The activities, competencies and conditions necessary for public-health policy advisers in a Dutch local government setting to contribute to a healthier living environment: a qualitative multiple-case study

Abstract

The inclusion of health considerations in the design of the physical living environment can contribute to solving wicked health problems, such as obesity and mental health. Such projects demand an integrated approach and strong collaboration between policy domains. At the level of local government, public-health policy advisers can play an important role in this regard. The aim of this study is to explore how public-health policy advisers in the Netherlands deploy cross-border activities to promote a healthy living environment and to identify the organizational dynamics under which they operate. Drawing on the theory of boundary spanning, a qualitative multiple-case study was conducted in three Dutch pioneering local governments, based on a combination of semi-structured interviews and in-depth project analysis. The results indicate that public-health policy advisers engage in a wide range of boundary-spanning activities at the political-administrative, strategic, tactical and operational levels, including participating in spatial-planning processes, understanding the language of the physical domain and providing the right knowledge about health in relation to the environment. Further, this study demonstrates that creating a healthier living environment is the shared responsibility of the entire local government system, thereby calling for leadership, collective accountability, an integrated approach, coordination, and sufficient staffing capacity. Within this context, policy advisers perform guiding, signaling and connecting roles by undertaking a variety of boundary-spanning activities.

INTRODUCTION

According to the National Institute for Public Health and the Environment of the Netherlands, 4% of the total disease burden in the Netherlands is attributable to environmental factors (e.g. air quality, noise and odor), whereas 18.5% can be attributed to individual health behaviors within the Dutch population [1]. The design of the environment and infrastructure has a major influence on the behavior—and therefore the health—of its inhabitants [2–4]. When space is provided for greenery or opportunities for physical activity within the infrastructure of the living environment, this can contribute to the solution of wicked health problems (e.g. obesity) [5–7]. Wicked problems are complex issues that are characterized by unclear definitions and the influence of differing views and interests amongst stakeholders and decision-makers. These characteristics make it challenging to predict outcomes and could potentially cause further issues [8, 9]. For addressing complex health issues, the scientific literature emphasizes the importance of health policy integration [10–13] and working to change systems [14] in order to achieve collective impact [15].

At the local government level, Dutch municipalities operate within a framework of national and regional policies, and they are responsible for the urban design of the town and villages within their jurisdictions. In this article, we use the term ‘local government’ instead of the term ‘municipality’, which is more commonly used in the Netherlands. Local governments determine policy and rules in such areas, as housing, mobility and greenery. After several postponements, a new Environment and Planning Act has been in force in the Netherlands since 1 January 2024 [16]. This new law combines previous laws relating to the physical environment that are aimed at ensuring a safer and healthier living environment. The law requires a more integrated working approach within local government, with more attention to the various policy interests and greater involvement of inhabitants in spatial-planning projects. As indicated by previous studies, health does not receive sufficient attention in spatial developments and other relevant areas [17], even though its inclusion is crucial for addressing wicked health problems. Wicked problems call for an integrated approach that incorporates collaboration and agreements amongst a variety of organizations and policy sectors [4, 18, 19]. Although strong collaboration between the various policy areas is essential in this regard, studies have indicated that this kind of collaboration is difficult to achieve [4, 20]. This is due in part to the existence of two separate domains (silo’s) [4] within the context of local government in the Netherlands: the social domain (regulation of health and welfare) and the physical domain (regulation of the built environment). If health interests are to be included in spatial developments, active efforts must be made to seek connections between the various policy sectors. This article suggests that the public-health policy advisers at the level of local government can play an important role in making these connections. In local government organizations in the Netherlands, public-health policy advisers are responsible for advising local authorities and implementing local health policy. They accomplish this by preparing policy documents, taking grant decisions, making substantive agreements, and working with both internal and external stakeholders.

At present, public-health policy advisers work within a context in which (i) the social and physical domains continue to be largely separate, (ii) limited attention is directed towards the inclusion of health in spatial-planning projects and (iii) health effects are difficult to quantify [17, 20]. As demonstrated by research on intersectoral action between policymakers and community organizations within the context of sports and youth-care services, policy advisers can act as boundary spanners to adapt multiple strategies and practices in local health policy [21]. Boundary spanners perform the cross-border tasks required to encourage collaboration and coordination across departmental and organizational boundaries [22]. To our knowledge [23], however, little is known about how public-health policy advisers within this difficult context try to strengthen collaboration aimed at promoting a healthier living environment, thus acting as boundary spanners within local government organizations.

