Objective: To better understand how public health nutrition has been represented during the past decade in Australia this paper critically analyses Eat Well Australia: An Agenda for Action for Public Health Nutrition 2000 – 2010 and its accompanying National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan.
Method: The paper uses an interpretive approach, drawing on Bacchi's method of problem representation, to examine the strategies being offered within the policy. It uses this framework to uncover how public health nutrition has been represented and examines if the representation provided considers all aspects of the issue. The paper also considers how contextual factors affected policy development through examination of publicly available documents.
Results: The problem is represented as being both an individual one and one due to social, structural and economic circumstances. There is a large focus on collaboration, research and capacity building. The context of the policy's development has affected the solutions contained within.
Conclusion: The policy's proposed actions reflect the policy-making environment in which it was conceived. A manifestation of this was unclear division of roles and responsibilities, lack of dedicated resources and inadequate focus on the social determinants of health.
Implications: As the policy's timeframe is drawing to its end, critical reflection on how the problem of nutrition has been represented over the previous decade provides greater insight and awareness to direct future public health nutrition work.
As the disease burden and costs of diet-related diseases in Australia are high, and are unequally distributed among the population, nutrition is considered a priority public health issue that has been gaining increasing attention over the past two decades.1–7
Eat Well Australia: An Agenda for Action for Public Health Nutrition 2000–2010 (EWA), and its accompanying National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP), is the national public health nutrition policy that guides the work of public health nutrition across Australia.8,9 While the document is not called a policy per se, the strategic framework and associated agenda for action is the only current national document that provides broad direction for government and partners. The 1992 Food and Nutrition Policy marked a shift in the focus on nutrition from an individual focus towards a population health approach. Despite this shift, many interventions within public health nutrition still focus on changing individual health behaviours rather than the social, cultural, environmental, structural and economic circumstances within which people live, known as the social determinants of health.10
Some policy commentators have identified various ‘stages’ of policy making that decision makers move though; problem identification, option consideration, decision on policy options, implementation and evaluation. However, this staged view ignores the historical, political, social and cultural factors that have an impact on policy-making.11 Given the Australian government system is federal and decentralised – that is the power is divided between the central government, state/territory government and local governments – policy making in Australia tends to follow a horizontal process whereby policy emerges from a complex set of relationships between these layers of government and influential professional associations, special interest groups and private industry bodies.12
With the lifespan of this public health nutrition policy nearing its end, it is timely to conduct a critical analysis of the policy, giving consideration to the political and contextual factors at the time of its development and the process through which it was conceived. Within the published literature there is no evidence of analysis or evaluation at any stage during the policy's 10-year timeframe. This is despite commitments to evaluate at regular intervals.8
Given this lack of literature there are many frameworks by which the policy could be assessed. This paper sets to outline a critical account of the contextual factors affecting on the policy's development and to conduct an interpretive analysis to uncover prevailing values and beliefs that influenced the representation of public health nutrition in Australia during the previous decade. It considers what solutions were offered within the policy and whether these focus on individual behaviour change or address the social determinants of health and theorises the impact of this for health inequalities.
Ham and Hill assert that public health policy can benefit from an analysis at three broad levels: by understanding the structural (economic, political, social and cultural) influences of the time, by observing the policy-making process, including power relations between key stakeholders, and by considering the decision-making process and how evidence has been used.13 With the current focus on evidence-based policy making, the impact of contextual factors often gets bypassed. An analysis of history leading up to policy development provides greater awareness of the impact of contextual factors.14
Interpretive approaches to policy analysis are based on the premise that there can be various ways of viewing or understanding the world in which we live rather than an absolute objective truth. Policies can represent problems in various ways through the types of solutions they offer. Bacchi in her ‘What's the problem?’ approach to policy analysis is interested in understanding how the representation of policy problems close off the space for thinking about the issue in different ways and thus constrict social vision.15 Interpretive policy analysis identifies the various values and beliefs that are expressed when defining a problem in a certain way.16 Policy statements may represent the values or beliefs of society at that point in time.17 However, as more powerful groups in society usually dominate policy development, the values and beliefs being represented are usually those of the most powerful, wealthy or influential.18 An interpretive policy analysis of EWA and NATSINSAP provides insight into the prevailing values and beliefs surrounding public health nutrition within government and key stakeholders at the time of its development.
