Meet the local policy workers: Implementation of health promotion guidelines in Denmark

Abstract

Reporting on an interview and observation-based study in Danish municipalities, this article deals with local policy workers and takes it's departure in the great variation we observed in implementation of centrally issued health promotion guidelines. We present five types of local policy workers, each of whom we found typified a specific way of reasoning and implementing the guidelines. This typology illustrates the diversity found within a group of local policy workers and helps explain the variability reported in most studies on policy/guideline implementation. On the level of individuals, variation in implementation is often explained by the implementers’ perceptions of need for, and potential benefits of the policy, self-efficacy and skill proficiency. We add ‘professionally related experiences’ as another explanation. We introduce the concepts of translation and hinterland to understand how and why people in the same positions receiving the same set of guidelines implement them differently and suggest that local policy workers’ professionally related experiences affect the frames in which they translate the guidelines and decide upon the strategies of implementation. As such, this article illustrates a residual order of implementation practice: the unruly and elusive part of public policy implementation, ordered only partly by the centrally issued policies.

Keywords

Guidelines health promotion implementation local policy workers public administration

Introduction

This article deals with the local implementation of centrally issued public policies by taking the national Danish health promotion guidelines as a case. In so doing, it focuses on the people who are presupposed to implement the guidelines locally – namely, the local policy workers, defined as the people working with the local government's strategy, implementing and assigning the local priorities and managing as well as shaping the local services. In this article, we put a face on the local policy workers and illustrate how the implementation of public health guidelines is shaped by the policy workers' professionally related experiences.

In public policy, and especially within the field of public health, guidelines are abundantly issued by central governments to streamline or standardise the local authorities’ practices (Rod and Høybye, 2015) according to an often evidence-based routine or sound practice. Thus, we regard guidelines as a policy in the following. Inherent in the use of guidelines as a form of regulation (Timmermans and Epstein, 2010) is the premise of a linear knowledge-to-action process (Hjelmar and Møller, 2015). This premise is a matter of a rather straightforward and top-down mechanistic and apolitical process of implementation in which the local policy workers are expected to carry out the guidelines as formulated and endorsed by those in authority such as politicians – reflecting the belief that local policy workers are neutral conduits through which guidelines flow intact and unmediated (Kingfisher, 2013). As such, regulation by the use of guidelines adheres to a ‘technocratic idea of rational policy’ (Jenkins, 2007), even though scholars decades ago showed that such rational models of policy-making were ‘not effective in practice, nor convincing in theory’ (Parsons, 1995: 468). Yet the premise of regulation by the use of guidelines greatly resembles the belief in ‘rational policy’ processes and practices (Cairney, 2009; Hjelmar and Møller, 2015; Jenkins, 2007; Markussen and Wackers, 2015).

Inspired by the seminal work of Michael Lipsky (1980), a range of scholars have shown that the actions of the local policy workers very often diverge from the stated policies (May and Winter, 2009). Lipsky (1980) illustrated how so-called ‘street-level-bureaucrats’ adapted the objectives of social policies to suit their clients’ or their own preferences, and concluded that policy implementation, in the end, comes down to the people who actually implement it. This strand of academic work is grounded in a constructionist view of social reality, presenting public policy as a (discursive) construct that turns on multiple interpretations (Fischer, 2003), and shows how ideals of basic societal goals, pursued by policy-making, often conflict in policy implementation (Stone, 2002).

Though Lipsky's work concerned the discretion used by those directly engaged in policy delivery on the frontline, other studies (e.g. Brewer, 2005; Freeman, 2006; Kingfisher, 2013) have likewise shown that local policy workers influence the policies; they interpret and reformulate the policies when they put them into practice. Actually, as Kingfisher (2013: 62, emphasis in original) claims, ‘in the business of taking up and doing social policy, those [local policy workers] are key: they are the means by which policy practices and the ideas informing them are materialised and sustained’. As a result, centrally issued public (health) policies and guidelines are not merely implemented but rather made through the everyday practices of the local policy workers (Freeman, 2006; Freeman and Maybin, 2011; Jenkins, 2007; Kingfisher, 2013). In other words, the local policy workers are very influential in regard to the actual realisation of centrally issued public health guidelines and thus in terms of the services provided to citizens.

The empirical findings of these studies stress the importance of methodologies that emphasise studies of local policy workers’ roles. Such approaches with an explicit interest in what happens ‘on the ground’ have greater explanatory potential (Hupe, 2014; Hupe and Hill, 2016). Our ‘advanced implementation study’ (Hupe, 2014) treats the intentions of the guideline (makers) as only one among a range of variables explaining the implementation variation. In so doing, we emphasise that local policy workers are not merely ‘local policy workers’; they are people – they are human individuals whose actions are, like everyone else's, guided by unarticulated and embodied understandings rather than expressed rules and prerogatives (Freeman and Sturdy, 2014; Kingfisher, 2013; Taylor, 1995). Yet the local policy workers, as implementers of public health guidelines, have been handled as a homogeneous group of people (such as ‘the civil service’, ‘street-level bureaucrats’, etc.) in most studies, implying that the knowledge we have of those people is limited – in fact, we know ‘surprisingly little’ (Freeman et al., 2011: 128; Wagenaar, 2004: 643).

The aim of this paper originates from an empirically based curiosity. While studying how the Danish national set of centrally issued health promotion guidelines was enacted locally in the Danish municipalities, the variation we saw in how the guidelines were implemented could not be (fully) explained by ‘traditionally’ suggested modifying implementation factors, such as organisational structure, perceived need and agency or financial resources (Durlak and DuPre, 2008; McConnell, 2015). Focusing on the level of individuals, variation in implementation has primarily been explained by the implementers’ perceptions of need for and potential benefits of the policy (Winter, 2003); self-efficacy and skill proficiency (Durlak and DuPre, 2008); self-interest (Maynard-Moody and Musheno, 2000) and ‘policy accumulation’: that public professionals often are confronted with (a series of) policy changes, intended to refine, replace or complement other policies which results in professionals having a certain predisposition towards policies in general (van Engen et al., 2016). However, in general, and as Steijn et al. (2012: 4) argue, at the level of individuals ‘public administration has historically looked primarily at the content of public policies and discretion issues for explaining the implementers’ willingness to implement public policies, [but] it seems that this does not provide the full picture.’

The closer we looked at the moments in which decisions pertaining to the guidelines were made, the more the guidelines dissolved into a multiplicity of logics and strivings for different goals. In some of those moments, the guidelines related to the centrally issued guidelines in nothing but name. In analysing the variation in the implementation of the guidelines, we noticed the significance of the policy workers’ professionally related experiences for how they put the guidelines into practice. The term ‘professionally related experiences’ should not be confused with professional ‘skills’ or ‘capabilities’ as are handled in literature on ‘professions’ and ‘professionalism’. Rather, we have constructed this term to grasp the concrete experiences/situations that the local policy workers have encountered in their professional lives and which have formed the local policy workers’ attitudes and meaning-making of the guidelines. Designating the local policy workers’ experiences in their professional life, we found that in order to understand the local implementation we needed to know more about the acting persons and thus place them in the foreground of our study.