The aim of this study is to examine the complex, dynamic context of Dutch local government in order to explore the types of boundary-spanning activities that public-health policy advisers undertake in their efforts to integrate health into spatial developments, to describe how they deploy their skills and competencies, and to identify the conditions they encounter within their respective organizations. The sample for this study consists of Dutch local governments that anticipated the arrival of the new law, despite repeated postponements and that are therefore seen as pioneers. These local governments have managed to include health as a prominent component of spatial-planning projects, thereby ensuring that the environment can contribute to the prevention and/or reduction of wicked health problems. The research question for this qualitative multiple-case study is as follows: What activities can a public-health policy adviser undertake to increase the focus on health in spatial developments within the local government organization, and under what conditions do these efforts enhance the integration of health in spatial-planning projects?

THEORY

The academic literature provides several theoretical concepts that offer guidance for analysing the professional activities of public-health policy advisers and the contexts (policy, network, organization) within which they work. Various terms (e.g. ‘brokers’, ‘intermediaries’ and ‘boundary spanners’ [24] are used to refer to people who actively and specifically promote the discussion of health-related themes in settings that have not traditionally been related to health by engaging in collaboration with and coordination between various policy areas and organizations. The public-health literature defines a variety of roles in this area. For example, Karlsen et al. refer to public health coordinators [25], Harting et al. introduce the term ‘health broker’ within the context of the Netherlands [26] and Franssen et al. propose public-health experts as game changers for public health [27]. In addition, Kingdon’s theory on agenda-setting introduces the concept of a policy entrepreneur, who explores policy, problems, potential policy solutions and identifies political opportunities, building bridges to other policy sectors and seizing the windows of opportunity arising as these three streams come together [28, 29].

Building bridges and working across policy/organizational boundaries is also known as cross-boundary work, which is performed by ‘boundary workers’ or ‘boundary spanners’ [23, 30]. Boundary work is currently regarded as one of the most important activities for addressing wicked problems within the context of public governance, as it gives substance to coordination and collaboration across the boundaries of policy, organizations and domains [22]. Van Meerkerk and Edelenbos distinguish [23] four types of boundary-spanning activities: (i) information collection and knowledge exchange, (ii) relational activities, (iii) coordination and negotiating with internal and external actors, and (iv) mediation and facilitating collaboration. For these activities, boundary spanners should possess a variety of competencies, including substantive expertise, communication skills, political-administrative awareness and the ability to cope with differences [22, 31]. The work of public-health policy advisers can be compared to the roles and activities of boundary spanners, as described in the available literature on that topic [23]. The literature nevertheless offers little knowledge concerning how such boundary spanning operates for specific themes (e.g. health) at the level of local government.

The work of boundary spanners and the outcomes of their work are also influenced by the contexts of network, policy and organization [23]. One factor is the network context. For our study, this concerns the interaction between policy advisers and their networks. An adviser must have the ability to build a powerful network with relevant individuals and organizations, as well as to maintain and exploit these relationships in order to take concrete actions and achieve decisions concerning health in spatial-planning projects. A second factor is the policy context. For our study, this consists of the local government and its institutions, political composition, policy priorities and established policy documents. The third factor is the organizational context. For our study, this includes the local government organization and its structure, culture, and approach to work, as well as the position of policy advisers, the conditions under which they must work, and the facilities at their disposal [25].

As a theoretical framework, we use the integrative and dynamic framework on boundary spanning activities and behavior developed by Van Meerkerk and Edelenbos [23] (Fig. 1). In this study, we concentrate on certain aspects of the aforementioned framework, which are highlighted in bold in Fig. 1: the behavior and activities of the policy adviser and the relational dynamics within the policy adviser’s network, along with organizational structure, culture and support, as well as the complexity and dynamics of policies.

METHOD

This qualitative multiple-case study is based on a combination of semi-structured interviews with public-health policy advisers and in-depth project-group interviews, which enabled the collection of more detailed data about the work and activities of public-health policy advisers within a local government [32]. The approach of this research is neither inductive or deductive, but iterative and abductive drawing on open data collection and open encoding in interaction with appropriate theories in the analysis.

