Policy Evaluation Network

Policy Evaluation Network - Public policies addressing health-related behaviours in Europe

Project description

Background and aim

The Joint Programming Initiative on a Healthy Diet for a Healthy Life (JPI HDHL), involved 28 research institutes from seven European countries and New Zealand combined their expertise to form the Policy Evaluation Network (PEN). PEN, true to its vision, has improved knowledge, tools and capacity among its network and beyond to identify, evaluate and benchmark policies designed to directly or indirectly address physical inactivity, unhealthy diets and sedentary behaviour while accounting for existing health inequities.  

Through a series of consortium-wide activities, network meetings, presentations at (inter)national conferences and capacity building workshops with policy makers PEN has met, and indeed exceeded, its deliverables. PEN has published the first EU Food Environment Policy Index (Food-EPI) for Europe, and the first Physical Activity Environment Policy Index (PA-EPI).  PEN has developed a set of Selected Instruments for Multilevel PoLicy and impact Evaluation (SIMPLE) modules for physical activity and diet, and created an expert-led Methodologic Competence Platform to guide and sustain the data harmonization process across Europe long term.  PEN scientists have created simulation models, applied multiple research designs and used innovative online research methods –during COVID-19 restrictions– to deliver 50+ peer-reviewed publications. These include meta-, systematic- and narrative-reviews advancing, synthesizing and consolidating state-of-the-art evidence on policy determinants, frameworks, tools and research methods.  PEN has advanced our understanding of the unintended effects of policy interventions on persons with low income, and as part of its Early Career Network provided mentorship and prompted changes within JPI programmes to support early career professionals.  The Policy Symposium on NCDs prevention in Brussels (June 2022), organised by PEN, the H2020 projects CO-CREATE and STOP, and the Joint Action Best-ReMaP, culminated in a Call To Action outlining key policy, research and funding priorities necessary to prevent obesity.  In summary, PEN has provided a comprehensive roadmap for policy improvement for health promotion and prevention of non-communicable diseases, including obesity. 

Expected impact
WP1 Policy mapping and EPI development

The current health status of people living in Europe, lifestyle factors and inequalities in health outcomes must be urgently addressed through the food and physical activity environment policy reform. Policy action is needed by government to create healthier food and physical activity environments. It is now clearly understood that to prevent chronic disease, we need to understand and address the “foodscape” the wide range of interconnected factors such as food production, processing, marketing and distribution, that characterise our food system and largely determine our dietary intakes and the daily determinants and our physical activity ’scape’, factors which determine our physical activity levels including (but not limited to) physical environment, access to facilities transport policies and urban planning policies. WP1 has provided a better understanding within both the scientific and the policy-making communities of existing policies that directly or indirectly affect physical activity (PA) and food environments and behaviours.

The implementation of the Food Environment Policy Index (Food-EPI) in 5-European countries (11 if you include the collaboration with the STOP partners) and at the EU has increased the understanding of what good benchmarking indicators are for the food policy environment. The Food-EPI evidence documents and accompanying reports in Norway, Ireland, The Netherlands, Poland, Germany and the EU received considerable attention from policy makers and media circles. These discussions extended to discussions with policy makers at national level on the key findings of the reports. In Ireland, the recent report of the Commission on Taxation and Welfare cites the Food-EPI (Ireland) Evidence Document and accompanying report as important documents providing evidence of support for policies to improve the food environments.

During the development of the Food-EPI evidenced reports and the launch and publication of the Food-EPI score cards we have highlighted the gaps and priority recommendations to create healthy food environments across European countries. Within each country each team has engaged with key stakeholders and policy makers, in particular in the Ministries of Health, to highlight the findings from the Food-EPI work.

The outputs from task one and the mode of engagement with key stakeholders, in particular policy makers has the potential to influence real change in the policy making environment.

Capacity building and collaboration is to the fore in Task 1.1. In collaboration with STOP partners, the 11-country comparison paper, a first in Europe, highlights the priority gaps in food policies to improve the food environment s in Europe. This has been accepted for publication in the Lancet Europe. Further, as a result of PEN, Task 1.1 partners were invited to contribute to two Horizon Europe applications based on building healthy and sustainable food environments. One of these applications has been successful.

The development of the PA-EPI prototype and the implementation of PA-EPI in Ireland (with more countries to follow) provide for the first time an opportunity to analyse Government action to improve the physical activity environment across the all domains which influence citizens physical activity and sedentary behaviours. The PA-EPI is conceptualised as a two-component ‘policy’ and ‘infrastructure support’ framework. The two components comprise eight policy and seven infrastructure support domains. The policy domains are education, transport, urban design, healthcare, public education (including mass media), sport-for-all, workplaces and community. The infrastructure support domains are leadership, governance, monitoring and intelligence, funding and resources, platforms for interaction, workforce development, and health-in-all-policies. Forty-five ‘good practice statements’ (GPS) or indicators of ideal good practice within each domain concludes the PA-EPI. A potential eight-step process for conducting the PA-EPI is described. Once pre-tested and piloted in several countries of various sizes and income levels, the PA-EPI GPS will evolve into benchmarks established by governments at the forefront of creating and implementing policies to address inactivity.

Task 1.2, building on the Food-EPI framework will develop the first PA Environment Policy Index (PA-EPI). Following on from the two publications on 2021, a further four publications are currently under review (two of which are part of the PEN Special Issue).

This has resulted in two further publications in 2021

  • Woods CB, et al. The evidence for the impact of policy on physical activity outcomes within the school setting: A systematic review. J Sport Health Sci. 2021 Jan 19: S2095-2546(21)00006-5. doi: 10.1016/j.jshs.2021.01.006. Epub ahead of print. PMID: 33482424;
  • Volf K, et al. Policy Evaluation Network (PEN): Protocol for systematic literature review examining the evidence for impact of policies across seven different policy domains [version 2; peer review: 1 approved]. HRB Open Res 2020, 3:62 (https://doi.org/10.12688/hrbopenres.13089.2)

A systematic mixed studies review examining the evidence of the impact of sport policies on PA and sport participation is currently under review with the Int J Sport Policy Politics. The evidence identified seven unique ‘policy actions’ which were categorised into the ‘policy areas’ Facilities, Financial, Collaboration and Exhortation. Policy actions to promote PA and sport participation have demonstrated qualified success but there is limited evidence of success in engaging hard to reach groups. Therefore, policymakers utilising sport to increase PA should treat it as a complementary intervention alongside other policy actions based on a systems perspective.

The impact of mass-media campaigns on PA: a review of reviews through a policy lens, is currently under review as part of the PEN Special Issue. Results indicate that the most consistent evidence was found for the effectiveness of mass-media campaigns on proximal outcomes, while the evidence for distal outcomes was mixed. Good practice statements were derived: 1) to achieve behaviour change, mass-media is an important component of larger, multilevel, and multicomponent strategies, 2) mass-media strategies should be coordinated and aligned at local- and national-level, and be sustained, monitored and resourced at these levels, 3) media should be tailored to reduce socioeconomic inequalities. Findings suggest that mass-media can play an important role in the promotion of PA. In general, evidence was more inconsistent for effectiveness on distal outcomes than for proximal outcomes. The policy-relevant recommendations identified will serve to inform the PA environment policy index (PA-EPI), a tool for monitoring, evaluating and benchmarking government progress in implementing public policies.

A Systematic Review examining which transport policies influence PA of the whole of society is currently under review with the J Transport Health. Three main transport policy areas with 51 individual policy actions were identified that had a direct or indirect effect on PA. These were: convenient transport infrastructure development, active travel promotion, and shift of transport mode. More than half of the policy actions identified had a positive effect on PA. Results suggest that PA levels can be increased by implementing policies that provide convenient, safe, and connected walking and cycling infrastructures, promote active travel and give strong support to public transport. There is also clear evidence that active travel policies work best when implemented in a comprehensive way. This may include infrastructure and facility improvements as well as educational programmes to achieve substantial shifts towards active modes of travel.

Combining the outputs of Task 1.1 and 1.2 will provide a comprehensive description of the food and PA policy landscape in five European countries.

