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«Anna Marie Hendriks Colophon © A-M Hendriks, Maastricht 2016 Cover design: Friesland Holland: Henk Doornbos, Frank Hendriks Layout: A-M Hendriks, ...»

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Wicked problems and

challenging opportunities

Development of integrated public health policies

for the prevention of obesity

Anna Marie Hendriks


© A-M Hendriks, Maastricht 2016

Cover design: Friesland Holland: Henk Doornbos, Frank Hendriks

Layout: A-M Hendriks, Henk Doornbos

Production: Datawyse / Universitaire Pers Maastricht

ISBN: 978 94 6159 532 4

All rights reserved. Illustrations and brief excerpts from this publication may be

used for scientific and educational purpose provided that the source is acknowledged.

This dissertation has been supported by the Academic Collaborative Centre for Public Health Limburg, a collaborative between 18 municipalities in South Limburg, the regional Public Health Service (GGD Zuid Limburg) and Maastricht University Medical Centre (MUMC+).

The studies presented in this dissertation were performed at the Department of Health Promotion, School for Public Health and Primary Care (CAPHRI), Maastricht University. CAPHRI is part of the Netherlands School for Primary Care (CaRe), which has been acknowledged since 1995 by the Royal Netherlands Academy of Arts and Sciences (KNAW).

This dissertation was funded by ZonMw, the Netherlands Organization for Health Research and Development (project no. 200100001) and is part of the Consortium for the Integrated Approach to Overweight (CIAO); sub-study ‘From fiction to Action’. CIAO is a research consortium of five Academic Collaborative Centers aiming for an effective set of local intervention activities for primary prevention of childhood overweight.

Wicked problems and challenging opportunities:

Development of integrated public health policies for the prevention of obesity Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Maastricht, op gezag van de Rector Magnificus, Prof dr. L.L.G. Soete volgens het besluit van het College van Decanen, in het openbaar te verdedigen op vrijdag 4 maart 2016 om 12:00 uur door Anna Marie Hendriks Geboren op 29 juni 1987 te Heerenveen UM P



Promotores Prof. dr. NK de Vries Prof. dr. ir. MWJ Jansen Prof. dr. SPJ Kremers Beoordelingscommissie Prof. dr. D van de Mheen (voorzitter) Dr. M-J Aarts (GGD Limburg-Noord) Dr. PT van Assema Prof. dr. JAM Maarse Prof. dr. ir. AJ Schuit (Vrije Universiteit, Amsterdam) This dissertation is dedicated to the dung beetle, which excels in recognizing a challenging opportunity in a complex problem.

Dit proefschrift draag ik op aan de mestkever die uitblinkt in het zien van een uitdagende mogelijkheid in een complex probleem.

Preface ‘The mandate is clear and the needs and opportunities are obvious. Rhetoric is easy, and we need to move towards tangible, concrete and replicable insights into how integrated policy responses to complex health issues come about’ (Tang et al., 2014, p. 2).

This quote illustrates the main goal of this dissertation, which is to operationalize the concept of integrated public health policies and to study how we can facilitate and guide their development.

A famous Native American proverb inspired the type of data we gathered in this dissertation, which was qualitative in nature and based on capturing in-depth the experiences of policymakers: ‘Don't judge any man until you have walked two moons in his moccasins’.

While preparing for the research work reported on in this dissertation, we found that few had actually tried to step into the shoes of the persons of whom so much is expected with regard to the development of integrated public health policies: the policymakers themselves.

By trying to view the development of integrated public policies from their perspective, we aimed to collect data that made it possible to identify and understand the reasoning (or lack of reasoning) behind the policymakers’ behaviors.

To capture policymakers’ views, we integrated insights from organizational change, political and policy science within a behavioral science perspective. This interdisciplinary view of the development of integrated public health policies was relatively new, and we hope to have made an original contribution to the field and taken the development of integrated public health policies a step further.