Description and choice of study area

According to the Dutch Public Health Act, the local council in each local government is responsible for health policy and its implementation within its jurisdiction [33]. This task is often assigned to a department within a local government organization called ‘social development’ or ‘society’, also called the social domain. Depending on the size of the local government and the political character of the local council, one or more policy advisers are engaged with this task. The amount of staffing capacity and the number of hours available within local government organizations vary widely across local governments [34]. Although all public-health policy advisers provide advice on policy and implementation to address health issues (e.g. obesity, health inequality and healthy living environment), the precise interpretation—and especially the implementation—of their tasks can vary greatly. In this article, we focus on public-health policy advisers, whose primary concern is the creation of a healthy living environment: an environment in which the health of the inhabitants is protected and promoted and in which healthy behavior is encouraged. A healthy living environment includes such elements as environmental factors, active mobility, natural environment, public spaces, housing, the food environment and services. The choice of local governments to be included in this study was guided by the expertise of established public health professionals and based on previous work by the authors concerning the local governments in the Netherlands that have devoted the most attention to health in the physical environment. In addition to the knowledge and expertise of other public health professionals, important criteria included the presence of health in the physical environment in coalition agreements and policy documents over the past decade and the existence of concrete projects around this theme. The local governments selected for the current study are pioneers, as they have taken explicit steps to promote health in recent years, despite well-known obstacles (e.g. collaboration between the physical and social domains) [20]. Given the in-depth nature of this study, we chose to focus on only three local governments. Background information on these three local governments is provided in Table 1. Although the three local governments differ in terms of population size, all consist primarily of urban space, with only a limited rural area. Two of the three local governments have been governed primarily by a coalition of left-wing political parties, and the other had coalitions of various political parties throughout the years. One local government has a separate public health department with its own healthy living environment team, and the other two have assigned health policy to a larger social department with multiple policy areas.

Recruitment participants

Author K.M.’s national network as a public-health policy adviser facilitated direct contact with public-health policy advisers who were actively involved in incorporating health into spatial-planning projects within these three pioneering local governments. The advisers were invited either to participate in the study themselves or to forward the invitation to a direct colleague. This resulted in the participation of four policy advisers: one from each local government and an additional participant from Local Government B, which has two types of advisers (i.e. strategic and implementation). Information about the participants is provided in Table 1.

Together with the participating policy advisers, one spatial-planning project from each of these local governments was selected for in-depth investigation. The criteria for selecting these projects were as follows: the interviewees had been actively involved in the project; the project involved the creation of a vision document for a spatial-planning project after 2015; decision-making had been completed (but implementation need not have been completed) and health had been a substantial topic of discussion. It was ultimately impossible to choose the same type of project for all three local governments, but all projects devote attention to health. Due to other priorities and limited staffing capacity at Local Government A, only two projects were investigated. For Local Government B, the implementation adviser was involved in the selected project.

Data collection

The interviews with the public-health policy advisers were held from September to November 2022. All interviews lasted ~90 min. Written informed consent was obtained from all participants prior to data collection. Each interview was audio recorded. A two-part interview guide was used for the interviews with public health policy advisers. The first part focused on the context (policy, network and organization), and the second part concerned the respondent’s role, activities, competencies, tensions and challenges. The interviews with policy advisers were transcribed verbatim. The interviews were conducted in Dutch, as were the coding and analysis. The quotations were translated into English by a translator from Radboud into Languages (a professional academic language-services company).

The project-group interviews were held in February and April 2023 with the public-health policy adviser, the project leader and an involved policy adviser from another policy area. Informed consent was obtained from all participants prior to data collection, and each group interview was audio recorded. The first part of this interview focused on the processes involved in the case, defining specific moments within the project, as well as involvement and collaboration within the project team and with stakeholders. In the second part of the interview, specific questions were asked about the focus on health in the project and about the role and activities of the public-health policy adviser.

Data analysis

Atlas.ti 23.07 qualitative software was used to facilitate the analysis of data from the interviews with the policy advisers. The transcripts were coded with open coding, after which certain parts of the interview guideline (policy, network, organization, person) and elements of the concepts of policy entrepreneur/boundary spanner served as an initial guideline (coding framework). Authors K.M. and H.S. coded each interview separately, after which they compared and discussed the coding to reach consensus on the final coding framework and coding.

After open coding, the data from the interviews with the policy advisers were analysed and summarized by code for each local government, and an in-depth description was prepared of the policy, network and organizational components of each local government. Next, the codes regarding the roles, competencies and activities of the participants were used to distil an overall picture of the boundary spanner characteristics of ‘public-health policy advisers’, including and the tensions and challenges they faced. This overall view was created for two reasons: first, to decrease the identifiability of specific individuals, and second, to create a broad depiction of public-health policy advisers as boundary spanners.

In addition to the individual interviews, project-group interviews were conducted. The recordings of these interviews and notes taken during them yielded an extensive report and summary for each project. The summary included the aim, organization and highlights of the process, as well as any obstacles encountered. For purposes of data validation, it was sent by email to the participants, with the request to verify that the information had been interpreted correctly. The data from the projects were discussed several times within the research team and used to shed more light on the context-dependent part of the work of a policy adviser. The data were further used to enhance understanding concerning the interplay and dynamics of the project, as well as the contributions and roles of other civil servants in the overall outcome.

RESULTS

This section opens by presenting the results concerning the behavior and activities of a policy adviser with regard to boundary-spanning work, followed by the results concerning the three factors of the framework that influence such work; the policy (environmental) context, the organizational context and the context of the network in which the public-health policy adviser worked. Results from the interviews about two concrete projects in two local governments are included to provide additional insights into the situations within which public-health policy advisers work.

