised, risk averse government; and the general system of
governance.
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6.7 DISCUSSION
Despite the rising incidence and costs of nutrition-related diseases in Australia
there has been limited coordinated, national nutrition policy action, particularly
regarding legislation or regulation. To better understand the process of nutrition
policy change or lack thereof, it is essential to understand the barriers to policy
change. In-depth interviews with 37 key influencers and decision-makers in Australia
were undertaken to identify these barriers to policy change. Furthermore, the findings
from this chapter were analysed to determine whether the policy process theories
were applicable and relevant to the Australian nutrition policy context.
Political science policy process theories can aid in understanding the policy
process, including the Multiple Streams Theory (MST), Punctuated Equilibrium
Theory (PET), and the Advocacy Coalition Framework (ACF). These theories were
all developed in the United States of America and broadly describe mechanisms that
result in policy stasis and change. However, these theories have been criticised for
being too broad and ‘high-level’, and designed for an academic, rather than a
practitioner audience, with concepts that are often difficult to understand and
translate to the real world (Cairney, 2015).
Ten key themes were identified from the in-depth interviews. These themes sat
within three overarching categories: lack of political will, name/issue not top of mind
and the complexity of the policymaking process. Surrounding these categories and
themes were the macro-political factors of the neoliberal ideology; the pressurised,
risk-averse environment; and the system of governance. To identify if these barriers
provide new and useful knowledge for nutrition advocates in Australia, it is
important to compare these findings with the policy process theories and nutrition
policy literature generally. This process allows new and unique factors specific to the
nutrition policy process and/or the Australian context to be determined and
discussed.
Broadly, the findings from the interviews do conform with the policy process
theories; however there are some important differences that need to be
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acknowledged. Firstly, the theories are too broad to account for the specific issues
identified by participants in this study which relate to nutrition policy. Secondly,
barriers have been identified in this study that the policy process theories do not
consider. The remainder of this chapter will discuss the specific barriers found in this
study as they relate to the broad mechanisms of policy stability identified in the
policy process theories, followed by a discussion of the unique factors identified.
In identifying the barriers to nutrition policy change, it was clear from
participants’ comments that nutrition policy change is difficult and challenging.
These findings are broadly in line with the three policy process theories, but in
particular ACF and PET, which identify that policy stability is the norm and that
significant policy change rarely occurs. If policy change does occur it often requires
a minimum of ten years to take place (Baumgartner et al., 2009; Jenkins-Smith &
Sabatier, 1994). According to the ACF, MST and PET, this lack of change or
preference for policy stability is associated with negative feedback mechanisms in a
policy system (Baumgartner & Jones, 1993). These mechanisms are outlined below.
Firstly, policymakers often accept a group’s preferred way to frame an issue
for long periods; for example, framing obesity as an individual’s responsibility
(Cairney, 2012; Gollust et al., 2013). This acceptance of a frame by policymakers is
known as a policy monopoly. The resulting policy monopoly may be institutionalised
when rules are created and resources are devoted to solving the policy problem on
those terms. Policy monopolies typically limit the participation and access of other
participants. If citizens excluded from a monopoly remain apathetic, the institutional
arrangement usually remains in place with minimal policy change (True et al., 2007).
The second negative feedback mechanism is the ability of interest groups or
coalitions to organise opposition to policy change (Sabatier & Weible, 2007).
Finally, there is the mechanism where policymakers make only marginal changes to
existing policy, based on their limited ability to foresee the consequences of their
changes because of surrounding complexity and uncertainty (Baumgartner & Jones,
1993).
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All of these negative feedback mechanisms were present in the findings
although expressed in different ways. The first mechanism, the ‘power of a policy
monopoly to ensure policy stability’ corresponds with the themes ‘beliefs of
decision-makers, the lack of public will, the abdication of responsibility, the power
and influence of the food industry, and evidence is only one factor. The second
mechanism of ‘interest groups ability to organise opposition to policy change’
corresponds with the themes the power and influence of food industry, and the lack of
leadership. Finally, the mechanism whereby policymakers make only marginal
changes based on their limited ability to foresee the consequences of their changes
due to surrounding complexity and uncertainty, corresponds with the themes
pressurised, risk-adverse environment, the complex, multifaceted problem as well as
neoliberal ideology and beliefs.
6.7.1 Policymakers accepting the frame: the policy monopoly
As described above, the policy monopoly concept highlights the challenge in
changing the political and public will around policy issues. It demonstrates how the
current “winners” (those who hold the policy monopoly or dominant advocacy
coalition), will do everything to ensure it remains that way. Participants in this study
generally agreed, or were actively promoting, that the current policy monopoly frame
accepted by policymakers and the general public surrounding nutrition and nutrition-
related diseases is a neoliberal one of personal responsibility and market-driven
prosperity. This frame has been promoted by governments who ascribe to this
ideology as well as by the food industry, who rely on this frame to ensure their
business continues without interference from government.
Neoliberal ideology and the power of the food industry
The infiltration of neoliberalism as a key influence on nutrition policymaking
in Australia was noted by a wide range of respondents from a variety of
backgrounds. Neoliberalism, which places markets at the centre of all economic and
social life, shapes government decisions on whether to recognise issues and whether
to intervene to address these issues (Bryant, 2013). Across the world, this has
resulted in governments decreasing support for social and health programs and
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adopting austerity measures to ensure competitiveness in the global economy (Ortiz
& Cummins, 2013). Where neoliberalism is particularly damaging for public health
nutrition policy action, however, is around the promulgation of personal
responsibility. Neoliberal ideology assigns responsibility for healthy lifestyles
primarily to individuals. This framing ensures that poor health and poverty are
treated as “individual shortcomings, products of poor individual choices, to be
remedied by emphasising individual responsibility” (Cossman & Fudge, 2002, pp.
21-22).
The neoliberal frame of personal responsibility has been widely promoted by
the food industry, as it limits government intervention that might negatively impact
on sales and profits (Jenkin, Signal, & Thomson, 2011; Swinburn & Wood, 2013;
Vogel, Burt, & Church, 2010). In order to do this the food industry must maintain the
policy monopoly that consists of the frames: economic profits of business are a
priority; and dietary intake is the responsibility of the individual. The different
strategies food industry use to maintain the policy monopoly and discount other
competing frames were outlined in the findings, and include: continuously
challenging the evidence for public health nutrition action; agreeing to programs that
will not make a difference to their product sales; using their financial and
organisational position to access and persuade the government; and finally,
effectively framing the message to decision-makers and to the general public. The
ability of the food industry to effectively frame and secure the policy monopoly was
aided by the shared values of short-term economic gain of both the government and
the food industry.
Further support of neoliberal ideology by the government and general
community can also be seen in the endorsement of the biomedical model, and a
behaviour-focused view of the cause of poor nutritional status. This endorsement was
evident in this study with one participant explaining that the lack of clinical
champions was the reason nutrition policy had not gained traction. Bambra et al.
(2005) contend that support for the biomedical model is pervasive across the political
spectrum, and is reinforced by the health care industry, the medical establishment,
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the pharmaceutical industry and public opinion. These groups are powerful in their
own right and often drown out arguments around preventative health.
While not specifically identified in any of the policy process theories, the
influence of neoliberal ideology and the simultaneous power of the food industry
have been identified as a barrier in public health nutrition policy for some time
(Kersh & Morone, 2002; Shill et al., 2012). The power of the food industry in
maintaining the policy monopoly by appealing to ideology and using effective
frames has been supported by nutrition policy literature, as identified in the
systematic literature review in Chapter 4. Frames used by the food industry to fight
regulatory interventions included ‘regulation interferes with market driven
economies,’ or ‘personal freedom,’ and ‘the market will solve the problem’
(Campbell, 2012; Caraher et al., 2013; Corvalán, Reyes, Garmendia, & Uauy, 2013;
Crammond et al., 2013; Shill et al., 2012; Swinburn et al., 2013; Vogel et al., 2010).
Influenced by the neoliberal ideology, the Australian government as well as
governments around the world, in most cases, have accepted the food industries’
argument on these points and maintained the status quo, with limited policy action in
public health nutrition. From these findings it appears that rather than acting to
protect public health, governments are often catering to the interests of industry
(Swinburn & Wood, 2013). One such occurrence is the creation of trade agreements
around the world. These agreements appear to strengthen the influence of
transnational (food) corporations and weaken a government’s ability to protect their
populations against unhealthy commodities (Friel et al., 2013; Thow & Snowdon,
2010).
This acceptance of neoliberalism and the subsequent policy monopoly that
accompanies it becomes a barrier that influences almost all other parts of the
nutrition policymaking process, ultimately resulting in a lack of political and public
will for public health nutrition policy change. As identified by PET, the policy
monopoly has been ‘institutionalised’ when rules are created and resources are
devoted to solving the policy problem on those terms (Baumgartner & Jones, 1993).
All participants, bar those from the food industry, indicated that the policy monopoly
for nutrition policy in Australia, currently held by the food industry, appears to be
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institutionalised. Further evidence for the food industry policy monopoly can be seen
in the limited action by federal government on nutrition policy. This action to date
consists of a voluntary front-of-pack labelling systems developed in collaboration
with the food industry, and the Healthy Food Partnership, a food-industry-heavy
committee looking at voluntary self-regulation methods of food reformulation. These
industry-led initiatives are not unique to Australia, there are further international
examples of food industry co-creating favourable voluntary policy action (Field &
Gauld, 2011; Miller & Harkins, 2010; Norum, 2005; Panjwani & Caraher, 2014). A
further benefit to the food industry partaking in these industry-led initiatives is the
‘halo effect’ it creates, where the food industry is able to present themselves as good
corporate citizens. As a consequence, nutrition professionals can be framed as
problematic and not wanting to be part of the solution (Brownell & Warner, 2009).
Beliefs
Neoliberal ideology was noted by participants as a strong influence on the
acceptance and promotion of the current frame and subsequent policy monopoly in
nutrition. However, it was also identified that pragmatic beliefs, such as whether an
issue is a ‘vote-winner,’ and beliefs based on personal experience or the media, play
an important role. This finding is contrary to the ACF, which posits that the
motivation for policy decisions is based on the deeply held beliefs of individuals.
Equally, the influence of these other beliefs, such as pragmatic and personal
experience beliefs, has had limited acknowledgment in the nutrition policy literature
(Lyn et al., 2013; Nathan, Develin, Grove, & Zwi, 2005). However, pragmatic
beliefs and beliefs based on personal experience are noted in the PET, where
Baumgartner et al. (2009) notes that frames based on values and beliefs can be
activated by the media or skilled advocates to encourage support for a particular
policy direction. Equally Kingdon (1995) highlights that the biases and interests of
the audience, whether they are policymakers or the general public, are often what
determines whether attention will be given to a problem.
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Evidence is only one factor
Beliefs also play an important role in whether individuals acknowledge or
dispute evidence. This is a key tenant of ACF and is recognised in broader political
communication literature as ‘confirmation bias’ or ‘motivated reasoning’. ‘Motivated
reasoning’ is the process by which people process information selectively to confirm
and maintain prior beliefs, rather than being persuaded by information which is
incongruent with their values and beliefs (Gollust, 2016). As witnessed by many
participants in this study as well as by policy scholars, presenting reams of evidence
does not change people’s minds unless the evidence is framed to coincide with their
values and beliefs (True et al., 2007). This reality is contrary to common perceptions
of nutrition policymaking by nutrition professionals, that evidence is (or should be)
the starting point for developing new policy or revising existing policy. Policy
process theories and some participants in this study suggested that rather than being
the instigator for policy change or revision, evidence is often used as a political
resource. Sabatier and Jenkins Smith (1993) explain that the motivation for an
advocacy coalition to use research is to build support for their arguments while
undermining their opponents’ arguments, as they compete for power and control of
the policy subsystem. Despite the use of research as a tool in the struggle for power,
ACF contends that research can eventually prompt a change to beliefs and
subsequently policy. This happens because advocacy coalitions cannot afford to be
too far out of step with credible research if it makes them liable to attack from
opponents. Unfortunately, this practice does not seem to hold true for public health
nutrition, where evidence of policy problems and solutions exist, yet it is still being
ignored by policymakers.
System of governance and political hierarchies
Government silos are often cited in nutrition policy literature as one of the
reasons that nutrition policy does not progress (Ceccarelli, 2011; Crammond et al.,
2013; Shill et al., 2012; Vogel et al., 2010). Silos were identified by participants in
this study as one reason it is hard to progress nutrition policy, particularly with cross-
sector programs. However, the findings in this chapter suggest that a more important
factor is at play in matters of legislative or regulatory nutrition policy, namely
political hierarchies. Participants explained that in Australia, legislative and
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regulatory policy needs to be taken by the relevant minister and presented to Cabinet
for agreement and sign-off. Theoretically, this requires the whole Cabinet to be in
support of the decision; however, participants explained that there is a hierarchical
system in place within the Cabinet which is structured on the status and power of the
ministerial portfolio, and the party position an individual holds. It was revealed that
generally, the portfolios concerned with raising revenue had higher status than other
portfolios. Consequently, the Treasurer or the Trade Minister overrides the Health
Minister and the Prime Minister is generally able to override everyone. Study
participants revealed that while Cabinet decisions are often based on party policy,
ideology, the personal beliefs of ministers and whether the policy will be a vote
winner, critical to the decision-making process is the status and power of the
individual championing the policy. Unfortunately, participants reported that the
Minister for Health is low on the status and power hierarchy. It seems that the
requirement of taking these policy decisions to Cabinet, and the subsequent “joined-
up” decision-making process that requires the support of ministers whose portfolios
are diametrically opposed to improving nutrition, is a key barrier to nutrition policy
progressing.
The prioritisation of other portfolios and the subsequent resulting hierarchy has
not been identified by the policy process theories. However, Kingdon (1995) does
acknowledge the power of the President and prominent members of Congress in the
policymaking process in the United States of America, in the preamble to the MST.
Prioritisation of economic portfolios over health has however been identified in
nutrition policy literature (Kersh & Morone, 2002; Nestle, 2013; Shill et al., 2012).
6.7.2 Ability of interest groups to organise opposition
As previously stated, policy monopolies typically limit the participation and
access of other participants in order to contest the dominant frame and influence
policy decisions. If individuals and organisations are excluded and do not feel they
are able to challenge the policy monopoly, the institutional arrangement usually
remains in place with minimal policy change (True et al., 2007). Typically, therefore,
only well organised and resourced interest groups can challenge the policy
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monopoly. In Australian nutrition policy, the power of the food industry in
maintaining the status quo and the policy monopoly is unquestionable. The many
strategies the food industry use to maintain the policy monopoly were described by
participants and are also outlined in nutrition policy literature. However, the power
and influence of one group also highlights the lack of power and influence of
competing groups or coalitions, namely nutrition advocates. By ignoring groups with
little political visibility (or power), the policy monopoly made up of decision-makers
and interest groups can develop policy and allocate limited resources in ways that
serve their interests without having to address complicated, longer-term solutions
(Baumgartner et al., 2009).
While the food industry does hold a dominant role in influencing nutrition
policy, most nutrition advocates do not. One reason for this is because nutrition
groups lack the ability to organise opposition. This is due to a number of factors
including lack of resourcing for and prioritisation of advocacy, and lack of leadership
and coordination amongst the many nutrition issues/groups; but also, many nutrition
advocates lack skills and knowledge around advocacy. Similar barriers have been
noted in the international policy literature (Dodson et al., 2009; Vogel et al., 2010).
Furthermore, the nature of nutrition-related diseases is that they are complex in
aetiology and often multi-faceted. As a result of this complexity, many participants
and nutrition policy scholars noted that the area had become a contestable space
when attempting to identify solutions and the best way forward (Freudenberg,
McDonough, & Tsui, 2011; Oppenheimer & Benrubi, 2014).
Leading the charge?
Participants explained that the complexity of nutrition-related diseases with no
easily identifiable solution meant that limited attention was given to nutrition policy,
as it was considered ‘too hard.’ This was compounded by the number of non-
government organisations that target a specific chronic disease combined with
professional associations competing for influence amongst policymakers and for
their issue to be given priority. Consequently, there was strong consensus from
participants that there is no clear voice or leader in public health nutrition, and this is
a barrier to policy action. This lack of leadership, whether from nutrition or general
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health professionals, but also from government bureaucrats and ministers, means a
void is left in this policy space. As a result of this void, a multitude of ‘voices’ in
public health nutrition as well as the general health sector, often saying different
things, confuse the issue for decision-makers and the general public. Shelley (2012)
explains the resultant “noise” makes it nearly impossible to determine what policies
would be most effective.
Lack of unity in the message or solution around public health nutrition issues
and the resulting confusion or inaction by policymakers has been identified by
several nutrition policy scholars (Freudenberg et al., 2011; Gilson Sistrom, 2010;
Shelley, 2012). Similarly, study respondents noted that the complexity around
nutrition and the perception that the ‘nutrition message’ was constantly changing had
led to a lack of public will in Australia. Additionally, funded alliances with the
manufactured food industry also created confusion around credibility. While
confusion over nutrition messages in the general public has been reported in nutrition
literature (Goldberg, 1992), there does not appear to be literature noting the
connection between this confusion and subsequent lack of public will for policy
change.
Effective leadership (or lack of) is not explicitly mentioned within the three
policy process theories, although a policy entrepreneur looking for opportunities to
champion an issue could be seen as taking on a leadership role. In this study, lack of
leadership was linked to broader issues, including lack of unity in message as well as
the limited number and capacity of individuals and organisations to engage in and
champion public health nutrition issues. The challenge of leading in nutrition and
negotiating a consensus is a particularly vexed and difficult process, as there are so
many interests at play.
Not playing the game
Many participants noted that nutrition professionals have a limited
understanding of the policymaking process and the context within it operates. This is
consistent with findings in nutrition and broader public health literature. Sources of
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confusion regarding the policy process identified in the literature include: not
knowing the entry point or responsibility of government departments for certain
nutrition issues (Shill et al., 2012); not understanding that politicians usually decide
on whether policy goes ahead, not the bureaucrats (Crammond et al., 2013); the
dogged persistence that is required (Gilson Sistrom, 2010); and the hierarchy of
power within governments and government departments (Shill et al., 2012). This
lack of policy process knowledge may be due to insufficient training within nutrition
courses in tertiary institutions or lack of on-the-job mentoring.
Although an in-depth understanding of the policymaking process was not
explicitly stated as a requirement for policy change by any of the three policy process
theories, it is implied in the MST. The policy entrepreneur in MST epitomises
someone who has an in-depth understanding of the policymaking process and uses
this knowledge to hook policy solutions to policy problems and policy solutions to
political momentum (Kingdon, 1995). Similarly, study participants highlighted it was
essential to understand which decision-maker was responsible for a problem and
solution, and that establishing and maintaining a relationship with those individuals
was very important.
