Content Analysis of the Global Strategy on Diet, Physical Activity and Health

diet¹⁸² and PA on a global scale through the cooperation of a wide range of function systems.

This section analyses the contents of the final version of the Strategy approved on May 22, 2004 in the 57th WHA. The analyses have been carried out through a mix of word frequency count¹⁸³ and content analysis which is the prototype for the analysis of this dissertation. The design has been developed for assessing two topics: the role of the sport system and the characterisation of PA.¹⁸⁴ A frequency analysis first evaluated the occurrence of related terms and identified the most important passages in the document. The content analysis (Mayring

180 Governments also ‘have a central role, in cooperation with other stakeholders, to create an environment that empowers and encourages behaviour changes by individuals, families and communities, to make positive, life-enhancing decisions on healthy diets and patterns of physical activity’ (WHO, 2004, p. 3).

181 See section: ‘Content Analysis of the Global Strategy on Diet, Physical Activity and Health’ (pages 15-19).

182 The analysis of the promotion of a healthy diet is not contained in the analysis below because it is not relevant to the focus of the present research.

183 The word count methodology includes counting not just the particular word in question, but also derivatives from and compounds of the word in question (example for ‘sport’: sport; sports; sporting; sport-; sporting-). The document’s transcription encompasses the formatting of images, logos, page headers and the page’s theme.

184 The results of this analysis are not to be considered representative for the general logic of the WHO.

117 2007: 89) then extracted the information needed from the selected passages in order to describe and make inferences about them (Holsti, 1969). The contents have been than critically discussed by way of personal observations, clarifications found within the texts and secondary literature.

In the following, a mention of the SDPA will only refer to the Strategy without the additional annexes contained in the official document.¹⁸⁵ The SDPA is divided into 14 topics¹⁸⁶ and 67 sections.¹⁸⁷ For reason of synthesis, the parts of the Strategy will be identified in this section exclusively by the number of the respective section. A copy of the document, available on the WHO website (WHO, 2004), would be helpful to follow the discussion and to reap the full benefits of the analysis.

During the analysis of the Strategy, a general tendency has been identified: ‘PA’ is a central topic and a recurrent word, but it is often mentioned together with diet.¹⁸⁸ In this regard, section 13 of the SDPA argues that:

‘Diet and physical activity influence health both together and separately. Although the effects of diet and physical activity on health often interact, particularly in relation to obesity, there are additional health benefits to be gained from physical activity that are independent of nutrition and diet, and there are significant nutritional risks that are unrelated to obesity. Physical activity is a fundamental means of improving the physical and mental health of individuals.’

Even in light of this explanation, this is a questionable characteristic of the Strategy because, from a governance perspective, ‘if the effector arms of physical activity programmes are different to nutrition, then strategic implementation and partnerships might be kept separate, although the health-related consequences of poor diet and physical inactivity show large degrees of overlap’ (Bauman & Craig, 2005, p. 3).

185 The official SDPA document includes: an introduction, the Strategy (pages 1 to 14), the WHA’s Resolution 57.17 (pages 15 to 18) and a page containing references and copyright data.

186 In detail: Global Strategy on Diet; Physical Activity and Health; The Challenge; The Opportunity; Goal and Objectives; Evidence for Action; Principles for Action; Responsibilities for Action; Member States; WHO;

International Partners; Civil Society and Nongovernmental Organizations; Private Sector; Follow-up and Future Developments; and Conclusions.

187 Some of them (sections 18, 40, 41, 42, 45, and 46) have additional numerical subsections and others (sections 22, 51, 58, 60, 61, and 63) have additional points listed by means of square-shaped bullet points.The subsections will be referred to in the following way: ‘number of the section’.’number of the subsection’.

188 To be more precise, in the 14 pages of the Strategy, PA and diet are mentioned together on 82 occasions, with 37 slightly different formulations. PA is mentioned autonomously from diet 26 times. Furthermore, these are all contained in six sections (out of a total of 67) of the Strategy (sections 13, 23, 24, 29, 39.3 and 42.1-2-3-4), which are in fact the only passages that consider PA as an independent topic.

