The Implementation and Maturity of Health in All Policies in Local Governments in the United States: A Qualitative Multiple Case Study

Public health problems are complex and are influenced by many factors related to social and structural determinants of health that contribute to inequities and differences in health outcomes. Evidence shows that current public health approaches are not fully addressing population health challenges. Today’s increasingly wicked and complex public health challenges cannot be solved in silos. Instead, they require cross-sector and collaborative policy, systems, and environmental (PSE) approaches, like Health in All Policies (HiAP). HiAP has the potential to address complex public health problems and improve health outcomes and health inequities because it is a cross-sector approach that does not concentrate on one issue. Rather, it takes a holistic view of upstream PSE factors that influence health (Green et al., 2021).

While HiAP is an active and growing practice in the United States, it is difficult to know whether the patterns of adoption and implementation have changed over time (Onside Partners, 2023). Additional comparison case studies and evidence of local HiAP implementation are needed to better understand HiAP, the contexts in which it is most valuable, and what factors are required to support implementation (Green et al., 2021; Guglielmin, 2020; Huang et al., 2018). Much of the existing literature that describes HiAP implementation is internationally focused and may apply only partially to the U.S. context due to differences in public health systems, government structures, and politics (Huang et al., 2018).

This study used a qualitative multiple-case study with a document review, key-informant interviews, and a facilitated discussion. First, it examined how local governments have implemented HiAP, focusing on the strategies that facilitate implementation, the role of HiAP characteristics, and achieved maturity levels. Second, it aimed to explore the opportunities for enhancing HiAP implementation in local governments.

Throughout this exploration, this study provides valuable insights that inform policymakers, practitioners, and stakeholders, enabling more effective HiAP implementation strategies and contributing to improved health outcomes and equity at the community level. The study found that local governments used various strategies to implement HiAP. Higher-maturity cases had characteristics that supported HiAP, including supportive leadership, knowledgeable staff, and organizational structures to tackle complex challenges collaboratively and impactfully. The more mature cases also evidenced formal processes, evaluation and reporting systems, more comprehensive and multifaceted strategies, and sustained resource allocations. Opportunities for improving HiAP include securing dedicated funding, staff, and infrastructure to support implementation, and listening to and leveraging community voices, strong leaders, and champions. Overall, this study contributes to the existing literature to help practitioners better evaluate and modify their HiAP approach within their local contexts and provide more evidence to support implementation.