The application of theories of the policy process to obesity prevention: a systematic review and meta-synthesis

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childhood obesity 21464 et al. 2009 [[69]]Multiple states across USAState level policy making (across several states)General childhood obesity prevention legislation. Not a specific policy or set of policies.Stages of focus not specified however
obesity 77 Title: BMC Public HealthThe application of theories of the policy process to obesity prevention: a systematic review and meta-synthesisBrydie ClarkeBoyd SwinburnGary SacksPublication date
obesity 495 change.MethodsA systematic review of the application of such theoretical frameworks within the field of obesity prevention policy was conducted. A meta-synthesis was also undertaken to identify the key influences
obesity 673 to identify the key influences on policy decision-making.ResultsThe review identified 17 studies of obesity prevention policy underpinned by political science theories. The majority of included studies were conducted
obesity 1472 future theoretically based research into the complexity of policy-making and multiple influences on obesity prevention policy processes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3639-z)
obesity 1701 (doi:10.1186/s12889-016-3639-z) contains supplementary material, which is available to authorized users.BackgroundThe global obesity epidemic warrants urgent government action [[1]]. There is extensive literature advocating policy action
obesity 1818 warrants urgent government action [[1]]. There is extensive literature advocating policy action for obesity prevention, with numerous studies outlining the various approaches available to governments [[2]–[14]].
obesity 1943 numerous studies outlining the various approaches available to governments [[2]–[14]]. Policy-led obesity prevention interventions are cited as having the potential to affect the whole population (including
obesity 2292 in the long term [[2]]. The World Health Organization (WHO) calls for policy action in the area of obesity , as articulated in documents such as the Global Action plan for the prevention and control of non-communicable
obesity 2568 recently increased the use, and widened the scope of policy and legislative interventions to reduce obesity [[16]–[19]]. A recent review found 89 % of developed countries reported having a unit, branch or
obesity 2755 having a unit, branch or department in their Ministry of Health tasked with acting upon NCDs, including obesity [[19]]. High-level policy and strategy action has also been increasing with most countries now having
obesity 2894 strategy action has also been increasing with most countries now having a strategy or action plan on obesity or healthy eating [[1]]. Worldwide, policy action has included some ‘hard’ regulatory approaches
obesity 3396 based health promotion programmes or social marketing strategies as their primary policy response to obesity [[1], [20]–[22]]. Yet despite numerous policy responses globally, no government has implemented a
obesity 3608 comprehensive set of policy approaches, which may explain, in part, the limited success in stemming the obesity epidemic [[1], [12]].Policy change in support of obesity prevention faces political difficulty, particularly
obesity 3665 part, the limited success in stemming the obesity epidemic [[1], [12]].Policy change in support of obesity prevention faces political difficulty, particularly for ‘hard’ policy approaches [[2], [23], [24]].
obesity 4201 deemed to infringe on the free market or personal liberties [[25], [26], [28], [29]]. As a result, obesity is often perceived to be policy resistant [[30]].Nevertheless, there is limited evidence of the specific
obesity 4479 been calls to examine the processes surrounding the formulation and adoption of policy in support of obesity prevention [[24], [31]–[35]]. Recent studies conducted in Australia have explored the general barriers
obesity 4661 explored the general barriers and enablers to implementing various policy approaches in support of obesity prevention [[13], [32], [33], [36]]. Similar studies have also been conducted in the US [[37], [38]],
obesity 4947 some of the policy process determinants that influence the policy decision-making processes related to obesity prevention. They include: individual skills, knowledge and capabilities of policy actors, and the processes
obesity 6391 theoretical perspectives to be used in order to better understand public policy decision-making related to obesity prevention [[34], [44]]. As Breton and de Leeuw (2011) suggest, “without proper theoretical grounding,
obesity 6829 policy processes in this domain. Lyn and colleagues investigated ways in which policy science can inform obesity prevention change efforts [[46]]. However, they only looked at a limited number of policy science theories.