Roles of a public-health policy adviser

According to the participants, the roles and duties of public-health policy advisers are not clearly defined. The participants indicated that their work was designed in a manner that involved considerable personal responsibility and discretionary freedom. As a result, the interviewed policy advisers differed in terms of how they interpreted their roles and the activities that they performed. The results indicate that a policy adviser needs the following individual skills/qualities in order to be an expert with regard to a of healthy living environment: active networking/establishing and maintaining connections; the ability to translate policy into implementation; and the ability to translate concepts between the social and physical domains. Public-health policy advisers negotiate and lobby for more attention to a healthy living environment, and they are constantly seeking new and different possibilities for achieving this aim. To this end, they must fulfil and shift amongst a variety of roles within their positions depending on what is needed at any given time. In this regard, one participant said:

‘You have to be able to change your tone of voice. I also think it’s good if you can distance yourself from things, analyse, reflect, connect with people and be empathic. But you also have to get some results. But then, before you know it, you are a jack-of-all-trades.’ (Case B).

Boundary strategies and activities of policy advisers

The policy advisers who were interviewed performed various types of activities, the following three of which were the most important. First, the participants invested a substantial amount of time in building up a network, both within the local government organization and with various external organizations. One important aspect of this network and the collaboration that was observed across all three local governments appeared to be that building a network requires four levels of involvement: political-administrative, strategic, tactical and operational. Our results suggest that it is only with these levels of involvement that sufficient support can be created to ensure decisions and implementation plans that will contribute to a healthier living environment.

‘We had a clear vision that was shared. Then, once you start talking about strategic, tactical or operational issues, the operations have to work, as does the tactical level, and they have to have the same sort of strategy, which involves having everyone do what they do best.’ (Case B)

A second important activity of a policy adviser involves explaining the ‘why’ of certain aspects (e.g. why is it important to include health in spatial-planning projects) and sharing specific knowledge or ideas on how to do so. The participants also described consciously seeking new knowledge and ideas on their own, given the relative new area of interest within local governments. The complexity of environmental influences on health is often difficult to comprehend, and vision and policy objectives are primarily limited to words. Although policy documents may refer to the importance of health, they do not necessarily say anything about the extent to which such importance is translated into implementation. The timing and use of the ‘right’ language are particularly important in this regard. Public-health policy advisers can draw greater attention to the issue by repeatedly using the right words to provide input in the right places and to the right individuals.

‘It’s the same mechanism working here. The spatial-planning department had a very crucial role in health, but, at the time, they didn’t realise it. Once we found the words to explain this in language they could understand, like for their design research, it was suddenly okay to aim for quality.’ (Case B)

A final important observation is that the participants were actively seeking concrete actions in projects from other policy areas that could contribute to health goals. For example, in Case A the policy adviser collaborated on a project aimed at creating an exercise-friendly environment, and in Case B, the policy adviser was part of a spatial neighborhood team working on physical projects. The respondents nevertheless stated that they had also worked with their own plans, containing possible actions on certain topic, and that this had helped them to work step by step towards developing a long-term approach. For example, the policy adviser from Case C focused on seeking for opportunities in neighborhoods (e.g. neighborhood garden) and the advisers from Case B were consciously working to attract more attention at the strategic level in various departments and organizations. Regardless of these differences, the policy advisers needed to remain flexible in order to adapt and respond to changes and new developments.

Competencies of a policy adviser

The diverse tasks and roles of policy advisers require a variety of competencies. Above all, the participants mentioned being proactive and taking the initiative, being able to work together, making connections and negotiating with different people and organizations at different levels. They also noted the importance of being alert to the context in order to recognize opportunities and take advantage of the circumstances. Policy advisers must thus also possess a certain level of flexibility, in addition to being able to know their own limits. Given the difficulty and complexity of the issue, participants also mentioned intrinsic motivation, drive, and tenacity as important competencies and personal characteristics.

‘You have to be very flexible. One moment, you’re at the kitchen table with one of the neighbourhood inhabitants and, the next moment you’re talking with an area manager or an educational institution.’ (Case C)

‘You have to be enterprising, to be able to see connections, forge them and follow up on them.’ (Case A)

Tensions and challenges faced by policy advisers

Participants reported experiencing personal tension due to the diversity of their roles, activities, and levels of collaboration. Given the broad extent of the policy area, choices must always be made, as not everything is possible. Furthermore, because the results of a policy adviser’s work are neither immediately visible nor measurable, it is difficult to determine whether they are having an impact. This is also difficult for others to see. For example, one participant reported having received little appreciation for what had been done. Given that the work demands extensive collaboration with colleagues from the physical domain, at least one of the participants reported feeling disconnected from the assigned department or the department where most time was spent. Participants mentioned that the type of work and duties that advisers have involve a large amount of responsibility, and that, combined with the high level of work pressure, this can sometimes compromise an adviser’s health.

