Policy Instruments for Health Promotion: A Comparison of WHO Policy Guidance for Tobacco, Alcohol, Nutrition and Physical Activity

Document Type : Original Article

Authors

1 Department of Sport Science and Sport, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany

2 WHO European Office for Prevention and Control of Noncommunicable Diseases, Moscow, Russia

Abstract

Background 
Policy is an important element of influencing individual health-related behaviours associated to major risk factors for non-communicable diseases (NCDs) such as smoking, alcohol consumption, unhealthy eating and physical inactivity. However, our understanding of the specific measures recommended in NCD prevention policy-making remains limited. This study analysed recent World Health Organization (WHO) documents to identify common policy instruments suggested for national NCD prevention policy and to assess similarities and differences between policies targeting different health-related behaviours.
 
Methods 
Evert Vedung’s typology of policy instruments, which differentiates between regulatory, economic/fiscal and soft instruments, served as a basis for this analysis. A systematic search on WHO websites was conducted to identify documents relating to tobacco, alcohol, nutrition and physical activity. The staff of the respective units at the WHO Regional Office for Europe conducted an expert validation of these documents. The resulting documents were systematically searched for policy instruments. A word frequency analysis was conducted to estimate the use of individual instruments in the different policy fields, followed by an additional in-depth coding and content analysis by two independent reviewers.
 
Results 
Across all health-related behaviours, the following policy instruments were suggested most frequently in WHO guidance documents: laws, regulations, standards, taxes, prices, campaigns, recommendations, partnerships and coordination. The analysis showed that regulatory and economic/fiscal policy instruments are mainly applied in tobacco and alcohol policy, while soft instruments dominate in the fields of nutrition and especially physical activity.
 
Conclusion 
The study confirms perceived differences regarding recommended policy instruments in the different policy fields and supports arguments that “harder” instruments still appear to be underutilized in nutrition and physical activity. However, more comprehensive research is needed, especially with respect to actual instrument use and effectiveness in national- level NCD prevention policy.

