Number of Case Studies

After deciding to compare national political organisations, the question of ‘How many countries should be compared?’ is still open. The choice of the number of countries is deeply connected with the level of abstraction of the comparison: the more countries are analysed, the more abstract the comparison (Mair, 1998, p. 316). This concept has been represented in the graph below:

137 In fact, the health ministry is one of the ministries with the greatest expenditure capacity in many countries of the world. In particular, the total expenditure on health as % of GDP in 2010 was: 9.5 in Italy; 11.6 in Germany;

11.9 in France (WHO, 2012).

88

Figure 5 Number of Countries and Abstraction of the Comparison (Landman, 2002, p. 4)¹³⁸

Usually it is impossible to examine all the relevant cases (complete sampling) and it is necessary to identify a limited sample. Consequently, there are three choices concerning the number of countries to be compared (Landman, 2002, p. 4): one, few and many. Each one of these options has advantages and disadvantages.¹³⁹ For the social phenomenon at hand, a comparison of a few countries has been selected. This can involve between 2 and 20 or more countries (Landman, 2003, p. 27). The empirical analysis compares three countries, a number of units which permit a very low level of abstraction within the group of ‘small-n’

comparisons. Such a ‘focused comparison’ permits the careful selection of cases (Landman, 2002, p. 13) and thereby a very detailed enquiry (Kohn, Naoi, Schoenbach, Schooler, &

Slomczynski, 1990, p. 95; Øyen, 1990, p. 11), which represents an advantage for the purpose of the present dissertation. However, in the absence of a clear logic for the selection, a small-n sampling can provoke selection bias¹⁴⁰ and produce incorrect inferences (Landman, 2003, p.

28). For this reason, the type of research design used for the sampling will be explained in the next section.

138 Based on Mair (1998) and Sartori (1970).

139 For further insight into this topic, see Mair (1998) and Landman (2002).

140 In brief, this is the phenomenon which makes the sampling influential for the result of an analysis (Berk, 1983).

89 4.1.3 Framework and Sampling of the Case Studies

The welfare policies¹⁴¹ play a great role in many socio-political areas and particularly in healthcare (Lampman, 1984).¹⁴² This justifies a choice of countries based on the typology of welfare. Although many theories on welfare policies exist, in recent times the discussion has been dominated by Gøsta Esping-Andersen (Hicks & Kenworthy, 2003, p. 1). Indeed, his works (Esping-Andersen, 1990, 1999) have stimulated a great body of research and are highly accredited in politics (Hicks & Kenworthy, 2003, p. 1). In particular, the book ‘Three worlds of welfare capitalism’ (Esping-Andersen, 1990) theorises a different degree of countries’

‘decommodification’, which points out how much a citizen is protected by the state from the insecurity of market. Among other argumentations, Esping-Andersen differentiaties three typologies of welfare states in capitalist economies (Esping-Andersen, 1990, p. 74):¹⁴³

Typologyof

Welfare Description Countries

Liberal

Market logic and private insurance dominate this typology. Even if a wage minimum is normally secured, welfare state benefits are mild and

coupled to population’s needs

This type increases the welfare basic benefits with pensions, unemployment assistance and social insurance. It is also called

‘conservative welfare’ because it tends to preserve people’s living standards. In fact, social security is paid according to the equivalence

principle and depends on the amount and duration of previously contributions

This type reduces the character of work as a tradable commodity and offers government-guaranteed salary replacement benefits. Monetary hedging is completed by dense networks of social services, active labour

market policies and quality childcare

Norway, Sweden, Denmark, and

Finland Figure 6 Typologies of Welfare States in Capitalist Economies (Esping-Andersen, 1990)

141 For Luhmann, welfare policies are an intervention of politics outside its areas of competences (Kuchler, 2006, p. 7): they endanger the autonomy of function systems because they directly intervene into the internal operations of function systems through the medium of power (Luhmann, 1981a, p. 140). His assumption is presumably connected with the political situation at the beginning of the 80s in which states were substantially reducing their investments in welfare policies (Kuchler, 2006, p. 7) and has been considered right-wing from some authors (Kuchler, 2006; Østerberg, 2000).

142 For some authors welfare policies play a major role also in sport matters (Heinemann, 2003). However this connection has never been clearly demonstrated or taken for granted in the scientific community and has instead been often proved inconsistent.