Another important component in ensuring advocates can organise opposition
effectively is understanding that more and better evidence will not necessarily result
in policy change. This approach ignores that facts are always value-laden and
judgements are context-dependant (Russell, Greenhalgh, Byrne, & McDonnell,
2008). Consequently, policy solutions need to appeal to, and resonate with, those
values and beliefs. The results show that the food industry operates very effectively
within this context, but it is noted that nutrition professionals need to increase their
understanding of the levers of the policy process if they want to challenge the policy
monopoly.
Devil shift
One of the perceived failures of nutrition professionals that several participants
noted was their perceived inflexibility and their demonisation of the food industry.
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These perceived traits undermined nutrition professionals’ ability to advocate
effectively to decision-makers. The demonisation of opposing coalitions is reported
as a common occurrence amongst competing coalitions in the ACF. This concept,
named the ‘devil-shift’ occurs when actors from different coalitions perceive
opponents to be stronger, less trustworthy and more ‘evil’ than they actually are
(Sabatier & Weible, 2007). This perception increases the density of ties to members
within the same coalition and exacerbates heightened emotional responses and
conflicts across competing coalitions.
The findings here regarding nutrition advocates’ inability to compromise and
their adversarial approach are supported by the nutrition policy literature which
highlights both of these issues (Gilson Sistrom, 2010; Hobbs et al., 2004; Webster,
Dunford, Kennington, Neal, & Chapman, 2014). This behaviour resulted in some
nutrition advocates being excluded from the policymaking process (Gilson Sistrom,
2010; Webster et al., 2014). Sabatier explains the devil-shift tendency is amplified
the longer opponents are in the non-dominant coalition, resulting in the belief that
anyone disagreeing with them must be “mistaken about the facts, operating from the
wrong value premises, or acting from evil motives” (Sabatier, Hunter, &
McLaughlin, 1987, p. 452). This method of operating, which often comes from a
place of passion, unfortunately can cloud judgement and decrease credibility, thereby
decreasing the effectiveness of advocacy efforts.
The third and final negative feedback mechanism is where policymakers make
only marginal changes in existing policy because of their limited ability to foresee
the consequences of their changes, due to the surrounding complexity and
uncertainty. For food and nutrition, this issue is particularly salient, due to the
complex, multifaceted nature of the problem and solutions. Furthermore, the food
industry takes advantage of this complex nature by continually challenging the
evidence for public health nutrition action, further increasing the complexity and
uncertainty around the issue. Other aspects of this issue have been discussed within
the previous section, regarding the ability of the interest groups to organise
opposition.
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6.7.3 Democratisation of knowledge and the amplification of the ‘expert’
A new factor that emerged from the findings as a barrier to nutrition policy
action is the ‘democratisation of knowledge’. This concept acknowledges that in the
current digital age, access to the same information and evidence has increased and
therefore more people can become an ‘expert’. This is particularly relevant to food
and nutrition, as most people has a vested interest in food, because everyone eats.
This sentiment can result in some members of society feeling that they are, or have
the right to be, an expert in nutrition.
The emergence of the ‘democratisation of knowledge’ is part of a broader shift
in society towards greater citizen scepticism about science; this corresponds with the
image of ‘experts’ as problem-solvers becoming more blemished (Armitage et al.,
2015; Kienhues, Stadtler, & Bromme, 2011). This is particularly evident in nutrition
where some ‘experts’ and professional associations have been associated with food
industry organisations that the public and often other nutrition professionals deem to
be diametrically opposed to health (Dixon, Sindall, & Banwell, 2004; Simon, 2015).
Consequently, the nutrition experts’ reputation and the profession as a whole
becomes tarnished (Dixon et al., 2004; Gornall, 2015). Corresponding with this is the
ever increasing amount of information, including scientific evidence, available online
which allows individuals to assess and make their own decisions regarding nutrition
related issues, often based on their beliefs, negating the need for formally qualified
‘nutrition experts’ (Kienhues et al., 2011).
In addition, the ‘democratisation of knowledge’ has been recognised and even
promoted by some health systems; for instance, the Department of Health in the
United Kingdom has suggested that the increased availability of health information
via the internet will lead to more informed patients who are better able to assess the
risks and benefits of different treatments for themselves (Department of Health,
2001). It has been suggested that the availability of health and nutrition information
online has served to usurp the monopolies of health professionals over their
knowledge base (Horrocks & Johnson, 2014). While this usurping may have been
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identified at the individual level, no studies to date have been undertaken looking at
the influence of social media on nutrition policy. However, studies examining
independent political blogs have observed that citizens have more influence and
power in setting new agendas, although this influence lags behind the power of
traditional media (Meraz, 2009).
Adding to the ‘democratisation of knowledge’ trend and the subsequent
amplification of the ‘expert,’ some participants identified a form of professional
arrogance coming from nutrition professionals. This arrogance was perceived as
nutrition professionals and organisations protecting their profession, possibly due to
limited funding and a desire for self-preservation, rather than working towards the
common good for the population. Furthermore, it may reveal a limited understanding
of the new possibilities that may accompany the democratisation of knowledge. We
are moving into an era where knowledge is no longer determined authoritatively, but
rather, it is negotiated collaboratively and democratically (Carolan, 2008). Therefore,
shared understanding of problems and solutions is essential for dealing with complex
issues such as nutrition-related disease. Ensuring that the public is brought along and
consulted during this process results in a win-win for those trying to influence
nutrition policy change, as well as for the general public. Indeed ensuring a shared
understanding of problems and solutions can result not only in increased public will,
but potentially in increased political will for the problem and solution.
Academics
With the democratisation of knowledge comes a cacophony of noise. Ensuring
a credible voice is heard over this noise is a role that some participants felt public
health nutrition academics should be filling. However, the public health academic
participants explained that the academic system in Australia was not set up to reward
or encourage advocacy. It has been suggested internationally that academics,
particularly in science based fields, fear a blurring of boundaries between advocacy
and science and accordingly are wary of advocating, for fear of being misrepresented
in the media, or being labelled “attention seekers” (Shonkoff & Bales, 2011).
Chapman (2001) claims that efforts by scientists to promote their research findings
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widely can rightly or wrongly undermine their credibility. Furthermore, with the
current financially restrictive climate, Smith (2010) believes researchers are very
aware of the damage that speaking out about political issues or undertaking overly
political research can have on perceptions of their objectivity and the ability to attract
future funding. This can result in a deliberate watering-down of ideas and
recommendations to please funders (Farrer, Marinetti, Cavaco, & Costongs, 2015).
However with the democratisation of knowledge, the void that is left by academics
not filling this space will be filled by other ‘experts’.
Summary
The three policy process theories provide advocates with insight into the
barriers to influencing public policy. These barriers have not been explored before
across the general Australian nutrition policymaking context with such a wide range
of policy actors. While the barriers identified in this study align with the policy
process theories, a further step in this study is the identification of how these
mechanisms apply specifically for nutrition policy. This has confirmed that evidence
alone is not enough to influence nutrition policy change. The values and beliefs of
decision-makers and the general public are crucial, as is the neoliberal environment
within which the government operates, and which supports the powerful role the
food industry has in Australia. Furthermore, competing for the attention of decision-
makers is very difficult, particularly when you are communicating a complex,
multifaceted issue. Finally, a new mechanism, the democratisation of knowledge has
been identified. This acknowledges the rise of general and scientific information
available to all, corresponding with the rise in citizens’ scepticism about nutrition
experts. To address these barriers, advocates will need to acknowledge and work
within the constraints of the neoliberal ideology and the belief systems that
policymakers and the general public hold. There is also the need to ensure a unified
approach with a clear problem and solution. Finally, there is the need to
communicate openly and engage with the public throughout the process.
224
225
Enablers for increasing Chapter 7:
nutrition policy action in
Australia
The systematic literature review of nutrition policy change in high-income
countries in Chapter 4 identified several enablers for influencing political and public
will and ultimately policy action. These included: framing problems based on values
and emotion; effectively coupling problems with well-considered solutions; and
working with coalitions of stakeholders to communicate politically palatable
solutions both to decision-makers and to the general public. This chapter presents the
results of in-depth interviews with key influencers and decision-makers in nutrition
policy in Australia, in order to ascertain the enablers of public health nutrition policy
action in Australia. As stated in the barriers chapter (Chapter 6), the findings will be
analysed through the lens of three political science policy process theories. By using
three theories, different elements can be explored, and the possibility of whether any
or all of these theories are applicable to the Australian nutrition policymaking
context can be determined.
Three overarching categories were identified when analysing the in-depth
interviews. Although coded and analysed separately, these categories contrasted with
the suggested barriers to public health nutrition policy action identified in the
previous chapter. The overarching enablers for increasing nutrition policy action
included:
Issue and/or organisation top-of-mind;
Credibility;
Understand the policymaking process.
As with the barriers to policy change, these categories were related to each
other and there were numerous intersecting themes demonstrating the complexity of
Chapter 7: 226
influencing policy change at a federal level. However, the theme of invest in
relationships was one standout enabler and a key strategy that intersected with all the
categories and almost all other themes.
The enablers were conceptualised into a diagram (see Figure 7.1) which
illustrates the complexity and the inter-related nature of the enablers to policy
change. The development of the diagram involved mapping how the different
enablers interacted with one another to ultimately influence policy change.
Numerous iterations of the diagram were undertaken, with each version allowing
further synthesis. Figure 7.2 summarises and distils the key elements to these
enablers of nutrition policy change in Australia. This figure was subsequently sent to
a graphic designer to represent the results in a clearer and more stylised way. The
resulting representation can be seen in Figure 7.3. Further to this, the characteristics
of influential individuals were also explored with interview participants. While some
of these findings aligned with the identified themes, others did not, and will be
presented in this chapter, as they provide further practical guidance for advocates.
227
Your nametop-of mind
appeal to beliefs
cultivate a media
profile
invest in
relationships
able to create
noise
communication
skills
personal stories
use of framing
personal interest of
politicians
organisation brand
publish work &
acheivments
understand what will
attract the media
continuous
engagement
understand competing
points of view
engage both ministers
& bureacrats
relationships with
journalists
build/mobilise
coalitions
be bold
sophisticated media
strategy
persuasive pitch
succinct
accessible
create an
opportunity
engage with the
'other side'
appeal to ego
engage a range of
politicians
engage opposition
bi-partisan support
develop relationships at
different entry points
support of
unexpected voices
Credibility
high profile
organisation represent many
voices trust
respect
expert
transparentprove you can
deliver
prove your commitment
to the issue
don't criticise people
personally
industry as experts
researchers as
experts
strong evidence
base
Understand thepolicymaking
process
provide an
attractive solution
be alert for policy
window
consider
different venue
play the long
game
engage a champion
academic
champion
politician champion
Snr bureaucrat
champion
NGO Champion
high profile
champion
be prepared
listen
timing
State govts in
position of influence
change of govt
changes priorities
election promises
vote winner
political points
intellegence
gatheringknow who is resp for
your prob/soln
understand what the
govt wantsidentify key points
of leverage
clear problem
identification
align with govt
policy
be realisticmakes sense
tangible outcome
win-win
unity in message
multiple solutions
consider policy
implications
desire for outcome
pick your battles
identify rising stars
patience
persistance
incremental change
increase public
will
Figure 7.1: Enablers to nutrition
policy change
Chapter 7: 228
Your nametop-of mind
appeal to beliefs
invest in
relationships
able to create
noise
able to attract the
media
understand competing
points of view
build/mobilise
coalitionscreate an
opportunity
Credibility
represent many
voices
trustrespect
expert
Understand thepolicymaking
process
provide an
attractive solution
be alert for policy
windowconsider
different venue
play the long
game
engage a championchange of govt
changes priorities
intelligence
gathering
identify rising stars
persistance
increase public
will
Figure 7.2 Summary of enablers
for nutrition policy change
229
Figure 7.3: Representation of the enablers for nutrition policy change.
Chapter 7: 230
7.1 INVEST IN RELATIONSHIPS
The theme ‘invest in relationships’ is a foundational theme which underpins all
three categories and intersects with most other themes and sub-themes. This theme
was identified by the majority of participants to ensure their ‘name/issue was top-of-
mind,’ to ensure ‘credibility’ and to help them ‘understand the policymaking
process.’ Consequently while ‘invest in relationships’ is not a category, its
importance warrants further elucidation. Respondents suggested that it was important
to invest in relationships, not only with current decision-makers, but also with a
range of politicians (back-benchers, opposition, cross-benchers), bureaucrats,
journalists, those on the opposing side to your argument or with differing agendas,
the general public, and other advocates. By investing in a wide range of relationships
advocates can transcend political terms, build bi-partisan support, as well as develop
coalitions and gather intelligence.
Look at the end of the day it comes down to relationships and the ability to get
on with people and develop relations and a level of understanding. If there’s no
meeting of minds, there’s never going to be any meeting of hearts.
Food Industry 10
Particular emphasis was placed on developing authentic relationships with
decision-makers, which was defined as being a relationship characterised by at least
semi-regular contact, accompanied by a level of trust and transparency. Establishing
this level of relationship puts an advocate and their organisation at a distinct
advantage through increased levels of trust. This could result in increased attention
for a proposal and possibly greater support. It could also result in decision-makers
elevating the status of an advocate or their organisation so that they were ‘top-of-
mind’ if there was a particular problem requiring a solution. This privileged position
allows actors to influence the policy agenda.
The organisations that are influential to me are the organisations that get in
touch with me… I know who they are, I trust them, the information they have,
231
you have that constant relationship…so you think of them at the top of the pile,
as xxx was saying before, credibility, you know.
Federal Politician
7.1.1 Intelligence gathering
Intelligence gathering was a key reward of investing in relationships. Several
participants highlighted the importance of investing in relationships with opponents
to your argument in order to determine the key points from the opposition. Gathering
intelligence can provide a deeper understanding of competing points of view, which
enables advocates to develop convincing counter arguments before meeting with
policymakers.
The other thing I have always tried to do is engage with as many stakeholders
as I can. I try to make sure that we can understand everybody else's position
and then also at the same time communicate what our position is and our
constraints and our own issues.
Food Industry 5
Some of your best sources of intel will come from the food industry…
NGO General Health 1
7.1.2 Develop relationships at different levels
It was noted by participants that advocates do not necessarily need to develop a
direct relationship with the Minister to be effective in influencing policymaking.
Broadening the number of people you engage with at different levels of the
policymaking process can also increase your influence. Participants highlighted the
importance of engaging with bureaucrats, who were often required to make a
successful case for policy change.
Chapter 7: 232
In terms of political will, there are interacting sets of people. One is the
politicians themselves, so the minister really does matter in areas like this, and
whether there is sympathy there and whether there is an obvious willingness to
back the strategy. And the other thing that matters is actually the bureaucrats
or somebody high enough in the bureaucracy to actually give it some weight.
So from a former policy and implementation point of view those are the two key
players.
Federal Bureaucrat 4
I think it’s about developing that relationship but also, but developing a
relationship at different entry points in the organisation. Don’t just think - go
to the minister. Look at, you know, look through the strata, through the
hierarchy in the organisation and have appropriate people targeting those
individuals within government.
Food Industry 1
The people that are sort of senior middle managers in the (state) department
are the people that are responsible for briefing, responsible for generating
ideas that are often the go-to people. When the powerbrokers have got an issue
the buck stops with them in the department. They’re the people I think are very,
very influential.
Public Health Academic 2
However, a few participants, particularly from the food industry, felt that
engaging with bureaucrats was not a good use of time as they believed bureaucrats
had limited influence in progressing agendas. There was a strong sense from these
participants that working directly with the Minister’s office, and in particular the
Ministerial Advisors gave the best result.
233
This government unlike the previous Labor government does not listen to the
department and they see the department as enemies, so there is no point in
going through the departments.
Food Industry 8
Develop good relationships with the advisors because it’s really hard to speak
to the minister. Just don’t, don’t underestimate the advisors, they are valuable
and important and those relationships can be really good.
Food Industry 4
7.1.3 Continuous engagement
For a relationship to be meaningful, a level of trust needs to be established.
This often requires time and a continual process of engagement. Meeting with a
decision-maker or influencer once only was not considered enough to establish a
relationship of trust. However, there was no consensus from respondents as to how
frequent this engagement should be.
You have to go see them a lot. It is not just one visit, you have to be in there all
the time to get some airspace because they’ve got every other bastard trying to
get their time as well…..If you’re trying to make a difference, you’d need to be
in there every month. Really? Yeah, you’re building a relationship.
Food Industry 8
I would say maybe a couple of times a year, not very frequently.
Food Industry 4
The politicians who were interviewed said they encouraged advocates to make
frequent contact, as they were often looking for new ideas and for attractive solutions
to problems. However, they emphasised it was important to ensure it was a continual
and authentic relationship.
Chapter 7: 234
I think that if you work in this space, most people are really genuinely
interested in hearing new ideas. I have people all the time that will say to me
‘oh this has happened, I’m just flicking you this link, have a look at it’.
Federal Politician
I’ve had drug company lobbyists come and see me in Canberra about various
things, one particular thing was about intellectual property and I couldn’t even
remember who they were. They were just ticking a box that said we’ve seen 20
politicians this week. That’s not a relationship, that’s boring. I don’t think I
ever had a follow-up about that issue.
Federal Politician
7.1.4 Friendships
Another very important component of relationships and influence was the
power of friendships. Friendship is recognised as a reciprocal relationship that entails
caring about each other, for the sake of the other, not for what can be gained from the
relationship (Cocking & Kennett, 1998). Participants explained that friendship was
different to work relationships, as there was a deeper degree of trust already
established between two parties, and therefore a willingness to give their idea/issue
attention.
And friendship is the most powerful thing out. You know, if someone's mates
with someone, then that can be quite influential. Power, and power
relationships.
Federal Bureaucrat 3
A lot of my knowledge of these people is centred in very long term say 20 years
of friendships, because they’re interested in the things I’m interested in and
they’re often my friends as well as colleagues.
Public Health Academic 2
235
7.1.5 Build/mobilise coalitions
A final ‘invest in relationships’ strategy used by non-government organisations
in positions of low power, was to build or mobilise a coalition. An advocacy
coalition “contains people from a variety of positions who share a particular belief
system and who show a non-trivial degree of coordinated activity over time”
(Jenkins-Smith & Sabatier, 1993, p. 139). Building and/or mobilising coalitions was
acknowledged as a useful and frequently used strategy by many participants,
including decision-makers.
The more <organisations> you can collect together and say I want this, the
stronger the message to the government I think.
Federal Bureaucrat 1
So you look for who else has an interest or what other organisations have an
interest in health policies or any individuals who have an interest in this space
and how do I align with them and how do we go as a bigger force and how do
we present a better solution instead of going with the problem.