118 In the following, the role of sport in the SDPA will be analysed. ‘Sport’ is mentioned six times, with the six references contained in four sections (38, 41.2, 42.1, and 61), specifically:

− Section 38: ‘Health ministries have an essential responsibility for coordinating and facilitating the contributions of other ministries and government agencies.’ Among others,¹⁸⁹ bodies ‘whose contributions should be coordinated include ministries and government institutions responsible for policies on [...] sports [...]’.

− Section 41.2: ‘Public policies can influence prices through taxation, subsidies or direct pricing in ways that encourage healthy eating and lifelong physical activity.’ The section recommends the usage of ‘public funds and subsidies to promote access among poor communities to recreational and sporting facilities’ where needed.

− Section 42.1: ‘National and local governments should frame policies and provide incentives to ensure that [...] sport and recreation facilities embody the concept of sports for all.’

− Section 61: ‘The private sector can be a significant player in promoting healthy diets and physical activity. The [...] sporting-goods manufacturers [...] have important parts to play as responsible employers and as advocates for healthy lifestyles’.¹⁹⁰

In summary, the sport system, embodied in the ministries and government agencies responsible for sport, sport facilities and sporting-goods, is identified as a partner for the promotion of PA. Moreover, the reference to ‘sports for all’¹⁹¹ can be interpreted as the acceptance by the WHO of the logic of sport in the promotion of PA.

This closely regards the characterisation of PA in the SDPA. PA is a broad concept, defined in this dissertation as ‘any bodily movement produced by skeletal muscles that results in energy expenditure above resting level’ (Bouchard & Shephard, 1994, p. 77). The activities covered in this broad definition can be further specified on the basis of their mode, intensity, duration, frequency and continuity (Ainsworth et al., 2000; Caspersen et al., 1986; Dishman et al., 1985; Evenson et al., 2002; Hagströmer, 2007; King, 2001). The information contained in the SDPA regarding each one of these attributes of PA is commented in the following:

− Mode: the SDPA furnishes 7 indicators contained in sections 24, 39.3 and 42.1. Three of these -‘other forms of physical activity’, ‘different types [...] of physical activity’ and

189 Specifically: food, agriculture, youth, recreation, education, commerce and industry, finance, transportation, media and communication, social affairs, and environmental and urban planning.

190 The term ‘sporting-goods’ is repeated in a very similar context.

191 Sport for all is ‘an internationally accepted term of proclaiming everybody’s right and giving everybody access to sport’ (Palm, 1991, p. 9).

119 HEPA¹⁹²- are general advice and do not represent examples of PA to be practiced. This reduces the concrete modes of PA to four types: walking, cycling, muscle strengthening and balance training. The latter two are contained in the sentence: ‘Muscle strengthening and balance training can reduce falls and increase functional status among older adults’.

They are hence limited to risk groups (older adults) and the sentence is weakened by the use of the verb ‘can’.¹⁹³ Furthermore, the Strategy does not contain any specific reference to sport disciplines.¹⁹⁴

− Continuity: the SDPA underlines in its ‘Principles for Action’ the relevance of a ‘life-course’ approach. Direct pieces of advice on the continuity of PA are contained in section 24, ‘for physical activity, it is recommended that individuals engage in adequate levels throughout their lives’ and in section 28 ‘(The life-course) approach [...] encourages [...]

regular physical activity from youth into old age.’

− Intensity, Frequency and Duration: the guidelines of the SDPA are contained in section 24 and can be summarised as being practiced regularly and moderately (intensity), on most days (frequency) and for at least 30 minutes (duration).

The analysis now will focus on section 24 of the SDPA because it is particularly significant for explaining the characterisation of the intensity, frequency and duration of the PA to be promoted in the SDPA (WHO, 2004, p. 4):

‘Different types and amount of physical activity are required for different health outcomes: at least 30 minutes of regular, moderate-intensity physical activity on most days reduces the risk of cardiovascular disease and diabetes, colon cancer and breast cancer.

[...]. More activity may be required for weight control.’

One can notice that the section containing unique precise recommendations on PA is accompanied by introductory and concluding sentences that provide important additional information about the topic. Nevertheless, these are both vaguely formulated and do not refer to any concrete measurement of intensity, frequency and/or duration. For example the sentence ‘different [...] amount of physical activity are required for different health outcomes’

is vague and the explanation of the different health benefits attainable is completely absent

192 HEPA is the abbreviation of Health-Enhancing Physical Activity. It is defined as ‘any form of physical activity that benefits health and functional capacity without undue harm or risk’ (Foster, 2000, p. 9).

