Healthy Public Policy Options to Promote Physical Activity for Chronic Disease Prevention: Understanding Canadian Policy Influencer and General Public Preferences

in Journal of Physical Activity and Health

Background: Attitudes and beliefs of policy influencers and the general public toward physical activity policy may support or impede population-level action, requiring improved understanding of aggregate preferences toward policies that promote physical activity. Methods: In 2016, the Chronic Disease Prevention Survey was administered to a census sample of policy influencers (n = 302) and a stratified random sample of the public (n = 2400) in Alberta and Québec. Using net favorable percentages and the Nuffield Council on Bioethics’ intervention ladder framework to guide analysis, the authors examined support for evidence-based healthy public policies to increase physical activity levels. Results: Less intrusive policy options (ie, policies that are not always the most impactful) tended to have higher levels of support than policies that eliminated choice. However, there was support for certain types of policies affecting influential determinants of physical activity such as the built environment (ie, provided they enabled rather than restricted choice) and school settings (ie, focusing on children and youth). Overall, the general public indicated stronger levels of support for more physical activity policy options than policy influencers. Conclusions: The authors’ findings may be useful for health advocates in identifying support for evidence-based healthy public policies affecting more influential determinants of physical activity.

Physical inactivity is a leading risk factor for global mortality1 and contributes to the development of chronic diseases including obesity, diabetes, cardiovascular and respiratory illnesses, and cancers.13 In Canada, 80% of adults do not meet the recommended 150 minutes of physical activity per week.4 Similarly, only approximately 7% of 5- to 19-year-olds meet the physical activity recommendations outlined in the Canadian 24-Hour Movement Guidelines for Children and Youth.5 Given the high prevalence of physical inactivity among Canadians across all age groups, it is not surprising that 1 in 5 adults are now living with a chronic disease.6 From an economic perspective, it is estimated that the total burden of chronic disease attributable to physical inactivity in Canada was $6.8 billion in 2009.3

Many experts in the field of physical activity have advocated that actions on the environmental (eg, natural/built) and policy (eg, regulation/legislation) determinants of physical activity are the 2 most promising strategies to promote physical activity at the population level.7,8 Policy influencers (eg, those who are in a position of authority or “with influence in multiple policy arenas,”9(p1684)) are the primary gatekeepers in turning these recommendations into action. Policy influencers are faced with a number of significant questions during the policy-making process, including the normative task of assessing acceptability among different policy interventions.1,10 Most commonly, the acceptability of policy interventions has been conceptualized according to the extent of their intrusiveness on individual autonomy.11,12 Policy influencers in Western countries with strong market economies have been shown to subscribe to this concept of acceptability,13 leading to the development of tools such as the Nuffield Council on Bioethics’ (NCB) intervention ladder14 framework to categorize public health interventions according to their effect on individual autonomy. As policy influencers ultimately determine whether healthy public policies are enacted, it is essential for chronic disease prevention advocates to understand policy influencers’ preferences for the acceptability of various means in promoting population-level physical activity. Similarly, it is essential that advocates further understand preferences for the acceptability of interventions among the public, as they are the constituents of elected policy influencers and who otherwise form the community base.

Previous research exploring policy influencers and general public support for population-level physical activity policy has focused on specific physical activity policy options,1517 barriers to the consideration of physical activity,18 and understanding different viewpoints on the responsibility for certain risk behaviors associated with obesity including physical activity.19 Support for specific physical activity policy options has included exploring public support for active transportation policies including public bike share programs,15 correlates of perceived workplace support for physical activity among employees,16 and public support for urban design practices and policies to increase physical activity.17 Other research has studied perceived barriers to consideration of physical activity in community planning and design among policy makers at the municipal level.18

The challenge for chronic disease prevention advocates working in the physical activity domain is that they have limited research to draw on in evaluating the intervention preferences of both policy influencers and the public simultaneously across a wide variety of policy options.11 To address this challenge, our research explored the following question: To what extent do members of the general public and policy influencers in Alberta and Québec support population-level policies to promote physical activity? To assess levels of support in 2 distinct Canadian provinces, we used the Chronic Disease Prevention Survey (described in the following section). Our analysis was guided to further assess the acceptability of these policies using the “NCB intervention ladder” framework.

Methods

The Chronic Disease Prevention Survey

The Chronic Disease Prevention Survey was first implemented in 20099,19 and subsequently in 2010, 2011, 2014, and 2016.20 The aim of this survey is to understand the knowledge, attitudes, and beliefs around healthy public policy among policy influencers and the public, focusing on population-level chronic disease prevention of 4 modifiable risk factors: physical inactivity, unhealthy eating, tobacco use, and excessive alcohol consumption. The complete survey consists of 6 components including (1) perspectives on the causes of chronic disease, (2) views on health promotion, (3) responsibility for programmatic and policy action, (4) support for policy approaches, (5) understanding the provincial/territorial environment, and (6) demographics. This current analysis specifically explores 29 measures in the 2016 Chronic Disease Prevention cross-sectional survey related to support for evidence-based healthy public policies for increasing physical activity at the population level. This study was approved by the Research Ethics Office (Research Ethics Board 2) at the University of Alberta.

Sample

Policy influencers and the public in Alberta and Québec were invited to participate in the survey in the summer of 2016. They were selected from Alberta and Québec because of the unique demographic differences between these provinces. Alberta is a western Anglophone province with higher household income levels due to work in extractive industries, whereas Québec is an eastern francophone province. These differences increase the diversity of the sample and are more reflective of a Canadian perspective. The complete instrument (ie, with 29 policies specific to physical activity) was administered to a census sample of policy influencers through an online survey. The introductory page of the survey outlined important ethics information including confidentiality measures and the voluntary nature of participation. Consent to participate was implied by continuing on to complete the survey. The policy influencer survey was estimated to take a maximum of 30 to 40 minutes to complete. For the purposes of the census sample, we defined policy influencers as all provincial members of legislative assembly in Alberta and national assembly in Québec, as well as deputy ministers at any rank; mayors and reeves, as well as senior administrative officials in municipal settlements; senior executives in workplaces with more than 500 employees; school board trustees; and print media editors and health reporters. For the general public, a smaller subset of the instrument (ie, with 13 of the 29 policies specific to physical activity) was administered through a stratified random-digit-dialed telephone survey conducted through a public opinion polling and communication research firm. The computer-assisted telephone interviewer informed potential participants that their participation was voluntary and asked for consent to administer the survey over the telephone. The general public survey was estimated to take a maximum of 20 to 25 minutes to complete. The public were sampled to mirror an equal distribution of gender, the age structure in each province, and a set proportion of urban versus rural residents. For both sample groups, there was no incentive, financial or otherwise, to participate.