Food Industry 4
Establishing wide coalitions of support was seen as an effective strategy that
may pique the interest of government. This requires engaging with and agreeing on a
common position with those on the opposing side to your argument; for example, the
food industry, or uncommon partners of nutrition such as the Australian Farmers’
Federation.
If someone is advocating a particular position it won’t come as a great
surprise to government that they are advocating that position. So if you want
less sugar in food of course there are some obvious groups that are going to be
out there advocating that position. What government is then going to do is they
look around and say ‘where are the unexpected voices?’ So in other words
‘where is the person I wouldn’t automatically assume holds that position but
nonetheless is advocating for it and has a good reason why they are arguing
for that position?’ So that’s where I say those coalitions can actually end up
Chapter 7: 236
becoming very important. So rather than trying to fight on the extremes,
anytime you can reach across the aisle and find people on the flipside of the
debate to you but nonetheless have got some sympathy for the opposition and
you’re both prepared to find a middle ground, government loves those
positions, for obvious reasons, because it’s not really in the business of
conflict.
Lobbyist
Coalitions were also identified as helpful for those smaller organisations who
may not be able to have direct access to decision-makers. Identifying and then
aligning with organisations who do have access to decision-makers can increase the
voice of smaller organisations.
We’re constantly wandering around the corridors of parliament house, we're
meeting with bureaucrats, we have alliances with other people who have
profiles, and sometimes that’s also a good way in building your profile, align
with somebody who has a really high level profile and ride on their coat tails.
NGO Nutrition 3
While many food industry participants suggested that public health nutrition
advocates should team up with other like-minded people and organisations, several
food industry participants outlined the pitfalls of this approach.
When I first took over the role at the xxxx, we weren’t having a seat at the
table. We had other organisations, much larger organisations that were really
controlling from an industry point of view who had the seats at the table. And
so we spent a fair amount of time letting key stakeholders know that if they are
wanting xxx ideas and insights and information, they need to be coming to the
peak body that represents xxxx. So, we’ve spent a fair amount of time
promulgating our credentials and ensuring that when issues regarding xxxx
are being discussed…..then they need to be listening to the pre-eminent
representative board that represents that industry.
Food Industry 3
237
Industry associations have large membership bases and members don’t always
agree on things; often the most common position for an industry association to
take is going to be the one that is the lowest common denominator one, so
what’s the position that we all will agree on, what’s the position that is least
repugnant to the least number of members <Oh, it always seems very united
from xxxxx?> No, the industry association is never united. Never ever there
has been a time when the industry association has been united. Never.
Food Industry 4
7.2 ISSUE AND/OR ORGANISATION TOP-OF-MIND
As mentioned in the previous chapter, one of the barriers to policy change is
that policymakers, and in particular politicians, are often overwhelmed with constant
requests from constituents, vested interests and other colleagues to prioritise certain
problems and solutions. To effectively compete against the constant demands for the
attention of policymakers, participants noted it was essential for advocates to ensure
their issue and/or name (either of an individual or an organisation) was ‘top-of-mind’
or foremost in the minds of policymakers and often of the general public as well. The
following themes encapsulate what participants reported to be the most effective
strategies to ensure their issue and/or organisation was top-of-mind, including:
Investing in relationships;
Ability to create noise;
Appealing to beliefs.
The importance of investing in relationships for ensuring your issue and
organisation is top-of-mind was discussed in the previous section. This section will
focus on the remaining two themes: ability to create noise and appealing to beliefs.
Chapter 7: 238
7.2.1 Able to create noise
To be effective, advocates must first have their issue acknowledged by
policymakers as a problem worthy of attention. ‘Creating noise’ is one way to have
your issue acknowledged. The concept of ‘creating noise’ encapsulates an advocate’s
ability to disrupt the status quo and draw attention to an issue within the government
or external to government, or both. This often requires excellent communication
skills and will usually involve garnering media attention to the issue and/or
mobilising the general public to take up the cause.
Having worked with ministers, in ministers’ offices, you know that people who
make things difficult for you A) annoy you but B) you’re actually more likely to
look at ways of how can we actually shut this mob up. So this is ‘squeaky wheel
syndrome’ and people who complain often enough and loud enough will either
be shunned and vilified, or occasionally if they do it in a reasonably nice way,
you know, they actually might get attention.
NGO General Health 6
The most commonly identified method of creating noise was to use the media.
This strategy required high level communication skills and was used by all nutrition
professionals, NGOs and food industry participants interviewed.
We’re very aware that the politicians read the newspapers, so if we want them
to understand our position, of course, we also talk to politicians directly, and
their advisors, and we do talk to bureaucrats on specific issues. But certainly
working through the media is one way of attracting the politicians’ and other
people’s attention to particular issues.
Food Industry 2
You often hear people say you can never trust them. I think you need to do a
cost-benefit analysis and I think, having dealt with the media for 25 years, in a
cost-benefit analysis I think the costs are around 2-3% and the benefits are
around 70-80%.
NGO General Health 4
239
Decision-makers and advisors also agreed that using the media was an
effective strategy to attract attention to an issue and possibly to initiate action.
Yeah, it’s always a positive strategy because at the end of the day, politicians
are accountable to their constituency. They’re the people who vote them in and
vote them out, if it sort of becomes…if the media is drawing attention to them,
if it’s an issue that the public is interested in and they have to focus on, then, of
course, it’s important, but it can be difficult to get the media interested.
Political Advisor 2
Taking the time to invest in an individual and/or organisational media profile
and developing relationships with journalists to increase the profile of an issue or
organisation was seen as a worthwhile investment to increase influence. This was
considered a particularly valuable strategy for smaller organisations. Some of the
respondents who worked for small organisations explained they had worked hard to
develop a significant media profile, which they felt gave them the credibility and
influence of a larger, better resourced organisation.
You’ve got to invest a lot of time in meeting people and raising the profile.
There is absolutely no doubt, you can be the best organisation in the world but
people have got to know who you are.
NGO Nutrition 3
While the majority of participants agreed that using the media was an effective
strategy, almost all cautioned that the media can be fickle and that advocates should
proceed with caution when using this strategy. Several participants advised that
going to the media should be a strategy of last resort and that using the media in a
negative way that criticises politicians was seen as a strategy that could result in
repercussions.
Yeah it can backfire, pretty heavily. There’ll be some issues where people
might be interested in doing something. But then a public story comes out one
way and you can’t be seen to cave into it without looking weak.
Federal Politician
Chapter 7: 240
No, I don’t play that game <using the media> because governments can
basically just kibosh you in 5 seconds, they can outlast you.
Federal Bureaucrat 2
Advocates wanting their issue to be in the media, and actually making that
happen were seen as two separate matters. Participants suggested that to increase the
likelihood that the media will take up an issue, advocates needed to ensure they had
invested in relationships with journalists and demonstrated they were accessible, but
most importantly, that they understood how they could turn their important issue into
a story the media would be interested in.
You have to know what kinds of stories they run in their publication. What I
think is an important issue, is not the same thing as what a story is, and what
can I do to translate something from important issue status to story status, and
once you start doing that and start seeing things from the journalists
perspective, it’s much easier to start establishing those relationships and
giving them ideas and direction to go in.
Journalist 2
You have to be prepared to do whatever the media want, get up at 6am in the
morning, do calls at 10pm at night, be hammered by some talkback shock jock
when they talk about tax and then play Nazi music. But you have to put a smile
on your face and do the interview.
NGO Nutrition 2
A final component of creating noise was a requirement to ‘be bold.’ This
required individuals to take risks and create opportunities rather than waiting for
them. This was mentioned by advocates in general health and nutrition as well as the
food industry.
241
We’re not afraid to speak our mind, xxx used to be afraid of its own shadow. I
am not afraid of my own shadow and xxx now is a courageous organisation.
We are prepared to say ‘no sorry, this is what we think and we’re not
apologising.’ We used to be worried about upsetting people, I actually don’t
care if we upset people who need to be upset – it just needs to be done.
NGO Nutrition 3
This is something that I try to tell the young people who come to the
organisation, that if you work for an association like ours, you’ve got to have a
really low indignation threshold. You got to be able to say to yourself and your
colleagues and to other people that you know, but that is not right. What they
are saying is wrong, it’s incorrect, it’s factual, you know, and it actually
doesn’t stand up, it’s a false argument, it’s a vested interest argument, and we
can’t have them imposing their will on our industry and the people we
represent, based on those forces. If you don’t have that low indignation
threshold, then I don’t think you’d be a good advocate for the industry.
Food Industry 2
However, it was noted that it can be hard for people, particularly younger
health professionals, to be bold and speak up because of the consequences they may
face.
I think all of us don’t want to speak up, but I’ve been inspired by a lot of other
people just to speak up. I also think when you’re older and have worked for a
long time you’re less worried about consequences. I feel sorry for young
people now that have particularly strong opinions that are inconsistent, that
they want to change the status quo but they’re too concerned about speaking
up.
Public Health Academic 2
Chapter 7: 242
7.2.2 Appealing to beliefs
A final theme for ensuring your name was top-of-mind was to appeal to beliefs
when communicating to the media, to the general public or in interpersonal
relationships. ‘Beliefs’ refers to a wide-ranging set of reactions to issues from
participants, which relate back to the personal and collective beliefs that shape values
and attitudes and drive decision-making processes. This can be achieved by the use
of framing, the use of personal stories, and targeting the personal interests of
politicians.
Framing
While framing how an issue is portrayed and categorised was not an overt
strategy nominated by participants, it underpinned many of the suggested strategies
of engagement. An ability to frame an argument was specified by one participant;
however, many others were using the concept but did not explicitly acknowledge it.
An ability to frame that, you know, within a broader policy context, in terms of
what the Government’s broad policies are, that’s going to make a big
difference. I think that’s a very important factor.
Federal Bureaucrat 5
It’s deliberately opportunistic that we pick on the marketing of junk food for
children, because if you just talk about the marketing of junk food, we're not going to
get the same kind of results.
NGO General Health 4
The concept of reframing the problem and/or solution was also identified as an
important enabler. This ability was particularly important when receiving feedback
from decision-makers or if your proposal/solution gets knocked-back.
They’re constantly bashing down the door and saying ‘regulate, regulate,
regulate…tax, tax, tax’ and government say ‘no, no, no’ and they keep banging
243
on the door. We’ll you’ve found the formula to failure … and I think that that’s
where the labelling arrangement worked, because effectively you had a review
that was undertaken, that got a group of experts together, that made some
recommendations to government, government considered those at the same
time as we were getting lobbied left, right and centre from all groups, but it
wasn’t radical, you took a considered approach that identified a problem, that
said ‘people need an easier, more interpretive way to make a decision.’
Federal Bureaucrat 2
Personal stories
Several participants highlighted that personal stories and anecdotes resonate
with people’s beliefs more than using evidence. In particular, advocates and
decision-makers explained that using personal stories often got more traction with
the general public, policymakers and the media than using facts and figures.
I think one of the reasons why I have been influential is that I am not into sort
of blathering on about a whole lot of figures and everything. I’ve actually
learned to really speak concisely and paint pictures; people like pictures and
I’ve learned to paint pictures. People like stories and I am good at doing that
and I think that’s actually helped.
NGO Nutrition 3
For the media you need to personalise it so that people understand this could
happen to me so I want to do something about this.
Federal Bureaucrat 1
Personal interest or experience
Appealing to the personal interests or the previous experience of decision-
makers was a strategy that some of the participants identified and had used
successfully in the past. Politicians also agreed that having a personal interest in an
issue was the key to getting a member of parliament to take your issue on and
potentially champion it within Government.
Chapter 7: 244
So kilojoule labelling in fast food outlets was first announced by the Victorian
Government and it was Steve Bracks who went to New York and he saw it and
thought ‘I’m going to do that’ and he came back to Australia and said ‘I’m
going to do it’.
NGO Nutrition 2
The best way to get in.…to have an impact on that process is to get in the ear
of someone who actually cares about what you’re talking about and get them
to be a champion of your issue. Because we’ve got 54 or 55 caucus members…
one of them is going to be interested in your issue and have time for it, but the
other 54 are going to be working on something completely uninteresting to
you.
Federal Politician
One of the things that I put in my maiden speech is that part about childhood
obesity and things like that, because that is very important to me, so I’m very
open to looking at anything that they give to me, you know.
Senator
7.3 CREDIBILITY
Being seen as a credible organisation or individual was a strong theme
throughout all the interviews, similarly lack of credibility was identified and
discussed as a key barrier to policy action in Chapter 6. Participants identified that
credibility could be gained in a number of ways, including: representing many
voices; being a high profile organisation; being trustworthy; having the respect of
peers and policymakers; and being an expert. Investing in relationships again
underpins this category, as in many cases, it gives advocates the means to prove
credibility.
245
7.3.1 Representing many voices
When an individual or an organisation not only spoke on their own behalf but
represented many others, they were seen as a credible force. Participants explained
that this was because they either did represent or were perceived to represent a
consensus of many constituents. In an effort to be perceived as an organisation that
represented many voices, several participants also described how hard they had
worked to make sure their organisation carried the illusion of importance and broad
representation among policymakers and the general public.
Obviously, some groups come with a certain level of status from the outset and
they carry influence by virtue of their membership and the influence they can
have on debate just because they are a major spokesperson, so whether that’s
the Public Health Association, the AMA, the National Farmers Federation, the
Food and Grocery Council. You’ve got some big players who are already in
that space. And they are considered member organisations that represent the
views of their board which are constituted by their member organisations.
Political Advisor 2
Well they have a broad membership, they have credibility, the really big ones
in that area as I said like the Heart Foundation, Diabetes Australia, Kidney
Health Australia, they have a big membership and often it’s easy for them to
get in to see the minister.
Federal Bureaucrat 1
7.3.2 Trust
Trust was mentioned by most participants as an important aspect of credibility.
Demonstrating that you ‘can deliver,’ keep people’s confidences, and act in good
faith were all aspects of this sub-theme. It was also identified as a prerequisite to
building effective relationships. Some of the most important aspects of trust in a
relationship were that individuals be seen as dependable and transparent, with a high
level of integrity.
Chapter 7: 246
There will be people who've been involved, who I know can deliver, for
whatever reason I've been involved with them or....where I know that they're
actually delivering something that is having a benefit. So that will often
be...someone that you feel has credibility.
Federal Bureaucrat 3
I think there needs to be an assumption of acting in good faith and being open
and honest and, as far as practicable, transparent in the dealings with what
might be negotiated.
Food Industry 3
If you’ve built up a relationship over time that gives you influence too, they
know that they can talk to you in an open way without the conversation being
splashed across the newspapers the next day. So, that trust is important, it’s
relationships. If you can build a relationship with a politician over time, they
will come to know you, trust you, understand that you’re a credible source of
advice. And sometimes, they’ll ring you up and say, listen, we’ve got an issue
here, could you pop in and talk to us about it. That’s when you know that
you’ve got a very good relationship with the Minister or Minister’s office or a
department or public servant.
NGO General Health 6
However, it was identified by some participants that developing trust can be
difficult as it requires a considerable outlay of time and often requires investing in
personal relationships. Participants from the food industry also warned that if you
abused the trust of a policymaker, it was very hard to have any influence at all.
The problem is with the Australian Department of Health is you need to have a
relationship of trust with these people because you’re working in an
environment where there is a lot of confidentiality considerations for people to
engage with others. So we need to have a personal relationship usually with
these people that is established over a long period of time, so they know we
247
won’t betray what they’re doing or thinking. You have to have a very ethical
and moral relationship with those people, it’s hard to do that within the federal
government.
Public Health Academic 2
Because if you…. if you're not trusted and then, you know, it's gone. That's all
I’ve got to say. It's gone. You won't get to square one.
Food Industry 1
If you sell…or try to convince a politician about something that turns out to
just be wrong, you’re not going to be trusted, and you’re not going to have any
credibility and so you won’t be influential.
Food Industry 7
7.3.3 Respect
Participants nominated respect as a key component of credibility. This was
often reflected as holding someone or an organisation in high regard as a result of
their abilities, qualities or achievements. Researchers were often mentioned as
meeting these requirements.
The people I think of as influential…I think that they are influential because
they're respected, they’ve done a lot of research. They have a sort of evidence
behind the ideas that they have and the things that they're promoting.
Journalist 2
If you’re the head of department in a large food company they probably think
you have some sort of track record and probably reflect some body of opinion
that’s legitimate.
Food Industry 10
Chapter 7: 248
More practically, those who were respected in the policy process were seen as
being calm, or the ‘voice of reason.’ Furthermore, not criticising others personally
was an important part of ensuring an advocate maintained respect. Important
guidance was provided by participants about encouraging positive, respectful
relationships with the individuals involved in the policymaking process. To ensure an
advocate or an organisation is held in high regard it was broadly recommended by all
participants not to personally criticise individuals, particularly decision-makers, as
negative consequences could arise from that strategy. Instead, participants advised,
criticise the facts and look for any opportunities to celebrate progress, no matter how
small.
Look, everyone likes to know if they’ve done a good job and it’s really
important to celebrate gains, be really grateful, not being nasty and sarcastic
and rude about things, that doesn’t get you anywhere, that just gets you
blacklisted.
NGO Nutrition 3
I never play the man, I always play the ball. I always let the facts, and have the
facts in mind, just talk for themselves.
Food Industry 2
If you look around those organisations or those people who have been calm,
persistent advocates for their cause but still prepared to acknowledge progress
even if it’s not everything they want, they’re usually the ones who over the long
haul maintain their influence.
Lobbyist
7.3.4 Expertise
Being an expert was raised on numerous occasions by participants, as an
important component of being perceived as credible. However, the term held
different meanings for different people. For public health academics an expert was
someone who was formally qualified and provided information based on peer-
249
reviewed evidence; whereas for policymakers, an expert included the academics’
definition, but also included those with personal experience of a situation, those who
represented the views of constituents and those with ‘real-world’ commercial
experience of how a problem/solution will affect them; for example, a CEO of food
industry.
You get some people with an academic interest in food security as well but you
know, that’s probably not where we're at. We’re at a very practical level.
Federal Bureaucrat 5
I think someone who does not come from government, someone who is not
academic, someone who has come from the commercial world. They’re the
ones who will get traction in Canberra. Why do they get traction? Because
they’re seen as having been out there and done it.
Food Industry 8
7.4 UNDERSTAND THE POLICYMAKING PROCESS
The policymaking process is often complex and dynamic. To identify
opportunities for leverage, an effective advocate needs to understand how the process
works. The themes which underpin understanding the policymaking process include:
Increase/demonstrate public will;
Be alert for policy windows;
Play the long game;
Consider a different policy venue.