193 The vocabulary generally used in the Strategy is characterised by a frequent usage of weakening verbs such as

‘can’, ‘may’ and ‘could’ instead of clearer imperative formulations (Cannon, 2004, p. 372). This confuses and reduces the strength of the contents by decreasing the sense of scientific urgency and the importance of the guidelines.

194 As seen above, sport is mentioned 6 times but never as a mode of PA.

120 from the SDPA. Furthermore, the sentence ‘More activity may be required for weight control’

is limited to risk groups (overweight persons) and its content is weakened by the usage of

‘may’.¹⁹⁵ On the one hand, the usage within the SDPA of the standard formula ‘30 minutes of moderate physical activity on most days’ is coherent with the Strategy’s philosophy on the clarity of the message contained in section 42.4: ‘simple, direct messages need to be communicated on the quantity and quality of physical activity sufficient to provide substantial health benefits.’ Bauman and Craig (2005, p. 3) also justify this simplification and the absence of recommendations for ‘vigorous PA’ as follows:

‘The recommendation of ‘half an hour of achievable moderate intensity activity on most days of the week’ fits well into social marketing and media campaign efforts. Additional physical activity, or activity at a greater intensity may be required for some health outcomes such as cancer prevention or weight loss, but making the message(s) more complicated may confuse efforts to raise community awareness’

On the other hand, this statement goes against the purpose of the Strategy to stimulate the cooperation of different systems in the promotion of PA. Indeed, the SDPA aims to create a palpable impulse through a message comprehensible for function systems with different logics. Only in this way can it stimulate cooperation for the promotion of PA. The simplification of the characteristics of PA in a unique standard and health-orientated formula does not seek to explain how the sport system could cooperate in the promotion of PA.

In summary, the messages of the SDPA regarding the role of sport and the characterisation of PA do not constitute a clear point of connection for the cooperation of the sport system. Even by recommending cooperation with the sport system, the PA recommended by the Strategy is not compatible with the logic of the sport system. In fact sport organisations promote a PA often orientated towards performance and many classical sport disciplines imply a form of PA that differs from the WHO’s standard. Nevertheless, vigorous activity also produces health benefits and sport can have benefits on the dietary habits and lifestyle of the participants that go far beyond benefits related to calorie consumption. Furthermore, sport organisations are appropriate for practicing and promoting PA and allow many forms of structural coupling with the health system, such as in the case of health-orientated sport activities.

195 See the previous footnote.

121 4.5Summary of the Methodology and Next Steps

This chapter has described the empirical design and the methodological instruments for enquiring the research question ‘What role does sport play in the health-related promotion of PA?’

As a first step, general reflections on the empirical approach for gaining knowledge on the subject have been made. Developing a reliable research basis is one of the most tenuous phases in planning a research project and has to be carefully carried out in order to prevent the selection bias. In summary, this dissertation:

− uses the comparison of countries over the same time span as a method to gain knowledge about the phenomenon being enquired into;

− takes into account three countries, because a small-n comparison permits a focused and deep analysis;

− analyses France, Germany and Italy, because the comparison of three conservative countries is expected to furnish conclusions that can be generalized for whole group of conservative countries and that can test whether a different sport system influences the social phenomenon inquired.

Alternative samplings exist and have been carefully considered. In particular, the power of comparison could be amplified by expanding the comparison to the groups of liberal and social democratic countries.¹⁹⁶ Even with its imperfection, the comparison of France, Germany and Italy has been identified as being the best choice for it feasibility and relevance.

Once clarified these points, the selection of the catalogue of documents to be analysed has been carried out as a further propaedeutic methodological step.

By using a semi-standardised procedure, five documents for each case study have been chosen. These documents have been issued by the national health ministries, are related to the topic of PA promotion and assess the role of sport in this context. In this way, a catalogue of documents (unit of analysis) has been created which is representative for the main topic, offers the chance to compare the results of the case studies and is suitable for answering the research question. The detailed and extensive explanation of the sampling procedure furnishes enough information for allowing another scientist to repeat the selection with very similar outcomes. A first observation of interest can be made regarding the sampling: the selection brought naturally to a profoundly different catalogue in general and within each case study.