Based on interviews and observations in Danish municipalities, we therefore explore the local policy workers as individuals, what is meaningful for them and how they perceive and perform their work. This article then adds to the existing literature in which the black box of ‘local policy workers’ is unpacked (Marston et al., 2005; May and Winter, 2009) and shows how the implementation of the guidelines is variously influenced by the individual local policy workers and their professionally related experiences. As such, it offers a detailed supplement to previous studies on individual factors that affect the implementation process (e.g. Barr et al., 2002; Cooke, 2000; Kallestad and Olweus, 2003; Ringwalt et al., 2003) as well as to studies on (Danish) local policy workers, which have been primarily quantitative and focused on the local policy workers’ demographics (Bo Smith-udvalget, 2015; Hansen et al., 2013) and values (Steijn et al., 2012; Tummers, 2012; Vrangbæk, 2009). Other Danish studies on local policy workers have focused on how professional, organisational and governance contexts affect frontline practice (e.g. Caswell and Larsen, 2015), the political and managerial influences on local policy workers’ policy emphases (e.g. May and Winter, 2007) and the forms and modes of authority deployed by case managers when implementing activation policies (e.g. Marston et al., 2005).

By putting a face on the local policy workers, we narratively illustrate a complexity that helps shed light on the variation often seen in guideline implementation. Thereby, we leave the acts of the production and formulation of the guidelines aside and illustrate the residual order of the implementation practice: the unruly and elusive part of guideline implementation in which things really happen, ordered, but only partly, by centrally issued guidelines (Freeman et al., 2011). Accordingly, we present five types of local policy workers we have constructed from an amalgam of traits from the 15 individuals encountered in our study. This is not to suggest a certain pattern or to conclude that one or any of these types are to be found in every local government, or that these are the only five types existing. Rather, the aim is to illustrate the complexity of individualities that constitute the group of ‘local policy workers’. Thus, readers who engage practically or theoretically with the implementation of public (health promotion) guidelines are sensitised to observe and remark – in other cases and other situations – slightly different but equally relevant phenomena for themselves. The stories we tell here aim to develop an open eye and inspire keen sensitivity for the complexity we see among the group of local policy workers. In addition to other conditions, such as political ambitions, the size of the municipalities and economic resources, we argue that this complexity provides partial explanation and insight into the various ways in which guidelines are implemented at local levels.

The Danish health promotion guidelines in context

Administratively, the Danish health-care system is fairly decentralised: planning and regulation take place at both the state and local levels. Following a major administrative governance reform in 2007, the responsibility for disease prevention and health promotion was redistributed and is now mainly located at the municipal level (Olejaz et al., 2012). Thus, the political context in which this case takes place is a ‘multilevel policy-making system’ as it is characterised by the existence of relatively autonomous layers of decision-making (Torenvlied and Akkerman, 2004).

In 2012 and 2013, the Danish Health and Medicine Authority (DHMA) issued a set of national health promotion guidelines (consisting of 11 health promotion ‘packages’, comprising a total of 262 recommendations for health promotion services) with the aim of supporting the municipalities in their new (post-reform) tasks and strengthening the quality of the health promotion services across the country (DHMA, 2013). According to DHMA, the guidelines serve as a means of communicating ‘how to establish systematic and effective health promotion and disease prevention actions in a Danish context, [where the notion of] ‘systematic’ implies that the disease prevention and health promotion work is conducted in order to reach the same goals and methods across the country’ (DHMA, 2012: 18; our translation), and thereby signify an attempt at standardisation. Moreover, as DHMA (2012) suggests that implementing the recommendations from all the guidelines will help achieve the best and most comprehensive health promotion practice, it indicates an intention for the municipalities to undertake complete implementation. To aid the municipalities with this comprehensive implementation task, the national organisation of municipalities, Local Government Denmark (LGDK), established the Centre for Health Promotion in Praxis in 2013. The centre is government funded and the initial support was prolonged for an additional three years. Thus, great efforts have been made to promote the guidelines and support the municipalities in the guideline implementation process in order to secure their success (Vallgårda, 2014) – where success is understood in the sense of DHMA: as complete implementation. Before beginning any implementation, the municipalities are strongly encouraged by the LGDK to map out their existing initiatives and rate them according to a ‘traffic light model’, where green signals the complete implementation of the initiative, yellow signals partial implementation and red signals no implementation.

The Danish health promotion guidelines are issued in an organisational and administrative context that more or less corresponds to that of other Western welfare states, such as the United Kingdom (Gorsky et al., 2014), Norway (Ringard et al., 2013) and Sweden (Anell et al., 2012). Though the (Danish) municipalities are differently organised, they all employ an administration consisting of local policy workers who, amongst other tasks, serve their local politicians with the basis for decision-making. Inherent in this system is the idea of neutral local policy workers-which is also the ideal (Vallgårda, 2008). However, recent studies show that Danish local politicians regard proposals that are not congruent with the desires and agendas of the municipality's local policy workers to be difficult – even impossible – to implement (Bo Smith-udvalget, 2015), signalling a general decrease in the perceived influence of the local politicians vis-à-vis the local policy workers (Kjaer et al., 2010). To a great extent, those local policy workers then contribute to the shaping of public health policies and guidelines through their arrangement and evaluation of the decisions (Bo Smith-udvalget, 2015; Vallgårda, 2008). Actually, it has been argued that the local policy workers may be more influential than the local politicians in terms of the local enactment of centrally issued policies (Jenkins, 2007; Olsen, 2013; Peters, 2001; Wimmelmann, 2016; Wimmelmann, forthcoming). To date, no studies have shown how the Danish local policy workers perceive their level of influence or how their professionally related experiences affect their decision making in regard to the implementation of centrally issued health promotion guidelines. As the local policy workers themselves suggest and are aware that, and how, their own professionally related experiences influence their decision-making regarding implementation of the health promotion guidelines, this article also indicates indirectly how they perceive their level of influence.