Study Measures

We asked survey participants to rank their support for evidence-based healthy public policies to promote physical activity levels using a 4-point Likert-style scale measuring opposition versus support (1 = strongly oppose, 2 = oppose, 3 = support, and 4 =strongly support). All policies included in the survey were vetted as being evidence based by expert members of the Alberta Policy Coalition for Chronic Disease Prevention who worked in the field of physical activity. In Alberta, the survey response rate among policy influencers and the general public was 10.2% and 8.0%, respectively, whereas in Québec, the response rate for these same 2 samples was 3.0% and 6.0%. The percentage of missing data among the policy influencer sample ranged between 21.5% and 36.4%, whereas the percentage of missing data among the general population sample ranged between 0.2% and 1.5%.

Data Analysis

Survey responses were aggregated and analyzed by deriving the net favorable percentage (NFP) for each healthy public policy option among both policy influencers and the public, within and between provinces. NFPs have the advantage of being easily interpretable (ie, positive NFPs are favorable, whereas negative NFPs are unfavorable). The NFP was calculated as:

NFP=quotient of favorable responsesquotient of unfavorable responsestotal responses.
Furthermore, as NFPs are descriptive statistics, we used Roselius21 7 categories to qualitatively interpret preference levels based on NFP scores (see Table 1).

Table 1

Roselius21(p58) Qualitative Definition of Favorability Level Based on Net Favorable Percentages (NFPs)

Range of NFPQualitative definition
+100.0 to +71.5Extremely favorable
+71.4 to +42.9Very favorable
+42.8 to +14.3Slightly favorable
+14.2 to −14.1Neutral
−14.2 to −42.7Slightly unfavorable
−42.8 to −71.3Very unfavorable
−71.4 to −100.00Extremely unfavorable

To facilitate further interpretation of our findings, we coded each of the physical activity policy options according to the highly cited intervention ladder framework for public health interventions proposed by the NCB. The 8-step NCB intervention ladder can be used to classify the level of “intrusiveness” of different policy interventions to improve population-level health. These levels, from least to most intrusive, include 0—“do nothing or simply monitor the current situation,” 1—“provide information,” 2—“enable choice,” 3—“guide choices through changing the default policy,” 4—“guide choices through incentives,” 5—“guide choice through disincentives,” 6—“restrict choice,” and 7—“eliminate choice.”14 Importantly, the NCB intervention ladder framework facilitated interpretation of our findings by assessing levels of support for population-level interventions to promote physical activity according to the acceptability preferences of survey respondents. Three research assistants used a codebook22 developed by our team to independently characterize the level of intrusiveness for each physical activity population health policy option. In cases requiring clarification of categorization or disagreements, a fourth senior research analyst coded the policies and helped to reach consensus.

Results

Description of Samples

Demographic profiles of the policy influencer and public samples are presented in Table 2. In total, 302 policy influencers responded to the online survey (174 participants from Alberta and 128 participants from Québec), whereas 2400 members of the general public took part in the telephone survey (1200 from each province). The vast majority of policy influencer respondents in both Alberta and Québec were male (70.9% and 67.6%, respectively), aged 46 years or older, and in a hired position. In Alberta, a higher percentage of public respondents had a household income of ≥$70,000 than Québec (63.4% compared with 47.2%).

Table 2

Demographics of General Public and Policy Influencer Respondent Samples From the 2016 Chronic Disease Prevention Survey in Alberta and Québec, Canada (Valid Percent)

General publicPolicy influencers
Alberta (n)%Québec (n)%Alberta (n)%Québec (n)%
Gender
 Male(591) 49.2(560) 46.7(107) 70.973 (67.6)
 Female(609) 50.8(640) 53.3(44) 29.135 (32.4)
Age, y
 18–45(390) 32.9(415) 34.8(15) 9.6(28) 25.7
 >46(797) 67.1(776) 65.2(141) 90.4(81) 75.3
Household Income
 <$70,000(383) 36.6(564) 52.8
 ≥$70,000(663) 63.4(504) 47.2
Education
 Up to postsecondary(244) 20.5(224) 18.8
 Postsecondary(944) 79.5(966) 81.2
Sector
 Provincial government(30) 19.2(11) 10.2
 Municipal authority(38) 24.4(60) 55.6
 Workplace(36) 23.1(26) 24.1
 School board(23) 14.7(4) 3.7
 Media(10) 6.4(3) 2.8
 Other(19) 12.2(4) 3.1
Nature of position
 Elected(39) 24.5(35) 31.8
 Appointed(18) 11.3(13) 11.8
 Hired(98) 61.6(57) 51.8
 Other(4) 2.5(5) 3.9

Intervention Ladder Categorization of Healthy Public Policies to Promote Physical Activity

The majority of healthy public policy options to promote physical activity from the full survey were categorized as policies that “enabled choice” (13/29 or 44.8%). Policies that were categorized as “eliminating choice” were the least common (2/29 or 6.9%). There were no policy options, in this analysis, that fell under intervention ladder levels related to “guiding choices through changing the default policy” or “guiding choice through disincentives.” We found a wide range of support within each intervention ladder category. For example, among policy influencer respondents, policy options categorized as “eliminating choice” had support ranging from “extremely favorable” (NFP = 81.3) to “neutral” (NFP = 7.0). Tables 3 and 4 present the complete NFPs of physical activity–related policy options for Alberta and Québec policy influencers and general public, respectively.