WP2 Monitoring and surveillance

With its work, WP2 successfully provides a sustainable scientific contribution to the harmonization of health indicators in Europe and connects the growing scientific interest in investigating interconnections between data – harmonised across several countries – and policies on different levels (e.g., supranational, national, communal) to improve individual health behaviour and inform policies to prevent obesity. This mainly concerns the evaluation and development of survey instruments and methods according to the latest research findings as well as the needs and current status of method development of each of the surveillance systems. In order to achieve this, prioritized indicators and their availability in existing European datasets were made usable for the scientific community and various European initiatives that use and/or collect and make available monitoring data themselves, e.g. the European Food Safety Authority (EFSA), Organisation for Economic Co-operation and Development (OECD), the European Commission (DG SANTE and EUROSTAT).

Furthermore, SIMPLE modules were developed which collate unified questionnaire items to harmonise collected data and assess comparable health-related data across European surveillance systems that will facilitate the evaluation of temporal and regional changes in physical activity, dietary behaviour, and associated health outcomes (individual level).

Finally, a close exchange has already been established with leading representatives of ongoing major European surveillance initiatives such as WHO-COSI, HBSC, STEPS and Nordic Monitoring System. A Methodological Competence Platform was established fostering the cooperation between WHO Collaborating Centres and counselling the WHO in health monitoring and methodological advancement of the WHO-COSI methodology.

The implementation of the developed SIMPLE modules and their further methodological development will help researchers to analyse the relationship between diet, physical activity and health across European countries and to identify factors affecting health-related and environmentally-sustainable behaviours. This will also help to inform policy makers about the effectiveness of health policies and thus can contribute to the aim that all citizens will have the motivation, ability and opportunity to consume a healthy diet from a variety of foods, and have healthy levels of physical activity.

WP3 Estimation and simulation of policy impact

WP3 is expected to have impacted and to generate a continued impact on the scientific community and policy audience over the next years. The WP has provided tools for better evaluation, hence better policies. It has provided a better understanding of the quantitative approaches to policy evaluation, especially in relation to the assessment of fiscal policies (soda tax), with a thorough comparison of experimental methods, ex-ante simulations and ex-post quasi-experimental methods.

The impact on the targeted audience and the interest in the project findings has clearly emerged from the final WP3 workshop in Rimini, where the findings of the project have been presented. The workshop gathered 82 registered participants from 21 different countries: Argentina, Belgium, Estonia, Finland, France, Germany, Hungary, Ireland, Italia, Lithuania, Luxembourg, Mexico, Netherlands, Norway, Portugal, Romania, Slovenia, Spain, United Kingdom, United States. Among represented public institutions there were the European Commission, the Estonian National Institute for Health Development, the Hungarian National School Sport Federation, the Belgian Federal Public Health Ministry, the French Agency for Food, Environmental and Occupational Health & Safety. the Finnish Institute for Health and Welfare, the Irish Food Safety Authority, the Lithuanian Ministry of Health, the Romanian National Institute of Public Health, the Portuguese Directorate-General of Health, the Mexican Instituto Nacional de Salud Pública, and the World Cancer Research Fund International. The aim of the international workshop was to discuss challenges, differences and synergies of different approach for policy impact quantification: simulation models, quasi-experimental methods, and virtual and field experiments. Speakers included Franco Sassi (Head of Director of the Centre for Health Economics and Policy Innovation at Imperial College London, and co-ordinator of the STOP project), Pierre Dubois (Toulouse School of Economics and Institute of Fiscal Studies), David Frisvold (University of Iowa), Federico Perali (University of Verona), Timothy Beatty (University of California, Davis) and Annalisa Belloni (World Health Organization and Public Health England).

The forthcoming publication of an article containing methodological recommendations (Emmert-Fees et al., 2022), envisaging and integrated evaluation strategy combining experimental, quasi-experimental and simulation methods has the potential to foster further research in this area, and to provide tools that may address unresolved issues in impact evaluation studies, such as the assessment of longer-term health impacts, the consideration of heterogeneous effects, and the evaluation of multi-level policies. The paper and the main conclusions were presented at the final multi-project symposium in Brussels, along with evidence on experimental methods.

WP4 Policy implementation evaluation

WP4 systematically described and evaluated policy implementation processes. A compilation of existing theoretical frameworks and key aspects as well as barriers/facilitators of policy implementation processes will help the scientific community to better understand what core aspects should be taken into account when (1) translating research into practice, (2) specifying influences on implementation outcomes and (3) and evaluating implementation success. The identified frameworks for implementation can be used by researchers, development actors, policy makers, NGOs, practitioners and other stakeholder of the public health area who aim to analyse and guide the implementation of a health policy in their setting.

Based on the results of all three sub-tasks of this work package and several case studies conducted in WP6, researchers and policy makers were provided with practical guidelines for policy implementation evaluation and a checklist for policy implementation in form of two application-oriented final reports of WP4. In addition, two manuscripts have been prepared for the scientific community that will be submitted in Sept. and Oct. 2022.

WP5 Equity and diversity of policies

WP5 aimed at achieving a strong emphasis in policies on those in lower socioeconomic groups and in ethnic minorities. Substantial improvements of population levels of PA, diet and sedentary behaviour can be made by prioritizing policies with an impact in these groups. Yet, there is a large variety of interventions and policies with relatively little effects. A structured and guided approach is needed, in which expertise about (mechanisms of) health inequalities is further incorporated in policy making. The impact of WP5 is that researchers and policy makers are increasingly aware of, and able to assess the implications of policies for those in lower socioeconomic groups and ethnic minorities in all stages of the policy cycle (including monitoring, surveillance, benchmarking, evaluation and implementation of policies). Our work might support the scientific and policy community to focus on actions beneficial for the above-mentioned target groups. We learned that the ‘systems approach’ is a promising approach in which both scientists, policy makers and stakeholders are involved. It leads to new entry points for interventions and policies and might prevent undesired effects of policies. Dissemination of the approach used and the findings will impact on the choice of interventions and policies. In order to make impact however, and to go beyond the statement that the problem is complex, methods are needed and applied to derive policy recommendations from these systems models. The approach provides way to consider not only actions targeting the elements (as done for many public health challenges), but also the mechanisms, structure and paradigm of the system. Results of our work are and will be disseminated in scientific papers, and in a symposium at the end of the project.

WP6 Policy in practice - Selected case studies

The results of the SSB-tax case study (Task 6.1) have provided (and still provide) direct input into the discussion about the implementation of a sugar tax that is currently going on in several European countries, for instance in the Netherlands. The case study for Poland coincides with the actual implementation of a sugar tax in this country. The study may provide a very early evaluation of the implemented tax, as well as may have impact on the public perception of the health-related taxation policy, being currently subject to controversies and distrust.

The systematic review on effects of Sustainable Urban Mobility Plans on physical activity (Task 6.2) helped to determine the level and type of evidence for policies within the transport area that promote physical activity. The interviews about SUMP adoption in different European cities have great potential to inform research and policy practice alike. From a scientific perspective, evaluation tools are currently lacking that assess SUMP implementation by probing the impact of various stakeholders. As SUMP take-up requires the interplay of several actors in diverse domains such as politics/administration, civil society and business, accounting for their underlying – and contrasting – rationales is pivotal. This in-depth analysis can boost policy evaluation. In a similar vein, the rigorous examination also allows for specific policy recommendations. By uncovering drivers of and barriers to SUMP adoption, we provide a concise yet specific overview of potential levers for implementing sustainable mobility regimes. Lastly, our approach covers multiple cities with differing progress in SUMP take-up. Consequently, we present a diverse picture applicable to a myriad of urban contexts. This outcome can encourage transport-related physical activity and contribute to positive health impacts. Regarding effect evaluations, we only identified data on motorisation rate, modal split, and public transport use to broadly compare the influence of SUMP implementation on PA across cities. This demonstrates the potential for developing additional uniform indicators to assess indirect changes in PA e.g., obesity rates, transport education, bicycle and pedestrian network, and PT infrastructure. Additionally, quantitative data on the effectiveness of transport-related intervention inducing a shift in the mode of travel from car to transport modes enhancing physical activity provided by meta-analysis may be of great importance when developing Sustainable Urban Mobility Plans.