Methods

Author one investigated how the Danish health promotion guidelines were implemented and enacted by visiting, observing and interviewing 15 local policy workers from ten Danish municipalities. The local policy workers were employed in municipalities that differed with regard to geographical area, number of citizens, socio-demographic profile and health profile. These ten municipalities were selected to highlight how the guidelines were translated and enacted in different places. For two years (from April 2014 to April 2016) Author one had on-going contact with the local policy workers and obtained deep and rich insight into their experiences, stories and intentions, which serve as the empirical data in this paper. The formal interviews had a semi-structured approach, and the themes covered concerned the interviewees’ practical work experience(s) and decisions taken regarding the implementation of the health promotion guidelines. The interviews varied in duration from 36 to 96 minutes and were transcribed verbatim. In addition to the interviews, Author one gained insight into the field through ‘appointed observations’ (Staunæs, 2004) of special occasions, such as meetings or workshops. These observations enabled us to note some of the circumstances that the local policy workers did not themselves think of as relevant, were not conscious of or were not willing to discuss when they were interviewed. Moreover, the observations shed light on elements of the enactments that might have been tacit, as they were in conflict with the intentions of the guidelines or with the municipality's strategic agenda. This study's data then also represents informal beliefs and practices, as well as personal narratives. Thus, the insight we obtained through observation, intrigued us to ask questions of how and why they enacted the guidelines (contrary to the politically stated intentions), implying that the observations also served to specify our interview guide continually.

Inspired by hermeneutic methods for analysis (Patterson and Williams, 2002), the data from the observations and interviews were read and coded in order to identify and organise relevant and dominant themes (Madden, 2010). At the outset of the study, the local policy workers’ professional experiences were not a central concern. However, we quickly realised that the local policy workers themselves introduced and referred to ‘experiences in their professional life’ and ascribed such experiences as overtly important, when they explained how they handled the guidelines. After the field studies, it was clear that these were unavoidable for understanding the actual implementation practices in Danish municipalities. Reading carefully through the material, we recognised five ways of reasoning and handling the guidelines that were all related to a more global theme of ‘experiences in their professional life’. In the following, we describe each of these five ways by constructing five types whom we found each represented a specific way of reasoning and handling the guidelines. The types we present constitute our analytical nomothetic work, as they are condensed from the 15 individuals we encountered in our study. We present the types using fictitious names followed by a supplementary explaining title. The reason for naming them is that it helps emphasise the fact that they are people, not implementation machines. We do however wish to emphasise that the names are purely fictitious, and that any inevitable assumptions of gender those names may bring, are not an analytical point. In other words, any belief of a correlation between each type as relating to a certain gender is not intended, and our research has been conducted as well as reported appropriately to secure the confidentiality of our informants.

We do however acknowledge that actions and types are contextualised (Le Grand, 2003), implying that this study's contribution is an analytical generalisation: we believe that such a typological framework illustrates a diversity found within a group of local policy workers, which helps explain the variety we see in the implementation of guidelines. This analytical approach also bears the potential to explain local variations in national implementation processes in other contexts.

Findings

When conducting the interviews and observations, there was not one grand story of the guideline implementation that emerged. The local policy workers’ different ways of interpreting and (re)representing the guidelines affected the ways in which the guidelines were enacted and allowed to act at different sites and in different situations. We now invite our readers to ‘meet’ the local policy workers, because, as we argue, they are so influential in the actual realisation of centrally issued public health guidelines, and thus in the services provided to citizens.

Sarah: The loyal operator

Meet Sarah. Sarah has held her position in the health administration of the municipality for the last 10 years, and she is both eager and happy to discuss her strategy for the health promotion guidelines. Initially, she proudly states that she has decided to implement all the guidelines. However, later on, she explains that she is not completely satisfied with the health promotion guidelines because, ‘in certain areas, they lack something; the evidence base of the guidelines is rather flimsy’.

Though Sarah points out inconsistencies in the evidence base that supports the guidelines, she explains that it did not influence the decision about complete implementation because, ‘if you only implement and initiate health promotion services that are evidence based, you will never become better or more skilful’. However, her motivation for implementing the guidelines completely seems not to be one of learning and/or innovation; rather, it is very much related to the task of mapping out the municipality's existing services according to the traffic light model. She says, ‘in our area of health promotion, we are “green” all around […] it is not really satisfying if you see something “red” in there… then you feel like “oh no, that is not good”’. In other words, she is motivated by, and focused on, fulfilling what is expected from her – from one in her position – and in this case, that is the complete implementation of the guidelines. As such, she is driven by loyalty and commitment to the mission of fully implementing the health promotion guidelines, even though she is not completely satisfied with them. By disregarding her own satisfaction with the health promotion guidelines, she takes the role as an operator and manages the guidelines according to the belief of an ideal local policy worker (Vallgårda, 2008). Though Sarah's driving force and logic are found to be general core values that local policy workers are expected to hold (Vrangbæk, 2009), in our study, she represents an exclusive kind of local policy worker. As we will see in the following presentations, the others are not striving to take on this loyal operator role. Actually, they believe they do a better job when they are not merely, and rather unreflectively, implementing the guidelines.

Michael: The moral rebellion

Meet Michael. Every time we meet, Michael passionately shares his concerns and his motivation and values when he expresses his critical view on the quality of the evidence base in the guidelines. According to Michael, it is his time back at university that familiarised him with, and focused his attention on, doing evidence-based work – that is, to only implement and initiate health promotion services that are evidence based. He says the following about himself:

I am more the kind of guy … well I live in [a city far away from his job], but I applied for this job because I thought it was exciting. […] I am very focused on evidence because I want us to make the most out of the citizens’ money [paid through taxes to the municipality], and that is my driving force. So, I am trying to be critical about what services we should provide. But often, the local politicians believe that if some young children [belonging to a minority group] have a problem with overweight, for example, then we need to help them by offering an individually oriented service … but then I say: ‘Is it really helping them, to give them something we know—at least from the knowledge we have now—might not have any effect?’ That is what we have to consider; do we help people by offering them a service that we know will not be effective in the long run? Is that help? Is that doing something about it? […] I believe, if we implement those initiatives that are not evidently efficient, that is just as bad as doing nothing—actually, it is worse because we are wasting the citizens’ money.

Holding this belief, Michael especially wants to make sure that the initiatives are cost effective. What Michael does then is to analyse each suggested service proposed in the guidelines according to his set of standards for what an effective service is. He is very well aware that by so doing, he is somewhat re-doing the work DHMA did when it made the guidelines, and he says:

That is crazy, right? But given the knowledge I have, and in my position as a health consultant, I would be very sad to say, “Okay, well let's just pretend this is good just because it is what DHMA says we should do”. Then I would not be able to look at myself in the mirror and feel that I am doing a good job.

To exemplify, he describes a situation where his analysis of one of the guidelines served as the argument for ending an existing health promotion service, even though it was suggested in the guidelines, because his analysis showed that this specific health promotion service was not based on solid evidence. He uses this example to justify his concerns and beliefs when he says the following:

That is why it is so important that we do this work. I have also considered if I should lower my income and do a PhD in order to show what we [in the municipal health departments] are confronted with. Right now, this work [trying to raise awareness among other municipal health consultants to make them more than unreflective operators] is something I also do in my leisure time, because I just feel it is extremely important. But if that is what it takes, it is okay.