This reflects the differences regarding the health ministries, their approaches to health

196 This topic will be deepened in the conclusions.

122 promotion and their ways of communicating with their respective populations. Also, it is a demonstration of the fragmentation of the global discourse.

To explore health-strategies issued by the health ministries of France, Germany and Italy, the dissertation uses an approach developed ad hoc to content analysis. This procedure¹⁹⁷ has been created by the author himself to better fit the aim of the analysis and it is based upon a mix of quantitative and qualitative approaches. This design is based on general methodological guidelines for document analysis retrieved in particular from the works of Lamnek (1989, 1995, 2010), Mayring (2000, 2001, 2002, 2003, 2007) and Flick (2008, 2011, 2007). A mix of methods indicates the use of both qualitative and quantitative approaches in the same research project, which is believed to enhance the quality of the dissertation by profiting from the strengths of both disciplines. This design: uses sequentially quantitative and qualitative content analysis; gives the dominant role to qualitative methods;

and discusses the results in light of the systems theory. More specifically, the passages to be analysed have been identified through the use of word count analysis. In a successive step, these have been analysed in depth with the interpretative technique of content structuring. The treatment of the analysis unit through these categories is expected to furnish a description of the social phenomenon inquired and to furnish the basis for the formulation of hypotheses and generalisations.

The provisory version of the methodology for content analysis has been tested on the WHO’s ‘Global Strategy on Diet, Physical Activity and Health’ (2004). The SDPA is a health-strategy that aims to promote PA on a global scale through the cooperation of a broad range of function systems, mostly external to health. The WHO represents a point of reference for the coordination of systems towards health matters. For this aim, the message of the WHO should be understandable by the various systems, which should mutually cooperate. Only by highlighting the opportunity of a win-win situation and by using a language adaptable to all contexts involved can the message impact other systems. The analysis of the role of sport and of the characterisation of PA in the SDPA demonstrates that the message fails to create a solid basis for the cooperation of the sport system. In fact, the Strategy mentions the sport system as an important partner for the cooperation in the promotion of PA. Nevertheless, it

197 By further categorizing this method through the reviewing of methodological literature, the most similarities with an already existing design are with the summative approach to quantitative analysis, which is characterised by the mix of the analytical methods of word frequency count and content analysis (Hsieh & Shannon, 2005).

Anyway, this further characterization is at least artificial because: the method has been independently developed following the general rules of mixed methods and then acknowledged as being similar to the summative approach; the two methods are only similar and not identical; the constant further differentiation in mixed method of ‘new’ designs create a kind of ‘lost in design’ effect which the author had to face in first person and which he doesn’t want to support further.

123 recommends ‘at least 30 minutes of regular, moderate-intensity physical activity on most days’ and does not specify how the sport system should participate in facilitating the implementation of such a recommendation. In this way, the SDPA limits the potential understanding of how the sport system should contribute to the Strategy’s goals and, more generally, what the role of sport in the prevention of NCDs is. This represents an obstacle for the cooperation between organisations within the sport system and other potential partners such as schools, workplaces and transport companies regarding the promotion of PA.

Moreover, this can cause a general misunderstanding and limit the potentially substantial contribution of sport in improving the population’s health.

However these results cannot be generalised for the discussion on the promotion of PA at national level. In fact, even though the WHO has a large influence on the setting of the health agenda, the health ministries develop and implement health-strategies independently and in different national contexts. For this reason, the national level has been considered particularly interesting for investigating the topic at the hand and will be analysed through the exploration of health-strategies issued by the health ministries of France, Germany and Italy.

In the following chapter, the sub-question ‘How are PA and sport spoken about in strategies for the health-orientated promotion of PA?’ will be assessed by applying the developed design to the unit of analysis.

124 5. Empirical Analysis of the Case Studies

‘Now obviously the propositions of the system have reference to matters of empirical fact;

if they did not, they could have no claim to be called scientific’

if they did not, they could have no claim to be called scientific’

Im Dokument The Role of Sport in Health-Related Promotion of Physical Activity. The Perspective of the Health System (Seite 127-0)