The results of the literature review on evaluations and implementation of School Fruit schemes (Task 6.3) contribute to the field of implementation science in particular through the use of Consolidated Framework for Implementation Research (CFIR) for the synthesis of existing research in regard to the implementation of fruit and vegetable interventions in schools. The paper highlights the importance of the following CFIR constructs, as determinants in the implementation of fruit and vegetable interventions in schools: ‘design quality and packaging’, ‘adaptability’, ‘cost’ (intervention characteristics domain), ‘cosmopolitanism’, ‘external policy and incentives’ (outer setting), ‘implementation climate’, ‘readiness for implementation’ (inner setting), ‘knowledge and beliefs about the intervention’ (characteristics of individuals domain) and finally, ‘engaging’(process domain). The study of the implementation of the EU SFVS in selected countries found that flexibility in how the scheme is designed and implemented enables country-level implementation. Newly established cooperation between implementing ministries is a potential facilitator. However, timing of the yearly top-down budget allocation is a barrier. Taking EU funding for granted is a potential disincentive to improvement, although the EU funding facilitates sustainability. Despite agreement on what the overall goals of the scheme are, there is some ambiguity as to what the primary goal is, which may influence design (duration, frequency) as well as implementation at country and school level. The qualitative system dynamics map of impact of EU SFVS is likely to provide useful information for strengthening the implementation and reach of the scheme, as well as input for ongoing evaluation of the scheme in 2023. The results have been presented to the EU-level authorities both at the Brussel conference of the PEN project and in an online meeting for all countries taking part in the EU SFVS.

WP7 Network coordination and dissemination

In terms of disseminating the results, PEN has and will continue disseminating the results, reaching all targeted audiences, among others through following activities:

The special journal issue titled “Creating evidence for public policies to improve dietary and physical activity behaviours in Europe” is to be published by the Eur J Public Health over autumn 2022. It includes 13 original articles presenting final results of all PEN work packages, including a paper on the development of the overarching theoretical PEN framework. It was important for the consortium to allow access to all interested groups by publishing this supplement Open Access.

As one of the concrete results of the symposium jointly organised with the projects STOP and CO-CREATE and JA Best-ReMaP, a document was compiled summarising the main messages and key achievements across the projects and recommendations of next steps for policy makers, stakeholders and funding programmes (see annex). This document is currently being broadly disseminated by the 4 projects and is available at the PEN website (https://www.jpi-pen.eu/images/reports/Policy_Symposium_Final_Statement_Oct2022.pdf). The collaboration with STOP and CO-CREATE and JA Best-ReMaP will continue to be explored for identifying opportunities for joint dissemination of results.

The PEN factsheets summarise the main results, conclusions and recommendations of the research areas covered by each PEN work package. This brochure will be disseminated to researchers, policy, and practice stakeholders, e.g., national funding bodies, public health decision makers at the national and European levels, public health promotion organisations at national and European levels. The PEN factsheets (16) are publicly available at the project website and have been and will continue being distributed as hand-outs at international conferences whenever the opportunity is given.

Consortium

Partner Organization Partner Country
University College Cork (CHDR) Ireland
Medical University of Silesia in Katowice (SILVeR) Poland
University College Dublin (UCD-PH) Ireland
Vrije Universiteit (VU-P&P) The Netherlands
Amsterdam University Medical Center (AmsterdamUMC) The Netherlands
Erasmus Medical Center Rotterdam (SocialEpiEMCR) The Netherlands
Oslo Metropolitan University (OsloMet) Norway
University of Bologna (UNIBO) Italy
Academic Medical Center, University of Amsterdam (PHP-DP) The Netherlands
Ludwig-Maximilians-Universität München (EBPH-LMU) Germany
Helmholtz Zentrum München (T-HMGU) Germany
Gdansk University of Technology (GUT) Poland
Grenoble Applied Economics Laboratory, French National Institute of Agricultural Research (GAEL- INRA) France
SWPS University of Social Sciences and Humanities (SWPS) Poland
Poznan University of Medical Sciences (PUMS) Poland
German Cancer Research Center (DKFZ) Germany
Università Cattolica del Sacro Cuore (UCSC) Italy
University of Limerick (UL) Ireland
Medical Center - University of Freiburg (IfEM) Germany
Friedrich‐Alexander University, Institute of Sport Science and Sport (FAU-ISS) Germany
University of Oslo, Institute of Basic Medical Sciences (UiO-PHN) Norway
University of Ulm, Division of Sport and Rehabilitation Medicine (UUlm) Germany
Robert Koch Institute (RKI) Germany
Johannes Gutenberg University Mainz (JGU) Germany
Leibniz Institute for Prevention Research and Epidemiology (BIPS) Germany
Alimentation et Sciences Sociales (INRA ALISS) France
Faculty of Geosciences, Utrecht University (HUL) The Netherlands
University of Auckland (UOA) New Zealand

Highlights

WP1 Policy mapping and EPI development

Launch of Food-EPI reports in each partner country and at the EU level. Engagement with key stakeholders and policy makers, and extensive print and broadcast media coverage.

Launch of the 11-country Food-EPI results in collaboration with STOP partners at the Policy Symposium in Brussels in Jun. 2022.

Over 70 academic experts from 20 countries, and 40 policymakers from four PEN countries engaged in an online consultation to advance PA-EPI development

A new PA-EPI was developed and disseminated through peer-review publication (N=1), online symposia at international conferences (N=3) and workshops (N=3)

PA-EPI tool was formally launched at the Policy Symposium in Brussels in Jun. 2022. The first PA-EPI was fully implemented in Ireland and formally launched in Aug. 2022.

WP2 Monitoring and surveillance

Key indicators for EU health monitoring for dietary, physical and sedentary behaviours were prioritized by policy-makers and researchers with the ultimate aim to embed policy evaluation measures in existing surveillance systems across the European Union.

A searchable online catalogue with key indicators was compiled to provide an opportunity for key stakeholders to view available European indicators that can be employed to evaluate national level, public and private policy actions which influence diet, physical activity and sedentary behaviour.

A set of unified questionnaire modules (SIMPLE modules) were developed and published to enable the measurement of variables that describe relevant key policy indicators for dietary, physical and sedentary behaviours and equity

A Methodologic Competence Platform, composed of experts from surveillance and monitoring systems, epidemiology and public health research was established to guide and sustain the harmonization process beyond the concluded PEN project.

WP3 Estimation and simulation of policy impact

A scoping review on the application of the GRADE system to support health policy making (e.g. guidelines) and policy evaluation (e.g. systematic reviews evaluating policy interventions) was developed and published (https://doi.org/10.1186/s13012-020-00984-2).

WP3 organized two very successful workshops on methods for impact evaluation in Munich and Rimini, involving internationally recognized scholars as contributors, and gathering more than 150 attendants in total.

Project outputs were published in a variety of journals including Implement Sci, Adv Nutr, Eur J Epidemiol, Transport Res Part A. Several other works are currently under review.

A set of methodological recommendations were delivered to improve impact evaluation through experimental methods, quasi-experimental methods on observational data, and simulation models and demonstrated through a series of applications, including nutrition labelling in France, the Catalunya soft drink tax, the Cycling May campaign in Gdansk, agricultural sugar price transmission in Italy, Vitamin D fortification in Europe.

An article drawing the final methodological recommendations from the PEN project was produced and accepted for the PEN Special Issue, Eur J Public Health (forthcoming), exploring complementarities and synergies between quasi-experimental methods using observational data and simulation models to predict longer term health effect and their distribution.

WP4 Policy implementation evaluation

We conducted a meta-review to (1) identify determinants that were systematically indicated as occurring during the implementation processes and (2) identify differences in the presence of determinants across reviews versus stakeholder documents on healthy diet/PA/SB policies, reviews/stakeholder documents addressing healthy diet policies versus PA/SB policies targeting any population/setting, and healthy diet/PA/SB policies focusing on school settings (https://doi.org/10.1186/s13012-021-01176-2).

Another meta-review was conducted to investigate the context-related implementation determinants from seven domains (geographical, epidemiological, sociocultural, economic, ethics-related, political, and legal) that were systematically indicated as occurring during the implementation of obesity prevention policies targeting a healthy diet and a physically active lifestyle (https://doi.org/10.1186/s12889-022-13340-4).

