(From the ISHN Member information service) The WHO released its 2013-2020 Action Plan on Non-Communicable Disease (NCD) prevention in January 2015. This commentary looks into the document from the perspective of the latest knowledge we have on school health promotion.
The action plan states "The action plan provides a road map and a menu of policy options for all Member States and other stakeholders, to take coordinated and coherent action, at all levels, local to global, to attain the nine voluntary global targets, including that of a 25% relative reduction in premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2025. 6. The main focus of this action plan is on four types of noncommunicable disease—cardiovascular diseases, cancer, chronic respiratory diseases and diabetes—which make the largest contribution to morbidity and mortality due to noncommunicable diseases, and on four shared behavioural risk factors—tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. It recognizes that the conditions in which people live and work and their lifestyles influence their health and quality of life" It is in this last sentence where the action plan fails. quite badly. In this analysis, we look more closely at the words in the document and then discuss one aspect drawing from the recent evidence and experience in school health promotion.
The vision described on page 12 of the document is revealing. it begins with the goal " A world free of the avoidable burden of noncommunicable diseases". Nowhere does the document contain the WHO vision of health, which, as we know, is "more than the absence of disease". The vision contains several nice concepts, including human rights, equity, national multi-sectorial action, life-course approach, empowerment, and managing potential conflicts of interest with food companies and others. But the implicit nature of the document becomes clearer when we note that the words population health, public health u or health promotion are not used. As well, the agenda becomes clearer when we note that of the five functions of public health (protection, promotion, prevention, services and surveillance) only universal health services is mentioned. The WHO intent in this document is clearly to galvanize action in countries in a disease prevention strategy. The first objective of the action plan (p. 5) is to "raise the priority accorded to the prevention and control of NCD's". This action plan really is about disease, and building the case for for access to universal health care. In our view, the document is part of and reflects a world wide trend for the health sector to retreat back to a medical model and move away from the principles of the Ottawa and ensuing charters related to health promotion and social development.
We will come back to the vision statement about evidence-based strategies later in this analysis.
As proponents of school health promotion and settings-based work, we were hopeful when we read on page 5 of the objective stating " to reduce modifiable risk factors for noncommunicable diseases and underlying social determinants through creation of health-promoting
environments." If there is any chance that WHO and the health ministries in countries are to secure the cooperation of other sectors in the Health in All Policies (HiAP) initiatives, then the health sector will need to "go to where those sectors do their work, ie in the settings where people live, learn, work and play. However, when we got to pages 29-37, we found no mention of healthy cities/communities, schools, workplaces, hospitals, universities and other settings. We found only recommended actions such as legislation on second-hand smoke, warnings on cigarette packages, controls on food marketing, promotion of physical activity guidelines and limitations on alcohol sales. These are all good things but they are also all "prescriptions" (medical pun intended) for behaviour change. This medical model has long been discredited in the research on behaviour change and, more recently, even more so on our growing understanding of ecological and systems-based approaches.
The document does suggest that the WHO Secretariat should provide technical assistance to countries through settings such as schools, cities, recreation etc but the investment (or re-investment) by countries in these settings-based strategies as the means to deliver the NCD prevention strategy is clearly not included as part of the recommended action by countries. Further, when we know that the current total investment of the global WHO office for working with all of these settings is one staff person, we must question the feasibility of the intent to provide such technical assistance.
In closing, we will pick out one aspect of the action plan that further illustrates how the WHO action plan is actually more of a medically-inspired, bureaucratic creation rather than being based on research evidence and professional experience in the real world. On page 33, we find recommendations that suggest countries should promote "active transportation" and "Improved provision of quality physical education in educational settings (from infant years to tertiary level) including opportunities for physical activity before, during and after the formal school day." If you are a reader of this blog you will recall that we have been tracking the research and reports on physical activity, particularly in regards to its connection to obesity/overweight. Based on several research reviews and articles, we now know that increased physical activity alone, has little effect on body weight. We also know that increased PE time does little to increase actual moderate/vigorous activity unless PE classes are transformed. We know that extensive school-based obesity prevention programs have not reduced obesity levels. We know that we can squeeze out more minutes of activity for some students through active recess, after-school and in-class activities but these efforts do not always engage the naturally less active or uncoordinated students. We know that walking and biking to schools is the best way to accumulate activity minutes. But we also know that structural barriers (perceived safety, parent work schedules, existing neighbourhood designs all prevent significant change in transportation patterns.
We also know that these economic and social barriers to active transportation to school may actually illustrate the more fundamental, deeper analysis that is missing throughout the WHO action plan. For example, a recent analysis of active school transportation in California notes that poor children are the ones most walking to school and they are also the ones that are more obese and overweight. As well, these poor children, who now comprise over one-half of the school children in the United States, actually have more urgent and important health problems. If we retreat to a medical, prescriptive model, one that ignores what we have learned about behaviour and ecological influences in the past two decades, then all of the words in documents like the NCD plan will be much less useful in the real world.
