Hypothetical mechanisms driving physical activity levels in ethnic minority groups living in Europe: a systematically identified evidence-based conceptual systems model.

BACKGROUND: In Europe, physical activity levels tend to be lower in ethnic minority groups than the general population. Interventions and policies based on research examining isolated determinants of physical activity have had limited success in increasing physical activity levels. This study used systems dynamics theory and the capability approach theoretical framework to develop a conceptual model of how individual characteristics, institutional and physical environments and the migration context may interact to promote or hinder physical activity in ethnic minority groups living in Europe. METHODS: A systematic update of Langøien et al.'s 2017 review of the determinants of physical activity in ethnic minority groups living in Europe was conducted. Our target population included individuals of all ages who reported a familial migration background from any low- and middle-income countries or belonging to minority indigenous population in Europe. Outcomes pertaining to non-work related physical activity of light, moderate or vigorous intensity performed in any setting were included. Included studies provided an evidence base from which to derive the causal loop diagrams comprising our conceptual model. Sub-system causal loop diagrams were interpreted in co-author review sessions to explicate non-linear system mechanisms, such as reinforcing and balancing feedback loops. RESULTS: Forty-one studies were identified, of which the majority was qualitative. The conceptual model consisted of 4 causal loop diagrams relating to psychosocial constructs; sociocultural constructs; health and health communication and social and material resources, in interaction with environmental/migration context. Four hypothetical mechanisms were identified, e.g. hypothesizing that participation in organised activities leads to increased self-efficacy, thereby enabling further participation. CONCLUSIONS: This study contributes an evidence-based conceptual systems model which elucidates how low levels of physical activity in ethnic minority groups in Europe could be supported by reinforcing and balancing mechanisms involving factors relating to physical and institutional environments, migration context and individuals. A pluralistic approach to literature review, integrating complexity methods such as CLDs into more conventional systematic literature review, supports novel insights into how factors could interact to support persistently low levels of activity, moving beyond the identification of potential relationships between isolated factors to indicating the ways in which these relationships are sustained and could be modified by intervention or policy.

Good practice recommendations on implementation evaluation for policies targeting diet, physical activity, and sedentary behaviour.

Health policies aim to achieve specific health goals through system-level changes, unlike common health interventions that focus on promoting specific health behaviors on individual level. However, reliable data on the feasibility and implementation of policy actions across Europe are lacking. Moreover, no practice-oriented guidance exists for policy makers and implementers on how to evaluate policy implementation.As part of the Policy Evaluation Network, we aimed to synthesise knowledge on how to evaluate the implementation of policies promoting healthy diets, physical activity, and reducing sedentary behaviours. The multidisciplinary working group comprised 16 researchers and conducted two scoping reviews, three systematic reviews, two meta-reviews, two qualitative case studies and one quantitative case study over three years. The target populations included the general population, those at risk for obesity, and school children. Based on these reviews and case studies, this article summarises and presents the findings and lessons learned regarding the implementation evaluation of policies in nine case reports.Drawing on these experiences, three critical 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. Finally, the consensus process resulted in 10 steps for the implementation evaluation of policies to promote physical activity and a healthy diet and to reduce sedentary behaviours, which adhere to the requirements and resources of the targeted policy.The findings of an implementation evaluation can lead to a better understanding of why policies work or not and can serve as a basis for developing solutions. This practice-oriented guidance outlines factors that should be considered in policy implementation evaluation to address its complexity. In this way, involved researchers and practitioners are empowered to engage in the evaluation process to close the knowledge gap regarding policy implementation.

[Perspective Paper "Future Prevention Research" - Current and Future Coordinated Research on Prevention and Health Promotion]. / Perspektivpapier "Zukunft Präventionsforschung": Koordinierte Forschung zu Prävention und Gesundheitsförderung ­ aktuell und in der Zukunft.