Chapter 1: Introduction 1

–  –  –

Chapter 3: Proposing a conceptual framework for integrated local public health policy, applied to childhood obesity - The Behavior Change Ball 27 Chapter 4: Towards health in all policies for childhood obesity prevention 51 Chapter 5: Local government officials' views on intersectoral collaboration within their organization - A qualitative exploration 73 Chapter 6: Interventions to promote an integrated approach to public health problems: an application to childhood obesity 93

–  –  –

Curriculum Vitae 209 Dissertation outline In this dissertation, the main research question is answered in nine chapters. After this introduction (chapter 1), the next chapters present our conceptual framework (chapters 2 and 3), the empirical application of our conceptual framework (chapters 4-7), theoretical reflections (chapter 8) and a general discussion (chapter 9).

Chapter 2 introduces two operational criteria (i.e., defining characteristics) that can be used to assess if integrated public health policies are present and determine which aspects require further work to make the policy more ‘integrated’.

Chapter 3 introduces a framework which we named the ‘Behavior Change Ball’ (BCB). This framework organizes ideas and theories regarding the development of integrated public health policies within ten organizational behaviors, determinants of those behaviors, and interventions and policies to address them. The BCB can be used as an analytical tool to make conceptual distinctions and study and guide the development and implementation of integrated public health policies from multiple theoretical perspectives.

Chapter 4 presents one case study in a relatively small Dutch local government examining local government policymakers’ views on factors that hamper or facilitate intersectoral collaboration, categorized as relating to capability, opportunity, and motivation.

Chapter 5 presents a study comparing the views of local government policymakers in two relatively small Dutch local governments as regards barriers and facilitators for intersectoral collaboration, again categorized as relating to capability, opportunity, and motivation.

Chapter 6 discusses nine categories of interventions that can promote the development of integrated public health policies. The aim of this study was to examine possible mechanism to stimulate the development of integrated public health policies and overcome barriers to intersectoral collaboration.

Chapter 7 presents a study in the Republic of Fiji on ways in which the obesity prevention policy landscape affects the development of integrated public health policies. We found that the policy landscape provides or restricts opportunities to implement organizational behaviors (OBs) and interventions relevant to the development of integrated public health policies. Understanding this landscape can therefore assist in understanding how the development of integrated public health policies by governments can be promoted.

Chapter 8 discusses how our conceptual framework can be improved by integrating policy and political science perspectives more productively, thereby applying a more comprehensive approach to understanding the development of integrated public health policies.

Finally, chapter 9 discusses our main findings, the strengths and limitations of the research we have undertaken, and recommendations for future studies and practice. The dissertation ends with a valorization proposal.

Chapter 1 Introduction ‘We must remember health is an outcome of all policies’ United Nations Secretary General Ban Ki Moon said this in his Statement to the 2009 World Health Assembly (UN, 2009). If we take this statement to be true, we must conclude that we have created many policies that lead to poor health (Carrera, 2014; Tang et al., 2014). Policies have changed our environment and, moderated by socio-cultural, socio-economic and transport modes, have stimulated high food and energy consumption and low physical activity levels (Swinburn et al., 2011). As a result, healthy diet and physical activity choices have become harder, instead of easier choices (Khandekar et al., 2011; Nguyen et al., 2011; Swinburn et al., 2011; Hardoon et al., 2012; Carrera, 2014; Sépulveda and Murray, 2014; Webber et al., 2014; WHO, 2014a; Tang et al., 2014). The current ‘obesity epidemic’ and related diseases (e.g., cardiovascular diseases, several forms of cancer, type 2 diabetes) reflect this (Alwan et al., 2010; Finkelstein et al., 2012;

Lozano et al., 2012; Ebrahim et al., 2013; Webber et al., 2014; World Health Organization, 2013a, 2014a,b,c, 2015a).

In 2013, 2.1 billion people were estimated to be overweight globally including 42 million children under the age of 5 (Ng et al., 2014; World Health Organization, 2014a,c). Between 1980 and 2013, overweight increased by 28% in adults; from 28.8% to 36.9% in adult men and from 29.8% to 38.0% in adult women. In 2014, 39% (38% of men and 40% of women) of adults aged 18 years and over were overweight (more than 1.9 billion adults) and 13% (11% of men and 15% of women) were obese (600 million adults) (World Health Organization, 2014a,c).

