Local government policymaking environment for Health in All Policies: a case study research investigation

ABSTRACT

The local level of government is identified as being well placed to address the determinants of health due to their flatter governance structure and proximity to the community. Research has identified multiple factors that influence local governments to act on these health determinants, although few have applied theories of the policy process to understand the policymaking environment. Using two Australian local government case study sites, we explored the policymaking environment regarding policy decisions to address health determinants using the lens of four theories of the policy process. We conducted 20 interviews and one focus group with elected members and staff in local government, along with an analysis of 12 policy documents and participation in a policy reference group. Following thematic analysis, 13 factors influencing policy addressing health determinants were identified, mostly confirming previous research from within Australia and globally. New themes have emerged regarding the limited range of policy actors involved and the lack of advocacy, particularly by community or media, who have an identified influence over decision-making in a local government context. Applying theories of the policy process also demonstrates how they can be used to add meaning to the interconnectedness of influences in unique local government policymaking environments.

KEYWORDS:

• Municipality
• policy process
• political science
• health determinants
• health promotion

Introduction

The health of a population is largely influenced by environments outside of healthcare, namely the social, economic, and political environments in which people live (Marmot et al., 2008). Referred to as the determinants of health, examples include equitable access to housing, transport, and social services, as well as safe and fair conditions across home, school, work, and play (Marmot et al., 2008). Addressing determinants of health reflects the conceptually framed Health in All Policies (HiAP) approach recognized by the World Health Organization, whereby health is considered in policies across a range of sectors, including those outside of healthcare (World Health Organization, 2010). A HiAP approach requires effective systems, leadership, and collaboration across sectors to consider the health of populations when any policy decisions are made (World Health Organization, 2010).

One proposal is that local governments (LG), also referred to as municipalities, are best placed to address HiAP given their flatter governance structures and close connection with the community (Marmot et al., 2008; World Health Organization, 2012). For example, LG is well positioned to address health impacts through urban planning decisions, access to local services, opportunities for community connections, and affordable housing (World Health Organization, 2012). This potential for action has been evidenced in the mandated Public Health Act for Norwegian municipalities to address social inequities (Tallarek Née Grimm et al., 2013) and the shift of public health responsibilities from national to local-level government in the United Kingdom (Marks et al., 2015). Studies in Australia have also demonstrated that LG act on social determinants of health, often beyond their mandated health obligations (Browne et al., 2016, 2019). However, whilst the potential of LG to address health determinants is realised, understanding how or why LG make these decisions is less known (Cairney et al., 2021; Shankardass et al., 2014).

A scoping review of literature between 2011 and 2021 identified multiple factors that influence LG decision-making to pursue a HiAP approach (Lilly et al., 2023). Challenging factors included difficulty collaborating across sectors, few performance indicators for health, limited funding and staff capacity, absence of key champions, and uncertainty regarding the most effective governance and political structures (e.g. legislation) to support a HiAP approach (Lilly et al., 2023). Other factors found to influence a HiAP approach included strong leadership, high priority toward health determinants, an ambiguous understanding of health, differing individual values and political ideologies, reliance on community input and anecdotal evidence, and the largely disempowered yet autonomous role of LG in addressing health determinants (Lilly et al., 2023). However, few of the reviewed studies applied a theory of the policy process to make meaning of the factors in the policymaking environment (Lilly et al., 2023). Without a theoretical basis, it is challenging to identify how these factors collectively influence decision-making.

In response to calls for health promotion to better utilise policy theory to understand the policy decision-making process (De Leeuw et al., 2014; Embrett & Randall, 2014; Fafard & Cassola, 2020), this research explored the Australian LG decision-making environment through the lens of political science. It follows a survey of Australian LG decision-makers and staff that sought to understand the factors influencing decisions regarding health and well-being policy. The survey identified that Australian LGs report a high level of priority and commitment to health and wellbeing of their community, with both strong organisational and personal obligations to act (Lilly et al., 2020). The survey participants also reported challenges in working with other sectors and higher tiers of government, an unfavorable legislative environment for action, and limited financial and staff capacity to act (Lilly et al., 2020). The aim of this case study was to further investigate the survey results within a specific context, particularly how the factors of the policy process influence LG decision-making, and if theories of the policy process are helpful in guiding this investigation.

