Health Promotion Political Research as Policy Practice

Abstract

The application of theories from political science to health promotion policy research has distinct advantages. However, there are also a number of barriers to overcome. This chapter addresses some of the conceptual opacity around terms (what is policy; how to study policy; what is a theory; why is theory practical for policy research; how does this apply to a range of health issues?). The chapter discusses notions of Healthy Public Policy and Health in All Policies, and lands on the understanding that they are all policies for health. It then proceeds by identifying health promotion policy research challenges, first looking at two iterations of policy analysis (Did the policy do what it intended to do? Why does the policy look like it does?). After this, a very brief identification of descriptive and normative theories of the policy process leads to a small group of applicable ‘strong theories’ illustrated with examples and challenges to the field’s indolence. The chapter concludes by a call to action for political research with health promotion.

FormalPara Key Concepts Definitions

Policy: ‘…the expressed intent of government to allocate resources and capacities to resolve an expressly identified issue within a certain timeframe’ (De Leeuw et al., 2014).

Political science: The study of influence and the influential (Lasswell, 1936)

Policy research: The study of the development of public policy over time and the context, events and individuals surrounding this complex environment (Weible et al., 2012)

1 Introduction

Setting the conditions and opportunities to promote health of individuals and populations happens at many different levels. At an individual level, people and their families and communities make more or less conscious choices – what food to eat, what (psychotropic) addictions to access, choosing mobility and active transport opportunities and finding education and work that suits us. These examples also show that for many, the total exercise of ‘free will’ may not exist. A level playing field for making informed choices may not be accessible to everyone. If you live in what colloquially has become – wrongly – designated a ‘food desert’ (Cummins & Macintyre, 2002), the aspiration to eat the recommended quantities of fruits and vegetables may simply not be realistic without the need for some sort of systems action. In the absence of walkable and bicycle-able infrastructure or in adverse climate (e.g. because you happen to live in an urban heat island, e.g. Cutts et al., 2009), some people may be forced to use the less healthy option of owning and using a car with an internal combustion engine. It may be more convenient (and even perceived to be the only option) in the short run, but automobile ownership is associated with (a) lower social capital (Currie & Stanley, 2008; Nieuwenhuijsen & Khreis, 2016) and thus challenged health potential, and (b) carbon emissions, thus endangering planetary health.

This description of the interface between individual freedoms and choice, and collective engagement may lead to a level of frustration and asphyxiation among individuals, groups and communities in societies. They may not feel part of a world that involves policy responsiveness. There appear to be increasing levels of distrust in public policy and the political processes that drive them (OECD, 2020). In many places, people seem to disconnect from systems and processes that allow for collective action – such as democratic elections, participation in public institutions, community organisation in solidarity with ‘less fortunate’ members of society, etc. Policy, and the processes that create and maintain policy (‘politics and Politics’ – see below), is seen by many as a chaotic, ephemeral, unaccountable and an inherently suspicious enterprise. These beliefs, in fact, create a vicious cycle where those that ought to control – and be integral to, rather than just be at the receiving, pointy end of – policy processes become even more disjointed from the things and people that matter: (inequitably) affected communities and individuals.

Responsive, transparent and accountable policy making seems to be the answer to this complex situation. And research ought to be part of the answer – as it would enable us to understand why collective choice happens, how it happens and what its intended and collateral impacts and outcomes are. In the simplest of definitions of politics (who gets what, why and when – Lasswell, 1936), this research agenda is integral to the health promotion effort. It is argued that research is in fact policy practice.

A key remit of the health promotion value system is that any of its action areas can and must be supported by policy development. Creating supportive environments, reorienting health systems and shaping community action all depend on some level of direction which the Ottawa Charter identified as ‘policy’. Recognising the then (1986) recent insights from emergent social epidemiology and health equity research, the Ottawa Charter for Health Promotion followed inspiration by Milio and Hancock, and called for the development of ‘Healthy Public Policy’ (HPP).

