Effectiveness of existing policies for lifestyle interventions - Policy Evaluation Network (PEN)

Leading a physically active lifestyle and eating a healthy diet is associated with a reduced risk of diseases like obesity, coronary heart disease, type 2 diabetes, and certain cancers. Policy actions reducing physical inactivity and improving unhealthy diets have the potential to influence the health and well-being of the population. In the Policy Evaluation Network (PEN) project (https://www.jpi-pen.eu/), policies are defined as "decisions, plans, and actions that are implemented by national or regional governments to achieve specific health goals within a society.” PEN established a multi-disciplinary research network with 28 research centres from seven European countries and New Zealand to build capacity and to evaluate policy interventions regarding their level of impact on dietary, physical activity and sedentary behaviours at population level.The Public Health Nutrition group at the Department of Nutrition, University of Oslo, participated in PEN, and was in charge of the case study evaluating the EU school fruit and vegetable scheme (EU SFVS) as a pan-European policy. Task 1: A systematic qualitative review The review is published in the International Journal of Behavioral Nutrition and Physical Activity. We extracted the qualitative results pertaining to barriers and facilitators to implementation of interventions which provide fruit and vegetables directly to children in kindergartens and schools, and conducted a framework analysis based on the Consolidated Framework for Implementation Research (CFIR). We found that the following CFIR constructs were relevant: 1) intervention characteristics domain: ‘design quality and packaging’, ‘adaptability’ ‘cost’; 2) outer setting: ‘cosmopolitanism’, ‘external policy and incentives’ ‘patients’ needs and resources’; 3) inner setting: ‘implementation climate’, ‘readiness for implementation’ and ‘structural characteristics’; 4) characteristics of individuals: ‘individual stage of change’, ‘knowledge and beliefs about the intervention’ 5) process: ‘engaging’, ‘executing’ and ‘reflecting and evaluating’. The review stresses the dual role of parents as both supporting the implementation and targets of the intervention, which could have implications for the design and implementation of future fruit and vegetables interventions. Positive child perceptions of the value of the intervention and perceived behavior change due to the intervention were reported as relevant facilitators to implementation across several studies, and should be taken into consideration in future design efforts. Task 2: Implementation evaluation A protocol for studying the implementation of the EU SFVS using qualitative interviews and focus groups was written. The study on the barriers and facilitators to implementing the EU SFVS looking at the interactions between agricultural, health and education ministries at the country level was done in 10 EU countries, and resulted in 23 semi-structured interviews with a total of 29 respondents including one person from the EU level. The CFIR was used as the frame for analyzing the results. The manuscript is under review in a scientific journal. There are also country case studies focusing primarily on the school setting, and include implementation actors (scheme administrators, suppliers, headmasters, teachers) and target populations (teachers, children, parents) conducted by partners in Germany, Italy, Belgium, Ireland. A master thesis in the Flanders, found that generally, parents thought the EU SFVS acceptable and appropriate. However, they also expressed the need for more involvement and cooperation with the school in implementation of the EU SFVS. Parents also expressed the perceptions that educational measures linked to the EU SFVS were lacking, and that its duration (throughout the school year) and its frequency (times per week) were low. Task 3: Impact evaluation We used a system dynamics approach to study and illustrate the interconnected impact mechanisms of the EU SFVS. System dynamics utilises causal loop diagrams (CLD) to communicate hypotheses about the problem's causes. Analyzing the CLD allows the researcher to identify or design interventions that can lessen the problem and create lasting desirable changes (e.g., children eating the recommended amount of fruit and vegetable daily). The CLD of the EU SFVS has been developed based on evaluation reports of the scheme, scientific literature on factors influencing fruit and vegetable intake of children, and input from experts. The qualitative CLD places the scheme in a broader context with a more inclusive boundary of the causes of children's low fruit and vegetable intake. This integrated system perspective enabled us to better understand the sources of policy improvement or resistance, as the motivations of each actor interacting with the scheme in their respective contexts were taken into account. A scientific manuscript about the system dynamics model is accepted for publication.

In the Joint Programming Initiative on a Healthy Diet for a Healthy Life (JPI HDHL), 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 behavior 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 COCREATE 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. In the case study on implementation and impact of the European School Fruit scheme, the Public Health Nutrition group, University of Oslo collaborated with the administrators of the Scheme at the EU-level to ensure that the evaluation was relevant and could contribute to the ongoing evaluation of the Scheme due in 2023. The project led to a broad collaboration on policy implementation in public health with colleagues in Poland, Germany, Italy and Ireland. Furthermore, the project has led to combining expertise in implementation and system dynamics in a project funded by the Norwegian Cancer Society. The results have been disseminated to Norwegian researchers and stakeholders and will be followed up in future grant applications on policy evaluation.

As part of the Joint Programming Initiative on a Healthy Diet for a Healthy Life (JPI HDHL), 28 research institutes from seven European countries and New Zealand have combined their expertise to form a Policy Evaluation Network (PEN). PEN’s vision is to provide Europe with tools 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. Using structured evaluation principles and methods, PEN will examine the content, implementation and impact of lifestyle policies across Europe and will build on existing knowledge from DEDIPAC (Determinants of Diet and Physical Activity) and the INFORMAS (International Network for Food and Obesity/ non-communicable diseases Research, Monitoring and Action Support) framework. With seven inter-related work packages (WPs), PEN will provide an overview of the ‘best’ public policies most likely to sustainably reduce physical inactivity, unhealthy diets and sedentary behaviour. It will realise the first steps in a bespoke policy monitoring and surveillance system for Europe and refine our knowledge of appropriate research designs and methods for the quantification of policy impact. It will contribute to our understanding of how to achieve successful transnational policy implementation of these evidence-based or evidence-grounded policies in different cultural, demographic or socio-economic settings with particular focus on vulnerable groups. PEN will provide recommendations on equity and diversity to ensure that policy actions are inclusive as opposed to exclusive, are relevant to the changing landscape of Europe and are culturally sensitive. Finally, PEN will provide three worked examples of policy in practice. Three case studies will illustrate how best to evaluate the implementation and impact of policy in order to yield the best results for a healthy diet for a healthy life for European citizens.