In Australia, LG (also referred to individually as a council) is a non-constitutional tier of government, whereby the responsibilities and legislative actions are bound by the state or territory tier of the government in which they are located. Given that Australia has eight states or territories, it creates a diverse range of LG responsibilities across the country (Dollery et al., 2009). Common responsibilities include regulating the inspection of new developments, monitoring food safety, the development and maintenance of local traffic infrastructure, pet controls, and providing community services such as parks and libraries (Megarrity, 2011; Ryan & Woods, 2015). LG employs a range of staff in specialized fields to deliver the required functions, along with the election of a mayor (sometimes referred to as presidents) and elected members who are responsible for decision-making on behalf of their community (Megarrity, 2011). LG relies heavily on funding by higher tiers of government with other limited options for fiscal income, such as charging property rates and public fines (Dollery et al., 2009; Ryan & Woods, 2015). Notably, some LGs have legislative requirements to respond explicitly to their state’s strategic plan for health and well-being, which sometimes includes broader health determinants. However, LG has no consistently acknowledged national role in addressing health determinants.

Methods

Research design

A case study design was selected to explore the interconnectedness of policy influences in each LG context. This was supported by theories of the policy process used to understand the complex policymaking environment. Ethics approval was obtained from the Curtin University Human Research Ethics Committee SPH-88-2014. The consolidated criteria for reporting qualitative research is used to ensure comprehensive and quality reporting regarding the rigour of this study (Tong et al., 2007).

Recruitment and overview of case study sites

Two regional LGs were recruited to participate via connections within the professional networks of the primary author [KL]. Case study sites were deemed eligible if they were accessible to the researcher and willing to be involved, purposely located within the same state/territory to compare findings within similar political contexts. While efforts were made to recruit LGs in both metropolitan and regional areas, no metropolitan LGs agreed to be involved.

For anonymity, the case study sites were assigned pseudonyms. Finchville is a small regional council within 150 km of a capital city with a population of approximately 50,000 people, slow population growth, and an aging population. Compared with other LGs in the same jurisdiction, Finchville has a high level of unemployment, low median income, high rates of volunteerism, and a strong sense of coherence among the community. Roseford is a large regional council with a population of approximately 100,000 people over a large geographical area, located 300 km from a capital city. In comparison to state population-level data, the LG has a high proportion of Aboriginal and Torres Strait Islander people, an aging population, a high unemployment rate, and high levels of disadvantage.

Theoretical lens

The theoretical lens was based on theories of the policy process, including the Multiple Streams Framework (MSF) (Kingdon, 1995), the Advocacy Coalition Framework (ACF) (Sabatier & Weible, 2007), and the Punctuated Equilibrium Framework (PEF) (Baumgartner & Jones, 1993), each considered to be among the most established, tested, and clear political science theories in their conceptual assumptions (Heikkila & Cairney, 2018). The research also incorporated the Analysis of Determinants of Policy Impact (ADePT), which is adapted from behavioral science to focus on policy processes, is more inclusive of determinants that influence policy implementation and evaluation, and was initially tested in LG contexts (Rütten et al., 2013). The constructs of each theory were listed in a mind map (e.g. use of evidence, policy framing, external events). These constructs collectively informed data collection (e.g. interview questions) and formed the basis for deductive data analysis.

Interviews and focus group

LG decision-makers within the case study sites, comprising strategic managers including Chief Executive Officers (CEOs) and elected members (including mayors), were invited by email to participate in a semi-structured interview. A Research Information Sheet (RIS) was attached to the email outlining the study details. Non-responders were sent a reminder email two weeks later. All decision makers in LG were encouraged to forward the invitation to non-management staff for involvement in the focus group. Participants who agreed to an interview or focus group were sent a calendar invite with the RIS reattached for their reference. Interviews and focus groups were mostly conducted in person by the primary author [KL] at the LG workplace or held via phone, where this was not possible. Consent to participate in the study and demographic details were obtained at the time of the interview or focus group, both in writing and verbally. None of the participants were known to the interviewer prior to data collection. Interviews and focus group questions were designed to further interpret the findings of the previously administered national survey in a particular context. The interview and focus group questions are provided in the Supplementary Materials.