From 2014 to 2022, the BMBF has funded five research networks in prevention research and health promotion that are also jointly coordinated (Research Network Primary Prevention and Health Promotion, www.fp2g.net). The researchers have produced a large number of relevant research outputs with insights gained into essential aspects of prevention research and health promotion. The networks research focused on basic principles, application-relevant findings, and implementation conditions of long-term prevention and health promotion for non-communicable diseases (NCDs). The constraints imposed by the pandemic from 2020 onwards were partly addressed by integrating Corona-related research and transfer activities. The importance of resilience for dealing with multiple health and social challenges got increased attention and was analyzed and discussed during the pandemic. For prevention research, research questions such as how to better implement prevention measures through digital tools are gaining additional importance. Together, the research networks have presented achievements and desiderata for future research. This perspective paper with its nine theses formulated in conclusion is intended as a stimulus for discussion among funders as well as the communty of researchers on the subject of successful prevention and health promotion. It is explicitly part of the continuity of the memoranda on prevention research developed in 2012.

Frameworks for implementation of policies promoting healthy nutrition and physically active lifestyle: systematic review.

BACKGROUND: Policy frameworks focusing on policy implementation may vary in terms of their scope, included constructs, relationships between the constructs, and context factors. Although multiple policy implementation frameworks exist, the overarching synthesis characterizing differences between the frameworks is missing. This study investigated frameworks guiding implementation of policies aiming at healthy nutrition, physical activity promotion, and a reduction of sedentary behavior. In particular, we aimed at examining the scope of the frameworks and the content of included constructs (e.g., referring to implementation processes, determinants, or implementation evaluation), the level at which these constructs operate (e.g., the individual level, the organizational/community level), relationships between the constructs, and the inclusion of equity factors. METHODS: A systematic review (the PROSPERO registration no. CRD42019133251) was conducted using 9 databases and 8 stakeholder websites. The content of 38 policy implementation frameworks was coded and analyzed. RESULTS: Across the frameworks, 47.4% (18 in 38) addressed three aims: description of the process, determinants, and the evaluation of implementation. The majority of frameworks (65.8%; 25 in 38) accounted for constructs from three levels: individual, organizational/community, and the system level. System-level constructs were included less often (76.3%; 29 in 38) than individual-level or organizational/community-level constructs (86.8% [33 in 38 frameworks] and 94.7% [36 in 38 frameworks] respectively). The majority of frameworks (84.2%, 32 in 38) included at least some sections that were solely of descriptive character (a list of unassociated constructs); 50.0% (19 in 38) included sections of prescriptive character (general steps of implementation); 60.5% (23 in 38) accounted for explanatory sections (assuming bi- or uni-directorial associations). The complex system approach was accounted for only in 21.1% (8 in 38) of frameworks. More than half (55.3%; 21 in 38) of frameworks did not account for any equity constructs (e.g., socioeconomic status, culture). CONCLUSIONS: The majority of policy implementation frameworks have two or three aims (combining processes, determinants and/or the evaluation of implementation), include multi-level constructs (although the system-level determinants are less frequently included than those from the individual- or organizational/community-level), combine sections of purely descriptive character with sections accounting for prescriptive and/or explanatory associations, and are likely to include a little or no equity constructs. REGISTRATION: PROSPERO, #CRD42019133251.

Nudges used to promote physical activity and to reduce sedentary behaviour in the workplace: Results of a scoping review.

Physical inactivity is one of the most important risk factors for non-communicable diseases. Workplace health promotion is therefore of growing interest to support an active day using nudges. The scoping review aims to (a) analyse how frequently nudges are applied in workplace health promotion to increase physical activity and/or reduce sedentary behaviour, and (b) characterise the nudges used. A systematic database search was conducted for the period 2009 to June 2020. According to predefined inclusion and exclusion criteria, studies promoting physical activity and/or reducing sedentary behaviour using nudges were included. Nudges were classified according to MINDSPACE and TIPPME. A study protocol was previously published. Of the 256 studies identified, 26 used nudges. Most studies were conducted in Europe (n = 12) and the USA (n = 8). N = 18 studies targeted physical activity and n = 8 studies targeted sedentary behaviour. In most studies promoting physical activity, prompts were given to climb stairs (n = 11). Interventions targeting sedentary behaviour were more diverse, using digital interventions or mixed approaches (n = 8). Although nudges can help increase physical activity and reduce sedentary behaviour, there are still gaps in terms of their effective and efficient use. There is a lack of long-term studies that analyse habituation and behavioural changes beyond the intervention period. In addition, the potential of digital and mixed approaches is not yet fully exploited. Further studies from low- and middle-income countries with different climates and working conditions are needed to investigate the feasibility of approaches and advance the fight against physical inactivity.