143 Although many authors still debate the categories of welfare capitalism and the country memberships of those categories (Arts & Gelissen, 2002; Castles, 1993; Castles & Mitchell, 1993; Huber & Stephens, 2001; Ragin, 1994; Scharpf, 2000), a new classification accepted by the scientific community has never come forth from these discussions.

90 After deciding to compare a few countries and to choose them based upon their welfare typologies, a final step has must take place in order to complete the sampling.

Generally there are fundamentally two main types of research designs used for the sampling of a comparison of few and very few objects (Landman, 2003, p. 28): some studies compare different outcomes across similar countries, which is known as the Most Similar Systems Design (MSSD); others compare similar outcomes across different countries, which is known as the Most Different Systems Design (MDSD).¹⁴⁴ In particular, Przeworski and Teune (1970) have described these two approaches for selecting case studies: the MSSD is based upon the assumption that a sample of similar cases which present different outcomes permits the explanation of these outcomes. This research logic intends to find and explain meaningful differences in a sampling that is otherwise as homogeneous as possible. The MDSD also aims at explaining the outcomes, in this case similar, of a sample of intentionally selected heterogeneous, cases. In this case, the heterogeneity of the cases allows for focusing on the variables, which determine similar outcomes.

In a comparison of a few countries based on Esping-Andersen’s categorisation of welfare typologies, a researcher has two choices: comparing three different countries (MDSD) or comparing three similar countries (MSSD). The comparison of different typologies of welfare has been discarded because it has been considered too ambitious and difficult to defend by having a country for representing each group. For this reason, this dissertation compares three similar countries in a slightly modified version of the MSSD. In fact, enquiries based on this design are normally strongly premise-bounded because they test the most similar cases based upon a priori assumptions about mechanisms of action. Instead, in this case, a research question and not a hypothesis guides the research. This overcomes the problem bound to the case of a similar sample with similar outcomes, which is normally considered as a failure of the experiment (Przeworski & Teune, 107: 38). Furthermore, this dissertation does not focus on the relationship between dependent and independent variables and concentrates on qualitative and descriptive tasks. This is expected to add value because many social processes in the area of policy research are highly complex: the various influential factors for the characteristics of the cases are not easily able to be reduced and they can not be controlled in a quasi-experimental design like the classic MSSD (Scharpf, 2000, pp. 54-60).

144 Hybrid typologies of these two designs have reached a good level of acceptance within the scientific community, but they did not offer particular advantages for the present enquiry and have been discarded.

91 Within the three typologies of welfare capitalism, the conservative group has been chosen. In fact, among the three welfare typologies, these countries are expected to offer a more balanced scenario than the liberal or social-democratic typologies. More specifically, the analysis of France, Germany and Italy is considered a generalisation for the entire group of the five welfare conservative countries, which also includes Belgium and Austria. Indeed, the analysis of the whole group of conservative countries has been excluded for the purposes of reduction discussed previously in this section. Nevertheless, this sampling entails the majority and most populous conservative countries.¹⁴⁵ Finally, this sampling offers a further advantage:

the comparison of these three countries with similar welfare systems can prove whether a different sport system has influence on the social phenomenon being enquired into. In fact, the sport system of the three countries differs in many aspects:

− The French sport system is characterised by being highly politicised and extremely centralised (Defrance & Renard, 2003, p. 221; Digel & Fahrner, 2003, p. 259; Hartmann-Tews, 1996, p. 191; Tokarski & Steinbach, 2001, p. 184);

− Germany has a federal system in which the sport system is formally highly independent, but in practice influenced by regional policies (Engelhardt & Heinemann, 2003, p. 139;

Hartmann-Tews, 1996, p. 129; Tokarski & Steinbach, 2001, p. 178).

− the Italian sport system is characterised by the relevance of the Comitato Olimpico Nazionale (CONI), an independent public body which relies on public funds and which entails both the functions of NOC and of an umbrella organisation for sport federations (Digel & Barra, 2004, p. 287; Ferrari, Porro, & Russo, 2003, p. 275; Porro, Bizzaglia, &

Conti, 2003, p. 33; Tokarski & Steinbach, 2001, p. 193).

The comparison of France, Germany and Italy is expected to find conclusions able to be generalised for the group of conservative countries and to understand if a different sport system influences its ascribed role in strategies for the promotion of PA, issued by the health system. Given the theoretical and methodological premises of this dissertation, this sampling has been acknowledged as being the best country-clustering for the research at hand.