Interestingly, the father and mother of the term HPP argued for its development based on a retrospective inventory of the impact of (public) policy on (population) health. At the time they had no firm empirical and evidence-based perspective on how such policy was to come about. Milio documented such policies in Norway (the ‘Farm-Food-Nutrition Policy’, Milio, 1981) and Australia (‘Making Policy: a mosaic of Australian community health policy development’, Milio, 1988) and Hancock (1982) saw HPP as integral to Healthy Cities development.

In this chapter, we will do the following. First, we briefly explore what can be understood by the term ‘policy’. Second, we move this concept into the health promotion space and consider the prolific presence of neologisms around the health-policy interface. Third, we endeavour to present a very scant review of theories of the policy process and how they are relevant for health policy. Finally, our analysis will land on arguing for more and better health political science research in health promotion. First suggestions how to make this happen will be formulated.

2 What Is (Health) Policy and How to Research It?

With its preoccupation with interventionist perspectives, the health promotion field (and associated research) would benefit from a clear conceptual grounding when we talk of ‘policy’. Policy, to be brief, is not the intervention. It sets the parameters for a package of interventions and their connected context. Policies exist within a much larger societal brief that includes the notion of ‘governance’ (see de Leeuw, 2015, and Greer et al., 2017). The study of interventions in a policy context has its own body of literature (see, e.g. Bemelmans-Videc et al., 2011). Clear insight and guidance for policy intervention development and packaging exist. These do not always necessarily follow conventional ‘evidence-based’ or ‘knowledge-translated’ logics. The interface of governance and health has an even larger and fuzzier scope (e.g. Thomann et al., 2019). But in this chapter, we zoom in on ‘policy’.

Even those that professionally ponder policy have trouble defining policy. Sometimes it is considered merely equivalent to ‘the plan’ (‘This is how we will get from A to B’) or a rule (‘No access to people under three feet’). The latter is sometimes elevated to legislation or some high-level government institutional arrangement. For instance, in Australia the vast inequities experienced by Indigenous peoples (in health; housing; liveability; education; etc.) were – finally, after many years of malevolent ignorance and neglect – elevated to ‘policy’ level. But this happened through federal government that established, in July 2008, a National Indigenous Health Equality Council, and a Commonwealth arrangement called the National Indigenous Reform Agreement. Together, they set a number of targets which each contains series of specific policies (Gardiner-Garden, 2020). None of these, by the way, seem very effective (Dawson et al., 2020), perhaps precisely because no real policy has been made – only mere aspirations without mechanisms or accountabilities. The bottom line, however, is that scholars, politicians and bureaucrats can refer to any of the elements of this approach as a, or the, policy. The opacity of this realm is, indeed, confusing. Sometimes researchers simply skirt the issue. For instance, in a high-profile paper Carey and Crammond (2015) simply say that ‘the policy process’ is what happens ‘inside government’. But in a troubling twist, in their empirical research of the 23 ‘policy practitioners’ interviewed, ten are lobbyists (whom we cannot assume belong ‘inside government’ – Woll, 2007). That seems to be blurring the lines considerably, although the study does give some surprising insights into the roles actors play in the policy game.

De Leeuw et al. (2014) give a brief review of perspectives on ‘policy’. Noteworthy is the valuable nihilism that ‘no policy is also policy’ and the observation that sometimes policy is made that is demonstrably ineffective, or only aims to appease certain groups of stakeholders. This is known as ‘symbolic policy’. Ultimately, though, they land on a description of policy as ‘…the expressed intent of government to allocate resources and capacities to resolve an expressly identified issue within a certain timeframe.’ This lens takes into account that public (government) policy concerns itself with social issues (see, for instance, Gusfield, 1984) and the (re)distribution of resources (which include both tangible – money, infrastructure – but also intangible – ideas, access – dimensions). In fairly gross terms, policies (or policy instruments) then embark on three paths of instrumentation: communication (or ‘sermons’), facilities and incentives (‘carrots’) and coercion (‘sticks’). Public policy implementation tends to follow the ‘path of least coercion’, that is, politicians prefer first sermons, then carrots, and finally the sticks, cf. Bemelmans-Videc et al. (2011). In practical health promotion terms, for example in COVID-19 control, this translates into public sector’s first preference for media campaigns (distance yourself!), then the establishment of facilities (e.g. plastic shields in shops, markers on floors to encourage physical distancing) and finally regulatory action that enforces lockdowns, fines, etc. This faux-logic of (temporally) escalating intervention types may well reduce policy efficacy.