This paper uses a mixture of policy analysis approaches to focus attention to particular aspects of the policy making process (Table 1). To better understand the impact of contextual factors on the policy Ham and Hill's (1993), three broad levels of policy analysis are considered. An interpretive approach has been applied to highlight how strategies within EWA and NATSINSAP represent public heath nutrition in a certain light. The study draws on Bacchi's framework to identify different solutions offered, how these represent the issue and how a particular representation of public health nutrition may divert attention away from other aspects thus leaving them silenced.15 This analysis has combined these frameworks to provide greater depth and understanding of public health nutrition relative to the wider public health context during the previous decade.
Summary of methodology and key findings.
Policy analysis findings
Public health actions are determined by prevailing ideologies of the government in power and the extent to which interest groups are able to influence these. The Australian political system is a liberal democratic society; a political system with numerous channels for participation through political groups, special interest groups and media.19 However, within this liberal democratic society the extent to which government believes in equity and a welfare state varies. While both the left and the right are underpinned by free market philosophies, the Liberal and National ideologies believe in the power of the market to meet the needs of people, whereas the Labor and Democratic parties strive to protect the needs of those less powerful.20,21
Health promotion in Australia started to receive attention during the 1980s under the Labor government. The WHO Health for All agenda raised the profile of health promotion and the Better Health Commission (1986) suggested that further health gains could be made through inter-sector partnerships in prevention.22 The Health for All Australians report (1988) gave recognition to the social determinants of health23 and the hosting of the second Global Conference on health promotion in 1988 further raised the profile of health promotion and nutrition at that time.24 Development of the 1992 Food and Nutrition Policy reflected the Labor governments strong commitment to social justice, food supply issues, community participation and the whole food and nutrition system, especially ecologically sustainable development. This focus on agriculture and the environment is perhaps not surprising given the Labor Party has a history of links with primary producers and other rural interest groups and receives financial support from unions.18
The 1990s saw a proliferation of new programs, but funding was often limited in the face of recession, a general embrace of market ideology and reduced public sector spending.24 During this time the Chief Health Officers across Australia commenced discussions about the need for a national approach to public health. The Australian Health Ministers’ Advisory Council agreed to develop the National Public Health Partnership (NPHP).
EWA and NATSINSAP were developed under this partnership and the Liberal (Howard) government with a mixture of Liberal and Labor government at the state/territory level. The Liberal government's allegiance to free market economy and history of receiving financial support from private business and industry is reflected in EWA's strong partnership approach and emphasis on collaboration with stakeholders including interest groups, non-government organisations, universities and private industry.18 The emphasis on partnerships and collaboration may have been further influenced by the shrinking health care budget at this time.18 Furthermore, the development of this policy under the Liberal government explains the absence of attention to the whole food system including agriculture and environmental sustainability that was previously seen in the1992 National Nutrition Policy.
Increasing attention to health promotion throughout the 1980s and 1990s, the resulting development of the 1992 National Nutrition Policy and its subsequent review in 1998 and the formation of the NPHP and its public health nutrition subgroup SIGNAL (the strategic inter-governmental nutrition alliance) all influenced the circumstances in which EWA and NATSINSAP were developed.
Policy-making process and power relations
SIGNAL was established as a mechanism to ensure broad commitment of all jurisdictions to public health nutrition objectives. Its membership included the Commonwealth Department of Health and Aged Care, all eight state/territory Health Departments, the Australian Institute of Health and Welfare, the then Australian New Zealand Food Authority (now the Food Standards Australia New Zealand), the National Health and Medical Research Council and five independent experts (three heads or professors from universities, one community dietitian and one Aboriginal Medical Service nutritionist). It is difficult to know what the power relationships were in the decision-making process but domination by government representatives would have undoubtedly influenced the types of strategies chosen. Endorsement in the form of a forward by the chair of SIGNAL, rather than the Commonwealth government's Chief Health Officer, displays the level of commitment (or lack thereof) for the policy. This may have influenced the type and range of actions included due to less direct accountability for implementation. Priorities seen within EWA and NATSINSAP unsurprisingly reflect the main aims of the NPHP.
While there were two rounds of consultation, public submissions and seminars in major centres it is difficult to determine the power relations involved in the development of EWA.25 The list of key informants includes mostly professionals or representatives from peak special interest groups. From this it appears the lay or community voice went largely unheard. As there exists differential access to power holders within society, largely unorganised sectors of society rarely have a voice and if they do it is usually tokenistic in the form of one-off public meetings or invitations for submissions.18 This was the case with EWA.
