Study sample and data collection for the focus groups

For this case-study, the authors collaborated with a rural Dutch municipality that wanted to better understand how citizens’ health and wellbeing is impacted by their broader social environment and to integrate services and policies accordingly. For this study, purposive sampling [30] was used to ensure citizens representing each of the eight villages within the municipality’s boundary were reflected within the sample. Citizens were recruited by the municipality’s policymakers’ and communication officers’ local networks. Citizens were invited by the municipality and were asked to recommend other citizens for the focus group as well (snowball sampling). All focus groups were held when and where citizens would normally meet in order to reduce burden on participants.

EdW conducted the focus groups with citizens, while one of the municipality’s policymakers was there to observe and to provide explanations only when required. A semi-structured topic guide was used to anchor the focus group process (available upon request). During the focus groups, citizens were first openly asked to discuss their own priorities for the local health policy. After discussing their own priorities, citizens were asked to discuss the priorities health and care professionals working within the local health system had provided to the municipality a priori and then to rank all priorities (i.e. their own priorities and those of the professionals) in order of importance. Finally, citizens were asked how they wished to be involved in addressing the priorities and the support they required from the municipality.

To aid data analysis, all focus groups were recorded and transcribed. All study participants provided informed consent. The focus group data were supplemented and triangulated by fieldnotes and observations, e.g. of meetings between policymakers and involved citizens, and municipality’s council meetings. Furthermore, the focus group findings were anonymised and aggregated, after which the summarised findings were shared with focus group participants for final reflections and feedback to ensure findings had face validity and rigour. Focus groups were conducted until authors agreed the point of data saturation was reached; when no new themes emerged and when there was a high rate of recurrence of responses) [31]. Ultimately, four focus groups (each lasting about two hours) were held with a total of sixteen citizens representing the eight different villages. Finally, the focus group results were shared and discussed during a workshop with the reference panel. The study received ethics approval from Tilburg University (reference EC-2017.96) and data were collected between November 2019 and February 2020.

Focus group participants

One focus group involved five citizen, two focus groups involved four citizens, and another one involved three citizens. The average age of interviewed citizens was approximately 45, all interviewees were white Dutch, the majority were women (13 women, three men), most were employed (10), some were retired (4) and others were full-time carers for their spouses (2). All interviewees were volunteers within their villages (16), e.g. at their local football club, church or village council. Citizens were unanimous in the priorities described below, however there were contextual differences in the villages where the citizens lived, which informed how they discussed and ranked the priorities. For example, within one of the focus groups with citizens who lived in a more remote village, they discussed the need to improve the amount and accessibility of services and amenities. Whereas the other three focus groups talked more about the need to maintain the level of services and amenities they currently had access to.

Citizens’ health policy priorities stem from their holistic experiences and perceptions and differ from professionals’ priorities

The results indicate that citizens’ health policy priorities are cross-sectoral and holistic, touching on different policy sectors, including the health and care sector, the housing sector, public transport and the local infrastructure. Citizens perceived and experienced a wide-variety of public issues as having an impact on their health and wellbeing and particularly highlighted the importance of:

1. suitable and affordable housing for local residents, especially for young people (18–25), young families and elderly residents to live independently in their own homes and villages for as long as possible;
2. improving the accessibility of health and care services, i.e. primary care services, general practitioners, dementia care, carers’ support;
3. the living environment e.g. public transport and inviting green space to enable all age groups to exercise and to meet socially;
4. local shops and meeting places within village;
5. social activities which can bring different groups of residents together.

The results, as evidenced by the underpinning CMOs, suggest that citizens prioritise services and amenities because these strengthen feelings of social cohesion and ensure villages are suitable for all age groups, thus helping all citizens to live healthier and happier lives within their villages for as long as possible. Underlying these priorities was the idea that social cohesion was pivotal to citizens’ wellbeing and citizens’ fear that without such services or amenities local citizens would be forced to move out of the villages to ‘bigger city centres’ (for young people and families) or to retirement homes away from their families (for elderly residents). For example, one citizen who enjoyed living in one of the villages due to their roots and social network, expressed concern that the recently built housing was unaffordable to local residents, as none of it had been designated as social housing. She felt this was unfair to local residents and worried that due to the housing shortage increasing numbers of local residents would be forced out.

“Yeah, just a comfortable village life…My family lives here, I grew up here. It’s what we are familiar with and we don’t want to move away”

Furthermore, interviewees had also underscored the importance of accessible health and care services. Especially citizens who were carers for elderly relatives perceived that the changes in the Dutch health and care system (e.g. decentralisation, Participation Act 2015) now (over)emphasised citizens’ independence in seeking out and arranging suitable care for their older family members (context). They felt that carers were now under too much pressure especially because they experienced the current health and care system as fragmented and difficult to navigate (mechanism). They wanted better and more accessible carers’ support and better signposting of available services (outcome), in part as this would help to reduce carers’ stress and isolation (outcome). Some citizens enjoyed living in one of the villages as it provided them with easy access to primary care services, stating it ‘made life easier’ (See S1 Appendix for more CMO examples regarding residents’ priorities).

When citizens were presented with professionals’ priorities (after first openly discussing their own priorities) it became clear that residents and professionals perceived the priorities for the local health policy differently and citizens mostly ranked professionals’ priorities below their own. Professionals had highlighted public health topics such as prevention and lifestyle (e.g. a reduction in obesity, smoking and alcohol rates and an improvement in healthy eating and exercise rates). While citizens understood why professionals had highlighted public health issues, they did not see these as priorities and were not concerned with obesity or alcohol rates. Instead, citizens prioritised services, public (green) spaces, and social activities which would support their own health and wellbeing and their social connection to other citizens. However, there was some overlap between citizens and professionals when it came to dementia care and carers’ support. Both saw these as important priorities and described how a lack of support increased stress levels and social isolation for those involved.