There is strong evidence across social and health policies that good combinations of instrumentation in complex policy packages yield considerable synergies (Smedley & Syme, 2000). In the COVID-19 example: each of the types of instrumentations separately would have some effectiveness in reducing exposure, infection and spread, but only in their combination they reach their full potential (see, for a theoretical foundation of this assertion, Ruiter et al., 2020). This is colloquially known as the Swiss Cheese Slices Approach (e.g. Christakis, 2020). The development and implementation of such policies is one of the great health promotion challenges. And the research into development and advocacy of such complex policy packages (i.e. the stacks of cheese slices) should be a ‘sine qua non’.

Hygienic thinking about policy research is a challenge, which we will further dissect later on, in the health promotion policy research section. But at this stage, it is probably helpful to first discuss the idea of ‘policy analysis’. ‘Policy analysis’ in fact encompasses two distinct ways of assessing policy. The first presents an analysis of the policy achievements. If, as outlined above, public policy is to resolve social issues, it should be possible to identify whether it has been successful.

For instance, a local government Council could be troubled by the number of road injuries and fatalities in its jurisdiction. It decides (compelled by the scientific evidence) to solve this issue by managing traffic. It allocates resources and capacities (e.g. tactical urbanism involving road quality modification and speed bumps; speed limits; signage). This type of policy analysis would seek to identify whether the stated intent of the policy and its implementation yield the desired result, and if it is fine-grained enough, investigate which elements in the synergy package worked better than others and how they are best combined.

Another perspective on policy analysis is interested in how a particular policy came about and whether the most appropriate (or cost-effective; timely; socially acceptable) policy was identified. In the case of the Council’s injury policy, this type of analysis might include asking whether public resources (tax payers’ money…) could have been spent more wisely in other areas (would more health be created through securing better access to better education; to green space; or mitigating climate change, for instance?). It could also gauge how (economically; conceptually; temporally; etc.) important the issue really is, how much pork-barrelling¹ might have been appropriate, whether various interests were served accountably, etc. This research could create arguments for different public and community priorities, and support different (and preferably superior) policy processes and policy resolutions. The second type of policy analysis would generate deeper understanding of the reasons why, and how, policy is formulated, and what the foundations for possible implementation success could be.

The first type of policy analysis does not require a critical body of policy theoretical knowledge. For the second it may be helpful to go back to Lasswell’s ‘who gets what’ thinking and apply some conceptual insights from institutionalism or power theory (see Harris et al., 2020). There is a third view of research into and for the policy process that the remainder of the chapter explores.

3 Health Policy (or HPP, or HiAP)

Governments at every level, around the world, now recognise to a greater or lesser extent that they have a role to play in creating conditions for better (and sometimes more equitable) health of the populations they serve. How they do this depends on the (philosophical) foundations of their State. Esping-Andersen (1990) has outlined a few welfare state archetypes that range from a total belief in the agency of individuals at the detriment of state intervention, to full state control.

Regardless of welfare state conceptualisation, many governments have explicitly adopted the pursuit of policy development for health. This comes in many guises. There are some countries that at one point or another expressed a commitment to developing coherent whole-of-government approaches to health development rather than segmented health care industry policies (e.g. The Netherlands in the early 1980s, De Leeuw & Polman, 1995). Elsewhere, subnational regions moved towards such inclusive perspectives (e.g. North Karelia in Finland, from 1972 onward, Puska et al., 2009). Later, governments at every level embraced the Ottawa Charter call to build Healthy Public Policy (spearheaded by the international Healthy Cities movement, but also reflected in legislation mandating local government policy making for health, e.g. in South Korea, France, Denmark, The Netherlands and the Australian State of Victoria) and after the turn of the millennium, a new rhetoric of ‘Health in All Policies’ took hold, championed in California (Rudolph et al., 2013), South Australia (Kickbusch & Buckett, 2010) and Finland (Puska & Ståhl, 2010).