Scoping Review of Existing Evaluations of Smokeless Tobacco Control Policies: What Is Known About Countries Covered, Level of Jurisdictions, Target Groups Studied, and Instruments Evaluated?

OBJECTIVE: The implementation of smokeless tobacco control policies lags behind those for smoking. This scoping review summarizes the studies that evaluated public policies on smokeless tobacco regulation (SLT) and provides an overview of the jurisdictional level, target groups, and policy instruments. METHODS: Seven databases were systematically searched for studies reporting on public policies regulating SLT. Two reviewers independently screened all studies. Data extraction was performed using a predefined extraction form. Extraction was replicated for 10% of the identified studies for quality assurance. A narrative synthesis of the included studies was used to analyze and interpret the data. The protocol was published beforehand with the Open Science Foundation (OSF). RESULTS: Fourty articles comprising 41 studies were included. Most of the studies reported in the articles were conducted in the United States (n = 17) or India (n = 14). Most studies reported outcomes for students (n = 8), retailers/sellers (n = 8), and users/former users (n = 5). The impact of public policies on smokeless tobacco use, in general, was most frequently assessed (n = 9), followed by the impact of taxes (n = 7), product bans (n = 6), sales/advertising bans near educational institutions (n = 4), and health warnings (n = 3) on consumer behavior. CONCLUSIONS: There are significant gaps in the evaluation of smokeless tobacco regulation studies that need to be filled by further research to understand the observed outcomes. WHO reporting on Framework Convention on Tobacco Control (FCTC) implementation should be linked to studies evaluating smokeless tobacco control measures at all levels of jurisdictions and in countries not members of the WHO FCTC or do not provide data. IMPLICATION: Large gaps in the evaluation of SLT control policies exist. For some countries, WHO FCTC evaluations are available for different levels of jurisdictions. In countries with a strong federal structure, there is a lack of data beyond the national level to provide a more detailed look at compliance, indirect effects, or implementation gaps. More research is needed at all levels of jurisdictions, which add to the work of the WHO to understand what works for which target group, how the different levels of jurisdiction interact, how the real-world context can be incorporated, and what indirect effects may occur.

Awareness, perceptions of and compliance with tobacco control policies among naswar vendors in Khyber Pakhtunkhwa Pakistan.

INTRODUCTION: Regulatory compliance in the retail environment is integral to the success of tobacco control. We assessed compliance among naswar (smokeless tobacco product widely used in South Asia) vendors with tobacco control laws. We also assessed their awareness of tobacco-related harms and policies and perceived effect of policies on their sales. METHODS: We surveyed 286 naswar vendors in three districts of the Khyber Pakhtunkhwa province of Pakistan. We recruited general and specialty vendors from urban and rural areas through multistage cluster sampling. Compliance was measured for promotion, sale to/by minors and tax paid on naswar. We used logistic regression analyses for assessing the association between the outcome variables (awareness of tobacco harms and laws, perceptions about the effect of policies on business and compliance with laws) and their predictors. RESULTS: Most vendors (70%) were aware of tobacco-related harms of naswar. Although educated vendors were more aware of tobacco control policies, the greatest awareness was for a ban on sales to/by minors (21% overall). The majority of vendors (76%) violated this policy (measured by self-report), and violations were more common among rural than urban vendors (OR 2.27, 95% CI 1.05 to 4.96). Most vendors (71%) violated a ban on promotion of naswar. Vendors perceived tax increases and sales ban to/by minors as most detrimental for business. CONCLUSIONS: There was poor awareness and compliance among naswar vendors in Pakistan with tobacco control laws. This study finds potential areas for policy interventions that can reduce urban/rural disparities in implementation of and compliance with tobacco control laws.

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.

Development of a framework to guide research into policies promoting physical activity and healthy diets in the European context: the system-based Policy Evaluation Network (PEN) framework.

