Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences.

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity.

BACKGROUND: This meta-review investigated 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. METHODS: Data from nine databases and documentation of nine major stakeholders were searched for the purpose of this preregistered meta-review (#CRD42019133341). Context-related determinants were considered strongly supported if they were indicated in ≥60% of the reviews/stakeholder documents. The ROBIS tool and the Methodological Quality Checklist-SP were used to assess the quality-related risk of bias. RESULTS: Published reviews (k = 25) and stakeholder documents that reviewed the evidence of policy implementation (k = 17) were included. Across documents, the following six determinants from three context domains received strong support: economic resources at the macro (66.7% of analyzed documents) and meso/micro levels (71.4%); sociocultural context determinants at the meso/micro level, references to knowledge/beliefs/abilities of target groups (69.0%) and implementers (73.8%); political context determinants (interrelated policies supported in 71.4% of analyzed reviews/documents; policies within organizations, 69.0%). CONCLUSIONS: These findings indicate that sociocultural, economic, and political contexts need to be accounted for when formulating plans for the implementation of a healthy diet and physical activity/sedentary behavior policies.

Meta-review of implementation determinants for policies promoting healthy diet and physically active lifestyle: application of the Consolidated Framework for Implementation Research.

BACKGROUND: Although multiple systematic reviews indicate that various determinants (barriers and facilitators) occur in the implementation processes of policies promoting healthy diet, physical activity (PA), and sedentary behavior (SB) reduction, the overarching synthesis of such reviews is missing. Applying the Consolidated Framework for Implementation Research (CFIR), this meta-review aims 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. METHODS: A meta-review of published systematic scoping or realist reviews (k = 25) and stakeholder documents (k = 17) was conducted. Data from nine bibliographic databases and documentation of nine major stakeholders were systematically searched. Included reviews (72%) and stakeholder documents (100%) provided qualitative synthesis of original research on implementation determinants of policies promoting healthy diet or PA or SB reduction, and 28% of reviews provided some quantitative synthesis. Determinants were considered strongly supported if they were indicated by ≥ 60.0% of included reviews/stakeholder documents. RESULTS: Across the 26 CFIR-based implementation determinants, seven were supported by 66.7-76.2% of reviews/stakeholder documents. These determinants were cost, networking with other organizations/communities, external policies, structural characteristics of the setting, implementation climate, readiness for implementation, and knowledge/beliefs of involved individuals. Most frequently, published reviews provided support for inner setting and individual determinants, whereas stakeholder documents supported outer and inner setting implementation determinants. Comparisons between policies promoting healthy diet with PA/SB policies revealed shared support for only three implementation determinants: cost, implementation climate, and knowledge/beliefs. In the case of healthy diet/PA/SB policies targeting school settings, 14 out of 26 implementation determinants were strongly supported. CONCLUSIONS: The strongly supported (i.e., systematically indicated) determinants may guide policymakers and researchers who need to prioritize potential implementation determinants when planning and monitoring the implementation of respective policies. Future research should quantitatively assess the importance or role of determinants and test investigate associations between determinants and progress of implementation processes. TRIAL REGISTRATION: PROSPERO, # CRD42019133341.

Tunneling a crosstown highway: a natural experiment testing the longitudinal effect on physical activity and active transport.