In other words, Michael feels a moral obligation to ensure that the health promotion initiatives they implement are cost effective and optimise the conditions for the majority of the municipality's citizens. In order not to compromise his values, he even goes as far as conducting what he himself terms ‘civil disobedience’, when he deconstructs the guidelines – that is, when he ends and suspends recommended services and tries to convince local policy workers from other municipalities to be more reflective in making decisions about implementing the guidelines. Nevertheless, Michael keeps emphasising that he would like our conversations to be anonymous. Furthermore, his wish to arrange our meetings away from his workplace can be interpreted as a means of constructing a neutral site where he can openly describe how he handles the health promotion guidelines. This illustrates a man who is very well aware that he is acting against the social norms and expected behaviour of a local policy worker in public health promotion. Yet he is so passionate about his work that his moral beliefs and values trump those socially normative concerns when he rebelliously deconstructs and acts against the intentions of the guidelines. In that sense, he is utterly altruistic.

So far, we have met two local policy workers, who are in striking opposition to each other when it comes to complying with the guidelines. However, as we will see in the following, the implementation of the guidelines is not only a decision conditioned by what one believes is one's professional and/or moral obligation. Rather, we will see a variety of professionally related experiences and beliefs that affect the decisions and practices of implementation.

Louise: The reflective insider

Meet Louise. Previously Louise worked at DHMA, and, according to her, this made her reluctant to act on the recommendations from DHMA. She explains as follows:

I know how they work in the DHMA. It is not only scientific neutral truths they publish—there are many different agendas, and not all of them concern evidence. If the literature supports their ideas and beliefs, they do not critically assess the underlying evidence […] And I know that everything that comes from the DHMA is negotiated. Before they publish anything, it has to go through various filters, where something is removed and other things are added. Knowing this, I take their recommendations with a grain of salt.

Louise's previous job in DHMA has formed her current attitude, not only towards the scientific quality of these guidelines but in general towards DHMA. She explains as follows:

Because I used to work there [at DHMA], I know how they think of the [people working in the] municipalities … they think ‘they [the health administrations in the municipalities] need a helping hand because they do not have people who can do this work’. And maybe yes, we do not have all the time in the world for it, but we certainly know how to do it, and we thus also know when the quality is not good enough. And this work [the guidelines] is just too simplified […].

As such, Louise's scepticism is also related to the knowledge logistics inherent in these centrally issued guidelines; according to such logistics, knowledge flows in a supply chain from the experts to the users of supplied knowledge and thereby casts the local policy workers as neutral operators. Given her previous experience at DHMA, she is especially provoked by this role. As we learn, Louise emphasises the municipalities' and the local policy workers' local government mandate and their right to self-determination. As such, Louise does not fit into the knowledge supply chain as a neutral user of supplied knowledge (Markussen, 2014). Rather, she is provoked by her earlier professional experience, and those feelings manifest in a reflective attitude towards the guidelines and to any announcements from DHMA. Louise believes that different agendas are in play when DHMA publishes guidelines, and thus she closely scrutinises the guidelines before endeavouring to implement them. She also indicates that she is more reflective in her use of the guidelines than many of her colleagues in other municipalities when she says the following:

The national discourse is way more religious about those guidelines, in the sense that the goal is implementation for the sake of implementation. […] when I have been to some of those workshops [held to support the municipalities in the implementation of the guidelines], I have taken a reflective and nuanced approach and been critical of them; I do not just want to implement all these things and make the guidelines the agenda itself just because the DHMA tells us that these initiatives are the best things to do. Rather, we [the health administration in this municipality] work with our own agenda, and if we can use anything from the guidelines to achieve that, we will do so—but only if it makes sense for our own agenda. The unreflective discourse that otherwise surrounds those guidelines—that has the goal of complete implementation for the sake of complete implementation—is worrisome, rather worrisome, I believe.

As we see, Louise's past professional experience of working in a policy-making institution gives her insight that strongly affects her reaction to the guidelines. However, as we will see in the following, it is not only previous professional experiences within the field (in this case, public health promotion) that might influence the local policy workers' reasoning and (re)actions regarding a set of guidelines; professional experience in other fields also profoundly influences the mind-set of the local policy workers.

David: The innovative communicator

Meet David. After university, David started his career as a consultant in a management-consulting firm in the private sector. Subsequently, he shifted to the public health sector, and he has been employed in this municipality's health administration for the past four years. He is not concerned with the guidelines' (lack of) evidence base. Actually, he claims the following about the lack of solid evidence in the guidelines

[It] has no implications for the decisions regarding implementation because you cannot measure everything. The conditions for health promotion services are that we know very little about their effects, because lots of things influence their effectiveness. But that does not change the fact that we will have to do something about it. So, we have to be pragmatic and choose a strategy. And then we just believe in the good intentions of it.

In the case of the guidelines, David has employed a profound strategy. Each month in the year is dedicated to a specific health promotion package (the guidelines consist of 11 packages), where the particular package receives a public relations (PR) focus. For example, in the case of the health promotion package for physical activity, the health administration plans events, such as outdoor physical exercise workshops, and spots on the local radio station concerning the existing physical activity initiatives in the municipality.

In line with acknowledged ideas regarding health promotion development (Laverack, 2004; Talbot and Verrinder, 2009), David believes that the potential of health promotion initiatives is stronger when they are grounded in the needs and wishes of the target group. Holding this belief, David uses communicative strategies to raise awareness about these health topics among the citizens. He explains this by giving an example relating to the health promotion guideline focusing on sun protection. He states the following:

If parents hear about means of sun protection on the radio, for example, they will ask for these services in their children's institutions. Then the institutions will ask us for advice and services, and we will suggest some of these initiatives. By so doing, we turn the approach around, so the institutions now realise their need for a policy on sun protection. Hopefully, they will then feel ownership of the policy and the related initiatives, instead of the initiatives being something they are told to do, as doing this is often unproductive and creates resistance.

In other words, David reconstructs the guidelines from indicating a top-down approach to representing a bottom-up approach. As such, he implies that these guidelines targeting the municipal administration(s) cannot solely be enacted as an internal municipal administrational working tool (as is the case in most of the municipalities we have investigated); they need to be linked to the initiatives’ target group, to the citizens. In order to do so, he emphasises communicative efforts as an essential part of public health promotion. Actually, David claims that ‘it is meaningless not to incorporate and emphasise as well as prioritise resources to the PR part of health promotion’, and it makes absolutely no sense to him why the PR and communicative efforts are not prioritised in the other Danish municipalities. Yet those communication efforts do not merely serve to turn the approach around; they also serve a financial purpose. ‘Doing municipal health promotion is also a matter of attracting attention and financial resources’, David explains

If no one knows what we are doing, we will not attract any resources. If we instead are good at creating the best possibilities for our citizens to make healthy choices, and if we are good at narrating and publicly communicating our stories of success, we [the health administration] will be prioritised when the financial allocations are discussed, because all local politicians are interested in creating a successful municipality.