7.4.1 Increase/demonstrate public will
Many participants considered it very important to understand whether the
general public will support an issue, and to increase and then demonstrate this level
of support. This corresponds with the findings in the previous chapter on barriers;
that is, a lack of public support or will is a key barrier to policy action. Encompassed
Chapter 7: 250
within this sub-theme is the need to understand whether a policy solution is a vote-
winner; that is, whether a particular policy initiative could secure votes for an
individual or a party.
Some of the things that you learn very quickly in this political game, and I’ve
come from no political background either, is unfortunately, a lot of decisions
are made on how many votes they’ll receive for it.
Senator
It’s trying to get that swell of public opinion, ‘we don’t want that to happen.’
Just saying to the government ‘we don’t like this’…who cares? It’s really, the
important thing is getting public opinion on board.
NGO Nutrition 3
Food industry participants reflected a high level of awareness around the need
for policy solutions to be ‘vote-winners’.
But basically what I call the nod factor. It’s the community saying, “Yeah,
that’s sounding like a pretty reasonable approach, really.”….Governments
have more requirements for money than they have the money to go around. So
they will fund things with evidence, things that have community support.
Things that we could say that there is votes in them. For some things there’s
no votes in them, but generally you can’t blame them for funding things that
have votes in them.
Food Industry 7
I’ve met with lots of health ministers on different aspects of food and they need
to first of all understand that it is an issue for them, a potential voter issue and
then they’ll talk to you.
Food Industry 10
251
Developing a campaign that encourages members of the public to sign an
online petition or email a blanket letter to members of parliament was a key strategy
used by some NGO participants to demonstrate that an idea or solution was a vote-
winner and had the support of the public. However, politicians and advisors were
mixed in how effective these petitions were in influencing change.
The least effective way of getting someone’s attention is sending them an email
that is also sent to 50 other people. I just assume that they’re not for me….I
would get probably 15-20 emails a day from people who just email the entire
caucus or the entire parliament.
Federal Politician
They have no sort of legal force to them, even if they’re tabled in Parliament,
but people do look at them and do go, "okay 26,000 signatures isn’t nothing."
Political Advisor 1
7.4.2 Be alert for policy windows
On many occasions participants described the policymaking process as fluid
and dynamic, and commented that often luck and timing played a role in whether
your policy solution was taken on board or not. However, underpinning this fluidity
was the necessity for an advocate to notice and be ready with their solution when a
policy window does open. Kingdon (1984) describes the opening of a policy window
as a key time for policy change to occur. It occurs when the solution, the problem
and the political will all merge, increasing the political attention to a particular issue.
Sometimes policy is made very quickly for particular reasons, whatever it
might be. Sometimes it goes for a very long term process and other times it
comes about because of an opportunity and people identify a problem, people
see an opportunity to fix it, money becomes available and the government says
‘we want this’ and you go ‘you beauty, I’ve been waiting for that opportunity,
here in my bottom drawer, I’ve got something for you minister’.
Federal Bureaucrat 2
Chapter 7: 252
Being able to identify this policy window often requires a constant process of
intelligence gathering to determine such factors as: who is in a position of influence;
what does the government want; whether political appetite has changed; and whether
there are there opportunities for the solution to help the government or the
opposition.
The first rule is always understand who actually makes the decision – that’s the
first step. On what basis do they make the decision? Who are they genuinely
influenced by and how do you manage those processes?
Lobbyist
I observe the workings of government…and to succeed with anything that
requires government funding you just have to know the system
Food Industry 8
It was seen as essential, when a policy window opens, for advocates to be
ready with a solution-focused approach. This requires advocates not only to go to the
government with a technically-feasible solution, but if unsuccessful, to be ready and
able to negotiate an alternative solution. During the negotiation processes, an
advocate also needs to be nimble and agile, otherwise the policy window may close
by the time the next plan of action is decided.
You have all your stuff ready and you're kind of out the back of the wave and if
you're not there ready when the wave comes, you're not going to be able to get
on it. There are moments in time when the planets align and you can take
forward a policy and if you don't do it by that time the planets are not going to
align again.
Federal Bureaucrat 3
253
I’m reasonably good at working out where the win-win is. You know, trying to
work out what the government needs, and what we need, and what the solution
might be for that.
Food Industry 7
By the time they were in agreement it was too late, it was gone, it was off the
table – outrageous….anyway.
NGO Nutrition 2
7.4.3 Play the long game
Policymaking to achieve policy change is often a slow and complex process.
Participants recommended that, in order to successfully influence policy change,
advocates needed to be patient and persistent and “play the long game” with a very
long-term view (10+ years). This may require advocates to have a vison of the
ultimate long-term goal and the incremental steps required to achieve the goal.
Advocates are then able to acknowledge incremental change as a success and as part
of the influencing process. Another important component of playing the long game is
to invest in relationships with a long term view. Several participants noted that often
relationships needed to be established before politicians become Ministers and while
they are in opposition. Policies developed in opposition can be critically important,
especially if the party which has developed these then wins government.
Oh yes, it’s too late by the time they’re the Minister for Health, it’s too late.
You’ve got to see them before they become the minister, so when they become
minister they already know you…So when people like Simon Birmingham and Josh
Frydenburg were elected xxx was down there, in their ears constantly. So by the time
they got to be ministers they know who we are, they know what our issues are,
they’ve come to like us, they trust us, they seek us out for advice. Every new
parliament, you know Wyatt Roy, he’s going to be there for forty years! He’s
someone, people are mad if you’re not working with him.
NGO General Health 1
Chapter 7: 254
I think you have to be realistic about that these are incremental changes. You
don’t get this sort of big bang of reform and that it happens automatically. It’s
incremental and it takes time.
Political Advisor 2
7.4.4 Consider a different policy venue
Another strategy identified by participants for policy change was to consider a
different policy venue in which a problem and solution could be advocated. Policy
venues are the ‘institutional locations where authoritative decisions are made
concerning a given issue’ (Baumgartner & Jones, 1993). Consideration of a different
policy venue was recommended when advocates were having limited progress with a
particular government department or section.
The power of the states as an alternate policy venue and their ability to
influence federal policy was mentioned on several occasions by participants. This
power is written into the structure established by the Council of Australian
Governments (COAG) whereby the Australian and state and territory governments
have collective responsibility to promote policy reforms that are of national
significance, or which need co-ordinated action by all Australian governments
(Council of Australian Governments, 2016). Any nationally coordinated nutrition
policy actions, particularly regulatory or legislative changes, require the approval of
all members of COAG. Participants explained that the states were able to utilise this
power to block or promote policy ideas, and were therefore powerful actors in
national nutrition policy. It was also identified that some states had more power than
others in this process, which allowed them to have more influence over the national
agenda for nutrition.
And when that final decision was taken, you know because something like xxx,
it’s a political decision, and the states have to broadly align with the
commonwealth, they’re in a very influential role.
NGO General Health 1
255
Well anyone that sits around the table has a position of influence. But it’s still
a process of pragmatic agreement because you need to reach a consensus,
because those things are consensus based discussions.
State Politician
I would say those in New South Wales and those in Victoria have the biggest
influence on national policy. I mean that’s where the numbers are and the
money is, so that makes sense.
State Public Health Nutritionist
7.5 ADDITIONAL CHARACTERISTICS FOR INFLUENTIAL INDIVIDUALS
During the in-depth interviews, participants were asked what made someone
influential in the policymaking process and also what made them (the participant)
influential. Five key characteristics were identified:
Opportunistic;
Credible;
Able to play the long game;
Able to create noise; and
Having political clout.
Underpinning all of these characteristics was being an experienced actor.
While not an essential trait, respondents stated it was one reason they were so
effective. Being an experienced actor was related to trust, relationships and political
know-how. Having that experience meant that you had a greater knowledge of the
policymaking process, the policymakers and the most effective levers to pull to exert
influence. See Figure 7.3 for a visualisation of how these characteristics work
together to increase the influence of an individual.
Chapter 7: 256
The majority of these factors have been covered previously in this chapter
however the concept of communication skills within the themes ability to create
noise and political clout will be further explored in this section.
Figure 7.4. Personal traits of influential advocates
7.5.1 Communication skills
Although communication skills have been previously discussed in section 7.2
‘issue and/or organisation top-of-mind’, it was noteworthy that all participants who
Personal traits of
influential advocate
Communication
skillsPassionate
Visionary
Credible
Patient
Persistent
Opportunistic
Solution focussed
Political clout
Able to create
noise
Persuasive pitchSuccinct & clear
Listen
Personal stories
CalmTrustworthy
Continuous
engagement
Nimble
Flexible/pragmatic
Negotiator
Collaboration
Understanding
different points of view
Money speaks
volumes
Represent many
different voices
Able to attract
media
Understand what will
attract media
Consider policy
implications
Able to play the
long game
Able to build
relationships
257
were advocates in this study had exceptional communication skills, and enjoyed
answering the interview questions and talking about the policymaking process and
their role in it.
The other thing is, I think I’ve got... I’ve essentially got the gift of the gab. I can
talk, as you probably notice, without taking breath
Food Industry 2
Many also said they enjoyed speaking with the media and getting as much
attention as possible to their issue. To attract the media, it was essential for advocates
to have good communication skills appropriate for this context. This was often
described by participants as being clear and succinct in messaging and having a
persuasive pitch. In addition, the ability to listen was prioritised by several
participants as part of being solution-focused. Listening can provide an advocate
with clues as to whether the policy window is about to open, is open, or can provide
information which can increase political capital. This attribute was espoused as
essential for advocates, particularly by food industry participants.
I can’t underestimate, you listen and you listen and you listen. And you may not
always be able to, you know, accept or acknowledge or agree with the decisions that
are made, but if you have listened to what the issues are and then you get a deep
understanding of that, then working with the people say, ‘well what do you see is the
answer?’
Food Industry 1
From where I sit, part of it is listening really well to hear what’s going
on….the other thing that I think is really important is to not just say ‘no we can’t do
it.’ But to say ‘how about we look at this as an answer instead,’ I think being open to
compromise. That’s the, that’s the really important part of listening.
Food Industry 4
Chapter 7: 258
Another important aspect of being able to create noise was to be personable. It
was stated by participants that it is harder to get people to listen if they did not like
you. Many participants identified this was an important ingredient to their success as
advocates.
I think I am personable
NGO Nutrition 3
I am the type of guy who gets along with people …I’m thoughtful, persistent,
all of those sorts of qualities.
Lobbyist
7.5.2 Having political clout
Participants described three aspects of having political clout: firstly, being
employed in a senior role at, or in charge of, a very large, financially powerful or
high status organisation; secondly, representing many voices; and finally, being able
to attract the media. Having political clout meant that decision-makers were more
likely to listen and to give careful attention to the issue raised.
So the people who get in to see the ministers are either people that are in my
world, agri-political, and carry the weight of a number of producers, or people who
have got political clout in some other way, that is going to either negatively or
positively affect them.
Food Industry 8
I have been watching xxx and following him, he has very carefully cultivated a
media profile … and now all of a sudden he is one of the people mainstream media
rings to speak on health policy; I mean this is a guy that does not believe in climate
science! He is not an evidenced-based person and yet he has become this authority
on health policy through building this media profile!
Journalist 1
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7.6 DISCUSSION
Policy change requires advocates to overcome barriers and leverage enablers.
The previous chapter in this thesis explored the barriers to nutrition policy change in
Australia, this chapter explores the key enablers to nutrition policy change. These
enablers were identified by a wide range of policy actors, all of whom are directly
involved in the nutrition policymaking process in Australia. Understanding these
enablers is fundamental to navigating and influencing nutrition policy change in
Australia. The remainder of this chapter will focus on the most significant results,
which will be discussed in relation to the three policy process theories: Multiple
Streams (MST); Punctuated Equilibrium (PET); and Advocacy Coalition Framework
(ACF); as well as to the nutrition policy literature.
Twenty key enablers were identified from the participant interviews. All of
these enablers were broadly in line with the three policy process theories; however,
this alignment was mostly at the macro and meso level of policy change. The policy
process theories suggest that policy change occurs when there is sufficient external
interest at the macro and meso level to cause the collapse of a policy monopoly
(Cairney, 2012). External attention rises, and the issues are considered in the broader
political environment where new actors can set the agenda. The key mechanisms in
this process are reframing the policy image, and increasing the attention of the
general public and policymakers to this policy image, in an effort to elevate the issue
so that it becomes the policy monopoly. These mechanisms are broadly consistent
with the findings of this study. However, one area that the policy process theories
provide limited detail on is the micro-level aspects of policy change, which specify
what individuals or organisations can do to influence change. This may be why the
policy process theories are rarely used to guide nutrition advocacy work towards
policy change (Cullerton et al., 2016c). For this reason, the discussion will focus on
the key micro-level enablers to nutrition policy change in Australia that were
identified by participants while using the theories of the policy process to guide
analysis.
Chapter 7: 260
The results of this study demonstrate that a complex interplay between each of
the enablers influences the likelihood of nutrition policy action occurring.
Furthermore, the results suggest there is no one enabler that will result in policy
action, and that multiple enablers need to be activated to increase the likelihood of
action through increased political will. This conclusion is consistent with the findings
from the systematic review of the nutrition policy literature outlined in Chapter 4.
The results also demonstrate that in order to increase political will, and thereby
influence policy change, advocates or organisations need to have the following
elements: credibility; their issue or organisation top-of-mind for policymakers; and
an in-depth understanding of the policymaking process. Results from this study
indicate that a minimum of two elements: your name and/or issue top of mind and
credibility, must be in place before political will can be influenced and nutrition
policy change can occur. However, it seems that policy change with only these two
elements is rare. It is more likely, although not guaranteed, if the three elements are
present.
At an individual level, participants in the study identified that the requirement
to invest in relationships underpins the process of policy change. ‘Investing in
relationships’ stands out as a key cross-cutting enabler that advocates should not
ignore and, if possible, should devote resources to. Developing relationships with a
wide range of stakeholders potentially enables an advocate to gather intelligence on
what the government wants and needs, what opposing actors’ arguments are, the
values and beliefs of key decision-makers, and the values and beliefs of the general
public. Establishing these relationships also increases the credibility of the advocate
in the eyes of the decision-makers and the general public. Therefore, a core
component to challenging the policy monopoly is for advocates to continue to
establish and invest in relationships.
7.6.1 Invest in relationships
While investing in relationships is discussed in PET, particularly around
changing policy venues, and in the ACF, specifically in the context of fostering
coordination between those actors who realise they share similar policy beliefs, it is
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only MST that elevates the importance of relationships as one of the key roles of
the policy entrepreneur. Policy entrepreneurs play an important role in ‘softening up’
(Kingdon, 1984) policy communities and the public at large, by communicating their
ideas and building acceptance of them. The results of this study explicate this further
by emphasising the importance of developing meaningful relationships at all levels
of the policymaking process with bureaucrats and politicians, including those in
opposition, as well as with the general public. These relationships can provide
important intelligence on the factors that may lead to the opening of a policy window
(Haynes et al., 2011).
A further benefit to investing in relationships is the intelligence gained around
contextual factors. Most participants highlighted that policymaking requires
flexibility and compromise. By investing in relationships, advocates are better able to
gauge when it is appropriate to push on an issue and when it is better to pull back and
compromise. Moreover, the intelligence gathering process gained from investing in
relationships provides information on individual and organisational contexts, and on
levers of influence that may be useful in the future. However, results from this study
indicate that there often needs to be a certain level of trust established before
particularly unique or insightful intelligence is gathered. Again, this level of detail is
not provided in the policy process theories, although it has been acknowledged in
some of the nutrition policy literature (Freudenberg, Bradley, & Serrano, 2009;
Gilson Sistrom, 2010; Hobbs et al., 2004).
Investing in relationships and gathering intelligence on contextual factors may
lead to opportunities in other policy venues. This is pertinent to nutrition policy as it
cuts across several different departments federally as well as at the state level.
Consequently there are multiple strategic opportunities for establishing relationships
with these different bodies and reframing the issue so it is salient to them.
Developing relationships with individuals within alternative policy venues and
pursuing the agenda with them has not been identified as an important strategy in the
nutrition policy literature. However, Baumgartner and Jones (1993) emphasise the
importance of policy venue shopping as method to progress policy change when
faced with temporary obstacles in one jurisdiction or institutional setting. The policy
Chapter 7: 262
entrepreneur and/or policy champion, discussed in more detail in section 7.6.4, can
play an important role in identifying these alternative policy venues. They can also
alter people’s perspectives on a policy issue by suggesting different ways or new
frames for thinking about the issue. This can result in others adopting a new
definition of the problem and then justifying a different policy solution.
A final benefit to investing in relationships is that it can build public will.
Establishing and building relationships with interest groups, including community
and citizen groups, builds trust as well as support for an issue. Demonstrating that an
issue has wide-ranging support can provide a signal to the government that there is
consensus and support from constituents (Lyn et al., 2013). This demonstration of
support is an important lever for politicians who depend on the support of the public
to remain in office (Kingdon, 1995).
Trust
The requirement for trust in relationships is rarely commented on in policy
literature. While having the respect of policymakers and being seen as an ‘expert’
were both acknowledged as important in elevating credibility, trust was the key
component that study participants universally acknowledged. The concept of trust is
not acknowledged by the policy process theories, as they mostly focus on a system
level of change, although ACF alludes to it when describing the makeup of advocacy
coalitions. Within the nutrition policy literature, it has only been noted by Bedore
(2014, p. 2987), who explains that ‘trust is an important foundation for the
willingness to cooperate among stakeholders’.
Trust is also a critical element in determining what decision-makers and the
general public perceive as ‘truth’ or accept as evidence (Haynes et al., 2012). If an
individual or organisation is believed to be trustworthy, the knowledge that comes
from that individual or organisation is considered to be ‘true’. This heuristic allows
people to accept or reject messages without needing to examine the facts closely, on
the basis of whether they like or dislike the messenger (Eiser, Stafford, Henneberry,
& Catney, 2009). Rather than this being based on scientific credibility, Carolan
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(2006) explains that these social perceptions and everyday evaluations of knowledge
are rooted in concrete, sustained social relationships. This again highlights the
importance of investing in relationships. This sentiment was supported by decision-
makers in this study, who reported that the people they trust are the ones who are in
regular contact with them.
Participants also revealed that the building of trust may require a considerable
outlay of time, and often requires investing in personal relationships. This is
supported by policy scholars (Haynes et al., 2011; Mitton, Adair, McKenzie, Patten,
& Perry, 2007) who explain trust and credibility are grown through repeated
interactions of interest groups and decision-makers and their support staff. The food
industry has a significant advantage in trust-building due to their available resources,
that is, time and money. However, some participants claimed that the time needed to
establish trust may not be as arduous as others have claimed, and does not
necessarily need to occur face-to-face. This sentiment has some support in the policy
literature, where trust between parties can be developed in different ways, such as
participating in advisory groups, presenting at conferences, blogging, and media
engagement (Haynes et al., 2012; Levin, Whitener, & Cross, 2006). In addition,
identifying and actively participating in issues that are on the government agenda can
give an organisation or individual the opportunity to solidify impressions of its value
as an informed, trusted source (Peterson, 2001). Finally, trust increases between a
party and its audience when they both share the same values and the party is
perceived to be representing the interests of the audience (Eiser et al., 2009;
Montpetit, 2011). Clearly then, nutrition professionals can increase their
trustworthiness amongst different audiences by identifying their shared values, using
these to communicate, and avoiding conflicts of interest.