There is a lack of critical reflection on the core tenets of these slogans. The general consensus is that health is not made by hospitals, pharmaceuticals, care professionals and other elements of the medical-industrial complex – these entities and institutions fix disease. Health is made by people in their everyday lives, and determined by education, mobility, the food chain, workplaces, etc. (Whitehead & Dahlgren, 2006). To prevent disease, promote health and prolong life (Winslow, 1920²), action – and policy – must be framed around those sectors and determinants, and how society shapes them (the political determinants of health, cf. Kickbusch, 2015), rather than further agglutinating the powers of the healthcare system. To reiterate the consensus on the more philosophical dimensions of what we are discussing: current ‘health policy’ is hardly ever concerned with ‘health’ – it focusses predominantly on shaping and regulating just one field: the medical-industrial complex or ‘Medical Care Services’, which represents one family of determinants in the health field, the others being ‘Heredity’, ‘Life Styles’ and ‘Environment’ (Blum, 1974; Laframboise, 1990). This drives an almost obscene financial imbalance between such services and prevention of disease and promotion of health (Faust & Menzel, 2011 – who furthermore identify the most dire lack of investment in prevention intervention research, and utter absence of dedicated policy research funding in the realm).

So – the evidence base and ideological foundations for creating policies for health (whether labelled HPP, HiAP or simply ‘health policy’) are clear. But the evidence base for the creation of such policies is fragmented and mostly anecdotal (de Leeuw, 2017). Researchers in this arena tend to collect a wealth of often unstructured case material and compile (frequently very interesting and therefore compelling) narratives. Especially WHO has been doing a great effort in compiling global case studies (see the relevant WHO references in de Leeuw, 2017³). What communities and their representatives need, however, is a combination of good stories, strong evidence and a clear course for political action. Both the terms ‘Healthy Public Policy’ and ‘Health in All Policies’ seem to be evocative enough to have generated a considerable fan base. At the same time, the adoption of slogans is not sufficient for adequate policy advocacy. For this, a deeper understanding of the policy process and its drivers is required. And strong theories of the policies can come to the rescue.

4 Theories of the Policy Process

Breton and de Leeuw (2011) wondered whether the call for Healthy Public Policy in 1986 had stimulated a firm scholarly response. They performed a systematic review of the health promotion literature since the Ottawa Charter and queried to what extent theories of the policy process were rigorously applied to health (promotion) policy research. The results were disappointing. Only a tiny fraction of the (peer-reviewed!) articles that purported to do policy research applied any of the theories that have evolved over decades of political science development.

But why would you need to use theory to do (health policy) research? As we argued earlier, some analyses just need to show whether something has happened; e.g. whether measures have changed: ‘we developed a policy to abolish female genital mutilation, and now we are going to see how successful we are’. As interesting as these questions – and their answers – are, they miss an important point: this type of research will only be able to gauge whether there has been a change (if any), but not why or how. A simple attribution of success or failure to ‘the policy’ is not very insightful for the policy makers or for the community. There is no guarantee that the effect can be replicated in the same or other settings. There is no assessment or appreciation of the nature of the mechanism that has made the policy a success or failure (Birckmayer & Weiss, 2000). In short – we learn very little from theory-free research.

But what is a ‘good’ theory, then? This has been the subject of much debate among many philosophers of science. The scope of this chapter does not allow for a full description of this important body of work (see, for instance, Godfrey-Smith, 2009). For the policy research arena, we will take our cues from Paul Sabatier and his colleagues, who have been writing extensively about theories of the policy process and why they are important.