He explains that communicating the guidelines explicitly to the citizens also serves as a means of making the municipality's other administrations attentive to health promotion. He proudly shares his belief that he, ‘in all honesty, [has] succeeded in branding those guidelines as “the final truth” about health promotion in municipalities’. In other words, David is not as excited about the content of the guidelines as he is about the awareness the guidelines can create. As such, he shows an extraordinary joy for the guidelines because he can use them to brand the health administration and its services to make this area prioritised and efficient. To do this, David strategically uses the guidelines as a tool to foster and promote his and this municipality health department's ideals and goals regarding awareness and PR, and thereby asks not what he can do for the guidelines, but what the guidelines can do for him. Doing so, we sense his emphasis on optimising the internal cross-administrative engagement in health promotion by communicative means – an acknowledged strategy (Iyer and Israel, 2012) often applied by management (Ruck and Welch, 2012).

According to David, his background in management consultancy has sensitised him to transfer management strategies and communication to the world of municipal health promotion. In this way, and in regard to common municipal health promotion strategies, David is quite innovative – he uses his experience from the world of management and applies this to municipal health promotion to appeal to the local politicians, as they make many of their decisions according to business-related arguments, such as finance, effectiveness and marketing.

Linda: The experienced strategist

Meet Linda. Linda accepts as true that we have to think at a structural level in order to undertake effective health promotion. This implies that all the other administrative areas in the municipality are engaged in the work as well. However, during her years working with health promotion in a municipality, she has encountered significant challenges in terms of making health promotion part of the agenda in other administrative areas. Given her experience of those challenges being ever-present, she believes those guidelines are the best material for conducting health promotion in the municipality. Nonetheless, she has no intentions of implementing the guidelines, because she does not believe that it is realistic, or makes sense, to enact the guidelines as a prescriptive list of services to which the municipality should conform.

Linda has learnt from previous experiences that the other administrative areas protest vigorously when definite health promotion matters are imposed on them. She describes her work like this

To me, the work I do to do health promotion at the municipal level is, above all, to do work on the attitudes towards health promotion in the other administrative areas. We have to convince them to take part in this work, and we have never before had such an excellent opportunity to do so.

As such, Linda's view of policy work resembles that found in other studies on policy work (Adams et al., 2015). Her work with health promotion is then not merely a matter of deciding upon or initiating specific projects and services. Rather, she believes her work is that of forming the other administrative areas’ perceptions of public health matters, so they become something the other administrations will consider, prioritise and incorporate when they, for example, plan their infrastructural affairs. In order to do so, she uses the guidelines strategically, and she describes them as a ‘gift’ from DHMA. At Christmas time, she literally gift-wrapped the health promotion guidelines, attached a big red bow to them and sent them to the municipality's other administrative areas along with an invitation to attend a meeting. However, it is not as if she does not initiate and/or organise health promotion services in the municipality. She does. She explains as follows:

[The guidelines] serve as a means to pave the way and clarify which specific target groups and arenas we should work with. But from there we go our own way, because health promotion depends on the context in which it occurs. So, we take inspiration from the guidelines, but we contextualise the recommended services: we modify and integrate them with our existing practices.

As such, the services, which she initiates are not grounded in the guidelines – they are grounded in her belief in the municipality's existing health promotion initiatives.

In opposition to Michael, Linda makes no effort to conceal her non-implementation of the guidelines – that is, she only employs the guidelines strategically, as a means to foster collaboration across the administrations. Though she is acting somewhat against what is expected from her, she explains that she is confident in her decisions because she has an entire lifetime of experience of doing municipal health promotion.

Discussion

By proposing a typology of local policy workers and disclosing situations in which the local policy workers' reasoning and enactments of the health promotion guidelines related to the centrally issued guidelines in nothing but name, this article spotlights the human actors and individuality in implementation practices. As the local policy workers consciously related their decisions about the implementation of the guidelines specifically to professionally related experiences (such as previous jobs, actions or strategies), we found that the local policy workers' professionally related experiences was a consistent theme in our interviews. As such, our findings relate closely to Sandfort's (1999) findings in her study of welfare reform at the frontline. The study showed that frontline staff in the public bureaucracy draw on past relations, daily experiences and clients' stories as sources of evidence when they assess the organisations with which they are mandated to collaborate (Sandfort, 1999). Our study contributes hereto and shows that such professionally related parameters are not exclusively affecting the frontline staff in policy implementation. Professionally related experiences too affect the interpretation and reaction of local policy workers, who work with the local government's strategy, implementing and assigning the local priorities and managing as well as shaping the local services.

Grounded in our empirical data, we developed our typology to illustrate the complexity in the group of ‘local policy workers’. Though we were greatly inspired by Lipsky's (1980) grounding work on street-level bureaucracy, in which he proposes structural factors that enhance local policy workers’ use of discretion in patterned ways (Brodkin, 2012), we are not presenting our typology to propose that these professional experiences cause a fixed pattern of implementation practices. In other words, we are not suggesting that the reported professionally related experiences in this study always cause the specific implementation reasoning or practices we have shown. We do, however, argue that these types do exist, and that the local policy workers’ professionally related experiences influence their reasoning and thereby their strategy for guideline implementation. For example, we suggest that local policy workers with a previous position in the policy-making institutions assess any material from such institutions with an extraordinary focus on the intentions of it because they are familiar with the procedures in these institutions. Although ‘the reflective insider’ in this case was sceptical of the guidelines because of her experiences as an employee in the policy-making institution, we do suggest that the opposite can occur: that previous employment in the policy-making institutions might make the local policy worker less sceptical because he or she knows the procedures by which the material (in this case, the guidelines) have been conducted. Moreover, we suggest that other local policy workers, often those with a long history of experience in their current position, have faith in their already existing health promotion strategies. They thus merely, and strategically, deploy centrally issued guidelines in ways the guidelines support and improve the local policy worker's existing strategies. Doing so is a strategic means to affect the individual local policy workers’ conditions for doing his or her job. Another type of local policy worker is the one coming to municipal (health promotion) administrations from other sectors (e.g. more traditional business-related areas). Bringing their previously used business perspectives and modes of operating into municipal health promotion, they innovatively deploy the guidelines. Contrary to ‘the experienced strategist’, ‘the innovative communicator’ thinks in terms of the municipality's wider agenda and deploys the guidelines as means to enhance the overall strategy for the municipal health promotion. These local policy workers are driven by optimisation and business development. We do however also see that other local policy workers are driven by other, often moral, principles. Those principles may be variously grounded, e.g. in educational traditions, personal ideology, etc. For those local policy workers, and in order to align their working procedures with their moral beliefs and principles, (to some degree) the end justifies the means. As such, they might even end up conducting rebellious actions, not complying with the intentions or the norms. They do, however, know that their actions are not admired in public, and thus put effort into concealing their actions (Wimmelmann, 2016). This generalised account of types of local policy workers might seem to suggest that the decentralised organisation of health promotion services should be reconsidered as none of the described types of local policy workers act in line with the belief of an ideal local policy worker. However, though a small minority in our study, we do wish to emphasise ‘the loyal operators’ who disregard any personal (dis)satisfaction with the provided material in order to complete their role as an operator.