Interview and focus groups were recorded and transcripts were sent to participants to check and provide amendments, prior to being analysed using template analysis (King et al., 2018). The primary researcher [KL] read all transcripts to become familiar with the data, followed by a process of preliminary coding using a predominant inductive approach and informed deductively at a later stage using the theoretical lens. An initial theme template was devised by clustering similar codes under a common theme. The resultant themes were entered into NVivo¹ software to assist further data analysis, with themes modified as meanings of the data further interpreted and cross-referenced with theory and the initial data sources. The final template resulted in nine themes and 29 codes for the first case study site. This was used as the initial template for the second case study site. Further adjustments were made based on the analyses of both case study sites. The final stage of ‘writing up’ was completed separately for both case study sites, prior to a combined synthesis of findings using the technique of explanation building (Yin, 2018). This involved continual revision and triangulation of data to ensure that all the evidence had been included and that they were mindful of any possible rival interpretations (Yin, 2018). The data within and across the case study sites were primarily analyzed inductively, before applying a deductive lens comprised of theoretical constructs of the policy process to identify similarities, differences, and gaps.

Document analysis

Case study policy content was analysed to gain insight into policy outputs, although they were primarily used to inform the interview discussions. Existing policies, along with publicly available meeting minutes, were analyzed for manifest content (e.g. frequency of the term ‘health’) and latent content (e.g. use of evidence to inform actions) (Leung & Chung, 2017). Latent themes were informed by theoretical constructs of the policy process and a previously developed framework assessing policy content to address health equity (Fisher et al., 2015, 2016). Relevant policies and plans were considered as pertinent to the health of the community (e.g. housing, youth). Policies were excluded if they related to internal management of the council (e.g. human resources and finance). Policy documents were either publicly available or provided voluntarily to the researcher during interviews.

Reference group participation

An opportunity arose for the primary author to participate in a reference group to establish a community health and well-being policy in Finchville. The role of ‘participation-observation’ (Yin, 2018) allowed access to the policy process at a stage of development and approval. The data consisted of observations, field notes, meeting minutes, supporting documentation, and iterative policy drafts, with no predetermined themes or structures to guide the data collection (Mulhall, 2003). The data were analyzed using a deductive thematic analysis, congruent with the theoretical lens, as well as an inductive analysis based on personal reflections, as the results were interpreted post-involvement (Marvasti, 2014).

Results

Interviews and focus group participation

The interview and focus group participants represented approximately 50% of the elected members in the case study sites and 70% of senior management staff, most of whom had more than 10 years of experience working in LG. Reasons for non-participation are unknown. Demographic details are presented in Table 1. The interviews ranged from 30 to 45 min, and the focus group took 60 min.

Table 1. Demographics of participants within the two case study sites, including role and years of experience in local government.

		Finchville	Roseford
Role in LG	Mayor	1	1
	Elected member	3	5
	CEO	1	0
	Manager	3	6
	Non-management staff	5	0
Years working in LG	>10 years	7	6
	6–10 years	3	3
	0–5 years	3	2
	Unknown/Not answered	0	1
Total number of participants		13	12

Document analysis

Content analysis identified the term ‘health’ used 69 times across 12 policy documents, mostly referring to the role of the healthcare sector in generating employment opportunities. There were no explicit references to the term ‘health determinants’, although examples of addressing health determinants were identified in the latent content analysis, such as reducing social isolation, improving access to affordable housing, accessible infrastructure, cultural safety, and employment opportunities.

Reference group participation (Finchville)

Involvement in the reference group granted insight into decision-making practices, including the level of influence and power of invited stakeholders to influence the priorities of the plan, along with the lack of support to include performance indicators or consideration for stakeholder commitment, finances, or staff resources that would be required to implement any of the strategies.

Case study site themes

Thirteen themes were identified to describe the influencing factors within the LG policymaking environment regarding decisions and actions to address health determinants, as summarized in Table 2.

Table 2. Summary of themes identified as influencing the policymaking environment of local government to address health determinants.