Policy context

In addition to the information about context (Table 1), the interviews helped us reconstruct how the local governments developed their roles and reputations as pioneers with regard to a healthy living environment. In all three local governments, the participants identified a crucial moment in which all components of the puzzle fell together to prioritize a healthy living environment, which then became an explicit component of policy and implementation (Table 2). This moment was often preceded by years in which a healthy living environment largely remained the subject of sectoral policy dialogue. The crucial moment was accompanied by political-administrative power and the political decision to allocate management and staffing capacity. Thereafter, a healthy living environment received higher priority on the political-administrative agenda, with greater drive and staffing capacity to implement it.

The in-depth group interviews in Cases B and C highlight the significant impact of prioritizing health and creating a healthy living environment for a considerable period of time. The local governments expressed this desire directly in policy and concrete spatial-planning projects. At the same time, during the group interviews, the participants remarked on how little prominence, explicit mention, or discussion health had ultimately received as a theme in the projects. During the projects, the dialogue focused much more on such topics as housing, mobility, and climate. The focus on health was more indirect, but not underexposed, as stakeholders jointly clarified at the start of a project what they hoped to achieve by looking beyond their own fields and connecting health to activities in other policy areas. As demonstrated by Case B the focus on a healthy living environment in a project became stronger when various factors came together. Examples include the reason and need for development of a location of the project, collaboration between the owner and the local government and a policy area that could be linked to other health goals.

Organizational context

In all three local governments, the availability of budget and additional staffing capacity for policy and implementation was decisive in ensuring that the policy was properly followed up, both during and after the crucial moment. The participants mentioned their dependency on other policy areas. (e.g. mobility, greenery or public space) for available budgets, as well as the need to seek win-win combinations with other policy areas in order to utilize the available budget. Participants further observed that having political-administrative support and sufficient staffing capacity had made it possible to work at different levels (political-administrative, strategic, tactical and executive), at different moments and on different projects where decisions were taken. In two of the three local governments, the staffing capacity had been expanded temporarily, due to the inclusion of additional financial resources in the coalition agreement. The participants reported having learned what increases and reductions in staffing capacity mean for themselves and the theme of health. With more staffing capacity, the policy advisers had been able to be more involved in the spatial-planning projects, thus making it possible to generate more attention to health and included concrete interventions in the developing projects. They noted that they had felt more involved and that they had been able to achieve better results. An additional advantage is that this also allowed teams to engage in joint reflection on the strategy, follow the process, or discuss the desired input. The project in Case C demonstrates the significance of the local government’s investment in human resources, with individuals having been given ample time and space for active dedication to specific areas, thereby ensuring commitment and collaboration in the pursuit of a healthier living environment.

One difference between the three local governments was that only the one in Case B had an officially formed ‘healthy living environment’ team. In addition, the extent to which the theme of a healthy living environment permeated the entire organization was also apparently decisive. In Case B, it had been implemented to such an extent that it was self-evident and always had priority, whereas in the other cases. The theme of a healthy living environment was always facing competition from other interests.

In addition to budget and staffing capacity, it is also important to have the ability and space to move and act freely within a local organization. The participants recounted varying experiences with this. The organizational culture and working approach determine the ease with which a policy adviser can operate ‘autonomously’ at various levels and respond to any new developments or opportunities that arise. One policy adviser stated that it was no problem to contact the director, while the other perceived the director as extremely unapproachable.

Time was another significant factor that became particularly evident within the projects. Both projects under review revealed time as a determining factor. Within this context, time did not refer to speed, but to the availability of sufficient time to think, collect information, get to know each other, learn to trust each other, engage in comprehensive discussion of relevant issues and actually shape collaboration. It involved taking time to coordinate projects and manage various projects within a certain area by first understanding the issue and then creating a solid plan before taking concrete steps. Such time must be granted by authority figures (e.g. managers and politicians).

Network context

The networks of public-health policy advisers are essential to their work. With a larger and more diverse network, a policy adviser can take steps to draw attention to health in a more effective and targeted manner. Personal connections, trust and a willingness to help each other are not present right from the start, however, and public-health advisers do not automatically inherit them from their predecessors. They must establish these ties themselves. For this reason, the participants were convinced that it is highly beneficial for a policy adviser to be involved in the health field for a long time. Building and maintaining such a personal network is also a continuous process, given the many changes and staff turnover occurring within local organizations.