To understand how and why the local policy workers’ professionally related experiences come into effect – or more generally, how and why people in the same positions receiving the same set of guidelines implement them variously – we introduce the concept of translation as it is applied in critical policy studies (see Freeman, 2009; Freeman and Maybin, 2011; Kingfisher, 2013; Lendvai and Stubbs, 2007) and organisational theory (Røvik, 2007), in terms of movement and transformation. In so doing, we focus on ‘the practice of policy’ – that is, the process by which the guidelines are received and implemented (Freeman and Maybin, 2011) – leaving aside the theories of knowledge management (e.g. Alavi and Leidner, 2001) and public service motivation (e.g. Gofen, 2014; Perry and Hondeghem, 2008).

We make two claims: first, that guidelines only have a social existence and consequence(s) when they are called in words and converted into actions by the local policy workers (Freeman, 2012; Winter and Nielsen, 2008) – that is, when they are translated – and second, that the local policy workers recognise that they, to some degree, can influence on the decisions taken (Winter and Nielsen, 2008). When the guidelines travel in and between administrative units and workers, they are received, read, decided upon and converted into action – that is, they are translated and transformed into something else. Yet this is not an arbitrary transformation; rather, it is a conscious change made by conscious choices (Freeman, 2009; Kingfisher, 2013; Lendvai and Stubbs, 2007; Yanow, 2004). However, translations of guidelines do not take place in a vacuum or in the ‘anything goes’ mode. They take place in a certain setting – within a certain ‘hinterland’ (Law, 2004) of existing practices, beliefs, previous experiences, devices, political agendas, institutions, etc. The concept of hinterland could easily be considered as similar to ‘context’. However, whereas context seems to represent a space of static ‘presentness’: an (infra)structure of environment, framework or setting surrounding an event or occurrence, a hinterland is both irreducibly there and exists only insofar as it exists for something (Oppenheim, 2011). When the local policy workers narratively include professionally related experiences to explain their current actions, they connect situations across time and place. We introduce the concept of hinterland here to emphasise that it is not merely what is present now – the context or the current settings in the municipalities – but also what has previously been experienced, that provides a specific yet dynamic topography of possibilities and constraints for the translation (‘hinter’ means behind in German). The point here is that the current professional setting – that is, the municipality – cannot fully explain the variation in implementation. Rather, a historical conjunction of contexts – as grasped by the concept of hinterland – provides a more comprehensive explanation. In a nutshell, the concepts of translation and hinterland, then, explain why people in the same positions receiving the same set of guidelines implement them variously. Adding to this theoretical framework, our typology explicitly illustrates that professionally related experiences, among other factors, shape how the local policy workers perceive the ideological and practical possibilities for, and constraints to, guideline implementation.

This article contributes to the literature on local policy workers in the following ways. Most of the studies in this area introduce background data, such as age, gender, educational background and professional background (Bo Smith-udvalget, 2015; Hansen et al., 2013), values (Vrangbæk, 2009) and job characteristics (Winter and Nielsen, 2008), in an attempt to characterise the local administration as a group and/or reveal the profile of an average local policy worker. The existing literature, then, implicitly infers that the local policy workers’ implementation practices – decisions and practices – can be understood and explained by those variables. Whilst such surveys provide good descriptions of a certain group of people and are useful for investigating patterns between norms, values and background variables, for example, they are less helpful in exploring the complexity that nevertheless exists within a heterogeneous group of people. The causes suggested in the policy literature for implementation failures are multitudinous (McConnell, 2015). Most of these failures have been connected to the characteristics of the policies themselves (Peters, 2015) and a few others to the political or socio-economic environment within which those policies are made (Peters, 2015) as well as the characteristics relating to the institutions receiving the policies/guidelines, such as the internal organisational structure (Meyers et al., 1998; Olsen, 2013), resources and needs and organisational culture (Durlak and DuPre, 2008). Yet another segment of the policy literature likewise suggests the personalised, and arbitrary, treatment of policies and guidelines as a potential distortion in the implementation process (Goodsell, 1981; Meyers et al., 1998; Pesso, 1978). As we argue, the latter is unavoidable: in real-world situations, the enactment of policies and guidelines – the ‘know-how’ knowledge – invariably involves an element of ‘know-that’ knowledge or what Yanow (2004) calls ‘the local knowledge’.

Conclusion

First of all, this study reminds us that guidelines do not implement themselves – they need to be activated in the sense of being put into action by people (Schofield, 2001) – and the people putting the guidelines into action are not merely ‘local policy workers’ or a homogenous group of people. Rather, they come with different professionally related experiences that affect the enabling and constraining frames in which the guidelines are translated.

The inclusion of the concepts of translation and hinterland to our presentation of a typology serves to explain and acknowledge the uncertainty, the centrality of practice and the recognition of complexity (Freeman, 2009) that exist when people first de-contextualise and then contextualise guidelines (Røvik, 2007). Importantly, if we take into account this movement of the guidelines – as being translated by local policy workers within their own specific hinterland – then it becomes extremely difficult, if not impossible, to neglect the benefits of a deeper exploration of the people who constitute the group of local policy workers, to understand the variety in their implementation of the guidelines (Jenkins, 2007). In regard to motivation and perceived agency in public policy workers, Le Grand (2003: 17) argues that ‘the realities of human motivation and agency are far too complex to be adequately summarised by this kind of [typology] approach. […] In fact, most human beings are in all probability some combination […], with different aspects come to the fore in different circumstances’. Nevertheless, our typology illustrates the variety of local policy workers and offers an alternative way of thinking about local policy workers. The typology then serves as a tool for analysis and understanding policy implementation challenges. In other words, this article problematises the concept of implementation and draws attention to the personal characteristics of the people implementing and to the fact that implementation processes are always tied to local and individual contexts (Johnson and Hagström, 2007) and hinterlands.