Theme	Summary of findings
Strong organisational obligation	Decision-makers reported a strong commitment and obligation to respond to local community needs. The organisational commitments were often matched with personal beliefs and values that it was the ‘right thing to do’.
Internal leadership and multiple champions	There was widespread support by management and elected members, though no single key champion seeking opportunities to enable action on the determinants of health.
Difficulty defining health and wellbeing	Defining health, wellbeing, or determinants of health was considered difficult. The term ‘health’ was rarely or never used, and the determinants of health was never explicitly raised in policy decisions. Participants in both sites referred to action on health determinants as a by-product of other policy discussions.
Scope of LG role	The proximity to community was reported as raising the priority on determinants of health, with each LG community considered unique. The role of LG was identified as enabling, mediating and advocating for community wellbeing.
Evidence tends to be anecdotal	A range of evidence sources informed policy decisions, although no performance measures were in place for health and wellbeing outcomes. Scientific data was rarely used to guide decision-making, with a reliance on input by community organisations, census data and complaints by community members.
Mixed response regarding legislation	Mandatory action to address determinants of health was not considered necessary and proposed to narrow the focus and create a compliance approach, rather than having flexibility to respond to local priorities.
Lack of external advocates	External lobbying by community, local media or industry was reported as non-existent. There was no internal lobbying within LG to create a demand for action on determinants of health. Local media were identified as having limited capacity to drive social campaigns and were reported as largely apathetic.
Limited financial and staff capacity	Financial and staff resourcing was considered limited and competing with other priorities, in an environment of ongoing austerity.
Organisational stability	Organisational stability differed across the LG sites, determined by the community who elected representative members. Stability was recognised as necessary for public health planning, given the long-term actions required to see change.
Cooperation with higher tiers of government	The support of higher tiers of government was considered cooperative at a local level. Participants reported a reliance on higher tiers of government for short-term project funding, which was allocated for specific goals, and not always the priority of LG.
Support from other sectors	Cross sector collaborations were evident in Finchville, with formal collaborations around social issues, such as homelessness. Whilst less obvious, participants in Roseford expressed the need for partnerships to address health determinants and gave examples of this happening previously to address youth unemployment.
Role of community in decision-making	The community was reported to play a critical role in policy decision-making, although there were varying levels of community involvement in decision-making.
External events as a trigger for policy	There were few ‘external events’ that influenced decisions, except for LG amalgamations and local elections.

Applying theories of the policy process

Examples of how the themes were interconnected and how theories of the policy process were applied are outlined below.

Multiple streams framework

According to the MSF, solutions are waiting to be coupled with a policy problem and a supportive political environment (Herweg et al., 2018; Kingdon, 1995). LG participants reported that health determinants were always considered in policy decisions, although rarely in response to health as a policy problem. For example, priorities to focus on local employment were driven by concerns that community members could not afford amenities and council rates. Whilst implicitly acknowledging the beneficial health outcomes of employment and economic security, health became the ‘by-product’ of decisions made, rather than the reason for policy investment. Participants perceived health or health determinants as ambiguous and difficult policy concepts to define, potentially making it difficult to gain political traction (Herweg et al., 2018). In addition, measuring or accessing local data on health inequities was perceived as both complex and financially unviable and therefore unlikely to demonstrate the problem worsening over time to generate policy attention (Herweg et al., 2018). Finchville explained that financial constraints meant that investing in measures of local health outcomes was not justifiable. With limited local evidence of health priorities, the council was more likely to respond to priorities of higher tiers of government or broader media discourse, which MSF might refer to as the ‘national mood’ (Herweg et al., 2018). For example, the national debate regarding marriage equality in Australia initiated social justice and equity policy in Finchville.

Advocacy coalition framework

A key concept of the ACF is the power of policy actors forming coalitions and lobbying based on shared beliefs, conflicting over differing beliefs, or interacting with one another for policy learning opportunities (Heikkila & Cairney, 2018; Pierce et al., 2017; Weible et al., 2009). There are four observed coalitions that could be determined from the case study sites: LG decision-makers, community, local organizations, and media. According to the ACF, the ‘deep core’ beliefs of LG decision-makers, in this instance, the strong organizational and personal obligation of LG decision-makers centered on community well-being, have a strong influence on policy (Sabatier & Weible, 2007). In Finchville, this was perceived as a shared value across LG decision-makers and community, contributing to a policy monopoly, which theoretically strengthens the likelihood of policy initiation and action (Jenkins-Smith et al., 2018). At both sites, the community was seen as the reason for policy on community well-being, and their voice was a prominent source of influence in policy decisions. Participants in Roseford reported heavy reliance on conversations with community members and often a more reactive response based on the level of community complaints received. Participants at both case study sites acknowledged the limited staff resources to reach out to all members of the community, particularly those most impacted by social and health inequities.