Table 3

Net Favorable Percentage (NFP) of Physical Activity-Related Policy Options Among Alberta and Québec Policy Influencers

Alberta and Québec (n = 302)Alberta (n = 174)Québec (n = 128)
Policy optionsIntervention ladderNFPRoselius qualitative definition of favorabilityMissing (%)NFPMissing (%)NFPMissing (%)
Provide programs to educate the general public about the importance of regular physical activity(1) Provide information94.0Extremely favorable33.895.16.389.271.1
Fund media campaigns to educate the public about reducing sedentary behaviors(1) Provide information82.7Extremely favorable31.182.39.284.060.9
Fund media campaigns to educate the public about increasing physical activity(1) Provide information81.6Extremely favorable31.881.47.582.264.8
Encourage schools to reduce sitting time among students and staffa(1) Provide information76.7Extremely favorable28.879.69.869.054.7
Fund media campaigns to educate the public about using an active transportation (walking, cycling, public transit)a(1) Provide information73.0Extremely favorable33.870.510.381.865.6
Develop sedentary behavior guidelines for adults (currently there are only guidelines for children and youth)(1) Provide information65.9Very favorable26.267.511.562.346.1
Fund media campaigns to promote parents’ use of screen-time guidelines for all children <18 y, including toddlersa(1) Provide information63.2Very favorable26.259.78.671.950.0
Improve opportunities for physical activity through neighborhood revitalization programs(2) Enable choice89.8Extremely favorable34.890.16.988.672.7
Enhance the quantity and quality of green spaces in all neighborhoods(2) Enable choice89.2Extremely favorable32.588.87.590.766.4
Ensure adequate maintenance of active transportation infrastructure in communities (sidewalk repair, snow removal, bike lane painting)(2) Enable choice89.0Extremely favorable33.887.67.594.969.5
Provide more high quality resources to support the implementation of physical education school curriculum(2) Enable choice88.8Extremely favorable34.888.88.089.271.1
Promote safe active transportation to school through walk or cycle-to-school programs, crossing patrols, and school attendance confirmation(2) Enable choice87.3Extremely favorable32.587.76.985.767.2
Implement active transportation policies designed to promote walking through safe routes, adequate lighting, etc(2) Enable choice87.2Extremely favorable32.888.88.081.466.4
Invest in public transit to improve frequency, routes, and scheduling(2) Enable choice76.9Extremely favorable31.178.110.973.658.6
Provide incentives for workplaces to provide access to physical activity facilities for workers(2) Enable choice76.2Extremely favorable30.577.29.273.159.4
Ensure municipalities establish minimum standards for health promoting environments that developers need to address(2) Enable choice75.6Extremely favorable32.174.210.980.060.9
Provide incentives for workplaces to implement physical activity policies for workers(2) Enable choice74.1Extremely favorable33.474.410.373.364.8
Implement active transportation policies designed to promote bicycling through bike lanes, cycle facilities, multimodal transit, secure storage for gear, etc.(2) Enable choice74.0Extremely favorable33.873.49.276.267.2
Provide incentives for workplaces to reduce extended sitting time among their employees (eg, standing desks, walking meetings, active transportation)(2) Enable choice65.6Very favorable28.866.99.862.154.7
Modify bylaws to allow the safe use of sporting equipment (hockey and soccer nets) in municipal streets(2) Enable choice56.1Very favorable29.151.312.667.751.6
Provide monetary incentives (eg, reduced insurance premiums) for people who are involved in regular physical activity(4) Guide choices through incentives74.1Extremely favorable28.574.59.872.953.9
Subsidize programs for those who cannot afford to participate in organized physical activitiesa(4) Guide choices through incentives72.6Extremely favorable29.869.49.881.857.0
Provide tax credits for people who are involved in regular physical activity(4) Guide choices through incentives62.9Very favorable32.163.611.560.860.2
Remove sales taxes on all physical activity equipment(4) Guide choices through incentives61.4Very favorable31.563.19.856.060.9
Mandate daily physical activity in all schools (30 min of moderate to vigorous exercise)(6) Restrict choice80.4Extremely favorable35.881.09.277.871.9
Mandate daily physical activity in all preschools (180 min at any intensity spread throughout the day including 60 min of energetic play)(6) Restrict choice76.0Extremely favorable33.876.611.573.964.1
Implement skip-stop elevators that do not stop on every floor to encourage stair climbing (except special use only, eg, persons with a disability or persons with strollers)a(6) Restrict choice7.2Neutral21.5−6.713.831.032.0
Make physical education mandatory for all students (K–12)(7) Eliminate choice81.3Extremely favorable36.480.810.383.371.9
Ban all traffic in high-use pedestrian areas during peak hours to support active transportation (eg, walking, cycling) or public transportationa(7) Eliminate choice7.0Neutral24.5−4.612.130.741.4

aQualitatively different levels of support between policy influencer respondents in Alberta and Québec.

Table 4

Net Favorable Percentage (NFP) of Physical Activity–Related Policy Options Among the Alberta and Québec General Public