In short, a theory is an abstract version of reality, a kind of map, allowing navigation. There are two types of these maps, the descriptive ones and the normative ones. Descriptive theories are simplified versions of a particular area of interest and allow the astute observer to observe and predict phenomena that happen in that area. Very strong theories (that predict always and unequivocally what is going to happen) are referred to as ‘laws’. For instance, Boyle’s Law (on gas pressure and volume) predicts that compression of a gas into a smaller volume leads to a higher pressure.

Strong theory allows you to make projections with a particular certainty. For instance, in theories about political party coalitions forming government, the idea is that the least number of ideologically compatible parties required to make a majority will indeed make a government. To invite others does not make sense. However, there is an important condition in this ‘theory’ – the coalescing parties need to be ‘ideologically compatible’. This may be an issue that requires further qualification in doing research – and a scholar would want to interview party ideologues to see how fuzzy the boundaries of a particular ideology are, and to what extent they might seek compatibility with others that at first sight were deemed incompatible. An example of this, in the 1990s, was the initially obvious incompatibility between the Dutch Labour Party (PvdA) and the Liberals (VVD), seemingly coming from opposing ideologies on the notion of the welfare state. They found each other through the boundary spanning efforts of the Democrats (D66) and a joint appreciation of the political philosophy of John Rawls (De Leeuw, 2013). This ‘Purple’ coalition opened the door for a number of novel health promotion policies, and has stimulated new understandings (through theories on political coalitions) how previously controversial issues may be elevated to joint policy decision. Coalition theory would give the health policy researcher a good foundation to determine what to look for (and what not!) and how to understand what they see.

There are also, however, outliers to less-than-strong theory. The 2020 government formation in New Zealand/Aotearoa is a case in point. Even though Jacinda Ardern won an outright Labour majority, sufficient to form government, she invited the Green Party to join a ‘cooperation agreement’. Such deviations from expectation are integral to theory-based research and evaluation as they raise questions whether the theory should become more sophisticated (or thrown out), or whether the phenomenon observed is understood appropriately. This, in our view, is precisely why research is such an exciting endeavour.

Sabatier and his colleagues have been writing about theories of the policy process for a while now. For these political scientists, a theory is a clear and logically interrelated set of propositions, some of them empirically falsifiable, to explain fairly general sets of phenomena. Sabatier finds a distinction between conceptual frameworks, theories and models, which operate on a continuum from broadly applicable to any situation, to (preferably mathematical) modelling for highly specific situations. A ‘good’ theory of the political process should explain goals and perceptions, actions and events, among potentially hundreds of stakeholders in the process, leading to specific sets of policy outcomes.

The traditional perspective of the policy process is that of the ‘stages heuristic’: the notion that the policy process follows clearly distinguishable steps from problem definition, through alternative specification, to resource allocation and implementation and finally assessment and feedback. This conceptual framework seems to have served a purpose (e.g. in the agenda-setting mechanistic view of Cobb and Elder (1983) applied by De Leeuw & Polman, 1995). It is a conveniently straightforward protocol for the run-of-the-mill bureaucrat or street level health promoter. But this linear stages idea has since become the subject of devastating criticism, predominantly focussing on the fact that the stages heuristic fails to address the dynamics of multiple, interacting, iterative and incremental cycles of action at many different levels of mutual and reciprocal action at the same time (deLeon & Sabatier, 1999). For the Health in All Policies programme of work, De Leeuw and Peters (2015) show that different ‘stages’ can actually happen at the same time, and even that some (e.g. ‘implementation’) may start to happen before necessarily preceding stages (e.g. ‘resourcing’) are properly concluded.

Recognising these views, Sabatier (2007) established the following parameters to assess appropriate theoretical frameworks of the policy process:

• Each must do a reasonably good job of meeting the criteria of a scientific theory; that is, its concepts and propositions must be relatively clear and internally consistent, it must identify clear causal drivers, it must give rise to falsifiable hypotheses and it must be fairly broad in scope (i.e. apply to most of the policy process in a variety of political systems).

• Each must be the subject of a fair amount of recent conceptual development and/or empirical testing. A number of currently active policy scholars must view it as a viable way of understanding the policy process.