BACKGROUND: The Policy Evaluation Network (PEN) is a multidisciplinary Pan-European research consortium focussing on policies affecting dietary intake, physical activity and sedentary behaviour. At the start, the PEN consortium expressed the need for an overarching, system-based framework covering the complexities between the different domains of the policy process (design, implementation and outcomes) in order to execute all research activities in a coherent way. This article describes the PEN framework itself and its development process. METHODS: A staged approach to the development of a system-based framework was executed between February 2019 and February 2022. We started with a point-of-departure framework, made use of existing models, collected PEN outputs at different project stages (through online meetings, e-mail exchanges and workshops with PEN researchers) and drew updated versions of the framework, which resulted in the system-based PEN framework. RESULTS: The system-based PEN framework depicts the policy process as a complex system, visualizing the dynamic interrelations between and within policy domains (i.e. policy design, policy implementation and policy outcomes), the ways they interact with the context, and how to assure a focus on equity in each domain. CONCLUSIONS: The system-based PEN framework may guide researchers and professionals involved in the evaluation of health- or sustainability-related policies to consider their evaluation in a comprehensive picture, including domain interactions, contextual influences and equity considerations, as these can have important implications for the scope of their research. The stage-based process as applied for the development of the PEN framework can serve as a template for other research projects wishing to develop their own framework.

Using GRADE Evidence to Decision frameworks to support the process of health policy-making: an example application regarding taxation of sugar-sweetened beverages.

BACKGROUND: Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks are well-known tools that enable guideline panels to structure the process of developing recommendations and making decisions in healthcare and public health. To date, they have not regularly been used for health policy-making. This article aims to illustrate the application of the GRADE EtD frameworks in the process of nutrition-related policy-making for a European country. METHODS: Based on methodological guidance by the GRADE Working Group and the findings of our recently published scoping review, we illustrate the process of moving from evidence to recommendations, by applying the EtD frameworks to a fictitious example. Sugar-sweetened beverage (SSB) taxation based on energy density was chosen as an example application. RESULTS: A fictitious guideline panel was convened by a national nutrition association to develop a population-level recommendation on SSB taxation aiming to reduce the burden of overweight and obesity. Exemplary evidence was summarized for each EtD criterion and conclusions were drawn based on all judgements made in relation to each criterion. As a result of the high priority to reduce the burden of obesity and because of the moderate desirable effects on health outcomes, but considering scarce or varying research evidence for other EtD criteria, the panel made a conditional recommendation for SSB taxation. Decision-makers may opt for conducting a pilot study prior to implementing the policy on a national level. CONCLUSIONS: GRADE EtD frameworks can be used by guideline panels to make the process of developing recommendations in the field of health policy more systematic, transparent and comprehensible.

What we know about the actual implementation process of public physical activity policies: results from a scoping review.

BACKGROUND: Physical inactivity rates have remained high worldwide since 2001. Public policies are an essential upstream lever to target individual physical activity (PA) behaviour. However, implementers have different strategies and face implementation challenges that are poorly understood. The present study analyzes the implementation processes of public policies to promote PA in terms of: (i) the policies covered and their legal quality, (ii) the actors and stakeholders involved in the implementation process and (iii) the used implementation strategies (vertical, horizontal or a mix). METHODS: A scoping review was systematically conducted (registered Open Science Framework: osf.io/7w84q/), searching 10 databases and grey literature until March 2022. Of the 7741 titles and abstracts identified initially, 10 studies were included. RESULTS: The current evidence includes high-income countries (USA, n = 7; UK, New Zealand and Oman, n = 1 each). Policy areas covered are education (school sector) and PA promotion in general (national PA plans or city-wide approaches). The legal classification ranges from laws (school sector) to coordination and budgeting to non-legally binding recommendations. The jurisdictions covered were federal (n = 4), state (n = 1), county (n = 1), school district (n = 1) and city (n = 3). Implementation strategies for city-wide approaches are characterized by a coordinated approach with vertical and horizontal integration; federal PA policies by a mix of implementation strategies; and the school sector by a strict horizontal top-down integration without the involvement of other actors. CONCLUSION: Implementation strategies differ by policy field. Therefore, continuous evaluation of the implementation process is necessary to align policy implementation with policy goals to promote individual PA behaviour.

Reaching consensus on definitions for food and physical activity policies: experience from the Policy Evaluation Network.