Alberta and Québec (n = 2400)Alberta (n = 1200)Québec (n = 1200)
Policy optionsIntervention ladderNFPRoselius qualitative definition of favorabilityMissing (%)NFPMissing (%)NFPMissing (%)
Provide programs to educate the general public about the importance of regular physical activity(1) Provide information92.5Extremely favorable0.288.60.496.30.0
Encourage schools to reduce sitting time among students and staff(1) Provide information85.1Extremely favorable1.582.41.787.81.3
Ensure adequate maintenance of active transportation infrastructure in communities (sidewalk repair, snow removal, bike lane painting)(2) Enable choice95.6Extremely favorable0.792.81.098.30.3
Enhance the quantity and quality of green spaces in all neighborhoods(2) Enable choice94.7Extremely favorable0.691.61.197.80.1
Implement active transportation policies designed to promote walking through safe routes, adequate lighting, etc.(2) Enable choice94.5Extremely favorable0.592.30.696.70.3
Promote safe active transportation to school through walk or cycle-to-school programs, crossing patrols, school attendance confirmation(2) Enable choice92.8Extremely favorable1.091.71.493.80.7
Invest in public transit to improve frequency, routes, and scheduling(2) Enable choice88.1Extremely favorable1.383.02.093.10.5
Provide incentives for workplaces to provide access to physical activity facilities for workers(2) Enable choice86.5Extremely favorable0.381.30.391.60.3
Implement active transportation policies designed to promote bicycling through bike lanes, cycle facilities, multimodal transit, secure storage for gear, etc.(2) Enable choice85.6Extremely favorable1.076.31.694.80.4
Provide incentives for workplaces to reduce extended sitting time among their employees (eg, standing desks, walking meetings, active transportation)(2) Enable choice81.3Extremely favorable1.376.21.486.51.2
Provide tax credits for people who are involved in regular physical activitya(4) Guide choices through incentives65.8Very favorable1.056.30.975.41.0
Mandate daily physical activity in all schools (30 min of moderate to vigorous exercise)(6) Restrict choice92.4Extremely favorable0.589.10.495.60.6
Make physical education mandatory for all students (K–12)(7) Eliminate choice90.7Extremely favorable0.786.70.894.60.7

aQualitatively different levels of support between general public respondents in Alberta and Québec.

Comparing Levels of Support

Policy Influencers and the General Public

Policy influencers and the general public in both Alberta and Québec were “extremely favorable” toward the majority of population-level policy options designed to promote physical activity (72.4% [21/29] and 92.3% [12/13], respectively). However, public respondents had stronger support for policy options across intervention ladder categories. For example, the public had an NFP of ≥90.0 for 7/13 policy options compared with only 1/29 policy options for policy influencers.

Interestingly, the most and least supported policy options to promote physical activity differed between the policy influencer and public respondents. The highest supported policy option among policy influencer respondents was “providing programs to educate the general public about the importance of regular physical activity” (NFP = 94.0). By contrast, the policy option that received the most support among respondents from the general public was “ensuring adequate maintenance of active transportation infrastructure in communities” (NFP = 95.6). The policy options that were the least supported among policy influencers either “restricted choice” (ie, “implementing skip-stop elevators that do not stop on every floor to encourage stair climbing”) or “‘eliminated choice” (ie, “banning all traffic in high-use pedestrian areas during peak hours to support active transportation”). By contrast, the least favorable policy option among general public respondents was a policy that “guided choices through incentives” (ie, “providing tax credits for people who are involved in regular physical activity”).

Alberta and Québec

Overall, levels of support for policy options to promote physical activity among both policy influencers and the general public respondent samples were similar between the provinces of Alberta and Québec (ie, NFPs were in the same categorical qualitative range). However, there were 6 policy options where support among policy influencer respondents differed between provinces (differences indicated with a “a” under policy options in Table 3). For example, policy influencers in Québec were “slightly favorable” (NFP = 30.7) toward the policy option “banning all traffic in high-use pedestrian areas during peak hours to support active transportation” (an option targeting the built environment), whereas policy influencers in Alberta were “neutral” (NFP = −4.6). By comparison, there was less variation in levels of support between public respondents from Alberta and Québec. For example, the only policy option that had differing levels of support between Alberta and Québec was “providing tax credits for people who are involved in regular physical activity” (as indicated by a “a” in Table 4). In this example, support among the public in Québec was stronger than in Alberta.

Discussion

Our findings from the 2016 Chronic Disease Prevention Survey provide an important insight into the acceptability of evidence-based policy options to promote physical activity among Canadian policy influencers and the general public. We found that the policy influencer and public respondents were “extremely” or “very favorable” toward many evidence-based recommendations to promote physical activity echoed in the key Canadian practice and policy reports, suggesting a readiness for policy action. For example, participants in our survey supported various recommendations found in the 2016 Obesity in Canada: A Whole-of-Society Approach for a Healthier Canada report of the Standing Senate Committee on Social Affairs, Science, and Technology,23 including implementing a comprehensive public awareness campaign on healthy active lifestyles (NFPs = 92.5 and 94.0, for policy influencers and public, respectively). Policy influencers and members of the public in our survey were also “very favorable” toward fiscal policies to promote physical activity, another focus of the Senate Report.23 For instance, members of public and policy influencers were overall very supportive of “providing tax credits for people who are involved in regular physical activity,” whereas policy influencers were overall extremely supportive of “subsidizing programs for those who cannot afford to participate in organized physical activities.”

Recommendations to address the built environment as part of a socioecological approach to promoting physical activity have been highlighted in many practice and policy documents, in addition to our survey. For example, the 2018 A Common Vision for Increasing Physical Activity and Reducing Sedentary Living in Canada report24 recommended a variety of policies targeting the built environment, including active transportation solutions (eg, improving bike routes or providing bike storage). Other recommendations centered around ensuring wrap-around supports to encourage physical activity, for example, ensuring there is bicycle or bus access to a new swimming pool and providing incentives for people to drive less.24 Another positive finding from our survey indicated “extremely favorable” support among both policy influencers and the public toward built environment policies that enabled choice (ie, implementing active transportation policies designed to promote walking through safe routes, adequate lighting, etc). However, policy influencer respondents were far less supportive of built environment policies that “eliminated choice” (ie, “banning all traffic in high-use pedestrian areas during peak hours to support active transportation”). These findings are consistent with previous research demonstrating that support tends to be higher for interventions that are less intrusive, although this is not always the case.11 Yet, our findings suggest that there is also a meaningful support for policies that are higher on the intervention ladder (ie, more intrusive), in particular, those policies that “enable choice.”

Overall, the recommendations outlined in these key practice and policy reports,5,23 of which we have only highlighted a sample, emphasize that an ecological approach (eg, targeting individual, community, organizational, and policy levels) is essential to future directions in promoting physical activity. We found that the policy influencer and general public respondents echoed support for an ecological approach to promoting physical activity outlined in these reports.