On the other hand, during the development of NATSINSAP there were numerous opportunities for input in the form of questionnaires, workshops (three), conferences (two), written submissions and meetings. The list of key informants, while still dominated by individuals representing organisations, was much more extensive than EWA. The NATSINSAP working party contained more representation from community organisations in addition to the government agencies. This is reflected in the greater level of detail within the action plan and the translation of policy options into real world policy solutions.
Decision making process and use of evidence
The types of strategies and solutions offered within EWA strongly reflect and reference those in previous policies; 1992 Food and Nutrition Policy, Acting on Australia's Weight, Active Australia, the National Breastfeeding Strategy and the National Action Plan on Vegetables and Fruit. EWA uses an incremental decision-making process, where decisions build on previous policies, rather than a rational decision making process where options are identified after assessing all available evidence.26 Furthermore, NATSINSAP builds on EWA and also on previous reports and publications as outlined in appendix 2 of NATSINSAP.
The policy strongly acknowledges the importance of evidence in determining suitable strategies. In fact, many of the proposed actions themselves relate to conducting research or studies to gather more evidence. However, within EWA the evidence mentioned is seldom referenced; it seems to assume that because it has been included within the document that validates it as suitable and reliable. Conversely, the accompanying NATSINSAP uses evidence (and extensive referencing) to set the scene on why certain population groups and settings have been prioritised. As the actions within EWA build on existing policy or programs there may be an underlying assumption that these are already evidenced based. However, the policy's commitment to gathering evidence suggest there are gaps in this evidence base.
As research findings often do not coincide with the timing of policy development, a common issue experienced in incorporating evidence into policy, this could explain the lack of documented evidenced-based action.27 Another explanation could be that research diffused through multiple channels, such as scientific and professional journals, the mass media, and conversations between policy makers and researchers. This diffusion of research over time could have contributed to a series of concepts, generalisations and ideas that affected the policy's content.28 Furthermore, information is only one basis upon which decisions get made. It is likely the ideology and interests of more powerful non-government organisations, interest groups, professional associations, media representatives and private industry, combined with policy makers own ideologies, had an impact on how information and evidence was interpreted and used in developing this policy.29
Problem representation and implications
The problem of inadequate nutrition is represented in various ways throughout EWA and NATSINSAP. The initiatives on strategic management represent the problem as a lack of partnership and coordination. This highlights the various sectors that influence the issue, thereby increasing capacity and resources to undertake the work. However, this representation risks diffusion of responsibility and accountability. Use of language such as ‘will’ rather than ‘we will’, ‘government will’ or ‘x agency will’ lacks commitment to implementation. While naming numerous potential partners for collaboration is positive, without a driving force and associated resources one wonders if there will be any real achievements. Specific and detailed roles and responsibilities for partners would provide clearer role distinction and strategic direction. What is left unproblematic is the range of stakeholders outside of health that affect the social determinants of health and thus need to be engaged for change to be made.
The proposed solutions for vulnerable groups (targeting service providers, social policy and structural barriers) take an upstream approach. By posing the solutions in this way the responsibility, and thus blame, is taken away from individuals’ behaviour and focused on their circumstances. Within these broad solutions there are no specific actions detailed. Rather, an emphasis on further research and feasibility studies is detailed but it is unclear how these studies would look and who would conduct and fund them. The push for economic modelling of interventions within the policy diverts attention away from equity issues. An alternative representation would be to include an equity analysis.
The objective around healthy weight represents the problem as inadequate knowledge and lack of co-ordination, and places the blame on individuals, health professionals and government. There is a lot that is left unproblematic and no specific actions are detailed. Again more studies, research, guidelines and collection of evidence are proposed with no detail on who will lead or implement them. The response could differ by including upstream actions to create supportive nutrition environments such as working with industry to alter food composition, creating and implementing policies on food labelling, exploring the impact of food advertising and enforcing regulations, working with urban planners to ensure access to suitable food outlets, provision of healthy food at canteens and addressing the cost of healthy food.30,31
The problem of increasing fruit and vegetable intake is represented as lack of knowledge or understanding about what works. Researchers benefit from this as more funding is required to gather evidence. While health inequalities are acknowledged they are not addressed through proposed solutions and even risk being exacerbated with the focus on promotion and social marketing that can result in unequal uptake among vulnerable sectors of the population. Attention to the whole food system, from production to access to demand, through the use of agriculture policies and fiscal policies would provide a more comprehensive approach to addressing structural barriers.30 Furthermore, development and implementation of monitoring systems to track intake levels across various population groups would monitor nutrition inequalities.
