Public Health Nutrition: 20(3), 381–390 doi:10.1017/S1368980016002391 Level of implementation of best practice policies for creating healthy food environments: assessment by state and non-state actors in Thailand Sirinya Phulkerd1,2,*, Stefanie Vandevijvere3, Mark Lawrence4, Viroj Tangcharoensathien2 and Gary Sacks5 1School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia: 2International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand: 3Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand: 4Institute for Physical Activity and Nutrition, Deakin University, Burwood, Victoria, Australia: 5WHO Collaborating Centre for Obesity Prevention, Deakin University, Burwood, Victoria, Australia Submitted 29 April 2016: Final revision received 26 July 2016: Accepted 1 August 2016: First published online 13 September 2016 Abstract Objective: To determine and compare the level of implementation of policies for healthy food environments in Thailand with reference to international best practice by state and non-state actors. Design: Data on the current level of implementation of food environment policies were assessed independently using the adapted Healthy Food Environment Policy Index (Food-EPI) by two groups of actors. Concrete actions were proposed for Thai Government. A joint meeting between both groups was subsequently held to reach consensus on priority actions. Setting: Thailand. Subjects: Thirty state actors and twenty-seven non-state actors. Results: Level of policy implementation varied across different domains and actor groups. State actors rated implementation levels higher than non-state actors. Both state and non-state actors rated level of implementation of monitoring of BMI highest. Level of implementation of policies promoting in-store availability of healthy foods and policies increasing tax on unhealthy foods were rated lowest by state and non-state actors, respectively. Both groups reached consensus on eleven priority actions for implementation, focusing on food provision in public-sector settings, food composition, food promotion, leadership, monitoring and intelli- gence, and food trade. Conclusions: Although the implementation gaps identified and priority actions proposed varied between state and non-state actors, both groups achieved Keywords consensus on a comprehensive food policy package to be implemented by the Healthy food environments Thai Government to improve the healthiness of food environments. This Policy implementation consensus is a platform for continued policy dialogue towards cross-sectoral Obesity policy coherence and effective actions to address the growing burden of Non-communicable diseases non-communicable diseases and obesity in Thailand. State and non-state actors The WHO recommendations for the control and preven- than country governments. The WHO’s monitoring system tion of non-communicable diseases (NCD) include estab- specifically focuses on health outcomes, NCD risk factors lishing and strengthening country-level surveillance and and national system responses, but includes aspects of monitoring as a top priority(1). In recent years there have food environments, which are significant contributors to – been increasing attempts to monitor and evaluate gov- obesity and diet-related NCD, in only a limited way(2 4). ernment policy responses to address obesity and NCD. The WHO monitoring system includes two indicators on Often, such monitoring has been performed by WHO or food environment policies: one on reduction of food global non-governmental organizations (NGO) such as the marketing to children and one on limiting saturated and World Cancer Research Fund and World Obesity, rather trans-fats in the food supply(5). *Corresponding author: Email [email protected] © The Authors 2016 Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 12:19:48, subject to the Cambridge Core terms of use. 382 S Phulkerd et al. Involving diverse stakeholders, including state and First, all food environment domains and indicators of non-state actors, in the monitoring and evaluation of the version of the Food-EPI used previously were verified policy implementation is important to increase awareness, with two Thai experts: one from the Ministry of Public accountability and commitment on policy outcomes and Health and one from the Health Promotion Policy impacts(6) as well as to gain support for the implementa- Research Center of the International Health Policy tion of proposed priorities. A self-assessment by state Program Foundation, in order to ensure the indicators actors can help to set baselines, identify gaps, plan and were appropriate for Thailand. All of the Food-EPI prioritize actions, and increase commitment to addressing indicators were found to be applicable to the Thai the issue under assessment; for example, the assessment context and no new ones were added. Then, the indicators through WHO’s monitoring system on NCD(5) and were translated from English to Thai by S.P. and translated alochol(7). Non-state actors’ involvement in the assessment back to English by an independent person. The back- can help to promote government policies and actions by translation was used to check discrepancy between the raising their awareness, encouraging their acceptance and original and translated versions. increasing their knowledge on the policies and actions(6). Creating a platform for interactions between state and Evidence compilation and validation non-state actors is useful to identify areas of commonality Evidence for implementation was gathered for all forty- for reconciling differences associated with a particular two indicators of the Food-EPI. Government documents issue. To be effective, assessing the implementation of and budget information related to food environment recommended policies by the government, therefore, policy were collected from data sources such as official should be undertaken as a multi-stakeholder process. information requests, governmental websites and libraries, The objectives of the present study were to: (i) engage NGO publications and websites, major Thai newspapers, government officials (simply called ‘state actors’) and non- and via contact with government officials. Data were governmental experts (simply called ‘non-state actors’)todo collected in relation to current government policy, defined an assessment of the level of implementation of recom- for the purposes of the present study as policies in place mended food environment policies against international best from October 2014 (time when the current Cabinet was practice; (ii) propose and prioritize actions to improve the formed) to October 2015 (the date at which evidence healthiness of Thai food environments; (iii) compare the collection for the project finished). After gathering all findings on the implementation gaps and actions proposed evidence, the completeness and accuracy of the evidence and prioritized by state and non-state actors; and (iv) seek gathered were verified by government officials. Meetings consensus between state and non-state actors on the priority were held with all nine government officials (one each actions to be implemented by the Thai Government. from the Office of Agricultural Economics, Ministry of Agriculture and Cooperative; the Department of Health, the Bureau of Nutrition, the Food and Drug Administration Methods Office and the Bureau of Policy and Strategy, Ministry of Public Health; the Bureau of Student Activity Development, The Healthy Food Environment Policy Index (Food-EPI) Ministry of Education; and the Excise Department, Ministry tool and process from the International Network for Food of Finance; and two from the National Health Commission and Obesity/NCDs Research, Monitoring and Action Office of Thailand), supplemented with personal email Support (INFORMAS)(8) were adapted and made applic- communications with individual officials on some able to the Thai context. The Food-EPI includes two specificissues. components (food policies and infrastructure support), After compiling and validating the evidence, twelve thirteen domains and forty-two good practice indicators indicators out of the forty-two Food-EPI indicators were (nineteen food policy indicators and twenty-three infra- excluded from the rating process, since the level of structure support indicators; see online supplementary implementation of those was considered by the govern- material, Table S1). Two steps were added to the original ment officials to be nil. Ratings were performed for thirty Food-EPI process, namely (i) checking appropriateness of indicators only, including eleven food policy indicators domains and good practice indicators of the Food-EPI for and nineteen infrastructure support indicators. the Thai context and (ii) translating the indicators of the Food-EPI into the local language. The adapted Food-EPI process included ten key steps (Fig. 1). The international best practices used as benchmarks in the present study Pilot test were compiled by INFORMAS through deriving informa- The rating process using the translated Food-EPI and the tion from the World Cancer Research Fund NOURISHING validated evidence was pilot tested with ten experts from database(9) complemented with other best practice NGO and academic institutes. Two observations per parti- examples received from international experts on food and cipant (four weeks apart)