Policy advisers must be aware of the various levels in their networks, and they must exploit this knowledge. Individuals at various levels must be connected with each other, both horizontally and vertically. It is important for them to know what is happening, while also connecting in terms of content and sharing the same goals. Conversations and ideas occurring at a similar level between an external party and the local government can also serve as a catalyst for initiatives or pilot projects that would otherwise not have been initiated within the local government. Furthermore, both internal and external network partners are important support, allies or sparring partners for the policy adviser. These are mainly partners who also have a personal drive to work on health and a healthy living environment.

Although the focus of this study is on the human networks of policy advisers, the interviews also revealed distinct differences in how local governments position themselves and play a role in collaborating with other organizations. In Case B, the local government was in the lead, in contrast to Cases A and C, in which external stakeholders also had very clear roles. For example Case A, an external stakeholder occupied the important position of project leader, and knowledge institutions were explicitly involved. In Case C, stakeholders, hospital and knowledge institutions actively advocated the theme of health, after which the local council embraced it.

Tensions and challenges within the context of the local government organization

In addition to personal tensions and challenges, the participants referred to many challenges within the pioneering local governments. These challenges involved well-known barriers that are also encountered by other local governments in their collaborative projects and decision-making. The first barriers to be overcome are institutional barriers, including divergent working approaches and differences in culture between the social and physical domains. According to the participants, success largely depends on people having a ‘click’ with one another, as well as on the presence of trust that have been built up through previous projects. A second barrier has to do with the extent of coordination between various policy processes and spatial-planning projects, given that processes often run parallel and/or independently of each other. A third barrier concerns discussions revolving around how non-monetary values (e.g. health) should be included in decision-making. This is because there is no clear correlation between short-term investments and long-term returns, whereas decision-making in spatial-planning projects often involves quantifiable indicators. This issue is not easy to resolve when trying to adhere to a local government’s current budget and accountability methodology. The problem should be addressed with a genuinely different perspective on the distribution of budgets and accountability. One participant emphasized the importance of using jointly determined indicators at the beginning, in order to make it easier to assess if whether the execution is in line with the adopted policy and ambitions concerning health and well-being.

The pioneering local governments also faced additional challenges, including the need to ensure that attention to health is maintained and does not weaken. Local governments may strive to anchor health within the structure of their organizations and in spatial-planning projects, while also attaching less importance to regular opportunities for public-health policy advisers to participate in spatial-planning projects. The presence of this challenge can be confirmed by the fact that, in all cases, the staffing capacity of the health team was reduced after a period of time. If this occurs, it might signal that the knowledge of health and the input of the public-health policy adviser are no longer needed. In contrast, however, one of the participants referred to the importance of being present in order to avoid another new challenge: cherry-picking. Referring to selective choosing, cherry-picking, is a cause for concern, as decision-makers may consider it too burdensome or too inconvenient to maintain an overview of every health-related aspect, and they may prematurely declare that the environment is healthy. This is due to the difficulty of balancing all the different interests of a local government when taking a decisions. Different interests frequently clash, particularly at the level of implementation where not all possibilities are feasible and decisions must be taken. All participants, noted that ensuring that measures aimed at protecting and promoting health are translated from vision to actual implementation and realization continues to pose a challenge.

DISCUSSION

Public-health policy advisers

The objective of this study is to identify the types of boundary-spanning activities that public-health policy advisers performs within the context of a local government organization in order to draw more attention to health in spatial developments, as well as the conditions under which their efforts lead to the inclusion of health in spatial-planning projects. The results demonstrates that public-health policy advisers undertake many different boundary-spanning activities at the political-administrative, strategic, tactical and operational levels. They must participate in and understand the processes of spatial-planning projects, in addition to understanding and speaking the language of the physical domain, connecting to other more important policy themes (e.g. housing, mobility and climate) and introducing the right knowledge about environment-related health. In short, public-health policy advisers play an important role in continuously drawing attention to the theme of health in spatial-planning projects.

To fulfill their tasks, it is crucial for policy advisers to have their own extensive networks within and outside their organizations, along with a clear position that is supported by the local government organization. The results also highlight the importance of having sufficient staffing capacity within the local government to carry out this task. In the participating local governments, staffing capacity has decreased over the years, making it more difficult for public-health policy advisers to be properly involved in spatial-planning projects. The experiences recounted by the participants are in line with those reported by McGreevy et al., who conclude that it is very important to be actively involved in spatial-planning projects for a long period of time [12]. Furthermore, as demonstrated by Berglund-Snodgrass et al. the presence of a policy adviser specifically for public health, even with limited authority, can serve as a moral conscience to remind everyone involved in the project to ensure attention to health [35].