Inasmuch as guidelines are increasingly used in Western countries as a soft form of regulation (Timmermans and Epstein, 2010) to standardise the local governments’ public health practices (Rod and Høybye, 2015), it is worth considering who the people giving life to those guidelines are. Taking the personalised treatment of policies and guidelines as an unavoidable condition, we should engage and tackle the local policy workers’ translations and implementation strategies in ways that see them as productive, instead of focusing on varied implementation as a sign of implementation errors or failures. In saluting and exploring the experiences causing the variety, we will learn from the so-called ‘implementation failures’ and gain indispensable insight into ‘the local knowledge’ – that is, the practice- and experience-based knowledge that has proven to work over time (Yanow, 2004).

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work is carried out as a part of the research programme “Governing Obesity” funded by the University of Copenhagen Excellence Programme for Interdisciplinary Research ().

References

Adams

Colebatch

Walker

(2015) Learning about learning: Discovering the work of policy. Australian Journal of Public Administration 74(2): 101–111.

Alavi

Leidner

(2001) Review: Knowledge management and knowledge management systems: Conceptual foundations and research issues. MIS Quarterly 25(1): 107–136.

Anell

Glenngard

Merkur

(2012) Sweden: Health system review. Health Systems in Transition 14(5): 1–159.

Barr

Tubman

Montgomery

et al. (2002) Amenability and implementation in secondary school antitobacco programs. American Journal of Health Behavior 26: 3–15.

Bo Smith-udvalget (2015) Embedsmanden i det moderne folkestyre, Copenhagen, Denmark: Jurist-og Økonomforbundets Forlag.

Brewer

(2005) In the eye of the storm: Frontline supervisors and federal agency performance. Journal of Public Administration Research and Theory 15(4): 505–527.

Brodkin

(2012) Reflections on street-level bureaucracy: Past, present, and future. Public Administration Review 72(6): 940–949.

Cairney

(2009) Implementation and the governance problem: A pressure participant perspective. Public Policy and Administration 24(4): 355–377.

Caswell

Larsen

(2015) Frontlinjearbejdet i leveringen af aktiv beskæftigelsespolitik – Hvordan faglige, organisatoriske og styringsmæssige kontekster påvirker dette. Tidsskrift for Arbejdsliv 17(1): 9–27.

10.

Cooke

(2000) The dissemination of a smoking cessation program: Predictors of program awareness, adoption and maintenance. Health Promotion International 15: 113–124.

11.

DHMA [Danish Health and Medicines Authority] (2012) Introduktion til Sundhedsstyrelsens Forebyggelsespakker, Copenhagen, Denmark: Danish Health and Medicines Authority.

12.

DHMA [Danish Health and Medicines Authority] (2013) Health Promotion Packages – Introduction and Recommendations, Copenhagen, Denmark: Danish Health and Medicines Authority.

13.

Durlak

DuPre

(2008) Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology 41(3–4): 327–350.

14.

Fischer

(2003) Reframing Public Policy: Discursive Politics and Deliberative Practices, Oxford, England: Oxford University Press.

15.

Freeman

(2006) Learning in public policy. In: Rein

Moran

Goodin

(eds) The Oxford Handbook of Public Policy, Oxford, England: Oxford University Press, pp. 367–388.

16.

Freeman

(2009) What is ‘translation’? Evidence & Policy 5(4): 429–447.

17.

Freeman

(2012) Reverb: Policy making in wave form. Environment and Planning A 44: 13–20.

18.

Freeman

Griggs

Boaz

(2011) The practice of policy making. Evidence, policy – and practice. Evidence & Policy 7(2): 127–136.

19.

Freeman

Maybin

(2011) Documents, practices and policy. Evidence & Policy 7(2): 155–170.

20.

Freeman

Sturdy

(2014) Introduction. In: Freeman

Sturdy

(eds) Knowledge in Policy: Embodied, Inscribed, Enacted, Bristol, CT: Policy Press, pp. 1–17.

21.

Gofen

(2014) Mind the gap: Dimensions and influence of street-level divergence. Journal of Public Administration Research and Theory 24(2): 473–493.

22.

Goodsell

(1981) Looking once again at human service bureaucracy. Journal of Politics 43: 761–778.

23.

Gorsky

Lock

Hogarth

(2014) Public health and English local government: Historical perspectives on the impact of ‘returning home’. Journal of Public Health 36(4): 546–551. DOI: 10.1093/pubmed/fdt131.

24.

Hansen

Opstrup

Villadsen

(2013) En administrativ elite under forandring. Udviklingen i danske kommunale topchefers kollektive profil fra 1970 til 2008. Politica 45(2): 178–194.

25.

Hjelmar

Møller

(2015) From knowledge to action: The potentials of knowledge portals. Nordic Social Work Research 6(2): 126–137.

26.

Hupe

(2014) What happens on the ground: Persistent issues in implementation research. Public Policy and Administration 29(2): 164–182.

27.

Hupe

Hill

(2016) ‘And the rest is implementation.’ Comparing approaches to what happens in policy processes beyond great expectations. Public Policy and Administration 31(2): 103–121.

28.

Iyer

Israel

(2012) Structural equation modeling for testing the impact of organization communication satisfaction on employee engagement. South Asian Journal of Management 19(1): 5181.

29.

Jenkins

(2007) The meaning of policy/policy as meaning. In: Hodgson

Irving

(eds) Policy Reconsidered: Meanings, Politics and Practices, Bristol, CT: Policy Press, pp. 21–36.

30.

Johnson

Hagström

(2007) The translation perspective as an alternative to the policy diffusion paradigm: The case of the Swedish methadone treatment. Journal of Social Policy 34(3): 365–388.

31.

Kallestad

Olweus

(2003) Predicting teachers' and schools' implementation of the Olweus bullying prevention program: A multilevel study. Prevention & Treatment 6(1): 21a.

32.

Kingfisher

(2013) A Policy Travelogue: Tracing Welfare Reform in Aotearoa/New Zealand and Canada, New York, NY: Berghahn Books.

33.

Kjaer

Hjelmar

Olsen

(2010) Municipal amalgamations and the democratic functioning of local councils: The case of the Danish 2007 structural reform. Local Government Studies 36(4): 569–585.

34.

Laverack

(2004) Health Promotion Practice: Power and Empowerment, London, England: Sage Publications.

35.

Law

(2004) After Method. Mess in Social Science Research, London, England: Routledge.

36.

Le Grand

(2003) Motivation, Agency, and Public Policy: Of Knights and Knaves, Pawns and Queens, New York, NY: Oxford University Press.

37.

Lendvai

Stubbs

(2007) Policies as translation: Situating transnational policies. In: Hodgson

Irving

(eds) Policy Reconsidered: Meanings, Politics and Practices, Bristol, CT: Policy Press, pp. 173–190.

38.

Lipsky

(1980) Street-Level Bureaucracy: Dilemmas of the Individual in Public Service, New York, NY: Russell Sage Foundation.

