IJERPH, Vol. 16, Pages 4993: Public Health from the Middle-Out: A New Analytical Perspective (International Journal of Environmental Research and Public Health)

Obstacles to collaborative public health frameworks such as Health in All Policies continue to emerge. Partnership-based public health programs present opportunities to study how public servants and practitioners address these barriers in real time. To this end, we utilized `Middle-Out,` a socio-technical analytical approach that highlights the importance of Middle Actors-stakeholders positioned between policymakers and grassroots--to policy diffusion, innovation and collaboration in public health. We conducted participatory observation in administrative settings of Israel`s National Program to Promote Active, Healthy Lifestyle, 30 stakeholder interviews and document analysis. We examined two dimensions of impact from the Middle-Out: Directions of Influence--Middle-Up, Middle-Down and Sideways, and Modes of Influence--Enabling, Mediating and Aggregating. Through Middle-Out`s lens, our analysis transcends visible benchmarks such as legislation and macro-level resource-allocation, focusing, instead, on elusive administrative spaces within which Middle Actors shape policies, steer funding and facilitate continuity. Incorporating Middle-Out into public health`s conceptual toolbox, we conclude, can improve understanding of complex public health policy arenas, increase recognition of critical socio-technical changemakers and catalyze more effective design of policy tools and strategies that specifically harness Middle Actors` strengths and qualities.