obesity 7285 science theory. However, no reviews have investigated the use of political science theories to understand obesity prevention policy processes more generally (e.g., including policies related to both nutrition and physical
obesity 7691 study aimed to review the application of political science theoretical frameworks within the field of obesity prevention policy and synthesise qualitative findings in the area. In so doing, the study sought to
obesity 7860 area. In so doing, the study sought to answer the research question: what are the key influences on obesity prevention policy decision-making and how do they influence policy processes?MethodsStudy designA two
obesity 8346 that had applied theories of the policy process (as identified in the first stage of the review) to obesity prevention policy.Search strategyIdentification of theories of the policy processFor stage one, a search
obesity 9817 undertaken by BC and was supported by a research librarian.Application of theories of the policy process to obesity preventionFor stage two, BC conducted a systematic search of peer-reviewed literature was conducted
obesity 10121 Health Policy Reference Centre (see Additional file 2 for complete list). Keywords that would retrieve obesity prevention policies included terms related to nutrition (e.g., food, nutrition, sugar, salt) and physical
obesity 11651 data collection of data analysis phases.Focused on policies related to the prevention of overweight or obesity or the proximal determinants of dietary and physical activity behavioursWritten in EnglishPublished
obesity 11906 were:Reviews or conference proceedingsStudies focusing only on policies related to the treatment of obesity (e.g., bariatric surgery).Quality assessmentAll articles that met the inclusion criteria underwent a
obesity 18834 details of the theory were not available in English.Application of theories of the policy process to obesity preventionThe systematic search identified 17 studies of obesity prevention policy that were underpinned
obesity 18899 theories of the policy process to obesity preventionThe systematic search identified 17 studies of obesity prevention policy that were underpinned by a theory of the policy process (refer to Table 2 and search
obesity 21474 [[69]]Multiple states across USAState level policy making (across several states)General childhood obesity prevention legislation. Not a specific policy or set of policies.Stages of focus not specified however
obesity 22002 area represented also varied.HM-HMLThis was not a study of a specific policy process but rather of obesity prevention policy processes generally.Freundenberg et al. 2015 [[62]]Comparison of London and New YorkMunicipal
obesity 22178 [[62]]Comparison of London and New YorkMunicipal levelFood policies, which included strategies to reduce obesity Focused on election cycles providing opportunities for policies to be developed, and hence to stage of
obesity 23319 school board members.Gomez, 2015 [[51]]Comparative study of USA and BrazilNational policy levelGeneral obesity prevention policy.Stages not specified however long term perspective allowed consideration of all aspects
obesity 30508 policies, whilst one study focused on the local level only.Policy area of focusThe most commonly studied obesity prevention policy areas were those that focused on the integration of physical education into schools
obesity 30670 integration of physical education into schools (n = 5). There were also studies of overarching obesity prevention policy (n = 2), walking promotion/ active transport (n = 2), and food and nutrition/
obesity 33093 simply as a result of ‘poor’ research [[67]]. Given the limited evidence available with respect to obesity prevention policy processes, it was considered appropriate to synthesise the influences identified in
obesity 33497 studiesThere were several themes that emerged from the included studies regarding the key influences on obesity prevention policy adoption (Table 3). Refer to Additional file 4 for more details of the findings of
obesity 34028 exogenous factors, such as crises and excessive budget deficits.Table 3Summary of themes of influence on obesity prevention policy processes, by included studiesAuthor, yearTheory usedInfluences on policy processesCoalition/
obesity 36375 to policy makers [[68]]. Lobbying was certainly identified as a successful mechanism for influencing obesity prevention policy in a number of the included studies [[53], [64], [65], [75]]. For example, Mosier’s
obesity 38857 health policy processes [[51]].The leadership of key individuals was another key theme of influence on obesity prevention policy identified in the included studies [[51], [68]]. Political champions who advocated
obesity 40165 treatment compared with prevention responses, were both identified as a barrier to policy progress for obesity prevention [[69], [70], [72]]. Conversely, when leaders were able to shift the narrative to align with
obesity 40859 demonstrated to influence policy decision making through both its influence on the acknowledgement of obesity as an issue (i.e., agenda setting) as well as the type of policy instruments adopted. Three studies
obesity 41035 instruments adopted. Three studies identified that political ideology influenced the prioritisation of obesity prevention policy through historically held beliefs regarding the role of government in public health
obesity 41788 Similarly, the dominant ideological values of powerful groups were demonstrated to influence the progress of obesity prevention policy [[51], [69]].Timing within broader political systems contexts was identified as a
obesity 43023 [75]].Use of ‘evidence’, in its various forms and meanings, arose as an important influence on obesity prevention policy adoption, in a number of studies. Evidence of the need for action was one form of
