ReviewWhich public and why deliberate? – A scoping review of public deliberation in public health and health policy research
Introduction
The last decade has seen a convergence by healthcare and public health researchers on deliberative democracy methods as a means to bring people's opinions and values into health policy processes (Abelson et al., 2003, Street et al., 2014). Deliberative methods offer policymakers the promise of greater transparency and public accountability. Policies formed through public participation in deliberative processes can be considered to be more legitimate, justifiable, and, therefore, feasible than policies made through more traditional hierarchical modes of governance (Davies et al., 2006, Solomon and Abelson, 2012). What distinguishes deliberative methods from other forms of public engagement is a process of iterative two-way dialogue between representatives of the public and the deliberation sponsor (researchers, government or other agencies). A range of deliberative methods are available to engage citizens in a formal process of information exchange and knowledge-making (Online Supp file 1 – Fig. 1). It has been proposed that to be considered robust and reliable deliberative processes must (at a minimum):
- (i)
provide participants with balanced factual information;
- (ii)
ensure that a sufficiently diverse range of potentially conflicting, minority and marginal perspectives are considered; and
- (iii)
create opportunities for free and open discussion and debate within and between citizens and researchers or policy actors, or both, to challenge and test competing claims (Blacksher et al., 2012).
As a matter of democratic principle, deliberative forums involve a cross-section of the population; all citizens are meant to have equal opportunity to participate such that no social groups are systematically excluded (Dryzek, 2000). In practice these conditions are difficult to meet for reasons of cost, scale and efficiency.
Deliberative methods are not appropriate for all health policy questions. They are best-suited to resolving complex policy issues where people's values are of central importance – either because of the number of people affected or the profound impact on individuals. Deliberative methods are particularly useful for policy questions about: (i) situations involving clear conflicts between ethical imperatives (justice, beneficence, and respect for autonomy for example) – such that the decision entails the unavoidable creation of unlucky or even unjustly treated individuals or populations; and/or (ii) so-called ‘hybrid issues’. These are issues where the technical and normative aspects of a question are profoundly interwoven, including when there is significant technical uncertainty or normative conflict (Lehoux et al., 2009, Rychetnik et al., 2013).
In their recent review of the use of the “citizens' jury” method, Street et al. (2014), found that this deliberative technique has been applied to a wide range of healthcare and health policy issues. Their study suggests that researchers are adapting ‘jury’ methods to attempt to meet the needs of policymakers, but because of tension between research aims and deliberative ideals, their success has been limited. Looking beyond the use of citizens' juries, other reviews show that public participation in deliberative events is an increasingly prominent feature of research in healthcare priority setting (Mitton et al., 2009), and, to a lesser extent, health technology assessment [HTA] (Gagnon et al., 2011). Mitton (2009) and Gagnon's (2011) groups found that although the public's perspective added an important dimension to policy work, and governments appear to recognize the benefits of consulting multiple publics there is often poor alignment between deliberative research outcomes and actual policies.
This lack of alignment between deliberative processes and policy outcomes is only one of several common critiques of the use of deliberative methods (Abels, 2007, Abelson et al., 2007, Marres, 2011, Rowe and Frewer, 2004). Concerns are also commonly expressed about: (i) representativeness (i.e. small groups of people may not represent the views and interests of the broader public); (ii) authenticity (participants may lack sufficient expertise to understand, articulate, and form meaningful judgments on the relevant issues); and (iv) democratic credibility (the process may be used merely to legitimate a pre-decided policy outcome) (Abelson et al., 2012, Irwin et al., 2013). And, more broadly, Arnstein (1969) has argued that different techniques for public participation should be distinguished according to the degree to which the participants were empowered in the process.
These complaints revolve around a central concern: who, exactly, is the ‘public’ engaged with in deliberative processes. Abelson et al. (2013), in their recent mapping study, reported confusion as to the roles assigned and occupied by the publics in deliberative forums. Many authors agree that, although finding the right ‘public’ and the right mechanism for ‘participation’ in decision-making processes are central to the success of deliberative methods, these are in themselves political exercises (Irwin, 2006, Martin, 2008b).
With this central problem in mind, we reviewed the use of deliberative methods in public health and health policy research from 1996 to 2013. Our methods are consistent with the tenets of scoping studies. Scoping study methods are various, but their central feature is a focus on the systematic and transparent description of an area of research, rather than an assessment of the quality of the included studies (Arksey and O'Malley, 2005). Scoping methods allow findings from different study designs to be synthesized and then analytically reinterpreted to address questions beyond the scope of the original research (Daudt et al., 2013, Levac et al., 2010). In this study our aim is to survey the extent, range and nature of research activity using deliberative methods in public health and health policy, and characterize how deliberative publics are being constituted and situated within broader policy processes.