Two scoping reviews were conducted to examine implementation processes for sugar-sweetened beverage taxation (https://doi.org/10.1186/s12961-022-00832-3) and public physical activity policies (accepted for publication: PEN Special Issue, Eur J Public Health, forthcoming) in terms of pre-implementation context, taxation instruments used and interactions in the implementation process.

A systematic review was conducted that aimed to identify tools used to assess acceptability of policies targeting physical activity and dietary behaviour, and examine if acceptability differs depending on characteristics of the policy and of the respondents (accepted for publication: PEN Special Issue, Eur J Public Health, forthcoming).

Knowledge was synthesised on how implementation of policies promoting healthy diets, physical activity, and reducing sedentary behaviours is evaluated. The findings and lessons learned about policy implementation evaluation gathered within WP4 and WP6 were compiled and presented in nine case reports (submitted to BMC Public Health).

WP5 Equity and diversity of policies

Based on an umbrella review and expert panels, poor dietary intake in low-income groups is presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods.

An umbrella review suggests that there is enough evidence to state that a reduction of socioeconomic inequalities in diet can be achieved through food taxation, but that evidence for policies related to other aspects of the food environment is still poor.

Theories that aim to understand socioeconomic inequalities in health help to understand how broader daily living conditions (social practices, and material conditions that shape experiences of scarcity) may lead to a greater benefit of certain food environment policies for the healthfulness of diets of lower or higher socioeconomic groups.

Based on a review of the literature, lower levels of physical activity in ethnic minority groups can be understood as an emergent property of a complex system of individual, social, cultural, economic, environmental and organisational influences. This system can restrict attractive opportunities for physical activity or disempower individuals of the choice to be physically active.

WP6 Policy in practice - Selected case studies

Recommendations to enhance the acceptability, adoption and implementation of an sugar sweetened beverages tax are: (i) address inconsistencies between identified beliefs and scientific literature, (ii) use raised revenue for health initiatives, (iii) communicate transparently about the purpose of the tax, and (iv) generate political priority for solutions supporting implementation (https://doi.org/10.1186/s12966-019-0843-0).

An RCT to investigate effects of different tax schemes on consumer food purchases in a Virtual Supermarket showed that a nutrient profiling tax targeting a wide range of unhealthy foods and beverages (i.e. those with a low nutritional quality) has more beneficial effects on consumer food purchases than taxation of SSB alone (https://doi.org/10.1017/S1368980021004547).

Walking, cycling and using public transport instead of car driving can enhance physical activity levels. Interventions promoting such transport modes are effective in reducing car use, but the effect is small. The effect strongly varies across studies and interventions. (Okraszewska et al. submitted to journal).

The implementation of SUMPs in Danish, Polish and German cities is hampered by complex institutional structures, the dominant role of motorised traffic as well as complexities surrounding the integration of national, regional and local policies. Motorisation rate, modal split, and public transport use can be utilised to assess the influence of SUMPs on physical activity (Okraszewska et al., accepted for the PEN Special Issue, Eur J Public Health, forthcoming).

Positive child perceptions of the value of the intervention and perceived behaviour change were reported as relevant facilitators to implementation. Parents are both supporting the implementation and themselves targets of fruit and vegetables interventions at schools, which could have implications for the design and implementation (https://doi.org/10.1186/s12966-022-01246-8).

WP7 Network coordination and dissemination

The core paper describing the scope and design of PEN was published in Food Policy in 2019 (DOI: 10.1016/j.foodpol.2020.101873).

The consortium undertook a process to agree on a PEN glossary of key terms in the field of policy evaluation for use within the overall PEN project, and potentially beyond. This glossary is available at the project website (https://www.jpi-pen.eu/pen-glossary-of-definitions.html).

The PEN Early Careers Network was established and delivered a successful mentorship programme to facilitate the exchange of guidance, expertise and experiences between project members. The PEN ECN has been taken as model for creating an ECN among the project of the JPI PREPHOBES call. Its activities started in Sept. 2022.

16 PEN factsheets were created summarizing main results, conclusions and recommendations of the research areas covered by PEN, with the purpose to disseminate results to key target audiences in order to create long-term sustainable impact of the project results. The factsheets are available at the PEN website (https://www.jpi-pen.eu/outcome/fact-sheets.html).

In collaboration with the Horizon2020 projects CO-CREATE and STOP and the JA Best-ReMap, the Policy Symposium on NCDs prevention took place in Jun. 2022 in Brussels as a major event bringing together policymakers and experts working in nutrition and physical activity, to present and discuss recommendations for optimal policy implementation to promote healthy diets, physical activity and to reduce sedentary behaviour across Europe (https://www.jpi-pen.eu/policy-symposium.html).

A special scientific journal issue including 13 papers presenting final results of PEN is to be published by the Eur J Public Health over autumn 2022 with the title “Creating evidence for public policies to improve dietary and physical activity behaviours in Europe”.