BACKGROUND: An upsurge in policy evaluation research within public health sciences has led to multi-disciplinary research networks like the 'Policy Evaluation Network' (PEN). This multi-disciplinary collaboration highlighted the need for consensus on clear, common terminology and definitions to facilitate the multi-disciplinary research. This article outlines the development process of the PEN definitions glossary tool, with a focus on the key domains of policy design, implementation and outcomes as they apply to physical activity, sedentary behaviour and dietary behaviours. METHODS: A project specific participatory process was undertaken, involving PEN researchers (n = 48) from seven European countries across various disciplinary backgrounds. All involved researchers were invited to identify and collate definitions that were commonly used in their research field. Terms and definitions were discussed and debated during three online workshops. Subsequently, the definitions were discussed and refined until consensus was reached. RESULTS: Consensus definitions for 93 terms related to the evaluation of policy design, implementation and outcomes are provided. Consensus was reached on a range of terms where the terms were understood and used differently across represented disciplines (e.g. 'Outcome' and 'Impact'). A conceptual 'Inter-relations in policy-related concepts' diagram was developed to enable navigation through an online database with key terms. CONCLUSIONS: The definitions resulting from this participatory process has supported PEN researchers and practitioners across disciplines to reach a shared understanding of different terms related to policy evaluation. Thus, providing a platform for avoiding conflicting use of the same terms in differing contexts over the course of the PEN work programme, facilitating clear and consistent communication, and allowing for clarity within collaborative multi-disciplinary projects and in public-facing messages.

The impact of mass-media campaigns on physical activity: a review of reviews through a policy lens.

BACKGROUND: This review of reviews aimed to: (1) summarize the evidence from published reviews on the effectiveness of mass-media campaigns to promote physical activity (PA) or PA-related determinants (intermediate psychological and proximal outcomes) and (2) to identify policy-relevant recommendations related to successful PA campaigns. METHODS: An extensive literature search was performed on 1 March 2021. Reviews that evaluated the impact of campaigns on distal (e.g. PA) and/or proximal outcomes of PA (awareness, knowledge, etc.) and that targeted the general population or subsets were included. Quality of reviews was assessed using the AMSTAR-2 tool. Policy-relevant recommendations were systematically derived and synthesized and formulated as good practice statements. A protocol was registered beforehand (ID: CRD42021249184). RESULTS: A total of 1915 studies were identified, of which 22 reviews were included. 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 and (3) media should be tailored to reduce socioeconomic inequalities. CONCLUSIONS: 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. Policy-relevant recommendations include that mass-media strategies should be resourced, coordinated, aligned, sustained, monitored and evaluated on the local and national level.

The Physical Activity Environment Policy Index for monitoring government policies and actions to improve physical activity.

BACKGROUND: A multifaceted response, including government action, is essential to improve population levels of physical activity (PA). This article describes the development process of the 'Physical Activity Environment Policy Index' (PA-EPI) monitoring framework, a tool to assess government policies and actions for creating a healthy PA environment. METHODS: An iterative process was undertaken. This involved a review of policy documents from authoritative organizations, a PA policy audit of four European countries, and a systematic review of scientific literature. This was followed by an online consultation with academic experts (N = 101; 20 countries, 72% response rate), and policymakers (N = 40, 4 EU countries). During this process, consensus workshops were conducted, where quantitative and qualitative data, alongside theoretical and pragmatic considerations, were used to inform PA-EPI development. RESULTS: The PA-EPI is conceptualized 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' or indicators of ideal good practice within each domain conclude the PA-EPI. A potential eight-step process for conducting the PA-EPI is described. CONCLUSIONS: Once pre-tested and piloted in several countries of various sizes and income levels, the PA-EPI good practice statements will evolve into benchmarks established by governments at the forefront of creating and implementing policies to address inactivity.

Acceptability of policies targeting dietary behaviours and physical activity: a systematic review of tools and outcomes.

BACKGROUND: Successful implementation of health policies require acceptance from the public and policy-makers. This review aimed to identify tools used to assess the acceptability of policies targeting physical activity and dietary behaviour, and examine if acceptability differs depending on characteristics of the policy and of the respondents. METHODS: A systematic review (PROSPERO: CRD42021232326) was conducted using three databases (Science Direct, PubMed and Web of Science). RESULTS: Of the initial 7780 hits, we included 48 eligible studies (n = 32 on dietary behaviour, n = 11 on physical activity and n = 5 on both), using qualitative and quantitative designs (n = 25 cross-sectional, quantitative; n = 15 qualitative; n = 5 randomized controlled trials; n = 3 mixed-methods design). Acceptability was analysed through online surveys (n = 24), interviews (n = 10), focus groups (n = 10), retrospective textual analysis (n = 3) and a taste-test experiment (n = 1). Notably, only 3 (out of 48) studies applied a theoretical foundation for their assessment. Less intrusive policies such as food labels and policies in a later stage of the implementation process received higher levels of acceptability. Women, older participants and respondents who rated policies as appropriate and effective showed the highest levels of acceptability. CONCLUSION: Highly intrusive policies such as taxations or restrictions are the least accepted when first implemented, but respondents' confidence in the relevance and effectiveness of the policy may boost acceptability over the course of implementation. Studies using validated tools and a theoretical foundation are needed to further examine opportunities to increase acceptability.