As the theoretical framework of this study, we applied the framework of boundary spanning, as developed by Meerkerk and Edelenbos [23]. The role, competencies, and activities of public-health policy advisers largely correspond to those of boundary spanners. In contrast to the theory’s clearly defined profiles of boundary spanners (i.e. fixers, bridgers, brokers and innovative entrepreneurs) our results indicate that public-health policy advisers cannot be clearly characterized according to any one of these profiles. Instead, they shift between the various profiles during the course of their work, depending on the situation. This continuous awareness makes the work of public-health policy advisers challenging, and it demands a great deal from them. The activities and competencies that Van Meerkerk and Edelenbos [23] list for the four different roles are part of the daily work of a public-health policy adviser; relationship building, communication and translation skills, facilitation skills, and recognizing and seizing opportunities. In addition, the competency of ‘being persistent’ clearly emerged as an important quality, especially because the results of the work are difficult to visualize and because these advisers must be content with small steps. One element that is not addressed in the theory, but that should not be underestimated in the work of a public-health policy adviser, involves the adviser’s enthusiasm for the theme of health, substantive expertise and degree of internal motivation. This is because of the limited recognition and appreciation given to such laborious, invisible work. We are convince that, combined with boundary-spanning activities, these aspects are important, and they may make a difference in the work of public-health policy advisers. We agree with other scholars [36], this could also apply to other positions within the local government organization, given the current underestimation of the importance of content and long-term involvement in a subject, with an excessive focus on the process.

Public-health policy advisers often use the same types of skills and carry out the same tasks as described in boundary-spanning theory. It is nevertheless unclear whether public-health policy advisers are also recognized as boundary spanners within the contexts in which they operate, as is the extent to which this view is also embraced and supported by management. The fact that health can be easily connected to other policy areas does not mean that public-health policy advisers function as boundary spanners or that they are directly appointed as such. In our assessment, public-health policy advisers currently take on the role of connector themselves, as this is required in order to create an integrated approach to health policy. At the same time, however, public-health policy advisers are not yet sufficiently supported and positioned as boundary spanners within the local government organization. Given that the role and activities of public-health policy advisers who promote a healthier living environment are also relatively new and therefore evolving, this study could provide public-health policy advisers with more insight into how to address this complex issue. Furthermore, in light of the call by Fick et al. [37] for more boundary-spanning leadership by public health services, we recommend that local governments engage in deeper exploration of the importance of the role of boundary spanners and their activities, whether within an existing policy adviser position or possibly within a newly created position. These steps could ensure that public-health policy advisers can have more influence in the creation of a healthy living environment or other complex social challenges.

The context

Our study focused primarily on public-health policy advisers and their boundary-spanning activities in the integration of health into spatial-planning projects. As indicated by the results, however, the organizational environment and the conditions under which public-health policy advisers work have a significant impact on their level of success, influence, and satisfaction. Although boundary-spanning activities can be initiated by a public-health policy adviser, strengthening the process and cross-sectoral collaboration requires these efforts to be supported and incorporated by others. When necessary, adjustments must be made to the organizational structure and procedures. It is evident that achieving a healthy living environment requires the entire local organization, and it cannot be the sole responsibility of one or a few public-health policy advisers.

The lessons learned from the three local governments demonstrate that highlighting health in spatial initiatives and fostering a healthier living environment requires a combination of leadership, collective accountability, a holistic approach, coordination and a sufficient level of staffing capacity Without these elements, it is impossible to take steps to achieve a collective impact on health. Four of the five components of collective impact [38] could be observed in these three local governments. First, investments were made in establishing boundary-crossing collaboration, building an internal and external network and facilitating public-health policy advisers and other officials. Within local governments, this is still a major challenge [39]. Second, the local governments put health first and focused on health as a common goal. Years before, they had already demonstrated the courage and determination to address this issue, thereby providing a crucial foundation on which public-health policy experts could build. Courage was also exhibited in the approach chosen, thus demonstrating leadership and the willingness to be a pioneer. The third component of collective impact involved a focus on clear communication, learning to speak each other’s language and finding a common language. Fourth, additional financial resources were invested in staffing capacity and activities, thereby increasing the presence and involvement of public-health policy advisers in spatial-planning projects. The only component of collective impact that was observed to only a limited extent was the joint monitoring of collective impact on a healthy living environment. Participants nevertheless mentioned this as an important concept that should be addressed [40, 41]. The participants perceived their participation in this study as an opportunity for monitoring and reflecting on the process.

The results of this study reveal three additional aspects that, in our opinion, should be given more emphasis. First, the cases and projects vividly demonstrate the importance of taking time. More specifically, it is essential to take the time to understand things and learn how to work together, as well as to understand the persistence of the subject and the crucial importance of persevering for a long period of time [10, 12, 13, 42, 43]. It is definitely advantageous for those involved to have been in the same position for years, such that they are able to use their knowledge, experience and broad network. A second aspect concerns the importance of continuity for building knowledge and experience, as well as relationships of trust- in people, as well as in attention and the repeated highlighting of the importance of health in every new project. It is crucial to appoint a sufficient number of public-health policy advisers. Without sufficient staffing capacity, they cannot be represented in all projects and processes. To our view, it is at best dubious to assume that the goals could be accomplished without the assistance of a public-health policy adviser once health has apparently been incorporated into the spatial-planning procedures at a certain point. Third, it is also important to consider whether the theme of health has truly been embedded within the core of the organization.