Products

Title: Political and social acceptability of a sugar-sweetened beverages tax: a mixed-method systematic review
Author: Eykelenboom M, van Stralen M, Renders C, Olthof M, Schoonmade L, Steenhuis I (VU-P&P)
Link: https://doi.org/10.1186/s12966-019-0843-0
Title: Political and public acceptability of a sugar-sweetened beverages tax: a mixed-method systematic review and meta-analysis
Author: Eykelenboom M, van Stralen MM, Olthof MR, Schoonmade LJ, Steenhuis IHM, Renders CM (VU-P&P); PEN Consortium.
Link: https://doi.org/10.1186/s12966-019-0843-0
Title: European Project Policy Evaluation Network (PEN): geriatric point of view (Abstract)
Author: Krzyminska-Siemaszko R, Kropinska S, Lewandowicz-Umyszkiewicz M, Suwalska A, Wieczorowska-Tobis K (PUMS) on behalf the PEN consortium
Title: Determinants, barriers, and facilitators for implementation of policies promoting healthy diet and physically active lifestyle: a meta-review
Author: Lobczowska K (SWPS), Luszczynska A (SWPS), Banik A (SWPS), Forberger S (BIPS), Kaczmarek K (SILVeR), Kubiak T (JGU), Mons U (DKFZ), Mueller-Stierlin AS (Uulm), Romaniuk P (SILVeR), Scheidmeir M (JGU), Scheller D (Uulm), Zeeb H (BIPS)
Link: https://doi.org/10.1186/s13012-021-01176-2
Title: Frameworks for processes, determinants, and evaluation of implementation of policies promoting healthy diet and physically active lifestyle: a systematic review
Author: Lobczowska K (SWPS), Luszczynska A (SWPS), Banik A (SWPS), Forberger S (BIPS), Kaczmarek K (SILVeR), Kubiak T (JGU), Mons U (DKFZ), Mueller-Stierlin AS (Uulm), Romaniuk P (SILVeR), Scheidmeir M (JGU), Scheller D (Uulm), Zeeb H (BIPS)
Link: https://doi.org/10.1186/s12966-021-01242-4
Title: Stakeholder views on the potential impact of a sugar-sweetened beverages tax on the budgets, dietary intake, and health of lower and higher socioeconomic groups in the Netherlands
Author: Djojosoeparto SK (HUL), Eykelenboom M (VU-P&P), Poelman MP (HUL), van Stralen MM (VU-P&P), Renders CM (VU-P&P), Olthof MR (VU-P&P), Steenhuis IHM (VU-P&P), Carlijn B. M. Kamphuis (HUL), on behalf of the PEN Consortium
Link: https://doi.org/10.1186/s13690-020-00507-x
Title: Public acceptability of a sugar-sweetened beverages tax and its associated factors in the Netherlands
Author: Eykelenboom M (VU-P&P), van Stralen MM (VU-P&P), Olthof MR (VU-P&P), Renders CM (VU-p&P), Steenhuis IHM (VU-P&P), on behalf of the PEN Consortium
Link: https://doi.org/10.1017/S1368980020001500
Title: Systematic review examining the evidence for impact of school policies on physical activity
Author: Kelly L, Volf K, Garcia E, Woods C. (UL)
Link: https://doi.org/10.1093/eurpub/ckaa165.1138
Title: The impact of Sustainable Urban Mobility Plans (SUMPs) on adult’s transport-related physical activity levels – a protocol for systematic review and meta-analysis
Author: Laetsch DC (DKFZ), Reisch L (BIPS/CBS), Kamphuis C (HUL), Lakerveld J (AmsterdamUMC), Forberger S (BIPS), Brenner H (DKFZ), Romanika Okraszewska (GUT)
Title: Advancing the evidence base for public policies impacting on dietary behaviour, physical activity and sedentary behaviour in Europe: The Policy Evaluation Network promoting a multidisciplinary approach
Author: Lakerveld J (AmsterdamUMC), Woods C (UL), Hebestreit A (BIPS), Brenner H (DKFZ), Flechtner-Mors M (UUlm), Harrington J (CHDR), Kamphuis C (HUL), Laxy M (T-HMGU), Luszczynska A (SWPS), Mazzocchi M (UNIBO), Murrin C (UCD-PH), Poelman M (HUL), Steenhuis IHM (VU-P&P), Roos G (OlsoMet), Steinacker J (UUlm), Stock C (DKFZ), van Lenthe F (SocialEpiEMCR), Zeeb H (BIPS), Zukowska J (GUT), Ahrens W (BIPS)
Link: https://doi.org/10.1016/j.foodpol.2020.101873
Title: Protocol for review studies on evaluations and implementation of School Fruit Schemes
Author: Meshkovska B (UiO-PHN), Scheller D (UUlm), Wendt J (UUlm), Jilani H (BIPS), Scheidmeir M (JGU), Stratil J (EBPH-LMU), Lien N (UiO-PHN)
Link: https://www.crd.york.ac.uk/PROSPEROFILES/167697_PROTOCOL_20200203.pdf
Title: Determinants of dietary intake in low-income groups: a systems map
Author: Sawyer A. (PHP-DP)
Title: Policy Evaluation Network (PEN): Protocol for systematic literature review examining the evidence for impact of policies across seven different policy domains
Author: Volf K (UL), Kelly L (UL), Bengoechea EG (UL), Casey B (UL), Gobis A, Lakerveld J (AmsterdeamUMC), Zukowska J (GUT), Gelius P (FAU-ISS), Messing S (FAU-ISS), Forberger S (BIPS), Woods C (UL)
Link: https://doi.org/10.12688/hrbopenres.13089.1
Title: Use of the GRADE approach in health policy making and evaluation: a scoping review of nutrition and physical activity policies
Author: Zähringer J (IfEM), Schwingshackl L (IfEM), Movsisyan A, Stratil JM (EBPH-LMU), Capacci S (UNIBO), Steinacker JM (UUlm), Forberger S (BIPS), Ahrens W (BIPS), Küllenberg de Gaudry D, Schünemann HJ, Meerpohl JJ (IfEM), on behalf of the PEN consortium.
Link: https://doi.org/10.1186/s13012-020-00984-2
Title: Simulation Modeling for the Economic Evaluation of Population-Based Dietary Policies: A Systematic Scoping Review
Author: Emmert-Fees KMF (T-HMGU), von Philipsborn P (EBPH-LMU), Rehfuess EA (EBPH-LMU), Laxy M (T-HMGU), on behalf of the PEN Consortium
Link: https://doi.org/10.1093/advances/nmab028
Title: Stakeholder views on taxation of sugar-sweetened beverages and its adoption in the Netherlands
Author: Eykelenboom M (VU-P&P), Djojosoeparto SK (HUL), Kamphuis CBM (HUL), Poelman MP(HUL), Renders CM (VU-P&P), Olthof MR (VU-P&P), et al., on behalf of the PEN consortium
Link: https://doi.org/10.1093/heapro/daab114
Title: What happens between sugar tax enactment and the effects observed? Sugar-sweetened beverage tax implementation: Results of a scoping map
Author: Forberger S (BIPS), Reisch L (University of Cambridge, United Kingdom), Meshkovska B (UiO-PHN), Lobczowska K (SWPS), Scheller DA (UULM), Wendt J (UULM), et al., on behalf of PEN Consortium
Link: https://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-022-00832-3#citeas
Title: Selection of key indicators for European policy monitoring and surveillance for dietary behaviour, physical activity and sedentary behaviour.
Author: Garnica Rosas L (RKI), Mensink GBM (RKI), Finger JD (RKI), Schienkiewitz A (RKI), Do S (BIPS), Wolters M (BIPS), et al., on behalf of the PEN Consortium
Link: https://doi.org/10.1186/s12966-021-01111-0
Title: The added value of using the HEPA PAT for physical activity policy monitoring: A four-country comparison.
Author: Gelius P (FAU-ISS), Messing S (FAU-ISS), Forberger S (BIPS), Lakerveld J (Amsterdam UMC), Mansergh F, Wendel-Vos W, Zukowska J (GUT), Woods C (UL) on behalf of the PEN consortium
Link: https://doi.org/10.1186/s12961-021-00681-6
Title: Schaffung gesunder Ernährungsumfelder: Ergebnisse des Food-EPI.
Author: Klinger C (LMU), Geffert K (LMU), Hebestreit A (BIPS), Rehfuess E (LMU), von Philipsborn P (LMU)
Link: https://doi.org/10.1515/pubhef-2021-0088
Title: Politik zur Bewegungsförderung in Deutschland (Policies to promote physical activity in Germany)
Author: Messing S (FAU-ISS), Forberger S (BIPS), Woods C (UL), Abu-Omar K (FAU-ISS) and Gelius P (FAU-ISS)
Link: https://doi.org/10.1007/s00103-021-03403-z
Title: Dynamics of the complex food environment underlying dietary intake in low-income groups: a systems map of associations extracted from a systematic umbrella literature review
Author: Sawyer A (PHP-DP), van Lenthe F (SocialEpiEMCR9, Kamphuis C (HUL), Terragni L (OsloMet), Roos G (OsloMet), Poelman M (HUL) et al.
Link: https://doi.org/10.1186/s12966-021-01164-1
Title: Evaluation of acceptability of policies to change dietary and physical-activity related behaviours: a systematic review and narrative synthesis
Author: Scheidmeir M, Kubiak T (JGU), Luszczynska A (SWPS), Wendt J (UULM), Scheller DA (UULM), Meshkovska B (UiO-PHN), et al., on behalf of the PEN consortium
Link: https://doi.org/10.1093%2Feurpub%2Fckac053
Title: Nutrition Policies in Germany: A Systematic Assessment with the Food Environment Policy Index (Food-EPI)
Author: von Philipsborn P (EBPH-LMU), Geffert K (EBPH-LMU), Klinger C (EBPH-LMU), Hebestreit A (BIPS), Stratil J (EBPH-LMU), Rehfuess E (EBPH-LMU) on behalf of the PEN Consortium
Link: https://doi.org/10.1017/s1368980021004742
Title: The evidence for the impact of policy on physical activity outcomes within the school setting: A systematic review
Author: Woods CB (UL), Volf K (UL), Kelly L (UL), Casey B (UL), Gelius P (FAU-ISS), Messing S (FAU-ISS), et al. on behalf of the PEN consortium
Link: https://doi.org/10.1016/j.jshs.2021.01.006
Title: Impact evaluation of a cycling promotion campaign using daily bicycle counters data: the case of Cycling May in Poland
Author: Biondi B (UNIBO), Romanowska A, Birr K (GUT).
Link: https://doi.org/10.1016/j.tra.2022.08.017
Title: Implementation of sugar-sweetened beverages tax and its perception among public health stakeholders. A study from Poland
Author: Brukało K, Kaczmarek K, Kowalski O, Romaniuk P (SILVeR) on behalf of PEN consortium
Link: https://pubmed.ncbi.nlm.nih.gov/35967783/
Title: Strength of EU-level food environment policies and priority recommendations to create healthy food environments
Author: Djojosoeparto SK, Kamphuis CBM (HUL), Vandevijvere S (UOA), Murrin C, Stanley I (UCD-PH), Romaniuk P (SILVeR), et al., on behalf of the PEN Consortium
Link: https://doi.org/10.1093/eurpub/ckac010
Title: Frameworks for implementation of policies promoting healthy nutrition and physically active lifestyle: systematic review.
Author: Lobczowska K, Banik A (SWPS), Romaniuk P (SILVeR), Forberger S (BIPS), Kubiak T (JGU), Meshkovska B (UiO-PHN), et al.
Link: https://doi.org/10.1186/s12966-021-01242-4
Title: Meta-review of implementation determinants for policies promoting healthy diet and physically active lifestyle: Application of the Consolidated Framework for Implementation Research
Author: Lobczowska K, Banik A, Brukalo K (SWPS), Forberger S (BIPS), Kubiak T (JGU), Romaniuk P (SILVeR), et al.
Link: https://doi.org/10.1186/s13012-021-01176-2
Title: Social, economic, political, and geographical context that counts: Meta-review of implementation determinants for policies promoting healthy diet and physical activity
Author: Lobczowska K (SWSP), Banik A (SWPS), Forberger S (BIPS), Kaczmarek K (SILVeR), Kubiak T (JGU), Neumann-Podczaska A (PUMS), et al., on behalf of PEN Consortium
Link: https://doi.org/10.1186/s12889-022-13340-4
Title: The potential of food environment policies to reduce socioeconomic inequalities in diets and to improve healthy diets among lower socioeconomic groups: an umbrella review
Author: Løvhaug AL (OsloMet), Granheim SI, Djojosoeparto SK, Harrington JM, Kamphuis CBM, Poelmann MP (HUL), et al.
Link: https://doi.org/10.1186/s12889-022-12827-4
Title: Causal inference on the impact of nutrition policies using observational data
Author: Mazzocchi M, Capacci S, Biondi B (UNIBO)
Link: https://doi.org/10.22004/ag.econ.322730
Title: Vitamin D food fortification in European countries: The underused potential to prevent cancer deaths
Author: Niedermaier T (DKFZ), Gredner T, Kuznia S, Schöttker B, Mons U (DKFZ), Lakerveld J (Amsterdam UMC), et al.
Link: https://doi.org/10.1007/s10654-022-00867-4
Title: Health enhancing physical activity policies in Poland: Findings from the HEPA PAT survey
Author: Romanowska A, Morawiak A (GUT), Woods C, Kelly L, Volf K (UL), Gelius P (FAU-ISS), et al.
Link: https://doi.org/10.3390/ijerph19127284
Title: Evidence on the impact of sport policies on physical activity and sport participation: a systematic mixed studies review.
Author: Volf K, Kelly L, García Bengoechea E, Casey B (UL), Gelius P, Messing S (FAU-ISS), et al. on behalf of the PEN consortium
Link: https://doi.org/10.1080/19406940.2022.2127835
Title: Which transport policies increase physical activity of the whole of society? A systematic review
Author: Zukowska J (GUT), Gobis A, Krajewski P, Morawiak A (GUT), Okraszewska R (GUT), Woods CB (UL), et al.
Link: https://doi.org/10.1016/j.jth.2022.101488