Experience in the reference group alluded to the power that local organizations have in directing policy decisions related to the development of a health and well-being plan for the region. Whilst the policy was intended to focus on health determinants, the types of policy actors involved were largely representative of the healthcare sector, which then was reflected in a majority of the actions proposed focussed on individual level strategy or accessible health services, such as community awareness of healthy behaviours and improved access to family and child health services. In addition, there was little to no reference to scientific evidence in decision-making, despite its importance as a policy learning strategy to shift the more superficially held values and beliefs of policy actors (Pierce et al., 2017).

Decision-makers in the case study sites reported that local anecdotal evidence tends to be favored, including community complaints or news items in the media. The media, as the fourth coalition for possible advocacy, was considered largely apathetic at a local level, although more influential in the context of broader national debate and discourse.

Punctuated equilibrium framework

The PEF focuses on how policy is sustained or why it changes, based on the ability of decision makers to cognitively process the many policy issues being raised at once (Baumgartner et al., 2018). The framework emphasizes the role of external events, policy images, policy load, and how feedback loops influence policy directions (Baumgartner et al., 2018). LG decision-makers reported how election outcomes, amalgamations, and leadership stability can initiate policy change, for better or worse. For example, the leadership of CEOs and mayors was considered supportive of policy action on health determinants, particularly where there had been organizational stability.

However, there were few other examples of feedback loops that were likely to change LG policy directions. For example, a lack of performance indicators to monitor local health outcomes, no strong public concern, or any media coverage or lobbying at a local level to ‘punctuate’ current policy directions. Receiving complaints by the community was reported as the most likely reason for LG to raise policy issues regarding health and wellbeing, yet community rarely did.

Analysis of determinants of policy impact

ADePT has four policy considerations: goals, obligations, resources, and opportunities (Rütten et al., 2003, 2011). In this study, LG decision-makers reported a strong organizational and personal obligation to address the well-being of communities, with recognized leadership by mayors and CEOs being an important factor influencing policy direction. However, the lack of clear goals or performance indicators centred around health or health inequities is likely to challenge the policy process (Rütten et al., 2011). In addition, staff and financial resources were often reported to be challenging for both the capacity to develop policies around health determinants and moreso the capacity to action policy plans to address them. Experience in the reference group supported this, with the plan written aspirationally rather than considering feasibility. Participants in Roseford acknowledged that staff capacity was limited, with a growing region having a significant impact on sufficient staffing levels. Financial resources were restricted, with reluctance to increase property rates given the existing financial disadvantage in the community.

Discussion

The factors influencing Australian LG decision-making regarding determinants of health in the case study sites confirmed many of the findings synthesized across the global LG literature (Lilly et al., 2023). For example, the influence of strong leadership and organizational support, reliance on anecdotal evidence, and the absence of any performance measures for community health and well-being or health inequities (Lilly et al., 2023). The limited financial and staff resources confirmed the summary of previous literature in LG contexts worldwide, as well as both the challenges and opportunities of working with other sectors and reported action on addressing health determinants in the absence of health as a priority (Lilly et al., 2023).

With the theoretical lens of the policy process applied in this study, newer themes emerged regarding the limited range of policy actors involved in decision-making and the lack of advocacy, particularly by communities or media who have an identified influence over decision-making in a LG context. The findings also highlight the role of organizational stability or instability, the role of predictable and unpredictable events in triggering policy change, and a greater emphasis on the relationship and governance roles of higher tiers of government.

However, listed alone, these factors tell us little more other than Australian LG are likely to function similarly to other LGs internationally regarding decision-making to address health determinants. The value of the case study design applied in this research allows a specific context to describe how theories of the policy process can demonstrate the meaningfulness and interconnectedness of factors that influence the decision-making environment and further explain how and why decisions are made.

Each of the theories of the policy process provides a different perspective on the policymaking environment. For example, application of the MSF proposes that despite a strong level of commitment and personal value on health and well-being by LG decision-makers, it is unlikely that local policy problems include health. There are no local measures of health equity to raise the problem on the policy agenda, nor are they able to be measured due to limited resources. In addition, the legislative environment and broader support of other tiers of government are lacking. Therefore, there are likely limited windows of opportunity for policies to address health determinants, at least in response to health as a policy problem.

