How do policymakers involve citizens in advancing health? A mixed-method qualitative study in municipalities in the Netherlands.

Introduction: Citizen involvement in health policymaking is becoming imperative. Yet, implementing this practice in local policymaking often proves challenging. This study explores how local policymakers in the Netherlands experience and approach citizen involvement in health promotion policymaking. Methods: In 2023, a stratified random sample of 65 out of 342 Dutch municipalities was selected to participate in this mixed-method study, combining survey responses and interviews. Policymakers from 22 Dutch municipalities participated. Descriptive quantitative analysis and content analysis was applied. Results: Policymakers widely value citizen involvement in health policymaking for understanding community perspectives and needs, identifying priorities and agenda setting, identifying solutions and building public trust, accountability and transparency. In day-to-day practice, citizens are mainly approached for prioritising policy issues or for brainstorming on solutions. A range of consultation methods is used, sometimes in collaboration with public health services or research institutions. Time commitment and ensuring data quality are the main challenges for meaningful citizen involvement next to organizational challenges. Concerns about the quality of the data relates to low response rate and selective response. At times, policymakers may not have the appropriate resources or expertise to facilitate effective citizen involvement. In the domain of preventive health, the following questions on citizen involvement arose: How to address needs, how to include population groups with greater health risks, how to understand citizens' context well? Conclusion: Citizen involvement is a recognised and frequently applied practice in local health policymaking. However, efforts remain fragmented and face operational barriers. These challenges are particularly pronounced in the area of health promotion policymaking. Stronger support and local capacity can improve the inclusiveness and impact of citizen engagement, particularly in preventive health policy.