145 The three countries entail more than the 75% of the conservative countries’ population.

92 4.2Choice of the Documents

The analysis of all documents published in Italy, Germany and France about PA as a medium of health promotion constitutes a workload too great to be covered by a single researcher and far too unfocused a sample to answer the research question. For these reasons a limited sampling has been necessary for this dissertation. This section explains the procedure implemented for the selection of the relevant documents to be analysed. After this, the documents chosen for each case study have been listed and described in order to furnish their basic contextual information and make the reasons for their selection explicit.

4.2.1 Logic Behind the Choice of the Documents

The rough principle which orientated the collection of available written communications in the first explorative phase for the construction of a relevant catalogue of documents was to look for all health-strategies dealing with the promotion of PA and available for the case studies France, Germany and Italy.

The WHO’s ‘International inventory of documents on physical activity promotion’

(WHO, 2013) and the WHO’s ‘European database on nutrition, obesity and physical activity’

(WHO, 2011f) have been used to develop an initial, general idea of the existing documents regarding the promotion of PA. However, even though these inventories might have been helpful, they could not constitute the basis for sampling the documents because they are neither scientifically based nor up-to-date enough to fulfil this aim.

In order to limit the number of documents and better the focus of the sampling, only documents on the promotion of PA produced by the ministries of health of the selected countries have been considered.¹⁴⁶ These documents encompass a variety of different typologies such as: policies, legislations, programmes, reports, conference proceedings and information. This does not represent a problem per se, because the typology of the documents plays a secondary role for the relevance of the enquiry. Indeed, the analysis generally focuses on the role of sport in the health systems’ communication, which regards PA as a medium of health independently from the typology of the communication.

Even if all the documents were available on the website of the health ministries of the selected nations, the official websites of the ministries themselves do not furnish adequate tools for the selection of appropriate documents. In fact, these websites’ maps and contents differ greatly from one another. For this reason, they cannot represent a basis for the

146 The reason for this choice is argued to a more thorough extent in the section containing the logic of the sampling.

93 development of a standardised path to access the documents appropriate for all the websites.

For example, thematic sections dealing specifically with the topic of PA are present on the German and French websites but not on the Italian one. Furthermore, not even the health ministries’ website search engines represent a tool reliable enough for the identification of the documents because of technical reasons: they do not appear to function correctly and some documents are not listed in the search results.

For these reasons, the web search engine ‘Google Web Search’ by Google Incorporated has been preferred for identifying the documents rather than direct research on the health ministries’ websites. In particular, the following structured web search query has been developed and used for finding the documents:

site:*health ministry’s website domain* “*physical activity*” sport filetype:pdf¹⁴⁷ This query aims to find all documents which contain the key word “sport” and

‘physical activity’ on the health ministries’ websites and which are, for this reason, expected to treat relevant topics for the assessment of the research question. In practice, this search query has been translated for each case study and produced the following results:¹⁴⁸

Country Search Query N. of Results Date

Italy site:www.salute.gov.it/ “attività fisica” sport filetype:pdf 127 2011-07-20 Germany site:www.sante.gouv.fr/ “activitè physique” sport filetype:pdf 22 2011-07-20 France site:www.sante.gouv.fr/ “activitè physique” sport filetype:pdf 307 2011-07-20

Figure 7 Results of the Web Search

The substantial disparity in the number of documents found on the Health Ministries’

websites is due to their different publication strategy. In particular:

− The German Health Ministry’s website contains only a few focused documents. In fact, for the case study Germany just 22 documents were found through web research.

− The Italian Health Ministry’s website contains more documents (127) which are incomplete or not issued by the health ministry, which have the form of ministerial covenants of understanding, laws, or which assess a specific illness.

− The French Health Ministry’s website has the same characteristics as the Italian one and, in addition, contains a multitude of regional and local documents. Here, a total of 307 documents were found.

147 The asterisk indicates that the words have been translated differently for each case study.

148 The date for carrying out the research is casual and the results have not been updated afterwards.

94 For obtaining a more focussed and representative selection, the documents found via online research were sorted in a further step. In particular, the documents with the following characteristics were discarded at this stage:

− documents issued before the year 2000, because the social phenomenon analysed is relatively new and an older sample would falsify the results,

− documents with regional or local scope,

− documents not issued by the national health ministries,

− documents orientated towards the prevention or rehabilitation of particular diseases (for example arteriosclerosis),

− documents related to the promotion of a particular mode of PA (for example cycling or walking),

− documents containing the words ‘sport’ and ‘PA’ and ‘movement’ only occasionally.

