Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Health Information Science


Kothari, Anita


It is widely understood that the public policies of ‘non-health’ government sectors have greater impacts on population health than those of the traditional healthcare realm. Health Impact Assessment (HIA) is a decision support tool that identifies and promotes the health benefits of policies while also mitigating their unintended negative consequences. Despite numerous calls to do so, the Ontario government has yet to implement HIA as a required component of policy development. This dissertation therefore sought to identify the contexts and factors that may both enable and impede HIA use at the sub-national (i.e., provincial, territorial, or state) government level.

The three integrated articles of this dissertation provide insights into specific aspects of the policy process as they relate to HIA. Chapter one details a case study of purposive information-seeking among public servants within Ontario’s Ministry of Education (MOE). Situated within Ontario’s Ministry of Health (MOH), chapter two presents a case study of policy collaboration between health and ‘non-health’ ministries. Finally, chapter three details a framework analysis of the political factors supporting health impact tool use in two sub-national jurisdictions – namely, Québec and South Australia.

MOE respondents (N=9) identified four components of policymaking ‘due diligence’, including evidence retrieval, consultation and collaboration, referencing, and risk analysis. As prospective HIA users, they also confirmed that information is not routinely sought to mitigate the potential negative health impacts of education-based policies. MOH respondents (N=8) identified the bureaucratic hierarchy as the brokering mechanism for inter-ministerial policy development. As prospective HIA stewards, they also confirmed that the ministry does not proactively flag the potential negative health impacts of non-health sector policies. Finally, ‘lessons learned’ from case articles specific to Québec (n=12) and South Australia (n=17) identified the political factors supporting tool use at different stages of the policy cycle, including agenda setting (‘policy elites’ and ‘political culture’), implementation (‘jurisdiction’), and sustained implementation (‘institutional power’).

This work provides important insights into ‘real life’ policymaking. By highlighting existing facilitators of and barriers to HIA use, the findings offer a useful starting point from which proponents may tailor context-specific strategies to sustainably implement HIA at the sub-national government level.

Summary for Lay Audience

The public policies developed and implemented by several government ministries determine whether we experience good or poor health throughout our lives. Health Impact Assessment (HIA) is a tool used to ensure that public policies are beneficial rather than detrimental to our health. The Ontario government does not require HIA to be used as part of policy development. This dissertation identifies the contexts and factors that support or prevent HIA use at the provincial, territorial, or state government levels.

This dissertation consists of three studies. The first explores how policy staff search for the information needed to develop policies within Ontario’s Ministry of Education. The second describes how policy staff within Ontario’s Ministry of Health interact with other ministries to co-develop policies. The third identifies ‘what works’ to support health impact tool use within two regions like Ontario in order to adopt similar approaches.

Nine respondents from the Ministry of Education identified four tasks routinely undertaken as part of policy development, including collecting evidence, consulting and collaborating, referring to existing policies, and identifying the possible risks of proposed policies. They also confirmed that the Ministry does not require them to collect information for the purpose of preventing the possible negative health impacts of their policies. Seven respondents from the Ministry of Health identified a vertical approval process through which interactions between ministries are approved. They also confirmed that the Ministry does not typically inspect the policies of other ministries in order to prevent their possible negative health impacts. Finally, health impact tool use in both Québec and South Australia was initially supported by individuals with expertise in health policy (‘policy elites’), as well as shared value placed on preventing health problems before they occur (‘political culture’). The ongoing use of these tools was supported by efforts to preserve longstanding roles and responsibilities within government sectors (‘jurisdiction’), as well as rules and requirements to ensure that impact assessments are conducted (‘institutional power’).

Together the findings from this work offer a blueprint for action among individuals or groups who would like to see HIA used in the development of sub-national government policies.