BACKGROUND: In the city of Maastricht in the Netherlands, a highway crossing several deprived neighborhoods was tunneled in 2016. The vacant space on top of this tunnel was redesigned and prioritized for pedestrians and cyclists. The aim of this study was to evaluate the effect of this major infrastructural change, named the Green Carpet, on total and transport-based physical activity (PA) levels. METHODS: Participants (≥18 years) were part of one of three area-based exposure groups. The maximal exposure group lived in neighborhoods directly bordering the Green Carpet. The minimal exposure group consisted of individuals living at the other side of the city, and the no exposure group consisted of individuals living in a nearby city. Actual use of the new infrastructure was incorporated as a second measure of exposure. Data were collected before and 3-15 months after the opening of the Green Carpet. Device-based measurements were conducted to obtain PA levels and collect location data. Changes in PA over time and intervention effects were determined using linear mixed models. RESULTS: PA levels in the Green Carpet area increased for the maximal and minimal exposure groups, but did not lead to an increase in total or transport-based PA. For the no exposure group, transport-based MVPA decreased and transport-based SB increased. The significant interaction (time x exposure) for transport-based SB, indicated differences in trends between the no exposure and maximal exposure group (B=-3.59, 95% CI - 7.15; -0.02) and minimal exposure group (B= -4.02, 95% CI -7.85, -0.19). Trends in the results based on analyses focusing on actual use and non-use of the new infrastructure were similar to those of the area-based analyses. CONCLUSIONS: Results suggest that the Green Carpet led to more PA in this specific area, but did not increase the total volume of PA. The area-based differences might reflect the differences between users and non-users, but we should be careful when interpreting these results, due to possible interference of selective mobility bias. This paper reflects that the relationship between infrastructure and PA is not unambiguous. TRIAL REGISTRATION: This research was retrospectively registered at the Netherlands Trial Register ( NL8108 ).

A Scoping Review of Populist Radical Right Parties' Influence on Welfare Policy and its Implications for Population Health in Europe.

BACKGROUND: In light of worrying public health developments such as declining life expectancy gains and increasing health inequalities, there is a heightened interest in the relationship between politics and health. This scoping review explores the possible welfare policy consequences of populist radical right (PRR) parties in Europe and the implications for population health. The aim is to map the available empirical evidence regarding the influence of PRR parties on welfare policy reforms and to understand how this relationship is mediated by political system characteristics in different countries. METHODS AND ANALYSIS: A scoping review of peer-reviewed empirical literature addressing the relationship between PRR parties, political systems and welfare policy in Europe was performed using the methodology by the Joanna Briggs Institute. Data was charted on main study characteristics, concepts and relevant results, after which a qualitative content analysis was performed. The data was categorised according to the political system characteristics: constitution, political economy, interest representation and partisanship. Five expert interviews were conducted for validation purposes. Early evidence from 15 peer-reviewed articles suggests that exclusionary welfare chauvinistic positions of PRR parties are likely to have negative effects on the access to welfare provisions and health of vulnerable population groups. Differences in implementation of welfare chauvinistic policy reforms are partly explained by mediation of the constitutional order (judicial institutions at national and European Union [EU] level), political economy (healthcare system funding and European single market) and partisanship (vote-seeking strategies by PRR and mainstream parties). No clear evidence was found regarding the influence of interest representation on welfare chauvinistic policies. DISCUSSION: While early evidence suggests that the welfare chauvinistic ideology of PRR parties is harmful for public health, the possible mediating role of political system characteristics on PRR welfare policy influence offers risk and protective factors explaining why the PRR ideology plays out differently across Europe.

Comparative institutional analysis for public health: governing voluntary collaborative agreements for public health in England and the Netherlands.

Democratic institutions and state-society relations shape governance arrangements and expectations between public and private stakeholders about public health impact. We illustrate this with a comparison between the English Public Health Responsibility Deal (RD) and the Dutch 'All About Health…' (AaH) programme. As manifestations of a Whole-of-Society approach, in which governments, civil society and business take responsibility for the co-production of economic utility and good health, these programmes are two recent collaborative platforms based on voluntary agreements to improve public health. Using a 'most similar cases' design, we conducted a comparative secondary analysis of data from the evaluations of the two programmes. The underlying rationale of both programmes was that voluntary agreements would be better suited than regulation to encourage business and civil society to take more responsibility for improving health. Differences between the two included: expectations of an enforcing versus facilitative role for government; hierarchical versus horizontal coordination; big business versus civil society participants; top-down versus bottom-up formulation of voluntary pledges and progress monitoring for accountability versus for learning and adaptation. Despite the attempt in both programmes to base voluntary commitments on trust, the English 'shadow of hierarchy' and adversarial state-society relationships conditioned non-governmental parties to see the pledges as controlling, quasi-contractual agreements that were only partially lived up to. The Dutch consensual political tradition enabled a civil society-based understanding and gradual acceptance of the pledges as the internalization by partner organizations of public health values within their operations. We conclude that there are institutional limitations to the implementation of generic trust-building and learning-based models of change 'Whole-of-Society' approaches.