After this second step, the number of documents considered suitable for the analysis became manageable for each of the case studies: six for France, seven for Germany and nine for Italy. This means that the filter process conducted for the selection of a limited number of documents was independent from the starting number of documents found via online research.

In a final step of selection, the documents, which satisfied all the rules established, but which did not appear to be relevant for the assessment of the research question, have been excluded. In contrast to the previous steps, this last action has prevalent qualitative characteristics and has been conducted by reading the documents and by collecting information on their context. The logic and results of this last selection have been summarised below.

In conclusion, the method for the selection of the documents presents a mix of quantitative and qualitative characteristics, which ensure both a highly standardised, scientific and repeatable procedure and the security of having chosen documents, which have relevant contents for answering the research question.

4.2.2 List and Description of the Documents per Case Study

In the following, the list of documents taken into account until the last step for the analysis will be listed for each case study, briefly described and accompanied by basic contextual information. This also includes the explanation and the logic for the final documents’ selection.

95 4.2.3 French Documents

The French Health Ministry’s website also contains downloadable materials.

However, only few of these documents are suitable for answering the research question. The documents selected are three subsequent versions of the ‘Programme national nutrition santé’

(PNNS) for the years 2001-2005 (French Ministry of Health, 2001), 2006-2010 (French Ministry of Health and Solidarity, 2006) and 2011-2015 (French Ministry for Employment and Welfare & French Ministry of Health, 2011). The PNNS has been launched in January 2001 and aims at improving the general health conditions of the French population by principally changing nutritional behaviours. The first programme was issued in 2001, the second extended, clarified and strengthened the original PNNS and, in early 2011, a third version of the PNNS was released. The goals and strategies of this third document are developed in close collaboration with the ‘Obesity Plan’, launched in 2010. Even if these documents focus mainly on nutrition, the promotion of PA also plays a key role.

Within the context of the PNNS, the documents ‘Activité physique et santé. Arguments scientifiques, pistes pratiques’ (Physical Activity and Health) (French Ministry of Health and Solidarity, 2005) and ‘La santé vien en bougeant. Le guide nutricion pour tous’ (Health Comes by Moving) (French Ministry of Health, 2004) have also been analysed; the former aiming to confront the topic of PA promotion more exhaustively than in the PNNS and the latter being an informative document for the population.

Instead, even if relevant at first sight, the document ‘Plan National de Prévention par l’Activité Physique ou Sportive’ (PNPAPS) (French Ministry of Health, Youth, Sports and Community, 2008) has been discarded after a thorough analysis. In fact, the PNPAPS is a national prevention plan through physical activity or sports. However, it has a different format,¹⁴⁹ it is deeply influenced by the perspective of the Sport Ministry,¹⁵⁰ and resulted as less representative for the analysis at hand.

Title of the document

Author Date Type Pages

PNNS 2001-2005 French Ministry of Health 2001 Policy 40

PNNS 2006-2010 French Ministry of Health and Solidarity 2006 Policy 51 PNNS 2011-2015 French Ministry for Employment and Welfare and

Ministry of Health 2011 Policy 66

Physical Activity

and Health French Ministry of Health and Solidarity 2005 Information 58 Health Comes by

Moving French Ministry of Health, Youth, Sports and Community 2004 Information 36 Figure 8 French Documents

149 The document consists of six different and independent strategies.

150 The document is based on the report of the Commission on Prevention, Sport and Health, written in 2008.

96 4.2.4 German Documents

The website of the German Ministry of Health provided fewer resulting publications when compared to the Italian and French results. The publications, however, constitute a solid basis for a document analysis as well as for the other case studies. In fact, of the 22 results, more than ten documents were found to be suitable for the analysis and five of them have been chosen as most representative for the German case.

Among the documents analysed is the national plan ‘IN FORM Deutschlands Initiative für gesunde Ernährung und mehr Bewegung‘ (IN FORM) (German Ministry of Health &

German Ministry of Nutrition, 2008). This national action plan regards the prevention of malnutrition, physical inactivity, obesity and related diseases and has been presented jointly

German Ministry of Nutrition, 2008). This national action plan regards the prevention of malnutrition, physical inactivity, obesity and related diseases and has been presented jointly

Im Dokument The Role of Sport in Health-Related Promotion of Physical Activity. The Perspective of the Health System (Seite 98-0)