Opponents
This study also found that it is important to develop professional relationships
with opponents for the primary purpose of gathering intelligence. Traditionally,
nutrition policy studies have examined allies and opponents separately (Brownell &
Warner, 2009; Miller & Harkins, 2010); however, this approach fails to recognise
Chapter 7: 264
that both groups are interrelated. By investing in relationships with opponents and
gathering intelligence, this increases the ability of advocates to counter potential
threats. The importance of understanding the opposition has been raised by a number
of scholars previously (Brownell & Warner, 2009; Field & Gauld, 2011; Nestle,
1993; Nestle, 2013). However, this understanding usually occurs from an
observational standpoint, such as observing industry activities reported in the media
(Mialon, Swinburn, & Sacks, 2015), rather than directly interacting with these
individuals/organisations. Greater benefit through the provision of better quality
intelligence would be derived from engaging directly with opponents in a calm,
professional manner.
Walking a fine line between credibility and collaboration
When engaging with unusual allies or an opponent who may have different
core policy beliefs, it is essential to ensure credibility is maintained. The above
discussion on opponents refers to the prospect of engaging with the ‘opposition’ with
the primary aim of gathering intelligence. However, some nutrition advocates may
want to develop the relationship further and formalise a partnership or a coalition
with the food industry. In nutrition, one of the most obvious and common partners
when considering cross-cutting engagement is the manufactured food industry.
Several participants, however, warned that credibility can be damaged if you are
perceived to be working too closely with or receiving money from the food industry.
This assumption is not surprising, as it has been noted that a common tactic used by
the food industry is co-opting leading experts to ensure favourable association and to
diffuse the possibility of the expert writing against the interests of the industry
(Dixon et al., 2004; Nestle, 2013). Consequently, caution needs to be exercised if
seeking to form a coalition or partnership with a food industry body, particularly
when their core business is to increase consumption of their products (Dixon et al.,
2004).
If a coalition or advocate wishes to pursue a formal relationship/partnership
with the food industry, it would need to acknowledge the tension that may be
associated with the partnership, and act in a highly transparent manner to ensure trust
265
and respect is maintained for the coalition/advocate. Dixon et al. (2004) recommends
that any partnerships or coalitions being considered within the nutrition space need to
be evaluated for their impact on the consumption habits and nutritional status of the
population. Tools developed at an international level are currently available to assist
advocates with this process (Kraak & Story, 2010). Furthermore, Kraak et al. (2012,
p. 509) highlight that these tools can be used to answer six challenges
organisations/advocates are faced with when considering a partnership with the food
industry, namely: balancing private commercial interests with public health interests;
managing conflicts of interests and biases; ensuring co-branded activities support
healthy products and healthy eating environments; complying with ethical codes of
conduct; conducting due diligence; and evaluating partnership compatibility and
outcomes.
Additionally, it may be useful for nutrition advocates to think creatively about
partners with different perspectives and move beyond the manufactured food
industry. These partners could range from the National Farmers’ Federation to
consumer groups to the Business Council of Australia. Interestingly, while most
participants agreed coalitions were an effective strategy, food industry participants
and a large, powerful NGO revealed that very few large organisations use coalitions.
So while they are considered an effective strategy for poorly-resourced organisations,
they do not seem necessary for large, powerful organisations.
7.6.2 ‘Irrational’ decision-making
There was overwhelming acknowledgement from most participants in this
study that policymakers were very busy and struggled to keep up with all issues. This
is consistent with the policy process theories’ concept of bounded rationality,
whereby policymakers are unable to cope with the large amount of
information/demands they are faced with and so focus only on a few issues (Sabatier
& Jenkins Smith, 1993). What determines which issues an individual focusses on is
often the result of a cognitive process which relies on rapid, intuitive, affect-driven
sources of information rather than deliberate, conscious analytic ones (Kahan, 2016).
Chapter 7: 266
Framing and reframing
Supporting this mechanism of rapid, intuitive decision-making are heuristics or
‘frames’ which are mental shortcuts used to make processing of stimuli more
efficient. Frames help people make sense of what they see and hear by triggering
concepts that they already have at a conscious and pre-conscious level (Druckman,
2004). Using frames allows individuals to process an issue efficiently and move on
to the next issue.
The most effective frames appeal to common societal values that individuals
can connect with (Dorfman & Wallack, 2007). Using frames that appeal to values
defines the boundaries of a problem and guides the way people create shared
meanings which motivate them to act (Fischer, 2003). While framing was not an
overt strategy acknowledged by most participants, many were in fact using aspects of
it in their work. The use of frames as a method to appeal to values is mixed within
the three policy process theories. For Kingdon (1984, p115), policy issues only
become problems to be acted upon when a solution is reframed and ‘we come to
believe that we should do something about them.’ The use of reframing is also
consistent with the PET which claims that policy change occurs when an issue is
defined differently or when new dimensions of the issue get attention. Reframing can
result in new actors becoming involved and the issue becoming more salient, leading
to more media attention and broader public attention (Baumgartner et al., 2009). If an
issue is suitably framed, the probability of an issue progressing onto the policy
agenda is greatly enhanced. Effective framing of a problem can also advance some
policy solutions while eliminating others (Dorfman & Wallack, 2007; Marx et al.,
2007).
The acknowledgement and study of framing is gaining more prominence in the
nutrition policy literature (Freudenberg et al., 2009; Gollust et al., 2013; Shelley,
2012). For example, previously successful frames identified in the United States of
America and the United Kingdom to build policy support include: protecting the
health of children; truth and honesty; fairness and social justice; and an urgent crisis
or a looming evil (Freudenberg et al., 2009; Hawkes et al., 2015; Kurzer & Cooper,
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2011; Niederdeppe, Shapiro, Kim, Bartolo, & Porticella, 2014; Shelley, 2012).
However, framing has generally been used in a retrospective manner to identify
frames that advocates or opponents have previously used. Although there are several
examples of testing frames with the general public, no prospective studies have been
published that identify effective nutrition frames and then evaluate their application
by advocates to influence policy.
While effective reframing is an extremely important component of influencing
policy change, ensuring the new frame is accepted by the media and the general
public is perhaps the most difficult aspect, and considered by some experts to be a
major political accomplishment (Kingdon, 1995). This difficulty is amplified when
there are other competing definitions of a problem being promulgated. Repetition of
the frame and ensuring it receives as much attention as possible is one strategy to
encourage the acceptance of a new frame (Niederdeppe et al., 2014).
Narratives
It was highlighted in the findings that politicians and bureaucrats are always
seeking information and new ideas to help them answer policy problems or to inform
potential new policy. Consequently, organisations or individuals representing
knowledge-based or high-status institutions should be able to earn automatic
credibility through providing these ideas and information. However, several
participants explained that the government often privileges the practical experience
of business or the personal stories of constituents compared to peer-reviewed
evidence. This sentiment was also supported by the nutrition policy literature (Eyler,
Nguyen, Kong, Yan, & Brownson, 2012; Lyn et al., 2013; Shelley, 2012).
These findings illustrate another important factor in decision-making, which is
that stories from ‘real people’ are very powerful. Stories or narratives are able to
resonate strongly, as humans are cognitively designed to process narratives more
efficiently than they are hard data or statistics (Dawes, 1999). The consensus that
narratives are more powerful than statistics or facts is widely acknowledged in
cognitive science and political communication literature (Kahan, 2016; Marx et al.,
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2007; Niederdeppe et al., 2014), although it has received limited attention in the
three policy process theories.
Just as the most effective framing techniques appeal to values, the
persuasiveness of narratives can be further increased if they also appeal to values.
This technique has been found to be particularly effective when the message is
congruent with the recipient's own values (Slater & Rounder, 1996). Appealing to
values was highlighted in the barriers chapter (Chapter 7) where it was revealed in
the literature and by study participants that individuals discard evidence that does not
resonate with their beliefs and values (Sabatier & Weible, 2007).
Experts as storytellers
It is not only the narrative and the frame which can resonate strongly with
policymakers; the ‘expert’ or ‘storyteller’ is also important. The findings of this
study revealed that ‘experts’ in the policy process were not homogeneous, and the
definition of an ‘expert’ was often contested amongst participants. Some participants
only acknowledged tertiary trained nutrition professionals as experts in the policy
process, while others prioritised those with real-world experience of nutrition issues
or food-business related issues. Support for members of the public being ‘experts’ or
key spokespeople for a nutrition policy issue has been identified in nutrition policy
literature (Jou, Niederdeppe, Barry, & Gollust, 2014; Lyn et al., 2013; Nathan et al.,
2005). This tension around who is an expert is not acknowledged in the policy
process theories. ACF identifies academics as important components in the policy
process, although only in the context of evidence being used as a political tool to
reinforce a message or a policy image. While the policy process theories do
acknowledge the role of the public in terms of public mood, none of the theories
acknowledge members of the public as potential experts. This is an oversight, as
experts with personal experience and stories resonate more than facts and figures,
since they allow a connection with the listener above and beyond what would be
possible if the story were told by a dispassionate observer (Newman, 2003). This
diversification of expertise is a potential enabler for nutrition professionals, in that
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nutrition advocates could engage and partner with individuals with practical, lived
experience to create more persuasive arguments.
7.6.3 Your name/issue top-of-mind
To address the bounded rationality of policymakers, participants recommended
that advocates needed to make a concerted effort to ensure their issue or organisation
was top-of-mind for policymakers (and for those staff that support policymakers) and
the general public. That is, if a nutrition issue is mentioned to a policymaker or the
general public, the organisation or individual they automatically associate with the
issue is said to be ‘top-of-mind’. Themes underpinning this were invest in
relationships, able to create noise and appeal to beliefs. Interestingly, a large
component of these themes revolved around using the media to highlight the issue in
the hope of getting the attention of policymakers and the general public.
A widely acknowledged advocacy strategy is to use the media for drawing
attention to an issue and thereby increase the likelihood of nutrition policy change
(Lyn et al., 2013; Vogel et al., 2010; Webster et al., 2014). Previous studies have
shown that those organisations who engage with the media were more likely to
achieve policy change more frequently (Dodson et al., 2009; Lyn et al., 2013).
Successful strategies include leveraging media coverage off national and
international stories (Bedore, 2014), and using high profile organisations or
individuals to attract media attention (Kersh & Morone, 2002; Kurzer & Cooper,
2011). While PET acknowledges the significant role the media plays in policy
change, MST and ACF minimise this role. Kingdon (1995) explains that the media
report what is occurring in government rather than having an independent effect on
governmental agendas. However, this statement does not align with what the
participants in this study reported, and possibly reflects the era in which MST was
written, prior to the global digital knowledge network.
Study participants made limited acknowledgement of additional name/issue
top-of-mind enablers noted in the nutrition policy literature such as conducting high
profile events, releasing a high profile report, and utilising international data or
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targets as a comparison (Craig et al., 2010; Kugelberg, Jönsson, & Yngve, 2012;
Shiffman, 2007; Vogel et al., 2010). Policy process theories note that events like
high-profile conferences can act as focusing events to bring visibility to hidden
issues (Kingdon, 1995). The lack of acknowledgement of these strategies may reveal
that participants in this study valued closer, more personal interactions with
advocates, or perhaps they overlooked the importance of these events.
While gaining the attention of policymakers through the media and personal
interactions is a key enabler, it was not considered sufficient to influence policy
change on its own. Consistent with previous nutrition policy research and policy
process theories, participants highlighted the importance of gaining the attention of
the general public and increasing their ‘will’ for the issue at hand (Miller & Harkins,
2010). Again, the media play an important role in this process (Lyn et al., 2013;
Nathan et al., 2005). For a policy monopoly change, it generally requires an
environment of changing issue definitions as well as increased attentiveness from the
media and the broader public (Jones, 1994). A critical strategy highlighted in MST is
ensuring the support of the public; Kingdon (1995, p. 130) states that “many good
proposals have fallen on deaf ears because they arrived before the general public, the
specialised publics, or the policy communities were ready to listen.”
Unity and a solutions focus
As mentioned in Chapter 6 on barriers, study participants mentioned disunity
and no clear solution as a common explanation for a lack of nutrition policy action in
Australia. This disunity and the resulting competition among health rivals resulted in
reducing the influence of all groups competing for attention. Furthermore, without
clear solutions, advocates were seen to be irrelevant to the decision-making process.
If policy advocates have not generated a clear and widely accepted solution,
policymakers are unlikely to pay attention because they prefer to allocate resources
towards problems they believe can be effectively addressed (Shiffman, 2007).
Correspondingly, the MST has identified that policymakers are more likely to act on
an issue if they are presented with clear solutions that convince them that a problem
is surmountable (Kingdon, 1995). Similarly, the need for a solutions focus has been
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identified in the nutrition policy literature (Blay-Palmer, 2009; Lyn et al., 2013) as
well as the need for unity around those solutions (Kurzer & Cooper, 2011; Pérez-
Ferrer, Lock, & Rivera, 2010; Shelley, 2012).
These findings suggest that agreement on solutions needs to be prioritised by
nutrition professionals. However, ensuring unity of message and a solutions focus
requires leadership. While leadership is not specifically noted within the policy
process theories, both the MST and ACF agree that the structure and the organisation
of an advocacy group shapes how successful they will be in influencing national
priorities (Kingdon, 1995; Sabatier, 2007). Additionally, ACF identifies skilful
leadership as a specific factor in negotiated agreements (Sabatier & Weible, 2007).
Similarly, there was agreement in the nutrition literature that when issues become
linked based on a common goal, this creates synergy rather than competition and
increases the possibility of policy change (Freudenberg et al., 2011). In contrast,
disunity among interest groups creates confusion and weakens the position of each
interest group (Shiffman, 2007). This requirement for unity raises interesting
challenges within public health nutrition, as it is a broad topic that can be sub-divided
into a range of discrete issues. Furthermore, each of these discrete issues often has
one or more organisations representing it and competing for the attention and priority
of their issue with policymakers, potentially further confusing or diluting the
message (Balarajan, 2014).
Coalitions
An effective strategy to increase unity and thereby influence, is to build and
mobilise coalitions where different groups come together around a common cause.
This popular strategy was cited by non-government organisations in the study, and
forms the basis of the ACF. Coalitions are particularly beneficial to poorly-resourced
organisations, as they can enable organisations to share workloads and combine
organisational strengths. In line with the ACF, participants reported that most NGO’s
in Australia form coalitions with like-minded individuals/organisations. It was
highlighted by some participants that this may be a limiting strategy as governments
are not surprised by standard coalitions and may not give their attention to these
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issues without the presence of unusual allies in a coalition. Unusual allies can further
enhance a coalition if they do not have an overt vested interest and is therefore
considered independent and more credible by decision-makers (Frewer, Howard,
Hedderley, & Shepherd, 1996). However, this may be difficult in the Australian
context because of the different philosophical approaches taken by nutrition
organisations and those organisations that focus on chronic disease.
Another benefit of having a wide range of individuals/organisations in a
coalition is that an agreed partnership can defuse potential sources of opposition that
may arise in complex, contested areas such as nutrition (Johnson et al., 2012).
However, caution may be needed when considering coalition members as the
inclusion of a less credible organisation may decrease the credibility of the whole
coalition (Jacobson, 2005). Support for establishing diverse coalitions is present in
the nutrition policy literature, which highlights several examples of successful
coalitions with a mix of stakeholders, particularly non-traditional alliances; for
example, between nutrition and agricultural/producers or environmental interests
(Caraher et al., 2013; Vogel et al., 2010). Scholars report that these diverse coalitions
enable members to exert high levels of influence on policy decisions, due, in part, to
their ability to mobilise a wider cross-section of the population (Freudenberg et al.,
2009; Johnson et al., 2013).
7.6.4 Policy champion versus policy entrepreneur
Widely acknowledged in the literature and by the participants in this study is
the concept of policy windows opening which provide a unique opportunity for
policy change to occur (Caraher et al., 2013; Kersh & Morone, 2002; Kingdon, 1995;
Milio, 1991; Shiffman, 2007). Several participants referred to the serendipity around
this window opening; however, others acknowledged the skills of a policy champion
or policy entrepreneur in identifying or aiding the process of the policy window
opening, and being ready with a viable solution the government wants to hear. The
characteristics of a successful policy champion or policy entrepreneur were
mentioned throughout the findings. The MST defines the role of a policy
entrepreneur as someone who links solutions to problems, and couples both problems
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and solutions to the politics of the moment (Zahariadis, 2007). This provides a
macro-level perspective on the role of the policy entrepreneur in the policymaking
process whereby the coupling of the problems, solution and politics stream
comprises a process that is fluid, chaotic and serendipitous. The findings from this
study demonstrate that advocates or policy entrepreneurs are more strategic and
deliberate than suggested by the MST. Furthermore, advocates reported that they
play an active role in creating opportunities not just responding to them as MST
posits. This sentiment is reflected in some of the nutrition policy literature
(Kugelberg et al., 2012; Yeatman, 2003), where policy entrepreneurs and/or
champions were seen to be actively creating opportunities as well as being effective
conduits for disseminating evidence to policymakers and promoting recommended
strategies.
The terms ‘policy entrepreneur’ and ‘policy champion’ are used
interchangeably in nutrition policy literature. While policy entrepreneur is a well-
studied term (Kingdon, 1995), limited attention has been given to how a policy
champion differs from a policy entrepreneur. If indeed the two terms mean different
roles for individuals, and whether that difference matters for influencing nutrition
policy. In the study findings it seems clear that these two roles were considered
distinct in one particular way. A policy entrepreneur best describes the role of an
advocate – they could be an ‘insider’ operating within the bureaucracy or a political
representative, or they could be an ‘outsider’ from academia, non-government
organisation, or even a concerned citizen. These policy entrepreneurs can have
varying levels of power and status, but the very skilled policy entrepreneurs are
defined by their persistent, opportunistic, flexible and credible nature. From a
network analysis perspective policy entrepreneurs can also be policy brokers,
particularly when they take on the role to bridge different interests, approaches and
viewpoints (Burt, 1992; Granovetter, 1973).