Even among children and adolescents and in developing countries, rates have doubled. In 2013, 23.8% of boys and 22.6% of girls in developed countries were overweight or obese, while in developing countries, 12.9% of boys and 13.4% of girls were overweight or obese (Wagner and Brath, 2012; Ng et al., 2014; World Health Organization, 2014a,b,c). Obesity projections to 2030 indicate that these rates will continue to rise in most countries (Finkelstein et al., 2012; Webber et al., 2014). For example, between 2010 and 2030, rates of overweight (including obesity) in adult men in Ireland are expected to increase from 76% to 91%, and those of obesity from 24% to 27%. Projections for the Netherlands are slightly more encouraging; overweight is expected to decrease from 54% to 49% in men and obesity from 10% to 8%; for Dutch women, the obesity rate is predicted to decrease from 13% to 9%, while overweight is expected to remain stable (Webber et al., 2014).

Since overweight and obesity are associated with lower objective and subjective health (e.g., Daniels et al., 2006; Analitis et al., 2009; Okosun et al., 2010), interest in prevention and treatment has substantially grown over the last decade (Roberto et al., 2015). Studies showed that obesity in childhood was strongly linked to fatty liver disease among children (Sinatra, 2012) and that severely obese children and adolescents experience a quality of life similar to that of children and adolescents


with cancer (Schwimmer et al., 2003). Moreover, since childhood and adolescent overweight and obesity often track into adulthood, there are also long-term consequences (Freedman et al., 2005; Wree et al., 2010; Nguyen et al., 2011; Reilly and Kelly, 2011). One study showed that obesity is associated with several forms of cancer (Campbell et al., 2010; Khandekar et al., 2011; Bhaskaran et al., 2014;

Campbell, 2014) and another showed that obese adults receive lower wages, which in turn may lead to a higher risk of obesity (Lempert, 2014).

In addition to these consequences for individuals, communities and governments are also severely affected by the current obesity epidemic. Overweight, obesity and related non-communicable diseases are known to decrease workforce participation and productivity (Klarenbach et al., 2006; Tunceli and Williams, 2006; Puhl and Heuer, 2009; Lehnert et al., 2014), cause huge rises in health care costs and affect economic growth (Thorpe et al., 2004; Van Baal et al, 2006;

Finkelstein et al., 2009; Mayer-Foulkes, 2011; Wang et al., 2011; Finkelstein et al., 2012; Popkin et al., 2013; Lobstein et al., 2015). This is especially harmful in developing countries, where overweight and related non-communicable diseases are now emerging in addition to the existing problems of underweight and communicable (i.e., infectious) diseases (Bygbjerg et al., 2012; Varela-Silva et al., 2012). This ‘double burden’ of disease, in combination with often poorly developed health care systems, makes the prevention of obesity in developing countries even more urgent than in most developed countries (Maher et al., 2012; WHO Western Pacific Region, 2012; Snowdon and Thow, 2014; Lobstein et al., 2015).

However, even though governments worldwide are looking for ways to prevent overweight and obesity, few governments have so far been successful in this regard (Novak and Brownell, 2012; Trivedi et al., 2012; Roberto et al., 2015). One of the main reasons for this is that obesity is a problem with a ‘wicked’ character (Rittel and Webber, 1973). This is clarified by six characteristics (table 1.1). First of all, it is hard to formulate the exact nature of the obesity problem. For example, the ‘obesity paradox’ indicates that fit individuals who are overweight or obese are not automatically at higher risk for all-cause mortality. Therefore, it remains unclear wether obesity as measured by weight-height ratio (Body Mass Index 25) is the problem (Barry et al., 2014). Furthermore, experts often disagree about the precise causes of obesity. Some emphasize the lack of physical activity, others bad eating habits, others refer to genetic causes, and some blame the obesogenic environment. Since there are many possible explanations for obesity and individuals have different perceptions of obesity, the proposed solutions also vary.

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