• Each must be a positive theory seeking to explain much of the policy process. The theoretical framework may also contain some explicitly normative elements, but these are not required.

• Each must address the broad sets of factors that political scientists looking at different aspects of public policymaking have traditionally deemed important: conflicting values and interests, information flows, institutional arrangements and variation in the socioeconomic environment (p. 8).

Four such frameworks, also pertinent to health policy development, were identified by Sabatier as meeting these parameters. These are the event-driven Multiple Streams Theory empirically developed by Kingdon (2002) which claims there are three fairly autonomous societal streams (Problems; Politics and Policies) that can connect to form ‘windows of opportunity’ for policy change; the Punctuated Equilibrium framework by Baumgartner and Jones (1993) in which long periods of policy stability are alternated by general shifts in policy perspectives and ambitions; the Advocacy Coalition Framework (Sabatier & Jenkins-Smith, 1993; Sabatier, 1988) that emphasises the importance of coalition formation of camps of proponents and opponents to new policy directions and the Policy Domains approach coming from different perspectives on network governance (e.g. Laumann & Knoke, 1987; Börzel, 1998). Other theoretical frameworks that seem applicable, but have not necessarily been extensively validated empirically, are Social Movement theory (e.g. McCarthy & Zald, 1977) arguing that disenchanted people will join social movements to mobilise resources and political opportunity, so policy is changed to serve their interests; neo-corporatism (e.g. Olson, 1986) advocating that (semi-)political organisations in the social environment can play corporate roles to maximise competitiveness, and a host of hybrid approaches that mix these perspectives. Hybrid theorising (Greenhalgh & Stones, 2010), in fact, is considered a productive way forward (see for an example of hybrid approaches between framing theories and network theories de Leeuw et al., 2018). Finally, there are theoretical perspectives from neighbouring disciplines (e.g. sociology; administrative science; political economy; international relations; political psychology; etc.) that allow the researcher to formulate strong conceptual propositions and hypotheses to study policy processes. These should not necessarily be dismissed: as framed earlier, the policy concept sits in a context of larger governance and institutional conceptualisations; as well as more applied interventionist views.

‘Strong’ theory as framed by Sabatier and his colleagues allows for a useful delineation of the research area (for instance, the boundaries of the policy domain under study) and the type of variables that need to be generated in order to make sense of the policy process (for instance, the number and intensity of network engagements between policy actors). The other theories that provide a more generic lens or ‘gaze’ are, for instance, the group of theories that see the world through a perspective on institutions and power (see Harris, 2022, basing his work a.o., on Peters, 2019). Within this generic gaze, there is an opportunity to identify the limits and opportunities of the policy research endeavour.

5 Health Promotion Policy Research

Health promoters and health promotion researchers tend not to be trained very well in the political and administrative sciences. Even when their appreciation is a key dimension in the globally accepted health promotion competences frameworks (Battel-Kirk et al., 2009), this does not necessarily mean that theories related to policy-making are wholly and rigorously applied in health promotion practice and policy research. The context of policy also tends to be more complex, esoteric and dynamic, perhaps, than the applied health promotion challenges in other areas of the domain.

A frustration voiced by a number of political science commentators on the interface with public health (e.g. Fafard & Cassola, 2020) is that the health operators use profound political science work superficially. For instance, an influential group of obesity researchers (Allender et al., 2012) claims to review the conditions of policy change in their field. They briefly mention Kingdon’s Multiple Streams work to describe that one needs to be cognisant that ‘Key learnings from these theories that underpin this research are that the impetus, intention and objectives for policy-making can be rational, but, invariably, the development and implementation of policy is subject to political and social influences’ (p. 262) – and proceed without applying any of the theories they glanced at. Admittedly, Kingdon’s work is more than just a superficial description of three streams (policies; problems; politics) that need to align through the workings of a ‘policy entrepreneur’ to open a ‘window of opportunity’ for policy change (which is where most health promotion policy research reports that reference Kingdon stop).