The action plan states "The action plan provides a road map and a menu of policy options for all Member States and other stakeholders, to take coordinated and coherent action, at all levels, local to global, to attain the nine voluntary global targets, including that of a 25% relative reduction in premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2025. 6. The main focus of this action plan is on four types of noncommunicable disease—cardiovascular diseases, cancer, chronic respiratory diseases and diabetes—which make the largest contribution to morbidity and mortality due to noncommunicable diseases, and on four shared behavioural risk factors—tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. It recognizes that the conditions in which people live and work and their lifestyles influence their health and quality of life" It is in this last sentence where the action plan fails. quite badly. In this analysis, we look more closely at the words in the document and then discuss one aspect drawing from the recent evidence and experience in school health promotion.
The vision described on page 12 of the document is revealing. it begins with the goal " A world free of the avoidable burden of noncommunicable diseases". Nowhere does the document contain the WHO vision of health, which, as we know, is "more than the absence of disease". The vision contains several nice concepts, including human rights, equity, national multi-sectorial action, life-course approach, empowerment, and managing potential conflicts of interest with food companies and others. But the implicit nature of the document becomes clearer when we note that the words population health, public health u or health promotion are not used. As well, the agenda becomes clearer when we note that of the five functions of public health (protection, promotion, prevention, services and surveillance) only universal health services is mentioned. The WHO intent in this document is clearly to galvanize action in countries in a disease prevention strategy. The first objective of the action plan (p. 5) is to "raise the priority accorded to the prevention and control of NCD's". This action plan really is about disease, and building the case for for access to universal health care. In our view, the document is part of and reflects a world wide trend for the health sector to retreat back to a medical model and move away from the principles of the Ottawa and ensuing charters related to health promotion and social development.
We will come back to the vision statement about evidence-based strategies later in this analysis.
As proponents of school health promotion and settings-based work, we were hopeful when we read on page 5 of the objective stating " to reduce modifiable risk factors for noncommunicable diseases and underlying social determinants through creation of health-promoting
environments." If there is any chance that WHO and the health ministries in countries are to secure the cooperation of other sectors in the Health in All Policies (HiAP) initiatives, then the health sector will need to "go to where those sectors do their work, ie in the settings where people live, learn, work and play. However, when we got to pages 29-37, we found no mention of healthy cities/communities, schools, workplaces, hospitals, universities and other settings. We found only recommended actions such as legislation on second-hand smoke, warnings on cigarette packages, controls on food marketing, promotion of physical activity guidelines and limitations on alcohol sales. These are all good things but they are also all "prescriptions" (medical pun intended) for behaviour change. This medical model has long been discredited in the research on behaviour change and, more recently, even more so on our growing understanding of ecological and systems-based approaches.
The document does suggest that the WHO Secretariat should provide technical assistance to countries through settings such as schools, cities, recreation etc but the investment (or re-investment) by countries in these settings-based strategies as the means to deliver the NCD prevention strategy is clearly not included as part of the recommended action by countries. Further, when we know that the current total investment of the global WHO office for working with all of these settings is one staff person, we must question the feasibility of the intent to provide such technical assistance.
In closing, we will pick out one aspect of the action plan that further illustrates how the WHO action plan is actually more of a medically-inspired, bureaucratic creation rather than being based on research evidence and professional experience in the real world. On page 33, we find recommendations that suggest countries should promote "active transportation" and "Improved provision of quality physical education in educational settings (from infant years to tertiary level) including opportunities for physical activity before, during and after the formal school day." If you are a reader of this blog you will recall that we have been tracking the research and reports on physical activity, particularly in regards to its connection to obesity/overweight. Based on several research reviews and articles, we now know that increased physical activity alone, has little effect on body weight. We also know that increased PE time does little to increase actual moderate/vigorous activity unless PE classes are transformed. We know that extensive school-based obesity prevention programs have not reduced obesity levels. We know that we can squeeze out more minutes of activity for some students through active recess, after-school and in-class activities but these efforts do not always engage the naturally less active or uncoordinated students. We know that walking and biking to schools is the best way to accumulate activity minutes. But we also know that structural barriers (perceived safety, parent work schedules, existing neighbourhood designs all prevent significant change in transportation patterns.
We also know that these economic and social barriers to active transportation to school may actually illustrate the more fundamental, deeper analysis that is missing throughout the WHO action plan. For example, a recent analysis of active school transportation in California notes that poor children are the ones most walking to school and they are also the ones that are more obese and overweight. As well, these poor children, who now comprise over one-half of the school children in the United States, actually have more urgent and important health problems. If we retreat to a medical, prescriptive model, one that ignores what we have learned about behaviour and ecological influences in the past two decades, then all of the words in documents like the NCD plan will be much less useful in the real world.
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