Reports


Endreport

Main conclusions related to SSB tax:

  1. Use the revenue generated from an SSB tax for health initiatives
  2. Form advocacy coalitions to support the introduction of an SSB tax
  3. When introducing a SSB tax, raise retail prices by at least 20% to reduce consumption
  4. Look for opportunities to broaden the tax base
  5. Couple an SSB tax to societal problems other than public health
  6. Accompany the introduction of an SSB tax by other interventions to reduce SSB consumption in lower socioeconomic groups
  7. More beneficial effects on consumer food purchases could be expected from a nutrient profiling tax based on Nutri-Score targeting a wider range of foods and beverages with a low nutritional quality, compared to a tax targeting SSB alone.

Main conclusions related to Sustainable Urban Mobility Plans (SUMPs):

  1. Most promising SUMP-policies are those mainly aimed at infrastructure development, but also educational programmes and any indirect interventions that have a potential to achieve substantial shifts towards active modes
  2. Among the different types of policies, car restrictions produce the most substantial effects compared to other policies. This result suggests that interventions targeted directly at car users may be more effective
  3. Sufficient financial resources, horizontal and vertical co-operation between agencies as well as a fundamental emphasis on sustainable transitions are crucial for successful SUMP implementation
  4. Local idiosyncrasies need to be accounted for when assessing the implementation of SUMPs
  5. Consistent indicators and data transparency are needed for comparing the effectiveness of SUMPs and their impact on PA across cities and countries
  6. Motorisation rate, modal split, and public transport use can be used as indicators to assess the impact of SUMPs on physical activity.

Main conclusions related to nutrition policies and PA policies in schools/kindergarten:

  1. The relationship between those who supply the fruits and vegetables and those who receive them at the kindergarten/school requires special attention. Time and effort should be invested from the start in establishing these relationships and cultivating them during the implementation
  2. Teachers, target groups, and others responsible for distributing the fruit and vegetables should be consulted to determine what constitutes appropriate design, packaging, as well as frequency of delivery and overall duration of the school fruit provision program throughout the school year
  3. Future nutrition-related European and national policies should make use of the already established relationships between ministries of agricultural, health, and education
  4. Children’s fruit and vegetables consumption can be maintained over time when their motivation and capabilities are combined with sustained opportunities. Because multiple actors and settings influence children’s motivation, capability, and opportunity, activities that can align them and their objectives should be included in the SFPPs
  5. Qualitative research can provide valuable insights into the implementation of PA interventions in school settings. However, for the study of larger samples, there is a need for validated quantitative survey instruments to measure the constructs of important implementation frameworks.
WP1 Policy mapping and EPI development

Addressing the burden of diet-related NCDs and improving population nutrition requires a systems approach. The process of monitoring progress in the implementation of food and physical activity environment policies will contribute to establishing healthier food and physical activity environments that enable healthier diets, increased physical activity opportunities, reduce sedentary behaviours and reduce the burden of obesity and NCDs.

The assessment of the level of implementation of food and physical activity environment policies and infrastructure support by key experts in the Food-EPI and PA-EPI studies shows there is a vast potential for EU countries to improve their policies and infrastructure support influencing food and physical activity environments. Immediate implementation of policies and infrastructure support that enable healthy food and physical activity behaviours are required to tackle the burden of obesity and NCDs in EU countries.

WP2 Monitoring and surveillance

WP2 achievements contribute to the JPI HDHL objectives by facilitating the monitoring of health behaviours and obesity prevention across European countries. WP2 activities provide key prerequisites for the evaluation of the actual impact of population-level policies on behaviour and health. WP2 products facilitate the systematic collection of diet, physical activity and health related data in regular representative population surveys. Thus, it helps the European systems to measure comparable variables of obesity-related risk factors with better fit-for purpose and using state-of-the-art methods. This leads to variables that are comparable across countries and systems and that are suitable for the identification of specific and measurable characteristics of changes that demonstrate progress towards the desired policy outcome or impact. To achieve this, unified questionnaire modules were developed: The SIMPLE modules (Selected Instruments for Multilevel PoLicy and impact Evaluation) are the basis of a consolidated approach to collect comparable health behaviour indicators and the evaluation of population's adherence to health recommendations and the impact of health policies. Ideally, they are implemented in ongoing surveillance systems to collect comparable data at the individual level in voluntary modules or in sub-samples, without discarding existing instruments. Implementation will be guided by a Methodological Competence Platform, composed of experts from surveillance and monitoring systems, epidemiology and public health research, that aims at sustaining the harmonization process and the methodological advancement of European health surveillance. One of the platform’s goals is to conduct further studies investigating validity and reliability of questionnaire items in different age groups and evaluating their suitability to monitor WHO recommendations.