The breastfeeding initiative comprehensively considers health inequalities and social determinants across the macro (contextual), meso (community) and micro (individual) levels.32 By representing breastfeeding as being a ‘whole of community’ issue for which everyone is accountable the responsibility is placed across a range of settings and sectors. However, the impact of maternity leave policies (or lack thereof) within Australia is left unproblematic. The objectives on children address some of the upstream issues such as the impact of food advertising and food provision in school canteens but they leave the economic circumstances of families and their access to cooking facilities and time to shop and prepare food unproblematic (although these issues do get addressed elsewhere in the policy). The incorporation of more upstream actions, such as maternity leave, supportive workplace and whole of school food policies, would better represent the impact of the social determinants of health on maternal and child nutrition.31
A dominant focus on capacity building (12 of the total 26 initiatives are dedicated to this) represents the main problem to be inadequate knowledge, resources and commitment to address public health nutrition issues. In representing the problem as a lack of human resources, and the solution as training and education across a variety of sectors, the focus is on education of the individual practitioner. This leaves the cultural, structural and economic circumstances of their organisation unproblematic. Education is only one determinant of increasing workforce capacity. Infrastructure and resources, workforce instability, supportive organisational and policy environments and intelligence access and use are also important determinants.33 The problem could be represented differently; as a lack of high-level management commitment to public health nutrition and as requiring organisational change to facilitate work in this area. Furthermore as workforce capacity varies considerably across states and territories a national mandate and investment is needed to ensure real national change.
Key areas outlined in NATSINSAP target action towards issues or settings such as food supply in rural and remote areas, food security and social economic status and the environment and household infrastructure. The problem is strongly represented as being due to the social determinants of health. A lack of knowledge and understanding is represented through family-focused nutrition promotion but blame is placed on the health workforce for not knowing what to do rather than the individual for being at fault. Action on nutrition issues in urban areas places responsibility onto service providers and represents the problem as being theirs, as does the emphasis on capacity building. Perhaps the greater level of community consultation and local input into development of NATSINSAP compared to EWA explains this difference in problem representation as it is likely people who are experiencing the issues frame solutions towards what they perceive the real barriers to be.
Within EWA and NATSINSAP the problem is represented as having numerous components and various solutions are proposed. It is represented as due to individual behaviour through solutions on increased awareness and education while the focus on policy change, agencies, health professionals and capacity takes blame away from individuals and highlights the social, environmental, structural and economic barriers people experience to achieving a healthy diet. The policy is innovative in identifying upstream providers of the determinants of health as target groups rather than just individuals or priority population groups.
Significant weaknesses in health promotion within Australia around the time of the policy's conception are highlighted within the literature.34 These include the lack of health impact assessments, dissemination and implementation of best practice programs, investment in capacity development including workforce, research and evaluation, investment in the identification of indicators to measure progress and in particular indicators to measure progress towards addressing the determinants of health and in reducing health inequalities. This discourse on health promotion is reflected in EWA. From this analysis the policy aims to increase investment in capacity building, in identification and dissemination of best practice programs and in research and evaluation. There was less focus on monitoring and addressing the social determinants of health.
Strong partnership and inter-sector collaborative action is essential for public health nutrition and is clearly outlined within EWA. However the plethora of funders and providers working within the Australian public health system risks confusion about roles and responsibilities. With an emphasis on engagement across various sectors strong leadership is needed to ensure coordinated and directed effort. This leadership was aspired to within EWA and it is important subsequent policy builds on this to ensure clear direction.
The decision-making process for EWA took an incremental approach and was influenced by the context in which it was conceived. While a policy making process that is less susceptible to interests and ideologies of the powerful elite, more grounded by evidence and data and incorporates a process to capture the voice of those it aims to help would be desirable, a greater awareness of, and engagement with, the current policy making process in Australia can assist pubic health nutrition advocates to influence future policy.
Limitations of analysis and future research recommendations
The author of this work was not involved in the policy's development. This was an external analysis of publicly available documents accessed via journals, online and government website searches. This presents the limitation of not knowing the tacit or undocumented discussions that took place during policy development. While this point of analysis allows for a fairly neutral interpretation one's own life experiences inevitably impacts on discourse analysis.35 Access to information on how key players interacted during the policy decision making process, the criteria used to identify suitable options, how disagreements were resolved, the significance of data and research on influencing the identification of problems, issues and options and the sources where this data and research came from would provide a much deeper understanding of the decision making and policy making process and further enhance analysis. This report has not attempted to evaluate the effectiveness of EWA or NASTINSAP, however this would be a worthwhile future undertaking. A critical analysis of state/territory public health nutrition policies would also provide further insight.