With this study, we provide further insight into the operation of boundary-spanning activities at the local level, specifically for the theme of health, and the conditions that public-health policy advisers need to order to work on the theme of a healthy living environment. It is clear that attaining a healthier living environment requires the entire system within the local government organization to participate in the ongoing collective approach. Politicians and managers within the local government must recognize that this issue cannot be the sole responsibility of the public-health policy adviser: it is a joint responsibility. The local council and the management of the local government organization must create an array of important conditions within the local government system, including policy with clear long-term goals, sufficient budget and staffing capacity and involvement in the topic at all political and organizational levels [25, 44]. It is also important to incorporate health into existing accountability cycles, quality procedures and HR training programs. This calls for introducing a different way of working that is more area-oriented and that involves more boundary-crossing collaboration, in addition to training the public-health policy advisers in skills that are important within an ever-changing context. At the same time, it is important to acknowledge, that, when considering the creation of a healthy living environment, also it would be worthwhile to take additional factors into account, including the influence of power on decision-making [45, 46] and the crucial function of infrastructure in urban environmental design [2].

Strengths and limitations

One important strength and value of this study has to do with its in-depth research on the boundary-spanning activities of public-health policy advisers, based on information obtained from four participants and two cases. At the same time, however, this characteristic also constitutes the main limitation of this study. Although the results provide valuable insight into the world and duties of public-health policy advisers working to promote a healthier living environment, this does not imply that policy advisers do everything the same way in every Dutch local government, and certainly not outside the Netherlands. A larger study involving more local governments and policy advisers would provide a broader, more generic insight into the current state of affairs and the most important common denominator in such efforts. It would be interesting to conduct further research on how visions of a healthy living environment are actually implemented and how local governments cope with the variety of interests existing within a project. At present, such efforts often fail, due to a continuing preference for quantitative input and short-term returns.

CONCLUSION

This study demonstrates that local governments that are regarded as pioneers in the field of healthy living environments have acquired knowledge over time and have undergone a preliminary process that has produced conditions that facilitate the creation of a healthy living environment. Essential conditions include a shared vision; the involvement of actors at the political-administrative, strategic, tactical and operational levels; sufficient funding for personnel; and long-term approaches and continuity. Within the local governments participating in this study, the public-health policy advisers attempt to generate more attention to health in the process of spatial-planning projects by undertaking a variety of boundary-spanning activities, including bringing colleagues together, contributing knowledge and explaining why health is important. Although public-health policy advisers enjoy considerable freedom in the execution of their duties, they do not receive adequate institutional and managerial support for their boundary-spanning role. This study demonstrates that working towards a healthier living environment is a joint responsibility of the entire local government system and an ongoing process of building relationships and finding opportunities. Public-health policy advisers perform a guiding, signaling and connecting role within this process, but they cannot stand alone.

ACKNOWLEDGEMENTS

We would like to thank the participants for their time and effort.

STUDY FUNDING and APC FUNDING

This work was supported by the Municipality of Nijmegen and the Academic Collaboration Centre AMPHI for Integrated Health Policy at the Radboud University Medical Center.

CONFLICT OF INTEREST

Researcher K. Mourits also works as a policy adviser for the municipality of Nijmegen in the Netherlands.

AUTHORS' CONTRIBUTIONS

Kristine Mourits (Conceptualization, Data curation, Investigation, Methodology, Writing—original draft), Hilde Spitters (Conceptualization, Data curation, Investigation, Writing—review & editing), Koos Van der Velden (Supervision, Writing—review & editing), Marleen Bekker (Conceptualization, Supervision, Writing—review & editing), Gerard Molleman (Conceptualization, Supervision, Writing—review & editing).

DATA AVAILABILITY

The datasets presented in this article are not readily available because the qualitative data cannot be anonymized only pseudonymized. The participants of our study can be identified because it concerns a small group of people in specific positions at municipalities in the Netherlands. This makes it possible to find out who said what and when. It is therefore the policy of Radboudumc not to disclose this data in this manner. Requests to access the datasets should be directed to [email protected]

ETHICS ISSUES

The medical ethics committee for the Arnhem-Nijmegen area (number 2018–4251) approved this study. The study was conducted according to the principles of the Declaration of Helsinki (October 2013, 64th WMA General Assembly) and in accordance with the Dutch Personal Data Protection Act. Written informed consent was obtained from all participants prior to data collection.

References