WP3 Estimation and simulation of policy impact

The WP has reviewed the potential, strengths and limitation of three broad classes of methods (experiments, quasi-experimental methods and simulation models) aimed at quantifying the impact of nutrition and physical activity policy. Based on the review of the methods, and their application to real case studies, the main lessons drawn are summarized below:

  • When running randomized trials, lab experiments return different size effects compared to field experiments, as the former overestimate the impact of consumer-oriented policies (due to unrealistically higher attention)
  • Field experiments may be underestimating these effects (due e.g. to confounding factors or poor attention), but further research using market level data is needed
  • Lab experiments may be misleading if the aim is to capture magnitudes and/or run a cost-benefit analysis, but they are very useful when the objective is to discriminate between options
  • Assumptions behind impact evaluation models must always be transparent and credible. This implies rigorous testing whenever possible, and validation through recognized robustness checks and sensitivity analyses
  • Nutrition and physical activity policies may act rapidly on behaviours, but the health effects may only become apparent in the longer term. Quasi-experimental methods (QEM) for ex-post evaluations based on observational data are a powerful tool to identify immediate causal effects, simulation models (SM) are a better suited to project these behavioural changes into long-term outcomes
  • The growing interest in targeted policies and the variability in individual response, call for the application of QEM and SM to allow for heterogeneous responses, and consider the distribution of impacts across different population sub-groups. More research is desirable, also taking into account the recent advances in machine learning methods and in data availability
  • The implementation of multi-component lifestyle policies is a major challenge for QEM to elicit the contribution of individual measures. However, their joint application with SM has the potential to generate new evidence on the effectiveness of multi-component policies. Research looking at integrated QEM+SM modelling is highly desirable.

Finally, the evolution in methods for policy impact evaluation is closely related to the availability of adequate data. Until recently, the application of QEM and SM to nutrition and physical activity policies has been hindered by limitations in the quality and quantity of (longitudinal) data. Novel data technologies can help generate new evidence, and extend the toolkit for policy evaluation.

WP4 Policy implementation evaluation

To support JPI HDHL in its vision that by 2030 all citizens will have the motivation, ability and opportunity to consume a healthy diet from a variety of foods, have healthy levels of physical activity and that the incidence of diet-related diseases will have decreased significantly, the task of WP4 was to identify key aspects of implementation processes, barriers and facilitators to implementation, and tools to assess implementation processes, facilitators, and barriers as well as develop a protocol to assess central requirements of policy implementation.

Based on WP4 tasks we formulated the following six main conclusions:

  • Most implementation frameworks have a complex scope with combinations of processes, determinants and/or evaluation of implementation. They include both system-level constructs and those at the individual or organisational/community level. Furthermore, they combine sections that are purely descriptive with sections accounting for prescriptive and/or explanatory associations. They still contain few or no equity constructs
  • The implementation determinants cost, networking external policies, structural characteristics, implementation climate, readiness for implementation, and knowledge/beliefs were indicated in analysed reviews/stakeholder documents as occurring in implementation processes
  • Socio-cultural, economic and political contexts play a crucial role in successful policy implementation, as they can accelerate or slow down the implementation process
  • Highly intrusive measures such as taxation or restrictions are least likely to be accepted when first implemented, but confidence in terms of relevance and effectiveness increases over time, which in turn may increase acceptance
  • The existing evidence indicates that an SSB tax implementation process may involve existing structures, highlights potential conflicts and poses communication risks
  • Implementation processes for active design guideline use in planning and whole-of city approaches are characterised by a coordinative approach, whereby implementation of national physical activity guidelines is a mix of different processes. In addition, the findings and experiences of WP4 were integrated into a practice-oriented guidance for policy implementation evaluation. Three key requirements for policy implementation evaluation were set: 1) conduct a comprehensive policy implementation evaluation from a multi-level perspective, 2) use implementation frameworks to address processes, determinants, and outcomes, and 3) engage relevant stakeholders in policy implementation evaluation. Moreover, the findings and experiences of WP4 resulted in 10 steps for implementation evaluation of policies to promote physical activity and a healthy diet and to reduce sedentary behaviours, which can be flexibly adapted to the requirements and resources of the policy concerned.
WP5 Equity and diversity of policies

Prevalence rates of overweight and obesity are higher among lower as compared to higher socioeconomic groups in all European countries, although the size and magnitude varies between countries. Tackling these inequalities is a societal challenge in; experts believe that food-related governmental policies are potentially able to curb the epidemic, and perhaps more so for those in lower than in higher socioeconomic groups.

In an umbrella review, evidence of the impact of food environmental policies was summarized across domains of the Healthy Food Environment Policy Index. Sixteen systematic reviews, including 159 primary studies showed that the majority of evidence was related to policies on food prices; only few studies were identified investigating policies covering food composition, food labelling, food provision and food in retail. We found evidence that food taxation may reduce socioeconomic inequalities in diets, but for other policy areas, the evidence base was poor.

While methodologically improved studies may shed further light on the equity impact of food governmental policies, a better understanding of the underlying reasons may also guide further research. Importantly, lower and higher socioeconomic groups not only differ in the healthfulness of their dietary intakes, but also in the material and sociocultural circumstances in which they are born, grow up, work and age, i.e. their daily living conditions (e.g. income, housing, wealth). Theories aimed at understanding socioeconomic inequalities in heath, in which connections are made with daily living conditions may therefore provide insights in the ultimate causes of socioeconomic inequalities in diets, and how these may affect the impact of food environment policies. Applying two contemporary theories (Bourdieu’s theory of capital and the ‘scarcity theory’) helped understanding how elements of broader living conditions may lead to a greater benefits of some food environmental policies. We recommend applying these theories in empirical research testing hypothesis of differential effects of food environmental policies. For example, policies restricting the promotion of unhealthy food products and with that limiting the potential of marketing to be a classifying practice, can be especially beneficial for lower socioeconomic groups.  

Using theories on health inequalities made also clear that a single response in behaviour to a single change in food environments is too simplistic. In fact, many factors are involved in the interplay between food environments and dietary purchases. Increasingly, major societal challenges such as the prevention of obesity and the reduction of inequalities are seen as wicked problems, that best can be investigated using a complexity perspective. Indeed, how the food environment was related to dietary intake in lower socioeconomic groups could be described as a system operating as a supply-and-demand, economic paradigm, and including subsystems of geographical accessibility, household finances, household resources, individual and social and cultural influences. The main implication of these findings was that several, coordinated strategies are needed that together reshape the system driving unhealthy food environments. In addition, deeper levels of the system need to be targeted in order to make the food environment healthier. More specifically, management of household finances and socially oriented practices around the production, supply and intake of food are needed, in a system that prioritizes health more.

A complexity perspective can also shed light on the interacting influences on physical activity on ethnic minority groups. Preliminary results from a review of over 100 papers present a complex system of influences which underpin lower physical activity levels in ethnic minority groups in Europe. Using the Capability Approach as a theoretical basis, a causal loop diagram was built to identify the complex interactions between individual, social, cultural, economic, environmental and organizational factors (conceived as individual, social and environmental ‘conversion factors’). This system can function to obstruct opportunities for routine physical activity. Understanding these interactions between factors will allow us to assess and evaluate policies in terms of their ability to address tackle upstream causal pathways leading to low levels of physical activity.