In so doing we have drawn on recent studies that have also reviewed deliberative research, albeit with a different focus. For example, Abelson et al. (2013) explored how deliberative methods are being used: their purpose was to identify common features of deliberative studies, and to evaluate how well these processes meet current standards and definitions of deliberation. Street et al. (2014) reviewed and evaluated how citizen jury methods are being adapted and implemented in health research, with a focus on the detail of methods. Mitton et al. (2009) surveyed the intention and methods of public engagement exercises in health priority setting. And Gagnon's (2011) group focused on the extent of patient and public involvement in health technology assessment. We complement and extend this work by answering the following questions:
- 1.
What types of policy problems and questions are being addressed through deliberative methods?
- 2.
Which deliberative techniques are being used (including and in addition to citizens' juries)?
- 3.
For what purposes are funders and researchers conducting this research?
- 4.
Which types of ‘publics’ are being constituted in public health and health policy research that uses deliberative processes.
To answer research question four, we draw on critical social science scholarship (Braun and Schultz, 2010, Evans and Plows, 2007, Felt and Fochler, 2010), and recent discussion in health policy literature (Barnes et al., 2007, Litva et al., 2009, Martin, 2012), to examine how subjects of participation are conceptualized as ‘the public’ in deliberative public health and health policy research. It has been proposed that the conception of citizens in health policy research is ontologically shallow (Lehoux et al., 2012). Health-related discourses and practices constitute many types of public, including “service users” of primary healthcare, “in-home carers” of social benefit schemes, “taxpayers” of healthcare reformers, “citizens” of universal healthcare schemes, or special-interest groups (Martin, 2008a). Those who get to be ‘the public’ and how much real say the public has in framing the outcomes of deliberative processes are the two most fundamental concerns about the validity of deliberative methods (Martin, 2012). How a researcher recruits participants and facilitates a deliberation inevitably—intentionally or otherwise—creates a public that embodies certain institutional ideologies, assumptions, roles and priorities (Barnes et al., 2007). Drawing together key conceptualizations of how publics are positioned in deliberative forums, participatory research and other forms of public engagement exercise, we examine how ‘the public’ is defined, constituted and given a specific role in the use of deliberative techniques in public health and health policy research, and thus how certain speaking positions and roles are made available to them while others are foreclosed.
Section snippets
Search strategy
Searches were conducted in June 2014 on Medline®, Web of Science®, Current Contents Connect® and Scopus® databases for references containing the term “public health” or “health policy” and one or more of the following words in the title, abstract or keyword fields: “deliberat*” OR “jury” OR “issue forum” OR “citizens' assembl*” OR “public participation”. The scope was limited to empirical studies [not reviews, editorials, letters, conference papers], written up in English, published in
Results
Our scoping review identified 78 publications related to 62 distinct public consultation events that involved deliberative methods. Nineteen of these events were conducted in the UK, fourteen in the USA, eleven in Canada, six in Australia, two each in New Zealand and Tanzania, and one each in Belgium, Israel, Korea, the Netherlands, Spain, Sweden, Thailand and Taiwan. The results of 33 out of the 62 events were published after 2007. The 78 articles describe a heterogeneous sample of publics,
Discussion
Our findings confirm that public participation in deliberative forums is common in public health and health policy research and that Community or citizens' juries are the favored deliberative technique (Street et al., 2014). It is also clear that decision makers are seeking input from multiple publics on issues other than health priority setting. As Mitton and colleagues' (Mitton et al., 2009) review also highlights, they often combine deliberative and non-deliberative forms of consultation. In
Conclusions
Successful use of deliberative techniques in public health and health policy research requires the clear articulation of the purpose of the research, the deliberative processes employed, and the choice of public involved (Martin, 2012). Each of these could be improved for deliberative methods employed in health policy research. Although the questions asked in these studies were clear and well-reasoned, the overall purpose of many of the studies was ambiguous, the roles performed by the publics
Acknowledgment/s
CD, SMC and LR received funding support from NHMRC Project grant (#1023197).
CD received funding support from a NHMRC Project grant (#1083079). SMC is funded through NHMRC Career Development Fellowship (#1032963). The authors thank the anonymous reviewers for their insightful comments and Jacqueline Savard for her time and expertise in proofing the manuscript.
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