This study protocol has several strengths and potential limitations, which are discussed below.
Strengths
A first strength can be found in the cross-domain systems approach of health inequalities. Many of the various factors influencing health, such as social, economic, environmental, and commercial aspects, which are vital for safeguarding and fostering population health, are in fact not part of the traditional health domain (57). Therefore, the World Health Organization (57) argues to expand the boundaries of what are considered systems that contribute to population health beyond the traditional health systems, into “systems for health”. In this perspective, social policy systems are considered to be (potential) systems for health.
A strength of this study protocol is also that it enables both an in-depth understanding of how social policy contributes to health outcomes in citizens in vulnerable positions, and a strategical preparation for uptake and upscaling of these insights. To better understand the mechanisms through which social policy generate health outcomes, and under which contextual circumstances these mechanisms can fire, the project conducts a realist evaluation of existing policy interventions embedded in local social policy systems. To strategically prepare for uptake and upscaling of social policy interventions, the project takes an institutional approach to develop such strategies. The combination of these two complementing approaches is both innovative as well as suitable for the required systems change.
Another strength can be found in the settings of this study protocol. Both the forms and causes of vulnerability in populations and social policy practices (including means and possibilities) vary between municipalities, and across rural and urban settings. Both settings are represented in this study by multiple municipalities, varying in size.
A last strength can be found in the transdisciplinarity of this study protocol. To get a full understanding of the workings of social policies, a transdisciplinary team that works in close cooperation is required. The realist approach is particularly appropriate as a catalyst for achieving synergy between disciplines, as it brings together theory in a transdisciplinary way, and methods from different disciplines complement each other. (Behavioral) Health sciences is a multidisciplinary field of study, related to health and healthcare. Especially relevant to the project, is expertise from this field of study on (determinants and psychological pathways of) lifestyle behaviors, but also expertise on evaluating complex interventions. Sociology contributes expertise on the study of inequality in access to diverse forms of resources as well as the contextual nature of social phenomena. Empirical micro-economics adds expertise on micro-economic analyses of behaviour of households, with regard to household finance, employment and health outcomes. Governance and organizational science adds expertise on the development of implementation strategies, drawn from institutional approaches. Furthermore, the realist approach can be considered an integrative approach, as stakeholders are involved throughout the research process, including dual theorizing (i.e. integrating scientific theories with stakeholder theories, (49)), and validation of results. In other words, in this project, scientific knowledge, is combined with professional knowledge, and experiential knowledge.
Potential limitations
Although the cross-domain approach in this study can be considered promising, health inequalities are a genuine so-called wicked problem. Over the past decennia, despite multiple efforts, the gap in life expectancy between the wealthiest, and the least wealthiest group in the Netherlands, have only grown (5). It can be questioned whether social policy intervention can result in sufficient health gains to genuinely reduce health inequality. Possibly, the potential benefit of social policies lies in protecting the current health status of citizens in vulnerable positions (i.e. no further exacerbation of their health status), rather than actually promoting it (i.e. no actual increase in healthy lifestyle behavior, and improving mental health). However, given the current trend of the ever growing gap, no further exacerbation might then be still considered a relevant step. It might be, that in order to reach health inequality through actual health promotion, not only the social policy domain should be involved, but for example also other policy domains such as the built environment (e.g. the food environment, the physical activity environment, etc.).
Another limitation of the cross-domain approach might be, that some might consider evaluating health impact of policies that have other objectives (such as disposing of sufficient resources) a form of “health imperialism”. However, in this study, the primary objectives of social policies (i.e. redistribution of resources) are considered a crucial part of the pathway to health impact. Health is not considered more important than disposing of sufficient resources, but the bi-directional relation of health and disposing of resources is considered crucial for health inequalities. As such, this study protocol aligns with the health for all policies- development (58).
Another potential limitation that can be found in reaching the objective of this study, is the challenge that social policy (i.e. how should burdens and resources be distributed in society, and who is deserving of what?) is subject to political ideology. This particularly might play a role in the action research, for example in the willingness to change. Additionally, the political climate itself might change, which, through institutional design, might lead to a challenge for support among stakeholders.
Ethics
It is important that research participants are not harmed or emotionally burdened. However, data collection directly from citizens has a large added value. Their lived experiences provide relevant and accurate information on contexts, mechanisms and outcomes in the realist evaluation of selected existing social policy interventions. Data may be collected about experiences with deprivation in economic resources, social policies and (mental) health. These can be considered sensitive and stigmatized topics, possibly emotionally burdening them and causing psychological distress.
Where possible, less burdensome forms of data collection will be performed, such as using register data and document analyses. However, in case lived experiences provides indispensable insights, risk of emotional burden for participants will be diminished as much as possible, by properly preparing the methods, for example with mock interviews (59). This will help to get familiar with doing interviews about a certain topic, but also prepare for worst-case scenarios. This way, the researcher can learn to deal with for example psychological distress that can arise as a result of the research questions. The questions will also be prepared to be appropriately sensitive and avoid stigmatizing language (59).
Dissemination
The aim of dissemination within RASP is to reach and promote knowledge uptake among institutional actors at multiple system levels, beyond those involved in the study. The national partners involved in the action research have a large constituency among these actors and effective channels for knowledge dissemination and utilization. Dissemination and utilization activities will therefore align with these channels. In the beginning of the project, a communication plan will be formulated that maps out activities of actors involved in the study, that may offer opportunities for knowledge dissemination and utilization. The intended target population will have a key role in determining in which form results will be presented (i.e. co-creation).
We identify six types of relevant target groups for knowledge dissemination. These six target groups are listed below, together with tools, materials and activities, considered relevant for them:
1. Citizens with (risk of) problematic debts and/or receiving social assistance benefits
Communication materials will be developed in co-creation with citizens in vulnerable positions, including a representative from the interest group for people with mild cognitive limitations. An example is an icon folder, or videoclip.
2. Students
Educational materials for students of Social Work, and Social and Legal Services will be developed in co-creation with students, lecturers and current professionals, to ensure fitting of the material in the education program and the daily practice, such as an e-learning module or a guest lecture.
3. Professionals working in public services related to social policy
The publications in professional journals that are planned in this project, target mainly the executing professionals.
4. Policymakers and managers in municipal public services related social policy and/or public health
This target group will be reached through different channels and in different forms; factsheets and infographics will be provided to share the direct insights related to the research, contributions will be made to existing communication channels, such as journals, podcasts and blogs, recurrent symposium. In addition, and an end-symposium will be organized.
5. Policymakers at the national government, working in public health or social policy domain
This target group will be reached throughout the project as representatives of this group actively take part in the action research component, as well as at the end of the project through an (online) symposium.
6. Scientific community
This community will be reached through scientific publications and presentations at relevant conferences, such as the international debt research group that meets annually at the Law & Society Association Conference.
In addition to the specified target populations, the general audience will be informed about milestones in the project by issuing press releases, and/or LinkedIn messages, and/or corporate communication channels.