When comparing general public and policy influencer respondent groups, we found that there was generally more consistency in preference among survey respondents from the public between Alberta and Québec than policy influencer respondents (ie, policy influencers between provinces had different levels of support for 6/29 policy options compared with 1/13 among members of the public). This suggests that there may be a more unified perspective at the general population level between the 2 provinces than the policy influencer level, although additional provinces would have to be surveyed to further assess whether this is the case. Despite these differences, a recent review on the application of the ecological approach on the promotion of physical activity also found that over a 2 decade period (1980s–2000s), there has been an increasing trend toward interventions focused on physical activity addressing multiple targets and reaching higher levels of influence (ie, community and/or political targets).25 Interventions that focus on lower levels of influence have been generally shown to be less effective.11

Interestingly, both respondent groups were favorable to policy options categorized across a range of different levels on the NCB intervention ladder. Although support among policy influencers was strong for policies that “provided information,” there was also “extremely favorable” support for policy options at higher “restrict” and “eliminate choice” levels. For example, “making physical education mandatory for all students (K–12)” received strong support among policy influencers (NFP = 81.3). Our results reinforce findings in the literature that level of intrusiveness is only one factor that influences the acceptability of policy interventions.11 Other factors include whether the intervention had already been implemented, characteristics of the respondent, and the target population for the intervention.11 This latter factor may explain why the policy influencer and general public respondents in our survey were “extremely” or “very supportive” of more restrictive policies when the target population was children and/or youth.

We found that using the NCB intervention ladder was a valuable framework to interpret policy influencers’ and the general public’s preferences for policy options to promote physical activity based on policy “intrusiveness”; however, there is limited and sometimes conflicting literature on how to interpret the various steps on the ladder. We addressed these concerns by developing a detailed codebook22 to increase transparency of the process, which other researchers may find useful.

Strengths, Limitations, and Future Directions

Although we used the highly cited NCB intervention ladder as a framework to interpret our survey findings, we recognize that it may have certain limitations. For example, Griffiths and West12 challenge the assumption underpinning the NCB intervention ladder that personal autonomy is the best maximized by nonintervention. These authors make the case for a “balanced intervention ladder,” based on a positive freedom view of autonomy in which interventions can also increase autonomy.12 It may be the case that survey participants in our study were supportive of policies that “enabled choice” because they interpreted these types of interventions as enhancing rather than limiting individual autonomy. Despite these known challenges of using the Nuffield interventional ladder, we opted for this framework as it has been widely applied,11,2628 which allowed us to further interpret our study results within the broader literature.

Other potential limitations of this current study include the use of a cross-sectional survey design and low response rates among the policy influencer sample, which may implicate self-selection bias. Despite this limitation, the overall sample size is comparable with similar studies of this nature.26,29,30 Furthermore, the demographic profile of policy influencer respondents in our survey (eg, skewed toward older age and male) mirrors the demographic profile of policy leaders in Canada more generally.31,32 Although we also had a relatively low response rate for members of the general public, participants were selected to mirror the demographic profiles found within each province. In addition, as both policy influencers and members of the public completed the survey using different modalities (ie, online vs telephone), it would be valuable to assess the impact of these different modalities, as well as the relative differing lengths of the surveys, in future research.

One of the major contributions of this study is that to the best of our knowledge, very few studies to date have focused on the policy influencer and public acceptability of population-level policies specifically targeting physical activity.11 Given that physical inactivity is a key behavioral risk factor for chronic disease, our survey findings address a gap in the literature and provide richer insight into the acceptability of interventions specifically focused on physical activity. Health advocates may find the results of this survey useful in identifying which policy options may be “quick wins” among policy influencers, to begin to build momentum and take action on promoting physical activity. This survey also allowed us to examine support for the same policy items across different types of policy influencers and the general public and compare across sample groups. In particular, policy influencers working in an elected position who depend on the support of their constituency may find that understanding the general public’s attitudes toward the acceptability of interventions will be particularly valuable in the policy decision-making process. Another strength of this survey is the range of policy options included in the survey, both within the physical activity domain and across other chronic disease prevention risk factors (eg, unhealthy eating, tobacco misuse, and alcohol consumption). Although not assessed within this current study, the Chronic Disease Prevention Survey provides the ability to examine support for physical activity items relative to other chronic disease prevention policy options (reported elsewhere9,19).

We also identified a number of future directions for the Chronic Disease Prevention Survey. For instance, it would be valuable to explore whether survey participants’ physical activity levels impact the level of support for healthy public policies to promote physical activity. Similarly, it would be useful to assess whether current policy action related to promoting physical activity had an influence on survey participants support levels (eg, if a policy item is being discussed in the media, would that impact levels of support?). Finally, a pan-Canadian Chronic Disease Prevention Survey, assessing levels of support in all provinces and territories, would be beneficial in terms of understanding support for healthy public policies to promote physical activity from a Canadian perspective.

Conclusions

Physical inactivity is a major contributor to the increasing burden of chronic disease in Canada. There is increasing evidence that healthy public policies are an effective strategy to promote physical activity at the population level.7,8,33,34 Ultimately, it is policy influencers who have the power to adopt these policies. Furthermore, in the case of both elected officials and leaders in large workplaces and the media, preferences toward adopting such policies to promote population-level physical activity are influenced by attitudes of the general public. Findings from the Chronic Disease Prevention Survey address a gap in the literature and help to illuminate policy influencer and public attitudes toward healthy public policy options to promote physical activity in Alberta and Québec. Overall, we found that there was strong public support for population-level policies to promote physical activity. Health advocates may be able to use this evidence to encourage policy influencers to take action on promoting physical activity. Not surprisingly, we also found that support was strong among policy influencers and general public respondents for policy options that only “provided information.” However, there were also meaningful levels of support for more effective policies that are higher on the NCB intervention ladder (ie, policies that “enable choice”). Similarly, these findings identify specific policy option areas, where there is already a strong support. This knowledge can help to strategically focus health advocacy efforts by tackling some of these “quick wins” early on as a means to build momentum for long-term action. Although our findings suggest an increasing willingness to focus on higher levels of the ecological model, there is still a need for additional knowledge translation by chronic disease prevention researchers, practitioners, and policy advocates to better communicate the impacts of more effective policy options higher on the NCB intervention ladder to policy influencers in Canada.