In contrast to policy entrepreneurs, it was evident in this study that policy
champions are defined by their high level of power and status. Usually they are an
‘insider’ in a position of formal authority, for example, a senior level bureaucrat or a
federal politician and they believe in the issue they are promoting. However, there
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are other policy champions who are not ‘insiders’ and these individuals are from
large, powerful organisations who are able to command or demand an audience with
decision-makers. These could include CEO’s and Chairs of very large food industry
bodies, but also well-known, credible celebrities, for example, Jamie Oliver. These
individuals may not have or need the characteristics of successful policy
entrepreneurs; instead they are influential in the policymaking process because of
their high status and power. Policy champions are particularly important in matters of
regulatory or legislative policy, as these issues are ultimately decided by the Cabinet.
This study revealed that most policy entrepreneurs are not able to be policy
champions, and therefore need to spend time investing in relationships in an effort to
find a high-status policy champion who can take their cause forward on the inside.
No distinction between the two terms could be found in nutrition policy
literature, with most literature not providing a label for those individuals in key
policy advocacy roles, although Vogel et al. (2010, p. 90) does refer to policy
champions as ‘change-agents….who were passionate and visionary.’ Similarly,
within general health policy literature, there has been limited discussion of the
difference between these two terms. The term ‘policy champion’ is mentioned in a
small number of nutrition policy studies of low-income countries, but again there is
little clarification around the definition of a champion in comparison to a policy
entrepreneur, with most of these studies referring to Kingdon’s policy entrepreneur
definition (Balarajan, 2014; Ha, Mirzoev, & Mukhopadhyay, 2015). Interestingly,
one study which did not provide a definition of a policy champion, instead outlined
individuals who could be policy champions; these included: senior government
officials, partners of presidents and individuals able to link government, civil society
and other organisations (Spicer et al., 2014, p. 35). In this study, having both a policy
entrepreneur and a policy champion was seen as a critical enabler to influencing
nutrition policy change.
Another area that has received limited attention in nutrition policy literature is
the motivation of policy entrepreneurs. While many studies discuss the attributes of
policy entrepreneurs, none discuss the motivation. Policy process theories state that
policy entrepreneurs or champions are motivated to become involved in an issue for
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a variety of reasons. The ACF states it is because the core policy beliefs of an issue
resonate with them. However in this study, it was noted that many of the advocates
interviewed seemed to relish the ‘game’ of influencing policy. This sentiment is in
line with a finding from Kingdon (1995, p. 123), who found that “some policy
entrepreneurs simply like the game. They enjoy advocacy, they enjoy being at or
near the seat of power, they enjoy being part of action.” Seeing the policymaking
process as a game may be a useful strategy for advocates and assist them in taking
the emotion out of the process. In turn this will decrease the ‘devil-shift’ as discussed
in the Barriers Chapter 6.7.2, which can seriously impede effective advocacy and
increase their potential influence.
7.7 SUMMARY
This research has highlighted several aspects of enablers that are not identified
in the policy process theories and the literature. Firstly, the research has highlighted
the differences between, and the need for, both a policy entrepreneur and a policy
champion. Secondly, a focusing event was not identified as a significant enabler to
policy change. Finally, although the enablers had broad consensus with the policy
process theories, the findings identified specific micro-level enablers, which provide
clear guidelines for individuals wishing to influence the nutrition policymaking
process.
The suite of enablers and new insights presented highlights a number of areas
where advocates can attempt to influence political and public will and ultimately
change policy. Key enablers include: investing in relationships and intelligence
gathering; framing problems based on values and emotion, and using real stories to
gain traction; ensuring the issue is top-of-mind for decision-makers and the general
public; and finally, ensuring there is a skilled policy entrepreneur and a policy
champion to take the issue forward. Understanding these enablers allows advocates
to assess their strengths and weaknesses against them and determine the best route
forward. It is important to appreciate that no one enabler will result in policy change
on its own, and equally, undertaking all the documented strategies may not result in
policy change, as policymaking is often a complex and irrational process. However,
Chapter 7: 276
it was highlighted by participants and the literature that the greater the variety of
enabling strategies undertaken, the more likely advocates will be able to affect policy
change.
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Conclusion Chapter 8:
Over the past 30 years Australia has experienced increasing direct and indirect
costs associated with nutrition-related disease yet has had limited corresponding
national public policy action to address this (Swinburn & Wood, 2013). Nutrition-
related disease and potential policy solutions have been studied in great detail in
Australia and internationally; however, there has been little investigation into how
these solutions can be translated into policy action. Furthermore, limited research has
been undertaken exploring the roles and strategies of individuals in effectively
influencing nutrition policy in Australia. The primary aim of this research was to
explore the influential factors impacting on the public health nutrition policymaking
process in Australia, and to explicate strategies that could be used by poorly-
resourced organisations to increase their influence in public health nutrition
policymaking. Ultimately, it is anticipated that this research will transform how
nutrition practitioners in Australia, and in other high-income countries with a
democratic government, understand nutrition policymaking in order to increase their
influence over it.
This thesis begins by identifying that policymaking is not a linear process
informed solely by evidence. Political science policy process theory sheds light on
the complex and dynamic nature of the policy change process (Clavier & De Leeuw,
2013; Sabatier, 2007). By providing the first systematic literature review
investigating whether nutrition policy scholars are using policy process theory in
high-income, democratic countries (Paper 1), this thesis identifies a disjuncture
between the analysis of the nutrition policy process and empirically based theories of
the policy process. Following this, the thesis provides the first systematic meta-
narrative review of the barriers and enablers to nutrition policy change in high-
income, democratic countries (Paper 2). The results of this review highlight that to
influence nutrition policy change you need political will, and preferably public will.
The paper outlines the key enablers and barriers to achieving increased public and
political will for nutrition policy change.
Chapter 8: 278
The thesis then provides an analysis of the structural positions of actors
involved in nutrition policy in Australia, including who has the greatest power and
capacity to influence decision-makers (Paper 3). The study demonstrates that the
food industry has a greater capacity to influence than all other professional groups.
Following this, an analysis of brokers in the Australian nutrition policy space (Paper
4) reveals that the two key brokers in the Australian nutrition policy network are a
Public Health Nutrition Academic and an NGO General Health Professional. The
results highlight that brokers may not be as powerful as previously reported, and may
be fulfilling different roles within the policy network. Finally, the key barriers and
enablers to nutrition policy change specific to the Australian context are further
explored through interviews with key influencers and decision-makers (Chapters 6
and 7). Specific discussion of the limitations for each study is provided in each of the
papers and in Chapter 3. To conclude this thesis, this final chapter (8) provides: a
summary of key outcomes (section 8.1); an outline of the significance of these
outcomes (section 8.2); a synthesis of the findings resulting in recommendations for
how advocates can best influence nutrition policy in Australia (section 8.3);
recommendations for the nutrition profession (section 8.4); and recommendations for
ongoing research (section 8.5).
8.1 SUMMARY OF KEY OUTCOMES
The key purpose of this research was to explore the influential factors
impacting on the public health nutrition policymaking process in Australia and to
explicate strategies that could be used by poorly resourced organisations to increase
their influence in public health nutrition policymaking. To achieve this, three
research questions were devised in order to understand: the applicability of policy
process theories in Australia; the barriers and enablers for nutrition policy change;
and who are the powerful and influential actors in nutrition policy in Australia and
how they influence the policymaking process. The following section will describe
how the four studies undertaken in this thesis answer the three research questions.
279
Research question 1: What is the role of current policy process theory in public
health nutrition policymaking in high-income, democratic countries,
particularly Australia?
Paper 1 evaluates whether scholars of nutrition policy literature in high-
income, democratic countries use political science policy process theories to inform
their analysis of policy outcomes. Through systematic review, this study
demonstrated for the first time the limited use of policy process theories by nutrition
scholars (Cullerton et al., 2016c). Although there was a small increase over time in
the use of policy process theory, this was limited. Accordingly, the paper
recommends that nutrition professionals would benefit from a pragmatic approach
that ensures those trying to influence or understand the policymaking process are
equipped with basic knowledge around the policy process theories. Understanding
these theories can help advocates better comprehend the complexities of the
policymaking process and identify leverage points for influence.
Research question 1 was also considered in Paper 2, a synthesis of the barriers
and enablers to nutrition policy change in high income, democratic countries. The
results demonstrates that, despite few nutrition policy studies utilising political
science theory in their analyses (Cullerton et al., 2016c), the enablers and barriers
identified were consistent with these theories. The review demonstrates that these
theories are relevant for researchers and advocates wanting to analyse and influence
public health nutrition policy. Therefore researchers and advocates are encouraged to
understand and incorporate these theories into their practice to assist in policy
analysis as well as their ability to influence policy.
Finally, the in-depth interviews with key influencers and decision-makers in
Chapters 6 and 7 provide unique insights into the factors that influence nutrition
policy in Australia. Overall, this demonstrates that the three policy process theories
which were developed in the United States of America have resonance in Australia,
although mostly at the macro and meso level. It appears that the system of
governance has limited influence on their applicability, and that the broader
Chapter 8: 280
neoliberal ideology seems to be the primary influencer behind their transferability.
However, the findings from this thesis also highlight the limitations of these policy
process theories, in that they provide limited guidance for policy change at the
micro-level. Importantly, the results demonstrate that no theory on its own
adequately explains all components of the barriers and enablers to policy change;
however, using the three theories in combination gives helpful insights from different
perspectives.
Research question 2: Who are the powerful and influential individuals and
interest groups in public health nutrition policymaking in Australia and how do
they influence the policymaking process?
To date, many scholars have hypothesised that the influence of the food
industry is a key reason nutrition policy action is not occurring in Australia and other
high-income countries (Caraher et al., 2013; Ceccarelli, 2011; Swinburn & Wood,
2013). Paper 3 investigates this hypothesis through a social network analysis to
identify the individuals and organisations with the greatest capacity to influence
nutrition policy decision-makers in Australia. Analysis of the network data
empirically proves that the food industry holds a commanding position in their
ability to influence policymakers in Australia. This advantage for the food industry is
present both strategically in their overall network position, and in the number of
direct access points to decision-makers. In addition, this study has identified that
nutrition professionals have very strong links with each other but limited links to key
‘decision-makers’. The implication of this network position for nutrition
professionals as a whole is that their strong ties with other nutrition professionals,
combined with limited direct links to decision-makers, may be limiting their
influence on nutrition policy.
This study is unique in that the dataset is globally unprecedented with respect
to its scope and breadth across a range of general health, private industry, political,
media and nutrition stakeholders. This means that, for the first time internationally,
there has been an explication and explanation of a broad range of actors directly
involved in nutrition policymaking, whether within government and politics or
281
outside. The inclusion of private industry is particularly interesting, as they are not
normally included in nutrition policy studies, because it is such a contested space
Further exploration of power and influence in the Australian nutrition policy
space is undertaken in Paper 4. The network analysis reveals two key brokers are
present (General Health NGO and a Public Health Nutrition Academic), and that the
General Health NGO broker is in a much more prominent (strategic) position for
influencing policymakers than any other broker. While the Public Health Nutrition
Academic broker has a clear brokering role among nutrition professionals, their
overall network position is not as close to policy decision-makers, meaning a greater
investment of time and relational capital is required for them to access and link
information to decision-makers when compared to the General Health NGO broker.
The network data demonstrates that the General Health NGO broker held a
commanding position with respect to connections and strategic position within the
network that was not replicable by any other actor. Despite this commanding
position, limited nutrition policy action has occurred in Australia. This may reflect
the breadth and complexity of nutrition as an issue, or it may reflect the lack of focus
on nutrition by this broker, due to competing priorities associated with their general
health role. It is also possible that brokerage may not be as influential as other
network measures such as direct access to decision-makers, as discussed in Paper 3.
This research question also considered ‘how’ powerful and influential
individuals and interest groups influence nutrition policy. This was explored in two
ways. Firstly, as discussed previously, power and influence was explored through the
social network analysis of nutrition policy actors and the structural positions that
different actors hold. An actor’s position in a policy network is important because it
can bring power and influence through privileged access to information within the
network (Carpenter, Esterling, & Lazer, 1998), for its brokerage opportunities in the
network (Burt, 1992), and for its status within the network (Laumann & Knoke,
1987). In addition, in-depth interviews with key influencers and decision-makers
allowed a comprehensive examination of how nutrition policy actors effectively
Chapter 8: 282
influence the policymaking process. Participants gave many examples of the barriers
to effectively influencing the policymaking process in Australia and also identified
important enablers that they had used or witnessed others using in the past to
successfully influence the policymaking process. The findings of the in-depth
interviews are presented diagrammatically in Figures 6.3 and 7.3.
The key barriers to nutrition policy change fell under the following three
overarching categories: lack of political will; the issue and/or organisation was not
top-of-mind for decision-makers or the general public; and the complexity of the
policymaking process. The key enablers to nutrition policy change fell under the
following three categories: the issue and/or organisation is top-of-mind; the
credibility of the advocate or organisation; and that the advocate or their organisation
understand the policymaking process. As per the findings in Paper 2, no single
enabling strategy will deliver results on its own, and equally, utilising all the
documented enablers will not necessarily result in policy change. However, the
findings from this study highlighted that the greater the number of enabling strategies
undertaken, the more likely advocates will be able to affect policy change.
Research question 3: What are the barriers and enablers influencing public
health nutrition policy change in high-income, democratic countries,
particularly Australia?
To build on the limited international evidence in this area, a meta-narrative
(Paper 2) analysing the barriers and enablers to public health nutrition policy change
was undertaken. This was the first systematic review, internationally, of the barriers
and enablers to nutrition policy change in high-income, democratic countries. The
findings from this review confirm that evidence is only one component of
influencing policy change. For policy change to occur there needs to be political will,
and often public will, for the proposed policy problem and solution. The review
identified the main barriers to nutrition policy change and presented a suite of
enablers that can be used to increase political and public will in future advocacy
efforts. The barriers include: the rise of neoliberal ideology; pressure from industry;
283
lack of knowledge, skills and resources from health advocates; and government silos.
The enablers include: developing well thought through solutions; building
relationships; being visible; using emotions and values; engaging a policy
entrepreneur; and understanding the policymaking process.
Chapters 6 and 7 provide further understanding of the barriers and enablers for
influencing nutrition policy in Australia through the analysis of in-depth interviews
with key nutrition policy decision-makers and influencers. This was the first time
such a wide range of policy actors across different sectors, including the food
industry, had been included as participants in an analysis of the factors influencing a
national public health nutrition policy process. The research yielded unique insights
into the main barriers and enablers that influence nutrition policy in Australia.
Several of the barriers and enablers that were identified, as well as the interactions
that exist amongst them, had not previously been acknowledged in the policy process
theories or in the nutrition policy literature.
Firstly, the democratisation of knowledge was identified as a barrier, a concept
that acknowledges the ‘amplification’ of the expert due to the increased promotion
and availability of general and scientific information. This corresponds with the rise
in citizen scepticism towards nutrition experts and scientists in general. Secondly,
previously unidentified micro-level enablers specific to the Australian nutrition
policy context were identified, these included: the importance of investing in
relationships and intelligence gathering; developing a clear, unified solution;
engaging a policy entrepreneur and policy champion; and reframing an issue to
appeal to values and beliefs and then amplifying that frame. Generally, this level of
detail and direction is not provided in the policy process theories. These micro-level
enablers will be discussed in greater detail in Section 8.3. Finally, a more complex
picture of constantly-interacting, dynamic enablers and barriers to nutrition policy
change emerged. This provides greater detail and insight into the interacting factors
influencing policy change than some of the existing policy process theories, in
particular, the Multiple Streams Theory (Kingdon, 1995).
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8.2 SIGNIFICANCE OF OUTCOMES
This research incorporates many studies not previously undertaken, including:
the first systematic analysis of the contribution of political science policy process
theories to nutrition policy literature within high-income, democratic countries; the
first systematic analysis of the barriers and enablers to nutrition policy change in
high-income, democratic countries; the first network analysis of a national nutrition
policy subsystem, including the identification of highly influential individuals and
interest groups; and the first synthesis of the barriers and enablers to nutrition policy
change in Australia incorporating such a wide range of participants from different
sectors, including manufactured food, agriculture, academia, lobbyists, non-
government organisations, politicians, advisors and bureaucrats.
As can be seen from the above summary of key outcomes, the results of this
study confirm the applicability of policy process theory and network theory to the
Australian nutrition policy context, as well as adding significantly to new knowledge
around nutrition policymaking.
8.2.1 Previous concepts confirmed
The research within this thesis confirms a number of theoretical findings
relevant to nutrition policymaking in Australia.
1. The nutrition policy process in Australia is not linear, rather it is complex
and dynamic.
2. Evidence is only one component of many factors influencing nutrition
policy change. Furthermore, the evidence that is used in policymaking is
predicated on different notions of evidence, which can range from
personal opinion to peer-reviewed literature.
3. The three selected political science policy process theories, which were
developed in the United States of America, generally have applicability
for the nutrition policy process in Australia. However, no policy process
theory on its own is enough to fully explain the process for nutrition
policy change.
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4. The addition of network theory is significant in highlighting the
importance of relationships, and the associated power and influence
arising from these relationships and structural positions, in the policy
process.
5. A skilled policy entrepreneur plays a critical role in the policymaking
process and can increase the chance of success in influencing the nutrition
policy process.
8.2.2 New contributions to knowledge
The research has made several new contributions to knowledge, including:
1. The identification of the democratisation of knowledge and subsequent
amplification of the ‘expert’ within nutrition means that nutrition
professionals can no longer rely on science as the only ‘evidence’ to
influence the policymaking process. Furthermore, the democratisation of
knowledge is magnified in nutrition, more so than any other health field,
making this barrier particularly unique to nutrition policy change.
2. The identification of micro-level enablers for influencing the nutrition policy
process in Australia. The policy process theories explain policy change at the
macro-level which does not provide sufficient guidance for advocates who
wish to influence policy change. The micro-level enablers identified in this
thesis add clarity for resource poor advocates looking for realistic and
effective strategies they can undertake to influence the policymaking process.
3. The important role that both a policy entrepreneur and a policy champion
have in influencing policy change. The role of individual choice and power is
overlooked within the Advocacy Coalition Framework. This Framework
posits that individuals do not act on their own accord, only as part of a
coalition. While the findings of this thesis support the importance of
coalitions, they highlight the important roles that policy champions and
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policy entrepreneurs play in changing the beliefs of decision-makers and
potentially the general public.
Furthermore, none of the policy process theories identify that the role of
policy entrepreneurs and policy champions are different and are usually
undertaken by separate individuals. To maximise influence on the
policymaking process however, both roles are required. This is particularly
seen with the Punctuated Equilibrium Theory which focuses on bottom-up
policymaking and neglects how political decision-makers can shape policy
from above. Similarly the Advocacy Coalition Framework fails to
acknowledge the conflictual nature of politics and the power that certain
individuals in the policy subsystem can have (Boin et al, 2008). This may be
because the presidential system of government in the United States of
America operates in this way. However, in the Australian context the power
of key ministers and bureaucrats and those directly connected to them cannot
be underestimated.