obesity 43828 therefore remained unclear, from the studies included, how, if at all, evidence of effectiveness of various obesity prevention policy options actually drives policy decision-making.Finally, a number of studies suggested
obesity 44741 there has been limited application of political science theories of the policy process to the study of obesity prevention. The review revealed that, of the existing studies in this area, there was greater utilisation
obesity 45928 normally undertaken following agenda setting phases, and which are demonstrated herein as an influencer of obesity prevention policy [[52], [62], [68]–[70]]) can also strongly shape decisions made by policymakers.Studies
obesity 46483 increase the trustworthiness of findings. Nevertheless, several themes related to key influences on obesity prevention policy were prominent across numerous studies, including the role of groups and networks;
obesity 47291 role of key individuals) are congruent with those identified previously in a-theoretical studies of obesity prevention policy process [[13], [31]–[33], [82]], this review has illuminated additional effects
obesity 47402 prevention policy process [[13], [31]–[33], [82]], this review has illuminated additional effects on obesity prevention policy, such as personal values and beliefs and timing. Many of the studies included herein
obesity 47647 support the notion that policy-maker knowledge or capacity to utilise evidence is a key influencer of obesity prevention policy adoption. This is in contrast to findings from some previous a-theoretical studies
obesity 47938 health community to increase evidence-based policy (EBP) [[25], [35], [78]], at least in the area of obesity prevention, the role of evidence during policy decision-making remains unclear, and other barriers and
obesity 48229 begins to shed light on how such influences can both enable as well as prohibit, evidence informed obesity prevention policy progress.It is also crucial to highlight that the key influences identified herein
obesity 48510 to be highly appropriate to use ‘synthesis’ theories of the policy process in future studies of obesity prevention policy. The application of these more comprehensive ‘synthesis’ theories of the policy
obesity 48652 of these more comprehensive ‘synthesis’ theories of the policy process, within this context of obesity prevention, is broadly consistent with the recent political science literature, including the findings
obesity 50326 insufficient attention to the overall political climate [[86]–[88]], which has been identified in the obesity prevention literature as potentially impacting policy progress [[28]].The small number of studies applying
obesity 50468 potentially impacting policy progress [[28]].The small number of studies applying the ACF to this context of obesity prevention is somewhat surprising, given the ACF’s value in exploring the role of group power dynamics
obesity 51584 individuals [[58]]. Both of these factors have been identified previously as important influences of obesity prevention policy [[13], [39]].With theories of the policy process continuing to emerge and develop
obesity 52648 on the role of ideas through their utilisation of the NPF and the DOI. Whilst the role of ideas in obesity prevention policy processes has been identified as integral in the obesity prevention literature [[95]–[98]],
obesity 52723 Whilst the role of ideas in obesity prevention policy processes has been identified as integral in the obesity prevention literature [[95]–[98]], such theories have been criticised given their limited consideration
obesity 54145 systematic approach to searching for studies that had applied theories of the policy process to the area of obesity prevention. This search was aided by a research librarian and was conducted across a large number of
obesity 57793 recommended that future robust and theoretically based research be conducted across numerous types of obesity prevention policies, in respect to both physical activity and healthy eating.This review highlights
obesity 57968 healthy eating.This review highlights the value of bringing a political science approach to the study of obesity prevention policy to help inform practitioners and policy makers regarding how policy decision making
obesity 58162 decision making occurs in this area [[103]]. The study builds on previous a-theoretical research on obesity prevention policy to provide an overview of the current literature, which has utilised political science
obesity 58453 such theories, studies may be limited in their explanatory value of why certain policies responses to obesity are adopted whilst others are not [[44], [104]]. In contrast, the findings from theoretical studies,
obesity 58669 those presented in this review, may be better able to inform actors attempting to influence future obesity prevention policy as to the potential policy leverage points, as well as how to act to influence policy
obesity 59063 review investigated the application of political science theories of the policy process to the study of obesity prevention policy. The study found a number of political science theories available; however, there
obesity 59341 area. Where political science theories have been applied to understand policy processes with respect to obesity prevention, the studies had substantial methodological weaknesses, particularly in regard to credibility
obesity 59559 dependability of findings. Nevertheless, the meta-synthesis identified a number of key influences on obesity prevention policy decision-making that can be used to guide future investigations. The review highlighted
obesity 59722 guide future investigations. The review highlighted the complexity of decision-making in relation to obesity prevention policy, and therefore recommends that future rigorous empirical investigations incorporate
obesity 59959 perspectives to better guide policymakers as to potential leverage points and effective ways to influence obesity prevention policy

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