Sugar-sweetened beverage tax implementation processes: results of a scoping review.

Taxing sugar-sweetened beverages (SSB) is seen as a win-win situation for governments. It is argued that SSB taxes are relatively easy to implement from a practical perspective compared to for example other nutrition policies. However, the implementation of SSB taxation laws does not happen by itself. Therefore, this work examines implementation processes for SSB taxation in terms of (1) pre-implementation context, (2) taxation instruments used and (3) interactions in the implementation process. Ten databases and grey literature were systematically searched for studies reporting on SSB taxation implementation processes up to February 2020. All studies (N = 1248) were screened independently by two reviewers according to predefined criteria. The selection of variables to be extracted was based on the policy cycle heuristic and informed by intervention implementation research. Information on the process of implementing SSB taxation is limited. Only six cases based on three publications were identified, indicating a gap in this research area. SSB taxation implementation was accomplished by hiring a subcontractor for the implementation or using pre-existing tax collection structures. Political and public support within the implementation process seems to be supportive for the city of Berkeley and for Portugal but was not reported for the Pacific Islands. However, the existing data are very limited, and further research on SSB taxation implementation processes is needed to determine whether the aim of the policy and the envisaged outcome are linked in practice. Registration The protocol was registered with the Open Science Framework (OSF) (osf.io/7w84q/).

[Policies to promote physical activity in Germany : An analysis based on a policy audit tool from the World Health Organization]. / Politik zur Bewegungsförderung in Deutschland : Eine Analyse anhand eines Policy-Audit-Tools der Weltgesundheitsorganisation.

BACKGROUND: Physical inactivity is a key determinant of noncommunicable diseases. Therefore, the World Health Organization (WHO) as well as researchers worldwide have developed different tools to monitor and audit policies to promote physical activity. However, these tools have so far not been used to systematically collect and analyse data on physical activity promoting policies in Germany. AIM: This study aims to provide a systematic overview of policies to promote physical activity in Germany. METHODS: The study was conducted as part of the Policy Evaluation Network ( www.jpi-pen.eu ). Data from the European Union Physical Activity Monitoring Framework, desk research, and an expert survey were utilised and collected with the WHO's health-enhancing physical activity (HEPA) policy audit tool (PAT). RESULTS: The results highlight the wide range of relevant stakeholders and provide an overview of current policies as well as surveillance, evaluation, and funding. Significant accomplishments and persistent challenges are identified. DISCUSSION: An international comparison shows that, in contrast to Germany, other countries have formulated measurable goals for physical activity promotion on a national level. However, Germany is among a minority of countries with specific physical activity recommendations for adults with noncommunicable diseases. Further structural development of physical activity promotion in Germany is necessary.

Supply Chain Actors' Willingness to Switch the Business of Smokeless Tobacco: A Mixed-Methods Study on Naswar Business in Pakistan.