Acknowledgments

The authors wish to acknowledge Hannah Faye Mercader for assistance in developing the codebook and analyzing the data. Funding was provided by the Canadian Partnership Against Cancer (CPAC) as part of the Coalitions Linking Action and Science for Prevention (CLASP) initiative. Candace I.J. Nykiforuk received support as an Applied Public Health Chair from the Canadian Institutes of Health Research in partnership with the Public Health Agency of Canada and Alberta Innovates - Health Solutions (2014–2019; CPP 137909). The authors declare that they have no competing interest.

References

  • 1.

    World Health Organization. Physical Activity: Fact Sheet. 2017; http://www.who.int/mediacentre/factsheets/fs385/en/. Accessed November 10, 2017.

    • Search Google Scholar
    • Export Citation
  • 2.

    Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801–809. PubMed ID: 16534088 doi:10.1503/cmaj.051351

  • 3.

    Janssen I. Health care costs of physical inactivity in Canadian adults. Appl Physiol Nutr Metab. 2012;37(4):803–806. PubMed ID: 22667697 doi:10.1139/h2012-061

  • 4.

    Statistics Canada. Canadian Health Measures Survey: Directly Measured Physical Activity of Canadians, 2012 and 2013. 2015; http://www.statcan.gc.ca/daily-quotidien/150218/dq150218c-eng.pdf?. Accessed November 10, 2017.

    • Search Google Scholar
    • Export Citation
  • 5.

    ParticipACTION. Are Canadian kids too tired to move? The 2016 ParticipACTION report card on physical activity for children and youth. 2016; https://www.participaction.com/sites/default/files/downloads/2016%20ParticipACTION%20Report%20Card%20-%20Full%20Report.pdf. Accessed November 10, 2017.

    • Search Google Scholar
    • Export Citation
  • 6.

    Public Health Agency of Canada. How Healthy are Canadians? A Trend Analysis of the Health of Canadians from a Healthy Living and Chronic Disease Perspective. Ottawa, Canada: Public Health Agency of Canada; 2016.

    • Search Google Scholar
    • Export Citation
  • 7.

    Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Kerr J. An ecological approach to creating active living communities. Annu Rev Public Health. 2006;27:297–322. PubMed ID: 16533119 doi:10.1146/annurev.publhealth.27.021405.102100

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Raine KD, Muhajarine N, Spence JC, Neary NE, Nykiforuk CI. Coming to consensus on policy to create supportive built environments and community design. Can J Public Health. 2012;103(9 Suppl 3):eS5–eS8. PubMed ID: 23618090

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Nykiforuk CI, Wild TC, Raine KD. Cancer beliefs and prevention policies: comparing Canadian decision-maker and general population views. Cancer Causes Control. 2014;25(12):1683–1696. PubMed ID: 25319013 doi:10.1007/s10552-014-0474-3

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Health Serv Res Policy. 2005;10(suppl. 1):6–20. PubMed ID: 16053580 doi:10.1258/1355819054308576

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Diepeveen S, Ling T, Suhrcke M, Roland M, Marteau TM. Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis. BMC Public Health. 2013;13:756. PubMed ID: 23947336 doi:10.1186/1471-2458-13-756

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Griffiths P, West C. A balanced intervention ladder: promoting autonomy through public health action. Public Health. 2015;129(8):1092–1098. PubMed ID: 26330372 doi:10.1016/j.puhe.2015.08.007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Ayo N. Understanding health promotion in a neoliberal climate and the making of health conscious citizens. Crit Public Health. 2012;22(1):99–105. doi:10.1080/09581596.2010.520692

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Nuffield Council on Bioethics. Public Health: Ethical Issues. London, UK: Nuffield Council on Bioethics; 2007.

  • 15.

    Bélanger-Gravel A, Gauvin L, Fuller D, Drouin L. Implementing a public bicycle share program: impact on perceptions and support for public policies for active transportation. J Phys Act Health. 2015;12(4):477–482. PubMed ID: 24905364 doi:10.1123/jpah.2013-0206

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Umstattd MR, Baller SL, Blunt GH, Darst ML. Correlates of perceived worksite environmental support for physical activity. J Phys Act Health. 2011;8(s2):222–227. PubMed ID: 28829701 doi:10.1123/jpah.8.s2.s222

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Carlson SA, Guide R, Schmid TL, Moore LV, Barradas DT, Fulton JE. Public support for street-scale urban design practices and policies to increase physical activity. J Phys Act Health. 2011;8(s1):S125–S134. PubMed ID: 21350253 doi:10.1123/jpah.8.s1.s125

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Goins KV, Schneider KL, Brownson R, et al. Municipal officials’ perceived barriers to consideration of physical activity in community design decision making. J Public Health Manag Pract. 2013;19(3, suppl 1):S65. PubMed ID: 23529058 doi:10.1097/PHH.0b013e318284970e

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Raine KD, Nykiforuk CIJ, Vu-Nguyen K, et al. Understanding key influencers’ attitudes and beliefs about healthy public policy change for obesity prevention. Obesity. 2014;22(11):2426–2433. PubMed ID: 25131938 doi:10.1002/oby.20860

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    PLACE Research Lab. Chronic Disease Prevention Survey [Internet]. 2015; http://placeresearchlab.com/Chronic-Disease-Prevention-Survey/. Accessed November 28, 2017.

    • Search Google Scholar
    • Export Citation
  • 21.

    Roselius T. Consumer rankings of risk reduction methods. J Mark. 1971;35(1):56–61. doi:10.1177/002224297103500110

  • 22.

