key: cord-0425543-awpyye6s authors: Mindell, J. S.; Parag, Y.; Bartington, S. E.; Stoll, L.; Barlow, J. G.; Janda, K. B. title: The Middle-Out Perspective -- an approach to formalise 'normal practice' in public health advocacy date: 2021-11-21 journal: nan DOI: 10.1101/2021.11.17.21266405 sha: b4b521969509dae04e57fbd9481b0379da8e6dcf doc_id: 425543 cord_uid: awpyye6s Background: The Middle-Out Perspective (MOP) provides a lens to examine how actors positioned between government (top) and individuals (bottom) act to promote broader societal changes from the middle-out (rather than the top-down or bottom-up). The MOP has been used in recent years in the fields of energy, climate change, and development studies. Public health practitioners involved with advocacy activities and creating alliances to amplify health promotion actions will be familiar with the general MOP concept if not the formal name. Methods: This paper introduces the MOP conceptual framework and customises it for a public health audience by positioning it among existing concepts and theories for actions within public health. Using two UK case studies (increasing signalised crossing times for pedestrians and the campaign for smoke-free legislation), we illustrate who middle actors are and what they can do to result in better public health outcomes. Results: These cases studies show that involving a wider range of middle actors, including those not traditionally involved in improving the public's health, can broaden the range and reach of organisations and individuals involving in advocating for public health measures. They also demonstrate that middle actors are not neutral. They can be recruited to improve public health outcomes, but they may also be exploited by commercial interests to block healthy policies or even promote a health-diminishing agenda. Conclusions: Using the MOP as a formal approach can help public health organisations and practitioners consider potential 'allies' from outside traditional health-related bodies or professions. Formal mapping can expand the range of who are considered potential middle actors for a particular public health issue. By applying the MOP, public health organisations and staff can enlist the additional leverage that is brought to bear by involving additional middle actors in improving the public's health. and creating alliances to amplify health promotion actions will be familiar with the 26 general MOP concept if not the formal name. 27 Methods: This paper introduces the MOP conceptual framework and customises it for 28 a public health audience by positioning it among existing concepts and theories for 29 actions within public health. Using two UK case studies (increasing signalised crossing 30 times for pedestrians and the campaign for smoke-free legislation), we illustrate who 31 middle actors are and what they can do to result in better public health outcomes. 32 Results: These cases studies show that involving a wider range of middle actors, 33 including those not traditionally involved in improving the public's health, can broaden 34 the range and reach of organisations and individuals involving in advocating for public 35 health measures. They also demonstrate that middle actors are not neutral. They can 36 be recruited to improve public health outcomes, but they may also be exploited by 37 commercial interests to block healthy policies or even promote a health-diminishing 38 agenda. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint their influence in three directions: middle-up, middle-down, and sideways ( Figure 1 ). 66 They also examined the modes by which influence was exerted: 'enabling', 'mediating' 67 and 'aggregating'. 1 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint which impact upon physical and mental health and contribute to health inequity. 11 The 83 mechanisms by which such factors influence health are dynamic and inter-related, 84 involving a diverse array of multi-sectoral stakeholders operating within a broad, 85 complex system, which the public health community must effectively navigate and 86 ultimately influence to achieve desired outcomes. Therefore, public health 87 professionals are well accustomed to operating beyond organisational 'silos'. Yet the 88 role of critical actors who are in the 'middle' of the system is often neglected in 89 traditional public health practice. 12 Existing conceptual models include characterisation 90 of preventative public health action reflecting targeted interventions for 'upstream' 91 health determinants (structural, affecting the population) and 'downstream' 92 (individual) minimisation of harmful consequences, 13 and application of systematic 93 methodological frameworks, e.g., Health Impact Assessment processes. 14 94 Nearly all health promotion programmes and public health policy initiatives involve 95 changes in people's behaviour and practices and the introduction of new norms and 96 procedures. Their success depends on multi-faceted efforts, requiring collective action 97 to tackle and overcome different societal, technological and economic challenges. 98 Thus, actors such as government and regulators collaborate with public, third sector, 99 and sometimes private organisations and the public to achieve goals. In other words, 100 . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. Parag and Janda identified specific attributes necessary to be considered as middle 140 actors (Box 1). 