Keywords


  1. Sallis J, Owen N, Fisher E. Ecological models of health behaviour. In: Health Behavior and Health Education: Theory, Research, and Practice. United States: Jossey-Bass; 2008:482-665.
  2. Whitehead M, Dahlgren G. Concepts and Principles for Tackling Social Inequities in Health: Levelling up Part 1. Vol 2. Copenhagen: WHO; 2006.
  3. Bacchi C. Problematizations in alcohol policy: WHO's “alcohol problems.” Contemp Drug Probl. 2015;42(2):130-147. doi:10.1177/0091450915576116
  4. Chopra M, Galbraith S, Darnton-Hill I. A global response to a global problem: the epidemic of overnutrition. Bull World Health Organ. 2002;80(12):952-958.
  5. Edwards R. The problem of tobacco smoking. BMJ. 2004;328(7433):217-219. doi:10.1136/bmj.328.7433.217
  6. Rütten A, Abu-Omar K, Gelius P, Schow D. Physical inactivity as a policy problem: applying a concept from policy analysis to a public health issue. Health Res Policy Syst. 2013;11(1):9. doi:10.1186/1478-4505-11-9
  7. van Tongeren M. Standards and international trade integration: a historical review of the German 'Reinheitsgebot'. In: Swinnen JF, ed. The Economics of Beer. Oxford: Oxford University Press; 2011:51-61.
  8. Levine HG, Reinarman C. From prohibition to regulation: lessons from alcohol policy for drug policy. Milbank Q. 1991;69(3):461-494.
  9. Anderson OE Jr. Pioneer statute: the pure food and drugs act of 1906. J Public Law. 1964;13:189-196.
  10. West R. Tobacco control: present and future. Br Med Bull. 2006;77-78:123-136. doi:10.1093/bmb/ldl012
  11. Britton J, Bogdanovica I. Tobacco control efforts in Europe. Lancet. 2013;381(9877):1588-1595. doi:10.1016/s0140-6736(13)60814-4
  12. Maximova K, Raine KD, Czoli C, et al. Monitoring progress toward United Nations commitments: characteristics of Canadian legislation to promote tobacco control, physical activity and healthy eating. A descriptive study. CMAJ Open. 2019;7(4):E745-E753. doi:10.9778/cmajo.20190049
  13. Eide AH, Amin M, MacLachlan M, Mannan H, Schneider M. Addressing equitable health of vulnerable groups in international health documents. Alter. 2013;7(3):153-162. doi:10.1016/j.alter.2013.04.004
  14. Ledoux C, Pilot E, Diaz E, Krafft T. Migrants' access to healthcare services within the European Union: a content analysis of policy documents in Ireland, Portugal and Spain. Global Health. 2018;14(1):57. doi:10.1186/s12992-018-0373-6
  15. Phillips C, Fisher M, Baum F, MacDougall C, Newman L, McDermott D. To what extent do Australian child and youth health policies address the social determinants of health and health equity?: a document analysis study. BMC Public Health. 2016;16:512. doi:10.1186/s12889-016-3187-6
  16. Verra SE, Benzerga A, Jiao B, Ruggeri K. Health promotion at work: a comparison of policy and practice across Europe. Saf Health Work. 2019;10(1):21-29. doi:10.1016/j.shaw.2018.07.003
  17. WHO Europe. Comparative Analysis of Nutrition Policies in the WHO European Region. Copenhagen: WHO; 2006.
  18. Gelius P, Messing S, Goodwin L, Schow D, Abu-Omar K. What are effective policies for promoting physical activity? a systematic review of reviews. Prev Med Rep. 2020;18:101095. doi:10.1016/j.pmedr.2020.101095
  19. Kennedy PW. Economic incentives for a healthy diet: a comparison of policies in a Canadian context. BE J Econ Anal Policy. 2010;10(1):1-32. doi:10.2202/1935-1682.2475
  20. Cheung KK, Mirzaei M, Leeder S. Health policy analysis: a tool to evaluate in policy documents the alignment between policy statements and intended outcomes. Aust Health Rev. 2010;34(4):405-413. doi:10.1071/ah09767
  21. Martínez-García M, Vallejo M, Hernández-Lemus E, Álvarez-Díaz JA. Novel methods of qualitative analysis for health policy research. Health Res Policy Syst. 2019;17(1):6. doi:10.1186/s12961-018-0404-z
  22. WHO Europe. Health 2020: A European Policy Framework and Strategy for the 21st Century. Copenhagen: WHO; 2013.
  23. World Health Organization (WHO). Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020. Geneva: WHO; 2013.
  24. WHO Europe. European Programme of Work 2020-2025: United Action for Better Health. Copenhagen: WHO; 2021.
  25. Rütten A, Schow D, Breda J, et al. Three types of scientific evidence to inform physical activity policy: results from a comparative scoping review. Int J Public Health. 2016;61(5):553-563. doi:10.1007/s00038-016-0807-y
  26. Bellew B, Schöeppe S, Bull FC, Bauman A. The rise and fall of Australian physical activity policy 1996-2006: a national review framed in an international context. Aust New Zealand Health Policy. 2008;5:18. doi:10.1186/1743-8462-5-18
  27. Bull FC, Bellew B, Schöppe S, Bauman AE. Developments in National Physical Activity Policy: an international review and recommendations towards better practice. J Sci Med Sport. 2004;7(1 Suppl):93-104. doi:10.1016/s1440-2440(04)80283-4
  28. Sallis JF, Bauman A, Pratt M. Environmental and policy interventions to promote physical activity. Am J Prev Med. 1998;15(4):379-397. doi:10.1016/s0749-3797(98)00076-2
  29. Schmid TL, Pratt M, Witmer L. A framework for physical activity policy research. J Phys Act Health. 2006;3(Suppl 1):S20-S29. doi:10.1123/jpah.3.s1.s20
  30. Howlett M. Designing Public Policies: Principles and Instruments. London: Routledge; 2011.
  31. World Health Organization (WHO). Basic Documents. 45th ed. Geneva: WHO; 2020.
  32. World Health Organization (WHO). Best Buys’ and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases. Geneva: WHO; 2017.
  33. Lowi TJ. Distribution, regulation, redistribution: the functions of government. In: Ripley RB, ed. Public Policies and Their Politics: Techniques of Government Control. New York: WW Norton & Company; 1966:27-40.
  34. Lowi TJ. Four systems of policy, politics, and choice. Public Adm Rev. 1972;32(4):298-310. doi:10.2307/974990
  35. Cushman RE. The Independent Regulatory Commissions. London: Oxford University Press; 1941.