A close reading of Kingdon’s work, in our own research efforts to investigate health promotion policy in a collection of local government areas in The Netherlands (Hoeijmakers et al., 2007) led to a new appreciation of the breadth and depth of data and variables that are needed to deploy the Multiple Streams Theory. A full operationalisation of the theoretical framework would require the definition of each type of variable under study, the best way to assemble the particular data set, and an assessment of the core process one is trying to research. Figure 3.1 shows the cascade of events and actors across Kingdon’s three streams as gleaned from his dozens of policy analyses. The full application of the theory would require a consideration of each box and arrow in the figure. At first glance, it may appear a chaotic field. Yet – the boxes and arrows in the schematic would neatly allow for the framing of a comprehensive, bespoke and feasible research programme. If our research ambition really is to not only show the change, but explain the change (the how and why), any researcher ought to diligently take a theory apart into its constituent elements, and formulate justifiable choices on the focus of research, or explanations why certain sets of variables and connections are, or are not, part of the research agenda. Indeed, it may be somewhat of an effort, but we contend that this is what the research enterprise entails and deserves.

Fig. 3.1

Dimensions of Kingdon’s multiple streams framework. (cf. De Leeuw et al., 2016)

It is insufficient and even damaging to claim that health policy processes are messy; that many theories have proposed and that in publications such as the work referenced above (Allender et al., 2012), authors can then can comfortably resort to a naïve narrative that is driven by simplistic and superficial case study material. Health promotion policy process research deserves much better.

6 Policy Research with Health Promotion with Policy

Fafard and Cassola (2020) have argued for the interface between public health and political science because the policy research and development opportunities are potentially so incredibly rewarding. The premise – validated since the emergence of ‘modern’ public health and Virchow’s aphorism to that extent – is that public health and medicine are inherently political. The paradigmatic foundation of the scholarly tradition in the two fields, however, has rarely overlapped. Possibly worse: many health operators would claim – with good reason – that theirs is a mere technical and value-free effort. A research and practice view that would challenge those foundations and seek to apply a power lens (‘who gets what, why and how?’) is intrinsically threatening. If anything, the COVID-19 pandemic has shown more than ever before that technical evidence on reducing transmission risk is a nice fata morgana – turning the epidemiology into behavioural and political practice requires a political science transformation of ‘the facts’. Fafard and Cassola (2020) as well as others such as Greer et al. (2017) show that there are vast, untilled and rewarding opportunities for a forging of the conceptual planes of public health/health promotion and political science. They argue for the evolution (and institutionalisation) of a (public) health political science.

Clearly there are practical if not moral and ideological barriers in turning health promotion researchers into health political scientists. Therefore, we happily embrace the perspective offered by Mykhalovskiy et al. (2019) that this is an opportunity to do health promotion with political science rather than on, in, or for. And, incidentally, do political science with health promotion, rather than on, in, or for.

What would this look like? First, we contend that both fields are vast and that the scholarly gaze can rarely be wholly comprehensive. Choices have to be made, but they need to be made accountably and responsibly. The choice of health political science theory cannot be determined by a single scholarly operator. The identification of the research issue and its problems, and the delineation of its dimensions and (spatial, temporal and cognitive) parameters should be a reflexive exercise that may take substantial time and understanding – in a team.

Second, defining the research and the appropriate gaze ought to be a matter of considerable dialectic engagement. More of this work needs to be stimulated, funded and published. A critical mass of personnel, rhetoric and sound framing of the synergy of a political lens applied to health (and health promotion) issues is required. So – following Mykhalovskiy et al. (2019), there is an ample opportunity to re-appreciate the role of health political science in health promotion research. Following the success of accreditation and standard setting, globally, in public health and health promotion it is now time to move beyond the rhetoric and test real capacity of the workforce to take on a political analysis of its challenges and opportunities. Established public health competence and accreditation mechanisms (through, e.g. APHEA⁴ and CEPH⁵) and IUHPE’s positions for health promotion include a requirement of policy proficiency. Health promotion with political science will mean that we elevate this ambition from mere policy analysis (what has changed) to sophisticated policy analysis (why and how) – this is the only way the health promotion field can and must evolve.