1,4 Kranzler and colleagues described the domain of middle actors as 141 "elusive administrative spaces" within which they "shape policies, steer funding and 142 facilitate continuity". 5 Through these domains and activities, middle actors can exert 143 their influence, upwards to policy makers, downwards to the public, and sideways on 144 other middle actors in the policy arena. 145 Middle actors can be the immediate target that public health is aiming to influence 146 because of their potential to be powerful allies or communication channels for 147 knowledge exchange and suggested actions. They may be entities that affect the 148 public's health, without being recognised as public health organisations, such as 149 companies providing public transport information. 150 . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint types of contextual, technical, normative barriers and obstacles. 1 These modes of 164 action occur both within public health 5 and elsewhere. 2 165 Mediating is particularly suited to public health practitioners' strengths in using 166 language appropriate for different audiences and, where necessary, 'interpreting' 167 between different professional or disciplinary groups, policy-makers, and the public, is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint For each case study, we analysed who the actors were and how the actions taken by 205 the key actors were used, applying the MOP framework described above. 206 . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint against smoking, they can be invisible to decision-makers and their voice is not 226 heeded. Aggregating these voices in a coalition made them more visible and their 227 demand more influential. ASH's professional expertise and reputation made them a 228 trustworthy actor and granted them a professional legitimacy in the tobacco policy 229 domain. The middle actors' coalition's activities are summarised in Table 1 . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; Health's comments that poor women needed to smoke. Middle actors worked with employers, employees, and lawyers to raise the threat of legal action by employees. ASH's initial sideways work was with an existing core group of middle actor organisations. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint proposed that in future, Pelican crossings should not be installed -although existing 296 crossings could remain. The strong support in the ensuing consultation of many middle 297 actors, including several NGOs and two-thirds of local authorities, demonstrated the middle-298 sideways impact. In 2015, the DfT issued mandatory guidance that signalised pedestrian 299 crossings installed in future must either provide a 'countdown' (Figure 2b) is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint from NGOs, academics, and commercial organisations working together with traditional 336 public health bodies to influence policy-makers (middle-up), while implementation involves 337 the same actors working middle-down. 30 Many would argue that this, and the MOP, is how 338 public health works, and has always worked. 339 What this study adds 340 We suggest that using the MOP framework as a diagnostic lens and formal structure can 341 assist public health professionals and others to identify the 'missing middle actors' and the 342 interactions between them and other key actors. A more systematic approach would help in 343 the design of advocacy or implementation strategies to achieve desired policy or behaviour 344 changes and amplify the effectiveness of sideways, middle-up, middle-down, top-down and 345 bottom-up activities. 346 The MOP can lead to public health practitioners stepping back and working in the 347 background, leaving more overt action to others. While this low profile may be problematic 348 for some individuals, or for justification of resources such as staff time, the goal should be 349 the outcome in terms of the benefits for population health rather than the visibility of public 350 health departments. Public health advocacy is a core skill of public health, yet the requisite 351 skills and qualities are challenging, including familiarity with the evidence base and ability to 352 effectively articulate key messages and relevant narratives to influence opinion leaders and 353 the general public. 31 The process can also involve potential conflicts in the blending of 354 science, politics and activism in the context of wider public interest, such as the different 355 timeframes of politicians and outcomes of effective public health measures, 32 yet also has 356 the power to deliver major systemic change. Legislation has a role reducing non-357 communicable diseases 32,33 ; many recent public health laws that have been implemented 358 . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint were achieved through use of a middle-out approach, including banning tobacco marketing, 359 plain packaging of tobacco, and nutrition labelling. In case study 1, the lead middle actor 360 recruited a broad set of middle actors, including many who are not traditionally involved in 361 public health work. In case study 2, most of the middle actors were more traditionally 362 involved in promoting the health of the public. In both case studies, the lead actor was an 363 NGO but that role may be taken by local government, public health bodies or departments, 364 community groups, or others. 