INTRODUCTION: Provision of alternate livelihoods to smokeless tobacco (SLT) supply chain (SC) actors can help in curtailing SLT business and its consumption. We explored the reasons for SC actors' engagement in Naswar (SLT used in South Asia) business and their willingness to switch to other alternatives. AIMS AND METHODS: We conducted an equal-status concurrent mixed-methods study in four districts of Khyber Pakhtunkhwa province of Pakistan. We surveyed 286 general points of sale (GPOS) and exclusive Naswar (EN) vendors through multistage cluster sampling. Additionally, we interviewed 15 tobacco farmers interpretively, being distinct from other SC actors. We assessed the association between vendors' willingness to switch and their awareness about tobacco-harms, profit margin, Naswar as a family business, length of business, education level, and shop type using logistic regression. Qualitative data assessed the farmer's viable alternatives to switch and were analyzed using deductive-inductive thematic analysis. RESULTS: Product demand-77% and profit margins-75% were the main drivers for selling SLT by EN vendors. Half of the GPOS and 25% EN vendors expressed willingness to stop Naswar's sale. Vendors aware of tobacco-harms were more willing to switch, but less likely to switch if Naswar was perceived to bring "good profit." Farmers were mainly cultivating tobacco because of profitability, family-run farm, and perceived land-suitability for tobacco. Lack of government support was main constraint for farmers looking to switch. CONCLUSIONS: A considerable portion of Naswar SC actors in Pakistan are willing to switch to viable alternatives, with profitability of alternatives, support from authorities, and social obligations as key considerations in doing so. IMPLICATIONS: This study highlights that good profit margins in the Naswar business, lack of awareness of tobacco-related health harms, and absence of the government's support are key detriments to switching to alternative businesses among Naswar SC actors in Pakistan. These findings are the first to come out in the context of both Pakistan and Naswar product, making a case for policy interventions focusing on tax increases, awareness campaigns about tobacco-harms, and a proactive role by the government to provide support for the security of livelihoods to those tobacco SC actors who want to switch to other alternatives.

Implementing smokeless tobacco control policy in Pakistan: a qualitative study among Naswar supply chain actors.

OBJECTIVE: To obtain insights into the perceptions of barriers and facilitators to implementation of the WHO Framework Convention on Tobacco Control (FCTC) among smokeless tobacco (SLT) supply chain actors in the Khyber Pakhtunkhwa province of Pakistan. METHODS: We conducted a qualitative study to investigate the perceptions about SLT control policy formulation and implementation among exclusive Naswar sellers and point of sale vendors. We conducted five focus group discussions in three districts of Khyber Pakhtunkhwa using combined deductive-inductive thematic analyses. RESULTS: We identified three central themes that potentially impact policy formulation, its implementation and application. The first theme examines the role of children in the Naswar business: as potential customers, and as potential heirs to a Naswar-selling business. A second theme targets the 'business of Naswar', which includes a specific identity of Naswar sellers, its potential to generate profits and the special case of Naswar regulation as a socially accepted and culturally rooted product. The third theme addresses the unusual ingredients of Naswar and its production process, making Naswar a health risk for consumers and producers. We also report conflicting views regarding SLT control among the supply chain actors. CONCLUSIONS: This study provides insights into the perceptions of important SLT supply-side stakeholders regarding various SLT control policy options based on the FCTC. While there is some opposition to policy approaches like taxation and switching of business, implementing a ban on selling SLT to minors may be a viable option for policymakers in the short term.

The added value of using the HEPA PAT for physical activity policy monitoring: a four-country comparison.

BACKGROUND: Public policy is increasingly recognized as an important component of physical activity promotion. This paper reports on the current status of physical activity policy development and implementation in four European countries based on the Health-Enhancing Physical Activity Policy Audit Tool (HEPA PAT) developed by WHO. It compares the findings to previous studies and discusses the general utility of this tool and its unique features in relation to other instruments. METHODS: The study was conducted as part of the Policy Evaluation Network ( www.jpi-pen.eu ) in Germany, Ireland, the Netherlands and Poland. Data collection built upon information obtained via the EU Physical Activity Monitoring Framework survey, additional desk research and expert opinion. Data analysis employed Howlett's policy cycle framework to map and compare national physical activity policies in the four countries. RESULTS: In all countries under study, policy agenda-setting is influenced by prevalence data from national health monitoring systems, and the sport and/or health sector takes the lead in policy formulation. Key policy documents were located mainly in the health sector but also in sport, urban design and transport. Physical activity programmes implemented to meet policy objectives usually cover a broad range of target groups, but currently only a small selection of major policies are evaluated for effectiveness. National experts made several suggestions to other countries wishing to establish physical activity policies, e.g. regarding cross-sectoral support and coordination, comprehensive national action plans, and monitoring/surveillance. CONCLUSIONS: This study provides a detailed overview of physical activity policies in the four countries. Results show that national governments are already very active in the field but that there is room for improvement in a number of areas, e.g. regarding the contribution of sectors beyond sport and health. Using the HEPA PAT simultaneously in four countries also showed that procedures and timelines have to be adapted to national contexts. Overall, the instrument can make an important contribution to understanding and informing physical activity policy, especially when used as an add-on to regular monitoring tools like the EU HEPA Monitoring Framework.