Citizens felt ownership for enabling citizens’ engagement within the community by organising social activities and feeding back citizens’ wider health and care needs and experiences to the municipality

The following theme highlights that citizens felt ownership for enabling other citizens to also be involved in the community by organising social activities. They also felt responsible for sharing citizens’ experiences and needs with the municipality in order to improve local health(care) services and policies and the living environment. All interviewees were actively involved in community-led initiatives, including e.g. local football clubs, church parishes, village councils to improve village life (context). While they all held different roles in different types of community-led initiatives they all shared a sense of community and reciprocity (mechanism). They also stated that being engaged in such a manner helped them to maintain or improve their own social networks (outcomes) and helped them to improve the social cohesion within the villages (outcome). Additionally, citizens involved in church councils, village councils, and the municipality’s Advisory Board felt responsible for sharing citizens’ experiences, concerns, and ideas regarding local services, amenities, and the living environment with the municipality and wanted to play a linking-pin role in ensuring citizens’ perspectives were included and reflected within municipality’s plans and policies. They felt that reflecting back people’s experiences and needs would help to improve the quality of health(care) services and the living environment as these would be more centred on citizens’ priorities and experiences (See S1 Appendix for CMO examples).

Citizens need the municipality to better facilitate their involvement by improving their communication and accessibility for residents and community-led initiatives

Citizens had also discussed the barriers they experienced when organising social activities and collaborating with the municipality and how they wished the municipality would better support them in their involvement. Firstly, interviewees described how engaged residents were experiencing pressure due to increasingly higher workloads. This partly stemmed from the fact that the number of residents willing to volunteer was declining, but volunteers also felt that they had taken on tasks beyond their own remits which were perceived to have been traditionally within the municipality’s remit. For example, one participant described how they were now supporting low-income members to navigate the municipal care system and helping them to fill out the right forms and not only so they could continue paying their membership fees (context). This made the volunteer feel increasingly frustrated with their role as it made it more ‘bureaucratic’ and less fun (mechanism). They worried that this expanding volunteer-job remit, and the reduction in the number of volunteers, meant that it was becoming harder to keep the club going as fewer citizens would want to join or help out (outcome). Secondly, residents also described how it was more difficult to organise new activities or to further develop and improve their community-led initiatives as the municipality did not clearly communicate (new) funding opportunities or because it required initiatives to increasingly follow bureaucratic rules when applying for new funding or social activities. Finally, interviewees recognised that each community-led initiative only organised activities for their own ‘usual suspects’ and therefore did not offer opportunities for social bridging (across e.g. different age groups, religious and non-religious residents).

To overcome these barriers, interviewees said that one of the most important things the municipality could do was to listen and improve their communication with citizens. They suggested the municipality improve their accessibility by ‘getting out of the municipality building’ and attending meetings and social activities organised by citizens instead. They felt this would show a more open-approach and a willingness to listen to citizens. For example, citizens specifically mentioned it would help initiatives to have one central point of contact at the municipality and that better communication and outreach regarding services and funding opportunities for community-led initiatives would facilitate citizens’ involvement and volunteering. They also suggested that the municipality should help initiatives to reach a wider audience (than the ‘usual suspects’) by promoting the social activities and volunteering opportunities more widely (See S1 Appendix for CMO examples).

“I’ve noticed how important it is to feel heard as a citizen”

Study limitations

Study limitations included the fact that this case-study only examined one rural municipality’s approach to involving citizens in policymaking. Presumably, the rural context of this case-study influenced several important factors in the policy process, including e.g. citizens’ priorities, the extent to which citizens are already involved by the municipality, the scope policymakers are given to innovate and include citizens, the extent to which local counsellors listen to the policymakers and by extension citizens. Relatedly, while participants of this case-study covered all villages within the municipality’s boundary and covered a range of ages and employment and educational statuses, all participants were already involved within their own communities in some shape or form which meant they already had some links with the municipality. Citizens not already involved in their own communities are likely to have similar policy priorities, but may feel different about their roles in addressing the priorities. However, this case-study was, as far as the authors are aware, a first attempt to show municipalities and health(care) organisations how they can align their involvement approaches, services, and policies to citizens’ needs and priorities. Finally, there was a concern that the active participation of one of the municipality’s policymakers during the focus groups would prevent citizens from speaking openly about their experiences and collaboration with the municipality. However, in practice, citizens seemed to appreciate the opportunity to share their experiences not just with the researchers but also directly with the policymaker and that this had in fact helped them to feel more heard by the municipality.

The study limitations were mitigated by the reference panel’s workshop discussions as this validated and enriched the focus group findings. The panel suggested that the focus group results were representative. of the wider experiences regarding the development and implementation of CE in the Netherlands.

Future studies

This case-study seems to indicate that citizen involvement can help to better aligns policies to citizens’ lived experiences and could therefore increase the democratic legitimacy of policymaking. However, future studies are required, including (sub)urban municipalities and different citizens (e.g. harder-to-reach groups like, low-income households, elderly residents) to explore this further. For example, future research could investigate whether the gap between citizens and organisations is based on differences in language and framing, as the professionals on the local reference panel presumed and/or is rooted in more systemic issues, e.g. lack of available resources and collaborative working with citizens beyond organisational remits. Ultimately, future studies should also investigate if and how citizens’ involvement actually results in different policies and if and how the content of policies is indeed better aligned with citizens’ needs and lived experiences.