    PLACE Research Lab. PLACE Research Lab Intervention Ladder Policy Analysis Framework. 2017; http://placeresearchlab.com/chronic-disease-prevention-survey/#1510675691441-561b7d9e-0277. Accessed November 15, 2017.

    • Search Google Scholar
    • Export Citation
  • 23.

    Ogilvie KK, Eggleton A. Obesity in Canada: A Whole-of-Society Approach for a Healthier Canada. Ottawa, Canada: The Standing Senate Committee on Social Affairs, Science and Technology; 2016.

    • Search Google Scholar
    • Export Citation
  • 24.

    Public Health Agency of Canada. A Common Vision for Increasing Physical Activity and Reducing Sedentary Living in Canada: Let’s Get Moving. 2018; https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/lets-get-moving/pub-eng.pdf. Accessed February 26, 2019.

    • Search Google Scholar
    • Export Citation
  • 25.

    Richard L, Gauvin L, Raine K. Ecological models revisited: their uses and evolution in health promotion over two decades. Annu Rev Public Health. 2011;32:307–326. PubMed ID: 21219155 doi:10.1146/annurev-publhealth-031210-101141

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Stok FM, de Ridder DT, de Vet E, et al. Hungry for an intervention? Adolescents’ ratings of acceptability of eating-related intervention strategies. BMC Public Health. 2016;16:5. PubMed ID: 26729328 doi:10.1186/s12889-015-2665-6

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Hillier-Brown FC, Summerbell CD, Moore HJ, et al. The impact of interventions to promote healthier ready-to-eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review. Obes Rev. 2017;18(2):227–246. PubMed ID: 27899007 doi:10.1111/obr.12479

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Haynes E, Hughes R, Reidlinger DP. Obesity prevention advocacy in Australia: an analysis of policy impact on autonomy. Aust N Z J Public Health. 2017;41(3):299–305. PubMed ID: 28371184 doi:10.1111/1753-6405.12660

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Bos C, Lans IV, Van Rijnsoever F, Van Trijp H. Consumer acceptance of population-level intervention strategies for healthy food choices: the role of perceived effectiveness and perceived fairness. Nutrients. 2015;7(9):7842–7862. PubMed ID: 26389949 doi:10.3390/nu7095370

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Li J, Lovatt M, Eadie D, et al. Public attitudes towards alcohol control policies in Scotland and England: results from a mixed-methods study. Soc Sci Med. 2017;177:177–189. PubMed ID: 28171817 doi:10.1016/j.socscimed.2017.01.037

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Howlett M. Public managers as the missing variable in policy studies: an empirical investigation using Canadian data. Rev Policy Res. 2011;28(3):247–263. doi:10.1111/j.1541-1338.2011.00494.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    O’Flynn PE, Mau TA. A demographic and career profile of municipal CAOs in Canada: implications for local governance. Can Public Adm. 2014;57(1):154–170. doi:10.1111/capa.12055

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Egger G, Swinburn B. An “ecological” approach to the obesity pandemic. BMJ. 1997;315(7106):477–480. PubMed ID: 9284671 doi:10.1136/bmj.315.7106.477

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34.

    French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health. 2001;22(1):309–335. PubMed ID: 11274524 doi:10.1146/annurev.publhealth.22.1.309

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

McGetrick, Kongats, Raine, and Nykiforuk are with the School of Public Health, University of Alberta, Edmonton, AB, Canada. Voyer is with the Coalition québécoise sur la problématique du poids (the Weight Coalition), Montreal, QC, Canada.

Nykiforuk (candace.nykiforuk@ualberta.ca) is corresponding author.
  • 1.

    World Health Organization. Physical Activity: Fact Sheet. 2017; http://www.who.int/mediacentre/factsheets/fs385/en/. Accessed November 10, 2017.

    • Search Google Scholar
    • Export Citation
  • 2.

    Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801–809. PubMed ID: 16534088 doi:10.1503/cmaj.051351

  • 3.

    Janssen I. Health care costs of physical inactivity in Canadian adults. Appl Physiol Nutr Metab. 2012;37(4):803–806. PubMed ID: 22667697 doi:10.1139/h2012-061

  • 4.

    Statistics Canada. Canadian Health Measures Survey: Directly Measured Physical Activity of Canadians, 2012 and 2013. 2015; http://www.statcan.gc.ca/daily-quotidien/150218/dq150218c-eng.pdf?. Accessed November 10, 2017.

    • Search Google Scholar
    • Export Citation
  • 5.

    ParticipACTION. Are Canadian kids too tired to move? The 2016 ParticipACTION report card on physical activity for children and youth. 2016; https://www.participaction.com/sites/default/files/downloads/2016%20ParticipACTION%20Report%20Card%20-%20Full%20Report.pdf. Accessed November 10, 2017.

    • Search Google Scholar
    • Export Citation
  • 6.

    Public Health Agency of Canada. How Healthy are Canadians? A Trend Analysis of the Health of Canadians from a Healthy Living and Chronic Disease Perspective. Ottawa, Canada: Public Health Agency of Canada; 2016.

    • Search Google Scholar
    • Export Citation
  • 7.

    Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Kerr J. An ecological approach to creating active living communities. Annu Rev Public Health. 2006;27:297–322. PubMed ID: 16533119 doi:10.1146/annurev.publhealth.27.021405.102100

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Raine KD, Muhajarine N, Spence JC, Neary NE, Nykiforuk CI. Coming to consensus on policy to create supportive built environments and community design. Can J Public Health. 2012;103(9 Suppl 3):eS5–eS8. PubMed ID: 23618090

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Nykiforuk CI, Wild TC, Raine KD. Cancer beliefs and prevention policies: comparing Canadian decision-maker and general population views. Cancer Causes Control. 2014;25(12):1683–1696. PubMed ID: 25319013 doi:10.1007/s10552-014-0474-3

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Health Serv Res Policy. 2005;10(suppl. 1):6–20. PubMed ID: 16053580 doi:10.1258/1355819054308576

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Diepeveen S, Ling T, Suhrcke M, Roland M, Marteau TM. Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis. BMC Public Health. 2013;13:756. PubMed ID: 23947336 doi:10.1186/1471-2458-13-756

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Griffiths P, West C. A balanced intervention ladder: promoting autonomy through public health action. Public Health. 2015;129(8):1092–1098. PubMed ID: 26330372 doi:10.1016/j.puhe.2015.08.007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Ayo N. Understanding health promotion in a neoliberal climate and the making of health conscious citizens. Crit Public Health. 2012;22(1):99–105. doi:10.1080/09581596.2010.520692

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Nuffield Council on Bioethics. Public Health: Ethical Issues. London, UK: Nuffield Council on Bioethics; 2007.