4. Policy brokers may not be as powerful in the network as previous studies
indicate, and they potentially perform different roles in the nutrition policy
network compared to those previously identified. Traditionally, policy
brokers are synonymous with policy entrepreneurs; however, in this study
they performed less like policy entrepreneurs and instead operated as actors
that seek stability through connecting interest groups that differ in their
beliefs. While these positions are important for disseminating information
they do not seem to be as effective at influencing policy change as policy
entrepreneurs and policy champions.
5. Nutrition professionals are distant from nutrition policy decision-makers in
Australia. While they have good bonding ties with other nutrition
professionals, they have poor bridging ties with decision-makers and those
close to decision-makers and therefore have limited ability to influence policy
change.
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6. The food industry holds a commanding position in their ability to influence
policymakers in Australia. This influence arises from their strategic
placement in the overall nutrition policy network, and with respect to the
number of direct access points to ‘decision-makers’.
7. A unified voice and collective action to amplify the frame are critically
important to policy change. This finding contrasts to the Multiple Streams
Theory which does not address collective action and coordination amongst
participants. The Multiple Streams Theory also claims that the three streams:
political, solutions, problem streams operate independently and then
serendipitously come together to open a policy window. This differs from the
findings in this thesis which identified that nutrition policy change is complex
and inter-related.
8. Nutrition is a complex, multi-faceted issue imbued with many personal
beliefs from all members of society including policymakers; as a result there
are many interpretations of the priority issues. Furthermore, amongst nutrition
professionals there are a range of professional beliefs around which public
health nutrition problems and solutions should be prioritised. This results in
solution confusion, with no clear voice engaging with policymakers and the
general public.
8.3 SYNTHESIS OF THE FINDINGS AND RECOMMENDATIONS FOR
ADVOCATES
For nutrition policy change to occur, there must be political will for the change
and it helps if there is also public will (Cullerton et al., 2016b). This requires
consideration not only of the factors that will increase political and public will, but
also the factors that may detract from it. The barriers identified in this study outline
several factors that result in a lack of political and public will for nutrition policy
action. One key barrier to nutrition policy change is that nutrition practitioners and
researchers may undertake policy advocacy with the belief that providing high level
scientific evidence is all that is required to influence policy decisions. However,
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expecting a linear connection between scientific results and policymaking reveals a
misunderstanding of the political nature of policy environments (Bernier & Clavier,
2011; Clavier & De Leeuw, 2013). It also fails to acknowledge the role that personal
beliefs play in whether individuals acknowledge or dispute evidence (Sabatier &
Weible, 2007).
Public health nutrition policy is a particularly unique field. Unlike other areas
of public health, the healthfulness of particular foods can be open to individual
interpretation amongst the general public as well as nutrition professionals (Mann,
2002). Adding to this, choosing food is a necessary, but complex process that every
person must undertake. This complexity is due to cultural context surrounding food
choices and the influences of many factors external and internal to the individual,
including biological, economic, social, psychological and environmental (Burns,
Bentley, Thornton, & Kavanagh, 2015; Crammond et al., 2013; Drewnowski &
Darmon, 2005). The complexity of the issue is further exacerbated by the many
different voices of interest groups competing for the attention of policymakers and
the general public. These groups include not only those with obvious vested
(financial or social) interests such as public health and food industry groups, but also
“alternative” health practitioners as well as celebrities advocating dietary
recommendations (Cullerton et al., 2016c). This lack of cohesion in voice weakens
the influence of nutrition professionals while simultaneously strengthens the voice of
the food industry who have made a concerted effort to appear to have a united and
cohesive voice.
Another identified barrier is that current advocacy efforts are not targeting the
values and beliefs of decision-makers or of the general public. This results in
proposals for policy change being ignored while proposals that resonate at an
emotional level are given priority. Competing for the attention of decision-makers in
the pressurised, risk-averse environment in which they operate is very challenging,
particularly when communicating a complex, multifaceted issue. This challenge is
increased by the neoliberal environment within which the government operates,
which enables the powerful role of the food industry in Australia. The food industry
continues to capitalise on and encourage this ideology to ensure their influential
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position in nutrition policymaking remains. Furthermore, greater financial resources
means the food industry has been able to maintain regular, direct relationships with
policymakers and ensure their rhetoric is simple and yet appealing to the values and
beliefs of policymakers.
Additionally, the democratisation of knowledge, which results in the
amplification of the ‘expert,’ leads to increased ‘noise’ and competition for attention
in the nutrition policy space. The democratisation of knowledge is not unique to
nutrition; however unlike any other health field opinions and beliefs around nutrition
are ubiquitous; consequently it has a significant impact. As policymakers are already
struggling with limited attention to devote to policy issues, this increased noise
further decreases the strength of any one message trying to gain traction with
policymakers.
Finally, for the nutrition profession, concerns were raised by several
participants in this study regarding the credibility of different nutrition associations
which ultimately impacts on all nutrition professionals. It was identified that
nutrition professionals have a limited shared understanding of nutrition-related
problems and solutions as seen by the general public. Both of these issues decrease
the influence of nutrition professionals with policymakers and the general public in
the drive to influence policy change (Eiser et al., 2009; Jacobson, 2005).
All of these barriers and the subsequent lack of political and public will often
result in an entrenched desire of policymakers and institutions for the status quo, due
to a process of negative feedback as outlined in the policy process theories
(Baumgartner et al., 2009). As a result in the nutrition policy space, advocates need
to implement a range of practices in order to disrupt the status quo to elicit change.
The three policy process theories, as they stand, provide limited detail on how
to practically overcome these barriers and create the opportunities that can influence
policy change. The theories are helpful to a certain extent in providing general
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guidance; however, this thesis has highlighted that they have been designed from a
macro-level, theoretical perspective and are mostly used for retrospective analysis of
policy change. For advocates wishing to increase their power and influence in order
to overcome the status quo, the research findings in this thesis demonstrate there are
a number of specific strategies that can be used.
A simplified model has been developed to incorporate the key enablers
identified in this thesis and those from the policy process theories (Figure 8.1). It
must be noted that this model does not encapsulate all facets of the policymaking
process; rather, it has been developed to serve as a practical guide for poorly-
resourced organisations, outlining key steps that can be taken to increase an
individual’s or organisation’s influence in public health nutrition policymaking at a
national level. While the steps may appear sequential, this is not the case. Ideally
several of the steps will occur simultaneously, and refinement of the strategy should
occur continually, informed by intelligence gathering. Importantly, for poorly-
resourced organisations, there may not be the capacity to undertake all steps. For
those organisations, it is important to understand the essential steps: investing in
relationships; gathering intelligence; developing a clear, unified solution; and
employing or developing the skills/traits of a policy entrepreneur. For the remaining
steps, it is important to determine the strengths of the organisation and adopt as many
steps as resources permit that align with those strengths.
The following section will outline and discuss the different steps in the model
for increasing political will for nutrition policy change (Figure 8.1). Each component
of the model was synthesised from all four studies in this thesis together with the
policy process theories.
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Figure 8.1 Model for increasing political will for nutrition policy change
Chapter 8: 292
8.3.1 Awareness of the policymaking environment
Several of the studies in this thesis give a valuable insight into the complex and
dynamic nature of the policymaking environment in Australia and internationally.
This complex environment often presents many hurdles to policy change, and
consequently, there are limited opportunities or ‘policy windows’ for when policy
change can occur. It is important for advocates to understand the barriers to policy
change before embarking on an advocacy strategy as it is often the wider macro-
political environment that will inform the strategies an advocate should pursue
(Mahoney & Baumgartner, 2015). Firstly, advocates need to acknowledge that
policymakers are overwhelmed with demands for their time and attention, and that
they work in a pressurised, risk-averse environment which encourages the status quo
to remain (Baumgartner et al., 2009). This can mean policy change may take a long
time, and policy scholars acknowledge it may require a minimum of ten years
(Sabatier & Weible, 2007; True, Jones, & Baumgartner, 1999).
Secondly, advocates need to acknowledge and work within the constraints of
the neoliberal ideology and the belief systems that policymakers and the general
public hold. Different political parties may be more aligned with this neoliberal
ideology than others. If a neoliberal focussed party is in power, advocates need to
recognise that some policy solutions will never be adopted while they remain in
power. Instead a process of venue shopping and waiting for political change may
need to occur. If a receptive political party is in power, it is clear that evidence alone
is not enough to change policy, therefore identifying the values and beliefs of
policymakers and the general public and framing issues to align with those values
and beliefs is critical for effective advocacy (Lapping et al., 2012).
Thirdly, advocates need to understand the system of governance in their
country, including the norms and rules of policymaking (Duckett, 2004). It is also
critical to recognise who has power over these rules. The answer to this question can
be found by gaining an understanding of the structural make-up of the policy space.
This requires not only having insight into who the most influential individuals are,
but how power is concentrated within the policy subsystem. If power is concentrated,
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then breaking the policy monopoly increases in difficulty (Fischer, 2013). However,
if power is fragmented, this increases opportunities for the policy monopoly to be
challenged. The fundamental strategies to increase the power and influence of
nutrition advocates and their ability to challenge the policy monopoly will now be
discussed.
8.3.2 Invest in relationships strategically
While advocates in nutrition often focus on gathering sufficient evidence and
then presenting that evidence to policymakers, this strategy alone has limited impact
on influencing policymaking (Bernier & Clavier, 2011; Cullerton et al., 2016b). As
discussed above, a deep understanding of the macro and the micro policymaking
environment is crucial for advocates as it can provide insight into beliefs and values
of policymakers and the general public, future policy opportunities, and barriers to
policy change (Weible, Heikkila, deLeon, & Sabatier, 2012). This knowledge can be
gained by experience in the policymaking sector or by reading literature on the topic,
but also through intelligence gained from developing relationships with key people
involved in the policymaking process. Importantly, developing this knowledge
requires time and continual investment in relationships (Carolan, 2006).
Investing in relationships strategically is a key cross-cutting enabler in this
thesis for influencing policy change. By prioritising investing in relationships
strategically, advocates can: develop trust and credibility with a wide range of
stakeholders; identify potential policy champions; gather intelligence on policy
opportunities and risks as well as the values and beliefs of decision-makers and the
general public; and understand the arguments of their opponents. It is demonstrated
in Paper 3 that the food industry holds a commanding position in direct relationships
with decision-makers and also in their capacity to influence nutrition policy in
Australia. In contrast, nutrition professionals lack this strategic approach and instead
focus on building and maintaining relationships with community members,
community groups and other nutrition professionals. To increase their influence,
nutrition professionals and advocates need to step outside this comfort zone and
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broaden their relationships with a more diverse range of stakeholders across the
policy process spectrum (Granovetter, 1973).
When strategically targeting individuals or organisations, it is important to
consider the policy network as a whole and understand that allies and adversaries in
political networks are inextricably linked (Smith et al., 2014). The findings of this
research demonstrate the importance of cultivating a strategic network of
relationships, and using the network to gather intelligence on: who else is influential
in the decision-making process; what opportunities are available that may allow a
policy window to open; is there an opportunity in a different policy venue; and what
are the problems for which the government would like solutions. Importantly, it is
impossible to develop relationships with everyone, hence the requirement to be
strategic. If advocates try to keep active relationships with their entire suite of
contacts, they run the risk of falling prey to ‘dehydrated talk’ (Gratton & Ghoshal,
2003, p. 2) which loses the richness or value of the relationships by only paying lip
service to each engagement/discussion; or they may suffer burnout from the
excessive hours that would be required to foster, develop and maintain each
relationship simultaneously. Instead, it is important for individuals to acknowledge
the need to be pragmatic and strategic about the activation and maintenance of
relationships and target those with the potential for greatest outcomes in terms of
intelligence and influence (Hebbert et al., 2006).
Investing in relationships can also result in the formation of coalitions or
alliances, which is an effective strategy to increase influence, particularly for poorly-
resourced organisations (Sabatier & Weible, 2007). Demonstrating that a wide
variety of organisations are in agreement on an issue signals to decision-makers that
the issue has a large amount of support (Mahoney & Baumgartner, 2015; Sabatier &
Weible, 2007). Furthermore, coalitions or alliances allow poorly–resourced
organisations to exchange resources and coordinate activities with other individuals
or organisations who have complementary skills, interests and/or capacities (Weible
et al., 2012). However, there is a tendency for coalitions in public health nutrition to
involve homogenous members. This results in bonding social capital, with good
internal communication and networking, but not bridging social capital, which
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allows members to be outward looking and engaging others in new ideas (Burt,
1992; Granovetter, 1973). To achieve better outcomes, coalition partners need to
strategically cover a wide range of interests, skills and contacts. With this strategic
approach, the resources and contacts a large coalition or alliance can bring to an
advocacy campaign are more significant than the resources of any lone interest group
(Mahoney & Baumgartner, 2015).
Another outcome of investing in relationships is the increased intelligence
advocates can gather about the 'opposition' and their argument. This may involve
meeting with the opposition face-to-face, meeting with ‘friends’ of the opposition,
attending meetings they will be at or using online searches. Gathering intelligence
allows advocates to gain a deeper understanding of competing points of view, which
then enables them to develop convincing counter arguments before meeting with
policymakers (Brownell & Warner, 2009; Nestle, 2013). Importantly, relationships
with opponents need to be carefully navigated to ensure the credibility of the
advocate or their organisation/alliance remains and that the issue at hand is not
tarnished (Dixon et al., 2004). It is critical for nutrition organisations to carefully
consider who they establish financial relationships or partnerships with, particularly
when it involves the food industry. To ensure credibility, organisations must be
transparent about any financial relationships and be aware that regardless of
transparency, the public and policymakers may still perceive an incompatibility in
these relationships.
Continually investing in relationships and gathering intelligence underpins
every strategy in the model for influencing policy change. The next section will
discuss these strategies, they include: develop a clear, unified solution; employ or
develop the skills/traits of a policy entrepreneur; reframe issues to appeal to values
and beliefs; secure a policy champion; amplify the frame; and increase public will.
Each strategy will now be outlined; however, it is imperative to understand and
reiterate that investing in relationships strategically and gathering intelligence
underpins each of them.
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8.3.3 Develop a clear, unified solution
The policymaking process does not cope with complexity due to the bounded
rationality of policymakers (Baumgartner & Jones, 1993). Bounded rationality is the
notion that individuals have limited resources to process stimuli, therefore they will
rely on shortcuts for decision-making rather than comprehensive analysis (Simon,
1957). To overcome this and gain the attention and interest of policymakers requires
simplification of the problem and the solution. This may be challenging to nutrition
professionals and researchers as nutrition issues are inherently complex. When an
issue is presented as complex and requiring multiple solutions, the evidence to date
and participants in this study note that it is unlikely that policy action will be
achieved, as it is considered just too hard (Balarajan, 2014; Shiffman, 2007). This
may mean the strategy of incrementalism will need to be undertaken to address
complex issues, and advocates need to acknowledge that to reach the end goal may
take considerable time.
The necessity for clear, unified solutions which are politically palatable raises
the broader issue of competing or uncoordinated agendas within nutrition. While
there are advantages in advocating for specific issues, the findings of this thesis
demonstrate that fragmented advocacy efforts in nutrition can detract from bringing
about more integrated and coordinated progress. This finding was affirmed by
Balarajan (2014) who highlighted that competing priorities vying for attention can
result in attention fatigue and consequently policymakers may become uninterested
in repeated calls to action. Equally, Mahoney and Baumgartner (2015) highlighted
that when policymakers see demands of individual interest groups not backed up by
an extensive supporting side, they avoid a leadership role on the issue.
In order to strengthen cohesion, it is recommended that nutrition organisations
and associations consider establishing an overarching nutrition coalition or network.
This coalition could potentially include other organisations sympathetic to the end
goals of the public health nutrition profession. Coalitions such as this provide an
important forum where diverse organisations can be brought together behind closed
doors to determine an advocacy agenda that prioritises solutions all member
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organisations can agree on. Importantly, understanding the current policymaking
environment and developing solutions that will appeal to that environment is an
important strategy to increase the salience of the solutions. An example of one such
overarching coalition, seen at an international level, is in tobacco control where it
was used to great effect in presenting a strong and unified front, resulting in the
development of the powerful Framework Convention on Tobacco Control (Puska,
2016; Yach, 2014).
Ensuring unity around a clear solution increases its political palatability,
however solutions also need to be technically feasible and make sense to a lay person
(Kingdon, 1995). This thesis demonstrates that acquiring knowledge around these
factors requires intelligence gathering with decision-makers, their support staff and
the general public. Ideas may need to be tested and refined to ensure they have the
greatest appeal to policymakers and the general public. Finally, advocates need to be
prepared and ensure policy solutions have been thought through and are ready for
when a policy window opens and a new opportunity presents itself (Kingdon, 1995).
8.3.4 Develop the skills/traits of a policy entrepreneur
It was noted in the systematic literature review and the in-depth interviews that
the limited skills, resources, money and time of nutrition and health advocates are
significant barriers to policy change. By developing entrepreneurial skills as a
nutrition advocate or employing a policy entrepreneur, considerable influence can be
gained in the policymaking process for minimal cost (Kingdon, 1995). To develop
entrepreneurial knowledge and skills, potential advocates are firstly encouraged to
develop an understanding of political science policy process theories (Sabatier,
2007). These theories can help policy advocates understand the complexities within
the policymaking process as well as identify the drivers and leverage points for
influence (Clavier & De Leeuw, 2013).
Policy entrepreneurs understand the policymaking process and constantly look
for opportunities to disseminate evidence and promote recommended strategies
(Kingdon, 1995). They can have varying levels of power and status; however the
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studies in this thesis found that the very skilled policy entrepreneurs are defined by
their persistent, opportunistic, flexible and credible nature. They prioritise investing
in relationships in an effort to gather intelligence, which allows them to identify
opportunities, understand the strategies and end-goal of their opposition, as well as
leverage points for decision-makers (Zahariadis, 2007). The findings of this thesis
suggest that the most effective policy entrepreneurs see the policymaking process as
a game, and are able to take the emotion out of the process. This enables
relationships with people who have divergent views and can decrease the ‘devil-
shift,’ which, as discussed in Chapter 7.5.2, can impede effective advocacy (Sabatier
et al., 1987). The policy entrepreneur also plays a key role in reframing the issue
based on the values and beliefs of policymakers, and preferably the public, as well as
securing a high-status policy champion for the issue at hand.