365 It should be recognised that those with opposing goals may also use a middle-out approach. 366 For example, the tobacco industry involved the National Federation of Retail Newsagents 367 and the Tobacco Retailers Alliance (membership organisations for newsagents and 368 tobacconists) in opposing legislation to ban tobacco advertising 9 and the hospitality industry 369 to oppose proposed smoke-free legislation. 23 Such efforts include apparent bottom-up 370 activities using manufactured 'grass-roots' campaigns, referred to as 'astroturfing'. 9 Many 371 health-diminishing industries have used techniques trialled by the tobacco industry 34 ; 372 proponents of good health can also learn lessons. 9,35 The tobacco industry formerly, and the 373 food and beverage industry more recently, have used a 'sideways' approach, involving 374 national and international sporting bodies and individual clubs to promote unhealthy 375 products to those attending or watching such sporting events ('middle-down'). 36 It is not 376 known whether these bodies also support their sponsors' interests in a 'middle-up' fashion. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint The United Nations (UN) Inter-Agency Task Force on the Prevention and Control of Non-381 communicable Diseases has called for increasing effective health-promoting partnerships 382 with civil society and the commercial sector, giving due regard to managing conflicts of 383 interests. These include stronger regulation and legislation to provide an environment that 384 enables behaviours that promote health. 37 Much of this can be facilitated by taking a 385 middle-out approach, which assists formal consideration of the broader range of 386 organisations and groups that could be involved as allies. The MOP can also help with the 387 systems thinking that is now recognised as crucial in improving population health. 10 388 The main limitation is that the two case studies may not be representative. They were 390 selected because we believe they illustrate the impact of middle actors. The MOP may be 391 more or less applicable to other public health issues. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 21, 2021. ; https://doi.org/10.1101/2021.11.17.21266405 doi: medRxiv preprint A middle-out approach for improving energy performance in 421 buildings Strategizing demand management from the middle out: 423 Harnessing middle actors to reduce peak electricity consumption Reducing Carbon from the "Middle-Out": The Role of 426 Builders in Domestic Refurbishment More than filler: Middle actors and socio-technical change in the 428 energy system from the "middle-out Public Health from the Middle-Out: A New 430 Analytical Perspective A health map for the local human habitat More Than a Message: Framing Public Health 434 Advocacy to Change Corporate Practices The commercial determinants of health All in this together: the corporate capture of 438 public health Systems Thinking as a Framework for Analyzing 440 Commercial Determinants of Health: Framework for Analyzing Commercial 441 Determinants of Health WHO Commission on Social Determinants of Health: Closing the gap 443 in a generation Key concepts in 448 public health An effectiveness hierarchy of preventive interventions: 450 neglected paradigm or self-evident truth? London as a public health tool for increasing synergy between policies in other areas The need for a complex systems model of evidence 455 for public health Systems approaches to global and national physical 457 activity plans World Health Organization, Ministry of Social Affairs and Health, Finland. The Helsinki 459 Statement of Health in All Policies Public health advocacy: process and product Academic advocacy in public health: Disciplinary 'duty' or 465 political 'propaganda'? What principles should guide interactions 467 between population health researchers and the food industry? Systematic scoping 468 review of peer-reviewed and grey literature Voluntary agreements: designed to fail Most older pedestrians are unable to cross the 471 road in time: a cross-sectional study Comprehensive smoke-free legislation in 473 England: how advocacy won the day Action on Smoking and Health Department for Transport. DfT Circular: The Traffic Signs Regulations and General 477 Directions Physical activity and the environment NICE guideline ng90. Public Health England, 479 www.nice.org.uk/guidance/ng90 Department for Transport Public health activism: lessons from history? Childhood immunisation in South Asia -overcoming the hurdles 485 to progress Sustainable development goals: implementing the hygiene indicator in 487 schools Training to be unpopular: five short steps to becoming a public 489 health advocate Refocusing upstream -three decades of public health: a personal 493 reflection Legal capacities required for prevention and 495 control of noncommunicable diseases Partnerships with the alcohol industry at the 497 expense of public health Lessons from tobacco control for advocates of healthy transport Commercial determinants of health: advertising of 501 alcohol and unhealthy foods during sporting events Actions needed to prevent noncommunicable 504 diseases and improve mental health 414 We thank all participants in the Middle-Out Perspectives workshop held in Herzliya, Israel, 415