Target group Authors Means of communication Hyperlink Pdf
Scientific community [higher education, Research] CHermann Brenner, Tobias Niedermaier (DKFZ). Vitamin D supplementation or fortification and cancer mortality in Germany and other European countries, Joint International Symposium, Vitamin D in Prevention and Therapy and Biologic Effects of Light, Homburg/Saar, Germany, May 2022 Plenary lecture    
Scientific community [higher education, Research] Mahshid Zolfaghari (UiO-PHN), Applying a systems’ perspective to understand the mechanisms of the European School Fruit and Vegetable, Throne Holst Symposium, Oslo, Norway, May 2022 Poster    
Scientific community [higher education, Research] Catherine Woods (UL), Policy Evaluation Network (www.jpi-pen.eu) and the evidence for policy evaluation, benchmarking and implementation with a view to integrating PAB Determinants Research into policy implementation, DEPASS Network Meeting, Porto, May 2022 Talk    
Scientific community [higher education, Research] Sanne Djojosoeparto (HUL), Strength of European level policies and priority recommendations to create healthy food environments to prevent obesity and diet-related non-communicable diseases, Obesity Congress, Maastricht, the Netherlands, May 2022. Talk    
Scientific community [higher education, Research] Sanne Djojosoeparto (HUL), How a sugar-sweetened beverages tax may impact the budgets, dietary intake, and health of lower and higher socioeconomic groups differently. A qualitative study of stakeholder views in the Netherlands, ISBPNA, online Presentation, May 2022. Talk    
Scientific community [higher education, Research] Sanne Djojosoeparto (HUL), Implementation of food environment policies by the European Union and priority recommendations to create healthy food environments. ISBPNA, online presentation, May 2022. Poster    
EU policy makers Mahshid Zolfaghari (UiO-PHN), Applying a systems’ perspective to understand the mechanisms of the European School Fruit and Vegetable, meeting of the Expert Group for Agricultural Markets, Online, Jun. 2022 Talk    
EU policy makers Biljana Meshkovska (UiO-PHN), Barriers and facilitators to implementation of the EU School Fruit and Vegetables Scheme: cross country study, meeting of the Expert Group for Agricultural Markets, Online, Jun. 2022 Talk    
Scientific community [higher education, Research] Sanne Djojosoeparto (HUL). How can the national government encourage healthy diets by improving the food environment in the Netherlands? And the implementation of an SSB Tax, National Sugar Challenge, IIburg College, Amsterdam, Jun. 2022. Talk (invited)    
Scientific community [higher education, Research] Sanne Djojosoeparto (HUL). Strength of European level policies and priority recommendations to create healthy food environments to prevent obesity and diet-related non-communicable diseases, EASO Community, Online presentation, Jun. 2022. Talk (invited)    
Scientific community, project partners, stakeholders Sven Messing (FAU-ISS), The Physical Activity Environment Policy Index (PA-EPI): a Tool for Monitoring and Benchmarking Government Policies Promoting Physical Activity, eass & ISSA World Congress of Sociology of Sport, Tübingen, Germany, 7-10 Jun. 2022 Talk    
Scientific community, project partners, stakeholders Symposium “Future directions for nutrition and physical activity policies to prevent NCDs across Europe”, joint event with projects STOP, CO-CREAE and Best-ReMaP, in Brussels, Belgium, 14-16 Jun. 2022 Symposium LINK  
Scientific community [higher education, Research] Luszczynska, A. (SWPS), The development, implementation, and evaluation of obesity prevention interventions. 2022 Psychological Carnival Academic Conference, Beijing, China, Jul. 2022 Keynote lecture (invited)    
Scientific community [higher education, Research] Liam Kelly (UL) & Catherine Woods (UL), Insights into the development of the physical activity environment policy index, a tool for benchmarking implementation of public policies to create healthy physical activity policy environments, 11th Conference of HEPA Europe, Nice, France, Aug. 2022 Symposium    
Scientific community [higher education, Research] Sven Messing (FAU-ISS), The added value of using the HEPA PAT for physical activity policy monitoring: A four-country comparison, 11th Conference of HEPA Europe: An Ecosystem Approach to Health-Enhancing Physical Activity Promotion, Nice, France, Aug. 2022 Talk    
Scientific community [higher education, Research] Sven Messing (FAU-ISS), The impact of mass-media campaigns on physical activity: a review of reviews through a policy lens, 11th Conference of HEPA Europe: An Ecosystem Approach to Health-Enhancing Physical Activity Promotion, Nice, France, Aug. 2022 Talk    
Scientific community [higher education, Research] Wieczorowska-Tobis K., Neumann-Podczaska A. (PUMS), Europejski projekt Sieć ewaluacji polityk (Policy Evaluation Network – PEN) - najważniejsze wnioski z badań dotyczących aktywności fizycznej i diety, II Gerontological Dietetics Webinar, Poznan, Poland, Aug. 2022 Talk    
Scientific community [higher education, Research} Luszczynska, A., (SWPS) et al. A systematic review of frameworks for implementation of policies promoting healthy nutrition and physical activity, 36th Annual Conference of the European Health Psychology Society: Charting New Territories in Health Psychology, Bratislava, Slovakia, Aug. 2022 Poster    
Irish policy makers and health promotion practitioners Nanna Lien (UiO-PHN), Evaluation of the Implementation and impact of the EU School Fruit and Vegetable Scheme, Irish PEN dissemination seminar, Physical, Aug. 2022 Talk    
Scientific community [higher education, Research] Luszczynska, A., (SWPS) et al., Economic, socio-cultural, and political implementation determinants that count: findings from a meta-review on policies promoting healthy lifestyle, 2022 Conference of Society for Implementation Research Collaboration, San Diego, USA, Sept. 2022 Poster    
Scientific community [higher education, Research] Piotr Romaniuk (SUM), Krzysztof Kaczmarek, Katarzyna Brukało, Stefanie Vandevijvere, Karolina Łobczowska, Anna Banik, Aleksandra Luszczynska, Maartje Poelman, Janas Harrington, Elżbieta Grochowska-Niedworok, Healthy Food Environment in Poland: current state and priority actions identified with the use of Food-EPI tool, Twelfth International Conference on Health, Wellness, & Society, Johannesburg, South Africa, Sept. 2022 Talk    
Scientific community [higher education, Research] Piotr Romaniuk (SUM), Krzysztof Kaczmarek, Katarzyna Brukało, Stefanie Vandevijvere, Karolina Łobczowska, Anna Banik, Aleksandra Luszczynska, Maartje Poelman, Janas Harrington, Elżbieta Grochowska-Niedworok, The priority actions to improve healthy food environment: a Polish case, Population Health Congress 2022, Adelaide, Australia, Sept. 2022 Talk    
Scientific community [higher education, Research] Karolina Lobczowska, Anna Banik, Sarah Forberger, Krzysztof Kaczmarek (SUM), Thomas Kubiak, Agnieszka Neumann‑Podczaska, Piotr Romaniuk, Marie Scheidmeir, Daniel A. Scheller, Juergen M. Steinacker, Janine Wendt, Marleen P. M. Bekker, Hajo Zeeb, Aleksandra Luszczynska, It’s All about the Context: A Meta Review of Context Determinants of Implementing Policies on Healthy Diet and Physical Activity, Twelfth International Conference on Health, Wellness, & Society, Johannesburg, Sept. 2022 Talk    
Scientific community [higher education, Research] Brukało K, Kaczmarek K, Romaniuk P, Taxation of Sugar-sweetened Beverages as Health Policy Instrument to Reduce Unhealthy Dietary Behaviour and Its Acceptance among Public Health Stakeholders: A Study from Poland, Twelfth International Conference on Health, Wellness, & Society, Johannesburg, South Africa, Sept. 2022 Talk    
Scientific community [higher education, Research] Brukało K, Kaczmarek K, Romaniuk P, Taxation of sugar-sweetened beverages in term of justice, Population Health Congress 2022, Adelaide, Australia, Sept. 2022 Talk    
Scientific community [higher education, Research] Piotr Romaniuk (SUM), Krzysztof Kaczmarek, Katarzyna Brukało, Stefanie Vandevijvere, Karolina Łobczowska, Anna Banik, Aleksandra Luszczynska, Maartje Poelman, Janas Harrington, Elżbieta Grochowska-Niedworok, Healthy Food Environment in Poland: current state and priority actions identified with the use of Food-EPI tool, Twelfth International Conference on Health, Wellness, & Society, Johannesburg, South Africa, Sept. 2022 Talk    
Scientific community and stakeholders both public, private and NGOs in Norway Nanna Lien (UiO-PHN) for the Norwegian teams, Highlights of the PEN research with focus on the work in Norway and its applicability, Oslo, Norway, 16 Sept. 2022 Symposium    
Scientific community [higher education, Research] Piotr Romaniuk (SUM), Implementacja polityk promujących zdrowie odżywianie i aktywny styl życia: ramy formalne i rekomendacje, Konferencja Wyzwania Zdrowia Publicznego, Bytom, Poland, Oct. 2022 Talk (invited)    
Scientific community and stakeholders Wolfgang Ahrens (BIPS), Catherine Woods (UL). PEN Physical Activity Environment Policy Index (PA-EPI). Stakeholder Dialogue: STOP-Best-ReMaP, Ljubljana, Slovenia, 4 Oct. 2022 Talk (invited)    
Scientific community [higher education, Research] Catherine Woods (UL). Evaluating implementation of public policy for the promotion of physical activity and healthy nutrition: Why, how and what should this involve, EUPHA, Berlin, Germany, Nov. 2022 Talk    

 

Features

Project number:
PEN
Duration: 100%
Duration: 100 %
2019
2022
Related subsidy round:
Project lead and secretary:
Professor Wolfgang Ahrens
Responsible organisation:
Leibniz Institute for Prevention Research and Epidemiology - BIPS, Germany