  36. Doern GB, Phidd RW. Canadian Public Policy: Ideas. Structure, Process. Toronto: Methuen; 1983.
  37. Vedung E. Policy Instruments: Typologies and Theories. In: Bemelmans-Videc ML, Rist RC, Vedung E, eds. Carrots, Sticks, and Sermons: Policy Instruments and Their Evaluation. New Jersey: Transaction Publishers; 1998.
  38. MAXQDA, Software für qualitative Datenanalyse, 1989-2019. Berlin: VERBI Software GmbH; 2020.
  39. Roberts I, Wentz R, Edwards P. Car manufacturers and global road safety: a word frequency analysis of road safety documents. Inj Prev. 2006;12(5):320-322. doi:10.1136/ip.2006.012849
  40. WHO Europe. European Charter on Counteracting Obesity. Istanbul: WHO; 2006.
  41. WHO Europe. Action Plan for Implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012-2016. Copenhagen: WHO; 2012.
  42. World Health Organization (WHO). NCD Global Monitoring Framework. Geneva: WHO; 2013.
  43. WHO Europe. Vienna Declaration on Nutrition and Noncommunicable Diseases in the Context of Health 2020. Copenhagen: WHO; 2013.
  44. WHO Europe. Investing in Children: The European Child and Adolescent Health Strategy 2015-2020. Copenhagen: WHO; 2014.
  45. WHO Europe. Action Plan for the Prevention and Control of Noncommunicable Diseases in the WHO European Region. Copenhagen: WHO; 2016.
  46. World Health Organization (WHO). Report of the Commission on Ending Childhood Obesity. Geneva: WHO; 2016.
  47. WHO Europe. Strategy on Women’s Health and Well-Being in the WHO European Region. Copenhagen: WHO; 2016.
  48. WHO Europe. The Health and Well-Being of Men in the WHO European Region: Better Health Through a Gender Approach. Copenhagen: WHO; 2018.
  49. WHO Europe. A 5 Year Action Plan. Smoke free Europe. Copenhagen: WHO; 1987.
  50. WHO Europe. Third Action Plan for a Tobacco-Free Europe 1997-2001. Copenhagen: WHO; 1997.
  51. WHO Europe. European Strategy for Tobacco Control. Copenhagen: WHO; 2002.
  52. World Health Organization (WHO). WHO Framework Convention on Tobacco Control. Geneva: WHO; 2003.
  53. WHO Europe. WHO European Strategy for Smoking Cessation Policy. Copenhagen: WHO; 2004.
  54. World Health Organization (WHO). WHO Framework Convention on Tobacco Control. Guidelines for Implementation. Geneva: WHO; 2013.
  55. World Health Organization (WHO). Protocol to Eliminate Illicit Trade in Tobacco Products. Geneva: WHO; 2013.
  56. WHO Europe. Roadmap of Actions to Strengthen Implementation of the WHO Framework Convention on Tobacco Control in the European Region 2015-2025: Making Tobacco a Thing of the Past. Copenhagen: WHO; 2015.
  57. WHO Europe. European Charter on Alcohol. Copenhagen: WHO Europe; 1995.
  58. WHO Europe. European Alcohol Action Plan 2000-2005. Copenhagen: WHO; 2000.
  59. WHO Europe. Framework for Alcohol Policy in the WHO European Region. Copenhagen: WHO Europe; 2006.
  60. World Health Organization (WHO). Global Strategy to Reduce the Harmful Use of Alcohol. Geneva: WHO; 2010.
  61. WHO Europe. European Action Plan to Reduce the Harmful Use of Alcohol 2012-2020. Copenhagen: WHO; 2012.
  62. World Health Organization (WHO). International Code of Marketing of Breast-Milk Substitutes. Geneva: WHO; 1981.
  63. World Health Organization (WHO). World Declaration and Plan of Action for Nutrition. Rome: WHO; 1992.
  64. World Health Organization (WHO). Global Strategy on Diet, Physical Activity and Health. Geneva: WHO; 2004.
  65. WHO Europe. WHO European Action Plan for Food and Nutrition 2007-2012. Copenhagen: WHO; 2006.
  66. World Health Organization (WHO). Interventions on Diet and Physical Activity: What Works? Geneva: WHO; 2009.
  67. World Health Organization (WHO). Set of Recommendations on the Marketing of Foods and Non-Alcoholic Beverages to Children. Geneva: WHO; 2010.
  68. WHO Europe. European Food and Nutrition Action Plan 2015-2020. Copenhagen: WHO; 2014.
  69. World Health Organization (WHO). Maternal, Infant and Young Child Nutrition. Geneva: WHO; 2016.
  70. World Health Organization (WHO). Ending Inappropriate Promotion of Foods for Infants and Young Children. Geneva: WHO; 2016.
  71. World Health Organization (WHO). Global Recommendations on Physical Activity for Health. Geneva: WHO; 2010.
  72. WHO Europe. Physical Activity Strategy for the WHO European Region 2016-2025. Copenhagen: WHO; 2016.
  73. World Health Organization (WHO). Global Action Plan on Physical Activity 2018-2030: More Active People for a Healthier World. Geneva: WHO; 2018.
  74. Gelius P, Messing S, Abu-Omar K. Nine types of recommendations, guidelines and policies: an exploratory test of a proposed typology of physical activity promotion documents. Arch Public Health. 2019;77:52. doi:10.1186/s13690-019-0381-x
  75. Crammond B, Carey G. What is policy and where do we look for it when we want to research it? J Epidemiol Community Health. 2017;71(4):404-408. doi:10.1136/jech-2016-207945
  76. Asare B, Cairney P, Studlar DT. Federalism and multilevel governance in tobacco policy: the European Union, the United Kingdom, and devolved UK institutions. J Public Policy. 2009;29(1):79-102. doi:10.1017/s0143814x09000993
  77. Hawkins B, McCambridge J. Policy windows and multiple streams: an analysis of alcohol pricing policy in England. Policy Polit. 2020;48(2):315-333. doi:10.1332/030557319x15724461566370
  78. Mavrot C, Sager F, Balthasar A, Wight N. Quand le tabac s’affiche au Parlement. Débats sur les limitations en matière de publicité de la cigarette dans les cantons romands. Sociograph–Sociological Research Studies. 2016;25:281-308.
  79. Tapper J, McKie R. ‘Junk Food is the New Tobacco’: Experts Call for Restrictions to Tackle Obesity. The Guardian; 2020.

Articles in Press, Corrected Proof
Available Online from 25 August 2021
  • Receive Date: 02 November 2020
  • Revise Date: 06 July 2021
  • Accept Date: 24 July 2021