  • 15.

    Bélanger-Gravel A, Gauvin L, Fuller D, Drouin L. Implementing a public bicycle share program: impact on perceptions and support for public policies for active transportation. J Phys Act Health. 2015;12(4):477–482. PubMed ID: 24905364 doi:10.1123/jpah.2013-0206

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Umstattd MR, Baller SL, Blunt GH, Darst ML. Correlates of perceived worksite environmental support for physical activity. J Phys Act Health. 2011;8(s2):222–227. PubMed ID: 28829701 doi:10.1123/jpah.8.s2.s222

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Carlson SA, Guide R, Schmid TL, Moore LV, Barradas DT, Fulton JE. Public support for street-scale urban design practices and policies to increase physical activity. J Phys Act Health. 2011;8(s1):S125–S134. PubMed ID: 21350253 doi:10.1123/jpah.8.s1.s125

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Goins KV, Schneider KL, Brownson R, et al. Municipal officials’ perceived barriers to consideration of physical activity in community design decision making. J Public Health Manag Pract. 2013;19(3, suppl 1):S65. PubMed ID: 23529058 doi:10.1097/PHH.0b013e318284970e

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Raine KD, Nykiforuk CIJ, Vu-Nguyen K, et al. Understanding key influencers’ attitudes and beliefs about healthy public policy change for obesity prevention. Obesity. 2014;22(11):2426–2433. PubMed ID: 25131938 doi:10.1002/oby.20860

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    PLACE Research Lab. Chronic Disease Prevention Survey [Internet]. 2015; http://placeresearchlab.com/Chronic-Disease-Prevention-Survey/. Accessed November 28, 2017.

    • Search Google Scholar
    • Export Citation
  • 21.

    Roselius T. Consumer rankings of risk reduction methods. J Mark. 1971;35(1):56–61. doi:10.1177/002224297103500110

  • 22.

    PLACE Research Lab. PLACE Research Lab Intervention Ladder Policy Analysis Framework. 2017; http://placeresearchlab.com/chronic-disease-prevention-survey/#1510675691441-561b7d9e-0277. Accessed November 15, 2017.

    • Search Google Scholar
    • Export Citation
  • 23.

    Ogilvie KK, Eggleton A. Obesity in Canada: A Whole-of-Society Approach for a Healthier Canada. Ottawa, Canada: The Standing Senate Committee on Social Affairs, Science and Technology; 2016.

    • Search Google Scholar
    • Export Citation
  • 24.

    Public Health Agency of Canada. A Common Vision for Increasing Physical Activity and Reducing Sedentary Living in Canada: Let’s Get Moving. 2018; https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/lets-get-moving/pub-eng.pdf. Accessed February 26, 2019.

    • Search Google Scholar
    • Export Citation
  • 25.

    Richard L, Gauvin L, Raine K. Ecological models revisited: their uses and evolution in health promotion over two decades. Annu Rev Public Health. 2011;32:307–326. PubMed ID: 21219155 doi:10.1146/annurev-publhealth-031210-101141

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Stok FM, de Ridder DT, de Vet E, et al. Hungry for an intervention? Adolescents’ ratings of acceptability of eating-related intervention strategies. BMC Public Health. 2016;16:5. PubMed ID: 26729328 doi:10.1186/s12889-015-2665-6

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Hillier-Brown FC, Summerbell CD, Moore HJ, et al. The impact of interventions to promote healthier ready-to-eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review. Obes Rev. 2017;18(2):227–246. PubMed ID: 27899007 doi:10.1111/obr.12479

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Haynes E, Hughes R, Reidlinger DP. Obesity prevention advocacy in Australia: an analysis of policy impact on autonomy. Aust N Z J Public Health. 2017;41(3):299–305. PubMed ID: 28371184 doi:10.1111/1753-6405.12660

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Bos C, Lans IV, Van Rijnsoever F, Van Trijp H. Consumer acceptance of population-level intervention strategies for healthy food choices: the role of perceived effectiveness and perceived fairness. Nutrients. 2015;7(9):7842–7862. PubMed ID: 26389949 doi:10.3390/nu7095370

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Li J, Lovatt M, Eadie D, et al. Public attitudes towards alcohol control policies in Scotland and England: results from a mixed-methods study. Soc Sci Med. 2017;177:177–189. PubMed ID: 28171817 doi:10.1016/j.socscimed.2017.01.037

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Howlett M. Public managers as the missing variable in policy studies: an empirical investigation using Canadian data. Rev Policy Res. 2011;28(3):247–263. doi:10.1111/j.1541-1338.2011.00494.x

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    O’Flynn PE, Mau TA. A demographic and career profile of municipal CAOs in Canada: implications for local governance. Can Public Adm. 2014;57(1):154–170. doi:10.1111/capa.12055

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Egger G, Swinburn B. An “ecological” approach to the obesity pandemic. BMJ. 1997;315(7106):477–480. PubMed ID: 9284671 doi:10.1136/bmj.315.7106.477

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34.

    French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health. 2001;22(1):309–335. PubMed ID: 11274524 doi:10.1146/annurev.publhealth.22.1.309

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 6 6 0
Full Text Views 294 294 70
PDF Downloads 104 104 18