39.

McConnell

(2015) What is policy failure? A primer to help navigate the maze. Public Policy and Administration 30(3–4): 221–242.

40.

Madden

(2010) Being Ethnographic: A Guide to the Theory and Practice of Ethnography, London, England: Sage Publications.

41.

Markussen

Nielsen

(2014) Knowledge logistics: an epistemography of the genesis of a governmental guideline, Bodø, Norway: University of Nordland.

42.

Markussen

Wackers

(2015) On recursive policy envelopes and exposure management: The mysterious survival of a governmental guideline. Evidence & Policy 11(3): 439–458.

43.

Marston

Larsen

McDonald

(2005) The active subjects of welfare reform: A street-level comparison of employment services in Australia and Denmark. Social Work and Society 3(2): 141–157.

44.

May

Winter

(2009) Politicians, managers, and street-level bureaucrats: Influences on policy implementation. Journal of Public Administration Research and Theory 19(3): 453–476.

45.

Maynard-Moody

Musheno

(2000) State agent or citizen agent: Two narratives of discretion. Journal of Public Administration Research and Theory 10(2): 329–358.

46.

Meyers

Glaser

MacDonald

(1998) On the front lines of welfare delivery: Are workers implementing policy reform. Journal of Policy Analysis and Management 17: 1–22.

47.

Olejaz

Juul Nielsen

Rudkjøbing

et al. (2012) Denmark: Health system review. Health Systems in Transition 14(2): 1–192.

48.

Olsen

(2013) Absolut flertal og forvaltningens dagsordenssættende indflydelse–er der en kausal sammenhæng? Politica 45(2): 139–158.

49.

Oppenheim

(2011) Kyôngju Things: Assembling Place, (4th ed). Ann Arbor, MI: The University of Michigan Press.

50.

Parsons

(1995) Public Policy: An Introduction to the Theory and Practice of Policy Analysis, Cheltenham, England: Edward Elgar Publishing Ltd.

51.

Patterson

Williams

(2002) Collecting and Analyzing Qualitative Data: Hermeneutic Principles, Methods, and Case Examples, Urbana, IL: Sagamore Publishing.

52.

Perry

Hondeghem

(2008) Motivation in Public Management: The Call of Public Service, Oxford, England: Oxford University Press.

53.

Pesso

(1978) Local welfare offices: Managing the intake process. Public Policy 26(2): 305–330.

54.

Peters

(2001) The Politics of Bureaucracy, 5th ed. New York, NY: Routledge.

55.

Peters

(2015) State failure, governance failure and policy failure: Exploring the linkages. Public Policy and Administration 30(3–4): 261–276.

56.

Ringard

Sagan

Sperre Saunes

et al. (2013) Norway: Health system review. Health Systems in Transition 15(8): 1–162.

57.

Ringwalt

Ennett

Johnson

et al. (2003) Factors associated with fidelity to substance use prevention curriculum guides in the nation's middle schools. Health Education & Behavior 30: 375–391.

58.

Rod MH and Høybye MT (2015) A case of standardization? Implementing health promotion guidelines in Denmark. Health Promotion International. Epub ahead of print. DOI: 10.1093/heapro/dav026.

59.

Røvik

(2007) Trender og Translasjoner. Ideer som omformer det 21. århundredes organisatjon, Oslo, Norway: Universitetsforlaget.

60.

Ruck

Welch

(2012) Valuing internal communication: Management and employee perspectives. Public Relations Review 38(2): 294–302.

61.

Sandfort

(1999) The structural impediments to human service collaboration: Examining welfare reform at the front lines. Social Service Review 73(3): 314–339.

62.

Schofield

(2001) Time for a revival? Public policy implementation: A review of the literature and an agenda for future research. International Journal of Management Reviews 3(3): 245–263.

63.

Staunæs

(2004) Situering, dialog og forstyrrelse. Principper for produktions-og analysemetoder. In: Staunæs

(ed.) Køn, etnicitet og skoleliv, Copenhagen, Denmark: Forlaget Samfundslitteratur, pp. 75–94.

64.

Steijn

Tummers

Bekkers

(2012) Explaining The willingness of public professionals to implement public policies: content, context, and personality characteristics. Public Administration 90(3): 716–736.

65.

Stone

(2002) Policy Paradox: The Art of Political Decision Making, (rev. ed.). New York, NY: WW Norton and Company.

66.

Talbot

Verrinder

(2009) Promoting Health: The Primary Health Care Approach, Sydney, Australia: Elsevier.

67.

Taylor

(1995) To follow a rule. In: Taylor

(ed.) Philosophical Arguments, Cambridge, England: Harvard University Press, pp. 165–180.

68.

Timmermans

Epstein

(2010) A world of standards but not a standard world: Toward a sociology of standards and standardization. Annual Review of Sociology 36: 69–89.

69.

Torenvlied

Akkerman

(2004) Theory of ‘soft’ policy implementation in multilevel systems with an application to social partnership in the Netherlands. Acta Politica 39(1): 31–58.

70.

Tummers

(2012) Policy alienation of public professionals: The construct and its measurement. Public Administration Review 72(4): 516–525.

71.

Vallgårda

(2008) The Danish health system. In: Vallgårda

Krasnik

(eds) Health Services and Health Policy, Copenhagen, Denmark: Gyldendal Akademisk, pp. 133–198.

72.

Vallgårda

(2014) Ethics, equality and evidence in health promotion Danish guidelines for municipalities. Scandinavian Journal of Public Health 42(4): 337–343.

73.

van Engen

Tummers

Bekkers

et al. (2016) Bringing history in: Policy accumulation and general policy alienation. Public Management Review 18(7): 1085–1106.

74.

Vrangbæk

(2009) Public sector values in Denmark: A survey analysis. International Journal of Public Administration 32(6): 508–535.

75.

Wagenaar

(2004) ‘Knowing’ the rules: Administrative work as practice. Public Administration Review 64(6): 643–656.

76.

Wimmelmann CL (2016). Performing compliance: Performing compliance: The work of local policy workers during the implementation of national health promotion guidelines. Evidence and Policy. Online first. DOI: 10.1332/174426416X14663312126352.

77.

Wimmelmann CL (forthcoming). Enactments of national health promotion policies in local contexts: A Danish case.

78.

Winter

(2003) Implementation perspectives: Status and reconsideration. In: Guy Peters

Pierre

(eds) Handbook of Public Administration, London, England: Sage publications Ltd, pp. 213–222.

79.

Winter

Nielsen

(2008) Implementering af politik. 1. udg., 1. opl, Aarhus, Denmark: Academica.

80.

Yanow

(2004) Translating local knowledge at organizational peripheries. British Journal of Management 15(S1): S9–S25.