Initiative | Key findings from literature and supporting references |
A.Theory of change | |
Food labels (Chile) | Front of package (FOP) labels are postulated to work by providing consumers with additional information about contents of the food or beverage thereby encouraging them to choose the healthier option.33 It is also said to work at the industry level by encouraging manufacturers to improve their food and beverage items.34 |
Healthy food (New York City NYC) | Provision of information about calories will inform decision-making about food purchases.35 Adverse health effects of trans fats have been demonstrated.63 Cap on the size of sugary beverages sold changes choice architecture which means knowledge about caloric intake is less relevant;36 people eat more from bigger containers even if not hungry and food not palatable.37 |
COVID-19 Alcohol sales and transport ban (South Africa) | Alcohol use associated with undermining of social distancing and compromising immune response.22 38 |
Vision Zero road safety (Sweden) | Vision Zero is based on the ideas that responsibility for road safety is not limited to the actions of road users; it is also a responsibility of system operators: “tradition and road traffic rules for the road users have been used as an excuse for not undertaking necessary system changes and modifications” (p. 2) … “It is human to make mistakes, and we must design for the human as we are, not the perfect human that in reality does not exist” … (p. 4). System modifications, for example, airbags and road safety barriers, are designed based on strategies to “control, harness, reduce, cushion, or redirect harmful kinetic energy”, which was described as a key contributor to road traffic injury and death as far back as 1970.64 Ways of holding road users accountable through road laws such as speed and alcohol limits are well understood. The theory of change for system designers is similar, but based on formal regulations and road safety standards, for example, mandating airbags in car manufacturing.39 |
ThaiHealth (Thailand) | Social marketing is combined with strategically networked advocacy partnerships to promote both awareness-raising and behaviour change—based on the realisation that awareness alone is not sufficient for behaviour change; a conducive environment is also required.19 |
B. Effectiveness | |
Food labels (Chile) | There is evidence to suggest FOP labels change food at the system level by encouraging industry through reformulation of products.40 There is also evidence to suggest consumer’s knowledge is changed by the use of FOP.41 Little evidence for the ongoing effects of FOP on consumer behaviour.34 In Mexico, consumers were mistrusting of the labels.65 |
Healthy food (NYC) | Some evidence that people who see calorie labels purchase less calories.35 66 However, awareness and impact may wane over time67 and interpretation of meaning of messages may be difficult.68 Mixed evidence re labelling and BMI69 70 and impact on ordering.71 72 Restriction on the use of trans fats led to lower hospital admissions for heart attacks.42 Cap on the size of sugary beverages sold appeared to lower consumption when in place.73 |
COVID-19 Alcohol sales and transport ban (South Africa) | 80% decrease in rapes and aggravated assaults,43 halving of the unnatural death rate,44 reduction on trauma admissions especially violence related.74 75 Reduced consumption, but not in problem drinkers.45 |
Vision Zero road safety (Sweden) | ‘2+1’ roads (standard 2-lane road is converted to three lanes to create an overtaking lane which alternates every few kilometres, with the two directions separated by a physical barrier)76 reduced risk of fatality by 80%.77 Lowering speed limits has been shown to reduce fatalities.46 78 Reduction in road deaths per 100 000 people from 6 to 4.7 in the decade following implementation of Vision Zero.46 Where large-scale attempts to implement design principles have been made, fatalities can be reduced by up to 90% compared with 2%–3% reduction in areas where no such improvements have been made.46 The Decade of Action for Road Safety 2011–2020 aimed to stabilise, then reduce the global number of road fatalities. Although global road deaths are below the 1.9 million in a ‘no action’ scenario, these aims were not met.79 |
ThaiHealth (Thailand) | Decrease in smoking prevalence from 25.47% to 19.94%; 13% decrease in alcohol consumption; alcohol free Buddhist lent period led to 20% reduction in road accidents from drunk driving; road safety return on investment 130.2 baht for each 1 baht invested.19 |
C. Spread | |
Food labels (Chile) | Other countries have followed Chile’s use of FOP labels—Peru, Uruguay and Mexico; Australia uses a star image system.47 |
Healthy food (NYC) | Calorie labelling laws spread to other states, cities and countries following their introduction in NYC.35 80 Restriction on the use of trans fats has been adopted in >40 countries.42 |
COVID-19 Alcohol sales and transport ban (South Africa) | Other countries that instituted pandemic-associated alcohol restrictions included India, Nepal, Slovenia, India and Thailand29 Georgia, Greenland and Russia.30 |
Vision Zero road safety (Sweden) | Vision Zero approach has been adopted across many countries including Norway, Australia, New Zealand, Poland, UK, Germany, USA and India. However, implementation is in various stages and implementation challenges have been reported, for example, political commitment and funding.48 81 |
ThaiHealth (Thailand) | ThaiHealth has supported establishment of similar organisations in Malaysia, South Korea, Mongolia and Tonga; there is an International Network of Health Promotion Foundations further reflecting global spread—Austria, Taiwan as well as the above countries.19 |
D. Implementation considerations | |
Food labels (Chile) | Villalobos Dintrans20 notes barriers including involving multiple stakeholders, political changes and the process undertaken to define the law (lack of legal precedent). The law faced challenges from the food and advertising industries due to potential impacts on profits. This was countered by arguments spotlighting the need for drastic changes to affect change and reduce the prevalence of obesity in children. Practical lessons learnt through the process included separate consideration of the law vs the implementation; enabling time for consensus; strategic alliances; and broad goal setting. |
Healthy food (NYC) | Calorie Labelling in food service outlets: consider complementary strategies56 such as altering portion size and meal composition57 state and health departments ultimately succeeded after two legal challenges49 consider unintended consequences, for example, value for money for calories82 Restriction on the use of trans fats: Consider the need for health education programmes about trans fats54 55 including nutrition recommendations; awareness campaigns and voluntary / mandated labelling;83 freedom of choice argument50 Cap on the size of sugary beverages sold; Soda taxes have been opposed successfully in a number of US states; positive messaging better than negative campaigns;37 freedom of choice arguments61 84 can be circumvented, for example, free refills.32 |
COVID-19 Alcohol sales and transport ban (South Africa) | Raised awareness of the impact of alcohol on the community—trauma, domestic violence22 Unanticipated outcomes need consideration—alcohol withdrawal syndrome, including associated suicide; illegal home brewing/black market, looting, death from alcohol toxicity29 30 44, less informal alcohol trade=other income needed22 Industry opposition and lobbying need managing22 Consider employment/tourism implications on alcohol bans26 74 Given bans not sustainable, consider other measures, for example, excise taxes, minimum unit pricing, impactful health warnings, purchase limits; ban on the marketing of alcohol51 Other factors influencing alcohol use during COVID-19 closure of hospitality, belief that alcohol is therapeutic for COVID-1985 |
Vision Zero road safety (Sweden) | Distributing road safety responsibility beyond road users to system designers is complex28 and influenced by other government efforts (eg, information campaigns around car safety ratings/benchmarking) and external factors (eg, European Union directives)39 Facilitators21 include innovative thinking; institutionalised into policy with sustainable ongoing funding, demonstrated impact in Sweden; road safety education; shared commitment to goals across multiple agencies and stakeholders; and strong gov leadership, coordination and buy-in21 |
ThaiHealth (Thailand) | Strategic alliances more effective than isolated initiatives19 The Thai Public Broadcasting Service created a means of broadcasting health promotion efforts19 Four key ingredients of success—sustainable funding; strategic multisectoral approach; cutting-edge innovations; proficiency in policy advocacy and social marketing19 Independence from government bureaucracy enables efficient partnerships with others19 |
BMI, body mass index.