8.3.5 Reframe issues to appeal to values and beliefs
The cognitive limitations of individuals with bounded rationality necessitates
the use of heuristics or frames to assist reasoning, help allocate attention, and process
complex issues more efficiently (Weible et al., 2012). Frames help people make
sense of what they see and hear by triggering concepts that they already have at a
conscious and pre-conscious level (Druckman, 2004). The most effective frames
appeal to common societal values that individuals can connect with (Dorfman &
Wallack, 2007). Using frames that appeal to values defines the boundaries of a
problem and guides the way people create shared meanings which motivate them to
act (Fischer, 2003). Therefore, in order for evidence around nutrition-related
problems and solutions to be fully absorbed by those involved in the policy process,
the issue must be must be framed to appeal to the values of decision-makers and
preferably the general public (Dorfman & Wallack, 2007).
Determining the best frame requires intelligence gathering about the values of
the audience (Gregory & Lewis, 1999). Once these values have been ascertained,
advocates can consider how to frame their problem and solution to ensure the
message resonates with the orientation of the audience. This may require developing
several different frames and testing them on the target audience to determine which
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one receives the greatest traction (Koon, Hawkins, & Mayhew, 2016). Frames that
have been used successfully in the past include: protecting the health of children;
truth and honesty; fairness and social justice; and focusing on current and potential
losses related to inaction (Freudenberg et al., 2009; Kersh & Morone, 2002; Klein &
Dietz, 2010). Local frames have also been used successfully to increase the
audience’s sense of connection and solidarity with an issue (Freudenberg et al.,
2011).
8.3.6 Secure a policy champion
The research findings demonstrated that not only was a policy entrepreneur
required to influence nutrition policy change, policy champions also play a pivotal
role. Policy champions are defined by their high level of power and status within a
policy subsystem. Usually they are an ‘insider’ in a position of formal authority, such
as a senior level bureaucrat or a federal politician, and importantly, they believe in
the issue they are promoting. The crucial role of politicians in Australian
policymaking, particularly those who are members of the Cabinet, demonstrates the
importance of a policy champion. Consequently, a policy champion who is a Cabinet
minister is perfectly placed to take an issue into the Cabinet room and advocate for it.
Alternatively, if a Cabinet minister is not able to be secured as a champion, party
colleagues who are back-benchers are also in powerful roles to advocate to their
Cabinet colleagues through their personal and professional relationships.
The findings also identify that there are other policy champions who are not
‘insiders’. These individuals are from large, powerful organisations who are able to
command or demand an audience with decision-makers. Alternatively, very high
profile, credible celebrities can also fulfil this role. The findings from this study
reveal that securing a policy champion will increase the political will for an issue and
may also increase public will. While this knowledge is valuable it is also challenging
as the greatest difficulty most advocates will have is securing a policy champion. The
most efficient way a poorly-resourced organisation or advocate can secure a policy
champion is to interrogate their networks for potential connections. Furthermore,
success in securing a policy champion will be increased if nutrition advocates
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mobilise coalition members or members of their associations to increase the breadth
and depth of these networks. Advocates may wish to encourage coalition and/or
association members to specifically target and meet their local Member of Parliament
(MP) to become a champion, or alternatively seek their recommendation for other
MP’s who may have an interest in the issue.
8.3.7 Amplify the frame
To further increase the resonance of the frame and to stand out above the
‘noise’ surrounding policymakers and the general public, advocates need to amplify
their frame. The objective of amplification is to ensure the issue at hand and/or the
advocate or issue-based organisation becomes top-of-mind for policymakers (and for
those staff that support policymakers) and the general public. However, this can be
increasingly difficult, as there is a network of people constantly trying to influence
nutrition policy (Cullerton et al., 2016a). To overcome the ‘noise’ and effectively
amplify the frame, advocates can undertake a number of strategies. Firstly, the most
common method of frame amplification is to use the media, although ensuring the
media report on the issue or new frame can be challenging (Baumgartner et al., 2009;
Dodson et al., 2009; Lyn et al., 2013; Webster et al., 2014). The findings in this
thesis indicated that investing in relationships and building trust with journalists can
assist in this process.
Secondly, the findings suggest advocates need to identify individuals who are
best placed to strategically advocate for the issue. The policy champion is often best
placed to undertake this process internally; however, additional value can be gained
by ensuring policy entrepreneurs or brokers who are well-connected to decision-
makers amplify the frame simultaneously. Individuals best placed to amplify the
frame can be identified through mapping out a policy network. By undertaking this
process, less obvious or hidden patterns in relationships that transcend hierarchical
structure can be revealed, identifying an actor’s relative power (Christopoulos &
Ingold, 2011). Those who are well-connected to other informed individuals can use
this position to tap into larger stores of useful political information (Knoke & Yang,
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2008). Furthermore, they can use their position to transmit information back to
influential individuals.
For greatest impact, it is important that advocacy efforts do not rely on just one
well-connected individual to progress and amplify the frame, as this can make the
advocacy network vulnerable (Christopoulos & Ingold, 2015). The network analysis
findings indicate that this reliance on one individual is currently occurring for
nutrition policy advocates. To increase the chance of success, multiple individuals
need to be identified who can uniformly advocate and amplify the frame in a more
coordinated way. If resources allow, simultaneous frame amplification targeting all
members of parliament at a federal or state level, depending on the issue, could be
very effective. Associations with large membership bases are at a significant
advantage with this strategy as they may be able to mobilise large numbers of
members and increase the likelihood of successfully targeting all politicians with an
individual based in each politician’s electorate. Alternatively, investing in coalitions
or alliances can increase the range and depth of options for frame amplification.
Professional membership and advocacy associations and organisations have the
ability to amplify frames if they utilise their members in a co-ordinated manner.
Currently, members of nutrition and public health organisations and associations in
Australia are untapped resources that could be mobilised with potentially powerful
effects on nutrition policy action in Australia. Mobilising the membership of an
association to undertake advocacy strategies in a co-ordinated manner has the ability
to not only amplify the frame, it can also enhance intelligence gathering and securing
champions. This is a low-cost strategy that all associations and organisation could
undertake with potentially high rewards.
Finally, to further amplify the frame, advocates could partner with a member of
the general public with lived experience of the issue at hand. Securing a member of
the general public to present their story to decision-makers and/or the general public
is identified as a powerful strategy in the research findings. It is reported that
politicians often privilege the personal stories of constituents compared to peer-
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reviewed evidence (Newman, 2003; Shonkoff & Bales, 2011). This effect is due to
our ability to process narratives cognitively more efficiently than we can hard data or
statistics (Dawes, 1999). These narratives can evoke strong feelings in decision-
makers and the general public, therefore making the communication memorable and
more dominant in cognitive processing (Newman, 2003). Once this emotional
connection has been made, the scientific evidence can be presented, followed by the
suggested solution.
8.3.8 Increase public will
Gaining public support for the issue at hand and then demonstrating this level
of support to policymakers was considered very important by many participants in
this thesis. Decision-makers respond positively to issues that have the support of
their constituencies and colleagues, including public officials, community leaders,
and interest groups (Bedore, 2014; Eyler et al., 2012; Lyn et al., 2013; Shelley et al.,
2014). Conversely, failing to mobilise community support has been identified as a
key reason for a policy issue not getting policymakers’ support (Gilson Sistrom,
2010).
Methods for building public will identified in this thesis include: using an
effective frame and amplifying it; investing in personal relationships; and ensuring
the advocate or advocacy organisation has credibility and trust. As discussed earlier,
effective framing is not only important for persuading policymakers, it can also
increase public will for an issue (Shelley, 2012). Creating a frame that appeals to the
values of the general public, which is then amplified via different strategies, has been
demonstrated to increase public will for a policy issue (Freudenberg et al., 2009).
This may require advocates to consider frames that appeal to neoliberal values.
However, while appealing to this extrinsic value may resonate in the short-term, a
risk is that it perpetuates a neoliberal approach to the issue. A more effective long-
term framing strategy would be to appeal to the intrinsic values society shares, such
as responsibility, fairness and reciprocity (Zaki & Mitchell, 2011).
303
Public will can also be increased through establishing and building
relationships with interest groups including community and citizen groups. Not only
can these relationships result in increased trust, they can also provide credible public
support for an issue (Dodson et al., 2009; Kersh & Morone, 2002; Lyn et al., 2013).
Demonstrating that an issue has wide-ranging public support provides a signal to the
government that there is consensus and support from constituents (Lyn et al., 2013).
This demonstration of support is an important lever for politicians who depend on the
support of the public to remain in office (Kingdon, 1995).
Credibility and, more importantly trust, are critical elements in determining
whether there will be public support or will for an issue. This is often based on what
decision-makers and the general public perceive as ‘truth’ or accept as evidence. If
an individual or organisation is believed to be trustworthy, the knowledge that comes
from that individual or organisation is more likely to be considered true (Haynes et
al., 2012). One factor that can decrease credibility and trust in a nutrition
organisation is a perception the organisation is associated with food industries
diametrically opposed to health (Dixon et al., 2004; Gornall, 2015). A strategy that
can increase trust is to consult with the public to ensure there is a shared
understanding of problems and solutions (Weber & Khademian, 2008). A final
identified factor leading to decreased credibility is the complexity around nutrition
and the perception that the ‘nutrition message’ is constantly changing. Ensuring that
the public voice of nutrition associations and organisations on nutrition issues is
unified is imperative in addressing this issue. Furthermore, a unified public voice that
actively engages with the general public requires leadership. Negotiating a unified
consensus within nutrition is a particularly challenging process, as there are so many
interests at play. In sum, to increase public will, advocates need to: choose an
effective frame; consult regularly with the public to ensure a shared understanding of
problems, solutions and priorities; choose their alliances or partnerships carefully;
and as much as possible ensure there is unity in the nutrition message being
promoted.
Chapter 8: 304
8.4 RECOMMENDATIONS FOR FURTHER RESEARCH
There are significant opportunities for further research concerning this topic. It
is evident in the findings that effective reframing of the problem and solution to
appeal to values and beliefs can be an effective way to change political and public
will. However, while research on these frames has occurred in the United States of
America (Dorfman & Wallack, 2007), no research to date has been conducted in
Australia on what the most effective frames for progressing public health nutrition
issues are, and how best to use these frames. Further research is recommended to
identify the most effective frames for nutrition policy issues, as well as practical
considerations for ensuring their use amongst practitioners.
Similarly, there is value in reanalysing the social network analysis data using
the attributes of geographical location and gender. Analysis of capacity to influence
policy based on geographical location has not been undertaken previously in
Australia. As Australia is the sixth largest country in the world, covering a land mass
almost equal to the United States of America, the nation’s capital Canberra is
geographically distant for most Australians (Geoscience Australia, 2017).
Undertaking this analysis would help nutrition researchers and advocates to discern
whether the location of the advocate/issue is advantageous when attempting to
influence the policy process in Australia. Gender and potential influence on policy
action is particularly relevant for nutrition professionals, as it is a field dominated by
women. The most recent Australian data on gender and nutrition professionals is
specifically on dietitians, outlining that 95% of dietitians employed in 2011 were
female (Health Workforce Australia, 2014b). No research has been conducted on the
role of gender and subsequent level of influence in Australian health policy, let alone
nutrition policy.
In addition, it would be useful to test the proposed model for increasing
political will for nutrition policy change (Figure 8.1) in different international
settings as well as different areas of health or social services to determine whether it
is normative. The different settings could include high-income and/or low-income
countries or those with different systems of government. Undertaking this research
305
would provide an empirical analysis of whether the identified model for increasing
political will in nutrition policy in Australia is applicable in a range of different
environments as the principles of influence are the same.
Finally, the social network analysis undertaken in this thesis has a cross-
sectional design and therefore limits the ability to infer temporality or causality, and
may mask potential shifts in power over time. Replicating the study over points in
time would give insight into the potentially changing network dynamics over time.
8.5 CONCLUDING STATEMENT
This thesis makes an important contribution to transforming the way nutrition
practitioners in Australia, and other high-income countries with a democratic
government, understand nutrition policymaking in order to increase their influence
over it. Presented as four published papers plus additional chapters, this thesis
focusses on the influential factors impacting public health nutrition policymaking in
Australia, with the aim of explicating strategies that could be used by poorly-
resourced organisations to gain traction in public health nutrition policymaking. The
data presented demonstrates that influencing nutrition policy in Australia is a
complex and dynamic process, with a series of inter-related barriers and enablers. No
single enabling strategy will give results on its own, and equally, undertaking all the
documented enablers will not necessarily result in policy change, as policymaking is
often a complex and irrational process. However, the findings in this study and the
literature highlight that the greater the variety of enabling strategies undertaken, the
more likely advocates will be able to affect policy change.
For nutrition advocates, the data raises significant challenges to current
practices and highlights the need for individuals and nutrition organisations to ensure
unity, credibility and to invest in relationships strategically. Additionally, a renewed
focus on gathering intelligence and utilising effective frames will assist in developing
politically palatable policy solutions and identifying when policy windows open. If
individual nutrition advocates and nutrition organisations as a whole can collectively
Chapter 8: 306
undertake these strategies, it will greatly increase the effectiveness of future
advocacy efforts and ultimately improve the nutritional status of the population at
hand.
307
Appendices Chapter 9:
9.1 SABATIER’S CRITERIA FOR A PROMISING THEORY OF THE POLICY
PROCESS
1. Do a reasonable job of meeting the criteria of scientific theory; that is, its
concepts and propositions must be clear and consistent, it must identify causal
drivers, it must give rise to false hypotheses and it must be fairly broad in
scope.
2. Be the subject of recent conceptual development and/or empirical testing. A
number of active political scholars must view it as a viable way of
understanding the policy process.
3. Be a positive theory seeking to explain much of the policy process.
4. Must address the broad sets of factors that political scientists looking at
policymaking have traditionally deemed important: conflicting values and
interests; information flows; institutional arrangements; and variation in the
socioeconomic environment.
(Sabatier, 2007, p. 8)
Chapter 9: 308
9.2 RESOURCES OF THE ACF
The ACF assumes that actors employ available resources to carry out strategies
to influence policy change. These include:
Formal legal authority to make policy decisions, for example, department
officials or legislators. One of the most important features of a dominant coalition is
that it has more members in positions of formal authority than do minority coalitions.
Strategy: launch lobbying campaigns to sway officials with legal authority.
Public opinion: opinion polls showing support are a major resource. Strategy:
spend time garnering public support.
Information regarding severity and causes of the problem and cost-benefit
analysis of policy alternatives is an important resource. Stakeholders may spin or
even distort information to bolster their argument.
Mobilise troops: use members of the public who share their beliefs to engage in
political activities including public demonstrations and fund raising campaigns.
Coalitions with minimal financial resources rely heavily on mobilisable troops.
Financial resources: money can be used to purchase other resources, for
example, research, think tanks, funding sympathetic candidates to gain insider
access, and media campaigns.
Skilful leadership (policy entrepreneurs): a skilful leader can create an
attractive vision for a coalition, strategically use resources efficiently, and attract new
resources to a coalition. Most antecedents to policy change (for example external
shocks) dispose a political system to change but skilful entrepreneurs are needed to
bring about actual changes in policy.
(Sabatier & Weible, 2007, p. 201).
309
9.3 POLICY CHANGE – PUNCTUATED EQUILIBRIUM THEORY
Figure 9.1: Policy change via the Punctuated Equilibrium Theory adapted from
Stachowiak (2013).
Refine issue/Issue Framing
Mobilise new actors
- Public
- Legislators
- New allies/unexpected allies
Get media attention to focus on new
definition or aspect of policy
Strengthened Alliances
Increased number of allies/partners
Strengthened base of support
Increased media attention
Shift in Social Norms
Increased awareness of issue
Increased agreement about issue
definition & need for change
Increased prioritization of issue
Strengthened base of support
Increased visibility of issue
Increased political and public
will
“Significant” changes in institutions
“Significant” changes in policy
Chapter 9: 310
9.4 NETWORK ANALYSIS INSTRUMENT
Dear xxxx, I am conducting a survey to identify the most influential people in national nutrition policy in Australia. Please nominate the people you feel are influential in national nutrition policy in Australia, using the following definition: The person demonstrates a capacity to do one or more of the following:
- shape ideas about policy
- initiate policy proposals
- substantially change or vet other’s proposals, or
- substantially affect implementation of policy related to food and nutrition
Please nominate as many or as few people that you can think of. If you are unable to name a person, please name the organisation you feel meets the above criteria.
Name of person and organisation they work for
Are you in direct contact with this person? Y/N
How often are you in direct contact? Daily, weekly, monthly, 6-monthly, yearly
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
If you think about national nutrition policy specifically around Indigenous nutrition, who would you list as influential? If repeating names from the original list, please write the number associated with that name, for example, A3.
Name of person and organisation they work for
Are you in direct contact with this person? Y/N
How often are you in direct contact? Daily, weekly, monthly, 6-monthly, yearly
B1
B2
B3
311
B4
B5
If you think about national nutrition policy around school gardening and cooking programs, who would you list as influential? If repeating names from a previous list, please write the number associated with that name, for example, B3.
Name of person and organisation they work for
Are you in direct contact with this person? Y/N
How often are you in direct contact? Daily, weekly, monthly, 6-monthly, yearly
C1
C2
C3
C4
C5
If you think about national nutrition policy around front of pack food labelling, who would you list as influential? If repeating names from a previous list, please write the number associated with that name, for example, B3.
Name of person and organisation they work for
Are you in direct contact with this person? Y/N
How often are you in direct contact? Daily, weekly, monthly, 6-monthly, yearly
D1
D2
D3
D4
D5
Chapter 9: 312
9.5 INTERVIEW GUIDE
Introduction Thank them, outline purpose of interview, emphasise confidentiality,
consent form.
Questions Tell me a little bit about your job role and how you got into it? How long
have you been in this position?
Explain about the lack of traction public health nutrition has
politically and ask whether they had any thoughts on why.
Ask about the three case studies and find out their involvement? Ask why
involved with 1 or 2 and not others.
Explain that you want to ask about their experience with either/all of
those 3 case studies (or other issues if they like).
What strategies have you used or seen others used that have
successfully influenced policy?
Coalition strategy eg did you actively seek out people or organisations
that you want to work with?
Public eg what do you think the general public think about nutrition
issues? What about these 3 issues? Do you actively try and find out what
the general public feel/think? Do you try and change their beliefs about
nutrition issues?
Policymakers eg do you actively seek out policymakers to promote your
solutions to problems? How do you do this? What strategies have worked
for you when influencing policies? Least effective?
Politicians eg do you seek out politicians to promote your
solutions/issues? How do you do this? Who do you feel is most receptive?
What strategies have worked? Least effective?
Influence eg what factors gives someone influence? – knowledge,
public opinion, money, media coverage etc
What makes you influential?
Key influences on their own work practice – people, studies, texts,
learning experiences?
Clarify key themes
Closing
Thank them. Check whether they would like to add anything else
Would they like a copy of the transcript and/or summary of results?
313
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