The ACF supports the understanding of the policy process by acknowledging highly regarded personal values, such as social justice among decision-makers, and raises the conscious awareness of the broad scope of policy actors involved in decision-making. This study highlighted the absence of policy actors outside of healthcare and the lack of external or internal lobbying pressures for LG to act by any advocacy coalitions. While policy learning opportunities exist among community organizations and national media, they are often not formalized as policy coalitions or guided by credible sources of evidence.

The PEF highlights that the approach to addressing health determinants in LG is likely to maintain the status quo given the absence of ‘positive feedback’ loops to influence policy change. Based on these research findings, there is an absence of performance measures for health or health inequities that impact or demonstrate change over time. Leadership changes, or community complaints, have the most likely impact on policy change, with this impacting in either a positive or negative way depending on the values of the incoming elected members and the level of engagement and health literacy of the community.

The application of the ADePT model aids in understanding the importance of the strong organizational, professional, and personal obligations of LG decision-makers in addressing health determinants. However, it also raises the challenge that while the goal of health for all is unanimously agreed on, there are no articulated strategies or measures to achieve the goal, along with limited funding and staff capacity.

Overall, LG values and a strong obligation to act, as well as both willingness and actual responses to health determinants, suggest that they are well placed to address health determinants. However, an understanding of the complex and unique decision-making environment in LG must be considered in order to fully understand where support and resources are required to encourage policy initiation and action. The theories of the policy process reinforce that there is no simple solution for influencing policy decisions. However, by understanding the policymaking environment, health promotion practitioners and advocates can be better placed to navigate the policy process. For example, in response to Finchville’s understanding of the policymaking environment, practitioners might be best placed to generate a new policy image that aligns the policy problem with LG values and beliefs, such as social justice. This is more likely to gain attention from decision makers as opposed to framing policies around health (Herweg et al., 2018). In addition, facilitation of informal or formal advocacy coalitions to generate attention on social inequities at a local level, such as an organized lobbying approach by community-based organizations, would be beneficial as they are perceived as a credible source in the community. It is proposed that those hoping to influence the LG policymaking environment to address health determinants could learn from these findings to consider their unique policymaking environment and ultimately influence policy decision-making to address health determinants.

Limitations

This study only investigated two regional LG sites within the same jurisdiction of Australia. Given the uniqueness of LG, these findings may not apply to all LG contexts. However, the application of theories of the policy process demonstrates how useful theories can be to make sense of policymaking environments in different contexts. Further research should test this in diverse LG contexts, such as metropolitan, rural, or Aboriginal and Torres Strait Islander (Indigenous) controlled councils. Furthermore, given that the authors have a strong background in health promotion and focus on social justice, potential bias exists, whereby the researchers may have unintentionally omitted data that does not align with these values. However, steps were taken to verify the results and intentionally seek contradictory statements during data collection and analysis to avoid such bias. In addition, it is possible that the theories of the policy process have been applied inaccurately or superficially, in an attempt at ‘political science in public health’, which recognizes that public health academics are attempting to understand a public health priority, using political science (Patrick Fafard et al., 2022). Future research should consider applying political science alongside public health to maximize the perspectives of both disciplines (Patrick Fafard et al., 2022).

Conclusion

The case study findings reinforce previous research regarding the factors that influence LG decision-making environments regarding action to address determinants of health yet create a sense of meaningfulness using theories of the policy process. The study findings add support to the debate that LG are well-positioned to address health determinants, although it calls for a better understanding of the unique policy process by applying theories of the policy process, ideally by collaborating with political scientists.

Author contribution statement

All authors were involved in conceptualisation and design of the study. Kara Lilly completed data collection and analysis, wrote the original draft manuscript, and contributed to review and editing, along with project administration. Suzanne Robinson, Linda A Selvey and Jonathan Hallett provided supervision of the research and contributed intellectual content where relevant. All authors provide approval for the final manuscript to be published and agree to be accountable for all aspects of the work.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to ethical considerations, supporting data is not publicly available. Participants did not provide informed consent for the data to be shared outside of this study.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/09581596.2024.2334364.

Additional information

Funding

This research did not receive any specific funding from agencies in the public, commercial, or not-for-profit sectors.This research was supported by an Australian Government Research Training Program (RTP) scholarship.

Notes

1. QSR International Pty Ltd. NVivo Versions 11 (2015) and 12 (released 2018). https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home